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Admission Date: [**2185-8-4**] Discharge Date: [**2185-8-17**]
Date of Birth: [**2100-6-22**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
unresponsiveness, L sided weakness
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
Mr. [**Known lastname 112244**] is a 85-year-old right-handed man presenting with
Intracerebral hemorrhage on a background of dementia, congestive
heart failure, renal failure, prior pneumonia, prior "stroke"
(not worked-up).
He was asleep when his daughter arrived. [**Name2 (NI) **] refused to get up
for
breakfast at about 7:30 AM - this sometimes happens. He said
goodbye to his other daughter. [**Name (NI) **] then got up around 10 or 10:30
AM, walking to the bathroom without his walker. At 11 AM he was
back in bed and told his daughter to go away, he wanted to sleep
- again normal for him. At about 11:30 his daughter tried to
move
him, noted that he wasn't moving his left side and was drooling.
He was dysarthric, but able to speak and understand. 911 was
called and they were taken to [**Hospital3 **], but there was no
neurologist, per the patient's family. Head CT was performed
showing a large hemorrhage. He was intubated and transferred to
[**Hospital1 18**].
He just saw his Cardiologist and his blood pressure and
otherwise
stable - they were asked to come back in six months. Dementia
had
been diagnosed by PCP, [**Name10 (NameIs) **] an admission at [**Hospital3 **] for
pneumonia also resulted in a daignosis of Alzheimer's disease.
He
also had an AMI while there (6/[**2184**]). He has otherwise been
well,
but is eating poorly - he doesn't get out of bed as much and
seems less interested - but has eaten well for the last two
weeks.
Review of systems was negative except as above, per family. ROS
with patient limited.
Past Medical History:
- Coronary artery disease
- Dementia, provisionally Alzheimer's type
- Pneumonia
- 'TIA' - about five to six months ago, not worked up in full,
but seems to have been TIA - fluent aphasia without other
features, recovered over a few minutes.
- Congestive heart disease, likely post-infarctive and in the
setting of prerenal state and pneumonia, AMI
- Hypertension
- Hyperlipidemia
- No prior surgery
Social History:
Smoking: Smoked in youth, per daughter.
Alcohol: None.
Drugs: No.
Living Situation: Lives with daughter.
Education and Language: English.
Functional Baseline: Able to feed self, dress, and toilet
indpendently. Dependent for other ADL's.
Other: Retired mail handler.
Family History:
Mother had diabetes. Father unknown. Sibling with alcoholism.
Physical Exam:
Physical Exam on Admission:
Vitals: T afebrile F; HR 52 BPM; BP 152/64 (had been SBP ~ 100)
mmHg; O2Sat 100 % CMV 18 x 450, FiO2 0.5
General Appearance: Leaning to left, little spontaneous
movement,
but awake.
HEENT: NC, ETT in place.
Neck: Supple but reduced ROM.
Lungs: Clear within limits of exam, vent sounds.
Cardiac: Bradycardic regular. Normal S1/S2.
Abdominal: Soft, NT, BS+.
Extremities: No edema, cool (particularly right), delayed
capillary refill and trophic changes in feet.
Neurologic Examination:
Mental status:
Awake and attentive to events in room. Appropriate head shake or
nod to simple questions. Only mild behavioral discomfort given
ETT despite sedation being off. Tends to pay more attention to
right.
Cranial Nerves:
I: Not tested.
II: Pupils symmetric, round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation on right,
not left.
III, IV, VI: Extraocular movements conjugate and without
nystagmus, difficult to get over to left.
V, VII: Jaw midline, facial droop on left.
VIII: Hearing intact to voice.
IX, X: Not examinable.
[**Doctor First Name 81**]: Not examinable.
XII: Not examinable.
Tone and Bulk:
Tone is increased in legs, right arm flaccid.
Power:
Dense paresis of left arm, left leg moves to noxious stimulation
of foot.
Reflexes:
B T Br Pa Ac
R 2 1 2 0 0
L 3 2 2 1 0
Toes upgoing bilaterally.
Sensation:
Withdraws and increased arousal to painful stimulus to right,
withdraws on right (foot, not hand).
Coordination and Cerebellar Function:
Not tested.
Gait:
Not tested.
*****************
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2185-8-4**] 04:40PM TYPE-ART RATES-/16 TIDAL VOL-450 O2-100
PO2-412* PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1 AADO2-259 REQ
O2-51 INTUBATED-INTUBATED
[**2185-8-4**] 05:03PM GLUCOSE-147* LACTATE-2.0 NA+-136 K+-4.4
CL--102 TCO2-21
[**2185-8-4**] 05:04PM FIBRINOGE-263
[**2185-8-4**] 05:04PM PT-10.6 PTT-28.3 INR(PT)-1.0
[**2185-8-4**] 05:04PM PLT COUNT-205
[**2185-8-4**] 05:04PM WBC-8.8 RBC-4.04* HGB-12.8* HCT-38.3* MCV-95
MCH-31.7 MCHC-33.5 RDW-13.1
[**2185-8-4**] 05:04PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-8-4**] 05:04PM TSH-1.6
[**2185-8-4**] 05:04PM TRIGLYCER-149 HDL CHOL-42 CHOL/HDL-2.7
LDL(CALC)-41
[**2185-8-4**] 05:04PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-2.1
CHOLEST-113
[**2185-8-4**] 05:04PM CK-MB-2 cTropnT-<0.01
[**2185-8-4**] 05:04PM LIPASE-43
[**2185-8-4**] 05:04PM estGFR-Using this
[**2185-8-4**] 05:04PM UREA N-19 CREAT-1.7*
[**2185-8-4**] 05:15PM URINE HYALINE-1*
[**2185-8-4**] 05:15PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2185-8-4**] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2185-8-4**] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2185-8-4**] 05:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CT head [**8-4**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage involving mainly the right
frontoparietal region with intraventricular extension, no
significant change. Mass effect on the right lateral ventricle
and unchanged midline shift to the left.
2. New increase in size of right temporal [**Doctor Last Name 534**] of the lateral
ventricle
likely due to trapping.
3. Stable subarachnoid blood in the right sylvian fissure and
new
subarachnoid blood now seen in the left temporal region.
Brief Hospital Course:
85-year-old right-handed man with a hx of dementia, CHF, renal
failure, prior stroke who was found unresponsive at home. CT
head revealed large right lobar intraparenchymal hemorrhage with
mass effect and intraventricular extension. He was admitted to
the neuro ICU initially for close monitoring, then was later
made CMO.
Neuro:
He was monitored closely with Q1hr neuro checks overnight. He
was started on a nicardipine drip for BP control with a goal <
160. Aspirin and anticoagulants were held. Neurosurgery was
consulted and declined acute surgical intervention. Per
discussion with his daughters he was made DNR/DNI and was
extubated on [**8-5**]. Palliative care was consulted and after
further discussion he was made CMO. He was put on a morphine gtt
and PRN ativan. He was transferred to the floor under inpatient
hospice. Due to continued discomfort/agitation he was
transitioned to a dilaudid drip on [**8-16**] and ativan was increased.
He passed away peacefully at 12:40am on [**2185-8-17**]. Daughters were
at the bedside and declined autopsy.
Cardiovascular:
He was maintained on telemetry monitoring. BP was monitored
closely and controlled with nicardipine and metoprolol as above
while in the ICU, but once made CMO his cardiac meds were
withdrawn.
PENDING LABS:
None
TRANSTIONAL CARE ISSUES: None, pt expired on [**2185-8-17**].
Medications on Admission:
- Aricept 2.5 mg PO QD
- Metoprolol succinate 50 mg PO QD
- ASA 325 mg PO QD
- Remeron 15 mg PO QHS
- Lipitor 40 mg PO QHS
- Trazodone 12.5 mg PO QHS
- Vitamin D
- Namenda 10 mg PO BID
- Celexa 10 mg PO QD
- Eye drops
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right lobar intraparenchymal hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname **] was admitted to [**Hospital1 69**]
on [**2185-8-4**] after he was found unresponsive at home. A CT
scan of his head showed a large bleed in the right side of his
brain. A breathing tube was placed and he was admitted to the
neuro ICU. After discussion with his family the decision was
made to remove the breathing tube the next day and not to pursue
any further aggressive interventions. Palliative care was
consulted and per his family's wishes he was made CMO on [**8-5**].
He was started on a morphine drip and transferred out of the ICU
to inpatient hospice care. He passed away peacefully at 12:40am
on [**2185-8-17**].
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
| [
"5859",
"40390",
"41401",
"2724",
"412",
"V1582"
] |
Admission Date: [**2167-8-14**] Discharge Date: [**2167-8-15**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 M s/p unwitnessed fall today - wife heard him fall, found him
on his back on the living room floor - complained of a headache
and nausea afterwards. No LOC, mild confusion and solmnent.
Past Medical History:
PMH:
Hypertension
MI last year
s/p multiple falls, COPD, Anemia
Pulmonary fibrosis
polymyalgia rheumatica
neck arthritis
PSH:
Cataract surgery
TURP
R colectomy
Social History:
SH: remote tob, no ETOH or drugs, retired salesman, lives in
[**Location 583**] with wife
Family History:
FH: NC
Physical Exam:
PE: 97.9 90 161/96 16 95%3L NC
Oriented to year, not month, oriented to state, mild confusion,
somnolent
Difficulty following commands and participated with physical
exam
Moves all extremities with good strength
RRR
CTAB
soft NT.ND
2+ LE edema, swelling in hands
Pertinent Results:
Labs:
Trop-T: 0.03
138 100 11 116 AGap=15
3.6 27 1.0
estGFR: 71 / >75 (click for details)
CK: 81 MB: Notdone
Ca: 9.0 Mg: 2.1 P: 2.6
5.8>33.9<242
Rads:
CT Head:
Acute right 16 mm SDH overlying cerebral convexity with shift to
the left of 3 mm. Compression of the right lateral ventricle.
Subdural blood also layers along the falx superiorly and along
the tentorium bilaterally. Right parietal subgaleal hematoma.
No fracture.
CT C-spine:
Slightly limited by motion.
Mild anterior widening of the interspace at C2-3, C3-4, C4-[**5-11**]
be chronic but acute ligamentous injury cannot be excluded.
No fracture or subluxation. Mild septal thickening may reflect
pulmonary edema.
Brief Hospital Course:
Patient was intubated for airway protection -repeat CT with
shift - Dr. [**Last Name (STitle) 739**] thought if we were to proceed that
this would need to be surgically evacuated and given pts
comorbidities, worsening status, and being on aspirin and
plavix he thought the prognosis was very grave. Upon discussion
with his daughter and wife the decision was made that Mr.
[**Known lastname 168**] would not have wanted to proceed and that he would be
comfort measures only. He was extubated in ICU and keep him
comfortable. He expired [**2167-8-15**].
Medications on Admission:
[**Last Name (un) 1724**]: aspirin 325', B12, cymbalta 60', FeSO4 325', florinef 0.1
QOD, Lasix 20', Lipitor 80', Torprol 25', Plavix 75', Prednisone
5', Proscar 5', Protonix 40', senna, tylenol, tramadol', spriva,
MiraLax
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
traumatic cerebral hemorrhage
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2167-10-13**] | [
"496",
"2859",
"4019"
] |
Admission Date: [**2155-3-26**] Discharge Date: [**2155-6-10**]
Date of Birth: [**2098-11-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Autologous BMT
Major Surgical or Invasive Procedure:
continuous renal replacement therapy
hemodialysis
intubation and mechanical ventilation
tracheostomy
paracentesis
History of Present Illness:
Mr. [**Known lastname **] is a 56-year-old male who was diagnosed with
follicular lymphoma transitioning to a marginal zone lymphoma in
01/[**2154**]. He had a long preceding history of night sweats and dry
cough, followed by the development of right leg swelling and a
right inguinal mass.
In [**2154-1-31**] he developed swelling in his right lower
extremity and a mass in his inguinal area. CT scan of his
abdomen and pelvis on [**2154-2-18**] revealed generalized
lymphadenopathy beginning at the crural lymph nodes and
extending inferiorly into the periaortic, mesenteric, celiac,
pararenal, common iliac, and external iliac chains. In the right
groin, there was a large lymph node mass approximately 6 x 5 x
6.6 cm. There was also a rounded low-density area just medial to
the femoral artery which was felt to represent thrombosed
femoral and external iliac veins. Overall, the findings were
concerning for lymphoma. He was referred for a CT of his chest
on [**2154-2-19**] which showed prominent adenopathy, principally in
the left supraclavicular and left axillary regions, with the
largest mass measuring 2.6 cm in his left axilla. Based on that,
he was referred for excisional biopsy of the right inguinal
adenopathy on [**2154-2-26**] which revealed follicular lymphoma with
partial marginal zone differentiation, grade I-II by large cell
quantitation. These cells were CD19 and CD20 positive and also
co-expressed CD5 and CD10. They were also kappa light chain
restricted. There was no expression of CD-23 or cyclin D1. Ki67
was 20-30%. His lymphoma was felt to represent a transitional
state between follicular lymphoma and marginal zone B-cell
lymphoma. He was then started on R-CVP. He tolerated therapy
fairly well, but suffered from fatigue, hyperglycemia, flushing,
and hypertension. His prednisone dose during treatment was
eventually lowered from 200 mg daily to 100 mg daily. He
received 2 days of neupogen after each cycle of chemotherapy.
After three cycles of R-CVP, the vincristine was discontinued
due to neuropathy. He underwent a PET scan on [**2154-5-1**] after the
third cycle and this continued to show extensive FDG avid
disease. However, his night sweats and leg swelling had
improved. He continued on R-CVP for two additional cycles, but
after the fifth cycle, he noticed the recurrence of right
inguinal lymphadenopathy. He had also developed recurrent night
sweats and cough. The lymphadenopathy grew quite quickly and
became the size of a quarter over the span of 24 hours. He
underwent a second PET scan on [**2154-6-12**] which showed little
significant change, with hyperactive adenopathy at the left
axilla and extensively below the diaphragm in the mesentery,
para-aortic and pelvic regions. He underwent a second excisional
biopsy on [**2154-7-2**] which again showed follicular lymphoma, grade
I-II. The decision was made to hold on further R-CVP as his
lymphoma was no longer responding to the current therapy.
CYTOGENETICS
CD19 and CD20 positive, also co-expressed CD5 and CD10, and
kappa light chain restricted; no expression of CD-23 or cyclin
D1; Ki67 was 20-30%.
CHEMOTHERAPY HISTORY
[**Date range (1) 83066**]: He received cyclophosphamide, vincristine,
prednisolone plus rituximab (R-CVP) x 3 cycles; the vincristine
was discontinued due to neuropathy. Night sweats and leg
swelling improved.
[**2154-5-1**]: PET Scan showing extensive FDG avid disease
[**Date range (1) 83067**]: continued on R-CVP for two additional cycles, but
after the fifth cycle, he noticed the recurrence of right
inguinal lymphadenopathy. He had also developed recurrent night
sweats and cough.
[**2154-6-12**]: repeat PET - little interval change
[**2154-7-2**]: repeat lesion biopsy - similar findings
[**2154-8-5**]: transferred care to [**Hospital1 **], presented with bilateral
inguinal lymphadenopathy; received 4 cyclyes R-Bendamustine by
local oncologist at time of transfer; planned for two more
cycles of R-bendamustine
[**2155-1-22**]: Mobilization HiDAC, final cumulative CD-34 yield of
5.19 x 10e CD-34 cells/kg over three days, discharged on Cipro,
Neupogen and Compazine. WBC at discharge 20.9. Two weeks later
WBC 0.7 and one week later 0.5 w/ANC 0, asymptomatic. Started on
Moxifloxacin and neupogen. Stem cell harvesting [**Date range (1) 83068**].
[**2155-2-25**]: W1 Rituxan/Zevalin: WBC 7.3, Hct 34.9, Plt 244.
[**2155-3-4**]: W1 Rituxan/Zevalin: WBC 5.4, ANC 4560, Hct 32.5, Plt
292.
Today he presents for admission for his BEAM autologous BMT. No
current complaints. Denies headache, nausea, vomiting, diarrhea,
abdominal pain, weakness, fevers, chills, recent night sweats,
blurry vision, shortness of breath. Reports only mild ongoing
cough significantly improved from prior and occasional fatigue
when his counts get low.
Past Medical History:
Diagnosed with follicular lymphoma transitioning to a marginal
zone lymphoma in [**1-/2154**] (These cells were CD19 and CD20
positive and also co-expressed CD5 and CD10. They were also
kappa light chain restricted. There was no expression of CD-23
or cyclin D1. Ki67 was 20-30%.)
Right thigh lymphedema (significantly improved, per patient)
RLE DVT from compression (was on coumadin until [**2154-11-25**])
Mild diverticulitis
s/p vasectomy, tonsillectomy
Social History:
Works in a management position at a metal fabrication plant
overseeing production and quality control. He is married and has
four children, ages [**8-17**]. He and his family live in Hooksett,
[**Location (un) 3844**]. He denies any current tobacco use. He previously
smoked but quit 15 years ago after a 20-pack-year history. He
generally drinks several martinis a day but has decreased his
drinking while on treatment.
Family History:
father - died at 80, lung cancer, Charcot-[**Doctor Last Name **]-Tooth disease,
pulmonary embolism
mother - alive at 80, diabetes and asthma
three brothers - all in good health
no family history of leukemia or lymphoma
has 2 children from previous marriage and 2 children from his
current marriage
Physical Exam:
ON ADMISSION:
VS: 96.6 132/96 109 18 98/ra 195lbs 71"
GENERAL: NAD
HEENT: Sclerae are anicteric. PERRLA. EOMI. O/P clear.
Neck: Supple.
Lymph: No cervical, supraclavicular, or axillary
lymphadenopathy; some left supraclavicular fullness; possible
right inguinal lymphadenopathy although possibly just scar
tissue from biopsy
CARDIAC: RRR Normal S1/S2 No R/G/M
LUNGS: CTAB
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds; no HSM
EXTREMITIES: no edema
.
ON DISCHARGE: [**2155-6-10**]
Tmax: 36.5 ??????C (97.7 ??????F)
Tcurrent: 36.3 ??????C (97.3 ??????F)
HR: 117 (109 - 117) bpm
BP: 79/57(62) {64/40(48) - 93/59(68)} mmHg
RR: 30 (21 - 30) insp/min
SpO2: 95%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 80.3 kg (admission): 98.2 kg
Height: 72 Inch
24 HR: SMN:
Total In: 1,807 mL 722 mL
PO:
TF: 1,017 mL 602 mL
IVF:
Blood products:
Total out: 0 mL 0 mL
Urine: 0 mL 0 mL
NG:
Stool:
Drains:
Balance: 1,807 mL 722 mL
Respiratory support:
O2 Delivery Device: Trach mask 50%
SpO2: 95%
Physical Examination:
General Appearance: Well nourished, No acute distress, Thin,
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Tracheostomy in place,
NG tube in place
Lymphatic: No Cervical or Supraclavicular adenopathy
Cardiovascular: PMI Normal, S1: Normal, S2: Normal, No murmurs,
rubs, gallops.
Chest: Expansion: Symmetric Excursion, No Dullness, CTAB.
Abdominal: Soft, Non-tender, Bowel sounds present, Distended, +
fluid wave. Non-tender.
Extremities: No edema, Cyanosis, Clubbing, 2+ Peripheral pulses.
Musculoskeletal: Muscle wasting, Unable to stand,
Skin: Warm, No Rash, No Jaundice
Neurologic: Attentive, Follows commands, Responds to verbal
stimuli, Oriented x3, Moving all extremeties equally, Strength
[**4-2**] in UE & LE bilat, Dizzy if not in supine position, Moving
all extremeties equally, sensation intact.
Pertinent Results:
LABS ON ADMISSION:
[**2155-3-26**] 10:15AM BLOOD WBC-3.9* RBC-4.62 Hgb-13.8* Hct-41.5#
MCV-90 MCH-29.9 MCHC-33.3 RDW-15.7* Plt Ct-144*#
[**2155-3-26**] 10:15AM BLOOD Neuts-88.5* Lymphs-4.0* Monos-6.4 Eos-0.7
Baso-0.3
[**2155-3-26**] 10:15AM BLOOD PT-11.2 PTT-21.2* INR(PT)-0.9
[**2155-3-28**] 12:00AM BLOOD Gran Ct-4380
[**2155-3-26**] 10:15AM BLOOD UreaN-14 Creat-0.8 Na-141 K-4.6 Cl-102
HCO3-32 AnGap-12
[**2155-3-26**] 10:15AM BLOOD ALT-35 AST-33 LD(LDH)-157 AlkPhos-102
TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2155-3-26**] 10:15AM BLOOD TotProt-7.0 Albumin-4.5 Globuln-2.5
Calcium-10.0 Phos-3.8 Mg-2.0 UricAcd-8.3*
LAB TRENDS DURING ADMISSION:
WBC: MAX 47.8 on [**2155-5-13**] --> 35.3 on [**2155-5-20**] --> 25.9 on
[**2155-5-28**] -->18.9 on [**2155-6-3**] --> 15.5 on [**2155-6-10**]
HCT: stable at 28-33 for past 2 weeks
PLT: stable at 40-70 for past 2 weeks.
COAGS: have been within normal limits.
CHEM7: Patient on HD Tues, Thurs, Sat
LFTS:
AST: 1341 & ALT: 2472* MAX on [**2155-4-12**] trended down to AST: 59*
ALT: 40 by [**2155-4-23**] and AST & ALT have been normal since [**2155-5-28**].
LDH: 1466 MAX on [**2155-4-12**] trended down to normal by [**2155-5-17**]
ALK PHOS: 170 on [**2155-4-12**] trended up to MAX on 248 on [**2155-4-15**] and
then down to 172 on [**2155-6-10**].
TBILI: 10.0 MAX on [**2155-4-12**] trended down to 2.9 on [**2155-6-10**]
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD
LDLcalc
[**2155-5-8**] 08:46AM 173 196* 11 15.7 123
CORTISOL Stimulation Test:
[**2155-5-25**] 03:30PM 29.4*1
[**2155-5-25**] 02:37PM 17.91
HEPATITIS HBsAg HBsAb HBcAb HAV Ab
IgM HAV
[**2155-4-10**] 03:46AM NEGATIVE POSITIVE NEGATIVE POSITIVE
NEGATIVE
HEPARIN DEPENDENT ANTIBODIES: Negative [**2155-5-27**]
12:00PM
ASPERGILLUS ANTIGEN: 0.1 <0.5 considered to be negative
[**2155-5-20**]
B-GLUCAN: 65 pg/mL Negative Less than 60 pg/mL
Indeterminate 60 - 79 pg/mL
Positive Greater than or equal to
80 pg/mL
LABS ON DISCHARGE:
[**2155-6-10**] 04:21AM BLOOD WBC-15.5* RBC-2.61* Hgb-10.0* Hct-31.1*
MCV-119* MCH-38.1* MCHC-32.0 RDW-19.6* Plt Ct-40*
[**2155-6-10**] 04:21AM BLOOD PT-12.8 PTT-25.9 INR(PT)-1.1
[**2155-6-10**] 04:21AM BLOOD Plt Ct-40*
[**2155-6-10**] 04:21AM BLOOD Glucose-140* UreaN-54* Creat-5.0* Na-139
K-5.5* Cl-103 HCO3-23 AnGap-19 ****PRIOR TO HD TODAY*****
[**2155-6-10**] 04:21AM BLOOD ALT-27 AST-34 AlkPhos-172* TotBili-2.9*
IMAGING:
RUQ ULTRASOUND [**2155-4-8**].
IMPRESSION:
1. Apparent reversed flow in the main portal vein with normal
flow direction in the left and right portal veins. These
findings are discrepant and do not appear to be artifactual in
nature. Given that the etiology of these findings is unclear,
whether there is true portal vein reversal or possibly more
proximal thrombus, we would recommend focused MRI of the abdomen
including 2D time-of-flight sequences (with saturation bands to
determine directionality of
flow) through the portal vein to clarify this issue.
2. Cholelithiasis but no other evidence of acute cholecystitis.
3. Small amount of ascites.
MRI Abdomen. [**2155-4-9**].
IMPRESSION:
1. Reversal of flow within the main portal vein, both on
breath-hold imaging and free breathing.
2. Reversal of flow within the right anterior portal vein on
breath-hold imaging.
3. Suggestion of reversed flow within the right posterior portal
vein during breath-hold, but antegrade flow during free
breathing. This may reverse depending on phasicity of
respiration.
4. Directionality of flow within the left portal vein is not
clearly
demonstrated on this examination.
5. Interval increase in ascites since yesterday's examination.
6. No evidence of focal hepatic lesion or hepatic or portal vein
thrombus.
7. Suggestion of siderosis within the spleen. Possibility of
iron deposition within the liver cannot be excluded without
dual-echo gradient-echo images (omitted in this abbreviated
examination due to patient intolerance of examination).
8. Cholelithiasis. No biliary abnormalities noted.
MR HEAD W/O CONTRAST Study Date of [**2155-5-2**] 12:31 PM
IMPRESSION:
1. Hyperintense subarachnoid material, involving the sulci of
both cerebral
hemispheres, most likely representing subarachnoid hemorrhage,
less likely
proteinaceous material as seen in meningitis. Oxygen therapy can
also have
this appearance.
2. No evidence of masses, mass effect or infarction.
ECHO: [**2155-5-23**] at 3:47:46 PM Conclusions:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). 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. No mass or vegetation is seen on the
mitral valve. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2155-4-21**],
the findings are similar.
CT TORSO: [**2155-5-23**] 1:53 PM
CHEST CT: Bilateral small pleural effusions, on the left
increased as
compared to the prior study and the right slightly increased as
compared to the prior study. Linear atelectasis in the right
lower lobe and left lower lobe accompanied by small patchy
consolidations in the left lower lobe. This is new as compared
to the previous study.
Small amount of pericardial effusion is noted (series 2, image
34). Central line catheter is noted with its tip in the right
atrium. Tracheostomy. Nasogastric tube with its tip in the
stomach.
ABDOMINAL CT: Small-to-moderate amount of ascites is
demonstrated. Limited
evaluation of the liver due to lack of i.v. contrast and
artifacts. There is no evidence of intrahepatic or extrahepatic
bile duct dilatation. The
pancreas is within normal limits. Gallbladder is nondistended.
Adrenals are unremarkable bilaterally. Spleen is of normal size
and attenuation on this non-contrast scan. Visualized small
bowel demonstrate diffuse mucosal
thickening without evidence of dilatation. The findings may
caused by ascites or GVHD.
Retroperitoneal and mesenteric lymphadenopathy, small but
numerous, measuring up to 1 cm in mesentery and 1.4 cm in the
retroperitoneum.
PELVIC CT: Moderate amount of fluid is seen in the pelvis.
Urinary bladder
is not distended. Rectal tube is seen in the rectum.
OSSEOUS STRUCTURES: Degenerative changes in the lumbar and
sacral vertebra.
IMPRESSION:
1. Bilateral small pleural effusions, slightly larger as
compared to the
prior study.
2. Linear atelectasis in the right lower lobe and left lower
lobe and left
lower lobe patchy consolidation which is new as compared to the
prior study.
3. Moderate amount of ascites.
4. Limited evaluation of the liver due to artifacts.
CXR: [**2155-6-6**]
FINDINGS: Indwelling support and monitoring devices are similar
in position, and cardiomediastinal contours are unchanged. There
is a suggestion of increasing layering effusions on this
semi-upright projection. Persistent left retrocardiac opacity is
probably due to atelectasis. Patchy opacities in right mid and
right lower lung could be due to either atelectasis or early
sites of pneumonia, and followup radiographs may be helpful in
this regard.
Brief Hospital Course:
This is a 56 year old male with PMH of follicular lymphoma
transitioning to a marginal zone lymphoma s/p R-CVP admitted for
BEAM auto-SCT (C1D1 ([**2155-3-26**]) and as per BMT protocol,
initiated carmustine day -7, followed by etoposide/cytarabine on
days -6 to -3, then melphalan on day -2 ([**2155-3-31**]). He then
underwent Autologus stem cell transplant on [**2155-4-2**].
Post-transplant course was complicated by mucositis, diarrhea,
febrile neutropenia, and transient hyperuricemia that responded
to 1 dose of allopurinol. On [**2155-4-11**], the patient was
transferred to the ICU for respiratory distress, altered mental
status, renal failure, and transaminitis secondary to
[**Last Name (un) **]-occlusive disease.
1. Respiratory distress - The patient was tachypneic to the 40s
on admission to the ICU and had an increasing oxygen
requirement, thought to represent attempted compensation for
metabolic acidosis and low lung volumes with atelectasis. The
patient failed a trial of bipap and was intubated and placed on
A/C mechanical ventilation. He had no evidence of pneumonia but
was noted to be >7L fluid positive on admission, with increasing
ascites secondary to his hepatic complications. Serial CXRs
over course of his ICU stay demonstrated reduced lung volumes
with small amounts of atelectasis but no new consolidation,
effusion, or intravascular congestion. Patient remained
intubated in the [**Hospital Unit Name 153**] for a) impaired mental status and b)
restrictive physiology [**3-4**] increased intra-abdominal pressure.
The patient remained on the ventilator for approximately three
weeks; his respiratory status remained relatively stable but his
mental status precluded extubation. He did experience an episode
of leukocytosis, detailed below, and was treated for a
pseudomonas ventilator associated pneumonia with improvement in
his leukocytosis. The patient eventually received a tracheostomy
and was subsequently weaned down to trach collar, which
coincided with an improvement in his mental status.
2. Hypotension - The etiology was initially thought to be a
combination of a) intravascular volume depletion [**3-4**] decreased
effective circulating volume and splanchnic vasodilation from
liver failure, and b) sedation. Sepsis thought to be a
contributing factor as well, but he was maintained on
broad-spectrum antimicrobial coverage, with no infectious source
identified for the majority of his hospitalization. CT imaging
was unremarkable for an infectious source. The patient was
initiated on levophed [**4-12**] and had a prolonged ongoing pressor
requirement without an obvious cause for hypotension. Although
cortisol levels were normal, suggesting against adrenal
insufficiency, the patient was trialed on a three day course of
steroids, which temporarily improved his pressures and removed
his pressor requirement. Following the conclusion of the
steroid trial, the patient again required vasopressor support to
maintain his blood pressure. A cortisol stimulation test was
performed to better assess for impaired adrenal response, did
not reveal any significant abnormal findings. Ultimately,
vasopressin was started and levophed was weaned. After his CVVH
was stopped, the patient had an episode of symptomatic
hypotension, for which vasopressin was briefly restarted. For
the rest of his ICU course, the patient was maintained off of
pressors and perfusion was monitored by assessing mental status.
He was initiated on HD, and tolerated this well without
ultrafiltration. His hypotension may be related to his liver
disease in addition to severe deconditioning. He is
persistently orthostatic which has somewhat improved with
restarting midodrine. He mentates well with a blood pressure of
60s systolic. Please continue to encourage thigh high
compression stockings to increase peripheral resistance. Please
elevate head of bed as patient tolerates and continue passive
motion in bed. Autonomics was consulted prior to discharge and
feels like hypotension is not likely related to dysautonomia
given his hypotension even while supine. Autonomics recommended
continuation of midodrine and a trial of florinef to be started
at rehabilitation. Florinef will be started at low dose (0.1 mg
daily) and can be uptitrated based on patient response to a
maximum of 0.4 mg daily. It is felt that the hypotension is
likely related to deconditioning and aggressive PT should be
pursued.
