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Admission Date: [**2179-10-26**] Discharge Date: [**2179-10-29**]
Service: Acove/Medicine
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
with a history of encephalitis, spinal stenosis, early
dementia, who was recently admitted to the [**Hospital1 346**] for fever. During her stay she was
found to have UTI and [**1-17**] blood cultures grew E. coli. She
continued to spike temperatures despite Levaquin. She was
found to have bilateral pneumonia, bilateral pyelo and MR of
the back showed abnormal soft tissue mass at T10 to 11.
Additionally, she had right shoulder crystal disease and left
DVT. A TTE showed an EF of greater than 70%. Subsequently
she was discharged to [**Hospital 2716**] [**Hospital **] Rehab facility on
[**2179-10-22**]. The patient had previously declined further work-up
which could have included a colonoscopy/EGD, a TEE and
possible tagged white blood cell scan. On the morning of
admission she was found to be febrile at [**Hospital 2716**] [**Hospital **] rehab
facility and with altered mental status. In the Emergency
Room she was treated with IV fluids and one dose of
Levofloxacin and transferred to the Acove for further
management. Patient does not remember what happened this
a.m. She denies any shortness of breath, chest pain,
diaphoresis, chills, anorexia. She reports having a dry mouth
with some back pain.
PAST MEDICAL HISTORY: Encephalitis, status post epidural
steroid injection. Spinal stenosis. Early dementia.
Questionable history of obsessive compulsive disorder.
Decreased auditory acuity. Hypertension. Depression.
Anxiety. Recent admission to [**Hospital1 188**] for UTI/pneumonia.
MEDICATIONS: Levaquin 250 mg po q d, Oxycodone 5 mg po q 6
hours prn, Remeron 22.5 mg po q h.s., Clonazepam 0.5 mg po q
h.s., Timolol gtt, Vitamin E 250 mg po q d, Aspirin 81 mg po
q d.
SOCIAL HISTORY: Up until last admission she lived at home
with 24 hour [**Hospital 96161**] home health aide. She was recently
discharged to [**Hospital 2716**] [**Hospital **] rehab.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission temperature 98.8, pulse
88, blood pressure 94/50, respiratory rate 20, pulse ox 98%
on three liters. Generally alert and oriented, no acute
distress. HEENT: Pupils are equal, round, and reactive to
light, extraocular movements intact, no JVD, no LAD,
anicteric sclera. Neck supple. Heart, S1 and S2, regular
rate and rhythm, [**1-19**] holosystolic murmur. Pulmonary,
bilateral crackles. Abdomen soft, nontender, non distended,
positive bowel sounds. Extremities, no clubbing, cyanosis or
edema, multiple ecchymotic lesions of anterior leg, pulses 1+
bilaterally.
LABORATORY DATA: White count 9.9, hematocrit 35.2, platelet
count 563,000, neutrophils 91%, lymphs 5%, PT 12.6, PTT 26.7,
INR 1.1, sodium 138, potassium 4.8, chloride 102, CO2 25, BUN
10, creatinine 0.5, glucose 124. Urinalysis with nitrite
negative, trace protein, 1 white blood cell, no bacteria.
Blood cultures from [**10-26**] pending. Urine culture from [**10-26**]
pending.
RADIOLOGY: Chest x-ray bilaterally showed CP angle blunting,
patchy infiltrates, cardiomegaly.
HOSPITAL COURSE: This is a [**Age over 90 **]-year-old female with multiple
medical problems who presented with persistent fever and
mental status changes.
1. Infectious Disease: Given patient's fever and possible
multiple sources of infection, the etiology of her delta MS
likely is infectious in nature. Sources were thought to be
possibly multifactorial including pneumonia, epidural
abscess, gastrointestinal lesion. The patient was hydrated
for her low blood pressure with normal saline. The patient
was continued on Levofloxacin 250 mg po q d. The patient's
mental status appears to have cleared since arrival to the
Emergency Room. She was fairly lucid throughout her hospital
stay. Per discussions with Dr. [**Last Name (STitle) **], the family decided
not to aggressively pursue source of infection and declined a
transesophageal echocardiogram and colonoscopy/EGD. LP was
also deferred. The patient's family decided to focus on
comfort measures at this time. The patient's daughter, [**Name (NI) 96162**]
[**Name (NI) 96163**], met with him in [**Last Name (un) **] and it was agreed that
patient should be discharged there.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: The patient is DNR/DNI.
DISCHARGE DIAGNOSIS:
1. Fever of unknown origin with family refusing further
work-up.
DISCHARGE MEDICATIONS: Levofloxacin 250 mg po q d times 28
days, enteric coated Aspirin 81 mg po q d, Vitamin E 400 IU
po q d, Tylenol 650 mg po/pr q 6 hours prn, Timolol 25% one
gtt to right eye q d, Clonazepam 0.5 mg po q h.s. prn.
DISCHARGE PLACE: The patient was discharged to [**Hospital 2716**]
[**Hospital **] Rehab.
FOLLOW-UP: The patient should follow-up with primary care
physician on [**Name Initial (PRE) **] prn basis.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 910**]
Dictated By:[**Last Name (NamePattern1) 1324**]
MEDQUIST36
D: [**2179-10-29**] 07:33
T: [**2179-10-29**] 08:29
JOB#: [**Job Number 96164**]
| [
"4280",
"2859",
"4019"
] |
Admission Date: [**2196-4-20**] Discharge Date: [**2196-5-1**]
Date of Birth: [**2137-7-10**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old
male with underlying coronary artery disease who was admitted
after an episode of VF arrest after a stress test. The
patient had a cardiac catheterization at an outside hospital
in [**2193**] which reportedly showed moderate three vessel
disease. He had exertional angina for one year prior and had
been medically managed. Over the past two months, he had an
increasing frequency of exertional chest pain lasting five to
ten minutes, relieved by sublingual nitroglycerin and rest.
No radiation. No diaphoresis, palpitations, or shortness of
breath.
The patient was seen in his cardiologist's office and
underwent ETT and a standard [**Doctor First Name **] protocol. After 28
minutes, developed ST depression and chest pain, treated with
sublingual nitroglycerin, felt dizzy, went into VF arrest,
cardioverted times one with 300 joules and 100 of lidocaine,
reversed to normal sinus rhythm and was transferred to [**Hospital6 1760**].
In the Emergency Department, he was found to have a blood
pressure of 200/100 and was started on a nitroglycerin drip,
heparin drip, and Integrelin. He was given 5 mg of IV
Lopressor and magnesium. The patient was scheduled for
catheterization.
PAST MEDICAL HISTORY:
1. CAD.
2. Hypertension.
3. Renal artery stenosis.
4. Diabetes mellitus.
5. Hypercholesterolemia.
6. Chronic renal insufficiency.
ADMISSION MEDICATIONS:
1. Catapres 2 patch q. week.
2. Isordil 60 mg t.i.d.
3. Atenolol .................... 100/25 q.d.
4. Diovan 320 mg q.d.
5. Lipitor 20 mg q.d.
6. Minoxidil 10 mg q.d.
7. Norvasc 10 mg q.d.
8. Folate.
9. Amaril 1 mg q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a nonsmoker and uses only
social alcohol.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: On
admission, the patient was afebrile with vital signs stable
by the time he arrived on the floor and had a regular rate
and rhythm. Lungs: Clear to auscultation bilaterally.
LABORATORY DATA: White count 3, hematocrit 42, platelets
242,000. The electrolytes were within normal limits. CK
146, troponin less than 0.3.
HOSPITAL COURSE: The patient underwent cardiac
catheterization which showed a LVEF of 60%, LMCA 70% ostial
left main, LAD moderate diffuse distal 70%, moderate OM at
the LCX, RCA with probable ostial disease. Renal angio with
50% right renal proximal lesion, moderate aortic disease,
patent common iliacs, bilateral internal iliacs severe
disease, patent external iliacs, known SFA disease from prior
limited study.
The patient underwent a CABG times four on [**2196-4-22**] with LIMA
to LAD, SVG to OM1 and OM2, SVG to the distal RCA. The
patient tolerated the procedure without complications.
The patient was extubated on postoperative day number one.
The patient had a temperature spike to 102 on postoperative
day number two. The patient was started on antibiotics.
The patient was transferred to the floor on postoperative day
number three and continued to have a temperature spike.
Infectious Disease was consulted and opted for discontinuing
antibiotics as it was felt that it would be a probable source
of medication fever. The patient was also noted to have very
elevated LFTs with amylase and lipase which were believed to
be secondary to a pancreatitis episode which resolved by
placing the patient on n.p.o. and then enzymes improved as
time progressed. The patient was able to tolerate a regular
diet at the time of discharge.
The patient continued to have temperature spikes of
undetermined etiology until postoperative day number eight
when the patient's left lower extremity began to look
erythematous. The patient was started on ciprofloxacin and
improved symptom wise and with his temperatures.
By postoperative day number nine, he was felt to be ready for
discharge as he was tolerating a regular diet, ambulating
well, cleared by physical therapy and with good p.o. pain
control and much improved left lower extremity. The patient
is to follow-up with Dr. [**Last Name (STitle) 70**] in six weeks, Dr. [**Last Name (STitle) 11139**],
his primary care provider in one to two weeks, and his
cardiologist in two to three weeks.
DISCHARGE MEDICATIONS:
1. Ciprofloxacin 500 mg p.o. q. 12 hours for ten days.
2. Clonidine 2 patch q. week.
3. Isordil 60 mg t.i.d.
4. Diovan 320 mg q.d.
5. Atenolol 100 mg q.d.
6. Protonix 40 mg q.d.
7. Amaril 1 mg q.d.
8. Percocet one to two tablets q. 4-6 hours p.r.n.
9. Tylenol 650 mg q. four hours p.r.n.
10. Lasix 20 mg q.d. times five days.
11. Colace 100 mg q.d. times five days.
12. Potassium chloride 20 mEq q.d. times five days.
13. The patient is to follow a sliding scale until sugars are
adjusted.
The patient is to follow with his primary care provider in
the first week to follow electrolytes and also to come to
[**Hospital Ward Name 121**] II for a wound check of his left lower extremity to
assure improvement.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft times four.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2196-5-1**] 12:03
T: [**2196-5-1**] 12:30
JOB#: [**Job Number 49648**]
cc:[**Last Name (NamePattern4) 49649**] | [
"41401",
"25000",
"4019"
] |
Admission Date: [**2121-1-16**] Discharge Date: [**2121-2-19**]
Date of Birth: [**2049-10-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base / Tetracyclines / Nsaids / Aspirin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
chest pain,
Major Surgical or Invasive Procedure:
Open Left thoracotomy and decortication
picc line
History of Present Illness:
HPI: This is a 71 y/o M with h/o HTN, Hhypothyroidism, RA, L
side candidal pleural effussion s/p pigtail and IV caspofungin
([**Hospital1 18**] [**2120-8-13**]) who presents with pleuritic and sharp chest
pain.
.
She reports that she had been doing well until last night. While
lying in bed, she developed sharp substernal chest pain, [**8-31**],
radiated to the Left shoulder, worse with inspiration. She felt
short of breath at that time. She took tramadol and small nitro
patch since she did not know where her pain was coming from. Her
pain partially improved. she could not sleep well overnight
given persistent pain.
She called her PCP and was [**Name9 (PRE) 8148**] to the emergency department.
Denied orthopnea, PND, cough, fevers, chills, URI symptoms, or
sick contacts. [**Name (NI) **] urinary symtpoms either.
Patient recalls that this sympotms are very similar to her prior
presentation in [**Month (only) **].
.
As far as her cardiovascular status, she reports being able to
walk [**1-22**] blocks with no significant problems. She is able to go
up 1 flight of staris with no chest pain or SOB either. Per her
report, she had a clean cardiac cath early this year at [**Hospital1 112**]
prior to her knee surgery.
.
In the Ed, Vs 98.7, HR 96, 129/79, Rr 18, sats 99% on RA. A CtA
was done that r/o PE. However, it showed loculated pleural
effusion worse since last Ct. Levaquine 750xd1 was given.
Aspirin and tylenol were given.
.
ROS: No abdominal pain, weight gain or weigh loss.
Past Medical History:
1) Hypertension
2) Hypothyroidism
3) Hypercholesterolemia
4) Bilateral total knee replacement, [**2120-7-16**] on lovenox (d/c
[**2120-7-22**])
5) Video-assisted thoracoscopic surgery (in the past)
6) Gastric stapling [**2093**]'s, gastrogastrostomy [**1-/2117**]
7) Splenectomy - secondary to GI bleed, that given adhesion
during surgery, the spleen was taken out.
8) Rheumatoid arthritis
9) H/O UGIB
10) Polymyalgia rheumatica
11) L sided PNeumonia with + pleural efussion, s/p pig tail for
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and albicans s/p caspofungin and fluconazol
([**2120-8-13**])
s/p ccy and L hip replacement.
Social History:
Lives with husband. [**Name (NI) **] ETOH, No Tob.
Family History:
Mother - aneurysms
Father - CVA
[**Name (NI) **] family history of coagulopathies or propensities to clot
Physical Exam:
Vitals: T: 98.3 P:98 R:18 BP:126/82 SaO2:97% 2l
General: Awake, alert, NAD.
HEENT: oropharinx clear. moist oral mucose.
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: decrease breath sounds L base, Crackles R
base.Dullness to palpation R base.
Cardiac: RRR, nl. S1S2, holosystolic murmur apex.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no edema.
Skin: Skin fold over abdomen with mild erythema.
Neurologic: A&O x3, grossly nonfocal
Pertinent Results:
Admission labs
[**2121-1-16**] 08:05AM NEUTS-85.5* BANDS-0 LYMPHS-9.1* MONOS-4.0
EOS-0.8 BASOS-0.7
[**2121-1-16**] 08:05AM WBC-18.3*# RBC-4.02* HGB-12.8 HCT-38.4 MCV-95
MCH-31.7 MCHC-33.3 RDW-13.8
[**2121-1-16**] 08:05AM GLUCOSE-117* UREA N-21* CREAT-1.0 SODIUM-137
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2121-1-16**] 10:24AM LACTATE-1.8
CTA [**2121-1-16**]
IMPRESSION:
1. No evidence of acute pulmonary embolism or aortic process.
2. Recurrent left pleural effusion with evidence of loculation
and associated atelectasis, but no definite consolidation. This
finding is significantly worse since the [**2120-9-17**] CT (status post
removal of the pigtail drainage catheter) and should be
correlated with detailed clinical information. Although there is
a small right pleural effusion, there is no CT evidence of CHF.
3. Intra-abdominal findings, with very limited evaluation.
*****PREOPERATIVE DIAGNOSIS: Recurrent left pleural effusion.
POSTOPERATIVE DIAGNOSIS: Chronic empyema.
ASSISTANT: Bidman [**Name6 (MD) **] [**Name8 (MD) **], MD
ANESTHESIA: General endotracheal plus epidural.
IV FLUIDS: 2200 cc.
URINE OUTPUT: 500 cc.
ESTIMATED BLOOD LOSS: 600 cc.
INDICATIONS FOR PROCEDURE: Ms. [**Known lastname **] is a 71-year-old
woman who has suffered multiple recurrent left-sided empyemas
The last was in [**Month (only) 205**] and [**2120-8-21**]. She was treated with
pigtail drainage, TPA and antifungals for a candidal empyema.
She represented with acute chest pain and an elevated white
count. She was noted to have a loculated medial likely fluid
collection. This was not accessible via percutaneous
drainage.
PROCEDURE IN DETAIL: The patient was positioned supine and
through a double-lumen endotracheal tube flexible
bronchoscopy was performed to the segmental airway level
bilaterally. There were no anatomic abnormalities. There was
no blood, plugging, purulence, or endobronchial tumor noted.
The patient was then turned into the left thoracotomy
position and prepped and draped in the usual sterile fashion.
We started off thoracoscopically with a 15 mm port in
interspace 7 and the posterior axillary line. There were very
complete adhesions of the chest wall to the lung. We slowly
took these adhesions down bluntly and then were able to free
up enough space to put 2 more ports which we placed at
approximately interspace 6, one near the tip of the scapula
and the other anteriorly behind the pectoralis. We continued
this dissection to free up the lung and this took the better
course of approximately 2 hours. We eventually were able to
free up the anterior aspect of the lung and coming down into
the hilum just on the surface of the pericardium, we noted a
more solid appearing phlegmonous structure. The phrenic nerve
was right behind this as was the pericardium. I did not think
that we would be able to adequately dissect around this
inflamed/infected area without direct tactile feedback.
Therefore, I elected to perform a posterolateral thoracotomy
in which we divided the latissimus and spared the serratus.
We did shingle the sixth rib for more access. As we freed up
this medial abnormal soft tissue collection we realized that
there was no frank abscess with fluid within it but this was
a solid chronic phlegmonous process. We resected this and
sent it for microbiology. We also took some samples of some
fluid collection that we did encounter more superiorly above
the hilum in the region of the AP window. This we sent for
microbiology. We sent some of the pleural debris for
microbiology and pathology as well. As we came down to the
diaphragm, the lower lobe was densely adherent to the
diaphragm. We could feel a more necrotic and solid lesion
there. We slowly dissected this free and noted that there was
an old hematoma or necrotic cavity which was solid in nature.
This was at the base of the lung right on the diaphragm. We
debrided all this free and inspected the diaphragm. We did
not see any evidence of communication of the subdiaphragmatic
contents, i.e. stomach, to the pleural space. There were some
tears of the lung during the course of this decortication and
lysis of adhesions and we sewed some of the bigger air leaks
closed using 3-0 Vicryl. At the completion we irrigated
copiously with saline and then water. Hemostasis was
adequate. We inspected the thoracotomy and shingled rib site
and were happy with the hemostasis there as well. We placed 3
chest tubes; one anteriorly to the apex, one posteriorly to
the apex and one to the base and anchored these with 0
Prolene. We inflated the lung and it filled the chest space
well. We then closed the thoracotomy with #1 Vicryl. Then we
reapproximated the serratus to the chest wall using 0-Vicryl,
reapproximated the latissimus with 0-Vicryl, the subcutaneous
tissue with 2-0 Vicryl and the skin with 4-0 Vicryl. At the
completion, we did a toilet bronchoscopy to suction out the
secretions and then we brought the patient to the unit in
stable condition, intubated. I was present and scrubbed for
the entire procedure.
*****[**2121-1-28**] bronchoscopy
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
ASSISTANT: [**First Name8 (NamePattern2) 74204**] [**Name8 (MD) **], M.D.
PROCEDURE PERFORMED: Flexible bronchoscopy.
INDICATION: Ms. [**Known lastname **] had pigtail catheter placed with
persistent air leak concerning for bronchopleural fistula.
The bronchoscopy is being performed for airway evaluation.
PROCEDURE IN DETAIL: Informed consent was obtained from the
patient's husband after explaining the risks and benefits.
Conscious sedation was initiated with intravenous Versed and
fentanyl. One percent lidocaine was sprayed with an atomizer
in the hypopharynx and over the larynx. A flexible
bronchoscope was inserted orally to the level of the vocal
cords. Thrush was noted in the larynx along with mucosal
edema. The bronchoscope was advanced into the trachea.
Airways appeared normal. specifically, no mucosal lesions
were noted in the trachea, right and left mainstem bronchi,
right upper lobe, bronchus intermedius, right middle lobe and
lower lobe segmental bronchi, left upper lobe and left lower
lobe segmental bronchi. At the time of the bronchoscopy, the
air leak from the chest tube was absent and hence, the
presence or location of the bronchopleural fistula could not
be confirmed.
The patient tolerated the procedure well without any
complications.
*****[**1-29**] PIGTAIL PLACEMENT:
Reason: pigtail placement in both left effusions - especially
the la
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with 2 left loculated fluid collections
REASON FOR THIS EXAMINATION:
pigtail placement in both left effusions - especially the larger
basilar effusion
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post VATS for empyema. Please perform
catheter drainage of a loculated collection in the medial basal
left hemithorax and of separate left basilar collection if
possible.
COMPARISON: [**2121-1-27**].
PROCEDURE: The patient was initially placed prone on the CT
table and non- contrast CT scanning was performed through the
lungs to assess the presence of drainable collections in the
left hemithorax. A gas-filled space posteriorly at the left base
measures 2.4 x 4.3 cm, with minimal fluid. Medially at the left
base, a fluid and gas-filled collection measures approximately
4.8 x 8.3 cm in greatest transaxial dimension (2:25). Since the
previous examination of [**1-27**], patchy bilateral pulmonary
parenchymal opacities are probably little changed, although the
degree of opacity in the lower lobes bilaterally appears
improved, possibly due to prone positioning with decreased
dependent change. There is continued atelectasis and
consolidation in the left lower lobe. A left-sided chest tube
enters via an intercostal approach and terminates lateral to the
collections. There is contrast in the colon from previous
administration, and evidence of prior gastric surgery.
Due to patient discomfort and difficult access to the medial
(larger and fluid-containing) collection with the patient in the
prone position, the patient was placed in the right lateral
decubitus position and rescanned, which showed an accessible
approach to the medial collection.
PROCEDURE: The risks and benefits of the procedure were
explained to the patient, and written informed consent was
obtained. A preprocedure timeout was performed using two patient
identifiers. The skin of the left upper back was prepped and
draped in standard sterile fashion. After local anesthesia with
7 cc of 1% lidocaine, and under direct CT guidance, an 8 French
[**Last Name (un) 2823**] catheter was advanced into the more medial pleural
collection and 120 cc of milky yellow-pink fluid was aspirated,
along with a substantial amount of air. Samples were sent for
microbiology and chemistry, to include total protein, LDH,
glycerides, HDL and LDL. Post-procedural images show the
catheter in place within the thick- walled cavity, now evacuated
of the majority of its fluid, but with a large amount of air.
The walls of the cavity, better seen after the cavity became
pneumatized, are thick and irregular, and several air- filled
bronchial structures very closely approach the lumen of the
cavity (6:26).
The patient tolerated the procedure well, with no complications
evident at the time of the procedure, and remained stable
throughout her stay in the CT suite. The catheter was placed to
pleurovac drainage and the results of the procedure were
discussed with Dr. [**Last Name (STitle) **] at the time of the procedure. As
the second, more posterior, pleural cavity contained only a
minimal amount of fluid, this was not separately accessed.
The attending radiologist, Dr. [**First Name (STitle) **], was present and
supervising throughout the procedure.
MODERATE SEDATION: The patient received 150 mcg of fentanyl and
2 mg of Versed in divided doses for moderate sedation during a
total intraservice time of 50 minutes, during which time the
patient's hemodynamic parameters were continuously monitored.
IMPRESSION:
1. Technically successful CT-guided drainage of a left medial
pleural collection, yielding 120 cc of milky or purulent
appearing fluid. Samples were sent to microbiology and
chemistry. Failure of the cavity to collapse after catheter
drainage with continued return of air on aspiration, as well as
the presence of bronchial structures located very close to the
cavity lumen, suggest a possible bronchopleural fistula. The
catheter was placed to pleurovac drainage.
2. Smaller, more posterior left pleural cavity containing
primarily air was not separately accessed.
Results discussed with Dr. [**Last Name (STitle) **] at the time of the
procedure.
***** [**1-31**] OPERATIVE REPORT:
PROCEDURE: Reoperative left thoracotomy, decortication, and
drainage.
ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
ANESTHESIA: General endotracheal.
IV FLUIDS: 700.
URINE OUTPUT: 200.
ESTIMATED BLOOD LOSS: 400.
INDICATIONS FOR PROCEDURE: Ms. [**Known lastname **] is a 71-year-old
woman on whom I had performed a decortication and drainage on
[**2121-1-18**]. She has been having recurrent fevers and
elevated white count. Repeat CT scan showed that despite one
remaining empyema tube she seemed to collect a basilar and
medial fluid collection which, when accessed with pigtail
drainage, did have multiple bacterial organisms.
PROCEDURE IN DETAIL: The patient was positioned supine,
received a double-lumen endotracheal tube, and then was
turned into the left thoracotomy position. We initially
attempted a VATS exploration through her previous chest tube
site. It was apparent that nearly 2 weeks postoperatively her
chest was quite fused. Therefore, we elected to open up her
thoracotomy and extend it slightly medially. There was a
fractured rib which we guillotined to prevent the rib edges
from rubbing on one another. We bluntly and sharply took down
the bulk of her previous adhesions. This brought us around
the apex and posteriorly at the level of the aorta. Medially,
we were able to develop a plane between the medial surface of
the lung and the pericardium. Finally, we worked around the
pericardium posteriorly and on the base of the heart. There
was a very adherent section of lung to the diaphragm which,
when I started to dissect free, was tearing and quite
friable. There was some necrotic tissue there which we
sampled. I elected not to completely pull that region off the
lung because it likely would have involved wholesale
debriding of what appeared to be necrotic lung tissue. Once
we had the remainder of the lung completely freed up and her
samples taken, we then placed 3 chest tubes as well as [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 406**] drain. We then closed the wound with #1-Vicryl, 0-
Vicryl, 2-0, and then staples. All sponge and needle counts
were correct x 2. I was present and scrubbed for the entire
procedure.
Brief Hospital Course:
71 y/o F with h/o HTN, hyperlipidemia, s/p splenectomy and
recent admission for L pleural effusion with + [**Female First Name (un) **] cx s/p
caspofungin and fluconazol treatment who presents wtih chest
pain, elevated white count.
Mrs. [**Known lastname **] had a CT of the chest which revealed loculated L
pleural effusion. She underwent L VATS washout/decortication on
[**1-19**] and was started on levaquin and fluconazole. A pigtail
catheter was placed postoperatively, but as this had a
persistent air leak she underwent bronchoscopy on [**1-23**] which was
negative for fistula. She continued to spike fevers and
elevated white count even after the decortication, so a chest CT
was repeated and revealed new left sided pleural fluid
collections, one of which was drained by IR on [**1-29**]. She was
started on Zosyn in addition to continuing diflucan. She was
taken back to the OR on [**1-31**] for repeat thoracotomy and washout.
4 chest tubes were placed. She began to improve gradually, and
remained afebrile with a stable white cell count. Chest tube
output decreased consistently and serial chest xrays showed
improvement. She continued to do well, and chest tube output
slowed to a minimum, so she was discharged to home on [**2-19**] with
3 chest tubes in place
Medications on Admission:
Levothyroxin 88/day
Norvasc 5 mg/day
Celebrex 200/day
Maxide 75/25 (Triamterene/HCTZ) qd
Plaquenil 200mg/day
Zocor 40/day
Nexium 40 [**Hospital1 **]
Lunesta qhs
tylenol PRN
folic acid qd
reglan 1 day
Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Triamterene 50 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: [**3-26**]
MLs Intravenous SASH as needed.
Disp:*30 * Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 7 days.
Disp:*21 doses* Refills:*0*
14. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
16. Saline Flush 0.9 % Syringe Sig: [**5-31**] mL Injection twice a
day: flush PICC line with 5-10 cc [**Hospital1 **].
Disp:*30 * Refills:*0*
17. IV Supplies
IV Supplies per Critical Care Systems Protocol
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Fungal PNA w/ L pleural effusion, HTN, hypercholesterolemia,
hypothyroidism, RA, h/o GIB, GERD, angina
PSH:VATS, Gastric stapling, splenectomy, B knee replacement, L
hip replacement, CCY
Discharge Condition:
stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) 62110**] office [**Telephone/Fax (1) 170**] if experience: fever,
chills, increased cough or sputum production, chest pain.
Chest tube site dressing change daily to keep site clean and dry
No driving while taking narcotics.
take stool softners and laxative with narcotics to prevent
constipation.
No showering or tub bathing with chest-tube in place.
Weekly CBC/diff, chem 7, LFTs while on diflucan: fax results to
[**Telephone/Fax (1) 432**] to Dr. [**Last Name (STitle) 976**].
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on the
[**Hospital Ward Name **] [**Location (un) 448**] of the [**Hospital Ward Name 121**] building [**Hospital1 **] one at
11:00am on Wednesday, [**2-26**]. Please arrive 45 minutes prior
to your appointment and report to clinical center [**Location (un) 470**]
radiology for a chest XRAY
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7304**], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2121-2-21**] 10:30
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2121-5-1**] 10:30
Call Dr. [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) 100067**] for an appointment as outpatient
[**Telephone/Fax (1) 1983**]
Call [**Telephone/Fax (1) 2349**] to schedule a follow up appointment for your
voice with Dr. [**First Name (STitle) **] or Dr. [**First Name (STitle) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2121-2-24**]
11:00
Completed by:[**2121-2-19**] | [
"5119",
"5180",
"5990",
"4019",
"2449",
"2720",
"53081"
] |
Admission Date: [**2117-10-27**] Discharge Date: [**2117-11-4**]
Date of Birth: [**2053-2-7**] Sex: F
Service: MEDICINE
Allergies:
Flagyl
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
LLQ pain
Major Surgical or Invasive Procedure:
Placement of a left ureteral stent
History of Present Illness:
64 yo F w/ PMH of CHF, IDDM, hypothyroidism, ventricular
arrythmia with ICD who is admitted to the [**Hospital Unit Name 153**] with GNR
bacteremia s/p cystoscopy and stent placement for
nephrolithiasis with difficulty extubating. Pt presented to the
ED the day prior to transfer with left flank pain, nausea and
vomiting. KUB and CT abdomen showed 8-mm stone within the
proximal left ureter resulting in mild
hydronephrosis. When she was in the ED she got a dose of
ceftriaxone and a dose of ampicillin. She was admitted to
urology where they were planning to do an elective stent
placement. However overnight she developed low grade fevers to
100.8 and her blood cultures grew out GNR and her procedure was
moved up to be emergent. She had a stent placed in her left
ureter, and she received 700ml fluids total in the OR plus 125cc
in the PACU. Post operatively she remained hypotensive (to
unclear BPs) on 0.3 of phenylepherine which was weaned off in
the PACU. In the PACU when they tried to wean down to extubate,
on CPAP she was only pulling in tidal volumes in the 100s. She
received Vanc and Cefepime in the PACU. Blood sugars were
apparently elevated before to unclear levels, got 10u subcu
regular noonish. Only value recorded is 220s. Reportedly good
UOP while in PACU.
She is transferred to the [**Hospital Unit Name 153**] for management of her blood
pressure and respiratory status.
On arrival to the MICU, patient's VS. 99.8 133/69 92 100% on
CMV with TV 500, RR 15, FiO2 40%
Review of systems: Unable to obtain [**3-11**] intubation
Past Medical History:
Diabetes
CHF
Depression
Diverticulitis
Hypothyroidism
Spinal stenosis
ARthritis
Obesity
Ventricular Arrhythmia
PVD
Neuropathic pain
Hx hematuria
Social History:
The patient lives with her daughter. She previously worked as a
social worker. She does not smoke or drink alcohol. She has
remote cocaine use (quit [**2099**]) and alcohol use, 45 pack year
tobacco hx, quit in [**2099**].
Family History:
No family history of recurrent skin infections. No family
history of premature coronary artery disease or sudden death.
Father had kidney stones.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 99.8 133/69 92 100% on CMV with TV 500, RR 15, FiO2 40%
General: NAD, appears comfortable, AAOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, difficult to assess JVD d/t body habitus
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Dimished breath sounds at bases bilaterally anteriorly
Abdomen: soft, tender at lower quadrants, maximally on LLQ,
non-distended, no organomegaly, no rebound or guarding.
Hypoactive bowel sounds.
Ext: Trace edema in feet b/l. Warm, well perfused, 2+ pulses, no
clubbing, cyanosis
Pertinent Results:
KUB [**2117-10-27**]: IMPRESSION: 8-mm stone within the proximal left
ureter resulting in mild hydronephrosis.
CT abd: IMPRESSION: 7-mm proximal ureteral stone at the level
of the L3 vertebral body; upstream left hydroureteronephrosis
with delayed excretion of contrast in the dilated left
collecting system and proximal ureter. No definite contrast seen
in the left ureter distal to the level of the renal stone.
CXR [**2117-10-28**]: As compared to the previous radiograph, the patient
has been
intubated. The tip of the endotracheal tube projects 3 cm above
the carina. A left pectoral pacemaker is in unchanged position.
In the interval, lung volumes have substantially decreased,
there are signs indicative of mild-to-moderate pulmonary edema
and atelectasis at both lung bases. No evidence of pneumonia.
Short-term followup with chest radiographs is required.
.
ECHO:
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with basal to mid inferior and
inferolateral hypokinesis. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal.
Compared with the prior study (images reviewed) of [**2115-11-8**],
the right ventricle appears dilated and hypokinetic and there is
evidence of pressure/volume overload of the left ventricle.
Findings are suggestive of acute right heart strain - probably
from pulmonary embolism although right ventricular ischemia is
also possible.
.
CTA chest:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Mild pulmonary edema and bilateral atelectasis, right
greater than left.
3. Incompletely imaged left kidney showing a 6-mm stone and
start of the
double J-stent but also small foci of air in the kidney of
unclear
significance.
.
microbiology:
[**2117-10-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2117-10-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2117-10-28**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2117-10-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2117-10-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2117-10-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2117-10-27**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY [**Hospital1 **]
URINE CULTURE (Final [**2117-10-29**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2117-10-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL
**FINAL REPORT [**2117-10-30**]**
Blood Culture, Routine (Final [**2117-10-30**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2117-10-31**] 08:10AM BLOOD WBC-5.7 RBC-4.12* Hgb-12.4 Hct-38.8
MCV-94 MCH-30.2 MCHC-32.0 RDW-13.6 Plt Ct-150
[**2117-10-30**] 08:15AM BLOOD WBC-5.9 RBC-3.86* Hgb-12.1 Hct-36.6
MCV-95 MCH-31.3 MCHC-33.1 RDW-13.6 Plt Ct-134*
[**2117-10-29**] 07:18PM BLOOD Hct-37.1
[**2117-10-29**] 02:44AM BLOOD WBC-8.6 RBC-3.93* Hgb-12.3 Hct-37.1
MCV-94 MCH-31.3 MCHC-33.2 RDW-13.8 Plt Ct-122*
[**2117-10-28**] 12:15PM BLOOD WBC-11.9* RBC-3.95* Hgb-12.4 Hct-37.4
MCV-95 MCH-31.3 MCHC-33.0 RDW-14.7 Plt Ct-144*
[**2117-10-28**] 07:10AM BLOOD WBC-12.4*# RBC-3.83* Hgb-11.9* Hct-36.2
MCV-95 MCH-31.1 MCHC-32.9 RDW-13.7 Plt Ct-140*
[**2117-10-27**] 11:53AM BLOOD WBC-8.2 RBC-4.57 Hgb-14.3 Hct-43.0 MCV-94
MCH-31.3 MCHC-33.3 RDW-13.4 Plt Ct-210
[**2117-10-30**] 08:15AM BLOOD Neuts-57 Bands-0 Lymphs-30 Monos-11 Eos-1
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2117-10-29**] 02:44AM BLOOD Neuts-71.9* Lymphs-18.4 Monos-7.9 Eos-1.6
Baso-0.3
[**2117-10-31**] 08:10AM BLOOD Plt Ct-150
[**2117-10-30**] 08:15AM BLOOD Plt Smr-LOW Plt Ct-134*
[**2117-10-30**] 08:15AM BLOOD PT-13.5* PTT-37.1* INR(PT)-1.3*
[**2117-10-29**] 06:11PM BLOOD PT-14.5* PTT-40.8* INR(PT)-1.4*
[**2117-10-29**] 02:44AM BLOOD Plt Ct-122*
[**2117-10-29**] 02:44AM BLOOD PT-17.1* PTT-31.8 INR(PT)-1.6*
[**2117-10-28**] 12:15PM BLOOD Plt Ct-144*
[**2117-10-28**] 07:10AM BLOOD Plt Ct-140*
[**2117-10-27**] 11:53AM BLOOD Plt Ct-210
[**2117-10-27**] 11:53AM BLOOD PT-13.3* PTT-33.5 INR(PT)-1.2*
[**2117-10-29**] 06:11PM BLOOD Fibrino-597*
[**2117-11-3**] 03:00PM BLOOD Glucose-169* UreaN-14 Creat-0.7 Na-138
K-4.4 Cl-94* HCO3-36* AnGap-12
[**2117-11-3**] 07:00AM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-141
K-4.1 Cl-95* HCO3-44* AnGap-6*
[**2117-11-2**] 06:40AM BLOOD Glucose-186* UreaN-12 Creat-0.9 Na-140
K-4.5 Cl-94* HCO3-46* AnGap-5*
[**2117-11-1**] 06:30AM BLOOD Glucose-143* UreaN-14 Creat-0.8 Na-140
K-4.3 Cl-95* HCO3-40* AnGap-9
[**2117-10-30**] 08:15AM BLOOD Glucose-235* UreaN-14 Creat-0.7 Na-136
K-4.5 Cl-98 HCO3-33* AnGap-10
[**2117-10-29**] 02:44AM BLOOD Glucose-215* UreaN-13 Creat-0.7 Na-136
K-4.1 Cl-100 HCO3-29 AnGap-11
[**2117-10-28**] 12:15PM BLOOD Glucose-229* UreaN-19 Creat-1.0 Na-136
K-4.1 Cl-97 HCO3-29 AnGap-14
[**2117-10-28**] 07:10AM BLOOD Glucose-241* UreaN-17 Creat-1.0 Na-137
K-4.3 Cl-99 HCO3-30 AnGap-12
[**2117-10-27**] 11:53AM BLOOD Glucose-231* UreaN-14 Creat-0.9 Na-140
K-4.3 Cl-100 HCO3-34* AnGap-10
[**2117-11-3**] 03:36PM BLOOD CK(CPK)-176
[**2117-10-27**] 11:53AM BLOOD ALT-42* AST-48* AlkPhos-132* TotBili-0.5
[**2117-10-27**] 11:53AM BLOOD Lipase-20
[**2117-11-3**] 03:36PM BLOOD CK-MB-2 cTropnT-<0.01
[**2117-11-3**] 07:00AM BLOOD cTropnT-<0.01
[**2117-11-3**] 03:00PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.3
[**2117-10-29**] 06:11PM BLOOD Hapto-223*
[**2117-10-29**] 02:44AM BLOOD %HbA1c-9.7* eAG-232*
[**2117-11-2**] 06:40AM BLOOD TSH-3.3
[**2117-11-2**] 06:40AM BLOOD Cortsol-16.9
[**2117-11-1**] 03:40PM BLOOD Type-ART Temp-37 pO2-84* pCO2-67* pH-7.39
calTCO2-42* Base XS-11 Intubat-NOT INTUBA
Brief Hospital Course:
64 yo F w/ complex PMH including systolic CHF, DM2, s/p ICD,
hypothyroidism, OSA who was taken to the OR urgently for septic
nephrolithiasis with Ecoli bacteremia who developed post-op
hypotension transiently requiring pressors and failure to
extubate.
.
#E.coli urosepsis with obstructive uropathy/nephrolithiasis and
hydronephrosis- Imaging revealed nephrolithiasis and
hydronephrosis. Bcx and UCX revealed Ecoli. Pt was taken to the
OR for uretral stent placement on [**2117-10-28**].[**Name (NI) **], pt was
hypotensive and there was a failure to extubate and pt was
admitted to the ICU. Upon admission to the ICU, she was no
longer hypotensive and HR was within normal limits. Vancomycin
and cefepime were initially continued. Pt improved and was
transferred to the medical floor on [**2117-10-29**]. Her antibiotics
were weaned to IV ceftriaxone given susceptibility pattern. Plan
is to continue IV antibiotics through [**2117-11-11**]. Picc line was
placed. Pt will be following up in urology clinic on [**2117-11-17**]
for further evaluation and discussion on further treatment of
nephrolithiasis and hydronephrosis. Of note, pt still with
bloody tinged urine. Pt will be discharged with the foley
catheter in place. Would plan for voiding trial and foley
removal as soon as urine becomes more clear.
#Respiratory failure/hypoxia/hypercarbia- Patient was intubated
for the procedure and likely failed initial weaning because it
was initiated when she was still too sedated. She had
successful SBT on admission to the ICU and was extubated within
two hours of admission. However, while on the medical floor, pt
was noted to have asymptomatic hypoxemia, often requiring 1-2L
NC. Pulmonary was consulted and felt as though pt likely has
obesity hypoventilation and OSA. CPAP initiated. Pt will be
discharged with oxygen NC and CPAP with instructions to follow
up in pulmonary clinic. Of note, pt's echo revealed RV dilation
with moderate global free wall hypokinesis. RV pressure overload
noted. Echo suggesting RV strain. However, CTA of the chest was
performed on the same day and was negative for PE, showing some
mild pulmonary edema. In addition, EKG performed and similar to
prior. Cardiac enzymes were negative. Some atelectasis noted,
but no sign of PNA.
.
#systolic heart failure-Diuretics, BB, and [**Last Name (un) **] initially held in
ICU due to sepsis. Lasix, spironolactone and BB Restarted. Plan
to restart [**Last Name (un) **] upon discharge. TTE revealed evidence of pressure
overload and CTA revealed some pulmonary edema. Pt was continued
on her home dose of lasix 20mg daily and given an additional
dose of 20mg IV lasix on [**2117-11-3**] given CTA findings. No
evidence for ischemia. CTA without PE. ECHO suggested acute RV
strain, however, EKG did not reveal ischemia, cardiac enzymes
were negative.
.
#DM: On U500 at home, has not been seen at [**Last Name (un) **] in over 1 yr.
Blood sugars here had have been in 200s. [**Last Name (un) **] was consulted.
Per their final recommendations:
lantus 45units, 15units of standing premeal humalog with humalog
sliding scale. Pt will need to follow up with [**Last Name (un) **] upon
discharge from rehab or during rehab.
.
#H/o Ventricular Arrhythmia: ICD in place
.
#hypothyroidism-continued home levothyroxine 200mcg qday
.
#Depression: continue home meds
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Citalopram 40 mg PO DAILY
3. Fluocinonide 0.05% Ointment 1 Appl TP [**Hospital1 **]
Apply to legs and feet twice a day, avoid use on face, unerarms,
and groin.
4. Furosemide 20 mg PO DAILY
As needed for SOB or swelling.
5. Gabapentin 600 mg PO DAILY
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
Please hold for SBP <100 or HR <50.
8. Nystatin-Triamcinolone Ointment 1 Appl TP [**Hospital1 **]:PRN Rash
9. Simvastatin 40 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
Please hold for SBP <100.
11. traZODONE 50 mg PO HS:PRN Insomnia
Please hold for oversedation
12. Valsartan 40 mg PO DAILY
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Citalopram 40 mg PO DAILY
4. Furosemide 20 mg PO DAILY
As needed for SOB or swelling.
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Metoprolol Succinate XL 200 mg PO DAILY
Please hold for SBP <100 or HR <50.
7. Simvastatin 40 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
Please hold for SBP <100.
9. Gabapentin 100 mg PO DAILY
10. CeftriaXONE 2 gm IV Q24H
please prepare in normal saline (no dextrose) given very high
blood sugars
11. Docusate Sodium 100 mg PO BID
please hold for loose stools
12. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
hold for sedation
13. Senna 1 TAB PO DAILY
please hold for loose stools
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Nystatin-Triamcinolone Ointment 1 Appl TP [**Hospital1 **]:PRN Rash
16. Fluocinonide 0.05% Ointment 1 Appl TP [**Hospital1 **]
Apply to legs and feet twice a day, avoid use on face, unerarms,
and groin.
17. Polyethylene Glycol 17 g PO DAILY
18. Valsartan 40 mg PO DAILY
THis medication was held during admission. PLease restart [**11-5**]
and monitor creatinine
19. Glargine 45 Units Breakfast
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Obstructive nephrolithiasis of the left ureter with gram
negative septicemia resulting from this and associated bacterial
urinary tract infection.
.
Hypoxemia
metabolic acidosis
hypercarbia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for evaluation of a severe kidney infection
causing sepsis. You were found to have a kidney stone and
blockage in your kidney due to your kidney stone. You symptoms
improved with urinary drainage and antibiotics.
.
You were noted to have low oxygen levels. For this, you were
evaluated by the lung doctors who are recommending that you have
an outpatient sleep study and lung function testing. See below.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2117-11-17**] at 10:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2010**]
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2117-11-29**] at 3:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2117-11-29**] at 4:00 PM
With: DR. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2117-12-15**] at 10:20 AM
With: RADIOLOGY [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PODIATRY
When: THURSDAY [**2118-1-13**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
| [
"5990",
"4280",
"V5867",
"2449",
"311",
"V1582",
"32723",
"2875",
"51881",
"5180"
] |
Admission Date: [**2116-6-2**] Discharge Date: [**2116-7-25**]
Date of Birth: [**2076-9-30**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Iodine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Here for allogeneic transplant for refractory multiple myeloma
Major Surgical or Invasive Procedure:
central line placement and removal
chemotherapy with cytoxan and busulfan
allogeneic bome marrow transplant
PICC line placement
VATS/pleurodeisis
History of Present Illness:
39 yo male with multiple myeloma diagnosed in [**2114**] He was
initially treated with Decadron alone and then began treatment
with thalidomide and dexamethasone, which was started in
09/[**2114**]. He also underwent radiation therapy to the sacral area
in 11/[**2114**]. His course was complicated by a DVT and PE at the
time of his diagnosis, and he was on anticoagulation
particularly while receiving thalidomide and Decadron. He was
noted for a very good response to his treatment with a repeat
bone marrow biopsy in [**2115-3-19**] showing
5% plasma cells as well as marked improvement in his lesion in
the sacral area. In [**Month (only) 547**]/05, he was noted to have a drop in his
white blood count, and repeat bone marrow biopsy showed
increasing plasma cells with 20% involvement. His IgG level had
also increased with a concern for more refractory disease. He
received a cycle of DVD chemotherapy on [**2115-4-25**]. Following
this therapy, he had increasing pain with increasing IgG levels
and SPEP with a poor response to therapy, he was switched to
treatment with Velcade and Decadron. He was given four cycles
of this therapy. A repeat bone marrow aspirate and biopsy
revealed CD138 staining of plasma cells for approximately 10% of
the cellularity. His IgG level had decreased to a low of 1680.
His SPEP had also decreased to 1100 mg/dL of the total protein.
He then received high-dose Cytoxan on [**2115-7-25**] in preparation
for stem cell mobilization with his stem cell collections
completed during the week of [**2115-8-5**]. He then was admitted
on [**2115-8-23**] for high-dose chemotherapy with melphalan followed
by stem cell transplant. Followup evaluation of his disease at
2 months post-transplant at the end of [**10/2115**] showed
approximately 10% involvement by plasma cells by CD138 staining.
This was essentially stable, and he was continued to be
monitored. His IgG level had decreased to 1314 following his
transplant. On [**2116-1-19**], pt has increasing pain in the
left groin area. An x-ray of the area did not show any evidence
for fracture or lesion. He did undergo an MRI as well, which
showed a lesion near the groin area with no pathologic fracture.
He received radiation therapy to this area. Also in this
setting, his IgG level had now increased to almost 4 g. He
underwent a bone marrow aspirate and biopsy by his local
oncologist, Dr. [**Last Name (STitle) 59071**], which revealed extensive relapsed
disease with plasma cell myeloma accounting for 80-90% of the
core biopsy specimen. As a result of this, it was felt that Mr.
[**Known lastname 40270**] required more systemic therapy in addition to continuing
the radiation therapy to the groin area, he was started Velcade
with Decadron [**2116-3-2**]. He had been requiring increasing
platelet transfusion support prior to beginning Velcade as well
as during the course of Velcade with a platelet count less than
20,000 as well as red blood cell transfusion support, his IgG
level had increased to 7 g with his SPEP now representing 50% or
4900 mg/dL of the total protein. He was started on more
aggressive chemotherapy with D-PACE on [**2116-3-4**]. Within one
week, he was noted for an increase of his IgG to over 6 g. As
he clearly had an agressive refractory myeloma, he is being
admitted for with a myeloablative transplant with cytoxan and
busulfan conditioning. Mr. [**Known lastname 40270**] is being admitted today to
begin his allogeniec transplant.
Past Medical History:
1. Multiple myeloma as described above.
2. History of DVT and PE while receiving thalidomide, status
post 6 months of anticoagulation.
3. Recent pneumonia treated with a 14-day course of Levofloxacin
in 02/[**2116**].
Social History:
Mr. [**Known lastname 40270**] previously worked as a florist but is currently
unemployed. He does coach a girls basketball team and tries to
keep active although since his most recent admission, he has not
been keeping up with this. He denies any
history of tobacco or alcohol use. He is married with a very
supportive wife and has two young children, ages 4 and
1-year-old.
Family History:
Mr. [**Known lastname 40270**] has no hematologic malignancies in his family.
There is type 2 diabetes in the family with elevated
cholesterol. His mother died of a cerebrovascular accident. He
has a brother and sister, both of whom have been HLA typed and
do not match him. He currently has a non-related [**9-27**] HLA match
Physical Exam:
Admission:
VS: T 97.6 BP108/65 HR110 O2sat97%RA
Gen: young AA male lying in bed in flat affect
HEENT: anicteric sclera, MMM, OP clear
Neck: Supple. No LAD.
Cardio: RRR, nl S1 S2, no m/r/g
Lungs: CTAB no RRW
Abd: soft, NT, ND +BS, no hepatosplenomegaly
Ext: 2+pulses. No edema. .
Neuro: A&Ox 3
Back: no point tenderness to palpation
Pertinent Results:
.
[**6-2**] CXR: Slight improvement in the multiple patchy opacities
which may be consistent with improving multifocal pneumonia
.
[**6-2**] Line placement 1: Successful placement of a 7-French triple
lumen central line through the left internal jugular vein with
the tip in the superior vena cava. The line is ready for use
.
[**6-2**] Line Placement 2: Successful placement of a 29 cm
cuff-to-tip 10 French double- lumen tunneled [**Doctor Last Name 3075**] catheter
with the tip in the superior vena cava. The line is ready for
use.
.
[**6-2**] ECHO: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
Tissue velocity imaging demonstrates an E/e' <8 suggesting a
normal left ventricular filling pressure. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. Compared with the prior study (images
reviewed) of [**2116-5-22**], left ventricular systolic function now
appears slightly more vigorous.
.
[**6-2**] ECG: Sinus tachycardia. Normal ECG except for rate
.
[**6-8**] CXR: Stable appearance of multiple airspace opacities
within the bilateral lungs which may represent multifocal
pneumonia
.
[**6-8**] ECG: Sinus tachycardia. Diffuse ST-T changes are
nonspecific
.
[**6-8**] Transfusion reaction investigation: Mr [**Known lastname 40270**] had diffuse
trunk
and arm pain, tachycardia, mild hypertension and difficulty
breathing
while undergoing a transfusion of compatible red cells. Although
there
are a few laboratory parameters that are suspicious for
hemolysis (mildy
elevated LDH), other labs (negative DAT, normal haptoglobin) are
not
supportive of hemolysis, nor is his clinical picture. We feel
that this
reaction is an atypical non-hemolytic transfusion reaction that
does not
have a clear underlying cause. At this time we do not recommend
changes
in transfusion practice in this patient except careful
monitoring during
future transfusions.
.
[**6-9**] ECG: Sinus rhythm. Non-specific diffuse T wave changes.
Compared to the previous tracing of [**2116-6-2**] no significant
diagnostic change.
.
[**6-11**] US Liver: No evidence of liver, gallbladder, or biliary
tree pathology to explain the patient's symptoms. Tiny 2 mm
polyp or non-shadowing stone in the gallbladder lumen. Small
bilateral pleural effusions.
.
[**6-12**] CXR: The bilateral central venous lines are in stable
position. There is no pneumothorax. There is persistent left
lower lobe opacity presumably atelectasis which appears slightly
increased with the medial diaphragm obscured. No new areas of
consolidation or effusion are identified.
.
[**6-13**] CT CAP: 1. Interval development of large left and smaller
right pleural effusions. A new focal area of consolidation is
seen at the left lung base which may represent atelectasis or
possible pneumonia.
2. Resolving multifocal areas of peribronchovascular nodular
opacification.
3. Progressive areas of soft tissue density in the paraspinal,
pleural/extrapleural bases and left pelvis. Multifocal skeletal
lesions are relatively unchanged and most severe at T11 with
associated wedge compression fracture and in the left scapula.
4. No radiographic findings to explain the patient's abdominal
pain.
.
[**2116-6-14**] ECHO: 1. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
2. Compared with the prior study (images reviewed) of [**2116-6-2**],
there is no significant change.
[**2116-6-18**] Transthoracic Echocardiogram:
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF 70%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
There is a small pericardial effusion. The effusion appears
loculated around the right atrial free wall. There are no
echocardiographic signs of cardiac tamponade, although there is
brief right atrial diastolic invagination.
Compared with the findings of the prior study (images reviewed)
of [**2116-6-14**], the loculated pericardial effusion appears
somewhat larger.
[**2116-6-17**] CXR:IMPRESSION: Markedly increased right pleural
effusion, compared to the prior study, worrisome for hemothorax
in this patient with recent thoracentesis if it was on the right
side. Edema in the right lung. Opacity in right lower lobe,
which may be due to atelectasis, however, the evaluation is
somewhat limited on this portable exam.
[**2116-6-18**]: CT CHEST BEFORE AND AFTER CONTRAST:
IMPRESSION:
1. Large pleural fluid accumulation in the right hemithorax,
with findings
suggestive of clot in the inferior aspect. No definite
extravasating vessel identified. Stable appearance of left
pleural effusion.
2. No pulmonary embolism.
3. Otherwise, no significant interval change since examination
of [**2116-6-13**]
[**2116-6-19**]:
CHEST AP: IMPRESSION: Stable pulmonary edema. Tiny right apical
pneumothorax. Worsening left lower lobe consolidation, which
could represent atelectasis or pneumonia.
[**2116-6-19**]: RIGHT UPPER QUADRANT ULTRASOUND: IMPRESSION:
Unremarkable abdominal ultrasound. Normal liver Doppler vascular
examination.
[**2116-6-22**]: CXR - Interstitial edema has cleared though pulmonary
vascular redistribution persists. Left lower lobe has been
consolidated since at least [**6-18**] and could be either
persistent atelectatic or infected. Right pleural tube still in
place, but there is no pneumothorax or appreciable right pleural
effusion. Tip of the left PIC catheter projects over the SVC.
Heart size top normal, midline.
[**2116-6-28**] Right Upper extremity ultrasound: IMPRESSION: No
evidence of left upper extremity DVT.
[**2116-6-28**] CXR: FINDINGS: Comparison is made to prior study from
[**2116-6-23**].
The right apical pneumothorax is no longer visualized. The heart
size is
upper limits of normal and unchanged. There is a persistent left
retrocardiac opacity and bilateral pleural effusion, which are
stable. There is no overt pulmonary edema.
[**2116-7-1**] CXR UPRIGHT AP VIEW OF THE CHEST: A left PICC is present
with tip in the distal SVC. The heart is normal in size. The
mediastinal and hilar contours are normal. The lungs are clear,
and there are no pleural effusions or pneumothorax. Pulmonary
vascularity is normal. The osseous structures are unremarkable.
.
[**7-2**] ECHO: Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
4. There is moderate pulmonary artery systolic hypertension.
5.There is a small pericardial effusion with fibrin deposits on
the surface of
the heart.
6. Compared with the prior study (images reviewed) of [**2116-6-18**],
there is no
significant change.
.
[**7-2**] EEG:
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background and bursts of generalized slowing. These findings
indicate a
widespread encephalopathic condition affecting both cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There were no areas
of
persistent focal slowing, and there were no epileptiform
features.
.
[**7-4**] DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname 40270**] has
a clinically significant red cell alloantibody, anti-S. S is a
member of the MNS blood group system. Anti-S can cause hemolytic
transfusion reactions.
In the future he should receive S negative red cells for
transfusion.
He is also restricted to irradiated and leukoreduced red cells.
.
[**7-15**] RUQ U/S
IMPRESSION: No son[**Name (NI) 493**] abnormalities in the right upper
quadrant.
.
[**7-20**] MRI of C-spine and T-spine:
CONCLUSION: T11 vertebral body collapse, unchanged since [**3-22**], [**2116**].
C5-6 disc protrusion to the right with indentation on the spinal
cord and occlusion of the neural foramen.
No evidence of epidural abscess.
.
[**7-21**] CT Chest w/o contrast:
IMPRESSION:
1. Persistent small right pneumothorax, as seen on an earlier
radiograph of the same day.
2. Improvement in bilateral pleural effusions, with small
residual left effusion.
3. Improved aeration of the right lung since the prior CT,
although the entire right lung remains involved with
heterogeneous consolidations.
4. Worsening consolidations throughout the left lung.
5. Similar prominent soft tissue densities in the left pelvic
side wall, probably lymphadenopathy.
Brief Hospital Course:
Mr [**Known lastname 40270**] was admitted for a MUD allogeneic BMT with Cytoxan
and Busulfan conditioning. He was treated according to the
transplant protocal. He was transfused to keep his hct>25 and
plt>10. He had one suspected transfusion reaction to pRBCs, and
an investigation was performed. He received additional units of
pRBCs without further reaction.
After the allogeneic BMT, he had febrile neutropenia. On [**6-7**] blood cultures grew MRSA. He was started on Vancomycin,
Cefepime and then Caspofungin was added. He was persistently
febrile to 104-105 degrees. He had a chest x-ray and CT scan
that demonstrated bilateral pleural effusions, left greater than
right. He was diuresed with some decrease in effusion size,
although left sided effusion was still large. On [**6-18**], given the
persistent, high fevers, and consolidation within the left
pleural effusion, there was a concern for empyema.
Interventional Pulmonary was contact[**Name (NI) **]. Platelets were
transfused to keep > 50 prior to procedure. They attempted
thoracentesis on left, but were unable to drain any fluid
despite being able to visualize fluid on ultrasound. Ultrasound
was performed on the right side and effusion was seen.
Thoracentesis was performed on the right side and very small
amount of fluid was drained. Approximately 10 hours after the
procedure, patient noted severe substernal chest pain,
difficulty breathing. He was tachycardic to 130's. Pain
responded to iv morphine. A chest x-ray was performed and
demonstrated new right pleural effusion. His hematocrit had
decreased to 15 (approx 8 point decrease) and concern for
hemothorax. The medical ICU team was contact[**Name (NI) **]. [**Name2 (NI) **] was
transferred to the ICU. A contrast CT Chest/Abdomen/Pelvis was
performed. Given concern for contrast administration in patient
with Multiple Myeloma, he was given 4 doses of mucomyst
immediately following the CT scans. Thoracics was contact[**Name (NI) **] and
placed a chest tube on [**6-18**] on the right which drained bloody
fluid.
Patient was feeling much better after the chest tube was placed.
His LFTS were noted to be increasing, and especially his
Bilirubin (direct bilirubinemia). There was a concern for
[**Last Name (un) **]-occlusive disease. His weight had not been increasing,
though. An ultrasound with dopplers was performed on [**6-20**] and
was normal with normal blood flow. His LFTs started trending
down and chest tube output was decreasing. He was transferred
back to oncology floors on [**6-21**]. Chest tube was removed by
Thoracics surgery on [**6-22**]. He continued to have serosanguinous
drainage from chest tube site while he was neutropenic, but this
stopped when his blood counts started rising.
On [**7-1**], patient was noted to be diaphoretic and complained of
not feeling well.
In the afternoon he underwent a sharp decline in mental status,
becoming confused and then increasingly somnolent. An ABG on
the BMT floor showed hypercarbia (ABG: 7.27/58/89/28) with
stable vital signs and a PE notable for poor respiratory
excursion. He was given 125mg Solumedrol and 1U plts/1U blood
were transfused.
When the ICU team arrived the pt was noted to be stuporous. Pt
was given 0.8mg Narcan-- > became more alert for a couple of
minutes and then again lapsed obtunded state, had tonic clonic
sz activity, and was noted to have LOC, disconjugated gaze and
bowel incontinence. He was intubated on floor for airway
protection and transferred back to the ICU.
.
In the [**Hospital Unit Name 153**], patient was noted to be in hypercarbic resp failure
as above. His vent settings were titrated as needed to maintain
normal pCO2. His MS appeared to have improved. His seizure/MS
changes as above were thought due to his hypercarbia and no AEDs
were initiated as per the neurology c/s service. It was felt
that his hypercarbic resp failure was due to DAH, and he
received He was noted to develop ARF with his Cr rising to 2.0
from 1.0 over the span of a few days. It was thought that this
was likely iatrogenic in nature rather than prerenal azotemia as
he was fluid overloaded on exam, with nml vital signs and urine
lytes c/w ATN. His acyclovir was held and his CSA dose was
decreased to prevent further nephrotoxicity. He was steadily
weaned from the vent until [**7-8**] am when he was noted to have a
sudden increase in oxygen requirement. He was bronched ([**7-8**])
and was noted to have progressive bloody return on BAL,
concerning for recurrent diffuse alveolar hemorrhage. He
continued to intermittently spike and was pan-cultured.
.
From [**2116-7-22**] to [**2116-7-25**], Mr. [**Known lastname 59072**] mental status deteriorated
such that he was no longer awake and responsive. His oxygen
requirements continued to go up such that he was on 100% FiO2
and was satting in the low 90s and was persistently tachypneic
in the 30s-40s. He also continued to spike fevers of unknown
origin and had rising Cr. On the night of [**7-25**], in light of
increasing oxygen requirements/decreasing sats and upon
consultation with the BMT team and his wife, the decision was
made to withdraw life support due to dismal prognosis and his
wife's feeling that he had fought and suffered long enough. He
died at 2359 on [**2116-7-25**].
.
Fever & neutropenia: While in the ICU, the patient was continued
on Vancomycin and Meropenem given his prior MRSA bacteremia and
neutropenic fever. His Caspofungin was initially changed to
Ambisome but given his rise in creatinine, he was switched back
to Caspofungin and then back to Ambisome once his Bili and
AST/ALT began to rise. Two thansthoracic echocardiograms were
performed looking for valvular vegetations but none seen. He
was maintained on his Acyclovir ppx until his creatinine rose to
1.8, and this was held.
.
Back pain: Mr [**Known lastname 40270**] has chronic back pain secondary to his
myeloma. He was continued on MSSR, with a dose increase to 60
[**Hospital1 **], and covered for breakthrough pain with prn MSIR.
.
Peripheral neuropathy: He was usually on Neurontin and B6, but
these were held for high dose chemotherapy given unknown
durg-drug interactions with high dose chemotherapy.
.
FEN: He was on a neutropenic, cardiac diet, with prn repletion
of electrolytes and IVF per protocol. TPN was started on
[**2116-6-27**] given poor po intake, low albumin.
.
PPX: he was on a PPI and a bowel regimen.
.
FULL CODE
***
Of note, he has a bactrim allergy, so he will need to have
pentamidine as PCP [**Name Initial (PRE) 1102**].
Medications on Admission:
Lexapro has been dicontinued
Neurontin 400 mg t.i.d.
B6 vitamin 50 mg daily
MS Contin 15 mg b.i.d.
MSIR 15 to 30 mg q.4-6h. p.r.n.
Protonix 40 mg daily
acyclovir 400 mg t.i.d.
aerosolized pentamidine q. monthly
last given on [**2116-5-28**]
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Multiple Myeloma
MRSA bacteremia
bilateral pleural effusions
Hemothorax
Discharge Condition:
Death
Discharge Instructions:
None
Followup Instructions:
None
| [
"0389",
"4280",
"5859",
"5849",
"2851",
"99592"
] |
Admission Date: [**2114-11-27**] Discharge Date: [**2114-12-8**]
Date of Birth: [**2039-8-6**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Hydralazine / Ace Inhibitors / Diovan / Heparin Agents
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
CT Guided Thoracentesis
Bronchoscopy
Central line placement
History of Present Illness:
75 yo F w/PMH R pleural effusion, CAD, CHF (EF 55), DM, ESRD on
HD recent admission from [**Date range (1) 96973**] w/MRSA sepsis on
vancomycin(??osteomyelitis) now admitted for fever, shortness of
breath and cough.
.
At the NH, her fever was found to be 102.8. On presentation to
ED, her VS were T98.3 P68 BP106/41 R 14 and 96% on 2L. She
received 2L of NS and zosyn in ED.
.
Patient went for bronchoscopy today for RLL collapse which
showed severe tracheobronchomalacia on tidal respiration.
Pigtail was unable to be done. She then went to dialysis which
removed 1.5L of fluid. Dialysis was stopped early because she
was shivering and feeling cold. Upon return to the floor, she
required increased oxygen support, 92% on 6L(95% on 2L the same
AM), tachypneic to 40s and also hypertensive to 170s. Her ABG
showed 7.32/63/60 on 6L. She was given nebs x1 with no
improvement.
.
The patient reports increased cough, occassionally productive of
clear phlegm/sputum over the past several days. She also notes
increasing shortness of breath. She denies chest pain, PND,
orthopnea, abdominal pain, nausea, vomiting, diarrhea, urinary
symptoms(she does have minimal urine output), headahce,
dizziness.
Past Medical History:
- chronic R pleural effusion w/ RML, RLL collapse, tapped in
[**7-29**] transudative (attempted tap x 3 without success, on fourth
attempt were able to remove 200cc only) - on 2L oxygen at NH
- CAD: cath [**11-26**] with 3VD, s/p cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to RCA.
- CHF: echo [**10-29**] show hyperdynamic EF, mild LVH
- Atrial Fibrillation
- Pulmonary HTN
- Hypertension
- Hyperlipidemia
- DM2
- ESRD from contrast nephropathy post cardiac catheterization
[**11-26**] on HD since [**12-28**] (baseline creatinine ([**2-24**])
- Severe lumbar spondylosis and spinal stenosis s/p laminectomy
in [**2110**]
- Basal Cell Carcinoma
- Osteomyelitis T5-T6 on suppressive vancomycin for 3 months
([**2113-4-13**] was day 1)
- MRSA bacteremia from HD line infection
- Admission [**Date range (1) 96974**] for MRSA sepsis. At that time, the
patient had back pain and their was concern for osteomyelitis.
She refused an MRI so was discharged on 6 weeks of abx.
Social History:
Lives at [**Hospital **] [**Hospital **] Nursing Home since [**2111**] and has been
bedridden since that time [**1-25**] spinal stenosis. Past tobacco
(quit [**2111**] 10py). Has three children - daughter nad son both in
[**Name (NI) 86**] area and split her HCP. Widowed in [**2108**]. Retired -
worked in retail clothing.
Family History:
Father died of CVA at 64yo. Mother died of MI at 86yo. Brother
had CAD. Grandmother had T2DM
Physical [**Year (4 digits) **]:
T101.4 BP173/86 P104 R40s 88-98% on 6L
Gen- lethergic, in respiratory distress
HEENT- anicteric, PERRLA, dry mucus membrane, neck supple, JVD
hard to appreciate
CV- tachycardic, no r/m/g
RESP- course inspiratory and expiratory stridor, accessory
muscle use, speak in few-word sentence, no cyanosis
ABDOMEN- soft, obese, nontender, nondistended, no bowel sounds
EXT- no peripheral edema, DP pulses not palpable, extremities
cold
NEURO- alert and oriented x3, oeby commands, CNII-XII intact,
neuro [**Year (4 digits) **] deferred due to respiratory distress
SKIN- no jaunduce
Pertinent Results:
[**2114-11-27**] 08:30PM PT-13.4* PTT-26.9 INR(PT)-1.2*
[**2114-11-27**] 08:30PM PLT COUNT-119*
[**2114-11-27**] 08:30PM PLT COUNT-119*
[**2114-11-27**] 08:30PM NEUTS-77.4* LYMPHS-14.3* MONOS-4.9 EOS-2.7
BASOS-0.6
[**2114-11-27**] 08:30PM WBC-5.7 RBC-3.33* HGB-10.8* HCT-32.3* MCV-97
MCH-32.6* MCHC-33.5 RDW-15.2
.
CTA Chest: IMPRESSION:
1. Almost complete atelectasis of the right lung due to
secretion in right main bronchi.
2. Longstanding loculated right pleural effusion with
homogeneous pleural thickening, unchanged.
3. Steadily increasing mediastinal lymph nodes, and pleural
thickening might have a benign explanation due to longstanding
pleural effusion. An indolent malignancy such as lymphoma cannot
be excluded, justifying thoracentesis and cytologic cell-block
examination.
.
CXR [**2114-12-7**]:
Portable AP chest radiograph compared to [**2114-12-3**].
Left PICC line tip terminates at the junction of the
brachiocephalic vein and SVC. The left lung is unremarkable. The
right pleural effusion again demonstrated with adjacent lung
atelectasis, slightly increased comparing to the previous film.
No evidence of pneumothorax is present.
.
Cytology: Negative for malignant cells
Brief Hospital Course:
75yo F with ESRD on HD, CAD, CHF, HTN, chronic right sided
effusion and R lung collapse, s/p bronch showing
tracheobronchomalacia, transferred to MICU for acute
exacerbation of hypoxia.
.
MICU COURSE:
# Acute exacerbation of hypoxia - correctable w/ O2(baseline
home O2 2L: initial DDX on admission included acute mucus plug,
worsening pneumonia/pulmonary edema, worsening collapse,
fever/high metabolic rate, PE. CXR show persistent RML and RLL
collapse, no PTX; bronch [**11-28**] show severe TBM. Patient was
given aggressive pulmonary toillette. There was some
improvement in her hypoxia however she continued to require
oxygen. She underwent a CT guided thoracentesis with pigtail
placement which revealed a transudate. There was a concern for
trapped lung and not much improvement in her oxygenation. She
was also treated with vanc/zosyn for 7 days for possible PNA.
.
# Longstanding loculated right pleural effusion with homogeneous
pleural thickening w/ enlarging mediastinal [**Doctor First Name **] - As above pig
tail placed under CT guidance but no relief. Likely trapped
lung.
.
# ESRD on HD QMWF: last HD [**11-28**]. Renal followed patient while
she was admitted. Continued epogen, calcitriol, folic acid.
# CAD: continue on plavix
# DM- continue on insulin sc
# thrombocytopenia: DIC lab negative, patient has history of
HIT.
# Anxiety:continued on citalopram, clonazepam
# spinal stenosis: on morphine at baseline
# PPX-PPI, pneumoboots
# code- DNR/DNI.
-----
During the day [**12-4**] patient went into A. fib with RVR upto 160s
and dropped her systolic bp to 60s. Given patients prior wishes
and after discussion with the family and PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], the
decision was made to change her goals of care to comfort
measures. All her regular medications were discontinued and she
was started on a morphine drip with titration to comfort. The
patient was transferred to the medical floor where this care
goal was continued. This was confirmed with family. On HOD #11,
patient expired.
Medications on Admission:
MEDICATION AT HOME
Metoprolol Tartrate 12.5 mg TID
Calcitriol 0.25 mcg QOD
Lidocaine 5 %(700 mg/patch) Q8AM-8PM
Folic Acid 1 mg daily
Vancomycin in Dextrose 1 g QHD Continue until [**2114-12-26**].
Ascorbic Acid 500 mg [**Hospital1 **]
Omeprazole 20 mg daily
Clopidogrel 75 mg daily
Citalopram 20 mg daily
MSSR 30 mg PO QMOWEFR
Morphine 15 mg q4h prn
Klonopin 0.5 mg twice a day.
Albuterol Sulfate neb prn
Ipratropium Bromide neb prn
Lactulose 30 ml PRN
Docusate Sodium 100 mg po bid
Miconazole Nitrate 2 % Powder [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Epoetin Alfa 4000 QHD
Insulin Lispro (Human): sliding scale 151-200 give 2u, 201-250
give 4u, 251-300 give 6u, 301-350 give 8u, 351-400 give 10u,.
.
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2114-12-17**] | [
"5119",
"486",
"4280",
"5180",
"40391",
"42731",
"25000",
"4168",
"2724"
] |
Admission Date: [**2184-6-10**] Discharge Date: [**2184-6-24**]
Date of Birth: [**2137-11-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
massive hematemesis
Major Surgical or Invasive Procedure:
Esophageal gastro-duodenoscopy
Transjugular Intrahepatic Portal-Systemic Shunt
[**First Name9 (NamePattern2) 25667**] [**Last Name (un) **] Tube Placement
Emoblization of gastric arteries
History of Present Illness:
46 yo M with sleep apnea, GERD, asthma, no known hx of liver
failure who presents hematemesis with bright red blood. He
states 2 days prior to admission, he had BRBPR and dark stools
and felt pre-syncopal while sitting on a toilet as if things
were "graying out". He however did not have any abdominal pain,
nausea, vomiting at this time. He then went to work the day
after and continued his daily desk job at an investment firm and
did okay throughout the day. He after dinner then exactly at
9:10 pm began vomiting up a sink full of blood. He then felt
extremely pre-syncopal in teh bathroom and may have had a period
of syncope in the bathroom. His wife found him lying on the
bathroom floor awake and called 911. He then got up and layed
down on his bed. EMS arrived at that time and he walked down the
stairs and then was brought to the ED. His vitals on arrival
were 98.8, 111, 108/64, 100% on RA. He then had 1.5L of bloody
vomitus in the ED. His initial hct was 22 and he was given 2U of
PRBC and 2L of NS and his hct increased to only 25. He was
transferred up to the ICU urgently and GI plans doing a stat
EGD.
.
He states that he does not drink, no tobacco, does not use any
NSAIDS/ASA products. He does not have any hx of liver disease.
Stable GERD with diet control and prevacid.
Past Medical History:
GERD
Asthma
OSA
Social History:
works, married, no tob, no ETOH
Family History:
none
Physical Exam:
Temp 98.1, BP 133/84, HR 80, RR 21, O2 sat: 100% on 2L NC
GEN- lying in bed in NAD, AAOX3, obese
HEENT- NG tube with bright red blood
CV- tachy, regular, no M
CHEST- CTAB
ABD- soft, NT/ND, +BS
EXT- no edema bilaterally
NEURO- AAOX3
Pertinent Results:
[**2184-6-10**] 10:30PM BLOOD WBC-8.5 RBC-2.59* Hgb-7.7* Hct-22.0*
MCV-85 MCH-29.7 MCHC-35.0 RDW-16.5* Plt Ct-125*
[**2184-6-11**] 02:40AM BLOOD WBC-7.2 RBC-2.98* Hgb-8.9* Hct-25.3*
MCV-85 MCH-29.8 MCHC-35.0 RDW-15.0 Plt Ct-59*#
[**2184-6-11**] 04:57AM BLOOD Hct-29.1*
[**2184-6-11**] 07:48AM BLOOD Hct-28.1*
[**2184-6-11**] 10:45PM BLOOD WBC-16.8*# RBC-3.95*# Hgb-12.0*#
Hct-32.7* MCV-83 MCH-30.4 MCHC-36.8* RDW-16.3* Plt Ct-118*
[**2184-6-14**] 01:39PM BLOOD Hct-25.9* Plt Ct-61*
[**2184-6-24**] 03:27AM BLOOD WBC-4.0 RBC-3.03* Hgb-9.1* Hct-26.7*
MCV-88 MCH-29.9 MCHC-34.0 RDW-17.5* Plt Ct-131*
[**2184-6-10**] 10:30PM BLOOD PT-15.8* PTT-26.5 INR(PT)-1.4*
[**2184-6-23**] 03:54AM BLOOD PT-15.6* PTT-32.1 INR(PT)-1.4*
[**2184-6-11**] 11:30AM BLOOD Fibrino-167
[**2184-6-10**] 10:30PM BLOOD Glucose-216* UreaN-15 Creat-0.9 Na-141
K-3.6 Cl-106 HCO3-27 AnGap-12
[**2184-6-17**] 03:01AM BLOOD Glucose-120* UreaN-18 Creat-1.0 Na-143
K-3.6 Cl-108 HCO3-26 AnGap-13
[**2184-6-24**] 03:27AM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-142
K-3.3 Cl-107 HCO3-29 AnGap-9
[**2184-6-10**] 10:30PM BLOOD ALT-29 AST-35 LD(LDH)-145 AlkPhos-59
TotBili-0.9
[**2184-6-12**] 02:00AM BLOOD ALT-38 AST-53* AlkPhos-61 TotBili-4.6*
[**2184-6-12**] 10:54AM BLOOD DirBili-0.5*
[**2184-6-13**] 03:30AM BLOOD ALT-122* AST-177* AlkPhos-56 TotBili-3.1*
[**2184-6-22**] 03:30AM BLOOD ALT-29 AST-48* TotBili-1.2
[**2184-6-10**] 10:30PM BLOOD Lipase-30
[**2184-6-21**] 06:45PM BLOOD proBNP-150*
[**2184-6-10**] 10:30PM BLOOD Albumin-3.2* Calcium-8.4
[**2184-6-23**] 03:54AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
[**2184-6-11**] 08:23AM BLOOD Iron-250*
[**2184-6-11**] 08:23AM BLOOD calTIBC-261 Hapto-<20* Ferritn-51 TRF-201
[**2184-6-13**] 03:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2184-6-11**] 08:23AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2184-6-11**] 09:35AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2184-6-11**] 09:35AM BLOOD IgG-1069 IgA-361 IgM-74
[**2184-6-21**] 12:34AM BLOOD Vanco-5.9*
[**2184-6-11**] 05:09AM BLOOD Type-ART pO2-139* pCO2-54* pH-7.27*
calHCO3-26 Base XS--2
[**2184-6-16**] 06:42AM BLOOD Type-ART Rates-18/ Tidal V-650 PEEP-5
FiO2-40 pO2-104 pCO2-39 pH-7.43 calHCO3-27 Base XS-1 -ASSIST/CON
[**2184-6-22**] 01:58PM BLOOD Type-ART pO2-85 pCO2-42 pH-7.46*
calHCO3-31* Base XS-5
[**2184-6-11**] 10:58PM BLOOD Lactate-2.5*
[**2184-6-20**] 08:48AM BLOOD Lactate-1.6
[**2184-6-21**] 12:08AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2184-6-21**] 12:08AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2184-6-21**] 12:08AM URINE RBC-[**12-6**]* WBC-0-2 Bacteri-RARE
Yeast-NONE Epi-0
[**2184-6-21**] 12:08AM URINE CastHy-0-2
.
[**6-15**] TIPS procedure:
IMPRESSION:
1. Successful placement of a tip using 10-mm x 94-mm Wallstent.
Portosystemic gradient post-procedure was 7 mm H2O.
2. Innumerous gastroesophageal varices are present, which were
embolized by using 15 mL absolute alcohol and two 8-mm by 5-cm
coils. The blood flow in the gastroesophageal varices has been
decreased.
.
CXRs: starting on [**6-11**] demonstrated mild vascular prominence,
bibasilar opacities consistent with atelectasis, worsened over
the week with addiotional fluid resuscitation.
.
[**6-11**]: Duplex dopplers:
IMPRESSION:
1. Very coarse and echogenic liver consistent with chronic liver
disease.
2. The portal vein is patent. However, the flow is slow and
reversed.
3. The hepatic veins appear to be patent.
.
[**6-12**]: RUQ u/s:
RIGHT UPPER QUADRANT ULTRASOUND: Limited study. There is a new
TIPS in place. There is wall-to-wall flow demonstrated. The
velocities are 18, 21, and 55 cm/sec in the proximal, mid and
distal TIPS respectively. The hepatic veins and arteries are
patent. The portal vein could not be imaged.
IMPRESSION: Wall-to-wall flow within the TIPS, with slow
velocities as described above. This could be related to the
immediate post-procedure period, however, short interval follow
up is recommended to ensure patency.
.
[**6-13**] TIPS u/s:
TIPS ULTRASOUND: A TIPS is patent. There is wall-to-wall flow
inside the TIPS. The main portal vein is patent. There is normal
direction of flow in the main portal vein. The blood flow
velocity in the main portal vein is 50 cm/sec which is adequate.
There is no velocity gradient through the TIPS. The flow
velocities in the TIPS are as follow: Proximal TIPS 88 cm/sec.
Mid TIPS 115 cm/sec, and distal TIPS 930 cm/sec. The left portal
vein was adequately imaged and there is reversed flow.
IMPRESSION: TIPS is patent with satisfactory flow velocities. No
evidence of TIPS dysfunction.
.
Echo [**6-22**]:
Conclusions: The left atrium is moderately dilated. There is
severe symmetric left ventricular hypertrophy. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF 80%). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The number of aortic valve leaflets cannot be determined. The
aortic valve is not well seen. There is no valvular aortic
stenosis. The increased transaortic gradient is likely related
to high stroke volume. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion.
Brief Hospital Course:
46 yo M with hx of GERD, asthma who presents with UGIB, syncope.
.
# Variceal Bleed with Blood Loss Anemia and hemorrhagic shock:
Patient presented with large amounts of hematemesis and
pre-syncope. On arrival to the ICU, he began vomiting ~2L of
bright blood briskly. He had an emergent EGD secondary to
concern for variceal bleed with questionable NASH given obesity.
He was resuscitated with 7 units of PRBCs and 2U of FFP. He was
given Unasyn IV x 1 and an octreotide bolus and drip were
started given variceal bleeding. He had 3 large bore IVs in
place. During the EGD, he continued to have brisk hematemesis
and bleeding varices were found. However, due to severe
bleeding, the EGD was terminated early and a decision was made
to take him to the OR for intubation and placement of a
[**Last Name (un) 10045**] tube. After the [**Last Name (un) 10045**] was placed, the gastric
balloon was inflated to 40 and the position in the stomach was
confirmed by fluoro in the OR. The patient was subsequently
taken for embolization by IR, with EtOH and coil embolization of
varices. He continued to have a large amount of bleeding and an
emergenct TIPS procedure was performed. U/S with dopplers was
initially questionable for proper flows, however repeat U/S
showed good flows s/p TIPS. The bleeding stabilized after a
total of 12 Units of PRBCs. His HCT remained stable, and the
octreotide was discotinued and [**Last Name (un) **] tube was removed. A
Dophoff tube was placed nasogastrally and tube feeding initiated
without any recurrence of bleeding.
.
# Resp failure: The patient was found to have a LLL infiltrate
initially on admission, completed 10 day levo course, also
started on flagyl on admission, subsequently found to have
c.diff in stool. Plan to continue flagyl for additional 14 days
(until [**7-6**]) for c.diff.
- sedated on fentanyl, versed, took several days for sedation to
wear off. Pt was extubated on [**6-21**] without any difficulty
- he was about 10L positive after extensive fluid resuscitation,
required lasix and diuril to remove the fluid, diuresed
approximately 1-2 L daily. Pt orthostatic once getting out of
bed, likely [**2-19**] long period of inactivity, stopped agressive
diuresis. Patient may remain fluid overloaded given suggestion
of diastolic CHF in presence of hyperdyamic EF on echo, although
difficult to assess clinically.
.
# Fevers:
- pt continued to have high fevers on levo, flagyl, known
sources included klebsiella pneumonia, c.diff colitis. He
completed a 10 day course of levofloxacin, continue flagyl for
additional 14 days. Central lines were removed, no evidence of
line infection. Pt was also clinically felt to have sinusitis
related to nasal intubation given presence of purulent nasal
secretions. He defervesced after extubation.
.
# Cirrhosis:
- no significant hx of etoh, thought to be [**2-19**] NASH. Hep B
serology c/w previous vaccination, neg Hep C, Hep A
- possible liver bx in the future, f/u with hepatology as outpt
- echo revealed hyperdynamic left ventricular systolic function
(EF 80%)
- INR elevated initially, responded to PO vitamin K.
- started on rifaximin and lactulose for prophylaxis s/p TIPS,
titrate to [**3-20**] BMs daily
.
#PPX - protonix twice daily, sc heparin
.
#FEN: started on a soft diet after extubated, iniatially on tube
feeds via Dophoff gastric tube, repleted lytes prn
.
# acceess: R Arterial line replaced [**2184-6-19**]. Picc placed [**6-22**].
.
# Full CODE
.
#Contact [**Name (NI) **] [**Name (NI) 25668**] - wife, cell: [**Telephone/Fax (1) 25669**]
Medications on Admission:
prilosec
albuterol
[**Doctor First Name 130**]
advair
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 12 days. Tablet(s)
5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inh
Inhalation twice a day as needed for shortness of breath or
wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Variceal bleeding
Cirrhosis
Obstructive Sleep Apnea
Discharge Condition:
stable
Discharge Instructions:
Please follow-up with your primary care doctor after your
rehabilitation. [**Location (un) **] a follow-up appointment with your
liver doctor to discuss further treatment plans. You were
admitted with large amounts of bleeding requiring multiple
invasive procedures to stop this bleeding. Please take your
lactulose and rifaximin every day in order to prevent toxins
from building up as your liver will not clear them fully.
Do not hesitate to seek medical attention if you develop
lightheadedness, dark or bloody stools, nausea, vomiting or any
other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care physician
[**Name9 (PRE) **] your liver doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment in [**3-20**] weeks.
Completed by:[**2184-6-24**] | [
"2851",
"4280",
"51881",
"5070",
"0389",
"99592",
"32723",
"53081",
"49390"
] |
Admission Date: [**2146-2-7**] Discharge Date: [**2146-2-9**]
Service: ICU
HISTORY OF PRESENT ILLNESS: This is an 86-year-old male
nursing home resident with advanced dementia, coronary artery
disease, cerebrovascular accident since [**2141-8-1**],
PEG placed in [**2144-8-1**] in the setting of pneumonia
and sepsis who presents status post PEA arrest. The patient
was noted to be lethargic on the [**8-8**] and chest x-ray
was done at that time which showed a question of a right
lower lobe pneumonia. He was started on Levaquin. By
report, the patient improved the next day and became more
verbal.
On the morning of admission, the patient was found to be
again lethargic and less responsive. At that time,
temperature was normal. His blood pressure is 104/76, heart
rate 118, respiratory rate was increased with an oxygen
saturation of 86% on room air. Fingerstick was 326 and he
was given insulin and EMS was called. He was brought to the
Emergency Room. On arrival, the patient was unresponsive and
cyanotic. His temperature was 98 and his oxygen saturation
was 30% and he had no blood pressure. Rhythm was pulseless
electrical activity.
CPR was started. Atropine and Epinephrine were given with
restoration of his pulse. Pressors were started for
hypotension. Patient was intubated. There is an unclear
duration of arrest prior to the code being called. The code
itself lasted nine minutes. CT angiogram of the chest
revealed no pulmonary embolism. Hematocrit was noted to be
20 and he was transfused 1 unit of packed red blood cells,
and was admitted to the Intensive Care Unit for further
management.
PAST MEDICAL HISTORY:
1. Coronary artery disease with coronary artery bypass graft
in [**2136**].
2. Dementia.
3. Cerebrovascular accident with left sided weakness
resulting.
4. Diabetes mellitus type 2.
5. Peptic ulcer disease.
6. Atypical psychosis.
7. Prostate cancer.
8. Hypercholesterolemia.
9. Ejection fraction of 40-50% with left ventricular
hypertrophy, moderate mitral regurgitation, and moderate AS
with global hypokinesis.
10. AVR for aortic insufficiency.
11. PEG tube for feeding placement [**2144-8-1**].
12. Aspiration pneumonia and sepsis with no identified source
in [**2144-8-1**].
13. Upper gastrointestinal bleed.
14. Abdominal aortic aneurysm.
15. Seizure disorder.
16. Gout.
MEDICATIONS:
1. Norvasc 5 mg po q day.
2. Prevacid 30 mg po q day.
3. Risperdal 0.25 mg po bid.
4. Allopurinol 100 mg po q day.
5. Aspirin 81 mg po q day.
6. Dilantin 300 mg po q am, 400 mg po q pm.
7. NPH insulin 3 units q am, 4 units q pm.
8. Cardura 4 mg po q day.
9. Lipitor 10 mg po q day.
10. Trazodone 25 mg po bid prn.
11. Tramadol 25-50 mg po q6h prn.
12. Lactulose 20 cc po prn.
13. Levaquin 500 mg po q day since [**2-6**].
14. ProMod with fiber at 95 cc per hour.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Nursing home resident x2.5 years at the
[**Hospital3 2558**]. No tobacco or ethanol. PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7514**] and
Dr. [**Last Name (STitle) **] from [**Hospital3 4262**] Group.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Not able to obtain.
VITAL SIGNS ON ADMISSION: Temperature 95.0, blood pressure
109/43 with a MAP of 65, heart rate is 97, and oxygen
saturation of 99%. He was mechanically ventilated on SIMV
plus pressure support of 600 cc tidal volume with a
respiratory rate of 12 and a FIO2 of 1.0. No spontaneous
respirations, PEEP of 5, and pressure support of 10. He was
on dopamine at 21 mcg/kg/minute.
PHYSICAL EXAMINATION: In general he was unresponsive and
intubated. Pupils were fixed and dilated. There is no
response to confrontation. Jugular venous pressure was not
seen. The chest was clear anteriorly. Heart has a normal
S1, S2 without murmur, and is regular, rate, and rhythm.
Abdomen was obese with a G tube in place with no surrounding
erythema or pus. He is guaiac positive according to the exam
in the Emergency Room. Extremities were without edema and
were warm. Distal pulses were not felt in the feet, but
there were 1+ radial pulses. Skin was intact without rash.
There is no response to voice, and he did withdraw to pain.
Toes were upgoing bilaterally. Tone was increased with
flaccid tone noted on the left and decreased but flaccid on
the right.
PERTINENT LABORATORIES: Hematocrit was 20.5, white count
7.0, platelets 182. INR is 1.3. Sodium is 139, potassium
4.4, chloride 103, bicarb 13, BUN 62, creatinine 1.1, and
glucose of 609. Anion gap was 23. Transaminases were
normal. Amylase and lipase 103 and 22. CK was 44 with a
troponin of 0.3. Albumin 1.9. Calcium 7.1, phosphate 6.3,
magnesium 2.2.
Arterial blood gas showed a pH of 7.13, pCO2 of 40, and a pO2
of 252. Lactate was 5.7.
Chest x-ray showed ET tube 7 cm above the carina with heart
size within normal limits and low lung volumes. There is
normal pulmonary vasculature and a widen mediastinum.
CT angiogram of the chest showed a right lower lobe
aspiration pneumonia. No pulmonary embolism. A right lower
lobe mass 3.2 x 2.9 cm encasing the right lower lobe bronchus
and pulmonary artery. Mediastinal lymphadenopathy including
pericarinal and AP window lymphadenopathy. An anterior 8 mm
nodule and ascites with intraabdominal hemorrhage.
Electrocardiogram showed atrial fibrillation at 127 beats per
minute with ST depressions 1 mm in leads V3 to V6 with T-wave
inversions in those leads. There was also T-wave inversions
seen in leads I, aVL, II, III, and aVF.
CT scan of the abdomen showed a layering hematoma adjacent to
the liver extending down the right pericolic gutter. A 5.1 x
4.8 cm exophytic simple cyst in the right kidney in the lower
pole, a large 8.8 x 12 cm infrarenal abdominal aortic
aneurysm just above the bifurcation concerning for recent
expansion and no obvious liver disease or injury.
CT scan of the head showed a large chronic right middle
cerebral artery territory infarct that was felt to be old as
well as right cerebral watershed infarct also felt to be old.
There is also an old left caudate lacune. There was no new
mass effect or intracranial hemorrhage.
IMPRESSION: This is an 86-year-old male with advanced
dementia, abdominal aortic aneurysm, coronary artery disease,
who presented with pulseless electrical activity, cardiac
arrest, and was successfully resuscitated, but now with
examination suggestive of anoxic brain injury.
HOSPITAL COURSE: The cause of the patient's PEA arrest was
not clear. It was felt to most likely be multifactorial
secondary to anemia, pneumonia, and hypovolemia. PE and
tamponade were effectively ruled out on CT angiogram. The
patient's troponin rose to over 50, which was felt to be
consistent with the patient's cardiac arrest. There is no
intervention that was felt to be required according to the
Cardiology consult service.
In terms of the patient's abdominal aneurysm, there was
radiographic evidence of recent expansion, but rupture was
ruled out by the abdominal CT scan. Patient received packed
red blood cells for a hematocrit less than 28. Blood sugar
was managed with insulin drip initially and changed to
regular insulin-sliding scale. The patient's new lung mass
was not known prior to this admission and this was felt to
worsen the patient's overall prognosis. This was
communicated to the family, who understood.
It was felt that the appearance of the mass was most
consistent with malignancy. In terms of the patient's
pneumonia, he was given Levaquin and Flagyl. The Neurology
Service was consulted and agreed to the Intensive Care Unit's
assessment that the patient had a very poor prognosis given
his multiple comorbidities and the prolonged arrest.
On [**2-8**], the patient developed new anisocoria and
repeat CT scan of the head revealed massive left sided edema
with subfalcial herniation and probable uncal herniation.
Mannitol was given as per the Neurology and Neurosurgery
consultants. Vancomycin was added to the patient's
antibiotic regimen once blood cultures returned positive for
gram-positive cocci.
On [**2-9**], the family meeting was held with patient's
wife, son, daughter, and several of the physicians. The
grave prognosis was communicated to the family. The family
decided to withdraw the ventilator which was done. Morphine
was given and titrated for comfort.
The patient died that night at 11:35 pm.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.
MEDQUIST36
D: [**2146-3-25**] 15:00
T: [**2146-3-29**] 06:34
JOB#: [**Job Number 7515**]
| [
"5070",
"2762",
"51881"
] |
Admission Date: [**2159-6-8**] Discharge Date: [**2159-6-16**]
Date of Birth: [**2102-11-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
burning sensation in chest/fatigue/lightheadedness that began
[**2159-6-1**]
Major Surgical or Invasive Procedure:
CABGx2(LIMA->LAD, SVG->RCA)/MV repair(28mm band)/PFO closure
[**2159-6-11**]
Extraction of a tooth [**2159-6-10**]
History of Present Illness:
56 yo female transferred in from [**Hospital3 35813**] Center with
burning sensation in chest/nausea/diarrhea/cold sweats 1.5 weeks
ago. On Wed experienced weakness as other sx subsided over 24-48
hours. Five days later she sought medical care when fatigue
continued and diagnosed with MI. Workup revealed 100% LAD, 100%
RCA and MR. Referred for surgical repair. TEE on [**6-8**] showed EF
35%, severe MR, PFO with left to right shunting. Carotid US [**6-5**]
showed [**Doctor First Name 3098**] 40-59%, right ICA less than 40% stenoses. She also
had a + UA and was treated with IV levaquin.
Past Medical History:
PVD with decreased iliac circulation
HTN
elev. chol.
[**2124**] wedge resection of bilat. ovaries/appy
Social History:
works as insurance [**Doctor Last Name 360**]
smokes 1 ppd for 16 years
no ETOH
last dental exam [**2157**]
lives with 2 sons
Family History:
non-contributory
Physical Exam:
HR 66 RR 18 97/66 5'3" 79.7 kg
NAD
skin/HEENT unremarkable
neck supple with full ROM
CTAB
RRR
abd soft, NT, ND, +BS
extrems warm and well-perfused, no edema or varicosities
neuro grossly intact
1+ bilat fem/DP/PTs
2+ radials
Pertinent Results:
[**2159-6-16**] 04:57AM BLOOD WBC-12.2* RBC-3.63* Hgb-10.3* Hct-31.0*
MCV-86 MCH-28.3 MCHC-33.1 RDW-14.6 Plt Ct-489*
[**2159-6-15**] 10:20PM BLOOD Glucose-118* UreaN-22* Creat-0.6 Na-133
K-4.7 Cl-96 HCO3-25 AnGap-17
[**2159-6-8**] 09:26PM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
[**2159-6-16**] 04:57AM BLOOD Plt Ct-489*
[**2159-6-15**] 10:20PM BLOOD Glucose-118* UreaN-22* Creat-0.6 Na-133
K-4.7 Cl-96 HCO3-25 AnGap-17
[**2159-6-16**] 04:57AM BLOOD UreaN-20 Creat-0.7 K-5.1
[**2159-6-15**] 10:20PM BLOOD Calcium-8.1* Phos-4.8*# Mg-3.6*
[**2159-6-8**] 09:26PM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
FINAL REPORT
PA AND LATERAL CHEST ON [**2159-6-16**] AT 10:50.
INDICATION: Followup after MVR and CABG.
COMPARISON: [**2159-6-14**].
FINDINGS:
Compared to prior study, the Swan-Ganz catheter has been
removed. There are
diminished interstitial markings consistent with improving fluid
status and
only small posterior effusions were identified on the lateral
view. There is
no PTX. The cardiac silhouette is enlarged but not substantially
different
from prior.
IMPRESSION: Improved chest x-ray with resolving pulmonary edema
and
resolution of previously seen right PTX.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SAT [**2159-6-16**] 2:44 PM
Procedure Date:[**2159-6-16**]
Brief Hospital Course:
The pt. was admitted on [**6-5**] and underwent a tooth extraction on
[**6-10**] prior to surgery. CABG x2/ MV repair / PFO closure performed
by Dr. [**Last Name (STitle) **] on [**6-11**] and transferred to the CSRU in stable
condition on milrinone, levophed, and propofol drips. Seen by
vascular that evening for decreased pulses in right LE.This
improved the next day. Extubated, and remained on insulin and
milrinone drips on POD #1. Diuresis started, foley and chest
tubes removed on POD #2. Repeat CXR noted small right apical ptx
after chest tubes removed, moderate CHF. Swan removed and
milrinone weaned on POD #3. Transferred to the floor and
restarted on amiodarone for PVCs and transfused one unit PRBCs
on [**6-15**]. Pacing wires removed without incident on POD #4.
Cleared for discharge to home with VNA services on POD #8. Pt to
follow up with Dr. [**Last Name (STitle) **] in 2 weeks as per discharge
instructions.
Medications on Admission:
protonix 40 mg daily
ASA 325 mg daily
lipitor 20 mg daily
RISS
temazepam 15mg
digoxin 0.25 mg daily
lisinopril 2.5 mg daily
lopressor 25 mg TID
heparin drip 1350u/hr
colace 100mg
spironolactone 12.5 mg
paxil 10 mg daily
albuterol
levaquin 500 mg IV
amiodarone 400 mg TID
Discharge Medications:
1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: Decrease dose to 400 mg PO daily for 7 days
after [**Hospital1 **] dose completed, then decrease dose to 200 mg PO daily
after 400 mg daily dose completed.
Disp:*50 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily) for 7 days.
Disp:*7 Capsule, Sustained Release(s)* Refills:*0*
14. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
Disp:*1 months supply* Refills:*2*
15. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 months supply* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA OF GREATER [**Doctor Last Name **]
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, powders, or creams on wounds.
Call our office for sternal drainage, temp.>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) 2072**] for 1-2 weeks.
Completed by:[**2159-6-21**] | [
"4240",
"41401",
"4280",
"2859",
"2720",
"4019",
"3051"
] |
Admission Date: [**2194-8-18**] Discharge Date: [**2194-8-27**]
Date of Birth: [**2108-10-18**] Sex: F
Service: SURGERY
Allergies:
Lisinopril / Metformin
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Bright red [**First Name3 (LF) **] per rectum
Major Surgical or Invasive Procedure:
[**2194-8-19**] SMA arteriogram, selective ileocolic arteriogram
exploratory laparotomy with extended right colectomy.
[**2194-8-20**] end ileostomy
History of Present Illness:
85 year old female h/o afib with RVR on pradaxa with BRBPR x
several weeks with increased amount of [**Month/Day/Year **] this week. Patient
reports the increased bleeding was also associated with
suprapubic pain accompanied by dysuria and some fevers, chills,
nausea and vomiting. Patient previously diagnosed with UTI and
has been taking Nitrofurantoin with improvement of her symptoms.
Patient additionally noted chest pain prior to presentation to
ED. The chest pain resolved without intervention and she is
currently chest pain free. Initially an EKG showed afib without
any acute changes. SBP 100, not lightheaded or dizzy.
In ED patient noted to be mildly tachycardic, with increasing
heart rate after volume resuscitation with 2L NS. Patient
underwent CTA of the abdomen which showed active venous
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements in [**2182**]
Depression
Asthma, diagnosed in [**2184**]
C-sections in past
Social History:
Husband died many years ago. Patient lives with her
granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in
[**2181**], remote social ETOH.
Family History:
Family history of CVA/CAD.
Physical Exam:
Physical Exam upon presentation:
Vitals: 97.4 111 127/78 17 100% RA
GEN: A&O to self, appropriate, resting comfortably, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, rate controlled, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, minimally tender, no rebound or
guarding, normoactive bowel sounds, no palpable masses
DRE: normal tone, guiac positive, no gross [**Year (4 digits) **]
Ext: No LE edema, LE warm and well perfused. R femoral sheath
intact.
Physical Exam upon discharge:
VS:97.6, 95, 125/58, 20, 99/RA
GEN: Arousable to voice, NAD.
HEENT:HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, rate controlled. No M/R/G.
PULM: Faint expiratory wheezes bilaterally. No rales/rhonchi.
ABD: Soft, nondistended, nontender. Ileostomy + fecal output.
EXT: + 1 pitting edema all four extremities. No Cyanosis,
clubbing. WWP.
Pertinent Results:
[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.76*# Hgb-8.7*# Hct-26.9*#
MCV-97# MCH-31.4 MCHC-32.3 RDW-15.2 Plt Ct-204
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] WBC-7.8 RBC-2.32* Hgb-7.2* Hct-22.1*
MCV-96 MCH-31.1 MCHC-32.5 RDW-15.5 Plt Ct-164
[**2194-8-19**] 06:03AM [**Month/Day/Year 3143**] WBC-10.5 RBC-2.97*# Hgb-8.6* Hct-26.3*
MCV-89# MCH-29.0 MCHC-32.8 RDW-16.7* Plt Ct-124*
[**2194-8-19**] 11:00AM [**Month/Day/Year 3143**] Hct-29.0*
[**2194-8-19**] 03:01PM [**Month/Day/Year 3143**] WBC-8.9 RBC-3.06* Hgb-9.1* Hct-26.4*
MCV-90 MCH-29.8 MCHC-33.2 RDW-16.5* Plt Ct-124*
[**2194-8-19**] 07:18PM [**Month/Day/Year 3143**] Hct-28.5*
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] WBC-5.4 RBC-2.96* Hgb-9.1* Hct-26.4*
MCV-89 MCH-30.8 MCHC-34.5 RDW-15.1 Plt Ct-71*
[**2194-8-20**] 05:26AM [**Month/Day/Year 3143**] WBC-12.7*# RBC-3.57* Hgb-11.3* Hct-31.3*
MCV-88 MCH-31.5 MCHC-35.9* RDW-15.3 Plt Ct-92*
[**2194-8-20**] 09:25AM [**Month/Day/Year 3143**] Hct-30.3*
[**2194-8-20**] 01:38PM [**Month/Day/Year 3143**] Hct-26.7*
[**2194-8-20**] 03:24PM [**Month/Day/Year 3143**] Hgb-9.9* Hct-29.0*
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] WBC-13.0* RBC-2.63*# Hgb-7.8* Hct-23.4*
MCV-89 MCH-29.8 MCHC-33.6 RDW-16.0* Plt Ct-104*
[**2194-8-21**] 04:02AM [**Month/Day/Year 3143**] Hct-26.9*
[**2194-8-21**] 09:31AM [**Month/Day/Year 3143**] Hct-25.5*
[**2194-8-21**] 01:05PM [**Month/Day/Year 3143**] Hgb-8.3* Hct-23.6*
[**2194-8-21**] 05:05PM [**Month/Day/Year 3143**] Hct-22.0*
[**2194-8-21**] 09:44PM [**Month/Day/Year 3143**] Hct-27.1*
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.99* Hgb-9.1* Hct-26.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-16.0* Plt Ct-105*
[**2194-8-22**] 07:22AM [**Month/Day/Year 3143**] Hct-19.8*
[**2194-8-22**] 09:30AM [**Month/Day/Year 3143**] Hct-25.5*#
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] WBC-5.8 RBC-2.97* Hgb-9.1* Hct-26.2*
MCV-88 MCH-30.5 MCHC-34.5 RDW-16.5* Plt Ct-113*
[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] PT-19.8* PTT-33.9 INR(PT)-1.9*
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] PT-18.7* PTT-47.9* INR(PT)-1.8*
[**2194-8-19**] 03:27PM [**Month/Day/Year 3143**] PT-15.6* PTT-38.1* INR(PT)-1.5*
[**2194-8-19**] 09:50PM [**Month/Day/Year 3143**] PT-17.9* PTT-43.0* INR(PT)-1.7*
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] PT-18.2* PTT-43.2* INR(PT)-1.7*
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] PT-20.4* PTT-46.7* INR(PT)-1.9*
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] PT-18.0* PTT-53.8* INR(PT)-1.7*
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] PT-15.6* PTT-46.8* INR(PT)-1.5*
[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] Glucose-154* UreaN-42* Creat-1.8* Na-139
K-4.1 Cl-104 HCO3-18* AnGap-21*
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] Glucose-121* UreaN-39* Creat-1.5* Na-141
K-3.6 Cl-110* HCO3-19* AnGap-16
[**2194-8-19**] 06:03AM [**Month/Day/Year 3143**] Glucose-165* UreaN-38* Creat-1.2* Na-143
K-3.3 Cl-113* HCO3-19* AnGap-14
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] Glucose-168* UreaN-34* Creat-1.1 Na-146*
K-3.5 Cl-120* HCO3-17* AnGap-13
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] Glucose-218* UreaN-36* Creat-1.4* Na-145
K-4.9 Cl-118* HCO3-14* AnGap-18
[**2194-8-21**] 09:31AM [**Month/Day/Year 3143**] Glucose-166* UreaN-34* Creat-1.3* Na-144
K-4.0 Cl-115* HCO3-19* AnGap-14
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] Glucose-118* UreaN-28* Creat-0.7 Na-144
K-3.7 Cl-116* HCO3-19* AnGap-13
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] Glucose-114* UreaN-23* Creat-1.1 Na-144
K-3.3 Cl-115* HCO3-20* AnGap-12
[**2194-8-19**] 07:43PM [**Month/Day/Year 3143**] Lactate-1.2
[**2194-8-19**] 09:56PM [**Month/Day/Year 3143**] Glucose-124* Lactate-2.4* Na-141 K-3.7
Cl-119*
[**2194-8-19**] 11:37PM [**Month/Day/Year 3143**] Glucose-247* Lactate-2.0 Na-142 K-4.1
Cl-115*
[**2194-8-20**] 01:01AM [**Month/Day/Year 3143**] Glucose-189* Lactate-2.1* Na-140 K-3.8
Cl-119*
[**2194-8-20**] 02:02AM [**Month/Day/Year 3143**] Glucose-153* Lactate-2.7* Na-139 K-3.5
Cl-120*
[**2194-8-20**] 10:02PM [**Month/Day/Year 3143**] Lactate-3.5* K-4.1
[**2194-8-21**] 12:56AM [**Month/Day/Year 3143**] Lactate-5.0* K-4.7
[**2194-8-21**] 04:09AM [**Month/Day/Year 3143**] Lactate-3.0* K-4.2
[**2194-8-21**] 09:39AM [**Month/Day/Year 3143**] Lactate-2.1*
[**2194-8-21**] 01:19PM [**Month/Day/Year 3143**] Lactate-1.8
[**2194-8-21**] 05:16PM [**Month/Day/Year 3143**] Lactate-1.7
[**2194-8-21**] 08:49PM [**Month/Day/Year 3143**] Lactate-1.6
[**2194-8-22**] 02:56AM [**Month/Day/Year 3143**] Lactate-1.0
[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.68* Hgb-8.2* Hct-25.6*
MCV-96 MCH-30.8 MCHC-32.2 RDW-16.9* Plt Ct-249
[**2194-8-26**] 05:54AM [**Month/Day/Year 3143**] WBC-8.2 RBC-2.76* Hgb-8.7* Hct-25.9*
MCV-94 MCH-31.4 MCHC-33.5 RDW-16.8* Plt Ct-230
[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] Glucose-185* UreaN-17 Creat-0.9 Na-141
K-3.5 Cl-108 HCO3-27 AnGap-10
[**2194-8-26**] 06:21PM [**Month/Day/Year 3143**] Glucose-211* UreaN-16 Creat-0.9 Na-144
K-3.8 Cl-110* HCO3-26 AnGap-12
[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] Calcium-7.7* Phos-2.3* Mg-1.8
[**2194-8-26**] 06:21PM [**Month/Day/Year 3143**] Calcium-8.5 Phos-2.1* Mg-2.0
[**2194-8-18**] Mesenteric CTA abdomen/pelvis
ABDOMEN: Focal area of scarring in the right middle lobe base
is similar to prior exam (3A:3). The liver shows no intrahepatic
biliary dilatation. A 4-mm focus of arterial enhancement in the
left lobe of the liver persists during the venous phase, likely
making this a small hemangioma as opposed to more aggressive
lesion with washout features; its appearance is similar to prior
chest CTA (3B:206). The gallbladder is distended, but shows no
stones or wall edema. The CBD is prominent in diameter,
measuring up to 11 mm in diameter and tapering to 5 mm more
distally. The spleen is normal in size. The pancreas and
adrenal glands show no masses.
The kidneys enhance with and excrete contrast symmetrically
without evidence of hydronephrosis. A small hypodensity in
right upper pole is too small to characterize and likely
represents a simple cyst and measures 6 mm in diameter (3B:211).
In the mid pole of the left kidney is an area of cortical
thinning, likely representing scarring from either prior
infection or infarct (3B:222). Incidental note is made of a
fat-containing ventral wall hernia (3B:279). The small and large
bowel show no evidence of obstruction or wall edema. The right
colon contains liquid stool with peripheral aerosolized
contents. No pneumatosis or portal venous gas is present. A
focal blush of intraluminal contrast is present within the right
colon during the venous phase (3B:253). There is no free air,
free fluid, or lymphadenopathy.
PELVIS: The bladder is decompressed around a Foley balloon.
The uterus
demonstrates calcified fibroids. The rectum is unremarkable.