3. Leukocytosis - Elevated WBC count beginning [**4-13**] with
persistent hypotension. Filgrastim discontinued [**4-12**]; therefore,
this could not account for the persistent leukocytosis. Patient
was at high risk for nosocomial infection (critically ill,
ascites, multiple tubes/lines) with difficult-to-interpret fever
curve on CVVH. He was empirically started on broad spectrum
antibiotics with a mild improvement in his leukocytosis but with
no obvious source on cultures. Multiple paracenteses were
negative for SBP. Much later in the [**Hospital 228**] hospital course,
a re-elevation in his white blood cell count corresponded with a
new positive sputum culture for Pseudomonas. The patient was
treated with seven days of ceftazidime per infectious disease
recommendations, after which his leukocytosis improved but still
remained dramatically elevated. A large volume paracentesis was
performed with fluid sent for cytology and flow cytometry, which
was not revealing. Ultimately, only his CVVH catheter tip grew
out the same strain of pseudomonas on [**6-4**] that was in his sputum
on [**5-12**]. It is felt that this was a colonizer only as
surveillance blood cultures were negative. No other infectious
sources were identified. His antibiotics were ultimately all
discontinued and he did well. He should no longer be on
precautions as he has no active infections. His leukocytosis
continues to improve, but does remain elevated. A component of
this elevation may be due to auto splenectomy that appears to
have occurred during this hospitalization.
4. Transaminitis/Hepatic Failure - Right upper quadrant
ultrasound and abdominal MRI demonstrated reversal of flow
through portal vein, suggestive of cirrhosis. On admission to
the intensive care unit, he was noted to have new significant
ascites. Rising INR and worsening mental status were suggestive
of progression to hepatic failure. Liver biopsy confirmed a
diagnosis of [**Last Name (un) **]-occlusive disease. Infectious workup of
hepatitis was negative. Per Hepatology, patient would not be a
candidate for liver transplant. The patient was then started on
a defibrotide treatment protocol on [**2155-4-9**] with close
monitoring of coags, plts, hct, fibrinogen due to concern of
bleeding (goal INR < 1.5, plts > 30, Hct > 30, Fibrinogen >
150). LFTs peaked [**Date range (1) 14806**] with TBili 10, then trended down
gradually. After 25 days of treatment for defibrotide, a head
MRI revealed a subarachnoid hemorrhage, which necessitated
discontinuation of the treatment. The patient subsequently
continued to show gradual, mild improvement in functional
status, but continued to have large ascites on exam requiring
periodic taps. Currently he is requiring paracentesis every
10-14 days and his ascites should continue to be monitored and
tapped PRN. Through his ICU course, his LFTs gradually
improved; however, his bilirubin did remain elevated at 2.9 on
discharge. He should have liver clinic follow-up with Dr. [**Last Name (STitle) 497**]
within one month after discharge.
5. Depression: The patient appears to be extremely frustrated
and depressed about his current state. He was started on low
dose amphetamine salts at 5mg [**Hospital1 **] to increase his energy and
blood pressure. His cardiac status should be monitored closely
as well as his mood on this new medication. It can also be
titrated up slowly in an attempt to increase his energy.
6. Thrombocytopenia: His platelets have fallen dramatically
during his hospitalization. They have remained stable around
50. There was initial concern for HIT, but antibody returned
negative on [**5-28**]. Platelets should be transfused only if the
patient is actively bleeding. Caution should be used with blood
thinners due to his low platelet level.
7. Ileus - Attributed to critical illness with ascites and
opioid -based sedation. Abdominal x-ray and CT scan were
negative for obstruction. The patient was started on reglan and
an aggressive bowel regimen. Following withdrawal of sedation
as patient's respiratory status improved, his ileus improved as
well. Lactulose was continued less frequently as prophylaxis
against hepatic encephalopathy and was eventually discontinued.
The reglan was stopped. He developed loose stools/ diarrhea that
was treated as below.
8. Diarrhea - Patient has had continued loose stools ever since
his ileus resolved. His stool frequency has improved after
stopping lactulose but have continued to remain loose. C diff.
toxin has been checked multiple times and has remained negative.
It is likely that the diarrhea is related to tube feeds and
banana flakes have been added recently with subsequent
improvement in diarrhea.
9. Altered mental status - Attributed to hepatic encephalopathy
in addition to sedating meds for treatment of his abdominal
pain. Standing lactulose was started for therapy of hepatic
encephalopathy and was also given broad spectrum antibiotics for
treatment of possible infections. Patient had a protracted
hospital course with minimal improvement in mental status but
began to show dramatic improvement in mid [**Month (only) 547**], approximately
one month after initiation of defibrotide. His mental status
continued to improve throughout his ICU course and he is now
able to interact appropriately. His antibiotics and lactulose
were ultimately discontinued.
10. Renal failure - The patient was found to have new renal
failure that began on [**2155-4-10**]. Per renal, the etiology was most
consistent with ischemic ATN. His initial hypotensive insult
was likely secondary to hepatorenal syndrome. The patient was
started on CVVH on [**2155-4-12**] for worsening metabolic acidosis. He
continued to be severely oliguric throughout his admission with
no restoration in renal function. The patient's severe volume
overload was corrected gradually via CVVH while he continued to
have an ongoing pressor requirement. Midodrine was started in
an effort to improve the patient's blood pressures so that he
could be transitioned to HD. He was eventually transitioned to
HD without ultrafiltration, and has tolerated it well.
11. EKG Changes: The patient had subtle ST depressions at the
beginning of [**Month (only) 116**] in the setting of decreased mentation and
hypotension. He was ruled out for an MI and these depressions
have since resolved. It was likely related to demand in setting
of hypotension.
12. Neutropenic fevers - On admission, patient was kept on broad
spectrum antibiotics for neutropenic fevers
(vancomycin/cefepime/ganciclovir/micafungin). Infectious disease
was consulted. Patient was culture negative and no source of
infection was identified. Antibiotics were stopped [**4-12**]
following recovery of his neutrophil counts. He was treated
later in his hospital course for a pseudomonas pneumonia (see
above).
13. Hyperglycemia: Patient with blood sugars persistently
between 200-300. Regular insulin was added to the TPN, and the
patient was placed on a Regular Insulin SS. This may represent
diabetes. He will need ongoing monitoring and upon discharge
from rehabilitation center follow-up with his primary care
provider.
14. Follicular Lymphoma: Patient is status post BEAM Auto SCT on
[**2155-4-2**]. Patient engrafted. Received IV solumedrol x1 for
anti-inflammatory effect. Received filgrastim until ANC>1000
(discontinued [**2155-4-12**]). He was continued on atovaquone
prophylaxis for PCP but there was concern that it was not being
absorbed as it appeared to be present in his diarrhea. He was
given one dose of inhaled pentamidine on [**2155-6-9**] and will be
continued on atovaquone. If his diarrhea continues to improve,
he can remain on atovaquone and will likely not need another
dose of inhaled pentamidine one month from [**2155-6-9**]. He also
remains on Acyclovir prophylaxis.
15. Deep Vein Thombosis Prophylaxis: Patient not started on
heparin due to low platelets. Patient repeatedly offered
pneumoboots, but usually declined to wear the pneumoboots.
Encourage aggressive physical therapy.
Medications on Admission:
Multivitamin
No other current medications
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. Midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a
day).
3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours): give every day, on dialysis days give daily dose after
dialysis.
4. 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.
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
7. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
8. Insulin Regular Human 100 unit/mL Solution Sig: per scale
Injection ASDIR (AS DIRECTED).
9. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
10. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
11. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): uptitrate as tolerated.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
- Follicular Lymphoma
- Renal Failure, Acute tubular necrosis, now requiring
hemodialysis.
- Respiratory Failure
- Hepatic Failure Secondary to Venous Occlusive Disease
- Hypotension
- Multi-Drug Resistant Pseudomonal Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Blood pressure: SBPs 50-80s with good mentation. If concerned
about blood pressure, monitor for change in mental status.
Patient tolerating very low blood pressures attributed to
deconditioning.
Discharge Instructions:
You were admitted for bone marrow transplant. You had a
prolonged hospital course that was complicated by liver failure,
infection, persistent low blood pressure, kidney failure, and
respiratory failure that ultimately required trach tube
placement. Your clinical status ultimately improved. You are now
being discharged to a rehab facility for further care.
You were started on many different medications during your
hospital course. You should follow the medication list provided
at the time of discharge.
It was a pleasure taking part in your medical care.
Followup Instructions:
You will need to see the following providers within the
timeframe below. We are working to schedule appointments for
you, please call the following offices in [**2-1**] days time to get
the appointment information:
PROVIDER: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
SPECIALTY: HEMATOLOGY/ONCOLOGY
TELEPHONE: ([**Telephone/Fax (1) 3936**]
TIMEFRAME: within 2-4 weeks
PROVIDER: [**Name10 (NameIs) **] [**Name8 (MD) **], MD
SPECIALTY: LIVER
TELEPHONE: ([**Telephone/Fax (1) 1582**]
TIMEFRAME: within 2-4 weeks.
You will need to see you primary care doctor within 2 weeks
after discharge from the rehab facilty.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
| [
"5845",
"51881",
"2762",
"5180",
"2875",
"311"
] |
Admission Date: [**2182-8-1**] [**Month/Day/Year **] Date: [**2182-8-23**]
Date of Birth: [**2103-1-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin / Cephalosporins
Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
Weakness/Fluid Overload
Major Surgical or Invasive Procedure:
drainage of pericardial effusion
drainage of plerual effusion
pleacement and removal of temporary dialysis catheter
placement of tunneled dialysis catheter
History of Present Illness:
79M with PHX h/o A Fib on Coumadin, moderate to severe AI s/p
AVR [**2182-6-27**], reccently readmitted [**7-15**] for BRBPR likely [**1-17**]
anticoagulation and diverticulosis and was discharged [**7-23**] to
[**Hospital1 100**] Home, now readmitted for worsening weakness and fluid
overload. Patient states that since he was sent to [**Hospital 100**] Rehab,
he has gotten worse, not better. He can participate in the
physical therapy, but he is not able to walk with his walker as
well as before. His breathing is not much worse than baseline-
he mostly feels weak.
He was seen by Dr [**Last Name (STitle) 911**] in office [**7-31**] who found the patient to
be in fluid overload and he is admitted for monitoring of his
fluid status in house with likely IV diuresis.
While in house previous admission, Aspirin was stoppd and
coumadin continued. Patient was also complaining of new stool
incontinence, was found to be c. diff positive per PCR and was
started on 2 weeks of metronidazole to be completed on [**2182-8-2**].
On the same admission patient had TTE's on [**7-19**] and [**7-22**] which
demonstarted moderate pericardial effusion without signs of
tamponade (likely [**1-17**] recent CT surgery). Admission was c/b
initially difficult to control Afib/RVR which was finally
controled with diltiazem CD 120 mg po daily and metoprolol
tartrate 75 mg po daily; also had fluid over load (known CHF
with LVEF 45%) which was treated with IV diureis. He was
discharged to [**Hospital 100**] Rehab on [**7-23**].
.
On arrival to the floor, patient is comfortable with no
complaints.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, or hemoptysis. 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.
Cardiac review of systems is notable for absence of chest pain,
syncope or presyncope.
The patient does have occasional PND, [**1-18**] pillow orthopnea,
occasional palpitations from his A Fib, and sometimes trouble
breathing on exertion.
Past Medical History:
- Moderate-to-severe aortic insufficiency with dilated LV (LVEF
50-55%), s/p bioprosthetic AVR on [**2182-6-27**]
- Recent cardiac catheterization showing no obstructive
coronary artery disease, however, found to have elevated filling
pressures, requiring diuresis
- Atrial fibrillation, currently on Coumadin for
thromboembolic prophylaxis
- Hypertension
- Kidney transplant in [**2155**] due to PCKD, the baseline
creatinine approximately 1.6
- Hyperlipidemia
- Peripheral neuropathy
- Diverticulitis
- Pseudogout
- Osteoporosis
Social History:
Patient previously worked as an engineer for channel 5. He
currently lives in a house himself. His wife passed away 9 years
ago. Prior history of 3 ppd X 20 years, quitting 34 years ago.
Occasional ETOH (few beers per week). No illicits. His daughters
([**Doctor First Name **] (daughter) - ([**Telephone/Fax (1) 101330**], [**Female First Name (un) **] (daughter)
[**0-0-**]) are very involved.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ON ADMISSION
VS- T=98.1 BP=103/69 HR=101 RR=18 O2 sat=97RA Pulsus-10mmHg
GENERAL- in mild resp distress. 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 with JVP of 16 cm.
CARDIAC- PMI located in 5th intercostal space, midclavicular
line. irregularly irregular, normal S1, S2. No murmurs
appreciated. No thrills, lifts. No S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were somewhat labored, [**Month (only) **] breath sounds b/l bases
ABDOMEN- Soft, NTND. No HSM or tenderness, mild ascites
percussed, Abd aorta not enlarged by palpation. No abdominial
bruits.
EXTREMITIES- warm, pulses not well palpated, 3+ pitting edema
distal LE up to lower knee b/l
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
Back- 2+ pitting sacral edema
[**Month (only) 894**]
VITAL SIGNS: 98.0. 85. 140/76. 24. 98% RA
GENERAL: A&Ox3. NAD.
HEENT: Sclera anicteric. PERRL, EOMI, MMM. JVP not elevated.
CARDIAC: irregularly irregular, nl S1, S2. III/VI systolic
ejection murmur.
LUNGS: Decreased breath sounds bilaterally at bases.
ABDOMEN: +BS, soft, NTND. No HSM.
EXTREMITIES: 1+ lower ext edema bilaterally to ankles.
SKIN: large ecchymosis on left leg and small ecchmyosis around
tunneled cath site.
ACCESS: tunneled catheter in place.
Pertinent Results:
ON ADMISSION
[**2182-8-1**] 07:30PM GLUCOSE-150* UREA N-57* CREAT-1.8* SODIUM-141
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
[**2182-8-1**] 07:30PM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.7
[**2182-8-1**] 07:30PM WBC-5.5 RBC-3.65* HGB-11.3* HCT-36.7*
MCV-101* MCH-31.0 MCHC-30.8* RDW-19.4*
[**2182-8-1**] 07:30PM PLT COUNT-162
[**2182-8-1**] 07:30PM PT-40.4* INR(PT)-4.0*
OTHER LABS:
[**2182-8-23**] 06:07AM BLOOD WBC-6.6 RBC-2.60* Hgb-7.9* Hct-25.7*
MCV-99* MCH-30.5 MCHC-30.9* RDW-19.7* Plt Ct-169
[**2182-8-23**] 06:07AM BLOOD PT-33.8* PTT-36.0 INR(PT)-3.3*
[**2182-8-22**] 05:51AM BLOOD PT-27.4* PTT-34.1 INR(PT)-2.6*
[**2182-8-21**] 07:10AM BLOOD PT-23.5* PTT-32.9 INR(PT)-2.2*
[**2182-8-20**] 06:00AM BLOOD PT-22.1* INR(PT)-2.1*
[**2182-8-18**] 05:58AM BLOOD PT-17.3* PTT-31.2 INR(PT)-1.6*
[**2182-8-17**] 06:39AM BLOOD PT-15.5* PTT-31.8 INR(PT)-1.5*
[**2182-8-15**] 02:51AM BLOOD PT-16.5* PTT-99.3* INR(PT)-1.6*
[**2182-8-14**] 05:19AM BLOOD PT-17.5* PTT-32.2 INR(PT)-1.6*
[**2182-8-13**] 05:05AM BLOOD PT-17.3* PTT-34.4 INR(PT)-1.6*
[**2182-8-23**] 06:07AM BLOOD Glucose-76 UreaN-33* Creat-3.2* Na-135
K-4.8 Cl-97 HCO3-26 AnGap-17
[**2182-8-13**] 05:05AM BLOOD ALT-13 AST-23 AlkPhos-283* TotBili-0.8
[**2182-8-23**] 06:07AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1
[**2182-8-18**] 05:58AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2 Iron-37*
[**2182-8-18**] 05:58AM BLOOD calTIBC-131* Ferritn-748* TRF-101*
[**2182-8-11**] 06:07AM BLOOD Hapto-173
[**2182-8-1**] 07:30PM BLOOD TSH-2.3
[**2182-8-13**] 03:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
PERICARDIAL FLUID CYTOLOGY:
NEGATIVE FOR MALIGNANT CELLS.
PLEURAL FLUID CYTOLOGY:
NEGATIVE FOR MALIGNANT CELLS.
Paucicellular specimen with scattered mesothelial cells,
histiocytes, and predominantly blood.
[**2182-8-2**] 5:15 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2182-8-2**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2182-8-5**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2182-8-8**]): NO GROWTH.
FUNGAL CULTURE (Final [**2182-8-16**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2182-8-3**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2182-8-4**] 10:55 am BLOOD CULTURE Source: Line-picc.
**FINAL REPORT [**2182-8-10**]**
Blood Culture, Routine (Final [**2182-8-10**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES STRAIN 2.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES STRAIN 3.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| | KLEBSIELLA
PNEUMONIAE
| | |
AMPICILLIN/SULBACTAM-- 4 S 8 S 4 S
CEFAZOLIN------------- <=4 S <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2182-8-5**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 101334**] ON [**2182-8-5**] AT
0530.
GRAM NEGATIVE ROD(S).
[**2182-8-4**] 10:54 am URINE Source: Catheter.
**FINAL REPORT [**2182-8-6**]**
URINE CULTURE (Final [**2182-8-6**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
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
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 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-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2182-8-4**]):
Test performed only on suprapubic and kidney aspirates
received in a
syringe.
TEST CANCELLED, PATIENT CREDITED.
[**2182-8-7**] 6:09 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT [**2182-8-13**]**
GRAM STAIN (Final [**2182-8-7**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2182-8-10**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2182-8-13**]): NO GROWTH.
[**2182-8-6**] 11:38 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2182-8-12**]**
Blood Culture, Routine (Final [**2182-8-12**]): NO GROWTH.
[**2182-8-6**] 2:52 am CATHETER TIP-IV Source: left picc line.
**FINAL REPORT [**2182-8-8**]**
WOUND CULTURE (Final [**2182-8-8**]): No significant growth.
[**2182-8-5**] 10:10 am BLOOD CULTURE Source: Line-white port
PICC.
**FINAL REPORT [**2182-8-11**]**
Blood Culture, Routine (Final [**2182-8-11**]): NO GROWTH.
Echo [**2182-8-2**]
There is moderate global left ventricular hypokinesis (LVEF =
35%). Right ventricular chamber size is normal. with moderate
global free wall hypokinesis. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis cannot be
adequately assessed. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Tricuspid regurgitation is
present but cannot be quantified. There is a large pericardial
effusion. The effusion appears circumferential. No right
ventricular diastolic collapse is seen.
IMPRESSION: Large circumferential pericardial effusion. No
echocardiographic signs of tamponade. Right ventricular
hypertrophy and enlargement raise suspicion of underlying
pulmonary hypertension (not confirmed on this study), which may
limit the sensitivity of echocardiographic evaluation for
tamponade.
CXR [**2182-8-1**]:
Large right pleural effusion has markedly increased. Moderate
cardiomegaly is
partially obscured by the right pleural effusion. There are
atelectasis in
the lower lobes bilaterally, right greater than left, and in the
right upper
lobes. There is probably a small left pleural effusion. There
is no
pulmonary edema. Sternal wires are aligned.
IMPRESSION: Markedly increase in size in large right pleural
effusion.
CXR [**2182-8-14**]:
Small-to-moderate bilateral pleural effusions have decreased
substantially.
Although the cardiac silhouette remains enlarged, there is less
distention of
mediastinal veins and previous mild pulmonary edema has largely
cleared. Left
lower lobe remains collapsed. A supraclavicular central venous
dual-channel
catheter has replaced a small-bore catheter, ending in the
mid-to-low SVC.
TTE [**2182-8-5**]:
Left ventricular wall thicknesses and cavity size are normal.
There is a very small (<0.5cm) pericardial effusion along the
basal inferolateral wall, basal lateral, and apical lateral
wall. There is no evidence for hemodynamic compromise.
IMPRESSION: Very small pericardial effusion without evidence of
hemodynamnic compromise
RENAL ULTRASOUND [**2182-8-9**]:
1. Persistent though improved high resistance waveforms
throughout the
arterial system including intrarenal and main renal arteries.
2. Irregularly irregular waveforms suggests arrhythmia.
3. Stable large rounded calcifications are of unclear etiology.
Predominantly
pyramidal location is suggestive of medullary nephrocalcinosis;
however, the
scattered cortical calcifications are not consistive with this
diagnosis. No
hydronephrosis.
RIGHT AND LEFT CARDIAC CATH [**2182-8-12**]:
1. Resting hemodynamics revealed markedly elevated left and
right-sided
filling pressure consistent with severe diastolic heart failure.
There
was also moderate pulmonary arterial hypertension.
2. The cardiac output and cardiac index were preserved.
FINAL DIAGNOSIS:
1. Severely elevated filling pressures consistent with diastolic
heart
failure.
2. Preserved cardiac output and cardiac index.
Brief Hospital Course:
79 yo M with a PMHx of moderate to severe AI with decreased EF
s/p bioprosthetic AVR [**2182-6-27**], recently admitted [**Date range (1) 57819**] for
BRBPR, now presenting with weakness and fluid overload, cardiac
echo significant for worsening pericardial effusion, going for
pericardiocentesis on the day of admission, with hospitalization
complicated by renal failure requiring dialysis, klebsiella
urosepsis, atrial fibrillation with RVR.
#Acute on Diastolic Heart Failure: Patient presented to Dr. [**Name (NI) 39743**] office weighing 15 lbs more than previous [**Name (NI) **] and
was edemetous on exam. He was admitted to [**Hospital1 1516**] for diuresis. He
was transferred to the CCU following pericardial drainage for
aggressive diuresis. He was started on a Lasix ggt with moderate
UOP. He was below goal of 2L daily and metolazone was added with
minimal improvement. Diuresis was eventually held in the setting
of rising creatinine and poor UOP and ultimately dialysis was
initiated for removal of fluid (see below). It was believed that
symtoms might be secondary to a constrictive cardiomyopathy.
Cath [**8-12**] showed elevated R and L-sided pressures but preserved
CI and CO. Due to progressive renal failure of his renal graft,
he commenced HD via temporary catheter and had a tunnelled line
placed for more durable access. With volume removal during HD,
his respiratory status and peripheral edeam improved.
#Moderate Pericardial Effusion: Previously visualized but
increased based on echo done this admission. Small amount of RV
diastolic collapse. Pulsus 10mmHg, ECG shows mild electrical
alternans. Voltage unchanged from prior ECG. Pt had bloody
pericardial drainage with drain placement, felt to be [**1-17**] high
INR (4). Repeat echo showed resolution of the effusion.
#Respiratory distress: When pt was admitted he required several
liters of 02 via face mask to maintain saturations in the low
90's. CXR was consistent with pulmonary edema. Oxygen
saturations improved following pericardial drainage and
diuresis. He continued to have SOB and and an O2 requirement and
a right sided thoracentesis was performed which drained 2L of
exudate with many RBCs. With diuresis and later HD, his volume
overload and oxygen requirement likewise improved.
#Klebsiella sepsis: Pt had a positive blood culture and urine
culture for Klebsiella, with the blood growing three
pan-sensitive strains. He was febrile and hypotensive at time of
diagnosis and treated broadly with vanc/cefepime prior to
narrowing to ceftriaxone. Pt remained afebrile and normotensive
following initiation of abx. Pt's PICC line was removed as (+)
BC was drawn from it. He completed a total 2 week course of CTX
ending [**2182-8-18**].
#Atrial Fibrillation with RVR: CHADS2 score of 3, on coumadin at
home. Coumadin was held intially as INR was supratherapeutic on
admission, but resumed prior to d/c. Prior to admission, pt was
rate-controlled with metoprolol 75mg [**Hospital1 **] and 120mg daily of
diltiazem. His dilt was held briefly to allow pt to tolerate
HD, but resumed after the first few HD sessions. On [**Hospital1 **],
doses adjusted to toprol xl 100mg daily and diltiazem CR 180mg
daily. He does occasionally have RVR to 110-120 if he is late
for his doses, but responds quickly to oral meds. His INR was
3.3 on [**Hospital1 **] and had been increasing slowly over the past
few days of hospitalization despite decreasing warfarin. Will
need 1mg daily with daily INR checks until stabilized.
Nutritional optimization will be necessary.
#Renal Failure: He is s/p renal transplant 25 years ago for PKD
and has a baseline creatinine of 1.6. He was initally kept on
home cyclosporine and prednisone for immunosupression. Renal
transplant service followed pt throughout admission. Pt's Cr
continued to trend up with diuresis to 3.9. The etiology was
initially felt to be ATN, but given lack of renal recovery, the
eitology became unclear. Further diuresis was held at as pt was
believed to be pre-renally intravascularly depleted despite
being fluid overloaded. he did not respond to albumin and
ultimately became oliguric. Given anasarca and lack of response
to diuretics, HD was initiated. He received a tunnelled HD line
on [**8-20**] for durable access. His CSA was discontinued initially
but was restarted on [**Month/Day (4) **] to attempt a 2 week trial course
to rescue his graft. He will continue 100mg daily. If no urine
output increase noted over 2 weeks, he probably will discontinue
cyclosporin. but the prednisone was continued at 5mg daily. He
may regain some renal function, but remains oligo-anuric at
[**Month/Day (4) **]. If anuric x24hr or greater, please bladder scan to
rule out obstruction/retention. Will need HD MWF at LTAC,
followup with renal and transplant surgery.
#Recent GI Bleed: H/H was monitored. He recieved 1 unit pRBCs
this admission for anemia felt to be [**1-17**] decreased epo in the
setting of renal failure and phelbotomy. He had marroon stools
for about 5 days without signfiicant HCT drop in the setting of
heparin gtt, likely diverticular. GI was consulted and no
intervention taken. Will f/u with GI as outpatient.
#Delirium: Felt to be multifactorial, ICU delerium as well as
uremia. Pt's mental status improved with HD. He was not
aggitated but rather endorsed delusions of grandeur and
hypoactivity. Care was taken to maintaine sleep-wake cycle.
#Hyperlipidemia: Patient was maintained on home on atorvastatin
20mg daily.
#Depression: SW provided support to the pt and his famiyl during
his hospital stay. He was maintained on home SSRI.
#Gout: Febuxostat was changed to renally-dosed allopurinol in
the setting of renal failure
#depression: started citalopram 10mg daily, will need titratrion
up if depressive symptoms continue over next several weeks.
# Code status: Pt had intially been full code on admission. As
he became mroe ill in the setting of his renal failure, he
expressed wishing to die but also endorsed wanting things done
that could prolong his life. Multiple conversations were had
with the pt and his family, particularly prior to starting HD.
Ultimately, the pt endorsed wanting to be DNR/DNI and, given
episodes of delerium, the pt's daughters felt this was
consistant with their father's wishes. All were in agreement
with going forward with HD.
# dysphagia: diet advanced to regular at time of discharge1. PO
diet: thin liquid and regular consistency solids.
2. Meds whole with thin liquid or applesauce.
Transitional Issues:
- will need titration of warfarin for INR goal [**1-18**]
- f/u with renal and transplant surgery
- f/u with cardiology and CHF for volume management
- HD MWF
- Trial of cyclosporin 100mg daily for roughly 2 weeks. Check
24hr trough in one week with level goal of <100. If oliguria
persists in 2 weeks, likely will stop cyclosporin.
.
MEDICATIONS STARTED
Allopurinol 150 mg PO EVERY OTHER DAY
.
MEDICATIONS CHANGED
Diltiazem ER increased from 120mg daily to 180 mg daily
Metoprolol Tartrate 75 mg PO BID to Metoprolol Succinate XL 100
mg PO DAILY
Warfarin 2.5mg to 1mg daily
.
MEDICATIONS STOPPED:
Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
Flagyl course completed
Furosemide
Febuxostat
.
Pending tests at [**Hospital1 **]:
-none
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ascorbic Acid 500 mg PO TID
3. Calcium Carbonate 1000 mg PO DAILY
4. Cholestyramine 4 gm PO DAILY
5. CycloSPORINE (Sandimmune) 100 mg PO Q24H
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Febuxostat 40 mg PO DAILY
8. Ferrous Sulfate 325 mg PO TID
9. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
11. Furosemide 40 mg PO BID
12. Lovastatin *NF* 20 mg ORAL DAILY Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
13. Metoprolol Tartrate 75 mg PO BID
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 40 mg PO DAILY
17. PredniSONE 5 mg PO DAILY
18. Vitamin D 800 UNIT PO DAILY
19. Warfarin 2.5 mg PO DAILY16
[**Hospital1 **] Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol 150 mg PO EVERY OTHER DAY
3. Citalopram 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
7. Senna 1 TAB PO BID:PRN constipation
8. Ascorbic Acid 500 mg PO TID
9. Calcium Carbonate 1000 mg PO DAILY
10. Ferrous Sulfate 325 mg PO TID
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
12. PredniSONE 5 mg PO DAILY
13. Vitamin D 800 UNIT PO DAILY
14. Lovastatin *NF* 20 mg ORAL DAILY Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
15. Omeprazole 40 mg PO DAILY
16. Diltiazem Extended-Release 180 mg PO DAILY
hold for SBP < 100, HR < 60.
17. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
18. Cholestyramine 4 gm PO DAILY
19. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP < 100, HR < 60
20. Warfarin 1 mg PO DAILY16
21. CycloSPORINE (Sandimmune) 100 mg PO Q24H
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital **] rehab macu
[**Hospital **] Diagnosis:
primary: pericardial effusion with tamponade s/p drainage
renal failure
.
secondary: Klebsiella UTI and bacteremia
atrial fibrilation
acute on chronic dialstolic heart failure
[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Hospital **] Instructions:
Mr. [**Known lastname 57554**],
.
It was a pleasure taking care of you at [**Hospital1 **]. You were admitted to the hospital after you were
found to have too much fluid on your body in clinic. You were
found to have fluid around your heart, which was drained.
Unfortunately, while you were here, your kidney failed and you
were started on dialysis. We also treated you for an infection
in your blood and urine while you were here.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
You will need to continue your dialysis on Monday, Wednesdays
and Fridays. You will also need to follow up with your
cardiologist as an outpatient.
You had some mild bleeding of your intestines, we will have you
see a GI doctor as an outpatient. You will also see a heart
failure specialist as an outpatient.
You will now spend time getting stronger in rehab with more
physical therapy.
Many changes were made to your medications and are explained on
the following sheet.
We wish you the best of luck, Mr. [**Known lastname 57554**]!
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2182-8-28**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2182-9-5**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Congestive Heart Failure Clinic
[**2182-9-10**] at 1pm with Dr. [**Last Name (STitle) **]
[**Location (un) 436**] [**Hospital Ward Name **] center, [**Hospital Ward Name **]
Phone: ([**Telephone/Fax (1) 2037**]
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2182-8-27**] at 2:00 PM
With: [**Doctor First Name 23138**] [**First Name8 (NamePattern2) 23139**] [**Name8 (MD) 815**], 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:[**2182-8-25**] | [
"5845",
"5070",
"5990",
"2761",
"4280",
"42731",
"4168",
"4019",
"311",
"2724",
"V1582"
] |
Admission Date: [**2109-3-28**] Discharge Date: [**2109-4-4**]
Date of Birth: [**2032-2-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB with exertion
Major Surgical or Invasive Procedure:
CABG X 3 (LIMA > LAD, SVG>OM, SVG>PDA), AVR (tissue) on [**2109-3-28**]
History of Present Illness:
Ms. [**Known lastname **] is a 77 ywar old male who presented with DOE, he
underwent a stress test which was positive, he was then referred
for cardiac catheterization which showed severe thre vessel
disease and aortic stenosis.
Past Medical History:
Hypercholesterolemia
AS
Anemia
Bilateral knee arthritis
s/p TURP
s/p appy
Social History:
pipe smoker, no etoh.
Works as director of a research center
Family History:
Father deceased from MI at 72
Mother deceased from MI at 76
Physical Exam:
On admission:
NAD
HEENT unremarkable
Lungs CTAB
RRR with 3/6 systolic murmur
Abd benign
no edema
Neuro intact
Carotids with transmitted bruits
Pertinent Results:
[**2109-4-3**] 06:23AM BLOOD Hct-25.0*
[**2109-4-2**] 06:23AM BLOOD Hct-25.6*
[**2109-3-31**] 05:55AM BLOOD WBC-11.4* RBC-3.56* Hgb-10.1* Hct-29.1*
MCV-82 MCH-28.5 MCHC-34.9 RDW-18.2* Plt Ct-155
[**2109-4-4**] 06:32AM BLOOD PT-19.9* PTT-60.5* INR(PT)-1.9*
[**2109-4-3**] 06:23AM BLOOD UreaN-28* Creat-1.1 K-3.9
Brief Hospital Course:
Mr. [**Known lastname **] was admitted the morning of surgery, he was taken to
the operating room on [**2109-3-28**] where he underwent a CABG x 3
(LIMA->LAD, SVG->OM & PDA) and AVR with a 25 mm CE pericardial
valve. He wsa transferred to the intensive care unit in critical
but stable condition. Postoperatively he was noted to have a
right pneumothorax for which a chest tube was placed with near
total resolution of the pneumothorax. He ws extubated on POD 0,
His invasive lines and mediastinal drains were discontinued on
POD 1. He did have multiple episodes of atrial fibrillation for
which he ws treated with amiodarone and anticoagulated with
heparin and coumadin. His INR on [**4-4**] was 1.9 and he was ready
for discharge to home. Dr.[**Name (NI) 5765**] office was contact[**Name (NI) **] to follow
his INR after discharge.
Medications on Admission:
Lipitor
Toprol
ASA
FeSo4
Glucosamine
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. 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*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: 400 mg(2 tablets) once daily for 1 week, then 200
mg(1 tablet) daily until d/c'd by Dr. [**Last Name (STitle) **].
Disp:*90 Tablet(s)* Refills:*0*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 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. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Check INR [**4-5**] with results called to Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
AS
hypercholesterolemia
arthritis
post-op AFib
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# for 10 weeks
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (STitle) **] in [**12-28**] weeks
with Dr. [**Last Name (STitle) **] in [**12-28**] weeks and for INR check and coumadin dosing
with Dr. [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2109-4-4**] | [
"41401",
"4241",
"42731",
"2720"
] |
Admission Date: [**2154-1-7**] Discharge Date: [**2154-1-17**]
Date of Birth: [**2090-2-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal cancer.
Major Surgical or Invasive Procedure:
[**2154-1-7**]: Transhiatal esophagectomy, placement of a jejunostomy
tube, pyloroplasty, umbilical hernia repair.
History of Present Illness:
The patient is a 63-year-old lady who presented with a
nine-month history of voice change. Despite her medical
history, she had an excellent performance status preoperatively.
Upon her daughter's request, she underwent an upper endoscopy
in [**2153-9-26**] that showed a nodule in the gastroesophageal
junction that was biopsied. Pathology of that specimen
indicated high-grade dysplasia. However, repeat pathologic
evaluation of the specimen that was obtained at [**Hospital1 24300**] Hospital confirmed presence of an intramucosal carcinoma
in the setting of high-grade dysplasia. Endoscopy, EUS and PET
scan were all performed suggesting T1a, N0, stage I esophageal
carcinoma. With this operative indication, the patient was
brought to the operating room for transhiatal esophagectomy.
Past Medical History:
Non-insulin dependent diabetes
Hypertension
Hypercholesterolemia
Rheumatic fever
Glaucoma
Diverticulosis
Roscea
PSH: lap chole [**2151**] right tigger finger [**Doctor First Name **] [**2152**], L rotator
cuff repair [**2149**], C4-6 laminectomy and foraminotomy [**2147**], facial
resurfacing [**2149**], b/l glaucoma [**Doctor First Name **], left LE vein striping
Social History:
Married, lives with family. Tobacco quit 34 years ago, ETOH
occasional
Family History:
Father- throat ca died 60yrs
[**Name (NI) 82040**] sister died [**Name2 (NI) 499**] ca [**2128**]
Physical Exam:
VS: T: 98.8 HR: 95-100 SR BP: 110-120/60-70 Sats: 96% RA
Wt: 77.1 kg
General: sitting up in chair in no apparent distress
Card: RRR
Resp: diminished breath sounds at bases otherwise clear
GI: bowel sounds positive, abdomen soft. J-tube in place site
clean no erythema
Extr: warm 1+ bilateral edema
Incision: neck incision clean, dry intact with steri-strips,
abdominal clean dry intact with staples
Neuro: non-focal
Pertinent Results:
[**2154-1-14**] WBC-6.3 RBC-3.07* Hgb-9.0* Hct-26.4* Plt Ct-304
[**2154-1-12**] WBC-7.5 RBC-2.79* Hgb-8.1* Hct-23.5* Plt Ct-254
[**2154-1-11**] WBC-7.2 RBC-2.78* Hgb-8.2* Hct-23.4* Plt Ct-217
[**2154-1-7**] WBC-5.6 RBC-3.51* Hgb-10.3*# Hct-28.9* Plt Ct-227
[**2154-1-17**] Glucose-250* UreaN-18 Creat-0.6 Na-135 K-4.9 Cl-94*
HCO3-33*
[**2154-1-16**] Glucose-244* UreaN-24* Creat-0.7 Na-134 K-3.9 Cl-97
HCO3-29
[**2154-1-15**] Glucose-235* UreaN-29* Creat-0.7 Na-139 K-4.2 Cl-103
HCO3-27
[**2154-1-15**] Glucose-235* UreaN-29* Creat-0.7 Na-139 K-4.2 Cl-103
HCO3-27
[**2154-1-14**] Glucose-257* UreaN-30* Creat-0.7 Na-141 K-4.0 Cl-107
HCO3-22
[**2154-1-13**] Glucose-139* UreaN-27* Creat-0.8 Na-143 K-3.4 Cl-110*
HCO3-23
[**2154-1-12**] Glucose-116* UreaN-21* Creat-0.7 Na-142 K-4.5 Cl-112*
HCO3-21*
[**2154-1-8**] Glucose-183* UreaN-8 Creat-0.6 Na-138 K-4.5 Cl-106
HCO3-24
[**2154-1-7**] Glucose-120* UreaN-11 Creat-0.7 Na-139 K-3.1* Cl-104
HCO3-25 AnGa
[**2154-1-9**] ALT-74* AST-69* LD(LDH)-257* AlkPhos-57 Amylase-41
TotBili-0.8
[**2154-1-15**] Calcium-8.8 Phos-2.4* Mg-1.8
Culture: Blood cultures [**2154-1-9**]: NO growth x2, Urine Culture
No growth
CXR:
[**2154-1-16**]:
There is significant interval improvement within right
subpulmonic effusion, which is now small in size. There is
persistent
bibasilar atelectasis. The lungs are otherwise clear with no
signs of
pneumonia or congestive heart failure. Cardiomediastinal
silhouette is stable with moderate cardiomegaly and tortuosity
of the aorta.
[**2154-1-13**]: 1. No pneumothorax following chest tube removal.
2. Slight worsening right lower lobe atelectasis with adjacent
pleural
effusion. No substantial change in left lower lobe atelectasis.
[**2154-1-10**]: There has been improvement of the left small
pleural effusion and atelectasis, however progression of the
small
right pleural effusion and atelectasis. Lines and tubes remain
in similar
position. The cardiomediastinal silhouette is stable with a tiny
amount of
mediastinal air consistent with post-esophagectomy changes
[**2154-1-7**]: Interval placement of ET tube, NG tube, left chest
tube, and
epidural catheter in appropriate positions. Interval left
pleural effusion
and bibasilar atelectasis.
Brief Hospital Course:
Mrs. [**Known lastname 4886**] was admitted on [**2154-1-7**] for Transhiatal
esophagectomy, placement of a
jejunostomy tube, pyloroplasty, umbilical hernia repair. She
was transferred to the ICU intubated in stable condition with a
left chest tube to suction, NGT to low-wall suction, foley, neck
JP, and a Bupivacaine/Dilaudid epidural for pain control. On
POD1 she was extubed. She was found to be hypotensive and the
epidural was titrated down and administered a fluid bolus with a
good result. On POD2 she was out bed to chair transferred to
the Floor but returned to the ICU for respiratory distress,
atelectasis and hypoxemia. She spiked a fever, pan cultured
which grew no organism. She was very sensitive to narcotics and
the epidural was removed. Her pain was managed with Tylenol and
Toradol. Beta-blockers were started for tachycardia. On POD3
her pain was under better control, she was gently diuresed and
pulmonary toileting was continued. On POD4 the chest film
showed a right lower lobe effusion/atelectasis. A right lower
lobe ultrasound showed minimal effusion. She was started on
trophic tube feeds. She continued to improve and transferred out
of the ICU on POD5. On POD6 The chest-tube and NGT were removed.
Her activity increased with increase in discomfor and was
started on Roxicet with good control. She was seen by physical
therapy who recommended STR. Her bowel function returned and
the tube feeds were increased. Nutrition was consulted who
recommended Fibersource HN Goal rate 55 cc/hr. On POD7 [**Hospital **]
clinic was consulted for better management of her diabetes. She
was started on insulin. A grape juice challenge was given with
no obvious anastomoses leak. She was started on a clear liquid
diet advanced to fulls. On POD8 the JP was removed. Her
insulin was titrated for elevated blood sugars. Her medications
were converted to PO meds. On POD 9 she required gentle
diuresing. Her electrolytes were replete. She continued to make
steady progress and was transferred to rehab. She will
follow-up with Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
Lisinopril 40mg qAM, Lipitor 20mg qHS, metformin 500mg [**Hospital1 **],
Avandia 4mg [**Hospital1 **], glyburide 5mg [**Hospital1 **], Aspirin 81mg daily, vitamin
2 AM, 2PM, Calcium 600mg +VitD 1 AM, 1PM, HCTZ 25mg qAM,
doxycycline 100mg [**Hospital1 **], omeprazole 20mg qAM, Lunigan
drop 1 drop each eye qHS
Discharge Medications:
1. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Five (5) PO BID (2
times a day).
3. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once
a day.
7. Nutren Pulmonary Full strength;
Tube Feeds via J-tube Cycle 70 ml/hr x 15 hrs or
8. Ibuprofen 100 mg/5 mL Suspension [**Last Name (STitle) **]: One (1) PO Q8H (every
8 hours) as needed.
9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1)
PO DAILY (Daily).
10. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) MMML PO Q4H
(every 4 hours) as needed for pain.
11. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) ML PO every
six (6) hours as needed for pain.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: Three (3) Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: Three (3) ML
Inhalation Q6H (every 6 hours).
14. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Thirty Two (32)
Units Subcutaneous Dinner time.
15. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
please titrate as blood pressure tolerates. Home dose 20mg
daily.
16. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. Regular Insulin Sliding Scale
71-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 2 Units 2 Units 2 Units 0 Units
141-160 mg/dL 4 Units 4 Units 4 Units 0 Units
161-180 mg/dL 6 Units 6 Units 6 Units 0 Units
181-200 mg/dL 8 Units 8 Units 8 Units 4 Units
201-220 mg/dL 10 Units 10 Units 10 Units 6 Units
221-240 mg/dL 12 Units 12 Units 12 Units 10 Units
241-260 mg/dL 14 Units 14 Units 14 Units 12 Units
261-280 mg/dL 16 Units 16 Units 16 Units 14 Units
281-300 mg/dL 18 Units 18 Units 18 Units 16 Units
301-320 mg/dL 20 Units 20 Units 20 Units 18 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] Healthcare Center
Discharge Diagnosis:
Non-insulin dependent diabetes
Hypertension
Hypercholesterolemia
Rheumatic fever
Glaucoma
Diverticulosis
Roscea
PSH: lap chole [**2151**] right tigger finger [**Doctor First Name **] [**2152**], L rotator
cuff repair [**2149**], C4-6 laminectomy and foraminotomy [**2147**], facial
resurfacing [**2149**], b/l glaucoma [**Doctor First Name **], left LE vein striping
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills.
-Increased shortness of breath, cough or sputum production
-Chest pain
-Difficulty or painful swallowing, abdominal pain, diarrhea
-Incision develops drainage
-HOB elevated 30 degree or more indefinitely
Feeding tube sutures become loose or break, please tape tube
securely and call the office [**Telephone/Fax (1) 4741**]. If your feeding tube
falls out, save the tube, call the office immediately
[**Telephone/Fax (1) 4741**]. The tube needs to be replaced in a timely manner
because the tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form.
Flush your feeding tube with 50cc every 8 hours if not in use
and before and after every feeding.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4741**] [**1-31**] at 2:00 pm on the
[**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**]
Report to the [**Location (un) 861**] Radiology Department for a Barium
Swallow before your appointment.
Completed by:[**2154-1-17**] | [
"5180",
"5119",
"25000",
"4019"
] |
Admission Date: [**2118-7-18**] Discharge Date: [**2118-7-22**]
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Ventricular Tachycardia
Major Surgical or Invasive Procedure:
Cardiac Catheterization
EP study
History of Present Illness:
86 y/o man w/ hitory of CAD s/p 4vessel CABG [**2096**], CHF EF 35%,
Atrial Flutter (not anticoagulated) and chronic renal
insufficiency who was sent to the [**Location (un) **] ED when an outpatient
stress test revealed inssesant non-sustained ventricular
tachycardia. He was asymptomatic and hemodynamically stable. He
was given a dose of lidocaine and transfered to the [**Hospital1 18**] ED.
.
@ [**Hospital1 18**] ED he was started on lidocaine drip and seen by EP.
Preliminary plans are for a possible EP study and VT ablation.
ROS is posative for dyspnea on excertion which has been stable,
with no history of synope or presyncope.
Past Medical History:
CAD s/p CABG [**2096**] with 4v disease
CRI
severe COPD ([**9-24**] FEV1 0.91, FVC 1.76, decreased TLC, nl DLCO)
HTN
Hyperlipidemia
subclavian stenosis
aflutter on sotalol
prostate CA
Social History:
Social: Patient lives with son, non-[**Name2 (NI) 1818**], no etoh or illicits.
Ballroom dancing a few times per week.
Family History:
Family: no family history of premature heart disease
Physical Exam:
VS - 96.6 129/86 86 20
Gen: WDWN elderly 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 with JVP of 8cm.
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 slightly unlabored, no accessory muscle use. Lungs with
crackles @ bases bialterally, rhonchi and diffuse soft wheezing.
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:
LABS ON ADMISSION:
[**2118-7-18**] 06:55PM CK-MB-NotDone cTropnT-<0.01
[**2118-7-18**] 01:00PM GLUCOSE-107* UREA N-33* CREAT-1.7* SODIUM-140
POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
[**2118-7-18**] 01:00PM WBC-11.1* RBC-4.38* HGB-14.6 HCT-43.9
MCV-100* MCH-33.3* MCHC-33.3 RDW-13.7
[**2118-7-18**] 01:00PM CK-MB-NotDone cTropnT-0.01
.
CARDIAC CATH:
1. Three vessel native coronary artery disease with LMCA
disease.
2. Patent LIMA, SVG to Diaganol, and SVG to OM. SVG to PDA with
moderate stenosis.
3. Moderate in-stent restenosis of left subclavian artery stent.
4. Severe distal subclavian artery stenosis proximal to the
LIMA.
5. Severe pulmonary arterial hypertension.
6. Moderate systemic arterial hypertension.
7. Severe left ventricular diastolic heart failure.
.
Brief Hospital Course:
86 yo male with CAD s/p 4v CABG [**2097**], CHF with EF 35%, atrial
flutter/fib, CRI who presented to [**Hospital1 18**] with stable sustained
VT.
.
#Sustained VT / Rhythm
He was taken to the EP lab for a VT ablation which was
successful. VT terminated and primary rhythym was atrial
fibrillation post procedure. Post-procedure, he was also
noticed to have a blue toe in the PACU. He was transfered for
further care to the CCU. His arterial and venous sheaths were
pulled and blood flow returned to his foot. DP pulses were
present w/ doppler bilaterally. He was re-started on his home
dose sotalol [**2118-7-20**] and resumed normal sinus rhythm on [**2118-7-21**]
around 10am. A 6 point hct drop was noted along with continued
bleeding from groin, and a CT abdomen was performed which ruled
out a retroperitoneal bleed. A right groin ultrasound was also
performed to rule out pseudoaneurysm and was normal.
Subsequently patient was started on heparin gtts to bridge to
coumadin therapy for goal inr [**1-22**] with lovenox 80 mg daily for
permanent atrial fibrillation.
.
#CAD
Patient also underwent L + R cardiac catheterization. LIMA and
other grafts were intact and patent. No angioplasty was
performed nor were stents placed. He was continued on ASA 325
mg, moexepril 7.5 mg daily, sotalol 80 mg daily. Atorvastatin
10 mg daily was changed to simvistatin 40 mg daily since LDL was
101 (above goal 70).
.
#COPD
Patient was continued on home medications of atrovent and
albuterol. Ipratroprium albuterol nebulizer was added on final
hospital day. He was discharged on home medication advair +
combivent. Right cardiac catheterization showed severe
pulmonary hypertension.
.
#Subclavian stenosis
The patient was admitted to the [**Hospital Ward Name 121**] 6 cardiology service. He
was taken to the cath lab [**7-19**] which showed proximal L
subclavian disease (60-70% stenosis), but it was not intervened
upon due to technical factors.
.
#CHF
He was continued on home medications of sotalol, moexepril.
Lasix was initially held due to low blood pressures. Pressures
remained in systolic 80-90's; on [**7-21**] he also experienced one
episode of bradycardia and hypotension with a likely junctional
rhythm after dosage of sotalol so home sotalol was reduced to 80
mg once daily and moexepril was decreased to 7.5 mg daily.
Blood pressures remained subsequently in sbp's 90-110s and maps
60-70's. He was discharged on sotalol 80 mg daily and moexepril
7.5 mg daily.
.
#Incidentaloma
Renal cysts were found bilaterally during CT abdomen exam. A
renal ultrasound was performed which only showed simple renal
cysts bilaterally.
.
Mr. [**Known lastname 25699**] remained afebrile during entire hospitalization. He
remained hemodynamically stable in the 24 hrs prior to
discharge. His home dose sotalol was decreased to 80 mg daily
and moexepril decreased to 7.5 mg daily. His atorvastatin was
stopped and converted to 40 mg daily simvistatin. ASA 325 mg
daily was initiated and coumadin therapy was started 5 mg daily
for persistent atrial fibrillation. Home dose medications
advair was continued and started on combivent. Lovenox 80 mg
daily should be given for 4 days and coumadin 5 mg for 5 days.
INR should be checked Sunday [**2118-7-24**] and the dose of warfarin
should be adjusted accordingly.
Medications on Admission:
sotalol 80 mg [**Hospital1 **]
lasix 20 mg daily
lipitor 10 mg daily
univasc 15 mg daily
advair 250/50 1 puff [**Hospital1 **]
flonase
Discharge Medications:
1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 vial* Refills:*2*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day): rinse mouth after
use.
Disp:*60 puff* Refills:*2*
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*qs inhaler* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: This
dose will change based on your INR. .
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] geriatric
Discharge Diagnosis:
Primary
Stable vtac s/p VT ablation
atrial fibrillation
CAD s/p catherization without intervention
Secondary
HTN
severe COPD
subclavian stenosis
Discharge Condition:
HD stable and afebrile.
Discharge Instructions:
You were admitted with an irregular rhythm called Ventricular
tacchycardia and went to the catherization lab and
electrophysiology lab where you had an ablation of the abnormal
rhythm. Your heart rhythm is still irregular and you will need
to be on coumadin to thin your blood.
Please take all medications as directed. We changed some of your
medications. We decreased your sotalol from 80 mg twice daily to
once daily. We also decreased your moexipril from 15 mg daily to
7.5 mg daily. We also added coumadin 5 mg daily.
Please follow-up with all outpatient appointments.
Please return to the hospital or call your doctor if you
experience fever, dizziness, chest pain, trouble breathing,
abdominal pain or any other concerning symptoms.
Followup Instructions:
Please follow-up with your cardiologist, Dr. [**Last Name (STitle) **]. You have
an appointment with him on Thursday [**8-18**] at 1:30 pm in
[**Location (un) 620**].
.
Please follow up with your PCP when you are discharged from
rehab.
| [
"4280",
"496",
"42731",
"41401",
"4019",
"2859"
] |
Admission Date: [**2199-7-3**] Discharge Date: [**2199-7-5**]
Date of Birth: [**2138-4-19**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 61-year-old gentleman with a history of gastric cancer
s/p resection years ago, hypertension, presenting with several
days of palpitations, which he describeds as a "fluttering"
sensation. Denies chest pain or dyspnea. Says he has has these
episodes every once in a great while, but cannot give specific
frequency. When he has these symptoms, they typically resolve on
their own in a matter of seconds. Today, however, his symptoms
persisted for several minutes, and he decided to come to the ED.
Of note, he has also reported left leg swelling since [**5-11**], when he sustained a fall while crossing the street.
.
In the ED, initial vs were: 97 133 135/102 18 99%, with ECG
revealing atrial flutter. He was given ASA 325 mg and diltiazem
20 mg IV x1, which transiently brought his heart rate down to
the 80s, then subsequently increased to the 120s. D-dimer + to
the 800s. CTA chest revealed no pulmonary embolism or
dissection, but was significant for LLL pneumonia. LENIs
negative for DVT. Lactate was 4.7, which decreased to 2.2 after
four liters of IV fluids.
.
In the ICU the patient denies any respiratory symptoms of any
kind. He is no longer feeling the fluttering sensation. Denies
fevers, chills, chest pain, dyspnea, cough. Denies abdominal
pain, nausea, vomiting, diarrhea, constipation, dysuria.
.
Review of sytems:
(+) Per HPI. Also endorses dark urine when he drinks alcohol.
(-) Denies recent weight loss or gain. Denies headache or
congestion. Denied arthralgias or myalgias.
Past Medical History:
-Gastric cancer s/p gastrectomy in [**2175**], at [**Hospital1 112**]
-Thyroid nodules
-S/p quadriceps tendon rupture [**2196**]
-Hypertension
-Self-reported hx of WPW
-Etoh abuse (Last drink earlier today, in the morning. Denies
ever needing medical care for withdrawal symptoms, but admits to
having drinks in the morning to get rid of "the shakes")
Social History:
Lives by himself. Divorced. Several grown children and
grandchildren. Former chef, no longer working. Drinks several
drinks per day, with etoh history as above. Reports smoking [**2-9**]
cigarettes/month, but earlier told RN he smokes daily. Denies
illicit drug use.
Family History:
Mother's family with "circulatory problems." Mother had
non-fatal MI in her 60s. Mother's relatives (unspecified) with
strokes.
Physical Exam:
Vitals: T:98.3 BP:149/99 P:64 R:12 O2:99% 2 liters
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, OP clear. Poor dentition.
Neck: supple, no JVD or LAD
Lungs: CTAB. No wheezes, rales, rhonchi. Good inspiratory effort
and air movement throughout.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, NT/ND, bowel sounds present, no rebound
tenderness or guarding, no organomegaly or pulsatile masses.
Well healed midline vertical incision scar
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAO x3, speech fluent, thought process generally clear.
Sensation grossly intact throughout. 5/5 strength bilateral
upper extremities and right lower extremities. Left LE: Can
extend knee from 90 to 45 degrees.
Pertinent Results:
[**2199-7-3**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2199-7-3**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2199-7-3**] 08:56PM LACTATE-2.2*
[**2199-7-3**] 06:35PM GLUCOSE-53* LACTATE-4.7*
[**2199-7-3**] 03:17PM GLUCOSE-68* UREA N-12 CREAT-1.0 SODIUM-139
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-21* ANION GAP-24*
[**2199-7-3**] 03:17PM ALT(SGPT)-29 AST(SGOT)-61* ALK PHOS-84 TOT
BILI-0.4
[**2199-7-3**] 03:17PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-1.9
[**2199-7-3**] 03:17PM D-DIMER-826*
[**2199-7-3**] 03:17PM WBC-5.3 RBC-4.02* HGB-12.8* HCT-38.5* MCV-96
MCH-31.7 MCHC-33.2 RDW-14.3
[**2199-7-3**] 03:17PM NEUTS-67.3 LYMPHS-26.4 MONOS-5.6 EOS-0.5
BASOS-0.3
[**2199-7-3**] 03:17PM PLT COUNT-164
[**2199-7-3**] 03:17PM PT-12.6 PTT-25.7 INR(PT)-1.1
LENI [**7-3**]: No evidence for DVT in the left lower extremity.
CTA [**7-3**]:
1. Early left lower lobe pneumonia.
2. No evidence of pulmonary embolism or acute aortic process.
3. Severe coronary artery disease.
4. Fatty liver.
5. Thyroid nodularity for which clinical correlation is advised.
Brief Hospital Course:
This is a 61-year-old gentleman with history of gastric
adenocarcinoma s/p remote surgical resection, hypertension, and
likely regular significant ETOH intake, who presents with
palpations. EKG concerning for atrial flutter and CTA
concerning for PNA.
# ATRIAL FLUTTER: EKG in ED showed atrial flutter with rates in
the 130s. Unclear whether this is chronic however, patient has
undergone holter monitoring in the past without evidence of
sustained dysrhythmias. Patient also relates history of WPW as
a child; he was seen by EP in [**2191**] who saw no evidence of active
bypass tract. Not currently on any rate control as outpatient.
Possible triggers for episode may include hypoxia from pneumonia
or ETOH use. Mr. [**Known lastname **] [**Last Name (Titles) 35325**] diltiazem in ED and rate
slowed into the 80s. In the ICU, patient was monitored on
telemetry and no further rate control was necessary. EP was
consulted who recommended patient follow-up in 1 month with Dr.
[**Last Name (STitle) **]. A beta-blocker was not started as patient's HR's
were continually in the 40s-50s.
Cardiology also recommended obtaining an ECHO as an outpatient
as patient had a right parasternal heave on exam. Atrial
flutter likely exacerbated by some intrinsic lung process, and
may be amenable to ablation.
# LUNG INFILTRATE: Mild opacity in left lower lobe reported as
possible early pneumonia on CTA. No clinical symptoms or signs
of pneumonia--not hypoxic or febrile, no cough or dyspnea, no
leukocytosis. Although Mr. [**Name13 (STitle) **] received ceftriaxone and
azithromycin in the ED, these were not continued in the ED as
suspicion for true PNA was low.
# HYPERTENSION: BP of high 140s/high 90s upon arrival in [**Hospital Unit Name 153**].
Patient states that he has not been taking his
anti-hypertensives for the past several days. Patient was
continued on HCTZ and lisinopril was increased to 20mg QD. His
pressures were monitored closely, especially as he was at risk
for ETOH withdrawal as below.
# ETOH ABUSE: Upon arrival in [**Hospital Unit Name 153**], patient gave different
histories to different interviewers. Admits to having a drink
before presenting to the ED in order to "get rid of the shakes."
Patient was put on a CIWA scale but did not require benzos
throught [**Hospital Unit Name 153**] stay. A social work consult was put in for
addiction counseling.
# CAD: CTA shows evidence of severe CAD. Patient has risk
factors for CAD including sex, age, hypertension, and ETOH
abuse. It is important for him to see cardiology as an
outpatient for further work-up of this issue. He would likely
benefit from ASA therapy or beta-blocker (if heart rate
tolerates). He also needs counseling on reducing CAD risk
factors.
# ELEVATED ANION GAP: Elevated lactate on admission, which
resolved with IV fluid administration. Gap closed on first
morning of admission. Ketonuria may be due to starvation/ETOH
ketoacidosis.
# LEFT LOWER EXTREMITY SWELLING: Possibly from site of previous
trauma. US negative for DVT. Patient was instructed to
follow-up with orthopedics.
Medications on Admission:
-Lisinopril 10 mg daily
-HCTZ 25 mg daily
-Folate 1 mg daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coarse atrial fibrillation
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 on this admission. You
came to the hospital because you were experiencing palpitations.
You were seen by the cardiologist who thought that you had a
condition called atrial flutter. You should see Dr. [**Last Name (STitle) **]
as an outpatient for evaluation and treatment of your atrial
flutter.
The following changes were made to your medications:
1. Increase lisinopril to 20mg QD
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Return to the hospital if you develop chest pain, shortness of
breath, continuing palpitations, severe headache, nausea,
vomiting, diarrhea, pain with urination, cough, fever, increased
swelling in your legs, or any other concerning signs or
symptoms.
Followup Instructions:
PCP/NP [**First Name9 (NamePattern2) 83923**] [**Doctor Last Name 122**]/ Dr. [**Last Name (STitle) **] at [**Hospital3 26956**] on [**7-16**]
at 2pm
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2199-9-4**]
9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2199-7-30**] 1:20
[**Hospital Ward Name 23**] [**Location (un) **]
| [
"42731",
"2762",
"4019",
"41401"
] |
Admission Date: [**2123-8-25**] Discharge Date: [**2123-9-2**]
Date of Birth: [**2042-6-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Atenolol
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Lung Cancer
Major Surgical or Invasive Procedure:
Left lower lobe non-small cell lung cancer, Left vocal cord
paralysis
7/5 L VATS pleuroscopy & mediastinoscopy (neg med nodes)
7/12 L thoracotomy/LLL lobectomy, L chest wall resect with
gortex mesh repair, LUL wedge resect
History of Present Illness:
Mr. [**Known lastname 14859**] is an 81-year-old gentleman with a
biopsy proven carcinoma of the left lower lobe, which by
imaging abuts the chest wall. On his prior visit, he underwent a
staging operation which showed no nodes involved and a
pleural effusion negative for malignancy, with negative
pleural biopsies. He had adequate reserve to tolerate
resection and was surprisingly asymptomatic regarding the
tumor, which was clearly adherent if not invading the chest
wall. We recommended left lower lobectomy with en bloc chest
wall resection and he agreed to proceed.
Past Medical History:
- A.fib s/p ablation and pacemenaker [**2123-5-28**]
- Chronic obstructive pulmonary disease
- +TOBacco
- Perihilar lung mass
Social History:
Married with one grown daughter. Used to be in the army, studied
physical education. TOB+ x >50 yrs, quit 2 months ago. ETOH 1 x
per week.