There is no
free fluid or lymphadenopathy. A lipoma is incidentally noted
anterior to the right hip, measuring 5 x 3 cm in the axial plane
(3B:339). Sigmoid diverticulosis is present without
diverticulitis.
CTA/CTV: The aorta is of a normal caliber along its course.
The origins of the celiac and SMA are narrowed but patent. The
renal arteries demonstrate calcified atherosclerotic disease at
their origins, but are also patent. The [**Female First Name (un) 899**] is open. The iliac
and femoral arterial branches are also patent. In the venous
phase, the portal vein, splenic vein, and SMV are all patent.
Again is noted a blush within the lumen of the right colon on
this phase.
IMPRESSION:
1. Focal blush of intraluminal contrast in the right colon
during the venous phase concerning for active hemorrhage
2. No evidence of pneumatosis or portal venous gas or bowel
wall edema.
3. Sigmoid diverticulosis without evidence of diverticulitis.
4. Prominent CBD raises the question of a stenotic sphincter of
Oddi -
correlate with LFT's.
[**8-19**] SMA arteriogram, Selective ileocolic arteriogram
Using a combined palpatory and fluoroscopic guidance and
following
administration of local anesthetic, the right common femoral
artery was
accessed with a 19-guage single wall puncture needle. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**]
wire was
easily advanced into the lower order and the needle exchanged
for a 5 French [**Last Name (un) 2493**]-Tip vascular sheath. A Cobra catheter was
then advanced over the [**Last Name (un) 7648**] wire and the SMA selectively
calculated. An initial nonselective SMA DSA run in 2
projections demonstrated a normal anatomy of the SMA branches,
specifically with no evidence of active extravasation in the
area of the cecum (area of hemorrhage on previous CTA). The same
procedure for a selective DSA run with a microcatheter inserted
into
the ileocolic artery. Wires and catheters were withdrawn. Given
an INR of 1.8 and Pradaxa use, the sheath was left in place to
be withdrawn after successful correction of coagulopathy.
IMPRESSION:
Normal appearance of SMA branches, specifically without evidence
of active
extravasation in the area of the cecum (site of extravasation on
prior CTA). Given an INR of 1.8 and Pradaxa use, the sheath is
left in place and should be continuously flushed until removed
in the setting of corrected coagulopathy.
[**2194-8-21**] Echocardiogram
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF 65%). The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a prominent
fat pad.
Compared with the findings of the prior study (images reviewed)
of [**2191-5-6**], the heart rate is increased, the left ventricle
is smaller (underfilled), with persistent right ventricular
dysfunction.
[**2194-8-20**] OR pathology R colon - pending
Brief Hospital Course:
Ms. [**Known lastname 3647**] was initially admitted to the MICU service with
BRBPR in the setting of chronic atrial fibrillation on pradaxa.
CTA positive for blush in right colon, mesenteric angiogram
negative for active extravasation. On [**8-19**], hospital day 2, GI
was planning to perform a colonoscopy to evaluate for a possible
source of the bleed. The patient was unable to tolerate the prep
and was becoming increasingly tachycardic with a worsening
abdominal exam. She continued to pass maroon stools and received
4 units of [**Month/Day (4) **] that day. In the evening, she became more
diffusely tender with concern for peritonitis and was taken to
the OR for exploratory laparotomy, found to have ischemic areas
throughout the transverse and right colon, as well as an
abnormal cecal appendage. There was a significant amount of
[**Month/Day (4) **] throughout the ascending and transverse colon. She
underwent an extended right colectomy, end ileostomy. She
received 3 more units of [**Month/Day (4) **] and 2 units of FFP during the
case. She was transferred to the SICU intubated and sedated.
On [**8-20**], the patient had periods of atrial fibrillation with RVR
to 130's alternating with sinus tachycardia 120-130. A diltiazem
gtt was started and an a-line was placed. Her BP did not
tolerate the drip and it was stopped as she remained mostly in
sinus. She continued to pass old [**Month/Day (1) **] per rectum and her urine
dropped to 15/hour. She was given a 1L bolus. IR removed her
right groin sheath at the bedside. Her hematocrit was ranging
between 26 and 30 on serial checks and no transfusion was given.
On [**8-21**], she continued to be tachycardic, in and out of afib, and
her hematocrit drifted to 23. She was transfused 1 unit of [**Month/Day (4) **]
and bumped to 26.9. She was given albumin 500cc 5% x 3 and 1L of
LR for ongoing tachycardia. Hematocrit down again throughout the
day to 22.4 and was given a second unit of [**Month/Day (4) **], up to 27.1.
Her diltizem drip was restarted for better rate control and a
right IJ CVL was placed to assess CVP which was found to be >20.
Heparin prophylaxis was restarted. Ileostomy teaching was
initiated by the Wound/Ostomy nurse.
On [**8-22**], Ms. [**Known lastname 3647**] was extubated without difficulty and weaned
to room air, lasix 10 x 1 given. She was having scant ostomy
output at this point, tube feeds were started on [**8-23**] and
advanced to goal, tolerated well, low residuals. On [**8-23**], the
ostomy output started to pick up. Diltiazem was transitioned to
enteral via NG route and heart rates remained in atrial
fibrillation, 70-90 range.
On [**8-24**], the patient was transferred to the surgical floor in
stable condition.
0n [**8-25**], the patient was experiencing inspiratory wheezes, lasix
20mg IV was given. She had a Speech and Swallow evaluation,
however she was too sleepy to be able to have a thorough
evaluation, and they recommended keeping patient NPO for the
time being. Her nasogastric tube remained in place for tube
feeds, which were being transfused at goal. Her hematocrit
remained stable at 25.
On [**8-26**], the patient's foley was discontinued and she voided
large quantity of urine. Her mental status improved and she was
more alert. She became tachycardic to the 130s and complained of
chest pain. An EKG revealed she was in atrial fibrillation. She
was given IV Lopressor and an adult dose aspirin. An ABG was
drawn which showed hypoxia, so the patient also received 40mg IV
lasix to improve her pulmonary function. A CXR also revealed a
presentation consistent with congestive heart failure. A foley
catheter was replaced for urine output monitoring. Patient's
chest pain resolved; troponins and CKMBs were drawn and were
negative. Physical therapy evaluated patient and they
recommended a rehab facility.
On [**8-27**], the patient passed her speech and swallow evaluation
and was advanced to a puree diet and nectar thickened fluids.
She was able to tolerate PO medications. Her nasogastric tube
was discontinued. She was restarted on her all her home
medications, including Pradaxa. She was still exhibiting signs
of fluid overload and received 40mg IV lasix x 2. Foley remained
in place for urine output monitoring. Vitals remained stable,
and patients heart rate was controlled with Metoprolol.
Medications on Admission:
1. Isosorbide Mononitrate 30 mg PO QDAILY
2. Furosemide 40 mg PO DAILY
3. GlyBURIDE 2.5 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Valsartan 160 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Allopurinol 100 mg PO BID
9. Oxybutynin 5 mg PO BID
10. Dabigatran Etexilate 150 mg PO BID
11. Colchicine 0.6 mg PO PRN arthritis
12. Diltiazem Extended-Release 240 mg PO DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Pravastatin 40 mg PO DAILY
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
5. Pantoprazole 40 mg PO Q24H
6. Allopurinol 100 mg PO BID
7. Colchicine 0.6 mg PO PRN arthritis
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
9. Gabapentin 300 mg PO Q12H
10. Diltiazem Extended-Release 240 mg PO DAILY
11. GlyBURIDE 2.5 mg PO DAILY
12. Isosorbide Mononitrate 30 mg PO QDAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Oxybutynin 5 mg PO BID
15. Valsartan 160 mg PO DAILY
16. Ipratropium Bromide Neb 1 NEB IH Q6H
17. Insulin SC
Sliding Scale
Fingerstick q 6
Insulin SC Sliding Scale using REG Insulin
18. Dabigatran Etexilate 75 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Lower Gastrointestinal bleed
Atrial fibrillation
Acute [**Hospital6 **] Loss Anemia
Acute on chronic pulmonary edema
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital with rectal bleeding. You lost a
significant amount of [**Last Name (LF) **], [**First Name3 (LF) **] you were taken to the OR for an
exploratory lapartomy in order to find the source of your
bleeding, and underwent a Right colectomy and ileostomy
placement. You had a nasogastric tube which was used to give you
tube feedings, but before you were discharged we were able to
start a puree diet. Pathology results are still pending of your
colon.
Please follow up in [**Hospital 2536**] clinic at the appointment sdcheduled for
you below. Your staples will be removed at this appointment.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Hospital 5059**] at your next visit.
Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red [**Name2 (NI) **] or foul smelling discharge coming from the
wound
- an increase in drainage from the wound.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 249**]
[**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2010**]
Date/Time:[**2194-10-20**] 10:50
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2194-9-18**] at 1 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2194-8-28**] | [
"2851",
"5990",
"5849",
"9971",
"4280",
"42731",
"40390",
"2449",
"25000",
"5859",
"49390",
"2875",
"2724",
"311",
"V1582"
] |
Admission Date: [**2113-1-27**] Discharge Date: [**2113-2-8**]
CHIEF COMPLAINT: Malaise.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 38707**] is an 81-year-old
gentleman with a history of coronary artery disease, obesity,
apnea, obesity, peripheral vascular disease, status post AAA
repair, status post right BKA who presents with "feeling
terrible" and diarrhea for one week. He presented with these
symptoms from an outside hospital. The patient complained of
leg pain, back pain, shoulder pain in the Emergency Room. He
denied any shortness of breath or chest pain. He reports
minor diaphoresis and low grade temperatures. In the
blood pressure of 78, heart rate of 27-45, he received
Atropine and Dopamine and was intubated, had a Swan Ganz
catheter placed and was sent to the ICU. It was found that
he had a troponin of 19.6 with a CK of 280 and a peak MB of
14.5. Of note, an echocardiogram was done on [**12-21**] which
revealed normal left ventricular function. The patient had a
CT scan of the chest and abdomen which revealed no evidence
of pulmonary embolism or ischemic bowel, however, chest CT
had evidence of bilateral pneumonia right greater than left.
He was started on Levofloxacin, Ceftazidime. His creatinine
and potassium were also found to be elevated, likely due to
acute renal failure from dehydration secondary to the
diarrhea. The patient was given Kayexalate and gentle
hydration. He was also started on Solu-Medrol for suspected
adrenal insufficiency. On [**1-25**] the patient failed ventilator
wean secondary to cardiogenic pulmonary edema. Since the
patient had a recent non Q wave MI and may have worsening
coronary artery disease, he was sent to [**Hospital1 190**] for cardiac catheterization.
PAST MEDICAL HISTORY: 1) Chronic obstructive pulmonary
disease, on home oxygen three liters per minute by initial
cannula. 2) Coronary artery disease with cath in [**2109**] that
revealed normal EF with inferior base hypokinesis, RCA was
totally occluded and had collaterals from left to right.
Echocardiogram on [**12-21**] revealed normal left ventricular
function, mild AS, aortic insufficiency, LVH and trace MR.
3) Obstructive sleep apnea for which he does not tolerate
C-pap. 4) Obesity. 5) History of AAA repair five years ago,
right BKA secondary to compartment syndrome. Outpatient
management, Imdur 90 mg po q d, Verapamil 120 mg po tid,
Combivent 2 puffs inhaled qid, Albuterol inhaler 2 puffs q
4-6 hours prn, Nitroglycerin sublingual prn, Aspirin 81 mg po
q d, Probenecid 500 mg po bid, Lasix 20 mg po q d, Plavix 75
mg po q d, Lopressor 12.5 mg po bid.
MEDICATIONS: On transfer, Aspirin 325 mg po q d, Atrovent
and Albuterol nebs q 4 hours prn, Protonix 40 mg po q d,
artificial tears both eyes q 4 hours prn, Plavix 75 mg po q
d, Levofloxacin 250 mg po q d, Methylprednisolone 30 mg IV
bid, Nitro drip, Ceftazidime 1 gm q 8 hours, Senna 2 tablets
po q h.s., Heparin drip, Versed drip, Morphine drip, Dulcolax
10 mg po q d prn, Lopressor 2.5 mg IV q 4 hours, Reglan 10 mg
IV q 6 hours.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: Lives with his wife, retired from the Air
Force. Smokes 1?????? packs of cigarettes per day and drinks
alcohol socially.
PHYSICAL EXAMINATION: Vitals on admission, temperature 97.9,
pulse 54, respiratory rate 14, blood pressure 136/62, satting
97%. He was on assist control with total volume of 800, rate
14, PEEP 8, 55% FIO2. In general he was in no acute
distress. Cardiovascular, regular but bradycardic, had a
grade 2/6 systolic ejection murmur at the right upper sternal
border. Had S3 heard at the apex. Respiratory, lungs were
clear to auscultation anteriorly, no wheezes heard. Abdomen
with good bowel sounds, soft, nontender, non distended.
Extremities, had a right BK, lower extremities were warm, he
had 1+ distal lower extremity pulses, no cyanosis, clubbing
or edema.
LABORATORY DATA: White count 9.7, hematocrit 30.5, platelet
count 81,000, PTT 15.3, PTT 20.9, INR 1.2, sodium 136,
potassium 4.4, chloride 103, CO2 24, BUN 47, creatinine 1.2,
glucose 110, CK 33, albumin 2.7, calcium 8.0, phosphorus 4.6,
magnesium 1.7. Uric acid 8.9. ABG 7.39, PCO2 47, PAO2 91.
Chest x-ray showed cardiovascular enlargement, bilateral
pleural effusions and patchy opacities in inferior perihilar
region consistent with CHF, probable left pleural effusion.
EKG showed normal sinus rhythm, left axis deviation, Q's in
lead 3 and AVF, ST depressions in V3 through V6. CT of the
abdomen and pelvis from the outside hospital revealed liver,
pancreas and spleen were normal. There are three gallstones.
There are simple cysts in both kidneys, no evidence of
ischemic bowel. CT of the chest also at the outside hospital
revealed no evidence of pulmonary embolism but evidence of
bilateral pneumonia, right greater than left. Here, at [**Hospital1 1444**] cardiac catheterization
revealed a 70% osteal lesion of left main with 100% occlusion
of RCA with collaterals from the left. His LAD and
circumflex revealed no significant obstructive disease.
Cardiovascular surgery was then notified to evaluate the
patient for CABG.
HOSPITAL COURSE:
1. Cardiovascular: Cardiovascular surgery was contact[**Name (NI) **] to
perform a possible CABG on the patient. They requested a TTE
which revealed that he had a left ventricular ejection
fraction of 55%, his AV gradient was 23 mmHg with a mean
gradient of 12. Aortic valve area is 1.72 cm sq which is
consistent with mild aortic valvular stenosis. His left
atrium was mildly dilated. He had moderate left ventricular
hypertrophy. AV leaflets were markedly thickened. He had a
mild 1+ AR and mild to moderate MR. Cardiovascular surgeons
declined to operate on the patient since he was at very high
risk of complications given his severe COPD, severe
peripheral vascular disease and mild aortic stenosis. He was
taken back to the cardiac catheterization lab where his left
main lesion was successfully stented. He will need repeat
catheterization in three months to evaluate the patency of
the stent. When he was extubated he became hypertensive and
tachycardic with a rhythm consistent with multifocal atrial
tachycardia. A combination of ACE inhibitor, calcium channel
blocker, low dose beta blocker, and nitrates successfully
controlled his hypertension and tachycardia.
2. Respiratory: Pulmonary records were obtained from outside
hospital which revealed that the pain did not have any
evidence of interstitial lung disease by a CT scan which was
performed last year. A repeat CT scan was performed on this
admission which confirmed these findings. He was then
started on Atrovent, Serevent and Flovent and Albuterol prn
for severe chronic obstructive pulmonary disease. The
patient then tolerated a pressor support wean and was then
successfully extubated.
3. ID: The patient remained afebrile for his entire
hospital stay. All cultures that were obtained were negative
for any signs of infection. Once the patient finished a 7
day course of Levaquin and Ceftazidime started at the outside
hospital for his pneumonia, antibiotics were discontinued.
He had no further signs of infection for the rest of his
hospital stay.
4. Heme: The patient was found to be thrombocytopenic on
admission. Heparin induced antibodies were sent and were
found to be negative. Eventually his thrombocytopenia had
resolved by the time of discharge.
5. Endocrine: The stress dose steroids started at outside
hospital were weaned to off.
6. Gastrointestinal: He was continued on tube feeds until he
was transferred to the medicine floor. A speech and swallow
consult was obtained which revealed that he had no signs of
aspiration. The patient was started on a cardiac diet.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to rehab facility.
DISCHARGE MEDICATIONS: Protonix 40 mg po q d, Verapamil 90
mg po tid, Imdur 60 mg po q d, Lisinopril 60 mg po q d,
Albuterol MDI 2 puffs q 4 hours prn, Atrovent MDI 2 puffs
qid, Serevent MDI 2 puffs inhaled [**Hospital1 **], Plavix 75 mg po q d,
Aspirin 325 mg po q d, Flovent 110 mcg 2 puffs [**Hospital1 **], Senna 2
tabs po q h.s., Lopressor 25 mg po bid, Nystatin swish and
swallow q d.
DISCHARGE INSTRUCTIONS: Return to the hospital if he
developed worsening shortness of breath or chest pain.
FOLLOW-UP: Follow-up with pulmonologist and cardiologist in
one week. He will need to have a repeat cardiac
catheterization in three months to evaluate the patency of
stent placed to the left main coronary artery.
PROBLEM LIST:
1. Coronary artery disease.
2. Severe chronic obstructive pulmonary disease.
3. Obstructive sleep apnea.
4. Obesity.
5. History of AAA repair.
6. Status post right BKA.
7. Pneumonia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 7690**]
MEDQUIST36
D: [**2113-2-7**] 21:57
T: [**2113-2-7**] 22:06
JOB#: [**Job Number 38708**]
| [
"42731",
"2859",
"41071",
"4280",
"2875"
] |
Admission Date: [**2171-7-16**] Discharge Date: [**2171-7-30**]
Date of Birth: [**2171-7-16**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname 23203**] was born at 30 1/7 weeks gestation
to a 27-year-old gravida I, para 0 now I woman. The delivery
was by cesarean section for reversed end diastolic flow and
nonreassuring decelerations on the external [**Known lastname 43807**] monitor.
The prenatal history is remarkable for pregnancy achieved on
the first cycle off Depo-Provera. Last menstrual period
dating is uncertain. Dating by 12 week ultrasound was
consistent with last menstrual period. Prenatal screens are
blood type A positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, and group B
strep unknown. The mother originally had planned to have
prenatal care with Dr. [**Last Name (STitle) 43808**] at [**Hospital3 **]. She
was found to have hypertension at her first visit (chronic
vs. pregnancy-induced), with diastolic of about 90. She was
started on Aldomet and labetalol. Screening on Level II
ultrasound was normal. She was consulted by [**Hospital1 **] [**First Name (Titles) 37544**] [**Last Name (Titles) **] Medicine service for hypertension
and [**Last Name (Titles) 43807**] surveillance. She has a history of carpal tunnel
syndrome.
The mother had received a complete course of betamethasone
prior to delivery. The infant emerged with a cry. Apgars
were 7 at one minute and 9 at five minutes. Birth weight
1045 grams, birth length 38 cm, and birth head circumference
27 cm.
PHYSICAL EXAMINATION: Reveals a premature infant with
intermittent grunting, mild retractions, anterior fontanel
open and flat, palate intact, positive bilateral red reflex.
Air entry fair, no murmur, femoral and brachial pulses +2 and
equal, no hepatosplenomegaly. Testes present in canal,
normal hip and spine examination. Appropriate tone for
gestational age.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant initially required some nasal
cannula oxygen, and weaned to room air by day of life number
one, where he has remained. He was treated with caffeine
from day of life six to day of life 11 for apnea of
prematurity. His last episode of apnea occurred on [**2171-7-26**].
2. Cardiovascular: He has remained normotensive throughout
his Newborn Intensive Care Unit stay. He has a normal S1, S2
heart sound, no murmur. He is pink and well perfused.
3. Fluids, electrolytes and nutrition: Enteral feeds were
begun on day of life number two, and advanced without
difficulty to full volume feedings by day of life 12. He was
advanced to 22 calorie/ounce breast milk or preemie Enfamil
on [**2171-7-29**]. He is eating 150 cc/kg/day by gavage, and
tolerating that well. His last set of electrolytes on [**2171-7-28**]
were sodium 139, potassium 5.2, chloride 105, and bicarbonate
27.
He had some spits with slightly "loopy" abdomen on evenings,
[**2171-7-29**]. Exam soft, non-distended, with good bowel sounds. KUB
with normal bowel gas pattern, no pneumotosis.
4. Gastrointestinal: He was treated with phototherapy for
hyperbilirubinemia of prematurity from day of life one until
day of life 13. His peak bilirubin occurred on day of life
five, with total 8.2, direct 0.3. A rebound bilirubin on the
day of transfer, [**2171-7-30**], was 8.1/0.3. Phototherapy was
restarted.
5. Hematology: The last hematocrit on [**7-20**] was 38.3. He
has received no blood products or transfusions during his
Newborn Intensive Care Unit stay. Platelets at the time of
admission were 135,000. The lowest level occurred on day of
life three, and was 129,000. A repeat on [**7-20**] was 154,000,
and that was the last level checked.
6. Infectious Disease: He was started on ampicillin and
gentamicin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours when the
blood cultures were negative and the infant was clinically
well. On day of life three, he had some abdominal distention
and bilious aspirate, prompting a sepsis evaluation. The
blood culture at that time was positive for staphylococcus
coagulase negative. He completed seven days of vancomycin
and gentamicin for that on day of life 12. Follow-up blood
cultures were negative, and cerebrospinal fluid cultures also
remained negative. The cerebrospinal fluid laboratory
results done on [**7-20**] were red blood cell count 0, white blood
cells 3, protein 89, and glucose 116.
7. Neurology: He had a head ultrasound on [**2171-7-23**] that was
within normal limits.
8. Sensory: The infant has not yet had a hearing screening
test or an ophthalmology examination.
9. Psychosocial: The infant's first name is [**Name (NI) 8957**]. The
parents are happy with the transfer to [**Hospital3 **].
CONDITION AT DISCHARGE: Good
DISCHARGE STATUS: The infant is being transferred to
[**Hospital3 **] special care nursery for continuing care.
PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**Last Name (STitle) 36246**].
CARE RECOMMENDATIONS:
1. Feedings: Total fluids 150 cc/kg/day of breast milk or
preemie Enfamil 22 calories/ounce by gavage every four hours.
2. Medications: The infant is on no medications.
3. The infant has not yet had a car seat position screening
test.
4. State newborn screen was sent on [**7-19**] and [**2171-7-30**].
5. The infant has received no immunizations.
DISCHARGE DIAGNOSIS:
1. Prematurity
2. Status post transitional respiratory distress
3. Sepsis ruled out
4. Status post staphylococcus coagulase negative bacteremia
5. Physiologic hyperbilirubinemia
6. Apnea of prematurity
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2171-7-30**] 03:08
T: [**2171-7-30**] 03:13
JOB#: [**Job Number 43809**]
| [
"7742"
] |
Admission Date: [**2173-11-19**] Discharge Date: [**2173-11-22**]
Date of Birth: [**2103-1-19**] Sex: M
Service: CT [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 70-year-old male with
a past medical history significant for hypertension,
diabetes, hypercholesterolemia, who has had a two year
history of dyspnea on exertion. In the last several months
prior to this admission, he has noted increase in his
symptoms. He was ultimately evaluated by his cardiologist,
with a cardiac catheterization as well as an echocardiogram,
and the cardiac catheterization data revealed three vessel
coronary artery disease with severe left ventricular
dysfunction. There was no evidence of mitral regurgitation
or aortic stenosis. Cardiac echocardiogram data actually
showed mitral valve prolapse with moderate mitral
regurgitation and the ejection fraction was approximately 40
to 45%.
ALLERGIES: None.
MEDICATIONS: Glucophage 500 mg once daily, Glyburide 5 mg
by mouth twice a day, Lipitor 10 mg by mouth once daily,
hydrochlorothiazide 25 mg by mouth once daily, Zestril 10 mg
by mouth once daily, lasix 20 mg by mouth once daily,
potassium chloride 10 mEq by mouth once daily, Coreg 3.125 mg
by mouth twice a day, aspirin 81 mg by mouth once daily.
FAMILY HISTORY: Significant for mother and brother who are
both status post coronary artery bypass graft, sister with
coronary artery disease.
SOCIAL HISTORY: He has no tobacco history.
PHYSICAL EXAMINATION: On presentation, he had a blood
pressure of 126/63, heart rate 56, respiratory rate 18,
oxygen saturation 98%. Well-appearing 70-year-old male, in
no acute distress, grossly intact skin. Head, eyes, ears,
nose and throat examination was unremarkable. The neck was
supple. The lungs were clear to auscultation bilaterally.
The heart was regular rate and rhythm, with an S1 and S2,
with no murmur noted. The abdomen was slightly distended,
soft, nontender, positive bowel sounds. The extremities were
warm, with no edema. There were no varicosities noted.
Neurologically, he was grossly intact. He had palpable
pulses at the femoral bilaterally. Left dorsalis pedis was
nonpalpable and the right Dopplerable, posterior tibial was
palpable on the left and right, radial was also palpable left
and right. There were no carotid bruits appreciated.
LABORATORY DATA: Pending at the time of initial evaluation.
HOSPITAL COURSE: The patient was therefore brought to the
operating room for elective coronary artery bypass grafting.
On [**2173-11-19**], he went to the operating room, where he underwent
a four vessel coronary artery bypass graft including a left
internal mammary artery to the left anterior descending, a
saphenous vein graft to the posterior descending artery,
another saphenous vein graft to the obtuse marginal, and
another saphenous vein graft to the ramus. The patient
tolerated the procedure well.
Postoperative ejection fraction was noted to be approximately
35% by transesophageal echocardiogram, with 1 to 2+ mitral
regurgitation. The patient was rapidly extubated on the
night of the operation. He had no issues in his first
postoperative day. He was maintained on an insulin drip.
His postoperative laboratories included a white count of
15,000, hematocrit of 33, platelets 110, potassium 4.6,
calcium 1.09. BUN and creatinine were normal. The patient
had his chest tubes removed on postoperative day one. He was
started on a cardiac diet, as well as diabetic diet. His
Lopressor, lasix and aspirin were additionally started after
his Swan was removed. He was transferred to the floor and
hemodynamically stable. Chest tubes had been removed. His
Foley catheter was subsequently removed on postoperative day
number two. The patient was without complaints, and he was
already ambulating at a Level II on postoperative day number
two. His sternum was stable. There was no drainage. He was
afebrile. His laboratories were remarkable for a hematocrit
of 27, down from 33, white count stable at 15, BUN and
creatinine 32 and 1.3, up from .9 postoperatively. Therefore
his diuresis was decreased from lasix twice a day to once
daily. His Lopressor was titrated accordingly to 25 mg twice
a day for heart rates of 80s to 90s that were in sinus. His
hematocrit drop was felt to be secondary to postoperative
state, and revascularization as well as chest tube losses.
His hematocrit was watched and, on postoperative day number
three, his hematocrit was stable at 26. The remainder of his
electrolytes were unremarkable. His renal function was
preserved, with a creatinine of 1.1. He was ambulating and
tolerating a regular diet. He was urinating spontaneously,
and he had no tubes. Wires were discontinued. He was Level
V by activity after completing the stairs with Physical
Therapy.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Severe coronary artery disease status post coronary
artery bypass graft x 4, left internal mammary artery to left
anterior descending, saphenous vein graft to posterior
descending artery, saphenous vein graft to obtuse marginal,
saphenous vein graft to ramus.
DISCHARGE MEDICATIONS: Glucophage 500 mg by mouth once
daily, Glyburide 5 mg by mouth twice a day, Lipitor 10 mg by
mouth once daily, hydrochlorothiazide 25 mg by mouth once
daily, Zestril 10 mg by mouth once daily, lasix 20 mg by
mouth once daily, potassium chloride 10 mEq by mouth once
daily, aspirin 325 mg by mouth once daily, Lopressor 25 mg by
mouth twice a day, percocet 5/325 one to two tablets by mouth
every four to six hours as needed for pain, Motrin 600 mg by
mouth three times a day with meals as needed for pain, Colace
100 mg by mouth twice a day as long as he is on percocet.
The patient will have follow up with Dr. [**Last Name (STitle) **] in
approximately six weeks. He will have a wound check in the
Wound Care Clinic in one week here at [**Hospital1 190**] on Far 6 with the Physician's Assistant
Clinic, as well as seeing his cardiologist in follow up in
approximately three to four weeks from the time of this
discharge.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2173-11-21**] 23:38
T: [**2173-11-22**] 00:00
JOB#: [**Job Number 37618**]
| [
"41401",
"4280",
"4240",
"25000",
"4019",
"2720",
"2859"
] |
Unit No: [**Numeric Identifier 77535**]
Admission Date: [**2198-2-11**]
Discharge Date: [**2198-2-22**]
Date of Birth: [**2198-2-11**]
Sex: F
Service: NB
HISTORY AND PATIENT IDENTIFICATION: This infant's post
discharge name is [**Name (NI) **] [**Name (NI) 52774**].
HISTORY OF PRESENT ILLNESS: This is the former 3.385 kg
product of a 36 and [**6-9**] week gestation pregnancy, born to a
39 year-old, g1, P0 woman. Prenatal screens blood type B
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, GBS negative. The
mother's medical history is notable for insulin dependent
diabetes mellitus for 28 years, treated with an insulin pump.
The pregnancy was notable for development of severe pregnancy
induced hypertension, requiring treatment with magnesium
sulfate. There was induction of labor for worsening pregnancy
induced hypertension. Rupture of membranes occurred 14 hours
prior to delivery. There was no intrapartum antibiotic
treatment or maternal fever. The infant was delivered by
Cesarean section, performed for failure to progress in labor.
Apgars were 8 at 1 minute and 9 at 5 minutes. She developed
respiratory distress shortly after birth and was admitted to
the NICU for further evaluation and treatment.
Anthropometric measurements upon admission to the NICU:
Weight was 3.385 kg, 75th to 90th percentile. Length 48 cm,
50th percentile. Head circumference 34 cm, 50th percentile.
PHYSICAL EXAM ON DISCHARGE: Weight 3.150 kg. Head
circumference 34 cm. General: Alert, non dysmorphic infant
in room air. Skin warm and dry. Color pink. Well perfused.
HEENT: Anterior fontanel open and level. Sutures open and
apposed. Symmetric facial features. Palate intact. Positive
red reflex bilaterally. Ears normal. Neck supple without
masses. Chest: Breath sounds clear, equal and well-aerated.
Cardiovascular: Regular rate and rhythm. No murmur. Normal
S1 and S2. Femoral pulses +2. Abdomen soft, nontender,
nondistended, no masses. Positive bowel sounds. No
hepatosplenomegaly. Cord on and drying. Genitourinary:
Normal female. Spine straight. Normal sacrum. Extremities:
Moving all well. Hips stable. Clavicles intact. Neurologic:
Alert, positive suck,. positive grasp, intact Moro.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
Respiratory: This infant was placed on continuous positive
airway pressure shortly after admission to the Neonatal
Intensive Care Unit. Her chest x-ray was consistent with
surfactant deficiency. Her maximum support required was
continuous positive airway pressure of 7 cm of water pressure
and up to 100% oxygen. By day of life 2, she had weaned to
continuous positive airway pressure of 5 and oxygen
requirement of 25%. She transitioned to nasal cannula on day
of life #3 and weaned to room air on day of life #4. She had
rare episodes of apnea and bradycardia but none for the 5
days prior to discharge. She did have one associated choking
episode with a feed 3 days prior to discharge. At the time of
discharge, she is breathing comfortably in room air with a
respiratory rate of 20 to 40 breaths per minute, with oxygen
saturations greater than or equal to 96%.
Cardiovascular: This infant has maintained normal heart rates
and blood pressures. No murmurs have been noted. At the time
of discharge, she has a baseline heart rate of 110 to 140
beats per minute, with a recent blood pressure of 78/44 mmHg.
Mean arterial pressure of 59 mmHg.
Fluids, electrolytes and nutrition: Initial serum glucose
was 49. The infant was initially n.p.o. and maintained on IV
fluids. Enteral feedings were started on day of life 3 and
were well tolerated. The infant has been breast feeding or
taking expressed breast milk by bottle. Her weight gain and
urine output were decreased on the exclusive breast feeding
so the infant is being offered a bottle of expressed breast
milk after each breast feeding session. Weight on the day of
discharge is 3.15 kg which is up 15 grams from the weight the
previous day.
Infectious disease: The infant was evaluated for sepsis upon
admission to the NICU. A white blood cell count and
differential were within normal limits. A blood culture was
obtained prior to starting IV ampicillin and gentamycin. The
blood culture was no growth at 48 hours and the antibiotics
were discontinued.
Hematologic: This infant is blood type A positive and is
direct antibody test negative. Hematocrit at birth was
58.1%. Hematocrit at discharge is 55.7%. She did not receive
any transfusions of blood products.
Gastrointestinal: This infant required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life 3 with a total of 15.7
mg/dl. She was treated with phototherapy for approximately 3
days and the The initial rebound bilirubin was 10.3/0.3.
However, 2 days later the bilirubin was 14.3/0.3 and
phototherapy was restarted and provided over another 3 days;
the lights were turned off with a bilirubin level of 11.4/0.3
on [**2-21**]. A rebound bilirubin 24 hours off phototherapy today
([**2-22**]) was 12.6/0.3. With a negative Coombs test and a
hematocrit essentially unchanged from birth it is unlikely
that the persistently mildly elevated bilirubin levels are
hemolytic in origin. This process may be due to breast milk
jaundice and an increased enterohepatic circulation as a
result of delayed establishment of enteral nutrition.
Neurologic: This infant has maintained a normal neurologic
examination during admission and there were no neurologic
concerns at the time of discharge.
Sensory:
Audiology: Hearing screening was performed with automated
auditory brain stem responses. This infant passed in both
ears on [**2197-2-21**].
Psychosocial: [**Hospital1 69**] social
work has been involved with this family. The contact social
worker is [**Name (NI) 36130**] [**Name (NI) 36527**], and she can be reached at [**Telephone/Fax (1) 77536**]. This family has been very attentive to their
infant and visited frequently.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 7647**] [**Name (STitle) **], [**Hospital **] Pediatrics, One
[**Location (un) **] Place, [**Apartment Address(1) 50442**], [**Location (un) **], [**Numeric Identifier 1428**]. Telephone
number [**Telephone/Fax (1) 43701**]. Fax #[**Telephone/Fax (1) 43702**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Ad lib breast feeding with after feed supplementation with
a bottle of expressed breast milk.
2. Medications recommended:
Ferrous sulfate 25 mg per ml, 0.3 ml p.o. once daily.
Goldline baby vitamins, 1 ml p.o. once daily.
Iron and vitamin D supplementation: Iron
supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
All infants fed predominantly breast milk should
receive Vitamin D supplementation at 200 i.u. (may be
provided as a multi-vitamin preparation) daily until
12 months corrected age.
3. Car seat position screening was performed. This infant
was observed in her car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
4. State newborn screens were sent on [**2-14**] and [**2198-2-22**].
No notification of abnormal results to date.
5. Immunizations:
Hepatitis B vaccine was administered on [**2198-2-16**].
6. Immunizations recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following four criteria: (1) Born at less than 32
weeks; (2) Born between 32 weeks and 35 weeks with
two of the following: Day care during RSV season, a
smoker in the household, neuromuscular disease,
airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically
significant congenital heart disease.
b. Influenza immunization is recommended annually in the
Fall for all infants once they reach 6 months of age.
Before this age, and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
c. This infant has not received the rotavirus vaccine.
The American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable or at least 6 weeks but fewer than 12 weeks of
age.
FOLLOWUP: Follow-up appointment with Dr. [**First Name (STitle) **] within 1 day of
discharge. Family has an appointment for [**2-23**]. A visiting
nurse also has been arranged.
DISCHARGE DIAGNOSES:
1. Late preterm infant at 36 and 6/7 weeks gestation.
2. Infant of a diabetic mother.
3. Respiratory distress secondary to surfactant deficiency.
4. Apnea of prematurity, resolved.
5. Suspicion for sepsis, ruled out.
6. Unconjugated hyperbilirubinemia.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2198-2-22**] 01:39:27
T: [**2198-2-22**] 04:53:57
Job#: [**Job Number 77537**]
| [
"7742",
"V290",
"V053"
] |
Unit No: [**Numeric Identifier 104705**]
Admission Date: Discharge Date: [**2198-1-10**]
Date of Birth: [**2126-11-25**] Sex: M
Service: CARD
The patient was a 71-year-old man with history of severe
aortic stenosis, ischemic congestive heart failure with
ejection fraction of 10 percent to 15 percent, peripheral
vascular disease, chronic obstructive pulmonary disease, and
insulin-dependent diabetes mellitus, who initially presented
to an outside hospital on [**2197-12-31**] with increasing lower
extremity edema, increasing shortness of breath, and
orthopnea. The patient was found to have a peak troponin of
4.6 at the outside hospital and transferred to [**Hospital1 18**] on
[**2198-1-4**] for catheterization and consideration of coronary
artery bypass graft and aortic valve replacement. On the
catheterization table, the patient became agitated and
confused and was intubated. Catheterization showed 80
percent proximal LAD, 88 percent ostial diagonal 1, and 80
percent ostial OM1 stenosis as well as elevated filling
pressures. The patient was admitted to the Coronary Care
Unit for further management. The patient became febrile,
started on multiple antibiotics, and his pulmonary status
continued to be grim. After continued attempts at management
that were unsuccessful, the patient continued to be
hypotensive on multiple pressor agents as well as
hyponatremic and intubated on a ventilator. After a family
meeting between the Coronary Care Unit team and the patient's
wife and family, decision was made to make the patient
comfort measures only; and the patient passed away on
[**2198-1-10**].
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1399**] [**Last Name (NamePattern1) **], [**MD Number(1) 56294**]
Dictated By:[**Last Name (NamePattern1) 4959**]
MEDQUIST36
D: [**2198-6-13**] 14:53:26
T: [**2198-6-13**] 23:09:04
Job#: [**Job Number 104706**]
| [
"4280",
"0389",
"99592",
"4241",
"5845"
] |
Admission Date: [**2125-6-29**] Discharge Date: [**2125-7-6**]
Date of Birth: [**2091-7-20**] Sex: F
Service: SURGERY
Allergies:
Amoxicillin / Sulfa (Sulfonamide Antibiotics) / Melatonin
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
mass in the left lobe of the liver
Major Surgical or Invasive Procedure:
[**2125-7-2**] left hepatic lobectomy, ccy, ious
5/15/09ex lap, liver biopsy and cpr/defibrillation
History of Present Illness:
Per Dr.[**Name (NI) 1369**] operative note: 33-year-old female, with a
history of right upper quadrant abdominal
pain, who was found to have a left lobe liver mass. She was
evaluated in hepatology clinic and on [**4-12**] had an MRI
with gadolinium/BOPTA that demonstrated a mass in the left
lobe of the liver centered in segment III and IVB with a
superior extent which also involves segments II and segment
[**Doctor First Name **]. The mass measured 7.3 x 8.8 x 8.6 cm. The lesion had
imaging characteristics of a benign focal nodular
hyperplasia. After extensive discussions with the patient she
wished to proceed with hepatic resection because of the
abdominal pain and requirement for ongoing follow-up. She
provided informed consent and was brought to the operating
room for left hepatic lobectomy.
Past Medical History:
Focal liver lesion, Sinusitis with two surgeries, Depression.
Social History:
She is single, with no children. She works as a school teacher.
She does not smoke and drinks alcohol on rare occasions.
Family History:
Mother 58 and healthy. father 58 with hypertension.
maternal grandmother is 87 has had CVAs. maternal grandfather
died in his 70s of an MI. paternal grandmother is 81 and has
hypertension. paternal grandfather is 83 and has had an MI and
diabetes mellitus.
Physical Exam:
VS: 99.3, 94, 123/84, 20, 99% 2L
General: epidural reported as not providing adequete pain
relief, switched to IV pain meds in conjunction with APS.
HEENT: moist mucous membranes, NO JVP or LAD
Card: RRR, on telemetry
Lungs; CTA bilaterally
Abd: Soft, obese, appropriately tender, incision C/D/I
Extr: WWP, no edema
Neuro: A+O x3
Pertinent Results:
Upon Admission: [**2125-6-29**]
WBC-11.8*# RBC-4.00* Hgb-11.8* Hct-35.8* MCV-90 MCH-29.6
MCHC-33.1 RDW-13.8 Plt Ct-237
PT-14.0* PTT-26.2 INR(PT)-1.2*
Glucose-155* UreaN-7 Creat-0.4 Na-138 K-3.7 Cl-107 HCO3-22
AnGap-13
ALT-248* AST-237* AlkPhos-63 TotBili-0.6
Calcium-7.5* Phos-3.8 Mg-1.9
TSH-3.5 Free T4-1.3
At Discharge: [**2125-7-5**]
WBC-6.5 RBC-3.08* Hgb-9.8* Hct-27.3* MCV-89 MCH-31.7 MCHC-35.8*
RDW-13.8 Plt Ct-275
Glucose-92 UreaN-5* Creat-0.4 Na-137 K-3.5 Cl-100 HCO3-29
AnGap-12
ALT-114* AST-66* AlkPhos-57 TotBili-0.4
Albumin-2.9* Calcium-8.1* Phos-3.4 Mg-1.7
Brief Hospital Course:
33 y/o female taken to the OR for symptomatic FNH with Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient was intubated without incident and
the procedure was initiated. The initial dissection was done and
the cut edge along the diaphragm was cauterized with the argon
beam. When the argon beam was turned off, anesthesia noted that
the patient did not return to normal sinus rhythm. Two
pre-cordial thumps were performed and the patient remained in
coarse VFib. Chest compressions were begun and epinephrine was
administered, this did not resolve the coarse VFib and
defibrillation was
accomplished with 360 joules and the patient returned to [**Location 213**]
sinus rhythm. Transthoracic echo was in place immediately and
demonstrated no evidence of pulmonary embolus or air embolus.
The intraoperative ultrasound and a Tru-Cut
biopsy of the mass lesion was done with the patient stable in
normal sinus rhythm. The resection was not completed that day
until the arrhythmia could be evaluated further. The liver was
again cauterized following the biopsy with no arrhythmias. The
abdomen was closed and she was returned to the PACU in stable
condition. She was monitored in the ICU for the next two days
and evaluated by the EPS service who could find no cause for the
VFib arrest. Echo showed No PFO or ASD with normal global and
regional biventricular systolic function.
She remained stable over the weekend and was taken back to the
OR on [**7-2**] for Left hepatic lobectomy and cholecystectomy
following review of the previous events and cardiology
clearance. The mass in the left lobe of the liver was removed
and cholecystectomy performed. Frozen section diagnosis was that
of focal nodular hyperplasia and the final pathology gave the
same diagnosis.
In the post op period, she was kept overnight in the ICU and
then transferred to the regular surgical floor the following
day.
She made excellent post op progress, was tolerating diet,
ambulating and had some return of bowel function and positive
flatus.
The JP drain remains in place. The incision was clean dry and
intact.
Medications on Admission:
Cymbalta 60 mg p.o. daily, ibuprofen 400 mg p.o. twice daily
p.r.n. pain, Singulair 10 mg p.o. daily, tramadol 50 mg p.o.
daily p.r.n., ascorbic acid 500 mg p.o. daily, Tums E-X one
tablet p.o. daily, Mucinex 600 mg daily,
Lactobacillus acidophilus dosage uncertain, loratadine 10 mg
p.o.
daily, multivitamin one p.o. daily, and triprolidine
pseudoephedrine dosage uncertain.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Loratadine 10 mg Tablet Sig: One (1) Tablet PO qd ().
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) cc
PO daily PRN constipation as needed for constipation: Do not
take within 2 hours of thyroid medication.
10. Dulcolax 10 mg Suppository Sig: One (1) Rectal daily as
needed for constipation: Use only as needed for daily BM.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] District Nursing Association
Discharge Diagnosis:
FNH
Vfib arrest
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, abdominal distension, incision redness or
drainage.
Drain and record JP bulb drainage daily and as needed. Bring
record of drain output with you to you clinic visit with Dr
[**Last Name (STitle) **]. Call the office if you note increased drainage, if the
drainage appears bloody or develops a foul odor. Place a drain
sponge around the drain site daily. If you shower make sure the
drain does not hang without support, allow water to run over
incision and drain site, place new dressing once area is patted
dry.
No heavy lifting
No driving while taking pain medication
[**Month (only) 116**] shower
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2125-7-11**]
2:00
Cardiology followup through [**Hospital 5700**] Clinic (Dr [**Last Name (STitle) 2357**] has
been recommended)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2125-7-6**] | [
"9971",
"49390"
] |
Admission Date: [**2122-2-9**] Discharge Date: [**2122-2-14**]
Date of Birth: [**2063-2-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
CABGx2 [**2122-2-9**]
[**Last Name (NamePattern4) 15255**] of Present Illness:
Mr. [**Known lastname 81833**] is a delightful 59 year old gentleman who
developed chest pain on a preoperative stress test for a
cholecystectomy. He has had a two year history of angina with a
past cardiac catheteization that showed a 50% stenosed left main
coronary artery. He was managed medically at that time. A repeat
cardiac catheterization was performed following his positive
stress test which revealed an 80% stenosed left main. Due to the
severity of his disease, he was referred to Dr. [**Last Name (Prefixes) **] for
surgical management.
Past Medical History:
Past inguinal hernia repair
Diabetes
Cholelithiasis
Obstructive sleep apnea
Seasonal allergies
GERD
Gout
Social History:
Married. No Children. Quit smoking 5 years ago after a 40 pack
year history. He is retired.
Family History:
Father with myocardial infarction at age 57. Underwent bypass.
Currently 83 with 7 stents.
Physical Exam:
Pulse: 60 BP: (R) 128/72 (L) 130/70 Weight: 161
GENERAL: Alert in no acute distress
SKIN: Warm and dry
HEENT: PERRL, no lymphadenopathy
NECK: Supple, no JVD
LUNGS: CLear
HEART: RRR, No murmur
ABDOMEN: SOft, nontender, nondistended, normoactive bowel sounds
EXT: No edema
VARICOSITIES: None
NEURO: Non focal.
PULSES: 2+ throughout
Pertinent Results:
[**2122-2-12**] 06:20AM BLOOD WBC-10.1 RBC-2.89* Hgb-8.5* Hct-25.2*
MCV-87 MCH-29.3 MCHC-33.6 RDW-13.7 Plt Ct-189
[**2122-2-12**] 06:20AM BLOOD Glucose-103 UreaN-13 Creat-0.7 Na-140
K-4.1 Cl-103 HCO3-33* AnGap-8
[**2122-2-10**] CXR
Left-sided pleural fluid but no pneumothorax status post left
chest tube removal.
[**2122-2-12**] EKG
Sinus rhythm at 70. Diffuse ST-T wave changes with ST segment
elevation - could be in part early repolarization pattern but
clinical correlation is suggested for pericarditis. Since
previous tracing of the same date, no significant change
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 81833**] was admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center [**2122-2-9**]. He was taken to the operating room where he
underwent coronary artery bypass grafting to two vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr.
[**Known lastname 81833**] awoke neurologically intact and was extubated. He
developed a brief, self limiting run of atrial fibrillation
which resolved without intervention. On postoperative day two,
Mr. [**Known lastname 81833**] was transferred to the cardiac surgical step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. His
drains and wires were removed per protocol. Iron supplement was
started for postoperative anemia. Mr. [**Known lastname 81833**] continued to
make steady progress and was discharged to his home on
postoperative day five. He will follow-up with Dr. [**Last Name (Prefixes) **],
his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Mevacor 80mg daily
Nadolol 30mg daily
Accupril 5mg daily
Nitroglycerin as needed
Zetia 10mg daily
Prilosec 20mg daily
Glucophage 1000mg twice daily
Wellbutrin 200mg Daily
Flonase as needed
Aspirin 325mg daily
Claritin 10mg as needed
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day: 400 mg QD x 1 week then 200mg QD.
Disp:*45 Tablet(s)* Refills:*2*
11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily) for 10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p CABG x 2 LIMA-LAD, SVG->OM
PMH:DM2,^chol,Gallstones(needs elective CCY),?sleep apnea-CPAP
at noc,GERD,Gout,Bilat THR
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr [**Last Name (Prefixes) **] in 4 weeks
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-20**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2122-3-9**] | [
"41401",
"9971",
"42731",
"25000",
"2720",
"53081"
] |
Admission Date: [**2194-9-1**] Discharge Date: [**2194-9-4**]
Date of Birth: [**2125-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Bleeding at Trach site
Major Surgical or Invasive Procedure:
Flexible bronchoscopy and exploration of tracheostomy site with
revision of tracheostomy.
History of Present Illness:
Mr. [**Known lastname 37339**] is a 69 year-old male who s/p trach on [**5-/2194**] who
presented to the [**Hospital1 18**] emeragency department with bleeding from
his trach site.
Past Medical History:
1. OSA s/p trach [**5-26**]
2. Asthma
3. HTN
4. DM
5. Hyperlipidemia
6. PUD
7. CHF - diastolic heart failure (documented on Echo in [**2192**])
8. Pulmonary hypertension
Social History:
Social history: Lives with his wife, used to work in Demolition,
Never smoked, no EtOh, no IVDU
Family History:
Family history: Father had an MI at 49, Mother with MI at 44,
Brother with MI at 75
Physical Exam:
General: 69 year-old male in NAD
HEENT: normocephalic, mucus membranes moist, ppor dental hygiene
Neck; supple no lymphadenopathy
Card: regular, rate & rhythm, normal S1S2 no murmur/gallop/rub
Lungs: decreased breath sounds, occasional experitory wheeze
GI: obese, bowel sounds positive, soft non-tender/non-distended
Extr: warm no edema
Skin: trach site clean no heme or edema
Neuro: non-focal
Pertinent Results:
[**2194-9-3**] WBC-12.0* RBC-4.41* Hgb-13.8* Hct-40.7 Plt Ct-223
[**2194-9-3**] Glucose-193* UreaN-20 Creat-1.0 Na-137 K-5.2 Cl-99
HCO3-32
[**2194-9-3**] CXR: Tracheostomy tube is in adequate position. There
are low lung volumes. Bibasilar atelectases are persistent.
Right pleural effusion is small. Mild enlarged cardiomediastinal
silhouette is unchanged.
Brief Hospital Course:
Mr. [**Known lastname 37339**] was taken directly to the operating room and
underwent successful flexible bronchoscopy and exploration of
tracheostomy site with revision of tracheostomy. He was
transfered to the PACU in stable condition. His oxygenation
requirements improved over the day. His blood gas on 50% face
mask was 7.37/46/87. He was transferred to the floor on
postoperative day 1 with oxygen saturation 85-87% with activity.
On postoperative day 2 he continued to improve with room air
saturation of 94% and was discharged to home.
Medications on Admission:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Trach stomal revision 6.5 cuffed fenestrated F. Aline
Asthma
OSA s/p trach [**5-26**]
Pulmonary hypertension
Diabetes Mellitus
Congestive heart failure
PVD
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Name (NI) 25781**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills.
-Bleeding at trach site or discharge
-Difficulty breathing or increased secretions
-Trach care as previous: 6.5 cuffed Fenestrated
Followup Instructions:
Follow-up with Dr.[**Name (NI) 25781**] on [**9-11**] at 10:00 am on
the [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]. [**Telephone/Fax (1) 170**] Suture
removal.
Completed by:[**2194-9-9**] | [
"4280",
"32723",
"4168",
"2724",
"25000",
"4019",
"49390"
] |
Admission Date: [**2131-9-30**] Discharge Date: [**2131-10-5**]
Date of Birth: [**2071-10-10**] Sex: M
Service: TRANSPLANT SURGERY
CHIEF COMPLAINT: Cadaveric kidney transplant.
HISTORY OF THE PRESENT ILLNESS: This is a 59-year-old male
with end-stage renal disease on peritoneal dialysis from type
2 diabetes (20 years), who presents for a cadaveric kidney
transplant. The patient was last seen in the hospital on [**2131-4-27**] where he was admitted for bacterial peritonitis.
Since that time, he has had no medical problems or
complaints. The patient denied any headache, fever, chest
pain, shortness of breath, abdominal pain.
ALLERGIES: Diazepam, Prinivil.
ADMISSION MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Pravachol 40 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Imdur 60 mg p.o. q.d.
5. Zantac 150 mg p.o. b.i.d.
6. Lasix 80 mg p.o. q.d.
7. Calcium acetate 667 mg p.o. t.i.d.
8. Iron 325 mg q.d.
9. Epogen.
10. NPH insulin q.a.m. 30 units.
11. Regular insulin.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.6, blood pressure 128/68, heart rate 61, respirations 20,
saturation 100% on room air. General: The patient was in no
acute distress, alert and oriented times three.
Cardiovascular: Regular rate and rhythm with a II/VI
systolic ejection murmur. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended.
Extremities: Bilateral lower extremity edema.
HOSPITAL COURSE: The patient went to the OR the same day,
[**2131-9-30**], and underwent a kidney transplant
(cadaveric). The patient underwent the procedure without any
complications. He was transferred to the floor the same day
and was started on perioperative antibiotics (Cephazolin).
He was on IV PCA, morphine, for pain control. The patient
was able to tolerate liquids on postoperative day number one.
On postoperative day number two, his pain medication, IV PCA,
morphine, was changed to Percocet with good pain control.
The patient was followed by the Renal Service for his
end-stage renal disease and by Endocrinology ([**Last Name (un) **]) for
control of his blood sugar.
On postoperative day number two, the patient was started on
half NPH of his usual home dose, 15 units q.a.m. along with a
regular insulin sliding scale. The patient's urine output
has been satisfactory throughout the [**Hospital 228**] hospital stay.
The patient was also started on his immunosuppressant
medications; specifically, the patient was started on
CellCept 1 gram b.i.d. and Tacrolimus was adjusted according
to daily levels. The patient's blood pressure was controlled
throughout his stay with his home medications
(antihypertensives).
On postoperative day number three, the patient received 2
units of packed RBCs (red blood cells) for a low hematocrit
of 25. The patient has shown significant improvement over
the following days. His central line was discontinued on
postoperative day number four. He was placed on a renal
diet. His Foley was discontinued. He was ambulatory without
any fever and stable with blood glucose under sufficient
control.
The patient was discharged home on postoperative day number
five, [**2131-10-5**] with instructions to follow-up with
Dr. [**Last Name (STitle) **] at the Transplant Center on [**2131-10-11**] and
Dr. [**Last Name (STitle) **] at the Transplant Center on [**2131-10-15**].
DISCHARGE MEDICATIONS:
1. Bactrim.
2. Pantoprazole.
3. Docusate.
4. Metoprolol.
5. Isosorbide mononitrate.
6. Percocet.
7. Nystatin.
8. Valgancyclovir.
9. Mycophenolate.
10. Tums.
11. Prednisone.
12. Insulin (regular).
13. Tacrolimus 5 mg p.o. b.i.d.
14. Aspirin 81 mg.
The patient was provided with all the information necessary.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 23784**]
MEDQUIST36
D: [**2131-10-5**] 12:44
T: [**2131-10-6**] 07:46
JOB#: [**Job Number 31482**]
| [
"2859",
"V4581",
"412"
] |
Admission Date: [**2153-9-18**] Discharge Date: [**2153-9-23**]
Date of Birth: [**2080-2-28**] Sex: F
Service: MEDICINE
Allergies:
ice cream / Penicillins
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
exertional angina
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement to stenosis of
right internal carotid artery
History of Present Illness:
73 y/o with a history of COPD, CAD, s/p mid RCA and OM PTCA
[**2133**], tobacco abuse, HTN was referred for cardiac cath done for
exertional angina done on [**9-18**]. Cath showed LCX 70%, complete
RCA occlusion with collaterals, right axillary 95%, right
carotid 90%. She was admitted to NP service and on [**2153-9-19**]->
s/p axillary PTA, RRA appoach. She was placed on ASA/Plavix. On
[**9-21**] she returned to OR for right carotid stent.
.
The patient was noted to have an RCA that fills well via
collaterals in [**8-11**]. Stress testing on [**2152-10-25**] showed a small
reversible inferior defect in the AC non-corrected images. In
[**7-12**], she was referred for aortoiliac ultrasound, carotid study
that showed severe stenosis of the R internal carotid artery and
moderate stenosis of the L internal carotid artery. She
developed exertional pain in her arms and chest and back
recently, and so she was referred to Dr. [**Last Name (STitle) **] here at [**Hospital1 18**].
Neurology was consulted pre-procedurally prior to the carotid
intervention. Neuro and patient note a baseline left facial
flattness/mouth edge droop.
.
She states that she was refered for cardiac catheterization
because she has had anginal sxs of chest pain to her left arm,
particularly after an hour of working/sanding her deck this
summer. She states that she can ride her exercise bike for 10
minutes but has to stop because of hip pain. She is able to
climb her stairs at home and do oher activitiy without
difficulty. The sxs she reported this summer were relieved with
15 minutes of rest and did not go away with nitro.
.
She notes that she has a dry cough from her COPD at baseline but
is not on home oxygen. Reports no recent CP or dyspnea. No BM
since Monday. She does occassionally have zigzags in her vision,
more in her right eye than her left, due to cataracts. Upon
arrival to the floor she noted neck pain, which quickly
improved. Further, upon being on the floor she twice stated that
upon awakening from sleep she had feelings of being dissoriented
with the "bed vertical, feeling higher in the air, the clock and
the calendar sideways." She denies having this before but states
that this feeling/vision was in both eyes and resolved in less
than 1 minute. She denies feeling/seeing it upon evaluation. On
review of systems, s/he denies any prior history of pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. S/he
denies recent fevers, chills or rigors. S/he denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes on insulin, +Dyslipidemia,+
Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**2133**]: s/p cardiac cath with PTCA of mid RCA and OM
[**2134**] showed chronically occluded RCA
[**2137**] & [**2139**] showed no significant change -- see above for today
LHC)
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-Emphysema, no home oxygen
-GERD
-Degenerative lumbar spine disease
-S/P left and then right parotidectomy, "the mass was benign"
-History of ? TIA in [**2131**]
-Osteoporosis
-h/o Cholecystectomy
-?afib/arrythmia -- this is not documented on the available
notes, but the patient endorses it, without knowing any details.
She denies any h/o anticoagulation.
-?h/o DVT in [**2111**] -- also not documented, also no A/C, also
does not recall details other than her leg hurt and it came on
all of a sudden, and it went away with some sort of short-term
treatment. Denies PE, but unsure.
Social History:
Lives alone, from [**Location 90637**]near Wolfeboro. Husband died last New
Years Eve after a long illness of COPD.
- Tobacco: 40 pack year history; recently smokes 10 cigs/day,
but desires to quit. Smoked 6 of the last 20 days. Declined
nicotine patch.
- Ethanol: denies.
- Illicit / recreational drug use: Denies
Family History:
- Mother: never knew birth mother
- Father: CAD/CVA
Physical Exam:
Admission exam
VS: 96.7, 62, 113/62, 99/RA, 14
GENERAL: NAD. Oriented x3. Anxious affect. Slow slightly
slurred-speaking (baseline per interventional fellow).
Tangential but appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6cm.
CARDIAC: Distant heart sounds. PMI located in 5th intercostal
space, midclavicular line. RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi from anterior.
ABDOMEN: Soft, NT, mild distention. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No edema. Femoral artery catheter in place right
groin.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Discharge exam:
96.5 116/44 57 15 98%RA
GENERAL: NAD. Oriented x3. Normal mood and affect.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to earlobe (assessed on the right side)
when lying flat.
CHEST: 0.5 cm hyperpigmented seborrheic keratosis on upper part
of left breast
CARDIAC: Distant heart sounds. PMI located in 5th intercostal
space, midclavicular line. RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB w/ slightly
decreased breath sounds at the bases R >L
ABDOMEN: Soft, NT, mild distention. No HSM or tenderness. +BS.
EXTREMITIES: No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+Radial 2+ DP 1+
Left: Carotid 2+ Radial 1+ DP 1+
Pertinent Results:
Admission Labs
[**2153-9-20**] 03:15PM BLOOD WBC-9.2 RBC-4.30 Hgb-13.9 Hct-41.6 MCV-97
MCH-32.3* MCHC-33.4 RDW-13.1 Plt Ct-174
[**2153-9-20**] 03:15PM BLOOD Glucose-197* UreaN-20 Creat-0.9 Na-139
K-4.8 Cl-104 HCO3-27 AnGap-13
[**2153-9-22**] 02:50AM BLOOD ALT-15 AST-20 AlkPhos-65 TotBili-0.4
[**2153-9-22**] 06:29PM BLOOD CK-MB-2 cTropnT-<0.01
[**2153-9-19**] 07:05AM BLOOD %HbA1c-7.0* eAG-154*
[**2153-9-19**] 07:05AM BLOOD Triglyc-98 HDL-39 CHOL/HD-3.9 LDLcalc-92
.
Relevant Labs:
[**2153-9-22**] 06:29PM BLOOD CK(CPK)-57
[**2153-9-23**] 04:42AM BLOOD CK-MB-2 cTropnT-<0.01
.
Discharge Labs:
[**2153-9-23**] 04:42AM BLOOD WBC-6.7 RBC-3.72* Hgb-11.5* Hct-34.8*
MCV-94 MCH-30.9 MCHC-33.0 RDW-13.2 Plt Ct-180
[**2153-9-23**] 04:42AM BLOOD Glucose-105* UreaN-16 Creat-0.8 Na-142
K-3.7 Cl-108 HCO3-24 AnGap-14
[**2153-9-23**] 04:42AM BLOOD CK(CPK)-47
[**2153-9-23**] 04:42AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
.
Cardiac cath [**9-19**]:
1. Severe right axillary stenosis with pressure gradient
indicating
severe stenosis.
2. Successful PTA alone of right axillary stenosis with 4.0x20mm
NC
balloon and then 5.0x15mm NC balloon with 10% residual stenosis
and
virtual elimination of gradient.
3. Successful hemostasis of right radial arteriotomy with TR
band.
FINAL DIAGNOSIS:
1. Severe right axillary stenosis.
2. Successful PTA alone of right axillary artery with 5.0mm NC
balloon.
3. Successful RRA TR band.
4. Continue ASA, plavix.
.
Cardiac cath [**9-21**]:
Angiography and PTA COMMENTS:
After clearing the guide, first
the right brachiocephalic artery was engaged and then the right
common
carotid artery. Cerebral angiography showed patent RMCA and
RACA.
Angiography of the right carotid confirmed a severe stenosis in
the
right internal carotid artery just after the bifurcation. A
7.0mm [**Doctor Last Name **]
Freedom embolic filter wire crossed the [**Country **] stenosis with
minimal
difficulty and was deployed distal to the stenosis. The stenosis
was
predilated with a 2.5x20mm NC Quantum Apex MR balloon at 8 and
10 atms.
Nitroglycerin was started for hypertension. A [**8-8**] x 40mm XACT
RX
Carotid Stent was then deployed in the [**Country **] across the
bifurcation. The
stent was then postdilated with a 4.5x20mm NC Quantum Apex MR
balloon at
10 atms with 1 amp of atropine given immediately prior to post
balloon
inflation. The [**Doctor Last Name **] freedom filter was then retrieved. Final
angiography
showed the [**Country **] stent with no residual stenosis, excellent flow.
At the
end of the case the patient's blood pressure was low and IVF and
neosynephrine was started. Cerebral angiography at end of case
showed
the RMCA and RACA patent. The patient's neurologic exam was
unchanged
and the patient tolerated the procedure well. She was
transferred to the
CCU in stable condition.
.
COMMENTS:
1. Severe [**Country **] stenosis.
2. Successful stenting of [**Country **] with 9-7x40mm XACT RX stent with
[**Doctor Last Name **]
filter distal protection. Stent postdilated with 4.5x20mm NC
Quantum
Apex balloon.
3. Transient hypertension and then hypotension treated with IVF
and
neosynephrine.
.
FINAL DIAGNOSIS:
1. Severe [**Country **] stenosis.
2. Successful stenting of [**Country **] with 9-7x40mm XACT stent.
3. Goal SBP 100-120 mmHg.
4. Monitor in CCU.
Brief Hospital Course:
Patient is a 73 y/o with a history of CAD, exertional angina,
initially referred for cardiac catheterization done on [**9-19**]
which showed LCX 40-60%, right axillary 95%, right carotid 90%,
now s/p axillary ballooning [**9-20**] and carotid stenting [**9-21**].
.
.
ACTIVE ISSUES:
#. S/P right carotid stenting: Patient with 90% right carotid
stenosis s/p stent [**9-21**]. Neuro examination stable without any
gross motor or sensory defects. Neurologic exam was performed
every four hours and was not concerning cfor any changes, noting
baseline left facial droop and visual sxs of zigzags which she
occasionally gets with migraines. Her SBP were tightly
controlled with phenylephrine and nitroglycerin intermittlently
to a goal of 90-120s. She was started on aspirin 325mg and
plavix 75 mg daily. The patient will need to f/u with study team
by returning to holding area on [**10-22**] Monday, at 11am.
.
# CAD: Pt had non occlusive CAD of LCX at OM1 bifurcation of
70% and RCA chronically occluded with collaterals. This was not
intervened upon. She was having intermittent episodes of [**4-10**]
dull pain that is substernal, in both arms, and radiates through
to back. These were similar to prior episodes of angina, but
more intense than usual, and relieved by SL NTG x1 each time.
She was started on ASA and plavix as above. She was continued on
her home atorvastatin. Her Atenolol was held while in-house due
to bradycardia secondary to vagal stimulation after carotid
stenting. This can be started as an outpatient as heart rate
allows.
.
.
CHRONIC ISSUES:
# Pump: NL EF at 70% on recent pharmacologic nuclear stress.
.
# RHYTHM: Currently in sinus with PVCs though notes hx of afib.
Due to bradycardia, her atenolol was held on discharge. This
can be restarted by her PCP.
.
# HTN: Her SBP goal was kept at 90-120 as above. She was
restarted on her Imdur before discharge, but her home Atenolol
was held due to bradycardia.
.
# HLD : LDL was measured at 92 here, and she was continued on
her home Atorvastatin.
.
# DM: Pts current A1c at goal of 7. She was continued on her
home long acting insulin with sliding scale while in-house, and
was restarted on her home metformin upon discharge.
.
# COPD: currently stable on RA, but was continued on her home
Fluticasone-Salmeterol 250/50 IH [**Hospital1 **] and albuterol prn.
.
.
TRANSITIONAL ISSUES:
1.) PCP can restart atenolol if bradycardia resolves.
2.) PCP can follow up on seborrheic keratosis noted on left
breast.
Medications on Admission:
Albuterol inhaler Q6H prn (not used 3 weeks)
- Alendronate 70mg weekly
- Atneolol 50mg daily
- Atorvastatin 50mg QHS
- Advair 250/50 mcg daily (not using)
- Humulog 5U am, 5U before dinner
- Imdur 60mg ER daily
- Metformin 500mg [**Hospital1 **]
- Nitro 0.4mg SL prn (not using)
- Omeprazole 40mg daily
- ASA 81 mg daily
- Vitamin D
- NPH 15U in am, 7U at dinner
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
discomfort.
5. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*2 inhaler* Refills:*2*
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. NPH insulin human recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous QAM.
8. NPH insulin human recomb 100 unit/mL Suspension Sig: Seven
(7) units Subcutaneous at dinner.
9. Humalog 100 unit/mL Solution Sig: Five (5) units Subcutaneous
QAM and again before dinner.
10. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual PRN as needed for chest pain: can take a 2nd dose
after 5 minutes if still having chest pain. Can take a 3rd dose
after 5 more minutes if still having chest pain. .
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
13. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Right internal carotid stenosis of 90%
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 2433**],
You were admitted to [**Hospital1 69**]
because you were having pain with exertion. You were found to
have a blockage in your right carotid (neck) artery. This
blockage was treated with catheterization and stent placement.
You had several important changes to your medications. Please
take all medications EXACTLY as prescribed, as failure to do so
can cause acute stent blockage, which can be life threatening.
The following changes were made to your medications:
** CHANGE atorvastatin to 80mg by mouth once daily (lowers
cholesterol)
** START plavix 75mg by mouth once daily. This is EXTREMELY
IMPORTANT to take as prescribed, to keep your stents open. No
one except your cardiologist can tell you to stop it, including
other doctors.
** CHANGE aspirin to 325mg by mouth once daily (up from 81mg).
This will also help keep your stents open.
** STOP taking atenolol until your primary care provider tells
you to restart this medication
** STOP taking omeprazole
** START taking pantoprazole 40mg by mouth once daily. This is
similar to omeprazole (for acid-reflux), but interacts with your
heart medications less.
Wishing you all the best!
Followup Instructions:
Dr. [**Last Name (STitle) 59323**] [**2153-10-5**] 8:30AM
For your follow-up study, you will need to return to the
Catheterization Lab holding area at 11am on Monday [**10-22**].
| [
"496",
"V4582",
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"25000",
"V5867",
"2724",
"53081",
"3051"
] |
Admission Date: [**2121-10-15**] Discharge Date: [**2121-10-22**]
Date of Birth: [**2043-5-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2121-10-15**] cabg x4 (LIMA to LAD, SVG to OM, SVG to RCA, SVG to
PDA)
[**2121-10-15**] med. re-exploration
History of Present Illness:
78 yo female with abnormal EKG and ETT done as pre-op workup for
abdominal hernia repair.Referred for cath which revealed three
vessel disease, and then referred for CABG.
Past Medical History:
IDDM
HTN
elev. lipids
glaucoma
GERD
CRI
LE neuropathy
uterine Ca
macular degeneration
abdominal hernia
Social History:
retired
no tobacco use or ETOH use
divorced, lives with daughter
Family History:
mother died of MI at 61
Physical Exam:
HR 64 RR 16 right 176/53 left 187/59
NAD , flat after cath
skin/HEENT unremarkable
neck supple, full ROM, no carotid bruits
CTAB anterolaterally
RRR, no murmur
sift, NT, ND, + BS, large ventral hernia
extrems warm, well-perfused, no edema
left calf varicosities, difficult to assess while flat
neuro grossly intact
2+ bil. fem/DP/PT/radials
Pertinent Results:
CHEST (PA & LAT) [**2121-10-20**] 10:06 AM
PA and lateral upright chest radiographs compared to [**2121-10-16**].
The patient was extubated in the meantime interval with removing
of the NG tube, Swan-Ganz catheter, mediastinal drain, and left
chest tube. The heart size is stable. Mediastinal position,
contour, and width are unremarkable. The sternotomy wires are
intact.
Small left apical pneumothorax is noted, new. The bibasal
atelectasis accompanied by small bilateral pleural effusion are
demonstrated, markedly improved compared to the previous study.
New fracture of second right rib is demonstrated with no
adjacent pneumothorax.
IMPRESSION:
1. Small new left apical pneumothorax.
2. New fracture of second right rib.
3. Decrease in bilateral pleural effusions and adjacent
atelectasis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Date/Time: [**2121-10-15**] at 19:26
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mildly
depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is mildly depressed (LVEF= 40%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
[**2121-10-20**] 06:30AM BLOOD WBC-6.9 RBC-3.42* Hgb-10.5* Hct-30.9*
MCV-90 MCH-30.6 MCHC-33.9 RDW-14.5 Plt Ct-92*
[**2121-10-20**] 06:30AM BLOOD Plt Ct-92*
[**2121-10-18**] 03:41AM BLOOD PT-12.7 PTT-26.6 INR(PT)-1.1
[**2121-10-21**] 06:15AM BLOOD Glucose-82 UreaN-41* Creat-1.4* Na-143
K-3.6 Cl-108 HCO3-30 AnGap-9
[**2121-10-20**] 06:30AM BLOOD Glucose-87 UreaN-44* Creat-1.5* Na-143
K-3.6 Cl-110* HCO3-29 AnGap-8
[**2121-10-19**] 05:05AM BLOOD Glucose-131* UreaN-44* Creat-1.7* Na-144
K-4.4 Cl-113* HCO3-21* AnGap-14
Brief Hospital Course:
Admitted [**10-15**] and underwent cabg x4 with Dr. [**First Name (STitle) **].
Transferred to the CSRU in stable condition on a titrated
propofol drip. Returned to the OR later that evening for a
mediastinal re-exploration for bleeding after acute hypotension
in the CSRU. Transfered back to the CSRU in stable condition on
nitroglycerin and propofol drips. Extubated on POD #2 and
swallow eval. done to assess aspiration risk with no signs of
aspiration seen. Transferred to the floor on POD #3 to begin
increasing her activity level. Chest tubes and pacing wires
removed without incident. She progressed well and was ready for
discharge to home on POD #7.
Medications on Admission:
humulin N 16 units QAM
humulin N 6 units QPM
metoprolol 25 mg [**Hospital1 **]
plavix 600 mg (SINGLE dose 10/3)
vasotec 2.5 mg daily
protonix 40 mg daily
ASA 81 mg daily
metamucil one cap daily
MVI daily
macular protect one tab [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 16 in
AM/6 in PM units Subcutaneous twice a day.
Disp:*QS 1 month* Refills:*0*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p cabg x4
s/p mediastinal re-exploration for bleeding\nIDDM
HTN
elev. chol.
glaucoma
GERD
CRI
postop A fib
Discharge Condition:
good
Discharge Instructions:
SHOWER DAILY , pat incisions dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
home physical therapy
Followup Instructions:
see Dr. [**Last Name (STitle) 11559**] in [**1-7**] weeks
see Dr. [**Last Name (STitle) 11493**] in [**2-8**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2121-10-22**] | [
"41401",
"5180",
"2762",
"42731",
"2859",
"4240",
"40390",
"5859",
"2724",
"53081",
"V5867"
] |
Admission Date: [**2180-1-18**] Discharge Date: [**2180-1-26**]
Date of Birth: [**2143-3-3**] Sex: F
Service: CARDIAC INTENSIVE CARE UNIT
CHIEF COMPLAINT: Chest pain and shortness of breath.
HISTORY OF PRESENT ILLNESS: This is an unfortunate
36-year-old, gravida 2, para 2, [**Location 7979**] speaking female
with a past medical history of sinus venosus ASD, anomalous
pulmonary return and Eisenmenger's physiology, which was
diagnosed in [**2177**]-[**2178**], on home oxygen, who presented with
chest pain and shortness of breath on [**1-18**].
The patient was initially admitted to a medical floor with
oxygen saturations of 88% on 100% nonrebreather. At the time
of presentation, review of systems was positive for dyspnea
on exertion, shortness of breath, pleuritic chest pain,
chronic fevers, however, no syncope or palpitations. The
patient of note, may have had mechanical difficulty with her
home oxygen equipment.
During the initial work-up, a CT angiogram was positive for
progression of her known pulmonary embolus despite a
therapeutic INR. She was started on Lovenox on the medical
floor. She was peristently hypoxemic with obvious increased
work of breathing. The decision was made to see if pulmonary
vasodilators would improve her condition and hemodynamic
assessment was planned in the cardiac catheterization
laboratory.
The patient was brought to the Catheterization Lab on
[**1-21**] for a right heart catheterization. She was noted
initially to become nearly unresponsive on transfer to the scale
for weighing, but spontaneously resolved. During the
catheterization, her right atrial pressures were noted to be
elevated, right ventricle systolic pressure of 100, pulmonary
arterial pressure of 100-110, mean pulmonary artery pressure in
the 70s. She had a systemic pAO2 of 25, with a +/- response to a
nitric-oxide trial. Saturations remained in the 40s to 50s
despite intervention and there profound right to left shunting
continued.
Due to her severe systemic hypoxemia, obvious cardiogenic shock
and worsening hemodynamics, she was transferred to the Cardiac
Intensive Care Unit where she continued to do rather poorly. She
was responding to voice but was unable to speak in full
sentences. Her arterial saturations remained in the 40% range.
Her blood gas returned with a pH of 7.17, CO2 of 41, and a pAO2
of 26.
She did receive some bicarb at that time in an attempt to correct
her acidosis. CPAP was also initiated to try to increase her
oxygen saturations, and she was also started on Dopamine for
pressor support in an effort to reduce right to left shunt.
She survived throughout the night and was followed by the CCU
Team during the rest of her admission.
PAST MEDICAL HISTORY: 1. Eisenmenger's diagnosed in [**2178**].
2. ASD (sinus venosum). 3. Home oxygen dependent. 4.
Chronic pulmonary embolus secondary to extreme pulmonary
hypertension.
MEDICATIONS: Oxygen, Coumadin 2 mg q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: She is a single, [**Location 7979**] speaking
woman, who came here about 1?????? years ago. She is an illegal
alien. She has two children, boy and an 11-year-old
daughter, who live with her father and step-mother in [**Country **].
FAMILY HISTORY: Question of ASD in father/son. Primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Company 191**].
PHYSICAL EXAMINATION: Vital signs: Temperature 97??????, blood
pressure 95/52, heart rate 100-130, respirations 30, oxygen
saturation 40-50% on 100% nonrebreather. General: Lethargic
and cachectic woman. HEENT: JVP at 9-10 cm. Pupils equal,
round and reactive to light and accommodation. Oropharynx
dry. Pulmonary: Clear to auscultation anteriorly. No
wheezes rubs, or rhonchi. Cardiovascular: Hyperdynamic.
Right ventricular heave. No murmurs, rubs, or gallops. PMI
5-10 cm. Abdomen: Normoactive bowel sounds. Soft,
nontender, nondistended. No hepatosplenomegaly.
Extremities: No clubbing, cyanosis, or edema. Neurological:
Intact.
LABORATORY DATA: WBC 10.7, hematocrit 50.9 down from 63 on
admission, platelet count 173; INR 1.8; bicarb 18, sodium
135, potassium 4.1, BUN 10, creatinine 0.6, glucose 87; ALT
12, AST 15, alkaline phosphatase 57, total bilirubin 1;
urinalysis with 26 WBCs, no RBCs; CK of 120, troponin less
than 0.3; HCG quantitative less than 5;
CTA showed increased thickness in extent of mural thrombus
and a markedly dilated proximal pulmonary artery with some
irregularity in the mural thrombus at the bifurcation of the
right pulmonary artery, new small right pleural effusion,
stable, a morphos calcification of the dome of the liver, no
renal stones or abnormal pathology.
Electrocardiogram showed normal sinus rhythm at 92, right
ventricular hypertrophy with repolarization, abnormal V1-V5,
right axis deviation.
HOSPITAL COURSE: This is a 36-year-old female with
Eisenmenger's physiology, chronic pulmonary emboli and chest
pain. The patient with inarguably significant disease now,
who is status post catheterization confirming anatomy and
increased right-sided pressure. She became clinically much
worse than on admission with depressed oxygen saturations on
100% nonrebreather, with increased symptoms, increased
lethargy, and dismal ABG.
She had partial response to nitric oxide, and Catheterization
Lab suggested possible response to other vasodilators. She
was therefore started on Flolan 0.5 ng/kg/min the night of
admission as salvage therapy and was slowly titrated up daily to
3 ng/kg/min.
Supportive measures were also begun including Dopamine drip,
which over the next several days was slowly titrated down to
off, a Heparin drip for her PEs, CPAP/oxygen support, packed
red blood cells to increase to oxygen delivery, and Levaquin
was continued for a urinary tract infection.
She was determined to be CPR not indicated secondary to the
irreversibility of her cardiopulmonary anatomy.
She was followed closely by the Pulmonary Hypertension
Service (Dr. [**Last Name (STitle) **], Pharmacy department, the Ethics Service,
Case Management, and further congenital heart disease input via
telephone was obtained from [**Hospital3 1810**].
Her right pleural effusion was monitored closely via exam and
repeat chest x-ray; however, she was always considered too
high risk for diagnostic or therapeutic tap.
Her many social issues were addressed during her stay in the
CCU. Family members were found and [**Hospital3 653**]. [**Name2 (NI) **] cousin,
[**Name (NI) 36972**] [**Name (NI) 32126**], was deeply involved. [**Location 36973**] Embassy
and community in [**Location (un) 86**] were also involved in helping with
translation and providing support for the patient. An
attempt was made to have her daughter and stepmother, who do
not have visas to visit from [**Country 3587**]. The American
Consulate in [**Country 3587**] was consulted who did decline the
request. This was then pursued by contacting the U.S.
Embassy.
Discussions of how the patient would afford the Flolan and
have the Flolan administered while she was at home was
initiated during this stay. She was also determined not to
be eligible for a heart/lung transplant secondary to her
illegal immigrant status in the United States.
She remained somewhat stable, although critically ill for
several days. Her oxygen saturations remained in the 40-50s,
and it was unclear as to whether the Flolan was providing any
clear benefit at this time.
By [**1-24**], her creatinine had begun to increase. Renal was
consulted and attributed her acute renal failure to
hypotension, as well as recent administration of intravenous
contrast. Intravenous fluids were limited in order to try to
prevent fluid overload. A renal ultrasound revealed
hyperechoic kidneys but no overt obstructions.
Her liver function tests, as well as her amylase and lipase
were noted as well to increase, likely consistent with a
shocked pancreas/liver. A right upper quadrant ultrasound
revealed an enlarged liver with prominent hepatic but patent
veins.
On the morning of [**1-26**] after morning rounds, we were
called in by the nurse who noted that she had become
unresponsive while she was being turned. This came on
abruptly. The patient was noted to be apneic with
[**Last Name (un) **]-[**Doctor Last Name 6056**] breathing. Eyes were deviated to the right
initially and then moved to midline. The pupils were
unresponsive to light. She became bradycardiac. She was
given Morphine for comfort, and slowly her heart rate and
respiration rate decreased. She expired around 10 a.m.
The likely cause of death clinically seemed to be either
pulmonary embolus or a cerebrovascular accident. Her family
members were [**Name (NI) 653**]. [**Name2 (NI) **] family in [**Country 3587**] did give
permission for an autopsy, and the death certificate was
filled out.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 36974**]
MEDQUIST36
D: [**2180-3-20**] 17:19
T: [**2180-3-20**] 19:00
JOB#: [**Job Number 36975**]
| [
"4168",
"5990",
"5845",
"2762"
] |
Admission Date: [**2191-3-23**] Discharge Date: [**2191-3-31**]
Date of Birth: [**2125-3-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Sarcoma of the left lung extending to and including the main
pulmonary artery, as well as the left and right pulmonary
arteries.
Major Surgical or Invasive Procedure:
[**2191-3-23**]:
1. Left pneumonectomy with pulmonary artery reconstruction
using a 20-mm Dacron tube graft.
2. Ligation and division of the patent ductus arteriosus.
3. Flexible bronchoscopy.
4. Mediastinoscopy
5. Intercostal muscle flap buttress to the left bronchial
stump.
History of Present Illness:
Mr. [**Known lastname **] is a 66M w a recently diagnosed pulmonary artery
sarcoma admitted for resection. Patient was in his usual state
of good health until [**4-/2190**] when he developed a cold while
traveling abroad. Since then, he has noticed a decrease in
overall stamina. In [**7-/2190**], he saw his PCP and several tests
were done including Holter monitor, stress test, pulmonary
function tests and chest x-ray all of which reportedly were
normal. A chronic dry cough developed over this time, and he
was started on PPI. Cough improved some but stamina remained
low. In [**11/2190**] continued complaint of cough prompted ENT
evaluation.
Laryngoscopy demonstrated changes consistent with PND and he was
started on a nasal spray, nasal wash and a course of
antibiotics.
In [**1-/2191**], progressive DOE and dry cough lead to pulmonary
specialist referral. Noncontrast CT scan demonstrated a 1.3 cm
nodule. At this time, pt was referred to Dr. [**Last Name (STitle) **] for
further evaluation of the solitary pulmonary nodule. Subsequent
contrast CT scan revealed a soft tissue mass arising within the
left pulmonary artery, vascular occlusion and expansion highly
suggestive of pulmonary artery sarcoma. There was also
extravascular extension and bronchial artery transpleural
collaterals suggesting longstanding pulmonary artery
obstruction. PET/CT scan later demonstrated a lobulated
low-attenuation FDG avid mass which occupies an experience of
left main pulmonary artery and extends beyond its wall. There
was a new FDG avid left pleural effusion which developed over
the 7-day interval since the CT scan suggestive of tumor spread.
On [**2191-2-24**], the patient underwent bronchoscopy and biopsy of the
soft tissue mass, which revealed a spindle cell neoplasm with
necrosis, likely malignant. By immunohistochemistry, the tumor
cells were diffusely positive
for vimentin, focally positive for cytokeratin cocktail, actin
and desmin; negative for S-100. The profile was suggestive of a
smooth muscle phenotype. Corresponding cytology was also
consistent with this diagnosis.
Patient presents now for operative resection.
Past Medical History:
PMH: Hyperlipidemia, Hx prostate CA s/p rsxn ([**2188**])
PSH: prostatectomy for early stage prostate cancer at [**Hospital1 2025**]
([**9-/2189**]), B/L inguinal hernia repair ([**2191-1-5**])
Social History:
Married, lives with wife. [**Name (NI) 1139**] never. ETOH: 1 drink per week
Family History:
Father died age 73 of breast cancer. Brother has prostate
cancer.
Physical Exam:
VS: T: 99.0 HR: 88-93 SR BP: 103/76 Sats: 98% RA
GEN: WD, WN M in NAD
HEENT: MMM, anicteric sclerae
CV: RRR, +S1S2 w no M/R/G
PULM: clear breath sounds no crackles
ABD: S/NT/ND
EXT: WWP, no edema
Incision: L. thoracotomy incision margins well approximation. R
groin site mild erythema, no discharge
Neuro: awake,alert oriented
Pertinent Results:
LABORATORIES:
ADMISSION:
[**2191-3-23**] 06:03PM BLOOD WBC-14.6* RBC-2.25*# Hgb-6.6*# Hct-18.8*#
MCV-84 MCH-29.4 MCHC-35.2* RDW-14.1 Plt Ct-227#
[**2191-3-23**] 06:03PM BLOOD PT-17.0* PTT-37.7* INR(PT)-1.5*
[**2191-3-23**] 08:00PM BLOOD UreaN-17 Creat-0.9 Na-139 K-4.0 Cl-108
HCO3-25 AnGap-10
MICROBIOLOGY:
MRSA Screen [**2191-3-23**]: NEG
CXR:
[**2191-3-30**]: The left apical air collection is unchanged. The
post-surgical cavity continues to be occupied by fluid.
Subcutaneous air appears to be grossly unchanged. Right lung is
unremarkable, except for small amount of right pleural effusion
that appears to be decreased as well.
[**2191-3-23**] (postop): s/p L pneumonectomy. pneumonectomy space
filled w air/min amount of fluid. mild vascular congestion on
right. ET tube in standard position. tip 4.6 cm above carina. R
IJ catheter tip in the mid-to-lower SVC. postoperative
mediastinal widening. Cardiac size top normal.
mild left chest wall subcutaneous emphysema. Elevation L
hemidiaphragm is new. Left chest tube in place.
PATHOLOGY:
PENDING
Brief Hospital Course:
Mr.[**Known lastname **] is a 66M with a recently diagnosed left pulmonary
artery sarcoma admitted to the thoracic surgery service on
[**2191-3-23**] following: cervical mediastinoscopy, left exploratory
thoracoscopy, left thoracotomy and left pneumonectomy with
pulmonary artery reconstruction, cardiopulmonary bypass,
intercostal muscle flap buttress to the bronchial stump,
mediastinal lymph node dissection, bronchoscopy with
bronchoalveolar lavage. Postoperatively, the patient was
transferred to the CVICU intubated, sedated, on pressors, foley,
Left chest tube and IV opoids for pain control.
Neuro: Post-operatively, the patient remained intubated and
sedated. Sedation was weaned and patient was extubated on POD1.
Upon extubation, patient received percocet and IV morphine with
good effect and adequate pain control. Analgesia was eventually
adjusted to po oxycodone and tylenol RTC with improved effect.
Cardiac: Required pressors initially to maintain MAP > 60 ajd
was discontinued on [**2191-3-26**]. His SBP remained stable at
100-120. He remained in sinus rhythm without ectopy. Low-dose
lopressor was started [**2191-3-27**] for tachycardia and increased to
25 mg tid on [**2191-3-29**] for HR 90-100.
Respiratory: Patient was successfully extubated on [**2191-3-24**].
Aggressive pulmonary toilet and nebs were initiated with oxygen
saturations of 95-98% on 1-2L NC. On [**2191-3-29**] he titrated off
oxygen room with a saturation of 98% at rest and activity.
Serial CXRs were followed postoperatively to assess status of L
thorax and aeration of R lung. L thorax demonstrated expected
fluid collection s/p pneumonectomy while R lung expanded well.
Chest tube: immediate postoperative output large amount of heme
which trended down.
The chest tube was removed [**2191-3-25**] and U stitch was placed to
seal chest tube tract.
GI/GU: Post-operatively, the patient was given IV fluids while
extubated. Upon extubation, patient's diet was advanced as
tolerated to regular/heart healthy and fluids were discontinued.
He was also started on a bowel regimen to encourage bowel
movement. Urine output was monitored via foley catheter
postoperatively. Lasix 20 iv x 1 dose given on [**3-25**] for
assistance w diuresis. Foley was removed on [**3-28**] and patient
voided appropriately. Intake and output were closely monitored.
Patient was noted to be hyponatremic to 129 on [**3-28**] prompting
free water restriction of 500cc/day. Urine electrolytes were
also evaluated [**3-28**]. Electrolytes were followed [**Hospital1 **].
ID: Patient was given appropriate preoperative antibiotic
prophylaxis. The patient's temperature was closely watched for
signs of infection.
Heme: Postop, serial HCT were done in setting of sanguinous
chest tube output. He was transfused 7 units of PRBC to
maintain HCT > 24. His last transfusion was [**2191-3-26**] with a
stable HCT of 29. HCT remained stable throughout remainder of
admission.
Prophylaxis: Initially postoperatively, DVT prophylaxis was held
given concern for hemorrhage. Subcutaneous heparin and ASA were
started on [**3-27**] when HCT stable. Patient was also encouraged to
get up and ambulate as early as possible.
At the time of discharge on [**2191-3-31**] the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
pravachol 40 qhs, omeprazole 20'
Discharge Medications:
1. Nebulizer Machine
and equipment
2. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: Three (3) mL Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
Disp:*30 vials* Refills:*1*
3. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. sennosides-docusate sodium 8.6-50 mg Tablet Sig: One (1)
Tablet PO twice a day: with narcotics.
hold for loose stool.
Disp:*60 Tablet(s)* Refills:*2*
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO twice a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
9. tizanidine 4 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain.
Disp:*90 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Regional VNA
Discharge Diagnosis:
Left main pulmonary artery sarcoma
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Left thoracotomy incision develops drainage
Pain
-Take acetaminophen 650 mg every 6 hours for pain
-Oxycodone 5-10 mg every 4-6 hours for pain.
-Tazanidine 4 mg every 8 hours as needed for pain
Activity
-Shower daily. Wash incision with soap & water, rinse, pat dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics.
-No lifting greater than 10 pounds
-Daily weights: keep a log. Call if you have greater than [**1-21**]
pound weight gain
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] 617-632-:[**Telephone/Fax (1) 3020**]
Date/Time:[**2191-4-19**] 11:00 in the [**Hospital Ward Name 121**] Building [**Location (un) **]
[**Hospital1 **] [**First Name (Titles) 479**] [**Last Name (Titles) 7755**] Clinic
Chest X-Ray [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology 30
minutes before your appointment
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2191-4-19**] 1:30 in the [**Last Name (un) 2577**] Building Cardiac Surgery
Suite [**Location (un) 551**]
Completed by:[**2191-3-31**] | [
"2851",
"2761",
"2724"
] |
Admission Date: [**2166-11-27**] Discharge Date:[**2166-12-5**]
Date of Birth: [**2109-10-4**] Sex: F
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: This is a 57-year-old woman who
was referred for outpatient cardiac catheterization due to
recent complaints of chest discomfort and shortness of
breath.
The patient reports that she has been under increased stress
since late [**Month (only) 216**] and has noticed intermittent symptoms of
chest pressure and shortness of breath. These symptoms are
now recurring on a daily basis, and these symptoms resolve
with rest.
On [**2166-10-21**] she was admitted to [**Hospital3 3583**] for
increasing symptoms of congestive heart failure. She ruled
out for a myocardial infarction. She underwent further
cardiac testing that suggested that she had coronary artery
disease, and she was referred to [**Hospital1 190**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Diabetes.
4. Human T cell leukemia-lymphoma virus.
5. Elevated C-reactive protein.
6. Environmental allergies.
7. Macular degeneration.
8. Eosinophilia.
9. Lupus.
10. Severe degenerative joint disease of both knees.
11. Positive Lyme titer.
12. Positive toxoplasmosis.
13. Sleep apnea; on CPAP at home.
14. Status post thyroidectomy.
15. Status post appendectomy.
16. Status post tonsillectomy.
ALLERGIES: TETRACYCLINE which results in vaginal
candidiasis.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Actos 30 mg p.o. q.d.
3. [**Doctor First Name **] 60 mg p.o. b.i.d.
4. Atenolol 50 mg p.o. q.d.
5. Prozac 50 mg p.o. q.d.
6. Glyburide 10 mg p.o. b.i.d.
7. Ibuprofen 800 mg p.o. t.i.d.
8. Levoxyl 175 mcg p.o. q.d.
9. Lipitor 10 mg p.o. q.a.m. and 20 mg p.o. q.p.m.
10. Glucophage 500 mg p.o. t.i.d.
11. Minocycline 100 mg p.o. t.i.d.
12. Lisinopril/hydrochlorothiazide 12/12.5 two tablets p.o.
q.a.m.
13. Lasix 40 mg p.o. q.a.m.
14. Potassium 20 mEq p.o. q.d.
15. Multivitamin.
16. Calcium supplements.
PERTINENT LABORATORY DATA ON PRESENTATION: Blood urea
nitrogen was 21, creatinine was 0.9.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
pulse was 50 and blood pressure was 117/45. Head, eyes,
ears, nose, and throat examination was unremarkable. The
neck was without bruits. Heart was regular in rate and
rhythm. No murmurs. The lungs were clear. Extremities
revealed normal peripheral pulses. No vascular disease.
HOSPITAL COURSE: The patient underwent cardiac
catheterization on [**2166-11-27**] which showed a left
ventricular ejection fraction of 40%, with mild diffuse
hypokinesis, a 60% to 70% distal left main occlusion, a 70%
proximal left anterior descending artery occlusion, a 70%
left circumflex occlusion, a 90% first obtuse marginal
occlusion, 70% ostial right coronary artery occlusion.
The patient was taken to the operating room on [**2166-11-28**] for a coronary artery bypass graft times four; left
internal mammary artery to left anterior descending artery,
left radial to posterior descending artery, saphenous vein
graft to obtuse marginal, with a sequential graft to the
first diagonal. Please see the Operative Note for further
details.
The patient was transferred to the Intensive Care Unit in
stable condition. The patient was weaned and extubated from
mechanical ventilation on the first postoperative night. The
patient required some volume resuscitation as well as a
Neo-Synephrine infusion to maintain an adequate blood
pressure.
On postoperative day one, the patient's hematocrit was noted
to be 21.8. The patient was transfused 2 units of packed red
blood cells. The patient was on an insulin infusion to
maintain adequate blood glucose control. The patient
remained in the Intensive Care Unit due to labile blood
pressures. The patient required aggressive pulmonary toilet,
and the patient was placed on her nocturnal CPAP settings
which she tolerated well.
On postoperative day three, the patient was transferred from
the Intensive Care Unit to the floor in stable condition.
The patient required some aggressive diuresis and aggressive
pulmonary toilet. The patient began ambulating with Physical
Therapy, and it was determined that the patient would need
[**Hospital 3058**] rehabilitation. The patient was intermittently
complaining of shortness of breath which she stated was at
her baseline. This shortness of breath was improved with
diuresis and the use of nocturnal CPAP which she was on at
home. The patient's chest tubes and epicardial pacing wires
were discontinued without complications.
A chest x-ray showed small bilateral pleural effusions as
well as bilateral atelectasis. The patient was cleared for
discharge on [**2166-12-5**] to a rehabilitation facility.
CONDITION AT DISCHARGE: Temperature maximum was 97.2, pulse
was 69 (in sinus rhythm), blood pressure was 145/68, oxygen
saturation was 94% on room air, respiratory rate was 25.
Neurologically, grossly intact. Heart had a regular rate and
rhythm. Positive rub. No murmur. Lungs revealed breath
sounds were clear anteriorly; posteriorly with minimal
crackles at the bases. The abdomen was obese. Positive
bowel sounds. Nontender and nondistended. The extremities
were warm with 1+ edema. The sternal incision was clean and
dry without erythema. Left radial artery harvest site was
clean and dry with Steri-Strips intact. There was no
erythema or drainage. The vein harvest site in the right
thigh was clean and dry and without erythema or drainage.
PERTINENT LABORATORY DATA ON DISCHARGE: On [**2166-12-5**]
hematocrit was 31.8. Potassium was 4.3, blood urea nitrogen
was 19, and creatinine was 0.7.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft.
2. Hypertension.
3. Hyperlipidemia.
4. Diabetes.
5. Human T cell leukemia-lymphoma virus.
6. Elevated C-reactive protein.
7. Environmental allergies.
8. Macular degeneration.
9. Eosinophilia.
10. Lupus.
11. Severe degenerative joint disease of both knees.
12. Positive Lyme titer.
13. Positive toxoplasmosis.
14. Sleep apnea; on CPAP at home.
15. Status post thyroidectomy.
16. Status post appendectomy.
17. Status post tonsillectomy.
MEDICATIONS ON DISCHARGE:
1. Lopressor 12.5 mg p.o. b.i.d.
2. Lasix 40 mg p.o. q.12h.
3. Potassium chloride 20 mEq p.o. q.12h.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Percocet 5/325 one to two tablets p.o. q.4-6h. as
needed.
7. Ibuprofen 400 mg p.o. q.4-6h. as needed.
8. Imdur 60 mg p.o. q.d. (times three months).
9. Actos 30 mg p.o. q.d.
10. Glyburide 10 mg p.o. b.i.d.
11. Prozac 50 mg p.o. q.d.
12. Levoxyl 175 mcg p.o. q.d.
13. Lipitor 30 mg p.o. q.d.
14. Minocycline 100 mg p.o. t.i.d.
15. [**Doctor First Name **] 60 mg p.o. b.i.d.
16. Heparin 5000 units subcutaneous q.8h. (until fully
ambulatory).
17. A regular insulin sliding-scale; for blood sugars of
120 to 150 give 2 units subcutaneous, for blood sugars of 151
to 170 give 3 units subcutaneous, for blood sugars of 171 to
190 give 4 units subcutaneous, for blood sugars of 191 to 210
give 5 units subcutaneous, for blood sugars of 211 to 230
give 6 units subcutaneous, for blood sugars of 231 to 250
give 7 units subcutaneous, for blood sugars of 251 to 270
give 8 units subcutaneous, for blood sugars of 271 to 290
give 9 units subcutaneous, for blood sugars of 291 to 310
give 10 units subcutaneous, for blood sugars of 311 to 330
give 11 units subcutaneous, for blood sugars of 331 to 350
give 12 units subcutaneous.
DISCHARGE INSTRUCTIONS:
1. The patient was to have her blood sugar checked before
meals and at bedtime; covered with her regular insulin
sliding-scale.
2. The patient was to be placed on nocturnal CPAP with 7 cm
of water with 3 liters nasal cannula.
3. Diet is 1800 American Diabetes Association.
DISCHARGE FOLLOWUP:
1. The patient was to follow up with her primary care
physician upon discharge from rehabilitation.
2. The patient was to follow up with Dr. [**Last Name (STitle) 70**] in four
to six weeks.
3. The patient was to follow up with cardiologist in four to
six weeks.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2166-12-5**] 11:45
T: [**2166-12-5**] 14:13
JOB#: [**Job Number 24178**]
| [
"41401",
"4168",
"25000",
"4019",
"2720"
] |
Admission Date: [**2147-6-12**] Discharge Date: [**2147-6-22**]
Date of Birth: [**2072-12-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
persantine MIBI cardiac stress test
thoracentesis
Chest Tube
History of Present Illness:
74 yo M with lung cancer DVT who presents with 1 day of
substernal chest pain. Patient developed chest pain the night
prior to admission. The pain was substernal [**6-21**], did not
radiate. He reports that the pain was similar to his prior MI.
The patient had shortness of breath.
.
In the ED the patients pain resolved with NTG and morphine. he
was given ASA and bblocker. At time of my evaluation, the
patient denied nausea, vomitting, abdominal pain, dysuria,
dizziness, changes in vision/hearing
Past Medical History:
- Lung cancer - Non-small cell lung cancer stage IIIA, status
post weekly carboplatin and Taxol chemotherapy with XRT for
seven weeks
followed by surgery on [**2147-3-28**].
- CAD - s/p inferior STEMI [**11-16**], stent to L Cx
- CHF(EF 55% on [**4-17**])
- HTN
- paroxismal afib
- CVA
- Left LE DVT on coumadin
- s/p IVC filter
Social History:
non-smoker, occasional etoh, no drugs
Family History:
father and mother with CAD
Physical Exam:
VS - 98.0 67 140/63 22 99% on RA
Gen - A+Ox3, NAD
HEENT - EOMI, OP clear
Neck - supple, no LAD, no JVD
Cor - RRR no murmurs
Chest - R base with poor excursion and poor breath sounds.
Clear otherwise.
Abd - s/nt/nd +BS
Ext - w/wp, no edema, R leg swollen compared to left
Pertinent Results:
[**2147-6-12**] 05:15PM CK(CPK)-67
[**2147-6-12**] 05:15PM CK-MB-NotDone cTropnT-<0.01
[**2147-6-12**] 09:55AM GLUCOSE-159* UREA N-17 CREAT-1.0 SODIUM-137
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
[**2147-6-12**] 09:55AM CK(CPK)-76
[**2147-6-12**] 09:55AM cTropnT-<0.01
[**2147-6-12**] 09:55AM CK-MB-NotDone
[**2147-6-12**] 09:55AM WBC-10.4 RBC-4.41*# HGB-12.8*# HCT-38.2*#
MCV-87 MCH-29.0 MCHC-33.5 RDW-15.9*
[**2147-6-12**] 09:55AM NEUTS-86.1* LYMPHS-5.4* MONOS-5.7 EOS-2.2
BASOS-0.6
[**2147-6-12**] 09:55AM MICROCYT-1+
[**2147-6-12**] 09:55AM PLT COUNT-372
[**2147-6-12**] 09:50AM URINE HOURS-RANDOM
[**2147-6-12**] 09:50AM URINE GR HOLD-HOLD
[**2147-6-12**] 09:50AM PT-20.4* PTT-28.6 INR(PT)-2.0*
[**2147-6-12**] 09:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2147-6-12**] 09:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2147-6-12**] 09:50AM URINE RBC-[**4-16**]* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
.
CXR - Increased right pleural effusion and partial collapse of
the
right upper lung.
.
EKG - NSR 70, nl axis, nl int, old TWI III, F; old J pointing V
[**3-18**]
.
[**6-16**] CT
CT CHEST: The heart, pericardium, and great vessels are stable.
There is a small amount of pericardial fluid. No definite
axillary, mediastinal, or hilar lymphadenopathy is seen. Again
seen is a moderate-to large-sized right pleural effusion. There
has been interval development of moderate amount of
high-attenuation fluid within the effusion consistent with
hemorrhage. Patchy consolidation of the right lung is stable.
Hazy patchy opacities are noted in the left lung field but no
frank consolidation is seen.
CT ABDOMEN: Within the limits of this non-contrast study, the
liver, gallbladder, pancreas, spleen, adrenal glands, kidneys,
stomach, and small bowel loops are within normal limits. There
is colonic diverticulosis most prominent at the hepatic flexure.
There is no free air or free fluid. No mesenteric or
retroperitoneal lymphadenopathy is identified. An IVC filter is
seen.
CT PELVIS: The bladder is unremarkable. The patient appears to
be status post prostatectomy. The rectum is unremarkable. There
is no free fluid and no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: A lytic area is again seen in the L5 vertebral
body but unchanged from prior examination. Several subacute or
chronic rib fractures are identified on the right.
IMPRESSION:
1. Interval development of a moderate amount of hemorrhage
within the right pleural effusion.
2. No acute intra-abdominal abnormalities identified.
.
[**6-14**] Stress MIBI
New moderate and fixed inferior myocardial wall perfusion
defect.
Mild inferior wall hypokinesis. Calculated LVEF 42%.
.
Brief Hospital Course:
A/P 74 yo M with lung cancer, DVT, CAD s/p MI presents with
chest pain shortness of breath.
.
# Chest Pain/Ischemia - Patient with history of CAD a/p MI. Now
with an episode of pain consistent with his anginal equivalent.
No changes on EKG but not in pain at time of EKG. Patient was
ruled out by enzymes. He also had a stress test which revealed
an irreversible deficit from his prior known IMI. Continued on
asa, bblocker, [**Last Name (un) **], statin, plavix. BP meds held while was
unstable. ASA, plavix held during hemothorax.
.
# CHF - patient does not seem volume overloaded at this time.
He has no JVD, no edema in legs (other than swelling from DVT).
Last Echo with EF 55%. Does have increased effusion although
loculated. Continued on lasix, bblocker [**Last Name (un) **]. BP meds held
while unstable.
.
# Afib - In sinus during admission. Patients anticoag held
during hemothorax.
.
# Shortness of Breath/loculated Effusion - patient with
increaing loculated pleural effusion. Has chronic shortness of
breath which has worsened over the past few days. No sign of
infeciton at this time. Had thoracentesis by interventional
pumonology on [**2147-6-14**] revealing almost 2 L of serous exudative
fluid. Patient had improved breathing. Cytology was negative.
However on [**6-15**] Hct dropped. CT revealed hemothorax. All
anticoagulation stopped despite the risk of DVT, afib. Risk
discussed with family. Thoracics consulted and chest tube
placed. Frank blood was taken out. Patient continued to bleed
in and around the tube. Patient sent to MICU for observation
after Hct continued to drop. Patient spontaneously stablized
and output of CT became more serous. Output resent for cytology
which was pending at time of discharge. When output became <100
cc the tube was removed. Patient follwed with serial CXR that
did not demonstrate reaccumulation. Hct also remained stable.
.
# DVT - patient therapeutic on heparin. Improving clots on LENI.
CTA neg for PE. Anticoagulaiton held during hemothorax.
Patient restarted on coumadin and will be discharged on 3mg
coumadin qday.
.
# Lung Cancer - patient currently with no evidence of disease.
s/p neoadjuvant chemo/XRT now s/p surgery. 1st cytology
negative. 2ng cytology pending. WIll follow up tih outpatient
oncologist.
.
Contacts - son [**Telephone/Fax (1) 40633**]
Medications on Admission:
Lipitor 80mg qday
Asa 81mg qday
bowel reg
percocet prn
plavix 75mg qday
losartan 25mg qday
coumadin 3mg qday
lasix 20mg qday
atenolol 25mg qday
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*60 Capsule(s)* Refills:*3*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
14. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
Disp:*QS 1 month ML(s)* Refills:*0*
15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Angina
Pleural Effusion
Secondary
HTN
Non small cell lung cancer
CAD
DVT
h/o afib
Discharge Condition:
stable, eating, on room air
Discharge Instructions:
Please take all medications as listed in the discharge
paperwork. Please make all appointments listed in the discharge
paperwork. If you have chest pain, shortness of breath,
abdominal pain, nausea or other concerning symptoms please [**Name6 (MD) 138**]
your MD or come to the emergency room.
.
I have changed some of your blood pressure meds. Your atenolol
has increased to 50mg a day. Your losartan has increased to 50
mg a day.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2147-7-20**] 9:00
You should call Dr. [**Last Name (STitle) **] to also see him again sooner [**8-21**]
days.
[**0-0-**].
Please see Dr. [**Last Name (STitle) 2903**] [**Telephone/Fax (1) 2936**] on monday and have your
coumadin level checked.
| [
"5119",
"2851",
"4280",
"42731",
"V5861",
"41401",
"V4582",
"412",
"4019"
] |
Admission Date: [**2128-10-25**] Discharge Date: [**2128-11-4**]
Date of Birth: [**2051-3-8**] Sex: M
Service: MEDICINE
Allergies:
Altace
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
fever/chills and coffee ground emesis
Major Surgical or Invasive Procedure:
Percutaneous cholangiography with drain (external)
History of Present Illness:
77yo Man with h/o metastatic Huerthle cell cancer of thyroid
with known mets to pancreas and lung including s/p biliary
stricture that was stented via ERCP 4/[**2127**]. Complicated by
bleeding from mass in ampulla of Vater requiring EGD
cauterization. He presents to the ER today with CC of fever and
chills for two days as well as 1 day of coffee ground emesis and
weakness. Per OMR notes he has had recent transfusion-dependent
anemia from suspected upper GI source - pt states last
transfused about 2w ago.
.
In the ER the pt was febrile to 102. Blood and urine cultlures
were sent and UA was negative. CXR revealed bilateral nodules
and masses and a possible retrocardiac opacity. He received
vanc/levo/flagyl and 3L crystalloid. NG lavage revealed coffee
ground return. He was guaiac positive. A R IJ line was placed
and was adjusted after CXR showed poor positioning. He received
3u prbc and protonix IV. GI was notified and will follow
patient.
.
ROS: denies sob/cp/nausea/vomiting, notes decreased appetite
marginally better with marinol. constipation with no BM x 4
days. No change in his baseline cough, no phlegm.