Family History:
NC
Physical Exam:
LYMPHATICS: He has no adenopathy in the neck region or
supraclavicular fossa.
HEENT: His sclerae are muddy but nonicteric. He has no
thyromegaly, and I can appreciate no carotid bruits.
HEART: Irregular rhythm with a controlled rate.
LUNGS: There is no focal wheezing in the lungs.
EXTREMITIES: He has no peripheral edema.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2123-8-28**] 05:34AM 11.1* 3.11* 9.0* 26.3* 85 28.9 34.1 15.9*
228
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2123-8-25**] 09:00PM 84.8* 9.7* 3.9 1.1 0.5
NO RED TOP RECEIVED FOR MG
RED CELL MORPHOLOGY Anisocy Poiklo Microcy
[**2123-8-25**] 09:00PM 1+ 1+ 1+
NO RED TOP RECEIVED FOR MG
BASIC COAGULATION (PT, PTT, PLT, INR) PT Plt Ct INR(PT)
[**2123-8-28**] 05:34AM 228
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2123-9-1**] 04:05PM 116* 15 1.0 138 4.31 100 25 17
SLIGHTLY HEMOLYZED
1 HEMOLYSIS FALSELY ELEVATES K
HEMOLYZED, SLIGHTLY
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2123-9-1**] 04:05PM 8.8 3.0 2.11
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2123-9-1**] 1:13 PM
Reason: eval for interval change/ptx s/p last Ct d/c
[**Hospital 93**] MEDICAL CONDITION:
81 year old man s/p LLL lobectomy, left chest wall resection
w/mesh, LUL wedge; had L CT d/c now
REASON FOR THIS EXAMINATION:
eval for interval change/ptx s/p last Ct d/c
PA and lateral chest, [**9-1**].
HISTORY: Left lower lobectomy and chest wall repair, left upper
lobe wedge resection. Chest tube discontinued.
IMPRESSION: PA and lateral chest compared to [**8-30**]:
Left posterior air and fluid collection in the region of chest
wall resection has increased in size, predominantly in the
anteroposterior dimension from roughly 31 to 39 mm in diameter,
still between 10.5 and 12 cm in length, and now contains a large
component of fluid. There is no appreciable layering left
pleural effusion or significant pneumothorax along the other
pleural margins. Subcutaneous emphysema in the left
supraclavicular soft tissues has diminished. Small right pleural
effusion is stable. Right lung is clear. Heart is top normal
size and remains shifted slightly to the left. Transvenous pacer
lead in standard position.
RADIOLOGY Final Report
VIDEO OROPHARYNGEAL SWALLOW [**2123-8-31**] 11:13 AM
Reason: eval for swallow prophiciency.
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with left vocal cord paralysis per ENT [**8-30**] s./p
Thoracic surgery, meds/ lobectomy.
REASON FOR THIS EXAMINATION:
eval for swallow prophiciency.
INDICATIONS: 81-year-old man with left vocal cord paralysis
following thoracic surgery.
TECHNIQUE: Videotaped oropharyngeal swallowing study.
FINDINGS: The study was performed in conjunction with the speech
and swallow pathologist. Various consistencies of barium were
administered under videofluoroscopy. Due to poor bolus control,
premature spillover was observed into the piriform sinuses with
thin liquids. Laryngeal valve closure was mildly impaired, and
the left vocal cord showed paralysis. Residue in the piriform
sinuses and valleculae could be cleared with multiple swallows.
Pharyngeal contraction was symmetric. Mild penetration with sips
of thin liquids was observed with spillover, but throat clearing
was effective.
A moderate amount of silent aspiration was observed with
multiple sips of thin liquids, related to spillover, and cough
was not effective at clearance. Also, there was reduced
sensation with a lack of spontaneous cough. This aspiration
occurred with larger boluses only. With smaller boluses of thin
liquids via straw, only trace penetration was observed.
IMPRESSION: Moderate aspiration with larger boluses of thin
liquids, with only penetration into the vestibules seen at
smaller boluses. Paralysis of left vocal cord.
SUMMARY:
Pt presents with a mild oropharyngeal dysphagia. He
demonstrated
aspiration and penetration with thin liquids during the
examination, however, small bolus sizes were effective at
preventing aspiration when pt was focused on the swallowing
task.
Pt also demonstrated deep penetration with small straw sips of
thin liquids. In consideration of pt's left vocal cord paresis,
it is very likely that this is the cause of his poor valve
closure and thus compromising his airway protection with larger
boluses. Therefore, based on this examination, it is
recommended
that pt continue with a regular PO diet with thin liquids while
taking small sips of thin liquids and NO STRAWS. Pt
demonstrated
a good understanding of the instructions given after the
evaluation. We will follow-up with the pt to ensure that these
instructions are being followed at meals.
RECOMMENDATIONS:
1. recommend that pt continue on regular PO diet with thin
liquids and PO meds
2. pt should take small sips of thin liquids
3. Pt should not use straws
Pathology Examination
SPECIMEN SUBMITTED: LIPOMA, LATERAL CHEST WALL MARGIN, NEW
LATERAL CHEST WALL MARGIN, LEFT LOWER LOBE AND CHEST WALL, L10
LYMPH NODE, L11 LYMPH NODE
Procedure date Tissue received Report Date Diagnosed
by
[**2123-8-25**] [**2123-8-26**] [**2123-8-30**] DR. [**Last Name (STitle) **]. BROWN/lfb
Previous biopsies: [**-7/2603**] LT PARIETAL PLEURA, 4 R, LOWER
PARATRACHEAL, 4 L LOWER
DIAGNOSIS:
1. Excision, central back: lipoma.
2. Lung, left lower lobe and chest wall: Squamous cell
carcinoma, see synoptic report.
3. Margin, lateral chest wall: Squamous cell carcinoma.
4. New margin, lateral chest wall: Skeletal muscle, no carcinoma
seen.
5. L10 nodes: No carcinoma seen.
6. L11 nodes: No carcinoma seen.
Lung Cancer Synopsis
MACROSCOPIC
Specimen Type: Lobectomy.
Laterality: Left.
Tumor Site: Lower lobe.
Tumor Size
Greatest dimension: 7 cm.
MICROSCOPIC
Histologic Type: Squamous cell carcinoma.
Histologic Grade: G2: Moderately to poorly differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor of any size that directly invades
any of the following: chest wall, diaphragm, mediastinal pleura,
parietal pericardium; or tumor of any size in the main bronchus
less than 2 cm distal to the carina but without involvement of
the carina; or tumor of any size associated atelectasis or
obstructive pneumonitis of the entire lung.
Regional Lymph Nodes: pN0: No regional lymph node
metastasis.
Location: T 10.
Number examined: Multiple fragments
Number involved: 0.
Location: T 11.
Number examined: Multiple fragments
Number involved: 0.
Location: Hilar .
Number examined: 6.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins: Tumor is focally present adjacent to the inked lateral
chest wall margin in the lobectomy/chest wall resection
specimen.
Direct extension of tumor: Chest wall.
Venous invasion (V): Indeterminate.
Lymphatic Invasion (L): Indeterminate.
Clinical: Left lower lobe lung cancer.
Gross: Specimen submitted: 1. central back soft tissue,
lipoma, 2. lateral chest wall margins, 3. new lateral chest
wall margins, 4. left lower lobe and chest wall, 5. L10
lymph node, 6. L11 lymph node. The specimen is received
fresh in six parts each labeled with the patient's name,
"[**Known lastname 14859**], [**Known firstname **]" and with the medical record number.
Part 1 is additionally labeled "central back soft tissue lipoma"
and consists of a 6 x 6 x 2.5 cm portion of fatty tissue. The
specimen is sectioned to reveal unremarkable fatty cut
surfaces. The specimen is submitted in cassettes A-C.
Part 2 is additionally labeled "lateral chest wall margin" and
consists of a 1.5 x 1.0 x 0.5 cm fragment of soft tissue, which
is entirely submitted for frozen section diagnosis. Frozen
section diagnosis by Dr. [**First Name8 (NamePattern2) 32953**] [**Name (STitle) 10165**] is as follows: "lateral
chest wall margin: positive for non small cell carcinoma." The
specimen is entirely submitted as follows: D=frozen section
remnant.
Part 3 is additionally labeled "new lateral chest wall margin"
and consists of a 2 x 2 x 1.5 cm portion of soft tissue, with a
stitch indicating the new margin. The margin is shaved, and
submitted for frozen section diagnosis. Frozen section
diagnosis by Dr. [**Last Name (STitle) **] is as follows: "new lateral chest
wall margin, negative for carcinoma." This specimen is
represented as follows: E=frozen section remnant, F=portions of
soft tissue.
Part 4 is additionally labeled "left lower lobe with attached
chest wall" and consists of a left lower lobe of lung, portion
of upper lobe, and chest wall. The portion of the upper lobe
measures 6 x 3 x 2 cm, the lower lobe measures 12 x 7 x 6 cm,
the chest wall measures 14 x 9.5 x 2 cm. The specimen has been
oriented with a white suture at the superior posterior aspect of
the chest wall. There is additionally a black suture located on
the lateral surface of the chest wall located just inferior to
the 5th rib. The bronchial margin is shaved and submitted for
frozen section diagnosis. Frozen section diagnosis by Dr.
[**Last Name (STitle) **] is as follows: "negative for carcinoma." The specimen
is sectioned to reveal a largely necrotic tumor mass within the
left lobe of the lung with extension into the soft tissue. The
mass overall measures 7 x 7 x 6 cm. It comes to within less
than 1 mm of the soft tissue margin, within 0.5 cm of the
stapled upper lobe margin, and to within 1 cm of the bronchial
and vascular resection margin. The mass does not appear to
involve the chest wall between ribs 4 and 5, however between
ribs 5 and 6 it extends between the bones to the soft tissue.
Additionally, on the posterior internal surface of the 6th rib
there is a small 0.5 cm nodule which may represent tumor, may
represent lymph node. This specimen is represented as follows:
G=bronchial margins frozen section remnants. H=vascular margin,
I=stapled upper lobe margin, with adjacent nodule, J=hilar lymph
nodes, K=soft tissue margin between ribs 5 and 6, L=soft tissue
margin between 6 and 7, M=soft tissue margin between 6 and 7,
N=soft tissue margin internal to rib 6, posteriorly on the
pleural surface, O=tumor in relationship to normal lung and
pleura, P=tumor with necrosis with relationship to vessels. X,Y
= 6th rib margin, Z,AA = 7th rib margin, AB = cross section of
rib. Portions of this specimen are submitted for
decalcification.
Part 5 is additionally labeled "L10 lymph nodes" and consists
of a 1.5 x 0.4 cm anthracotic lymph node, which is bisected and
entirely submitted in cassette Q.
Part 6 is additionally labeled "L11 lymph nodes" and consists
of multiple anthracotic lymph nodes measuring in aggregate 2.5 x
1 x 1 cm. The largest is bisected and submitted in R. The
remainder is entirely submitted in cassette S.
Brief Hospital Course:
[**8-25**]: Patient admitted for surgery (L thoracotomy, LLL
lobectomy, L chest wall resection with gortex mesh repair, LUL
wedge resection. Post-operatively, the patient was transferred
to the ICU.
[**8-26**]: Patient was extubated in the ICU. Patient's pacemaker was
interrogated for abnormal rhythms and found to be normal.
[**8-27**]: Patient's L IJ CVL (3 lumen) was withdrawn 2cm because of
improper placement ,patient became hoarse shortly thereafter.
[**8-28**]: Patient transferred to floor.
[**8-30**]: Patient's chest tube dislogded accidentally while in
radiology early in am. Patient seen by ENT for c/o hoarseness,
discovered L Vocal cord paralysis.
[**8-31**]: Patient had speech and swallow evaluation for c/o
hoarseness.see report for detail.
[**9-1**]: Patient's chest tube was removed. ENT recommended
outpatient follow up in two weeks.
[**9-2**] Pt stable overnight and pain controlled on po rx. Pt stable
for discharge to home in company of wife. [**Name (NI) 269**] services w/
[**Location (un) **] [**Location (un) 269**].Coumadin to restart at home.
Medications on Admission:
Coumadin 2.5qd, Lasix 40qd,fluticasone, azatioprine, tictropium
1 puff qd, mucinex, prednisone
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-15**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*1*
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,TH).
5. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO q12 ().
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*80 Tablet(s)* Refills:*0*
9. 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*
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Left lower lobe lung 9cm massNSCLC, L vocal cord paralysis
7/5 L VATS pleuroscopy & mediastinoscopy (neg med nodes)
Atrial fibrillation s/p ablation/pacer [**5-20**], Chronic obstructive
pulmonary disease, Left lower lobe lung 9cm mass, bullous
pemphigoid
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**]/Thoracic Surgery office [**Telephone/Fax (1) 170**] if you
experience chest pain, shortness of breath, fever, chills, pain
not relieved with oral pain medication.
Take medications as previous to surgery.
Take new medications as directed on discharge instructions.
You may shower in 2 days, then remove dressing at chest tube
site and change daily as needed.
No driving if taking narcotic pain medication.
Ambulation as much as possible.
Take bowel medication for regularity.
Followup Instructions:
Dr.[**Name (NI) **] office will contact you regarding your follow up
appointment
Follow up with ENT, Dr. [**Last Name (STitle) 1837**] ([**Telephone/Fax (1) 26719**]) in 2 weeks.
Completed by:[**2123-9-2**] | [
"42731",
"496",
"V5861"
] |
Admission Date: [**2128-10-28**] Discharge Date: [**2128-11-4**]
Date of Birth: [**2054-7-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Olanzapine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
AFIB
CHF exacerbation
Major Surgical or Invasive Procedure:
Cardioversion
Right Internal Jugular catheter
History of Present Illness:
This is a 74 year old man with history of CHF who was intially
admitted to [**Hospital **] Hospital with atrial fibrillation and CHF
exacerabtion and is now transfered to [**Hospital1 18**] for further
management. History was obtained from patient and medical
records since the patient could not address many aspects of his
presentation.
On [**2128-10-7**] he presented to his PCP with shortness of breath
and weight gain. At the time his weight was 251 lb (aproximately
25 lb increase) and he was noted to have worsened lower
extremity edema. On this visit he was also noted to be in atrial
fibrilation with a ventricular rate of 130 bpm (most recent ECG
in [**12/2124**] is reported as sinus). At that time he was on
diltiazem 240 mg daily, furosemide 40 mg daily and lisinorpil 20
mg daily. His furosemide was increased to 40 mg twice daily and
he was started on metoprolol succinate 50 mg daily. For unclear
reasons his lisinopril was discontinued.
On [**2128-10-14**] he presented to his PCPs office again with symptoms
of shortness of breath and was found to have atrial fibrillation
with a rate of 150. He was refered for admission at [**Hospital **]
Hospital. There he was initially treated with diltiazem,
metoprolol, digoxin and heparin ggt. ACS was ruled out with
cardiac enzymes and ECG. He was also given intravenous
furosemide boluses for management of his CHF exacerabtion.
On [**2128-10-16**] he desaturated and he developed rapid ventricular
response. A code was called without CPR administration. The
patient was transfered to the ICU. He was intubated and placed
on furosemide ggt. He was started on digoxin and his diltiazem
ggt was continued. Acetazolamide was also started. He was
extubated on [**2128-10-25**] and he has done well on 4L NC since then
(02 sat 98%). His [**Location (un) **] admission weight was 279 lb, which
improved to 250 lb with diuresis. A TTE on [**2128-10-16**] showed EF55%
with septal hypokinesis as well as severe MR (with limited
windows). Repeat TTE on [**2128-10-20**] confirmed severe MR with two
separate jets tracking up. LENIs were negative bilaterally. His
urine output ranged from 100 to 300 ml/hr??. His hospitalization
course at [**Location (un) **] has been complicated by delirium with
disorientation and combativeness. He developed hypokalemia in
the setting of diuresis and although sputum cultures grew GNR (?
E. Coli) he has been afebrile without CXR changes suggesting
PNA.
.
On arrival to the CCU, he reported only intermittent cough that
is non-productive and buttock pain at the site of his sacral
ulcerations. He denied shortness of breath, chest pain, nausea,
vomiting, diarrhea, fevers, chills. He is a poor historian and
could not comment further on prior history.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
HTN
CHF
COPD
?CVA
obesity
Social History:
-Tobacco history: quit 40 yrs ago
-ETOH: no
-Illicit drugs: no
-wife deceased, former truck driver, lives alone
.
Family History:
NC
Physical Exam:
admission PE:
VS: T=99.8 BP=125/56 HR=110 RR=22 O2 sat= 94% on 15L FM
GENERAL: obese male in NAD. Oriented x2, drowsy but arousable.
Mood, affect appropriate. Inattentive on questioning.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: RIJ in place, CVP transduced at 15.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachy, irreg, irreg, normal S1, S2. Unable to appreciate
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. Decreased BS b/l with
few inspiratory crackles at the bases.
ABDOMEN: Obese, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. No sacral edema.
SKIN: 4 sacral decubitus/periscrotal ulcers - stage two, two
unstagable. No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2128-10-28**] 04:01PM GLUCOSE-104 UREA N-21* CREAT-1.1 SODIUM-141
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-34* ANION GAP-11
[**2128-10-28**] 04:01PM estGFR-Using this
[**2128-10-28**] 04:01PM CALCIUM-9.0 MAGNESIUM-2.9*
[**2128-10-28**] 04:01PM VIT B12-845 FOLATE-17.1
[**2128-10-28**] 04:01PM %HbA1c-5.9
[**2128-10-28**] 04:01PM DIGOXIN-1.2
[**2128-10-28**] 04:01PM HCT-38.0*
[**2128-10-28**] 04:01PM PTT-74.9*
[**2128-11-2**] 08:19AM BLOOD WBC-9.0 RBC-4.64 Hgb-13.3* Hct-39.9*
MCV-86 MCH-28.6 MCHC-33.4 RDW-14.7 Plt Ct-304
[**2128-11-2**] 08:19AM BLOOD Plt Ct-304
[**2128-11-2**] 08:19AM BLOOD PT-13.0 PTT-27.4 INR(PT)-1.1
[**2128-11-2**] 08:19AM BLOOD Glucose-98 UreaN-13 Creat-0.8 Na-144
K-4.6 Cl-103 HCO3-35* AnGap-11
[**2128-10-29**] 05:17AM BLOOD ALT-28 AST-22 LD(LDH)-226 AlkPhos-75
TotBili-0.5
[**2128-11-2**] 08:19AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.3
[**2128-10-28**] 04:01PM BLOOD VitB12-845 Folate-17.1
[**2128-10-30**] 02:20PM BLOOD %HbA1c-5.9
[**2128-10-30**] 12:25AM BLOOD Triglyc-192* HDL-23 CHOL/HD-8.3
LDLcalc-129
[**2128-11-2**] 02:30PM BLOOD Type-ART pO2-64* pCO2-63* pH-7.38
calTCO2-39* Base XS-8
[**2128-11-2**] 02:30PM BLOOD Lactate-1.4
[**2128-11-4**]: INR 1.1
CXR - [**11-2**]:
FINDINGS: In comparison with the study of [**10-31**], there is little
overall
change. Continued moderate cardiomegaly with mild engorgement of
pulmonary
vessels.
Progressive clearing of the left basilar atelectasis and
effusion. Elevation
of the right hemidiaphragm persists with atelectatic streaks in
the right
lower zone.
ECHO: [**10-28**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is normal free wall contractility.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Trace aortic regurgitation is seen.
There is moderate/severe mitral valve prolapse. There is partial
mitral leaflet flail. An eccentric, anteriorly directed jet of
severe (4+) mitral regurgitation is seen. There is no
pericardial effusion.
Brief Hospital Course:
Atrial fibrillation: Apparently new onset since [**2128-10-14**],
however his most recent ECG prior to this was in [**2119**]. Also pt
is a poor historian. This was likely precipited by his CHF
exacerbation. After a TEE revealed no clot, he was DC
cardioverted. He was rhythm control with an amiodarone load and
rate controlled with metoprolol. He was anticoagulated with
heparin gtt (CHADS 2, note unclear h/o CVA), and once he was
determined not to be a current surgical candidate bridging with
warfarin was undertaken. Titrate to INR 2.0 - 3.0.
.
Decompensated diastolic/systolic LV dysfunction: On presentation
at OSH, nearly euvolemic here. The exact etiology of the
exacerbation was not known. The most concerning precipitant is
worsening mitral regurgitation, although may be precipitated by
dietary or medication noncompliance or gut edema and poor
absorbtion. TTE showed preserved systolic function. Given his
severe MR there is a component of systolic dysfunction as well
given his EF<60. No baseline TTE was available to determine
progression of his LV dysfunction. His weight decreased by aprx
30 lb with furosemide gtt, and he was stabilized on his diuresis
regimen with furosemide 60mg po QD. Afterload reduction with a
goal SBP<120 was acheived with BB and ACEI (lisinopril). There
was some element of Co2 retention with sedation, normalized now.
As goal O2 sat is 88-90%, pt was weaned off O2 on day of
discharge.
.
Mitral regurgitation: Most likely this is a chronic process. A
history of RHD is not reported. No evidence of ischemic disease
at OSH to suggest acute MR [**First Name (Titles) 767**] [**Last Name (Titles) 8546**] mm rupture, but he has
not been evaluated in past. TEE shows no intracardiac
thrombus. TEE revealed partial posterior mitral leaflet with
severe eccentric mitral regurgitation. Patient was seen by CT
surgery and deemed not to be a candidate at this time given AMS,
hypercarbia, deconditioning. Dr. [**First Name (STitle) **] was contact[**Name (NI) **] and he
decided to postpone Cardiac Catheterization until a time more
proximal to his surgery. We will look into the mitral valve
clip placement trial as a possible therapeutic alternative,
though this was not immediately obvious as an option.
.
Preventative Medicine- His Lipid panel revealed(TC-190, LDL-130,
TG-192, HDL??????23) His A1C-5.9 was.
.
Delirium: Most evenings Mr [**Known lastname 12667**] became disoriented and
occasionally combative in the setting of acute illness. Likely
ICU delirium vs. toxic metabolic cause exacerbated by sundowing.
Mr [**Known lastname 12667**] [**Last Name (Titles) 53183**] poorly to zydis. Per sister, patient is
independent at baseline. We attempted to regulate his sleep and
wake cycle with seroquel QHS. RPR, B12, folate were all WNL.
.
Medications on Admission:
home meds confirmed with outpt pharmacy:
metoprolol succinate 50 mg daily
furosemide 40 mg twice daily
diltiazem 240 mg daily
20 meq KCL Po daily
- on transfer
amio ggt 20cc/hr
lopressor 5 mg q4 IV
heparin gtt
lasix 20 mg gtt
digoxin 250mcg IV daily
aspirin 325mg po
acetazolamide 250 [**Hospital1 **]
colace 100mg [**Hospital1 **]
omeprazole 40mg daily
Potassium
miconazole topical TID
insulin SS
albuterol/ipratropium nebs QID
reglan prn
Ativan prn
bisacodyl prn
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
2. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) in D5W Intravenous
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: TITRATE TO INR 2.0 - 3.0.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
7. Lamisil AT 1 % Cream Sig: One (1) Topical twice a day.
8. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for aggitation.
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing. vial
16. Outpatient Lab Work
Please check INR daily until > 2.0
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Acute on Chronic Diastolic congestive Heart Failure
Atrial fibrillation with rapid ventricular response
Acute Delerium
Mitral Regurgitation
Chronic Obstructive Pulmonary Disease
Onychomycosis and Tinea Pedis
Hypertension
Discharge Condition:
Alert, oriented x2, delerium is clearing
1 assist to chair, able to take a few steps.
Discharge Instructions:
You had an acute exacerbation of your congestive heart failure
and needed to be treated with Furosemide intravenously and with
increased pill doses. Weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet. You also had atrial fibrillation, an
irregular heart rhythm that increases your risk of stroke. You
were started on coumadin to prevent strokes and will stay on a
heparin IV drip until the coumadin is therapeutic. You also
became delerious in the hospital because you were sick. This
should clear slowly once you get better.
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 8577**] Date/Time: Please make an
appt after you get out of rehabilitation
.
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] A. Phone: [**Telephone/Fax (1) 23882**] Date/Time: Monday [**12-13**]
at 10:30am.
Completed by:[**2128-11-4**] | [
"42731",
"4280",
"4240",
"496",
"4019",
"V1582"
] |
Admission Date: [**2132-10-7**] Discharge Date: [**2132-10-14**]
Date of Birth: [**2054-12-31**] Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
sudden onset dyspnea
Major Surgical or Invasive Procedure:
Intubation x2 days;
History of Present Illness:
Mr. [**Known lastname 5057**] is a 77yo M with HTN, HL, COPD, and newly diagnosed
NSCLC , now s/p his first round of chemotherapy. He was
transferred to the [**Hospital1 18**] ED in the midst of a RBC transfusion
when he developed sudden shortness of breath that was
interpreted as a possible transfusion reaction.
.
He appears to have severe COPD caused by an extensive smoking
history. He has poor exercise tolerance which has only worsened
in the preceding months. Any exertion, including walking down
the street, can cause increased RR and profound SOB. Albuterol
can help stop these episodes. He has been pursed-lip breathing
for years. He recently underwent TTE evaluation of his exercise
intolerance, at which point a relatively large pericardial
effusion with tamponade physiology was seen. He was admitted to
the CCU [**9-2**]- [**9-6**] and underwent pericardiocentesis, which
revealed malignant cells. He recently underwent his first chemo
session with taxol for NSCLC. His oncologist is Dr. [**Last Name (STitle) 349**] at
[**Location (un) 2274**].
.
His fatigue and poor exercise tolerance persisted. He was found
to be anemic to 25 and subsequently was brought to 7 [**Hospital Ward Name 1826**]
for blood transfusion. Midway through the transfusion, he
developed worsening SOB and increased RR. He thinks this episode
was similar to his usual bouts of breathlessness, and he
admittedly was upset with how long the transfusion was taking.
Fearing a transfusion reaction, he was brought to the [**Hospital1 18**] ED
for further evaluation.
.
In the ED, he was found to be tachycardic and tachypneic.
Received 20mg IV lasix and underwent BiPAP trial, which was
poorly tolerated. Of note, he continued to saturate in the
upper90s on 3-4LNC, though remained tachypneic. A bedside echo
was done which showed no pericardial effusion per the ED read.
He was transferred to the MICU for concern of increased WOB. VS
prior to transfer were 97.9 108 150/80 36 99/4L.
.
On arrival to the MICU, his intial VS were 96.5, 107, 153/63, 95
3LNC. He continues to purse-lip breath. He describes frequent
episodes similar to his breathlessness on transfusion, which
often pass after coughing or spitting. He otherwise feels well
aside from fatigue. He notes no recent couging or cold-like
smpyotms, no sore throat, fevers, chills, chest pains or
pressure. He has lower extremity edema but no PND, orthopnea. No
recent F/C. In the midst of our interview, he had the urge to
urinate and abruptly stood to use his urinal- he developed
respiratory distress with saturations dipping to the 80s and
tachypnea to 50. This episode resolved with supplemental 02. He
felt it was similar to the events surrounding his infusion.
.
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:
- Non-small cell lung cancer
- squamous cell carcinoma, s/p MOHS
- colonic polyps, last colonoscopy 1 year ago
- COPD
- gastritis
- h/o gout
- h/o nephrolithiasis
- hypertension
- Hyperlipidemia
Social History:
Lives with his wife in [**Location (un) **]. Retired hardware store
owner. Has two boys, both live in [**State **], and one
grandson.
- Tobacco history: 97.5 pack-year history, still smokes 1.5 ppd
- ETOH: 1 glass of wine/night
- Illicit drugs: denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death
- Mother: chronic leukemia, died at age 89
- Father: h/o MI, pancreatic cancer, died at age 69
Physical Exam:
Admission Exam:
Vitals: 96.5, 107, 153/63, 95 3LNC
General: Alert, oriented, pursed-lip breathing in the 30s
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse wheezing heard throughout anterior and posterior
lung fields. Fair air movement. No crackles or rhonchi.
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Abdominal
musculature used in exhalation.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
At the time of his discharge, the patient's vital signs were
stable and he had O2 sats of 96% on 2L NC. While he continued
to have wheezes with fair air movement on lung exam, there were
no basilar crackles. THere was no edema or elevation of the
JVP. The Foley had been removed.
Pertinent Results:
Admission Labs:
[**2132-10-7**] 08:23PM URINE HOURS-RANDOM UREA N-679 CREAT-97
SODIUM-71 POTASSIUM-81 CHLORIDE-86
[**2132-10-7**] 08:23PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2132-10-7**] 08:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2132-10-7**] 08:23PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2132-10-7**] 08:23PM URINE GRANULAR-2* HYALINE-14*
[**2132-10-7**] 08:23PM URINE MUCOUS-RARE
[**2132-10-7**] 06:36PM LACTATE-1.3
[**2132-10-7**] 06:30PM GLUCOSE-124* UREA N-30* CREAT-1.5* SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17
[**2132-10-7**] 06:30PM estGFR-Using this
[**2132-10-7**] 06:30PM LD(LDH)-395* CK(CPK)-115 TOT BILI-0.8
[**2132-10-7**] 06:30PM cTropnT-1.00*
[**2132-10-7**] 06:30PM CK-MB-5 proBNP-[**Numeric Identifier 91421**]*
[**2132-10-7**] 06:30PM IRON-83
[**2132-10-7**] 06:30PM WBC-3.2*# RBC-2.79*# HGB-9.1*# HCT-25.2*#
MCV-90# MCH-32.7* MCHC-36.2* RDW-20.8*
[**2132-10-7**] 06:30PM NEUTS-22* BANDS-2 LYMPHS-47* MONOS-19* EOS-7*
BASOS-1 ATYPS-0 METAS-0 MYELOS-2* NUC RBCS-3*
[**2132-10-7**] 06:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-1+ SCHISTOCY-2+
BITE-1+ ACANTHOCY-1+
[**2132-10-7**] 06:30PM PLT SMR-LOW PLT COUNT-132*
[**2132-10-7**] 06:30PM PT-17.8* PTT-26.5 INR(PT)-1.6*
Notable Labs:
[**2132-10-9**] 05:15AM BLOOD FDP-40-80*
[**2132-10-7**] 06:30PM BLOOD cTropnT-1.00*
[**2132-10-8**] 04:41AM BLOOD CK-MB-6 cTropnT-0.99*
[**2132-10-8**] 05:24PM BLOOD CK-MB-5 cTropnT-0.65*
[**2132-10-7**] 06:30PM BLOOD calTIBC-257* Hapto-<5* Ferritn-590*
TRF-198*
[**2132-10-7**] 06:36PM BLOOD Lactate-1.3
EKG [**2132-10-7**]:
Sinus tachycardia. Left axis deviation. Right bundle-branch
block. Probable small R waves in leads II, III and aVF but
consider prior inferior myocardial infarction. ST-T wave
abnormalities. Low precordial voltage. Compared to the previous
tracing of [**2132-9-3**] the rate is faster. ST-T wave abnormalities
are more prominent. Precordial voltage is less prominent.
Clinical correlation is suggested
CXR [**2132-10-7**]:
1. Moderate enlargement of the cardiac silhouette, similar
compared to the
prior PET-CT.
2. Dilated and tortuous ascending thoracic aorta.
3. Patchy opacities within the lung bases, which could reflect
atelectasis, infection, or aspiration.
4. Known spiculated nodule in the right upper lobe is better
appreciated on the recent PET CT.
TTE [**2132-10-8**]:
The left atrium is elongated. The right atrium is markedly
dilated. The estimated right atrial pressure is 5-10 mmHg. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is mild global left ventricular hypokinesis (LVEF = 40-45 %).
Right ventricular chamber size is normal. with borderline normal
free wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**1-13**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-13**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a very small
pericardial effusion.
IMPRESSION: Mild global left and right ventricular hypokinesis.
Mild to moderate mitral regurgitation. Mild to moderate aortic
regurgitation. Very small pericardial effusion. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2132-9-6**],
biventricular function is now impaired. Valvular regurgitation
is now apparent (previous study was focused). Pulmonary
hypertension is identified.
.
Labs on Discharge:
[**2132-10-14**] 09:45AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.8* Hct-31.2*
MCV-99* MCH-31.2 MCHC-31.6 RDW-20.8* Plt Ct-135*
[**2132-10-14**] 09:45AM BLOOD Plt Ct-135*
[**2132-10-14**] 09:45AM BLOOD Glucose-131* UreaN-45* Creat-1.3* Na-143
K-3.7 Cl-99 HCO3-34* AnGap-14
[**2132-10-14**] 09:45AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 5057**] is a 77yoM with COPD, HTN, HLD, and a recent
hospitalization for cardiac tamponade who presents from [**Hospital Ward Name **]
7 transfusion unit with acute SOB during transfusion.
1. ACUTE HYPOXIC RESPIRATORY FAILURE:
--PNEUMONIA and ACUTE SYSTOLIC CHF: He developed acute shortness
of breath early into his blood transfusion which he was
receiving for anemia. Transfusion reaction/TRALI was initially
suspected though he lacked severe pulmonary edema or hypoxia to
support this diagnosis. He was admitted to the MICU due to
apparent increased WOB, and was briefly tried on BiPAP in the ED
despite normal saturations. Tamponade was ruled out with US in
ED. He initially was stable on room air with saturations in the
90s upon admission to the ICU. He related numerous similar
episodes of shortness of breath at home and related a
progressive worsening of his overall respiratory status and
exercise stamina over the preceding months. His CXR showed mild
edema and RLL haziness. Widespread wheezing prompted treatment
for COPD exacerbation. He decompensated quickly in the unit
after getting agitated during a foley adjustment. He
desaturated to the 70s-80s and had an increased WOB refractory
to nebs, lasix, and NRB. He was urgently intubated. The cause
of his decompensation was felt to be multifactorial. He had a
trop of 1.00 on admission with flat CK/MB, but new
LAD-distributed TWI on EKG, and new onset systolic dysfunction
with EF to 40-45% on TTE (new since last month). A cardiac
event could have potentially caused his deterioration and CHF
exacerbation. Pneumonia was possible based on his RLL
infiltrate, and he was treated for HCAP with
vanco/cefepime/levaquin. Sputum culture revealed commensal resp
flora and sparse GNR. He was started on nebs and steroids for
possible COPD exacerbation as well,though these were quickly
tapered due to suspicion for more of a CHF etiology. He was
aggressively diuresed. He was extubated on [**2132-10-9**] and
transfered to the floor on [**2132-10-10**].
.
On the floor he was initially saturating in the 90's on 4L NC.
He continued to be diuresed gently with PO and occasional IV
lasix. His oxygen was weaned as tolerated with a goal of 02 sat
of 92%. His steroids were discontinued on [**2132-10-13**] as the
etiology of his SOB was thought to be related to pulmonary edema
and a possible pneumonia rather than a COPD exacerbation. His
vancomycin was discontinued based on sputum data and cefepime
and levaquin were continued until further speciation was
available. His nebulizers were continued throughout his hospital
stay. On the day prior to discharge, cefipime was discontinued
as the patient had remained afebrile and without leukocytosis;
prednisone was also discontinued since COPD flare appears to not
have been the primary etiology of SOB and his symptoms were
resolving. PT was consulted and worked with the patient on
improving functional status. He was discharged home with home
PT services, home 02, and cardiac telemonitoring.
.
2)NSTEMI: His troponin elevation to 1.00 is without any similar
MB or CK elevation. He had some nonspecific lateral T wave
changes, but no chst pain or pressure to suggest ACS. TTE
revealed new onset systolic dysfunction with EF 45-50%.
Cardiology was consulted, who felt that the chemotherapy
(taxol/cisplatin) is not likely to blame and that he had a
recent MI. Based on EKG and echo data, there was a possible
partial occlusion in the LAD and that the patient may benefit
from elective cathetrization. However, based on the absence of
symptoms and the comorbidities in the patient, oncology,
medicine and the patient's family were in agreement with medical
management. On [**2132-10-12**] the patient had an 8 beat run of
v-tach. An EKG was essentially unchanged and troponins showed a
continued downward trend.
.
3. ANEMIA: HCT to 25 of unclear source, though inflammatory
disease from malignancy or myelosupression from chemo are both
possible. Though his hematrocrit trended downwards in the days
prior to discharge, a transfusion was not thought to be
necessary by cardiology (goal 25).
.
4. NON SMALL CELL LUNG CANCER: currently undergoing taxol chemo;
will resume as outpatient. Atrius oncology service followed
while the patient was in house.
5. HYPERTENSION: The patient had recently been taken off his
dose of 20 mg linisnopril QAM due to low blood pressures. Based
on his new diagnosis of CHF, lisinopril was restarted at a dose
of 10 mg QAM; his blood pressures remained stable with systolics
greater than 110 while in house.
.
6. GOUT: Allopurinol and colchicine were continued, this was not
an active issue on this admission.
Medications on Admission:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation q4-6 hours as needed for SOB, wheezing.
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Spray Inhalation twice a day.
4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Capsule Inhalation once a day.
Disp:*30 capsules* Refills:*2*
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-13**] puff Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
8. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Home Oxygen
1-4 liters per minute continuous oxygen via nasal cannula [**Male First Name (un) **]:
99 months
Diagnosis: COPD
11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every
other day for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Congestive Heart Failure, Possible Pneumonia, COPD, Non-Small
Cell Lung Cancer, Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(walker).
Discharge Instructions:
Dear Mr. [**Known lastname 5057**],
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the medical ICU after presenting to the emergency
department for acute onset shortness of breath during a blood
transfusion. A reaction to the blood transfusion itself was
ruled out. A chest xray showed possible signs of a pneumomia and
you were started on broad spectrum antibiotics. It is possible
that yoru COPD was contributing to your shortness of breath and
you were also given a steroid as well as your usual inhalers.
In the MICU you had a second acute episode of shortness of
breath that was not responsive to oxygen. Because of your
worsening respiratory status you were intubated (given a
breathing tube). Laboratory results and an EKG suggested that
you may have had a heart attack prior to the hospitalization.
An echo cardiogram showed that you had a new onset of congestive
heart failure (CHF). It is likely that your shortness of breath
was due to too much volume backing up in your lungs. You were
given lasix to help reduce the volume in your lungs and your
respiratory status improved to the point that you were extubated
(breathing tube was removed) two days after you were intubated.
Cardiology was consulted to help with your care and suggested
the possibility of a cardiac cathetrization to look at the
vessels of your heart. However, along with your oncolgy team,
it was determined to be best to try to manage your heart disease
with medical management.
Due to your continued improvement you were transferred to the
general medical floor where we continued to monitor your
respiratory status and give you lasix to manage your fluid
balance. Your steroids were stopped on the medical floor and the
medicines for your pneumonia were narrowed to treat the most
likely organism. Your regular inhalers were continued.
We followed your blood counts throughout your stay and it was
not deemed necessary to transfuse additional blood at this time.
You will return home with home nursing, oxygen, and physical
therapy services. You should keep your oxygen saturation bewteen
88-92% and should use 3L of oxygen when active. You will also
have cardiac telemonitoring to assist with monitoring your daily
weights and blood pressures. The results of this will
automitically be sent to Dr.[**Name (NI) 17793**] office.
You should resume the medicines you were previously taking at
home with the following changes:
START: lisinopril 10 mg QD (daily)
START: lasix 20 mg PO (by mouth) QD
START: atorvastatin 80 PO QD
START: Spiriva 1 puff [**Hospital1 **] (twice daily)
CONTINUE: Levofloxacin 750 mg x1 dose ([**10-16**])
Followup Instructions:
Please follow up with the appointments below after your
discharge from the hospital:
Name: [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **], NP
Specialty: Internal Medicine
When: Tuesday [**10-21**] at 9:30am
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**]
Phone: [**Telephone/Fax (1) 17530**]
Dr. [**Last Name (STitle) **] is out of the office next week so you will see
his nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **] at this visit.
Name: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**], MD
Specialty: Hematology/Oncology
When: Thursday [**10-23**] at 1:30p
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
Name: [**Doctor First Name 30513**] [**Doctor First Name 88276**], PA
Specialty: Cardiology
When: Wednesday [**10-29**] at 11:30am
Location: [**Hospital1 641**]
Address: [**Hospital1 **], [**University/College **], [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 72622**]
You will see Dr. [**Last Name (STitle) 91422**] physicians assistant [**First Name5 (NamePattern1) 30513**] [**Last Name (NamePattern1) 88276**] at
this visit.
Completed by:[**2132-10-15**] | [
"41071",
"51881",
"4019",
"41401",
"4280",
"2724"
] |
Admission Date: [**2141-2-23**] Discharge Date: [**2141-3-2**]
Date of Birth: [**2063-3-10**] Sex: M
Service: CARDIOTHOR
The anticipated date of discharge is [**2141-3-3**]. This
dictation is done for the Cardiothoracic Service.
REASON FOR ADMISSION: The patient is a postoperative admit
directly to the Operating Room on [**2-24**] for an aortic
valve replacement and coronary artery bypass graft. The
patient was seen on [**12-16**] during a hospital admission
for a cardiac catheterization by the Cardiothoracic Surgery
Service and his surgery was scheduled for [**2-24**] at that
time.
At the time that the patient was initially seen, his history
and physical is as follows:
CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: Asked by
Dr. [**Last Name (STitle) **] to see this 77 year old man with a history of
aortic stenosis. The patient is morbidly obese with long
standing hypertension and a history of only mild dyspnea on
exertion without chest pain. No rest symptoms. The patient
with severe bilateral venous stasis currently on diuretics.
No history of congestive heart failure per the patient.
Recently, he stopped his diuretics.
Serial echocardiograms have shown increasing severity of
aortic stenosis. He was admitted to [**Hospital1 190**] in [**2140-1-13**] for a cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Aortic stenosis.
3. Morbid obesity.
4. Tobacco use.
5. Venous stasis ulcers.
PAST SURGICAL HISTORY:
1. Status post left cataract surgery.
2. Status post tonsillectomy.
3. Status post varicocele surgery.
MEDICATIONS:
1. Lisinopril 40 mg q. day.
2. Spironolactone 25 mg q. day versus twice a day.
ALLERGIES: Norvasc, which causes increasing lower extremity
edema.
SOCIAL HISTORY: Tobacco use is remote; discontinued 40
years ago. Positive ETOH use; decreased per report by wife
over the last four years.
PHYSICAL EXAMINATION: Height is 5'[**47**]"; weight 310 pounds.
Heart rate 68 and in sinus rhythm; blood pressure 146/60;
respiratory rate 20; O2 saturation 99% on room air. In
general, an obese man with severely draining venous stasis
ulcers in no acute distress. HEENT: Anicteric, noninjected.
Extraocular movements intact. Neck is supple with no jugular
venous distention, no lymphadenopathy and no bruits.
Oropharynx is clear. Cardiovascular is regular rate and
rhythm with a III/VI perisystolic murmur at the left sternal
border. Lungs clear to auscultation bilaterally. Abdomen is
soft, obese, nontender. Bilateral tinea of the groins.
Extremities with bilateral venous stasis changes to just
below the knees. Ulcers with clear to green drainage on the
lateral right and medial left. Pulses: Carotids two plus
bilaterally, radial two plus bilaterally, femoral - left is
the catheterization site; the right is two plus. Popliteal
two plus bilaterally dorsalis pedis and posterior tibial,
both two plus bilaterally. Neurological: Motor and sensory
is grossly intact. Cranial nerves II through XII grossly
intact.
LABORATORY: Data is white blood cell count 9.3, hematocrit
33.9, platelets 288. Sodium 136, potassium 4.7, chloride
100, carbon dioxide 30, BUN 23, creatinine 1.1. INR was 1.3.
EKG was sinus rhythm with left ventricular hypertrophy,
nonspecific ST-T wave changes in leads 5 and 6.
Echocardiogram with concentric left ventricular hypertrophy,
severely dilated left atrium with an ejection fraction of
75%. Mild resting LVOT obstruction.
Catheterization showed 50% left main, 20% ostial right
coronary artery, 40% diagonal, aortic valve area 1.3
centimeters squared.
The patient was discharged to home following his
catheterization for further treatment of his venous stasis
ulcers and an appointment with Vascular Surgery for follow-up
regarding lower extremity ulcers.
HOSPITAL COURSE: He returned on [**2-23**] where he was
admitted directly to the Operating Room. At that time, he
underwent an aortic valve replacement with a #23 tissue valve
and coronary artery bypass graft times one with the left
internal mammary artery to the left anterior descending.
Please see the Operating Room report for full details.
The patient tolerated the operation well and was transferred
from the Operating Room to the Cardiothoracic Intensive Care
Unit. At the time of transfer, the patient had a heart rate
of 91. He was a-paced with a mean arterial pressure of 65
and a central venous pressure of 10. He had Levophed at 0.12
mics per kg per minute and Propofol at 20 mics per kg per
minute.
In the immediate postoperative period, the patient
experienced a labile blood pressure. A transesophageal
echocardiogram was performed at the bedside which showed some
systolic anterior motion. His Levophed and Neo-Synephrine
were weaned to off and he was given volume. The patient did
well hemodynamically following these maneuvers.
Then, his anesthesia was reversed. He was weaned from the
ventilator and successfully extubated. He remained
hemodynamically stable throughout the night of his surgery
and on postoperative day one
DICTATION ENDS
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2141-3-2**] 18:39
T: [**2141-3-2**] 21:01
JOB#: [**Job Number 22266**]
| [
"4241",
"5180",
"41401",
"4019"
] |
Admission Date: [**2152-5-3**] Discharge Date: [**2152-5-25**]
Date of Birth: [**2086-8-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin / Iodine-Iodine Containing / Coreg /
Rosuvastatin / metronidazole / alendronate sodium / simvastatin
/ Ezetimibe / risedronate sodium / Vitamin D
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Anticoagulation with heparin for colonoscopy
Major Surgical or Invasive Procedure:
Elective colonoscopy on [**2152-5-5**] (with MAC)
Colonoscopy on [**2152-5-9**]
Colonoscopy on [**2152-5-12**]
History of Present Illness:
65 yo F pt with hx of rheumatic heart disease s/p mitral valve
replacement ([**Doctor Last Name 1395**]-[**Doctor Last Name **] metallic prosthesis) [**2104**],
complicated by diastolic dysfunction, mild stenosis,paravalvular
leak prone to occasional heart failure and mild hypotension
admitted for an elective colonoscopy with need for MAC
anestheisa and heparin bridging. Pt has never had a colonoscopy.
She recently had a (+) blood test for colon cancer last week,
done by Quest (Colovantage). Patient denies any recent weight
loss, night sweats, fevers, chills, melena, BRBPR, diarrhea,
constipation. Patient has mild SOB at baseline. GI are planning
to perform colonscopy on [**Year (4 digits) 2974**]. Pt's last dose of coumadin was
Sunday. She will also need SBE prophylaxis as per her primary
cardiologst (although guidelines don't say it is necessary, he
recognizes this and would like to err on the side of caution).
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, chest pain or tightness, palpitations. Denied
nausea, vomiting, or abdominal pain. No recent change in bowel
or bladder habits. No dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
1. Rheumatic heart disease status post mitral valve replacement
with a [**Doctor Last Name 1395**]-[**Doctor Last Name **] metallic prosthesis in [**2104**].
2. Congestive heart failure - ECHO in [**6-28**] EF 50-55% mitral
insuffiency
3. Chronic atrial fibrillation.
4. Hypertension
4. HLD
5. Carotid stenosis
6. Vitamin D deficiency
7. Borderline diabetes, not on medications.
8. Anemia, on iron supplements.
9. Spontaneous hemarthroses in right knee in [**2150-7-21**], [**2150-8-19**],
[**10-27**]
10. Osteoarthritis of the knees
11. Migraine headaches
12. Allergic rhinitis
.
Past Surgical History:
1. Mitral valve replacement [**2104**]
2. CCY for gallstones [**2108**]
3. Tubal ligation in [**2110**]
Social History:
The patient lives with her husband. She is a nonsmoker (she
quit
smoking in [**2114**]). She does not drink alcohol. Denies IVDU.
Family History:
FHx negative for premature coronary artery disease or sudden
cardiac death. She does mention that one of her uncles had a
heart condition at an older age as well as her mother who had a
valve problem in her 50s, but she eventually passed away at the
age of 96.
Physical Exam:
Physical Exam:
Vitals: T: 96.3 BP: 119/62 P: 80 irreg irreg; R: 22 O2: 96 RA
General: Alert, oriented, no acute distress. Pleasant woman.
HEENT: Sclera anicteric, MMM, oropharynx clear skin warm smooth
and dry.
Neck: supple, JVP elevated with prominent V wave height 12.5 cm.
Carotids 2+ equal without bruit.
Chest: Clear to auscultation bilaterally, no wheezes, fine dry
atelectatic rales at both bases about 1/4 up.Left parascapular
thoracotomy scar.
CV: Irregularly irregular rate and rhythm, normal S1 + S2, Gr
[**1-23**] hololsystolic murmur loudest in midaxillary line 5th ICS, Gr
2/6 SEM at RUSB, no rubs or gallops, prominent parasternal RV
lift.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, 13 cm liver, 3 FB's below the
costal margin, pulsatile. Cholecystectomy scar.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
pedal medial malleolar and some pretibial edema.
Neuro: Normal muscle tone, moves all extremities bilaterally,
reflexes 2+ UE and LE bilaterally, toes downgoing bilaterally.
CNI: not tested, CNII: PERRLA 4mm to 2mm bilaterally. CNIII, IV,
VI: EOMI. CN VII: Facial muscles intact. CN VIII: Intact
bilaterally CNIX,X: Palate elevates symmetrically. CNXI: Intact
CNXII: Tongue protrudes midline. Gait: normal.
Pertinent Results:
Admission labs:
[**2152-5-3**] 09:45PM WBC-3.2* RBC-4.03* HGB-11.6* HCT-34.8* MCV-87
MCH-28.9 MCHC-33.4 RDW-14.4
[**2152-5-3**] 09:45PM PT-21.1* PTT-150* INR(PT)-1.9*
[**2152-5-4**] 05:15AM BLOOD Glucose-86 UreaN-38* Creat-1.2* Na-142
K-4.3 Cl-106 HCO3-26 AnGap-14
[**2152-5-4**] 05:15AM BLOOD ALT-31 AST-52* LD(LDH)-340* AlkPhos-117*
TotBili-1.0
[**2152-5-4**] 02:55AM BLOOD proBNP-2791*
[**2152-5-4**] 05:15AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9 Iron-112
[**2152-5-4**] 05:15AM BLOOD calTIBC-295 VitB12-1741* Folate-GREATER
TH Hapto-<5* Ferritn-117 TRF-227
.
Imaging:
ECHO [**2152-5-4**]:
IMPRESSION: Normal left ventricular function. Ball and cage
mitral prosthesis with normal gradient and at least mild mitral
regurgitation. Dilated and hypokinetic right ventricle with
severe tricuspid regurgitation and moderate pulmonary
hypertension. Mild aortic regurgitation. Biatrial dilatation
with the right atrium being markedly dilated.
.
Splenic US [**2152-5-5**]:
FINDINGS: Transverse and sagittal images were obtained of the
spleen. The
spleen is enlarged measuring 16.2 cm. The splenic appearance is
unremarkable. No ascites is seen in the left upper quadrant.
IMPRESSION: Splenomegaly.
.
Colonoscopy [**2152-5-5**]:
Impression: Polyp in the proximal ascending colon (polypectomy)
Otherwise normal colonoscopy to cecum.
.
Colonoscopy [**2152-5-9**]:
Impression: There was blood throughout the colon making
visualization difficult. The mucosa was not examined.
There was a large blood clot in the proximal ascending colon at
the site of prior polypectomy. There was a clip buried within
the clot. The area was washed extensively but the clot could not
be removed. Biopsy forceps were used to try to remove the clot
but this was not successful. There was erythema and active
oozing seen at the superior aspect of the clot. (endoclip,
injection)
.
Colonoscopy [**2152-5-12**]:
Impression:Blood in the colon
The polypectomy site was identified by presence of clips. An
adherent clot was noted adjacent to the clips. Fresh bleeding
was noted from the base. The clot was removed by wash and
suction. A small visible vessel was noted. Three clips were
applied with successful hemostasis. 5 cc of epinephrine was
injected into the mucosa for hemostasis.
The rest of the colon was not fully examined.
Otherwise normal colonoscopy to cecum.
Polyp described as serrated adenoma requiring repeat colonoscopy
in 5 years given increased risk of finding of serrated polyp.
Discharge Labs:
Brief Hospital Course:
65 yo F pt with hx of rheumatic heart disease at age 7, s/p
mitral valve replacement ([**Doctor Last Name 1395**]-[**Doctor Last Name **] mechanical prosthesis)
[**2104**], complicated by mitral insufficiency, ? ball variance/and
or paravalvular leak, pulmonary hypertension and RV
failure,tricuspid insufficiency and normal LV function, admitted
for an elective colonoscopy with need for MAC anesthesia and
heparin bridging.
.
# Positive Colovantage test: Patient has not undergone routine
screening colonoscopy however she underwent the Colovantage
testing which came back as positive on [**2152-4-12**], indicating that
she has increased likelihood of colorectal cancer. She was
admitted for IV heparin bridge due to her mechanical valve (pt
must be anticoagulated; at high risk for thrombus) starting [**12-23**]
days after discontinuing her coumadin (stopped on [**4-30**]).
Colonoscopy performed on [**5-5**] under MAC anesthesia with removal
of a single sessile polyp in the ascending colon. Post procedure
her stay was complicated by bleeding, see below.
.
#Loose bloody stools: On [**5-7**], patient experienced loose stools
mixed with blood. Her coumadin was held, heparin initially
continued. Hct started to fall on [**5-8**] to 25 and she was given 2
units RBCs. Heparin was stopped and she was reprepped for a
colonscopy (#2). She remained hemodynamically stable. On [**5-9**], a
large clot was visualized at the polypectomy site which could
not be evacuated, so additional clips were placed along with
epinephrine. Heparin was restarted after procedure. However, on
[**2152-5-11**], patient's hct dropped to 28 and patient experienced
increased bloody stools. Patient received one more unit RBCs and
heparin was dc'd for 6 hrs. She was repreped for a repeat scope
that was done on [**2152-5-12**]. The clot was removed and more clips
were placed and epi injected. Post procedure her hct remained
stable.
.
# Mechanical Mitral Valve: Patient is s/p mitral valve
replacement ([**Doctor Last Name 1395**] [**Doctor Last Name **] valve) for mitral stenosis/atrial
fibrillation in [**2104**]. Patient was admitted for heparin bridge
for her procedure. She was given SBE prophylaxis (clindamycin
600mg IV) with her procedures. Her home coumadin was initially
restarted on [**5-5**], but it was dc'd on [**5-7**] due to bloody bowel
movements. For her bleeding episodes as stated above her heparin
was stopped at given intervals. Her coumadin was restarted on
[**2152-5-15**]. She had increasing warfarin requirement from her usual
dose of 5.5 mg with slow rise in INR until therapeutic plateau
(2.3) was reached with 8 mg of warfarin Q PM likely related to
increase in PO nutrients supplemented with Boost.
She may need less warfarin as she returns to her usual home
diet. She was bridged with heparin until [**2152-5-25**].
.
# CHF: Patient had an ECHO in [**2151-6-20**] with a EF of 50-55%
and moderate to severe tricuspid regurgitation and pulm artery
htn noted. CXR on [**2152-4-12**] performed by her cardiologist revealed
probable small left pleural effusion, no evidence of CHF; BNP
was 218 on [**2152-4-12**]. Patient presents volume overloaded with
systolic ejection murmur; repeat ECHO essentially unchanged from
[**6-/2151**], worsening pulm htn. Pro-BNP elevated to 2791 on [**5-4**].
Her home medications, including nebivolol, valsartan, and
diltiazem were discontinued in setting of bleed so that symptoms
of blood loss would not be masked. Transfusions were performed
slowly over 4 hours in order to not fluid overload. Patient was
without an oxygen requirement and clear lungs throughout the
hospitalization. In the ICU, home diltiazem was restarted and
tolerated well.
.
#Splenomegaly/pancytopenia: Patient presented with
thrombocytopenia on admission labs (plts 79); unclear etiology
(heme had low suspicion for HIT). Per outpt cardiology records,
patient's platelets were 129 on [**2152-4-12**]. Patient's anemia [**12-22**]
hemolysis from mechanical valve (LDH elevated, low haptoglobin).
Splenic ultrasound shows splenomegaly; heme will likely perform
outpt BM bx. Valsartan can be associated with leukopenia;
further investigation revealed that pt had a cough with
ace-inhibitor. No ACE or [**Last Name (un) **] was rx'd pending consultation i f/u
with Dr. [**Last Name (STitle) **]. Will also follow up with heme-onc as outpatient.
.
#Atrial fibrillation: Patient is rate controlled with diltiazem,
nebivolol; anticoagulated with heparin (was on coumadin) while
in house. During colonoscopy, pt had episode of AFib with RVR,
and required a dose of esmolol. She was transferred to the ICU
for overnight monitoring. In the ICU, home regimen of diltiazem
was restarted. On a dose of Dilt ER without beta blocker her
ambulatory HR was 120-130. Dilt ER was increased to 180 PO daily
with excellent rate control, never greater than 90. While
febrile to 99.6 on the day of discharge peak rate over 12 hrs
was 114. Patient was successfully bridged back to coumadin with
discharge INR of 2.3.
.
#Fever: the day prior to discharge, [**2152-5-24**], the patient had a
low-grade temperature to 100.4. She felt well, without cough,
diarrhea, abdominal pain or dysuria. A urinalysis was negative.
Abdomen was benign on exam and she was eating and drinking
normally. The day of disharge she had a temperature of 99.6 at
12pm. She was counseled to continue monitoring her temperature
at home and call her primary care doctor with any new symptoms.
No antibiotics were started. She has close follow-up with Dr.
[**Last Name (STitle) **].
.
#Difficult to crossmatch blood: Patient required several
transfusions and was difficult to crossmatch. Further
investigation by the blood bank revealed a new clinically
significant alloantibody, anti-E. The patient was notified of
this new finding and is to carry this information with her. A
card describing this finding will be issued by pathology.
.
# HTN: Patient is stable on her home medications. No
hypertension was recorded.
.
#Transition of care: She will need close monitoring of her INR
after discharge and follow up for blood loss. She should have a
hematocrit checked after discharge. She should also have heart
failure medications re-evaluated and restarted. Unclear why she
is on nebivolol rather than carvedilol. Some concern as to
whether Valsartan is causing pancytopenia and may want to
consider restarting ACE inhibitor instead of Valsartan. She has
a hematology/oncology appointment to evaluate her pancytopenia.
Medications on Admission:
Home Medications (reconciled with Dr. [**Last Name (STitle) **]:
Valsartan 160 mg once daily
Diltiazem 120mg once daily
Furosemide 20mg once daily
Coumadin 5.5mg daily
Nebivolol 10mg 1 tablet once daily
Iron 325 mg 1 tablet twice a day
Calcium citrate 600mg +400 iu 1 tablet twice a day
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
5. warfarin 8 mg PO once a day: Dose to be adjusted per Dr. [**Last Name (STitle) **].
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Elective colonoscopy
Secondary Diagnosis:
s/p mitral valve replacement [**Doctor Last Name 1395**] [**Doctor Last Name **] mechanical prosthesis
diastolic CHF
RV failure secondary to Pulmonary Hypertension
Mitral insufficiency
Atrial fibrillation,chronic
Transfusion reaction alloantibody Anti E.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a planned colonoscopy to follow up a
positive Colovantage colon cancer screen. You required heparin
while you were not taking Coumadin because of your mechanical
mitral valve. During your colonoscopy on [**2152-5-5**] a polyp was
removed and you started to bleed from your colon. This required
two additional colonoscopies [**2152-5-9**] and [**2152-5-12**] to stop the
bleeding. After the bleeding stopped, you were able to start
your Coumadin again [**2152-5-15**] to get you back close to your goal
INR 2.5-3.5. You were very patient and we were able to get you
close to you goal INR 2.3 with your Coumadin before leaving the
hospital. You will need to have you INR closely followed. You
should have your INR checked [**2152-5-26**] at 1pm with Dr. [**Last Name (STitle) **] and
continue follow up with him.
Your temperature was slightly elevated at 100.4 on [**2152-5-25**], but
you had no symptoms of feeling unwell. It will be important for
you to continue to check your temperature. If you begin to feel
unwell please follow up with your primary care doctor or nearest
emergency department.
.
Please go to all your follow up appointments. If you see any
evidence of bleeding please contact your primary care physician
immediately or go to your nearest ED.
Also you have congestive heart failure that causes you to hold
on to water in your legs. If you notice increased swelling in
your legs or an increase in your weight please contact your
primary care doctor or cardiologist. You nebivolol and valsartan
were stopped. Please discuss with your cardiologist what
medications you should resume for your congestive heart failure.
Please follow-up with hematology for follow-up of your low blood
counts and possible bone marrow biopsy.
.
Changes were made to your medications. Please:
- STOP Bystolic (nebivolol)
- increase diltiazem to 180mg daily
- increase warfarin (Coumadin) to 8mg daily (4 x 2mg tablets)
- STOP valsartan for now. Dr. [**Last Name (STitle) **] may want to restart this
medication in the future.
Followup Instructions:
Name: [**Last Name (LF) 7726**],[**First Name3 (LF) 177**] A.
Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 7728**]
Appt: [**Last Name (LF) 2974**], [**4-26**] at 1pm
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2152-6-7**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], 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:[**2152-5-25**] | [
"V5861",
"42731",
"4168",
"4019",
"4280"
] |
Admission Date: [**2154-11-14**] Discharge Date: [**2154-11-24**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Erythromycin Base / Lactose Intolerance
Attending:[**First Name3 (LF) 11217**]
Chief Complaint:
fever and cough
Major Surgical or Invasive Procedure:
Left Midline placed [**11-22**]
History of Present Illness:
Ms. [**Known lastname 31102**] is a [**Age over 90 **] yo with h/o COPD and aspiration pneumonia
who was noted to have a cough over past several weeks. She saw
her PCP and was started on mucinex and robitussin. She was doing
well until day of admission at 1 pm when she had the onset of
nonbloody nonbilious emesis x 3. Her home nurse noted a fever to
101.2, HR of 140, and that the patient's "lungs weren't so good"
today. For this reason, the patient was brought in by ambulance.