Past Medical History:
1) Hurthle cell thyroid ca
- metastatic to lungs, pancreatic head-dx by EUS bx in [**9-16**],
neck)
- s/p total thyroidectomy on [**2127-1-15**] (8x7x6 cm mass extending to
the capsule. Follicular carcinoma, Hurthle cell variant with
clear cell features. Vascular invasion)
- s/p RAI rx in [**2-15**]
- s/p resection of neck recurrence ([**3-18**])
- s/p distal CBD stent [**1-15**] stricture from pancreatic head ([**3-18**])
2) Type II Diabetes mellitus
3) malignant melanoma: resected approximately 10-12 years ago
4) BPH
5) s/p inguinal herniorrhaphy
6) s/p right total knee replacement 6 or 8 years ago
Social History:
The patient is a dairy farmer from upstate [**State 531**]. He chews
tobacco, but has never smoked and consumes alcohol limited to
one beer a day.
Family History:
colon cancer in two siblings
Physical Exam:
On admission:
temp 100.4, HR 103, BP 111/57, RR 19, O2 99% RA
Gen: NAD, talkative, more interested in changing subject than
giving history
HEENT: NCAT, conjunctivae pale, OP not injected, dentures in
place, PERRL, EOMI, R eye ptosis, NG tube in place
Neck: R IJ in place , no LAD, supple
Cor: s1s2, high pitched holosystolic murmur heard best at apex,
nonradiating
Pulm: trace wheezes bilaterally
Abd: soft, scaphoid, NTND, no hsm, +bs
Ext: no c/c/e, w/w/p
Skin: no rashes
Pertinent Results:
[**2128-11-2**] 09:05AM BLOOD WBC-8.0 RBC-4.15* Hgb-12.5* Hct-37.3*
MCV-90 MCH-30.2 MCHC-33.6 RDW-17.8* Plt Ct-120*
[**2128-10-28**] 05:30AM BLOOD WBC-7.2 RBC-2.72* Hgb-8.4* Hct-24.4*
MCV-90 MCH-31.1 MCHC-34.6 RDW-17.4* Plt Ct-83*#
[**2128-10-25**] 01:15AM BLOOD WBC-10.8# RBC-2.64* Hgb-8.5* Hct-23.7*
MCV-90 MCH-32.4*# MCHC-36.0* RDW-18.0* Plt Ct-99*
[**2128-10-27**] 06:00AM BLOOD Neuts-89.0* Lymphs-5.0* Monos-3.0 Eos-3.0
Baso-0
[**2128-11-2**] 06:15AM BLOOD PT-21.9* PTT-49.8* INR(PT)-2.1*
[**2128-10-25**] 01:15AM BLOOD PT-12.8 PTT-25.1 INR(PT)-1.1
[**2128-11-2**] 09:05AM BLOOD Glucose-102 UreaN-10 Creat-1.0 Na-138
K-3.9 Cl-100 HCO3-23 AnGap-19
[**2128-10-25**] 01:15AM BLOOD Glucose-190* UreaN-16 Creat-0.7 Na-135
K-3.8 Cl-93* HCO3-24 AnGap-22
[**2128-11-2**] 09:05AM BLOOD ALT-24 AST-36 AlkPhos-253* TotBili-3.1*
[**2128-10-25**] 01:15AM BLOOD ALT-365* AST-842* AlkPhos-1389*
Amylase-36 TotBili-3.7*
[**2128-10-31**] 06:10AM BLOOD Lipase-9
[**2128-10-25**] 01:15AM BLOOD Lipase-50
[**2128-11-2**] 09:05AM BLOOD Mg-1.5*
[**2128-11-1**] 05:50AM BLOOD Calcium-8.0* Mg-1.6
[**2128-10-31**] 06:10AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.0
Mg-1.5*
[**2128-10-25**] 01:15AM BLOOD Albumin-3.4 Calcium-9.5 Phos-3.5 Mg-1.7
[**2128-10-30**] 12:50PM BLOOD Hapto-199
[**2128-10-25**] 02:50AM BLOOD Cortsol-41.5*
[**2128-10-25**] 02:50AM BLOOD CRP-255.8*
[**2128-11-2**] 05:45AM BLOOD Lactate-4.0*
[**2128-10-25**] 01:17AM BLOOD Lactate-5.4*
[**2128-10-26**] 12:13AM BLOOD Lactate-1.8
[**2128-10-25**] 01:17AM BLOOD Hgb-8.8* calcHCT-26
[**2128-10-28**] 02:56AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.015
[**2128-10-28**] 02:56AM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-NEG Ketone-50 Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM
[**2128-10-28**] 02:56AM URINE RBC-292* WBC-42* Bacteri-NONE Yeast-NONE
Epi-<1
[**2128-10-27**] 05:47PM URINE WBC Clm-RARE
[**2128-11-2**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2128-10-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
{CLOSTRIDIUM DIFFICILE} INPATIENT
[**2128-10-28**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2128-10-28**] BILE GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY
{ENTEROCOCCUS SP., GRAM NEGATIVE ROD #1, GRAM NEGATIVE ROD #2,
GRAM POSITIVE BACTERIA} INPATIENT
[**2128-10-28**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2128-10-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2128-10-27**] URINE URINE CULTURE-FINAL INPATIENT
[**2128-10-25**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2128-10-25**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
{ENTEROCOCCUS SP.} INPATIENT
[**2128-10-25**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2128-10-25**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2128-10-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL EMERGENCY [**Hospital1 **]
[**2128-10-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {ESCHERICHIA
COLI}; ANAEROBIC BOTTLE-FINAL {ESCHERICHIA COLI} EMERGENCY [**Hospital1 **]
PORTABLE AP CHEST RADIOGRAPH: The study is limited secondary to
respiratory motion. Again seen are pleural opacities along the
right pleural surface, and nodular opacities within the right
upper lobe, corresponding to the patient's history of known
metastatic nodules. Additionally, there are bilateral pleural
effusions and an area of opacity at the right lung base which
may represent associated atelectasis and/or consolidation. The
cardiac and mediastinal contours are relatively stable. There is
an area of opacity in the left lung base, which may represent an
area of pleural thickening or atelectasis, though there is
limited evaluation secondary to motion. No definite pneumothorax
is seen. An internal external biliary stent is seen overlying
the right upper quadrant.
IMPRESSION:
1. Again seen are findings from the patient's known history of
metastatic malignancy, including areas of pleural opacity and
thickening within the right hemithorax.
2. Right pleural effusion and associated opacity which may
represent volume loss and/or consolidation.
3. Area of opacity in the left lower lobe which is not well
evaluated secondary to respiratory motion.
CT ABDOMEN:
Within the visualized lung bases, there are bilateral pleural
effusions with enhancing pleural metastases. Adjacent
compressive atelectasis is also evident, greater on the right.
Numerous parenchymal nodules are identified.
A percutaneous biliary drain is present and terminates within
the duodenum. Two plastic stents are identified within the
common bile duct and duodenum.
There is no significant intrahepatic biliary duct dilatation.
Multiple low attenuation lesions are identified scattered
throughout the liver. A small amount of perihepatic fluid is
identified, new from the previous examination.
The pancreatic head is enlarged, and a mass is identified within
the pancreatic tail. There is soft tissue within the porta
hepatis.
A 1 cm right adrenal nodule is again identified. The left
adrenal gland appears unremarkable. The kidneys show cysts, but
are otherwise unremarkable. There is no evidence of
hydronephrosis.
Note is made of small retroperitoneal lymph nodes. Free fluid is
identified within the pelvis, which is of increased attenuation,
and likely hemorrhagic. There is no evidence of colonic
obstruction.
There are multiple osseous metastases noted within the left
femoral head, right iliac crest, left L3 vertebral body. Note is
made of gas within the urinary bladder likely incident to
instrumentation.
IMPRESSION:
1. Other than a small increase in perihepatic fluid, there has
been no appreciable change compared to the [**2128-10-29**]
examination. The high- attenuation fluid within the pelvis
(likely hemorrhagic) has not appreciably increased in size.
2. Widespread metastatic disease.
CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases show interval
progression of both parenchymal and pleural-based nodules,
consistent with metastatic disease. There are bilateral
low-density pleural effusions with adjacent areas of opacity
most likely to represent atelectasis. Numerous metastases in the
liver were much better demonstrated on the recent ultrasound
from [**2128-10-25**].
There is a new percutaneous biliary drain extending into the
right lobe of the liver and terminating in the duodenum. There
is interval improvement in the degree of intrahepatic biliary
ductal dilatation. There is again pneumobilia within the left
lobe. Ill-defined abnormal soft tissue is present in the hepatic
hilum.
A large mass in the head of the pancreas is perhaps minimally
increased in size, now measuring 6.2 x 4.8 cm in axial
dimensions, compared to 5.9 x 4.8 cm previously. A further mid
body metastasis which is new is seen also. A stent in the distal
common bile duct is in an unchanged position. There is a new
stent in the duodenum since the prior study with partial
opacification by contrast in its proximal course, although not
distally. However, contrast passes freely and is present in the
colon. The stomach is not dilated.
There is a new small right adrenal nodule of 10 mm in diameter
raising concern for metastatic disease. Otherwise, the adrenal
glands are unremarkable. The spleen is within normal limits. A
left-sided renal cyst is unchanged.A new left sided
retroperitoneal; deposit is seen-represewnting progressive mets.
The small and large bowel are within normal limits.
There is a small rim of high-density ascites about the liver
anteriorly. There are multiple small retroperitoneal lymph
nodes, not meeting size criteria for pathological enlargement.
CT OF THE PELVIS WITH IV CONTRAST: There is a small-to-moderate
amount of high- density ascites, up to 40 Hounsfield units in
the lower pelvis, most consistent with recent hemorrhage,
probably related to recent percutaneous drain placement.
The distal ureters and bladder are within normal limits,
although air is noted in the bladder. This appearance could be
seen in recent catheterization. There is sigmoid diverticulosis,
without diverticulitis. Contrast has passed to the rectum. There
is no pelvic or inguinal lymphadenopathy. Subcutaneous tissues
show edema.
BONE WINDOWS: There is a new lytic lesion in the left femoral
head. In fact, there are increased lucencies in both femoral
heads. There is also a new soft tissue mass along the right
iliac crest with bony destruction, measuring 2.8 x 2.0 cm in
axial dimensions, new since the prior study. There is also a new
soft tissue mass with bony destruction along the posterior
aspect of the left L3 vertebral body, also new since the prior
study. It is about 1 cm in diameter and extends slightly into
the spinal canal.
IMPRESSION:
1. Status post placement of percutaneous biliary catheter and
duodenal stent.
2. Hemoperitoneum in the pelvis, which may relate to recent
instrumentation, as well as small amount of hemoperitoneum
adjacent to liver.
3. Progressive metastatic disease, including new osseous
metastases, progressive lung nodules, and perhaps slightly
increased size of pancreatic mass. Possibly because of the phase
of contrast administration, the liver metastases are not as
conspicuous as on the recent ultrasound.
4. Bone metastases include a small mass in L3 with slight
posterior extension into the spinal canal. It is doubtful that
this lesion produces mass effect on the spinal cord at present,
although posterior extension into the canal may become a
consideration later if it were to become larger.
5. No evidence of obstruction, with free distal passage of
contrast.
Approved: SUN [**2128-10-31**] 9:59 AM
PTC:
IMPRESSION:
1. Cholangiogram demonstrating intrahepatic biliary ductal
dilation as well as dilation of the common bile duct; contrast
extended into the duodenum. Sludge and debris were seen within
the common bile duct. A common bile duct as well as a duodenal
stent were in situ.
2. Successful placement of a 10-French internal-external biliary
drain from the right approach. The catheter was connected to a
bag for gravity drainage. Approximately 30 mL of dark brown bile
and sanguinous material were extracted during the procedure.
ERCP
ERCP: Three fluoroscopic images were obtained in the ERCP suite
without the presence of a radiologist. Metallic stent is seen in
the region of the CBD. Duodenoscope could not be negotiated past
a reported extrinsic stenosis of the post-bulbar duodenum.
Subsequent image shows deployment of an incompletely expanded
metallic stent across the stenosis.
For further details, please see the ERCP report of the same day.
ECHO:
Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color
Doppler. Left ventricular wall thickness, cavity size, and
systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal.
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I
(mild) LV diastolic dysfunction. Right ventricular chamber size
and free wall
motion are normal. The aortic root is moderately dilated. The
ascending aorta
is mildly dilated. There are three aortic valve leaflets. The
aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic
pressure is normal. There is no pericardial effusion.
US:
CONCLUSION: Large pancreatic/portahepatus mass, which has
increased in size compared to the CT of [**2128-5-25**]. More
significantly, there has been blossoming of diffuse hepatic
metastatic disease with very extensive progression since the CT
scan.
There is also mild-to-moderate dilatation of the common hepatic
and intrahepatic bile ducts, despite the presence of biliary
stent.
Brief Hospital Course:
# Acute blood loss anemia: from GI bleeding - coffee ground
emesis/[**Last Name (un) 15557**]: with most likely source is bowel invasion of
tumor given pt's history. Was transfused as needed and also
given platelet transfusion. Treated with PPI.
The patient also had hemoperitoneum which could be from tumor
bleeding which was slightly increased on a subsequent CT. He was
managed conservatively with general surgery, GI and ERCP teams
followed.
# acute cholangitis - due to VRE - on culture from the bile. PTC
done by IR with external drain in place. LFT improved.
# C diff colitis - during the course in the hospital, pt
developed C diff diarrhea that was treated with flagyl.
# Pulmonay metastasis - caused intermittent hemoptysis.
# thrombocytopenia: pt is below baseline. Was possibly due to
bone marrow invasion by tumor. Required transfusion.
also has DM, hypothyroidism - medically managed.
During the ast few days, the patient developed severe
hypotension, tachycardia and severe abdminal pain. End of life
issues were discussed by Dr [**Last Name (STitle) **], [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] (palliative
care team) and me with the family and patient and given the very
poor long term prognosis of the patient, comfort measures were
maintained. The patient died on [**2128-11-4**] at 11-15 am. Family was
present at bedside and did not request an autopsy when offered.
Medications on Admission:
Synthroid 200 mcg po daily, metformin 500 mg po
daily, doxazosin .4 mg po daily, ferrous gluconate 324 mg po
daily, and Prilosec 1 tab po daily, ibuprofen 600mg po tid prn
arthritis pain. baby asa [**Name2 (NI) 24018**]. ( per pt never takes his
albuterol 1-2 puffs q6-8 prn. benzonatate capsules tid prn,
flovent 2 sprays per nostril [**Name2 (NI) 24018**])
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to Metastatic thyroid cancer
C diff colitis
Acute cholangitis
Intestinal obstruction
Hypotension
Discharge Condition:
Died from metastatic thyroid cancer
Discharge Instructions:
Died from metastatic thyroid cancer
Followup Instructions:
Died from metastatic thyroid cancer
| [
"2851",
"5070",
"25000",
"99592"
] |
Admission Date: [**2151-8-28**] Discharge Date: [**2151-9-1**]
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Intracranial hemorrhage
Major Surgical or Invasive Procedure:
n
History of Present Illness:
This is an 83year old man with a past medical history
significant for dementia, dm, htn, and TIAs who presents today
with confusion and vomiting. Apparently he was "acting confused
while driving" and was stopped by the police and taken to the
station and the car was towed. According to the daughter who
picked him up from the station, he was "confused," not talking
much and seemed lethargic when they brought him home. While at
home, he complained of neck pain (though this is not unusual for
him since an outbreak of zoster in that area 2yrs ago) but
continued to be "confused." His wife states (per [**Name (NI) **] physicians)
that at home, he went to the bathroom and she found him sitting
on the toilet vomiting. He was taken to an OSH where head CT
showed right parietal occipital intraparenchymal hemorrhage. He
was also noted to have ST depressions in V3-V6 and a troponin of
0.02 at the OSH. He was started on a nipride gtt for the BP at
the OSH and intubated for unclear reasons - presumably for
airway
protection. On arrival to [**Hospital1 18**], he was changed to labetolol gtt
because ruling in for MI. Cards was consulted and agreed he is
having NSTEMI, troponin currently 0.11. Heparin and asa,
however,
are contraindicated at this time.
Past Medical History:
1.Alzheimers
2.TIAs
3.htn
4.DM
Social History:
Lives at home with his wife. Mostly independent of ADLs, though
recently has been more dependent on wife and family.
Physical Exam:
Physical Exam: Tafebrile ; BP 153/70 ; HR 76 ; RR 8; O2
sat100% on vent
gen - intubated. appears cachectic.
heent - mmm. o/p clear. no scleral icterus or injection.
neck - supple. no lad or carotid bruits appreciated.
lungs - cta bilaterally
heart - rrr, nl s1/s2, +sm at USB
abd - soft, nt/nd, nabs. ?mass in LUQ.
ext - warm, no edema.
neurologic:
MS: Intubated and sedated. Not opening eyes spontaneously or to
noxious stimuli. No spontaneous mvmts. Not following commands.
CN: pupils 2.0, do not seem reactive. Fundi very difficult to
visualize. No Doll's eyes. +corneals. occasional coughing.
Motor: localizes to pain in all extremities. no spontaneous
movement. Lifts right arm and right leg off bed.
Reflexes: reflexes diminished on the left side as compared to
the
right throughout. toes upgoing bilaterally.
Sensation: localizes to pain in all extremities
Coordination:
cannot test
Gait: cannot test
Pertinent Results:
[**2151-9-1**] 04:40AM BLOOD WBC-15.2* RBC-4.04* Hgb-12.4* Hct-38.2*
MCV-95 MCH-30.7 MCHC-32.4 RDW-13.0
[**2151-8-31**] 03:12AM BLOOD Plt Ct-229
[**2151-8-28**] 02:55AM BLOOD Fibrino-294
[**2151-9-1**] 04:40AM BLOOD Glucose-85 UreaN-54* Creat-1.2 Na-144
K-3.9 Cl-112* HCO3-22 AnGap-14
[**2151-8-28**] 02:55AM BLOOD cTropnT-0.11*
[**2151-8-28**] 02:09PM BLOOD CK-MB-23* MB Indx-10.2* cTropnT-2.46*
[**2151-8-28**] 10:50PM BLOOD CK-MB-10 MB Indx-6.8* cTropnT-1.38*
[**2151-8-29**] 06:32AM BLOOD CK-MB-9 cTropnT-1.60*
[**2151-9-1**] 04:40AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.2
[**2151-8-30**] 03:22AM BLOOD Ammonia-22
[**2151-8-28**] 06:04AM BLOOD Phenyto-11.9
[**2151-8-29**] 05:15AM BLOOD Phenyto-4.9*
[**2151-8-30**] 03:22AM BLOOD Phenyto-13.9
Brief Hospital Course:
Mr [**Known lastname 20296**] was admitted to the neurology ICU. Etiology of this
bleed may be amyloid angiopathy, HTN, underlying mass lesion,
aneurysm or AVM. His blood pressure was initially controlled
with labetolol drip until the patient developed bradycardia with
junctional escape beats. He was found to have a NSTEMI on
admission. He was seen by cardiology who recommended low dose
beta blocker 2.5mg q 6 h as tolerated for cardiac protection.
All sedation was held and the patient remained minimally
responsive. Repeat head CT was done on [**8-29**] which showed:
stable extent of right parietal interparenchymal hemorrhage, but
new hypodense regions in bilateral cerebellar hemispheres as
well as within the right occipital lobe, likely relating to
evolution of infarction. His mental status remained poor and an
EEG was obtained to r/o seizure. EEG showed a diffuse
encephalopathy without epileptiform activity.
His course was further complicated by development of pneumonia
with MSSA positive sputum. He was treated with antibiotics.
Due to his continued poor mental status a repeat head CT was
obtained on [**8-31**] which revealed: Largely stable appearance of
right parietal intraparenchymal hemorrhage as well as multiple
infarcts of the cerebellum, right occipital lobe, and pons,
suggestive of an embolic mechanism to the posterior circulation.
Significant interval increase in mass effect and swelling of the
posterior fossa causing compression of the brain stem and fourth
ventricles as well as mild increase in ventricle size. Results
were discussed with the family and neurosurgery. The family
declined placement of vent drain or other surgical measures
since a meaningful neurologic recovery was not likely. Based on
the patient's known wishes, the family made him CMO after
lengthy discussions with SICU and neurology teams. He expired
on [**9-1**]
Medications on Admission:
metformin, digoxin, sertraline, hctz, glyburide,
lisinopril, felodipine, gabapentin
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
intracerebral hemorrhage
stroke
Discharge Condition:
pt expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
| [
"41071",
"5849",
"5070",
"4280"
] |
Admission Date: [**2149-11-20**] Discharge Date: [**2149-11-24**]
Service: MED
HISTORY OF PRESENT ILLNESS: An 82-year-old male with a past
medial history significant for CAD status post 4-vessel CABG
in [**2147-8-25**], question of sick-sinus syndrome, history
of PAF, not anticoagulated, question of renal insufficiency,
who presented to the ED with 5 to 6 melenic stools. The
patient was in his usual state of health until 6 days ago
when he developed diarrhea.
He underwent colonoscopy on [**11-10**] days prior to admission
as part of a work up for diarrhea. Findings included a single
sessile 2.5 cm polyp, 2 small 2 to 3 mm sessile benign
appearing polyps and several small mild diverticula. He had
been off aspirin therapy for colonoscopy and just restarted
aspirin 3 days prior to admission. Polypectomy was performed
and the polyps were completely removed. Path showed no
invasive carcinoma and the procedure was performed without
complication. Diarrhea resolved several days prior to
admission which the patient attributes to starting taking
acidophilus.
On the morning of admission the patient was in his usual
state of health and had an outpatient abdominal CT scan at
[**Hospital3 **] Hospital to evaluate "kidney cysts" per his
reports. He reports that after drinking PO contrast he had an
episode of bright red blood noted on the toilet tissue
followed by 6 melenic bowel movements. He denies recent
heartburn, abdominal pain, rectal pain, nausea, vomiting,
chest pain, shortness of breath. No recent NSAID use. He
reports brief episode of lightheadedness upon standing while
in the emergency room.
In the ED he had a temperature of 96.5, heart rate of 83,
blood pressure 128/58, respiratory rate of 18 with an oxygen
saturation of 100% on room air. Orthostatics in the ER showed
lying heart rate of 56, BP of 119/60, and standing heart rate
of 76 and blood pressure of 56/36 with lightheadedness on
standing, however notably he later was able to stand and walk
to te bathroom without any lightheadedness. He received
Protonix 40 mg IV x1, 1 liter of normal saline x1. NG lavage
was performed yielding less than 10 cc of bright red blood.
The patient refused RBC scan. While in the ED he reported 5
to 6 episodes of black stools with an episode of bright red
blood per rectum in the ER of 200 cc. Given the question of
GI bleed and severe orthostasis, he was admitted to the MICU.
GI was consulted and recommended bleeding scan if bleeding
continues.
PAST MEDICAL HISTORY:
1. History of gastritis, colitis diagnosed by EGD and
colonoscopy 20 years ago in [**Country 532**] but no recent
heartburn.
2. History of syncope. Negative EKG and Holter in [**2147**].
Negative Holter in [**2149**]. Thought to be vagal in origin.
3. History of paroxysmal atrial fibrillation postop '[**47**],
again [**2148-9-25**]. Originally treated with
amiodarone, discharged from [**Hospital1 18**] in [**2148-9-25**] on
Coumadin. Echo [**2149-9-25**] showed no PAF or flutter
but did reveal underlying sinus bradycardia with
intermittent PR prolongation, left atrial abnormality, no
significant AV block or prolonged pauses, moderate atrial
ectopy, low grade ventricular ectopy.
4. Question of sick sinus syndrome. Autonomic testing [**6-9**], [**2149**] with evidence of parasympathetic nervous system
dysfunction on Valsalva and heart rate variability
testing. Possible junctional tachybradycardia, tachy-
brady sick sinus. Normal tilt table testing, so not
indicative of orthostatic hypotension.
5. CAD status post silent MI. CABG x4 in [**2147-8-25**]. No
complications. Percutaneous PTCA. Echo [**2147**], EF of 50 to
55%. Mild mitral regurgitation.
6. Cervical spondylosis. MR cervical spine [**2149-5-25**].
7. Liver hemangioma, ultrasound and CT [**2148-2-25**].
8. Chronic renal insufficiency. Baseline creatinine 1.2 to
1.5. Small left kidney. History of nephrolithiasis since
[**2130**], last symptomatic stone [**2132**].
9. Hyperlipidemia.
10. Glaucoma. Left cataract surgery.
11. MRI showing lacunar infarcts.
12. Essential tremor.
13. Prostate adenoma resection.
14. Removal of toes on left foot from frost bite.
HOME MEDICATIONS:
1. Neurontin 300 mg PO t.i.d.
2. Aspirin 81 mg PO once daily.
3. Lipitor 10 mg PO once daily.
4. Atenolol 100 mg PO once daily.
5. Metamucil QID.
6. Xalatan eye drops.
7. Cosopt eye drops.
ALLERGIES: Novocain and sulfa causes rash.
SOCIAL HISTORY: The patient denies tobacco. He drinks
socially. Immigrant from [**Country 532**]. Married and lives with wife
in [**Name (NI) 745**]. Formally a physics researcher.
FAMILY HISTORY: Mother died of coronary artery disease,
father of [**Name2 (NI) 51531**], sister has asthma.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 97.5,
heart rate 67, blood pressure 124/71, respiratory rate 15,
97% on room air. GENERAL: Awake, alert, and in no apparent
distress lying comfortably in bed. Does not appear pale.
HEENT: Normocephalic, atraumatic. Oropharynx clear. Mucous
membranes moist. Right eye surgical. Neck supple. No masses.
No thyromegaly. JVP about 5 cm. CV: Regular and normal S1 and
S2; [**3-2**] holosystolic murmur at apex. PULMONARY: Clear to
auscultation bilaterally. BACK: No CVA tenderness. ABDOMEN:
Hyperactive bowel sounds. Nontender. Nondistended. Liver span
5 cm in the mid clavicular line. EXTREMITIES: Warm and well
perfused. No clubbing, cyanosis or edema. Radial pulse 1+, DP
1+. SKIN: Normal turgor. No masses. NEUROLOGIC: Alert and
oriented x3, nonfocal.
LABORATORY DATA: Notable for hematocrit of initially 48 and
then on recheck 36 dropping to 33 in the emergency room. INR
1.4. Chemistry is notable for creatinine of 1.0. Iron indices
show iron level of 141, ferritin of 41, TIBC of 244.
ASSESSMENT: An 82-year-old male with a past medial history
significant for CAD status post 4-vessel CABG, question of
sick-sinus syndrome, history of atrial fibrillation, not
anticoagulated, syncope, cervical spondylosis, liver
hemangioma, and chronic renal insufficiency who presents with
lower GI bleed and orthostasis.
PROBLEM: GI bleed. The patient was initially admitted to the
ICU. Two large bore IVs were placed. The patient was placed
on nothing by mouth. Started on Protonix 40 mg IV b.i.d. His
aspirin and Lopressor were held. Serial hematocrits were
obtained. Vitamin K was given to reverse his slightly
elevated INR. The patient was evaluated by gastroenterology
and he had a colonoscopy. The patient had BiCAP of the
polypectomy site. His hematocrit was stable after his
colonoscopy. Aspirin was held for 14 days post his
colonoscopy. He was called back to the floor. His hematocrit
remained stable 2 days after his procedure.
CONDITION ON DISCHARGE: Stable. Hematocrit 34.
DISCHARGE MEDICATIONS: The patient was discharged on:
1. Lipitor 10 mg PO once daily.
2. His eye drops.
3. His Neurontin 300 mg PO t.i.d.
4. Protonix 40 mg PO once daily.
5. Aspirin was to be held for 14 days post discharge.
PLAN: The patient will follow up with his primary care
physician [**Name Initial (PRE) 176**] 1 week.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 6648**]
Dictated By:[**Last Name (NamePattern1) 19183**]
MEDQUIST36
D: [**2150-2-19**] 09:49:32
T: [**2150-2-19**] 10:41:30
Job#: [**Job Number 51532**]
| [
"2851",
"42731",
"5859",
"V4581",
"2724"
] |
Admission Date: [**2127-4-16**] Discharge Date: [**2127-4-18**]
Date of Birth: [**2043-12-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Digoxin / belladonna alkaloids / Aspirin /
Doxycycline / Shellfish / Pork/Porcine Product Derivatives /
latex gloves / Iodine-Iodine Containing / Levofloxacin
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
83 yo F with CAD, CHF (EF of 40% in [**4-/2126**]) presenting with
chest pain. Patient has had three episodes of chest pressure
over the past two days. First episode was on Sunday night, where
she experienced substernal chest pressure with radiation to her
left jaw associated with some nausea. She thought it might be
indigestion and ate some food and felt better. She had another
similar episode the next day but does not remember when. Her
most concerning episode was at 10 pm the night of admission
where she experienced sudden onset [**11-17**] substernal chest
pressure at rest that radiated to her left jaw and lasted
slightly longer than her previous episodes. All episodes were
non-exertional in nature and she was sitting in a lounge chair
at those times. This last episode was associated with LH and a
feeling of pre-syncope although she did not pass out. No
palpitations. Also with some SOB. She has no anginal equivalent
and states she had a 'silent MI' in the past. She has had this
chest pain about three years ago and states she was hospitalized
at [**Hospital1 112**] at the time and had a negative stress test. Last cardiac
catherization was in the [**2096**] but she states she is allergic to
the contrast and cannot take aspirin due to an allergy as a
child (which is unknown) Given her symptoms, she presented to
the ED for further evaluation.
.
In ED VS were 98 76 134/85 20 100% on RA. Labs sig for WBC of
3.4, BNP of 1833, and Trop-T of < 0.01. U/A with moderate
leukocytes and +WBCs. CXR shows no focal pneumonia or effusions,
thoracic vertebral compression fracture (likely from fall
suffered in [**7-/2126**] and known to PCP). EKG with ST depressions in
V5 and V6 and TWI in same leads. Pt received Plavix 75 mg PO x1,
Nitro 0.3 mg PO x1, Morphine 2 mg IV x1 (had no reaction to it
although listed as an allergy), and Zofran, and Ciprofloxacin
500 mg PO x1 for positive UTI. Pt wwith 2/10 chest pain so
started on heparin gtt. Guiac negative. VS on transfer: 71
121/57 20 98% on 2 L NC.
.
On the floor, the patient endorses [**2126-2-9**] chest pressure but
states it is much improved compared when she first presented.
She is very tired and would like to sleep.
Past Medical History:
# Systolic CHF (EF 40% in [**4-/2126**])
# CAD (evidence of inferior posterior infarct on [**4-/2126**] echo)
# Asthma/COPD mild in nature on PFT in [**2119**]
# h/o Falls
# IBS
# ventricular tachycardia - ?diagnosis
# atrial fibrillation - ?diagnosis
# hypercholesterolemia
# Diverticulitis
# GERD/Dyspepsia
# Back and pelvic frxr [**2119**], no surgery
# Multiple fractures including: wrist, elbow shoulder and b/l
hip fracture
# Rt shoulder AVN
# s/p hip repairs b/l with revision on the left hip
# Chronic pain
# degenerative osteoarthritis
# depression
# left breast cancer in [**2090**], s/p mastectomy
# s/p hysterectomy
# s/p L5/S1 laminectomy in [**2100**]
# s/p Gallbladder surgery in [**2111**]
# Meniere's disease since [**2074**]
# Migraines since [**2062**]
Social History:
Worked as a medical archiver and is now retired and on
disability. Lives alone, but has aides and VNA services. 3
children.
- Tobacco: Pt reports recently quitting in [**4-8**]/2ppd x many
years
- Alcohol: none
- Illicits: none
Family History:
The patient has no siblings, 2 sons, one daughter.
- Father: Died of MI [**68**]
- Mother: Died age 60's of bladder cancer, h/o HTN, asthma
- Son: MI, hypercholesterolemia
- Son: [**Name (NI) **] medical issues
- Daughter: No medical issues
Physical Exam:
ADMISSION EXAM
GA: elderly F AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. pulsatile mass
on L neck with no bruit auscultated
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, distended, +BS. no pitting edema. no g/rt. neg HSM.
neg [**Doctor Last Name 515**] sign. ?positive fluid shift.
Extremities: wwp, no edema noted. DPs, PTs 2+.
Neuro/Psych: extremely anxious.
.
DISCHARGE EXAM
VS: T97.4 P:90 86-92 BP153/83 (122-153/61-83) rr18 saO296%2LNC
GA: Elderly female appearing annoyed, in NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. strong carotid
pulse BL with slight bulge over left carotid.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: Faint BL rales rales mid way up, no wheezes no ronchi.
Equal air entry BL.
Abd: soft, distended, BS normoactive, no rebound no guarding.
neg [**Doctor Last Name 515**] sign.
Extremities: Right radial cath site with 5cm dia ecchymosis no
cyanosis, warm, well perfused. Right #3 digit TTP and with small
ecchymosis. wwp, no edema noted. Radial pulse, DPs, PTs 2+.
Neuro/Psych: annoyed. AAOx3
Pertinent Results:
ADMISSION LABS
[**2127-4-15**] 11:30PM BLOOD WBC-3.4* RBC-4.55 Hgb-14.4 Hct-42.5
MCV-93 MCH-31.6 MCHC-33.8 RDW-12.7 Plt Ct-232
[**2127-4-16**] 05:34AM BLOOD WBC-4.0 RBC-4.32 Hgb-13.7 Hct-40.5 MCV-94
MCH-31.6 MCHC-33.8 RDW-12.8 Plt Ct-211
[**2127-4-17**] 05:34AM BLOOD WBC-4.1 RBC-3.75* Hgb-12.2 Hct-34.7*
MCV-93 MCH-32.5* MCHC-35.1* RDW-12.7 Plt Ct-204
[**2127-4-15**] 11:30PM BLOOD Glucose-121* UreaN-17 Creat-0.8 Na-138
K-4.1 Cl-98 HCO3-30 AnGap-14
[**2127-4-16**] 05:34AM BLOOD Glucose-100 UreaN-15 Creat-0.7 Na-138
K-3.6 Cl-102 HCO3-28 AnGap-12
[**2127-4-17**] 05:34AM BLOOD Glucose-201* UreaN-18 Creat-0.8 Na-139
K-4.0 Cl-106 HCO3-21* AnGap-16
.
Cardiac enzymes
.
[**2127-4-16**] 01:41PM BLOOD CK-MB-3 cTropnT-<0.01
[**2127-4-16**] 08:35PM BLOOD CK-MB-3 cTropnT-<0.01
[**2127-4-17**] 05:34AM BLOOD CK-MB-3 cTropnT-<0.01
[**2127-4-15**] 11:30PM BLOOD proBNP-1833*
.
DISCHARGE LABS
[**2127-4-18**] 07:45AM BLOOD WBC-5.8 RBC-4.19* Hgb-13.3 Hct-37.4
MCV-89 MCH-31.7 MCHC-35.5* RDW-12.7 Plt Ct-224
[**2127-4-18**] 07:45AM BLOOD Glucose-132* UreaN-20 Creat-0.8 Na-145
K-2.7* Cl-107 HCO3-27 AnGap-14
[**2127-4-18**] 07:45AM BLOOD ALT-16 AST-26 AlkPhos-64 TotBili-0.4
.
IMAGES/REPORTS
.......................
CXR [**2127-4-16**]
UPRIGHT PA AND LATERAL CHEST RADIOGRAPHS:
Mild cardiomegaly is unchanged. The hilar and mediastinal
contours are within normal limits and stable. Linear left
retrocardiac densities are most compatible with atelectasis.
There is no focal consolidation, pleural
effusion, or pneumothorax. An anterior wedge compression defect
of the lower thoracic vertebral body is new since the [**2126-5-13**] examination.
.
IMPRESSION:
1. No pneumonia.
2. Anterior wedge compression defect of a lower thoracic
vertebral body, new since [**2126-5-13**].
....................................
Plain film of right hand [**2127-4-18**]
ADDITIONAL INFORMATION: New bruising and pain over the right
middle finger.
.
FINDINGS: Unremarkable soft tissues. Osteopenia which limits the
evaluation of subtle fractures. No fracture is identified. No
dislocations. No degenerative or erosive changes.
.
IMPRESSION: No fracture.
.......................................
ECHO [**2127-4-16**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal
hypokinesis of the basal to mid inferior and inferolateral
walls. The remaining segments contract normally (LVEF = 40-45
%). Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
.
IMPRESSION: Regional left ventricular systolic dysfunction.
Mildly depressed ejection fraction. Normal right ventricular
systolic function.
.
Compared with the prior study (images reviewed) of [**2126-4-19**],
there is slightly less mitral regurgitation.
.
................................................
Cardiac Catheterization [**2127-4-17**]
Coronary angiography: left dominant
LMCA: No angiographically-apparent CAD.
LAD: Mild luminal irregularities
LCX: Total occlusion mid vessel after large ectatic segment.
Left to left collaterals fill the distal CX and OM2 and LPDA.
Occlusion appears to be chronic.
RCA: nondominant and small
Assessment & Recommendations
1. One vessel coronary artery disease.
2. Medical management of CAD
Brief Hospital Course:
Mrs. [**Known lastname 18806**] is an 83 year-old woman with CAD and systolic CHF
who presented with chest pain concerning for acute coronary
syndrome, negative biomarkers, nonspecific ST changes on EKG,
she underwent cardiac catheterization which showed single vessel
disease with no intervention performed, she was medically
managed.
.
ACTIVE ISSUES
=============
# Chest pain: Mrs. [**Known lastname 18806**]' chest pain was concerning for
unstable angina given previous history of likely CAD given the
quality of chest pain, history of abnormal TTE, and increasing
length duration and associated symptoms. She had multiple CAD
risk factors including family history, current smoker, and
hyperlipidemia. Her TIMI score was 4 and active CP prior to
floor transfer necessitated heparin gtt. Her EKG revealed <1mm
ST depressions in V5 and V6 which are nonspecific and possibly
related to left ventricular hypertrophy however she did not meet
voltage criteria for LVH. She was placed on heparin and
nitroglycerin drips and taken to the CCU for aspirin
desensitization (see below). She was loaded with plavix and
continued on metoprolol. Given history of contrast allergy, she
was premedicated prior to cardiac catheterization (performed
without allergic response) which showed left circumflex total
occlusion mid vessel after large ectatic segment, no
intervention was performed. Metoprolol was continued, she was
started on aspirin 81mg, isosorbide mononitrate 30mg and
pravastatin (baseline LFTs were within normal limits).
Gemfibrozil was discontinued. She was discharged with cardiology
and PCP follow up.
.
# Chronic congestive heart failure with systolic dysfunction:
LVEF 40% in 3/[**2126**]. Repeat ECHO showed LVEF 40-45%. She appeared
euvolemic and not to be in acute exacerbation.
.
# Aspirin Desensitization: Patient reported unknown allergy to
aspirin from youth. She was transferred to the CCU for aspirin
desensitization and tolerated the protocol without allergic
reaction. She was discharged on 81mg of aspirin and given
instructions not to miss a dose as this can increase her risk of
allergic reaction.
.
# Code Purple: On the night of HD2, patient became acutely
disoriented and combative, code purple was called and she was
placed in restraints and given haldol. The following morning she
had returned to baseline mental status. She complained of right
#3 finer pain, xrays of the finger showed no evidence of
fracture. Acute mental status change is attributed to baseline
dementia and sedatives given during cardiac cath.
.
# Thoracic compression fracture: Chest xray noted an incidental
thoacic vertebral compression fracture. She had no signs of
neurologic compromise and complained of chronic low back pain.
Discussed with her primary care phsyician who will monitor her
for worsening symptoms and osteoporosis.
.
# Depression: Patient was emotionally labile and fractious
throughout hospital stay. On the day of admission, she stated
that she had considered staying home with chest pain untreated
so that he life would end. Denied specific plan for suicide,
denied active suicidality in hospital stay. Continued paroxetine
and clonazepam.
.
INACTIVE ISSUES
=============
# Rhythm: Reported questionable history of atrial fibrillation,
not on coumadin. EKG showed sinus rhythm, atrial fibrillation
was not observed on tele.
.
# Positive U/A: Patient with asymptomatic bacteriuria, urine
culture was negative and, aside from one dose of ciprofloxacin,
no further treatment was warranted.
.
# Asthma/COPD: continued home inhalers.
.
# Hypercholesterolemia: discontinued gemfibrozil, started
pravastatin.
# GERD/Dyspepsia: continued PPI.
.
# Chronic low back pain: continued percocet
.
# IBS, constipation predominant: continued home bowel regimen
.
TRANSITION OF CARE ISSUES
=========================
# Home safety: daughter reported history of falls, she was seen
by PT and cleared for home with PT. She was sent with home
safety evaluation and VNA.
.
# Pravastatin started, will need to have lipids and LFTS checked
in [**4-13**] months
.
# Could consider the addition of an ACE/[**Last Name (un) **] if tolerated by
blood pressure, none started in this hospitalization as imdur
was added and we did not want to start two blood pressure
medications simultaneously.
.
# Compression fracture found incidentally will need to be
monitored for worsening symptoms.
.
# Mental status: she may benefit from reduction of
benzodiazepines and opoids from her regimen in addition to
counseling or antidepressant modifications.
.
#Code: FULL
.
#Communication: DTR [**Name (NI) **] [**Name (NI) **] HCP [**Telephone/Fax (1) 97586**]
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**2-9**] HFA(s)
inhaled every six (6) hours
BREAST PROSTHESIS AND 3 BRAS - - Use as directed Dx: 174.9
Breast Cancer
CLONAZEPAM - 0.5 mg Tablet - 2 (Two) Tablet(s) by mouth QHS, and
1 in AM
GEMFIBROZIL [LOPID] - 600 mg Tablet - 1 Tablet(s) by mouth twice
a day
LACTULOSE [GENERLAC] - 10 gram/15 mL Solution - 30 ml(s) by
mouth one to three times per day as needed for constipation.
MASTECTOMY BRA - - DX: BREAST CANCER
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
NEBULIZER & COMPRESSOR - Device - once a day
OXYCODONE - 5 mg Tablet - 1 (One) Tablet(s) by mouth three times
a day as needed for pain To be filled on [**2127-2-28**]
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 (One)
Tablet(s) by mouth once a day in morning before eating
PAROXETINE HCL - 20 mg Tablet - 1 (One) Tablet(s) by mouth once
a day
PROSTHESIS - - DX: BREAST CANCER
Medications - OTC
ACETAMINOPHEN - 325 mg Tablet - 2 (Two) Tablet(s) by mouth three
times a day
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 (One)
Capsule(s) by mouth once a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
LACTASE [LACTAID] - 3,000 unit Tablet, Chewable - 2 Tablet(s) by
mouth once a day before eating dairy
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] - 400 mg/5 mL Suspension
- 1 tbls by mouth once a day as needed for constipation
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - 1 (One)
Tablet(s) by mouth once a day
PSYLLIUM [METAMUCIL SMOOTH TEXTURE S/F] - Powder - 1 (One) tsp
by mouth once a day as needed for constipation
SENNOSIDES [SENOKOT] - 8.6 mg Tablet - 1 (One) Tablet(s) by
mouth at bedtime
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Once in the
Morning and Once at night.
3. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO one
to three times per day as needed for constipation.
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: by mouth once
a day in morning before eating .
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three
times a day: Do not exceed 4000mg in one day.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. lactase 3,000 unit Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO once a day: before eating dairy.
9. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1)
tablespoon PO once a day as needed for constipation.
10. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
11. psyllium Powder Sig: One (1) tbsp PO once a day as
needed for constipation.
12. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day.
13. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
15. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
16. pravastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
17. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Do not miss a dose
of this medication, doing so will increase your risk of allergic
reaction.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Non cardiac chest pain
.
Hypertension
Hyperlipidemia
Depression
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Known lastname 18806**],
As you know, you were admitted to the hospital with complaints
of chest pain. We performed a cardiac catheterization to examine
your heart and did not see any blockges that would explain your
symptoms. We performed an aspirin desensitization procedure so
that you can safely take aspirin. It is important that you take
aspirin every day and do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] as this can put you
at risk of an alergic reaction.
.
We noted on a routine xray that you have a compression fracture
in your lower back. The fracture is not dangerous but it may be
contributing to your lower back pain, please discuss this with
your primary care doctor at your next appointment.
.
You became confused and we restrained you to prevent you from
hurting yourself. You were concerned that your finger had been
broken and we checked an xray that did not show any broken
bones.
.
MEDICATION CHANGES
START Aspirin 81mg daily, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]
START Isosorbide mononitrate [Imdur] 30mg Daily to prevent chest
pain
START Pravastatin 20mg daily for cholesterol
STOP Gimfibrozil
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: GERONTOLOGY
When: MONDAY [**2127-4-28**] at 8:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2127-5-7**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| [
"41401",
"42731",
"3051",
"53081",
"2720",
"4280"
] |
Admission Date: [**2162-8-23**] Discharge Date: [**2162-9-2**]
Service: NEUROSURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
right sided weakness
Major Surgical or Invasive Procedure:
L Burr holes for SDH
History of Present Illness:
84 year old male s/p recent burr holes for Right SDH presents
from [**Hospital 100**] Rehab with several days of progressive right-sided
weakness. His son also noted that he was speaking less than
normal. That patient does not report any pain at this time. He
was initally seen as a Code Stroke in the ER today because of
the
right-sided weakness. Then he had a CT scan which showed an
enlargement of the previous SDH and neurosurgery was called to
evaluate him.
Past Medical History:
-CAD
-AAA s/p repair
-HTN
-CVA in [**2150**]
-vascular dementia
-syncope
-hypercholesterolemia
-chronic renal insufficiency
-urinary retention, acontractile bladder without obstruction
-BPH
-constipation
-chronic pain, narcotic dependence
-depression
-severe anxiety
-GERD with barretts esophagus
-COPD
-Asthma
-Chronic low back pain
-UTI oxacillin resistant coag + staph
Social History:
World War II veteran. Lives with his wife, [**Name (NI) 24990**]. Past
smoking history is 30 pack-years. No alcohol or drugs.
Family History:
Denies history of seizures or syncopal events.
Physical Exam:
On admission:
T:98 BP:140/80 HR:64 RR:18 O2Sats:96%
Gen: Awake and alert.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, but not to date.
Language: Speech is limited.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Full strength on the left side. He is plegic on the
right.
No withdrawal of the RUE, slight movement of the fingers. There
is withdrawal of the RLE.
Sensation: Intact to light touch bilaterally.
Toes mute bilaterally
On Discharge
a&ox2 self and location
Pupils:2-1mm bilaterally
face symmetrical
tongue midline
Motor- full strength in all four extremities.
Incision- clean, dry and intact, staples in place
Pertinent Results:
CT BRAIN PERFUSION [**2162-8-23**] 2:04 PM
FINDINGS: As compared to CT head from [**2162-8-12**], there has
been
interval increase in size of left cerebral subdural (air and
fluid) collection measuring 3.2 cm in thickness, previously
measured 2.2 cm. The fluid portion of this collection appears
more dense with layering hyperdensity which may represent acute
hemorrhage. There is increased mass effect on the left cerebral
hemisphere and approximately 7 mm shift of midline structures
(compared with 4-mm on prior CT). There is no definite [**Doctor Last Name 352**]-
white matter differentiation abnormality. Dilatation of the
ventricles corresponds to sulcal prominence, likely secondary to
age- appropriate involution. Periventricular and subcortical
foci of hypodensity are likely related to microvascular ischemic
changes. Left- sided skull defects representing location of
prior drainage catheter are noted. Right- sided craniotomy
defect is also noted. There is no depressed skull fracture.
There is right nasal septum deviation with small right-sided
spur.
IMPRESSION: Interval increase in size of left subdural air and
fluid
collection with increased mass effect on the left cerebral
hemisphere and
midline shift.
CTA HEAD W&W/O [**2162-8-23**] 2:04 PM
FINDINGS: As compared to CT head from [**2162-8-12**], there has
been
interval increase in size of left cerebral subdural (air and
fluid) collection measuring 3.2 cm in thickness, previously
measured 2.2 cm. The fluid portion of this collection appears
more dense with layering hyperdensity which may represent acute
hemorrhage. There is increased mass effect on the left cerebral
hemisphere and approximately 7 mm shift of midline structures
(compared with 4-mm on prior CT). There is no definite [**Doctor Last Name 352**]-
white matter differentiation abnormality. Dilatation of the
ventricles corresponds to sulcal prominence, likely secondary to
age- appropriate involution. Periventricular and subcortical
foci of hypodensity are likely related to microvascular ischemic
changes. Left- sided skull defects representing location of
prior drainage catheter are noted. Right- sided craniotomy
defect is also noted. There is no depressed skull fracture.
There is right nasal septum deviation with small right-sided
spur.
IMPRESSION: Interval increase in size of left subdural air and
fluid
collection with increased mass effect on the left cerebral
hemisphere and
midline shift.
CT HEAD W/O CONTRAST [**2162-8-23**]
FINDINGS: A non-contrast CT of the head was obtained.
There is a new left frontal/parietal craniotomy, as well as
preexisting
calvarial postsurgical chagnes. The left subdural hematoma has
decreased in size, now measuring 1 cm in greatest diameter, with
evidence of new acute blood products. There is a small left
epidural collection underlying the craniotomy. In addition to
left-sided pneumocephalus, there is a small amount of
right-sided pneumocephalus and a small right parafalcine
isodense subdural collection, not seen previously.
There is diffuse sulcal effacement in the left cerebral
hemisphere. There is mass effect on the left lateral ventricle
which is improved compared to the prior study. The right lateral
ventricle is stable in size. There is
approximately 5 mm of left to right midline shift on the current
study
compared to 8 mm previously.
There is stable prominence of the extra-axial space in the left
posterior
fossa without evidence of acute hemorrhage.
There are periventricular white matter hypodensities which are
most likely
related to chronic ischemic microvascular disease. Age-related
cerebral
atrophy is again noted.
There is polypoid mucosal thickening in the lateral recess of
the right
sphenoid sinus.
IMPRESSION:
1. The left subdural hematoma has decreased in size but
demonstrates new acute blood products, which could be related to
recent evacuation or post-operative bleeding. Partial
improvement in associated mass effect. These findings were
communicated to Dr. [**Last Name (STitle) **] on [**2162-8-23**] at 11:50 p.m.
2. New small right parafalcine isodense subdural collection.
CT HEAD W/O CONTRAST [**2162-8-25**]
FINDINGS: Pneumocephalus has slightly redistributed, though with
overall
volume appearing similar to study from 1 day earlier.
Heterogeneous subdural collection layering over the left
convexity is stable in size with similar hyperdense hemorrhagic
component. There is associated right deviation of normal midline
anatomy of approximately 7 mm, unchanged, resulting in mild mass
effect on the left lateral ventricle. Overall, the ventricles
and sulci are unchanged in size and configuration. There is no
new focus of hemorrhage. Bilateral craniotomy changes are also
stable. Subcutaneous gas overlying the left frontotemporal
region is unchanged.
IMPRESSION: Minimal change from one day prior, with
redemonstration of left subdural hematoma, pneumocephalus, and
7mm rightward shift of midline
structures with probable trapping of the contralateral ventricle
(based on
comparison with [**2157**] studies).
CT HEAD W/O CONTRAST [**2162-8-26**]
Overall unchanged study from prior of [**2162-8-25**]. Stable
rightward shift and stable appearance of subdural hematoma.
CHEST (PORTABLE AP) Study Date of [**2162-8-30**] 2:05 PM
Bilateral areas of pulmonary edema appear relatively unchanged;
however, there is an area of increased density within the right
upper lobe which might be related to asymmetric pulmonary edema
or aspiration. Increasing small left pleural effusion. Unchanged
left basilar atelectasis. No pneumothorax.
CHEST (PA & LAT) Study Date of [**2162-9-1**] 3:43 PM
As compared to the previous radiograph, the pre-existing right
upper lobe opacity has minimally decreased in severity. The
minimal areas of opacities at the right lung base are unchanged.
Also unchanged is the extent of the small left-sided pleural
effusion, the retrocardiac atelectasis and the size of the
cardiac silhouette. No newly appeared lung parenchymal
opacities.
Brief Hospital Course:
On [**8-23**] the patient was taken to the OR emergently for a left
craniotomy for SDH evacuation On [**8-24**], the patient had a right
hemiplegia. CT was repeated and revealed
subdural collection along the left convexity is stable in size,
with grossly
unchanged amount of hyperdense blood products. A small epidural
collection of
fluid and air underlying the new left frontal/parietal
craniotomy is unchanged
in size. On [**8-25**] the patient had a CT which showed worsening
shift. Bedside evacuation of 40-50 cc through the burr hole was
performed. The patient coninued to wax and wane with respect to
his right hemiplegia and his expressive dysphasia.
He was without change on [**8-26**]. Head CT was relatively unchanged.
Blood Pressure parameters were liberalized to SBP <160. on [**8-27**]
he was titrated off Nicardipine gtt and transferred to SDU.
Pt. remained in the ICU for some respiratory distress,
requirieng frequent Neb treatments and Lasix for developing
pulmonary edema. He also had one episode of hematochesia
without a significant drop in his hematocrit.
On [**2162-8-30**] a Chest x-ray showed a question of a new right upper
lobe consolidation questionable for aspiration. Patient then
became tachypneic with a RR of 30 and crackles. He was placed on
a NRB mask with O2 and transferred to SICU for respiratory
distress. He was also given 40mg of lasix and nebulizer
treatment. His SBP was also in the 200s and was given
hydralazine. On [**8-31**], patient was neurologically stable,
complaint of SOB. Crackles were heard on exam, but with lasix,
there was some improvement in vital signs, heart rate 83 and SBP
140. Respiratory rate was 97% on 15L O2 on NRB mask.
Video swallow evaluated by speech therapy revealed moderate
oropharyngeal dysphagia characterizedas above including
penetration and aspiration of thin liquids.
She is recommmended for a puree diet with nectar thick liquids.
Patient is A&Ox2, and reports that his breathing is improved. He
will be discharged to [**Hospital 100**] rehab facility on [**9-2**].
Medications on Admission:
Amphogel, Wellbutrin, Vitamin D, Klonopin, Vitamin B12, Nexium,
Fentanyl Patch, Ferrous Sulfate, Keppra, Lopressor, Oxycodone,
Miralax, Tamsulosin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
8. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Ten (10)
ML PO Q4H (every 4 hours) as needed for pain.
11. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-1**] Inhalation Q6H (every 6 hours) as needed
for wheezes.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezes.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
18. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
20. Ondansetron 4 mg IV Q8H:PRN nausea
21. HydrALAzine 10 mg IV Q6H SBP > 160
22. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Left SDH
Pulmonary edema
Malnutrition
hematochesia
Discharge Condition:
Stable.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after your staples have been
removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing in one
week. Please have results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-9**] days for removal of your
staples.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
. While in the hospital you had one bowel movement that showed
a trace amount of blood in it which is abnormal, you should
follow up with your primary care provider for further work up.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2162-9-2**] | [
"4019",
"41401",
"53081"
] |
Admission Date: [**2149-2-21**] Discharge Date: [**2149-3-3**]
Date of Birth: [**2099-7-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Left Foot Infection, DKA
Major Surgical or Invasive Procedure:
Mr. [**Known lastname 24962**] underwent podiatric surgery on [**2149-2-24**] to for left
wound debriment and underwent wound closure on [**2149-3-3**].
History of Present Illness:
Mr. [**Known lastname 14611**] is a 49 year old male with a history of type II
diabetes, charcot's foot s/p multiple surgeries, and previous
MRSA infection who presented to his podiatrist on [**2149-2-21**] with
two days of nausea, vomiting (clear, non-bilious, non bloody) ,
productive cough (sputum color not noted), fatigue, and pain and
redness of his left foot. He was found to have a draining wound
(approximately 1 cm in width x 1 cm in depth) on his left lower
leg, just superior to the lateral malleolus with an area of
surrounding cellulitis. He was transferred to the Emergency
Department for treatment with IV antibiotics, and observation.
Of note is that the patient missed his last four doses of lantus
insulin, due to running out of medication.
.
In the ED his vitals were: T 99.3, HR 102, BP 134/74, R 18, and
O2 sat 100% on room air. Labs were drawn and significant for a
glucose of 377, Anion Gap of 24, lactate of 1.2 and ketones in
this urine, consistent with Diabetic Ketoacidosis. He was given
6 units of insulin, 2 liters of IV fluid, a dose of Vancomycin
x1 (for cellulitis), and a percocet in the ED and transferred to
the MICU for further management of his DKA and infection.
.
In the MICU he was treated with his 5th liter of normal saline
and started on an insulin drip. He was continued on Vancomycin
and started on Zosyn. He was stable with a heart rate of 77 and
a blood pressure of 140/66. Podiatry reported that plain film
imaging showed "interval osteolysis adjacent to the fixation
screws that is suggestive of infection or interval losening".
Blood and swab cultures were obtained, and a urine culture was
negative for growth. Mr. [**Known lastname 14611**] developed skin reactions in the
MICU on his back and neck, consistent with a similar exanthem
his developed in [**2148-10-12**] during his previous admission
and was seen by dermatology. He was subsequently admitted to
the [**Doctor Last Name **] B service of CC7.
Past Medical History:
PMH:
-Diabetes Mellitus Type 2
-Bilateral Charcot Foot with multiple surgeries
-History of MRSA
-Left Lower Extremity DVT ([**2145-7-13**])
.
PSH
-Left Charcot foot reconstruction ([**2148-10-12**])
-Right pan-metatarsal resection and [**Doctor First Name **] ([**2148-10-12**])
-Right foot I& drainage with 2nd Metatarsal head resection
packed open ([**2147-10-13**])
-Left and right foot debridment ([**2147-12-13**])
-Cataract extraction of right eye ([**2147-4-12**])
-Excision of right foot ulcer ([**2145-11-12**])
-Skin lesion biopsy from sensitivity reaction done by
dermatology during MICU stay.
Social History:
Mr. [**Known lastname 14611**] lives in [**Location 24963**], MA in an apartment unit alone,
however his mother and aunt live in the unit downstairs. He is
not married, nor in a relationship and does not have children.
He has a brother whom he considers his closest contact and
person who would make medical decisions for him. Mr. [**Known lastname 14611**] is of
Irish descent and has a high school education. He worked at an
auto dealership until he was fired in [**Month (only) **]. He has not been
able to look for a job because of his recent hospitalizations
and he states that he may not have medical insurance, but he is
not too concerned about it. He smoked 2-3 packs per day but quit
over two years ago. He drinks 3-5 beers per day, sometimes more.
Patient denies illicit drug use.
Family History:
Mother has a history of type II Diabetes Mellitus.
Physical Exam:
Exam:
Vital Signs during exam on [**2149-2-23**]: T=97.5 HR=18 BP=152/90
RR=18 SaO2=97% on room air
FINGERSTICKS 24h: [**Telephone/Fax (3) 24964**] - [**Telephone/Fax (3) 24965**]
.
General:No apparent distress
Skin:Raised and erythematous, non-pruritic lesions visible
across back and neck.
Lymph:No occipital, submandibular, cervical, supraclavicular,
axillary, epitrochlear, or inguinal LAD.
HEENT:Normocephalic; no proptosis; anicteric sclera;
conjunctiva clear and nonerythematous; moist mucous membranes
Neck:Supple; full ROM; no c-spine tenderness to palpation; JVP
+1; carotids 2+ w/o bruits; no thyromegaly or nodules; trachea
midline
Back: no t-spine or l-spine tenderness to palpation; no CVAT
Core:CTAB; symmetrical air movement bilaterally, no wheezes,
rales, or rhonchi; resonant to percussion bilaterally; PMI
non-displaced; S1, S2; no murmurs, gallops, or rubs
Abd:obese; +BS; nondistended; resonant to percussion; soft;
nontender; no rebound; no HSM; no ventral hernias
GU:Deferred (no inguinal hernias)
Rectal:Deferred
Extr:Lateral, lower left foot noted to have erythema, increased
warmth, consistent with cellulitis. A small ulceration superior
to lateral malleolus that was 1cm in length by 1cm in depth,
with slight pus and without odor. 2+ edema of lower extremities
bilaterally without cyanosis. Femoral, and radial pulses 2+
bilaterally. Pedal pulses could not be palpated bilaterally.
Neuro:
MS:
Orientation: to person, place, date, and purpose for visit
Attention: repeats 10 digits forwards
Frontal:follows and repeats 3-step motor pattern with both hands
Speech:spontaneous; fluent
Memory:knows current events. patient refused more extensive
memory testing.
Parietal:correctly performs crossed-body, 2-step command
Cognition:explains proverbs "an apple doesn't fall far from the
tree"; good insight; appropriate judgment
Thought Content:no hallucinations; no delusions
Mood:upset and agitated at the moment.
CN:
I:not tested
II,III:PERRL, blinks to threat
III,IV,VI:gaze full in all directions; no ptosis.
V:sensation symmetric to LT V1-V3
VII:face symmetric w/o weakness
VIII:hearing symmetric to finger rub
IX,X:palate rises symmetrically; no dysarthria or dysphagia; gag
reflex intact
[**Doctor First Name 81**]:SCM??????s and trapeziums [**6-16**]
XII:tongue midline; no gross atrophy or fasciculation
Motor:Normal bulk in upper extremities. Lower bulk in lower
extremities. Normal tone; no spasticity or rigidity. No
tremor, chorea, athetosis, hemiballismus, or bradykinesia. No
pronator drift. Could not stand without assistance or support.
EXT: 2+ radial pulses bilat, unable to palpate DP, slightly cool
LE, paler L than right foot, charcot feet, onychomycosis
Sensory:
Patient has decreased light touch, vibration, pain and
temperature in both feet. Patient did not allow for examination
of proprioception nor upper extremities.
Reflexes
No clonus or asterixis.
Coordination / Gait:
Patient would not cooperate with testing.
Pertinent Results:
ADMISSION LABS:
130 93 18
============< 377
4.8 18 1.0
.
CK: 150 MB: 5 Trop-T: <0.01
.
12.1 D > 34.1 < 336
N:87.7 L:7.6 M:4.2 E:0.3 Bas:0.2
.
U/A: trace protein, 1000glucose, 150ketones, neg for infxn
.
TRANSFER LABS:
138 106 5
============< 196
3.5 23 0.7
Ca: 8.4 Mg: 1.7 P: 3.2
Vanco: 9.5
.
4.7 > 27.3 < 319
.
SED-Rate: 58
Discharge Labs:
[**2149-3-3**] 06:55AM BLOOD WBC-4.9 RBC-3.02* Hgb-9.2* Hct-26.7*
MCV-88 MCH-30.4 MCHC-34.5 RDW-14.5 Plt Ct-353
[**2149-3-3**] 06:55AM BLOOD Glucose-163* UreaN-8 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-27 AnGap-12
MICRO:
GRAM STAIN (Final [**2149-2-22**]): 2+(1-5 per 1000X
FIELD):POLYMORPHONUCLEAR LEUKOCYTES. No MICROORGANISMS SEEN.
.
WOUND CULTURE (Final [**2149-2-24**]):
KLEBSIELLA PNEUMONIAE.SPARSE GROWTH.
.
GRAM STAIN (Final [**2149-2-28**]):1+(<1 per 1000X
FIELD):POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
.
WOUND CULTURE (Final [**2149-3-3**]):STAPHYLOCOCCUS, COAGULASE
NEGATIVE.RARE GROWTH.
.
WOUND CULTURE (Final [**2149-2-26**]): CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS). RARE GROWTH.
.
WOUND CULTURE (Final [**2149-2-28**]): BETA STREPTOCOCCUS GROUP B.
RARE GROWTH.
ANAEROBIC CULTURE (Final [**2149-3-6**]):NO ANAEROBES ISOLATED.
.
Blood Culture, Routine (Final [**2149-2-27**]):NO GROWTH.
.
URINE CULTURE (Final [**2149-2-23**]): <10,000 organisms/ml.
.
FOOT XR [**2149-2-21**]:
IMPRESSION:
1. No skin ulcer or focal osteolysis is noted to suggest
osteomyelitis.
2. Interval osteolysis adjacent to the fixation screws is
suggestive of
infection or interval loosening.
3. Relatively stable neuropathic changes of the foot.
.
CXR [**2149-2-22**]:
There are low lung volumes in the semi-upright position. The
lung fields
appear clear. No failure or pneumonia is identified.
IMPRESSION: No pneumonia.
Brief Hospital Course:
Mr. [**Known lastname 14611**] is a 49 year old male with a history of type II
diabetes, charcot's foot s/p multiple surgeries, and previous
MRSA infections who presents with left foot cellulitis,
ulceration, and a resolving DKA. He developed drug rash allergy
on his neck and back while in the ED.
.
1. Left foot abscess/cellulitis/drug reaction:
Mr. [**Known lastname 14611**] presented to his podiatrist on [**2149-2-21**] with two days
of nausea, vomiting(clear, non-bilious, non bloody) , productive
cough (sputum color not noted), fatigue, and pain and redness of
his left foot. He was found to have a draining wound
(approximately 1 cm in width x 1 cm in depth) on his left lower
leg, just superior to the lateral malleolus with an area of
surrounding cellulitis. He as admitted to the ED for IV
antibiotics and observation. In the ED 2 liters of IV fluid, a
dose of Vancomycin x1 (for cellulitis, first dose [**2149-2-22**]), and
a percocet and transferred to the MICU for further management.
In the MICU he was treated with his 5th liter of normal saline.
He was stable with a heart rate of 77 and a blood pressure of
140/66. Podiatry reported that plain film imaging showed
"interval osteolysis adjacent to the fixation screws that is
suggestive of infection or interval loosening". Blood and swab
cultures were obtained, and a urine culture was negative for
growth. He was then admitted to the medicine floor for further
management. On the floor He was continued on Vancomycin 1g [**Hospital1 **]
and started on Zosyn (Pip-tazo) 4.5g Q8H on [**2149-2-22**]. He also
developed a allergic reaction on his back, which appeared as
erythematous, non-raised target lesions. He was taken by
podiatry to the operating room on [**2149-2-24**] for surgical
debridement of his foot ulcer, and found to have an abscess that
was drained. Wound cultures grew Klebissela pneuomiae with
sensitivites to Cipro, Meropenum, Gent, ceftriaxone and less
sensitivities to Zosyn, amp/sublactam. He was continued on Vanc,
but the Zosyn was stopped and he was started on Cipro (500mg PO
bid) on [**2149-2-25**]. Wound cultures came back with gram positive
cocci, so he was started on Keflex PO 500mg qid (first dose
[**2149-2-26**].)Mr. [**Known lastname 24962**] improved with pain management after the
debridement, and underwent surgical closure on [**2149-3-3**] and was
discharged in good condition.
.
2. Diabetic Ketoacidosis:
The patient presented to the emergency department with a glucose
of 377, Anion Gap of 24, lactate of 1.2 and ketones in this
urine, consistent with Diabetic Ketoacidosis. Of note he also
had missed his previous 4 doses of lantus insulin.
He was given 6 units of insulin, 2 liters of IV fluid and
transferred to the MICU where he was started on an inslin drip.
His anion gap eventually close, he glucose was controlled in the
150-240's range, and his anion gap closed before he was admitted
to the medicine floor. On the medicine floor the patient was
followed by the [**Hospital **] clinic. His lantus dose was reduced to
half while he was NPO before procedures, and kept at 20mg [**Hospital1 **]
when eating regularly. His humalog scale was increased 2 units
during his stay because of increasing glucose levels. Upon
discharge his glucose was stable at 163 and his anion gap was
12.
.
3. Anemia: [**Known lastname 14611**] had a hematocrit of 27.3 on admission, with a
range of 24.4 to 28.3, with a discharge hematocrit of 26.7. Of
note, he loss 300cc of blood during the surgical debridement of
his foot ulcer on [**2149-2-24**]. Two units of blood were cross and
matched, but a transfusion was not needed. He was mainted on
Iron supplementation with ferrous sulfate, 325mg PO. His anemia
was stable at discharge.
.
4. Skin lesions: The patient has developed blanching, raised,
erythematous lesions with a target like appearance on his back
and neck in a similar distribution to a previous admission in
[**2148-10-12**]. Dermatology consulted on the patient, and a biopsy
was performed and found to be consistent with a drug reaction,
although erythema multiforme could not be excluded. The patient
was treated with HydrOXYzine 25 mg PO PRN/Q6H, and Sarna lotion
application PRN. The drug allergy improved over the course of
the admission and was stable at discharge. A follow up
appointment was made with the allergy clinic for the patient.
Medications on Admission:
Lisinopril 20mg qd
Lantus 20U (AM&PM)
Humalog SS
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for 20 doses: do not exceed 8
tablets in 24 hours.
Disp:*20 Tablet(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for Rash.
Disp:*QS QS* Refills:*0*
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days: FINISH ALL OF YOUR ANTIBIOTICS.
Disp:*40 Capsule(s)* Refills:*0*
10. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: please follow new sliding scale
and adjust [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations.
Disp:*QS QS* Refills:*2*
11. SYRINGE
BD ultra-fine Ii short - syringes 31g 1/2cc as directed use
5x/day. Dispense: QS x 1 month, Refill 6
12. glucose strips
one touch ultra fine strips. QS for one month, 6 refills
13. lancets
one-touch lancets for glucose meter. QS one month, 6 refills
14. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous at bedtime.
15. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous qAM.
Disp:*QS QS* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Diabetic Ketoacidosis
Diabetic foot ulcer infection
.
SECONDARY:
Bilateral Charcot Foot with multiple surgeries
Drug sensitivy skin rash
Discharge Condition:
Good
.
FSBG 85-277
.
Afebrile, comfortable
Discharge Instructions:
You were admitted with Diabetic Ketoacidosis and a left foot
infection. Your glucose was at 377 and you were dehydrated, thus
you were treated with an insulin drip and IV fluids. You were
started on the IV antibiotics piperacillin and tazobactam and
vancomycin for your foot infection. Your wound culture grew the
bacteria klebisella pneumonia and group [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24966**], [**First Name3 (LF) **] you
were switched to a 14 day course of the oral antibiotics
ciprofloxacin and cephalexin. You were taken to surgery by the
podiatry service for debridement of the wound on [**2149-2-24**]. Your
incision was left open for 4 days to heal, and was then reclosed
in the operating room on [**2149-2-28**] and a wound vaccum was placed
as they were not able to close the entire wound.
.
Wound vac will be removed and you will need to perform wet to
dry dressings 2 times per day. You will f/u with podiatry next
week.
.
You were also noted to have a rash on your back. You were seen
by dermatology who thought that you had a drug sensitivity
reaction. Your rash appeared to improve after discontinuation of
the antibiotics piperacillin and tazobactam, but the exact cause
was unknown. You will need to see allergy specialist at [**Hospital1 18**].
Please call the allergy clinic at [**Telephone/Fax (1) 8645**].
.
CHANGES IN MEDICATIONS:
Humalog scale adjusted according to print-out
Ciprofloxacin finish additional 10 day course
Cephalexin four times a day finish additional 10 day course
Glargine (lantus) insulin remains 20units in AM but now PM dose
increased to 25units.
.
No other changes to your medications were made
.
Please adhere to all of your appointments adn call to reschedule
if needed.
.
If you develop any concerning symtoms such as increased urinary
frequency, dizzyness, chills, fever above 101 degrees, light
headedness or any other major concerns, please see your doctor
immediately.
Followup Instructions:
1)Please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for a PCP follow up within
the next week. Call ([**Telephone/Fax (1) 24967**].
.
2) [**Hospital **] Clinic with Dr. [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**] on Thursday, [**2149-3-6**] at 9:30 am. Phone number ([**Telephone/Fax (1) 17484**]. Please bring
referral from PCP.
.
3)Podiatry- with Dr. [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], on [**Last Name (LF) 766**], [**2149-3-10**] at 2:30 pm. Phone:[**Telephone/Fax (1) 543**].
.
4) [**Hospital 9039**] clinic: Please call [**Telephone/Fax (1) 8645**] to schedule an
appointment next week.
| [
"V5867"
] |
Admission Date: [**2119-5-20**] Discharge Date: [**2119-6-1**]
Date of Birth: [**2045-6-9**] Sex: M
Service: CCU
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
male with the diagnosis of ischemic cardiomyopathy who awoke
on the morning of admission and presented to an outside
hospital. He had previously been seen as an outpatient for
shortness of breath one week ago and was diagnosed with CHF
exacerbation at which time his Lasix dose had been doubled
and resulted in a 6 pound weight loss over two days.
Subsequently his urine output started to decline. In the
emergency room at the outside hospital he was given 80 mg IV
of Lasix which resulted in hypotension and tachycardia with
minimal urine output. He then received a normal saline bolus
which improved his blood pressure and heart rate. He was
then transferred to [**Hospital1 69**].
PAST MEDICAL HISTORY: Coronary artery disease. History of
postoperative myocardial infarction after surgery. He has a
pacemaker placed in [**2113**] dual chamber placed after a
bradycardiac episode. Diabetes type 2 recently started on
glipizide. Peripheral vascular disease. Abdominal aortic
aneurysm status post repair. Colon cancer status post
resection and diverting colostomy in [**2084**]. Melanoma status
post resection. Congestive heart failure with EF of
approximately 15% attributed to ischemia.
Hypercholesterolemia. Renal insufficiency baseline
creatinine approximately 2 to 2.5. Status post right CEA.
Known 100% occluded left carotid artery.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Lasix 40 mg p.o. q.d., Lipitor 40
mg p.o. q.d., captopril 12.5 mg t.i.d., Lopressor 50 mg
t.i.d., glipizide 2.5 mg p.o. q.d., aspirin 81 mg p.o. q.d.,
amiodarone 200 mg p.o. b.i.d.
FAMILY HISTORY: Stomach cancer. History of rheumatoid
arthritis and coronary artery disease.
SOCIAL HISTORY: Ex-tobacco use, quit approximately 40 years
ago. No alcohol use. Used to work for the telephone
company.
PHYSICAL EXAMINATION: On admission vital signs were
temperature of 98.7, heart rate 115, blood pressure 114/60,
oxygen saturation 98% on 2 liters nasal cannula. In general,
an elderly male in no apparent distress. HEENT PERRL, EOMI,
MM dry, OP clear, poor dentition. Neck normal carotid
upstroke, bounding carotid pulses, engorged EJV with JVD up
to 10 cm, no thyromegaly, no lymphadenopathy. Chest diffuse
expiratory wheezes plus rales left greater than right half
way up lung fields. Heart tachycardiac, regular, [**4-6**]
holosystolic murmur heard best at the left lower sternal
border, left ventricular heave. Abdomen colostomy in place
without erythema, soft midline scar well healed, bowel sounds
positive. Extremities positive cyanosis bilateral lower
extremities, dopplerable pulses, 2 to 3+ pitting edema up to
mid-shin, no clubbing. Neuro alert and oriented times three,
grossly intact.
LABORATORY DATA: On admission white blood cell count 6.1,
hematocrit 37.4, platelets 163. Sodium 137, potassium 4.9,
chloride 99, CO2 20, BUN 103, creatinine 3.9, glucose 138.
Magnesium 2.7, phosphate 5.4, calcium 9.4, albumin 3.4. ALT
36, AST 29, LK 294, LDH 352. CK 186, MB 7, troponin 0.08.
Urinalysis was clean. EKG was v-paced with 100% capture rate
of 115 with magnet rate of 60, sinus tachycardia with left
bundle branch block. Chest x-ray showed cardiomegaly with
preserved redistribution, no infiltrates, blunting of
costophrenic angle on right.
HOSPITAL COURSE:
1. Cardiac:
A. Ischemia. The patient was ruled out for myocardial
infarction. There were no ischemic issues during this
hospitalization.
B. Pump. The patient arrived in congestive heart failure
exacerbation. He was unable to be adequately managed with
Lasix and Bumex and required Natrecor for adequate diuresis.
Patient diuresed well. We were able to continue his beta
blocker, aspirin and statin as well as his ACE inhibitor.
His ACE inhibitor was switched from captopril to lisinopril
for more convenient once daily dosing.
C. Rhythm. The patient was found to be in a-fib on
admission. An echo to evaluate for possible cardioversion
showed an apical thrombus, thus, cardioversion was
contraindicated. He was started on heparin and Coumadin for
this thrombus with an INR goal of 2 to 3. Heparin was
discontinued prior to discharge when this goal was reached.
EP was also consulted and recommended discontinuation of
amiodarone as atrial fibrillation had occurred while on this
medication. In addition, low dose digoxin was added for
further rate control and augmentation of cardiac output.
2. Renal. The patient came in in acute on chronic renal
failure. This was felt to be secondary to heart failure
exacerbation with pre-renal failure. Creatinine peaked at
4.2 well above baseline of approximately 2.5. This then
subsequently decreased to approximately 2.8 where it stayed
for the remainder of the hospitalization and on discharge.
3. Of note, during attempted placement of a right subclavian
line, a large hematoma of his neck formed with tracheal
compression. Otolaryngology was consulted and did not feel
there was a risk of airway compromise. The hematoma slowly
improved without further management.
4. GI. Protonix was continued throughout hospitalization.
There were no GI issues.
5. Heme. The patient was started on Coumadin for atrial
fibrillation with apical thrombus. In addition, his
hematocrit declined and he needed to be transfused during the
hospitalization to maintain hematocrit above 28 as he has
known heart failure and coronary artery disease.
DISCHARGE STATUS: The patient was discharged to acute rehab
as he was significantly decompensated from this
hospitalization and heart failure exacerbation.
DISCHARGE INSTRUCTIONS: During rehab at home he should
closely follow his 2 gm sodium diet and fluid restriction to
less than 2 liters per day as well as he should weigh himself
daily and if there is a gain of greater than 1 kg or any new
shortness of breath or increased lower extremity edema, his
cardiologist or PCP should be [**Name (NI) 653**] immediately for
management to reduce the risk of further congestive heart
failure exacerbation requiring hospitalization.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
3. Sublingual nitroglycerin 0.3 mg p.r.n.
4. Lipitor 40 mg p.o. q.d.
5. Digoxin 0.125 mg p.o. q.d.
6. Epoetin alfa 5000 units subcu q.week.
7. Toprol XL 100 mg p.o. q.d.
8. Lisinopril 5 mg p.o. q.d.
9. Warfarin 3 mg p.o. q.h.s.
10. Glipizide 2.5 mg p.o. q.d.
11. Salmeterol inhaler one to two puffs b.i.d.
12. Lasix 40 mg p.o. q.d.
13. Trazodone 50 mg p.o. q.h.s. p.r.n.
DISCHARGE DIAGNOSES:
1. CHF exacerbation.
2. Atrial fibrillation.
3. Apical thrombus.
4. Acute on chronic renal failure.
5. Diabetes type 2.
6. COPD.
7. Coronary artery disease.
8. Peripheral vascular disease.
9. Anemia thought to be secondary to renal failure.
CONDITION ON DISCHARGE: He was discharged in stable
condition to rehab.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 18032**]
MEDQUIST36
D: [**2119-5-31**] 13:12
T: [**2119-5-31**] 13:03
JOB#: [**Job Number 49066**]
| [
"42731",
"5849",
"496",
"4280",
"2720"
] |
Admission Date: [**2151-1-10**] Discharge Date: [**2151-1-19**]
Date of Birth: [**2082-4-16**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Percocet / Sulfamethoxazole / Thorazine / Codeine /
Loperamide / macrolides
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Ureteral stone
Major Surgical or Invasive Procedure:
Interventional radiology placed right percutaneous nephrostomy
tube
History of Present Illness:
Ms. [**Known lastname **] is a 68 year old female with PMH HTN,
Hyperlipidemia, CAD, is transferred from [**Hospital 8125**] [**Hospital 6136**]
Hospital for hypotension and sepsis after presenting with
nausea/vomiting and flank pain and found to have a large right
uretral stone.
.
According to the patient, she was experiencing nausea/vomiting
with bilateral flank pain and "tightness" radiating to the groin
(she is unable to assign another quality to the pain). The pain
was constant and became progressively worse over 2 days, she
developed confusion on the day of admission. She presented to
[**Hospital 8125**] hospital where she was hypotensive to SBP 80-90 and
tachycardic to 120, she was given 3L IVNS and started on
peripheral phenylephrine. Initial labs were remarkable for WBC
60 with 40% bands, Creatinine 3.3 (baseline unknown though last
in [**Hospital1 18**] records is 0.5 in [**2141**]), AST 70, ALT 50, INR 1.3,
Lactate 4.5. She had a CT head which was negative for acute
hemorragic stroke, CT abdomen/pelvis revealed bilateral
nephrolithiasis with a 5mm stone located in the right ureter
without evidence of hydronephrosis. She was given Zosyn 3.73g
IV, Vanco 1gm IV, Magnesium 1gm, Zofran 4mg IV and Morphine 4mg
IV. Given hypotension and sepsis, she was transported by
[**Location (un) **] to [**Hospital1 18**] for further workup.
.
Patient was received in the ED on phenylephrine with initial
vitals
HR 120, BP 123/67 RR 28, 98% on NRB, 89% on RA. A right IJ CVL
was placed with initial CVP 7-10. She was given another 3L IVNS
(total 6L IVNS including those given at OSH), and phenylephrine
was weaned with SBP 110/50. Labs were remarkable for WBC 43.1,
94% PMN, Plt 132, BUN/Cr 37/3.0, K 3.0, HCO3 20, with AG 15, mg
1.5, Lactate 2.4, TropT: 0.09, CK 119, UA was grossly positive
with 140 WBCs and 20 RBC. She again became hypotensive to 98/56,
CVP 15mmHg, Phenylephrine was resumed. O2 saturation remained
mid 90's on NRB, attempts to wean were unsuccessful. Urology was
consulted who recommended clinical stabilization prior to
intervention and admission to the [**Hospital Ward Name **]. She was given
magnesium 2g prior to transfer.
.
On arrival to the ICU, she reports chest "tightness" that she
feels when she needs to use her pumps for asthma, stating that
the pain is different from her anginal equivalent which is back
pain. She reports that the abdominal/flank pain was alleviated
by morphine at [**Hospital 8125**] hospital and has not returned.
Past Medical History:
Past Medical History:
- Myocardial infarction [**2137**] at [**Hospital1 2025**], by report no intervention
performed
- Stroke [**2137**] no residual
- Breast CA s/p BL lumpectomy, no chemo/radiation
- Hyperlipidemia
- Hypertension
- Degenerative joint disease
- Asthma
PAST SURGICAL HISTORY:
- Appendectomy
- TAH BSO
- Cervical spine fusion
- Lumpectomy
Social History:
Lives with husband in [**Name (NI) **], daughter [**Name (NI) 717**] is nearby and
involved in her care.
- Tobacco: Never smoker
- Alcohol: Denies
- Illicits: Denies
Family History:
Mother: breast cancer in 60's
Grandmother: Breast cancer in 60's
Father: Coronary artery disease first MI at age 51
Physical Exam:
Admission Physical Exam:
Vitals: T: BP:97/55 P:114 R:24 O2: 93% 50% face tent
General: Eyes closed, opens to command, wearing NRB mask. Alert,
oriented to person, city:[**Location (un) **].
HEENT: Sclera anicteric, mucous membs dry, false upper/lower
teeth
Neck: Right IJ in place, left EJ, no lymphadenopathy. Unable to
assess JVP.
Lungs: Clear anteriorly, left sided inspiratory rales, decreased
breath sounds at the base on the right
Back: TTP at LEFT costal margion, no TTP at RIGHT costal
margion.
CV: Tachycardic, regular rate, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Well healed surgical scar midline and in RLQ, soft,
non-tender, non-distended, bowel sounds present, mild TTP on LLQ
with no rebound tenderness
GU: Foley in place
Ext: Warm, well perfused, no peripheral edema.
Discharge Physical Exam:
VS: Tc 98.5, Tm 98.9, BP 108-143/54-71, HR 76-93, RR 18, O2 sat
96% RA
GEN: well-appearing woman in no acute distress, comfortable
HEENT: PERRL, EOMI, sclerae anicteric
NECK: supple, no LAD, no JVD
PULM: fine bibasilar crackles, no wheezes
CARD: RRR, nl s1 and s2, no murmurs
ABD: +BS, well-healed surgical scar midline and in RLQ, soft,
non-tender, non-distended, no hepatosplenomegaly
EXT: warm, well-perfused, no edema
NEURO: AOx3, CN II-XII grossly intact, moving all extremities
Pertinent Results:
[**Hospital1 18**] [**2151-1-10**]
144 109 37 AGap=18
------------< 97
3.0 20 3.0
43.1 >10.6/30.8< 132
Trop-T: 0.09
Microbiology:
Blood culture ([**2151-1-10**]) x 2- no growth to date, pending
Urine culture ([**2151-1-10**])-
GRAM STAIN - UNSPUN (Final [**2151-1-11**]):
GRAM STAIN PERFORMED ON UNSPUN SPECIMEN.
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
URINE CULTURE (Final [**2151-1-13**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
____________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
CT Head [**Hospital 8125**] hospital [**2151-1-10**]- Negative head CT
CT Abdomen/pelvis [**Hospital 8125**] hospital [**2151-1-10**]
1. Bilateral nephrolithiasis 7mm calculus in the proximal right
ureter with no significant
2. Colonic diverticulosis without diverticulitis
3. bilateral lower lung consolidation which is non-specific
4. fat deposition in the liver
EKG: Sinus tachycardia at 120 bpm, normal axis, no pathologic Q
waves, and 1mm STD in v3-v6, compared with tracing [**2142-1-4**]
tachycardia and STD are new (Medicine PGY2 read).
Portable Chest Xray [**2151-1-10**]
IMPRESSION: Right IJ central venous catheter tip in a low
position.
Retraction by at least 6 cm is advised for more appropriate
positioning.
Persistent mild vascular congestion and bibasilar atelectasis.
Portable Chest Xray [**2151-1-10**]
Right internal jugular line has been pulled back to the distal
SVC. Mild
edema still present in both lungs along with mild cardiomegaly
and mediastinal vascular engorgement. More discrete
consolidation in the right lower lung, where there is also a
clear atelectasis, and in the infrahilar left lower lobe could
be due to concurrent pneumonia.
TTE [**2151-1-11**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Portable Chest Xray [**2151-1-11**]:
Right internal jugular line tip is currently low, at the level
of the right
atrium and should be pulled back approximately 2.3 cm. There is
interval
placement of the right nephrostomy, partially imaged. Pulmonary
edema is
still present, although minimally improved since the prior
study. Right
middle lobe atelectasis and left retrocardiac density with air
bronchogram
persist, highly worrisome for pneumonia.
Portable Chest Xray [**2151-1-12**]:
There is no change in the position of the right internal jugular
line but
there is interval progression of pulmonary edema. Bibasilar in
particular
left lower lobe consolidations are unchanged.
Portable Chest Xray [**2151-1-12**]:
Right supraclavicular central venous line has been withdrawn to
the level of the superior cavoatrial junction. No mediastinal
widening. A heterogeneous opacification predominantly in the
perihilar left lung and right lung base and in the infrahilar
left lower lobe has improved, probably representing asymmetric
edema in most locations and atelectasis in the left lower lobe,
which is relatively unchanged. Small left pleural effusion is
presumed. Heart size is normal. No pneumothorax.
Discharge labs:
[**2151-1-19**] 07:35AM BLOOD WBC-8.8 RBC-3.93* Hgb-11.5* Hct-34.1*
MCV-87 MCH-29.2 MCHC-33.6 RDW-14.2 Plt Ct-436
[**2151-1-19**] 07:35AM BLOOD Glucose-98 UreaN-8 Creat-0.9 Na-137 K-4.0
Cl-100 HCO3-30 AnGap-11
Brief Hospital Course:
Primary Reason for Hospitalizaiton:
68F with PMH of HTN, HL, [**Hospital **] transferred from OSH for
hypotension and sepsis, and found to have large R ureteral
stone, diagnosed with urosepsis.
Active Diagnoses:
# Urosepsis: Patient was found to have large 5.3mm stone in
right proximal ureter, now s/p right-sided nephrostomy tube
placement by IR. Blood cultures were obtained in ICU, all NGTD.
Urine cx grew pan-sensitive e. coli. She was originally on
vanc/zosyn, but was narrowed to cipro after urine culture came
back. Pain was initially controlled wit oxycodone, then with
tylenol prn; zofran prn nausea. Continue cipro for until stone
is retreived. At discharge, patient was scheduled for an
appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] retrieve stone in OR on [**1-27**]. Per
IR, patient can be discharged with nephrostomy care manual, Dr. [**Name (NI) 44614**] office will schedule f/u with IR to remove tube after
stone is removed in surgery.
# Acute Kidney Injury: Baseline creatinine unknown however last
measurement in [**2141**] at [**Hospital1 18**] was 0.5. On presentation to the
ICU, patient's Cr was 3.0, but trended down to 0.7, which is
near baseline, at the time of discharge. Lisinopril was held in
the ICU but restarted on the floor when Cr normalized. Most
likely cause of [**Last Name (un) **] is ATN from hypotension/sepsis. Patient was
informed at discharge not to take Ibuprofen due to [**Last Name (un) **].
# Hypoxia: Patient was extremely hypoxic on admission to the ICU
requiring face mask ventilation. Patient was never intubated.
Hypoxia was thought to be secondary to pulmonary edema in the
setting of aggressive volume resuscitation. BNP was 9568 on
admission, suggesting heart failure, but TTE in ICU showed
normal EF>55% and essentially normal cardiac function, despite
MI in [**2137**] s/p CABG. Thus, BNP elevation most likely secondary
to hypervolemia and myocardial stretch. Patient was still
requiring 2L NC on transfer to the floor and still has crackles
in bilateral lower lung fields. She was diuresed with IV lasix
and was breathing well on room air at the time of discharge.
# Coronary Artery Disease: Patient with reported history of
myocardial infarction in [**2137**] with cardiac cath at [**Hospital1 2025**] and no
stents placed. EKG remarkable for STD in pre-cordial leads which
is likely rate-related. Troponin 0.09 in the setting of Cr 3.0
on admission. Repeat CK-MB and trops have remained flat, so
likely a result of demand ischemia from sepsis. Although
troponin continued to rise very slowly in the days after she was
sent to the floor, CK-MB remained flat, thus low suspicion for
ACS. Patient denied chest pain throughout admission.
# Hypertension: Patient was hypotensive in the ICU, was fluid
resuscitated and on pressors. Blood pressure normalized and was
transferred to the floor. Patient was reinitiated on diltiazem
in ICU and blood pressure remained in the 130s on transfer to
the floor. She was later also started on lisinopril when her
renal function normalized. On the day of discharge, SBP ran low
into mid-80s, likely from high dose of antihypertensives in the
setting of recent sepsis and weight loss. She was not
orthostatic, but bolused 250cc fluids. Upon discharge, her SBP
was 100s-110s and she felt fine walking with walker, no
lightheadedness. Patient will f/u with PCP/NP a few days after
discharge to ensure she is still on the right BP regimen.
Chronic Diagnoses:
# Asthma: No wheezes on exam throughout admission. Patient was
maintained on nebs prn and Zafirlukast 20 mg Daily (home
medication).
#Neuropathy: Patient reports history of bilateral lower ext
neuropathy, not diabetes related, for which she takes Neurontin
at home. Neurontinw as initially held due to renal dysfunction,
but restarted when Cr normalized.
Transitional Issues:
# Patient discharged with nephrostomy tube worksheet and receive
nephrostomy care assistance from visiting nurse.
# Patient will continue Ciprofloxacin until she gets her stone
retreived.
# Patient has OR appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**1-27**] for stone
retrieval.
# Patient will follow up with PCP regarding BP management and if
she needs further diuresis.
# Dr.[**Name (NI) 10529**] secretary will help patient schedule IR appointment
to remove nephrostomy tube. Patient provided with IR phone
number in case she has questions.
# Communication: Patient, daughter [**Name (NI) 717**] [**Telephone/Fax (2) 44615**]c,
[**Telephone/Fax (2) 44616**]h
# Code: Full code (confirmed with pt [**2151-1-13**])
Medications on Admission:
Diltiazem ER 300 mg Daily
Neurontin 800 mg TID
Lisinopril 5 mg Daily
Zafirlukast 20 mg Daily
Ibuprofen 800 mg TID
Beclomethasone dipropionate 80 mcg/Actuation Aerosol Inhaler
Inhalation 2 Puffs [**Hospital1 **]
Discharge Medications:
1. gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. zafirlukast 20 mg Tablet Sig: 1-2 Tablets PO once a day.
3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation twice a day.
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days: Please take two tablets/day until
[**2151-1-24**] for a total of 14 day course.
Disp:*11 Tablet(s)* Refills:*0*
5. diltiazem HCl 180 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **] Inc.
Discharge Diagnosis:
Urosepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking vare of you at [**Hospital1 827**]. You were admitted with urosepsis, hypotension,
and a stone was found blocking your ureter. You were treated in
the intensive care unit for two days, where a neprhostomy tube
was placed in your right kidney to drain your urine. You will
follow-up with urology to remove the stone and with
interventional radiology to take the tube out. When your blood
pressure had normalized and you were seen by physical therapy,
we felt you were safe to go home.
Please note the following changes have been made to your
medications:
- Please START taking Ciprofloxacin and continue taking it until
you are told to stop after you follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] get the
stone retrieved from your ureter.
- Please STOP taking Lisinopril as your blood pressure has been
low in the days preceding discharge
- Please DECREASE your dose of Diltiazem to 180mg daily as your
blood pressure has been low in the days preceding discharge
- Please STOP taking lisinopril as your blood pressure was low
before discharge
** When you follow up with your PCP [**Last Name (NamePattern4) **] [**1-22**], please discuss
whether you should restart these medications.
- Please STOP taking Ibuprofen unti you kidney function
normalizes. You can discuss this issue when you follow-up with
your PCP.
[**Name Initial (NameIs) **] Please take oxycodone 5mg every 6 hours as needed for pain
- Please take a bowel regimen (docusate and senna) for as long
as you are on oxycodone to prevent constipation
** Please come to the ED if you feel short of breath, as you may
have accumulated fluid in your lungs again.
** Please make sure you get assistance when you get up and
especially when you get in and out of cars.
Followup Instructions:
Please follow up with the following appointments:
Name: [**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) **], NP
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 8724**]
Phone: [**Telephone/Fax (1) 8725**]
Appointment: Friday [**2151-1-22**] 10:40am
Name: Dr. [**Last Name (STitle) **]
[**Last Name (STitle) **]: SURGICAL SPECIALTIES/ UROLOGY
When: [**2151-1-27**] at 8:30 AM (10:00 AM procedure)
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
** This will be a procedure in the operating room to remove the
stone in your ureter. You will need to arrive at 8:30am for a
10:00 procedure. Please do not eat or drink anything after
midnight of the day of procedure.
Dr.[**Name (NI) 10529**] office will schedule you with an appointment with
Interventional Radiology after they remove your stone.
Interventional Radiology will take out your nephrostomy tube
when you no longer need it after the urology surgery. If you do
not hear from Interventional Radiology after , you can reach [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6745**] at ([**Telephone/Fax (1) 44617**].
***A nephrostomy tube care sheet has been included with your
discharge paperwork. This caresheet will include information on
how to clear and care for your tube, the date it was inserted,
as well as the contact information to people to get in touch
with regarding questions.***
Completed by:[**2151-1-20**] | [
"5990",
"5845",
"4019",
"2724",
"41401",
"49390",
"412",
"V4581"
] |
Admission Date: [**2157-11-7**] Discharge Date: [**2157-11-12**]
Date of Birth: [**2098-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Indocin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain for 2 days
Major Surgical or Invasive Procedure:
S/P emergency Coronary Artery Bypass Graft x3 (Left internal
mammary artery -> Left anterior descending artery, Saphaneous
vein graft -> Obtuse marginal, Saphaneous vein graft ->
Posterior descending artery) with intra aortic balloon pump
[**2157-11-7**]
History of Present Illness:
59 yo male with 2 day hiostory of chest pain and some SOB
presented to ER on [**11-7**] in the morning. Had endoscopy last wek
with some nausea and ?GERD. Now with substernal CP radiating
across left chest and down L arm.Started on integrilin and
heparin drips, and given 600 mg plavix in ER. Taken emergently
to cath and had IABP placed for acute MI/ severe LM disease.
Referred to Dr. [**Last Name (STitle) **] for emergent surgery.
Past Medical History:
sleep apnea with CPAP
depression
familial tremor
severe gastritis
HTN
GERD
Social History:
quit smoking 3 years ago, 20 pack/yr hx
Family History:
no premature CAD
Physical Exam:
T 95.6 HR 95 140/114 RR 18 99% 2L NC 192#
PERRLA EOMI
neck supple, no lymphadenopathy
CTAB
RRR S1 S2
abd soft/NT/ND
neuro appropriate
Pertinent Results:
[**2157-11-11**] 06:45AM BLOOD WBC-11.4* RBC-3.28* Hgb-9.9* Hct-29.5*
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.4 Plt Ct-340#
[**2157-11-11**] 06:45AM BLOOD Plt Ct-340#
[**2157-11-11**] 06:45AM BLOOD Glucose-111* UreaN-21* Creat-0.8 Na-141
K-4.4 Cl-105 HCO3-26 AnGap-14
[**2157-11-7**] 11:45AM BLOOD ALT-31 AST-73* CK(CPK)-749* AlkPhos-80
Amylase-53 TotBili-0.3
[**2157-11-7**] 11:45AM BLOOD cTropnT-0.75*
PROCEDURE DATE: [**2157-11-7**]
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class IV, unstable.
global ischemia; NSTEMI; chest pain refractory to medical
therapy
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease and LMCA disease.
2. Acute myocardial infarction, managed by IABP and emergent
surgery.
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
severe three vessel disease and 70% distal LMCA stenosis. The
LAD had a
proximal aneurysmal 80% lesion. The LCX was proximally totally
occluded
and thrombotic. The RCA had sequential mid and distal 99%
stenosis.
2. Left ventriculography was deferred.
3. Hemodynamic assessment showed normal systemic aortic
pressure.
4. Placement of the aortic baloon pump.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour12 minutes.
Arterial time = 0 hour12 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 80 ml,
Indications - Hemodynamic
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 0 units IV
Other medication:
Heparin 1000 U/hr
Intergrilin 14 cc/hr
Cardiac Cath Supplies Used:
6F CORDIS, XBLAD 3.5
7.5 DATASCOPE, IABP 40CC
150CC MALLINCRODT, OPTIRAY 150CC
- ALLEGIANCE, CUSTOM STERILE PACK
FINAL REPORT
INDICATIONS: 59-year-old male with chest pain.
COMPARISONS: Comparison is made to [**2157-11-7**].
TECHNIQUE: AP upright single view of the chest.
FINDINGS: Status post median sternotomy. The left chest tube and
NG tube
have been removed. Right IJ central line tip is in the mid SVC.
Mild
cardiomegaly. There is interval improvement of left lower lobe
opacity which
could represent atelectasis or consolidation. Persistent right
infrahilar
opacity stable since the prior study. No pneumothorax. Small
left pleural
effusion.
IMPRESSION:
1. Interval improvement in left retrocardiac, right infrahilar
consolidations.
2. Small left pleural effusion is [**Year (4 digits) 1506**]
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name8 (NamePattern2) 16699**] [**Name (STitle) 16700**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SAT [**2157-11-12**] 9:09 AM
Procedure Date:[**2157-11-9**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 102506**]
(Congenital) Done [**2157-11-7**] at 4:51:16 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2098-1-26**]
Age (years): 59 M Hgt (in): 69
BP (mm Hg): / Wgt (lb): 192
HR (bpm): BSA (m2): 2.03 m2
Indication: Left ventricular function. Intra-op TEE for emergent
CABG
ICD-9 Codes: 745.5, 424.0, 786.05, 786.51
Test Information
Date/Time: [**2157-11-7**] at 16:51 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Congenital) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2006AW03-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.6 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.5 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Valve Level: 2.5 cm <= 3.6 cm
Aorta - Ascending: *3.8 cm <= 3.4 cm
Aortic Valve - LVOT diam: 2.1 cm
Mitral Valve - E Wave: 0.4 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 0.80
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. PFO
is present. Left-to-right shunt across the interatrial septum at
rest.
LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. Moderate regional LV systolic dysfunction. Moderately
depressed LVEF. [Intrinsic LV systolic function likely depressed
given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size. Focal apical
hypokinesis of RV free wall.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root. Mildly dilated ascending aorta. There are complex
(>4mm) atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. Mild to
moderate ([**2-7**]+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was under
general anesthesia throughout the procedure. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
1. A patent foramen ovale is present.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is moderate to
severe regional left ventricular systolic dysfunction with
inferior, lateral and inferolateral hypokinesis. Overall left
ventricular systolic function is moderately depressed.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.]
3. Right ventricular chamber size is normal. There is modertate
focal hypokinesis of the apical free wall of the right
ventricle.
4. The ascending aorta is mildly dilated. There are complex
(>4mm) atheroma in the aortic arch and in the descending
thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are structurally normal. There is
central regurgitant jet by color doppler c/w mild to moderate
(2+) mitral regurgitation is seen.
7. There is no pericardial effusion.
POST-BYPASS:
Pt is being Apaced and is on an infusion of phenylephrine and
epinephrine
1. Slight improvement of RV and LV systolic function
2. Aorta is intact
3. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
?????? [**2154**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted through ER to cath lab and then taken emergently to OR
on [**11-7**] for CABG X3 with Dr. [**Last Name (STitle) **]. Transferred to the CSRU in
stable condition on epinephrine, phenylephrine and propofol
drips. Extubated that night and epinephrine weaned on POD #1.
IABP also removed on POD #1. Chest tubes removed on POD #2 and
transferred to the floor. Beta blockade titrated and gentle
diuresis started. Pacing wires removed on POD #3. He made good
progress and was cleared for discharge to home with VNA on POD
#5. Pt. is to make all follow-up appts. as per discharge
instructions.
Medications on Admission:
ASA 81 mg daily
diovan
topamax
klonopin
trazedone
nexion/zantac
norvasc
wellbutrin
Discharge Medications:
1. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Provigil 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Zantac 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Coronary artery disease
MI
Acute Coronary Syndrome
S/P Coronary Artery Bypass Graft
Primary medical history
Hypertension
Depression
Sleep Apnea - with CPAP
Familial Tremor
Gastritis
Gastric esophageal reflux disease
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use powders, lotions, or creams on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 2204**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2157-11-17**] | [
"41071",
"4240",
"41401",
"4019",
"42789",
"2859",
"32723",
"53081"
] |
Admission Date: [**2166-3-25**] Discharge Date: [**2166-4-2**]
Date of Birth: [**2111-5-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
STEMI (Chest Pain)
Major Surgical or Invasive Procedure:
Cardiac Catherization
Swan Ganz Catheter
Arterial line
History of Present Illness:
54F HTN, tobacco abuse, h/o pulmonary embolism,
neurofibromatosis, alcohol abuse, transferred to [**Hospital1 18**] for cath
from OSH following diagnosis of STEMI. Usual state of health
until the morning prior to admission, had substernal chest pain,
[**7-26**], with nausea and diaphoresis. Patient waited 2-3 hours,
however, pain persisted, and so she called EMS, who brought her
to [**Hospital1 487**] and was found to have ST elevations in I,II, V2-3.
Patient was transferred to [**Hospital1 18**] for catheterization. Upon
arrival to cath lab, pressures were low 100s SBP. Total
occlusion LAD, 90% in OM3, RCA 70%. LAD was stented w/ heparin
coated stents X 2 and Reopro such that Plavix could be DC'd if
needed in the setting of acute GI bleed.
Following intervention, patient dropped SBP to 70s, and was
started on dopamine drip, w/ HR in 120s-130s, and bolused w/
1400cc NS. Heparin was stopped, and no additional IIB/IIIA
inhibitor given due to history of BRBPR X few days and decreased
hematocrit.
Of note patient had BRBPR by rectal exam in cath lab, as well as
at home on tissue. No blood in toilet bowl at home, no melena or
hematemesis. Does have nausea and vomiting but able to tolerate
liquids. Has lost 60 pounds over last 6 months.
Patient has had claudication after walking 10 feet, sleeps on
[**1-17**] pillows for "breathing".
Past Medical History:
- Neurofibromatosis
- Hypertension
- Pulmonary embolism [**2158**]
- Malignant nerve sheath tumor (s/p removal from left anterior
chest wall [**6-19**] and radiation [**2166**])
- Depression
- Hypothyroidism
- Pneumonia in [**2-18**]
- Hypercalcemia
- Alcoholism
- Schizoaffective disorder
Social History:
Tobacco: 1PPD
Alcohol: Quit 8 years ago, but history of abuse.
Family History:
Neurofibromatosis in multiple family members with history of
early death
Physical Exam:
97.3 84 93/60 20 99%RA
General: No acute distress, lying in bed, comfortable. Diffuse
neurofibromas from head to toe. Cafe [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28584**] spots in axillae.
CV: S1, S2, regular, no murmurs rubs or gallops. JVD not
appreciable
Lungs: CTAB, no wheezes, rales or rhonchi
Abdomen: Active bowel sounds, Soft, NT, ND, no rebound or
guarding. Scar on left anterior chest wall.
Extremities: Warm, no clubbing cyanosis or edema. DP and PT
pulses 2+ bilaterally.
Neuro: Alert and oriented X 3, strength and sensation grossly
intact. Walks with walker as per baseline.
Pertinent Results:
[**2166-3-25**] 11:09PM URINE HOURS-RANDOM
[**2166-3-25**] 11:09PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2166-3-25**] 10:14PM TYPE-ART PO2-93 PCO2-29* PH-7.37 TOTAL
CO2-17* BASE XS--6
[**2166-3-25**] 10:14PM O2 SAT-97
[**2166-3-25**] 10:12PM TYPE-MIX
[**2166-3-25**] 10:12PM O2 SAT-69
[**2166-3-25**] 10:06PM SODIUM-141 POTASSIUM-3.6 CHLORIDE-115*
[**2166-3-25**] 10:06PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2166-3-25**] 10:06PM HCT-32.2*
[**2166-3-25**] 07:56PM TYPE-ART RATES-/16 PO2-77* PCO2-23* PH-7.44
TOTAL CO2-16* BASE XS--5 INTUBATED-NOT INTUBA
[**2166-3-25**] 07:56PM K+-3.5
[**2166-3-25**] 07:56PM HGB-9.4* calcHCT-28 O2 SAT-96
[**2166-3-25**] 07:40PM WBC-10.2 RBC-3.27* HGB-9.7* HCT-27.7* MCV-85
MCH-29.6 MCHC-35.0 RDW-16.5*
[**2166-3-25**] 07:40PM NEUTS-79.6* LYMPHS-15.6* MONOS-3.5 EOS-0.9
BASOS-0.3
[**2166-3-25**] 07:40PM ANISOCYT-1+ MICROCYT-1+
[**2166-3-25**] 07:40PM PLT COUNT-262
[**2166-3-25**] 07:40PM PT-19.1* PTT-150* INR(PT)-2.4
[**2166-3-25**] 06:56PM TYPE-ART PO2-164* PCO2-18* PH-7.54* TOTAL
CO2-16* BASE XS--3 INTUBATED-NOT INTUBA
[**2166-3-25**] 06:56PM K+-3.1*
[**2166-3-25**] 06:56PM O2 SAT-98
[**2166-3-25**] 06:50PM GLUCOSE-137* UREA N-19 CREAT-0.9 SODIUM-140
POTASSIUM-3.1* CHLORIDE-111* TOTAL CO2-15* ANION GAP-17
[**2166-3-25**] 06:50PM CK(CPK)-215*
[**2166-3-25**] 06:50PM CK-MB-32* MB INDX-14.9* cTropnT-0.41*
ECG Study Date of [**2166-3-25**] 7:28:12 PM
Baseline artifact. Sinus rhythm. Ventricular ectopy with
ventricular couplets. Left axis deviation. Anterior Q waves with
a late transition consistent with prior anterior myocardial
infarction. Diffuse non-specific ST-T wave changes. No previous
tracing available for comparison.
C.CATH Study Date of [**2166-3-25**]
1. Selective coronary angiography of this right dominant system
revealed
multi vessel disease. The LMCA contained mild, diffuse disease.
The
LAD was totally occluded after the first diagonal branch. The
LCX was
without flow limiting disease but gave off an OM3 branch with
90%
lesion. The RCA contained a 70% proximal lesion.
2. Resting hemodynamics revealed an elevated mean PCPW of 25mmHg
with a
low cardiac index of 2.3 l/min/m2.
3. Left ventriculography was not performed.
4. Successful PTCA/stenting of the proximal/mid LAD with
2.5x18mm and
2.5x18mm overlapping Hepacoat stents. Final angiography revealed
no
residual stenosis, no dissection and TIMI-3 flow (see PTCA
comments).
5. Distal aortography revealed severe bilateral iliac and common
femoral
disease procluding the potential placement of IABP.
6. At completion of the case, the patient's HCT was noted to be
28, down
from 40 at case start. A rectal exam revealed gross blood. The
patient's blood pressure transiently dropped to SBP in the 80s,
but
responded to fluid boluses, blood transfusion, and dopamine.
The
patient left the lab hemodyamically stable on low dose dopamine.
ECHO Study Date of [**2166-3-26**]
EF 25- 30%
There is moderate to severe regional left ventricular systolic
dysfunction
with akinesis of the antero-septum and entire distal LV
including the apex. The remaining segments are hyperdynamic. No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. There is no
aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral regurgitation. The left ventricular
inflow pattern suggests impaired relaxation. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a fat pad, with a
superimposed trivial pericardial effusion. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
54F neurofibromatosis, HTN, hypothyroidism, recent PNA,
transferred here w/ ?STEMI, revasc LAD, hypotension post
intervention.