Here, the patient was found to be satting 97%4L and low 90s on 2
L. Her baseline is 93% on 2L). CXR showed RLL infiltrate. Of
note, she has been at baseline wit her activities, helping with
cooking even on the day prior to admission.
.
In the ED, the patient was given Ipratropium Neb, Albuterol
0.083% Neb, CefTRIAXone 1g, Metronidazole 500mg, and
MethylPREDNISolone 125mg for ? COPD. Blood and urine cultures
were obtained.
.
ROS: no chest pain, dysuria, or frequency. + weight loss
Past Medical History:
1) Diabetes mellitus (Hgb A1C 5.8% in [**2-8**])
2) Frequent UTI
3) Gastroesophageal reflux disease
4) S/p CVA w/residual mild R hemiparesis
5) Osteoporosis
6) Mild cognitive impairment
7) Depression/Anxiety
8) Osteoarthritis
9) Hypothyroidism (last TSH 2.8 in [**11-7**])
10) Chronic diarrhea
11) COPD, on night O2 at home (FEV1 0.88 (73% pred), FVC 1.2,
elevated EV1/VC ratio in [**1-6**]), no prior intubations, was
placed on steroid taper at last admission in [**3-11**].
Social History:
Smoked 2ppd until [**2131**]. [**2-4**] glass of wine 3-4x/week. Worked as a
secretary. Independent with ADLs, not IADL. Has 24 hour
caretaker. [**Name (NI) **] (daughter) is the Healthcare proxy. Pt
confirmed FULL CODE.
Family History:
non-contributory
Physical Exam:
Vitals: T96 BP 150-180/62-69 P 68-73 R 20 sat 97%RA, 93%4LNC
Gen: elderly cachectic female sitting in bed at 60 degrees,
sleepy but awakens with difficulty, NAD
HEENT: NCAT, sclerae anicteric/noninjected, EOMI, PERRL, OP
clear, uvula midline, dry MM
Neck: JVP 8 cm, no HJR, no LAD, no thyromegaly, no carotid
bruits
CV: distant heart sounds, nl S1/S2, no m/r/g noted
Lungs: decreased breath sounds at the bases, otherwise CTA
Ab: soft, NTND, NABS, no HSM by percussion, no rebound or
guarding
Extrem: wwp, no c/c/e
Neuro: MAFE
Skin: no rashes
Pertinent Results:
[**2154-11-14**] 08:25PM BLOOD WBC-24.5*# RBC-3.75* Hgb-12.6 Hct-36.8
MCV-98 MCH-33.6* MCHC-34.3 RDW-14.9 Plt Ct-350
[**2154-11-17**] 04:11AM BLOOD WBC-10.6 RBC-3.19* Hgb-10.6* Hct-31.4*
MCV-99* MCH-33.1* MCHC-33.6 RDW-15.1 Plt Ct-257
[**2154-11-22**] 08:45AM BLOOD WBC-13.5* RBC-3.86* Hgb-12.5 Hct-37.9
MCV-98 MCH-32.5* MCHC-33.1 RDW-15.4 Plt Ct-349
[**2154-11-14**] 08:25PM BLOOD Neuts-88* Bands-0 Lymphs-7* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2154-11-16**] 06:25AM BLOOD Neuts-93.5* Bands-0 Lymphs-4.8*
Monos-1.4* Eos-0.1 Baso-0.1
[**2154-11-16**] 06:25AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Burr-1+ Stipple-1+ Tear Dr[**Last Name (STitle) **]1+
[**2154-11-14**] 09:15PM BLOOD Glucose-210* UreaN-35* Creat-1.4* Na-140
K-5.1 Cl-105 HCO3-23 AnGap-17
[**2154-11-18**] 03:33AM BLOOD Glucose-53* UreaN-41* Creat-0.9 Na-152*
K-3.7 Cl-119* HCO3-23 AnGap-14
[**2154-11-21**] 05:20AM BLOOD Glucose-60* UreaN-31* Creat-0.9 Na-142
K-3.9 Cl-105 HCO3-25 AnGap-16
[**2154-11-15**] 11:25AM BLOOD ALT-36 AST-30 LD(LDH)-204 AlkPhos-109
Amylase-55 TotBili-0.3
[**2154-11-15**] 11:25AM BLOOD Lipase-12
[**2154-11-18**] 08:09PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-11-19**] 03:35AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2154-11-19**] 02:38PM BLOOD cTropnT-<0.01
[**2154-11-17**] 04:11AM BLOOD Calcium-7.6* Phos-1.6* Mg-2.8*
[**2154-11-15**] 12:11PM BLOOD Type-ART pO2-53* pCO2-28* pH-7.48*
calTCO2-21 Base XS-0 Intubat-NOT INTUBA
[**2154-11-18**] 12:13PM BLOOD freeCa-1.16
.
Micro:
Urine culture [**11-16**], [**11-17**] Negative
Stool culture [**11-17**] negative
Blood cultures: 10/12 [**2-6**] + Strep Pneumo sensitive to
ceftriaxone, all others negative or NGTD
.
CXR: [**11-18**] FINDINGS: There is dense consolidation in the right
lower lobe. No pleural effusions are identified. The pulmonary
vasculature is normal. The heart and mediastinal contours are
stable. Soft tissue and osseous structures are remarkable for
scoliosis. Surgical staples are present in the right upper
quadrant. IMPRESSION: Right lower lobe pneumonia.
.
CXR: [**11-21**] The heart size is normal. The aorta is unfolded.
There is a small improved right-sided layering pleural effusion.
Right basilar consolidation may represent atelectasis or
aspiration pneumonitis. Left lung field is clear. No
pneumothorax. IMPRESSION: Small stable right effusion with
right basilar consolidation which may represent either
atelectasis or pneumonia.
.
CXR: [**11-23**] FINDINGS: There is a small right apical pneumothorax,
which has decreased in size in the interval from approximately
18 mm to 11 mm of maximal visceral and parietal pleural
separation. There is no tracheal deviation or other findings
suggestive of tension physiology. There is interval clearing of
a right lower lobe opacity previously described. No further
consolidation is identified. There is no superimposed edema. A
mildly tortuous atherosclerotic aorta is again noted. The
cardiac silhouette is within normal limits for size with a mild
left ventricular configuration. There is no definite effusion.
There is a levoconcave curvature of the thoracic spine. Surgical
clips are identified in the right upper quadrant.
IMPRESSION: Right apical pneumothorax decreased in size. No
evidence of underlying tension
Brief Hospital Course:
Patient is a 90-year old female with MMP admitted for fevers and
cough, initially on the floor, transferred to the unit, and
transferred back to the floor prior to discharge.
# Cough: The patient had a history of aspiration pneumonia and
also had a history of COPD and is oxygen dependent. Due to the
location of the infiltrate on radiographs and the quick
decompensation, the clinical picture seemed to fit an aspiration
pneumonia. Blood cultures, [**2-8**], returned positive for strep
pneumoniae sensitive to ceftriaxone. She was begun on a 14-day
treatmet regimen of ceftriaxone, 1g IV to treat the pneumonia.
As regards to the COPD element of the clinical presention, the
patient was continued on advair, ipratropium, albuterol, and PO
steroids with a taper. Her steroid taper was completed on
[**11-23**].
It was also noted that the patient had a small right apical
pneumothorax on CXR noted on [**11-22**] amenable to monitoring. This
was likely secondary to a bleb bursting from her ICU stay. She
was otherwise asymptomatic. Follow up CXR showed marked
improvement in the size on [**11-23**]. She will need follow up CXR
in [**6-9**] days to assess for resolution
The day prior to discharge, the patient's white count showed
a mild elevation. A UA and urine culture were sent to ensure no
urinary tract infection was the cause. Consideration was given
to restarting an additional abx, possibly flagyl, to cover for
possible aspiration pneumonia. The urine was negative for UTI.
Blood cultures were NGTD. The patient's WBC stabilized at 14.
She remained entirely asymptomatic with no localizing signs.
However, given a low threshold for an aspiration component, we
started Flagyl 500mg PO TID x 10days ([**12-3**]). Her steroids may
also have contributed to her lymphocytosis
.
# UTI: The patient had no urinary complaints, but the UA was
positive for a UTI and her urine culture grew E-Coli, sensitive
to ceftriaxone. She is being treated appropriately for this.
.
# ARF: Initially, the patient's renal function was impaired with
a slight elevation in her creatinine level, which was up from
baseline. These levels resolved with some fluid boluses and
remained steady throughout her stay.
.
# Hypothyroidism: The patient was continued was continued on her
levothyroxine.
.
# Psych: As per the daughter, the patient has history of
depression and anxiety. During this stay, the patient showed
period of somnolence, including on her second stay on the floor,
which her daughter stated was somewhat normal. The patient was
continued on mirtazapine and fluoxetine and lorazepam PRN.
.
# HTN: Patient has history of hypertension, but had below normal
levels during this stay, often remaining in the high 80s and 90s
despite fluid boluses. Her ace inhibitor and beta blockade were
held initially, but when her SBPs tolerated, they were added to
her regimen.
.
# CHF: Initially, due to her underlying diastolic cardiac
dysfunction and her hypovolemic status initially, diuresis was
implemented. But once the patient's vital signs stabilized and
the her clinical illness began to improve, gentle diuresis was
attempted to help with her respiratory status. She can
continued to be diuresed gently as needed at rehab.
.
# TIA history: Not a clinical issue during this stay, but the
patient was continued on her aspirin.
.
# FEN/aspiration risk: Patient was placed on a nectar thickened
liquid diet for aspiration risk.
Medications on Admission:
Ipratropium Bromide Neb 1 NEB IH Q8H
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Aspirin 81 mg PO DAILY
Fluoxetine HCl 20 mg PO DAILY
GlipiZIDE 2.5 mg PO DAILY
Metoprolol 12.5 mg PO BID
Mirtazapine 30 mg PO HS
Levothyroxine Sodium 50 mcg PO DAILY
Lisinopril 2.5 mg PO QD
Lorazepam 0.5 mg PO QD
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
q6hrs:prn.
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
q4-6hrs:prn.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for perineal redness.
14. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours) for 3 days: [**11-28**] last
dose.
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO qd:prn.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO prn as needed for
fluid overload: Will need to be assessed daily.
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) INJ
Injection TID (3 times a day).
19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: To complete 10 day course (last day
[**12-3**]) for empiric coverage against possible aspiration
component of pneumonia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. Pneumonia
2. COPD
3. Pontine stroke
4. Hypothyroidism
5. Depression and anxiety requiring hospitalization
6. Hypertension
7. Diabetes mellitus II
8. CHF
Discharge Condition:
Patient was discharged to the rehab facility in stable
condition, requiring oxygen for adeqaute saturations, tolerating
PO feeds, and without fever.
Discharge Instructions:
Patient advised to return to the emergency department if she
acquires chest pain, shortness of breath, nausea, vomiting,
fevers, chills, or pain that is out of the ordinary for her.
Patient is advised to keep all follow-up appointments as
assigned.
Followup Instructions:
1. PCP [**Name Initial (PRE) 176**] 1 week. Please call for this appointment.
2. Will need to have Midline removed after assessment by a
physician and after antibiotic regimen is completed.
3. Will need follow up Chest X-Ray to re-assess for resolution
of infectious processes/pneumothorax
| [
"5070",
"496",
"4280",
"5849",
"5990",
"2760",
"2449",
"25000"
] |
Admission Date: [**2116-3-8**] Discharge Date: [**2116-3-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Infected Pacemaker
Major Surgical or Invasive Procedure:
Screw-in pacer wire placement ([**2116-3-12**])
PICC line placement ([**2116-3-13**])
TEE
Removal of pacemaker
History of Present Illness:
Patient is an 86 year old female patient with PMHx significant
for mechanical aortic valve, CHB s/p PM that was complicated by
large hematoma requiring evacuation who presents from OSH after
found to have abscess at previous hematoma site.
.
Patient was recently discharged from [**Hospital1 18**] during which she was
found to be in complete heart block. Patient had pacemaker
placed however developed large chest hematoma in setting of
being anticoagulated for mechanical valve. Patient required 9
units of PRBC and had hematoma evacuated.
.
She was discharged to nursing home on [**2-13**] and then was found to
have infected PM with abscess at previous hematoma site. At NH
her incision under her clavicle began to open and start draining
while she was having temps of 104. At OSH, she had a WBC of
[**Numeric Identifier 71077**] (69% PMNs, 17% Bands) pacemaker was removed by local
surgeon and patient was started on vanc and gent (per an ID
consult). She continues to spike temperatures and prelimanary
wound and blood cultures at OSH are growing gram + cocci in
clusters. Patient was also found to be tachycardic with HR
ranging from 114-140s. She was transferred to [**Hospital1 18**] for further
management.
Past Medical History:
CAD s/p 2-vessel CABG [**2104**]
CHB s/p PM complicated by large hematoma and evacuation
s/p [**First Name8 (NamePattern2) **] [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] in [**2104**] for AS
CHF
HTN
Diabetes
Hypothyroidism
Dementia, mild-moderate
s/p appy
s/p TAH
Social History:
Recently living in nursing home after previous discharge from
[**Hospital1 18**]
non-smoker
non-drinker
Family History:
unable to obatin from patient due to dementia
Physical Exam:
T 99.2 BP 123/55 HR 77 RR 20 Sat 95% on 5L nc
Gen: moaning, NAD
HEENT: OP clear, no scleral icterus
Neck: no carotid bruits, prominent a-waves , JVP 7cm
Chest: 5cm x 3cm x 1.5cm incision on left upper chest extending
into pectoral muscle tissue without any frank drainage or
erythema; lungs with bibasilar rales
CV: irregular, II/VI systolic murmur across precordium with
mechanical S2
Abd: mildly distended, nontender, soft, normal bowel sounds, no
HSM
Extr: 2+ DP pulses, no edema, cool
Neuro: alert, conversant, oriented to self only
Pertinent Results:
TTE ([**2116-3-11**]):
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Regional left ventricular wall motion is normal.
Left ventricular systolic function is hyperdynamic (EF>75%).
Right ventricular chamber size and free wall motion are normal.
A mechanical aortic valve prosthesis is present. The transaortic
gradient is higher than expected for this type of prosthesis. No
masses or vegetations are seen on the aortic valve but cannot be
excluded. Significant aortic regurgitation is present, but
cannot be quantified. The mitral valve leaflets are moderately
thickened. There is severe mitral annular calcification. There
is mild mitral stenosis (area 1.5-2.0cm2). 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. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
Labs:
[**2116-3-8**] 01:51AM BLOOD WBC-28.0*# RBC-3.53* Hgb-10.8* Hct-31.3*
MCV-89 MCH-30.6 MCHC-34.5 RDW-17.0* Plt Ct-271
[**2116-3-24**] 03:41AM BLOOD WBC-11.2* RBC-3.26* Hgb-10.2* Hct-29.8*
MCV-92 MCH-31.2 MCHC-34.1 RDW-16.5* Plt Ct-352
[**2116-3-8**] 01:51AM BLOOD Neuts-75* Bands-15* Lymphs-2* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2116-3-21**] 01:11PM BLOOD Neuts-92.9* Bands-0 Lymphs-4.2* Monos-2.9
Eos-0.1 Baso-0
[**2116-3-24**] 03:41AM BLOOD Plt Ct-352
[**2116-3-24**] 03:41AM BLOOD PT-80.0* PTT-52.8* INR(PT)-10.5*
[**2116-3-8**] 01:51AM BLOOD PT-22.2* PTT-39.7* INR(PT)-2.2*
[**2116-3-24**] 09:00AM BLOOD FDP-10-40
[**2116-3-24**] 09:00AM BLOOD Fibrino-410* D-Dimer-[**2125**]*
[**2116-3-21**] 01:11PM BLOOD Ret Aut-4.3*
[**2116-3-24**] 03:41AM BLOOD Glucose-165* UreaN-24* Creat-2.1* Na-133
K-3.5 Cl-104 HCO3-17* AnGap-16
[**2116-3-8**] 01:51AM BLOOD Glucose-190* UreaN-22* Creat-0.8 Na-139
K-4.0 Cl-105 HCO3-23 AnGap-15
[**2116-3-21**] 01:11PM BLOOD LD(LDH)-336* CK(CPK)-126
[**2116-3-23**] 02:33AM BLOOD TSH-6.0*
[**2116-3-23**] 02:33AM BLOOD T4-2.9* T3-53*
[**2116-3-23**] 02:56AM BLOOD Type-ART Temp-37.7 pO2-76* pCO2-30*
pH-7.39 calTCO2-19* Base XS--5
.
[**3-15**] CT Head
FINDINGS: There is no evidence of acute intracranial hemorrhage,
mass effect, hydrocephalus, or shift of normally midline
structures. There remain large areas of periventricular white
matter hypodensity consistent with chronic small vessel
infarction. A right thalamic lacune is again seen. There is a
fluid level in the sphenoid sinus. The soft tissues are
unchanged.
IMPRESSION: No evidence of intracranial hemorrhage or mass
effect.
.
[**3-20**] TTE
Conclusions:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial
appendage. A left-to-right shunt across the interatrial septum
is seen at
rest. A small secundum atrial septal defect is present. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic prosthesis appears well
seated, with normal leaflet/disc motion. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. No mass or vegetation is seen on the
mitral valve. Mild to moderate ([**1-21**]+) mitral regurgitation is
seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2116-3-20**]
there is no
significant change.
.
[**3-23**] CT Head
FINDINGS: The study is significantly motion degraded at the
lower and mid levels. Allowing for this deficiency, no acute
intracranial hemorrhage is appreciated. There is diffuse
cerebral periventricular white matter hypodensity consistent
with chronic small vessel infarction. Chronic lacunar infarcts
in the left basal ganglia and right thalamus are stable. No
evidence to suggest acute major vascular territorial infarction
is seen. Sphenoid sinus air- fluid level is noted. Carotid
vascular calcification is seen.
IMPRESSION: Motion limited study; allowing for this limitation,
no acute intracranial hemorrhage seen. Sphenoid sinus air-fluid
level (are there symptoms of sinusitis?).
.
[**3-24**] CT Head
FINDINGS: As was the case yesterday, a number of the images are
degraded by patient motion. Allowing for this deficiency, there
is no definite interval change identified. Once again, there is
a chronic lacunar infarct noted within the right thalamic
region, as well as more generalized bilateral cerebral
periventricular white matter hypodensity, consistent with
chronic small vessel infarction. There is no sign for the
presence of an intracranial hemorrhage. There is heavy
atherosclerotic calcification of the distal vertebral arteries
and cavernous carotid arteries. The surrounding osseous and soft
tissue structures are remarkable for redemonstration of the
sphenoid sinus air-fluid level. As was stated yesterday, the
finding suggests possible acute sinusitis but requires clinical
correlation, as sinus drainage could be impeded by the presence
of a nasogastric tube.
CONCLUSION: No intracranial hemorrhage.
Brief Hospital Course:
Assessment/Plan: 86 yo woman with abscess surrounding pacemaker
site, s/p surgical pacemaker removal and in NSR, but had a 9
second period of asystole, treated with temporary external pacer
and plan for permenant pacer once course of Abx completed. Her
pacer infection seemed to be resolving but on [**3-20**] she had
another TEE to eval for endocarditis. Her mental status never
seemed to improve after that and her po intake was very poor.
On [**3-21**], she had a hypotensive episode that required pressors and
intubation. It appeared to have been from [**Month (only) **] po and inability
to mount a tachycardic response [**2-21**] heart block. She was
quickly weaned off pressors and off the vent but her mental
status never improved. CT scans did not show an acute
intracranial event. Her daughter then made the decision to make
her CMO, which was consistent with the patient's stated wishes.
She passed away two days later.
.
Hospital course complicated by:
.
## Wound abscess/bacteremia: Wound grew VRE and MRSA
.
## Hematoma: recurred at pacer site, s/p 1uPRBC's with
appropriate hct increase, but no further bleeding.
- U/S of area just showed a small cystic structure which we did
not aspirated
.
## Delerium: Continues with waxing and [**Doctor Last Name 688**] mental status.
Likely related to infection, pacer, hematoma, hospitalization,
underlying dementia. Head CT without bleed [**3-15**], [**3-23**], [**3-24**].
Became acutely hypotensive on [**3-21**] requiring intubation and has
not recovered mental status after that. Unclear etiology but
likely multifactorial and from episodes of hypotension.
.
## Valves: s/p St. [**Male First Name (un) 1525**] aortic valve placement in [**2104**]; also
has moderate MS (valve area 1.0-1.5cm^2), [**1-21**]+ MR, 2+ TR on
recent TTE
- TTE and TEE were negative for vegetations
- INR intermittently high and then low so was on heparin gtt off
and on with fluctuating doses of coumadin
.
## Rhythm: history of recent CHB
- due to episode of 9 second asystole, EP screwed in pacer wires
on [**3-12**] with external device.
- telemetry
- resumed beta blockade now that pacer is in place
.
## Coronaries: s/p 2-v CABG at OSH in [**2104**] (anatomy unknown)
- cont aspirin, statin; continue beta-blockade
.
## Pump: diastolic CHF with LVEF of 70-75% on [**1-/2116**] TTE;
- cont home dose of PO Lasix
.
## HTN
- resumed beta blockade now that pacer wires in place
- on Lisinopril 80
- hydral added on [**3-19**]
.
## Hyperlipidemia
- atorvastatin per outpatient dose
.
## Dementia
- held psychotropics given altered mental status
.
## Hypothyroidism
- cont thyroid replacement
.
## DM2
- hold sulfonylurea; cover with RISS
.
## COPD
- cont Spiriva; prn ipratropium nebs
.
## FEN: now with NGT [**2-21**] po getting tube feeds
- cardiac/purreed diet, encourage pos
- trend lytes; replete prn
.
## Prophylaxis
- bowel regimen; on heparin gtt
.
## Code: DNR/DNI /CMO.
- appreciate palliative care consult
.
## Access: L PICC placed by IR
.
Medications on Admission:
Meds on transfer:
Vancomycin 1gm [**Hospital1 **]
Gentamycin 100mg qd
synthroid 0.1mg daily
Protonix 40mg IV qam
.
Outpt meds:
glyburide, metoprolol, lipitor, coumadin, lexapro, diovan,
risperdal, lasix, amlodopine
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Cardiopulmary arrest
2. Sepsis
3. Infected hematoma
4. Pacemaker removal
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
None
| [
"51881",
"496",
"99592",
"5849",
"V4581",
"4019",
"25000",
"2449"
] |
Admission Date: [**2146-8-7**] Discharge Date: [**2146-8-20**]
Date of Birth: [**2066-7-17**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation on [**2146-8-7**]
History of Present Illness:
Mr. [**Known lastname 32913**] is an 80-year-old male who presented from rehabwith
respiratory distress. This was in the setting of recent
hospitalization ([**141-12-2**]) during which he was
treated for a florid urinary tract infection, acute kidney
injury, J-tube clogging, severe fluid imbalances, and intubation
for respiratory distress in the context of a LLL PNA which grew
out E.coli. All this took place after a duodenal perforation s/p
a laparoscopic cholecystectomy at an OSH on [**2146-6-2**], after
which he was brought to [**Hospital1 18**] for repair of duodenal injury,
placement of lateral duodenostomy tube, feeding jejunostomy
tube, and PTBD (6/[**2146**]).
Past Medical History:
Past Medical History: HTN, prostate CA, duodenal ulcer
Past Surgical History: partial gastrectomy with BII
reconstruction, prostatectomy with bilateral inguinal node
dissection, laparoscopic cholecystectomy
Social History:
He lives in a long term care facility. He does not drink
alcohol, and has not smoked for 20 years.
Family History:
non-contributory
Physical Exam:
ADMIT EXAM:
Vitals: T =100.4, HR = 109, RR = 20, O2Sat = 100% NRB, BP =
132/74
General: Sedated, intubated, thin and ill appearing white male
HEENT: Sclera anicteric,Pupils of 5 minimally reactive, moving
eyes around, not blinking very much but blinks to light shinning
in the,
Neck: supple, JVP not elevated when recumbent at 0 deg no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse breathsounds at the left base compared to the
right
Abdomen: soft, midline scar is well healed. Drains on left
appear to be intact, with multiple bags full of dark
yellow/[**Location (un) 2452**] fluid. No erythema of the skin surrounding them.
Hypoactive bowel sounds but normal pitch.
Ext: warm, well perfused, 2+ pulses DP pulses bilaterally no
clubbing, cyanosis or edema
Neuro: Unable to assess as patient is sedated and intubated
DISCHARGE EXAM:
Vitals: 98.2 97.8 89 113/56 16 99%RA
General: In no distress, thin appearing male, interactive upon
stimulation
HEENT: anicteric sclera, PERRLA
CV: RRR, +S1/S2, no m/r/g
Lungs: Sparse coarse breath sounds diffusely, otherwise CTAB
Abdomen: soft, well-healed incision. Drains x4 intact. +BS, NT,
ND, no r/r/g
Ext: warm, well perfused, 2+ distal pulses
Pertinent Results:
IMAGING:
1) CHEST (PORTABLE AP) ([**2146-8-7**]): An endotracheal tube is
positioned 4.2 cm above the level of the carina. A nasoenteric
catheter courses below the diaphragm with the tip in the
stomach. A left PICC is in unchanged position terminating in
the mid SVC. There is consolidation within the left lung base.
which appears similar to prior examination and likely reflects
atelectasis or resolving pneumonia. No new confluent opacity is
identified. There is no pneumothorax. Blunting of the
bilateral costophrenic angles is unchanged from prior and likely
suggests possible small effusions. There is no overt
interstitial edema. Cardiomediastinal and hilar contours are
within normal limits. IMPRESSION: Expected position of support
devices. No pneumothorax. Persistent retrocardiac opacity
possible atelectasis or resolving pneumonia. Probable small
bilateral pleural effusions.
2) BILAT LOWER EXT VEINS ([**2146-8-7**]): [**Doctor Last Name **]-scale and color Doppler
images of bilateral common femoral, superficial femoral, deep
femoral, popliteal and calf veins demonstrate normal flow,
compressibility and response to augmentation. IMPRESSION: No
evidence of deep venous thrombosis in bilateral lower
extremities.
3) CT HEAD W/O CONTRAST ([**2146-8-7**]): There is no evidence of
hemorrhage, edema, mass effect or infarction. Prominence of the
ventricles and sulci is compatible with age-related global
atrophy, unchanged. There is mild left cavernous carotid artery
calcification. No osseous lesions are seen. There are mucosal
retention cysts and mucosal thickening within the maxillary
sinuses. A small amount of aerosolized secretions are seen
within the left sphenoid sinus. The mastoid air cells are
grossly clear. IMPRESSION: Age appropriate volume loss and mild
carotid calcification.
Otherwise normal study. No evidence of acute intracranial
process.
4) CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST ([**2146-8-7**]):
Wet read- bibasilar atelectasis, left greater than right. given
history, an aspiration is certainly possible. dense
atherosclerotic calcifications. hypodense vascular space
consistent with anemia. unchanged right upper lobe pulmonary
nodules. known multiple biliary drains and stent from prior
procedure with bile leak. scattered free fluid however no focal
collection or evidence of abscess.
MICRO/PATH:
GRAM STAIN (Final [**2146-8-7**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2146-8-7**]):
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended
ADMIT LABS:
[**2146-8-7**] 12:25PM BLOOD WBC-16.2* RBC-3.03* Hgb-9.0* Hct-29.5*
MCV-97 MCH-29.8 MCHC-30.6* RDW-16.8* Plt Ct-738*
[**2146-8-7**] 12:25PM BLOOD Neuts-66.5 Lymphs-22.6 Monos-2.4 Eos-7.8*
Baso-0.7
[**2146-8-7**] 12:25PM BLOOD PT-11.5 PTT-30.5 INR(PT)-1.1
[**2146-8-7**] 12:25PM BLOOD Plt Ct-738*
[**2146-8-7**] 12:25PM BLOOD Glucose-890* UreaN-68* Creat-2.3* Na-134
K-5.6* Cl-105 HCO3-18* AnGap-17
[**2146-8-7**] 12:25PM BLOOD ALT-12 AST-29 AlkPhos-196* TotBili-0.5
[**2146-8-7**] 12:25PM BLOOD Albumin-2.6*
[**2146-8-7**] 03:04PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
[**2146-8-7**] 02:17PM BLOOD Type-ART Temp-38.0 Tidal V-450 FiO2-100
pO2-159* pCO2-41 pH-7.28* calTCO2-20* Base XS--6 AADO2-513 REQ
O2-86 Intubat-INTUBATED
[**2146-8-7**] 12:31PM BLOOD Lactate-1.0
DISCHARGE LABS:
[**2146-8-18**] 05:39AM BLOOD WBC-9.4 RBC-2.63* Hgb-8.2* Hct-24.5*
MCV-93 MCH-31.0 MCHC-33.2 RDW-17.1* Plt Ct-628*
[**2146-8-18**] 05:39AM BLOOD Plt Ct-628*
[**2146-8-18**] 05:39AM BLOOD Glucose-108* UreaN-69* Creat-1.5* Na-131*
K-4.1 Cl-105 HCO3-18* AnGap-12
[**2146-8-18**] 05:39AM BLOOD ALT-13 AST-36 AlkPhos-313* TotBili-0.4
DirBili-0.2 IndBili-0.2
[**2146-8-18**] 12:50PM BLOOD Vanco-19.2
Brief Hospital Course:
80 year old male s/p CCY complicated by duodenal perforation
with multiple drains in place and recently discharged after
prolonged hospital course where he was treated for pan sensitive
Ecoli pneumonia to rehab who presents with acute respiratory
distress and leukocytosis.
On [**2146-8-7**]: The patient was tachypnic on admission and hypoxemic
with increased oxygen requirement. He was intubated, and his CXR
post-intubation revealed stable infiltrates bilaterally. He was
admitted to the medical ICU. ABG revealed a non-anion gap
acidosis without appropriate respiratory compensation. CT Chest
revealed on PNA, and LE ultrasound revealed no DVT. He was
continued on TPN. He was started on vancomycin, cefipime, and
flagyl empirically given a leukocytosis without a left shift and
no obvious initial course. Blood and urine cultures were
obtained. CT abdomen and CT head were obtained.
On [**2146-8-8**]: The patient remained intubated and sedated, on
CMV/Assist settings. His care was transferred to the Surgical
ICU team. He was continued on TPN, and remained NPO, with
nothing but medication by J tube. Antibiotics as stated above,
were continued.
On [**2146-8-9**]: The patient's ventilator settings were adjusted to
CPAP/PS. He was continued on TPN, kept NPO, with nothing but
medication by J tube. Antibiotics were continued, but adjusted
to include only vancomycin and cefipime.
On [**2146-8-10**]: The patient was successfully extubated on this day.
He was continued on TPN, and kept NPO, with nothing by
medication by J tube. On this day, he was able to spend much
time sitting in a chair, and was noted to be conversational and
interactive. Antibiotics were continued. Planning was begun to
transfer him to the regular floor.
On [**2146-8-11**]: The patient was kept NPO, and continued on TPN. On
this day, he was transferred back to the floor for his continued
recovery. He continued to look well. Antibiotics were continued.