* HYPOTENSION: Initially hypotensive in cath lab following
procedure. Required initiation of dopamine, then addition of
levophed on hospital day 2. Of note, CI was never low (>3.0)
and SVR was intermittently 600s-700s during episodes of
hypotension (SVR increased appropriately with uptitration of
pressors). Although this was physiology consistent with sepsis
or adrenal insufficiency, patient was never febrile, CXR and
pan-cultures were negative, and cosyntropin stimulation yielded
appropriate secretion of cortisol.
Rec'd one unit of blood on HOD2 for Hct 29->35->32.
Spontaneously weaned off of dopamine on hospital day 3 without
complications. Indeed, patient became hypertensive to SBP160s,
and was started easily on carvedilol and lisinopril at that
point. Intermittently, however, patient continued to have
episodes of asymptomatic hypotension while sleeping at night.
Given this clinical picture, patient's initial hypotension post
STEMI was thought to be secondary to cardiogenic shock despite
Swan-Ganz values, and as patient's cardiac function recovered,
blood pressure improved appropriately.
* ACID BASE DISTURBANCE: When patient arrived, had AG of 14,
potassium of 3.1 and ABG 7.54/18/164 suggesting a respiratory
alkalosis w/ mixed gap and non gap metabolic acidemia. This may
have been due in combination to cardiogenic shock and volume
repletion with saline. RTA Type II was felt to be a
possibility, and bicarb load was considered- however, this was
not attempted given patient's cardiac issues and need for
euvolemic status. As patient's clinical status improved, gap
continued to close and bicarb normalized, and other than
hypotension early during course, patient never had any signs or
symptoms localizing metabolic disturbance. Of note patient's
laboratory values often fluctuated within hours, suggesting
large fluid shifts (intra->extravascular) of unclear etiology.
Further, cosyntropin stim revealed no adrenal insufficiency that
would explain patient's condition. Given resolution without
clear clinical etiology, further workup of this issue was
deferred to outpatient.
* ISCHEMIA: Occluded LAD reopened with hepacoat stents, OM3 and
RCA significant unrevascularized disease. Patient was started
on ASA, Plavix, Lipitor 80, and carvedilol and lisinopril as
hypotension resolved. Although further intervention could be
pursued, given high grade malignant peripheral nerve sheath
tumor and multiple nodules noted on MRI and CT at [**Hospital1 2025**] and
[**Hospital3 1443**], it was felt that patient would be best served
with workup and thorough staging and prognostic evaluation of
malignancy to further determine utility of revascularization.
Followup was arranged with Dr. [**Last Name (STitle) 5686**] in [**Hospital1 487**] within
one month of discharge.
* Pump: EF 30% bedside echo w/ anterior hypokinesis post cath.
Hypotensive but weaning dopamine, continue IV fluids for now.
Wedge ~20 in lab. As noted above, as hypotension improved,
patient was started on carvedilol and lisinopril to improve
cardiac remodeling.
* Rhythm: While on dopamine, patient was in continuous sinus
tachycardia (110s-140s). However, patient did have one isolated
episode NSVT X 14 beat run. With weaning of dopamine and
uptitration of carvedilol, patient's heart rate improved to
60s-80s at the time of discharge. Further consideration for
prophylactic ICD placement would pend revascularization of
remaining 2 vessel disease.
* PVD: Severe iliac disease seen on cath, as correlates with
patient's baseline claudication (can walk 10ft). This was not
intervened upon at the time of catheterization given patient's
hemodynamic instability. Again, further intervention of these
lesions would depend upon patient's malignancy and prognosis.
* BRBPR: Following catheterization, patient was noted to have
BRBPR and required one unit of packed red cells. However,
following this acute episode, patient had guaiac negative stools
and no longer required any further transfusions. It was
recommended to the patient that she undergo outpatient
colonscopy for further evaluation.
* Hypothyroidism: TSH 8.7 and Free T4 0.5. Patient was
empirically started on 100mcg levothyroxine given history of
noncompliance and unclear dose to reach euthyroid level (patient
intermittenly on 50-200mcg levothyroxine [**First Name8 (NamePattern2) **] [**Hospital1 487**] records).
On this, patient was clinically euthyroid, but would require
followup thyroid function test evaluation following discharge.
* COMMUNICATION: Extensive communication with son [**Name (NI) 915**] [**Name (NI) 805**]
[**Telephone/Fax (1) 62116**]
At the time of discharge, patient was hemodynamically stable
with no further episodes of chest pain or GI bleeding. Patient
was to followup with oncologist for PET/CT evaluation of
malignant peripheral nerve sheath CA.
Medications on Admission:
Toprol XL 50
Levoxyl
Albuterol
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*35 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Quetiapine Fumarate 25 mg Tablet Sig: Four (4) Tablet PO HS
(at bedtime).
Disp:*120 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Malignant peripheral nerve sheath tumor
Hypothyroidism
Neurofibromatosis
Cardiogenic shock
Anorectal bleeding
Discharge Condition:
Good - no further episodes of chest pain, shortness of breath.
Continued to have episodes of asymptomatic hypotension at night
while sleeping.
Discharge Instructions:
Please take all medications as directed.
Followup Instructions:
Colonoscopy - Recommend followup colonoscopy given anorectal
bright red blood to rule out malignancy as outpatient.
.
Hypothyroidism - Recommend repeat thyroid function tests to
monitor thyroid replacement.
.
Oncology: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 2025**] ([**Telephone/Fax (1) 62117**] as scheduled on Please go for your PET scan and CT of
the chest and abdomen at [**Hospital1 2025**] as scheduled by Dr.[**Name (NI) 62118**]
office.
.
Cardiology: Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5686**] at ([**Telephone/Fax (1) 62119**] as scheduled on Tuesday, [**4-15**] at 11:15am on the [**Location (un) 1385**] of [**Hospital3 1443**] Hospital.
| [
"41401",
"4019",
"3051",
"2449",
"311"
] |
Admission Date: [**2185-7-30**] Discharge Date: [**2185-8-6**]
Date of Birth: [**2147-4-12**] Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Alcohol intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 38 year-old man with a medical history notable for
alcohol abuse and alcohol withdrawal seizures. He was brought to
the ED by EMS after being found lying in traffic on [**2185-7-29**].
He reportedly was covered in feces when EMS found him.
Vitals on arrival to [**Hospital1 18**] ED: T 96, P 88, BP 117/75, 100% on
RA. He was intoxicated on arrival. His evalution in the ED was
notable for a head CT with no acute intracranial abnormalities
and an ethanol level of 306. He also had an anion gap of 31. In
the ED, he received MVI, folate, and thiamine. The patient
reported no other drug use in the ED.
Past Medical History:
- History of chronic pancreatitis from alcoholism. Per the OMR,
he also reports a partial Whipple procedure in [**State 1727**] in [**2179**]
(per the patient, the operation was aborted after incision was
made because his pancreas appeared swollen)
- Polysubstance abuse including heroin/cocaine/alcohol
- H/o alcohol withdrawal seizures
- Depression s/p hospitalization at [**Hospital **] [**Hospital 1459**] Hospital
- Diabetes mellitus, on insulin. Previous notes suggest this is
type I insulin
- Hepatitis C- genotype 1; no previous treatment
- Per patient reportedly PPD positive at some point in the past
but never received treatment and then had repeat negative PPD
- C3/C4 fracture [**6-/2185**] from injury while intoxicated
Social History:
On disability. Smokes 1 ppd. Drinks [**11-20**] gallon of vodka/day
since age 14. Past cocaine and IV heroin use. After his last
admission at [**Hospital1 18**], he was discharged to the [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 23752**]
House.
Family History:
Brother died of leukemia. Both parents are alive. Mother is a
heroin addict.
Physical Exam:
- Gen: Well-appearing in NAD.
- HEENT: Conj/sclera/lids normal, PERRL, EOM full, and no
nystagmus. Hearing grossly normal bilaterally. Sinuses
non-tender. Nasal mucosa and turbinates normal. Oropharynx clear
w/out lesions.
- Neck: Supple with no thyromegaly or lymphadenopathy.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: PMI normal size and not displaced. Regular rhythm. Normal
S1, S2. No murmurs or gallops. JVP <5 cm. 2+ carotids. No
carotid bruits.
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
Liver/spleen not enlarged.
- Rectal: No external lesions. Normal tone, stool guaiac
negative.
- Extremities: No ankle edema.
- MSK: Joints with no redness, swelling, warmth, tenderness.
Normal ROM in all major joints.
- Skin: No lesions, bruises, rashes.
- Neuro: Alert, oriented x3. Good fund of knowledge. Able to
discuss current events and memory is intact. CN 2-12 intact.
Speech and language are normal. No involuntary movements or
muscle atrophy. Normal tone in all extremities. Motor [**3-23**] in
upper and lower extremities bilaterally. Gait normal. DTRs 2+ at
brachioradialis and patella bilaterally. Plantar reflex down
(neg Babinski). Finger-to-nose and heel-to-shin normal. Romberg
and pronator drift negative. Sensation to light touch intact in
upper and lower extremities bilaterally.
- Psych: Appearance, behavior, and affect all normal. No
suicidal or homicidal ideations.
Pertinent Results:
Admission Labs:
- [**2185-7-30**] 12:15AM GLUCOSE-372* UREA N-9 CREAT-0.7 SODIUM-135
POTASSIUM-4.8 CHLORIDE-93* TOTAL CO2-16* ANION GAP-31*
LACTATE-2.2*
- [**2185-7-30**] 12:15AM WBC-5.8 (NEUTS-70.0 LYMPHS-26.0 MONOS-2.2
EOS-0.5 BASOS-1.2) RBC-4.78# HGB-15.2# HCT-44.0# MCV-92 MCH-31.7
MCHC-34.5 RDW-17.5* PLT COUNT-78*
- [**2185-7-30**] 02:22AM TYPE-ART PO2-106* PCO2-36 PH-7.39 TOTAL
CO2-23 BASE XS--2
- [**2185-7-30**] 12:15AM ASA-NEG ETHANOL-306* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
- [**2185-7-30**] 03:30AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
- [**2185-7-30**] 03:30AM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-1.030 BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-1000
KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0
WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 RENAL EPI-0-2
CXR [**2185-7-30**]: No signs for acute cardiopulmonary process.
Head CT [**2185-7-30**]: No acute intracranial abnormality.
CT ABD [**2185-8-5**]: Preliminary Report !! PFI !!
1. Diffuse fatty infiltration of the liver increased since prior
exam in
[**2183-12-21**].
2. Pancreatic calcifications consistent with chronic
pancreatitis. No
evidence of any complications associated with acute
pancreatitis.
3. Fat stranding within umbilical hernia.
Brief Hospital Course:
1. Alcohol intoxication: Intoxicated on arrival to the ED with
initial EtOh level of 306. Reported history of withdrawal
seizures, most recent 3 months ago. SW consult was placed as pt
expressed the desire to attempt to undergo treatment for this
issue. PPD placed on [**8-2**] as part of screening process, per pt
has been negative in the past.
2. Alcohoic / diabetic ketoacidosis: Presented with + anion gap
and ketones in the urine; possible combination of alcoholic and
diabetic ketoacidosis. After insulin and IVF, gap closed.
3. Chronic pancreatitis: Abdominal pain was consistent with
prior chronic pancreatitis, although initially appeared
comfortable. Pain worsened and was transitioned to IV pain
medications and made NPO with improvement in his pain. Diet was
restarted and advanced and initiallly he complained of pain and
had to return to IV medication, but it was then noted that
patient was electing to eat a regular diet by getting his own
food, despite clear instruction to remain NPO. He was returned
to PO pain medication only.
4. Thrombocytopenia: Recently noted with possible direct
alcohol effect. No evidence of cirrhosis on exam and
INR/albumin were preserved.
5. Hand Cellulitis/abscess- infection developed on right hand at
site of his IV, treated with Kelflx for one week.
6. Diabetes mellitus, on insulin: On insulin sliding scale
inpatient and small dose NPH [**Hospital1 **]. Pt with very high sugars in
300-400's once diet restarted. Given questionable ability to
comply with complex insulin regimen, discharged home with once
daily Lantus and f/u with PCP [**Name Initial (PRE) 176**] 1 week. Pt instructed to
log blood sugars at home and bring log to next PCP appt on
[**2185-8-11**].
7. Smoker: Nicotine gum prescribed.
8. Homeless: Pt given vouchers/train pass to get to Fall Rivers
where his mother lives.
Medications on Admission:
[**2185-7-17**] [**Hospital1 18**] Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Ibuprofen 200 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
4. Valium 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for withdrawal sx, agitation, anxiety: please
take if score on CIWA>10 or for agitation/anxiety.
5. Insulin Glargine 100 unit/mL Solution Sig: 10 units
Subcutaneous at bedtime.
6. Insulin sliding scale with fingersticks QID
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for mild to moderate pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days: For skin infection on hand. Finish all of
the antibiotics.
Disp:*16 Capsule(s)* Refills:*0*
6. Nicotine (Polacrilex) 2 mg Gum Sig: One (1) Gum Buccal Q1H
(every hour) as needed for smoking craving.
Disp:*30 Gum(s)* Refills:*0*
7. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for moderate to severe pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Twenty
(20) units Subcutaneous QHS.
Disp:*3 pens* Refills:*0*
9. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: as instructed for blood sugar check.
Disp:*50 strips* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Alcoholic ketoacidosis
- Alcohol withdrawal
- Chronic pancreatitis
SECONDARY DIAGNOSES:
- Depression
- Diabetes mellitus, on insulin.
- Hepatitis C- genotype 1
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with acidosis from alcohol use, and
pancreatitis treated with pain medication. An abdominal CT did
not show any worsening of your pancreatitis. Abstinence will be
essential going forward.
DIABETES INSTRUCTIONS:
- Insulin Glargine (Lantus) 20 units once a day at night. Check
your blood sugar as you were instructed (before each meal and at
night before going to sleep). Write down your blood sugars on a
paper and bring this log to your next appointment. Please
follow up with your Primary Care Doctor [**First Name (Titles) **] [**Last Name (Titles) 16337**], [**2185-8-11**] for adjustment in your insulin dosing.
Followup Instructions:
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2185-8-11**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 74280**], MD [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Phone [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| [
"2875",
"3051",
"V5867",
"311"
] |
Admission Date: [**2190-10-8**] Discharge Date: [**2190-10-15**]
Date of Birth: [**2122-5-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2190-10-11**] Coronary Artery Bypass Graft x 3 (LIMA to Diag, SVG to
LAD, SVG to RCA)
History of Present Illness:
68 y/o male with three month h/o exertional dyspnea andjaw pain.
Had a positive stess test. Referred for cardiac cath which
revealed severe three vessel coronary artery disease.
Transferred to [**Hospital1 18**] for surgical management.
Past Medical History:
Hypertension, Hypercholesterolemia, Diabetes Mellitud, Anxiety,
s/p hernia repair
Social History:
Remoted smoking history. Occasional ETOH use.
Family History:
Non-contributory
Physical Exam:
Neuro: A&O x 3, MAE, non-focal
Puml: CTAB -w/r/r
Cor: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, -edema
Pertinent Results:
[**10-11**] Echo: PRE-CPB The left atrium is moderately dilated. The
left atrium is elongated. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thickness, cavity size,
and systolic function are normal (LVEF>55%). The right
ventricular cavity is mildly dilated. Right ventricular systolic
function is normal. There are complex (>4mm) atheroma in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
POST-CPB Normal biventricular systolic function. Mild mitral
regurgitation. Thoracic aorta intact.
[**10-13**] CXR: Patient has been extubated. Multiple lines and tubes
have been removed. There are low lung volumes with bilateral
bibasilar atelectasis worse in the right lower lobe. Bilateral
pleural effusions are small. Patient is post-median sternotomy
and CABG. Cardiac size is top normal. The stomach is moderately
dilated.
[**2190-10-8**] 07:22PM BLOOD WBC-8.9 RBC-4.14* Hgb-14.1 Hct-38.7*
MCV-94 MCH-34.1* MCHC-36.4* RDW-13.6 Plt Ct-256
[**2190-10-14**] 12:55PM BLOOD WBC-10.4 RBC-3.26* Hgb-10.6* Hct-30.8*
MCV-95 MCH-32.4* MCHC-34.3 RDW-13.2 Plt Ct-192
[**2190-10-8**] 07:22PM BLOOD PT-12.3 PTT-25.5 INR(PT)-1.1
[**2190-10-11**] 11:59AM BLOOD PT-14.1* PTT-71.8* INR(PT)-1.2*
[**2190-10-8**] 07:22PM BLOOD Glucose-138* UreaN-24* Creat-1.1 Na-139
K-3.9 Cl-105 HCO3-28 AnGap-10
[**2190-10-14**] 12:55PM BLOOD Glucose-107* UreaN-13 Creat-1.0 Na-143
K-3.7 Cl-108 HCO3-28 AnGap-11
[**2190-10-14**] 12:55PM BLOOD Calcium-7.8* Phos-1.5*# Mg-2.1
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 20825**] was transferred to [**Hospital1 18**]
following his cath. He received medical management over several
days while be worked-up prior to surgery. On [**10-11**] he was brought
to the operating room where he underwent a coronary artery
bypass graft x 3. Please see operative report for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned off sedation, awoke neurologically intact and extubated.
On post-op day one he was started on beta blockers and
diuretics. He was gently diuresed towards his pre-op weight.
Later on post-op day one he was transferred to the SDU for
further care. Chest tubes were removed on post-op day two.
Epicardial pacing wires were removed on post-op day three. He
did have some post-op confusion which resolved by time of
discharge. He continued to slowly improve while working with
physical therapy. On post-op day four he appeared to be doing
well and was discharged home with VNA services and the
appropriate follow-up appointments.
Medications on Admission:
Atenolol 25mg qd, Aspirin 325mg qd, Celexa 20mg qd, Protonix
40mg qd, MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Hypercholesterolemia, Diabetes Mellitud,
Anxiety, s/p hernia repair
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 1295**] in [**2-20**] weeks
Dr. [**First Name (STitle) **] in [**1-19**] weeks
Completed by:[**2190-10-15**] | [
"41401",
"4019",
"2720",
"25000"
] |
Admission Date: [**2186-11-21**] Discharge Date: [**2186-11-30**]
Date of Birth: [**2144-2-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
seizure activity
Major Surgical or Invasive Procedure:
central line placement - right IJ
History of Present Illness:
42yo woman with Cerebral palsy, mental retardation and epilepsy
was admitted from her group home today after she was noted to
have right sided facial and shoulder twitching starting at
3:15pm.
Patient arrived at [**Hospital1 18**] by EMS at roughly 5pm and was noted to
have persistent twitching. She was treated with valium 5mg at
5:30pm, and her suspected seizure stopped. Her FS was 86.
Thoughout, she had been unresponsive. After breaking her
suspected seizure, she returned closer to her usual baseline
mental status which involves responding to verbal and tactile
stimuli. In total, she received 5mg valium, 2mg ativan,
ceftriaxone 1g IV.
Past Medical History:
1. Mental retardation, baseline non-verbal
2. Refractory epilepsy, usually focal onset with secondary
generalization
3. insulin-dependent diabetes mellitus
4. h/o stroke with residual left arm weakness
5. diabetes insipidus, nephrogenic in origin
Social History:
Lives in group home, needs assistance with all ADLs
Family History:
Noncontributory
Physical Exam:
vitals: 98.9F, 100, 102/59, 14-20, 96-100% on 3L nc
Gen: non-responsive to painful stimuli or sternal rub
HEENT: pupils 3mm, and somewhat responsive bilaterally
neck: supple
CV: RRR, no m/r/g
Chest: distant breath sounds; CTAB, no w/r/r
Abd: obese, soft, ND, +BS
Extr: cool; tr LE edema bilaterally, trace dp pulses
Neuro: minimally responsive to sternal rub
Pertinent Results:
EEG - Abnormal due to frequent bifrontal epileptiform sharp
discharges and independent slowing. This suggests medication
effect. No seixure activity seen.
.
Urine Culture grew E. coli resistant to levaquin and bactrim.
.
CXR - no pneumonia
.
ABD CT - Patchy bibasilar consolidations that could represent
aspiration. Stable renal cysts. Fat containing umbilical
hernia. Stable right adnexal cyst. Probable fecal impaction.
Brief Hospital Course:
She was initially admitted to the medical floor, she became
hypotensive to 70-80's systolic, and she was volume resuscitated
with near 5L total of normal saline; however she remained
hypotensive. A right IJ TLC was placed for central venous
access, and she was started on dopamine gtt. She was given one
dose of po levaquin 500mg. A lumbar puncture was performed,
which showed no cells, slightly elevated protein (64) and normal
glucose. She was transferred to the [**Hospital Unit Name 153**] for further management
of presumed urosepsis.
.
In the [**Hospital Unit Name 153**], she was hypothermic to 90F and hypotensive to 95/51
on dopamine 10mcg/hr. UA showed evidence of E. coli UTI, found
on [**11-24**] to be fluoroquinolone and bactrim resistant. Her
mebaral was held, and she was placed on phenobarbital with no
loading. Her goal dilantin level is 20-30, and dilantin was held
until the level fell into that range. Her goal phenobarbital
level is 30-40, and this was held as well until level fell into
the appropriate range. The patient was well known to the
neurology service from multiple prior admissions, and the
neurology team followed her throughout her hospitalization. Her
EEG showed improvement from baseline with fewer spikes and no
evidence of ongoing seizures. After treating the urinary tract
infection with ceftriaxone, the patient returned to baseline and
was able to restart her oral anti-epileptics.
The patient also suffered from fecal impaction and constipation
which was unable to be manually disimpacted as stool could not
be appreciated in the vault. She was treated with multiple
enemas and with lactulose from above.
By the day of discharge, Ms. [**Known lastname 13461**] had returned to her
baseline mental status. She had restarted her oral
antiepileptics and had no evidence of any seizures or worsening
infection. She was d/c'ed back to her facility on two additional
days cefpodoxime 200mg PO bid for total of seven days
antibiotics.
Medications on Admission:
1. NPH 6units in am; regular insulin sliding scale
2. Mebaral 150mg [**Hospital1 **]
3. Senna
4. Nystatin
5. Miralax
6. Phenytoin 200mg am, 230mg pm (recent decrease in dose, given
supratherapeutic levels)
7. desmopressin 0.01% spray nasal [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Desmopressin 0.01 % Aerosol, Spray Sig: One (1) spray Nasal
DAILY (Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Dulcolax 10 mg Suppository Sig: One (1) Rectal tiw.
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
7. Mephobarbital 50 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
8. Dilantin 30 mg Capsule Sig: One (1) Capsule PO at bedtime.
9. Dilantin 100 mg Capsule Sig: Two (2) Capsule PO at bedtime.
10. Dilantin 100 mg Capsule Sig: Two (2) Capsule PO qAM.
11. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days: Last dose: [**2186-11-30**].
12. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
One (1) spray Nasal twice a day.
13. Humulin R 100 unit/mL Solution Sig: One (1) Injection four
times a day: Per sliding scale insulin protocol.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Six (6)
units Subcutaneous qAM.
15. Insulin Syringe 1 mL 29 x [**12-18**] Syringe Sig: One (1) syringe
Miscell. five times a day.
16. Nasacort AQ 55 mcg/Actuation Aerosol, Spray Sig: One (1)
spray Nasal twice a day.
Discharge Disposition:
Extended Care
Facility:
St. [**Doctor Last Name 11042**]
Discharge Diagnosis:
Urosepsis
Seizure
Discharge Condition:
Improved. Afebrile and non-hypothermic, no seizure activity,
taking PO, believed to be at baseline mental status.
Discharge Instructions:
You have been diagnosed with a seizure, and with a urinary tract
infection. Your dose of dilantin was changed, and you are being
discharged on additional oral antibiotics for your urinary tract
infection. You should be brought to the ED for fever,
hypothermia, seizures, or for any other concerning problems.
Followup Instructions:
You should see Dr. [**Last Name (STitle) 4026**] within the next 1-2 weeks for follow
up. An appointment can be made by calling [**Telephone/Fax (1) 250**].
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11347**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 857**]
Date/Time:[**2187-1-4**] 11:15
Provider: [**First Name8 (NamePattern2) 5257**] [**Last Name (NamePattern1) 5258**], [**Name12 (NameIs) 280**] Date/Time:[**2186-12-19**] 9:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
| [
"0389",
"78552",
"5990",
"2760",
"99592",
"25000",
"V5867"
] |
Admission Date: [**2139-8-24**] Discharge Date: [**2139-8-29**]
Date of Birth: [**2096-11-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever and HA
Major Surgical or Invasive Procedure:
IJ catheter placement
History of Present Illness:
42M with h/o HIV/AIDS, last CD4 312 [**2139-8-20**] and h/o bacterial
and crytopcoccal meningitis presents to ED with complaint of
fever to 101-102 and HA over the last seven days. HA is new,
gradual in onset, steady and unremitting in intensity. He rates
pain at worst between [**2144-8-3**]. States he had taken taken tylenol
initially for relief but has since been ineffective. Evaluated
by PCP 3 days PTA, no intervention at that time except
recommendation to return to ED if HA persisted. Pt endorses mild
photophobia nad neck stiffness, no other symptoms. No chills, no
n/v, no CP or SOB, no urinary changes except "dark urine." In
ED, CT negative, LP also essentially negative (Protein and
glucose normal, tube 4 with 2 WBC and no RBC, 88% lymphocytes).
Transient hypotension in ED, predominantly 90/50s, eventual
response to fluid. Received 2g CTX and 1g Vanco in ED, as well
as 6 liters NS. Admitted to MICU under MUST protocol, initial
lactate 5.0.
Past Medical History:
1. HIV/AIDS, last CD4 312, nadir 135 in [**2136**]
2. hepatitis B
3. hepatitis C
4. pancytopenia [**1-28**] HIV, baseline hct 35 and baseline plt 80
5. distant h/o cryptococcal menigitis
6. distant h/o bacterial menigitis
7. distant h/o e.coli sepsis
8. h/o STI including chlamydia, molluscum, herpes
9. h/o PSA
10. h/o oral candidiasis
11. s/p L herniorrhaphy
Social History:
Uses tobacco, approximately 1 pack weekly, denies alcohol or
IVDU currently. Pt is currently unemployed but was a former
airline analyst. Lives with roommate.
Family History:
NC
Physical Exam:
T 101.5 in ED, 96.5 in MICU BP 120/66 HR 92 RR 15 Sats 100%
RA
Gen: Pt lethargic but appears ok, NAD
HEENT: ncat, perrla, eomi, conjunctiva non-injected, sclerae
with mild icterus
CV: rrr s mrg, flat neck veins
Lungs: CTAB, good air movement
Abd: sntnd, +bs, no hsm appreciated.
ext: 2+ ble pulses, no peripheral edema. 1-2 cm purplish
blanching lesions on BLE that are chronic, appear c/w chronic
venous stasis change
Neuro: AO x 3, MAE, neuro grossly intact
Pertinent Results:
[**2139-8-24**] 11:04PM LACTATE-2.7*
[**2139-8-24**] 10:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-25
GLUCOSE-56
[**2139-8-24**] 10:30PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 POLYS-0
LYMPHS-88 MONOS-6 MACROPHAG-6
[**2139-8-24**] 10:10PM LACTATE-3.4*
[**2139-8-24**] 09:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2139-8-24**] 09:30PM URINE BLOOD-LG NITRITE-POS PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-MOD
[**2139-8-24**] 09:30PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2139-8-24**] 05:39PM LACTATE-5.0*
[**2139-8-24**] 05:32PM GLUCOSE-125* UREA N-50* CREAT-3.7*#
SODIUM-120* POTASSIUM-5.0 CHLORIDE-85* TOTAL CO2-22 ANION GAP-18
[**2139-8-24**] 05:32PM ALBUMIN-2.5* CALCIUM-8.3* PHOSPHATE-2.0*
MAGNESIUM-1.6
Brief Hospital Course:
A/P 42M with h/o HIV/AIDS, hep b and c, distant h/o cryptococcal
and bacterial meningitis with UTI, septic shock, likely
secondary to urinary source. Also with resolving hyponatremia,
ARF, metabolic acidosis, anemia, concerning mental status
changes, new abdominal distension.
.
1. Septic Shock:
Patient with SIRS plus suspected source of infection given UA,
hypotension and evidence of inadequate end-organ perfusion.
Initial WBC in ED 24.0, lactate 5.0. Blood/urine cx growing
E.coli, pansensitive to antibiotics. LP in the ED was negative
for infxn. Pt was admitted to ICU, administered aggressive NS
IVF hydration, given Vanco/CTX for empiric Abx coverage until
E.Coli was isolated, and vanco was discontinued. Pt was
discharged on a course of cefpodoxime to complete a 14 day
course for E.Coli bacteremia.
.
2. Hyponatremia:
Due to infxn and hypovolemia, corrected with IVF hydration.
.
3. Mental status changes:
Initially seen in MICU in setting of infection, long-term HIV
and rapid sodium correction and liver disease. LP was negative
for infxn. Resolved with treatment of infection.
.
3. ARF:
Pre-renal in etiology given patient's hypovolemic and
distributive picture, but differential includes HRS. FeNa 0.9%,
which does not help in differenting prerenal vs. HRS. Creatinine
trended down during admission from 3.7 ---> 1.8 on discharge to
be followed up as an outpatient. His previous baseline had been
0.9-1.2.
.
4. Anemia:
Hct stable 27.4 today (27.1 yest). Slow to return to baseline
36-37.
.
5. HIV:
Pt with h/o HIV, hepatitis. Initially HAART held due to
metabolic acidosis in setting of ARF and sepsis. HAART was
restarted prior to discharge once patient was stable and
infection was under treatment. Pt with elevated
.
6. Hepatitis
Pt with Hx of Hep B/C, during this admission found to have
elevated AFP, but patient declined further w/u at this time. Pt
to consider MRI as outpatient to r/o HCC. No mass seen on abd
u/s.
.
DISPO
- Full Code. Pt to f/u with Dr. [**Last Name (STitle) 4844**] as an outpatient.
Medications on Admission:
1. ABACAVIR SULFATE 300MG [**Hospital1 **]
2. BACTROBAN 2%--Apply to open sore twice a day
3. EFAVIRENZ 600MG QHS
4. LAMIVUDINE 300MG q day
5. NADOLOL 30 MG daily
6. PROTONIX 40 mg po BID
7. TEMAZEPAM 15MG prn QHS
8. TENOFOVIR 300MG po daily
9. TOBRADEX 0.3-0.1%--Two gtts each eye twice a day
10. ZOLOFT 50 mg po daily
Discharge Medications:
1. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Tobramycin Sulfate 0.3 % Drops Sig: Two (2) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*0*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
8. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO every other day.
Disp:*15 Tablet(s)* Refills:*0*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
11. Nadolol 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: E.coli bacteremia/sepsis from urinary source
Secondary: HIV, hepatitis B, hepatitis C
Discharge Condition:
Stable, afebrile >48 hours. Ambulating without difficulty.
Discharge Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 4844**] in 1 week. Please call
([**Telephone/Fax (1) 1300**] to schedule a follow up.
.
2. Take the medications as directed below.
.
3. If develop urinary pain or burning, fevers or chills,
temperature >101, lightheadedness, or any symptoms, please call
Dr. [**Last Name (STitle) 4844**] or proceed to the nearest ER.
Followup Instructions:
1) Primary Care
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-10-19**] 6:40
- your blood pressure has been high during your hospital course.
This should be monitored closely as an outpatient.
2) Renal
Please call to schedule an appointment with Dr. [**Last Name (STitle) 4090**] at [**Last Name (un) **]
([**Telephone/Fax (1) 7403**]) to be seen within 2 weeks following discharge
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2140-5-4**] | [
"78552",
"2761",
"2762",
"2875",
"5849",
"5990",
"99592"
] |
Admission Date: [**2189-2-2**] Discharge Date: [**2189-2-11**]
Date of Birth: [**2147-1-22**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Sulfonamides / Biaxin / Levaquin /
Cefzil / Motrin / Erythromycin Base
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
For full HPI please see admission note. Briefly, this is a 42F
with CVID on IVIg, HepC, Tyoe 1 DM, distant IBD > 20 yrs ago
last flare, recent cryptospordial infection, c/o increasing
voluminous nonbloody diarrhea (up to 20 BMs daily) and worsening
diffuse [**7-3**] sharp abdominal pain. Seen at [**Hospital 107**] Hospital,
treated with IV fluids and discharged. The following morning
abdominal pain, palpiations and diarrhea and fever of 103.5. In
the ED she was found to be febrile to 101.5 88 120/38 16 100 RA,
with tense abdomen and CT A/P was notable for pancolitis without
a vascular distribution. She was started on broad spectrum abx,
surgical consultation noted patient was not a surgical
candidate. She was admitted to the ICU. In the ICU, vancomycin
and cefepime were continued as were fluids.
-Of note she has been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in ID for
cryptosporidium, which was diagnosed in [**2188-9-24**] and she was
started on Nitazoxanide. She was on therapy until the end of
[**Month (only) 1096**] at which time her insurance would no longer pay for the
medications and was prescribed Flagyl for treatment, but did not
start the medication. She denies raw foods, recent travel, NSAID
use, EtOH use.
She currently feels better. Her diarrhea has decreased today,
she has had 1 BM that was a little less watery and more formed
today. She continues to have abdominal pain but less so than
yesterday. She tolerated a small ginger ale without
nausea/vomiting.
Past Medical History:
1)Type 1 Diabetes, difficult to control, she has frequent
admissions for AMS from hypoglycemia. Followed at [**Last Name (un) **].
2)CVID: treated with IVIG q2 weeks, last [**10-14**]
3)UTIs
4)Asthma
5)CBP
6)HCV: diagnosed in [**10-31**]. Most recent VL [**8-1**] 7,980,000 IU/mL
Biopsy [**9-1**] showed Grade 2 inflammation, stage 2 fibrosis:
1. Marked portal, periportal, and lobular mixed-cell
inflammation with focal bridging (Grade 3).
2. Marked bile duct proliferation with neutrophils (see note)
3. Trichrome stain: Moderate increase of portal and septal
fibrosis (Stage 2).
7) cryptosporidium, as above
8) ? inflammatory bowel disease (UC)--per patient, last flare
many years ago, not on any treatment
Social History:
lives with fiancee and daughter, smokes [**12-26**] pack per day, denies
any alcohol since [**7-1**], formerly used IV drugs but none since
[**2184**]
Family History:
No family history of diabetes. Multiple family members with
[**Name2 (NI) 109976**] anemia. Mother has hypercholesterolemia and
diverticular disease, father has peripheral vascular disease
Physical Exam:
Vitals - T: 94.9 BP:106/58 HR:83 RR:18 02 sat: 100% RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: NCAT anicteric sclera, pink conjunctiva, MMM,
CARDIAC: RRR, S1/S2, no mrg
LUNG: crackles at bilateral bases otherwise clear
ABDOMEN: nondistended, +BS, tender to palpation throughout,
worst in RLQ, + rebound tenderness but no guarding, no
hepatosplenomegaly
EXT: moving all extremities well, no cyanosis, [**12-26**]+ pitting
edema in bilateral extremities to mid-shin,
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact, gait not assessed
Pertinent Results:
[**2189-2-2**] 02:30PM PT-17.6* PTT-35.4* INR(PT)-1.6*
[**2189-2-2**] 02:30PM PLT COUNT-144*
[**2189-2-2**] 02:30PM NEUTS-82.4* LYMPHS-14.5* MONOS-2.0 EOS-0.8
BASOS-0.3
[**2189-2-2**] 02:30PM WBC-14.2*# RBC-3.98* HGB-12.9 HCT-38.4 MCV-97
MCH-32.5* MCHC-33.6 RDW-17.2*
[**2189-2-2**] 02:30PM TOT PROT-5.9* ALBUMIN-3.4 GLOBULIN-2.5
[**2189-2-2**] 02:30PM CK-MB-NotDone
[**2189-2-2**] 02:30PM cTropnT-<0.01
[**2189-2-2**] 02:30PM LIPASE-32
[**2189-2-2**] 02:30PM ALT(SGPT)-343* AST(SGOT)-389* CK(CPK)-59 ALK
PHOS-222* TOT BILI-2.9*
[**2189-2-2**] 02:30PM estGFR-Using this
[**2189-2-2**] 02:30PM GLUCOSE-179* UREA N-13 CREAT-1.0 SODIUM-135
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17
[**2189-2-2**] 02:30PM GLUCOSE-179* UREA N-13 CREAT-1.0 SODIUM-135
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17
[**2189-2-2**] 02:37PM LACTATE-2.6* K+-3.9
[**2189-2-2**] 02:37PM COMMENTS-GREEN TOP
[**2189-2-2**] 09:36PM PT-19.6* PTT-41.8* INR(PT)-1.8*
[**2189-2-2**] 09:36PM PLT COUNT-107*
[**2189-2-2**] 09:36PM NEUTS-72.9* LYMPHS-22.6 MONOS-2.8 EOS-1.5
BASOS-0.2
[**2189-2-2**] 09:36PM WBC-11.4* RBC-3.27* HGB-10.4* HCT-31.1*
MCV-95 MCH-31.9 MCHC-33.5 RDW-17.1*
[**2189-2-2**] 09:36PM CALCIUM-7.6* PHOSPHATE-3.0 MAGNESIUM-1.4*
[**2189-2-2**] 09:36PM ALT(SGPT)-253* AST(SGOT)-244* LD(LDH)-203 ALK
PHOS-173* TOT BILI-2.4*
[**2189-2-2**] 09:36PM GLUCOSE-144* UREA N-11 CREAT-0.8 SODIUM-136
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-20* ANION GAP-12
Brief Hospital Course:
# Pan-colitis: Differential included cryptosporidium, c.diff,
multiple bacterial/viral etiologies given CVID, and IBD. Broad
spectrum antibiotics were intiated on admission including PO/IV
vancomycin, cefepime and flagyl. The patient was started on IV
fluids; leukocytosis and lactate were trended in the ICU. CT
abdomen/pelvis showed diffuse severe pancolitis, small ileocolic
intussiception wihtout evidence of obstruction. The surgical
service was consulted but saw no acute indication for surgery
and followed the patient with serial abdominal exams. The
patient remained afebrile and hemodynamically stable in the ICU
and was subsequently tranferred to the regular medical floor.
The GI service was consulted and recommended a flexible
sigmoidoscopy, stool cultures and labs to evaluate the etiology
of her diarrhea. Thus far all stool labs for infectious causes
are negative. The biopsy upon flexible sigmoidoscopy showed mild
dysplasia and inflammation. It was recommended the patient
continue her PO flagyl for a 2 week course and follow up with GI
for a colonoscopy after discharge.
.
# Bacteremia: the patient was found to have S.pneumoniae on
blood culture while on vancomycin. The Infectious Disease
service was consulted. TTE and TEE were negative for
endocarditis. Ceftriaxone was initiated and PICC placed for IV
treatment for a 2 week course. The remainder of the blood
cultures are negative to date. The patient remained afebrile
during her admission. She has ID follow-up with Dr.[**First Name (STitle) **] in
several weeks.
.
# Chronic Hepatitis C: LFTs were elevated above baseline on
admission. Initially cholestyramine, ursodiol and spironolactone
were held. Her LFTs were trended and slowly returned back to
baseline. After transfer to the medical service, given agressive
fluid resuscitation in the ICU, the patient was fluid overloaded
and required diuresis. Spironolactone was restarted and lasix
20mg po daily was added. An abdominal US showed a moderate
amount of ascites which was tapped via ultrasound guidance.
Approximately 500cc of fluid was removed, and labs were
consistant with SBP, althought the patient was asymptomatic and
already on ceftriaxone at that time. She will need follow-up for
her ascites as an outpatient to ensure it does not reaccumulate.
Her cholestyramine, ursodiol were restarted prior to discharge.
A follow-up appointment was scheduled with Dr.[**Last Name (STitle) 497**]
(hepatology).
.
# DM Type I: Patient reportedly hypoglycemic was hypoglycemic in
the ICU, glargine was discontinued while the patient was NPO.
Once her diet was advanced her home DM was restarted and
fingersticks monitored. No changes were made to her regimen
prior to discharge.
.
# Asthma: Home regimen of albuterol, pulmicort and tiotropium
were continued.
.
# Coagulopathy: at baseline probably due to underlying liver
disease.
.
# Follow-up: the patient has follow-up with the GI service,
Infectious Disease, Hepatology and her PCP (which she will make
on her own).
Medications on Admission:
ALBUTEROL - (Prescribed by Other Provider) - 90 mcg Aerosol - 2
puffs inhaled four times per day
BUDESONIDE [PULMICORT] - (Prescribed by Other Provider) - Dosage
uncertain
CHOLESTYRAMINE-ASPARTAME [CHOLESTYRAMINE LIGHT] - 4 gram Packet
-
1 packet by mouth once a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 Disk(s) inhaled twice a day
INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100
unit/mL Cartridge - as per sliding scale
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 16 unit in
the
morning and 12 units at night as directed
MORPHINE - (Prescribed by Other Provider) - 60 mg Tablet
Sustained Release - 1 Tablet(s) by mouth at night
NITAZOXANIDE [ALINIA] - 500 mg Tablet - 1 Tablet(s) by mouth po
[**Hospital1 **]
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day
OXYCODONE - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Last Name (STitle) 67537**] - 5 mg
Capsule - 1 Capsule(s) by mouth two times per day as needed for
pain
PROMETHAZINE [PROMETHEGAN] - (Prescribed by Other Provider) -
Dosage uncertain
SPIRONOLACTONE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by
Other Provider) - 18 mcg Capsule, w/Inhalation Device -
URSODIOL [[**Last Name (un) 390**] 250] - 250 mg Tablet - 1 Tablet(s) by mouth twice
a day with meals
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - 10 x
day - No Substitution
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE ULT-FINE II] -
31 gauge X [**5-9**]" Syringe - 8 x day
LANCETS [ONE TOUCH ULTRASOFT LANCETS] - Misc - 8 x day
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. NEHT
NEHT per protocol
8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 14 days: last day
[**2189-2-18**].
Disp:*7 * Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*2*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
DAILY (Daily).
12. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) Inhalation once a day: take as prescribed by Dr.[**Last Name (STitle) **].
14. Novolog 100 unit/mL Cartridge Sig: One (1) Subcutaneous
once a day: use as directed.
15. Lantus 100 unit/mL Solution Sig: One (1) Subcutaneous twice
a day: 16U in the morning, 12U at night.
16. Morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
17. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for pain.
18. Promethazine 12.5 mg Tablet Sig: One (1) Tablet PO once a
day: take as directed by your doctor.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Diarrhea
Chronic hepatitis C
Discharge Condition:
hemodynamically stable
Discharge Instructions:
You were admitted to the hospital for abdominal pain, diarrhea
and fever. You were initially treated in the ICU for low blood
pressure and infection with IV fluids and antibiotics. Your
stool studies are negative for an infectious process. On
flexible sigmoidoscopy you had a biopsy of the colon shows
inflammation and mild dysplasia, which needs to be further
evaluated by the GI physicians.
You were also found to have bacterial infection in your blood
for which you need to be treated with IV antibiotics. A PICC
line was placed to allow for a full 2 weeks of antibiotics
(ceftriaxone). You will also need to complete the course of
flagyl (antibiotic) for which you have a prescription.
Your Alinia has been discontinued.
Please make sure to keep your appointments below with the [**Hospital **]
clinic, Infectious disease clinic and make sure to see your
primary care doctor at your earliest convenience for follow-up.
If you experience worsening abdominal pain, nausea/vomiting, no
bowel movements for more than one day with abdominal distension,
fevers, chills, chest pains, or any other concerning symptoms
please return to the ER or call your doctor.
Followup Instructions:
Please make an appointment to see your primary care doctor
within 1-2 weeks of your discharge.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2189-2-20**] 8:40
Provider: [**First Name8 (NamePattern2) 3722**] [**Name11 (NameIs) 3723**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2189-3-3**] 3:00
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2189-2-18**] 10:30
| [
"49390",
"5849",
"2762"
] |
Admission Date: [**2200-7-27**] Discharge Date: [**2200-7-29**]
Service: MEDICINE
Allergies:
Barbiturates / Sulfonamides / Opioid Analgesics / Novocain
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
fall off toilet
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a [**Age over 90 **] yo woman who fell off the commode on the day of
admission. Denies hitting head or losing consciousness. Found
down by home aide [**Doctor Last Name **] and was brought to ED at [**Hospital1 18**] for eval.
Past Medical History:
1. CAD s/p CABG in [**2193**] residual deficits
2. PM for bradycardia in [**2184**]
3. s/p partial colon resection in [**2183**] for diverticulitis
4. HTN
5. hypothyroidism
6. h/o Zoster
7. CVA s/p CABG with residual left hemiparesis
8. hx of recurrent falls
9. urinary incontinence
10. OA
11. bilat hearing loss
12. hx of post herpetic neuralgia with residual right shoulder
weakness
13. dep
14. cognitive impairment
15. s/p TAH BSO, cataract surgery,
16. s/p ileorectal [**Doctor First Name **] for diverticulitis in [**2173**]
17 cognitive impairment x 3 yrs
Social History:
Lives at [**Hospital3 537**]. Remote history of tobacco use. Denies
etoh or illicit drug use. Avid tennis player in past. Close to
family. When asked what the secret of longevity was, she said a
supportive and loving family.
Family History:
non contributory
Physical Exam:
admission
96.1 140/46 60 97% RA
hard of hearing
dry membranes, op clear
supple neck
no jvd
no thyroidmegaly
RRR, no murmur
decreased breath sounds, minimal crackles LLL
nbs, soft, ND
ext - no c/c/e
multiple ecchymoses and bandages over left arm and left lat shin
neuro - no aware of location or yr; 5/5 strength throughout
except [**5-22**] left shoulder
Pertinent Results:
[**2200-7-27**] 01:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2200-7-27**] 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2200-7-27**] 01:30PM URINE RBC-[**4-21**]* WBC-[**7-27**]* BACTERIA-NONE
YEAST-NONE EPI-[**4-21**]
[**2200-7-27**] 11:41AM URINE HOURS-RANDOM
[**2200-7-27**] 11:41AM URINE GR HOLD-HOLD
[**2200-7-27**] 11:41AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
[**2200-7-27**] 11:41AM URINE RBC-[**4-21**]* WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-[**7-27**]
[**2200-7-27**] 10:00AM GLUCOSE-102 UREA N-24* CREAT-0.9 SODIUM-143
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-29 ANION GAP-13
[**2200-7-27**] 10:00AM CK(CPK)-147*
[**2200-7-27**] 10:00AM CK-MB-7 cTropnT-0.01
[**2200-7-27**] 10:00AM WBC-5.9 RBC-4.34 HGB-13.5 HCT-39.0 MCV-90
MCH-31.2 MCHC-34.7 RDW-16.1*
[**2200-7-27**] 10:00AM NEUTS-69.6 LYMPHS-20.2 MONOS-6.2 EOS-3.1
BASOS-1.0
[**2200-7-27**] 10:00AM PLT COUNT-202
[**2200-7-27**] 10:00AM PT-11.8 PTT-25.1 INR(PT)-1.0
Brief Hospital Course:
Pt was borderline hypotensive in the ED so was admitted to the
[**Hospital Unit Name 153**]. Cause of fall uncertain. They attributed it to increased
dose of Ditropan vs UTI. She was placed on teletry and cardiarc
enzymes were checked. Given abx for ques of UTI with
levofloxacin. Given tetanus shot for laceration to right shin.
Pt was in ICU x 1 day and then tx'ed to 11 [**Hospital Ward Name **]. She had no
complaints and demanded to go back to [**Hospital3 537**]. I spoke
with her outpt provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who agreed with not
giving the Ditropan or Cipro. Discharged pt back to [**Hospital **].
Medications on Admission:
ASA 325mg daily
ditropan XL 5mg q hs
Ditropan 2.5mg q hs
Effexor XR 75 mg daily
synthroid 100mcg daily
metoprolol 12.5mg [**Hospital1 **]
carafate 1g [**Hospital1 **]
vit D 800 units daily
MVI tab once daily
calcium 500mg tid
tylenol prn
immodium prn
metamucil prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
4. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Fall
hypotension
UTI
decreased hearing
CAD
Discharge Condition:
stable
Discharge Instructions:
seek medical attention if you do not feel well
Followup Instructions:
followup with your primary care doctor Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 31517**]
| [
"5990",
"2449",
"4019",
"V4581"
] |
Admission Date: [**2133-4-13**] Discharge Date: [**2133-4-18**]
Date of Birth: [**2061-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
progressive angina
Major Surgical or Invasive Procedure:
[**2133-4-13**] redo cabg x2 (LIMA to LAD, SVG to OM)
History of Present Illness:
71 yo male with prior cabg x3 in [**2117**] presents with progressive
angina over the past several months. ETT was positive and cath
was done. This revealed occluded native vessels, and 2 occluded
vein grafts. referred for surgery.
Past Medical History:
CAD s/p SVG stent [**2128**], CABG [**2117**]
PVD with right iliac stent/occlusion right AT
HTN
elev. lipids
PUD/GERD
prior right LE fungal infection
Social History:
retired
smoked for 60 years, quit 2 months ago
denies ETOH use
lives alone
Family History:
brother with sudden death at 68
Physical Exam:
5'[**35**]" 190#
(exam on [**3-25**] in cath lab):
NAD, lying flat
multiple scars on face, RLE/ankle with fungal infection, mild
erythema and flaking
HEENT unremarkable
neck supple with full ROM, no carotid bruits appreciated
CTAB anterolaterally
RRR no murmur
abd soft, NT, ND, + BS
extrems warm, well-perfused with trace ankle edema
upon standing, extensive bilat. varicosities noted
neuro grossly intact, unable to assess gait
2+ right fem/cath site c/d/i
2+ left fem/DPs
1+ bil. PTs
Pertinent Results:
Conclusions
PRE-BYPASS:
1. No spontaneous echo contrast is seen in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
3. The right ventricular cavity is mildly dilated with mild
global free wall hypokinesis.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 6. Trivial
mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced
1. Biventricular function is normal.
2. Aorta is intact post decannulation
3. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2133-4-13**] 15:56
CHEST (PORTABLE AP) [**2133-4-15**] 11:39 AM
CHEST (PORTABLE AP)
Reason: eval for pneumothorax s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
71 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval for pneumothorax s/p chest tube removal
HISTORY: 71-year-old male status post CABG. Please evaluate for
pneumothorax after chest tube removal.
COMPARISON: Chest radiograph from two days prior.
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: A right internal
jugular Swan-Ganz catheter, an endotracheal tube, and a
nasogastric tube have been removed. There is evidence of
improved hyperhydration. There is slight increase in density of
the left retrocardiac opacity consistent with atelectasis. There
is no evidence of pleural effusion or infectious consolidation.
There is no change in appearance of CABG clips or sternotomy
wires. The bony thorax is otherwise unremarkable.
IMPRESSION: Increase in left retrocardiac atelectasis. No
evidence of effusion, pneumothorax, or pneumonia.
Brief Hospital Course:
Admitted [**4-13**] and underwent redo cabg x2 with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
phenylephrine and propofol drips. Extubated later that evening,
and transferred to the floor on POD #1 to begin increasing his
activity level. Plavix was resumed given his past coronary
peripheral vascular stents. Beta blockade slowly titrated and he
was gently diuresed toward his preopewrative weight. He
continued to make steady progress and was discharged home on
postoperative day four. He will follow-up with Dr. [**Last Name (STitle) **], his
cardiologist and his primary care physician.
Medications on Admission:
ASA 25 mg daily
plavix 75 mg daily
atenolol 100 mg daily
lipitor 20 mg daily
zantac 150 mg [**Hospital1 **]
ranexa 500 mg [**Hospital1 **]
norvasc 10 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Ranexa 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p redo cabg x2, SVG stent [**2128**], CABG [**2117**]
PVD with right iliac stent/occlusion right AT
HTN
elev. lipids
PUD/GERD
prior right LE fungal infection
Discharge Condition:
good
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Take lasix and potassium once daily in the morning for five
days and then stop.
8) Call with any questions or concerns.
Followup Instructions:
Follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 250**] Date/Time:
[**2133-5-28**] 2:30
Follow-up with Cardiologist Dr. [**First Name (STitle) **] in [**1-4**] weeks [**Telephone/Fax (1) 920**]
Follow-up with Cardiac [**Telephone/Fax (1) 5059**] Dr. [**Last Name (STitle) **] in 4 weeks
[**Telephone/Fax (1) 170**]
Completed by:[**2133-4-17**] | [
"41401",
"2724",
"4019",
"53081"
] |
Admission Date: [**2111-5-4**] Discharge Date: [**2111-5-9**]
Date of Birth: [**2075-5-31**] Sex: F
Service: PSU
HISTORY OF PRESENT ILLNESS: This is a pleasant 35-year old
female who unfortunately has extensive carcinoma in situ of
the right breast. She presented with extensive
microcalcification's and had previously underwent a core
needle biopsy in late [**Month (only) 1096**]. At that time thought that she
would be a good candidate for breast conserving surgery or
mastectomy were recommended. She chose to undergo a
mastectomy with immediate reconstruction.
HOSPITAL COURSE: On [**2111-5-4**] she underwent a skin
sparing right mastectomy with axillary and lymph node biopsy
and immediate reconstruction using a gluteal artery
perforator flap done by Dr. [**Last Name (STitle) 11635**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Please see the operative note for further information.
Postoperatively, she was admitted to the plastic surgery
service under the care of Dr. [**First Name (STitle) **]. She was admitted to the
surgical ICU for flap checks and monitoring. She did well
with good Doppler signals and good capillary refill. No
evidence of a hematoma. On postoperative day 1 ([**5-6**]), she
had come out from the operating room on the early morning of
the 14th. Her Foley was discontinued, and the patient was
transferred to the floor. She was continued on aspirin, and
she did well. She continued to have some pain control issues,
but otherwise was managed relatively well. She began to
ambulate, and throughout this time her incisions looked well
with no evidence of any hematoma, some minimal bruising, and
serosanguineous drainage from her JP's. The patient was
tolerating a regular diet and removed afebrile, and had her
pain controlled by the [**5-8**].
DISCHARGE STATUS: The patient was discharged to home in good
condition with stable vital signs and JP drains in place.
DISCHARGE FOLLOWUP: She is to follow up with Dr. [**First Name (STitle) **] in
approximately 1 week and is to follow up with Dr. [**Last Name (STitle) 11635**] in
approximately 1 to 2 weeks.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg take 1 tablet p.o. daily.
2. Famotidine 20 mg p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d. (to take while taking narcotic
pain medication; do not take if having watery bowel
movements or diarrhea).
4. Dilaudid 4 mg p.o. q.2h. p.r.n. (for pain).
5. Dulcolax 10 mg p.o. daily as needed.
6. Keflex 500 mg 1 tablet p.o. 4 times a day (x 7 days).
7. Oxycodone 60 mg p.o. b.i.d.
DISCHARGE DIAGNOSIS: Status post total right mastectomy with
GAP flap reconstruction.
DISCHARGE INSTRUCTIONS: Follow up with Dr. [**First Name (STitle) **] in
approximately 1 week. The patient is to keep her incision
clean and dry. She may sponge bath. She is to call if she has
any fevers of greater than 101, chills, or any redness near
her incision. She is also to wear her lower extremity girdle
to help with support from her gluteal site.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Discharged to home with services.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 39103**]
Dictated By:[**Doctor Last Name 22186**]
MEDQUIST36
D: [**2111-5-9**] 10:21:33
T: [**2111-5-9**] 15:08:48
Job#: [**Job Number 61001**]
| [
"2851"
] |
Admission Date: [**2149-5-5**] Discharge Date: [**2149-5-12**]
Date of Birth: [**2087-9-28**] Sex: F
Service: MEDICINE
Allergies:
Ms Contin
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Fever, abdominal pain.
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] with metal stent placement on [**2149-5-6**].
RIJ placement on [**2149-5-6**]
Arterial line placement on [**2149-5-6**]
Arterial line removal on [**2149-5-9**]
RIJ removal on [**2149-5-11**]
Left midline placement on [**2149-5-11**]
History of Present Illness:
Ms. [**Known lastname 2973**] is a 61 yo woman w/hx of recently diagnosed
pancreatic
cancer metastatic to the liver who presents with fever, jaundice
and pain for the last 2 days. Patient states that after being
discharged she was doing great at home. Her pain was controlled,
she was urinating and moving her bowels, very active. She only
noted that her apetite was slighlty decreased. She went to see
her oncologist, who decided to get a liver MRI as outpatient to
stage the cancer and to assess for possible liver infiltration
and biopsy. She was getting herself her antibiotics (unasyn 3 g
q6hrs) for cholangitis. She finished the treatment Saturday
afternoon (2 days ago). 24 hours later, she started noticing
chills, rigors and fever up to 102.7 today in the morning. She
was scheduled for and MRI today and was not eating or drinking
anything. She came to the ER.
.
In the ER was found to have T 99.3, BP 126/99, HR 146, RR 16,
SpO2 97% on RA. Then she spiked to 102.7 F. She had nondistended
abomen, was very dehydrated and received 3 L NS. Her bilirubin
was slighlty elevated from discharge (5.4 from 5.1). Her lactate
was 3.6. Her liver USG showed persistent pneumobilia, with large
gallbladder without any duct dilation. She received Vanc/Zosyn,
Tylenol and IV Dilaudid (1 mg). She was admitted to OMED for
further management of her cholecystitis. Her VS before transfer
per ED report were: 98.3 HR 83 BP 100/60 o2 sats 90's on 2L.
.
While on the OMED service, she continued to spike fevers and her
lab data showed a worsening leukocytosis to 22.1 with 20% bands.
Today she became tachycardic to the 140s which was fluid
responsive but her SBP concurrently dropped from the 140s to the
low 100s. She underwent an abdominal MRI which showed worsening
CBD dilation and numerous cm and sub-cm lesions in the liver,
concerning for new mets vs. abscesses. She went to [**Known lastname **] and
became hypotensive to the systolic 70s prior to the procedure.
She received 2L NS bolus and was started on peripheral
phenylephrine. In [**Known lastname **], pus was draining from her old stent
which was pulled and replaced with a larger metal stent of 10mm
diameter. Upon placement, found to have good drainage of frank
pus.
A-line was placed in the OR. She was on both Levo and Neo prior
to transfer and has received an addition 4L of LR.
.
In the [**Hospital Unit Name 153**], her sedation was weaned and she was extubated
without difficulty. Pressors were weaned. Vancomycin and zosyn
were continued. He was given PO vitamin K.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
Initially presented with abdominal pain to [**Hospital3 **],
had T. Bili of 24. Abdominal CT and ultraound demonstarted a
pancreatic mass obstructing the bile duct. She underwent [**Hospital3 **]
with stent placement [**4-11**] at OSH and then due to rising total
bilirubin had a repeat [**Month/Year (2) **] at [**Hospital1 18**] on [**2149-4-15**] during which her
initial stent was removed and a new stent was placed. She
underwent an EUS guided biopsy of her pancreatic mass on [**2149-4-17**]
showing adenocarcinoma.
.
PAST MEDICAL HISTORY:
==================
GERD
Social History:
Lives at home with her husband and daughter. Smokes 1 pack/day.
Denies IV drug use, EtOH.
Family History:
Mother with COPD. Brother with cirrhosis (due to EtOH). 2
Aunts with breast cancer, 1 of them also had uterine cancer.
Grandmother with DM. Uncle had MI.
Physical Exam:
VITAL SIGNS - Temp 99.3 F, BP 113/82mmHg, HR 102 BPM, O2 100% on
A/C TV 500 RR 14 PEEP 5 FIO2 100%
GENERAL - Intubated and sedated
HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, mildy dry mucous
membranes, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, jaundice
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - Intubated and sedated but moving all four extremities
Pertinent Results:
On Admission:
[**2149-5-5**] 10:40AM WBC-12.6*# RBC-3.68* HGB-11.8* HCT-33.1*
MCV-90 MCH-32.1* MCHC-35.6* RDW-18.1*
[**2149-5-5**] 10:40AM NEUTS-89* BANDS-6* LYMPHS-1* MONOS-0 EOS-1
BASOS-1 ATYPS-2* METAS-0 MYELOS-0
[**2149-5-5**] 10:40AM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-1+ TEARDROP-OCCASIONAL
[**2149-5-5**] 10:40AM PLT SMR-HIGH PLT COUNT-467*
[**2149-5-5**] 10:40AM PT-16.2* PTT-25.4 INR(PT)-1.4*
[**2149-5-5**] 10:40AM GLUCOSE-132* UREA N-8 CREAT-1.0 SODIUM-137
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-18* ANION GAP-21*
[**2149-5-5**] 10:40AM ALT(SGPT)-98* AST(SGOT)-123* ALK PHOS-343*
TOT BILI-5.4*
[**2149-5-5**] 10:40AM LIPASE-18
[**2149-5-5**] 10:40AM ALBUMIN-3.7
[**2149-5-5**] 11:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2149-5-5**] 11:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG
.
Abdominal USG [**2149-5-5**]:
1. Increased size of right and left lobe liver lesions compared
to prior
study, with focal adjacent biliary ductal dilatation.
2. Persistent pneumobilia.
3. Aside from aforementioned ductal dilatation adjacent to focal
liver
lesions, there is no generalized intrahepatic ductal dilatation.
Common bile
duct measures 5 mm.
4. Decompressed gallbladder, with unchanged cholelithiasis and
mild wall
thickening. Findings may be seen with chronic cholecystitis.
5. Redemonstration of a simple left kidney cyst.
.
MRI of the liver [**2149-5-6**]:
1. Significant dilatation of the common bile duct which is
increased from the
previous study. There is also intrahepatic biliary ductal
dilatation. There
is sludge within the gallbladder. Distal biliary stent is seen
in the common
bile duct.
2. Rapidly enlarging liver lesions. The larger ones are not
clearly
enhancing and are of increased signal intensity on T2-weighted
images. The
concern is for multifocal abscesses (vs metastatic disease) and
short-term
followup is recommended.
3. Mass in the pancreatic head without significant change,
compatible with
pancreatic carcinoma.
4. No evidence to suggest acute cholecystitis
.
Unilateral (left) venous USG:
Focused exam without evidence of DVT. If more complete exam for
superficial thrombosis is desired, a dedicated exam can be
obtained in the
future.
Brief Hospital Course:
61 year-old woman with metastatic pancreatic cancer was admitted
with cholangitis culminating in septic shock, now s/p biliary
drainage procedure, improving.
.
# Cholangitis: Patient presented with fever and RUQ that was
concerning for cholangitis. She was immediately started in IVF
and antibiotics (Vanc/Zosyn Day 1 [**2149-5-6**]). Since prior
therapy with Unasyn failed Zosyn was chosen. The following day
her WBC almost doubled (11-->22) and her bilirubin was trending
up (5.4-->5.9). An [**Year (4 digits) **] was planned to be done the same day,
while waiting a repeat MRI was done to further assess her liver
metastasis. The report came as new masses in the liver
concerning for abscesses or cancer in the liver that were new
from prior MRI 2 weeks prior as well as 2.5 cm ductal dilation
(See report for details). Patient became tachycardic and did not
respond to 1.5 L NS. Minutes later patient required central line
placement, arterial line and intubation prior to [**Year (4 digits) **]. In the
[**Year (4 digits) **] pus was drained from the biliary duct. The plastic stent
was removed and new metal stent was placed. She was transfered
to the ICU, due to pressor and ventilator requirements. Both
were stopped (levophed and mechanical ventilation) on day 3 of
ICU stay. Antibiotics were continued and she improved. On
[**2149-5-11**] she was transfered to the oncology floor, where she
tolerated regular diet and her pain was controlled. Vancomycin
was stopped. Upon discharge her bilirubin was 2.8 and trending
down. Follow up with oncology was arranged and warning signs and
symptoms were explained. She was discharged with home VNA and a
left midline to complete a 14-day of IV Zosyn.
.
# Pancreatic cancer: With possible metastatic disease in the
liver. MRI findings equivacal for abscess vs MRI. She will need
follow up MRI.
.
# LUE swelling: concerning for DVT while in the ICU and before
placing midline. DVT was ruled out with USG/doppler. It was
thought it was due to fluid administration.
.
#. GERD: currently asymptomatic. Therapy with
omeprazole/ranitidine was continued.
.
#. FEN: Regular diet.
.
#. Access: RIJ, midline and peripherals (See above).
.
#. PPx -
-DVT ppx with SQ Heparin
-Bowel regimen colace/senna
-Pain management with home regimen Fentanyl Patch plus Dilaudid
.
#. Code - Full code.
.
#. Dispo - Home with VNA.
Medications on Admission:
Colace 100mg PO BID
Ursodiol 300mg PO BID X 10 days
Nicotine Patch 21mg/24H
Ranitidine 150 mg PO BID
Omeprazole 20 mg PO DAily
Hydromorphone 2 mg PO 14hrs PRN pain
Fentanyl 25 mcg/hr TD Every third day
Discharge Medications:
1. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Piggyback Intravenous Q8H (every 8 hours) for 7 days:
Last day [**2149-5-16**].
Disp:*21 Piggyback* Refills:*0*
2. Line care
Please do midline care per protocol.
3. Remove Line
Please remove midline after antibiotic course is finsihed.
4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Polyethylene Glycol 3350 100 % Powder Sig: One (1) Packet PO
DAILY (Daily) as needed.
Disp:*10 Packets* Refills:*0*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*15 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Saline Flush 0.9 % Syringe Sig: One (1) Syringes Injection
once a day as needed for As needed for 7 days.
Disp:*7 Syringes* Refills:*0*
13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*10 Syringes* Refills:*0*
14. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
16. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis:
Acute cholangitis secodnary to stent obstruction due to
pancreatic cancer.
.
Secondary Diagnosis:
Pancreatic cancer
GERD
Discharge Condition:
Stable, tolerating PO, walking.
Discharge Instructions:
You were seen at the [**Hospital1 18**] for fever. You had an USG done that
did not show any ductal dilation. You were given fluids and
antibiotics. The following morning you had an MRI of your liver
to evaluate your cancer and we found multiple new lesions and
big ductal dilation. You had a fever, you received more
natibiotics, fluids and had an [**Hospital1 **] where they removed a lot of
pus in your biliary ducts, your stent was removed and then a new
metal stent was palced.
.
You required ICU care with central line placement, arterial line
and ventilatory support with aggresive antibiotic therapy as
well as medications to keep your blood pressure adequate. Then
you improved. You been tolerating diet and afebrile. You will
need to follow with your oncologist as below.
.
If you have fever, get yellow, have abdominal pain, chills,
rigors or anything else that concerns you come back to our ER.
Followup Instructions:
Please follow up with your oncologist:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2149-5-23**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23551**], MD Phone:[**Telephone/Fax (1) 447**]
Date/Time:[**2149-5-23**] 9:00
| [
"0389",
"78552",
"2762",
"99592",
"53081"
] |
Admission Date: [**2122-3-17**] Discharge Date: [**2122-3-23**]
Date of Birth: [**2038-10-20**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal pain with constipation
Major Surgical or Invasive Procedure:
[**2122-3-17**] EXPLORATORY LAPAROTOMY; DE-TORSION OF SIGMOID VOLVULUS;
SIGMOID COLECTOMY
History of Present Illness:
83yo M PMHx hepB, HTN, BPH with chronic indwelling foley who
presented to ED with abd distention. Onset: approx 4d prior.
Charac: gradual worsening of abd distention. No relieving
factors. Exacerbated by 1d of lack of flatus and no BM x4 days.
ASx: -f/c, -n/v/d, mild diffuse abd pain, -CP/SOB/cough,
-HA/change in vision/neck pain, -skin color changes, stable BIL
LE edema, no dysuria and foley remain patent
Past Medical History:
Hepatitis B
Arthritis
Bursitis
HTN
Chronic bilateral leg swelling
Social History:
Originally from [**Country 3587**] and speaks creole only. Has been in
the United States for 7 years. Lives with wife and son who
straight caths him daily. Patient attends adult day care. No
cigarettes but occassionally sniffs tobacco powder and
occasionally has alcohol.
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Vitals: T 97.1 HR 74 BP 146/76 RR 16 95%
GEN: AAO x 3, NAD, [**Location 12189**]
[**Location 4459**]: No scleral icterus, mucus membranes dry
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, very distended, nontender, no rebound or guarding,
normoactive bowel sounds, chronic indwelling Foley catheter
Ext: 2+ non-pitting LE edema, LE warm and well perfused, venous
stasis changes
Pertinent Results:
[**2122-3-16**] 09:15PM BLOOD WBC-8.1 RBC-4.04* Hgb-13.0* Hct-35.5*
MCV-88 MCH-32.1* MCHC-36.5* RDW-14.6 Plt Ct-206
[**2122-3-16**] 09:15PM BLOOD Plt Ct-206
[**2122-3-16**] 09:15PM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-139
K-2.7* Cl-99 HCO3-29 AnGap-14
[**2122-3-17**] 08:19AM BLOOD Type-ART Rates-/10 Tidal V-590 FiO2-50
pO2-111* pCO2-43 pH-7.47* calTCO2-32* Base XS-6
Intubat-INTUBATED Vent-CONTROLLED
[**2122-3-17**] 08:19AM BLOOD Glucose-109* Lactate-1.3 Na-142 K-2.2*
Cl-97
[**2122-3-18**] 02:03AM BLOOD WBC-9.9# RBC-3.43* Hgb-10.8* Hct-30.6*
MCV-89 MCH-31.4 MCHC-35.2* RDW-15.1 Plt Ct-148*
[**2122-3-18**] 02:03AM BLOOD Plt Ct-148*
[**2122-3-18**] 02:03AM BLOOD Glucose-112* UreaN-12 Creat-0.8 Na-142
K-3.1* Cl-105 HCO3-27 AnGap-13
[**2122-3-18**] 02:28AM BLOOD Type-ART O2 Flow-4 pO2-118* pCO2-45
pH-7.43 calTCO2-31* Base XS-5 Intubat-NOT INTUBA Comment-SIMPLE
FAC
CT abd/pelvis:
IMPRESSION:
1. High-grade obstruction at the distal sigmoid colon with
twisting of the
adjacent mesentery and tethering of the distal descending colon,
concerning for sigmoid volvulus. Stranding and edema surrounding
the distal mesenteric vessels is concerning for early ischemic
change.
2. Tethering of the distal descending colon raises the risk for
future
obstruction at this level.
3. No free air.
4. Very large fat-containing left inguinal hernia.
5. Bibasilar opacities may represent mild aspiration.
6. Mild aortic valve calcification.
Brief Hospital Course:
He was admitted to the Acute Care Surgery team and taken
urgently to the operating room for exploratory laparotomy,
sigmoid colon resection, primary anastomosis and detorsion of
volvulus.
His hospital course by systems:
Neuro: Initially intubated and sedated with propofol and
fentanyl, after extubation pain under control with Dilaudid IV
prn. Patient remained alert and oriented. At time of discharge
he only required prn Tylenol.
Cardiac: History of hypertension, atrial fibrillation on
warfarin which was held initially due to supra therapeutic INR
on admission. He was given FFP. His blood pressures were
intermittently elevated and managed with Labetalol IV prn.
Cardiology was consulted who recommended Diltiazem XL 120mg
daily and resuming warfarin once INR <3. Warfarin was restarted
at a lower than his usual home dose. His home diuretic was
restarted as well.
Lungs: Initially intubated and on POD 1 he was successfully
extubated with no acute respiratory distress. His oxygen
saturations remained adequate on room air. There were no other
active issues at time of discharge.
GI: NPO initially while awaiting return of bowel function
following surgery. Once return of function his diet was advanced
slowly for which he was able to tolerate without any
difficulties.
GU: His Foley which was chronic in nature remained in place
without any active issues.
ID: Patient was given perioperative antibiotic prophylaxis. WBC
remained under normal parameters, afebrile, incision was clean,
dry and intact.
HEME: Supra therapeutic INR upon admission. He was given 6Units
of FFP before and immediately after surgery. INR continue to be
elevated up to 3.6 on POD 1 and he was given another unit of
FFP. Platelet count at time of discharge was 170 and his
hematocrit stable at 34.0.
MSK: He was evaluated by Physical and Occupational therapy early
on and was deemed appropriate for home with services upon
discharge.
Medications on Admission:
Miralax prn, torsemide 20mg daily, coumadin 7.5 mg
daily, acetominophen prn
Discharge Medications:
1. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
2. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO every evening as
directed: Dose adjusted to maintain goal INR 2.0-3.0.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Large bowel obstruction sigmoid volvulus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You were hospitalized with an acute condition of your intestines
called a volvulus which required an immediate operation to
repair. You were seen by the Physical therapist who recommend
that you have physical therapy at home after you are discharged
from the hospital.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-19**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
*
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
When: THURSDAY [**2122-4-2**] at 3:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: WEDNESDAY [**2122-3-25**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2123-2-10**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2122-3-23**] | [
"4019",
"42731",
"V5861",
"4240"
] |
Admission Date: [**2102-5-31**] Discharge Date: [**2102-6-3**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MED
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: This is a 63 year old male with
chronic obstructive pulmonary disease, status post multiple
recent admissions for chronic obstructive pulmonary disease
flares, status post recent discharge from [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**5-16**], when he was intubated in
the Medicine Intensive Care Unit for a chronic obstructive
pulmonary disease flare. The patient was doing well at home
according to his wife, until early in the evening of
admission when he complained of shortness of breath which did
not respond to inhalers. The patient says he tried his
nebulizer in the bathroom as he was getting more short of
breath. It did not help. He then took a shower and felt
more short of breath after that. The patient called 911. He
was intubated in the field for air movement and respiratory
distress, with minimal breath sounds reported and somnolence,
however, his oxygen saturation was 90 percent on room air.
In the Emergency Department, the patient was initially
started on a Propofol drip which dropped his dropped his
blood pressure from 167/104 to the 90s. He was then given
approximately 5 liters of intravenous fluids. He also
received Solu-Medrol and Levofloxacin. In the Emergency
Department, a femoral line was placed, given his low blood
pressure and he was started on Dopamine for the hypotension.
The patient arrived at the [**Hospital Unit Name 153**] stated and easily ventilated
with the ventilator.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease
on 4 liters of home oxygen, status post multiple admissions
for chronic obstructive pulmonary disease flares, status post
multiple intubations, status post a history of tracheostomy
color.
Hypertension.
Hyperlipidemia.
Coronary artery disease, status post multiple myocardial
infarctions, most recently an NSTE myocardial infarction in
[**2102-4-6**].
Chronic low back pain, status post L1-2 laminectomy.
Steroid-induced hyperglycemia.
MEDICATIONS ON ADMISSION: Combivent, Flovent, Lipitor,
Aspirin, Prednisone 40 on a taper, Metoprolol 25 b.i.d.,
Lisinopril 5 once a day, Calcium, Vitamin B, Colace, Percocet
and Protonix.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has a 28 pack year smoking
history. He has quit. He is married. He has rare ethyl
alcohol.
FAMILY HISTORY: His mother had [**Name (NI) 2481**] and asthma.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 100.4, heart
rate 79, blood pressure 100/42, respiratory rate 20, oxygen
saturation 95 percent. This was on his control at 480 by 20,
40 percent FIO2 and 5 of positive end-expiratory pressure.
General: This was a chronically ill-appearing gentleman.
Head, eyes, ears, nose and throat: He had edematous sclera.
Pupils equal, round and reactive to light. Mucous membranes
were dry. Heart was regular rate and rhythm, normal S1,
tachycardiac. Lungs: Essentially clear to auscultation with
occasional rhonchi. Abdomen was soft, nontender,
nondistended with positive bowel sounds. Extremities were
without cyanosis, clubbing or edema. There was a right
femoral line in place. The patient was sedated and
intubated.
LABORATORY DATA: White blood count was 11.8, hematocrit
40.9, platelets 228, INR 1.1, urinalysis was negative for
infection. Sodium was 138, potassium 4.0, bicarbonate 27,
BUN 28, creatinine 1, glucose 187. Blood gas after
intubation 7.23, 74, 476. Lactate was 2.4. Chest x-ray
showed the endotracheal tube in good position, tortuous
aorta, emphysematous changes with no evidence of pneumonia or
failure. An electrocardiogram was sinus tachycardiac at 130
without any acute ST changes with enlarged P waves in 2, 3
and AVF.
HOSPITAL COURSE: Chronic obstructive pulmonary
disease/respiratory failure - The patient carries the
diagnosis of chronic obstructive pulmonary disease with
multiple admissions and intubations, all of which seemed to
resolve rather quickly once the patient was intubated. This
one was similar. Within 24 hours after admission the patient
was easily extubated and did quite well after that, making
great improvement, back to his baseline within two days. It
was felt that this is not consistent with either an asthma
attack or a true chronic obstructive pulmonary disease
exacerbation or infection. There is concern that some other
process was causing the patient's acute episodes of shortness
of breath. In fact, it is not clear the extent of his
respiratory distress when he was intubated in the field,
initially even though he was oxygenating well and had poor
breath sounds at baseline. The patient was treated with high-
dose steroids initially as well as q. 4 hour nebulizer
inhalers. However, his lungs have been clear almost
immediately upon admission. Because of concern that there
might be airway collapse contributing, the patient underwent
a computerized tomography scan which was designed to look for
tracheomalacia. The computerized tomography scan was
misprotocoled and this could not be evaluated. There was a
suspicion that there might be left main stem bronchus
collapse during expiration and it was read as probable distal
tracheomalacia. The patient was provided with a BiPAP
machine and teaching. He responded very well to this at
nighttime. It was suggested that he use the BiPAP at
nighttime and as needed when he feels short of breath and his
shortness of breath is not helped by his usual nebulizers.
The hope is that this might prevent him from needing to call
911 and from repeated intubations. The patient did receive
one dose of Levofloxacin, however, there is no sign of
infection and this antibiotic was discontinued.
Hypotension - The patient was initially hypotensive in the
[**Hospital Unit Name 153**]. This was after receiving Propofol and then other
sedating medications. He required pressors briefly for
Dopamine which increased his heart rate and made him
tachycardiac. He was then switched to Levophed. It was felt
this was all in the setting of sedating medications as well
as ventilator positive end-expiratory pressure as the patient
did not actually appear septic at any time, he has had all of
that quite well and was normotensive once he was extubated,
in fact, on discharge he was restarted on his blood pressure
medications.
Hypertension - The patient has hypertension as an outpatient
at baseline. His Metoprolol and ACE inhibitor were held.
Initially they were restarted on the day of discharge.
Coronary artery disease - The patient has a coronary artery
disease history. He was continued on his Aspirin and his
Lipitor during the admission. In the setting of hypotension,
he did have some hyperacute T waves on electrocardiogram.
His enzymes were cycled and they were negative for
infarction. As noted, his Metoprolol and ACE inhibitor were
restarted prior to discharge.
Renal failure - Initially the patient presented with elevated
lactate and slightly elevated creatinine but these corrected
quickly with fluids.
Prophylaxis - The patient was continued on a proton pump
inhibitors as well as with heparin subcutaneously while in
the hospital. He was then ambulatory by the day of
discharge.
Code status - The patient confirmed that he is a full code.
DISPOSITION: The patient will be discharged to home with his
usual services. He will also be provided with a BiPAP
machine for use as described above. The patient should
follow up with both his primary care physician and Dr.
[**Last Name (STitle) 575**] within the next one to two weeks.
DISCHARGE INSTRUCTIONS: Resumed medications as before
including a taper of Prednisone.
Call your primary doctor or the Emergency Department with any
concerns for shortness of breath, chest pain, nausea or
vomiting.
See your primary doctor, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 8499**] within one
week.
See Dr. [**Last Name (STitle) 575**] within two weeks.
Use BiPAP machine at night and if you feel your shortness of
breath is worsening and your inhalers are not improving your
symptoms.
DISCHARGE MEDICATIONS:
1. Lipitor 10 once a day.
2. Aspirin 325 once a day.
3. Percocet 1 to 2 tablets every 4-6 hours as needed.
4. Protonix 40 mg once a day.
5. Lisinopril 5 once a day.
6. Metoprolol 25 twice a day.
7. Prednisone 40 mg once a day, continue steroid taper as
before admission.
8. Combivent 2 puffs every six hours.
9. Flovent 2 puffs twice a day.
10. BiPAP inspiratory pressure 10, positive end-
expiratory pressure 5 with 2 liters of oxygen at night and
as needed.
DISCHARGE DIAGNOSIS: Chronic obstructive pulmonary disease.
Coronary artery disease.
Hypertension.
MAJOR PROCEDURES: Intubation.
Arterial line.
Central line.
CONDITION ON DISCHARGE: Stable at respiratory baseline.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**]
Dictated By:[**Last Name (NamePattern1) 20173**]
MEDQUIST36
D: [**2102-6-3**] 13:37:57
T: [**2102-6-3**] 15:11:44
Job#: [**Job Number 20174**]
| [
"51881",
"2762",
"4019",
"2859"
] |
Admission Date: [**2166-1-24**] Discharge Date: [**2166-2-1**]
Date of Birth: [**2108-4-9**] Sex: M
Service: MEDICINE
Allergies:
Iron Dextran Complex
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
-L IJ central line
-AV fistulagram with recannalization attempt by Interventional
Radiology
-CT with contrast
-Echocardiogram
-Pericardiocentesis
-Thrombectomy of AV graft thrombus
History of Present Illness:
HPI: Mr. [**Known lastname 30197**] is a 57 year-old man with hx of ESRD on
hemodialysis since [**Month (only) 205**] who presented with 1 day history of
fever to 101 at home and 1 week history of cough. The patient
reports he developed a cough approximately one week ago that has
been productive of copius white sputum. He describes daily
episodes of coughing upon waking and "throwing up white stuff."
There is no evidence of food or bile in the secretions and he
believes they are coming from his lungs rather than his stomach.
He also notes that these coughing fits make him feel nauseus. 2
days prior to admission he was given Reglan for nausea and
"throwing up." He subsequently developed diarrhea, and has had
approximately 5 mushy brown, non-bloody stools daily. He has not
experienced any sore throat, chills, abdominal pain, dysuria. He
notes lightheadedness on changing positions but has been
experiencing this since begininning dialysis in [**Month (only) 205**]. He also
experiences achiness following dialysis. He denies any fever
prior to the day before admission.
.
ROS: Has DOE at baseline, cannot walk up a flight of stairs.
Denies chest pain, abdominal pain, sweats.
.
In the ED, the patient's temperature was 100.6. He underwent CXR
(clear) and CT with contrast. Blood cultures were sent and he
received Levofloxacin 500mg, Flagyl 1000mg, Vancomycin 1g
Past Medical History:
1. ESRD on hemodialysis, awaiting placement on transplant list
2. Renal cell carcinoma of left kidney (s/p partial nephrectomy
[**5-17**]) T1, N0, M0. Surveillance MR [**First Name8 (NamePattern2) **] [**2165-5-15**] was negative
for recurrence.
3. Hypertension
4. Diabetes type 2, recently diagnoses, HbA1C 9
5. Hepatitis C infection
6. Bilateral hearing loss
7. Gout
8. Anemia
9. [**Doctor Last Name 15532**]??????s Esophagus
10.Prostate nodule, PSA 2.8 fall [**2164**]
Social History:
Lives with sister, previously worked in a hotel, quit after [**Month (only) **]
admission to hospital.
Previous 80 pack year smoking history, quit in [**2165-5-15**].
Previous ETOH history of 1 pint per week, quit in [**2165-5-15**]
Previous crack cocaine use (1-2 times per month), quite in [**Month (only) **]
[**2164**]
Previous heroin use, quite 5-6 years ago
Family History:
Sister- DM
[**Name (NI) **] reported CAD.
Positive for alcoholism.
Mother died of "liver problems"; father died of stroke at 51. He
is unsure of any other medical problems in his family.
Physical Exam:
Physical Exam:
VS: T100.6 BP 107/76 HR 101 RR 22 O2sat 94%RA
GEN: Subdued-appearing middle-aged man in NAD
HEENT: Icteric sclera, OP clear, MMM
NECK: supple, no LAD, no JVD
CARD: Tachycardic, regular rhythm, normal S1, S2. 3/6 systolic
murmur at L upper sternal border
LUNG: Crackles on R from base to middle lung field. Crackle on L
at base only. Moving air well.
ABD: Protuberant, soft, ND, slightly tender in site of recent bx
in RUQ, no ascites. Liver edge nonpalpable. No splenomegaly
EXT: WWP, dry, scaly skin on lower legs and feet bilaterally. DP
2+ bilaterally
Pertinent Results:
CXR [**2166-1-24**]:
The left-sided IJ central venous line has migrated slightly more
proximally and the distal tip is in the distal left
brachiocephalic vein. The cardiac size is prominent but
unchanged. There is some tortuosity to the thoracic aorta.
Some streaky density seen at the left base, best seen on the
lateral radiograph. This is likely secondary to atelectasis,
however, early infiltrate cannot be completely excluded.
Attention to this region is recommended on followup studies.
.
.
CT ABDOMEN/PELVIS W/ CONTRAST [**2166-1-24**]:
CT ABDOMEN: There is bilateral pleural thickening and bibasilar
atelectasis, which is unchanged from prior exam. There has been
interval development of a large pericardial effusion. The
effusion measures higher than fluid density at 30 Hounsfield
units and was not present previously. The liver, gallbladder,
pancreas, spleen, adrenal glands, and kidneys are stable in
appearance. The patient is status post partial left nephrectomy.
Multiple low attenuation renal foci are noted and may represent
cysts but are too small to be fully characterized. The stomach
and bowel loops are within normal limits. There is no free air
or free fluid. Of note, are prominent left diaphragmatic,
paraesophageal, and para vena caval lymph nodes. They are
increased in size compared to prior examination.
CT PELVIS: The bladder, prostate, seminal vesicles, and rectum
are unremarkable. There is focal segment of narrowing in the
sigmoid colon, which may relate to transient peristalsis.
Contrast is seen passing beyond this point. There is no free
fluid and no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Interval development of a large pericardial effusion with
high attenuation fluid.
2. Interval increase in size of left diaphragmatic,
paraesophageal, and para vena caval lymph nodes. These could be
inflammatory, however, given the patient's history of renal cell
carcinoma, neoplastic involvement cannot be excluded.
3. Low attenuation renal foci, which may represent cysts but are
too small to be fully characterized.
4. Pleural thickening and atelectasis at both lung bases.
.
.
CXR PA & LATERAL [**2166-1-26**]:
Cardiomegaly is unchanged. A left internal jugular central
venous catheter is in unchanged position, with the tip in the
superior portion of the SVC. No pneumothorax is identified.
There is no consolidation or evidence of congestive failure. No
pleural effusion. IMPRESSION: Cardiomegaly. No evidence of
pneumonia.
.
.
EKG [**2166-1-26**]:
Sinus tachycardia
Modest ST-T wave changes with Probable QT interval prolonged
although is
difficult to measure - are nonspecific but clinical correlation
is suggested. Since previous tracing of [**2166-1-24**], probable no
significant change
.
.
Echocardiogram [**2166-1-27**]:
Conclusions:
1.The left atrium is mildly dilated. The left atrium is
elongated. The
inferior vena cava is dilated (>2.5 cm).
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are structurally normal. No mitral
regurgitation seen.
6.There is a moderate to large sized pericardial effusion. The
effusion
appears circumferential. There is very mild diastolic
invagination of the
right ventricular outflow tract and there is respiratory
variation of mitral valve inflow consistent with early
tamponade.
.
.
Cardiac Cath/Pericardiocentesis [**2166-1-28**]:
1. Right heart catheterization revealed severe elevation of
right and
left sided filling pressures along with equalization of RA, RV
end
diastolic, PA diastolic and PCWP at about 20mmHG. The cardiac
index was
preserved at 3.7. There was marked respiratory variation (peak
to peak
of 30mmHG) in the femoral artery pressure tracing.
2. Pericardiocentesis was uncomplicated and revealed an opening
pressure of 20mmHG and was essentially identical to RA pressure.
600 cc
of bloody fluid were drained with improvement in RA pressure to
10mmHG.
The cardiac index remained unchanged at 3.6.
3. Echo done post procedure revealed only minimal effusion
posteriorly
(pt had 2.5cm circumfrential effusion yesterday).
FINAL DIAGNOSIS:
1. Pericardial effusion with tamponade physiology
2. Successful pericardiocentesis.
.
.
ECHO [**2166-1-29**]:
Conclusions:
There is a trivial/small pericardial effusion. There are no
echocardiographic
signs of tamponade.
.
.
LABS:
[**2166-1-24**] 01:50PM:
WBC-15.1* RBC-3.41* HGB-9.6* HCT-30.4* PLT COUNT-692
MCV-89 MCH-28.1 MCHC-31.5 RDW-16.0*
NEUTS-69.3 LYMPHS-23.3 MONOS-5.7 EOS-1.0 BASOS-0.8
PT-13.4* PTT-24.9 INR(PT)-1.2*
GLUCOSE-79 UREA N-29* CREAT-7.9*# SODIUM-138 POTASSIUM-3.7
CHLORIDE-93* TOTAL CO2-27 ANION GAP-22* LACTATE-1.6
[**2166-1-24**] 06:10PM:
URINE SP [**Last Name (un) 155**]-1.022 BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2
Brief Hospital Course:
#. Issues to be followed-up as outpatient:
1) Needs echo to assess for reaccumulation of pericardial
effusion in 4 weeks followed by appointement with Dr. [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**]. The patient has been instructed to call to schedule echo
and appointment.
2) Assymetric LAD of the left paraesophageal, diaphragmatic and
vena caval lymph nodes seen on CT chest [**1-24**]. Needs repeat CT in
[**3-20**] weeks.
3) Had one dark, guaiac-positive stool on [**1-31**]. Should have
outpatient colonoscopy.
4) RCC, PSA
.
#.Pericardial effusion: First noted on CT chest on [**1-24**]. Viral
etiology was felt to be most likely. Despite his ESRD it was
thought that this was unlikely to be a uremic effusion because
he has been well-dialyzed. On [**1-26**], the patient's SBP was in the
90's. It was unclear if this drop in BP Was secondary to the
effusion or to intravascular depletion from dialysis the day
before. He was given 3 boluses of IVF and BP improved. Pulsus
paradoxus was monitored and remained stable at 10-12mmHg.
Cardiology was consulted and the patient underwent TTE on [**1-27**]
which showed 1.5-2cm pericardial effusion. On [**1-28**] he underwent
pericardiocentesis: 600cc of fluid was removed and a pericardial
drain was placed which drained 80cc of serosanginous fluid over
24 hours. The patient tolerated the procedure well and went to
the CCU for post-procedure monitoring. Pericardial fluid was
found to be an exudate. [**2159**] WBCs were seen. Diff was: N 27%, L
41%, Mono 4%, Eos 4%, Macros 24%. Gram stain and Acid Fast smear
were negative. Fluid culture showed no growth, anaerobic
culture preliminarily no growth. Fungal cultures preliminarily
negative, Acid Fast culture pending. Cytology was negative for
malignant cells. PPD was negative. He tolerated the procedure
well and a pericardial drain was placed. On [**1-29**], drain output
was minimal and removal of the drain was attempted. Removal was
not successful and the patient underwent angiography for removal
of the drain, which was found to be incorporated into a
loculated portion of the pericardial sac. Given these findings,
this is most likely viral etiology, however, malignancy must
still be considered. On echocardiogram 24 hours post-procedure,
no re-accumulation of fluid was seen. The patient remained
hemodynamically stable until discharged. He is to schedule a
follow-up echocardiogram with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] ([**Telephone/Fax (1) 128**]) in
about 4 weeks ([**3-1**]).
.
#.Fever:
The patient presented with fever to 101 at home, in the setting
of 1 week of productive cough. His WBC was also elevated to 15.1
on admission, and he received Vancomycin, Levo and Flagyl in the
ED. Blood cultures, urine cultures and stool cultures were sent
and found to be negative. There was no evidence of pneumonia on
chest films. Given that Mr. [**Known lastname 30197**] is a hemodailysis patient,
the team's greatest concern was for infected venous access
causing bacteremia, and blood cultures were repeated x3. As
there was no evident source of infection, no further antibiotics
were given. Tylenol was held so fever curve could be monitored,
and he continued to have low grade fever until his effusion was
drained on [**1-28**]. Following drainage of the effusion the patient
continued to become febrile during/after hemodialysis
treatments, but was otherwise afebrile. Given his history of
renal cell carcinoma, this was also considered as a possible
source of fevers. RCC is being followed as an outpatient. By the
day of discharge, Mr. [**Known lastname 30197**] was afebrile and his WBC had
decreased to 9.9.
.
#.ESRD:
The patient has received hemodialysis since [**2165-6-14**], on Tues,
Thurs, Sat schedule. Dialysis was continued on this schedule
while the patient was hospitalized. On Saturday [**1-25**], 2.2kg
fluid was removed resulting in SBP in 90's. He also reported
lightheadedness with changes in position. Subsequently, he
received IV fluid boluses and his blood pressure improved. On
[**1-27**] the patient underwent fistulagram that had been scheduled
as an outpatient to work-up difficulty with fistula access. The
graft was found to be stenosed, and revision by angiography was
performed. On post-procedure imaging the graft was found to be
thrombosed, and re-cannulation was again attempted that
afternoon. Ultrasound the following morning ([**1-28**]) revealed
complete occlusion of the fistula throughout its graft portion
from the arterial anastomosis to the venous anastomosis.
Transplant surgery performed thrombectomy on [**1-29**], and
post-procedure exam revealed 2+ graft pulse and restoration of a
graft thrill. The patient missed his Tuesday hemodialysis
secondary to graft thrombosis and was subsequently dialyzed
Wednesday-Thursday-Friday-Saturday. He continued to have good
pulse and graft thrill at discharge. In addition to continuing
dialysis, the patient was continued on calcium carbonate 500mg
TID. Electolytes were monitored. The transplant service was
aware of the patient, and the renal service followed him while
inpatient.
.
#. Hypoxia: On [**1-26**] the patient became hypoxic to 88% on RA. He
was placed on 2L NC with sats 94-97%. He denied SOB or chest
pain at the time. Concern was for pneumonia of CHF, given his
reports of dyspnea on exertion at baseline. CXR was checked with
no evidence of pneumonia, pulmonary edema, or pleural effusion.
His oxygen sats were monitored and the patient was instructed to
use an incentive spirometer. Sats improved over the next two
days and supplemental oxygen was discontinued.
.
#.Anemia:
The patient has had anemia requiring transfusions in the past,
likely related to ESRD. On admission HCT was 30.4, then declined
over several days to 25.3. He was transfused 1 unit prior to
pericardiocentesis, and his HCT increased appropriately with the
transfusion. On [**1-31**] he had one dark, soft formed stool that was
guaiac positive. HCT was monitored. It remained stable and was
30.4 on the day of discharge.
Given recent negative colonoscopy ([**2-16**]) patient will simply
require regular follow-up in 5 years.
.
#.Nausea and Diarrhea:
At baseline, the patient has frequent nausea associated with
acid reflux, for which he takes prilosec 40mg [**Hospital1 **]. He also gives
a history of food "getting stuck" and being regurgitated,
suggesting gastroparesis. On admission, the patient reported
post-tussive nausea for 1 week. He has also described daily
episodes of "throwing up" upon waking up in the morning, but
these episodes were always associated with coughing, and the
description given of the secretions was suggestive of sputum
rather than emesis. On the day following admission the patient
had one episode of vomiting after eating breakfast. He noted
that he had not been eating for the week prior to adimission. He
continued to experience intermittent nausea until [**1-26**], when his
appetite improved. The patient had been started on Reglan 2 days
prior to admission for presumed nausea and vomiting and
subsequently developed soft stools, approximately 5 per day.
Stool cultures were sent, and c. difficile toxin was negative.
He continued to have guaiac-negative soft stools while
hospitalized. One guaiac-positive dark, soft formed stool was
recorded on [**1-31**]. HCT remained stable and the patient had a
normal brown colored BM prior to discharge. He was not
orthostatic on discharge.
.
#.Depression:
Patient has had ongoing discussion with his outpatient treaters
about starting an antidepressant medication. During his
hospitalization he informed the team that he now feels that he
needs to start a medication to help with depression. He was
started on Zoloft 25mg daily and advised of possible side
effects of nausea, vomiting and diarrhea. He was also advised
that the medication would most likely not have any effect on his
mood for several weeks.
.
#. Hypertension: Remained stable. Home medications (Valsartan
360mg, diltiazem 320mg, amlodipine 5mg) were continued until
[**1-26**], when the patient found to have low BP. Valsartan was then
decreased to 80mg daily and amlodipine was held. All BP meds
were held on [**1-27**] due to concern for early tamponade. Home
regimen was resumed after drainage of pericardial effusion; the
patient's BP remained stable.
.
#. Diabetes: The patient was placed on QID finger sticks and
insulin sliding scale while hospitalized. He was continued on
glipizide 5mg daily and Lantus 10 units daily except when NPO
for procedures. The majority of his finger sticks were at goal.
.
#.Gout: Remained stable, without symptoms. Allopurinol 100mg QOD
was continued.
.
#.[**Doctor Last Name 15532**]??????s Esophagus: Continued PPI 40mg [**Hospital1 **]
.
#.Hepatitis C: Viral load was sent (currently pending).
.
#.Prophylaxis: While on bed rest, the patient was maintained on
SC heparin. This was discontinued when he began to feel better
and get out of bed frequently.
.
#.Fluids, electrolytes, nutrition: The patient was maintained on
a renal/cardiac diet. Electrolytes were checked daily and the
patient received hemodialysis on his outpatient schedule plus
two additional sessions.
Medications on Admission:
Aspirin 81 mg daily
Nephrocaps 1 cap daily
Allopurinol 100 mg QOD
Valsartan 320mg daily
Amlodipine 5mg daily
Diltiazem SR 360mg daily
Glipizide 5mg daily
Lantus 10units QAM
Prilosec 40mg [**Hospital1 **]
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Prilosec 40mg one tablet twice daily
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Sertraline 50 mg Tablet Sig: half Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 units
Subcutaneous once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
New pericardial effusion
End-stage renal disease on hemodialysis
Occlusion of hemodialysis fistula graft
Anemia
Diabetes
Discharge Condition:
Good
Discharge Instructions:
1. Please call your doctor or return to the Emergency Department
if you develop fever >101, chills, vomiting, abdominal pain,
chest pain, fainting, shortness of breath at rest or lying down,
lightheadedness, or for any other concerning symptoms.
2. Please keep all of your appointments as scheduled (see
below).
3. Please keep your dialysis schedule of Tues/Thurs/Sat.
4. Restart all of your home medications, including your diabetes
medicines. We have added an antidepressant to your medications
(Sertraline 25mg); take half a tablet once a day
Followup Instructions:
1. DR. [**First Name8 (NamePattern2) **] [**2-12**] at 4PM Phone:[**Telephone/Fax (1) 250**]
2. DR. [**First Name (STitle) **] [**Name8 (MD) **], MD--[**3-5**] at 8:40AM Phone:[**Telephone/Fax (1) 673**]
3. Please call ([**Telephone/Fax (1) 19380**] to schedule an appointment with
Dr. [**Last Name (STitle) 911**] to have an echocardiogram in 4 weeks.
| [
"40391",
"25000"
] |
Admission Date: [**2171-5-24**] Discharge Date: [**2171-6-1**]
Date of Birth: [**2093-4-30**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine / Oxycodone
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
R knee swelling, pain, drainage
Major Surgical or Invasive Procedure:
Irrigation and debridement, resection arthroplasty, and
insertion of cement spacer
History of Present Illness:
Ms. [**Known lastname 22365**] returns today for
followup. She is approximately three weeks out from her
surgery.
She was readmitted to the hospital on the 14th for some
incisional drainage as well as knee swelling. At that time, she
was transfused blood switched from Lovenox to Coumadin. Her
goal
for Coumadin has been 2-2.5. She is complaining of continuous
bloody drainage from her knee as well as increased swelling and
pain in her knee. The bleeding increased especially last night
enough to soak her knee immobilizer and her sheets. She has had
no fevers or chills.
Past Medical History:
CAD s/p MI x2 [**88**] years ago in setting of diet pill use
Colon cancer s/p 5-FU in [**2162**] and partial resection
Cervical cancer s/p TAH
Anemia
Transaminitis
Urge incontinence
HTN
.
PSH:
Tonsillectomy
Appendectomy
Rectosigmoidectomy for colon ca
Right Knee replacement [**2169**]
Social History:
Recently widowed over the past year and lost her son. Lives
alone at home. She does not currently smoke, quit 30 years ago,
[**6-8**] year history of 3 packs/week. She does not drink coffee.
No ETOH. No IVDU.
Family History:
[**Name (NI) **] father died in his 90s of an MI, and the patient's
mother died of unknown causes.
Physical Exam:
MUSCULOSKELETAL: Her right knee is swollen and exquisitely
tender. It is ecchymotic throughout her knee and her calf. Her
staples are intact. There is some bloody and serosang drainage
coming from most of them. There is no frank pus noted. She is
neurovascularly intact distally.
Post Op
Tmax: 102.3 Temp:97.9 BP:118/80 Vent: 95% RA
General: Alert, conversant in NAD
HEENT: Mucous membranes moist
Neck: Supple
Cardiovascular: Regular, S1 S2 only with II/VI sytolic murmur to
axilla
Respiratory: Clear bilaterally
Back: Non-tender
Gastrointestinal: sort, NT, ND
Musculoskeletal: Right knee swollen, warm, erythematous/ Wound
with drainage, staples in place
Skin: No generalized rashes
Pertinent Results:
[**2171-5-24**] 05:20PM SED RATE-62*
[**2171-5-24**] 05:20PM PT-35.1* PTT-38.8* INR(PT)-3.7*
[**2171-5-24**] 05:20PM PLT COUNT-227
[**2171-5-24**] 05:20PM WBC-5.4 RBC-3.85* HGB-10.7* HCT-31.5* MCV-82
MCH-27.7 MCHC-33.9 RDW-15.4
[**2171-5-24**] 05:20PM WBC-5.4 RBC-3.85* HGB-10.7* HCT-31.5* MCV-82
MCH-27.7 MCHC-33.9 RDW-15.4
[**2171-5-24**] 05:20PM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-2.7
MAGNESIUM-1.9
[**2171-5-24**] 05:20PM ALT(SGPT)-13 AST(SGOT)-17 LD(LDH)-399* ALK
PHOS-69 TOT BILI-2.0*
[**2171-5-24**] 05:20PM estGFR-Using this
[**2171-5-24**] 05:20PM GLUCOSE-146* UREA N-16 CREAT-0.8 SODIUM-136
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-17
[**2171-5-24**] 07:25PM URINE RBC-0-2 WBC-3 BACTERIA-MANY YEAST-NONE
EPI-[**7-9**]
[**2171-5-24**] 07:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-TR
KNEE (2 VIEWS) RIGHT
Reason: post-op eval
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with right knee infection s/p removal of
hardware and placement of antibiotic spacer
REASON FOR THIS EXAMINATION:
post-op eval
HISTORY: Postop right knee, removal of hardware and placement of
antibiotic spacer.
FINDINGS: Two views from the operating suite show removal of
previous total knee prosthesis with the placement of an opaque
antibiotic spacer. Multiple surgical clips are in place.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 22366**]Portable TTE
(Complete) Done [**2171-5-28**] at 3:00:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Orthopaed
[**Location (un) 830**], [**Hospital Ward Name 23**] 2
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2093-4-30**]
Age (years): 78 F Hgt (in): 60
BP (mm Hg): 125/62 Wgt (lb): 149
HR (bpm): 80 BSA (m2): 1.65 m2
Indication: Bacteremia. Evaluate for endocarditis
ICD-9 Codes: 424.1
Test Information
Date/Time: [**2171-5-28**] at 15:00 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W029-1:02 Machine: Vivid [**8-4**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm
Left Atrium - Peak Pulm Vein S: 0.5 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.52 >= 0.29
Left Ventricle - Ejection Fraction: 70% to 80% >= 55%
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: *6.6 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 224 ms 140-250 ms
TR Gradient (+ RA = PASP): *>= 36 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Hyperdynamic LVEF >75%. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. No 2D or Doppler evidence of
distal arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or vegetations on aortic valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
masses or vegetations on mitral valve, but cannot be fully
excluded due to suboptimal image quality. Moderate mitral
annular calcification. Mild thickening of mitral valve chordae.
Calcified tips of papillary muscles. No MS. Mild (1+) MR. [Due
to acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
masses or vegetations are seen on the tricuspid valve, but
cannot be fully excluded due to suboptimal image quality.
Thickened/fibrotic tricuspid valve supporting structures. No TS.
Moderate [2+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. No masses or vegetations on pulmonic
valve, but cannot be fully excluded due to suboptimal image
quality. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality as the patient was difficult to
position.
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF 70-80%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve, but cannot be fully excluded due to suboptimal
image quality. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. The supporting structures of the tricuspid valve
are thickened/fibrotic. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
No masses or vegetations are seen on the pulmonic valve, but
cannot be fully excluded due to suboptimal image quality. There
is no pericardial effusion.
IMPRESSION: no obvious vegetations but suboptimal study
Brief Hospital Course:
The patient was admitted from clinic on [**2171-5-24**] with a knee
prosthesis infection. Pre-operatively she was seen by the
medical and cardiology consult services for pre-operative
clearance. She was cleared for the OR by the two services. She
was given FFP and vitamin K preoperatively. She was found to
have MRSA bacteremia. On [**5-26**] she was taken to the OR for
removal of hardware and placement of antibiotic spacers. She
required 3 U PRBCs intraoperatively. Post operatively she was
given Vancomycin and ceftriaxone. Post operatively she was
noted to be febrile and hypotensive with low UOP. She was
transfused PRBCs and seen by the medical service. On the evening
of POD#0 she was transferred to the SICU. She was maintained on
antibiotics and fluid/PRBC resuscitated in the SICU. An Echo was
obtained which did not show any vegetations. Her Vanco trough
was checked per ID. On POD#3 she was transferred to the floor in
stable condition. Her drains were removed and she had a repeat
knee x-ray. A PICC line was placed and her central line was
removed. On POD#5 her ceftriaxone was discontinued per ID. She
worked with PT who recommended rehab and she received 1 U PRBCs
for hct of 25. On POD#5 her hct was stable at 28, her INR had
dropped to 1.3. She was voiding without difficulty, tolerating
a regular diet, and her pain was controlled on oral medications.
She was discharged to rehab in stable condition with follow up
with Dr. [**Last Name (STitle) **].
Medications on Admission:
Active Medication list as of [**2171-5-24**]:
Medications - Prescription
Amlodipine [Norvasc] - (Prescribed by Other Provider) - 5 mg
Tablet - Tablet(s) by mouth
Ciprofloxacin - 250 mg Tablet - 1 Tablet(s) by mouth twice daily
Metoprolol Succinate - (Prescribed by Other Provider) - 50 mg
Tablet Sustained Release 24 hr - [**1-30**] Tablet(s) by mouth
Oxybutynin Chloride [Ditropan XL] - 5 mg Tab,Sust Rel Osmotic
Push 24hr - 1 Tab(s) by mouth daily
Warfarin - 1 mg Tablet - 4 Tablet(s) by mouth at bedtime
Medications - OTC
Aspirin [Aspirin EC] - (Prescribed by Other Provider) - 81 mg
Tablet, Delayed Release (E.C.) - Tablet(s) by mouth
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
11. Oxycodone 5 mg Tablet Sig: 0.5-1 tab Tablet PO Q4H (every 4
hours) as needed for pain.
12. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Vancomycin 1000 mg IV Q 12H
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
infected right total knee arthroplasty.
Discharge Condition:
Stable
Discharge Instructions:
1) Patient will need CBC with differential, Vancomycin trough,
Chem7, and LFTs drawn weekly and the results faxed to
[**Telephone/Fax (1) 432**] attention My [**Name8 (MD) **], MD.
2) She needs to have her staples removed in 2 weeks (3 weeks
from the date of surgery)
3) She must complete one month of lovenox 30mg sc bid.
4) She must complete a total of 6 weeks of IV Vancomycin (5
weeks from the date of surgery)
5) She should ambulate and be out of bed as much as possible.
But she should not bear weight on her right leg. She should
wear a knee immobilizer when out of bed.
Physical Therapy:
Activity: Out of bed w/ assist
Pneumatic boots
Right lower extremity: Touchdown weight bearing
Left lower extremity: Full weight bearing
Treatments Frequency:
PT, IV antibiotics
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 3 weeks (4 weeks from the date of surgery).
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2171-7-12**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2171-7-15**]
10:00
9:45 (office is located in the basement of the [**Hospital Unit Name **])
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2171-8-15**] 10:00
| [
"2851",
"5990",
"4019",
"41401",
"412"
] |
Admission Date: [**2175-5-24**] Discharge Date: [**2175-5-25**]
Date of Birth: [**2108-5-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Cordis line placement, endotracheal intubation
History of Present Illness:
66 YOM with CAD on high dose ASA, locally advanced pancreatic
cancer s/p gastrojejunostomy (c/b colon perforation s/p right
colectomy & ileostomy), hx GI bleed from GJ anastamotic site
[**7-/2174**], at which time EGD with extensive clipping failed to
achieve hemostatsis and eventually underwent successful GDA
embolization, but rebled in [**2174-11-19**] (BRBPOstomy) with negative
ileoscopy, and EGD/enteroscopy showing oozing from GJ
anastomosis but no active bleeding and no intervention, as well
as ulcer at the ampulla associated with migrated biliary stent
who presents now with reportedly hematemesis and BRBPO earlier
today without associated symptoms. Of note, was recently
admitted with obstructive jaundice, ERCP [**2175-3-19**] showed biliary
stent protruding from the ampulla but no blood or ulceration
described.
En route to [**Hospital1 18**] became transiently hypotensive (details
unknown) and diverted to [**Hospital1 **] [**Location (un) 620**]. Hct there 29 (stable from
[**2175-5-19**]), given IVF, protonix and morphine, and xfered to [**Hospital1 18**].