On [**2146-8-12**]: The patient was kept NPO, on TPN, with foley
catheter and PTBD, T Tube, [**Doctor Last Name 406**] drain in place. Physical
Therapy continued to work with the patient. He was continued on
antibiotics (vancomycin and cefepime).
On [**2146-8-13**]: The patient was kept NPO, on TPN, with all catheters
and drains in place, and antibiotics runing.
On [**2146-8-14**]: All prior drains were maintained. The patient
remained NPO, on TPN. He continued to work with physical
therapy. Dispo planing to rehab was initiated.
On [**2146-8-15**]: All drains as above (PTBD, T Tube, foley, [**Doctor Last Name 406**]
drain) were maintained. The patient remained NPO, on TPN, and
antibiotics.
Thereafter, the patient continued to recover well, with no
remarkable events. His drains were all maintained, and he
remained NPO, on TPN, and the above stated antibiotics. These
antibiotics are to be continued until [**2146-8-21**].
The patient's blood sugar was monitored throughout his stay;
insulin dosing was adjusted accordingly. The patient's complete
blood count was examined routinely. he patient's white blood
count and fever curves were closely watched for signs of
infection. The patient received subcutaneous heparin and
venodyne boots were used during this stay; he was seen by and
worked with Physical Therapy.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was on TPN, with nothing
by J tube except medication. He is to receive IV antibiotics
(cefipime and vancomycin) until [**2146-8-21**]. Discharge planning to
an extended care facility was made, and thorough follow-up
instructions were provided.
Medications on Admission:
1. Acetaminophen IV 1000 mg IV Q6H:PRN pain
2. Carbidopa-Levodopa (25-100) 1 TAB NG TID
please crush and give via j-tube with 60cc water to avoid j-tube
clogging
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Heparin 5000 UNIT SC TID
6. Insulin SC Fingerstick QACHS Insulin SC Sliding Scale using
REG Insulin
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
8. Pantoprazole 40 mg IV Q24H
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Carbidopa-Levodopa (25-100) 1 TAB PO TID
via j-tube
3. CefePIME 2 g IV Q24H
4. Heparin 5000 UNIT SC TID
5. Insulin SC
Sliding Scale
Fingerstick Q4h
Insulin SC Sliding Scale using REG Insulin
6. Octreotide Acetate 200 mcg SC Q8H
7. Ondansetron 4 mg IV Q8H:PRN nausea
8. Pantoprazole 40 mg IV Q24H
9. Senna 1 TAB PO BID:PRN constipation
10. Vancomycin 750 mg IV Q 24H
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
13. Heparin Flush (10 units/ml) 10 mL IV PRN PICC Flush
14. 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.
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Respiratory distress, in setting of recent hospitalization
([**2146-7-14**]) during which he was treated for a florid urinary
tract infection, acute kidney injury, J-tube clogging, severe
fluid imbalances, and intubation for respiratory distress in the
context of a LLL PNA which grew out E.coli. All this took place
after a duodenal perforation s/p a laparoscopic cholecystectomy
at an OSH on [**2146-6-2**], after which he was brought to [**Hospital1 18**] for
repair of duodenal injury, placement of lateral duodenostomy
tube, feeding jejunostomy tube, and PTBD (6/[**2146**]).
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:
Mr. [**Known lastname 32913**] was admitted to the surgery service at [**Hospital1 18**] for
evaluation and management of respiratory distress. He has
recovered well, and is now safe to return to an extended care
facility to complete his recovery with the following
instructions:
Please resume all regular medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please allow patient to get plenty of rest, continue to ambulate
as tolerated, and continue TPN. Please do NOT administer any
tube feesd, the patient is to receive only CRUSHED Cinemet by J
tube.
Please follow-up with surgeon and Primary Care Provider (PCP) as
advised.
Care for Drains:
*Please look at the sites every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb drains, and allow the bag-drains
to hang to gravity.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor or nurse practitioner if the amount increases
significantly or changes in character.
*Be sure to empty the drains frequently. Record the output, if
instructed to do so.
*The patient may shower; wash the area gently with warm, soapy
water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge in water.
*Make sure to keep the drain attached securely to the patient's
body to prevent pulling or dislocation.
Please call the doctor or nurse practitioner if the patient
experiences the following:
*New chest pain, pressure, squeezing or tightness.
*New or worsening cough, shortness of breath, or wheeze.
*Vomiting and cannot keep down fluids or medications.
*Dehydration due to continued vomiting, diarrhea, or other
reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*Blood or dark/black material in vomit or bowel movement.
*Burning on urination, blood in urine, or discharge.
*Shaking chills, or fever greater than 101.5 degrees Fahrenheit
or 38 degrees Celsius.
*Any change in symptoms, or any new symptoms that concern you.
Followup Instructions:
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office as needed at [**Telephone/Fax (1) 2998**] as
needed.
Appointment:-
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2146-9-9**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2146-8-18**] | [
"0389",
"51881",
"486",
"5849",
"99592",
"412",
"4019"
] |
Admission Date: [**2150-5-1**] Discharge Date: [**2150-5-10**]
Date of Birth: [**2098-2-21**] Sex: F
Service: MICU
The patient was admitted to the Medical Intensive Care Unit
Service on [**5-1**] and was transferred from the Intensive
Care Unit service to the [**Hospital1 139**] Service on [**2150-5-6**],
and planned for discharge on [**2150-5-12**].
CHIEF COMPLAINT: Altered mental status.
HISTORY OF PRESENT ILLNESS: This is a 52 year old woman
with a history of insulin dependent diabetes mellitus and a
history of self-induced hypoglycemic episodes, who presented
on [**2150-5-1**], to [**Hospital1 69**]
with agitation and altered mental status. The EMS checked
her fingerstick which was about 102 at that time. She was
brought to [**Hospital1 69**] Emergency
Room for evaluation.
In the Emergency Department, her fingerstick was about 400.
She was given Ativan, Versed and Haldol, 7 mg of Droperidol
and insulin 10 units. She underwent a lumbar puncture at
that time with her cerebral spinal fluid showing 24 white
blood cells, 350 red blood cells, 70 protein, 152 glucose
with 81% neutrophils, 1% band and 14% lymphocytes. She got
dexamethasone 10 mg intravenously, Ceftriaxone 2 grams
intravenously, Vancomycin 1 gram intravenously, Acyclovir 500
mg intravenously and Toradol. After getting all this
medication, she dropped her systolic blood pressure to the
90s and received several liters of intravenous fluid and was
thought to have aspirated.
She also got Dilantin due to a question of some seizures.
She was transferred to the Medical Intensive Care Unit on the
night of [**5-1**] and early morning of [**5-2**].
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus for 13 years with
multiple episodes of self-induced hypoglycemia as attention
seeking behavior.
2. Migraine headaches relieved with Fioricet.
3. Depression.
4. Dementia with memory difficulties that have been
progressing through recent years.
Her primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7516**] at [**Hospital 8503**].
ALLERGIES: No known drug allergies.
HOME MEDICATIONS:
1. Insulin.
2. Fioricet.
SOCIAL HISTORY: She is divorced with two children. Her son
is in [**Doctor First Name 1191**] for heroin abuse. She has one other son who is
very involved in her care. She lives alone. She smokes one
pack per day.
FAMILY HISTORY: Son has heroin abuse; otherwise unknown.
While in the Medical Intensive Care Unit she was treated
presumptively with Vancomycin, Ceftriaxone and Acyclovir for
meningitis, encephalitis and aspiration pneumonia. The
patient became hypoxic. Chest x-ray showed congestive heart
failure and left retrocardiac opacity. Bronchoscopy was
performed but was unrevealing. The patient self-extubated
after bronchoscopy and remained stable, however, still
requiring oxygen via face mask. She was eventually weaned
off the face mask onto nasal cannula.
A repeat lumbar puncture was performed on [**5-5**] showing
one white blood cell, eight red blood cells. At that time,
the culture from the first lumbar puncture came back
negative. The Vancomycin and Ceftriaxone were discontinued.
Levofloxacin was started for treatment of pneumonia.
Acyclovir was continued for herpes simplex virus
encephalitis/meningitis. Herpes simplex virus PCR was sent
on the second sample of cerebrospinal fluid from the [**5-5**] lumbar puncture. It eventually came back negative. The
patient received a ten day course of Acyclovir which was then
discontinued due to the negative PCR.
While in the Medical Intensive Care Unit she was also given
intravenous Lasix for effective diuresis with improvement in
her O2 saturation.
She was evaluated by Psychiatric who recommended adding
multivitamins, thiamine, and folate to her medication regimen
given concern for alcohol use. They also recommended Haldol
for her agitation and further medical work-up.
She was also seen by Neurology, whose impression was that
this was encephalitis and to continue treating and also to
rule out other metabolic etiology such as myocardial
infarction, adrenal insufficiency, thyroid disease. They
agreed with the thiamine and folate supplementation.
LABORATORY: Data on admission was white blood cell count of
20.4, hematocrit 37.6 with 91% neutrophils, 7% lymphocytes.
Platelet count was 333. INR 1.1, PTT 29.1.
Urinalysis showed 250 glucose, 50 ketones. Serum sodium of
143, potassium 3.8, chloride 107, bicarbonate 23, BUN 12,
creatinine 0.6, glucose 122, calcium 7.8, phosphate 2.3,
magnesium 1.7. ALT was 40, AST was 68, which increased
slightly. LDH was 278, alkaline phosphatase was 93. Total
bilirubin was 0.4.
Due to the increase in ALT and AST, hepatitis panel was done.
Hepatitis C virus antibodies was negative. Hepatitis B
surface antigen and surface antibodies were both negative.
ANCA was negative. [**Doctor First Name **] was positive with 1:80 titer. HIV
antibodies was negative. Vitamin B12 came back at 1071.
Folate was normal at 10.2. Thyroid stimulating hormone was
0.96. Free T4 level was 1.2. Cortisol stimulation test
pre-stimulation was 9.0, at 30 minutes was 26.7; at 60
minutes was 36.6. Serum toxicology screen and urine
toxicology screen were both positive for barbiturates due to
the Fioricet for her headaches.
RPR was negative. CK and troponin were sent off as well and
the patient had a troponin leak of 8.2, which subsequently
decreased to less than 0.3.
Cardiology consultation was obtained. They recommended a
transthoracic echocardiogram which showed normal left
ventricular wall thickness and cavity sizes. Due to
sub-optimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal, greater than 55%
ejection fraction. Right ventricular chamber size and free
wall motion were normal. Aortic valve leaflets were mildly
thickened. No masses or vegetations were seen. No aortic
valve stenosis or regurgitation. The echocardiogram was
essentially normal.
They recommended continuing with aspirin and continuing to
follow troponin. They recommended outpatient follow-up for
cardiac issues in one month. The patient remained
asymptomatic without chest pain or hemodynamic instability.
Her mental status improved throughout the Intensive Care Unit
stay. Herpes simplex virus two antibodies were negative.
Herpes simplex virus one IgG was positive, showing previous
exposures.
EEG showed encephalopathy but no seizure activity. Influenza
B was negative. RSV antigen was negative. BAL cultures were
negative. Urine cultures were negative times two. Blood
cultures were negative. Legionella urinary antigen was
negative. Insulin A was negative.
MRI of the head was negative. CT scan of the head was
negative.
Bartonella IgG and IgM were sent off which were still pending
at the time of this dictation.
The patient was transferred to the Floor and continued to
improve, although her mental status did not get back to her
baseline. The patient had very poor insight into her
illness. She remained not oriented to month and day and
demanded to go home. She was deemed not competent and
incapable of taking care of herself given her cognitive
deficits and the fact that she lives home alone.
The patient refused to consider any other options. She
finished a ten day course of antibiotics including
ceftriaxone, Vancomycin and Levofloxacin for presumed
pneumonia. Her congestive heart failure resolved with stable
O2 saturation on room air.
She was evaluated by Physical Therapy who felt that she had
no physical therapy issues. She was also evaluated by
Occupational Therapy who felt that she had cognitive deficits
that would prevent her from taking care of herself at home.
[**Last Name (un) **] consultation was obtained who gave their input in
formulating an insulin regimen for the patient.
A family meeting was scheduled for [**2150-5-11**] to
determine the safest disposition for the patient.
The patient's discharge condition, medications, and plan will
be dictated in an addendum by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**].
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 6371**]
MEDQUIST36
D: [**2150-5-10**] 20:50
T: [**2150-5-10**] 21:20
JOB#: [**Job Number 25485**]
| [
"41071",
"5070",
"4280"
] |
Admission Date: [**2103-8-8**] Discharge Date: [**2103-8-16**]
Date of Birth: [**2034-12-3**] Sex: F
Service: VASCULAR
CHIEF COMPLAINT: Cold foot with pain progressive over the
last three days prior to admission. Information was obtained
from the patient and transfer of records.
The patient was transferred from [**Hospital6 18346**].
HISTORY OF PRESENT ILLNESS: The patient is a 68 year-old
black female well known to our service status post abdominal
aortic repair with an aorta bifemoral status post right ABF
limb removal with interposition saphenous vein graft
secondary to infection, status post left fem [**Doctor Last Name **] with jump
graft to fem [**Doctor Last Name **] to tibial peroneal artery with vein presents
with a three day history of left foot pain with onset of
coldness and numbness within the last 24 hours. She was seen
at [**Hospital3 22439**] and was diagnosed with acute ischemic
foot. IV heparin 5000 unit bolus and a 1000 units per hour
was started at 1600. It was discontinued at 1820 for
transfer to the main land.
REVIEW OF SYSTEMS: Positive for numbness, coolness and pain.
She denies any other interval changes since last
hospitalization in [**Month (only) 547**] of this year secondary to left thigh
abscess. She denies chest pain, shortness of breath. She is
nondiabetic.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Coronary artery disease, hypertension,
hypercholesterolemia, peripheral vascular disease, history of
MRSA, sacroiliitis, infected right ABF limb secondary to
MRSA, status post removal.
PAST SURGICAL HISTORY: Abdominal aortic aneurysm repair with
an aorta bifemoral in [**2092**], right ABF limb with removal with
interposition graft in [**2102-6-8**], left fem [**Doctor Last Name **] in [**2098**],
left jump graft from fem [**Doctor Last Name **] to [**Doctor First Name **] peroneal artery in [**2102-8-8**], right breast biopsy in [**2099**], I&D of left thigh
abscess in [**2103-4-8**].
MEDICATIONS ON TRANSFER: Lipitor 20 mg q day, Colace 100 mg
b.i.d., Lopressor 25 mg b.i.d., ferrous sulfate 325 mg q day,
aspirin 81 mg q.d.
SOCIAL HISTORY: The patient lives with her son.
The remaining review of systems is unremarkable.
PHYSICAL EXAMINATION: The patient was afebrile. This is an
alert black female complaining of left foot pain. HEENT
examination was unremarkable. Pulse examination shows an
intact carotid, brachial and radial pulses bilaterally with
bilateral carotid bruits. Femoral pulses were 2+ on the
right and absent on the left by palpation of doppler. There
were no bruits. Popliteal pulses were absent bilaterally.
On the right, the DP was dopplerable. The PT was absent by
palpation and doppler. The pedal pulses and popliteal pulses
on the left were absent by palpation and doppler. Chest was
clear to auscultation bilaterally. Heart was a regular rate
and rhythm. Normal S1 and S2. There were no murmurs, rubs
or gallops. Abdomen was benign. There was no bruits, masses
or organomegaly. Right foot toes were cool. The left foot
was cold to the ankle and cool from the ankle to mid calf.
The foot was modeled. There was no capillary refill. The
foot had diminished dorsiflexion and plantar flexion. The
left first toe strength was [**4-12**] and the left foot strength
was [**4-12**]. The left leg had moderate amount of weakness of [**4-12**]
with elevation on off bed. Neurological examination except
for the motor sensory on extremities were unremarkable.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. She was made NPO, IV hydration normal saline at 80
cc per hour was begun. Interventional Radiology was
requested to see the patient for anticipated intervention.
The patient's admitting laboratories were white count 15.8,
hematocrit 33.9, platelets 456, electrolytes 137, 4.6, 103,
19, 22 and 0.7. PT/INR were normal. PTT 26.7.
The patient was taken to angio. Initial arteriogram
demonstrated hydronephrotic obstructed right kidney. Left
limb graft open. Has stenosis at the aorta anastimosis.
This was dilated 6 mm with a 15 mm residual gradient clot in
the fem [**Doctor Last Name **] graft. Tissue plasminogen activator was
continued.
Follow up thrombolysis arteriogram demonstrates successful
recanalization of the left common femoral with access of the
catheter to the fem [**Doctor Last Name **] graft injection of the AT at the
level of the distal anastomosis demonstrated complete
occlusion. They were not able to identify the distal run
off. The catheter was removed at this point.
At this time the patient became hypoxic, hypertensive and
tachycardic. Emergency head CT was obtained to rule out
intracranial hemorrhage, which was negative. The patient was
transferred to the SICU for continued monitoring and care.
The patient was given 1 gram of vancomycin prior to any
interventional work on the night of admission.
Infectious disease was consulted regarding antibiotic
coverage for positive blood cultures from the sheath. She
had been started on Ceptaz 1 gram q 8 hours and Gentamycin 80
IV q 8 hours. Vancomycin 1 gram q 12 hours was continued.
Blood cultures obtained on the second 2/2 bottles grew gram
negative rods, anaerobic bottle growing gram positive cocci.
Identifications and speciation pending.
Infectious disease recommended continued antibiotics as they
were for both a history of MRSA and enterococcus infection.
The abdominal pelvic CT was reviewed and they felt that the
graft could be a possible site of infection along with a
right hydronephrosis. At this point was consulted.
Urology felt this was a chronic hydronephrosis and had not
changed from previous abdominal CT. The urine cultures were
pending. Urinalysis showed only 0 to 2 white blood cells.
They felt at this point given this picture that the
hydronephrosis was not the etiology of her bacteremia. Urine
culture on [**8-10**] was negative and urine specimen from the right
kidney gram stain showed no bacteria and no polys. The white
count peaked at 25.5. The patient did require intubation at
the time of her hypertension, tachycardia and was extubated
on SICU day three. Blood cultures were poly microbial and
predominantly GI flora, Flagyl was added to the antibiotic
regimen on [**2103-8-12**]. A right nephrostomy tube was placed on
[**3-11**]. This was removed after urine cultures were proven to be
negative.
The patient returned to angio on retrieval of foreign body at
the time of line change and loss of guidewire. The guidewire
was removed from the inferior vena cava with a snare and a IJ
triple lumen catheter was placed and continued to show
improvement with diminished white count of 17.0, hematocrit
was 23.8 and no transfusion was given secondary to patient's
Jehovah's witness beliefs.
She was transferred to the VICU for continued monitoring and
care. The left foot was stable and showed some improvement
with diminishment in pain, but not complete relief of pain.
The patient was beginning to wiggle her toes. The patient
continued to show clinical improvement and was transferred to
the regular nursing floor on hospital day number seven. IV
heparin and coumadinization were continued. Abdominal CT and
pelvic and upper left leg were obtained, which showed a
diminished collection in the inguinal area. No discreet
collection noted. Multiple diverticuli, no free fluid in the
pelvis.
White count continued to defervesce. Her renal numbers
remained stable. Her heparin was adjusted for PTT of 60 to
80. Her Lopressor was adjusted for her persistent
tachycardia. Physical therapy was requested to see the
patient and begin ambulation and case management was
requested to see the patient regarding rehabilitation
screening.
Her Flagyl was discontinued on [**2103-8-15**]. She is continued on
her Ceptaz 1 gram q 8 hours, Gentamycin 80 mg q 12 hours,
Vancomycin 1 gram q 12 hours. Her cultures are as follows,
8/2 cultures blood grew enterococcus cloacae, Klebsiella,
pneumonia, MRSA and enterobacter buccalis. The Enterobacter
was sensitive to Ceptaz, Ceftriaxone, Gentamycin, _______,
Penicillin, Tobra and Bactrim. The enterococcus was
sensitive to Ampicillin, Gentamycin, Penicillin, Vanco.
Resistant to streptomycin and Cipro. The staph aureus MRSA
was sensitive to Gent, Rifampin, Tetracycline and Vanco.
Klebsiella was pan sensitive. Repeat cultures on [**8-9**] grew
the same organisms and on [**8-12**] blood cultures were no growth.
At the time of dictation her white count was 16.7 with
hematocrit of 25.0 and platelets 339. Her BUN was 9,
creatinine 0.7, K 4.0, Gentamycin levels on [**8-14**] peak was 5.9,
trough 2.6.
Final recommendations regarding antibiotic course of therapy
will be determined just prior to discharge from Infectious
Disease. The patient's heparin drip was discontinued on
[**2103-8-16**]. Coumadin 5 mg q day was begun. Lopresor was
adjusted to 50 mg t.i.d.
DISCHARGE MEDICATIONS: Coumadin 5 mg q.d. goal INR is 2.0 to
3.0, Gentamycin 100 mg IV q 12 hours, this was begun on
[**2103-8-15**] and a trough and peak were pending after the third
dose. Lopressor 50 mg t.i.d., Colace 100 mg b.i.d.,
antibiotics are Ceftazidime 1 gram q 8 hours and Vancomycin 1
gram q 12 hours. Percocet tablets 5/325 one q 4 to 6 hours
prn for pain, Zantac 150 mg b.i.d., Procrit 40,000 units subQ
q week. Dressings include nephrostomy dressing, which should
be changed on a daily basis. Ambulation as tolerated, full
weight bearing, essential distances with healing sandal.
PT/INR should be checked on a daily basis until the patient
is therapeutic with an INR between 2.0 and 3.0. No heparin,
so no PTT.
The patient should follow up with Dr. [**Last Name (STitle) 1391**] in two to
three weeks or post discharge from rehab or prn as needed.
DISCHARGE DIAGNOSES:
1. Left foot ischemia status post tissue plasminogen
activator with improvement.
2. Right hydronephrosis etiology unknown status post right
nephrostomy tube.
3. Polymicrobial bacteremia treated.
4. Hypertension controlled.
5. Peripheral vascular disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2103-8-16**] 09:01
T: [**2103-8-16**] 10:26
JOB#: [**Job Number 31666**]
| [
"9971",
"41401",
"4019",
"2720"
] |
Admission Date: [**2147-8-1**] Discharge Date: [**2147-8-8**]
Date of Birth: [**2107-7-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Chocolate Flavor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2147-8-1**] - Mitral valve replacement (27mm St. [**Male First Name (un) 923**] Mechanical
Valve)and Tricuspid Valve Repair with MC3 Annuloplasty system.
History of Present Illness:
40 year-old woman, known to our service, who presented to
[**Hospital **] Hospital in [**Month (only) 205**] after waking up with shortness of
breath. She reported that was the first time she has had such an
episode, but in retrospect she probably has had increasing
dyspnea on exertion. A chest CT was done and ruled out PE. An
echocardiogram revealed severe mitral valve regurgitation and
significant pulmonary hypertension. She was referred for
surgical evaluation.
Past Medical History:
severe mitral regurgitation
hypertension
pulmonary hypertension
cardiomegaly
anemia
depression
Social History:
Occupation: on disability Last Dental Exam >1 year
Lives with: children Race:
Tobacco: smoked for 20 years, quit 5 years ago
ETOH: rarely
Family History:
non-contributory
Physical Exam:
Pulse: 96 Resp: 16 O2 sat: 97% RA
BP: 150/90
Height: 5'4" Weight: 115.1 kg
General: WDWN female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: SEM III/VI Crisp valve
snap
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: - Left:-
Pertinent Results:
[**2147-8-1**] ECHO
Pre-bypass:
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is moderate symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
mildly depressed (LVEF= 40 %). The right ventricular cavity is
mildly dilated with normal free wall contractility. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve shows characteristic
rheumatic deformity. There is moderate thickening of the mitral
valve chordae. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Moderate to severe (3+) mitral regurgitation is
seen. Moderate to severe [3+] tricuspid regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
Post-bypass:
At the time of post-bypass exam, the patient is receiving
norepinephrine at 0.08 mcg/kg/min. There is a mitral valve
mechanical prothesis well-seated without paravalvular
regurgitation. Both mechanical leaflets are opening
appropriately and there are small regurgitant "washing" jets.The
mean gradient across the mitral valve is 7 mm hg with a heart
rate of 90. The tricuspid valve has a minimal transvalvular
gradient of 4 mm Hg. There is no tricuspid stenosis and mild
tricuspid regurgitation. Ventricular function is similar to
prebypass findings. The aorta is intact post decannulation. All
findings communicated with [**Month/Day/Year 5059**] at time of exam.
[**2147-8-4**] WBC-23.2* RBC-3.70* Hgb-8.6* Hct-28.5* RDW-19.4* Plt
Ct-185
[**2147-8-5**] WBC-21.0* RBC-3.94* Hgb-9.6* Hct-31.2* RDW-19.0* Plt
Ct-227
[**2147-8-6**] WBC-13.5* RBC-3.70* Hgb-8.4* Hct-28.6* RDW-19.6* Plt
Ct-223
[**2147-8-7**] WBC-10.0 RBC-3.69* Hgb-8.8* Hct-29.0* RDW-18.9* Plt
Ct-297
[**2147-8-8**] WBC-9.2 RBC-3.78* Hgb-9.0* Hct-29.6* RDW-18.9* Plt
Ct-346
Warfarin dosing:
[**2147-8-3**]: 5mg
[**2147-8-4**]: 4mg
[**2147-8-5**]: 5mg
[**2147-8-6**]: 5mg
[**2147-8-7**]: 2mg
[**2147-8-8**]: 4mg - discharge dose
PT/INR Results:
[**2147-8-4**] PT-20.9* INR(PT)-1.9*
[**2147-8-5**] PT-23.4* PTT-31.4 INR(PT)-2.2*
[**2147-8-6**] PT-29.0* PTT-48.5* INR(PT)-2.9*
[**2147-8-7**] PT-38.3* PTT-39.3* INR(PT)-4.0*
[**2147-8-8**] PT-38.4* INR(PT)-4.0*
[**2147-8-4**] Glucose-97 UreaN-16 Creat-0.7 Na-135 K-3.7 Cl-102
HCO3-25 AnGap-12
[**2147-8-5**] Glucose-87 UreaN-20 Creat-0.7 Na-139 K-3.6 Cl-105
HCO3-25 AnGap-13
[**2147-8-6**] Glucose-93 UreaN-18 Creat-0.6 Na-136 K-3.5 Cl-105
HCO3-24 AnGap-11
[**2147-8-7**] Glucose-82 UreaN-15 Creat-0.8 Na-138 K-3.9 Cl-105
HCO3-24 AnGap-13
[**2147-8-8**] UreaN-14 Creat-0.8 K-4.2
Brief Hospital Course:
Ms. [**Known lastname 82901**] was admitted to the [**Hospital1 18**] on [**2147-8-1**] for surgical
management of her valvular heart disease. She was taken to the
operating room where she underwent a mitral valve replacement
using a St. [**Male First Name (un) 923**] mechanical valve and a tricuspid valve repair
using a MC3 annuloplasty system. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring. On postoperative day one, she awoke
neurologically intact and was extubated. She was weaned from
her pressors. Her chest tubes and epicardial wires were removed
and she was transferred to the step down floor. There she
experienced copious diarrhea and was found to be c.dif positive,
so oral Vancomycin was begun. Coumadin and heparin were
initiated for her mechanical mitral valve. Warfarin was
monitored daily and dosed for a goal INR between 3.0 - 3.5.
Heparin was eventually discontinued once her INR reached above
2.0. The remainder of her postoperative course was uneventful.
Over several days she continued to make clinical improvements
with diuresis and was medically cleared for discharge to home on
postoperative day seven. INR at discharge was 4.0. Prior to
discharge, arrangements were made and confirmed with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17466**] for management of Warfarin dosing as an
outpatient.
Medications on Admission:
Zestril 30mg qd
Nifedipine ER 60 qd
Metoprolol XL 50 qd
Ativan prn
Tylenol
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: take
2 tabs(4mg) daily...daily dose may vary according to INR..use as
directed by local MD.
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: then drop to 1tab(40mg) daily for seven days then
discontinue.
[**Last Name (Titles) **]:*21 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days: then drop to 1 tab(20mEq) daily for seven days then
discontinue.
[**Last Name (Titles) **]:*21 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 7 days.
[**Last Name (Titles) **]:*28 Capsule(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Mitral and Tricuspid Valve Regurgitation
Possible Rheumatic Valvular Heart Disease
Hypertension
Pulmonary Hypertension
Anemia
C. difficile Colitis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues.
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) You should wash incision daily with soap and water. No
lotions creams or powders to incision until it has healed. No
bathing or swimming for 6 weeks.
5) No lifting more then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month from date of surgery.
7) Take Warfarin as directed for goal INR between 3.0 - 3.5.
Please check PT/INR on [**8-10**] call results to Dr [**Last Name (STitle) **],[**First Name3 (LF) **] @
[**Telephone/Fax (1) 50485**].
8) Take Lasix and KCl as directed for two weeks then stop
9) Complete one week course of PO Vancomycin as directed
10) Please call with any questions or concerns
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 17466**] in [**12-27**] weeks. [**Telephone/Fax (1) 50485**]
Please follow-up with Dr. [**Last Name (STitle) 2603**] in 3 weeks.
please call to schedule all appointments
Completed by:[**2147-8-8**] | [
"4019",
"2859",
"311"
] |
Admission Date: [**2162-1-7**] Discharge Date: [**2162-1-20**]
Date of Birth: [**2107-9-8**] Sex: M
Service: CA [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 54 -year-old gentleman
with multiple medical problems, including diabetes,
hypertension, hyperlipidemia, and peripheral vascular
disease, status post bilateral femoral popliteal bypasses,
presenting with unstable angina and increased shortness of
breath. Cardiac catheterization showed three vessel disease
and an ejection fraction was moderately depressed. The
patient was admitted to the Medical service and referred to
Cardiac Surgery for surgical revascularization.
PAST MEDICAL HISTORY: Coronary artery disease, status post
percutaneous transluminal coronary angioplasty times one,
peripheral vascular disease, status post bilateral femoral
popliteal bypasses, hypertension, hyperlipidemia, peripheral
neuropathy, diabetes insulin dependent.
ADMITTING MEDICATIONS: Include Lipitor 20 mg q HS, Actos 45
mg a day, Celebrex 200 mg a day, Neurontin 300 mg a day,
Atenolol 25 mg a day, Monopril 20 mg a day, and NPH 90 units
subcutaneous q AM and 60 units subcutaneous q PM.
Ciprofloxacin and clindamycin started during his medical
admission.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: On admission, alert and oriented male
in no acute distress. Head and neck examination is
unremarkable. Cardiovascular examination: regular rate and
rhythm without murmurs. Lungs were clear to auscultation
bilaterally. Extremity examination was significant for
bilateral healed femoral popliteal incisions. In the left
lower extremity there is a demarcated area of erythema and
edema / induration. There were no palpable distal pulses
and the patient had pain in the left shoulder upon
abduction. The abdomen was mildly distended, but soft and
nontender.
ADMISSION LABORATORY DATA: White count on admission was 7.6,
hematocrit 26, platelets 288,000.