On arrival here BP 102/44, HR 66. Ostomy output was heme
positive but without gross blood, NGL showed coffee grds that
did not clear with 500cc lavage. While in ED became unresponsive
and hypotensive to 50's - intubated for airway protection and
started on pressors. Given IVF but no blood yet. Labs here show
hct 26, plts 180 (were 46 on [**2175-5-19**]), lactate 3.3, nl BUN/cr.
Received 4u pRBCs in ICU, initially stable with BP 122/36, HR
100 on minimal levo in ED. PPI ordered but not yet initiated.
Surgical team involved in ED but not felt to be a surgical
candidate given unresectable cancer.
Evaluated pt as he was arriving in ICU. Initially SBP 90s, HR
130s sinus tach. Shortly after arrival to ICU pt became
hypotensive to 60s systolic and tachy to 130s on 2 pressors ->
converted to VT -> shocked x 1, 3 pressors started at max dose.
Copious BRB per OG tube (600cc in past 20 mns per ED transport).
Past Medical History:
- hypertension
- hyperlipidemia
- CAD s/p MI [**4-/2174**] s/p DES, also s/p CABG x5 [**6-/2173**]
- carotid stenosis (70% left carotid)
- pancreatic head adenocarcinoma s/p staging lap [**3-/2174**], s/p
gastrojejunostomy, open CCY, open wedge liver Bx, pancreatic Bx
[**2174-7-5**]
- colon perforation s/p ex-lap, right colectomy, ileostomy,
mucous fistula [**2174-7-15**]
ONCOLOGIC HISTORY:
- Mr. [**Known lastname 30113**] developed weight loss back in [**2172**]. He had
undergone a quadruple bypass at that time and noticed he lost
approximately 45-50 pounds despite eating well.
- He developed painless jaundice first noted in 04/[**2173**]. He
underwent an ERCP with stent placement by Dr. [**First Name (STitle) 39335**] and Dr.
[**Last Name (STitle) **] subsequently performed endoscopic ultrasound.
- He underwent a CT angiography at [**Hospital1 1170**] on [**2174-6-15**] and was felt that his disease was generally
resectable. He went on to undergo a staging laparoscopy with
laparoscopic liver biopsies performed on [**2174-4-15**].
- He underwent a side-to-side gastrojejunostomy, open
cholecystectomy, open wedge liver biopsy and multiple open
pancreatic biopsies on [**2174-7-5**] at which time the tumor was
found to be unresectable.
- His recovery was complicated by a ruptured colon for which he
underwent emergency right hemicolectomy and ileostomy,
debridement and reclosure of right subcostal excision on
[**2174-7-15**].
- He was seen again on [**2174-8-3**] for a mesenteric bleed.
- Has been on Gemcitabine
Social History:
Married with 3 kids. Quit smoking and alcohol (former heavy
EtOH).
Family History:
No known FH of pancreatic cancer.
Physical Exam:
No admission physical exam given critical status and code
situation.
Discharge exam: Expired.
Pertinent Results:
[**2175-5-24**] 09:20PM BLOOD WBC-11.3*# RBC-2.28* Hgb-8.6* Hct-25.5*
MCV-112* MCH-37.6* MCHC-33.6 RDW-20.5* Plt Ct-180#
[**2175-5-24**] 09:20PM BLOOD Neuts-78.4* Lymphs-15.3* Monos-5.1
Eos-0.2 Baso-1.0
[**2175-5-24**] 09:20PM BLOOD PT-11.9 PTT-26.9 INR(PT)-1.0
[**2175-5-24**] 09:20PM BLOOD Glucose-136* UreaN-10 Creat-0.6 Na-133
K-5.8* Cl-105 HCO3-23 AnGap-11
[**2175-5-24**] 10:52PM BLOOD Type-CENTRAL VE Tidal V-450 PEEP-5
FiO2-100 pO2-114* pCO2-45 pH-7.16* calTCO2-17* Base XS--12
AADO2-567 REQ O2-92 Intubat-INTUBATED
[**2175-5-24**] 10:52PM BLOOD Glucose-155* Lactate-6.0* Na-131* K-5.4*
Cl-110
[**2175-5-24**] 10:52PM BLOOD Hgb-12.0* calcHCT-36
[**2175-5-24**] 10:52PM BLOOD freeCa-0.92*
CXR:
Initial images demonstrate the endotracheal tube to be 7.5 cm
above
the carina, although later images after adjustment showed to be
6 cm above the carina. An endogastric tube courses inferiorly
and into the stomach. The right-sided Port-A-Cath tip sits in
the superior right atrium. A right
central venous catheter tip sits in the right brachiocephalic
vein. Clips and coil material are seen in the right upper
quadrant. Additionally, a stent like structure is seen in the
left upper quadrant.
The cardiomediastinal and hilar contours are normal. The lungs
are clear.
There is no large pleural effusion or pneumothorax.
IMPRESSION:
1. Lines and tubes as described above.
2. No acute cardiopulmonary process.
Brief Hospital Course:
67M with metastatic pancreatic cancer who presented with small
volume hematemesis, subsequently became hemodynamically unstable
and expired upon transfer to the MICU.
.
Hematemesis: The patient was NG Lavaged in the ED with bright
red blood after 500cc lavage. He subsequently dropped his BP to
the 60s systolic and was intubated in the ED, Cordis was placed
for access, Levophed was started He was transfused 4 units PRBCs
in the ED. GI and surgery were consulted. GI initially planned
to perform EGD upon transfer to the ICU. Surgery felt he was not
a surgical candidate and suggested getting IR involved for
possible embolization. He was transferred to the MICU on
Levophed and Dopamine. He had 600cc bright red blood output
during transfer from the ED to the MICU. Massive transfusion
protocol was initiated and PRBC, PLT, FFP transfusion was
started with calcium supplementation. The patient went into
monomorphic VT soon after transfer to the MICU and returned to a
sinus rhythm after 1 shock. The NG tube subsequently stopped
functioning and he began to extravasate bright red blood per
mouth. Rapid transfusion protocol was continued while the family
was contact[**Name (NI) **]. Ultimately, he went into PEA and then asystolic
arrest and the family did not wish to pursue continued
aggressive measures. He expired at 0100 on [**2175-5-25**]. Immediate
cause of death was cardiopulmonary arrest, chief cause of death
was pancreatic cancer, other cause of death was acute blood
loss. Significant time was spent with the family and they seemed
satisfied with care provided.
Medications on Admission:
Active Medication list as of [**2175-5-23**]:
LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
(One) Tablet(s) by mouth once a day
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - [**11-20**] Tablet(s) by mouth 30
minutes prior to your CyberKnife treatment.
METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other
Provider) - 25 mg Tablet Extended Release 24 hr - 1 (One)
Tablet(s) by mouth once a day
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - 1 Tablet(s) by mouth
twice
a day as needed for hiccups
OXYCODONE - 5 mg Tablet - [**11-20**] Tablet(s) by mouth q4-6h as needed
for pain
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every six (6) hours as needed for nausea
ASPIRIN - (OTC) - 325 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day as needed for constipation
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Cardiopulmonary arrest
2. Acute blood loss
3. Pancreatic cancer
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
| [
"2851",
"412",
"V4581",
"V4582",
"4019",
"2724"
] |
Admission Date: [**2175-2-7**] Discharge Date: [**2175-2-10**]
Date of Birth: [**2094-6-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
esophagogastroduodenoscopy
History of Present Illness:
This is an 80 year old male with history of coronary disease s/p
CABG with a patent LIMA-LAD per cath [**2171**] on plavix, peripheral
[**Year (4 digits) 1106**] disease s/p popliteal to posterior tibial graft on
right lower extremity, atrial fibrillation on coumadin,
presenting with new onset of bright red blood per rectum. Mr
[**Known lastname 25280**] developed acute onset of bright red blood this AM prior
to making it to the bathroom - he had no abdominal pain or
cramping, but daughter reported that he felt weak and looked
pale. He passed about 200 ccs of blood in the toilet. EMS
arrived on the scene and apparently had a difficult pressure to
appreciate; however consequently BP was noted in the 160s. He's
never had hematochezia before. Does take plavix and coumadin;
INR was 3.9. Usually INRs are within range of [**2-10**]. No recent
history of motrin, aspirin, ibuprofen. Had colonoscopy in [**2174**]
which showed just external hemorrhoids with no other lesions.
Transferred to MICU for further workup. GI evaluated and plan
on scoping in AM (endoscopy and colonoscopy).
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
PVD w chronic LE ulcers
CHF NYHA Class II, EF 20-30% (echo [**2-18**])
CAD s/p CABG x4 (LIMA->LAD, SVG->Diag->left-PL, SVG->ramus) in
[**2-/2166**]
Cath with SVGx2 occluded, patent LIMA-LAD in [**6-/2171**]
VT s/p [**Year (4 digits) 3941**] placement ([**Company 2267**] Confient model E030
dual-chamber [**Company 3941**])
s/p rsxn R 1st MT joint [**2-10**]
s/p R BK [**Doctor Last Name **] -DP w/nrsvg [**4-11**]
s/p plasty of bpg [**4-13**]
s/p agram [**3-14**]
arteriogram 12/10
[**2174-2-10**] R 3rd toe debrid by podiatry
[**2174-2-8**] right BK [**Doctor Last Name **] to PT bypass w/ NRSVG
Social History:
married. has 6 children. previously worked with polaroid. [**Doctor Last Name 4273**]
tobacco. Quit ETOH 25 years ago. [**Doctor Last Name 4273**] illicits.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
VS: HR 80, BP 120/80, RR 12, 98% RA, temp 99
Gen: Black male, pleasant, alert, in no apparent distress
Cardiac: Nl s1/s2, RRR
Pulm: clear bilaterally
Abd: soft, NT, ND, normoactive
Ext: no edema noted
.
discharge exam
VS: 97.9 118/65 (118/65-141/68) 59 (59-75) 16 97% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - sclerae anicteric, MMM
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - irregular, 2/6 systolic murmur heard throughout, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, trace to 1+ pitting edema L>R, 2+ peripheral
pulses (radials, DPs)
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS
[**2175-2-7**] 12:56PM BLOOD WBC-10.8 RBC-2.78* Hgb-8.0*# Hct-25.3*#
MCV-91 MCH-28.8# MCHC-31.7 RDW-15.8* Plt Ct-238
[**2175-2-7**] 12:56PM BLOOD Neuts-55.4 Lymphs-38.1 Monos-3.9 Eos-1.7
Baso-0.8
[**2175-2-7**] 12:56PM BLOOD PT-36.8* PTT-29.2 INR(PT)-3.6*
[**2175-2-7**] 12:56PM BLOOD Glucose-195* UreaN-37* Creat-1.5* Na-143
K-3.8 Cl-105 HCO3-21* AnGap-21*
[**2175-2-8**] 03:38AM BLOOD ALT-21 AST-26 LD(LDH)-177 AlkPhos-43
TotBili-0.9
[**2175-2-8**] 03:38AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1
[**2175-2-7**] 01:01PM BLOOD Hgb-8.3* calcHCT-25
.
OTHER LABS:
[**2175-2-7**] 12:56PM BLOOD WBC-10.8 RBC-2.78* Hgb-8.0*# Hct-25.3*#
MCV-91 MCH-28.8# MCHC-31.7 RDW-15.8* Plt Ct-238
[**2175-2-7**] 10:04PM BLOOD Hct-24.3*
[**2175-2-8**] 03:38AM BLOOD WBC-9.8 RBC-2.59* Hgb-7.3* Hct-23.4*
MCV-90 MCH-28.0 MCHC-31.0 RDW-16.0* Plt Ct-266
[**2175-2-8**] 05:45PM BLOOD Hct-23.9*
[**2175-2-9**] 07:00AM BLOOD WBC-9.9 RBC-2.78* Hgb-8.0* Hct-25.0*
MCV-90 MCH-28.7 MCHC-31.9 RDW-16.8* Plt Ct-246
[**2175-2-9**] 04:10PM BLOOD Hct-29.4*
[**2175-2-10**] 06:55AM BLOOD WBC-7.0 RBC-2.94* Hgb-8.8* Hct-26.6*
MCV-91 MCH-30.0 MCHC-33.1 RDW-16.3* Plt Ct-271
[**2175-2-8**] 03:38AM BLOOD PT-23.6* INR(PT)-2.3*
[**2175-2-9**] 07:00AM BLOOD PT-16.1* PTT-30.0 INR(PT)-1.5*
[**2175-2-8**] 10:44PM BLOOD CK(CPK)-59
[**2175-2-9**] 07:00AM BLOOD CK(CPK)-80
[**2175-2-9**] 04:10PM BLOOD CK(CPK)-87
[**2175-2-8**] 10:44PM BLOOD CK-MB-4 cTropnT-0.04*
[**2175-2-9**] 07:00AM BLOOD CK-MB-6 cTropnT-0.11*
[**2175-2-9**] 04:10PM BLOOD CK-MB-5 cTropnT-0.12*
.
discharge labs
[**2175-2-10**] 11:20AM BLOOD Hct-28.2*
[**2175-2-10**] 06:55AM BLOOD PT-13.4* PTT-29.1 INR(PT)-1.2*
[**2175-2-10**] 06:55AM BLOOD Glucose-111* UreaN-15 Creat-1.4* Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
[**2175-2-10**] 06:55AM BLOOD CK(CPK)-66
[**2175-2-10**] 06:55AM BLOOD CK-MB-3 cTropnT-0.10*
[**2175-2-10**] 06:55AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0
.
micro
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2175-2-10**]):
POSITIVE BY EIA.
.
studies
ECG [**2175-2-7**]. HR 82, axis -30, old inferior q wave,
non-specific t
wave I, avel and t wave inversions laterally ? LVH.
.
ECG [**2175-2-8**]: HR 88, NS, + APC, old q waves inferiorly, <1mm
st
elevation III, t wave flatening I -avl and v4-v6
.
ECG [**2175-2-9**]: HR 65, NSR, biphasic t wave waves v2-v3-v4
compared to
prior.
.
EGD:
Excavated Lesions Five cratered non-bleeding ulcers, with clean
white base, ranging in size from 5 mm to 10 mm were found in the
duodenal bulb. No fresh or old blood was noted.
Impression: Ulcers in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations: Check H. pylori serology and eradicate if
positive.
F/U with inpatient GI team.
.
COLONOSCOPY:
Protruding Lesions: Small internal & external hemorrhoids were
noted.
Excavated Lesions: A few diverticula were seen in the whole
colon. Diverticulosis appeared to be of mild severity.
Other Semi-solid and liquid stool was noted scattered in the
whole colon. This was copiously irrigated and the patient was
re-positioned to improve mucosal visualization. Despite these
measures, small size pathology may have been missed.
Normal terminal ileum
No fresh or old blood was noted.
Impression: Diverticulosis of the whole colon
Bowel prep was fair.
Normal terminal ileum
No fresh or old blood was noted.
Otherwise normal colonoscopy to cecum
Recommendations: F/U with inpatient GI team.
.
Brief Hospital Course:
Initial Presentation: 80 yo M with hx of CAD, PVD, HTN, HLD on
plavix and coumadin who presented with GI bleed found to have
drop in HCT and elevated INR.
.
# GI Bleed: Patient presented to the ED after found to have 1
episode of blood mixed with stool. In the ED he had stable vital
signs but was found to have a Hgb/HCT of [**9-2**] (down from 12/35
in [**9-19**], however was previously anemic with HCTs between 25-30),
and an elevated INR of 3.6. Patient was given 2 units of FFP and
subsequently developed hives. He was then given benadryl and
hives resolved. He was evaluated by GI with plans to do
EGD/colonoscopy the following morning. His ASA, plavix, and
coumadin were held. Patient was monitored overnight in the MICU.
He was given IVF but no additional blood products. HCT remained
stable around 24-25. He subsequently underwent an
EGD/colonoscopy and was transferred to the medicine floor.
Endoscopy was significant for duodenal ulcers, diverticulosis,
and small internal and external hemorrhoids. He was transfused
with 2 units of PRBC given demand ischemia (see below) and
responded appropriately. ASA, plavix, and warfarin were
restarted. H. pylori serology was ordered and patient was
started on omeprazole 40 mg po BID. Patient had no further
episodes of hematochezia or melana and HCT remained stable
through remainder of admission. He was discharged with plans to
follow up with his PCP and with gastroenterology. After
discharge h.pylori serology were +, patient will need to be
treated by PCP as an outpatient.
.
# Chest pain: On evening after endoscopy, patient had an episode
of substernal chest pain with associated ECG changes. Troponins
were elevated but CKMB was WNL. His chest pain resolved with
sublingual nitro x2. The patient was evaluated by cardiology and
it was felt this chest pain was most likely due to demand
ischemia in the setting of GI bleed and anemia. He was
subsequently transfused 2 units of PRBC. He remained chest pain
free through the remainder of the admission and his troponins
started to trend down by time of discharge. He was continued on
his ASA, statin and plavix. He was also started on metoprolol.
He has plans to follow up with cardiology as an outpatient.
.
# Chronic systolic CHF - Patient remained euvolemic throughout
admission. His torsemide was initially held in the setting of GI
bleed. However, it was subsequently restarted prior to
discharge. He was also started on metoprolol and lisinopril
during admission.
.
# Diabetes - Metformin was held during admission. His blood
sugars were controlled with insulin sliding scale.
.
# Afib on coumadin - INR initially supratherapeutic (3.6) on
presentation. He was treated with FFP initially and coumadin was
held in the setting of GI bleed. Coumadin was restarted prior to
discharge. He has plans to have his INR rechecked on [**2175-2-13**] at
PCP follow up
.
# HTN - cont medications as above
.
# HLD - continued pravastatin
.
# PVD - Plavix and ASA initially held with GI bleed but
restarted prior to discharge
.
Transitional Issues:
- Just after discharge patients H. pylori antibody returned as
positive. PCP and gastroenterologist were notified. Patient
should be treated with Prevpac.
- Patient was started on omeprazole 40 mg [**Hospital1 **] for PUD until GI
follow up.
- Patients INR was subtherapeutic upon discharge. His INR will
need close follow up after discharge and coumadin dosing will
likely need additional adjustment.
- Patient was started on metoprolol and lisinopril during
admission given his hx of CAD and CHF. Patient will need his
electrolytes checked within 2 weeks of discharge. He will also
need his blood pressure and heart rate rechecked.
- patient was full code during admission
Medications on Admission:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please start on 9/31.
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Coumadin 2 mg Tablet Sig: 1-2 Tablets PO once a day: as
directed by your PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] your home dose.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
please take as directed by your PCP.
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain :
take 1 tablet at onset of chest pain. if chest pain continues
for 5 minutes take a second tablet. if chest pain contines after
10 minutes take a 3rd tablet and call 911.
9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnoses: GI bleed, Peptic Ulcer disease, chest pain
secondary diagnoses: Coronary artery disease, congestive heart
failure, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 25280**],
It was a pleasure caring for you while you were admitted to
[**Hospital1 18**]. You were admitted because you were bleeding from your
gastrointestinal tract. You were evaluated by the
gastroenterologists and underwent an EGD and colonoscopy which
showed some ulcers in the beginning of your small intestines and
mild outpouchings of your colon. There was no evidence of an
active bleeding site. You were started on a medication called
omeprazole for your ulcers.
.
During your admission, your also had an episode of chest pain.
Your electrocardiogram showed some changes and your heart
enzymes were elevated. You were evaluated by the cardiologists
who felt there was no need for intervention or additional
testing and that the chest pain was most likely due to your low
blood counts. You were subsequently transfused with 2 units of
blood. You were also started on two medications to help your
heart health.
.
The following changes have been made to your medication regimen
Please START taking
- omeprazole 40 mg twice daily for your ulcers (you can discuss
decreasing this dose at your follow up appointment with your
gastroenterologist)
- lisinopril 2.5 mg daily
- metoprolol succinate 25 mg daily
Please take the rest of your medications as prescribed and
follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
.
You will need to have your INR checked on Monday at your
appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25287**].
You will need to have your electrolytes rechecked in 2 weeks to
monitor your potassium and creatinine with your new medications.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25287**], PA (works with Dr [**Last Name (STitle) 25288**]
Location: [**Hospital 4323**] MEDICAL
Address: [**Location (un) 4324**], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 4326**]
Appt: [**2-13**] at 11am
Department: CARDIAC SERVICES
When: THURSDAY [**2175-2-23**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2175-3-1**] at 1:30 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2175-2-13**] | [
"41071",
"42731",
"4280",
"2724",
"25000",
"4168",
"V4581",
"V1582",
"V5861"
] |
Admission Date: [**2187-1-3**] Discharge Date: [**2187-1-14**]
Date of Birth: [**2142-3-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
intubated at OSH
radial arterial line placement
History of Present Illness:
Mr. [**Known lastname **] is a 44y/o gentleman with paranoid schizophrenia, HTN,
and recent treatment for pneumonia last week who was found by
his VNA to be short of breath and is now intubated. Per EMS
records, VNA found him to be extremely agitated, speaking in
"choppy" sentences. He reported 30 minutes of sudden shortness
of breath, wheezing, difficulty speaking, and non-productive
cough. On the scene, initial VS were BP 140/80, HR 120, RR 38,
62%RA - 88% on 6L NC. He was given nebs with minimal relief and
was brought to the [**Hospital1 18**] ED.
.
In the ED, he was given Levofloxacin and Methylprednisolone. He
was put on a NRB and continued to be somnolent, lethargic with
bilateral rhonchorous breath sounds. He was intubated
(mallampati 3), started on Norepinephrine, and was initially
sedated w/ propofol but BP dropped so he switched to Fentanyl
and Versed. Right IJ central line was placed. He was started on
empiric Vancomycin + Levofloxacin. He was then transferred to
MICU for his respiratory distress.
.
On arrival to the MICU, he was intubated and sedated. His
Pinspiratory and plateau pressures were elevated, with an
elevated differential. Nebs, steroids, and diuresis were
initiated.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
DM2
Schizophrenia
h/o pneumonia
Social History:
Raised by grandmother from age 10, at which time both parents
died (father from [**Name (NI) **], mother "choked on her own vomit).
Currently lives in a studio in [**Location (un) 4398**]. He has a VNA that goes
to his home three times per day. He spends
days going to grandmother's house and they run errands together.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
Vitals: T 100.7, O2 sat 98% on 100% FiO2, HR 80, BP 120/70, RR
20
Gen: Morbidly obese black male, sedated
Cardiac: Nl s1,S2 RRR, no murmurs appreciable, JVP not
appreciably elevated
Resp: mild wheezes bilaterally, mild crackles at bases
Abd: obese abdomen, soft, nondistended
Ext: 1+ lower extremity edema, pulses present bilaterally, warm
DISCHARGE EXAM
Physical Exam:
Vitals: 98.3 136-160/80-95 19-22 86-93%RA
Gen: Morbidly obese black male, A&Ox3, pleasant and cooperative
Cardiac: Nl s1,S2 RRR, no murmurs appreciable, JVP not
appreciably elevated
Resp: mild wheezes bilaterally, no crackles
Abd: obese abdomen, soft, nondistended
Ext: no lower extremity edema, pulses present bilaterally, warm
Pertinent Results:
ADMISSION LABS
[**2187-1-3**] 10:15AM BLOOD WBC-11.8* RBC-4.83 Hgb-13.7* Hct-43.4
MCV-90 MCH-28.3 MCHC-31.5 RDW-16.1* Plt Ct-464*
[**2187-1-3**] 10:15AM BLOOD Neuts-70.0 Lymphs-24.1 Monos-4.4 Eos-0.9
Baso-0.8
[**2187-1-3**] 01:10PM BLOOD PT-13.7* PTT-32.5 INR(PT)-1.3*
[**2187-1-3**] 10:15AM BLOOD Glucose-160* UreaN-16 Creat-0.8 Na-142
K-5.2* Cl-98 HCO3-39* AnGap-10
[**2187-1-4**] 03:31AM BLOOD ALT-19 AST-13 LD(LDH)-181 CK(CPK)-68
AlkPhos-101 TotBili-0.4
[**2187-1-3**] 10:15AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.6
[**2187-1-3**] 10:37AM BLOOD Lactate-1.5
[**2187-1-3**] 10:15AM BLOOD cTropnT-<0.01
[**2187-1-3**] 05:46PM BLOOD CK-MB-2 cTropnT-<0.01
[**2187-1-4**] 03:31AM BLOOD CK-MB-2 cTropnT-<0.01
[**2187-1-4**] CXR
Volume overload and cardiomegaly.
[**2187-1-4**] TTE
Suboptimal study. No echocardiographic evidence of intraatrial
or pulmonary-arterial shunting. Normal left ventricular cavity
size and mild symmetric hypertrophy with preservation of global
left ventricular systolic function. Borderline normal right
ventricular systolic function with evidence of pressure/volume
overload consistent with possible primary pulmonary process
(COPD vs pulmonary embolus vs infection). Moderate pulmonary
artery systolic hypertension. Very small, circumferential
pericardial effusion without echocardiographic evidence of
tamponade.
[**2187-1-4**] CTA CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or acute thoracic aortic
pathology.
2. Bibasilar dense consolidations, concerning for pneumonia,
less likely
atelectasis. Trace bilateral pleural effusions.
3. ETT, right IJ central venous line, feeding tube are all in
optimal
position.
.
CXR [**2187-1-13**]
FINDINGS: The ET tube and NG tube have been removed. The heart
is mildly
enlarged. There is pulmonary vascular redistribution and
probable small left
effusion, but no focal infiltrate. Compared to the prior study,
there has
been some mild improvement in fluid overload.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Mr. [**Known lastname **] is a 44y/o morbidly obese gentleman with schizophrenia
who presented to [**Hospital1 18**] intubated/sedated for respiratory failure
from pneumonia
.
ACTIVE ISSUES
.
#. Hypoxemic and hypercarbic respiratory failure: He has a
history of COPD and obstructive sleep apnea and likely has a
component of obesity hypoventilation syndrome. He the developed
a pneumonia. He presented in respiratory failure and was
intubated and admitted to the MICU. He was treated with a course
of vancomycin and zosyn for his pneumonia. He was also diuresed
with lasix gtt and treated with albuterol and ipratropium
nebulizers. He had a prolonged intubation because of his poor
baseline lung function but was successfully extubated. He did
very well post extubation. No new medications were started for
his COPD but this may be considered as an outpatient. He would
also benefit from encouragement of his CPAP use.
.
#. Schizophrenia: Continued on his home antipsychotics.
.
INACTIVE ISSUES
.
#. HTN: Stable. Initially held his lisinopril but this was
restarted on discharge.
Medications on Admission:
Lisinopril 5mg QAM
Omeprazole 20mg daily
Haldol 10mg PO QID
Benztropine 1mg PO TID PRN EPS
Risperidone 2mg QAM, 4mg QHS
Metformin 850mg [**Hospital1 **]
Albuterol HFA 2 puffs QID PRN
Fluticasone 440mcg inh [**Hospital1 **]
Nicotine patch
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
4. benztropine 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for extrapyramidal side effects.
5. risperidone 2 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
6. risperidone 2 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
7. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
9. fluticasone 110 mcg/actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Home With Service
Facility:
Nizhoni
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Secondary Diagnoses:
COPD
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
You were in the hospital because you had pneumonia. You were put
on a breathing machine and treated with antibiotics. We are glad
that you are feeling much better. You finished the antibiotics
and do not need to continue taking these. You should mae sure to
call your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to schedule a follow up
appointment this week.
.
Please continue taking all medications as you have been
Followup Instructions:
Please call your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to schedule a follow
up appointment this week.
[**Last Name (un) **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 96996**] MD
[**Last Name (NamePattern1) **], [**Location (un) 538**], [**Numeric Identifier 96997**]
1([**Telephone/Fax (1) 14771**]
| [
"486",
"51881",
"4019",
"25000",
"32723",
"4168"
] |
Admission Date: [**2159-4-3**] Discharge Date: [**2159-4-24**]
Date of Birth: [**2158-12-6**] Sex: M
Service: Neonatology
HISTORY: This is a discharge summary covering the time from
[**2159-4-3**] until [**2159-4-24**]. Please refer to the
previous discharge for the previous hospital courses.
[**Known lastname **] was admitted back to [**Hospital1 188**] at 118 days of age for persistent vomiting and feeding
intolerance. His previous course is that he was twin number
two born at 24-5/7 weeks gestation to a gravida 1 mother. [**Name (NI) **]
was twin number two of a dichorionic, diamniotic pregnancy.
The pregnancy was complicated by vaginal bleeding at six
weeks gestation, cervical shortening and preterm labor. He
was delivered by cesarean section for breech presentation and
unstoppable labor. His Apgar scores were 5 at one minute and
7 at five minutes.
His neonatal course was remarkable for respiratory distress
syndrome treated with high-frequency oscillator ventilation
for nine days. He had hypotension treated with dopamine. He
had a large patent ductus arteriosus at two weeks of life
which was treated with indomethacin. He developed severe
necrotizing enterocolitis requiring surgical treatment and
was transferred to [**Hospital3 1810**] on [**2158-12-11**] at 15 days
of life. He was found to have a perforation of the splenic
flexure of the bowel and an ileostomy was performed. The
surgery was complicated by hepatic hemorrhage. He was
treated with high-frequency ventilation postoperatively and
then transitioned to conventional ventilation and CPAP prior
to transfer back from [**Hospital3 1810**] on day of life 32.
Feedings were advanced with breast milk and were well
tolerated. He was transitioned to Neosure formula prior to
discharge and was sent home on 30 calorie per ounce Neosure.
He developed problems with his feedings within two days of
discharge with irritability and spitting of his formula from
his mouth and nose. He continued on these feedings for one
week, taking approximately 60-70 cc every four hours and
spitting up approximately 5-10 cc at each feeding. He was
then evaluated at [**Hospital3 1810**] in the emergency room
where a KUB was performed and the family was sent home. He
was treated with hourly feedings of Pedialyte and then
transitioned to half and then three-quarters strength Neosure
with recurrence of vomiting. He was then transitioned to
Enfamil formula and then Alimentum and then ultimately
Neocate over the next two days. He has been fed at least
every two hours since then with volumes of 20-40 cc.
Regurgitation and fussiness with feedings has persisted. He
was prescribed ranitidine then Prilosec, Reglan and Mylanta
for the two days prior to admission. The ileostomy drainage
previously was partially-formed stool and has changed to dark
green watery output. He was evaluated by his pediatrician on
the day of admission and the decision was made to admit for
further diagnostic work-up.
HOSPITAL COURSE: 1. Respiratory: He has always remained in
room air with comfortable respirations. There are no
respiratory issues.
2. Cardiovascular: He has remained normotensive throughout
his Neonatal Intensive Care Unit stay. There are no
cardiovascular issues.
3. Fluids, electrolytes and nutrition: At the time of
discharge his weight is 2,850 grams. His length is 47.5 cm
and head circumference 34 cm.
At the time of discharge he is eating Pregestimil 22 calories
per ounce on an ad lib schedule, taking approximately 140-200
cc per kg per day.
4. Gastrointestinal: Prior to admission to the [**Hospital1 346**] Neonatal Intensive Care Unit an
abdominal ultrasound was performed and was remarkable for
mild thickening of the pylorus possibly consistent with
gastritis but not consistent with pyloric stenosis. On
[**2159-4-4**] he had an upper GI study which showed distal
esophageal stricture and proximal esophageal dilatation.
Follow-up x-ray showed passage of the contrast distally. On
[**2159-4-6**] he had a balloon dilatation of the stricture, which
was felt to be an inflammatory stricture due to peptic
reflux. Currently he has spitting with three to four
hour feeding intervals and has been restarted on Prilosec,
Mylanta and Reglan. He did continue to have some spitting
after that. On [**2159-4-10**] he had increase in stool and liquid
consistency from his ostomy site. He had stool cultures sent
and they were negative for Salmonella, Shigella, E. coli,
Yersinia, Campylobacter, and Clostridium difficile. At that
time he was changed to Pregestimil formula and has tolerated
that well. On [**2159-4-19**] a repeat upper GI study was performed
which showed still some stricture of the esophagus but no
restriction. A plan for a repeat esophageal dilation was
planned for [**2159-5-4**]. His ostomy was noted to have some
superficial skin breakdown on [**2159-4-22**] that was treated with
topical skin barrier. He is being followed by enterostomal
therapist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 46317**], [**Hospital3 1810**] beeper #[**Numeric Identifier 46318**].
5. Hematology: He has received no transfusions during his
Neonatal Intensive Care Unit stay. His last hematocrit on
[**2159-4-6**] was 33.1. He is receiving supplemental iron of 2 mg
per kg per day.
6. Infectious disease: He has remained off antibiotics
during his stay and his stool cultures are as above.
7. Sensory: Eyes were examined most recently on [**2159-4-11**] and
were found to have mature retinal vessels. A follow-up
examination is recommended in six months.
8. Psychosocial: The parents have been very involved in the
infant's care during the Neonatal Intensive Care Unit stay.
His twin sibling remains in the hospital.
CONDITION ON DISCHARGE: Good.
DISPOSITION: He is being discharged home with his parents.
PRIMARY PEDIATRIC CARE: Dr. [**Last Name (STitle) 3394**], telephone number
[**0-0-**].
RECOMMENDATIONS: Return to feedings of Pregestimil 22
calories per ounce made with concentration.
MEDICATIONS:
1. Metoclopramide 0.3 mg p.o. every 8 hours.
2. Mylanta ?????? tsp p.o. every 6 hours.
3. Iron sulfate (25 mg per mL) 0.2 cc p.o. q. day.
4. Omeprazole (Prilosec) 1.3 mg p.o. q. 12 hours.
IMMUNIZATIONS: He received his second cycle of immunizations
during this hospital stay. They are as follows: DaPT on
[**2159-4-13**], IPV [**2159-4-13**], hepatitis C vaccine [**2159-4-14**],
pneumococcal 7-valent conjugate vaccine (Prevnar) on
[**2159-4-14**], and Hib [**2159-4-15**].
FOLLOW UP:
1. He will follow up with the gastrointestinal service
endoscopy unit at [**Hospital3 1810**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5749**],
telephone number [**Telephone/Fax (1) 47123**] two weeks after discharge.
2. Surgery follow up will be with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 732**].
3. He will also have [**Hospital6 407**] and Early
Intervention services, which were initiated at his previous
discharge.
DISCHARGE DIAGNOSES:
1. Gastroesophageal reflux disease.
2. Esophageal stricture.
3. Status post esophageal dilation.
4. Status post necrotizing enterocolitis.
5. Status post ileostomy.
6. Formula intolerance.
7. Anemia of prematurity.
8. Resolved retinopathy of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2159-4-24**] 02:53
T: [**2159-4-24**] 07:10
JOB#: [**Job Number 47124**]
| [
"53081",
"V053"
] |
Admission Date: [**2196-8-6**] Discharge Date: [**2196-8-10**]
Date of Birth: [**2138-2-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Fever, abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 F w/ IDDM, ESRD on PD, HTN, presents with fever, abd pain.
The patient notes that at 11 AM today she developed fevers and
chills. She also had significant diffuse abdominal pain and
nausea/vomiting. Per a note from her PCP [**Last Name (NamePattern4) **] [**8-2**], the patient had
been having some intermittent nausea at that time as well, but
patient reports that the fevers and abd pain started the day of
admission. She also noted a mild headache, no photophobia or
neck stiffness. She had some dysuria, which she has chronically.
No blood in her stools or her urine or from the PD catheter. She
says she has been performing PD sterilely and there had been [**Last Name **]
problem with her last PD, which was the night prior to
admission.
In the ED, the patient was febrile to 102, hypertensive, and
tachycardic. She had a lactate of 6 initially and a wbc of 16 w/
20% bands. Her peritoneal dialysate was tapped and showed 7000
wbcs, 100% of which were polys. In the ED, she got a RIJ sepsis
catheter and Vanc/Levo/Flagyl IV. She also had a CT scan on the
recommendation of transplant surgery. She was then transferred
to the MICU for further monitoring of her sepsis, treatment of
her peritonitis.
Past Medical History:
1. CRI secondary to diabetic nephropathy
2. type II DM with retnopathy, nephropathy and peripheral
neuropathy
3. HTN
4. CVA [**2-/2194**]
5. anemia
6. s/p tubal ligation
7. negative stress MIBI in [**10/2194**]
8. hypercholesterolemia
Social History:
no tobacco, no ETOH
Lives at home. Married. Children in area and involved. No
tob/etoh/drugs.
Family History:
No kidney disease. Mother had DM.
Physical Exam:
PE: T 98.4 HR6 BP 159/59 RR20 SaO2 96
GEN: NAD obese, comfortable, speaking full sentences, aaox3
HEENT: PERRL, EOMI, missing lower teeth, OP Clear, MMM
NECK: supple, no LAD, RIJ in place
CV: rrr s1s2 no m/r/g
LUNGS: CTA b/l no w/r/r
ABD: Normactive BS, distended, diffusely tender, soft, fluid
filled, PD catheter in place
EXT: No C/C/E
Neuro: CNII-CNXII intact, no focal deficits
Pertinent Results:
[**2196-8-6**] 10:30PM LACTATE-3.8*
[**2196-8-6**] 09:07PM GLUCOSE-106* UREA N-28* CREAT-11.1*
SODIUM-137 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
[**2196-8-6**] 09:07PM WBC-16.2* RBC-3.05* HGB-8.6* HCT-26.0* MCV-85
MCH-28.1 MCHC-33.0 RDW-15.7*
[**2196-8-6**] 09:07PM NEUTS-67 BANDS-20* LYMPHS-5* MONOS-6 EOS-0
BASOS-1 ATYPS-0 METAS-1* MYELOS-0
[**2196-8-6**] 09:07PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ STIPPLED-1+
TEARDROP-OCCASIONAL
[**2196-8-6**] 09:07PM PLT COUNT-285
[**2196-8-6**] 09:00PM LACTATE-4.3*
[**2196-8-6**] 06:49PM TYPE-[**Last Name (un) **] PO2-66* PCO2-54* PH-7.38 TOTAL
CO2-33* BASE XS-4
[**2196-8-6**] 06:49PM GLUCOSE-87 LACTATE-3.2* NA+-141 K+-4.4
CL--100
[**2196-8-6**] 06:30PM WBC-13.7* RBC-3.36* HGB-9.7* HCT-28.3* MCV-84
MCH-28.9 MCHC-34.3 RDW-15.6*
[**2196-8-6**] 06:30PM NEUTS-77* BANDS-14* LYMPHS-5* MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2196-8-6**] 06:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2196-8-6**] 06:30PM PLT SMR-NORMAL PLT COUNT-315
[**2196-8-6**] 06:01PM TYPE-MIX PO2-68* PCO2-50* PH-7.41 TOTAL
CO2-33* BASE XS-5 COMMENTS-GREEN TOP
[**2196-8-6**] 06:01PM GLUCOSE-114* LACTATE-3.5* NA+-141 K+-4.4
[**2196-8-6**] 05:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2196-8-6**] 05:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2196-8-6**] 05:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2196-8-6**] 04:30PM TYPE-MIX
[**2196-8-6**] 04:30PM LACTATE-4.3*
[**2196-8-6**] 04:30PM O2 SAT-76
[**2196-8-6**] 03:00PM ASCITES TOT PROT-0.6 LD(LDH)-72 ALBUMIN-LESS
THAN
[**2196-8-6**] 03:00PM ASCITES WBC-7775* RBC-1075* POLYS-100*
LYMPHS-0 MONOS-0
[**2196-8-6**] 02:13PM COMMENTS-GREEN TOP
[**2196-8-6**] 02:13PM LACTATE-6.4*
[**2196-8-6**] 02:10PM GLUCOSE-209* UREA N-27* CREAT-12.1*#
SODIUM-140 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-27 ANION GAP-22*
[**2196-8-6**] 02:10PM WBC-12.9* RBC-4.15* HGB-11.5* HCT-35.9*
MCV-87 MCH-27.8 MCHC-32.1 RDW-15.6*
[**2196-8-6**] 02:10PM NEUTS-71.0* LYMPHS-25.4 MONOS-2.0 EOS-1.3
BASOS-0.3
[**2196-8-6**] 02:10PM HYPOCHROM-1+
[**2196-8-6**] 02:10PM PLT COUNT-368
[**2196-8-5**] 10:10AM POTASSIUM-5.1
[**2196-8-5**] 10:10AM CHOLEST-221*
[**2196-8-5**] 10:10AM TRIGLYCER-341* HDL CHOL-48 CHOL/HDL-4.6
LDL(CALC)-105
Brief Hospital Course:
A/P:
58 F w/ ESRD on PD, IDDM, HTN, h/o CVA, who presents with fever,
n/v, abdominal pain, evidence peritonitis in peritoneal fluid.
1. Peritonitis: Peritoneal cultures grew Strep viridans and
klebsiella sensitive to ceftazadine. Per renal recommendations,
she was initially dosed with both vancomycin IP and IV, and
ceftazidine IP/IV to cover the gram positive and negative
organisms. Her abdominal CT on [**8-6**] showed Diffuse stranding of
the mesentery and small amount of free fluid in the abdomen.
These findings could be secondary to peritoneal dialysis and
peritonitis. However, no discrete abscess or focal bowel
abnormality to account for this process can be identified. An
abdominal series showed no obstruction. No blood cultures grew
out organisms, and she remained afebrile. She was dosed with IP
vancomycin and ceftazadine, and her WBC count from peritoneal
fluid decreased from 7700 to 70 over her hospital course. She
was treated with a fourteen day course of levoquin upon
discharge.
2. Sepsis: She met sepsis criteria via elevated lactate (6),
fever, tachycardia, leukocytosis. SHe was admitted for a brief
course in the MICU and for sepsis, and her pressures were
stabilized without need for pressors. She was continued on
vancomycin and ceftazidine through her MICU stay.
3. HTN: Has been hypertensive in ED, likely related to
pain/fever. Her antihypertensives were initially held for
sepsis. Later during her hospital course her pressures were
increased, and she was restarted on her admission medications of
betablocker, and lisinopril was added.
4. DM: Her sugars were well controlled on her insulin sliding
scale, she was restarted on her outpatient insulin regiment
prior to discharge.
5. Anemia: Chronic, related to ESRD. On epo, will continue. Hct
went from 35--> 28 after 1.5 L fluid. It remained stable
through the rest of her hospital course, her discharge hct was
28.9. She did not require transfusions
6. Hyperlipidemia/CAD risk: Cont. lipitor. Cont. ASA.
7. FEN: Diabetic diet as tolerated. Follow electrolytes since
ESRD.
8. PPX: SQ heparin TID, POs
9. Full Code
10. Access: RIJ [**8-6**]
11. Communication: Patient and her family.
Medications on Admission:
ASA 81
atenolol 50
atorvastatin 20
clonazepam prn
docusate
epogen [**Numeric Identifier 961**] tiw
insulin NPH70/30 25am, 18pm
minoxidil
mirtazepine 15
mvi
niferex
phoslo 2 tid
rocaltrol .25
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*30 ml* Refills:*2*
4. Insulin Needles (Disposable) Needle Sig: One (1)
Miscell. three times a day.
Disp:*30 * Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Insulin 70/30 70-30 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: Take 25Units in the AM
Take 18 Units in the PM.
Disp:*100 cc* Refills:*2*
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Peritonitis
Discharge Condition:
Good, stable, afebrile
Discharge Instructions:
You developed acute peritonitis and were treated with
antibiotics.
You should take your medications as directed
You should follow up with your peritoneal dialysis nurse [**First Name8 (NamePattern2) 3040**] [**Last Name (NamePattern1) 18013**] on this Friday [**2196-8-12**]
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2196-8-23**] 8:50
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 15928**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2196-9-15**] 10:45
Provider: [**Name10 (NameIs) **] RECORDS Where: [**Hospital1 7975**] PODIATRY
Date/Time:[**2196-10-4**] 11:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
| [
"40391",
"0389",
"V5867",
"2720"
] |
Admission Date: [**2110-8-1**] Discharge Date: [**2110-8-11**]
Date of Birth: [**2110-8-1**] Sex: F
Service: NB
ADMISSION STATUS: Baby Girl [**Known lastname 30833**] was 2195 grams and born
premature at 34-2/7 weeks of gestation. EDC was [**2110-9-10**]. The mother is a 33-year-old gravida 4, para 2, and she
was type A-positive, antibody negative, RPR negative, rubella
immune, hepatitis B negative, and GBS unknown. She has
previous 2 pregnancies with placenta previa.
Current pregnancy was complicated by gestational diabetes.
She had preterm labor and stopped the tocolysis. She was
treated with betamethasone prior to delivery. Infant born by
C-section because of uterine scar dehiscence. The baby
received brief blow-by 02 in the delivery room. She had Apgar
scores of 8 at 1 minute and 9 at 5 minutes, and generally she
was active and in no distress.
Admission weight was 2195 grams, length was 43 cm, and head
circumference 30.5 cm. Her vitals on admission were a
temperature 97.4, heart rate 160, respirations 52, blood
pressure 63/38 with a mean of 48. Her oxygen saturation 96%
on room air and Dextrostix was 35. HEENT: Normocephalic,
atraumatic. Nondysmorphic. Anterior fontanel was open and
flat, and red reflex present bilaterally. Neck: Supple.
Lungs: Clear bilaterally. Cardiovascular: Regular rate and
rhythm and a 1/6 systolic murmur was noted. Femoral pulses:
2+ bilaterally. Abdomen: Soft, good active bowel sounds, no
masses or distention. Normal preterm female external
genitalia. Anus: Patent. Spine: Midline with no sacral
dimple. Clavicles: Intact. Good tone, normal suck and normal
gag on neuro exam. Extremities: Warm, well perfused with
stability. Hips: Stable.
HOSPITAL COURSE BY SYSTEM:
Respiratory: She received brief blow-by O2 in the delivery
room and then she was stabilized in the NICU without any
intervention. Currently, she is breathing room air and her
respiratory rate is between 44-50. She did not receive any
methylxanthines nor did she experience any apnea of
prematurity.
Cardiovascular: She had a 1/6 systolic murmur initially on
admission, which gradually disappeared. Currently, she is
having normal 1st and 2nd heart sounds and there are no
murmurs or additional sounds. Femoral pulses are present
bilaterally.
Fluid & Nutrition: Initially, she received some parenteral
fluids at 60 cc per kilogram body weight and then on the 2nd
day of life, she was started with p.o. feedings. She is
currently on BM and/or Similac 24, and it is currently taking
full volumes all p.o. Discharge growth parameters: Weight is
2210 grams; length is 47 cm; and head circumference is 32 cm.
GI: She has a soft, nondistended abdomen. There are no
masses; bowel sounds are present. She does have an
umbilical hernia which is soft and easily reducible.
Hematology: A CBC was sent on the day of admission and it
was reported as normal. Hematocrit 43.6. Platelets 329K.
Her peak bilirubin was 8.6 on day of life 4. She did not
receive phototherapy.
ID: An initial CBC and blood culture were drawn on admission.
The blood culture was negative and the infant did not receive
antibiotics.
Neurology: She did not meet criteria for routine head
ultrasounds or ophthalmology screening. Her neurological
examination is normal.
Sensory: Hearing screen was done on [**2110-8-10**] and she
passed in both ears.
Car seat: Passed.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: She is going to be seen [**Hospital1 **]Clinic with Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 4223**] and her phone number
is ([**Telephone/Fax (1) 2535**].
RECOMMENDATIONS ON DISCHARGE:
1. Feeds are BM24 (with added Similac powder) and/or
Similac 24 PO ad-lib.
2. There are no discharge medications.
3. Car seat position screening passed.
4. State newborn screening status has been sent on [**8-4**] and
[**8-11**]. There have been no abnormal reports.
5. Received hepatitis B vaccine on [**2110-8-7**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1) born at less than 32
weeks; 2) born between 32-35 weeks with 2 of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-age
siblings, or 3) with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
Follow-up appointment is scheduled with Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 4223**]
within 2 days ([**2107-8-13**] at 0900).
DISCHARGE DIAGNOSES:
1. Premature female
2. Infant of diabetic mother
3. Umbilical hernia
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 67754**]
MEDQUIST36
D: [**2110-8-11**] 09:26:07
T: [**2110-8-11**] 09:52:43
Job#: [**Job Number 67755**]
| [
"7742",
"V053",
"V290"
] |
Admission Date: [**2126-8-6**] Discharge Date: [**2126-8-19**]
Date of Birth: [**2126-8-6**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 32687**], Twin No. 2, was
born at 34 2/7 weeks gestation to a 37 year old gravida 2,
para 1 now 3 woman. The mother's prenatal screens were blood
type A positive, antibody negative, Rubella immune, RPR
nonreactive, hepatitis surface antigen negative, and Group B
Streptococcus unknown. This pregnancy was complicated by
complete placenta previa. This was an intrauterine
insemination, twin gestation. The pregnancy was also
complicated by antepartum hemorrhage with the onset of
preterm labor prompting a cesarean section. There were no
interpartum sepsis risk factors. The infant emerged
vigorous. Apgars were 8 at one minute and five minutes.
PHYSICAL EXAMINATION: The birth weight was 2,785 gm. The
birth length was 47 cm. The birth head circumference was 35
cm.
The admission physical examination revealed a vigorous
nondysmorphic preterm infant. Anterior fontanelles were soft
and flat. Palate intact. Mild nasal flaring. No
retractions. Good air entry bilaterally. Mild grunting and
no crackles. Heart was regular rate and rhythm, no murmur.
Normal femoral pulses. Abdomen was soft, nontender,
nondistended. No masses. Patent anus. Three vessel
umbilical cord. Testes were descended bilaterally and
symmetrical tone and reflexes appropriate for gestational
age.
HOSPITAL COURSE: Respiratory status - [**Known lastname **] required
nasopharyngeal continuous positive airway pressure from the
time after delivery until day of life No. 3 when he weaned to
nasal cannula oxygen, and then weaned successfully to room
air on day of life No. 8. He has remained on room air since
that time. He has had no apnea or bradycardia. The
respirations are comfortable and lung sounds clear and equal.
Cardiovascular status - He has remained normotensive
throughout his Neonatal Intensive Care Unit stay. His heart
was regular rate and rhythm, no murmur and no cardiovascular
issues.
Fluids, electrolytes and nutrition status - At the time of
discharge his weight is 2,740 gm. Length is 49 cm and head
circumference 35 cm. Enteral feeds were begun on day of life
#3 and advanced without difficulty to full volume feeding.
At the time of discharge he is breastfeeding and
supplementing with 24 cal/oz breastmilk or formula on an ad
lib schedule.
Gastrointestinal status - His peak bilirubin occurred on day
of life No. 3 with a total of 9.3 and direct 0.4. He never
received any phototherapy.
Hematological status - His hematocrit at the time of
admission was 54. He has never received any blood product
transfusions.
Infectious disease status - He was started on Ampicillin and
Gentamicin at the time of admission. He did complete seven
days of antibiotics for pneumonia. His blood and
cerebrospinal fluid cultures from that time remained
negative.
The infant had an infiltration of intravenous fluid in his
right foot on [**2126-8-13**]. The area is healing with
good granulation tissue. Parents are putting a dressing on
it three times a day.
Sensory - Audiology, hearing screening was performed with
automated auditory brain stem responses and the infant passed
in both ears.
Psychosocial - Parents have been very involved in the
infant's care throughout his Neonatal Intensive Care Unit
stay.
The infant is discharged in good condition. He is discharged
home with his parents.
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 745**]
of [**Location (un) 3307**] at [**Hospital 1774**] Pediatrics.
RECOMMENDATIONS AFTER DISCHARGE: Feeds - Breastfeeding with
supplementation of 24 cal/oz breastmilk or formula with a
goal to wean to exclusive breastfeeding.
Medications - Iron sulfate, 25 mg/ml, 0.2 ml p.o. daily.
Carseat position screening - He passed the carseat position
screening test.
State newborn screen - Sent on [**2126-8-9**].
Immunizations given - His first hepatitis B vaccine was given
on [**2126-8-18**].
Immunizations recommended - I. Synagis respiratory
syncytial virus prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria, 1. Born at less than 32 weeks, 2. Born between 32
and 35 weeks with two of the following, daycare during
respiratory syncytial virus season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings or 3. With chronic lung disease. II.
Influenza Immunizations recommended annually in the fall for
all infants once they reach six months of age, before this
age and for the first 24 months of the child's life
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW UP: Visiting nurse will be coming to assess the
dressing change on the right foot.
DISCHARGE DIAGNOSIS: Status post prematurity at 34 2/7 weeks
gestation.
Twin No. 2.
Sepsis ruled out.
Status post pneumonia.
Status post respiratory distress syndrome.
Status post right foot intravenous infiltrate.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56576**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2126-8-19**] 03:37:58
T: [**2126-8-19**] 08:51:55
Job#: [**Job Number 56890**]
| [
"V290",
"V053"
] |
Admission Date: [**2182-9-5**] Discharge Date: [**2156-3-1**]
Service: [**Hospital Unit Name 14178**]
CHIEF COMPLAINT: Congestive heart failure
HISTORY OF PRESENT ILLNESS: This is an 85-year-old woman
with a history of coronary artery disease status post
coronary artery bypass graft in [**2173**], aortic valve
replacement for aortic stenosis, DDD pacemaker for
tachy-brady syndrome, breast cancer, transferred from
[**Hospital3 4527**] Hospital for congestive heart failure
management and cardiac catheterization.
The patient was reported to be independent, per her daughter,
until [**8-1**], when she had a syncopal episode and was diagnosed
with tachy-brady syndrome. At that time, she received a
pacemaker. In [**2182-2-1**], she had her first episode of
congestive heart failure and required intubation, per her
daughter. The daughter states that she had another admission
since that time for sudden onset congestive heart failure
complicated by chronic obstructive pulmonary disease.
In [**2182-7-1**], the patient had both congestive heart
failure and chronic obstructive pulmonary disease
exacerbation at [**Hospital3 1196**], requiring
intubation. She also had a right effusion that was tapped
for 1.5 liters. This was transudative and not believed to be
malignant. She also had new onset atrial fibrillation during
that period, and was started on Coumadin. She was discharged
to rehabilitation on [**7-27**]. An echocardiogram during this
admission also revealed an ejection fraction of 50 to 55%. A
stress test revealed an old anterior infarct and inferior
wall ischemia.
The patient did well until [**2182-8-4**], when she had
increased shortness of breath, as noticed by the
rehabilitation staff. She was admitted to [**Hospital3 4527**]
with a congestive heart failure exacerbation, and started on
amiodarone. She had an echocardiogram that revealed no
changes from her previous, and an aortic valve area of 0.8
cm.sq. She underwent thoracentesis of the right effusion,
consistent with transudate. She was also started on an ACE
for afterload reduction.
Over the next few days, the patient had diuresis that
plateaued, and worsening renal failure. Her ACE inhibitor
was stopped. She remained on lasix. Renal consult was
obtained at that time for a creatinine of 2.0. She remained
to have difficult-to-control blood pressure with very low and
very high. She also was noted to be very sensitive to
Hydralazine. Cardiology wanted to consider renal artery
stenosis that could contribute to her decreased perfusion to
her kidney.
On [**8-14**], she was transferred to the Intensive Care Unit
after an acute episode of shortness of breath and
hypertension. She had flash pulmonary edema that likely
occurred from high blood pressure, the etiology of which was
unknown. It may have been precipitated by atrial flutter.
She continued to have problems with her fluid balance, and
was diuresed with high-dose Diuril and lasix. She had a Swan
to help determine her volume status, and her creatinine
increased to 2.4.
She was also noted to have methicillin resistant
staphylococcus aureus of the blood and urine. She was
treated with Zosyn and vancomycin until cultures were
negative. As her diuresis improved, she was transferred to
[**Hospital1 69**] for cardiac
catheterization and workup of a question of renal artery
stenosis. Upon admission, she was without chest pain,
shortness of breath, nausea, vomiting or diaphoresis.
PAST MEDICAL HISTORY:
1. CLL with hypogammaglobulinemia
2. Coronary artery disease status post coronary artery
bypass graft of one vessel disease in [**2173**]
3. AVR for AS in [**2173**]
4. DDD pacemaker in [**2181**] for tachy-brady syndrome
5. Atrial fibrillation/flutter
6. Congestive heart failure secondary to diastolic
dysfunction
7. Mitral regurgitation, severe
8. Breast cancer status post right mastectomy
9. Chronic obstructive pulmonary disease
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Colace 100 mg by mouth twice a day
2. Advair 250/50 mg one puff twice a day
3. Combivent two puffs four times a day with spacer
4. Amiodarone 200 mg by mouth twice a day
5. Digoxin 0.0625 mg by mouth every other day
6. Coumadin on hold
7. Diamox 250 mg by mouth twice a day
8. Hydralazine 10 mg by mouth three times a day
9. Zoloft 50 mg by mouth once daily
10. Lopressor 25 mg by mouth three times a day
11. Protonix 40 mg by mouth once daily
12. Lipitor 10 mg by mouth once daily
13. Diuril as needed
14. Lasix as needed
SOCIAL HISTORY: The patient was noted to be independent
until one year ago. Now she has become bedridden for months
secondary to her congestive heart failure and other
conditions. Her daughter is extremely involved in her care.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vital signs: 96.2, 90/48, 96, 22,
weight 95 pounds, 5'0" tall. General: Thin woman, lying in
bed, in no acute distress. Head, eyes, ears, nose and
throat: Jugular venous distention to jaw.
Cor: Regular rate and rhythm, mechanical heart sounds.
Lungs: Decreased breath sounds to the right base, dull to
percussion.
Abdomen: Soft, nontender, nondistended, positive bowel
sounds.
Extremities: No cyanosis, clubbing or edema. Posterior
tibial 1+ on the right, negative on the left.
LABORATORY DATA: BUN 77, creatinine 1.8, hematocrit 31.7,
INR 3.1, PTT 33.7.
IMPRESSION: This is an 85-year-old woman with history of
multiple medical problems, admitted with difficult-to-manage
congestive heart failure, question of renal artery stenosis.
HOSPITAL COURSE:
1. Cardiovascular:
a. Ischemia. The patient did not have any episodes of
ischemia on admission. She denied any chest pain at that
time. It was felt that her congestive heart failure could be
worsened by ischemia; therefore, the patient was referred for
cardiac catheterization. She underwent cardiac
catheterization on [**2182-9-9**], that demonstrated
severe three vessel disease. She had a LMCA with 30%
proximal lesion. The left anterior descending was diffusely
diseased proximally and totally occluded in the mid-segment,
with filling via collaterals. The left circumflex had
diffuse disease up to 70%. The right coronary artery had a
calcified ostial 80% lesion. She had an saphenous vein graft
to left anterior descending that was totally occluded
proximally. She had a normal filling pressure with reduced
cardiac output of 2.3. She had renal artery angiography with
no renal artery stenosis. She underwent successful
percutaneous transluminal coronary angioplasty and stenting
of the mid-left anterior descending lesion with two stents.
Following the patient's catheterization, she had a brief
episode of hypotension requiring dopamine. She was then
transferred to the Coronary Care Unit for further monitoring.
On arrival to the Coronary Care Unit, she was found to be
short of breath and hypertensive, with diffuse wheezes
bilaterally. She had the dopamine discontinued, and a nitro
drip was started. She was also noted to be in congestive
heart failure at that time, and was diuresed aggressively.
The patient had a Swan floated for help with management of
her volume status. Then she was brought back to the
catheterization laboratory on [**2182-9-13**]. At that
time, intervention on the right coronary artery lesion was
attempted. She had rotatherapy on the right coronary artery.
She then underwent stenting with a final residual of 10%.
The patient then attempted to have intervention on her left
circumflex proximal R1 that had a 90% lesion. The lesion
could not be crossed, and therefore was not treated. The
patient then underwent adjustment of her medicines to
optimize her medical management of her ischemia in light of
her severe disease.
b. CV pump: The patient has a known history of diastolic
dysfunction with normal ejection fraction. She has had many
episodes of flash pulmonary edema in the past, as evidenced
by recent Intensive Care Unit admission to [**Hospital3 4527**]
prior to transfer to [**Hospital1 69**].
Following the catheterization, the patient again, on
[**9-9**], experienced flash pulmonary edema. The patient
was started on lasix, morphine and nitroglycerin for her
initial flash. She had fluctuating periods of hypertension
vs. hypotension. She had a Swan floated to determine volume
status. She required dopamine intermittently. Overall the
patient required diuresis of approximately 5 liters,
including high-dose lasix and Bumex. She also was on
Natrecor for a brief period. The patient's heart failure was
also initially managed with ACE inhibitor, but this had to be
discontinued on the 19th secondary to rising creatinine. At
that time, she was switched to Hydralazine for control of her
afterload. She also received Zaroxolyn for further diuresis.
She had her Swan discontinued and her dopamine discontinued
on the 19th. At that time, she was determined to be fairly
euvolemic, and ready to be transferred to the floor.
c. CV rhythm: The patient had her pacemaker interrogated on
the [**9-10**]. At that time, she was reprogrammed to
many different modes, including DDI, but had hypotension.
Eventually it was reprogrammed to DDD at 70, and demonstrated
stable blood pressure and reduced atrial ectopy. The patient
then underwent additional evaluations by the EP service, and
adjustments of her pacemaker. Ultimately the patient
demonstrated no evidence of A wave, and no P waves on
electrocardiogram despite increased atrial output. She was
determined to have probable atriopathy or "dead atria" vs.
fine atrial fibrillation. Her pacemaker was then changed to
a final set of VVIR at 70.
2. Pulmonary: The patient is noted to have severe chronic
obstructive pulmonary disease. She was noted to have
wheezing upon admission to the Coronary Care Unit, which
could be consistent with her congestive heart failure or
chronic obstructive pulmonary disease exacerbation. She
received Atrovent and albuterol inhalers as per her normal
schedule. She also had a large right pleural effusion, which
she has had tapped several times in the past. This was again
tapped on [**9-16**]. The result was consistent with a
transudate without evidence of pathology.
3. Hematology: The patient underwent one unit of blood
transfusion on [**9-8**]. She underwent an additional unit
on [**9-12**], and again on [**9-16**] and 19, receiving
a total of four units of packed red blood cells. The
etiology of her blood loss was not clear, and she did not
appear to have gastrointestinal bleeding. Some of this may
have been due to her renal failure. The many procedures
could also have contributed to this blood loss, although
probably not that significantly. The patient was started on
Epogen. The patient's renal function upon admission was
fairly stable at 1.8. This was likely due to volume
depletion, however, following the holding of her diuresis,
her renal function improved to a value of 1.0 prior to her
catheterization. She received Mucomyst for renal protection.
Following the initial catheterization, her creatinine rose to
1.5. This again rose up to 2.5 after the second cardiac
catheterization. This was felt to be due to a dye
nephropathy as well as possible volume depletion. This was
according to the Renal consult that was obtained in the
Coronary Care Unit. The patient was also noted to have a
urinary tract infection on [**9-18**], and was started on a
course of Levaquin. The patient's initial cardiac
catheterization and shooting of the renal arteries did not
demonstrate renal artery stenosis, and this was excluded as a
cause for her renal difficulties.
4. Infectious Disease: The patient had a urinary tract
infection as previously described.
5. Fluids, electrolytes and nutrition: The patient has had
a long history of going into flash pulmonary edema with
minimal volume. This helped to explain her difficulty in
volume management in the outside hospital as well as in the
Coronary Care Unit here. She is currently slightly volume
depleted, as evidenced by mild hypotension. When she
receives intravenous fluids, she needs to receive very slow
infusions.
DISPOSITION: The patient is currently doing fairly well,
however, her volume status still needs to be optimized, as
does her medical management of her ischemic heart disease and
congestive heart failure.
The rest of the dictation will be completed by the intern who
takes over her care.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Known lastname 103212**]
MEDQUIST36
D: [**2182-9-21**] 18:49
T: [**2182-9-22**] 00:40
JOB#: [**Job Number 36238**]
| [
"42731",
"5849",
"5119",
"5990",
"41401",
"40390"
] |
Admission Date: [**2113-1-2**] [**Month/Day/Year **] Date: [**2113-1-6**]
Service: MEDICINE
Allergies:
Prednisone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 29250**] is a [**Age over 90 **] year old male with a history of CHF who
presents in CHF exacerbation as a transfer from [**Location (un) 745**]-[**Location (un) 3678**].
He reports feeling extremely short of breath this morning at
approximately 9 PM yesterday. This was preceeded by a day of
increasing dyspnea, but no symptoms otherwise including no
shortness of breath or syncope. Of note he has had mild
presyncope for a few weeks. He reports that while he is very
compliant with his low salt diet he did eat a lot more food
during the [**Holiday **] holiday. Especially the day prior to
admission, he ate foods that he knew were high in salt and not
ideal for his congestive heart failure. While at the OSH he was
found to have a blood pressure of 220s and was started on a
nitro gtt as well as a heparin gtt and aspirin. He was given
large doses of diuretics (unclear amounts) and was reportedly
incontinent of large volumes of urine. He was transferred to the
[**Hospital1 18**] ER. At the OSH, he was started on heparin gtt, but this
was stopped at [**Hospital1 18**] ED. Additionally the patient reports a
sharp left shoulder pain that was not associated with any other
symptoms and did not radiate that was treated with morphine. It
promptly resolved after the morphine and has not recurred.
In the ED initial vitals were 98.2 60 130/84 24 97% 10LNRB. The
patient received lasix and diuril with 200mL out. However, per
report he desatted and became tachypnec after decreasing the
oxygen.
Of note he was last seen by Dr. [**First Name (STitle) 437**] on [**12-21**] where he was
noted to be in good control of his CHF and his hydralazine was
increased to 75 mg TID.
Currently he feels much improved. While he does have persistent
shortness of breath, he is much improved. He is currently chest
pain free.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. He has had no nausea,
vomiting, or diarrhea. He has chronic constipation. He has
noAll of the other review of systems were negative.
Cardiac review of systems is notable for positive presyncope x
several weeks and persistent lower extremity edema. There is
the absence of chest pain, paroxysmal nocturnal dyspnea,
orthopnea, palpitations, syncope.
Past Medical History:
CAD s/p at least 2 MIs per patient, first at age 58
CHF with past hospital admissions for this
Chronic Kidney Disease
DM II
Peptic Ulcer Disease s/p rx for H.pylori
HTN
h/o Testicular cancer
h/o pancreatitis
s/p cholecystectomy
s/p L parotidectomy complicated by facial nerve paralysis
Social History:
The patient lives with his wife in a senior housing where they
have their own apartment. He is a retired truck driver. He
smoked tobacco for about 50 years at two to four packs per day
and quit in [**2080**] after his first myocardial
infarction. No ETOH. He has two daughters and four
grandchildren and six great grandchildren with one on the way.
Family History:
He has multiple other relative with hypertension, coronary
artery disease, and diabetes.
Physical Exam:
VS: T 97.8, BP 165/72, HR 59 , RR 24 , O2 100 % on NRB ED
weight 160, ICU 166 lbs
Gen: Elderly aged male with rapid breathing. Able to speak, but
not more than short sentences. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Mucous
membranes were dry
Neck: Supple with JVP 16 cm
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, soft S3. Systolic murmur at RUSB
Chest: Resp were rapid, abdominal movement with breathing.
Crackles at upper lung fields, dullness at bases.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 1+ lower extremity bilateral edema. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ ; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ ; 2+ DP
Pertinent Results:
Admission labs:
Trop-T: 0.07
CK: 52 MB: Notdone
.
143 107 61
---------------< 213
4.7 24 2.7
proBNP: 5006
.
WBC: 8.9
HCT: 41
Plt: 193
N:78.4 L:16.0 M:3.9 E:1.5 Bas:0.2
.
PT: 16.9 PTT: 150 INR: 1.5
.
[**2113-1-2**]: ECHO:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg.There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal severe hypokinesis
of the basal inferior wall. The remaining segments contract
normally (LVEF = 50 %). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are mildly
thickened. No aortic valve stenosis is present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-9**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2112-9-15**], the
severity of mitral regurgitation is slightly increased. :Left
ventricular systolic function is similar.
.
CLINICAL IMPLICATIONS:
Based on [**2112**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**2113-1-3**] CXR:
Comparison is made to prior study performed a day earlier.
Cardiac size is normal. Small bilateral pleural effusions
greater in the left side are unchanged. There is persistent
left lower lobe retrocardiac
atelectasis, moderate pulmonary edema is unchanged
.
EKG: Sinus rhythm. Incomplete left bundle-branch block.
Non-specific ST-T wave changes. Prolonged QTc interval. Compared
to tracing of [**2113-1-2**] no
significant change. QTc 483
.
MRI BRAIN: There are no areas of abnormal restricted diffusion.
There is no evidence of intracranial hemorrhage, mass effect, or
shift of normally midline structures. [**Doctor Last Name **]-white matter
differentiation is preserved. There is mild diffuse global
atrophy. Periventricular white matter FLAIR hyperintensity along
with a few focal areas within the deep and subcortical white
matter bilaterally are consistent with chronic microvascular
infarctions. Old small infarctions are noted within the
cerebellum bilaterally. The left maxillary sinus is opacified.
The mastoid air cells and surrounding osseous and soft tissue
structures are unremarkable.
IMPRESSION: No evidence of infarction.
.
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man walking w/ PT. Hurt ankle while walking.
REASON FOR THIS EXAMINATION:
Looking for fractures
INDICATION: [**Age over 90 **]-year-old man hurt ankle while walking.
COMPARISON: None.
THREE VIEWS OF THE LEFT ANKLE
There is no evidence of acute fracture or dislocation. The talar
dome is intact and the mortise is grossly congruent. Vascular
calcifications noted.
IMPRESSION: Unremarkable views of the left ankle.
.
[**1-3**] CXR: REASON FOR EXAM: Cardiac failure exacerbation.
Comparison is made to prior study performed a day earlier.
Cardiac size is normal. Small bilateral pleural effusions
greater in the left side are unchanged. There is persistent left
lower lobe retrocardiac atelectasis, moderate pulmonary edema is
unchanged.
.
TRENDS:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2113-1-6**] 4.5 3.99* 12.5* 36.2* 91 31.3 34.4 14.8 172
[**2113-1-5**] 4.7 4.13* 12.5* 37.1* 90 30.1 33.6 15.0 172
[**2113-1-4**] 4.7 4.14* 12.7* 37.0* 89 30.7 34.3 15.1 151
[**2113-1-3**] 6.0 4.07* 12.3* 36.1* 89 30.3 34.2 15.1 179
[**2113-1-2**] 5.7 4.27* 13.2* 39.0* 91 31.0 33.9 15.0 196
[**2113-1-2**] 8.9# 4.59* 14.3 41.1 90 31.1 34.7 15.1 193
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2113-1-6**] 06:05AM 132* 80* 3.1* 143 3.7 102 29 16
[**2113-1-5**] 06:15AM 127* 80* 3.3* 142 4.0 101 28 17
[**2113-1-4**] 06:40PM 200* 79* 3.4* 139 3.9 101 28 14
[**2113-1-4**] 05:50AM 132* 82* 3.5* 139 3.9 100 28 15
[**2113-1-3**] 05:43PM 113* 79* 3.6* 139 3.6 99 27 17
[**2113-1-3**] 06:33AM 111* 76* 3.3* 137 4.1 101 26 14
LP ADDED 12:45PM
[**2113-1-2**] 11:37PM 146* 73* 3.2* 141 3.6 103 25 17
[**2113-1-2**] 04:06PM 170* 68* 3.0* 139 4.21 104 27 12
[**2113-1-2**] 09:28AM 179* 65* 2.9* 140 4.5 103 27 15
[**2113-1-2**] 01:15AM 213* 61* 2.7* 143 4.7 107 24 17
[**2112-12-21**] 05:49PM 60* 2.6* 142 3.5 104 27 15
.
CK: 52 - 45 - 36 - 36
Trop: 0.07 - 0.08 - 0.08 - 0.09
.
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2113-1-3**] 06:33AM 199 160*1 28 7.1 139*
Brief Hospital Course:
Hospital course by problem:
.
Diastolic CHF exacerbation: Systolic function relatively
preserved, 50% LVEF. Ruled out for acute MI, likely etiology of
CHF exacerbation was hypertension and dietary indescretion.
Patient was admitted to the CCU initially and had a significant
O2 requirement. He had an echo which showed slightly worse
mitral regurgitation but no other changes when compared to his
previous echo in [**2112-9-7**]. His home weight is 156-160 lbs
(dry weight), his weight upon [**Year (4 digits) **] was 158. Diuresis was
acheived with IV lasix. He will continue on his aspirin, beta
blocker and hydralazine, imdur was added to his regimen to
provide some decrease in preload and BP and also to provide a
survival benefit in heart failure. He should continue a low
sodium diet and a fluid restriction to 1.5 liters per day. He
will continue his home lasix dose of 40mg po daily.
.
TIA/Neuro: On [**1-5**], patient had dysarthia. Neuro was consulted
(pls see OMR note for details). MRI was obtained as above. His
symptoms rapidly resolved. This was considered a TIA. A
carotid u/s was pending upon [**Month/Year (2) **] and he has f/u with
neuro. He should remain on atorvastatin 80 and ASA 325.
.
Hypercholesterolemia- total 199, trig 160, LDL 139, HDL 28.
Lipitor 40mg po daily was added to his regimen. This was
increased to 80mg daily after his TIA.
.
Renal insufficiency: Baseline from last hospitalization appears
to be approx 2.2. Currently with slight elevation, but likely
in the setting of CHF exacerbation. Creatinine initially
increased with diuresis to a peak Creatinine of 3.6, this
trended downward to 3.4 upon [**Month/Year (2) **]. He likely had some
renal impairment not only from his CHF exacerbation but also
during his diuresis, as his home regimen was reinstated he was
diuresing well and Creatinine was improving. Continue to trend
creatinine while on lasix as an outpatient. Patient will follow
up with his outpatient nephrologist Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] in
[**2113-1-7**].
- please check a repeat electrolyte panel in [**2-9**] weeks.
.
Code status; Pt requests to be resuscitated but NOT intubated
.
Communication: Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73985**] [**Telephone/Fax (1) 73986**]
Medications on Admission:
ASPIRIN 325 mg--1 tablet(s) by mouth daily
COLACE 100 mg--1 capsule(s) by mouth twice a day
COREG 25 mg--1 tablet(s) by mouth twice a day
DEBROX 6.5 %--5 drops both ears at bedtime for 7 days in both
ears starting [**2113-1-18**]
GLIPIZIDE 2.5 mg--1 tab(s) by mouth daily
HYDRALAZINE 25 mg--1 tablet(s) by mouth three times a day with
50mg tablet
Hydralazine 50 mg--1 tablet(s) by mouth three times a day
LASIX 40 mg--1 tablet(s) by mouth daily
NEURONTIN 100 mg--2 capsule(s) by mouth three times a day
SENOKOT 8.6 mg--1 tablet(s) by mouth twice a day
[**Month/Day/Year **] Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
5. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
9. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
10. Neurontin 100 mg Capsule Sig: Two (2) Capsule PO three times
a day.
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**Hospital **] rehab
[**Hospital **] Diagnosis:
Primary diagnosis:
- Acute on Chronic Diastolic Heart Failure
- Status post TIA
- CAT s/p AMIs in the past
- CKD
- DMII
Secondary:
- PUD in past
- HTN
- hx testicular cancer
[**Hospital **] Condition:
stable
[**Hospital **] Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters per day
You were admitted with high blood pressure (hypertension) and
fluid overload. The fluid was taken off you with diuretic
medications (lasix). Your breathing improved.
Additionally, you likely had a TIA while you were admitted. You
had mild symptoms which resolved on their own. This is likely a
result of your coronary artery disease. You should continue to
take all your medications as directed and follow up with your
doctor [**First Name (Titles) **] [**Last Name (Titles) **].
You should call your doctor if you have any weight gain greater
than 3 pounds, shortness of breath, chest pain or any other
concerning symptom.
Please note that you have some medication changes:
1. Imdur is added to your regimen
2. You have been started on lipitor
Followup Instructions:
You have the following appointments:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2113-1-11**]
2:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], D.O. Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2113-1-25**] 1:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2113-1-25**] 1:30
Please see Dr. [**Last Name (STitle) **] in neurology on [**2-22**] at 2:30.
His office is in [**Hospital Ward Name 23**] [**Location (un) **]. His number is [**Telephone/Fax (1) **]
| [
"4280",
"41401",
"2720",
"412",
"40390",
"25000",
"5859"
] |
Admission Date: [**2178-7-16**] Discharge Date: [**2178-7-19**]
Date of Birth: [**2130-5-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Angioedema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 496**] is a 48 year old female with history of C1
esterase inhibitor deficiency type III w/ angioedema diagnosed
one year ago. She is currently treated with Cinryze 1000 units
IV every 3 days for prophylaxis and received it today prior to
admission. She states that she is currently menstruating and
usually more symptomatic around this time, but her symptoms have
been going on for about 3 weeks (scratchy throat, dysphagia)
with acute worsening today manifested by hoarse voice,
odynophagia and intense pain in her lower jaw and teeth. She
has never been intubated in the past. She has had these
symptoms since age 17, but "just dealt" with the symptoms up
until she was 24 when she finally decided to be seen by a
doctor. On her intermittent trips to EDs, she was given
steroids and she improved slowly, but always wondered if the
steroids were actually working. She was most recently seen by a
physician at [**Name9 (PRE) 2025**] who made the initial diagnosis with serial C1
esterase inhibitor levels (normal) and her constellation of
symptoms and started her on Cinryze in [**Month (only) 956**]. When her
insurance no longer covered this doctor, she transferred her
care over to [**Hospital1 18**] Allergy and Immunology, seen yesterday by a
covering doctor, with no note in OMR at the time of this
admission note. Of note, she denies any abdominal symptoms or
new skin findings.
In the ED, initial VS were: 97.2 72 134/82 16 99% RA Patient
was given moprhine 4mg IV for neck pain, but did not complain of
any trouble breathing or difficulty swallowing saliva. She
mentions that the pain in her neck is consistent with her "usual
flare". She does not demonstrate any stridor was able to speak
in full sentences. 2 units of FFP were prepared prior to
transfer of patient, but were not administered. Vitals on
transfer were: HR 59, BP 129/76, O2 97% RA.
.
In the ICU, she is still in pain around her jaw with difficulty
swallowing her own secretions and a hoarse voice. She is
uncomfortable, but breathing well on her own without stridor or
increased effort.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
C1 esterase inhibitor deficiency, type III
GERD
Social History:
- Tobacco: 1pk/day for ~35 years (since 5th grade)
- Alcohol: never
- Illicits: denies
Family History:
DM2 and breast cancer
Physical Exam:
ADMITTING PHYSICAL EXAM:
Vitals: T: 96.0 BP: 65 P: 125/77 R: 14 O2: 95%RA
General: Alert, oriented, mild distress secondary to pain and
fear of choking on her own saliva
HEENT: Sclera anicteric, MMM, oropharynx clear without swollen
mucosal surfaces and visibly normal-sized tonsilar pillars
Neck: supple with mild swelling through, JVP not elevated, no
LAD appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. No stridor appreciated
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical exam
VSS
Gen: alert and orientedx3 nad
Heent mmm
CV rrr no m/r/g
pulm: ctab
abd soft nt nd bs+
ext no le edema good pedal pulses bilaterally
Pertinent Results:
==============
Admitting labs:
==============
[**2178-7-16**] 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2178-7-16**] 02:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2178-7-16**] 02:00AM PLT COUNT-340
[**2178-7-16**] 02:00AM NEUTS-64.2 LYMPHS-29.5 MONOS-3.6 EOS-1.9
BASOS-0.8
[**2178-7-16**] 02:00AM WBC-9.7 RBC-4.60 HGB-13.9 HCT-40.1 MCV-87
MCH-30.3 MCHC-34.8 RDW-13.0
[**2178-7-16**] 02:00AM URINE UCG-NEGATIVE
[**2178-7-16**] 02:00AM URINE HOURS-RANDOM
[**2178-7-16**] 02:00AM estGFR-Using this
[**2178-7-16**] 02:00AM GLUCOSE-94 UREA N-13 CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-29 ANION GAP-12
[**2178-7-16**] 04:25AM PT-12.0 PTT-24.9 INR(PT)-1.0
[**2178-7-16**] 04:25AM PLT COUNT-315
[**2178-7-16**] 04:25AM NEUTS-63.7 LYMPHS-30.2 MONOS-2.9 EOS-2.5
BASOS-0.7
[**2178-7-16**] 04:25AM WBC-9.3 RBC-4.48 HGB-13.7 HCT-37.6 MCV-84
MCH-30.6 MCHC-36.4* RDW-12.3
[**2178-7-16**] 04:25AM GLUCOSE-96 UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
===============
Imaging:
===============
None
.
===============
Micro:
===============
None.
.
==============
Discharge labs:
==============
Brief Hospital Course:
# C1 esterase inhibitor deficiency: Patient appeared to be in an
acute flare on presentation to the ICU. She was monitored to
ensure she does not develop laryngeal edema and her respiratory
status was also monitored. She did not require intubation.
Upon presentation, she had already received the 1st line
treatment for an angioedema flare in hereditary angioedema
(Cinryze) as prophylaxis. FFP, for replacement of factors in
the complement pathway, was considered, but was held per
Allergy/Immunology recommendations. Per allergy/immunology the
patient was started on ranitidine. Pain was controlled with
morphine. MRI of the soft tissues of the neck showed no acute
swelling but did have some canal narrowing at c5-c7 Patient
with improavement in symptoms and will f/u with allergy clinic
for continued management.
Medications on Admission:
-C1 esterase inhibitor [Cinryze] 1000 units IV q 3 days
-ranitidine HCl 150 mg daily (just prescribed, not yet started)
-sertraline 50 mg daily
-zolpidem 5mg PRN
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Cinryze 500 unit Recon Soln Sig: One (1) 1000U Intravenous
q3days ().
3. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
5. Nicorette 4 mg Gum Sig: One (1) tab Buccal as directed:
Please follow packaging instructions.
Disp:*1 package* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
C1 esterase inhibitor defficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were diagnosed with episode of angioedema(swelling in your
neck) from C1 esterase inhibitor deficiency. Your symptoms
improved with your cinryze. An MRI of the neck was performed
and the final [**Location (un) 1131**] can be reviewed at the allergy clinic
visit. Please also start taking the nicotine gum to help you
quit smoking.
Followup Instructions:
Please call the allergy clinic ([**Telephone/Fax (1) 44274**] on Monday to make
a follow up appointment
| [
"53081",
"3051",
"311"
] |
Admission Date: [**2102-12-8**] Discharge Date: [**2102-12-18**]
Date of Birth: [**2025-11-5**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This 77-year-old white male was
found to have pulmonary nodules on a routine chest x-ray.
Further work-up included a chest CT which also demonstrated
calcified pleural plaques and dense coronary calcification.
The chest nodules were found to be benign, and he was sent
for a stress test which was positive, and he was found to
have an EF of 64% with inferior ischemia. He then had a
cardiac cath done at [**Hospital6 1109**] on [**2102-12-7**]
which revealed that the left main had a 70% distal stenosis.
The LAD had diffuse narrowing. The left ventricle was
normal, and no MR. The left circumflex was dominant with a
70% ostial lesion involving the origin of the OM, and the RCA
was nondominant and likely occluded. He also had carotid
duplex which revealed a 40-60% stenosis of the right ICA, and
a less than 40% stenosis of the left ICA. He was transferred
to [**Hospital1 18**] for CABG.
PAST MEDICAL HISTORY:
1. History of hypertension.
2. History of hypercholesterolemia.
3. Status post hernia repair x 2.
4. History of nephrolithiasis x 4.
ALLERGIES: Valium.
MEDICATIONS ON ADMISSION:
1. Lipitor 10 mg po qd.
2. Lisinopril 20 mg po qd.
3. Atenolol 25 mg po qd.
4. Aspirin 325 mg po qd.
5. Hydrochlorothiazide 12.5 mg po qd.
SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **]
is a retired pipe fitter. He smoked a pack a day and quit 40
years ago.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAM: He is a well-developed, elderly white male in
no apparent distress. Vital signs stable, afebrile. HEENT
exam - normocephalic, atraumatic, extraocular movements
intact, oropharynx benign. Neck is supple, full range of
motion, no lymphadenopathy, or thyromegaly, carotids 2+ and
equal bilaterally. Lungs are clear to auscultation and
percussion. Cardiovascular exam - regular rate and rhythm,
normal S1, S2, without rubs, murmurs or gallops. Abdomen is
soft, nontender with positive bowel sounds, no masses or
hepatosplenomegaly. Extremities were 2+ and equal
bilaterally without clubbing, cyanosis or edema. Pulses are
2+ and equal bilaterally throughout.
HOSPITAL COURSE: He was admitted, and he was monitored on
telemetry. On [**12-12**], he underwent a CABG x 2 and LIMA to the
LAD, reversed saphenous vein graft to the PDA and diagonal.
He tolerated the procedure well and was transferred to the
CSRU in stable condition. He was extubated on this
postoperative night and transferred to the floor on postop
day #1.
On postop day #2, he had his chest tubes DC'd. His Lopressor
was increased. He was transfused 1 unit of blood.
On postop day #3, his epicardial pacing wires were DC'd, and
he continued to slowly progress with physical therapy. His
Lopressor was gradually increased to 100 mg [**Hospital1 **]. On postop
day #6, he was discharged to home in stable condition.
LABS ON DISCHARGE: Hematocrit 31.6, white count 10,400,
platelets 260,000, sodium 135, potassium 4.1, chloride 100,
CO2 28, BUN 14, creatinine 0.8, blood sugar 176.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po bid x 7 days.
2. Potassium 20 mEq po bid x 7 days.
3. Colace 100 mg po bid.
4. Ecotrin 325 mg po qd.
5. Percocet [**1-26**] po q 4-6 h prn pain.
6. Lopressor 100 mg po bid.
7. Lisinopril 10 mg po qd.
8. Lipitor 10 mg po qd.
FO[**Last Name (STitle) **]P: He will be followed by Dr. [**Last Name (STitle) 27187**] in [**1-26**]
weeks, and by Dr. [**Last Name (STitle) 5874**] in [**2-27**] weeks, and by Dr. [**Last Name (Prefixes) 411**] in 4 weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2102-12-18**] 11:54
T: [**2102-12-18**] 12:05
JOB#: [**Job Number 54511**]
| [
"41401",
"4019",
"2720"
] |
Admission Date: [**2135-12-12**] Discharge Date: [**2135-12-17**]
Service:
HISTORY OF PRESENT ILLNESS: This was a patient of Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] who was admitted for congestive heart failure in the
setting of recent aortic valve replacement for aortic
stenosis.
HOSPITAL COURSE: The patient was initially admitted to the
Medicine Service. Diuresis was attempted with little
clinical improvement. After discussion with the patient and
her family, it was decided to transfer the patient to the
Coronary Care Unit where she could have more accurate
hemodynamic monitoring as well as administration of pressors
as needed. She was transferred to the Coronary Care Unit
where a pulmonary artery catheter was placed. She was placed
on Dobutamine for inotropic support and diuresed. In order
to improve her respirations, bilateral thoracentesis was
performed. However only four hours after the thoracentesis,
fluid reaccumulated in the pleural space. The following
morning which was [**2135-12-17**], the patient became
hypotensive and required CPAP with pressure support to
maintain adequate oxygenation. The family was contact[**Name (NI) **] and
the [**Hospital 228**] health care proxy which was her husband as well
as the patient decided to approach the situation with comfort
being the main goal. The patient was started on a morphine
drip and CPAP was discontinued. At 4:03 p.m., the patient
was unresponsive with no pulse and no respirations and she
was pronounced dead. The cause of death was congestive heart
failure.
FINAL DIAGNOSIS: Congestive heart failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2135-12-17**] 17:03
T: [**2135-12-20**] 20:58
JOB#: [**Job Number **]
| [
"4280",
"5990",
"42731",
"4019"
] |
Admission Date: [**2181-1-15**] Discharge Date: [**2181-1-18**]
Date of Birth: [**2155-4-21**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
25 y/o male with hx of closed head injury as teenager,
cocaine OD, lumbar spine surgery was transferred from an outside
hospital with C6 Lamina fracture and ? C5 Fracture. Pt slipped
and fell in puddle of water, hitting head as he fell down
reports
immediate neck right shoulder pain, no LOC no loss of bowel or
bladder sensation
Major Surgical or Invasive Procedure:
ACDF C6-7
History of Present Illness:
25 y/o male with hx of closed head injury as teenager,
cocaine OD, lumbar spine surgery was transferred from an outside
hospital with C6 Lamina fracture and ? C5 Fracture. Pt slipped
and fell in puddle of water, hitting head as he fell down
reports
immediate neck right shoulder pain, no LOC no loss of bowel or
bladder sensation
Past Medical History:
Closed head injury as teenager, Cocaine OD, Lumbar spine
surgery in [**6-22**].
Social History:
Currently Prisoner went to jail on [**1-11**] for violating
a restraining order according to patient. Smokes 1.5ppd, drinks
6-12 beers per day last drink [**1-10**]; Uses coccaine occassionaly
Family History:
Non contributory
Physical Exam:
T:98.0 BP:128/70 HR: 68 R 18 O2Sats 97%
Gen: Awake on ICU bed conversant
HEENT: Pupils: EOMs
Neck: in collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Toes cool no injuries.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 4+ 4+ 4+ 4+ 4+ 5 5 5 5 5
L 5 5 5 5 5 3 3 3 3 0
Sensation: Intact to light touch decreased on left leg, normal
senation in pubic area and penis
Reflexes: B T Br Pa Ac
Right 2 2 2+
Left 2 2 2+
No clonus
Propioception intact
Toes mute
Rectal exam normal sphincter control per ER and trauma resident
Pertinent Results:
[**2181-1-15**] 06:30AM PLT COUNT-264
[**2181-1-15**] 06:30AM NEUTS-64.9 LYMPHS-26.4 MONOS-5.9 EOS-0.9
BASOS-1.8
[**2181-1-15**] 06:30AM WBC-9.0 RBC-5.04 HGB-16.5 HCT-46.2 MCV-92
MCH-32.7* MCHC-35.6* RDW-13.0
[**2181-1-15**] 06:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2181-1-15**] 06:30AM PHOSPHATE-4.6* MAGNESIUM-2.4
[**2181-1-15**] 06:30AM estGFR-Using this
[**2181-1-15**] 06:30AM estGFR-Using this
[**2181-1-15**] 06:40AM GLUCOSE-100 LACTATE-1.5 NA+-144 K+-3.8
CL--108 TCO2-23
[**2181-1-15**] 06:40AM GLUCOSE-100 LACTATE-1.5 NA+-144 K+-3.8
CL--108 TCO2-23
[**2181-1-15**] 06:40AM PH-7.40 COMMENTS-GREEN TOP
Brief Hospital Course:
Mr [**Known lastname 1968**] was admitted to the trauma ICU he underwent
cervical,thoracic, lumbar MRI:
showing: Large disc protrusion at C6/7 extending from just left
of midline
rightward into the right neural foramen. This disc protrusion
results in
compression of the right anterolateral aspect of the spinal
cord.
2. Small disc protrusions at T2/3 and T7/8.
3. Degenerative disc changes and protrusions as described at
L3/4, L4/5, and
L5/S1.
It was felt that his C6/7 disc was the one that causing the
majority of his symptoms, on [**1-16**] he underwent a ACDF with
allograft plate C6-7. Post operatively he was full in strength
in his right arm with continued neck pain.
On Post operative day 1 he was moving all extremities with good
strenght though was hesitent to move left leg at times though
when pushed he had full strength. His pain medication was
weaned and he was placed for a physical therapy consult. He was
tolerating a regular diet and voiding without difficulty.
Medications on Admission:
None
Discharge Medications:
Percocet
Colace
Discharge Disposition:
Extended Care
Discharge Diagnosis:
C6-7 HNP with C7 pedicle fracture
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? If you have steri-strips in place ?????? keep dry x 72 hours. Do
not pull them off. They will fall off on their own or be taken
off in the office
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection
?????? you are required to wear cervical collar asinstructed
?????? You may shower briefly without the collar / back brace unless
instructed otherwise
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
PLEASE RETURN TO THE OFFICE IN ____________DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURES ( IF YOUR SUTURES ARE UNDER THE SKIN YOU
WILL NOT NEED TO BE SEEN UNTIL THE FOLLOW UP APPOINMENT
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) 548**] in 6 weeks YOU WILL NEED XRAYS (AP/lat) PRIOR TO YOUR
APPOINMENT
Completed by:[**2181-1-18**] | [
"3051"
] |
Admission Date: [**2140-1-28**] Discharge Date: [**2140-2-8**]
Date of Birth: [**2104-9-10**] Sex: F
Service: MEDICINE
Allergies:
Tape [**1-25**]"X10YD / Augmentin / Hydrocodone / Levofloxacin /
Ciprofloxacin / fentanyl / Keflex / ceftriaxone / Ativan
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
35 yo F with T1DM complicated by retinopathy/nephropathy/
gastroparesis and recent admission for nausea and vomiting and
DKA, who presents to the ED for recurrent nausea/vomiting. Per
ED note, patient's symptoms started the day after discharge
([**2140-1-23**]). Diarrhea started the evening she returned home.
Diarrhea lasted one and a half days. She also started having a
cold with nasal congestion and cough, taking nyquil. She had
associated chills, but no fevers. Her blood sugars have been
runing high for the last 5 days despite whether or not she eats.
She has not had abdominal pain, nausea or vomiting until this
morning when she was dizzy and nauseaus. She has had minimal
eating, but she has been drinking apple juice (not sugar free).
She had eaten a different type of grape. She was also eating
tabouli the same day she at the grapes. Then she woke up
yesterday with the face swollen, but swelling improved by
afternoon.
On the day prior to admission, she had a headache, by afternoon
feeling better. Went to dinner with her son, ate a salad. At
9pm, BG was low 40s, made an english muffin and ate half. Then
she went to bed. This morning blood sugar was 182. She came to
the hospital because she was feeling dizzy and getting nauseous
again at 7:30 and came to the ED.
Above history from patient's mother who lives with her.
Pt had recent hospitalization for nausea and vomiting thought
likely [**2-25**] gastroparesis, DKA placed on insulin drip in MICU,
CONS UTI given ceftriaxone and completed a 3 day course.
In the ED, initial vs were: 99.8 107 117/64 18 95%.
Patient was given 4mg Zofran, 2mg Ativan, 650mg Tylenol PO with
improvement in nausea, pain. FS 345 on arrival, 240's by lab. UA
with few bacteria and WBC, given Nitrofurantoin 100mg.
Vitals prior to transfer HR 110, BP 137/86, RR 16, 95% RA.
.
On the floor, pt initially unresponsive to command, voice,
touch, arouse briefly to sternal rub. BG ~500, given 12 U
humalog. Trigger was called. ABG demonstrated no acidosis,
though ph 7.49. Pt was also noted to be hypoxic to 49% unclear
if accurate pleth, easily weaned off O2 to RA when awake. Low
grade temp to 100.3 noted.
BP, HR, remained stable. No tachypnea.
.
Review of systems:
(+) per HPI. Headache yesterday morning, took an excedrin
resolved. when seen by mother subsequently, looked great.
(-) Denies fever, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denied
shortness of breath. Denied chest pain or tightness,
palpitations. No recent change in bladder habits. No dysuria.
Denied arthralgias or myalgias.
Past Medical History:
- Type 1 diabetes: c/b retinopathy, nephropathy, and
gastroparesis, diagnosed at age 11. Poorly controlled per recent
records, with the exception of during her pregnancy when she
required TPN (with insulin it) for hyperemesis. She has had
multiple episodes of diabetic ketoacidosis. A1c was 10.6 on
[**2139-8-17**]. Last eye exam [**5-1**] - "quiescent" PROLIFERATIVE
diabetic retinopathy.
- Barrett's esophagitis
- GERD, antral ulcer
- Normocytic Anemia
- HLD
- HTN
- dCHF EF > 60% in [**8-/2139**]
- Accquired hemophilia (FVIII inhibitor in [**2132**]) treated with
steroids and rituximab
- Depression
- Migraines
- Anti-E and warm autoantibody but recent negative Coombs Test
- Hydronephrosis
- Osteoporosis ([**2138-11-12**] T-score L spine -2.2, femoral neck
-3.1)
- h/o avascular necrosis
- H/o severe hyperemesis gravidarum requiring TPN.
- s/p C section at 33 weeks because of hyperemesis
- s/p repair for ruptured [**Last Name (un) 18863**] tendon
- s/p ORIF of right distal radius
Social History:
The patient does not smoke or drink alcohol, transfusion in
[**2132**]. Married, living with her mother, husband and one son. A
homemaker currently. On disability since [**2132**]. Exercises
regularly at a gym
Family History:
Has 1 sister, no hx of cancer or bleeding/ blood disorders in
family but positive IBD history in grandfather and [**Name2 (NI) 12232**]
Physical Exam:
Admission exam:
Vitals: T:98.2 BP:136/71 P:112 R:18 O2:94% NRB
General: Alert, oriented, anxious, speaking in full sentences,
not using accessory muscles of respiration
HEENT: Mild conjunctival injection, no icterus or pallor, MMM,
oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffuse rhonchi bilaterally, with occasional expiratory
wheeze. No crackles.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred
Discharge exam:
Vitals: T: 98 BP: 166/88 P: 66 R:18 O2: 96%
General: Alert, oriented, speaking in full sentences, not using
accessory muscles of respiration
HEENT: Mild conjunctival injection, no icterus or pallor, MMM,
oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: No wheezes, rales, rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN II - XII intact
Pertinent Results:
Admission labs
[**2140-1-28**] 09:45AM BLOOD WBC-12.3*# RBC-2.90* Hgb-8.7* Hct-26.7*
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.1 Plt Ct-380
[**2140-1-28**] 09:45AM BLOOD Neuts-82.2* Lymphs-14.5* Monos-2.3
Eos-0.6 Baso-0.4
[**2140-1-28**] 09:45AM BLOOD PT-11.0 PTT-32.0 INR(PT)-1.0
[**2140-1-28**] 09:45AM BLOOD Glucose-274* UreaN-25* Creat-2.2* Na-133
K-5.0 Cl-97 HCO3-27 AnGap-14
[**2140-1-28**] 09:45AM BLOOD ALT-14 AST-16 AlkPhos-99 TotBili-0.1
[**2140-1-28**] 04:40PM BLOOD Calcium-7.6* Phos-4.8* Mg-1.8
[**2140-1-28**] 04:18PM BLOOD Lactate-1.2
Discharge labs:
[**2140-2-8**] 06:50AM BLOOD WBC-7.2 RBC-3.61* Hgb-10.9* Hct-32.6*
MCV-90 MCH-30.1 MCHC-33.4 RDW-13.6 Plt Ct-672*
[**2140-2-8**] 06:50AM BLOOD Glucose-297* UreaN-18 Creat-1.2* Na-135
K-5.0 Cl-98 HCO3-26 AnGap-16
Studies
CXR [**2140-1-28**]: Low lung volumes with patchy opacities in the left
lung base,
likely atelectasis, but infection cannot be ruled out in the
correct clinical setting.
CXR [**2140-2-1**]: Severe bilateral pneumonia has not improved since
[**1-31**]. There is also a component of mild pulmonary edema
which is probably worsened. Heart size is top normal. No
pneumothorax. At least a moderate left pleural effusion is
presumed.
Chest CT w/o contrast [**2140-2-1**]: 1. Bilateral asymmetrically
distributed ground-glass and consolidative opacities involving
the left lung to greater degree than the right, accompanied by
smooth septal thickening and bilateral pleural effusions. These
findings likely represent a combination of multifocal pneumonia
and pulmonary edema. 2. Small pericardial effusion. 3. Anasarca
and small amount of ascites.
4. Healing sternal fracture and several anterior rib fractures,
which are not appreciated on the older CT of [**2139-9-15**] but
are age indeterminate.
CArdiac ECHO: IMPRESSION: Normal left ventricular cavity size
and wall thickness with preserved global and regional
biventricular systolic function. At least mild mitral
regurgitation. Very small to small, circumferential pericardial
effusion without echocardiographic evidence of tamponade. Left
pleural effusion. Indeterminate pulmonary artery systolic
pressure.
Compared with the prior study (images reviewed) of [**2140-9-1**], a
very small to small pericardial effusion is present. The
pulmonary artery systolic pressure was not able to be determined
on the current study. Previously, at least borderline pulmonary
artery systolic hypertension was appreciated. The left pleural
effusion is new.
Brief Hospital Course:
35 y/o F with hx of T1DM with severe gastroparesis, prior
episodes of DKA, acquired hemophilia, htn, multiple recent
admissions for nausea and vomiting, initially presented with
nausea, vomiting, diarrhea found to have multifocal pneumonia
requiring ICU monitoring, acute exacerbation of diastolic heart
failure, difficult to control blood sugars, and acute kidney
injury.
Pt was s/p 2mg IV ativan in the ED for management of nausea and
she initially presented to the floor extremely lethargic and
barely responsive. She triggered for hypoxia 46% on RA but was
never cyanotic and rapidly improved to 100% on RA. She was also
hyperglycemic to 500 which improved with insulin and IVF. ABG
did not demonstrate hypoxia or hypercarbia or acidosis. Her
symptoms improved over half an hour when she was mildly
lethargic but responding to questions appropriately and
conversant, falling easily into sleep but arousable. When awake
patient endorsed symptoms of dysuria and diarrhea. She was
started on bactrim for UTI. For renal failure IVF were given
and home diuretics held.
The following day, her lethargy was resolved and she was having
fever to 101, productive cough and diarrhea. CXR demonstrated
multifocal PNA. Given numerous allergies to antibiotics she was
started on meropenem and vancomycin for hospital acquired
pneumonia, though aspiration pneumonia remained on the
differential. Legionella was considered and urine legionella
sent and ultimately returned negative twice. She remained on 3L
O2 with sats dropping to high 80s and low 90s. On [**2-6**] she
desaturated to low 80s on 4L requiring nonrebreather and
transferred to the ICU. In the ICU, she was observed to be
volume overloaded and treated with diuretics in addition to
broadening her antibiotics to include antiviral treatment and
azithromycin for legionella.
During her ICU course she was diuresed with 40mg IV lasix, her
O2 requirement improved. ID was consulted who recommended
discontinuation of antiviral treatment after negative influenza
swab. She was also found to have hypoglycemia, [**Last Name (un) **] was
consulted, who recommended reducing insulin. She continued to
have intermittent diarrhea and nausea/vomiting. After 3 days in
the ICU and addressing the above issues, she was transferred
back to the floor.
On the floor, her oxygen requirement continued to improve such
that she was on room air. She continued to have fevers to 101,
for which drug fever was a concern per ID. So per their
recommendation Meropenem and Vancomycin were discontinued after
a 7 day course. Per ID recommendations Azithroymycin was
discontinued on day 9 due to thrombocytosis.
Upon return to the floor she continued to have fluctuating high
and low blood sugars requiring frequent and daily adjustments of
her lantus dose and sliding scale. At time of discharge she was
on 4units of lantus [**Hospital1 **] with sliding scale recommended by
[**Last Name (un) 387**].
During her hospitalization she required 2 units of blood
products for hematocrit of 21 thought to be secondary to acute
illness and phlebotomization. Hct was 25 at time of admission
dropped to 21 during the course of her ICU stay. Her Hct
remained stable at 32 for several days prior to her discharge.
She was also given IV Iron given concern for occult GIB.
Unclear remain the cause of her diarrhea which may have been
viral in nature. Stool studies were all negative. Though this
had resolved by time of discharge. Nausea vomiting, initially
thought to be gastroparesis were minimal during this
hospitalization compared to prior. She was tolerating regular
diet at time of discharge. Renal failure had improved to
creatinime of 1.2 on day of discharge. She was restarted on her
home diuretics at time of d/c. She was not started on ACE/[**Last Name (un) **]
due to history of hyperkalemia.
Hospital course was also complicated by a number of social
issues. Her mother and grandfather continued to be major
supports. Pt admitted to not feeling supported by her husband
with her medical issues. She was very stressed and was in a low
mood during her hospitalization with flat affect. She was never
suicidal or homicidal. She was seen by social work who did not
feel that an inpatient psychiatry evaluation was needed. She
was started on buspar and continued on zoloft.
TRANSITIONAL ISSUES:
- nutrition consult for gastroparesis
- [**Last Name (un) 387**] follow up with classes for nutrition classes and
learning carb counting.
- CT scan in [**3-27**] weeks for resolution for pneumonia, per ID
recommendation (vs CXR given the severity of her PNA and concern
for cavitation)
- Follow up depression
- Social work follow up, consider referral to psychiatry
- follow up of hematocrit and renal function
- will need repeat endoscopy and possibly capsule endoscopy for
evaluation of occult GIB.
Medications on Admission:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
please stop taking if you are unable to tolerate food or liquid.
3. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day: do not take if constipation or stomach
upset.
6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day.
7. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
8. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
9. gabapentin 800 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-25**] Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
12. metoclopramide 5 mg Tablet Sig: 1-2 Tablets PO three times a
day: with meals.
Disp:*180 Tablet(s)* Refills:*0*
13. Lantus 100 unit/mL Solution Sig: ASDIR Subcutaneous twice a
day: take 6 units int he morning and 4 units at bedtime. .
14. Humalog 100 unit/mL Solution Sig: ASDIR Subcutaneous QACHS:
per sliding scale.
15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
stop taking if you are not eating or drinking well.
3. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
6. Ambien 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for insomnia.
7. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
8. gabapentin 800 mg Tablet Sig: One (1) Tablet PO once a day.
9. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-25**] Tablet,
Rapid Dissolves PO once a day.
11. metoclopramide 5 mg Tablet Sig: 1-2 Tablets PO three times a
day: with meals when for gastroparesis if needed.
12. insulin glargine 100 unit/mL Solution Sig: One (1) 4 IU in
am and 4 IU in pm Subcutaneous twice a day.
13. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous
sliding scale.
14. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): twice a day for one week, then increase to three times a
day. THIS IS A NEW MEDICATION FOR LOW MOOD AND ANXIETY.
Disp:*60 Tablet(s)* Refills:*0*
15. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Acute kidney injury
Diabetes mellitus
Decompensated diastolic heart failure
Normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you. You came because of nausea
and vomiting. After you came you developed the lung infection
and impairment of the kidney function. The lung infection was
treated with antibiotics. Kindey inpairment was treated with the
intravenous fluid. During the hospital stay you started having
difficulty breathing and were transferred to the intensive care
unit and when you were able to breath without difficulties you
were transferred back to the [**Hospital1 **].
.
We have made the following changes in your medication:
CONTINUE azithromycin for the next 10 days
CONTINUE your home medication.
.
Followup Instructions:
Please contact Dr.[**Name2 (NI) 51374**] office for an appointment on
Tuesday or Wednesday to check your blood pressure, sugars,
oxygen level.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2140-2-24**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2140-2-10**] | [
"0389",
"5849",
"5070",
"4280",
"2761",
"40390",
"486",
"5990",
"V5867",
"2724",
"311",
"5859"
] |
Admission Date: [**2205-8-7**] Discharge Date: [**2205-8-13**]
Date of Birth: [**2130-12-20**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Occluded aorto-bifemoral bypass
graft.
Major Surgical or Invasive Procedure:
1. Bilateral groin exploration.
2. Thrombectomy of aorto-bifem graft, bilateral SFA,
bilateral profunda, bilateral common iliac arteries.
3. Patch closure of arteriotomies.
4. Endovascular stents of aorto-[**Hospital1 **] fem limbs.
5. Bilateral fasciotomies.
History of Present Illness:
This is a 74-year-old female who
is status post aorto-bifemoral graft in [**2201**] who presented
with acute onset of left leg pain starting at 8:30 this
morning. The patient had previously been ambulatory without
claudication or rest pain. The patient was brought to
[**Hospital3 4527**] and was started on heparin and emergently
transferred to [**Hospital1 **] for further care. Upon
examination, the patient had no palpable femoral pulses. The
patient had poor motor function of her left leg below the
knee as well as decreased sensation of the left leg compared
to the right leg. The patient was taken urgently to the
operating room. Her preoperative creatinine was elevated at
1.2. Her bicarbonate was 15. Her CK was 40.
Past Medical History:
Lung cancer, Emphysema, s/p Lt CEA [**2-21**], Rt carotid 100%
occluded, h/o TIAs post-CEA, HTN, Chol, Arthritis
PSH- Right middle and lower lobectomies in [**1-22**], Left CEA [**2-21**],
Hysterectomy remote, Tonsillectomy remote, aortobifem in [**2201**]
Social History:
x smoker
non drinker
Family History:
n/c
Physical Exam:
Vitals: 98.6, HR 74 BP 142/80 RR18 96%RASat
Gen: NAD
Neuro: A&OX3
RESP: CTA
ABD: soft, NT
B/L DP/PT doppler
Pertinent Results:
[**2205-8-12**] 03:06AM BLOOD
WBC-9.9 RBC-3.22* Hgb-9.9* Hct-29.2* MCV-91 MCH-30.6 MCHC-33.8
RDW-15.9* Plt Ct-201
[**2205-8-12**] 03:06AM BLOOD
PT-11.6 PTT-34.9 INR(PT)-1.0
[**2205-8-12**] 03:06AM BLOOD
Glucose-131* UreaN-13 Creat-0.9 Na-138 K-4.4 Cl-109* HCO3-18*
AnGap-15
[**2205-8-12**] 03:06AM BLOOD
Calcium-7.9* Phos-1.5* Mg-2.0
CT ABDOMEN W/CONTRAST [**2205-8-12**] 7:57 PM
CT OF THE ABDOMEN WITH IV CONTRAST: The visualized portion of
the lung bases demonstrates severe centrilobular emphysematous
changes of the lung. No parenchymal opacification or pulmonary
nodule is seen. The left atrium is mildly enlarged.
The liver, gallbladder, intra and extrahepatic bile ducts,
spleen, pancreas, stomach, duodenum and loops of small bowel are
unremarkable. Colonic pandiverticulosis is noted. Both kidneys
contain multiple hypodense lesions which are too small to
characterize. No free air or fluid is noted within the abdomen.
The patient is status post mesh placement of anterior abdominal
wall. No pathologically enlarged retroperitoneal or mesenteric
nodes are noted.
The thoracic aorta demonstrates mural thrombus and aneurysmal
dilatation
measuring 3.9 x 4.4 cm which extends for 7.1 cm and extends into
the
suprarenal aorta. The patient is status post aorto- biliac
bypass grafting. Complete opacification of the both external
iliac arteries are noted. Severe stenosis is noted at the origin
of the right common iliac artery. The abdominal aorta
demonstrates severe calcification with calcification noted at
the origin of celiac artery, superior mesenteric artery and both
renal arteries.
CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder contains
small locules of air most likely related to the prior Foley
catheter placement. The rectum contains impacted stool. The
sigmoid colon contains multiple diverticula. No evidence of
diverticulitis is seen. Left-sided rectus sheath hematoma is
noted which measure 4.3 x 5.9 in transverse diameter and
measures 10.9 cm in craniocaudal diameter. In the right inguinal
region a fluid density material is surrounding the right common
femoral artery consistent with the patient history of recent
thrombectomy on the right inguinal region. Right indirect
inguinal hernia is noted which contains fluid. No evidence of
bowel obstruction or incarceration is noted. No free air or
fluid is noted within the pelvis. No pathologically enlarged
pelvic or inguinal nodes are detected.
BONE WINDOWS: No concerning lytic or sclerotic lesions are
noted. Degenerative changes of lower lumbar spine are
identified.
IMPRESSION:
1. Relatively large rectus sheath hematoma which extends into
the left inguinal region measuring 4.3 x 5.9 x 10.9 cm. No
evidence of bowel entrapment within the inguinal canals were
noted.
2. Small fluid containing right-sided inguinal hernia was noted.
3. Status post aorto-biiliac bypass garfting.
4. Abdominal aortic aneurysm measuring 3.9 x 4.4 cm in
transverse diameter which extends 7.2 cm in craniocaudal
diameter.
5. Status post thrombectomy at the right inguinal region with a
small amount of fluid tracking along the common femoral artery.
6. Stool impaction is noted within the rectum.
7. Small right-sided pleural effusion is seen. Emphysematous
changes of lung bases are noted.
8. Colonic pandiverticulosis.
Brief Hospital Course:
[**2205-8-7**] The patient was brought to [**Hospital3 4527**] and was
started on heparin and emergentlytransferred to [**Hospital1 **] for further care. On arrival to [**Hospital1 18**], patient with
B/L cold feet and pain L>R. Acutely ischemic, taken to OR for
Bilateral groin exploration, Thrombectomy of aorto-bifem graft,
bilateral SFA,
bilateral profunda, bilateral common iliac arteries, Patch
closure of arteriotomies, Endovascular stents of aorto-[**Hospital1 **] fem
limbs, Bilateral fasciotomies.
Pulses at end of case: palpable RT DP, doppler PT. LT dop PT/DP.
pt did well post opeative with out complications. She progressed
with PT / PT recommended reah.
To note pt did have abdominial pain. Thi sprompted a US of
abdomen. This showed fluid collection vs strangulated bowel, A
CT scan was done. Negative for bowel entrapment. There was a
small hematoma.
Pt stable for DC
Medications on Admission:
asa, [**Hospital1 17339**], zestril 20
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day: Discontinue when fully ambulatory.
10. Regular Insulin Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-60 mg/dL [**1-22**] amp D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 2 Units 2 Units 2 Units 2 Units
141-160 mg/dL 4 Units 4 Units 4 Units 4 Units
161-180 mg/dL 6 Units 6 Units 6 Units 6 Units
181-200 mg/dL 8 Units 8 Units 8 Units 8 Units
201-220 mg/dL 10 Units 10 Units 10 Units 10 Units
221-240 mg/dL 12 Units 12 Units 12 Units 12 Units
241-260 mg/dL 14 Units 14 Units 14 Units 14 Units
261-280 mg/dL 16 Units 16 Units 16 Units 16 Units
281-300 mg/dL 18 Units 18 Units 18 Units 18 Units
301-320 mg/dL 20 Units 20 Units 20 Units 20 Units
321-340 mg/dL 22 Units 22 Units 22 Units 22 Units
341-360 mg/dL 24 Units 24 Units 24 Units 24 Units
> 360 mg/dL Notify M.D.
11. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for constipation.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Dulcolax 10 mg Suppository Sig: One (1) Rectal at bedtime
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
74F s/p Thrombectomy b/l aorto-bifem limbs, SFA, profundas;
patch closure of arteriotomies, stents to aorto-bifem, b/l
fasciotomies [**8-7**] for occlued ABF
.
PMH:Lung cancer, Emphysema, s/p Lt CEA [**2-21**], Rt carotid 100%
occluded, h/o TIAs post-CEA, HTN, Chol, Arthritis.
Discharge Condition:
Stable
Discharge Instructions:
Division of [**Month/Year (2) **] and Endovascular Surgery
Lower Extremity Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 17751**] in the office in one week. Call for
an appointment [**Telephone/Fax (1) 3121**]
Previously scheduled:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-9-2**]
8:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-9-2**]
9:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-9-2**]
9:30
Completed by:[**2205-8-13**] | [
"4019",
"2720"
] |
Admission Date: [**2153-6-27**] Discharge Date: [**2153-6-29**]
Date of Birth: [**2096-6-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
AMI in cath lab folowing abnormal outpt ETT
Major Surgical or Invasive Procedure:
cardiac catheterization
echocardiogram
History of Present Illness:
57 yo M hx HTN, hyperlipidemia and obesity. Pt presented with
worsening of palpitation x6 months, less frequently for several
years prior to that. Describes these as sensation of fluttering,
lasting seconds, associated with some nausea and weakness.
Denies any associated chest pain or associated with exertion.
He evaluated with outpt event monitor revealing NSVT, started on
toprol with some symptomatic improvement.
In addition he had an outpt ETT with a small reversible
anterolateral defect.
He presented today for elective cardiac cath.
While performing diagnostic cath, pt developed heavy chest pain,
nausea, palpitations. Cath revealed an evolving anterior STEMI,
initially with 80% mid LAD progressing to complete LAD occusion,
this was stented with 2 bare metal stent. A clot was noted in
1st diag., attempted IC eptifibatide, tPA, balloon dilation and
aspiration catheter, however clot persisted. Procedure performed
via R radial approach, no groin sticks were attempted.
After pt arrived in CCU, he developed an episode of nausea,
diaphoresis, blurry vision following cleaning of his groin, felt
to be a vagal reaction. BP reduced to 80's, HR remained in 80's.
BP improved to 105/69 with 500 cc NS. Pt's symptoms resolved.
EKG repeated, unchanged.
Pt currently feeling well, denies CP, SOB, nausea, diaphoresis.
Past Medical History:
HTN
Hypercholesterolemia
Obesity
Sleep apnea (could not tolerate CPAP)
NSVT
Bronchospastic airway disease
Prior history of hematuria in the late [**2126**]??????s (patient reports
being told that his hematuria might be due to "varicose veins of
the kidneys")
GERD
Lower back pain, s/p steroid injections
Social History:
Patient smoked 4ppd for approximately 12-13 years, quitting
about 30 years ago. Patient is married with three children. He
lives with his wife, [**Name (NI) 553**] ([**Telephone/Fax (1) 73004**]). Works as a general
contractor
Family History:
no family history of premature CAD
Physical Exam:
per Dr. [**Last Name (STitle) 6812**]
VS: T 97.6 BP 105/69 HR 70 RR 14 O2 96% on RA
Gen: WDWN obese middle aged male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple without JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
EKG demonstrated NSR, nl axis, nl intervals + RBBB, TWi in V1,
old, no ST changes, no significant change compared with prior
dated [**2153-6-15**]
.
Admit labs:
134 97 12
------------< 248
4.4 22 0.8
Ca: 8.9 Mg: 2.1 P: 3.5
.
15
11.9 >---< 249
43
.
CK [**Telephone/Fax (3) 73005**]
MB [**2070-10-9**]
Cholesterol 209, Trig 124, HDL 51, LDL 133
.
Cardiac cath
1. Selective coronary angiography in this left dominant
circulation
demonstrated single vessel coronary artery disease. The LMCA
had no
flow limiting disease. The LAD had a mid 80% stenosis after
takeoff of
a large diagonal branch. The D1 had no flow limiting disease.
The LCx
was a large vessel with no flow limiting disease. The major OM
and
L-PDA had no flow limiting disease. The RCA was a relatively
small
vessel with no flow limiting disease.
2. Opening aortic pressure was moderately elevated.
3. During the procedure, the patient developed chest pain and
had runs
of NSVT and then sinus tachycardia. The sinus tachycardia
responded to
IV metoprolol. Upon re-engagement of the LMCA with the guide
catheter,
the proximal to mid LAD was found to be totally occluded along
with the
D1.
4. Successful direct stenting of the LAD lesion with two 3.0
bare metal
stents. Final angiography showed no residual stenosis in the
stented
segment of the LAD with residual thrombus in the diagonal branch
unchanged with administration of IC IIb/IIIA inhibitor and
thrombolytic.
There was normal flow in the distal vessel. (See PTCA comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate systemic arterial hypertension.
3. Successful PCI of the LAD.
4. Residual angiographic evidence of thrombus in the diagonal
branch of
the LAD.
.
Echocardiogram:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
Pt is a 57 year old man with an abnormal ETT referred for
cardiac catheterization. Pt developed anterior STEMI during
diagnostic part of the cardiac cath. Hospital course by
problem:
.
#) Anterior STEMI - Patient was pretreated for his dye allegy.
Evolving anterior STEMI found on cath, treated with two bare
stents to the mid LAD. Pt had persistent clot in 1st diag. We
treated with ASA, plavix, statin, lisinopril, and beta blocker.
Integrillin peri-cath. He was monitored in the CCU postcath
given the acute onset of the thrombus. He did well and was
transitioned to the floor. We recommended plavix for at least 1
month then up to 1 year or as per his outpatient cardiologist.
.
# Cards pump: Echo showed above findings. Function preserved.
Diastolic dysfunction noted. Meds as above.
.
# Cards Rhythm: BB, Tele. no events
.
# Vagal: Postcath and in the CCU, patient had a vagal episode.
When his groin was examined, he developed nausea, diaphoresis,
hypotension, bradycardia. It improved with 250cc IVF and in
short time. There was no chest pain. The patient was otherwise
assymptomatic.
.
#) Hyperlipidemia: high dose statin
.
#) HTN: continue BB, ACEi
.
#) Nutrition: we discussed heart healthy diet options with
patient.
Medications on Admission:
MEDS: [**Hospital6 33836**] Pharmacy in [**Location (un) 16843**]
Fosinopril 10mg daily every morning
Omeprazole 20mg daily every morning
Lipitor 10mg daily every morning
Toprol XL 50mg daily every morning
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Fosinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- STEMI: acute occlusion noted duing cadiac cath of the LAD
- HTN
- hypercholesterolemia
- obesity
Secondary:
- GERD
- hx LBP
Discharge Condition:
well
Discharge Instructions:
You came to the hospital for a cardiac catheterization. You had
some blockages in your heart ateries and stents were placed. We
added the following medications:
1. Plavix: you MUST take this medication every day for the next
month. We recommend that you take it for a year or per the
recommendation of your cardiologist.
2. ASA 325 daily
3. Atorvastatin increased to 80mg daily
.
Please followup with your PCP and cardiologist. Please contact
your physicians or the [**Name (NI) **] if you experience chest pain,
abdominal pain, shortness of breath, nausea, sweating.
.
Please adhere to a low salt, low carb diet.
Followup Instructions:
Please followup with Dr. [**Last Name (STitle) 11493**] within the next 1-2 weeks.
Please followup with your PCP within the next 1-2 weeks.
| [
"9971",
"41401",
"2724",
"4019"
] |
Admission Date: [**2123-7-31**] Discharge Date: [**2123-8-22**]
Date of Birth: [**2081-12-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Generalized fatigue, dyspnea
Major Surgical or Invasive Procedure:
bronchoscopy
intubation
arterial line placement
PICC line placement
History of Present Illness:
The patient is a 41 yo man w/ hypoplastic MDS and
tracheobronchitis who presented to the heme malignancy service
for admission on [**2123-7-31**] with hemoptysis and worsened cough,
dyspnea. Prior to this, he was admitted from [**Date range (3) 48682**] for
treatment with ATG for 5 days. This course was complicated by
temps to 100.7 that were thought to be related to the ATG. No
antibiotics were given at that time. During that admission, he
also developed shortness of breath. CXR showed worsening
bilateral infiltrates. Chest CTA that r/o PE and demonstrated
diffuse b/l patchy airspace opacities and ground glass opacities
(marked progression from previous CT [**7-13**]). Pulmonary was
consulted and performed a bronchoscopy on [**7-19**] that demonstrated
tracheobronchitis with diffuse upper airway erythema and some
mucosal bleeding, but no signs of Diffuse Alveolar Hemorrhage.
BAL washings were sent which were negative for bacterial,viral
or fungal organisms. Etiology of the patient's respiratory
decompensation was not clear but was believed to be likely
secondary to the ATG therapy or related to an underlying viral
infection. Pt was treated with diuresis as needed, standing
atrovent inhaler (per pulm recs), steroids were tapered,
platelets were maintained > 50, and oxygen was weaned as
tolerated. Pt improved with these
limited interventions and repeat CXR on [**7-23**] showed marked
improvement compared to earlier one on [**7-19**]. Pt was d/ced
without oxygen requirement.
.
He was then re-admitted on [**9-1**]/05 with generalized fatigue.
Patient's presentation was thought most likely serum sickness
secondary to antithrombocyte globulin. Prednisone dose was
increased and he received 2units of PRBCs and 2 units of
platelets. At discharge the patient's Hct was 28.7 and plts were
28.He was discharged on [**2123-7-30**] on prednisone and PCP prophylaxis
[**Name Initial (PRE) **]/ bactrim. Of note, patient had severe headache but had
negative head CT. One day later, patient re-presented with
worsened sob as above.
.
Unit HPI:
cc: unit transfer for worsening hypoxia and dyspnea
.
HPI: pt is a lovely 41 yo man w/ hypoplastic MDS and
tracheobronchitis who presented to the heme malignancy service
for admission on [**2123-7-31**] with hemoptysis and worsened cough,
dyspnea. Prior to this, he was admitted from [**Date range (3) 48682**] for
treatment with ATG for 5 days. This course was complicated by
temps to 100.7 that were thought to be med-related. No
antibiotics were given at that time. During that admission, he
also developed shortness of breath. CXR showed worsening
bilateral infiltrates. Chest CTA that r/o PE and demonstrated
diffuse b/l patchy airspace opacities and ground glass opacities
(marked progression from previous CT [**7-13**]). Pulmonary was
consulted and performed a bronchoscopy on [**7-19**] that demonstrated
tracheobronchitis with diffuse upper airway erythema and some
mucosal bleeding, but no signs of Diffuse Alveolar Hemorrhage.
BAL washings were sent which were negative for bacterial,viral
or fungal organisms. Etiology of the patient's respiratory
decompensation was not clear but was believed to be likely
secondary to the ATG therapy or related to an underlying viral
infection. Pt was treated with diuresis as needed, standing
atrovent inhaler (per
pulm recs), steroids were tapered, platelets were maintained >
50, and oxygen was weaned as tolerated. Pt improved with these
limited interventions and repeat CXR on [**7-23**] showed marked
improvement compared to earlier one on [**7-19**]. Pt was d/ced
without oxygen requirement.
.
He was then re-admitted on [**9-1**]/05 with generalized fatigue.
Patient's presentation was thought most likely serum sickness
secondary to antithrombocyte globulin. Prednisone dose was
increased and he received 2units of PRBCs and 2 units of
platelets. At
discharge the patient's Hct was 28.7 and plts were 28.
He was discharged on [**2123-7-30**] on prednisone and PCP prophylaxis [**Name Initial (PRE) **]/
bactrim. Of note, patient had severe headache but had negative
head CT. One day later, patient re-presented with worsened sob
as above.
.
Upon presentation for the present admission, pt was hypoxic to
96% on 4L NC. He was afebrile (but on steroids) and his vitals
were otherwise stable. He was diuresed. Repeat chest CT with
diffuse, bilateral alveolar opacities thought to be ?drug
toxicity, diffuse viral pneumonia, ?TRALI. Over next days,
patients resp status waxed and waned but oxygen requirement
steadily increased. Steroids were increased for concern for
DAH, lasix intermittently given for concern for chf. Echo
repeated and was normal. SOB noted to be worse at night. Pulm
consulted and wished for bronch, but tenuous resp status of
concern. Patient requiring non rebreather for most of time, but
was still able to walk/talk. He would immediately desat to 80's
if mask off or with a lot of exertion. [**Hospital Unit Name 153**] team consulted
several times prior to today, but patient always remained stable
and decision by heme team to keep patient on their service. ARDS
from antithymocyte globulin has been reported in the literature
and is thought to be contributing to patient's progression.
Addition of broad spectrum antiviral, anti-pcp, [**Name10 (NameIs) 48683**], and
anti-bacterial treatments slowly added in succession and
treatment with high dose steroids completed. Today, patient
acutely hypoxic, dyspneic on floor, requiring 100% NRB and high
flow oxygen with sats in 80'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] called for emergent
transfer. Anesthesia called immediately and patient intubated on
floor. Patient then transferred to [**Hospital Unit Name **].
Past Medical History:
PMH:
**Hypoplastic MDS - primary oncologist- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]. Pt was
initially diagnosed in [**2116**] after w/u for fatigue. He was
maintained for years on initially just Aranesp, and then w/
Aranesp and Danazol.
Recently ([**Month (only) 596**]/[**Month (only) **]) pt with trending downward HCt, easy
bruisability. BM bx was performed in [**2123-5-28**], that
demonstrated normal cellularity of approx 30-40%, trilineage
dysplasia, <1% myeloblasts (on nucleated cells). At this time,
decision was made to proceed with ATG/cyclosporin therapy vs
BMT.
Family History:
NC
Pertinent Results:
[**2123-7-30**] 10:37AM WBC-6.5 RBC-3.13* HGB-10.1* HCT-28.7* MCV-92
MCH-32.3* MCHC-35.2* RDW-19.0*
[**2123-7-30**] 10:37AM PLT COUNT-28*
[**2123-7-30**] 10:37AM GRAN CT-4810
[**2123-7-31**] 12:47PM PT-12.5 PTT-20.0* INR(PT)-1.0
[**2123-7-31**] 12:47PM GLUCOSE-127* UREA N-27* CREAT-0.6 SODIUM-138
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13
Brief Hospital Course:
Upon presentation for the present admission, pt was hypoxic to
96% on 4L NC. He was afebrile (but on steroids) and his vitals
were otherwise stable. He was diuresed. Repeat chest CT with
diffuse, bilateral alveolar opacities thought to be ?drug
toxicity, diffuse viral pneumonia, ?TRALI. Over next days,
patients resp status waxed and waned but oxygen requirement
steadily increased. Steroids were increased for concern for
DAH, lasix intermittently given for concern for chf. Echo
repeated and was normal. SOB noted to be worse at night. Pulm
consulted and wished for bronch, but tenuous resp status of
concern. Patient requiring non rebreather for most of time, but
was still able to walk/talk. He would immediately desat to 80's
if mask off or with a lot of exertion. [**Hospital Unit Name 153**] team consulted
several times prior to today, but patient always remained stable
and decision by heme team to keep patient on their service. ARDS
from antithymocyte globulin has been reported in the literature
and is thought to be contributing to patient's progression.
Addition of broad spectrum antiviral, anti-pcp, [**Name10 (NameIs) 48683**], and
anti-bacterial treatments slowly added in succession and
treatment with high dose steroids completed. Today, patient
acutely hypoxic, dyspneic on floor, requiring 100% NRB and high
flow oxygen with sats in 80'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] called for emergent
transfer. Anesthesia called immediately and patient intubated on
floor. Patient then transferred to [**Hospital Unit Name **].
[**Hospital **]
[**Hospital 153**] Hospital Course
Plan: 41 yo man w/ hypoplastic MDS worsening hypoxia, ARDS, most
likely as result of ATG therapy.
.
1) Hypoxia/resp failure: ARDS w/ bilateral infiltrates on CXR
and CT, P/F ratio 78. The ddx is large; has completed tx for
bacterial and atypical pneumonias. Caspofungin is still on
board for possible diffuse fungal pna as a cause, will keep on
as he is immunosuppressed on steroids. Also was treated for DAH
and acute lung injury from ATG with high dose steroids, now
tapering, will likely need a 1wk taper. No growth from
cultures. Thoracic Surgery followed, VATS biopsy was not
indicated at the time as would likely have had nonspecific
findings after all his treatments. He was kept on PCV for ARDS
ventilation. Desatted with disruption of PEEP during bronch,
requiring high PEEP due to parenchymal disease. Some
improvement of oxygenation with diuresis. Respiratory status
stable, with only very gradual improvement, thought to likely be
slow wean. PEEP too high for bedside trach, so we were
anticipating the need for a surgical trach, also b/c of tracheal
tear.
.
2) Pneumomediastinum: Mr. [**Known lastname 48684**] developed a large amount of
air in his mediastinum and tracking through subcutaneously.
Thought to be secondary to tracheal perf seen on CT, although
not seen on bronch (?sealed off already). IP advanced ETT past
presumed area of tear. The differential also included
esophageal perforation, which was considered unlikely as the
patient had no history of esophageal intubation. He was kept
off tube feeds and on prophylactic antibiotics for
mediastinitis, but he remained without signs of infection, so
the antibiotics were stopped and tube feeds were restarted.
Also on the differential Could also be secondary to barotrauma.
?Increased mediastinal air on CXR, R ptx. Respiratory status
stable. Repeat CT still inconclusive for tracheal tear, no
pneumothorax.
.
2) MDS: s/p antithymoglobulin treatment. Hypoplastic. Onc team
following.
He was transfuses as needed to keep Hct>25 and plt>20. He was
followed by Oncology throughout his hospitalization.
.
3) Fever: On Vanc for line infection. Not neutropenic.
.
[**Date range (1) 48685**]: The patient's platelet count dropped as low as 6.
After transfusing 1 unit of platelets, platelet count remained
at 6, and the patient was transfused 2 more units of platelets
during the night. During the day of [**8-21**], the patient has been
having more bloody secretions via suctioning from his ETT,
requiring higher FiO2s. He started the day at FiO2 of 0.6, was
satting in the high 80's, FiO2 was turned up to 0.8, then to
1.0. Patient continued to sat in the high 80s, low 90s
throughout the day.
.
The patient began to have more respiratory distress after being
repositioned in bed at around midnight of [**8-21**]. Respiratory
suctioned his ETT, producing copious amounts of frank blood. The
patient was switched from PCV to APRV, but was still satting in
the low 80s and had to be bagged (with 20 of PEEP). With
bagging, Sats came up to low 90s. CXR was taken and showed
worsening bibasilar opacities, suggesting fluid or blood.
Oxygenation remained poor as his gases were
7.34/73/45-->7.37/66/39-->7.42/56/38. Patient was bagged and
intermittently placed on the vent, but did not tolerate
mechanical ventilation with sats dropping to low 80s. Patient
was also fighting the vent, being very dys-synchronous. Mr.
[**Known lastname 48684**] had to be heavily sedated with Fentanyl/Versed, and then
with propofol. He was then paralyzed with boluses of vecuronium
to make breathing ventilating the patient easier. Family was
called in. After discussing the situation with Dr. [**Last Name (STitle) **] and
the family, a decision was made not to proceed with bagging and
make the patient comfortable. Patient was placed on pressure
support ventilation and started on a morphine gtt at 430am. He
expired approximately 20 minutes later.
Medications on Admission:
n
Discharge Medications:
n/a
Discharge Disposition:
Home
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2123-9-12**] | [
"4280",
"5990"
] |
Admission Date: [**2146-2-18**] Discharge Date: [**2146-2-22**]
Date of Birth: [**2074-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain /STEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization with Drug Eluting stent to Obtuse
marginal Artery
History of Present Illness:
Mr. [**Known lastname 17922**] is a 72 year-old male with pmh of CAD s/p STEMI and
stent to the proximal LAD in [**2141**], DM, htn, HL who was admitted
from the ED to the cath lab with a STEMI s/p DES to OM1. He
presented from home with substernal CP radiating to his left
arm. The pain started at rest. Denied associated shortness of
breath, nausea, or vomiting. Not currently on plavix.
.
In the ED initial VS: T 99 BP 128/63 P 83 RR 18 Sat 97%. He
was given ASA 81 mg, nitro SL x3 without relief. EKG showed
inferior ST elevations. He was started on a heparin gtt, nitro
gtt, and was given 4 mg IV morphine and 5 mg IV metoprolol. No
integrillin was given due to his chronic kidney disease/single
kidney. Got 600 mg of plavix.
.
He was taken to the cath lab. His inital CK returned normal at
173 and trop was 0.02. Cardiac catheterization showed a patent
proximal LAD stent with proximal edge 40% and 60-70% lesion
distal to stent involving diagonal bifurcation. Left circ showed
80% large OM1. A DES was placed in the OM1. Anomalous RCA with
significant disease (totally occluded), however chronic as the
RV branches were open with good flow. He experienced pain in
his left shoulder and arm [**2146-8-9**] which he states is chronic of
many months duration. His post intervention EKG showed
resolution of the ST elevations.
.
On presentation, he denied chest pain, shortness of breath,
shoulder pain, or other symptoms.
.
On review of systems, he denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, black stools or red stools. He denied
recent fevers, chills or rigors. He did admit to a chronic
cough. He did have pain in his knees and left shoulder at
baseline. All of the other review of systems were negative.
.
Cardiac review of systems was notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. He stated his exercise
ability was limited by knee pain.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: STEMI in [**2141**] s/p PTCA at
[**Hospital1 2177**]
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
1)CAD s/p STEMI and PTCA of LAD [**2141**] at [**Hospital1 2177**], presented with
lower abd pain and SOB
2)Hypertension
3)dyslipidemia
4)BPH
5)Type 2 diabetes with peripheral neuropathy
6)s/p R nephrectomy 5 years ago - pathology benign per patient
7)early parkinsonism-followed by Neuro
8)Bells'palsy ([**2-1**] HTN) [**6-8**] s/p valtrex
9)CKD II baseline 1.1-1.2
10)Depression
11)Microcytic anemia-stable all his life-?thalassemia. neg,
[**Last Name (un) **]-egd in past.
12)Elevated PSA
13)Urinary frequency and incomplete emptying on UDS
14)Knee arthritis
Social History:
Married, lives with wife. Currently retired. Denies tobbaco,
alcohol, or IVDA. He and his wife take care of a 3 year old
grandchild.
Family History:
Significant for a father with diabetes.
No history of cancers or strokes.
One child with DM
Physical Exam:
GENERAL: Elderly male lying in bed in NAD. Alert and
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: No JVD present.
CARDIAC: RRR, 3/6 systolic murmur radiating to his carotids
present.
LUNGS: Patient is breathing comfortably. He has slight crackles
at the sides of his bases bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No edema present. Right femoral area with dressing
in place. No active bleeding present.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Femoral 2+ DP 2+ PT 2+
Left: Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2146-2-18**] 11:20PM BLOOD WBC-6.1 RBC-4.97 Hgb-9.9* Hct-32.8*
MCV-66* MCH-19.9* MCHC-30.1* RDW-14.1 Plt Ct-197
[**2146-2-20**] 05:50AM BLOOD WBC-10.6# RBC-4.45* Hgb-9.4* Hct-29.6*
MCV-67* MCH-21.1* MCHC-31.7 RDW-14.3 Plt Ct-184
[**2146-2-22**] 06:15AM BLOOD WBC-7.5 RBC-4.50* Hgb-9.5* Hct-30.0*
MCV-67* MCH-21.0* MCHC-31.5 RDW-14.1 Plt Ct-198
[**2146-2-21**] 06:50AM BLOOD PT-12.0 PTT-32.6 INR(PT)-1.0
[**2146-2-18**] 11:20PM BLOOD Glucose-265* UreaN-21* Creat-1.2 Na-140
K-3.6 Cl-103 HCO3-29 AnGap-12
[**2146-2-22**] 06:15AM BLOOD Glucose-135* UreaN-18 Creat-1.2 Na-139
K-4.3 Cl-102 HCO3-30 AnGap-11
[**2146-2-18**] 11:20PM BLOOD CK(CPK)-173
[**2146-2-18**] 11:20PM BLOOD cTropnT-0.02*
[**2146-2-19**] 05:27AM BLOOD CK-MB-9 cTropnT-0.13*
[**2146-2-21**] 06:50AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
[**2146-2-19**] 12:06AM BLOOD Type-ART FiO2-2 pO2-81* pCO2-45 pH-7.40
calTCO2-29 Base XS-1 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2146-2-19**] 12:06AM BLOOD Glucose-241* Lactate-1.0 Na-138 K-3.8
[**2146-2-19**] 12:06AM BLOOD Hgb-10.0* calcHCT-30 O2 Sat-94
Cardiac Cath Study Date of [**2146-2-18**]
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated 3 vessel CAD with likely culprit OM. The LMCA had
no
significant stenoses. The LAD had a patent stent with a 40%
stenosis at
the proximal edge and a 60-70% stenosis distal to the stent. The
LCx was
large and had an 80% stenosis at OM1. The RCA was small and had
diffuse
subtotal occlusion with TIMI 3 flow to the RV branches.
2. [**Name (NI) 18583**] PTCA and stenting of thr OM1 with a 2.5x18 mm
Promus DES
with excellent results (see PTCA Comments).
3. Successful closure of the RCF arteriotomy with a 6F
angioseal.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with likely culprit OM.
2. Stenting of the OM1 with a Promus DES
3. Closure of the R-CF arteriotomy with a 6F angioseal.
4. Severely diseased non-dominant RCA with patent RV branches
5. Anterior take off of the RCA that was difficult to
selectively engage
with AR2 diagnostic catheter
6. ASA 325 mg daily and Plavix 75 mg daily [**Hospital1 **] x 7 days then
once daily
x minimum of 12 months
7. High dose statin
8. Echo on Monday
9. ACE-inhibitor if renal parameters permit
10. beta blockers
11. Consider stress test in few weeks to evaluate the
significance of
the LAD (ostial and mid) lesions
TTE (Complete) Done [**2146-2-19**] at 10:57:04 AM FINAL
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with inferior hypokinesis. The remaining segmetns
are hyperdynamic and the LVEF is therefore preserved.. No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. There
is atypical mitral annular calcification (MAC) that occurs
mainly at the anterior annulus encroaching on the LVOT but
without evidence for LVOT obstruction or sub (aortic) stenosis
(LVOT diameter is 1.5 cm). Ther are small, bland-appearing,
mobile elements associated with the MAC. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 17922**] is a 72 year-old male with pmh of CAD s/p STEMI and
stent to the proximal LAD in [**2141**], DM, htn, HL who was admitted
from the ED to the cath lab with a question of STEMI s/p DES to
OM1.
# CORONARIES/STEMI s/p DES to OM1: Initial CK is normal at 173
and Trop of 0.02. STE in the inferior leads, however he was
found to have a new occlusion in his Lt Cx OM1 now s/p DES. His
STEs resolved after intervention. His peak CK was 173 and was
downtrending afterwards. The patient was continued on aspirin,
plavix, metoprolol and simvastatin. A TTE was done which showed
EF 55%. He was discharged with close follow up with his
cardiologist and primary care physician.
# Hypertension: The patient had elevated blood pressure that was
difficult to correct. He was started was eventually maintained
on valsartan, metoprolol, hydrochlorothiazide and amlodipine. At
discharge his blood pressure was controlled. If he needs further
management he may do well with clonidine. He will follow up with
his primary care physician in the near future.
# Hyperlipidemia: The patient was started on simvastatin 80mg
daily while an inpatient. Gemfibrozil was held. Further
management was deferred to primary care physician and
cardiologist.
# Diabetes type II: The patient was continued on his home
insulin regimen.
# Chronic kidney disease: The patient had a history of
nephrecomy. He was treated with n-acetylcysteine and fluids per
cath protocl. His creatinine remained stable at 1.2.
# Chronic anemia: The patient was at his baseline and has a
chronic microcytic anemia. This will be followed by his primary
care physician.
# Arm pain: chronic in nature. Not related to heart. The patient
will see orthopedics as an outpatient for further evaluation.
# BPH: He was continued on his home terazosin and finasteride.
# Code status: the patient was full code.
Medications on Admission:
Aspirin 81 mg po daily
Pravastatin 20 mg po daily
Terazosin 7mg po qhs
Valsartan 80 mg po daily
Gemfibrozil 600 mg po daily
Finasteride 5 mg po daily
Atenolol 50 mg po daily
Omeprazole 20 mg Capsule, Delayed Release(E.C.) po daily
Insulin NPH & Regular Human 100 unit/mL (70-30), 25 units SQ [**Hospital1 **]
Hydrochlorothiazide 12.5 mg po daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Terazosin 2 mg Capsule Sig: 3.5 Capsules PO HS (at bedtime).
3. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day.
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty Five (25) units Subcutaneous twice a day.
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hypertention
Diabetes mellitus
Coronary Artery Disease
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You had a heart attack and a cardiac catheterization showed a
blockage in one of your arteries that was opened with a stent.
It is extremely important that you take Plavix and aspirin every
day for at least one year. Don't stop taking Plavix unless Dr.
[**Last Name (STitle) 911**] tells you to. If you stop taking Plavix, you could have
another more serious heart attack. Your blood pressure was high
and we made the following changes to your medicines:
1. Increase your aspirin to 325 mg
2. Increase your Pravastatin to 80 mg daily
3. Increase your Valsartan to 160 mg twice daily
4. Stop taking Atenolol
5. Start taking Metoprolol XL daily
6. Take Plavix twice daily for the next 4 days, then decrease to
once daily for one year.
Followup Instructions:
Primary Care:
[**Last Name (LF) 72667**],[**First Name3 (LF) **] A. Phone: [**Telephone/Fax (1) 1260**] Date/time: Wednesday [**2-23**] at 2:45pm.
.
Cardiology:
Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] Phone: [**Telephone/Fax (1) 62**] Date/Time: Thursday [**3-24**] at 3:00pm.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
| [
"41071",
"41401",
"V4582",
"412",
"40390"
] |
Admission Date: [**2108-1-10**] Discharge Date: [**2108-1-13**]
Service: [**Company 191**]
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year-old female
with a distant history of deep venous thrombosis who is
admitted with fever and increased white blood cell count ?
and rule out sepsis who was enrolled in the sepsis protocol
in the Emergency Department. The patient reports that for
the past week she has not been feeling well, though it is
difficult for her to specify. Notes decreased po intake,
appetite, positive rhinorrhea and positive sneezing. She
took her temperature today and it was 102.8. She went to her
primary care physician who told her to come to the Emergency
Department. She denies headaches, sore throat, cough,
shortness of breath, chest pain, nausea, vomiting, diarrhea,
melena or hematochezia. She does not burning with urination
for about three days with an increase in urinary frequency,
but no hematuria and no rash. She denies any sick contacts.
She did have the flu vaccine in [**Month (only) 359**]. In the Emergency
Department her temperature was noted to be 102.0. Her blood
pressure initially 133/61, oxygen saturation 92% on room air
with a heart rate of 114. She was noted to have a white
blood cell count of 20,000 and a lactate of 4.1 on a venous
sample. She was therefore enrolled in the sepsis protocol.
She was started on Ceftriaxone and Azithromycin. She
received normal saline unclear volume. She was admitted to
the [**Hospital Ward Name 332**] Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Diverticulitis.
2. Recurrent deep venous thrombosis.
3. Hypertension.
4. Hip fracture in [**2101**].
5. Anxiety.
6. Depression.
7. Appendectomy.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg once a day.
2. Elavil 25 mg once a day.
3. Triavil 2.25 once a day.
4. Coumadin 2.25 five days a week and 3.75 two days a week.
ALLERGIES: Sulfa she gets a rash.
SOCIAL HISTORY: The patient is married for over 50 years.
She lives with her husband and is legally blind. She is
relatively independent in her activities of daily living.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.5. Heart
rate 92. Blood pressure 114/46. Respiratory rate 18.
Oxygen saturation 98% on 2 liters. HEENT normocephalic,
atraumatic. Dry mucous membranes. Neck supple with a right
IJ in place after the sepsis protocol. Pulmonary no
wheezing, left sided rales. Cardiac S1 and S2 were normal.
No murmurs, rubs or gallops. Abdomen normoactive bowel
sounds, soft, seems distended with diffuse mild tenderness.
Extremities 1+ pitting edema in the left lower extremity.
Neurological alert and oriented times three. Cranial nerves
II through XII intact. No focal weakness.
LABORATORIES ON ADMISSION: White blood cell count 20.3,
platelets 600, hematocrit 29.5, INR was noted to be 3.5. She
had 92% neutrophils, 4% lymphocytes, sodium 139, potassium
5.5, chloride 102, bicarb 22, BUN 20, creatinine 0.6, glucose
160. Liver function tests and pancreatic enzymes were
normal. Troponin was less then .01. Lactate went from 4 to
1.6. Initially blood cultures were no growth. Urine culture
was no growth. Chest x-ray showed left basilar linear
atelectasis with no infiltrate or consolidation.
Electrocardiogram was sinus with a rate of approximately 100
and intraventricular conduction defect, left anterior
hemiblock, T wave inversions in V2 and V3, which is different
from an electrocardiogram of [**2104-11-28**], normal axis at a
rate of 70 and no T wave inversions.
HOSPITAL COURSE: 1. Fever: A clear source of her fever had
not been identified at this point. Repeated chest x-rays
were negative for infiltrate continually showing simply left
basilar atelectasis. Blood cultures were no growth. Urine
cultures times two were no growth. The patient was initially
admitted to the [**Hospital Unit Name 153**] on a sepsis protocol and received
aggressive intravenous fluids, antibiotics and had a right IJ
placed. She did well rapidly and she was then transferred to
the floor for further management. On the day of this
dictation the patient had developed some wheezing on her lung
examination, however, she did not complaint of shortness of
breath and she was maintaining her saturations at 94% on room
air. Please note the patient was also ruled out for
influenza on this admission.
2. Rule out myocardial infarction: The patient had new T
wave inversions in V1 through V3 on electrocardiogram. Her
cardiac enzymes were cycled and were negative for ischemic
damage. She was started on aspirin in the Intensive Care
Unit. Her electrocardiograms were followed. She was felt to
be in sinus rhythm, though tachycardic for much of the time.
However, at this point in her admission her Atenolol had been
held to explain her tachycardia along with continued volume
depletion.
3. Gastrointestinal/anemia: The patient was found to be
guaiac positive and her hematocrit decreased from 29 to 23.
This may have been due to volume repletion, however, she did
have a supratherapeutic INR of 3.5 on admission. Her
Coumadin was held as it was only being given for deep venous
thrombosis prophylaxis. She did receive at least one unit of
packed red blood cells with an appropriate bump in her
hematocrit. GI was consulted to see the patient and there
impression was that she would benefit from a diagnostic
colonoscopy and upper endoscopy to evaluate this occult
gastrointestinal bleeding and to rule out a gastrointestinal
malignancy. At this time these procedures were planned for
later today.
4. History of deep venous thrombosis: The patient has a
distant history of deep venous thrombosis in the [**2043**] and
again in the [**2073**] and she has been on anticoagulation ever
since. As an outpatient the decision to continue
anticoagulating her should be reevaluated.
This concludes her discharge summary for hospital course from
[**2108-1-10**] to [**2108-1-13**]. The remainder of her hospital course
along with discharge disposition, instructions, medications,
diagnoses and condition will be addended in a later discharge
summary.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 6006**]
MEDQUIST36
D: [**2108-1-13**] 10:04
T: [**2108-1-13**] 10:35
JOB#: [**Job Number 14335**]
| [
"0389",
"2851",
"486",
"4019"
] |
Admission Date: [**2189-9-13**] Discharge Date: [**2189-10-8**]
Date of Birth: [**2144-11-9**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Zomig
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Arterial Line
Mechanical Ventilation
PICC placement
History of Present Illness:
44yo autoimmune hepatitis and transplant presented for AMS at
[**Hospital1 **] senior healthcare at [**Location (un) **]. Finger stick was 50 so
got D50, was combative and screaming in ED so got 10mg haldol,
tried NGT and desatted so decided to intubate for airway
protection given degree of AMS. Then got lactulose by NGT, got
CTX 2g, Vanc 1g. Nothing tapable on bedside U/S. CT abdomen no
acute process, no significant ascites. Got head CT which was
negative. Got limited portal doppler stud which was unchanged
from prior w/ known portal vein thrombosis. No family present so
far.
.
In the ED, initial vs were: T P 106 BP 90/54 R O2 sat 100% CMV
TV 550, 14, PEEP 5 FiO2 100%. UOP 1400cc since foley placed
which was around 9 hours ago.
Past Medical History:
- Autoimmune hepatitis, s/p orthotopic liver transplant in UAB
in 2/98, known chronic rejection and now with recurrence,
complicated by encephalopathy, portal vein thrombosis.
- Chronic portal vein thrombosis
- Chronic lymphedema, which developed after her liver transplant
- Psorasis
- Allergic rhinitis
- Dysfunctional uterine bleeding s/p partial hysterectomy
- s/p CCY
- Depression
- Adnexal masses noted on scan in [**12/2187**]
- Antiphospholipid antibody
- Staph epidermatis bactermia [**5-/2189**]
Social History:
- Lives with daughter and grandson
- [**Name (NI) 1139**]: Denies
- etOH: Rarely
- Illicits: Denies
Family History:
- Several relatives with heart disease and DM
- No history of auto-immune hepatitis or liver failure
Physical Exam:
General: Jaundiced woman, in restraints. Moves all extremities
spontaneously but does not follow commands. Does not open eyes
to command.
HEENT: Scleral icterus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present with dark urine
Ext: 3+ total body anasarca
Pertinent Results:
Admission labs:
[**2189-9-13**] 02:42PM TYPE-ART TEMP-37.8 TIDAL VOL-528 PEEP-5 O2-40
PO2-166* PCO2-29* PH-7.34* TOTAL CO2-16* BASE XS--8
INTUBATED-INTUBATED
[**2189-9-13**] 02:42PM LACTATE-2.4*
[**2189-9-13**] 02:42PM freeCa-1.09*
[**2189-9-13**] 02:22PM URINE HOURS-RANDOM
[**2189-9-13**] 09:55AM TYPE-ART TEMP-36.4 TIDAL VOL-610 PEEP-5 O2-40
PO2-136* PCO2-28* PH-7.33* TOTAL CO2-15* BASE XS--9 -ASSIST/CON
INTUBATED-INTUBATED
[**2189-9-13**] 09:55AM freeCa-1.09*
[**2189-9-13**] 05:17AM freeCa-1.00*
[**2189-9-13**] 03:52AM CALCIUM-7.1* PHOSPHATE-3.8 MAGNESIUM-1.5*
[**2189-9-13**] 03:52AM WBC-12.7* RBC-3.11* HGB-10.4* HCT-32.0*
MCV-103* MCH-33.5* MCHC-32.6 RDW-17.2*
[**2189-9-12**] 05:33PM LACTATE-3.3*
[**2189-9-12**] 04:33PM URINE BLOOD-SM NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2189-9-12**] 03:47PM LACTATE-5.5*
[**2189-9-12**] 03:42PM ALT(SGPT)-44* AST(SGOT)-81* TOT BILI-6.3*
[**2189-9-12**] 03:42PM AMMONIA-155*
[**2189-9-12**] 03:42PM NEUTS-85.9* LYMPHS-7.4* MONOS-5.9 EOS-0.3
BASOS-0.6
[**2189-9-12**] 03:42PM PT-19.7* PTT-41.4* INR(PT)-1.8*
MICRO (Many other studies other than those listed below were
negative)
-[**9-12**] UCx: ESCHERICHIA COLI. >100,000 ORGANISMS/ML. ESBL.
SENSITIVE TO Tigecycline <=1MCG/ML.
RESISTANT TO MEROPENEM <=1MCG/ML.
RESISTANT TO IMIPENEM <=1MCG/ML.
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- R
MEROPENEM------------- R
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- =>128 R
TETRACYCLINE---------- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
-[**9-13**] UCx: GRAM NEGATIVE ROD(S). ~4000/ML
-[**9-20**] Mycolytic BCx: BLOOD/FUNGAL CULTURE (Preliminary): NO
FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO
MYCOBACTERIA ISOLATED.
-[**9-28**] BAL: GRAM STAIN: 1+ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE: Commensal Respiratory Flora Absent.
YEAST 100/ML.
LEGIONELLA CULTURE (Final [**2189-10-5**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary): YEAST. OF TWO COLONIAL
MORPHOLOGIES.
ACID FAST SMEAR (Final [**2189-9-29**]): NO AFB SEEN ON CONCENTRATED
SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
-[**9-28**] Rapid Viral Screen/Culture: No respiratory viruses
isolated. No Cytomegalovirus (CMV) isolated. +HERPES SIMPLEX
VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY
-[**9-30**] UCx: YEAST >100,000 ORGANISMS/ML
-[**10-5**] BCx: GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
GRAM NEGATIVE ROD(S)
|
AMIKACIN-------------- S
AMPICILLIN------------ R
AMPICILLIN/SULBACTAM-- R
CIPROFLOXACIN--------- R
GENTAMICIN------------ R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ R
-[**10-5**] BAL: GRAM STAIN (Final [**2189-10-5**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
MODIFIED ACID-FAST STAIN FOR NOCARDIA: Test cancelled by
laboratory due to lack of branching gram positive rods in the
gram stain.
RESPIRATORY CULTURE (Preliminary):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
YEAST. ~ ~3000/ML.
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- PND
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- PND
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2189-10-6**]): Test
cancelled by laboratory.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2189-10-6**]): NO AFB SEEN ON CONCENTRATED
SMEAR.
ACID FAST CULTURE (Preliminary):
NOCARDIA CULTURE (Preliminary):
VIRAL CULTURE (Preliminary): No Virus isolated so far
STUDIES:
-[**9-12**] ECG: Baseline artifact. Sinus tachycardia. Early
precordial R wave progression. Compared to the previous tracing
of [**2189-8-27**] the sinus rate is much faster. The other findings are
similar.
-[**9-12**] CXR: No gross pulmonary process noted. If clinically
feasible, consider repeat study once patient is able to tolerate
the procedure.
-[**9-12**] CT Abd/Pelvis: 1. No acute intra-abdominal or pelvic
process to explain the patient's symptoms.
2. Status post orthotopic liver transplant with diffuse
anasarca. Known
portal vein thrombus is not well evaluated on the current study.
3. Trace pleural effusions and minimal atelectasis.
4. Unchanged 8 mm left renal stone.
-[**9-12**] CT Head 1. Stable appearance of the brain without evidence
of an acute intracranial abnormality.
2. The partially imaged orogastric tube appears to make a loop
in the
nasopharynx.
-[**9-12**] Abdominal U/S: Limited study as above with persistent main
portal vein thrombosis and no evidence of intrahepatic portal
vein flow, similar to [**2189-8-27**].
-[**9-21**] Renal U/S: 8-mm left renal calculus within the lower
pole, unchanged from CT scan of [**2189-9-12**]. No evidence of
hydronephrosis or obstruction.
-[**9-23**] CT Chest/Abd/Pelvis: 1. Bilateral, multifocal
consolidative airspace opacities. These have progressed compared
to recent chest radiographs, and are new compared to [**2189-9-12**] CT of the abdomen and pelvis (when the lung bases were
imaged). This most likely represents multifocal pneumonia.
Aspiration and a component of pulmonary edema could also be
considered. Clinical correlation is advised.
2. Malpositioned left upper extremity PICC, with tip extending
into the right ventricle. This should be withdrawn for optimal
positioning.
3. Findings compatible with anemia.
4. Large pulmonary artery compatible with pulmonary
hypertension.
5. Status post liver transplantation. There is small ascites and
diffuse
anasarca, a distended IVC, and mild cardiomegaly, all compatible
with fluid overload.
6. 11-mm non-obstructing left renal stone.
7. No retroperitoneal hematoma or other source of blood loss, as
questioned.
-[**9-23**] CT Head: 1. Study limited by motion shows no large
intracranial hemorrhage or other obvious acute intracranial
abnormality.
2. Persistent catheter fragment seen to course from one side
of nasal cavity to the other on prior CT of [**2189-9-12**]; clinical
correlation recommended.
-[**9-26**] RUQ U/S: Limited evaluation with the main portal vein
again not
visualized. However, flow appears present in the left hepatic
vein and left hepatic artery. Abdominal ascites.
-[**9-27**] Abd X-ray: No evidence for obstruction; NG tube in place.
Brief Hospital Course:
The patient was initially admitted to MICU [**Location (un) **] for severe
encephalopathy requiring intubation in the ED for airway
protection. She was treated for hepatic encephalopathy, with
lactulose and rifaximin. Initial cultures revealed
carbapenemase-resistant E.coli, for which she was initially
treated with nitrofurantoin and amikacin. Nitrofurantoin was
subsequently discontinued. Per ID recommendations, antibiotics
were changed to colistin, then ultimately to tetracycline. She
was weaned off of the ventilator and was transferred to the
internal medicine service on [**9-16**]. Her lactulose dose was
increased. Her renal function worsened, which was believed
likely due to nephrotoxic medications. She was also started on
octreotride, midodrine and albumin for hepatorenal syndrome. Se
was transferred back to MICU Green on [**9-19**] for worsening
encephalopathy and labs consistent with low-grade DIC, including
a ten point hematocrit drop, thrombocytopenia, worsening
coagulation studies, and indirect hyperbilirubinemia. Hematology
was consulted and agreed with diagnosis of DIC. Over the
subsequent days, the patient required large amounts of blood
products, including red blood cells, platelets, cryoprecipitate,
and fresh frozen plasma. Despite these measures, she still had
large amounts of bloody output from her rectal tube; she was
felt too unstable to undergo any GI procedures, and was treated
with further blood transfusions. Her significant hypernatremia
and hypercalcemia improved to some degree during her stay in the
MICU. The patient's mental status did not improve, and she was
reintubated for hypoxic respiratory failure, which was partially
due to a new pneumonia. Her mental status was sufficiently poor
that she only required intermittent sedation for her
endotracheal tube. She had high residuals through her OG tube,
and tube feeds frequently had to be held. She had frequent
bloody secretions from her endotracheal tube; bronchoscopy
revealed diffuse oozing of blood throughout her bronchi.
Multiple family meetings were held, including a meeting with the
patient's primary hepatologist, who confirmed that the patient
was not a candidate for retransplantation. As the patient's
liver disease was believed to be a central factor in her
deteriorating condition, measures were transitioned towards
making the patient comfortable and prolonging her life only long
enough for her family members to be able to say goodbye. She
passed away peacefully with her family at her side.
Medications on Admission:
Lactulose 30cc tid
Atovaquone 750 mg/5 mL 10cc daily
Citalopram 20 mg daily
Montelukast 10 mg daily
Mycophenolate Mofetil 500 mg [**Hospital1 **]
Omeprazole 20 mg daily
Rifaximin 550 mg [**Hospital1 **]
Spironolactone 50mg daily
Prednisone 10 mg daily
Sucralfate 1 gram QID
Tacrolimus 0.5 mg daily
Torsemide 15 mg daily
Calcium 600 with Vitamin D3 600 mg(1,500mg)-400 unit twice a
day.
Ursodiol 600 mg daily
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Disseminated intravascular coagulation
Hepatic encephalopathy
Fulminant hepatic failure
Urinary tract infection
Hypernatremia
Hypercalcemia
Secondary:
Autoimmune hepatitis, s/p orthotopic liver transplant in [**2176**]
Chronic portal vein thrombosis
Chronic lymphedema, which developed after her liver transplant
Psorasis
Allergic rhinitis
Dysfunctional uterine bleeding s/p partial hysterectomy
s/p cholecystectomy
Depression
Adnexal masses noted on scan in [**12/2187**]
Antiphospholipid antibody
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
| [
"5070",
"51881",
"5849",
"2760",
"5990"
] |
Admission Date: [**2153-5-20**] Discharge Date: [**2153-5-27**]
Date of Birth: [**2078-4-14**] Sex: M
Service: ACOVE
CHIEF COMPLAINT: Hematuria.
HISTORY OF PRESENT ILLNESS: This is a seventy-five-year-old
Russian male with a complicated recent admission to [**Hospital1 1444**] who was transferred here from
on [**2153-4-27**], for chest pain. The patient had ruled in for
myocardial infarction, underwent cardiac catheterization and
stenting. Post-catheterization, the patient had a
cerebrovascular accident, leaving him with a left
hemiparesis. Prior to discharge, he had developed hematuria
while continuing therapy on aspirin, Plavix and Heparin.
While at [**Hospital **] Rehabilitation, the patient was receiving
endoscopic gastrostomy tube was not possible at that time due
to risk of bleeding on those three medications. The patient's
Plavix was scheduled to run for thirty days ending on [**2153-5-31**]. Regarding the patient's complaint of hematuria, the
patient had developed this problem immediately prior to his
discharge in [**Month (only) **]. The patient does have a history of a
bladder mass and transurethral resection of prostate in [**2142**].
In [**2147**], cytology was done of the bladder which was negative
for malignancy. This hematuria was felt to be secondary to
Foley catheter trauma or recurrent nephrolithiasis or tumor
while in the setting of anticoagulation. The patient had to
be restrained while at [**Hospital **] Hospital because he had been
pulling on the Foley catheter which may have led to bleeding.
In addition, he had removed his nasogastric tube five to six
times. On admission, the patient did also have heme positive
stool.
PAST MEDICAL HISTORY: 1) Myocardial infarction in [**2143**],
status post percutaneous transluminal coronary angioplasty
and stent to left anterior descending artery and left
circumflex in [**2152-10-21**], re-stent of left anterior
descending artery in [**2153-4-21**], the patient has ejection
fraction of 25%. 2) Sick sinus syndrome, status post DDD
pacer. 3) Benign prostatic hypertrophy, status post
transurethral resection of prostate in [**2142**]. 4) Hypertension.
5) Hypercholesterolemia. 6) Pancreatitis. 6) Spinal stenosis.
7) Colon polyps. 8) Nephrolithiasis.
ALLERGIES: No known drug allergies.
MEDICATIONS: Enteric coated aspirin 325 mg every day, Lipitor
40 mg every day, Isosorbide Mononitrate 60 mg every day,
Prevacid 30 mg every day, Toprol XL 25 mg every day, Plavix
75 mg every day, Captopril 6.25 mg three times a day, Heparin
GTT at 1400 units per hour.
SOCIAL HISTORY: The patient was born in [**Country 532**], denies any
use of tobacco in the past and drinks alcohol socially.
PHYSICAL EXAMINATION: Physical examination on admission, the
patient was afebrile at 98.8 F, rectal temperature, heart
rate 72, respiratory rate 20, blood pressure 90/50, pulse
oximetry 92% on two liters by nasal cannula. In general, the
patient was in no acute distress. The patient is Russian
speaking only. The family is present and able to translate.
Foley catheter was draining amber colored urine at the time
of admission. On head, eyes, ears, nose and throat
examination, the patient's right eye is closed, pupil
measuring 5 mm to 6 mm. Left eye is opened spontaneously,
measuring 2 mm to 3 mm and minimal reactive. The patient had
a pediatric nasogastric tube in place receiving tube feeds
and he had dry oral mucosa. On neck examination, his neck was
supple, he had no jugular venous distension, lymphadenopathy
or bruits. Cardiovascular, the patient had a regular S1 and
S2 with a III/VI systolic murmur. The patient was in a
regular rhythm. The patient's lungs were clear to
auscultation bilaterally listening anterior and
anterolaterally. The patient's abdomen had normal active
bowel sounds, it was soft, nontender and nondistended.
Extremity examination, his upper extremities were in soft
restraints. The patient had no cyanosis, clubbing or edema.
On neurologic examination, his pupils were noted as above on
the head, eyes, ears, nose and throat examination. The
patient was uncooperative with testing of cranial nerves, as
well as strength. The patient was aphasic, although making
some sounds and occasional words to his daughter.
LABORATORY DATA: White blood cell count 8.3, hematocrit 33.7,
platelet count 288,000, baseline hematocrit known to be 47 to
48.
Sodium was 136, potassium 5.0, chloride 100, bicarbonate 26,
blood, urea and nitrogen 19, creatinine 0.9, glucose 98.
Calcium 8.5, magnesium 2.0, phosphorous 3.9.
Liver function tests, ALT was 33, AST 39, alkaline
phosphatase 89, total bilirubin 0.4, albumin 3.1.
Prothrombin time, international normalized ratio were 11.9
and 1.0 respectively, partial prothrombin time was 21.9.
Urinalysis showed a large amount of blood, 30 of protein,
small leukocytes, was amber in color, was otherwise,
negative, greater then 1000 red blood cells, 11 white blood
cells, occasional bacteria and no yeast.
HOSPITAL COURSE: Hospital course by problem, 1)
cardiovascular, given the patient's ejection fraction of less
then 25% and his recent stent last month, the patient was
continued on his anticoagulative agents including aspirin,
Plavix and Heparin. The Heparin drip was continued rather
then starting Coumadin immediately given the possibility of
the patient receiving a percutaneous endoscopic gastrostomy
tube this admission by Interventional Radiology. Initially,
on presentation, the patient's blood pressure was somewhat
labile and low running in the 90's/50's to 100's/60's. The
patient's blood pressure medications including his Isosorbide
and his ACE inhibitor were held initially. After gentle
hydration, the patient's blood pressure did correct. We were
able to administer those medications again. On [**2153-5-22**],
the patient was complaining of chest pain. Electrocardiograms
were taken every five minutes, following sublingual
Nitroglycerin administration. The patient's pain was relieved
with three sublingual Nitroglycerin. There were no
electrocardiogram changes seen. Cardiac enzymes were checked
and the patient ruled out for myocardial infarction with
three sets of negative enzymes. There were no other
complaints of chest pain following that one episode. The
patient's Captopril was discontinued and changed to Zestril
over the course of the admission, otherwise,
cardiovascularly, the patient remained very stable.
2) Hematuria. The patient had been continued on continuous
bladder irrigation through Foley catheter. The urine did
clear to a very light amber color and the continuous bladder
irrigation was turned off for a trial period. Urine ran very
clear without difficulty without passage of clots most of
that day but then began to become bloody again and the
irrigation was continued. Urology was consulted and felt that
inpatient cystoscopy was not necessary, rather planned to
follow-up as an outpatient appointment and cystoscopy after
discharge. The Foley catheter was actually discontinued on
[**2153-5-26**]. The patient voided without difficulty with
minimal hematuria.
3) Heme. Upon admission, the patient was on aspirin, Plavix
and Heparin with a lower hematocrit then his baseline as
hematocrit was followed closely reaching a low point of 31.1
on [**2153-5-21**], the patient received two units of packed red
blood cells. At the time of discharge, his hematocrit has
been stable at 44.8. At the time of discharge, the patient is
still on aspirin and Plavix. Plavix is to be discontinued on
[**2153-5-31**]. The patient has been started on Coumadin which
is not yet therapeutic.
4) Gastrointestinal. The patient had been receiving tube
feeds via pediatric nasogastric tube on admission.
Nasogastric tube had been pulled by the patient several times and
replaced by house staff. Interventional Radiology was
consulted and agreed to place percutaneous endoscopic
gastrostomy tube. Heparin was discontinued that morning. The
patient underwent percutaneous endoscopic gastrostomy tube
placement without complication. Following percutaneous endoscopic
gastrostomy tube placement, Heparin was reinstated and Coumadin
begun. Prior to percutaneous endoscopic gastrostomy tube
placement, the patient had undergone speech and swallow study
that was failed at the bedside. Video swallowing study was done
the morning of the percutaneous endoscopic gastrostomy tube which
the patient also failed providing for the percutaneous
endoscopic gastrostomy tube placement.
5) Neurologic. The patient's neurologic examination remained
unchanged throughout his admission. The patient's mental
status tended to wax and wane with his blood pressure and
hematocrit when hemodynamically stable, the patient was alert
and responded to questions and was able to have brief
conversations with family members who would translate for us.
There was no evidence of any new cerebrovascular accident
this admission.
DISCHARGE MEDICATIONS: The patient is discharged on, 1)
aspirin 325 mg by mouth per gastrostomy tube. 2) Plavix 75 mg
per gastrostomy tube every day and on [**2153-5-31**]. 3)
Heparin drip 1000 units per hour with a goal partial
prothrombin time of 50 to 70. This is to be discontinued once
international normalized ratio is therapeutic. 4) Coumadin,
the dose is still being titrated. The patient has received
two doses of 10 mg upon discharge. 5) Lopressor 12.5 mg by
mouth twice a day. 6) Zestril 5 mg by mouth every day. 7)
Prevacid 30 mg by mouth every day. 8) Isosorbide Mononitrate
60 mg every day. 9) Morphine Sulfate 2 mg subcutaneous every
four to six hours as needed for pain at percutaneous
endoscopic gastrostomy tube site. 10) Tube feeds, the patient
is receiving ProMod with fiber at a goal of 100 cc per hour,
residuals being checked every four hours and tube feeds being
held for residuals greater then 150 cc.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES: 1) Hematuria, while on aspirin, Plavix
and Heparin. 2) Status post percutaneous endoscopic
gastrostomy tube placement for failed swallowing study.
FOLLOW-UP: The patient is to follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15490**] MD, at [**Telephone/Fax (1) 250**]. In
addition, the patient should follow-up with Urology,
Dr. [**Last Name (STitle) 8872**] in one to two weeks following discharge at
[**Telephone/Fax (1) 95313**].
DISCHARGE STATUS: The patient is discharged to an inpatient
rehabilitation or [**Hospital1 1501**] facility until strong enough to return
home.
KHASIGIWALA,[**Name8 (MD) 95314**] M.D.12-869
Dictated By:[**Name8 (MD) 3491**]
MEDQUIST36
D: [**2153-5-27**] 11:06
T: [**2153-5-27**] 11:10
JOB#: [**Job Number 24528**]
| [
"5070",
"2762",
"4280",
"5845",
"2720"
] |
Admission Date: [**2183-1-22**] Discharge Date: [**2183-1-24**]
Date of Birth: [**2183-1-22**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname 2152**], twin #2, was born weighing [**2160**]
grams, the product of a 35-6/7 week gestation. Pregnancy with
an EDC of [**2183-2-20**]. This pregnancy was spontaneous di-di
twins and they were born to a 22-year-old G1, P0, now 2
mother with prenatal screen as follows: Blood type O+,
antibody negative, RPR nonreactive, rubella immune, HBsAg
negative, GBS unknown. This pregnancy was complicated by
growth restriction of this infant. The pregnancy was
otherwise uncomplicated. The mother was treated with
betamethasone prior to delivery. The infant was born by C-
section due to growth restriction issues. The infant was
vigorous at birth and had Apgar scores of 8 and 9 at one and
five minutes, respectively. The infant was admitted to the
NICU due to prematurity for 24-hour minimum evaluation due to
gestational age. Birthweight [**2160**] grams which is less than
the 10th percentile, head circumference 31.75 cm which is
25th-50th percentile, length of 42.5 cm which is the 10th
percentile.
DISCHARGE PHYSICAL EXAMINATION: Active and alert, well-
appearing preterm male. HEENT: Normocephalic. Anterior
fontanel open and flat. Intact palate. Bilateral red reflexes
present. Skin pink. Mongolian spots on lower back and
buttocks. Breath sounds clear and equal bilaterally with
slight retractions, comfortable respirations otherwise. CV:
Normal rate and rhythm, normal S1, S2, no murmurs, normal
femoral pulses. Abdomen: Soft and round with active bowel
sounds, no masses. Cord dry and intact. Anus patent. GU:
Testes descended bilaterally. The infant has a chordee with
borderline hypospadias. Skeletal: Spine straight no sacral
dimple. Hips intact. Clavicles intact. Normal extremities.
Neuro: Good tone. Moves all extremities equally. Normal
reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The infant has remained on room air
without any issues since admission to the NICU.
2. CARDIOVASCULAR: The infant has had no cardiovascular
issues, has normal blood pressure, heart rate, is pink
and well-perfused.
3. FLUIDS, ELECTROLYTES AND NUTRITION: The infant was
started on enteral feedings on admission to the NICU.
The infant is taking NeoSure 22 cal/oz or breast milk q.
3-4h. ad lib and has had normal D-sticks with the lowest
D-stick being 49 prior to a feeding. The infant is p.o.
feeding well 20-30 mL/feed, is voiding and stooling
normally, is still passing meconium.
4. GI: The infant is developing mild jaundice.
Thus far has had no bilirubins measured but will need a
bilirubin by day 3 of life with the state screen.
5. HEMATOLOGY: There are no hematologic issues on this
infant. No blood typing has been done. No hematocrits or
platelets have been measured.
6. INFECTIOUS DISEASE: There are no infectious disease
issues on this infant.
7. NEUROLOGY: The infant has maintained a grossly normal
neurologic exam for gestational age at this time.
8. SENSORY - AUDIOLOGY: A hearing screen will need to be
performed prior to discharge to home; it has not been
done thus far.
9. PSYCHOSOCIAL: There are no active psychosocial issues
at this time with this family.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to newborn nursery at [**Hospital1 18**]
for continued care.
NAME OF PRIMARY PEDIATRICIAN: Parents were undecided on the
pediatrician at the time of delivery. Due to the obstetrician
being Dr. [**Last Name (STitle) **], while at [**Hospital1 18**] the pediatrician who will
cover will be Dr. [**First Name8 (NamePattern2) 2174**] [**Last Name (NamePattern1) 38807**] whose telephone number is
([**Telephone/Fax (1) 76772**].
CARE RECOMMENDATIONS:
1. Ad lib p.o. feeding by breast, breast milk or NeoSure 22
cal/oz.
2. Medications: None.
3. Iron and vitamin D supplementation.
a. Iron supplementation is recommended for preterm
and low birthweight infants until 12 months corrected
age.
b. All infants fed predominantly breast milk should
receive vitamin D supplementation at 200 international
units which may be provided as multivitamin preparation
daily until 12 months corrected age.
4. This infant will need a car seat position screening
prior to discharge to home.
5. State newborn screen has not been sent yet but will need
to be sent by day 3 of life.
6. Immunizations received: The infant has not received any
immunizations thus far. Immunizations recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: 1) born at less than 32 weeks
gestation; 2) born between 32 and 35 weeks with 2 of
the following: either daycare during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school-aged siblings; 3) chronic lungs
disease; or 4) hemodynamically significant congenital
heart defect.
b. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age and for the first 24 months of a
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
c. This infant has not received the rotavirus
vaccine. The American Academy of Pediatrics recommends
initial vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks but fewer than 12 weeks of
age.
7. Follow-up appointment is recommended with the
pediatrician after discharge from the hospital.
DISCHARGE DIAGNOSES:
1. Prematurity, born at 35-6/7 weeks gestation.
2. Mild temperature instability resolved prior to discharge
from the neonatal intensive care unit.
[**Unit Number **]. Intrauterine growth restriction/small for gestational
age.
4. Twin infant.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2183-1-23**] 20:33:59
T: [**2183-1-23**] 22:05:11
Job#: [**Job Number 76774**]
| [
"V053"
] |
Admission Date: [**2101-9-14**] Discharge Date: [**2101-9-21**]
Date of Birth: [**2101-9-14**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Doctor Last Name **] is a former
2.47-kilogram product of a 34 and [**12-31**] week gestation
pregnancy born to a 27-year-old gravida 2, para 1 woman.
Prenatal screens revealed blood type O positive, antibody
negative, rapid plasma reagin nonreactive, hepatitis B
surface antigen negative, Rubella immune, and group B strep
status unknown.
The pregnancy was complicated by bleeding due to a previa at
24 to 26 weeks gestation. The previa resolved. She also
experienced preterm labor and was treated with bed rest and
terbutaline. The infant was born by spontaneous vaginal
delivery. He emerged limp and blue. He required positive
pressure ventilation for approximately 30 seconds. Apgar
scores were 5 at one minute of age and 7 at five minutes of
age. He was admitted to the Neonatal Intensive Care Unit for
treatment of prematurity. The labor was an induction for
spontaneous premature rupture of membranes.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
upon admission to the Neonatal Intensive Care Unit revealed
the infant's weight was 2.4 kilograms, length was 38 cm, head
circumference was 29.5 cm. In general, a pink preterm infant
in no acute distress. Head, eyes, ears, nose, and throat
examination revealed normal faces. Marked occipital molding.
Soft anterior fontanel. Intact palate. Positive red reflex
bilaterally. Chest examination revealed no grunting,
flaring, or retracting. Breath sounds were clear with good
air entry. Cardiovascular examination revealed a 1/6
systolic murmur. Positive femoral pulses. The abdomen was
flat, soft, and nontender. No hepatosplenomegaly.
Genitourinary revealed normal phallus, testes, and scrotum.
Extremity examination revealed the infant was moving all with
fair perfusion. The hips were stable. Neurologic
examination revealed tone and reflexes consistent with
gestational age.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The infant was initially on some
blow-by oxygen but was weaned to room air within a few hours
after admission. He remained on room air until discharge.
He did not have any episodes of spontaneous apnea of
bradycardia during his admission.
2. CARDIOVASCULAR ISSUES: A normal saline bolus was
administered shortly after admission for poor perfusion. The
infant has maintained normal heart rates and blood pressures.
The murmur noted on admission resolved by day of life two.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant was
initially nothing by mouth and maintained on intravenous
fluids. Feedings were started on day of life one and
advanced. He has been all by mouth feeding; Enfamil 20 with
iron. On the day prior to discharge, the infant's weight was
2.145 kilograms. His low weight occurred on day of life two
at 2.385 kilograms.
4. INFECTIOUS DISEASE ISSUES: Due to the premature rupture
of membranes and prematurity, the infant was evaluated for
sepsis. His white blood cell count was 17,000 with a
differential of 16% polys and 3% bands. A blood culture was
obtained prior to starting antibiotics. The blood culture
was no growth at 48 hours, and the antibiotics were
discontinued.
5. HEMATOLOGIC ISSUES: The infant's hematocrit at birth was
54%. The infant did not receive any transfusions of blood
products.
6. GASTROINTESTINAL ISSUES: The infant required treatment
for unconjugated hyperbilirubinemia with phototherapy. His
peak serum bilirubin occurred on day of life two with a total
of 12.4/0.2 mg/dL. He received phototherapy for
approximately 72 hours. His rebound total bilirubin was 5.8
mg/dL and of direct bilirubin was 0.3 mg/dL. A repeat bilirubin
on the day of discharge was 11.
7. SENSORY/AUDIOLOGY ISSUES: A hearing screen was performed
with automated auditory brain stem responses. The infant
passed in both ears.
8. NEUROLOGIC ISSUES: The infant maintained a normal
neurologic examination during this admission, and there were
no neurologic concerns at the time of discharge.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home with his
parents.
PRIMARY PEDIATRICIAN: The primary pediatrician is Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) 14495**], [**Location (un) 246**] Pediatric Associates, [**Last Name (NamePattern1) 50262**], [**Location (un) 246**],
[**Numeric Identifier 50263**] (telephone number [**Telephone/Fax (1) 37501**]).
CARE AND RECOMMENDATIONS:
1. Feedings: Ad lib by mouth Enfamil 20 or breast feeding.
2. Medications: No medications.
3. A car seat position screening was performed, and the
infant was observed for 90 minutes without oxygen or heart
rate drops.
4. Stage newborn screening was sent on [**2101-9-17**] with
no notification of abnormal results to date. A repeat screen
on the day of discharge was also to be sent.
5. Hepatitis B vaccine was administered on [**2101-9-15**].
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) born at less than 32 weeks gestation.
(2) born between 32 and 35 weeks gestation with plans for day
care during respiratory syncytial virus season, with a smoker
in the household, neuromuscular disease, airway
abnormalities, or with preschool siblings; and/or (3) with
chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE INSTRUCTIONS/FOLLOWUP: Follow-up appointment
recommended with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 14495**] within two days of
discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 2/7 weeks gestation.
2. Suspicion for sepsis ruled out.
3. Transitional respiratory distress.
4. Unconjugated hyperbilirubinemia.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2101-9-20**] 06:52
T: [**2101-9-20**] 06:57
JOB#: [**Job Number 50264**]
| [
"7742",
"V290"
] |
Admission Date: [**2200-3-7**] Discharge Date: [**2200-3-8**]
Date of Birth: [**2123-7-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
pacemaker placement
History of Present Illness:
76 year old male with DM, ESRD on HD via LUE AV fistula placed
[**12/2196**] s/p multiple stenoses and angioplasties with angioplasty
[**2200-1-16**] who is undergoing IV antibiotic therapy cefazolin at HD
for MSSA bacteremia of unclear duration and source. He was at HD
today for his regular visit and was noted to have hypotension.
His pulse was then checked and found to be low, and his dialysis
was cut short by 2 hours and he was transferred to [**Hospital1 18**] ER for
further evaluation.
.
Upon presentation, pt denied complaints, but was noted to be in
complete heart block with a wide complex escape rhythm (RBBB
pattern) at 40 bpm. Known to have second degree AV block on EKG
prior. BP was 110/68 and RR 18 with sats 94%. Pacer pads were
placed. Carotid sinus massage and exercise were performed with
no prominent effect on AV nodal conduction. He was noted to have
WCB that was likely in the His bundle. As a pacemaker was
recommended, ID was consulted due to recent
infection/bacteremia.
A TEE was performed and did not reveal any vegetations. He was
afebrile with negative Blood cx's since [**2-22**], maintained on Abx
at dialysis. Went for PPM placement today and was complicated by
very difficult to access anatomy. In holding area post procedure
pt delirius and confused, needed a team of ten people to keep
control of him. Glucose was 17 on one measurement. Repeat was
200. He started the procedure with a glucose of 100. He had been
NPO all day awaiting the procedure.He remained confused even
after and was admitted to CCU for 1:1 monitoring.
Past Medical History:
-Diabetes mellitus 2
-chronic kidney disease stage 4 on HD MWF
-Ulcerative colitis: no flares x 25 years
-Right adrenal adenoma.
-Gout.
-History of prostate cancer, status post prostatectomy.
-Remote history of nephrolithiasis.
-Hypertension
-Peripheral vascular disease s/p left [**Doctor Last Name **]-dp bypass
-carotid stenosis
-infrarenal abdominal aortic aneurysm
-deep venous thrombosis in [**2195**]
-iron deficiency anemia
-recent episode of aphasia which resolved - ? TIA
Social History:
Quit smoking at age 73. Retired as a chemical mixer from a
leather tannery. No alcohol or illicit drug use. Lives at home
with his wife and family.
Family History:
Brother had liver cancer. Father and mother had cerebrovascular
accidents. Paternal grandfather rectal cancer.
Physical Exam:
PE: T: 98.8 HR: 95 BP: 106/65 RR: 23 100% RA.
Neuro: PERRLA, A0X3
CVS: [**12-18**] HSM heard best at apex
R chest: dressing over pacemaker C/D/I
Lungs: CTA-B
abd: +bs, soft, nt, nd
Ext: wwp,trace edema
pulses dopplerable
Pertinent Results:
[**2200-3-7**] 11:28PM GLUCOSE-163* UREA N-25* CREAT-5.1*#
SODIUM-145 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-38* ANION GAP-15
[**2200-3-7**] 11:28PM ALT(SGPT)-0 AST(SGOT)-24 ALK PHOS-112 TOT
BILI-0.7
[**2200-3-7**] 11:28PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.1
[**2200-3-7**] 11:28PM WBC-11.9* RBC-2.84* HGB-7.8* HCT-27.3* MCV-96
MCH-27.6 MCHC-28.7* RDW-25.9*
[**2200-3-7**] 11:28PM PLT COUNT-151
[**2200-3-7**] 11:28PM PT-14.0* PTT-28.3 INR(PT)-1.2*
[**2200-3-7**] 11:50AM GLUCOSE-94 K+-4.0
.
Echo [**2200-3-7**]
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect is seen by
2D or color Doppler. with mild global free wall hypokinesis.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild to moderate ([**12-14**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is at least
mild pulmonary artery systolic hypertension. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations or peri-valvular abcesses
seen. Mild to moderate mitral regurgitation. Mildly depressed
left ventricular and moderately depressed right ventricular
systolic function. Complex plaque in descending aorta and aortic
arch. Mild pulmonary hypertension.
.
CXR [**2200-3-8**] - IMPRESSION: Evidence for mild vascular congestion
and very small pleural effusions. Cardiomegaly. A transvenous
pacemaker in place.
Brief Hospital Course:
76 yo M w/ PMHx of HTN, DM, and ESRD on HD who was known to have
second degree AV block on prior EKG noted on admission to have
deteriorated to complete heart block.
Altered Mental Status: His course post PM placement was
complicated by delirium, in the setting of hypoglycemia to 17.
He received an amp of d50 with improvement of his GFS to the
200s. He was delirious initially on the floor and per
discussions with his spouse he is confused at baseline. In
addition to the hypoglycemia, he may have been particularly
sensitive to sedating medications, and there may be some
metabolic component given his ESRD although his electrolytes
were not markedly abnormal. His GFS were checked every 4 hours,
he received repeated reorientation, and benzodiazepines were
avoided. His sensorium continued to improve.
Complete heart block s/p Pacemaker: He had a [**Company **] DDD
pacemaker placed set at 60-120. He was appropriately V paced on
telemetry and subsequent EKG. He received a CXR the day
following his procedure showing that the leads were
appropriately positioned. EP interoggation post procedure showed
the pacemaker was working appropriately. He was instricted to
wear a slight to immobilize his right arm for several weeks post
procedure. A plan was made for him to follow up with the device
clinic within one week of discharge. He needs a new cardiologist
and the phone number for the cardiology clinic was given to him
to set up an appointment.
ESRD on HD: He has ESRD on hemodialysis MWF. Due to his episode
of hypotension, his Friday hemodialysis session was terminated
prematurely, and he only received half of his dialysis. He was
discussed with our renal team and was not found to be grossly
volume overloaded nor were the electrolytes particularly
abnormal. Dialysis was deferred to his next scheduled session on
Monday.
MSSA bacteremia: undergoing IV antibiotic therapy cefazolin at
HD for MSSA bacteremia of unclear duration and source. At this
point he is 13 days into his course. He should complete the
course of cefazolin decided by his nephrologists at dialysis.
HTN: He was normotensive this hospitalization. His
antihypertensive regimen with metoprolol and lisinopril was
continued.
Carotid stenosis /Infrarenal AAA/PVD: He was continued on asa,
simvastatin, lisinopril.
Medications on Admission:
1. Albuterol Sulfate 2 puffs QID PRN
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TIDAC
3. Clopidogrel 75 mg PO q day
4. Fluticasone-Salmeterol 100-50 mcg/Dose [**Hospital1 **]
5. Lasix 40 mg PO BID
6. Glipizide 2.5 mg ER PO BID
7. Lisinopril 40 mg PO Q day
8. Metoprolol Tartrate 100 mg Tablet PO Q day
9. Ranitidine HCl 150 mg PO Q day
10. Silver Sulfadiazine 1 % Cream Sig: Q day
11. Simvastatin 10 mg Tablet PO Q HS
12. Aspirin 325 mg PO Q day
13. Folic Acid 1 mg PO Q day
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule PO Q day
15. Cefazolin at HD
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical
DAILY (Daily) as needed for apply to foot wounds.
12. Cefazolin 10 gram Recon Soln Sig: Two (2) grams IV Injection
HD PROTOCOL (HD Protochol).
13. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary.
Complete heart Block S/P pacemaker placement
Secondary
End Stage Renal Disease
Diabetes
Discharge Condition:
Alert and oriented to person, place and time. Mildly confused.
Discharge Instructions:
You were admitted to the hospital because you had dropped your
blood pressure during dialysis. You were found to have complete
heart block on EKG, a condition where the [**Doctor Last Name 1754**] of your heart
do not communicate electrically. For this reason, you had to
have a pacemaker placed. You were disoriented after the
procedure because your blood sugar was low however this has been
corrected. Some of the sedating medications may take some time
to wear off, so you may be a little confused intitially. Please
see your doctor if you still feel confused after a couple of
days.
The following changes were made to your medications:
- DECREASE glipizide to 2.5mg ONCE a day.
It is very important that you do not engage in any stretching or
lifting using your right arm. Please keep the pacemaker area
dry for 1 week. Please limit movement of your right arm and
wear the arm sling for six weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) **] Clinic. Please follow up within one week of
discharge. The number to call to make your appointment is
[**Telephone/Fax (1) 62**].
You need a new cardiologist. Please call [**Hospital1 18**] cardiology at
([**Telephone/Fax (1) 2037**] to set up an appointment
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2200-3-19**] 3:00
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2200-3-20**] 10:30
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2200-4-17**]
8:30
| [
"40391"
] |
Admission Date: [**2103-3-28**] Discharge Date: [**2103-3-30**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: Patient is an 88-year-old female
with a history of severe chronic obstructive pulmonary
disease and chronic syndrome of inappropriate diuretic
hormone who was recently admitted for a chronic obstructive
pulmonary disease exacerbation to [**Hospital6 649**]. She was discharged to [**Hospital3 537**] on
[**2103-3-24**]. She was noted to have a variable level of
responsiveness with intermittent hypoxia with oxygen
saturations in the 60s. She is known to become somnolent and
retain carbon dioxide if her oxygen saturations are too high.
She was brought to the Emergency Department for an
evaluation. She denied any chest pain, shortness of breath,
cough, fevers, or chills. An arterial blood gas revealed an
elevated carbon dioxide level of 78, higher than her baseline
in the 60s.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Chronic syndrome of inappropriate diuretic hormone.
3. Seizures.
4. Mild dementia.
5. Hypertension.
6. Colon cancer, status post resection.
7. Osteoarthritis.
8. Lacunar infarcts.
9. Iron deficiency anemia.
10. Hard of hearing.
ALLERGIES: Doxycycline.
MEDICATIONS:
1. Sodium chloride 1 gram po t.i.d.
2. Solu-Medrol inhaler 20 mcg 2 puffs po b.i.d.
3. Calcium carbonate 1.25 grams po t.i.d.
4. Vitamin D 400 units po q.d.
5. Protonix 40 mg po q.d.
6. Fosamax 70 mg po q. Friday.
7. Aspirin 81 mg po q.d.
8. Colace 100 mg po b.i.d.
9. Iron sulfate 225 mg po q.d.
10. Atrovent nebulizers, 1 nebulizer po q. 6 hours prn.
11. Combivent inhaler 2 puffs po q. 4 hours.
12. Ritalin 5 mg po b.i.d.
13. Prednisone taper, currently 40 mg po q.d.
14. Dilantin taper, currently 100 mg po b.i.d.
SOCIAL HISTORY: The patient lives at home with her family,
but was recently a resident of the [**Hospital3 537**].
PHYSICAL EXAMINATION: The patient was afebrile with a
temperature of 97. Heart rate 86. Blood pressure 150/80.
Respiratory rate 20. Oxygen saturation 89% on room air,
improving to 95% on two liters by nasal cannula. In general,
the patient was somnolent, but arousable. Head and neck exam
are significant for moist mucous membranes, supple neck, and
no lymphadenopathy. Lungs had crackles at the left base with
very poor air movement bilaterally. Cardiac exam revealed a
regular rate and rhythm with no murmurs. Abdomen was benign.
Extremities had no edema.
LABORATORIES STUDIES: Significant for a hematocrit of 36.7
and a platelet count of 516,000. Panel 7 is significant for
a sodium of 122, chloride 80, and bicarbonate of 32. The
patient's baseline sodium is known to be 125-132. Arterial
blood gas revealed a pH of 7.35, pCO2 of 75, pO2 of 78, and
bicarbonate of 43. Chest x-ray revealed hyperinflated lung
fields with no infiltrates or effusions. Electrocardiogram
showed normal sinus rhythm at 85 beats per minute with normal
axis and intervals and no ST-T wave changes compared to old
electrocardiograms.
HOSPITAL COURSE:
1. Chronic obstructive pulmonary disease: It is not
believed that the patient had an exacerbation of her chronic
obstructive pulmonary disease, but instead was somnolent from
elevated oxygen saturations. She was continued on her
current admission dose of steroids, continue with inhalers,
and started on antibiotics. She received BiPAP at night with
settings of 12 and 5, had an improvement in her arterial
blood gas showing a pH of 7.42, pCO2 of 59 and pO2 of 134.
She was quickly weaned down to 2 liters of oxygen by nasal
cannula, which the patient receives at home. At the time of
discharge, the patient had no shortness of breath or
productive cough, and maintained good oxygen saturations on
one liter of oxygen by nasal cannula. She will continue on
her steroid taper, as well as on her inhalers, but does not
require further antibiotic treatment. Of greatest benefit to
her, would be the continued use of her BiPAP machine at
night.
2. Syndrome of inappropriate diuretic hormone: The patient
was fluid restricted to one liter of free water per day, and
her sodium chloride tablets were continued. At the time of
discharge, her sodium had returned to her normal baseline
level of 127.
3. Neurology: The patient is continued on her Dilantin
taper. She did not have any seizures during her
hospitalization. It was felt that her prior seizures were
secondary to toxic metabolic events, which do not require
antiepileptic medications.
DISCHARGE CONDITION: The patient was discharged in stable
condition to the [**Hospital3 537**].
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Chronic syndrome of inappropriate diuretic hormone.
3. Seizures.
4. Mild dementia.
5. Hypertension.
6. Colon cancer, status post resection.
7. Osteoarthritis.
8. Lacunar infarcts.
9. Iron deficiency anemia.
10. Hard of hearing.
DISCHARGE MEDICATIONS:
1. Sodium chloride 1 gram po t.i.d.
2. Solu-Medrol inhaler 20 mcg 2 puffs po b.i.d.
3. Calcium carbonate 1.25 grams po t.i.d.
4. Vitamin D 400 units po q.d.
5. Protonix 40 mg po q.d.
6. Fosamax 70 mg po q. Friday.
7. Aspirin 81 mg po q.d.
8. Colace 100 mg po b.i.d.
9. Iron sulfate 225 mg po q.d.
10. Atrovent nebulizers, 1 nebulizer po q. 6 hours prn.
11. Combivent inhaler 2 puffs po q. 4 hours.
12. Ritalin 5 mg po b.i.d.
13. Prednisone taper, 40 mg po q.d. times two days, 30 mg po
times three days, 20 mg po q.d. times three days, 10 mg po
q.d. times three days, then off.
14. Dilantin 100 mg po b.i.d. times two days, then 100 mg po
q.d. times seven days, then off.
DISCHARGE FOLLOW-UP PLANS:
1. The patient should follow-up with her primary care
physician in one to two weeks.
2. The patient should follow-up with a pulmonologist as
needed for the treatment of her chronic obstructive pulmonary
disease.
3. The patient was encouraged and should continue to use her
BiPAP at night with settings of 8 and 5.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 6916**]
MEDQUIST36
D: [**2103-3-30**] 10:41
T: [**2103-3-30**] 11:03
JOB#: [**Job Number 19224**]
| [
"51881",
"4019"
] |
Admission Date: [**2137-10-31**] Discharge Date: [**2137-11-8**]
Date of Birth: [**2097-11-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
s/p fall, alcohol withdrawal
Major Surgical or Invasive Procedure:
endotracheal intubation
cardiopulmonary resuscitation
History of Present Illness:
Mr [**Known lastname 3517**] is a 39M with hx EtOH abuse, hx seizures, tx from
[**Location (un) 620**] for EtOH withdrawal and s/p fall. last drink was 2 days
ago. Per ED report, he was found down after an unclear period of
time by his father, and there was concern that he ahd a seizure
at top of 13 stairs and fell to the bottom. In the eedham ED, he
had a lactate fo 11. CT head, cervical spine, and
torso were done given fall history, with no acute findings. He
was transferred to [**Location (un) 86**] given "concerning mechanism for fall".
He was given KCl prior to transfer.
.
In the [**Hospital1 **] [**Location (un) 86**] ED, the patient was awake, alert, with mild
confusion, complaining of chest, back and L ankle pain. Exam was
notable for tongue lac (nonsuturable), neck nontender, c-spine
cleared. He continued to be tachy to 130 despite 20mg IV valium.
Ankle swelling was noted, therefore ankle films were repeated
and showed no obvious fracture. He was given 3 additional L of
fluid, lactate went from 11 to 1.8, also got an additional 4 mg
ativan in IV. Vitals on transfer were HR 140s, 132/80, r 23. He
was initially placed in a sling out of concern for small
fracture of humerus seen on shoulder films.
.
In the MICU, Pt was initially aao x1, states he is in pain in
his R shoulder and back. Was drinking one pint of vodka/day,
last drink [**2137-10-28**]. In the MICU, Pt initially had a Hct of 19
and was transfused 2 x PRBCs plus 6 pack of platelets. Pt had
coffee grounds on suctioning and was started on pantoprazole [**Hospital1 **]
before being switched to omeprazole. Pt also desaturated to 60s
and was pulseless for 30 seconds, requiring 30 seconds of CPR
and was intubated on [**2137-10-31**]. Pt was extubated without incided
on [**2137-11-2**] w/ no issues. Pt may have had an apiration event but
Pt has not been febrile, and CXR is not concerning. While
intubated, Pt had continuous recording EEG but no seizure
activity was noted. On presentation, pt was seizing, but has
been very stable and only [**Doctor Last Name **] 0-1 on CIWA scale on day of
transfer. Pt did not have repeat EGD due to [**2137-7-22**] EGD at
[**Hospital1 **] [**Location (un) 620**] showing portal gastropathy and gastritis but no
varices. Of note, Pt also has a R humerus greater tuberosity
fracture. Per MICU staff, orthopedics was not formally consulted
but recommended no sling and outpatient followup.
.
Pt was transferred to floor on [**2137-11-3**]. On arrival to the
floor, Pt's vitals were:
.
Review of sytems: Prior to admission, but had no fevers, no
chills, no weight loss, no nightsweats. No nausea or vomiting,
no diarrhea or constipation. No chest pain or dyspnea. No
palpitations. No focal numbness or weakness. No urinary
symptoms. No abdominal pain.
Past Medical History:
HTN
PUD
EtOH abuse complicated by withdrawal seizures, multiple prior
aborted attempts at detox
psoriasis (no formal diagnosis)
depression
Social History:
Pt lives in [**Location 620**] with his father. Not currently working.
Previously contractor / landscaper. 1 pt vodka/day, no tobacco,
no illicits, no iv drug use.
Family History:
mother had breast cancer. Father diabetes.
Physical Exam:
Vitals: T:99.7 BP:134/64 P:145 R: 18 O2:97% RA
General: Alert, orient x1.5, appears uncomfortable
HEENT: Sclera icteric, oropharynx clear, tongue bruised, eyes
with saccadic movements and rolling back into the head during
the exam
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse upper airways sounds, no rhonchi/rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Skin: erythematous plaques with silver scale on legs, bruising
on extremities and back
Pertinent Results:
Admission labs:
[**2137-10-30**] 11:40PM GLUCOSE-140* UREA N-8 CREAT-0.6 SODIUM-137
POTASSIUM-3.0* CHLORIDE-106 TOTAL CO2-20* ANION GAP-14
[**2137-10-30**] 11:40PM ALT(SGPT)-19 AST(SGOT)-136* CK(CPK)-350* ALK
PHOS-211* TOT BILI-10.6* DIR BILI-7.4* INDIR BIL-3.2
[**2137-10-30**] 11:40PM LIPASE-22
[**2137-10-30**] 11:40PM cTropnT-<0.01
[**2137-10-30**] 11:40PM CK-MB-6
[**2137-10-30**] 11:40PM CALCIUM-7.7* PHOSPHATE-1.1* MAGNESIUM-1.3*
[**2137-10-30**] 11:40PM WBC-11.0 RBC-2.98* HGB-8.9* HCT-27.8* MCV-94
MCH-30.0 MCHC-32.1 RDW-19.3*
[**2137-10-30**] 11:40PM NEUTS-89.6* LYMPHS-5.5* MONOS-3.8 EOS-0.9
BASOS-0.2
[**2137-10-30**] 11:40PM PLT SMR-VERY LOW PLT COUNT-44*
[**2137-10-30**] 11:40PM PT-17.7* PTT-32.2 INR(PT)-1.6*
[**2137-10-30**] 11:40PM URINE COLOR-DkAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2137-10-30**] 11:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-7.5 LEUK-TR
[**2137-10-30**] 11:40PM URINE RBC->182* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
[**2137-10-30**] 11:45PM LACTATE-1.8
Trauma plain films:
Ankles: IMPRESSION: Significant medial soft tissue swelling with
no fracure. Mild lateral clear space widening.
Right shoulder:
RIGHT SHOULDER, FOUR VIEWS: There is a fracture of the greater
tuberosity,
impacted and slightly comminuted. No other fracture. No
dislocation. Minimal AC joint spurring. The visualized portions
of the right lung and ribs are unremarkable.
Head CT: IMPRESSION:
1. Resolved small falcine subdural hematoma.
2. No acute intracranial abnormality.
[**Hospital1 18**]:
[**2137-11-1**] Radiology CT HEAD W/O CONTRAST
1. Resolved small falcine subdural hematoma.
2. No acute intracranial abnormality.
.
[**2137-11-1**] Radiology DUPLEX DOPP ABD/PEL
FINDINGS: Echogenicity of the liver is within normal limits with
no focal lesion identified. No intra- or extra-hepatic biliary
dilation is seen. The CBD measures 3 mm. The gallbladder is
mildly distended however no wall thickening or pericholecystic
fluid is seen. No evidence of cholelithiasis. The spleen is
enlarged measuring up to 14.5 cm. No free fluid is seen. The
kidneys appear normal. The right kidney measures 11.6 cm and the
left 12.9 cm. Limited views of the pancreas are normal though
the distal tail is obscured by overlying bowel gas. The aorta is
not well assessed due to overlying bowel gas. Doppler evaluation
of the liver was performed. There is reversal of flow in the
main portal vein as well as the anterior right portal vein. The
left portal vein and posterior right portal vein demonstrates
hepatopetal flow. The hepatic artery and major branches appear
normal. The hepatic veins appear normal though the right hepatic
vein cannot be followed in its entirety. The IVC, where
visualized, appears normal. The splenic vein is patent. There is
recanalization of the umbilical vein. There may be a small right
pleural effusion, partially imaged. IMPRESSION: Findings
consistent with cirrhosis and portal hypertension including
recanalized umbilical vein and splenomegaly. There is reversal
of flow in the main portal vein and anterior right portal vein.
No free fluid is seen.
.
- CT Cspine: mild C3-4 intervetebral disc herniation
- CT torso: acute fracture of greater tuberosity of R humerus, R
gluteal hematoma, cirrhosis with splenomegaly, esophageal
varices, no ascites, unchanged from [**4-1**]
Discharge labs:
[**2137-11-8**] 06:25AM BLOOD WBC-8.9 RBC-2.90* Hgb-8.9* Hct-28.4*
MCV-98 MCH-30.8 MCHC-31.4 RDW-20.3* Plt Ct-140*
[**2137-11-8**] 06:25AM BLOOD PT-16.6* INR(PT)-1.5*
[**2137-11-8**] 06:25AM BLOOD Glucose-83 UreaN-12 Creat-0.6 Na-135
K-3.7 Cl-102 HCO3-23 AnGap-14
[**2137-11-8**] 06:25AM BLOOD TotBili-9.2*
[**2137-11-8**] 06:25AM BLOOD Mg-1.9
Brief Hospital Course:
39 yo gentleman admitted with EtOH withdrawal, s/p fall likely
due to seizure, now with concern for ongoing seizure activity.
.
#. EtOH withdrawal: Patient with chronic EtOH abuse and a
history of withdrawal seizures, presented 2 days after last
drink with evidence of seizures. Story of fall downstairs was
highly suspicious for seizure. Given IV thiamine and IV ativan
in ED. On arrival to the ICU, the patient was confused and
tremulous. Around 7:30am the morning of admission, the patient
became minimally responsive with his eyes rolling up. He was
receiving boluses of IV ativan for withdrawal and began having
difficulty protecting his airway, so the decision was made to
intubate. He was difficult to intubate and became severely
hypoxemic. He was pulseless for about 1 minute, during which
time he received CPR. After intubation, his oxygenation
improved. He was started on multivitamin, thiamine and folate.
He was then continued on a midazolam infusion for sedation and
control of seizures. Continuous EEG monitoring showed just slow
wave forms without further seizures. His mental status improved,
and the next day he was able to be extubated. He did not require
further benzodiazepenes. Given that his seizures were in the
setting of withdrawal, he was not started on antiepileptics. Pt
also did not show any alcohol withdrawal symptoms since [**2137-11-2**]
and did not require benzodiazepenes for withdrawal. Pt's
electrolytes were repleted as needed, and he was treated with
thiamine, multivitamins, and folate daily.
.
#. GI bleed / anemia: after OG tube placement, patient had
coffee grounds on suction. Likely chronic from long-term
alcoholism, and portal gastropathy. Clinically stable. [**Month (only) 116**] be
exacerbated by gastritis. Started on pantoprazole 40mg [**Hospital1 **] IV
and continuous octreotide for 72 hours. Hematocrit went down to
19, requiring transfusion of 2 units PRBC. Patient had a recent
endoscopy at [**Hospital1 **] [**Location (un) 620**] that did not have esophageal varices, so
the decision was made to not do urgent endoscopy. His hematocrit
stabilized and OG suction mostly cleared prior to extubation.
Pt's Hct was stable at 24 for several days and improved to 28 by
day of discharge. Pt was started on nadolol 40mg daily to try to
decrease his portal hypertensive gastropathy. Pt did continue to
have blood-coated bowel movements due to his chronic
hemorrhoids, which improved with his home nightly hydrocortisone
suppositories.
.
# Transaminitis: also with severely elevated bilirubin,
consistent with alcoholic hepatitis. Has a history of repeated
episodes of alcoholic hepatitis. Hepatology service was
consulted. Discriminant function of 37 suggests suggested a
benefit from steroid therapy, so once his blood cultures and
hepatitis serologies were negative, he was started on prednisone
40mg daily, which was continued with plateau of Tbili at ~11. Pt
was therefore felt to be likely to benefit from full 4 week
course of steroids and was continued on prednisone 40mg daily.
However, given his rapid improvement, prednisone was
discontinued on [**2137-11-6**] and bilirubin continued to downtrend to
9.2 on day of discharge. Pt was also treated for several days
with aggressive nutrition via NG feeding tube. Nutrition consult
did a calorie count and estimated that Pt was consuming ~ 800
calories per meal. Since our goal for alcoholic hepatitis was ~
[**2125**] calories per day, tube feeds were not deemed necessary, and
feeding tube was discontinued no day of discharge. Pt was
instructed to eat large nutritious meals for the next few weeks
to aid his recovering liver. Pt was instructed not to restart
his pentoxyfiline on discharge.
.
# s/p fall, R humeral greater tuberosity fracture: Patient
arrived with multiple ecchymoses consistent with fall. Right
shoulder films showed a small fracture of the greater tuberosity
of the humerus. Orthopedics was formally consulted and suggested
sling and non-weightbearin status on R arm until he is seen in
outpatient orthopedic clinic on [**11-13**]. Pt was started on
vitamin D and calcium.
.
# Possible subdural hematoma: CT head from [**Hospital1 **] [**Location (un) 620**] showed a
possible subdural hematoma in the falx cerebri. Repeat imaging
at [**Hospital1 18**] showed resolution. Pt did not have any further
seizures. Pt did not have any focal neurological deficits.
.
# ? PNA: OSH CT reportedly with features concerning for
multilobular PNA. Pt certainly at risk for aspiration but did
not have fever or leukocytosis. Chest XR's at [**Hospital1 18**] did no show
any focal opacities or infiltrates. No antibiotics were given.
Pt remained afebrile and w/out any respiratory symptoms.
.
# ST depressions on EKG: Patient had ST depressions in V2-V4
without any symptoms concerning for ACS although pt unable to
clearly articulate. Likely rate related. Repeat EKG showed
resolution, and troponins remained negative. Pt did not have any
further concerning ECG changes or cardiac symptoms.
.
TRANSITIONAL ISSUES:
-Pt needs to stop drinking alcohol. Pt was given several choices
for detox programs. 1) [**Hospital 83176**] Hospital in [**Location (un) **], which
is an outpatient 5 days/week program. Contact [**Name (NI) **] at [**Telephone/Fax (1) 83177**]. 2) [**Hospital1 12671**] in [**Hospital1 1559**], which is an inpatient program.
Contact [**Name (NI) 41215**] at [**Telephone/Fax (1) 83178**]. He is supposed to call one of
these programs on Monday, [**11-11**], and [**Hospital1 18**] social worker
[**Name (NI) 501**] [**Name (NI) 56051**] will contact him to ensure he follows through.
-Pt needs to see orthopedics regarding further management of his
small R humeral fracture.
-Pt needs derm follow-up / workup of his extensive rash
-Pt has a murmur of unclear etiology and states that he has
never had any workup.
Medications on Admission:
CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
PENTOXIFYLLINE - (Prescribed by Other Provider) - 400 mg Tablet
Extended Release - 1 Tablet(s) by mouth three times a day
Medications - OTC
MAGNESIUM OXIDE - (OTC) - 250 mg Tablet - 1 Tablet(s) by mouth
once a day
MILK THISTLE [MILK THISTLE EXTRACT] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for sbp < 90 or hr < 55.
Disp:*60 Tablet(s)* Refills:*0*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydrocortisone acetate 25 mg Suppository Sig: One (1)
Suppository Rectal QHS (once a day (at bedtime)).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for psoriasis.
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
alcoholic hepatitis
alcohol withdrawal
fracture of right greater tuberosity of humerus
Secondary:
hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 3517**],
You were originally brought to the hospital by your father after
he found you down at the bottom of the stairs. You most likely
had an alcohol withdrawal seizure. You were transferred to [**Hospital1 18**]
for further care. You had to be intubated during your stay in
the ICU and you briefly needed cardiopulmonary resuscitation
(CPR). Your clinical condition improved with aggressive
nutrition and with steroids. You will need to see a liver
specialist (Hepatologist) about your alcoholic hepatitis. You
also had a small fracture of your right upper arm and you were
seen by our orthopedic specialists, who wanted to treat your
fracture with a sling for one week followed by arm exercises.
You should continue to wear your right arm sling until you see
your orthopedic surgeons on [**11-13**] (see below). You should also
see a dermatologist because your skin lesions may not be
psoriasis. YOU MUST STOP DRINKING ALCOHOL, or you will likely
shortly succumb to your disease.
We have made the following changes to your medications:
-Start nadolol 40mg tablets, 1 tab daily
-Start vitamin d and calcium
-start tramadol for pain, you can take it up to every six hours
-stop pentoxyfiline
Followup Instructions:
Department: ORTHOPEDICS
When: WEDNESDAY [**2137-11-13**] at 1:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2137-11-13**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: THURSDAY [**2137-11-21**] at 4:50 PM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: Gastroenterology
Name: [**First Name4 (NamePattern1) 5987**] [**Last Name (NamePattern1) 41573**], MD
When: Tuesday [**2137-12-17**] at 2:30 PM
Location: [**Hospital 864**] [**Hospital3 249**]
Address: [**2137**] [**Apartment Address(1) 44649**], [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 44650**]
Department: Dermatology
Notes: The Dermatology Department in [**Location (un) 620**]/ [**Location (un) 55**] is
working on a hospital follow up appointment in 1 month after
your hospital discharge. If you have not heard from the office
in 2 business days please call the number listed below.
Phone: ([**Telephone/Fax (1) 31239**]
Completed by:[**2137-11-8**] | [
"51881",
"42789",
"2875"
] |
Admission Date: [**2201-4-15**] Discharge Date: [**2201-4-17**]
Service: SURGERY
Allergies:
Nitrofurantoin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] year old female transferred from [**Hospital **] with a
ruptured AAA. She had a known AAA and was being followed by
serial US exams. She has refused surgery in the past. On [**2201-4-15**]
she complained of abdominal pain and had a syncopal episode. She
presented to [**Hospital6 17183**] where a CT abdomen was performed
and found a 7.1 cm AAA with retroperitoneal rupture. Patient was
transferred here because she wanted to consider operative
interventions.
Past Medical History:
Depression
AAA
Chronic renal insufficiency
CAD
Social History:
Lives alone. Husband died 5 months ago
Family History:
n/a
Physical Exam:
Physical Exam on Admission
Vital Signs: RR: 13 Pulse: 61 BP: 157/56
Neuro/Psych: Oriented x3, Affect Normal.
Neck: No right carotid bruit, No left carotid bruit.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear.
Gastrointestinal: Mildly distended, No masses, prominent
pulsation, tender to palpation.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE Femoral: P. DP: P. PT: P.
LLE Femoral: P. DP: P. PT: P.
Pertinent Results:
[**2201-4-15**] 07:05AM BLOOD WBC-6.1 RBC-3.58* Hgb-10.7* Hct-33.4*
MCV-93 MCH-29.9 MCHC-32.0 RDW-14.7 Plt Ct-89*
[**2201-4-15**] 07:05AM BLOOD Glucose-116* UreaN-30* Creat-1.6* Na-142
K-4.7 Cl-114* HCO3-24 AnGap-9
[**2201-4-15**] 07:05AM BLOOD Calcium-7.0* Phos-3.9 Mg-1.4*
[**2201-4-15**] 07:14AM BLOOD Glucose-109* Lactate-1.4 Na-141 K-4.7
Cl-111 calHCO3-21
CT Scan OSH: [**2201-4-15**] 03:30
Juxtarenal AAA with rupture.
Brief Hospital Course:
Mrs. [**Known lastname 86771**] was admitted to the cardiovascular intensive care
unit after transfer from [**Hospital3 15402**]. On review of her CT scan it
was found that her AAA was juxtarenal and therefore not amenable
to an endovascular stent graft for rupture. Discussions of an
open repair were held with the patient and her family and the
decision was made not to surgically repair. She was treated
with strict blood pressure control to avoid hypertension with
the knowledge that this likely would be fatal without surgery.
Her pain was controlled with minimal pain medication requirement
and she actively participated in discussions of her care. Over
the course of the first day the patient did quite well. Her
blood pressure was controlled initially with a nitroglycerin
drip. The nitro was stopped at 10PM on HD#1 and her systolic
blood pressures were stable at 110-120. The following morning
however her blood pressure dropped precipitously to 60s systolic
and she began to become more lethargic. Given this change in
her course, discussions were held with the family and per the
patients prior wishes she was made comfort measures only. Over
the course of HD#2 her blood pressure rebounded somewhat however
she became aneuric. She remained lethargic but was arousable
and responded to questions and denied pain. Overnight she
became more somnolent and obtunded with minimal responses. She
began moaning with movement and morphine was given for comfort.
She was noted to expire at 9:25AM. Her niece was at her
bedside. Autopsy was denied.
Medications on Admission:
Aspirin 81mg qdaily; Clonazepam 0.5mg qdaily; Esmoprezole 40mg
qdaily; Lopressor 25 mg [**Hospital1 **]; Pravastatin 20mg qdaily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Ruptured abdominal aortic aneurysm
Discharge Condition:
Expired
Discharge Instructions:
Patient expired
Followup Instructions:
n/a
| [
"V4581",
"40390",
"5859"
] |
Admission Date: [**2170-10-10**] Discharge Date: [**2170-10-18**]
Date of Birth: [**2126-9-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
left posterior fossa mass
Major Surgical or Invasive Procedure:
History of Present Illness:
Patient is a 44M electively admitted for surgical resection of
left posterior fossa mass, and angiographic embolization of mass
blood supply
Past Medical History:
1. Anxiety/Depression
2. Meniere's Disease with total deafness L ear
3. Hypertension
Social History:
Married, resides at home with wife and two children
Family History:
non-contributory
Physical Exam:
On Admission:
Patient is alert, oriented to person, place and date.
PERRL.EOMI, face symmetric; tongue is midline. No pronator
drift. Slight left sided dysmetria. Full strength and sensation
in the upper and lower extremities.
On Discharge:
Patient is alert, oriented to person, place and date.
PERRL.EOMI, face symmetric; tongue is midline. No pronator
drift. Full strength and sensation in the upper and lower
extremities.
Pertinent Results:
Labs on Admission:
[**2170-10-11**] 01:38AM BLOOD WBC-10.1 RBC-4.89 Hgb-14.6 Hct-41.7
MCV-85 MCH-29.9 MCHC-35.1* RDW-13.8 Plt Ct-219
[**2170-10-11**] 01:38AM BLOOD PT-11.3 PTT-22.5 INR(PT)-0.9
[**2170-10-11**] 01:38AM BLOOD Glucose-127* UreaN-13 Creat-0.8 Na-140
K-4.7 Cl-105 HCO3-24 AnGap-16
[**2170-10-11**] 09:20PM BLOOD Calcium-9.3 Phos-4.7*# Mg-2.0
[**2170-10-11**] 09:20PM BLOOD Osmolal-299
Post-op MRI Head [**10-12**]:
showing adequadte decompression of left temporal mass.
Brief Hospital Course:
Patient was electively admitted on [**2170-10-10**] for left posterior
fossa craniotomy for mass resection. He was taken to the OR on
[**2170-10-11**], after an uneventful/successful embolization procedure
the evening prior. Prior to incision; an external ventricular
drain was placed, to assist with post-operative intracranial
volume managment. Post-operatively, the patient was returned to
the ICU. On POD#1, he had an MRI which revealed significant
decompression of intracranial lesion. His EVD remained in the
event it was required for post-surgical hydrocephalus. On POD#4,
the EVD was clamped and tolerated well. Subsequently, the EVD
was discontinued on POD#5. He was tapered off steroids and
mannitol. On [**10-16**], he was transferred from the ICU to the
NSURG floor. He was seen and evaluated by PT and OT who
determined he would be appropriate for disposition to rehab. He
was discharged accordingly on [**2170-10-18**].
Medications on Admission:
Ativan 1mg", Propanolol SA 60mg',Lamictal 150mg", Cymbalta
60mg', Ibuprofen 600mg PRN
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
11. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left posterior fossa Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**6-15**] days (from your date of
surgery) for removal of your staples/sutures and a wound
check(including abdomen-these stitches are dissolvable). This
appointment can be made with the Nurse Practitioner, or they can
be removed during rehabilitation. Please make this appointment
by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**11-19**] at 3
pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your hospitalization.
Completed by:[**2170-10-18**] | [
"4019"
] |
Admission Date: [**2101-4-10**] Discharge Date: [**2101-4-13**]
Date of Birth: [**2038-10-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Recurrent malignant right main stem
obstruction and hemoptysis.
Major Surgical or Invasive Procedure:
Rigid bronchoscopy, flexible bronchoscopy, tumor
destruction, and tumor ablation with APC.
History of Present Illness:
62M with NSCCa in R bronchus with recent massive
hemoptysis. Patient also has C. diff colitis. He was admited
to
[**Hospital 1727**] medical center on [**2101-3-29**] with 2 wk h/o hemoptysis and
COPD
exacerbation. Patient treated with Augmentin and Prednisone.
Patient had flex bronch that showed mass in right mainstem
bronchus. Patient transferred to [**Hospital1 18**] for further care.
Patient underwent rigid bronch w/mechanical debridement on [**4-11**].
Patient found to have c. dif. at OSH and started on flagyl on
[**4-8**].
Past Medical History:
HTN, DM2, hyperlipid, GERD, Gout, OA, DVT/PE - IVC filter,
NSCLC stage 1 s/p RLL lobectomy in 98 at MMC c recurrence in RML
in [**2099**] tx with XRT and brachy, severe COPD, pulm HTN, cor
pulmonale
Physical Exam:
PE
T 97.3 HR 109 ST BP 95/55 RR 15 94% 4L NC
A&O
Sinus tachy
CTA bilateral
Soft, distended, none tender, no reboud, no guarding, no
hernias,
no surgical scar
Guiac negative
Pertinent Results:
[**2101-4-10**] 05:15PM GLUCOSE-226* UREA N-43* CREAT-1.3*
SODIUM-131* POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-28 ANION GAP-15
CT trachea [**2101-4-11**]
IMPRESSION:
1. Soft tissue thickening and nodularity of anterior wall
proximal right main bronchus with nonobstructive luminal
narrowing. In a patient with history of lung cancer, this is
concerning for endobronchial neoplasm involvement. However, if
the patient has had prior stent placement or other intervention,
granulation tissue is an additional consideration.
2. Abrupt cut off of the proximal right lower lobe bronchus,
possibly due to previous surgery for right lower lobe resection
for lung cancer. Correlation with operative history is
recommended to differentiate truly obstructed bronchus from
postoperative change.
3. Extensive abdominal ascites and mild anasarca.
4. Emphysema.
KUB [**4-12**]
IMPRESSION: Mildly dilated air-filled loops of large bowel,
consistent with colonic ileus. No evidence of obstruction.
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from [**State 1727**] and on HD#2, underwent right
mainstem bronchus stenting as a way to treat his malignant
obstruction and hemoptysis. The patient was hypotensive through
the procedure requiring pressors and and also had transient
episodes of hypoxemia. The patient was aggressively fluid
resuscitated, and a stat trans-esophageal echocardiogram was
performed showing severe pulmonary hypertension (PASP estimated
at 101mmHg), severe hypokinesis of the RV / septum, no evidence
of shunt, and a relatively normal LV. The patient was
transferred to the intensive care unit intubated and requiring
pressors. Of note, the patient was weaned from the vasopressor
agents 1 hour after arriving to the intensive care unit and was
extubated
immediately afterwards.
On HD#3, he persisted in being hypotensive. His breathing was
labored, and his abdomen was found to be more significantly
distended that before. A general surgery consult was obtained to
evaluate his abdomen. He was found to have C. difficile colitis
without signs of toxic megacolon, and was treated with IV
metronidazole and PO vancomycin.
Originally, the intention of the family and the team of people
taking care of him here at [**Hospital1 18**] was to stabilize him to the
point that he may be transferred back home to be with his family
for what was sure to be his final [**Known lastname **]. During extensive
conversations with both the family and the patient, it was again
reiterated that he wanted no surgery or no extraordinary
measures to save his life. As the night wore on, the patient was
in increasing amounts of pain, but pain medication precipitously
dropped his blood pressure. More conversations were had with the
patient and his family, after which the decision was made to
provide the patient with comfort measures only, this being the
only way to relieve his suffering with pain medication while
respecting wishes to avoid aggressive measures to save his life.
He passed away about 2 hours after being made CMO. Offer of an
autopsy was declined by the family.
Medications on Admission:
Albuterol-Ipratropium, Enalapril Maleate 2.5', Furosemide 40',
Guaifenesin, Insulin, Flagyl, Metoprolol, Prednisone 5'
Discharge Disposition:
Extended Care
Discharge Diagnosis:
NSCLC w/ right main stem hemoptysis.
s/p rigid bronch w/ mechanical debridement and cautery [**2101-4-11**]
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2101-4-28**] | [
"496",
"2724",
"25000",
"4019",
"4168",
"53081"
] |
Admission Date: [**2174-1-11**] Discharge Date: [**2174-1-21**]
Date of Birth: [**2106-4-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname 93733**] is a 67 year old man with history of severe COPD (on
3.5L home O2 and chronic steroids x 4 years, previously
intubated on several occasions), was who was hospitalized at
NEBH from [**Date range (1) 93734**] for a pseudomonal and proteus pneumonia,
and had been discharged on cefepime to pulmonary rehab at [**Hospital1 15454**] from [**Date range (1) 86904**], where on [**2174-1-10**] he was found to
have a bright red bloody bowel movement. His Hct was seen to
fall from 35.8 ([**1-8**] @11:40) to 32.7 ([**1-10**] @8:23). His Hct was
28.6 on [**1-10**] @10pm. He received one unit of pRBCs with Hct
increase to 33.2 ([**1-11**] @8:38). He was transfered to NEBH for
further evaluation however there were no ICU beds so he was
transferred to [**Hospital1 18**]. The patient's wife states that he had
worsening confusion for the 2 days prior to admission. She
states that he has been confused over the past few weeks over
the course of these illnesses.
.
In the [**Hospital1 18**] ED his initial vitals were unremarkable. He
received 1 dose of cefepime and flagyl and was admitted to the
MICU.
.
In the MICU he received one unit of PRBCs and serial HCTs bumped
appropriately and were stable. GI consulted and felt that there
was no urgent need for an inpatient colonoscopy. However, blood
cultures from [**1-11**] grew [**5-12**] bottle of pan-sensitive (ampicillin)
enterococcus. He was briefly treated empirically with vanc and
then linezolid until sensitivities were available, and then
switched to ampicillin [**1-14**]. He was not intubated but did have
an O2 requirement. His mental status was largely intact but he
did have episodes of agitation which responded to low dose
haldol. He was deemed stable for transfer to the floor on [**1-14**].
.
On the floor, he was afebrile and had no further GI bleeding.
Serial HCTs were stable. He continued to demonstrate an O2
requirement, satting in the high 80's to low 90's on 4-5L NC. On
the call of call-out he triggered for tachypnea, and he did
occasionally have brief (1 minute) self limited episodes of
tachypnea with associated desaturations to the mid-low 80's.
These were largely felt to be due to anxiety and he responded
well to low dose haldol and ativan. On [**1-17**], he reveived a PICC
line in anticipation of d/c. Later that afternoon, he became
hypoxic to the mid 70's and had increased somnolence. An ABG
showed extreme hypercarbia to 99. Due to his worsening CO2
narcosis/somnolence, he was voluntarily intubated and
transferred back to the MICU for further management.
.
Past Medical History:
CHF
atrial flutter s/p ablation
hypertension
multiple pneumonias
glaucoma
osteoporosis
compression fx spine
rib fracture
gastroesophageal reflux disease
cor pulmonale
obstructive sleep apnea
diabetes mellitus
Social History:
50yrs x 1.5 ppd smoking hx. Stopped smoking 4 years ago. Prior
to hospitalizations lived with wife, son, and daughter-in-law.
[**Name (NI) **] EtOH in 35 years.
Family History:
Noncontributory. no history of GI bleeds
Physical Exam:
Vitals: T 97.9 P 86 R 17 109/72 96%3L
Gen: plethoric. multiple ecchymotic patches
HEENT: PERRL (4->2mm) EOMI MMM
Neck: no IJ seen. supple
Chest: bilat wheeze with prolonged I:E ratio
CV: regular. tachy s1/s2 no m/r/g
Abd: obese. soft. active sounds. mild tenderness to LLQ w/o
rebound
Ext: marked calf wasting. trace edema to ankles.
Skin: multiple ecchymosis
Neuro:
-MS: alert, oriented to self, "hospital", "[**2174**]", "[**Last Name (un) 2450**]"
-CN: II-XII intact
-Motor: moving all 4 extremities
-[**Last Name (un) **]: intact to light touch over face, hands, feet.
Pertinent Results:
Na 145
K 3.9
Cl 98
HCO3 36
BUN 32
Creat 0.6
Gluc 141
.
WBC 12.4
HCT 35.2
Plt 277
.
[**2174-1-11**] 03:30PM LACTATE-1.5
.
Studies:
Abd X-Ray: Limited due to body habitus. Bowel gas pattern
demonstrates no definite evidence of ileus or obstruction.
There is no free air on upright view. Air is seen throughout
segments of the large bowel and appears unremarkable. Visualized
osseous structures are intact. Visualized lung bases are clear.
Brief Hospital Course:
Summary: 67 year old man with history of COPD, OSA, aflutter s/p
ablation with recent subacute altered mental status transferred
from OSH for w/u hematochezia found to have [**5-12**] blood cx
+enterococcus.
.
# Enterococcal bacteremia: The source of the infection was
unclear as culture data was incomplete. Urine or PICC line were
thought to be most likely sources. Pt initially treated with
linezolid; when sensitivities returned, he was transitioned to
IV ampicillin with a two week course planned. He received a R
PICC line on [**1-17**]. He was started on IV ampicillin and
remained afebrile until his transfer back to the ICU on [**1-17**]
for hypoxia and hypercarbia. (see below). He was noted to have
worsening leukopenia and thromocytopenia while on ampicillin and
although it has probable better coverage than vancomycin, the
ampicillin was replace by vancomycin for total 14-day course.
.
# Respiratory: Pt began treatment at OSH for pseudomonas and
proteus PNA with ceftazidime on [**12-30**]; this was d/c'd after a 14
days. There was initially a question of possible TB exposure
given cavitary lesions reported on OSH CT, but AFB stain of BAL
were negative. A CT in-house shows emphysematous lesions,
retained secretions with L upper lobe lung nodules and RML
collapse. CXR also confirms opacity L base and RML/RLL collapse.
Pt also w/ significant COPD on high-dose steroids. On [**1-14**] he
was called out from the ICU. The patient's solumedrol was
transitioned to PO prednisone daily, with a taper planned. He
was started on Bactrim DS 3x/week for PCP prophylaxis while on
high-dose steroids. However, on [**1-17**], he demonstrated
increasing somnolence and an ABG showed a CO2 of 99, so the
patient was intubated for ventilation and transferred back to
the ICU. He was extubated after 24 hours and continued to do
well. His respiratory distress appeared to be exacerbated by
anxiety as well as intolerance of face mask. His anxiety also
makes Bipap nearly impossible and he cannot use it to treat his
sleep apnea. He does best on nasal cannula with O2 sat goal
90%. Anxiety control is therefore paramount to his respiratory
status with emphasis on minimizing meds that will cause
somnolence and respiratory depression.
.
# Hematochezia: A lower source of bleeding was felt more likely
over upper source based on the presence of bright red blood.
Differential included diverticular bleed, ischemic colitis,
polyp, hemorrhoid. The pt's HCT responded appropriately to
transfusion of one unit pRBCs. GI was consulted; as the pt was
clinically stable, no inpt endoscopy was performed. The pt
should undergo colonoscopy as an outpt. [**Hospital1 **] PO PPI therapy was
initiated. His HCTs were entirely stable on the floor and he had
no further episodes of BRBPR.
.
# Mental Status and Anxiety: The patient's subacute change in MS
was felt likely related to steroids, sedating medications,
prolonged hospitalization. Sedating medications were limited,
although it was found that the patient has a good therepeutic
response to low-dose Haldol administered in the evenings. He was
evaluated by psychiatry who recommended discontinuing the
zyprexa the pt was on from his past hospitalization. No further
diagnoses were established, but per pt's wife, he has a baseline
anxiety. Haldol 0.5-1mg can be given on PRN basis but pt also
responds well to reasoning. Ativan 1mg PRN can be second-line
treatment.
.
# HTN: The pt's home dose of diltiazem had been lowered given
bleed; this was slowly titrated back up with good effect.
.
# Atrial Tachycardia: The pt's home dose of diltiazem had been
lowered given bleed; this was slowly titrated back up with good
effect, though is baseline HR is in 100s
.
# DM: The patient's home metformin was held and he was managed
on an insulin sliding scale with standing glargine.
Medications on Admission:
azopt eye drops 1 drop [**Hospital1 **]
lumigan eye drops 1 drop [**Hospital1 **]
lasix 40 mg daily
solumedrol 40 mg q12
ceftazidime 1 gm q8hours
fosamax 70 mg qTuesday
celexa 20 mg daily
zyprexa 2.5 mg daily
zyprexa 5 mg qHS
nexium 40 mg [**Hospital1 **]
regular insulin sliding scale
advair diskus 250/50 1 puff [**Hospital1 **]
levalbuterol 1 neb q6
diltizem CR 240 mg daily
colace 100 mg [**Hospital1 **]
guaifenesin 1200 mg [**Hospital1 **]
lidocaine patch daily
metformin 500 mg [**Hospital1 **]
potassium chloride 20mEq daily
remeron 15 mg qhs
levalbuterol 1 neb q3h:prn
atrovent neb q6h
tylenol 650 mg q4:prn
bisacodyl 10 mg daily
vicodin 1-2 tabs q4h:prn
ambien 10 mg qhs:prn
ativan 0.5 mg q6:prn
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
2. Erythromycin 5 mg/g Ointment Sig: 0.5 Ophthalmic [**Hospital1 **] (2
times a day): both eyes.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
5. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Ipratropium-Albuterol 0.5-2.5 mg/3 mL Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed.
13. Furosemide 10 mg/mL Solution Sig: Four (4) mg Injection
DAILY (Daily).
14. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for shakiness, agitation: hold for sedation or
respiratory rate <10; prn haldol should be first-line [**Doctor Last Name 360**].
15. Haloperidol 1 mg IV HS
16. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mg
Injection Q3H (every 3 hours) as needed for agitation.
17. Vancomycin 1000 mg IV Q 12H
day 1 [**1-11**], to stop [**1-25**]
18. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) neg
Inhalation Q2H (every 2 hours) as needed.
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
20. azopt eye drops 1 drop [**Hospital1 **]
21. lumigan eye drops 1 drop [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY:
Chronic obstructive pulmonary disease
SECONDARY:
Gastrointestinal Bleed
Anxiety
Multifocal Atrial Tachycardia
Enterococcal bacteremia
Discharge Condition:
Good; breathing comfortably on 2L nasal cannula with increased
control of anxiety.
.
BP 100s/60s, HR 110s, O2sat 91% on 4L
Discharge Instructions:
You were transferred from an outside hospital for evaluation of
a gastrointestinal bleed. You were seen by the GI consult
service and because you did not appear to have an acute active
bleed and your blood counts remained stable, you can follow-up
with them as an outpatient.
.
You were being treated for pneumonia on your arrival and you
finished a 14-day course of antibiotics.
.
You were noted to have bacteria in your blood and were started
on intravenous antibiotics. You will need to have a 2-week
course. It is unclear what [**Doctor Last Name **] source of the bacteria was, put
the indwelling IV catheter (PICC) from the OSH or a urinary
tract infection were suspected.
.
You also had difficulty with your breathing and required
intubation for respiratory distress. Exacerbation of your COPD
and over-sedation were thought to explain your respiratory
compromise. You were intubated for less than 24 hours and did
well.
.
Some changes in yoru medications were made. Please discard all
of your prior medications and start those prescribed.
.
If you develop any concerning symptoms, please call your
physician or proceed to the emergency department.
Followup Instructions:
Schedule a follow-up appointment with your primary care doctor
when you are discharged from the rehabilitation hospital, Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) **]
.
Please call [**Hospital **] clinic to schedule a follow-up colonoscopy. ([**Telephone/Fax (1) 667**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
| [
"51881",
"4019",
"53081",
"25000",
"32723",
"42789",
"42731"
] |
Admission Date: [**2128-8-6**] Discharge Date: [**2128-8-17**]
Date of Birth: [**2067-10-24**] Sex: F
Service:
DISCHARGE DIAGNOSIS: Bacteremia/hypotension.
CHIEF COMPLAINT: Hypotension/bacteremia.
HISTORY OF PRESENT ILLNESS: Sixty-year old female with
history of CAD status post CABG, end-stage CHF on chronic
dopamine, status post biventricular pacer with an EF of 20%,
a transthoracic echocardiogram on [**11/2127**] and diabetes
mellitus. Recently admitted on [**7-2**] to [**7-3**] for
bacteremia, coag-negative Staph, plus Stenotrophomonas, who
presents complaining of diarrhea x2 days, also with positive
fevers up to about 102. Pertinent details of her previous
hospitalization include a similar presentation with diarrhea
and fevers. The decision was made with ID to not to treat
her systematically and to leave her Hickman line intact.
She was then discharged on antibiotics.
Husband noted that patient was weak and unable to get out of
bed this morning and was lightheaded. Had diarrhea with mild
abdominal cramping, no nausea, no vomiting, nonbloody. No
change in diet. No sick contacts. [**Name (NI) **] chest pain, shortness
of breath, or dysuria. States that she has occasional calf
pain with no swelling. On arrival to ED, noted to be
hypotensive with blood pressures of 40s/20s. Normally she
runs 60s-80s/30s-50s. Noninvasive cuff correlates with
manual readings. Her dopamine was increased to 20 and was
given IV fluid bolus 500 cc x1.
PAST MEDICAL HISTORY:
1. CAD status post CABG in [**2120**], redo in [**2123**]. MR, CHF on
chronic dopamine drip, status post biventricular pacer in
'[**23**].
2. GI bleeds with AVM status post cauterization in 04/[**2127**].
3. Chronic renal insufficiency.
4. Diabetes mellitus.
5. Peripheral vascular disease.
6. History of coag-negative Staph line infection.
7. Prosthetic mechanical mitral valve, requiring coumadin
anticoagulation 8. Recurrent atrial reentrant tachyarrhythmia,
managed with recent pacer revision to atrial tachycardia
devise
HOME MEDICATIONS: 1. Bumex two b.i.d. 2. Coumadin.
3. Ativan.
4. [**Doctor First Name **].
5. Aldactone 5 q.d.
6. Lasix 120 q.a.m. and 80 p.m.
7. Zoloft 100 b.i.d.
8. Colace.
9. Senna.
10. Lipitor 10 q.d.
11. Enalapril 15 b.i.d.
12. Carvedilol 6.25 b.i.d.
13. Zantac.
14. Aspirin 81 mg q.d.
15. Trazodone 100 mg q.d.
16. Dopamine 8 mcg/kg/minute chronic home IV infusion
SOCIAL HISTORY: Lives with her husband in [**Name (NI) 13588**].
VITAL SIGNS: Temperature was 101, her T max and her T
current was 99.7 on admission. Her blood pressure was 63/33
on admission to CCU. Her pulse was 80. Respiratory 18. She
was sating 96% on 2 liters, later on 91% on room air.
PHYSICAL EXAMINATION: Generally: She was awake,
diaphoretic, sleepy, but easily arousable and verbally
responsive. HEENT: PERRLA and extraocular motor is intact.
Moist membrane mucosa. Neck was supple. Lungs are clear to
auscultation bilaterally. No murmurs, rubs, or gallops.
Cardiovascular: She had a metallic sound, more of a systolic
murmur best heard on her apex. Otherwise, regular, rate, and
rhythm. Abdomen: Bowel sounds were present, soft,
nontender, nondistended. Extremities: Cool extremities,
unable to palpate dorsalis pedis pulses bilaterally.
Neurologic is oriented x3. Strength is [**3-22**] throughout, no
focal deficits.
LABORATORIES ON ADMISSION: White blood cells 3.0, hematocrit
29.3, platelets 150. Sodium 131, potassium 5.3, chloride 96,
bicarb 20, BUN 71, creatinine 2.9, and glucose 80. Albumin
3.7, calcium 8.7, magnesium 1.8, phosphorus 5.3, INR 4.0, and
PTT of 39.1. ALT of 77, LDH 27, alkaline phosphatase 189,
AST 71. CK 318. Total bilirubin 1.6, and lipase 27.
EKG was AV sequentially paced, left bundle branch block, rate
81, normal QRS axis, no ST-T wave changes.
Chest x-ray: No acute redistribution of flow. Enlarged heart.
HOSPITAL COURSE: For CAD, no acute issues at this point.
She is continued on her aspirin and statin since she was
admitted. Her beta blockers and ACE initially were held in
the setting of low blood pressures.
For her pump, well compensated and likely hypovolemic. She
was challenged with IV fluid boluses 250 cc each time and the
Bumex and Lasix were held at that time initially, and
continued with the aldactone for now.
For hypotension, she was kept on dopamine. Dopamine drips
were increased with a titration goal given a systolic blood
pressures of greater than 60 with IV boluses and dopamine
drip. Her picture was most likely a mix between a
cardiogenic component and a distributive secondary to sepsis.
Rhythm: She was placed on telemetry, and was paced, and she
was biventricularly paced, but no right bundle branch block,
questionable though.
She had an acute renal failure on top of her chronic renal
insufficiency likely related to her hypovolemia which had
resolved upon her discharge and possibly secondary to her
diarrhea in setting of chronic requirement for diuretics.
Her fevers were likely secondary to infection of the Hickman
based on previous admission. We are awaiting culture data.
There was much discussion of her Hickman line previous
admission. We will need to clarify at time with Dr. [**Last Name (STitle) **]
for possible plans for her central access. On admission, she
was started on empirical Vancomycin, levofloxacin, and Flagyl
to cover the GI scan and Clostridium difficile, and she was
added for stool studies. Her Coumadin was held at the time
because she was supertherapeutic, INR of 4.0. Her goal INR
is 2.5. On her discharge, according to Dr. [**Last Name (STitle) **], her goal
INR has changed, now between 2-2.5 given that she has a
valve.
For diabetes, she was put on regular insulin-sliding scale.
She tolerated that well and sugars within acceptable goals.
Prophylactically, she was ambulating later on day two of
hospitalization. For her cardiovascular, we will still
continue with her aspirin and statin. We are still holding
the beta blockers until volume status stabilizes. Considering
restarting beta blocker as she can tolerate her blood
pressure.
In terms of her ID status, she was continued on her
Vancomycin, levofloxacin, Flagyl, and Zosyn for broad
coverage, and ID was consulted for further input. ID was
then consulted. ID recommended to discontinue Zosyn,
discontinue Vancomycin, and discontinue Flagyl, to continue
levofloxacin and to change the dose to 250 q.24h., also check
the stool for Clostridium difficile. They also recommended
repeat blood cultures x2 and labeled the site of the
specimens, which was done when she was admitted. They also
said that if blood cultures from [**8-6**] show Stenotrophomonas,
would consider transesophageal echocardiogram, and would
consider removing her Hickman catheter. It is recognized that
access for Hickman is formidable issue, requiring prior
replacement in operating room.
On [**8-8**], her levofloxacin was increased from
250 to 500 given that 2/3 bottles from [**8-6**] grew
gram-negative rods. She remained afebrile meanwhile and
lungs were clear. Her blood pressures with dopamine drip was
much improved by [**8-8**], and she was back to her home IV
dose of 8 mcg/kg/minute, which she continued to be on that
dose until discharge date.
On [**8-9**], ID suggested to continue levofloxacin, and also
because the blood cultures also grew budding yeast. They also
recommended to start fluconazole at which point, she was
started on fluconazole 400 mg IV q.24h. with close [**Month/Year (2) 7941**]
of INR because of the interaction of fluconazole with
Coumadin. Though her blood cultures from the previous
gram-negative rods actually grew Klebsiella, she was
continued on levofloxacin to cover the Klebsiella, which was
sensitive to levofloxacin.
Surgery was contact[**Name (NI) **]. The Cardiology service,
and Medicine service, and Infectious Disease service, they
all agree that the Hickman line should be removed and replaced
if feasible. Balancing risk/benefit, surgery disagreed and
wanted the Hickman line in thinking that
since the patient has been asymptomatic and afebrile, and
because of the need for dopamine drip and the need for central
access that medical management may suffice for the time
being including antibiotic coverage.
They noted that if the patient became symptomatic, then it is
necessary there might be a need for a high risk surgical
change in the line.
Later on in the course on [**8-9**], patient also grew
gram-positive cocci in clusters, which later on grew to be a
Staphylococcus aureus. Patient was started on Vancomycin 1
gram IV q.d. which she continued. On discharge date, patient
since [**8-11**], since being on the triple antibiotics and the
antifungal, the patient's blood cultures have been negative
to date. On discharge date, all cultures have been negative,
and patient was setup with followup with both Cardiology and
[**Hospital **] Clinic, and patient was sent home with an extra two weeks
of antibiotic treatments. If blood sterilization is not
accomplished, the Hickman line may in future need to per
Surgery's continued involvement balancing high risk / benefit.
DISCHARGE INSTRUCTIONS:
1. Patient was discharged to home with VNA services. Patient
was instructed to return to clinic if symptoms return or new
symptoms arise or seek medical attention as needed.
2. Keep all follow-up appointments.
3. Seek medical attention for fever, diarrhea, increased
shortness of breath, or hypertension.
4. Ongoing formal followup - both telephonic and clinic-
planned in detail with advanced Heart Failure Clinic program
FINAL DIAGNOSIS: Septic shock.
SECONDARY DIAGNOSES:
1. Hypotension.
2. End-stage congestive heart failure.
3. Acute and transient renal failure.
4. Chronic renal insufficiency.
5. Ischemic cardiomyopathy.
6. Prosthetic mitral valve.
7. Atrial tachyarrhythmias status post ablation attempt, now
with pacer revision to atrial tachycardia device 8. Diabetes
mellitus type 2. 9. Depression.
RECOMMENDED FOLLOWUPS: The patient is to followup with Dr.
[**Last Name (STitle) 3390**], [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13589**]. Most importantly, to followup with
appointments with Dr. [**Last Name (STitle) **], which she has on [**2128-9-2**] at 1
p.m. at [**Telephone/Fax (1) 3512**] at [**Hospital Ward Name 23**] Center Cardiac Services, also
patient has an appointment with Dr. [**Last Name (STitle) 1617**] at [**Hospital **] Clinic on
[**10-11**].
DISCHARGE CONDITION: Stable and good.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Trazodone 100 mg p.o. q.d.
3. Spironolactone 25 mg p.o. q.d.
4. Sertraline 100 mg p.o. b.i.d.
5. Atorvastatin 10 mg p.o. q.d.
6. Pantoprazole 40 mg p.o. q.d.
7. Lorazepam prn.
8. Enalapril 5 mg b.i.d.
9. Carvedilol 3.125 mg b.i.d.
10. Fexofenadine 60 mg p.o. b.i.d.
11. Docusate 100 mg p.o. b.i.d.
12. Senna prn.
13. Amiodarone 200 mg p.o. q.d.
14. Furosemide 80 mg q.h.s., 120 mg q.a.m.
15. Dopamine drip to titrate to systolic blood pressure over
60-80.
16. Warfarin 2.5 mg with close followup INR checks, first INR
check should be on this Monday when VNA comes in and the INR,
potassium and Vancomycin levels should be faxed to [**Hospital **] Clinic
as directed. The fax number was included in page 1 services.
17. Epoetin 10,000 mg once a week subQ.
18. Fluconazole 400 mg q.d. IV.
19. Vancomycin 1 gram q.d. IV.
Fluconazole, Vancomycin, and levofloxacin are to be taken for
the next 14 days. Levofloxacin 500 q.d. also for the next 14
days. The dates at which is it going to end is the [**10-1**], at which point, she will return to Dr.[**Name (NI) 13590**]
office on the 16th for followup culture.
FOLLOWUP: As discussed above.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2128-8-17**] 17:49
T: [**2128-8-18**] 12:45
JOB#: [**Job Number 13591**]
| [
"5849",
"40391",
"42731",
"41401"
] |
Admission Date: [**2155-8-28**] Discharge Date: [**2155-9-13**]
Date of Birth: [**2113-8-29**] Sex: M
Service: SURGERY
Allergies:
Benzodiazepines
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Anastomotic Leak
Major Surgical or Invasive Procedure:
Exploratory laparotomy, takedown of ileorectal anastomosis and
ileostomy.
History of Present Illness:
41 yo M who is well known to our service after undergoing total
abdominal colectomy on [**2155-8-19**]. He was recently discharged after
resolved ileus. Per report from patient and wife, he was up
this morning at 3 am to go to the bathroom and on his way back
to bed he fell down and was unconscious for approximately 1
minute. He was then taken by EMS to [**Hospital1 18**] for evaluation.
EMS found him with normal VS but were unable to find a suitable
vein for IVF.
In speaking with he and his wife, he has not been taking his
immodium or his narcotics as the prescriptions were not filled.
He has been having multiple bowel movements per day which are
described as liquid. His pain is centered along the lower
flanks bilaterally and is intermitent and crampy in nature.
Past Medical History:
FAP s/p colectomy, obstructive sleep apnea,
overweight.
Social History:
He is married, lives with his wife [**Name (NI) **], and has an 8 month
old son. [**Name (NI) **] works in the print shop at [**University/College 5130**] [**Location (un) **].
# Alcohol: Drinks 2-3 beers every other day, drinks up to [**8-22**]
beers socially on rare weekends
# Tobacco: Never smoked
# Drugs: None
Family History:
# Father -- heavy smoker, died from lung cancer
# Mother -- died from meningitis when patient was 1 year old
# Siblings -- only child
# Maternal Aunt -- died from MI at age 60, also had numerous
colon polyps, possibly from a hereditary syndrome
# Maternal Cousins -- HTN, diabetes, early CAD
No family history of arrhythmia, cardiomyopathy, or other
cancers.
Physical Exam:
On the day of discharge, Mr. [**Known lastname 90297**] was a pleasant male in no
acute distress, he was afebrile and his vitals signs were
stable, his cardiac exam revealed a regular rhythm and his lungs
were clear, his abdomen was soft, nontender, nondistended, with
a productive ileostomy.
Pertinent Results:
CTAP [**2155-9-1**]: Increase in size of the intra-abdominal fluid
collections with multiple new foci of intraperitoneal gas and
increased free intraperitoneal air. The findings are highly
concerning for an anastomotic leak.
[**2155-9-6**] 05:15AM BLOOD WBC-23.6* RBC-3.29* Hgb-8.5*# Hct-26.1*
MCV-79* MCH-25.9* MCHC-32.6 RDW-15.9* Plt Ct-346
[**2155-9-11**] 04:15AM BLOOD WBC-14.0* RBC-3.04* Hgb-7.8* Hct-24.1*
MCV-79* MCH-25.5* MCHC-32.1 RDW-16.7* Plt Ct-566*
[**2155-9-2**] 02:03AM BLOOD Glucose-148* UreaN-15 Creat-1.4* Na-134
K-4.5 Cl-103 HCO3-22 AnGap-14
[**2155-9-10**] 05:00AM BLOOD Glucose-134* UreaN-13 Creat-0.6 Na-138
K-4.7 Cl-107 HCO3-22 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 90297**] was readmitted to [**Hospital1 18**] on [**2155-8-28**], 9 days after a
TAC with IPAA for FAP with dehydration, nausea and vomiting. A
CT on admission showed dilated small bowel, with some associated
ascites. He was fluid resuscitated and an NGT was placed. On
HD5 in the setting of escalating abdominal pain, tachycardia and
altered mental status, he was transferred to the ICU. A CTAP
performed then showed an anastomotic leak, and he was taken back
to the operating room for a resection of the anastomosis and end
ileostomy, please see the operative report for more detail. He
was transferred to the floor on POD 1 and his NGT was removed on
POD2. He was kept on antibiotics. He was kept on TPN until
POD8 when he was taking in enough nutrition PO. His
postoperative course was complicated by high ostomy output for
which he was started on immodium that was titrated up, and
eventually required tincture of opium which was able to control
his output. It was further complicated by tachycardia treated
with metoprolol and insomnia for which he was started on
trazodone. On POD 10 a fistulous tract was noted to be draining
to the skin near the ostomy site but it was decided to just
monitor it. On POD11 he was doing well, his ostomy output was
controlled and was taking in good POs and was stable for
discharge.
Medications on Admission:
Immodium 3mg TID, Vicodin 5/500 q6hr PRN pain
Discharge Medications:
1. opium tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q6H
(every 6 hours).
Disp:*1000 ml* Refills:*0*
2. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day).
Disp:*240 Capsule(s)* Refills:*2*
3. psyllium 1.7 g Wafer Sig: [**2-16**] Wafers PO BID (2 times a day).
Disp:*120 Wafer(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed as needed for insomnia.
Disp:*31 Tablet(s)* Refills:*0*
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four
hours as needed as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Anastomotic leak from ileorectal anastomosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after an Exploratory
laparotomy, takedown of ileorectal anastomosis and ileostomy for
surgical management of your anastomotic leak from ileorectal
anastomosis. You have recovered from this procedure well and you
are now ready to return home. Samples from your colon were taken
and this tissue has been sent to the pathology department for
analysis. You will receive these pathology results at your
follow-up appointment. If there is an urgent need for the
surgeon to contact you [**Name2 (NI) 19605**] these results they will
contact you before this time. You have tolerated a regular diet,
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next 3-4 days. After anesthesia it is not
uncommon for patient??????s to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are explected however, if you notice that you are passing bright
red blood with bowel movments or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonges loose stool, or constipation.
You have a long vertical [**Name2 (NI) **] on your abdomen that is closed
with staples. The staples are spaced far apart as you were very
sick and the [**Name2 (NI) **] needed to drain. The [**Name2 (NI) **] will be
followed by the wound ostomy nurse. [**First Name (Titles) **] [**Last Name (Titles) **] can be covered
with a dry sterile gauze daily. The staples will stay in place
until your first post-operative visit at which time they can be
removed in the clinic. Please monitor the [**Last Name (Titles) **] for signs and
symptoms of infection including: increasing redness at the
[**Last Name (Titles) **], opening of the [**Last Name (Titles) **], increased pain at the
[**Last Name (Titles) **] line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run
over the [**Last Name (Titles) **] line and pat the area dry with a towel, do not
rub.
You have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. You must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
you find that your output has become too much or too little,
please call the office for advice. You will be send home with
prescriptions for your current regimen of imodium, tincture of
opium, and metamucil wafers. Please follow these instructions,
if you notice that your output has decreased to much, you may
take away one medication at a time. Keep yourself well hydrated,
if you notice your ileostomy output increasing, take in more
electrolyte drink such as gatoraide. Please monitor yourself for
signs and symptoms of dehydration including: dizziness
(especially upon standing), weakness, dry mouth, headache, or
fatigue. If you notice these symptoms please call the office or
return to the emergency room for evaluation if these symptoms
are severe. You may eat a mosified regular diet with your new
ileostomy. However it is a good idea to avoid spicy food, raw
vegetables, or fatty food. Your ileostomy was an emergent
procedure and these stomas can be more difficult. You have
developed a small connection bewtween the lower part of the
stoma and the outside enviornment, it is important that this is
controlled. If you get home and this output from the side of the
stoma is difficult to control with a pouch please call the
office. Please call the office if the skin in this area begins
to appear infected or you have increased abdominal pain.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for buldging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery, You
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until you are comfortable caring
for it on your own.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
excersise with Dr. [**Last Name (STitle) **].
You will be prescribed a small amount of the pain medication
dilaudid. Please take this medication exactly as prescribed. You
may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
You should continue to take the trazodone to help you with
sleep. Please see your PCP to discuss this medication. You must
continue to take the antibiotic augmemtin for 14 days.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] on [**2155-9-18**], please call [**Telephone/Fax (1) 160**]
to make this appointment.
Please call the wound ostomy clinic for a follow-up appointment
in 1 week after discharge. Cal [**Telephone/Fax (1) 3541**] to make this
appointment.
Completed by:[**2155-9-13**] | [
"0389",
"5849",
"2762",
"5119",
"99592",
"2761",
"32723",
"25000"
] |
Admission Date: [**2164-4-29**] Discharge Date: [**2164-4-29**]
Date of Birth: [**2103-12-25**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male, with unknown medical history, who was found down
asystolic. In the field, the patient had 3 rounds of
epinephrine and atropine followed by return of ventricular
fibrillation rhythm. He was shocked and then went into PEA.
He was again given epinephrine and atropine with return of
electrical activity and pulse. The patient has been noted in
the emergency room flow sheets to be pulseless for greater
than 15 minutes in the field. He was intubated in the field
after multiple failed attempts.
In the emergency room , the patient's blood pressure was
unstable, and he was started on dopamine and eventually
required Levophed as well. The patient's pupils were fixed
and dilated.
HOSPITAL COURSE: The patient arrived intubated, not
requiring sedation for comfort. His blood pressure was
maintained with pressor support of dopamine and Levophed.
The patient's pupils were fixed and dilated, and he had no
corneal reflex on admission. A head CT showed a massive
intracranial hemorrhage. On admission, the patient's pH was
6.91. The patient was given bicarb and ventilated, and his
pH on the day of his passing was 7.20 with a PCO2 of 48 and a
PO2 of 72.
The patient's family was notified, and his sisters arrived at
his beside, but did not know any further medical history for
this patient. The patient's 3 sisters were the closest
relatives, and after discussions with the family, the
decision was made to withdraw pressor support. Shortly after
withdrawing pressor support, the patient passed away. The
patient was declared at 2:22 pm on [**2164-4-29**]. The family
refused autopsy and medical examiner declined the case.
DEATH DIAGNOSES:
1. Intracranial hemorrhage.
2. Asystolic arrest.
3. Respiratory failure.
4. Multiorgan system failure.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], MD
Dictated By:[**Last Name (NamePattern1) 55654**]
MEDQUIST36
D: [**2164-5-12**] 22:20:39
T: [**2164-5-14**] 11:10:04
Job#: [**Job Number **]
| [
"5849",
"42731"
] |
Admission Date: [**2148-4-18**] Discharge Date: [**2148-4-19**]
Date of Birth: [**2123-1-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Post-procedure monitoring after explant of his atrial and
ventricular Fidelis lead and reimplantation of a new RV
lead/generator
Major Surgical or Invasive Procedure:
Pacemaker lead removal and reimplantation
History of Present Illness:
25 year old man with a history of repaired tetralogy of Fallot
at age 15 months, palpitation and syncopal episode while
watching a baseball game [**Hospital1 14628**] in [**2141-6-11**] with
subsequent implantation of a [**Company 1543**] [**Last Name (un) 19961**] ICD with a Sprint
Fidelis 6949 lead, which is currently on FDA advisory,
inappropriate shocks for sinus tachycardia in the past, and two
appropriate shocks in [**2145**] for fast VT, who was electively
admitted for explant of his Fidelis lead and reimplantation of a
new lead/generator
Of note, the patient was recently seen in clinic as he heard his
device beeping. Interrogation revealed that since his last
clinic visit in [**2147-9-11**], he had one nonsustained VT episode
but no sustained arrhythmias. His ICD has reached ERI and today
he underwent explant of his Fidelis lead and reimplantation of a
new RV lead/generator.
During his procedure, a 16 french sheath was placed. He had an
estimated blood loss of 500 cc. His SBP was down to 70s at one
point. He was placed on phenylephrine gtt. He presents from PACU
extubated.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
- Tetralogy of fallot s/p repair [**2123**] and [**2124**]
- Pericarditis age 7
- ICD implanted [**2141**] for syncope
- Inappropriate shocks for sinus tachycardia in the past.
- Two appropriate shocks in [**2145**] for fast VT
Social History:
- Tobacco history: rare
- ETOH: 1-2 drinks per week
- Illicit drugs: denies
- Works at Pier 1 Imports, student at Conn.
Family History:
no history of any sudden death; grandfather died of MI; parents
healthy
Physical Exam:
On Admission:
T-36.7 Hr-86 BP-123/70 RR:12 SpO2-94%
General Appearance: Well nourished, No acute distress,
Overweight / Obese AAox3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVD flat, no Lymphadenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal, No(t)
Widely split ) PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : ) : No chest wall deformities, scoliosis or kyphosis.
Midline sternotomy scar. Resp were unlabored, no accessory
muscle use. no crackles, wheezes or rhonchi.
Abdominal: Soft, Non-tender, Bowel sounds present. No HSM or
tenderness. Abd aorta not enlarged by palpation. No abdominial
bruits
Skin: Warm, No stasis dermatitis, ulcers, scars, or xanthomas.
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): , Movement: Purposeful, CNII-XII
intact, 5/5 strength biceps, triceps, wrist, knee/hip
flexors/extensors, 2+ reflexes biceps, brachioradialis,
patellar, ankle.
EXTREMITIES: No c/c/e. No femoral bruits. Left groin access
site, no bleeding, bruits, erythema or tenderness to palpation.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
On admission:
[**2148-4-18**] 06:40PM BLOOD WBC-9.1 RBC-4.09* Hgb-12.1* Hct-34.2*
MCV-84 MCH-29.6 MCHC-35.4* RDW-13.9 Plt Ct-244
[**2148-4-18**] 06:40PM BLOOD PT-12.1 INR(PT)-1.1
[**2148-4-18**] 06:40PM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
[**2148-4-18**] 06:40PM BLOOD Calcium-9.1 Phos-4.3 Mg-1.8
ON Discharge:
[**2148-4-19**] 06:41AM BLOOD WBC-9.1 RBC-4.04* Hgb-11.9* Hct-34.2*
MCV-85 MCH-29.6 MCHC-34.9 RDW-13.4 Plt Ct-211
[**2148-4-19**] 06:41AM BLOOD PT-12.0 INR(PT)-1.1
[**2148-4-19**] 06:41AM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
[**2148-4-19**] 06:41AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0
INTRA-OP TEE (PRELIM): Patient is a 25 yo male who had repair of
Tetralogy of Fallot at age 15 months. For replacement of
pacemaker/lead extraction.
Pre-Procedure:
No spontaneous echo contrast is seen in the left atrial
appendage.
No ASD or VSD is apparent.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with mild global free wall hypokinesis.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
Trivial mitral regurgitation is seen.
There is mild pulmonic regurgitation.
There is no pericardial effusion.
CXR [**2148-4-19**]: Cardiomegaly is unchanged from the day before but
increased from [**2141**]. Left transvenous pacemaker lead tip is in
the right ventricle. There is no pleural effusion. There is new
mild vascular congestion. Bibasilar atelectases have minimally
increased.
Brief Hospital Course:
HOSPITAL COURSE: 25y/o male with repaired tetralogy of Fallot,
syncopal episode in [**2141**] with subsequent implantation of a
[**Company 1543**] [**Last Name (un) 19961**] ICD with a Sprint Fidelis 6949 lead, which is
currently on FDA advisory, inappropriate shocks for sinus
tachycardia in the past, and two appropriate shocks in [**2145**] for
fast VT, who was electively admitted for explant of his Fidelis
lead and reimplantation of a new lead/generator. Underwent the
prcedure and had uneventful post op course.
# RHYTHM: Patient currently in sinus rhythm. Due to an episode
of palpitation and syncope in [**2141**], with a high concern for VT
during this event, he underwent implantation of a [**Company 1543**]
[**Last Name (un) 19961**] ICD with a Sprint Fidelis 6949 lead, which is currently
on FDA advisory. Since the device was implanted, he has had
runs of fast VT in [**2145**] requiring therapies and inappropriate
shocks due to sinus tachycardia. Last shock 2 years ago. Today
patient underwent explant and replacement of lead + generator.
This was uncomplicated, with exception of 300 cc EBL.
# Repaired Tetralogy of Fallot: details of surgery are unclear,
as this occurred in childhood, but presumably patient had repair
of VSD, pulmonic stenosis/regurgitation, and overriding aorta.
His most recent echo from [**2148-4-11**] showed, "no ASD or VSD,
normal left ventricular systolic function is low normal (LVEF
50-55%) with mild global free wall hypokinesis. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. Trivial mitral
regurgitation is seen. There is mild pulmonic regurgitation.
There is no pericardial effusion." He was dced on po keflex.
Medications on Admission:
- Toprol 75mg daily
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
2. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*27 Capsule(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every four (4)
hours as needed for pain: Do not drive while on this medication
as it can cause sedation.
Disp:*20 Tablet(s)* Refills:*0*
4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Repaired Tetralogy of Fallot
Ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 18**]. You were
admitted for removal of your previous pacemaker leads and
implantation of a new pacemaker lead. You underwent the
procedure successfully and were discharged back home in a stable
condition.
NEW MEDICATIONS:
- Please take Keflex everyday for 7 days to prevent infection
from the pacemaker insertion
- Take pain meds as needed. Do not take them if they cause over
sedation, and do not drive or operate heavy machinery while
taking oxycodone
Followup Instructions:
The following appointments were made for you:
Please also contact Dr. [**Last Name (STitle) **] to schedule a follow up
appointment
Department: CARDIAC SERVICES
When: THURSDAY [**2148-4-25**] at 10:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2148-7-16**] at 8:00 AM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
Department: CARDIAC SERVICES
When: TUESDAY [**2148-10-15**] at 11:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| [
"4019",
"2859",
"32723"
] |
Admission Date: [**2166-4-7**] Discharge Date: [**2166-4-19**]
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a [**Age over 90 **] year old male
with a past medical history of diabetes, hypertension,
coronary artery disease status post myocardial infarction,
chronic renal insufficiency who presented to [**Hospital6 1760**] on [**2166-4-7**] for
catheterization for management of a non-ST elevation
myocardial infarction. He presented from an outside
hospital. He initially presented to an outside hospital in
St. [**Doctor Last Name **] while on vacation with a left hip fracture. While
at this outside hospital he flashed, having pulmonary edema
requiring intubation times one day. There he ruled in for
myocardial infarction with a positive troponin. He denied
chest pain, palpitations and loss of consciousness, only
positive for shortness of breath. He presented to [**Hospital Unit Name 196**] on
[**2166-4-7**] and was catheterized on [**2166-4-9**]. Right
atrium 12, mean right ventricle 55/14, pulmonary airway
55/25, wedge 27, mid right coronary artery discrete 80%,
distal right coronary artery discrete 80%, both of these
lesions had percutaneous transluminal coronary angioplasty
and stent. Left main diffusely diseased 70%, mid left
anterior descending discrete 100%, collateral from an right
posterior descending artery. Distal left anterior descending
diffusely diseased, collateral from an right posterior
descending artery. Proximal circumflex discrete 60% lesion.
Overall impression, three vessel coronary artery disease,
status post successful stenting times two of the right
coronary artery, moderate systolic biventricular dysfunction,
elevated systolic pressure. Echocardiogram on [**2166-4-9**],
sinus rhythm, prior anteroseptal infarct, ST segment
depression in 2, 3, and AVF, ST flattening in 1 and AVL, rate
sinus at 85, prolonged at 160, QRS at 70, QTC 416, normal
axis. Also on the note of the patient's cardiac
catheterization, cardiac output was 3.3, index was 2, SVR was
1891.
REVIEW OF SYSTEMS: The patient reports stable exertional
angina over several years, relieved with nitroglycerin. He
has occasional nocturnal angina. He has been chest pain free
since arrival. Positive for fatigue.
PAST MEDICAL HISTORY: Notable for diabetes, 12 year history,
very brittle. Hypertension. Coronary artery disease with
the posterior anteroseptal myocardial infarction. Chronic
renal insufficiency. Distant seizure disorder, has not had
seizure for 40 years, status post prostatectomy, status post
right hip replacement, gastroesophageal reflux disease.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is a former composer of music. He lives
with his wife at [**Name (NI) 8**].
MEDICATIONS ON ADMISSION: Medications at home include
Atenolol, Altace, Dilantin, Zantac and Insulin. Medications
on transfer to CCU were Aspirin 325 q.d., Lopressor 25
b.i.d., Captopril 6.25 b.i.d., Dilantin 200 q. AM, 100 q. PM,
Protonix 40 q.d., Percocet, regular insulin sliding scale and
Mucomyst 600 b.i.d. times two days, insulin Lente 16 units q.
AM.
PHYSICAL EXAMINATION: Physical examination on presentation
to the CCU, the patient was lying in bed in no acute
distress. Extraocular movements intact. Pupils equal,
round, and reactive to light and accommodation. No oral
lesions. Jugulovenous distension, angle of the mandible.
Lungs clear to auscultation, anteriorly in the upper lung
fields, decreased breathsounds laterally. The patient was
unable to sit forward secondary to pain from his hip
fracture. He had regular rate and rhythm, S1 and S2. He had
a high-pitched systolic ejection murmur at the left sternal
border. Normoactive bowel sounds. Soft, nontender,
nondistended. +1 dorsalis pedis pulses, no cyanosis,
clubbing or edema. He has a deformity of the right hand.
Groin, no hematoma or bruit. Cranial nerves III through XII
intact. Alert and oriented times three. Good strength in
all of his extremities except for a broken leg, unable to
move it secondary to leg pain.
LABORATORY DATA: On [**2166-4-8**], he had hematocrit of 32,
white blood cell count of 12.5, hemoglobin 10.6, platelets
152, sodium 135, potassium 4.8, chloride 100, bicarbonate 22,
BUN 57, creatinine 2.2. His baseline seems to be
approximately 1.9 to 2.1, magnesium 1.9, calcium 8.3,
phosphorus 4.2, ALT 51, AST 21, alkaline phosphatase 201,
total bilirubin .3, INR 1.1. On [**2166-4-8**], showed
ejection fraction 25%, gradient 41 mm of mercury, right
atrium normal size, left ventricular wall thickness was
normal, left ventricular cavity size was normal. Overall
left ventricular function is severely depressed. No resting
systolic outflow obstruction. Right ventricular chamber
size, free wall motion is normal. +1 mitral regurgitation,
although the acoustic shadow, the severity of this may be
significantly underestimated, 2+ tricuspid regurgitation,
moderate pulmonary artery systolic hypertension.
HOSPITAL COURSE: So, the patient is a [**Age over 90 **] year old male with
a past medical history of coronary artery disease,
hypertension, hyperlipidemia, diabetes, chronic renal
insufficiency who presents from an outside hospital with left
hip fracture, non-ST elevation myocardial infarction,
resulting in congestive heart failure and status post
extubation, status post catheterization showing increased
filling pressures and right coronary artery with stent times
two.
1. Cardiology - Coronary artery disease, the patient had two
right coronary artery stents. His left system was totally
occluded. He fills collaterals from the right system from
the posterior descending artery. The patient in the future
may benefit from left-sided intervention to open up the left
anterior descending as he is dependent on a stented vessel
for flow of both his left and right systems. The patient
will follow up with Dr. [**Last Name (STitle) **] as an outpatient, his
cardiologist. The patient was continued on Aspirin, Plavix.
He was initially on Lopressor b.i.d. This was ramped up to
50 b.i.d. with improved control of his heartrate going from
high 80s to 90s to mid 70s. The patient initially was on
6.25 of Captopril. This was increased as high as 37.5 but
then discontinued and the patient experienced acute renal
failure, thought secondary to dye-induced nephropathy
approximately 48 hours after his cardiac catheterization.
The patient initially was on the Nitroglycerin and Integrilin
drip status post catheterization. These both were turned off
by 18 hours after the catheterization.
Congestive heart failure, the patient initially presented
from the Catheterization Laboratory in congestive heart
failure with recent intubation with elevated jugulovenous
pressure, pulmonary capillary wedge pressure in
Catheterization Laboratory and bilateral pleural effusions
with an ejection fraction of 25%. He was diuresed with
Lasix, initially printing out to 80 intravenously. Blood
pressure was said to be fine, overloaded and eventually did
not respond to further increasing doses of Lasix until again
he had initial course complicated by acute renal failure.
The patient had dialysis times two which helped remove fluid
and improve his volume status, greatly improving the
congestive heart failure that he had been experiencing.
Rhythm, the patient was on telemetry. He for the most part
had a normal sinus rhythm but in the contest of hyperkalemia
he had a wide complex rhythm with PTT waves, flattened Ps and
a prolonged PR interval. The patient received four gm of
intravenous calcium gluconate, 30 mg of Kayexalate and
insulin drip which reduced his potassium from a level of 7.2
to 5.6 and resolving his electrocardiogram changes. The
patient had hemodialysis later that day which further
improved his potassium levels as well as his acidosis and his
volume status. As outpatient has mitral regurgitation and
tricuspid regurgitation as per his echocardiogram.
Renal - As stated previously above, the patient had renal
failure with his creatinine to 4.9, baseline is 2.2 and his
potassium going to 7.2. The patient had bicarbonate of 15 as
well. Renal saw the patient, it was felt that his renal
dysfunction was the result of dye-induced nephropathy. The
patient had Quinton catheter placed at the bedside. This
improved and he had dialysis through his catheter. This
improved his creatinine to 3.3 with further improvement to
2.9 and then 1.9 being 1.9 the night before discharge without
dialysis. The patient only had dialysis twice and had
improvement of his renal function with resolution of the
temporary dye-induced nephropathy. The patient had received
intravenous fluids, Mucomyst peri-catheterization but still
had dye-induced nephropathy.
Heme - The patient had hematocrit on [**4-8**] of 32. He had a
hematocrit drop from 29.6 to 21.5 on [**4-13**]. The patient
was guaiac negative times two. Post having his dialysis
placed as well as internal jugular Swan-Ganz catheter placed,
he had computerized axial tomography scan of the abdomen and
chest which showed no retroperitoneal or mediastinal bleed.
The patient received 2 units of packed red blood cells and
increased his hematocrit to 29 and with dialysis the patient
then received 2 more units prior to his hip surgery as well
as dialysis to remove excess fluid with increase in his
hematocrit to 39. This decreased to 27.5 two days
postoperatively and he received 1 unit of packed red blood
cells on the night prior to discharge.
Orthopedics - The patient was followed by the Orthopedics
Team and greatly appreciated. The patient had a left open
reduction and internal fixation of his fractured hip. On
[**4-15**], he had this surgery by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 9694**]. The
patient tolerated this surgery well. Prior to his renal
failure he had been on Lovenox 40 mg subcutaneously q. day as
well as pneuma boots for deep vein thrombosis prophylaxis
with renal failure. This was discontinued and he was started
on 5000 units of subcutaneous heparin t.i.d., status post the
surgery as per Dr. [**Last Name (STitle) 9694**]. The patient was started on a low
dose Coumadin 2 mg q.h.s. with a goal INR of 1.5 to 2. When
he reaches his goal INR of 1.5, the subcutaneous heparin will
be discontinued. The patient currently is undergoing
physical therapy here in the CCU. He will require [**Hospital 5735**]
rehabilitation for improvement of his mobility. He is able
to bear weight on his leg.
Anticoagulation - The patient has apical AK on his
echocardiogram with an ejection fraction of less than 25%,
however, this is secondary to an old anterior myocardial
infarction and not an acute event, therefore he would not
benefit from anticoagulation as thrombus prevention as this
is an old lesion and the risk is in the acute setting of an
anterior myocardial infarction. As per above, the patient
will be receiving the low dose Coumadin for deep vein
thrombosis prophylaxis.
Diabetes - The patient was seen by the [**Hospital1 **] Service who
assisted in the management of his very brittle diabetes. The
patient was on an insulin drip prior to his surgery and
postoperative finally able to be removed from the drip on
[**2166-4-17**]. He is on a sliding scale as per [**Hospital1 **], a
little higher levels of Humalog. This will be accompanying
his discharge paperwork. The patient also is on Lente, now
starting on [**4-18**] through [**4-23**] in AM. This will be
titrated up to 20 as he requires insulin control. At the
current time, he ranged between 71 and 343, being very
brittle. I just hope with titration as above his AM dose of
Lente, we can get better control.
Neurological - The patient has a very distant seizure
history. His Dilantin level was .16 after dialysis. He was
reloaded with 1 gm p.o. Dilantin divided in three doses and
then placed back on his 200 q. AM, 100 q.h.s. Dilantin with
no seizure activity witnessed.
Prophylaxis - The patient received initially Lovenox then
switched to subcutaneous heparin t.i.d. with pneuma boot as
well as being changed to low dose Coumadin when the patient
is above an INR of 1.5. His .................. will be
discontinued in favor of the low dose Coumadin, it is helpful
that the patient is beginning to ambulate with physical
therapy. He is also on Protonix for gastrointestinal
prophylaxis. He is a full code.
The patient had agitation at night and was tried on 1 mg p.o.
b.i.d. of Haldol, the patient was very sedated. When his
Haldol as well as Morphine was discontinued his mental status
improved. He had Percocet for pain control related to
physical therapy but the patient should not receive more than
one pill at a time unless in extreme pain as he has had
decreased mental status and somnolence with narcotics and
Haldol.
DISCHARGE DIAGNOSIS:
1. Non-ST elevation myocardial infarction, right coronary
artery distribution, status post stenting times two to the
right coronary artery
2. Left hip fracture, status post open reduction and
internal fixation
3. Acute renal failure secondary to diabetes and dye-induced
nephropathy
4. Urinary tract infection
5. Delirium
6. Hypertension
7. Coronary artery disease
8. Distant seizure disorder
9. Gastroesophageal reflux disease
RECOMMENDED FOLLOW UP: The patient should call [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
for follow up appointment, [**Telephone/Fax (1) 22111**], the patient is to
see Dr. [**Last Name (STitle) **] within two weeks status post discharge of
surgical procedures or open reduction and internal fixation
of the left hip on [**2166-4-15**]. Insertion of right
internal jugular Swan-Ganz catheter and insertion of right
groin temporary dialysis catheter, discontinued after
hemodialysis times two.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS: ([**Month (only) 116**] be addended the morning of
discharge, and Page 1 which accompanies the patient's chart
will be the final say on the patient's discharge medications)
1. Protonix 40 mg q.d.
2. Dilantin 200 mg q. AM, 100 mg q. PM
3. Ampicillin for his urinary tract infection, this
enterococcus sensitive to Ampicillin, he is on 5 mg b.i.d.
for five days, status post discharge
4. Metoprolol
5. Lopressor 50 mg p.o. b.i.d.
6. Plavix 70 mg q.d.
7. Aspirin 325 mg q.d.
8. Lipitor 10 mg q.d.
9. Heparin 5000 units subcutaneous q. 8 hours, this can be
discontinued when the patient's INR is between 1.5 and 2 with
Coumadin
10. Warfarin 2 mg q.d., his INR should be monitored daily or
at the worst q.o.d. The patient is on many drugs including
the antibiotics which can affect his INR level as well as a
changing p.o. intake which is thankfully recently improved,
however, his INR will be labile, most likely and will require
monitoring.
11. Senna 1 tablet p.o. b.i.d. prn
12. Colace 100 mg p.o. b.i.d.
13. Sarna lotion topical t.i.d. as needed for pruritus
14. Bisacodyl 10 mg p.o. or p.r. q.d. as needed for
constipation
15. Percocet 5/325 mg tablets one to two tablets q. 4-6
hours, please use gingerly as the patient can become
oversedated with narcotics
16. Lente, at the current time the patient will be receiving
20 units in the morning, he is on a Humalog sliding scale
which will accompany this discharge
17. Hydrocortisone cream one q.i.d. to affected areas
18. Acetaminophen 325 mg tablets one to two tablets q. 4
hours prn for pain or fever.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2166-4-18**] 20:26
T: [**2166-4-18**] 20:59
JOB#: [**Job Number 22112**]
| [
"4280",
"5849",
"2767",
"5990"
] |
Admission Date: [**2181-6-6**] Discharge Date:
Date of Birth: [**2116-10-15**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 64-year old female
with a past medical history significant for aortic stenosis,
congestive heart failure, hyperlipidemia, hypertension,
hypothyroidism, [**Doctor Last Name **] syndrome, and arthritis.
SUMMARY OF HOSPITAL COURSE: The patient was admitted on [**2181-6-6**]; at which time she underwent an aortic valve
replacement with a 9-mm [**Company 1543**] mosaic valve and
replacement of the ascending aorta with a 22-mm gel weave
graft. The surgery was complicated by an aortic dissection
with replacement of the aorta and a transfusion of packed red
blood cells, platelets, and fresh frozen plasma for bleeding.
As well, due to a low cardiac output the patient was
transferred from the Operating Suite to the Cardiac Surgery
Recovery Unit with an open chest. The patient was on
Levophed, milrinone, epinephrine, and propofol.
While in the Cardiac Surgery Recovery Unit - that day - the
patient converted to atrial fibrillation. She was
cardioverted back to a sinus rhythm with large amounts of
serosanguinous drainage from the chest tube. A Quinton
catheter was placed on postoperative day one in order to take
off the excess volume.
The Renal Service was consulted, and they came by to see the
patient and recommended starting continuous venovenous
hemofiltration at an ultrafiltration rate of 100 per hour.
The patient was brought back to the Operating Room on [**6-9**]; at which time she underwent sternal debridement of
evacuation of a mediastinal hematoma, and closure of the
sternal incision, as well as placement of irrigation
catheters. The patient was transferred from the Operating
Room Suite to the Cardiac Surgery Recovery Unit
hemodynamically stable with her chest closed.
The Renal Service came by to see the patient again; at which
time they felt the patient was massively fluid overloaded.
However, they felt that there was no need to start continuous
venovenous hemofiltration dialysis at that time; and, if
necessary, would start hemodialysis. The Renal Service did
decide to perform continuous venovenous hemofiltration
dialysis the following day due to her persistent volume
overload.
On postoperative day four, the patient received one unit of
packed red blood cells for a hematocrit of 25 and continued
to be weaned off of her pressors. The patient remained
intubated and sedated for the next couple of days with a
transfusion of packed red blood cells to keep her hematocrit
greater than 30. However, her blood pressure continued to be
labile. She was receiving continuous venovenous
hemofiltration dialysis as needed. The patient continued to
be aggressively diuresed with high doses of Lasix and Diamox.
Neurologically, the patient was lethargic; however responsive
with purposeful movements.
On postoperative day eight, the patient became febrile; for
which her cortice was changed over to a triple lumen with the
cortice being sent for culture. On postoperative day eight,
the patient also had two brief bursts of atrial fibrillation
with a heart rate up to the 150s, with the heart rate coming
down to the 80s after being treated with Lopressor.
A computed tomography of the head was performed due to the
patient's continued somnolence, which revealed no evidence
of intracranial hemorrhage; however, with a calcified mass
(likely a meningioma)overlying the right frontal convexity
measuring 1.7 cm X 1.3 cm.
A Neurology consultation was called on [**6-15**] to evaluate the
patient's mental status changes after surgery - to rule out
stroke. The Neurology Service impression was that the
patient was now with likely subacute embolic stroke. They
recommended to watch the blood pressure carefully to avoid
hypertension. They did not recommend heparinization.
The Stroke team was also consulted and saw her on [**2181-6-16**]. At that time, they assessed that her examination was
significant for weakness of her right upper extremity. They
also felt that computerized axial tomography suggested
multiple infarctions of indeterminate age. They recommended
checking an echocardiogram to rule out a source of these
embolizations. They also recommended changing aspirin to
Plavix.
The patient continued to remain intubated over the next
several days with a stable white blood cell count and
hematocrit. She was in a sinus rhythm. The patient was
finally extubated on the evening of [**6-19**] without event.
She was continued on her tube feeds for nutritional support.
The patient was advanced to a liquid and puree diet following
a bedside swallow evaluation.
The patient was then transferred to the floor on
postoperative day 16 ([**6-22**]) in stable condition. She was
alert, oriented, and was following commands well. The
patient became confused on postoperative day 18; for which a
sitter was required at the bedside for safety precautions.
The patient's neurological status continued to improve, and
she started to be screened for rehabilitation.
On postoperative day 20, the patient had a 7-beat run of
ventricular tachycardia; at which time the patient was
asymptomatic. An electrocardiogram was obtained, and the
strips were reviewed. They revealed atrial fibrillation with
aberrant conduction.
DISCHARGE DISPOSITION: The patient continued to progress
slowly and is currently continuing to be screened for
rehabilitation placement. The remainder of this report is to
follow.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 28488**]
MEDQUIST36
D: [**2181-6-29**] 11:18:26
T: [**2181-6-29**] 12:39:38
Job#: [**Job Number 55483**]
| [
"4241",
"4280",
"9971",
"5845"
] |
Admission Date: [**2186-3-16**] Discharge Date: [**2186-3-22**]
Date of Birth: [**2118-6-9**] Sex: F
Service: MEDICINE
Allergies:
Dilantin Kapseal / Calcipotriene / Lorazepam
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
syncope and pleuritic chest pain upon waking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 67 year old female with epilepsy, hypertension,
and pancreatic cancer s/p Whipple with positive margin who is
currently undergoing chemotherapy and radiation. She had a
syncopal episode after returning home from a radiotherapy
session today and was initially seen at an OSH where she was
diagnosed with bilateral PEs. She was transferred to [**Hospital1 18**] and
admitted to the ICU for further management.
.
After returning home from her radiotherapy session today, she
had a syncopal episode as she was entering her home. Her
husband was next to her and managed to lower her to the ground
as she fell. She did not strike her head or sustain any other
injuries. She reports losing consciousness and waking up
several minutes later. She reports that it was very different
than prior seizures and there was no evidence of seizure
activity. After waking, she felt SOB with new bilateral chest
and back pain on inspiration. She felt somewhat better after
resting, but once again felt SOB, weak, and dizzy later in the
day when getting up to the bathroom. EMS was called and she was
brought to the [**Hospital3 417**] ED. While there, she was tachy to
the 140s with BP in the 80s-90s, and CTA showed bilateral PEs
and evidence of right heart strain. She was started on a
Heparin drip and received several liters of IV fluids. She was
given Zofran 4 mg IV and Ativan 1 mg PO for nausea. She was
transferred to [**Hospital1 18**] per patient request.
.
In the [**Hospital1 18**] ED, her initial vitals were T 98.3, HR 116, BP
103/67, RR 18, SpO2 98% on 3L. She was on a Heparin drip at
1000 units/hr. She complained of continued pleuritic chest pain
and back pain worse with inspiration. EKG showed sinus
tachycardia at 113 bpm and slight ST depressions in the lateral
leads, as well as a mild S1Q3T3 pattern. She was given
Acetaminophen 1000 mg, which she reports helped the pain
significantly. Her Heparin drip was titrated and she was
admitted to the ICU for further management.
.
Once in the ICU, she reported feeling much better than earlier,
but with some continued pleuritic chest pain. She reports
having a long history of varicose veins, but noted a recent
palpable vessel on her medial right thigh near the knee which
worsened and then improved a few days ago. She has chronic LE
edema and venous stasis changes. She has lost about 50 lbs
since her diagnosis with pancreatic cancer. She has chronic
nausea, vomiting, and diarrhea related to her chemotherapy and
radiation. She has had difficulty staying hydrated, requiring
periodic IV fluids in [**Hospital **] clinic.
Past Medical History:
# Pancreatic Cancer -- as below
# Epilepsy -- (Neurologist Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**Hospital1 1474**] MA)
-- No seizure in about 5 years
# Psoriasis
# Basal cell carcinoma of the skin, status post excision
# Hypertension -- now resolved
# Tonsillectomy History
.
ONCOLOGIC HISTORY:
# Pancreatic Cancer -- stage IIB (pT3, pN1, M0)
-- Summer [**2184**] developed epigastric discomfort
-- Few months later obstructive jaundice
-- [**2185-11-21**]: CT scan at [**Hospital1 18**] showed mass in the pancreatic
uncinate process
-- [**2185-12-8**]: Whipple procedure with Dr. [**Last Name (STitle) 468**]
-- Pathology showed a 2.4-cm moderately differentiated ductal
adenocarcinoma in the head of the pancreas. One of the 11 lymph
nodes examined was positive, although it was noticed that the
single lymph node that contained carcinoma appeared to be
involved by direct contiguous tumor growth. The primary tumor
was extending beyond the pancreas, but without involvement of
the celiac axis or superior mesenteric artery. The uncinate
process margin was positive for carcinoma. There was no
vascular or lymphatic invasion but there was extensive
perineural invasion.
-- [**2186-1-12**]: Started cycle 1 of chemotherapy with Gemzar.
-- [**2186-2-2**]: Cyberknife therapy to positive margin.
-- [**2186-2-9**]: External beam radiation and concomitant XELODA.
-- [**2186-2-22**]: Xeloda held due to GI toxicity.
Social History:
# Tobacco: Never smoked, but husband is a heavy smoker.
# Alcohol: Rare alcohol 1-2 drinks/month
# Drugs: None
Married with 5 children and 5 grandchildren. Denies tobacco,
drinks beer occasionally.
Family History:
The patient is an only child. She reports that the son and
grandson of her mother's sister died from pancreatic cancer, but
no more immediate family members. She has five children.
# Mother -- Died at age 89 of leukemia and had a history of CHF.
# Father -- Died at age 63 of MI.
Physical Exam:
VS: T 97.6, BP 95/67, HR 116, RR 21, SpO2 95-97% on 3L NC
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. JVP to jaw at 30 degree angle. No
cervical lymphadenopathy.
CV: Tachycardia, regular with normal S1, S2. No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
except for a few scattered crackles L>R. No wheezes or rhonchi.
Abd: Active bowel sounds. Soft, NT, ND. No organomegaly or
masses. Well healed transverse surgical incision across upper
abdomen.
Ext: WWP. Digital cap refill <2 sec. Distal pulses intact
radial 2+, DP 1+. LE edema 1+ bilaterally. Palpable cord right
medial thigh proximal to knee. No calf tenderness.
Neuro: CN II-XII grossly intact. Moving all four limbs. Normal
speech.
Pertinent Results:
ADMISSION LABS:
[**2186-3-16**] 02:35AM BLOOD WBC-8.1# RBC-3.36* Hgb-11.7* Hct-34.5*
MCV-103* MCH-34.8* MCHC-33.8 RDW-17.2* Plt Ct-136*
[**2186-3-16**] 02:35AM BLOOD Neuts-89.6* Lymphs-5.0* Monos-4.6 Eos-0.6
Baso-0.3
[**2186-3-16**] 02:35AM BLOOD PT-17.3* PTT-150* INR(PT)-1.6*
[**2186-3-16**] 02:35AM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-136
K-5.2* Cl-103 HCO3-21* AnGap-17
[**2186-3-16**] 02:35AM BLOOD ALT-38 AST-82* AlkPhos-169* TotBili-0.6
[**2186-3-16**] 02:35AM BLOOD cTropnT-0.32* proBNP-2404*
[**2186-3-16**] 02:35AM BLOOD Albumin-2.9*
IMAGING:
ECHO [**2186-3-16**]: Conclusions
The left atrium is normal in size. The left ventricular cavity
is unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a very small
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
CONCLUSIONS: Small underfilled hyperdynamic left ventricle.
Right ventricular systolic dysfunction with relative
preservation of the right ventricular apex consistent with acute
RV strain in the setting of her known PE. Likely severe
pulmonary artery systolic pressure.
BILATERAL LENIs [**2186-3-16**]:
IMPRESSION:
1. DVT involving the right peroneal vein. Superficial
thrombophlebitis of
the right great saphenous vein.
2. No DVT in the left lower extremity.
ABDOMINAL U/S [**2186-3-16**]:
FINDINGS: The liver is normal in echotexture, without focal
lesions. There
is no intra- or extra-hepatic biliary dilatation. The patient is
status post Whipple's procedure. The common hepatic duct is
normal, measuring 3 mm. Main, right, and left portal veins
demonstrate normal directional flow and waveforms. The right,
middle,left hepatic veins and IVC demonstrate normal venous
waveforms. The main hepatic artery is patent. The spleen is not
visualized due to extensive bowel gas. There is no
intra-abdominal free fluid.
IMPRESSION: Normal liver, with patent hepatic vasculature. No
evidence for
portal vein thrombosis.
CXR [**2186-3-19**]:
One portable view. Comparison with [**2186-3-15**]. The lungs remain
clear. The
left hemidiaphragm is indistinct. The cardiac silhouette is
prominent but may be exaggerated by AP technique. The aorta is
mildly tortuous. Mediastinal structures appear stable. The bony
thorax is grossly intact.
IMPRESSION: No active pulmonary disease. The retrocardiac area
is
suboptimally evaluated and a lateral view is recommended if
further evaluation is clinically indicated.
Brief Hospital Course:
The patient is a 67 year old female with epilepsy, hypertension,
and pancreatic cancer s/p Whipple with positive margin who is
currently undergoing chemotherapy and radiation. She presented
to OSH with syncope from bilateral PEs and was transferred to
[**Hospital1 18**] for further management.
# Pulmonary Embolism: She presented with syncope and then had
classic signs of PE including rapid onset SOB, pleurisy, and
tachycardia. She was at high risk given her pancreatic cancer
and ongoing treatments.
- Found to have bilateral PEs on CTA at the OSH and was started
on a Heparin drip.
- Thrombolysis was considered given her initial low BP
(80-90??????s), low UOP (10-20cc/hr), and echo showing right heart
strain.
- She and her family initially opted for thrombolysis, but her
rectal guaiac was positive and she was unable to receive it.
- No IVC filter will be placed as the benefit does not outweigh
the risk.
- Her LE dopplers showed DVT involving the right peroneal vein
and superficial thrombophlebitis of the right great saphenous
vein.
- Her hepatic vessels were normal on RUQ US.
- She was transitioned to Enoxaparin on [**2186-3-18**] and her Heparin
drip was stopped.
- She will be continued on enoxaparin 70mg SQ Q12H.
- Once the patient was transferred to the floor on [**3-19**], she was
foudn to be hemodynamically stable with no episodes of oxygen
desaturation, pleurisy, or tachycardia
.
# Atrial Fibrillation: She had an episode of AFib with HR in the
140s overnight [**Date range (1) 88312**], but was asymptomatic and her BP
remained fairly stable.
- She was given Metoprolol 2.5 mg IV once, and converted back to
sinus rhythm shortly thereafter.
- She again went back into AFib the morning of [**3-19**], and was
given 15mg total of IV lopressor, and then 1 hour after her last
lopressor dose, she went back to NSR.
- We started her on 12.5mg metoprolol tartrate TID with good
achievement of rate control
.
# Anemia: Her Hct on admission was 34.5, which was at her recent
baseline, but then was dropping after admission to 26.6 on [**3-19**].
- Her MCV is elevated in the 100s with an increased RDW.
- Her B12 and folate levels on [**2186-3-7**] were normal at 1081 and
9.5 respectively. Her Hct has fallen from 34.5 to 26.0 in the
setting of receiving some IVF, but not enough to account for the
observed fall in Hct.
- Her stools were guaiac positive and a mild GI bleed was
suspected given her treatment with Heparin
- She did not show any evidence of upper or lower GI bleeding
once transferred to the floor, and her hematocrit rose back up
to 30.5 on DOD
- Her hematocrit will be followed closely on her anticoagulation
treatment and any potential cessation of treatment or
intervention will be avoided while she is still in the subacute
phase of PE treatment
# Epilepsy: She has a history of epilepsy treated with
Carbamazepine and Levetiracetam, so we continued Carbamazepine
200 mg PO TID
and Levetiracetam 500 mg PO Q6H per her home dosing regimen.
.
# Pancreatic Cancer: She has pancreatic adenocarcinoma stage
IIB and is s/p Whipple procedure with positive margins on
[**2185-12-6**]. She is currently being treated with radiation and
chemotherapy. She was started on Dexamethasone [**2186-2-22**] for
nausea relief and improved appetite. She has had chronic nausea
and diarrhea after her surgery and with her ongoing treatments.
She is also on pancreatic enzyme supplements. She was briefly
placed on stress dose steroids due to concern that it may have
been contributing to her hypotension, however she was quickly
changed back to her home dexamethasone 2mg PO daily. We
continued pancreatic enzyme supplements with meals, and
continued lorazepam 0.5mg PO Q6H PRN anxiety or nausea.
Medications on Admission:
Carbamazepine 200 mg PO TID
Levetiracetam 500 mg PO Q6H
Dexamethasone 2 mg PO daily
Lipase-protease-amylase [Zenpep] (20,000-68,000-109,000 units)
-- Take 3 capsules PO with meals and 2 capsules PO with snacks
Pantoprazole 40 mg PO daily
Potassium chloride 10 mEq PO BID
Lorazepam 0.5 mg PO Q6H PRN anxiety or nausea
Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous twice a day.
Disp:*60 syringes* Refills:*2*
2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety or nausea.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Zenpep 20,000-68,000 -109,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO 3
caps with meals and 2 with snacks as needed for pancreas enzyme.
7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary:
Pulmonary Emboli
Paroxysmal atrial fibrillation
Secondary:
Pancreatic Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dr. [**Last Name (STitle) **] [**Known lastname 1458**],
You were admitted to the [**Hospital1 18**] for evaluation and treatment of
blood clots that were found in your lungs. You were intially
managed in the ICU, but recovered well and were able to be
transferred to the floor. There you regained good functional
status, finished your radiation treatments, and continued
lovenox therapy for your blood clots.
Because of your blood clots, you had evidence of strain on your
heart. This also likely caused your heart to go into an
irregular rhythm called atrial fibrillation. You will need to
start taking a medication called metoprolol for your heart
rhythm. Also please start taking lisinopril for heart protective
effects and for blood pressure.
The following changes have been made with your medications:
1. START using lovenox shots twice a day
2. START metoprolol succinate 1.5 tablets once a day (for your
new irregular heart rhythm)
3. START lisinopril for blood pressure control and for
protective effects on your heart
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2186-3-29**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2186-3-29**] at 11:30 AM
With: [**Name6 (MD) 5145**] [**Name8 (MD) 5146**], MD, PHD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PSYCHIATRY
When: TUESDAY [**2186-4-4**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23908**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
| [
"2762",
"42731",
"4019"
] |
Admission Date: [**2138-12-15**] Discharge Date: [**2138-12-24**]
Service: CARDIOTHORACIC
Allergies:
Quinidine/Quinine & Derivatives / Tetanus / Ephedrine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
fatigue, DOE
Major Surgical or Invasive Procedure:
MVR (tissue vale), ligation of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**], CABG X 1 (SVG>RCA)
on [**2138-12-17**]
History of Present Illness:
dilated cardiomyopathy, severe MR, recent decreased exercise
tolerance, increased DOE & fatigue.
Past Medical History:
-CAD: MI [**2108**], cath x 2 (pt states no angioplasty or stent)
-CHF: EF 30-35% [**9-/2138**]
-Afib: on amiodarone and warfarin
-Polymorphic VT: ICD implanted
-4+MR
[**Name13 (STitle) **]3+TR
-1+AR
-Pulm HTN
-CRI: baseline cr 1.8
-Gout
-Restless legs syndrome
.
PSH: None
Social History:
lives w/wife (who is presently in rehab center s/p CVA)
retired dentist
rare Etoh, none recently
remote smoking history
Family History:
Sisters died of ? ca in their 80's. Father died of esophogeal CA
in 70's. No known fhx of CAD.
Physical Exam:
Admission
Vitals 95.2F B/P 85/40, HR 67 Vpaced, RR 20, 96% RA Wt 73.5 kg
General: No acute distress
Cardiac: RRR, 3/6 SEM
Lungs: clear to auscultation
Abdomen: benign
Extremeties: +1 bilateral lower extremety edema, warm, pulses +2
Discharge
Vitals: 97.5F HR 70 Vpaced, B/P 116/60, RR 18, RA sat 98% wt
85.1kg
Neuro: alert and oriented, non focal
Pulmonary: Right clear throughout, Left no airation at base
clear upper lobe
Cardiac: RRR, no murmur/rub/gallop
Abdomen:+bowel sounds, soft, nontender, nondistended, last BM
[**12-23**]
Extremeties: warm, pulses +2, edema LE +2 L>R
Incisions: sternal midline steristrips, CDI no erythema, sternum
stable
Left leg endovascular harvest steri strips, CDI, no erythema
Pertinent Results:
[**2138-12-24**] INR 1.8
[**2138-12-23**] 07:10AM BLOOD WBC-10.7 RBC-3.31* Hgb-10.4* Hct-31.8*
MCV-96 MCH-31.5 MCHC-32.8 RDW-16.0* Plt Ct-104*
[**2138-12-23**] 07:10AM BLOOD Plt Ct-104*
[**2138-12-21**] 05:40AM BLOOD PT-14.0* PTT-44.8* INR(PT)-1.2*
[**2138-12-23**] 07:10AM BLOOD Glucose-89 UreaN-47* Creat-1.4* Na-143
K-4.5 Cl-109* HCO3-25 AnGap-14
[**2138-12-21**] 05:40AM BLOOD Glucose-95 UreaN-49* Creat-1.7* Na-140
K-5.1 Cl-108 HCO3-24 AnGap-13
[**2138-12-15**] 12:40PM BLOOD WBC-5.2 RBC-3.19* Hgb-10.7* Hct-31.6*
MCV-99* MCH-33.6* MCHC-34.0 RDW-15.0 Plt Ct-162
[**2138-12-15**] 12:40PM BLOOD PT-16.3* PTT-51.1* INR(PT)-1.5*
[**2138-12-23**] 07:10AM BLOOD Plt Ct-104*
[**2138-12-21**] 05:40AM BLOOD PT-14.0* PTT-44.8* INR(PT)-1.2*
[**2138-12-15**] 12:40PM BLOOD Glucose-66* UreaN-54* Creat-2.2* Na-141
K-4.8 Cl-103 HCO3-31 AnGap-12
CHEST (PA & LAT) [**2138-12-23**] 11:22 AM
CHEST (PA & LAT)
Reason: evaluate pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
84 year old man s/p MVR/CABG
REASON FOR THIS EXAMINATION:
evaluate pleural effusions
INDICATION: Status post CABG.
CHEST PA AND LATERAL: The moderate left-sided and small
right-sided effusions are unchanged since [**2138-12-19**].
There has been interval removal of the right IJ sheath. Interval
improvement of the mild pulmonary edema. The biventricular pacer
is present with its leads in unchanged position. Left lower lobe
collapse/consolidation is unchanged.
IMPRESSION: Interval improvement of mild pulmonary edema with
stable bilateral pleural effusions and left lower lobe collapse.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 21827**] [**Name (STitle) 21828**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: TUE [**2138-12-23**] 11:36 PM
Regular ventricular pacing, unchanged compared to the previous
tracing
of [**2138-12-15**].
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 0 162 452/487.71 0 -118 11
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient is in a ventricularly paced rhythm.
Results were
Conclusions:
Prebypass
1.The left atrium is elongated. The right atrium is markedly
dilated. No
atrial septal defect is seen by 2D or color Doppler.
2. There is severe regional left ventricular systolic
dysfunction. Overall
left ventricular systolic function is severely depressed.
Resting regional
wall motion abnormalities include severe hypokinesia of the
basal, mid and
apical portions of the inferior and inferolateral walls. The
basal and mid
portions of the anterior septum are also hypokinetic. Suboptimal
transgastric
images. LV is severely dilated. Due to poor transgastric views
unable to get
adequate measurements.
3.There is mild global right ventricular free wall hypokinesis.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic
aorta.
5. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is
not present. Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. There is
no systolic
anterior motion of the mitral valve leaflets. The mitral
regurgitation vena
contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen.
The mitral
regurgitation jet is eccentric.
7.The tricuspid valve leaflets are mildly thickened.
8.The pulmonic valve leaflets are thickened. Significant
pulmonic
regurgitation is seen.
Post Bypass
Patient is receiving infusions of epinephrine, milrinone and
phenylephrine.
1. Biventricular systolic function is unchanged.
2. Bioprosthetic valve seen in the mitral position. Trace
central mitral
regurgitation present. Valve appears well seated and the
leaflets move well.
Mean gradient across the prosthetic valve is 3 mm Hg.
3. Aorta intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2138-12-18**]
09:09.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Admitted on [**2138-12-15**] for IV heparin pre-op for MVR Carotid U/S
revealed < 40% stenosis bilat. Renal consult obtained due to
rising creatinine (from baseline of 1.5 to 2.2 on [**12-16**]) Lasix
was decreased, lisinopril was discontinued. He was taken to the
OR on [**2138-12-17**] for CABG X 1 (SVG>RCA), MVR (tissue), ligation of
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**]. He was taken to the cardiac surgery recovery unit
post-op, on milrinone, epinephrine, phenylephrine drips. The
vasoactive drips were weaned off over the next 48 hours, and he
remained hemodynamically stable. His ICD was interrogated on
POD # 1. He was transferred to the stepdown floor on POD # 2.
He was re-started on his Coumadin (target INR 2.0-2.5 for Afib).
He has progressed slowly from a mobility standpoint, remained
stable hemodynamically, and is ready to be discharged to a
rehabilitation facility to aid in mobility and independence.
Medications on Admission:
Lasix 60"
Lisinopril 20'
Coreg 12.5"
Digoxin 0.125'
Amiodarone 200'
ASA 81'
Zocor 80'
Mirapex 25"'
Warfarin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 2
days: please take 5mg [**12-24**] and [**12-25**] - have INR checked [**12-26**]
goal inr 2-2.5.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). Tablet(s)
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO BID (2 times a day).
10. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 32627**]
Discharge Diagnosis:
AFib
Mitral regurgitation
CAD
HTN
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
no lifting > 10# for 10 weeks
no creams, lotions or powders to any incisions
shower daily, no bathing or swimming for 1 month
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr.[**Last Name (STitle) 32628**] in [**3-7**] weeks
with Dr. [**First Name (STitle) 437**] in [**3-7**] weeks
with Dr. [**Last Name (Prefixes) **] in [**5-7**] weeks
Please have INR checked [**12-26**] am for coumadin dosing
Completed by:[**2138-12-24**] | [
"4240",
"4280",
"42731",
"5849",
"41401",
"4019"
] |
Admission Date: [**2115-11-12**] Discharge Date: [**2115-11-26**]
Date of Birth: [**2048-7-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal Cancer
Major Surgical or Invasive Procedure:
[**2115-11-14**] Transthoracic esophagectomy with Left cervical
esophagogastrostomy
History of Present Illness:
This is a 67 year old gentleman with Stage IIA esophageal cancer
who presented for surgical resection status-post induction
chemoradiotherapy. His disease presented with regurgitation
following his CABG surgery in [**10-30**], which was initially
presumed to be secondary to prolonged intubation, but later
workup with endoscopy revealed a T3N0Mx lesion and biopsy was
positive for adenocarcinoma. PET scan revealed FDG uptake to SUV
of 7.0 and CT scan did not reveal positive metastatic or nodal
disease. Sympotmatically he denied nausea or vomitting and had
no dysphagia. He started 1 month of neoadjuvant chemotherapy
with 5-FU and cisplatin in [**7-31**]. He has been eating small meals
and is currently on TPN. He had initially lost approximately 15
pounds while on chemotherapy but has since gained nearly 10
pounds.
Past Medical History:
Stage IIA Esophageal AdenoCA, T3N0M0 (PET positive)
Status-post MVR and CABG x 3 (LIMA to LAD, SVG to OM, SVG to
PDA) on [**2114-11-23**]
Status-post J-tube and portacath placement [**7-31**]
Hypertension
Status-post pace-maker/defibrillator implantation on [**2115-2-27**]
Heartburn x 20 years
Atrial Fibrillation
Hypothyroidism
Social History:
The patient is married and lives in [**Location 5110**], MA. He has three
children and is a former engineer. He has never smoked and
denies ever drinking alcohol. He does not use recreational
drugs.
Family History:
Denies any h/o cancer, CAD. Parents died when he was young,
unsure of causes.
Physical Exam:
On admission:
V/S: wt 114 lbs, 20, 100% on room air, 93/66, pulse 89
Gen: frail, pleasant elderly gentleman, alert, oriented
Neuro: no focal abnormalities, CN 2-12 grossly intact
HEENT: moist mucous membranes, PERRLA
Neck: no lypmhadenopathy
Pulm: clear to auscultation bilaterally; Right port site intact
Abd: soft, non-tender/non-distended, normoactive bowel sounds,
J-tube site intact without erythema or discharge
Extr: no edema
Pertinent Results:
SEROLOGIES:
[**2115-11-12**] 04:37PM BLOOD WBC-5.6 RBC-2.72* Hgb-9.2* Hct-25.4*
MCV-94 MCH-33.7* MCHC-36.0* RDW-16.5* Plt Ct-128*
[**2115-11-13**] 09:01AM BLOOD WBC-4.7 RBC-2.69* Hgb-9.1* Hct-25.1*
MCV-93 MCH-33.6* MCHC-36.1* RDW-16.1* Plt Ct-121*
[**2115-11-14**] 05:02AM BLOOD WBC-4.7 RBC-3.89*# Hgb-12.6*# Hct-34.8*#
MCV-89 MCH-32.3* MCHC-36.1* RDW-16.1* Plt Ct-117*
[**2115-11-15**] 03:06AM BLOOD WBC-14.8* RBC-3.95* Hgb-12.5* Hct-33.4*
MCV-85 MCH-31.5 MCHC-37.3* RDW-16.2* Plt Ct-90*
[**2115-11-16**] 03:29AM BLOOD WBC-13.6* RBC-3.09* Hgb-9.8* Hct-27.0*
MCV-88 MCH-31.8 MCHC-36.3* RDW-15.9* Plt Ct-73*
[**2115-11-16**] 06:00AM BLOOD WBC-15.3* RBC-3.19* Hgb-10.2* Hct-28.5*
MCV-89 MCH-32.1* MCHC-35.9* RDW-15.9* Plt Ct-71*
[**2115-11-16**] 02:22PM BLOOD WBC-15.6* RBC-3.79* Hgb-11.7* Hct-31.9*
MCV-84 MCH-30.8 MCHC-36.7* RDW-16.3* Plt Ct-66*
[**2115-11-18**] 03:20AM BLOOD WBC-11.9* RBC-3.29* Hgb-10.2* Hct-28.1*
MCV-85 MCH-31.1 MCHC-36.4* RDW-16.2* Plt Ct-89*
[**2115-11-20**] 05:22AM BLOOD WBC-9.0 RBC-3.30* Hgb-10.2* Hct-29.7*
MCV-90 MCH-30.8 MCHC-34.2 RDW-15.2 Plt Ct-108*
[**2115-11-25**] 04:45AM BLOOD WBC-10.6 RBC-3.06* Hgb-9.3* Hct-28.3*
MCV-92 MCH-30.3 MCHC-32.8 RDW-15.2 Plt Ct-218
[**2115-11-12**] 04:37PM BLOOD PT-16.5* PTT-87.4* [**Month/Day/Year 263**](PT)-1.7
[**2115-11-13**] 09:01AM BLOOD PT-15.2* PTT-66.0* [**Month/Day/Year 263**](PT)-1.5
[**2115-11-13**] 05:26PM BLOOD PT-14.3* PTT-97.5* [**Month/Day/Year 263**](PT)-1.3
[**2115-11-15**] 03:06AM BLOOD PT-14.3* PTT-150* [**Month/Day/Year 263**](PT)-1.3
[**2115-11-16**] 06:00AM BLOOD PT-13.7* PTT-60.3* [**Month/Day/Year 263**](PT)-1.2
[**2115-11-17**] 02:25PM BLOOD PT-13.4 PTT-53.9* [**Month/Day/Year 263**](PT)-1.1
[**2115-11-21**] 06:15AM BLOOD PT-21.2* PTT-110.7* [**Month/Day/Year 263**](PT)-2.8
[**2115-11-23**] 03:46AM BLOOD PT-23.2* PTT-39.8* [**Month/Day/Year 263**](PT)-3.4
[**2115-11-25**] 04:45AM BLOOD PT-21.3* PTT-39.5* [**Month/Day/Year 263**](PT)-2.9
[**2115-11-12**] 04:37PM BLOOD Glucose-98 UreaN-32* Creat-1.4* Na-138
K-4.1 Cl-108 HCO3-21* AnGap-13
[**2115-11-14**] 05:02AM BLOOD Glucose-118* UreaN-27* Creat-1.2 Na-139
K-3.5 Cl-103 HCO3-25 AnGap-15
[**2115-11-15**] 03:06AM BLOOD Glucose-158* UreaN-30* Creat-1.2 Na-133
K-4.3 Cl-109* HCO3-19* AnGap-9
[**2115-11-16**] 11:04PM BLOOD Glucose-122* UreaN-31* Creat-1.1 Na-136
K-3.7 Cl-107 HCO3-22 AnGap-11
[**2115-11-17**] 02:25PM BLOOD Glucose-127* UreaN-29* Creat-1.0 Na-134
K-3.9 Cl-104 HCO3-25 AnGap-9
[**2115-11-21**] 06:15AM BLOOD Glucose-134* UreaN-32* Creat-1.1 Na-133
K-4.3 Cl-101 HCO3-28 AnGap-8
[**2115-11-23**] 06:15PM BLOOD Glucose-134* UreaN-55* Creat-1.1 Na-140
K-4.3 Cl-102 HCO3-33* AnGap-9
[**2115-11-25**] 04:45AM BLOOD Glucose-120* UreaN-38* Creat-1.1 Na-140
K-4.2 Cl-106 HCO3-28 AnGap-10
[**2115-11-12**] 04:37PM BLOOD ALT-18 AST-30 LD(LDH)-351* AlkPhos-79
Amylase-73 TotBili-1.1
[**2115-11-20**] 05:22AM BLOOD ALT-21 AST-38 AlkPhos-156* Amylase-38
TotBili-0.8
[**2115-11-12**] 04:37PM BLOOD Albumin-3.6 Calcium-9.6 Phos-3.4 Mg-1.9
[**2115-11-14**] 05:02AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.3
[**2115-11-24**] 08:58AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.1
RADIOLOGY:
[**2115-11-22**] Video Swallow Study:
Aspiration secondary to impaired pharyngeal esophageal sphincter
and left pharyngeal wall paralysis.
[**2115-11-22**] Esophagram: Contrast flowed freely through a patent
anastomosis into the stomach, duodenum, and distal small bowel.
No leak was seen at the anastomosis site.
[**2115-11-22**] Chest Xray: 1. No pneumothorax. 2. Bibasiilar
atelectasis, and small left pleural effusion.
MICROBIOLOGY:
[**2115-11-22**] MRSA screen: negative
[**2115-11-22**] VRE screen: negative
Brief Hospital Course:
This is a 67 year old gentleman with stage IIA esophageal cancer
status-post neoadjuvant chemo/radiation who presented for
surgical resection. He underwent a three-hole thoracic
esophagectomy with cervical anastamosis on [**2115-11-13**]. He received
2 units of blood during the procedure and was extubated on
[**2115-11-15**]. He remained in the surgical intensive care unit for 6
days. His immediate post-operative period was complicated by
several episodes of atrial fibrillation and SVT which converted
on various occasions with beta-blockade; he never required
electrical cardioversion. He was started back on Coumadin
post-operatively for his atrial fibrillation and mechanical
mitral valve. He also underwent ultra-sound guided aspiration
of 1500 cc of fluid from his left chest on post-operative day 5
which resulted in much improvement in his respiratory status. He
was transfered to the floor on post-operative day 6 and tube
feeding was begun, with goal reached by post-operative day 10.
His chest tubes were removed on post-operative day 7. On the
floor he worked with physical therapy to assist with ambulation.
He had an esophogram study done on post-operative day 9 which
revealed no leak from his anastamosis and his cervical JP drain
was removed. A video swallow study revealed paralysis of the
left pharynx resulting in aspiration and the patient was kept
NPO with tube feeds. He was discharged with planned follow-up
with thoracic surgery.
Medications on Admission:
Protonix 40 mg oral daily
Zocor 10 mg oral daily
Levothyroxin 0.1 mg oral daily
Coumadin 1 mg oral QHS
Discharge Medications:
1. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO once a
day: goal [**Date Range 263**] 3-3.5.
[**Date Range **]:*40 Tablet(s)* Refills:*2*
2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
once a day.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID
(2 times a day) as needed for constipation.
[**Date Range **]:*500 ml* Refills:*0*
4. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q3-4H ()
as needed for pain.
[**Date Range **]:*100 Tablet(s)* Refills:*0*
5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Date Range **]:*60 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP < 95.
[**Date Range **]:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
[**Date Range **]:*20 Tablet(s)* Refills:*2*
8. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Impact/Fiber Liquid Sig: One (1) PO once a day: Per tube
feeding instructions.
Can substitute Nestle equivalent.
[**Date Range **]:*10 Liters* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
(1) Esophageal Cancer
(2) Atrial Fibrillation
(3) Left Pharyngeal Paralysis
Discharge Condition:
Fair
Discharge Instructions:
Please contact the office or come to the emergeny room with any
worsening shortness of breath, drainage from your incision site,
pain not controlled with pain medications, worsening nausea or
emesis, fever > 101.0. Please call with any questions. Do not
eat or drink; all your nutrition with be provided with the tube
feeding. Try to ambulate three times/day.
Followup Instructions:
Please call the office of Dr. [**First Name (STitle) **] [**Doctor Last Name **] at [**Telephone/Fax (1) 170**] to
set up a follow-up appointment at a time of your convenience
within the next 1-2 weeks.
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2115-12-16**] 2:00
Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2115-12-16**] 2:30
Completed by:[**2115-11-26**] | [
"9971",
"42731",
"42789",
"V4581"
] |
Admission Date: [**2105-11-30**] Discharge Date: [**2105-12-7**]
Service: MEDICINE
Allergies:
Penicillins / Quinine / Sulfonamides
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Hypotension, chest pain, SOB
Major Surgical or Invasive Procedure:
Cardiac cath
History of Present Illness:
84 yo F with PMHx of ischemic cardiomyopathy, MI and CABG in
'[**81**], PTCA [**October 2096**] with stent to SVG/LAD, rpeat stent to SVG/LAD
in '[**98**], stent to LMCA-LCX in '[**99**], brachytherapy for LMCA-LCx RCA
and PDA in [**December 2100**], LMCA intervention in [**May 2101**]. Recently
([**Date range (1) 92238**]), had 2 serial cath. 1sst with ulcerated 80%
lesion of the proximal SV to LAD graft s/p stent. 2nd LCx w/
serial 70% lesions at themid segment. The SVG-LAD was patent.
Mid LCx was successfully stented at that time.
Pt presented to [**Hospital3 1196**] after having anginal
sx, DOE prior to admission, went to scheduled HD and was sent to
ED for worsening dyspnea and CP. Pt also complained of cough
over the last few days with sputum. ROS: +orthpnea, +dietary
indiscretion consuming [**4-30**] 8 oz glasses of fluid/day, not
adhering CHF/renal diet. In OSH ED, BP 145/66 followed by
hypotension. In OSH ED, she got neb, CXR w/ bilateral patchy
infiltrates/? consolidation. WBC 19.1 Given a dose of
ceftriaxone and azithromycin. Pt given morphine for CP/SOB and
BP dropped to 74/42->66/39. Started on Dopa drip. EKG with
LBBB (old). She was ruled in by enzymes toponin 3.1->5.1->3.7.
Pt in CHF with elevated JVP, BNP of 2168. On [**11-28**], pt was
diazlyzed 2 L. Echo at OSH showing EF 25%, significant AS,
2+MR, trace TR. Heparin not started for guiac positive. [**11-30**],
Started dialysis at 11am but was dropping blood pressure/ no
fluid removed. Pt then developed chest pressure. At 1:30pm, pt
having CP, tachycardic in 120-130's, and was more tachypneic, BP
55/39. EKG w/ same LBBB. Dopa increaed to 20 mcg/kg/min and BP
improved to 100/60. Heparin gtt was then started. Due to
tachypneia, pt was on 100% NRB then pt was intubated and
transferred to [**Hospital1 18**].
In [**Hospital1 18**] cath lab: Pt found to have LAD occluded proximally,
LCX with 90% leision in the mid-distal segment, RCA without
lesions, SVG-LAD patent with previous proximal stent [**90**]% lesion.
S/P Cypher stent to LCx, and SVG-LAD. PCWP 20 mmHg Cardiac
index was preserved at 2.5 L/min/m2 by Fick.
Past Medical History:
1. CAD - s/p CABG '[**81**], multiple stents
2. HOCM
3. CRF (creatinine 3.0) s/p fistula placement rt. arm
4. HTN
5. CHF - EF 30-35% in [**Month (only) **]/04
6. HTN
7. Gout
8. LLL lung resection for carcinoid
9. s/p cholecystectomy
[**10**]. s/p abd hysterectomy
11. s/p rt ant tib surgery
[**12**]. rt. hip fracture [**10-28**], now with artificial hip
Social History:
Pt is a nonsmoker, does not use alcohol, retired and lives with
her husband.
Family History:
significant CAD in family
Physical Exam:
VS: T 97.6 BP 120/50 HR 76-52 Wt. 47.5 kg
GEN: Pt intubated, sedated.
HEENT: NC/AT: [**Name (NI) 2994**], pt intubated, neck supple. +R IJ
COR: RRR, S1, S2, III/VI high pitched vibratory systolic murmur
heard along left sternal border. Also holosystolic murmur at
apex. No S3.
LUNGS: +coarse breath sounds bilaterally. +cracklesat bilateral
bases.
ABD: +BS, soft, NTND
EXT: trace edema, no femoral bruit, 2+ DP bilaterlally.
NEURO: Pt intubated and sedated. No posturing, no facial
asymmetry.
Pertinent Results:
CATH:
1. Coronary angiography of this right dominant system
demonstrated
multivessel coronary artery disease. The LMCA had no
angiographically
apparent, flow-limiting disease. The LAD was totally occluded
proximally. The LCx had serial 90% lesions in the mid to distal
segment.
The RCA was without flow-limiting disease. The SVG-LAD had a
proximal
90% in-stent restenosis and diffuse noncritical distal disease.
2. Resting hemodynamics revealed elevated filling pressures with
mean
PCWP 20 mmHg. Central blood pressure was 102/61 mmHg on dopamine
IV.
Pulmonary pressures were elevated with PA systolic 40 mmHg.
Cardiac
index was preserved at 2.5 L/min/m2 by Fick.
3. Left ventriculography was not performed due to emergent
nature of the
procedure and to minimize contrast administration in patient
with known
renal failure.
4. Successful placement of 2.5 x 28 mm Cypher drug-eluting stent
in LCx
postdilated with a 3.0 mm balloon. Final angiography
demonstrated no
residual stenosis, no angiographically apparent dissection, and
normal
flow (See PTCA Comments).
5. Successful placement of 3.5 x 23 mm Cypher drug-eluting stent
in
SVG-LAD postdilated with a 4.0 mm balloon. Final angiography
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
ECHO:
1. The left atrium is moderately dilated.
2. The left ventricular cavity size is normal. There is severe
global left
ventricular hypokinesis with some preservation of basal lateral
and basal
inferior wall motion. Overall left ventricular systolic function
is severely
depressed. EF 20-25%
3. The aortic valve leaflets are moderately thickened. There is
mild aortic
valve stenosis. Trace aortic regurgitation is seen.
4. The mitral valve leaflets are moderately thickened. There is
moderate
thickening of the mitral valve chordae. Severe (4+) mitral
regurgitation is
seen.
5. There is mild pulmonary artery systolic hypertension.
6. Compared to the findings of the prior study of [**2105-9-30**], left
ventricular
systolic function has deteriorated, and the severity of mitral
regurgitation
has increased.
Brief Hospital Course:
1)Hypotension: Unclear as to what triggered her hypotension.
DDx: 1)HD related hypotension which caused chest pain secondary
to decreased coronary perfusion 2)Cardiogenic shock after NSTEMI
but CI 2.5 so unlikely. 3)Sepsis from pneumonia causing
hypotension then angina from decreased coronary persusion. Pt
reports SOB/Cough that came before chest pain which may suggest
pneumonia/sepsis -> hypotension ->angina. Pt was initially on
Neosynephrine gtt after cath to keep her MAP>60 but was able to
wean off 2 days post-cath/extubation. Eventually, she was able
to tolerate po metoprolol 12.5 mg po bid and lisinopril 2.5 mg
po qd with good BP.
2)CAD: Pt presented with NSTEMI with positive enzymes. Peak CK
360 and MB 68, and troponin 3.29. Pt got stents to LCx and
SVG-LAD. Pt was initially on Neosynephrine drip to keep her
MAP>60 but was able to wean off and able to start po metoprolol.
She was continued on [**Last Name (LF) **], [**First Name3 (LF) **], Lipitor; and was started on
metoprolol 12.5 mg [**Hospital1 **] and lisinopril 2.5 mg po qd.
3)Pump: Last echo done at [**Hospital1 **] showing EF 30-35% with 3+MR,
mil-mod AS. Echo done on [**12-1**] showing EF 20-25% (worsened), 4+
MR, mild pulm HTN. Worsened EF most likely secondary to
ischemia from the LCx and SVG-LAD territory prior to
intervention. Pt was discharged with po metoprolol and
lisinopril.
4)Rhythm: Pt has LBBB with underlying sinus.
5)Renal: Pt has chronic renal failure and HD dependent. Cr 3.8
on admission. Pt gets dialyzed 3x/week and has AV fistula that
is working well. Pt also came in with HD tunnel catheter on her
L chest. Pt was seen by renal and got HD with adequate
ultrafiltration, given EPOGEN, and PRBC transfusion. Pt
received Sevelamer 1600 mg po tid and Nephrocap 1 cap po qd.
Since her right arm AV fistula working well, her tunnel cath was
successfully removed by the transplant surgery.
6)Pulm: Pt intubated on arrival, but self-extubated on [**12-1**]. Pt
was maintaining good O2 sat initially with NC and later on RA
after HD with adequate fluid removal. Pt also had pneumonia on
CXR and productive cough on admission. Her symptoms improved
after treatment with ceftriaxone and azithromycin. Pt completed
5 day course of azithromycin 500 mg qd and Ceftriaxone was
continued. She will complete a total of 14 day course of
Ceftriaxone, last day [**12-14**].
7)ID: Pt was started on ceftriaxone and azithromycin for
possible PNA seen on CXR at OSH and WBC of 19. Pt showed
clinical improvement with lowering WBC and afebrile with these
antibiotic regimen. Azithromycin was later discontinued. She
was discharged with a 14 day course of ceftriaxone.
8)GI: Pt noted to have guiac+ on rectal exam at OSH. No
evidence of acute Hct drop during this admission. Pt was
getting Protonix 40 mg po qd.
9)Neuro: Pt noted to fell off from a bed and hit her head on the
night of [**12-5**]. Exam noted for 6-7 cm scalp hematoma on the
vertex. Complete neurological exam was intact. Pt denied
headache, visual changes, or changes in mental status. Head CT
was not obtained due to stable neurological exam. However, if
she were to develop worsening headache, changes in mental
status, or focal neuro findings, pt should get a STAT head CT to
rule out subdural/epidural hematoma.
Medications on Admission:
Captopril 6.25 mg po tid on non HD days, qhs on HD.
Lopressor 25 mg po bid
Lasix 60 mg po qd
Dig 0.0625 mg po qd
[**Date Range **] 75 mg po qd
Folic acid 1 mg po qd
Lipitor 20 mg po qd
Vit B6 200 mg po qd
Vit B12 200 mg po qd
Protonix 40 mg po qd
Zyprexa 2.5 mg po qd
Colace 100 mg po bid
Senna 8.5 mg po bid
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] TCU
Discharge Diagnosis:
CAD
Pneumonia
Hypotension
Chronic renal failure
Discharge Condition:
Hemodynamically stable, patient breathing on room air.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 L
Patient was instructed to take all of the medcations as
instructed. Pt needs to resume her scheduled dialysis. Pt
needs to seek medical attention if she were to develop chest
pain, SOB, dizziness, palpitation, diaphoresis, or any other
concerning symptoms. Pt needs to follow up with her PCP and
nephrologist as soon as possible.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2106-2-22**] 10:00
Completed by:[**2105-12-7**] | [
"41071",
"4280",
"40391",
"4240",
"486",
"41401",
"V4581",
"51881",
"2724"
] |
Admission Date: [**2193-1-5**] Discharge Date: [**2193-1-11**]
Date of Birth: [**2107-5-10**] Sex: F
Service: MEDICINE
Allergies:
Avelox / Omeprazole
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
Right pleurex drain insertion [**2193-1-11**]
History of Present Illness:
85 year old female with COPD on home O2 and recent left
exudative pleural effusion who presents with cough, SOB and
palpitations.
.
She reports 1 week of worsening cough productive of yellow
sputum. Also has shortness of breath. She reports that at
baseline she has difficulty walking from room to room in her
house. She wears 3L home O2. However, in the last week, she has
had significant cough and fits of cough. She hasn't been using
her nebulizers often because they make her cough. Endorses
occasional feelings of her heart double beating after a coughing
spell. Denies fevers, chest pain, or nausea/vomiting. States her
breathing sometimes requires her to sit upright, and she told
the on-call pulmonary fellow that she has been sleeping in a
chair due to her breathing. Denies worsening lower extremity
edema, but does endorse waking up at night short of breath.
.
In late [**11-18**] she had a mild COPD exacerbation and her Symbicort
was increased and she was given azithromycin. In [**12-19**] she was
admitted to the [**Hospital 882**] Hospital with a new left pleural
effusion. She was found to have an "undiagnosed lymphocytic,
exudative effusion with negative cytology, AFB, bacterial and
fungal cultures." It was felt that she may eventually need a
pleuroscopy for diagnosis but the decision has not been made
given her "respiratory frailty and DNR status." She also had a
[**Hospital1 882**] admission in [**10-19**] and she had a sputum culture that
reportedly grew cephalosporin-resistent pneumococcus. She was
seen by Dr. [**Last Name (STitle) 1632**] (pulm) last week and had an echo that was
unchanged from prior with normal EF >55% and boderline pulmonary
hypertension.
.
In the ED, initial VS were 97 91 104/52 24 95% 3L. She was found
to be wheezy and tachypneic. ECG showed NSR at rate 77
consistent with prior. She was given solumedrol, nebulizers, and
azithromycin. CXR was normal. Labs were significant for an
elevated lactate to 3.1. Vitals on transfer 97.4 77 126/55 19
96%3L.
.
Currently on the floor she feels much improved and denies
current SOB.
.
Review of systems:
(+) Per HPI. Endorses 3 episodes of bowel incontinence thought
to be due to her Glucerna.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
COPD on home O2
Recent exudative pleural effusions
Chronic sinusitis with secondary nasal drip and chronic cough.
Hypothyroidism
Chronic cough
OA
Glaucoma
Cataracts
Social History:
Lives with her son. Smoked x 44 years, quit 25 years ago. Drinks
one sombrero every evening (coffee flavored brandy plus milk and
ice). Ambulates at baseline but can barely walk from room to
room at baseline due to SOB. Former secretary. ET only 15 steps.
Family History:
Mother died 92 old age
Brother died ? MI
Other brother and sister well
5 children well
Physical Exam:
Vitals: 96.9 BP 121/70 HR 83 RR 24 92%2L 116.8 lbs
General: Alert, oriented, no acute distress. Mild intention
tremor L>R.
HEENT: Sclera anicteric, MMM, oropharynx dry
Neck: Supple, no LAD
Lungs: Decreased breath sounds at the bases with very mild
scattered wheeze
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, JVP not elevated.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis.
Trace bilat ankle edema.
Neuro: GCS 15/15 A+Ox3. CN II-XII normal and UL/LL exam normal
Pertinent Results:
Admission labs
[**2193-1-5**] 06:30PM BLOOD WBC-5.9 RBC-4.32 Hgb-13.6 Hct-39.4 MCV-91
MCH-31.4 MCHC-34.5 RDW-14.8 Plt Ct-263
[**2193-1-5**] 06:30PM BLOOD Neuts-66.7 Lymphs-23.0 Monos-4.4 Eos-5.3*
Baso-0.7
[**2193-1-5**] 06:30PM BLOOD Glucose-133* UreaN-20 Creat-1.1 Na-137
K-4.3 Cl-104 HCO3-22 AnGap-15
[**2193-1-5**] 06:30PM BLOOD CK(CPK)-48
[**2193-1-6**] 06:10AM BLOOD ALT-13 AST-20 CK(CPK)-33 AlkPhos-60
TotBili-0.3 [**2193-1-6**] 06:10AM BLOOD Albumin-4.2 Calcium-9.0
Phos-3.2 Mg-2.0
.
Other labs
[**2193-1-6**] 06:10AM BLOOD TSH-0.90
[**2193-1-6**] 06:10AM BLOOD CRP-2.1
[**2193-1-5**] 06:42PM BLOOD Lactate-3.1*
[**2193-1-6**] 07:54AM BLOOD Lactate-3.7*
[**2193-1-6**] 07:31PM BLOOD Lactate-4.7*
[**2193-1-7**] 12:23AM BLOOD Lactate-3.0*
[**2193-1-7**] 06:37AM BLOOD Lactate-1.9
[**2193-1-8**] 07:13AM BLOOD Lactate-1.3
.
Cardiac enzymes
[**2193-1-5**] 06:30PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-229
[**2193-1-6**] 06:10AM BLOOD CK-MB-2 cTropnT-<0.01
[**2193-1-6**] 08:25PM BLOOD CK-MB-3 cTropnT-<0.01
.
Discharge labs
[**2193-1-11**] 07:43AM BLOOD WBC-6.1 RBC-4.19* Hgb-13.2 Hct-39.2
MCV-94 MCH-31.6 MCHC-33.8 RDW-15.0 Plt Ct-267
[**2193-1-11**] 07:43AM BLOOD Glucose-80 UreaN-26* Creat-1.0 Na-140
K-5.1 Cl-105 HCO3-28 AnGap-12
[**2193-1-11**] 07:43AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.3
.
.
Microbiology:
.
BC [**1-6**] no growth
.
MRSA screen negative [**1-6**]
.
[**2193-1-7**] 12:00 pm Influenza A/B by DFA
Source: Nasopharyngeal swab.
**FINAL REPORT [**2193-1-7**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2193-1-7**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2193-1-7**]):
Negative for Influenza B.
.
.
Radiology
.
XR CHEST (PA & LAT) Study Date of [**2193-1-5**] 7:00 PM
Frontal and lateral views of the chest were obtained. Lungs
remain
hyperinflated with flattening of the diaphragms and increased AP
diameter ofthe chest on the lateral view, consistent with
chronic obstructive pulmonary disease. Small bilateral pleural
effusions are again seen. Small bilateral pleural effusions with
overlying atelectasis are again seen. Superimposed bibasilar
consolidation cannot be excluded. There is no pneumothorax. The
aorta remains calcified and tortuous. Cardiac silhouette is not
enlarged. Mild anterior wedging of a lower thoracic vertebral
body is unchanged.
IMPRESSION: Small bilateral pleural effusions with overlying
bibasilar
atelectasis. Underlying consolidation not excluded, particularly
in the
medial right lower lobe and infectious process not excluded.
.
XR CHEST (LAT DECUB ONLY) Study Date of [**2193-1-6**] 9:20 AM
Right and left chest decubitus were obtained. There is minimal
amount of left pleural effusion and moderate-to-large amount of
right pleural effusion demonstrated on the decubital views.
Otherwise, no change since the prior study has been
demonstrated.
.
XR CHEST (PA & LAT) Study Date of [**2193-1-10**] 4:31 PM
In comparison with the study of [**1-5**], there is no change in the
degree and extent of the bilateral pleural effusions with
compressive basilar atelectasis. Findings of chronic pulmonary
disease persists. No evidence of acute focal pneumonia.
.
XR CHEST (PORTABLE AP) Study Date of [**2193-1-11**] 11:46 AM
In comparison with study of [**1-10**], the patient has taken a much
better inspiration and is now upright. This may be responsible
for the
apparent decrease in the effusions, especially on the right,
though some of this may reflect the insertion of a right
tunneled catheter. Opacification at the left base is consistent
with volume loss in the left lower lobe.
.
.
Cardiology
ECG Study Date of [**2193-1-6**] 6:57:56 PM
Sinus rhythm. RSR' pattern (probable normal variant).
Anteroseptal
ST-T wave changes consistent with possible ischemia. Clinical
correlation is suggested. Compared to the previous tracing of
[**2193-1-5**] the rate has
increased. All other findings are similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 140 78 362/430 69 0 48
Brief Hospital Course:
85 year old female with COPD on home O2 and recent left
exudative pleural effusions, who presents with cough, SOB and
questionable palpitations and orthopnea. Decompensation [**1-6**]
requiring precautionary ICU transfer for consideration of BiPAP
but did not necessitate this. Still tachypneic on transfer back
to the [**Hospital1 **] [**1-7**]. Continued episodes of tachypnea, SOB and
anxious ++ re these. Improved with new regime including morphine
IR after palliative care consult. Had family meeting regarding
disposition [**1-10**]. Right Pleurex drain was inserted [**1-11**] for
symptomatic relief of effusions. She complained of pain at the
drain.
.
#. Shortness of breath: Has increased cough production without
fevers and worsening shortness of breath. Feel that this is most
likely a bronchitis triggering a mild COPD exacerbation.
Currently patient with baseline O2 requirement and appears
comfortable and minimally wheezy. Also with recent h/o pleural
effusions that were by report exudative. Always concern exists
for empyema given this history, but CXR shows only small
bilateral effusions and patient doesn't have leukocytosis or
fever. There was no xray or clinical evidence of pneumonia
although this could not be excluded on imaging. Also had a
history of SOB worse when lying flat, although did not appear
volume overloaded on physical exam and has had recent echo
without evidence of CHF (JVP not elevated and trace akle edema).
BNP 229. CEs -ve x2. She was treated with QID ipratropium and
albuterol nebulisers, prednisone 40mg po daily and azithromycin.
She had lateral decubitus CXR on [**1-6**] which showed a minimal
left and moderate-large right pleural effusion. She was noted to
have a rising lactate which was thought related to poor po
intake. She latterly decompensated on the evening of [**1-6**] with
a high RR, use of accessory muscles and feeling more SOB. Her
ABG showed a respiratory alkalosis with a low pCO2. She was then
started on IV ceftriaxone to cover for possibel infection
although her WBC were notelevated, she remained afebrile and had
no radiographic evidence of infection. Her lactate was seen to
be increasing. As a precautionary measure, she was transferred
to the ICU for consideration of BiPAP but this was not required.
In the ICU she did not receive NIV and improved with nebs and
lorazepam. The patient coped on baseline O2 requirement
saturating well but was very anxiou regarding er breathing which
was relieved by lorazepam. Her high lactate max 4.7 and was felt
likely due to effort of breathing and some dehydration. Sh was
seen by palliative care on [**1-8**] who recommended oral IR
morphine 7.5mg Q4 PRN to as treatment of her anxiety regarding
her pulmonary symptoms. She had a family meeting regarding her
care and preferred to stay at home if possible and was adamant
that she did not want to go to a nursing home. She had a family
meeting on [**1-10**] regarding her care and was informed that her VNA
services could also cover for hospice care. She worked with PT
who felt she would benefit from a period of rehabilitation. She
had ceftriaxone changed to oral cefpodoxime on [**1-10**] and this
will be continued to complete a 5 day course ending [**1-11**]. She
was seen by her pulmonologist Dr [**Last Name (STitle) 575**] on [**1-10**] who felt that
a Pleurex drain may be of value to symptomatically treat her
effusions as these effusions essentially excluded her best
functioning lung tissue and were a considerable reason to
account for her symptoms. She agreed to drain insertion and
interventional pulmonology inserted a right Pleurex catheter on
[**1-11**] and post procedure there was no evidence of pneumothorax on
CXR but she did note pleuritic chest pain. This was relieved
with oxycodone. She was discharged to rehabilitation on [**1-11**] and
her leurex drain can be drained 3x/week. She will be seen by her
PCP [**Last Name (NamePattern4) **] [**1-15**] and in due course by her pulmonologist. She will be
seen for interventional pulmonology follow-up on [**1-24**] and by
pulmonology in due course. Her wish was that if she were to
worsen again that she would re-present to hospital as this would
make her feel safe.
.
#. Pleural effusions: Currently with small bilateral pleural
effusions on CXR and recent admission for exudative effusion of
unclear etiology. DDx is broad but culture and workup have all
been negative so far. Recent CT chest does show multiple
pulmonary nodules but none changed from previous or suggesting
malignancy. Could consider inflammatory /autoimmune causes. This
could be contributing to her SOB. She went on to a lateral decub
CXR on [**1-6**] which showed R>L effusions. She was resistant to
the idea of diagnostic pleuroscopy on [**1-7**] when seen by
interventional pulmonology following a brief stay in the ICU for
a respiratory decompensation greatly worsened by extreme anxiety
regarding her shortness of breath. She was changed to a regime
to tackle her anxiety with breathing as above. She agreed to
Pleurex drain insertion on [**1-11**] and this was inserted in teh
right chest. 750ml was drained and limited by chest pain. Post
procedure CXR showed no pneumothorax. She had pain at the site
and this was relieved by oxycodone and a lidocaine patch can
also be used. She will be seen by IP on [**1-14**]. She can have her
Pleurex drained 3x per week on transfer to the community.
.
#. Elevated lactate: This rose from 3.1 on [**1-5**] to 4.7 on [**1-6**]
with a normal anion gap and settled and remained down at 1.9-1.3
on [**1-7**] to [**1-8**]. This was felt most likely due to volume
depletion in setting of poor po intake and increased work of
breathing. She was treated with IV fluids, her breathing settled
following anxiolytics and regular nebs and this fell to normal.
.
# Poor po intake: She noted little po intake past 2+ weeks.
While in house, her intake improved.
.
#. Hypothyroidism: We continued home levothyroxine. TSH was
normal.
.
#. Osteoporosis: Resumed alendronate.
.
#. Glaucoma: we continued home brimonidine and latanoprost eye
drops.
.
#. Anxiety and Palliative Care: We continued home mirtazepine
and increased lorazepam to 1mg PRN Q6H and she was seen by
palliative care on [**1-8**] and they followed her during the rest
pof her admission. They recommended adding morphine sulfate IR
7.5mg Q4H for anxiety regarding breathing. This considerably
improved matters. She had a Pleurex drain placed on [**1-11**] for
symptomatic relief of recurrent exudative effusions of unknown
cause. She had a family meeting on [**1-10**] and her wish was to
return home with services but not hospice at home although that
would be an option if she worsens. In addition, her wish was
that if she were to have another exacerbation again that she
would re-present to hospital as this would make her feel safe.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 (One) vial(s) inhaled via nebulizaiton up to 4
times daily as needed for shortness of breath or wheezing
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs inhaled up to four times a day as needed for
shortness of breath or wheezing when out of the house
ALENDRONATE - (Not Taking as Prescribed) - 70 mg Tablet - 1
Tablet(s) by mouth weekly
BRIMONIDINE [ALPHAGAN P] - (Prescribed by Other Provider) -
Dosage uncertain
BUDESONIDE-FORMOTEROL [SYMBICORT] - 160 mcg-4.5 mcg/Actuation
HFA
Aerosol Inhaler - 2 (Two) puffs inhaled twice a day
FINGERTIP OXIMETER - - use as directed to assess home oxygen
need
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray(s) in each
nostril once or twice a day as needed for nasal allergy symptoms
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005
%
Drops -
LEVOTHYROXINE [LEVOXYL] - 75 mcg Tablet - one Tablet(s) by mouth
once a day
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth four times a
day
as needed for anxiety
MIRTAZAPINE - 15 mg Tablet - 2 Tablet(s) by mouth at bedtime
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by
mouth once a day For severe neck pain
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - Contents of one capsule inhaled once a day
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
7. menthol-cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheeze and SOB.
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
QID (4 times a day).
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed for sob, wheeze.
12. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for anxiety and sob.
13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
17. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 1 days.
18. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation twice a day.
19. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day) as needed for nasal congestion.
20. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
21. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
22. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary diagnoses:
Chronic Obstructive Pulmonary Disease Exacerbation
Exudative pleural effusions
Pleurex drain insertion
Anxiety regarding respiratory symptoms
.
Secondary diagnoses:
Chronic sinusitis with secondary nasal drip and chronic cough.
Hypothyroidism
Chronic cough
OA
Glaucoma
Cataracts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a truly a pleasure looking after you during your stay at
the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented with
progressive shortness of breath and cough in addition to poor
oral intake. You were treated for a COPD flare with oral
steroids (to finish 5 days on [**1-11**]) and antibiotics in addition
to regular and as needed nebulisers. You had worsening of your
shortenss of breath and had a brief period of observation in the
ICU. You have fluid collections at the base of your lungs
(effusions) and you were seen by Interventional Pulmonology. You
decided that you did not want any further intervention regarding
these. You had considerable problems with anxiety regarding your
shortness of breath and this was well controlled with lorazepam
and latterly you were seen by Palliative Care to help with
symptom control and we added oral morphine which also helped
with your anxiety with breathing. You had a Pleurex drain
inserted on [**1-11**] to help with the effusions (fluid around the
lungs) and this can be drained at home 3x per week by VNA. You
had some pain at the drain site and this settled with pain
killers. By discharge, you were working with PT and discharged
to rehab.
.
Changes to medications:
We started oral cefpodoxime and should finish on [**1-11**]
We started oral prednisone 40mg daily which should finish [**1-11**]
We increased the frequency of your albuterol nebuliser to 4x
daily and as required
We stopped tiotropium and started ipratropium nebulisers 4x
daily and as required
We increased lorazepam to 1mg as needed up to every 6 hours
We started oral morphine at 7.5mg as needed every 4 hours to
help with distress and anxiety surrounding shortness of breath
We started ondansetron as needed for nausea
We started laxatives for constipation
We started guaifenasin for your cough
We started oxycodone for pain at the drain site
If you need this, we have prescribed a lidocaine patch to help
with pain at the drain site
.
Patient instructions:
You will need to take your nebulisers regularly.
Followup Instructions:
We made the following appointments for you:
We tried to make an appointment with Dr [**Last Name (STitle) 575**]. The secretary
has put you on a wait list and discuss with Dr [**Last Name (STitle) 575**]. If he
thinks you will need to be seen sooner, she will call pt at home
with an appointment. You can also contact [**Name2 (NI) 28271**] office
directly regarding this.
.
Department: [**Hospital3 249**]
When: TUESDAY [**2193-1-15**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-1-24**] at 9:30 AM
With: [**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| [
"2449",
"V1582"
] |
Admission Date: [**2134-8-14**] Discharge Date: [**2134-8-17**]
Date of Birth: [**2064-9-18**] Sex: M
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 33170**] is a 69 y/o man with PMH of metastatic insulinoma,
hypertension, and paroxysmal atrial fibrillation not
anticoagulated who presents with hypoglycemia. Patient's partner
notes that patient slept in this morning to 8 or 9 am (usual
wake up time is 6 am). At that time, his partner wanted to take
his blood sugar as this was unusual for him but patient would
not cooperate. His partner then called EMS who reportedly found
FSBS 20. An amp of D50 was given at that time with increased
alertness and FSBS to 136 and then to 113.
.
He arrived at [**Hospital3 **] Hospital at about 11 am, and FSBS at 1151
am was 27 and repeated to be 59. He got 1 amp D50 at 1200 pm. He
was then started on a D51/2NS infusion at 150 cc / hour.
.
On arrival to our ED, initial vitals T 98, HR 85, BP 110/76, RR
14, O2 98% on RA. Initial FSBS 106, with repeat 111 at 1650 and
99 at 1830 prior to transfer to floor. He was maintained on
D51/2NS at 150 cc/hour while in the ED. He vomited X 1 en route
to [**Hospital1 18**] after drinking OJ in the ambulance.
.
On arrival to the ICU, the patient denies any headache,
dizziness, chest pain, or difficulty breathing. He endorses
abdominal distension which is chronic but maybe slightly
increased in past few weeks. He reports decreased PO intake due
to decreased appetite for the past few days as well as feeling
overall "weak" and "tired." He denies any nausea/vomiting or
diarrhea at home. He denies any blood in his stools.
.
Typically checks fingersticks twice per day-morning and before
bed. No recent low fingersticks in past few days. Tried decrease
in dexamethasone to 1 mg alternating with 1.5 mg every other day
but did not tolerate this due to morning fingersticks in the
40s.
.
ROS: Denies headache, nasal congestion, sore throat, enlarged
lymph nodes, chest pain, difficulty breathing, and cough. Denies
fever, chills, or recent weight loss. Denies dysuria though
reports nighttime incontinence which has been ongoing for some
time. Denies blood in his stools. Endorses lower extremity
swelling which has been worse with dexamethasone treatment.
Endorses right hand tingling in all fingers for past few weeks
without right hand weakness or clumsiness.
Past Medical History:
* Hypertension
* Paroxysmal atrial fibrillation (s/p DCCV, now on dofetilide,
previously on coumadin)
* Transitional cell bladder cancer s/p cystectomy & prostatecomy
with ileal neobladder
* Metastatic insulinoma with metastases to liver resulting in
gastric/esophageal varices & portal hypertension
- s/p treatment with Adriamycin/5FU/streptozocin in [**4-6**] and
chemoembolization in [**5-7**] & [**5-8**]
- treated with temsirolimus [**10-8**] which was stopped due to side
effects
- initiated treatment with sirolimus in [**12-8**] which was stopped
on [**2134-8-10**]
- now followed at the [**Company 2860**], last CT there last week, Dr. [**Last Name (STitle) 33171**]
is oncologist, plan for initiation of avastin on [**8-19**]
* Gonadal insufficiency on topical androgen replacement
* h/o anal fissure s/p surgical repair
* GERD on PPI, recent GI bleed in [**3-9**] [**1-2**] to Dieulafoy lesion
* h/o pancytopenia
* s/p appendectomy
Social History:
Patient lives with his partner, [**Name (NI) **] [**Last Name (NamePattern1) 19952**], in [**Name (NI) 3615**].
Currently not working but previously worked in property
management. Denies tobacco, alcohol, and illicit drug use. No
pets.
Family History:
Father deceased age 56 with MI. Mother deceased age [**Age over 90 **] with
complications from hip repair. Has 5 siblings.
Physical Exam:
vs: T 99.2, BP 105/51, P 86, RR 19, 100% ra
gen: alert, oriented, no acute distress
heent: PERRL, EOMI, sclerae anicteric, MM slightly dry, no
lymphadenopathy in the neck, JVP at 7 cm
lungs: clear bilaterally without rhonchi or wheezing
CV: RRR, heart sounds distant, no appreciable murmur
abd: distended but tympanitic, normoactive bowel sounds,
slightly tender diffusely to palpation, + fluid wave on exam,
ext: 1+ pitting edema in bilateral lower extremities to knees,
warm throughout, DP pulses 2+ bilaterally
skin: scattered acneiform lesions on back, no rash
neuro: cranial nerves II-XII intact, speech clear, strength 5/5
in bilateral biceps/triceps, hand grip, wrist extension, hip
flexion, ankle dorsiflexion/plantarflexion; DTRs 2+ at biceps
and patellar tendons, sensation intact upper & lower extremities
to light touch
psych: appropriately answering questions
Pertinent Results:
ADMISSION LABS (from [**Hospital3 **] Hospital):
WBC 6.3 (83%N, 12%L, 5% monos), Hgb 13.1, Hct 39, Plt 165
Troponin I < 0.10
Alk phos 124
Total bili 0.9
Direct bili 0.2
Indirect bili 0.7
Total protein 6.6
Albumin 3.6
AST 29
ALT 32
Na 140, K 4, Cl 115, CO2 17, BUN 24, Cr 1.3
Ca 8.8
Glucose 167
INR 1.1
.
Labs from [**Company 2860**] ([**2137-8-10**]):
WBC 4.7 <-- 3.2
Hct 34.5 <-- 35
Plt 109 <-- 106
Na 140 <-- 139
k 5 <-- 4
Cl 118 <-- 116
CO2 14 <-- 12
BUN 31 <-- 33
Cr 1.6 <-- 1.4
glucose 96 <-- 101
calcium 9.3 <-- 9.1
albumin 3.7
alk phos 114 <-- 118
.
EKG: sinus rhythm at 90, normal axis, biphasic p wave in V1, TWI
in V1 and III, no ST-T elevations or depressions
[**2134-8-14**] 08:46PM GLUCOSE-114* UREA N-26* CREAT-1.4* SODIUM-142
POTASSIUM-3.7 CHLORIDE-117* TOTAL CO2-15* ANION GAP-14
[**2134-8-14**] 08:46PM ALT(SGPT)-32 AST(SGOT)-29 LD(LDH)-213 ALK
PHOS-120* AMYLASE-85 TOT BILI-0.6
[**2134-8-14**] 08:46PM LIPASE-29
[**2134-8-14**] 08:46PM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-2.6*
MAGNESIUM-1.8
[**2134-8-14**] 08:46PM WBC-3.1* RBC-3.77* HGB-11.8* HCT-34.1* MCV-90
MCH-31.3 MCHC-34.6 RDW-13.9
[**2134-8-14**] 08:46PM PLT COUNT-92*
[**2134-8-14**] 08:46PM NEUTS-76.5* LYMPHS-15.9* MONOS-5.8 EOS-1.5
BASOS-0.4
[**2134-8-14**] 08:46PM PT-13.1 PTT-25.0 INR(PT)-1.1
.
.
PERTINENT LABS/STUDIES:
.
Hct: 34.1 ([**8-14**]) -> 29.6 -> 30.1 -> 31.4 ([**8-17**])
WBC: 3.1 ([**8-14**]) -> 2.8 -> 2.5 -> 2.5 ([**8-17**])
Plt: 92 -> 82 -> 83 -> 92
HCO3: 15 ([**8-14**]) -> 11 -> 12 -> 12 ([**8-17**])
Cl: 117 -> 117 -> 118 -> 119
Glucose: 114 ([**8-14**]) -> 151 -> 123 -> 84 ([**8-17**])
ABG: 7.41 / 20 / 96 / 13
.
U/A: Small leukocytes, many bacteria
URINE CULTURE (Final [**2134-8-17**]):
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
CXR ([**8-14**]): Comparison is made to the prior study from [**2132-5-10**]. There are low lung volumes with mild bibasilar atelectasis.
The remainder of the lungs are clear. Cardiomediastinal
silhouette is unremarkable.
.
.
DISCHARGE LABS:
[**2134-8-17**] 04:55AM BLOOD WBC-2.5* RBC-3.48* Hgb-10.7* Hct-31.4*
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.9 Plt Ct-92*
[**2134-8-15**] 10:37PM BLOOD Neuts-78.7* Lymphs-15.5* Monos-5.4
Eos-0.4 Baso-0.2
[**2134-8-17**] 04:55AM BLOOD Plt Ct-92*
[**2134-8-17**] 04:55AM BLOOD Glucose-84 UreaN-27* Creat-1.3* Na-140
K-3.7 Cl-119* HCO3-12* AnGap-13
[**2134-8-17**] 04:55AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.0
Brief Hospital Course:
Patient is a 69 yo male with known metastatic insulinoma who was
admitted with hypoglycemia in the setting of progressive
metastatic disease.
.
#. Hypoglycemia: Patient had a recent CT on [**2134-8-12**], which
showed progressive disease per primary oncologist. Patient was
planning on starting Avastin therapy on [**2134-8-19**]. Patient had
decreased appetite for a few days prior to admission, and his
recent hypoglycemic episode was most likely secondary to
decreased PO intake. The patient was started on D10 IV fluids,
and was eventually transitioned to D5 IV Fluids. The patient's
dexamethasone was also increased to 4 mg [**Hospital1 **]. On hospital day
#3, the patient's IV Fluids were stopped, and his finger stick
glucoses remained within normal limits. The patient has a
follow-up appointment with his oncologist on Thursday, [**8-19**].
.
#. Possible UTI: The patient had a U/A on admission which showed
WBCs and bacteria. Patient has an ileal conduit, and thus he
may have chronic bacteriuria. Patient does not endorse any
symptoms, and urine cultures grew Klebsiella Oxytoca. The
patient was not started on antibiotics during this admission.
.
# Metabolic Acidosis: The patient had persistently low HCO3 on
this admission, which was thought to be secondary to his ileal
neobladder. An ABG was performed on the patient, which showed a
normal pH, but a decreased CO2 to 20, significant for a chronic
process. The patient has an ileal conduit, and a metabolic
acidosis is normally found in this setting when there is
increased transit time in the ileoconduit (i.e. possible stomal
stenosis). It was recommended that the patient visit his
urologist at his convenience to have a loopogram performed to
assess the patency of his ileoconduit. The patient was
discharged on bicarbonate replacement.
.
# Atrial fibrillation: The patient has a history of Atrial
fibrillation and was continued on his home dose of dofetilide.
He was in normal sinus rhythm throughout this admission. He is
not anticoagulated secondary to a recent GI bleed, but he
remained on ASA 81 mg daily during this admission.
.
#. Hypertension: The patient has a h/o hypertension and is
currently on dofetilide. He was continued on this medication
throughout his hospital stay and did not have any acute events.
.
#. GERD with recent UGI bleed: Patient has a history of a
recent GI bleed. He was stable throughout this hospital stay
and was maintained on his home dose of PPI.
.
# Code: Full
Medications on Admission:
Dofetilide 375 mcg twice a day
dexamethasone 1.5 mg daily
omeprazole 20 mg [**Hospital1 **]
nadolol 20 mg daily (pt unsure if he still takes this med)
AndroGel 1% pump (occasional use only)
vitamin C 1000 mg daily
aspirin 81 mg a day
simethicone 125 mg 2-4 times/day
Sirolimus 2 mg daily - stopped on [**8-10**]
spironolactone/hydrochlorothiazide 12.5 daily - stopped [**7-30**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Insulinoma
Hypoglycemia
Secondary:
Metabolic non-gap acidosis
Atrial Fibrillation
Discharge Condition:
Good. Patient's vital signs are stable, and his fingerstick
glucose levels have all been within normal limits.
Discharge Instructions:
You were admitted to the hospital because you experienced an
episode of hypoglycemia. While you were here, your dose of
Dexamethasone was increased and you were placed on IV fluids
with glucose. Your blood sugars remained stable on this
regimen, so we took you off of the IV fluids. Your sugars
remained stable overnight and appeared to have responded to the
increased dose of Dexamethasone.
While you were here, we made the following changes to your
medications:
1. We started you on Sodium bicarbonate to increase this level
in your blood.
2. We increased your dose of Dexamethasone to 4 mg [**Hospital1 **].
Please take all medications as prescribed.
Pleae keep all previously scheduled appointments.
Please return to the ED or your healthcare provider immediately
if you experience confusion, low blood sugars, weakness,
lethargy, chest pain, shortness of breath, fevers, chills, or
any other concerning symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33171**]. Date: [**2134-8-19**].
Provider: [**Last Name (NamePattern4) **]/EYE LIST OR EYE SURGERY Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2134-9-16**] 7:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2134-9-17**] 4:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2135-1-26**] 1:00
Completed by:[**2134-8-17**] | [
"5990",
"2762",
"42731",
"4019",
"53081"
] |
Admission Date: [**2153-12-18**] Discharge Date: [**2153-12-20**]
Date of Birth: [**2085-1-22**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
chest pain, aspirin desensitization
Major Surgical or Invasive Procedure:
cardiac catherization
History of Present Illness:
Mr. [**Known lastname 7749**] is a 68 yo M with history of asthma, hypertension,
hyperlipidemia and AS who has had 3-4 days of crescendo angina.
The patient reports that starting on Friday afternoon he began
to have substernal crushing chest pain/tightness. This pain was
persistent and improved with rest, but persisted for the
duration of the day. He did not have shortness of breath,
dizziness or lightheadedness with this episode. The pain
recurred several more times over the weekend, usually resolving
with rest. The pains required him to stop the participitating
activities (working, dancing, snowshoveling). After chest
tightness on Monday, the patient called his PCP. [**Name10 (NameIs) **] recommended
going to the ER if the pain persisted, but if not, then the
patient was to come to the PCP's office in AM. The patient
reported to the PCP's office on tuesday AM. He was found to have
ST depressions and mild troponin elevation. Thus the patient was
sent directly to the ED (instead of the scheduled stress test).
The patient was given plavix 600 mg, atorvastatin 80 mg,
metoprolol 2.5 mg x2 IV and started on heparin gtt with bolus.
The patient was then transferred to [**Hospital1 18**] for aspirin
desentization.
.
On arrival the patient has no chest pain or dyspnea. He reports
no current symptoms including no chest pain, no shortness of
breath, no dizziness. He is hungry.
.
On review of systems, he has intermittent cough and occasional
dyspnea on exertion x last 5 months. Also patient has been
having exertional left leg pain over the last few months. He
denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, hemoptysis, black stools or red stools. S/he denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
.
Initial vitals at the OSH were not recorded, but BPs by EMS were
164/88, HR 74, RR 16, 02 98%.
Past Medical History:
HTN
Asthma
hyperlipidemia
rhinitis
nasal polyps
mild to moderate aortic stenosis
single kidney
.
Social History:
Tobacco history: no history of tobacco, alcohol
Family History:
Brother with AAA at age 70, no SCD or CAD in family. Father with
lung disease
Physical Exam:
General appearance: Well appearing
Height: 74 Inch, 188 cm
Weight: 86 kg
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums
and palette: WNL)
Neck: (Jugular veins: JVP, 8), (Thyroid: WNL)
Back / Musculoskeletal: (Chest wall structure: WNL)
Respiratory: (Effort: WNL), (Auscultation: WNL)
Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL),
(Auscultation: S1: WNL), (Murmur / Rub: Present), (Auscultation
details: systolic murmur heard throughout precordium, loudest at
RUSB, crescendo-decrescendo, no delayed pulses)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (WNL)
Femoral Artery: (Right femoral artery: 2+, No bruit), (Left
femoral artery: 2+, No bruit)
Extremities / Musculoskeletal: (Digits and nails: WNL),
(Dorsalis pedis artery: Right: 2+, Left: 2+), (Posterior tibial
artery: Right: 1+, Left: 1+), (Edema: Right: 0, Left: 0),
(Extremity details: warm)
Skin: ( WNL)
Pertinent Results:
Admission labs:
[**2153-12-18**] 05:12PM GLUCOSE-89 UREA N-19 CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
[**2153-12-18**] 05:12PM WBC-10.8 RBC-4.71 HGB-14.1 HCT-39.7* MCV-84
MCH-30.0 MCHC-35.6* RDW-13.0
Cardiac enzymes:
[**2153-12-18**] 05:12PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2153-12-19**] 12:46AM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2153-12-19**] 04:26PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2153-12-19**] 12:46AM BLOOD CK(CPK)-74
[**2153-12-19**] 04:26PM BLOOD CK(CPK)-72
Admission EKG:
Sinus rhythm. Left ventricular hypertrophy with ST-T wave
abnormalities
The ST-T wave changes could be due in part to left ventricular
hypertrophy but are nonspecific and clinical correlation is
suggested
No previous tracing available for comparison
Brief Hospital Course:
68 yo M with unstable angina no CP free for >12 hours who
presents as transfer for aspirin desentization prior to cardiac
catherization.
.
ACS: the patient presented with chest pain consistent with
unstable angina, mild troponin elevation and ECG changes make
NSTEMI more likely. Given ST changes and mild troponin
elevation, the likely cause of the chest pain was CAD. Heparin
gtt, plavix, and high-dose atorvastatin were started. The
patient was desensitized to aspirin as below. He was taken to
the cath lab. The large dominant LCX had mild non-obstructive
disease proximally. The small non-dominant RCA had a 90%
proximal stenosis. Two bare metal stents were placed, with good
result. He will continue full dose ASA and Plavix x 1 month and
low dose ASA 81 mg thereafter.
.
Aortic stenosis/sclerosis: By history it was unclear whether he
had aortic stenosis vs aortic sclerosis. On catheterization
there was no transaortic pressure gradient. Despite this, valve
area on echo was 1.0-1.2 cm2.
.
Aspirin desentization: Patient reported an asthmatic reaction to
aspirin. Aspirin desensitization was undertaken with
premedication with singulair and prednisone. The patient
subsequently tolerated 325 mg aspirin daily without evidence of
bronchospasm or other adverse reaction
.
Hypertension: The patient was initially hypertensive and was
treated with low-dose nitro gtt. This was transitioned to
metoprolol after ASA desensitization was complete. Patient
continued to be hypertensive with SBP ~200. An ACE inhibitor
was added, and SBP fell to 140-150. Further optimization of BP
was deferred to PCP.
.
Hyperlipidemia: Lipids were well controlled on labs at OSH.
High-dose atorvastatin was started for NSTEMI, to continue
indefinitely.
Medications on Admission:
Atenolol 100 mg daily
Simvastatin 20 mg daily
Advair 250/50 [**Hospital1 **] (patient taking prn)
Flonase prn (not taking)
Amoxicillin prn dental procedure
proair (prescribed, not taking)
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
You must take this medication EVERY DAY. Please go directly to
the ER if you have any allergic reaction to this including
swelling, rash or wheezing.
Disp:*30 Tablet(s)* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Aspirin allergy
Non-st elevation MI
Secondary: hypertension
Discharge Condition:
Improved, no chest pain
Discharge Instructions:
You were admitted with a heart attack and were desensitized from
aspirin. You also had a stent placed in one of your coronary
arteries. Thus you are on new medications for your coronary
artery disease.
Your new medications include:
Aspirin, plavix, lisinopril and lipitor 80 mg.
You are not taking simvastatin for now.
You must take plavix for at least one month, but DO NOT stop
taking it until speaking with a cardiologist. Additionally you
should never go more than one day without aspirin as you will
have to be desensitized from aspirin if you miss more than one
to two days.
Please return to the ER or call 911 if you have any chest pain,
shortness of breath, passing out, light headedness.
Additionally any nausea, vomiting, fever or chills, please call
your doctor or 911.
Followup Instructions:
You should see Dr. [**Last Name (STitle) **] on [**12-26**] at 11 AM. Theh phone
number is [**Telephone/Fax (1) 4475**] ([**First Name8 (NamePattern2) 81568**] [**Hospital1 **], Ma).
If you are unable to make the appointment with Dr. [**Last Name (STitle) **], you
should see Dr. [**Last Name (STitle) **] in her clinic in the next 1-2 weeks. You
can call and make that appointment at [**Telephone/Fax (1) 62**].
You should also see Dr. [**First Name (STitle) 1356**] in [**1-8**] weeks after seeing Dr.
[**Last Name (STitle) 39288**].
Completed by:[**2153-12-20**] | [
"41071",
"41401",
"2724",
"4019",
"49390",
"4241"
] |
Admission Date: [**2142-11-26**] Discharge Date: [**2142-11-30**]
Date of Birth: [**2061-12-10**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
code stroke - L sided weakness
Major Surgical or Invasive Procedure:
Intubated - [**2142-11-28**]
History of Present Illness:
CC: Code stroke - L sided weakness
Code activated 6:12pm
Patient examined 6:20pm
NIHSS:
Best gaze - forced to R 2
Visual - Complete L hemianopia 2
Facial palsy - partial on L 2
Motor - L arm 4
L leg 4
Sensory - Severe/total loss on L 2
Dysarthria - mild dysarthria 1
Extinction - profound inattention to L side 2
Total 19
HPI: Patient is a 80yo RHM with Afib but not on Coumadin, HTN,
DM
and hx of stroke over 10 years ago with some residual L sided
weakness who was found down per VNA at 3pm with L slurred speech
and L sided weakness. Per report, he was taken by ambulance to
[**Location 84234**]where his initial BP was extremely elevated
with
SBP into 280s for which he was given labetalol x2~3. Head CT
was
negative for hemorrhage then patient was transferred to [**Hospital1 18**]
for
further care.
Per patient, he woke up around 10am and ate breakfast which was
delivered per meals on wheels. He did not speak to anybody - he
lives alone and ambulates with a walker and reports to have VNA
once or twice weekly. He then fell around 10:30 am - he is
unable to recall why he fell but he thinks he may have tripped
but he could not get up hence was on the floor until VNA found
him at 3pm.
He denies any recent illness, fever, cough, N/V/D or HA. He
reports to be smoking as much as possible (>1 PPD) which he has
been doing over 50 years and not taking any of his meds. He
reports to have not taken any meds for over 2 months at least,
however, per [**Hospital1 802**] who is also his HCP, she reports that his
meds
are overseen per VNA hence he may be more compliant than he
reports. Also, she recalls that when she accompanied him to his
PCP appt about 6 months ago, his PCP may have told him that he
can take ASA instead of Coumadin for his Afib.
Of note, patient was in nursing home about 6~8 weeks ago for PT
and rehab after vascular surgery for RLE artery occlusion.
Past Medical History:
1. Stroke - over 10 yrs ago, initially could not move L side,
talk or walk per patient.
2. Afib
3. HTN
4. DM - oral [**Doctor Last Name 360**] only
5. s/p abdominal surgery to remove tumor
6. PVD - s/p bypass surgery in RLE
7. s/p cataract repair bilaterally
Social History:
Lives alone with weekly VNA for assistance and has meals
delivered per Meals on Wheels. Walks with walker at baseline
and
does not leave the house much. Reports to smoke as much as
possible, >1 PPD for the past 50 years. Divorced and has 3
grown
children out in West Coast, nearest [**Doctor First Name **] and HCP is [**Last Name (LF) 802**], [**Name (NI) **]
[**Telephone/Fax (1) 84235**] in [**Location (un) 3844**]. Full code - confirmed per
HCP.
Family History:
NC
Physical Exam:
Exam:
T 98.0 BP 193/86 HR 64 RR 19 O2Sat 100% 2L NC
Gen: Lying in bed, disheveled appearing 80yo man.
HEENT: No teeth - does not wear dentures per patient
Neck: No carotid or vertebral bruit
CV: Irregularly irregular but difficult to auscultate due to
very
faint heart sounds.
Lung: Clear anteriorly.
Abd: Well healed abdominal scar with ventral hernia - reducible.
+BS, soft and nontender.
Ext: No edema, scar over R interior thigh.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and month. Fluent speech
with mild dysarthria, no dysnomia with high frequency words and
intact repetition.
Cranial Nerves:
II: R pupil slightly larger than L and more asymmetric. S/p
bilateral cataract - both are reactive but L more brisk than R.
No blinking to visual threat on L.
III, IV & VI: Forced deviation to R.
V: Decreased sensation on L to LT and PP.
VII: L facial droop.
VIII: Hearing intact to finger rub bilaterally.
X: Palate elevation symmetrical.
XII: Tongue midline.
Motor:
Normal bulk - slightly higher tone on L than R and more on LUE
than LLE. No adventitious movements. Unable to move L side but
appears full strength on R. Withdraws to noxious stim on L but
not anti-gravity.
Sensation: Intact to light touch, pinprick and cold on R but
decreased/near total absence on L body although intact to
noxious
stim.
Reflexes:
+2 for LUE and 2 for RUE. None for patellar or Achilles in
either lower legs. Toes upgoing bilaterally
Pertinent Results:
[**2142-11-28**] 02:06AM BLOOD WBC-12.8* RBC-3.12*# Hgb-9.8*# Hct-30.0*#
MCV-96 MCH-31.3 MCHC-32.6 RDW-14.4 Plt Ct-127*
[**2142-11-27**] 08:58AM BLOOD WBC-15.9*# RBC-4.32* Hgb-13.5* Hct-40.6
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.7 Plt Ct-183
[**2142-11-28**] 02:59AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.2*
[**2142-11-28**] 02:06AM BLOOD Glucose-121* UreaN-25* Creat-0.9 Na-145
K-3.0* Cl-114* HCO3-21* AnGap-13
[**2142-11-27**] 12:38AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2142-11-28**] 02:06AM BLOOD Calcium-7.0* Phos-2.1* Mg-1.6
[**2142-11-27**] 08:58AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9
[**2142-11-27**] 12:38AM BLOOD Triglyc-45 HDL-50 CHOL/HD-3.0 LDLcalc-92
[**2142-11-27**] 12:38AM BLOOD TSH-0.82
Echo [**2142-11-27**]:
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed (LVEF=
30-40 %) secondary to hypokinesis of the inferior septum and
akinesis of the inferior free wall and posterior wall. The basal
inferior and posterior walls are thin and fibrotic. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with depressed free wall contractility. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The supporting structures
of the tricuspid valve are thickened/fibrotic. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CTA head and neck and perfusion ([**2142-11-26**])
IMPRESSION:
1. Likely embolic occlusion of the M1 segment of the right
middle cerebral
artery with perfusion findings of infarct involving virtually
the entire right MCA distribution.
2. Just over 60% stenosis of the proximal left common carotid
artery.
3. Moderate atherosclerotic disease at the carotid bifurcations
bilaterally, with likely an ulcerated plaque involving the
proximal right external carotid artery and extensive soft plaque
within the carotid bulb on the right.
4. 8 mm nodular soft tissue density within the left paraglottic
fat may be a lymph node but is of unclear etiology and should be
correlated with clinical findings and/or direct visualization.
Associated mild thickening of the lingual tonsils,
glossoepiglottic fold and anterior surface of the epiglottis.
5. Extensive degenerative changes of the cervical spine.
6. Severe atrophy and evidence of old cortical embolic infarcts.
Extensive
chronic microvascular ischemic change.
CT head [**11-28**]
IMPRESSION:
1. Evolving acute and virtual-complete right middle cerebral
artery territory
infarction with hemorrhagic transformation and extension of the
hemorrhage
into the right lateral and third ventricles, layering in
bilateral occipital
horns.
2. Significant leftward shift of midline structures, with marked
subfalcine
herniation and less marked uncal herniation.
COMMENT: A wet read was also provided on [**2142-11-28**] at
14:07, and Dr.
[**Last Name (STitle) 656**] was notified of the results at 14:05 on [**2142-11-28**].
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
The patient is a 80yo RHM with Afib not on Coumadin but possibly
ASA, HTN, DM and hx of stroke with some residual L sided
weakness who smokes >1PPD found per VNA at home down on the
floor with slurred speech and L sided weakness around 3pm.
Patient initially presented to [**Location (un) **] ED then transferred
here for further care. Patient seen and examined 6:20pm - ~
8hrs after presumed onset of symptoms. His initial NIHSS score
was 19 for R gaze deviation, L sided weakness and sensory
deficit. His
CT of head shows dense R MCA with likely M2 level occlusion and
loss of [**Doctor Last Name 352**]/white matter differentiation over the distribution.
His INR was 1.2 but patient reports not to have taken meds
including Coumadin for possibly over 2 months.
The patient was admitted to the neurology ICU for further care.
He was initially started on a heparin drip but follow up CT scan
showed a large size of infarct and it was determined that the
risk of bleeding outweighed the benefits of heparin. In
addition the patient had an episode of emesis, and possible
aspiration.
On [**11-27**] the patient was less esponsive to commands and was
tachypneic, a CXR showed a worsening infiltrate in the right
lower lobe. His respiratory status worsened and he required
intubation.
Later in the afternoon the patient was found to have an fixed
and dilated right pupil. A head CT was obtained showing a large
hemorrhagic coversion. The bleed was catastrophic, and the
patient had negative brainstem reflexes by the time he returned
from the scan.
The patient was terminally extubated on [**11-27**]. The prognosis was
discussed in detail and he was extubated. He expired on
[**2142-11-30**].
Medications on Admission:
has not taken any meds over 2 months per patient
1. Metoprolol
2. Coumadin (?ASA)
3. Metformin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right middle cerebral artery stroke
Discharge Condition:
expired
Discharge Instructions:
You were admitted with left sided weakness and slurring of your
speech. You were found to have a large stroke on the right side
of your brain. This was likley a blood clot from your heart as
a result of your irregular heart beat and not taking a blood
thinning [**Doctor Last Name 360**]. You also had an episode were you vomitted and
likely aspirated requiring you to be started on antibiotics and
intubated
Followup Instructions:
none
| [
"51881",
"5070",
"42731",
"25000",
"4019",
"496",
"3051"
] |
Unit No: [**Numeric Identifier 70980**]
Admission Date: [**2179-12-19**]
Discharge Date: [**2180-1-6**]
Date of Birth: [**2179-12-19**]
Sex: M
Service: Neonatology
HISTORY AND PHYSICAL: Infant is now a 18 day old, corrected
post menstrual age of 34 weeks who is being transferred to
[**Hospital3 417**] Hospital for continued care of prematurity.
[**Known lastname **] [**Known lastname 70981**] is the former 1.310 kg product of a 31 and [**1-26**]
week gestation pregnancy born to a 19 year old, Gravida 3,
Para 2, living 1 woman. Prenatal screens: Blood type B
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis B surface antigen negative. Group beta strep status
negative.
Prenatal course was significant for close monitoring due to
the past obstetric history with delivery at 23 weeks. That
infant expired after 3 days and was treated at [**Hospital 8503**]. The mother was noted to have cervical
shortening with this pregnancy. She presented to [**Hospital 1474**]
Hospital on [**2179-12-6**] with worsening cervical changes. She
was treated with Terbutaline and betamethasone and
transferred to [**Hospital1 18**] for further management. She did not have
any further contractions and left against medical advice. She
presented again to [**Hospital1 1474**] with contractions on [**2179-12-9**]
and was transferred to [**Hospital1 69**]
for further care. On the day of delivery, she presented with
vaginal bleeding and presumed abruption.
Infant was delivered by stat Cesarean section. He emerged
from the breech position, active with good respiratory
effort. Apgars were 8 at 1 minute and 9 at 5 minutes. The
mother did not receive any intrapartum antibiotics as there
was no maternal fever. Rupture of membranes occurred at
delivery. The infant was admitted to the Neonatal Intensive
Care Unit for treatment of prematurity.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight was 1.31 kg, 10th to 25th
percentile; length 41 cm, 25th to 50th percentile; head
circumference 28.5 cm, 25 to 50th percentile. General:
Infant on C-Pap, comfortable work of breathing. Head, ears,
eyes, nose and throat: Non dysmorphic facies. Palate intact.
Cardiovascular: Regular rate and rhythm. No murmur. Chest:
Breath sounds clear with fair aeration on C-Pap. Some
intermittent grunting. Mild intercostal and subcostal
retractions. Abdomen soft, nontender, nondistended. No
masses. Genitourinary: Testes descending bilaterally,
premature genitalia. Anus patent. Musculoskeletal: Hips
stable. Spine intact. Skin pink, well perfused, no rashes.
Neuro: Tone and reflexes consistent with gestational age.
HOSPITAL COURSE:
1. Respiratory: [**Known lastname **] required continuous positive airway
pressure for about 12 hours. After delivery, he weaned to
room air and has continued in room air for the rest of
his Neonatal Intensive Care Unit admission. He has
intermittent spells of apnea and bradycardia. He has not
required any methylxanthines for the management of his
prematurity. At the time of discharge, he is breathing
comfortably in room air. Oxygen saturations were 94 to
99% and baseline respiratory rate was 30 to 70 breaths
per minute.
2. Cardiovascular: [**Known lastname **] has maintained normal heart rates
and blood pressures. No murmurs have been noted.
Baseline heart rate is 150 to 170 beats per minute with a
recent blood pressure of 78 over 48 mmHg with a mean
arterial blood pressure of 58 mmHg.
3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially
n.p.o. and maintained on IV fluids. Enteral feeds were
started on day of life 1 and gradually advanced to full
volume. At the time of discharge, he is on breast milk or
special care 26 calories per ounce. His weight on the
day of discharge is 1.745 kg. Serum electrolytes have
been within normal limits.
4. Infectious disease: Due to his prematurity and
respiratory distress at the time of admission, [**Known lastname **] was
evaluated for sepsis. A complete blood count and white
blood cell count differential were within normal limits.
A blood culture obtained prior to starting IV antibiotics
was no growth and the antibiotics were discontinued.
He is currently receiving Nystatin ointment for a diaper
rash.
5. Hematology: Hematocrit at birth was 54.9%. [**Known lastname **] has not
received any transfusions of blood products.
6. Gastrointestinal: [**Known lastname **] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life 1 with a total of
6.5 mg/dl. Most recent rebound was on [**2179-12-27**] with a
total of 5.9 mg/dl.
7. Neurologic: A head ultrasound was performed on [**2179-12-30**]
with results within normal limits. Of note, a tiny
midline cyst was noted and is not thought to have any
clinical significance. He should have his next ultrasound
at 1 month of age.
8. Sensory.
a. Audiology: Hearing screening is recommended prior to
discharge.
b. Ophthalmology: [**Known lastname **] will be due for an eye
examination for evaluation of retinopathy of
prematurity at approximately 4 weeks of age.
9. Psychosocial: [**Hospital1 69**]
social work has been involved with this family. The
contact social worker is [**Name (NI) 553**] [**Name (NI) **] and she can be
reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 417**] Hospital
for continued care.
PRIMARY PEDIATRICIAN: The primary pediatrician has not yet
been identified.
CARE AND RECOMMENDATIONS:
1. Feedings: 150 ml/kg per day of Special Care 26 calories
per ounce by gavage.
2. Medications:
a. Ferrous sulfate (25 mg per ml concentration) 0.15 ml
PO/PG once daily. Approximately 2 mg/kg/day of Fe.
b. Vitamin E 5 units po/pg once daily.
c. Nystatin ointment for a groin diaper rash.
3. Car seat position screening recommended prior to
discharge.
4. State newborn screening was sent on [**2179-12-23**] with a normal
report, a follow-up was sent on [**2180-1-2**] and the report is
pending.
3. No immunizations administered.
4. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 31 and 3/7 weeks gestation
2. Transitional respiratory distress
3. Apnea and bradycardia of prematurity, mild
4. Suspicion for sepsis, ruled out
5. Unconjugated hyperbilirubinemia, resolved
6. Diaper rash
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2179-12-31**] 02:12:04
T: [**2179-12-31**] 05:47:27
Job#: [**Job Number 70982**]
| [
"7742",
"V290"
] |
Admission Date: [**2178-5-16**] Discharge Date: [**2178-5-18**]
Date of Birth: [**2133-6-10**] Sex: M
Service: MEDICINE
Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Chief Complaint: Wheezing/SOB
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Mr. [**Known lastname **] is a 44-year-old man with a long history of
refractory asthma with > 100 hospitalization and 17 past
intubations now presenting with wheezing, SOB, with 1 week of
antecedent productive cough.
Roughly 1 week ago [**Known firstname **] developed a cough productive of
greenish sputum. No sick contacts, no fevers, chills, night
sweats. Did not feel more SOB than baseline and no wheezing over
baseline. Does endorse missing a dose or two of medications
(only pills, not inhalers) in the last week. This AM started
feeling "tight". Took 60mg Prednisone and 500mg Azithro and went
through whole albuterol inhaler. Worsened and came to the ER.
On ROS, (+) Per HPI. No significant weight changes, no chest
pain, no HA, no lightheadedness, no Abd pain, no diarrea, no
constipation, denies rash. No focal weakness.
Of note, he has been on multiple inhalers as well as very
high-dose oral steroids for the majority of the last several
years and has had multiple systemic complications as a result.
Has high Eos in past as well as midly elevated IgE levels. Has
been on Zolaire in the past and has been seen in allergy clinic
before. Saw Dr. [**Last Name (STitle) **] [**3-/2178**] but prior to that had been 15
months since pulmonary saw him.
In the ED, initial VS were: 146 197/90 28 95%. Patient reported
to have increased WOB, able to speak only in 1 word answers,
coughing up phlegm, tripoding intermittently. Wheezy and tight
on evam. Given 2mg mag, 60mg solumedrol, tons of nebs. No
improvement and actually said went from [**6-7**] asthma to [**9-7**]
asthma. Was placed on continuous nebs and started to stabilize.
Tachy to 120s with this, RR down to high 20s, sats in high 90s.
BPs okay. WBC elevated at 19.6. Admitted to the ICU over concern
that he would tire out and need intubation.
On arrival to the MICU, slightly improved. Able to speak in full
sentences and comfortably while lying on back.
Past Medical History:
- Severe asthma with greater than 100 hospitalizations, multiple
intubations (17), followed by Dr. [**Last Name (STitle) **] in pulm, plan to refer
to
Dr. [**First Name (STitle) **] at [**Hospital1 112**]
- OSA on CPAP at night
- Avascular necrosis of the hip and shoulder from prolonged
steroid use, status post hip replacement ([**2173**])
- GERD
- H/o L Achilles tendon rupture s/p repair
Social History:
Works as school bus driver. Lives with wife and one of his three
children. Still smoking. Has on average a bottle of wine/week.
Denies ilicits.
Family History:
Two children with asthma
Physical Exam:
Admission exam:
General: Alert, oriented, mild respiratory distress, some
accessory muscle use, lying on back
HEENT: Sclera anicteric, PERRL, continuous neb over face
Neck: supple
CV: tachy to 120s, no m/r/g
Lungs: poor air movement diffusely, diffuse fine exp wheezing
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O x 3, no focal deficits
Discharge PE:
VS: 97.9 Tm 98 148/86 (140-141/86-91) 102 (91-102) 18 95RA
General: well appearing middle aged gentleman, NAD, laying
comfortably in bed talking on telephone
HEENT: Sclera anicteric, PERRL, EOMI
Neck: supple
CV: RRR S1, S2 no murmurs/rubs/gallops
Lungs: diffuse inspiratory and expiratory wheezing throughout,
however unlabored respirations
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O x 3, CN 2-12 grossly intact, normal muscle strength
and sensation throught
Pertinent Results:
Admission labs:
[**2178-5-16**] 05:15PM BLOOD WBC-19.6*# RBC-5.45 Hgb-16.3 Hct-49.9
MCV-91 MCH-30.0 MCHC-32.8 RDW-13.2 Plt Ct-297
[**2178-5-16**] 05:15PM BLOOD Neuts-83.6* Lymphs-8.4* Monos-5.3 Eos-2.4
Baso-0.3
[**2178-5-17**] 05:23AM BLOOD PT-12.8* PTT-29.9 INR(PT)-1.2*
[**2178-5-16**] 05:15PM BLOOD Glucose-134* UreaN-16 Creat-1.0 Na-143
K-3.8 Cl-104 HCO3-23 AnGap-20
[**2178-5-16**] 05:15PM BLOOD Calcium-9.3 Phos-2.3* Mg-2.0
[**2178-5-16**] 05:20PM BLOOD Type-[**Last Name (un) **] pO2-61* pCO2-41 pH-7.40
calTCO2-26 Base XS-0 Comment-GREEN TOP
CXR Pa/Lat ([**5-16**]):
CHEST, AP: There is increased subsegmental atelectasis in the
lower lobes. No focal consolidation. Heart size is normal.
There are no significant pleural effusions, pneumothorax, or
pneumomediastinum.
IMPRESSION: Subsegmental atelectasis. No focal consolidation.
EKG: sinus tachy to 140s, no significant ST changes, normal
intervals
Discharge labs:
[**2178-5-18**] 06:30AM BLOOD WBC-29.8* RBC-4.96 Hgb-14.7 Hct-46.2
MCV-93 MCH-29.7 MCHC-31.9 RDW-13.5 Plt Ct-294
[**2178-5-18**] 06:30AM BLOOD Glucose-91 UreaN-24* Creat-0.9 Na-143
K-4.1 Cl-107 HCO3-23 AnGap-17
[**2178-5-18**] 06:30AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3
Brief Hospital Course:
44 yr/o M with severe refractory asthma presenting with
significant SOB and wheezing with increased WOB in the ER
requiring continuous nebs and raising concern for possible
decompensation to intubation.
# Asthma - Severe refractory: Currently with flare that started
the morning of admission and was not able to turn around at home
by starting prednisone/Azithro. [**Month (only) 116**] have been triggered by
bronchitis with 1 week of productive cough and clear CXR. Has
multiple past admissions and intubations raising likelihood that
he may not be able to turn around with just nebs. Had elevated
Eos at times in the past as well as mildly elevated IgE levels.
Abnormal RAST testing in past. Multiple negative aspergillus Abs
in the past. PFTs in [**March 2178**] showing severe obstructive
defect.
Patient was initially on continuous nebs, which were spaced out
to Q1H then to Q2H then to Q4H. Patient was started on IV
solumedrol 60mg IV Q8hrs. Also started azithro 250mg Q24 for
total of 5 day course. Patient continued on home inhalers. His
breathing improved and he was called out to medicine floor.
While on the floor, the patient was continued on his home
medications; he was also transitioned from IV solumedrol to
prednisone 60 mg daily. He was saturating well on room air,
breathing comfortably. A peak flow prior to discharge was 370,
which is near his baseline. The patient was discharged on a
prednisone taper (60 mg x5 days, 50 mg x5days, 40 mg x5days),
and then was instructed to continue his home dose of 30 mg
prednisone daily. He was also discharged on another two days of
azithromycin to complete a total five day course.
# Diabetes: Last A1C in [**Month (only) **] was 5.9 on only 500mg daily of
metformin. Gets lots of steroids for his lung disease which is
probably why is DM/Pre-DM. Continued metformin 500mg daily.
# Allergies: The patient was continued on all of his home
allergy medications, including fluticasone, loratidine, and
montelukast.
# smoking cessation: The patient was counseled re: the
importance of smoking cessation, especially in the setting of
his refractory asthma. He was give nicotine lozenges.
# OSA: The patient was continued on CPAP while in house.
Transitional Issues:
- The patient was discharged on prednisone taper (60 mg x5 days,
50 mg x5days, 40 mg x5days), and then was instructed to continue
his home dose of 30 mg prednisone daily.
Medications on Admission:
TIOTROPIUM BROMIDE - 18 mcg Capsule, puff Ih daily
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg Inh - 2 puffs Q4 PRN
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 6 puffs twice a
day
IPRATROPIUM-ALBUTEROL [DUONEB] - 1 Neb [**Month (only) **] PRN
SALMETEROL - 50 mcg 1 puff inh twice a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet daily
PREDNISONE - 30mg daily, increase to 60mg with asthma flare
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet
Qd
METFORMIN - 500 mg Tablet by mouth once a day
OMEPRAZOLE - 20 mg Capsule by mouth twice daily take 30 minutes
before eating or 2 hours after eating
AEROCHAMBER - Spacer - AS DIRECTED
FLUTICASONE - 50 mcg Spray, Suspension - 1 Nasal Spray daily
Medications - OTC
GUAIFENESIN [MUCINEX] - (Prescribed by Other Provider)
LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day PRN
NICOTINE (POLACRILEX) [COMMIT] - 4 mg Lozenge - 1 lozenge every
1-2 hours for first six weeks, then taper to q 2-4 hours x 2
weeks, then q 4-8 hours x 2 weeks. Max 20 pieces in 24 hours
Discharge Medications:
1. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal twice a day.
2. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
7. Flovent HFA 220 mcg/actuation Aerosol Sig: Six (6) puffs
Inhalation twice a day.
8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
9. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
10. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
13. nicotine (polacrilex) 2 mg Lozenge Sig: One (1) Lozenge
Buccal Q2H (every 2 hours) as needed for cravings.
14. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: START prednisone 60 mg (6 pills) by mouth daily for another
3 days (LAST DAY [**5-21**])
START prednisone 50 mg (5 pills) by mouth daily for 5 days
([**Date range (1) 88300**])
START prednisone 40 mg (4 pills) by mouth daily for 5 days
([**Date range (1) 78269**])
Then after [**5-31**], continue on your daily prednisone 30 mg daily
.
Disp:*63 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
acute asthma excacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you had an
asthma attack; you initially went to the intensive care unit
because of your severe condition. Your breathing improved after
getting continuous nebulizer treatments.
It is VERY important that you stop smoking. Smoking will only
worsen your asthma and increase not only the frequency, but also
the severity of your attacks. Please continue to try and quit
smoking.
We made the following changes to your medications:
START Azithromycin 250 mg by mouth daily for another 2 days
START prednisone 60 mg by mouth daily for another 3 days (LAST
DAY [**5-21**])
START prednisone 50 mg by mouth daily for 5 days ([**Date range (1) 88300**])
START prednisone 40 mg by mouth daily for 5 days ([**Date range (1) 78269**])
Then after [**5-31**], continue on your daily prednisone 30 mg daily
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2178-5-22**] at 10:10 AM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
We are working on a follow up appointment for your
hospitalization in Pulmonary with Dr. [**Known firstname **] [**Last Name (NamePattern1) **]. You need to
be seen within 2 weeks of discharge. The office will contact you
at home with an appointment. If you have not heard within 2
business days or have any questions please call the office at
[**Telephone/Fax (1) 612**].
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2178-6-5**] at 2:00 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2178-6-17**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2178-5-21**] | [
"25000",
"3051",
"32723"
] |
Admission Date: [**2126-3-1**] Discharge Date: [**2126-4-16**]
Date of Birth: [**2102-8-29**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 65388**]
Chief Complaint:
Transfer from OSH; 25 [**5-22**] wks GA, bacterial endocarditis, septic
pulmonary emboli
Major Surgical or Invasive Procedure:
1) Placement PICC line [**3-12**] for IV antibiotics
2) Tap of pleural effusion [**3-8**] bu interventional pulmonology->
negative for empyema
3) Arthrocentesis of R knee [**3-5**] ->culture negative for
infection
History of Present Illness:
The patient is a 23 yo G4P2012 F w/ recent history of IV heroin
use (last
use 1 month ago) at 25 [**5-22**] wks GA by 3rd TM U/S presents as a
transfer from [**Hospital6 33**] with tricuspid endocarditis
and suspected septic pulmonary emboli. In addition, +staph UTI
at outside clinic on Wednesday.
Pt reports she initially developed sxs of fatigue, LE pain and
joint pain at end of [**Month (only) 956**]. She was evaluated by OSH ED and
at an Ob/[**Hospital **] clinic and her sxs were attributed to pregnancy.
She developed chest pain yesterday w/ shortness of breath. Also
complained of pleuritic pain. Cannot tolerate lying flat and is
more comfortable in upright position. She has also noted
+productive cough. +fever to 101 at home. Denies abd pain,
contractions, LOF, VB. +FM today but decreased in ED. No
nausea/vomiting or change in BM.
PNC:
1) Dating:
- [**Last Name (un) **] [**2126-6-8**] by U/S [**2126-3-1**]
2) Labs:
- O positive
3) h/o IV heroin use
- currently on Methadone maintenance
Past Medical History:
POBH:
- NSVD x 2, term, no comps
- TAB x 1
PGYNH:
- No abnl Pap or STDs. Unknown LMP.
PMH: IVDA
PSH: None
Social History:
SH: Lives w/ parents and children
+IV heroin use - last use one month ago
+methadone maintenance as above
Occ EtOH
+tobacco
Family History:
Non-contributory.
Physical Exam:
PE: 102.5 110 120/80 88% RA -> 100% on NRB
Gen: In mild distress, tachypneic, somnolent (s/p Dilaudid)
Chest: Clear w/ scattered rhonchi, decreased BS at bases
CV: Tachycardic, +systolic murmur
Abd: Soft NT gravid
Back: No CVA tenderness; No focal spinal tenderness
Ext: 1+ edema B/L, LE sensitive to touch; 3+ DTRs, no clonus
SVE L/C/P
FHR: 150's
Labs/Studies ([**Hospital3 **]):
UA + nitrite
U tox +THC
+opiates
Blood Cx x 3 sent
Lyme serologies sent
ABG 7.45/37/140/25.7 (on NRB)
Echo: LV EF 65%,+8mm vegetation noted on tricuspid valve
(arterial side)
CTA chest: Multiple bilateral pulmonary lung nodules varying in
size, shape and location; some nodules contain central air
collections
OB u/s: EFW 715 gms, vtx, post placenta, nl AFI, nl cervix
[**Last Name (un) **] [**2126-6-8**] -> 25 [**5-22**] GA
CXR: Heart size WNL; patchy B/L opacities ?multifocal PNA
Pertinent Results:
[**2126-3-1**] 07:30PM URINE RBC-0-2 WBC-[**2-17**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2126-3-1**] 07:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-12* PH-6.5
LEUK-NEG
[**2126-3-1**] 07:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]->=1.035
[**2126-3-1**] 07:30PM PT-12.7 PTT-23.8 INR(PT)-1.1
[**2126-3-1**] 07:30PM PLT SMR-LOW PLT COUNT-135*
[**2126-3-1**] 07:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2126-3-1**] 07:30PM NEUTS-69 BANDS-23* LYMPHS-6* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2126-3-1**] 07:30PM WBC-9.7 RBC-3.10* HGB-9.7* HCT-27.8* MCV-90
MCH-31.3 MCHC-34.9 RDW-13.8
[**2126-3-1**] 07:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2126-3-1**] 07:30PM OSMOLAL-274*
[**2126-3-1**] 07:30PM ALBUMIN-2.2* CALCIUM-7.3* PHOSPHATE-3.0
MAGNESIUM-1.8
[**2126-3-1**] 07:30PM CK-MB-NotDone cTropnT-<0.01
[**2126-3-1**] 07:30PM LIPASE-10
[**2126-3-1**] 07:30PM ALT(SGPT)-19 AST(SGOT)-24 CK(CPK)-16* ALK
PHOS-221* AMYLASE-35 TOT BILI-1.0
[**2126-3-1**] 07:30PM GLUCOSE-112* UREA N-9 CREAT-0.4 SODIUM-133
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-23 ANION GAP-12
[**2126-3-1**] 07:39PM LACTATE-1.2
[**2126-3-1**] 10:37PM TYPE-ART PO2-51* PCO2-40 PH-7.39 TOTAL CO2-25
BASE XS-0
[**2126-4-11**] 08:45AM BLOOD WBC-8.5 RBC-3.77* Hgb-11.5* Hct-34.5*
MCV-91 MCH-30.5 MCHC-33.4 RDW-16.0* Plt Ct-333
[**2126-4-11**] 08:45AM BLOOD Neuts-63.3 Lymphs-29.2 Monos-4.1 Eos-3.2
Baso-0.3
[**2126-4-11**] 08:45AM BLOOD Hypochr-2+ Anisocy-1+ Macrocy-1+
[**2126-4-11**] 08:45AM BLOOD Plt Ct-333
[**2126-4-11**] 08:45AM BLOOD UreaN-6 Creat-0.4
[**2126-4-13**] 09:25AM BLOOD ESR-51*
[**2126-4-11**] 08:45AM BLOOD ALT-14 AST-16 AlkPhos-134* TotBili-0.2
[**2126-4-13**] 09:25AM BLOOD CRP-3.1
Brief Hospital Course:
1)Endocarditis/CV:
Pt was initially admitted to the ICU for stabilization,
continuous telementry and pulse ox monitoring. [**3-4**] TTE-
1.5x1.8 cm veg. tricuspid valve. CT SURGERY was consulted and pt
did not need immediate surgery. Pt was seen by ID team and
initially started on empiric IV Gent/Vanco. Pt had QD blood
cultures which were positive for MSSA. On [**3-3**] antibiotics were
tailored to Oxacillin 2g q4 + gentamycin 120 q8. Pt remained
stable and was transferred to the AP floor. Then on [**3-7**],
antibiotics were changed just to IV Oxacillin 2 g q4 (through
[**2126-4-16**] = 6 weeks total). Blood cultures were continued to be
checked until 3 were negative in a row ([**Date range (1) 56409**]). Pt was
taken off telemetry on [**3-11**]. On [**3-12**] pt was afebrile for > 24
hours and PICC line was placed for long term antibiotic
treatment. Weekly CBC and renal/liver function tests were
checked and followed by ID, which were WNL. WBC remained stable
and pt continued to be afebrile. Her PICC line tip was cultured
upon removal on [**2126-4-16**], and the results are pending at the time
of this dictation.
2)Fetal well-being:
Fetal testing including NST, BPP's were reassuring throughout
stay. NST [**Hospital1 **] and BPP 2 week were performed. Of note, ([**3-1**]):
EFW 715 gms (32%), vtx, post placenta
-[**3-19**] BPP [**7-23**] EFW 1274g 51% BREECH. [**4-2**] BPP [**7-23**], AFI 16, vtx.
[**4-5**] BPP [**7-23**], AFI 18, vtx. [**4-9**] BPP [**7-23**], AFI 19, BREECH, EFW
1887 (60%ile). [**4-12**]: BPP [**7-23**], BR, AFI 20. [**2126-4-15**]: BPP [**7-23**], AFI
17, vtx.
3) R knee effusion:
Pt was initially seen by Orthopedic Team who performed
arthrocentesis of Right knee to rule out septic/infectious joint
on [**3-5**]. Tap and fluid culture were negative for infection. Pt
then complained about knee pain again and ortho was re-consulted
on [**3-18**]. ESR=128; CRP=30.7 at that time. Though inflammed with
a mild effusion, knee was not noted to be semblant of a septic
joint and pt remained afebrile. [**3-19**] MRI of R Knee = Probable
quad sprain. Moderate knee joint effusion. Pt was reconsulted on
[**3-26**] and pt noted some improvement with PT and Percocet for pain
control. She was gradually weaned off Percocet and her effusion
improved.
4)Pulmonary:
Pt was slowly weaned off of nasal cannula after she reached AP
floor. As noted in HPI, pt has known septic emboli confirmed on
CXR [**3-1**], [**3-5**]. CT chest was also performed on [**3-6**] to rule out
empyema given that pt had temperature at that time. CT read was
significant for pleural effusions R>L; no obvious empyema or
splenic abscess. Lower extremety Doppler of R leg was also
performed and negative for DVT. On [**3-8**]-Interventional
Pulmonology performed thorocentesis which was negative for
empyema. Repeat U/S on [**3-11**] by pulm team showed no
reaccumulation of fluid. Pt's pleuritic discomfort improved
dramatically s/p thorocentesis and antibiotics were continued.
4)R molar cavity:
Pt complained of tooth pain and underwent s/p Dental consult.
Dental Xrays were performed and on [**3-16**] R molar extraction was
performed by oral surgery. Pt remained stable thereafter.
5)Substance use:
Chronic pain service was consulted and recommended that pt be on
Methadone 80 mg [**Hospital1 **] with Morphine for pain control. As pt
improved, Methadone 80 mg [**Hospital1 **] was continued, Morphine was
stopped and Percocet q4-6hrprn was used for breakthrough
pain/knee pain. She was gradually weaned off the Percocet. The
week of [**3-25**] Methadone was transitioned to QD dosing starting at
150 mg daily and weaned down to 140mg PO daily by discharge. Of
note, daily Utox screens were performed as pt left floor
frequently...signing out AMA to do so. THC pos on [**3-12**]. Utox
screens after that check were all negative for THC and only
positive for Methadone (as to be expected). Pt reported to
continue smoking while in house despite much counseling and
provision of nicotine patches.
7) Prophylaxis/Dispo:
PT was consulted and was active in providing exercises and
support to pt. Pt was ambulating freely several times a day by
discharge. SQ heparin d/c'ed [**3-14**]. Social work and case
mangement were closely involved with pt. It was attempted to
transfer pt back to [**Hospital3 **] to be close to her family, but
[**Hospital3 **] would not accept pt. No other step-down/rehab site
would accept pt given her pregnant status and medical
problems/history. Pt could not be sent home with PICC in place
given her IVDU history. Thus pt remained in house as inpatient
until full course of antibiotics completed on [**2126-4-16**].
8)OB:
Pt remained stable without si/sx PTL. SVE L/C/P. Further U/S of
importance noted in FWB section.
Medications on Admission:
Methadone 65 mg qd; PNV
Discharge Medications:
1. Methadone 10 mg/mL Concentrate Sig: One (1) tablet PO DAILY
(Daily). tablet
Discharge Disposition:
Home
Discharge Diagnosis:
1) Single intrauterine pregnancy
2) Bacterial endocarditis
3) Septic Pulmonary Emboli
4) s/p Dental Extraction for Cavity in R Molar
5) Right knee effusion
Discharge Condition:
Stable, Afebrile
Discharge Instructions:
Please call your doctor if you experience fevers/chills, vaginal
bleeding, leaking of fluid, decreased fetal movement, regular
contractions, or any other symptoms that concern you.
Followup Instructions:
Please follow-up in the Antenatal Testing Unit [**2126-4-24**] at 11:00
a.m. and [**2126-5-1**] at 11:00 a.m. ([**Telephone/Fax (1) 65701**].
Please call [**Telephone/Fax (1) 457**] to schedule a follow-up appointment
with Infectious Disease (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2505**]).
Please call to schedule a follow-up appointment with Cardiology.
([**Telephone/Fax (1) 2037**].
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 30286**] Appointment should
be in [**6-24**] days.
| [
"5119",
"3051"
] |
Admission Date: [**2187-4-18**] Discharge Date: [**2187-5-29**]
Date of Birth: [**2141-8-1**] Sex: M
Service: SURGERY
Allergies:
Azithromycin
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Liver failure
Major Surgical or Invasive Procedure:
[**2187-4-26**] Cadaveric liver transplant with splenectomy
using ABO incompatible liver.
[**2187-4-27**] ex lap, wash out,
plasmapheresis
hemodialysis
[**2187-5-7**] IR drainage of splenic fossa
[**2187-5-11**] transjugular biopsy
[**2187-5-14**] ERCP
[**2187-5-18**] collection drain placed in splenic fossa
[**2187-5-18**] hepatic artery angio
[**2187-5-21**] liver biopsy
ercp
History of Present Illness:
45M with a one month history of jaundice and progressive liver
failure. Pt states that he first starting noticing that he had
low energy last summer. He is the owner of an auto repair and
sales business and noted that he was having to sleep all day on
his days off starig last summer which was unusual for him. The
first week of [**Month (only) 956**], he went to the dentist and was referred
to his PCP because they notes jaundice. His PCP did basic liver
function test and referred him to a hepatologist who
subsequently referred him for liver biopsy that was performed on
[**2187-4-9**]. The patient was not scheduled to follow-up with his
hepatologist until [**4-30**], however, his father suggested that he
see another hepatologist sooner. The patient then was seen at
Brown. He has been followed daily since last Friday and was
transferred to [**Hospital1 18**] today in the setting of worsening renal
failure on top of liver failure.
The patient has a history of heavy drinking. He last drank in
[**Month (only) 956**] when his liver failure was diagnosed. At that point,
he drank [**3-6**] glasses of wine perday. He admits that he used to
drink to excess and that he would consistently drink close to a
6pack of beer a day. He also has a remote history of cocaine
and marijuana use. He smoked 1ppd until this diagnosis. He
denies any foreign travel. He has no sick contacts. [**Name (NI) **] did eat
raw oysters the Sunday before he saw his dentist, though no one
else who dined with him got sick. Pt also used to abuse
percocet and vicodin in combination with alcohol. He states
that he stopped doing this when he learned that this could be
bad for the liver several years ago.
In the ED, vitals 96.9 134/97 83 14 100% RA. The patient's labs
were significant for transaminases in the thousands, Tbili of 50
and a Cr of 3.0. Ammonia level 101. RUQ ultrasound performed.
On arrival to the ICU, vitals 97.2 73 150/93 15 99% RA. Pt
states that he was some abdominal pain, constipation, and
reflux. ROS positive for mild headache, shortness of breath for
the last 2-3 days, orthopnea since Monday, reflux, lower
abdominal pain and distention, constipation, pale stools, [**Location (un) 2452**]
urine, dry, itchy skin and worsening short term memory.
Past Medical History:
Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use
Social History:
Divorced, 3 children. Owns own auto repair and sale business.
Smoked 1 ppd for 20+ years, discontinued with onset of jaundice.
H/o alcohol abuse. Recently drank a couple glasses of wine or
beer with dinner discontinued with onset of jaundice. Remote
history of vicodin and percocet abuse. Remote history of
marijuana and cocaine use. Ate raw oysters the Saunday before
he was found to be jaundiced. Remote history of using
supplements from GNC. No IVDU, risky sexual behavior or
tattoos. No sick contacts. [**Name (NI) **] foreign travel.
Family History:
No liver disease.
Physical Exam:
97.3 75 152/91 18 O2 99%
nad, a&o
scleral icterus
neck supple
lungs clear
cor RRR
abd soft, distended, non-tender, nonrigid, exam positive for
shifting dullness
skin jaundiced
ext no edema
RUQ U/S gallbladder wall thickening likely secondary to
hepatitis with small amount of ascites. no intra or extra
hepatic bile duct dilatation or other son[**Name (NI) 493**] findings to
suggest acute cholecystitis. no hydronephrosis.
Pertinent Results:
[**2187-4-18**] 03:10PM WBC-11.8* RBC-5.13 HGB-16.6 HCT-47.2 MCV-92
MCH-32.4* MCHC-35.3* RDW-20.4* NEUTS-72.2* LYMPHS-20.3 MONOS-6.0
EOS-1.0 BASOS-0.5
[**2187-4-18**] 03:10PM GLUCOSE-120* UREA N-52* CREAT-3.0* SODIUM-138
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-20* ANION GAP-22*
[**2187-4-18**] 03:19PM LACTATE-2.7*
[**2187-4-18**] 03:10PM TOT PROT-4.8* ALBUMIN-3.7 GLOBULIN-1.1*
CALCIUM-9.7 PHOSPHATE-4.8* MAGNESIUM-3.0*
[**2187-4-18**] 03:54PM PT-28.5* PTT-44.0* INR(PT)-2.9*
[**2187-4-18**] 03:10PM ACETMNPHN-NEG
[**2187-4-18**] 03:10PM ETHANOL-NEG
Brief Hospital Course:
45y.o. M with hepatic failure of uncertain etiology and renal
failure transferred to [**Hospital1 18**] MICU for further work-up and
evaluation. Initially liver failure was of unknown etiology.
Autoimmune panels were negative. Biopsy was consistent with
viral hepatitis vs toxin or drug injury. He did consume raw
oysters the Sunday prior to the onset of jaundice. Slit lamp
eval for [**Last Name (un) 80544**]-[**Last Name (un) 23070**] rings was negative. Hepatitis E IgM
came back positive. There was also some thought that Zithromax
may have contributed to acute liver failure as he had taken this
prior to admission. A liver transplant evaluation was done. He
was listed as status 1.
He developed worsening hepatic function with consequent
encephalopathy. Ultimately, on [**4-23**], a right frontal bolt was
placed to monitor ICP pressures. On [**4-24**], the bolt was
repositioned. Hepatorenal syndrome developed. On [**2187-4-26**] an ABO
incompatible liver offer was available. His family consented to
transplant offer. Prior to transplant, he received
plasmapheresis. On [**2187-4-26**], he underwent cadaveric liver
transplant with splenectomy using an ABO incompatible liver.
Surgeons were Drs [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to
operative notes. He received multiple blood products to maintain
hemodynamic stability. On [**4-27**], JP started pouring out blood.
He was taken back to the OR for exploration,washout, control of
hemorrhage and abdominal closure. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**].
Postop, he returned to the SICU.
Hemodialysis was initiated on [**4-28**] for ATN on HRS and
discontinued as renal function improved. On [**4-29**] the bolt was
removed after receiving platelets and head CT was negative for
bleed. On [**5-2**], he was extubated.
Plasmapheresis continued based on anti-A titers for 5 treatments
postop. Liver u/s on [**5-4**] showed small perihepatic fluid; nl flow
and waveforms. On [**5-12**] liver U/S showed normal vasculature with
trace perihepatic fluid. LFTs started to trend up and a
transjugular biopsy was performed on [**5-11**] showing moderate
cholestasis and no rejection.
A total of 7 doses of ATG (125mg x5 and 75mg x2 due to lower wbc
counts)were given. Steroids were tapered per protocol. Prograf
was started on postop day 1 and titrated per trough levels.
Cellcept 1 gram was given [**Hospital1 **] until around postop day 26/16 when
he complained of nausea. Dose was divided into 500mg qid with
decreased complaints of nausea.
On [**5-4**] neurology was consulted for confusion. CT of head/neck
was wnl. He was following commands, but was disoriented,
confused and weak. He appeared encephalopathic with waxing and
[**Doctor Last Name 688**] mental status likely related to hepatic and renal
insufficiency. Given elevated wbc there was concern for
underlying infection. Weakness was likely from ICU
stay/myopathy. He also developed hyponatremia requiring free
water boluses. Flagyl was added for empiric c.diff. Several
stools were negative for c.diff and flagyl was stopped after 5
days. Speech evaluated at the bedside and recommended npo status
due to signs of aspiration. TPN was initiated then switched to
tube feeds. A post pyloric feeding tube was inserted for feeds
on [**5-2**].
An abd CT on [**5-6**] revealed a LUQ fluid collection in splenic bed.
A # 6 drain was placed into this LUQ collection on [**5-7**]. Vanco
and zosyn were started on [**5-6**] and continued thru [**5-10**]. Repeat Abd
CT on [**5-11**] showed unchanged splenic bed collection, bowel wall
thickening resolution, no obstruction, and b/l pleural effusions
with b/l atelectasis vs pneumonia. On [**5-16**], he was transfered
out of the SICU.
LFTS started to increase with a steady trend up of the alk phos
as high as 1400. Liver duplex was normal. CTA was done on [**5-17**]
which was a suboptimal exam of the distal hepatic artery, but
the proximal to mid hepatic artery was patent. Hepatic Artery
Angio was then done showing a patent hepatic artery anastamosis
with an irregular pattern of donor artery, normal parenchyma
enhancement. A biopsy was then performed on [**5-21**] revealing
moderate to severe cholestasis with foci of associated
hepatocellular necrosis. There was no cellular rejection noted.
On [**5-14**], ERCP was done showing no leak or stricture. There was
concern that cholestasis was due to either bactrim or
fluconazole. Both of these were stopped on [**5-19**]. Ursodiol was
also started. Gradually, LFTs improved with alk phos dropping
into the 600 range. On [**5-25**], a pentamidine treatment (bactrim
replacement) was attempted, but he was unable to complete
treatment due to nausea. He did receive a complete Pentamidine
treatment on [**5-28**].
He experienced several days of nausea with some vomiting. KUB on
[**5-22**] was negatie for ileus or obstruction. It was discovered
that the feeding tube had dislodged and was coiled in his
esophagus. This was removed and remained out. Nausea resolved
and he was able to take in a sufficient kcal count to warrent
cessation of the tube feeds.
On [**5-24**], a repeat abdominal CT was done to evaluate the splenic
bed collection given concern for drain culture that grew coag
neg staph. Drain fluid amylase was 10,840. CT showed splenic bed
collection gone with drain in place. A new infrahepatic
collection measuring 5x7cm was seen near the porta, but was
ammenable to drainage only thru a trans liver approach. Becausea
of this, CT drainage was not done. He was afebrile and WBC was
stable. In fact the wbc decreased.
Mental status improved allowing for medication teaching. He
worked with PT extensively. [**Hospital 38439**] rehab was recommended,
but he became independent with ambulation. He was declared safe
to discharge to home.
He had developed a sacral deep tissue injury while in the SICU
that initially measured 4cm x 1.5cm x .5 cm. This was treated
with commercial cleanser then duoderm gel followed by Mepilex
dressing q 72. Wound bed appeared clean with some fibrin making
the wound non-stageable. Size improved to 3cmx 1cmx 0.5cm. The
pigtail drain in the slenic bed was left in place with an
average output of 10cc. Abdomen was soft, non-distended and
transplant incision was intact without erythema/drainage.
VNA Care NE ([**Telephone/Fax (1) 80193**]was arranged. His parents were very
involved and he was discharged home to stay with them initially.
At time of discharge, vital signs were stable.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
9. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): started [**5-26**].
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): prevents fungal mouth infection.
Disp:*600 ML(s)* Refills:*1*
13. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous three times a day.
Disp:*1 bottle* Refills:*1*
14. syringes
Insulin low dose syringes qid for humalog sliding scale insulin
25 gauge
supply 1 box
Refill 1
15. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous three times a day.
Disp:*1 kit* Refills:*0*
16. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*1 box* Refills:*1*
17. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] four
times a day.
Disp:*1 box* Refills:*1*
18. NovaSource Renal Liquid Sig: Eight (8) ounces PO three
times a day.
Disp:*42 cans* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
acute liver failure
Hepatitis E
ABO incompatible liver transplantsplenectomy
cholestasis, medication related
Abdominal fluid collection near splenic bed
abdominal fluid collection near porta, undrained
malnutrition
sacral decrubitus
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications or
eat, jaundice, abdominal distension, incision/drain site
redness/drainage or any concerns
Empty abdominal drain and record output. Bring record of output
to next appointment in Transplant Office.
Labs every Monday and Thursday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-6-4**]
10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-6-11**]
9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2187-6-11**]
10:00
Completed by:[**2187-5-31**] | [
"5845",
"2761",
"5119",
"2875"
] |
Admission Date: [**2165-7-2**] Discharge Date: [**2165-7-10**]
Date of Birth: [**2097-3-13**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Posterior thoracolumbar fusion
History of Present Illness:
Ms. [**Known lastname **] has undergone a previous lumbar fusion in [**Month (only) **] of
[**2164**]. Unfortunately, she has displaced her instrumentation and
requires revision thoracolumbar fusion with instrumentation.
Past Medical History:
1. Status post left BKA in [**2150**] due to osteomyelitis (performed
at [**Hospital1 2025**])
2. Hypertension
3. Hypothyroidism
4. Hyperlipidemia
5. Lung nodules
6. Osteoporosis
7. Hx of Squamous and basal cell carcinomas
8. Chronic low back pain secondary to L5-S1 disc bulge
9. Status post left thumb CMC arthroplasty as well as left MP
joint volar plate advancement.
10. s/p hysterectomy
11. s/p L5-S1 ant/post fusion laminectomy
12. s/p kyphoplasty
13. s/p right ORIF patella
Social History:
The patient worked as a nurse practitioner until [**2159**] when she
developed back pain. She is single and lives with her sister.
She has never been pregnant. She smokes half a pack of
cigarettes a day. She has tried to quit. Has smoked for "many"
years and was unable to quantify. She does not drink alcohol.
She exercises regularly with a personal trainer.
Family History:
Sister with osteoarthritis of the back and hips.
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
LLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
RLE- BKA; otherwise sensation intact.
Pertinent Results:
[**2165-7-8**] 12:50PM BLOOD WBC-8.0 RBC-4.00* Hgb-11.7* Hct-34.6*
MCV-86 MCH-29.2 MCHC-33.8 RDW-13.2 Plt Ct-262
[**2165-7-6**] 06:50AM BLOOD WBC-9.0 RBC-3.91*# Hgb-11.5*# Hct-33.8*#
MCV-86 MCH-29.4 MCHC-34.0 RDW-13.8 Plt Ct-189
[**2165-7-5**] 06:20AM BLOOD WBC-11.9* RBC-2.86* Hgb-8.6* Hct-25.2*
MCV-88 MCH-29.9 MCHC-34.0 RDW-12.8 Plt Ct-212
[**2165-7-4**] 06:45AM BLOOD WBC-11.5*# RBC-3.38* Hgb-9.9* Hct-30.3*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.0 Plt Ct-281
[**2165-7-2**] 08:08PM BLOOD WBC-6.3# RBC-3.82* Hgb-11.1* Hct-33.3*
MCV-87 MCH-29.0 MCHC-33.2 RDW-12.9 Plt Ct-250
[**2165-7-8**] 12:50PM BLOOD Glucose-101* UreaN-6 Creat-0.3* Na-135
K-4.1 Cl-97 HCO3-28 AnGap-14
[**2165-7-7**] 03:21AM BLOOD Na-134 K-3.5 Cl-97
[**2165-7-6**] 06:50AM BLOOD Glucose-120* UreaN-6 Creat-0.4 Na-133
K-3.6 Cl-99 HCO3-27 AnGap-11
[**2165-7-5**] 05:35PM BLOOD Na-134 K-4.8 Cl-102
[**2165-7-5**] 06:20AM BLOOD Glucose-100 UreaN-9 Creat-0.4 Na-133
K-3.7 Cl-100 HCO3-27 AnGap-10
[**2165-7-8**] 12:50PM BLOOD Calcium-9.0 Phos-5.1*# Mg-1.8
[**2165-7-6**] 06:50AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.6
[**2165-7-5**] 06:20AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.6
[**2165-7-3**] 11:59AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2165-7-2**] and taken to the Operating Room for a T9 to L3 posterior
fusion with instrumetation and removal of previous segmental
instrumentation. Please refer to the dictated operative note for
further details. The surgery was without complication and the
patient was transferred to the PACU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were given per standard protocol.
Initial postop pain was controlled with a PCA. Postoperative HCT
was low and she was transfused PRBCs with good effect. A
bupivicaine epidural pain catheter placed at the time of the
posterior surgery remained in place until postop day one. A
medicine consult was obtained due to her previous diagnosis of
SIADH and her lengthy stay in the MICU. Recommendations were
followed from the Medical service. She was kept NPO until bowel
function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#3. She was fitted with a TLSO
brace. Physical therapy was consulted for mobilization OOB to
ambulate. Hospital course was otherwise unremarkable. On the day
of discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
gabapentin
trazodone
simvastatin
amlodipine
synthroid
lidocanie patch atenolol
fluoxetine
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*60 Adhesive Patch, Medicated(s)* Refills:*2*
10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical TID (3 times a day).
Disp:*1 tube* Refills:*2*
12. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*2*
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
14. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Hardware failure
Post-op acute blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Revisison POSTERIOR
thoracolumbar fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Pneumatic boots
TLSO for ambulation, may be out of bed to chair without.
Treatments Frequency:
Site: Lumbar back
Description: surgical incision
Care: Leave OTA, assess for s&s of infection
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days.
Completed by:[**2165-8-14**] | [
"2851",
"2449",
"4019",
"2724"
] |
Admission Date: [**2131-6-11**] Discharge Date: [**2131-6-21**]
Date of Birth: [**2061-9-24**] Sex: M
Service: MED
Allergies:
Sulfa (Sulfonamides) / Oxacillin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Line sepsis
ESRD requiring hemodialysis
Major Surgical or Invasive Procedure:
Removal of Quintin catheter
Insertion of new tunneled catheter
Insertion of PICC line, done by fluoroscopy
History of Present Illness:
69yo man with h/o ESRD s/p CRT x 2, both of which failed b/c of
chronic graft failure, also with PAF rhythm controlled without
anticoag b/c of GI bleeds in [**2126**], who p/w fever to 104 at [**Hospital **]
Clinic, found to have line sepsis.
Past Medical History:
ESRD s/p 2 failed attempts at CRT, on HD since [**2126**]
PAF
Social History:
Pt is a retired dentist with large, well-knit family.
No etoh
No tob
No drugs
Family History:
Noncontributory
Physical Exam:
Upon arrival to the medicine floor, post-ICU:
Vitals: T99.9 BP 112/60 HR84 RR20-24, 94%RA, 98%3L, wt 58.2kg
Gen: pt lying in bed, sleeping, lethargic, cannot stay awake or
concentrate
HEENT: NC/AT, EOMI, PERRL, OP clear except for food on tongue
CV: RRR nl s1s2 no M/G/R
Lungs: coarse rales b/l in lower [**11-25**] of lung fields, no
W/Rhonchi, tender to palp over L ant chest over previous cath
site, dressing C/D/I
Abd: thin, soft, nt/nd, +BS
Ext: no edema, C/C/E
Neuro: +asterixis, lethargy, not able to concentrate for further
testing
Pertinent Results:
[**2131-6-20**] 05:51AM BLOOD WBC-7.8 RBC-2.73* Hgb-8.5* Hct-26.5*
MCV-97 MCH-31.1 MCHC-32.0 RDW-14.6 Plt Ct-250
[**2131-6-12**] 04:33AM BLOOD WBC-10.3# RBC-3.47* Hgb-11.1* Hct-33.7*
MCV-97 MCH-32.1* MCHC-33.1 RDW-14.6 Plt Ct-151
[**2131-6-11**] 05:10PM BLOOD WBC-6.6 RBC-4.27* Hgb-13.3*# Hct-41.2#
MCV-97 MCH-31.1 MCHC-32.2 RDW-14.2 Plt Ct-140*
[**2131-6-12**] 04:33AM BLOOD Neuts-91* Bands-2 Lymphs-0 Monos-6 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2131-6-11**] 05:10PM BLOOD Neuts-85.8* Lymphs-8.1* Monos-3.9 Eos-1.8
Baso-0.4
[**2131-6-12**] 04:33AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2131-6-20**] 05:51AM BLOOD Plt Ct-250
[**2131-6-20**] 05:51AM BLOOD PT-14.4* PTT-94.7* INR(PT)-1.4
[**2131-6-19**] 10:46PM BLOOD PTT-150*
[**2131-6-19**] 05:10AM BLOOD Plt Ct-216
[**2131-6-19**] 05:10AM BLOOD PT-12.9 INR(PT)-1.1
[**2131-6-11**] 05:10PM BLOOD PT-17.2* PTT-150* INR(PT)-1.9
[**2131-6-11**] 05:30PM BLOOD Fibrino-521* D-Dimer-1728*
[**2131-6-16**] 03:00PM BLOOD Ret Aut-1.1*
[**2131-6-20**] 05:51AM BLOOD Glucose-102 UreaN-89* Creat-10.9*# Na-138
K-4.7 Cl-98 HCO3-22 AnGap-23*
[**2131-6-19**] 05:10AM BLOOD Glucose-99 UreaN-79* Creat-9.5*# Na-137
K-3.9 Cl-96 HCO3-23 AnGap-22*
[**2131-6-18**] 09:55AM BLOOD Glucose-148* UreaN-58* Creat-8.1*# Na-138
K-3.7 Cl-97 HCO3-26 AnGap-19
[**2131-6-17**] 04:45AM BLOOD Glucose-108* UreaN-34* Creat-5.6*# Na-142
K-3.4 Cl-102 HCO3-27 AnGap-16
[**2131-6-16**] 03:00PM BLOOD Glucose-102 UreaN-42* Creat-7.3* Na-142
K-3.1* Cl-99 HCO3-28 AnGap-18
[**2131-6-16**] 04:40AM BLOOD Glucose-82 UreaN-35* Creat-6.4*# Na-143
K-3.7 Cl-100 HCO3-30* AnGap-17
[**2131-6-15**] 08:00AM BLOOD Glucose-91 UreaN-41* Creat-8.5*# Na-143
K-3.9 Cl-104 HCO3-25 AnGap-18
[**2131-6-14**] 05:20AM BLOOD Glucose-80 UreaN-63* Creat-11.2*# Na-138
K-3.9 Cl-95* HCO3-23 AnGap-24*
[**2131-6-13**] 05:35AM BLOOD Glucose-87 UreaN-48* Creat-9.6*# Na-141
K-4.1 Cl-99 HCO3-27 AnGap-19
[**2131-6-12**] 04:33AM BLOOD Glucose-109* UreaN-33* Creat-7.2*# Na-140
K-3.7 Cl-100 HCO3-28 AnGap-16
[**2131-6-11**] 05:30PM BLOOD Glucose-93 UreaN-26* Creat-4.9* Na-141
K-3.0* Cl-103 HCO3-24 AnGap-17
[**2131-6-11**] 05:10PM BLOOD Glucose-110* UreaN-27* Creat-5.4*# Na-140
K-3.6 Cl-95* HCO3-28 AnGap-21*
[**2131-6-12**] 04:33AM BLOOD ALT-15 AST-13 AlkPhos-151* TotBili-0.3
[**2131-6-11**] 05:30PM BLOOD ALT-11 AST-13 CK(CPK)-36* AlkPhos-149*
Amylase-53 TotBili-0.4
[**2131-6-11**] 05:30PM BLOOD Lipase-27
[**2131-6-20**] 05:51AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.4
[**2131-6-13**] 05:35AM BLOOD Calcium-7.7* Phos-6.2*# Mg-2.4
[**2131-6-12**] 04:33AM BLOOD Calcium-8.3* Phos-4.5# Mg-1.4*
[**2131-6-11**] 05:30PM BLOOD Phos-1.7* Mg-1.1*
[**2131-6-11**] 05:10PM BLOOD Calcium-9.2 Phos-2.3*# Mg-1.3*
[**2131-6-16**] 03:00PM BLOOD VitB12-427 Folate-13.0
[**2131-6-11**] 05:30PM BLOOD Osmolal-300
[**2131-6-11**] 09:47PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:80
[**2131-6-11**] 05:30PM BLOOD RheuFac-<3
[**2131-6-14**] 05:20AM BLOOD Vanco-20.7*
[**2131-6-13**] 05:35AM BLOOD Vanco-21.8*
[**2131-6-11**] 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-6-12**] 04:55AM BLOOD Type-ART O2-35 pO2-127* pCO2-42 pH-7.46*
calHCO3-31* Base XS-6
[**2131-6-12**] 01:02AM BLOOD Type-ART pO2-168* pCO2-39 pH-7.50*
calHCO3-31* Base XS-7
[**2131-6-11**] 08:45PM BLOOD Type-ART Temp-39.3 Rates-14/ Tidal V-500
PEEP-5 O2-40 pO2-166* pCO2-41 pH-7.49* calHCO3-32* Base XS-8
-ASSIST/CON Intubat-INTUBATED
[**2131-6-11**] 05:48PM BLOOD Type-ART Temp-40.4 Rates-/16 pO2-230*
pCO2-38 pH-7.52* calHCO3-32* Base XS-8 Intubat-INTUBATED
Vent-CONTROLLED
[**2131-6-11**] 05:48PM BLOOD Lactate-2.5*
[**2131-6-11**] 05:33PM BLOOD Glucose-114* Lactate-3.3* Na-140 K-3.9
Cl-102
[**2131-6-11**] 05:33PM BLOOD Hgb-12.9* calcHCT-39
Brief Hospital Course:
Pt required ICU stay, sepsis protocol treatment.
After one week in ICU, pt recovered enough to be transferred to
the floor, where IV Vanco was changed to IV Oxacillin because of
sensitivites results, his cath was removed, he was hemodialyzed,
a new cath was inserted. Upon insertion it was noted that the
pt had blood clots in his left cephalic and brachiocephalic
veins, so pt was started on anticoagulation. Also, pt had PICC
line placed to cont to take IV oxacillin for one more week as an
outpatient.
HD done on [**6-14**], 27, 28.
Pt will be discharged to home with VNA assistance in providing
three additional weeks (four total weeks) of oxacillin to
ascertain that his blood has cleared the infection.
Medications on Admission:
Tylenol PRN
Epogen
Timolol
Xalata
Zantac
PhosLo
Lisinopril
Norvasc
Lopressor
Amiodarone
Discharge Medications:
1. Oxacillin Sodium in Dextrose 1 g/50 mL Piggyback Sig: One (1)
gram Intravenous Q6H (every 6 hours) for 3 weeks.
Disp:*64 gram* Refills:*0*
2. Amiodarone HCl 200 mg Tablet Sig: 0.5 Tablet PO QD (once a
day).
Disp:*15 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Calcium Acetate (Phos Binder) 667 mg Tablet Sig: One (1)
Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS) as needed for
ESRD on HD.
Disp:*90 Tablet(s)* Refills:*2*
5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*2*
6. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
Disp:*1 bottle* Refills:*2*
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
ESRD requiring dialysis
Line sepsis
Venous thrombosis
Discharge Condition:
Stable
Discharge Instructions:
Please continue to take all medications as prescribed.
Please take the antibiotic (Oxacillin) through the PICC line in
your left neck for three more weeks.
Please continue to take the coumadin for 6 months, and check
with your primary care provider to see if he or she would like
to adjust the dose.
Please follow up with your kidney doctor and primary care doctor
upon discharge from the hospital.
Followup Instructions:
Please follow up with your kidney doctor and primary care doctor
upon discharge from the hospital.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
| [
"0389",
"40391",
"42731",
"51881"
] |
Admission Date: [**2166-8-25**] Discharge Date: [**2166-8-29**]
Date of Birth: [**2090-4-10**] Sex: F
Service: VICU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 102983**] is a 76-year-old
female with an extensive past medical history including
adenocarcinoma of the right upper lobe and non-small-cell
lung cancer who was admitted on [**8-25**] for progressive
shortness of breath.
HOSPITAL COURSE: The patient had progressive shortness of
breath and hypoxemia over the subsequent five days. She
developed bilateral, left greater than right, diffuse
pulmonary infiltrates consistent with a pneumonia requiring
intubation on [**2166-8-28**].
On [**2166-8-29**] the patient developed hypotension refractory
to fluids and pressors and expired on the morning of [**8-29**]
despite aggressive intravenous fluid resuscitation and triple
pressors.
DISCHARGE DIAGNOSES: Non-small-cell lung carcinoma and
pneumonia.
DISCHARGE DISPOSITION: The family declined a postmortem
examination.
WOODY [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2166-8-29**] 10:42
T: [**2166-9-9**] 14:45
JOB#: [**Job Number 102984**]
| [
"5070",
"496",
"4019",
"2449",
"25000"
] |
Admission Date: [**2148-6-24**] Discharge Date: [**2148-6-28**]
Date of Birth: [**2117-7-10**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Fevers/chills/dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30 yo female with no PMH in good health who noticed 3 days of
subjective fevers and chills PTA. Pt had intermittent dysuria
for last week. + HA and myalgias. + constipation and no BM in
last 3 days.
Of note, pt developed pruritic rash about 1 week ago while
painting a room in bilateral antecubital areas, 'spreading' to
right lateral thorax and inguinal folds. No new fabrics or
detergents. Room was warm but not excessively.
ROS: No cough, no abd pain, no diarrhea, no sore throat, no
sinus pain, no ear pain. No bug bites, recent exposure to the
forest. Pt is sexually active monogamously with fiancee. No
vaginal itching or discharge. No photophobia or sick contacts.
In [**Name (NI) **], pt hypotensive with SBP in 70's, tachycardic to 130's.
Given 4L NS with response of SBP to 90-100's. Given Levo 500mg
IV x 1. Febrile to 104.5.
Pt admitted to MICU for urosepsis. Her blood pressure responded
to IVFs; no pressors were given. She defervesced on
Levofloxacin for sensitive E. Coli urosepsis, and is begining to
auto-diuresed.
Past Medical History:
None
Social History:
In monogamous relationship with fiancee, with whom she lives.
Denies smoking or alcohol. Currently unemployed.
Family History:
Father has HTN.
Physical Exam:
98.9, 118/76, 100, 25, 97%4L NC 380-IN/3930-OUT
Gen: comfortable nice young woman, pleasant and conversant, NAD,
supine
HEENT: PERRLA, EOMI, MMM, OP clear, NC/AT
Neck: Supple, 8cm JVP, right IJ bandage C/D/I with sl tenderness
Chest: decreased BS bilateral bases with associated dullness to
percussion, no egophany
Back: no vertebral tenderness, c/o 'ache' on palpation of both
CVA's
Cor: increased HR, nl S1 S2, no M/R/G
Abd: NABS, soft, slight suprapubic tenderness, no HSM, no
tenderness over liver/GB
Ext: MAE, no C/C/E
Neuro: A&Ox3, CN II - XII intact,
Skin: blanching papular slightly erythematous rash on bilateral
antecubital fossa, right lateral thorax, and bilateral inguinal
folds
Pertinent Results:
[**2148-6-24**] 03:50PM LACTATE-2.4* K+-4.8
[**2148-6-24**] 03:51PM NEUTS-70 BANDS-11* LYMPHS-9* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2148-6-24**] 03:51PM GLUCOSE-122* UREA N-8 CREAT-1.0 SODIUM-136
POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-21* ANION GAP-20
[**2148-6-24**] 04:20PM URINE RBC-[**1-26**]* WBC-[**5-2**]* BACTERIA-MANY
YEAST-NONE EPI-[**1-26**]
[**2148-6-24**] 04:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-1 PH-8.0 LEUK-TR
[**2148-6-24**] 06:40PM PT-12.9 PTT-35.3* INR(PT)-1.1
[**2148-6-24**] 08:15PM CRP-9.52*
[**2148-6-24**] 08:15PM CORTISOL-21.5*
[**2148-6-24**] 08:15PM PHOSPHATE-1.8* MAGNESIUM-1.4*
[**2148-6-24**] 08:15PM ALT(SGPT)-3 AST(SGOT)-10 TOT BILI-0.3
Renal U/S:
1. Normal renal ultrasound without evidence of stones, renal
masses, or
hydronephrosis. No perinephric abscess is identified.
2. Gallbladder wall edema without gallstones, sludge, or
pericholecystic
fluid collections. No biliary duct dilatation is identified.
These findings
are nonspecific and clinical correlation is recommended to
exclude the
possibility of acalculus cholecystitis. Follow-up with a
dedicated right upper
quadrant ultrasound is also recommended.
3. Trace amount of free fluid within Morison's pouch.
Abd/Pelvis CT:
1) Left-sided pyelonephritis with no hydronephrosis, perinephric
fluid
collection, or abscess.
2) Bilateral pleural effusions with associated atelectasis.
3) Equivocal wall thickening within the transverse colon which
may be related
to underdistention by contrast; however, clinical correlation
would be helpful
and if necessary delayed scanning to evaluate
contast-filledcolon.
CXRay (after IVFs)
IMPRESSION: Interval development of bibasilar infiltrates which
could
represent atelectasis vs. aspiration pneumonitis. Recommend
follow-up chest
x-ray for monitoring progression.
Brief Hospital Course:
30 yo previously healthy woman presenting with fevers, chills,
and dysuria, found to be hypotensive and tachycardic with fever
to 104.5 in ED.
Urosepsis/Pyelonephritis: Pt initially admitted to MICU and
responded to IVF's and IV Levofloxacin 500mg qd. Pt felt much
better, remained afebrile, and was transfered to floor on HD #3.
Pt was d/c'd on Levofloxacin 500mg PO, which is to be continued
for a total of 14 days.
Bilateral Pleural Effusions: d/t IVF's in MICU. Pt
self-diuresed until she was euvolemic, and her Foley was d/c'd.
She had >95% O2 sat on RA.
Rash: Likely contact dermatitis, which appears to be resolving.
No evidence of tic bite or meningitis. Sarna and benedryl prn.
Normocytic Anemia: Low iron and low TIBC. Not classic for
iron-deficiency. Bili normal. Iron supplements after pt done
with Levofloxacin.
FULL CODE
Medications on Admission:
None
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Disp:*1 bottle* Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Take for 10 more days.
Disp:*10 Tablet(s)* Refills:*0*
3. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for pruritis: Take as needed for
itchiness.
Disp:*30 Capsule(s)* Refills:*0*
4. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day:
Start taking in 10 days after you are done taking Levofloxacin.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Urosepsis
Iron-deficiency
Discharge Condition:
Pt was in good and stable condition
Discharge Instructions:
Please call your doctor or return to the hospital if you
experience flank pain, acute abdominal pain, discomfort or
burning with urination, blood in urine, shaking chills,
shortness of breath or difficulty breathing.
You may have some residual fever cycles which should improve.
If your fevers get worse or more frequent, call your doctor or
come to the hospital.
You have low blood iron. After completing 10 more days of
antibiotics, start taking iron supplements daily. (Don't take
iron and Levofloxacin concurrently)
To prevent recurrent urinary tract infections:
1. Don't use spermacide-containing products for contraception
2. Early post-intercourse urination
3. Ample fluid intake
4. Cranberry juice
5. Wipe front to back after bowel movements
If you continue to have recurrent urinary tract infections,
please speak with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
prevention.
Followup Instructions:
Follow up with your primary care doctor as needed.
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