HOSPITAL COURSE: Prior to surgery, the patient was seen by
Dermatology for his left lower extremity edema and erythema.
Diagnosis of elephantiasis nostra verrucosa. Treatment was
topical MetroGel to affected area [**Hospital1 **]. The patient also had
an area of erythema on his right pretibial area which was
diagnosed as necrobiosis lipoidica diabeticorum. This was
just followed with plan for treatment on an outpatient basis.
Infectious Disease was consulted and they placed the patient
on clindamycin and ciprofloxacin for his presumed left lower
extremity cellulitis.
Th[**Last Name (STitle) 1050**] was brought to the Operating Room on [**2162-1-11**] for
coronary artery bypass graft times three by Dr. [**Last Name (Prefixes) **].
The patient tolerated the procedure well and there were no
complications. The patient was transferred to the Cardiac
Intensive Care Unit postoperatively for hemodynamic
monitoring. He remained hemodynamically stable and afebrile,
was extubated on postoperative day zero.
The patient was transferred to the floor on postoperative day
one and he did well. Chest tube, pacing wires, central line,
and Foley catheter were removed without any problems. The
patient worked with Physical Therapy and was able to achieve
level 5 ambulation.
The patient's postoperative course was complicated only by
sternal drainage which he developed several days after
surgery. The patient's white count remained normal and he
remained afebrile throughout the postoperative course.
Cultures were sent of the fluid which had no organisms on
gram stain and culture showed only sparse growth of gram
positive cocci, believed to be contaminant from the skin.
The skin remained healthy appearing and the sternum remained
stable. The patient was watched several extra days at the
hospital for this sternal drainage and he remained without
any sign of infection.
[**Last Name (un) **] Diabetes service was consulted to manage his insulin
regimen. Finally, on postoperative day nine, the patient was
felt to be safe to go home with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 11197**]
the wound on a daily basis with dressing changes.
DISPOSITION: The patient was discharged on [**2162-1-20**]. He had
completed his course of ciprofloxacin and clindamycin as per
Infectious Disease for a complete two week course.
DISCHARGE MEDICATIONS: Include Lopressor 100 mg po bid, NPH
insulin 100 units subcutaneous q AM, 50 units subcutaneous q
HS, Lasix 20 mg po q day times seven days, potassium chloride
20 mEq po q day times seven days, aspirin 81 mg po q day,
Percocet one to two tablets po q four to six hours prn,
Colace 100 mg po bid, Zantac 150 mg po bid, Actos 45 mg po q
day, and Lipitor 20 mg po q HS, MetroGel 1% [**Hospital1 **] to left lower
extremity.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft times three.
2. Left lower extremity cellulitis.
DISCHARGE STATUS: The patient was discharged home with
[**Hospital6 407**] services as previously mentioned.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 33441**]
MEDQUIST36
D: [**2162-1-20**] 10:10
T: [**2162-1-20**] 10:21
JOB#: [**Job Number 34542**]
| [
"41401",
"4280",
"4019",
"2724"
] |
[**Numeric Identifier 38710**]
Admission Date: [**2118-3-12**] Discharge Date: [**2118-3-15**]
Date of Birth: [**2118-3-12**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname 38711**] [**Known lastname 38712**], twin number one,
was delivered at 34 3/7 weeks gestation, weighing 2350 grams
and was admitted to the Intensive Care Nursery from Labor and
Delivery for management of prematurity.
Mother is a 33-year-old gravida III, para I now III woman,
with estimated date of confinement of [**2118-4-20**]. Prenatal
screens included blood type A positive, antibody screen
negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative, and group B strep unknown.
Pregnancy by in [**Last Name (un) 5153**] fertilization conception, with
diamniotic dichorionic twin gestation. The mother was
admitted to [**Hospital1 69**] at 28 weeks
gestation with cervical shortening. She received
betamethasone at that time, and was discharged home on bed
rest.
She presented on [**2118-3-11**] with pre-term labor and progressed to
vaginal delivery under epidural anesthesia. Rupture of
membranes four and a half hours prior to delivery. Received
intrapartum antibiotics five and a half hours prior to
delivery for unknown group B strep and prematurity. No
maternal fever. This twin emerged with a spontaneous cry.
Was dried and bulb suctioned. Apgar scores were 8 and 9 at
one and five minutes respectively.
PHYSICAL EXAMINATION: On admission, weight 2350 grams (50th
percentile), length 45 cm (45th percentile), head
circumference 31.5 cm (30th percentile). In general, an
active, alert, pink premature female infant. Skin without
rashes. Anterior fontanel open, flat, sutures mobile. Eyes
with red reflex bilaterally. Palate intact. Breath sounds
bilaterally equal, clear, with easy work of breathing.
Regular rate and rhythm, without murmur. Normal pulses.
Abdomen soft, without hepatosplenomegaly, no masses.
Genitalia normal pre-term female external genitalia, anus
patent. Spine straight and intact. Extremities normal, no
hip clicks. Normal reflexes and tone for gestational age.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: No respiratory distress. Has remained in
room air since admission, with oxygen saturations in the high
90s. Is comfortable breathing 30 to 50 times per minute. No
apnea.
2. Cardiovascular: Soft murmur heard during first 12 hours
of life, that has resolved. Has been hemodynamically stable
since admission. Recent blood pressure 65/29 with a mean of
41.
3. Fluids, electrolytes and nutrition: Started ad lib feeds
with formula shortly after admission. Received intravenous
D-10-W for about 12 hours to maintain glucose above 40.
Since intravenous discontinued, has maintained glucose in the
60s before feeds. Discharge weight 2345 grams.
4. Gastrointestinal: Has mild jaundice at time of
discharge. Bilirubin level on [**3-14**] was 9.8. Follow-up
bilirubin level on [**3-15**] was 9.7.
5. Hematology: Hematocrit on admission 43.6%.
6. Infectious Disease: Received 48 hours of ampicillin and
gentamicin for rule out sepsis.
7. Neurology: Examination age appropriate. Head ultrasound
not indicated.
8. Sensory: Hearing screening was performed with automated
auditory brain stem response and she passed for both ears.
CONDITION ON DISCHARGE: Stable pre-term infant, feeding
well, with mild jaundice.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38713**], M.D.,
telephone number [**Telephone/Fax (1) 38714**], fax number [**Telephone/Fax (1) 38715**].
CARE RECOMMENDATIONS:
1. Feeds: Ad lib breast or bottle feeding every three to
four hours. Monitor for weight.
2. Monitor jaundice.
3. Medications: None.
4. Car seat position screening - infant was unable to
maintain saturations while positioned in car. Repeat
screening done in car bed. She remained well saturated
throughout the test. Recommend travel in car bed.
5. State newborn screen drawn prior to discharge, and is
pending.
6. Immunizations received: Received hepatitis B
immunization and Synagis on [**2118-3-13**].
7. 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, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
8. Follow-up appointments:
a. The parents will make follow-up appointment with
pediatrician at discharge.
DISCHARGE DIAGNOSIS:
1. AGA pre-term female
2. Rule out sepsis
3. Physiologic jaundice
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 36138**]
MEDQUIST36
D: [**2118-3-14**] 00:22
T: [**2118-3-14**] 01:00
JOB#: [**Job Number 38716**]
| [
"V053"
] |
Admission Date: [**2192-6-17**] Discharge Date: [**2192-7-6**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
PEG
History of Present Illness:
Pt. is an 88 year old with a history of HTN and bilateral hip
replacement who is brought in by EMS today after being found
down. History is per daughter and per EMS report.
Daughter reports that pt. is very active at baseline, lives
independantly, does her own shopping, takes care of a grandchild
2 days a week. She was last seen well yesterday afternoon by a
friend. [**Name (NI) **] friend was expecting her at church this morning but
she did not arrive. She went over to her house afterwards and
tried to knock but pt. did not answer. Her friend became
concerned and called EMS. EMS found her lying on the floor of
her bathroom, with a puddle of cleaning fluid around her. They
describe her as being awake but not oriented. She was unable to
state how long she had been on the floor. Her BP was 200/110 on
the scene.
Here she has been noted to be in A fib, with a rate in the
70s-80s. Pt. has no complaints at presents, denies pain,
weakness. Does not know where she is or why she is here.
Past Medical History:
Hypertension
Bilateral Hip replacement
Bilateral cataract repair, daughter reports she has anisocoria
at
baseline
No history of arrhythmia or stroke that daughter is aware of
Social History:
Lives alone in [**Hospital3 28354**], daughter, who is an Ob/Gyn at [**Hospital1 **],
lives in the area. No tobacco, occ social EtOH. Very active
and independant at baseline. Daughter, [**Name (NI) **] [**Name (NI) **], HCP
[**Name (NI) **] at [**Hospital1 **]), H [**Telephone/Fax (1) 73415**], C [**Telephone/Fax (1) 73416**], Bp
[**Telephone/Fax (2) 73417**]
Family History:
Father -> Aortic Stenosis
Mother -> Alzheimer's, ? stroke
Brother -> MI
Physical Exam:
T- 97.8 BP- 210/151 HR- 78 RR- 18 O2Sat- 96% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa, + racoon eyes bilaterally
Neck: in C collar
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert. Cannot say where she is, or
what
the month or year are, says first name when asked (not last
name). Speech is non-fluent, says a few words only (says her
name, answers simple Y/N questions, when asked her last name and
where she is says something unintelligible, paucity of
spontaneous speech); follows simple commands (stick out tongue,
wiggle toes, raise arm). No dysarthria. + R sided neglect.
Cranial Nerves: R pupil 6 mm, irregular, NR. L pupil 2.5 mm,
minimally reactive. R NLF flattening. Tongue midline. Blinks
to threat on L, not R. Crosses midline to R, but does not bury
sclera, burys sclera on L gaze. L gaze preference.
Motor:
Decreased bulk throughout. Tone normal. No observed myoclonus or
tremor. Holds L arm anti-gravity x 10 sec with no drift. Holds
R arm anti-gravity x 10 sec with some drift and some motor
impersistance. Holds R leg briefly anti-gravity, but quickly
drifts to bed. Holds L leg anti-gravity x 5 sec.
Sensation: Withdraws to pain all 4 extremities.
Reflexes:
+2 and symmetric throughout.
Toes upgoing on R, down on L
Pertinent Results:
[**2192-6-17**] 03:19PM BLOOD ALT-41* AST-73* CK(CPK)-923* AlkPhos-141*
Amylase-47 TotBili-1.4
[**2192-6-18**] 04:35AM BLOOD CK-MB-14* MB Indx-3.3 cTropnT-0.04*
[**2192-6-17**] 10:30PM BLOOD CK-MB-23* MB Indx-3.7 cTropnT-0.04*
[**2192-6-17**] 03:19PM BLOOD cTropnT-0.04*
[**2192-6-25**] 06:30AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.4*
[**2192-6-24**] 05:55PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.6
[**2192-6-21**] 07:25AM BLOOD Calcium-9.2 Phos-2.2* Mg-1.9
[**2192-6-18**] 08:55PM BLOOD %HbA1c-6.0*
[**2192-6-23**] 12:35AM BLOOD Triglyc-72 HDL-52 CHOL/HD-3.1 LDLcalc-94
[**2192-6-25**] 12:55PM BLOOD Osmolal-257*
[**2192-6-19**] 02:59PM BLOOD Osmolal-266*
[**2192-6-24**] 05:55PM BLOOD TSH-7.7*
[**2192-6-17**] 03:19PM BLOOD TSH-3.9
[**2192-6-24**] 05:55PM BLOOD Cortsol-23.8*
[**2192-6-25**] 06:30AM BLOOD T3-74* Free T4-1.2
[**2192-6-17**] 03:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-6-17**] 03:31PM BLOOD Lactate-4.1*
Head CT:
1. Left early subacute infarct with hemorrhagic transformation
in the posterior cerebral artery territory involving the left
posterior corona radiata, thalamus, temporal lobe, and occipital
lobe.
2. Right frontal lobe late subacute infarct
Echo:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are severely
thickened/deformed. There is moderate to severe aortic valve
stenosis (area 0.8-1.0cm2), but the valve area may have been
slightly DERestimated, because of the technically suboptimal
acquisition of LVOT velocities. Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
physiologic pericardial effusion.
MRA/MRI:
FINDINGS: The carotid and vertebral arteries are visualized from
their origins to their intracranial courses. There is no
evidence of stenosis or occlusion. There are mild
atherosclerotic changes identified. The distal cervical internal
carotid arteries measure 4.3 mm diameter on the left and 4.5 mm
diameter on the right following NASCET criteria. CONCLUSION:
Mild atherosclerotic changes of the cervical arterial vessels.
Otherwise, no evidence of stenosis or occlusion.
Brief Hospital Course:
Ms. [**Known lastname 39540**] is a 89-year-old woman with a history of
hypertension who presented after being found down. Her hospital
course by problem is as follows:
1. Neuro: STROKE. Ms. [**Known lastname 39540**] was admitted to the stroke service
for further evaluation. An MRI of the brain showed the left
subacute infarct of the posterior corona radiata, thalamus,
temporal lobe, and occipital lobe, as well as a right frontal
lobe infarct. As these appeared to be the result of multiple
emboli and as she was discovered to have atrial fibrillation
(previously unknown), she was started on a Heparin drip. The
next morning, she was found to be excessively somnolent; stat
Head CT showed hemorrhagic transformation of her ischemic
strokes. The ICH and heparin was discussed with her daughter who
is the medical decision maker. The daughter decided to continue
with the heparin despite the risk of worsening ICH. She was
transferred to the step-down for closer monitoring. Her blood
pressure was controlled with IV prn BB initally; ultimately it
was controlled with oral lisinopril and metoprolol. She was
maintained euglycemic and normothermic.
She was continued on Heparin with goal PTT 40-60 and started on
Coumadin. After several days of low INRs, her INR was found to
be 10.6 on [**7-4**]; she was given 5 mg of Vitamin K subcutaneously
and 5 mg orally, and 2 units of FFP. She was then resumed on the
Heparin drip while her INR was again sub-therapeutic; she was
restarted on a lower dose of warfarin. Her goal INR is [**1-7**].
Her exam improved somewhat so that she is fully awake and alert
and moving her left side well; she is hemiparetic on the right
but does have some movement in the R LE.
2. Hypercholesterolemia. LDL was found to be 94; as her goal
will be < 70, she was started on Lipitor 10.
3. DENS fracture. She was found to have a Dens fracture on CT
due to her initial fall. She was evaluated by the spine service
who recommended to keep the C-collar for 3 months (through
[**2192-9-17**]).
4. Atrial fibrillation. She was rate controlled with metoprolol
and anti-coagulated as above.
5. ID. She had mild temperature bumps for which she was
pan-cultured. She was empirically started on vanco and zosyn and
her leukocytosis improved. No infectious source was found, and
she remained afebrile after the completion of these antibiotics.
6. Hyponatremia. This was thought to be due to a combination of
cerebral salt wasting and SIADH. The renal service was
consulted. After fluid restriction failed to improve the sodium,
they recommended using 3% saline. This improved her Na, and once
her PEG was in place, her sodium was maintained with salt tabs.
7. Subclinical hypothyroidism. She was found to have elevated
TSH with a normal free T4 (1.2) and low T3 (73). This was not
clinically significant at this point, but should be followed as
an outpatient in the future.
8. Nutrition. She was evaluated by speech and swallow on several
occasions but failed her feeding trial. A PEG was therefore
placed for further feeding.
9. Airway edema. After being electively intubated for the PEG
placement, she was found to have significant epiglottal edema
preventing extubation. She was given 3 days of prednisone, but
bronchoscopic evaluation after these 3 days revealed persistent
edema. In consultation with her daughter, it was decided that
she should receive a tracheotomy.
10. CODE: She is DNR; intubated electively as above.
11. Dispo: She was discharged to a rehab facility.
Medications on Admission:
Lisinopril
Atenolol
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever: per PEG.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours): Per PEG.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Per PEG.
5. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3
times a day): Per PEG.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed): Per PEG.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: Per PEG.
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Per PEG.
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Per PEG.
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Per PEG.
11. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet Sig: Two (2) packets PO
once a day for 1 doses: Please give once per PEG at 8 pm [**2192-7-6**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Stroke
2. Intracranial hemorrhage
3. Atrial fibrillation
4. Pneumonia
5. Hyponatremia
Discharge Condition:
Stable. On neurological examination, the patient is awake and
alert, but aphasic, without speech. She has findings consistent
with a right homonymous hemianopsia. Right pupil is surgical
and the left reactive. Her left arm and leg are consistently
anti-gravity (3+). However, her right arm and leg are generally
weaker and have often fluctuated during the hospital course,
ranging between a 1+ and a 3+. On day of discharge her right
side was [**12-6**]+.
Discharge Instructions:
Please take your medications as prescribed and follow up with
your appointments as scheduled. If you have new, worsening, or
concerning symptoms, please call your phyician or return to the
nearest emergency room.
The patient is to contune to wear her cervical collar for 3
months until her follow up appointment with the orthopedic
clinic at that time. Please follow up the INR daily, as the
paient is on coumadin with a history of atrial fibrillation.
Her goal INR is [**1-7**]. Given her history of hyponatremia, please
check a chemistry (including soudium) and a CBC at least weekly.
Please aim for a systolic blood pressure in the 120's to 130's
if possible. Lisinopril was added just prior to discharge.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2192-8-21**] 3:30
2. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2192-9-27**] 10:40
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2192-9-27**] 11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2192-7-6**] | [
"42731",
"51881",
"5990",
"4019",
"2720",
"2449"
] |
Admission Date: [**2154-2-4**] Discharge Date: [**2154-2-20**]
Date of Birth: [**2099-5-31**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient complained of chest
tightness, dyspnea and palpitations for the past month.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Gout. 3. L4
through L5 and S1 through S2 herniated disks. 4. Pin implant
in the left fifth finger.
PAST SURGICAL HISTORY: Status post cholecystectomy.
SOCIAL HISTORY: The patient is a previous smoker but quit 20
years ago.
MEDICATIONS AT HOME: 1. Aspirin 325 q. day. 2. Lisinopril
10 mg q. day.
ALLERGIES: The patient has no known drug allergies.
REVIEW OF SYSTEMS: Negative for myocardial infarction,
transient ischemic attack, cerebrovascular accident,
claudication, orthopnea, hepatitis or peptic ulcer disease.
PHYSICAL EXAMINATION: Vital signs were heart rate 70s in
sinus rhythm, blood pressure 110/70. The patient was alert
and oriented x 3. There was no jugular venous distension, no
bruits. Chest was clear to auscultation. Cardiovascular
examination was regular rate and rhythm, S1 and S2, no S3 or
S4 and a 3/6 systolic ejection murmur. Abdomen had positive
bowel sounds, nontender, nondistended. Extremities had no
cyanosis, clubbing or edema.
An echocardiogram done in [**2153-12-15**] showed an ejection
fraction of 60%, severe atrial fibrillation, mild mitral
regurgitation, mild aortic insufficiency and left ventricular
hypertrophy.
Cardiac catheterization on [**2154-2-4**] showed preserved left
ventricular ejection fraction, left anterior descending 60%
mid vessel, obtuse marginal #1 40%, no mitral regurgitation,
moderate aortic stenosis with an aortic valve area of 0.7 cm.
LABORATORY DATA: White blood cell count was 11.6, hematocrit
44.6, platelet count 200, BUN 21, creatinine 1.0, liver
function tests within normal limits and a negative
urinalysis.
HOSPITAL COURSE: The patient was admitted on [**2154-2-4**] and
taken to the operating room on [**2154-2-5**] for an aortic valve
replacement with a [**Street Address(2) 11688**]. [**Male First Name (un) 923**] mechanical valve and a
coronary artery bypass grafting x 1 with left internal
mammary artery to the left anterior descending coronary
artery. Anesthesia was reversed and the patient was
transferred to the intensive care unit where he was
successfully weaned from vasopressors and was extubated on
postoperative day one. Chest tubes and pacing wires were
discontinued on postoperative day three and he was
transferred to the floor for continued recovery and
rehabilitation. He was placed on heparin and Coumadin for
anticoagulation. On postoperative day four he began
experiencing significant dyspnea with diaphoresis and
decreased blood pressure as well as tachycardia. He was
transferred back to the CSRU. Chest x-ray revealed hematoma
in the left middle lobe. A chest CT was also done and showed
no evidence of a PE. A large pericardial effusion was
present as well as moderate-sized bilateral pleural effusions
and a loculated effusion on the left.
The patient was aggressively diuresed and respiratory status
improved. He was also transfused with two units of packed
red blood cells for a 6% hematocrit drop. The Coumadin and
heparin were discontinued.
Renal was consulted for increasing creatinine as well as
decreased urinary output. An echocardiogram was done and
showed left ventricular ejection fraction of 55% and mildly
dilated left atrium.
The patient remained in the intensive care unit for the next
several days. He had remitting episodes of shortness of
breath that responded well to diuresis. Chest x-ray remained
stable.
On postoperative day six creatinine was trending downward and
urine output was improving. He was started on levofloxacin
for a positive urinalysis. Culture was pending.
The patient began experiencing decreased appetite with some
slight abdominal distention. Liver function tests were
trending upward. GI was consulted. They believed this to be
due to a low flow state. On postoperative day seven
hematology was consulted for continued decreasing hemoglobin
and hematocrit despite no evidence of real bleeding.
On postoperative day eight the patient began improving with
decreased liver function tests, increased appetite, decreased
creatinine. Urine output was stable. Respiratory status was
improving and hematocrit remained stable.
On postoperative day nine he was transferred back to the
floor. Physical therapy was involved with rehabilitation and
anticoagulation was resumed.
On postoperative day 10 the patient had some episodes of
sinus tachycardia with bursts of wide complex tachycardia.
Beta blocker was increased. No further episodes were noted.
On postoperative day 12 the patient complained of right ankle
pain and increased white blood cell count. Rheumatology was
consulted. The joint was aspirated and fluid sent for
culture. The results are still pending. Fluid analysis was
consistent with pseudogout. He was treated with colchicine
and intra-articular steroid injection with good pain relief.
On postoperative day 13 the patient continued to have
episodes of supraventricular tachycardia without a wide
complex tachycardia. Cardiology was consulted. Beta blocker
was changed from Lopressor to sotalol with no further
episodes of supraventricular tachycardia noted. The patient
continued to have the presence of bilateral pleural
effusions. A right thoracentesis was performed and drained
about 1.5 liters of bloody fluid. Culture was sent and was
still pending, and a left thoracentesis was also performed
and that drained about one liter of bloody fluid.
At this point on postoperative day 15 the patient's
respiratory status continues to improve. He is ambulating
independently in the hallways. He is eating well, making
sufficient urine and is continuing to recover nicely.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 17400**]
MEDQUIST36
D: [**2154-2-20**] 10:03
T: [**2154-2-20**] 10:17
JOB#: [**Job Number 49602**]
| [
"4241",
"5845",
"5990",
"41401"
] |
Admission Date: [**2106-10-23**] Discharge Date: [**2106-10-27**]
Date of Birth: [**2052-3-29**] Sex: M
Service: MEDICINE
Allergies:
Tylenol-Codeine #3
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
- Percutaneous Coronary Intervention w/ Drug-Eluting Stent
Placement (x2) in Right Coronary Artery.
History of Present Illness:
54 year old male with PMH of hypercholesterolemia admitted with
chief complaint of chest pain. Pt reports that this afternoon
he had substernal chest pain and diaphoresis. Previously he was
in good health and denies any h/o angina.
.
In the ED EKG revealed STE in inferior leads and in V5/V6. Pt
was loaded with 600mg of plavix, given 325 ASA and given heparin
bolus.
.
Cath revealed 70% mid-RCA lesion and occlusion of PDA.
Thrombectomy of RCA and PCI placed in RCA and PDA lesions. Was
given fentanyl for CP.
.
On transfer to CCU pt was in sinus rhythm, SBP 160 and vitals
were otherwise unremarkable. Venous sheath was still in place.
Pt still complaining of chest pain and STE have not yet
resolved, but improved.
.
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. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia.
2. CARDIAC HISTORY: Unremarkable.
3. OTHER PAST MEDICAL HISTORY: Left Inguinal Hernia.
Social History:
Works as skilled metal worker. Lives with fiance in [**Location (un) 6151**] but
stays every night with his mother in [**Name (NI) 86**]. Primary caretaker
of mother, has limited support from siblings.
- Tobacco history: no
- ETOH: no
- Illicit drugs: no
Family History:
Father died of MI
Mother s/p quadruple bypass
Physical Exam:
VS: T=afebrile (Tmax=99.7, Range=97-99.7 x 24 hrs)
BP=91-114/59-79
HR=80-104
RR=16-20 O2-Sat= 95-97%
GENERAL: NAD. Oriented x3.
HEENT: Sclera anicteric, non-injected. PERRL, EOMI.
NECK: Supple. No lymphadenopathy or asymmetry noted.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No m/r/g or S3/S4
noted. No thrills, lifts.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Venous sheath in place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Exam at Discharge:
GENERAL:54 yo M in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive. Pos
hernia.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. Gait
WNL.
SKIN: no rash
PSYCH: A/O , calm, appropriate
Pertinent Results:
ADMISSION AND HOSPITAL COURSE LABS
[**2106-10-23**] 10:22PM PLT COUNT-227
[**2106-10-23**] 10:22PM NEUTS-55.7 LYMPHS-37.0 MONOS-5.2 EOS-1.4
BASOS-0.7
[**2106-10-23**] 10:22PM WBC-8.3 RBC-5.00 HGB-15.5 HCT-42.0 MCV-84
MCH-31.0 MCHC-36.8* RDW-13.5
[**2106-10-23**] 10:22PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.1
[**2106-10-23**] 10:22PM GLUCOSE-160* UREA N-15 CREAT-0.7 SODIUM-142
POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-19* ANION GAP-17
[**2106-10-23**] 10:30PM PT-17.9* INR(PT)-1.6*
[**2106-10-23**] 10:22PM BLOOD cTropnT-<0.01
[**2106-10-24**] 04:51AM BLOOD CK-MB-261* MB Indx-8.1* cTropnT-7.56*
[**2106-10-24**] 01:22PM BLOOD CK-MB-209* MB Indx-7.2*
[**2106-10-25**] 05:12AM BLOOD CK-MB-83* MB Indx-5.1
[**2106-10-23**] 10:22PM BLOOD CK(CPK)-106
[**2106-10-24**] 04:51AM BLOOD CK(CPK)-3224*
[**2106-10-24**] 01:22PM BLOOD CK(CPK)-2917*
[**2106-10-25**] 05:12AM BLOOD CK(CPK)-1614*
[**2106-10-24**] 04:51AM BLOOD Triglyc-155* HDL-34 CHOL/HD-6.3
LDLcalc-150*
.
DISCHARGE LABS
[**2106-10-27**] 07:15AM BLOOD WBC-8.0 RBC-4.70 Hgb-14.6 Hct-40.6 MCV-86
MCH-31.0 MCHC-35.9* RDW-13.4 Plt Ct-201
[**2106-10-25**] 05:12AM BLOOD PT-14.9* PTT-36.4* INR(PT)-1.3*
[**2106-10-27**] 07:15AM BLOOD Glucose-134* UreaN-19 Creat-0.8 Na-141
K-4.1 Cl-104 HCO3-28 AnGap-13
.
IMAGING
[**2106-10-23**] Cardiac Cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated two vessel coronary artery disease. The LMCA was
normal.
The LAD was patent. The LCx had less than 50% stenosis. The RCA
had a
70% mid-vessel lesion and a subtotal occlusion before the
bifurcation
with complete occlusion of the PDA.
2. Limited resting hemodynamics revealed systolic and diastolic
arterial
hypertension.
3. Successful aspiration thrombectomy, PTCA and stenting of the
distal
RCA into the PDA with a 3.0 x 18 mm Promus DES (see PTCA
comments).
4. Successful direct stenting of the mid RCA with a 3.5 x 28 mm
Promus
DES (see PTCA comments).
5. Successful RFA AngioSeal (see PTCA comments)
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal ventricular function.
3. Successful aspiration thrombectomy and PCI fo the distal RCA
into the
PDA with a 3.0 x 18 mm Promus DES.
4. Successful PCI of the mid RCA with a 3.5 x 28 mm Promus DES.
[**2106-10-24**] TTE:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with severe hypokinesis of the basal 2/3rds of the
inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 40-45 %). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size is normal with focal basal free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size with regional
biventricular systolic dysfunction c/w CAD (prox/mid RCA
distribution). Mild pulmonary artery systolic hypertension.
Brief Hospital Course:
Mr. [**Known lastname **] is a 54 yo male with PMH of hyperlipidemia who
presented with chest pain and found to have STEMI s/p 2
drug-eluting stent placement.
.
# Acute Inferior Myocardial Infarction (STEMI): Initial EKG
showed ST elevation in II, III, aVF, V5 and V6, as well as ST
depression in I, aVL, aVR, V1 and V2. Pt underwent emergent
catheterization, which revealed 70% stenosis of RCA, and 100%
occlusion of PDA. Aspiration thrombectomy was performed, and 2
Drug-Eluting Stents were placed (distal-RCA into PDA, mid-RCA).
Post-PCI echocardiogram performed on HD 2 was notable for mild
LV dysfunction, w/ EF of 40-45%, and severe hypokinesis of basal
[**3-4**] inferior/inferolateral walls and mild pulmonary
hypertension. His post-cath course was complicated by right
groin hematoma at the site of access on HD 2, but resolved
without intervention. He also developed low-grade temps to Tmax
of 100.5, but was without other concerning signs or symptoms for
infection or acute thromboembolic event. He was started Aspirin,
Plavix, Atorvastatin, Lisinopril, and Metoprolol. He tolerated
these medications well, and at time of discharge, pt had
experienced no observed arrhythmias on telemetry, and was
asymptomatic, feeling well and ready to go home.
.
# Hypertension: Pt was previously on HCTZ/lisinopril, stopped
secondary to side-effects (lightheadedness). He was started on
Metropolol and Lisinopril for long-term improved cardiac
outcome.
.
# Hyperlipidemia: At time of admission, pt was not on any
lipid-lowering medications, and lipid panel on this admission
revealed LDL of 150, borderline low HDL and TG 155. As pt is
status-post acute myocardial infarction, he was started on
atorvastatin, which will require long-term continuation.
.
TRANSITIONAL ISSUES:
- Will have follow-up with NP [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 67876**] on [**2106-11-4**],
previous outpatient Cardiology (Dr. [**Last Name (STitle) **] on [**2106-11-23**], and Dr.
[**Last Name (STitle) **] on [**2106-12-21**]
- Will recommend CBC + BMP check-up at first outpatient
consultation.
- Dry weight estimated at 89kg. Will aim for healthy weight
reduction via low-salt/low-fat cardiac diet.
Medications on Admission:
None.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol succinate 50 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*
6. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation myocardial infarction
Acute Systolic dysfunction
Dyslipidemia
Discharge Condition:
Medically Stable.
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 during your hospitalization
at [**Hospital1 69**]. You were admitted
because you had a heart attack. Images of your heart
(catheterization) showed that critical vessels that supply blood
to your heart were blocked, and so 2 stents (drug-eluting) were
placed in order to keep the blood vessels open. Echocardiogram
(which is an ultrasound of your heart) after the catheterization
procedure showed impaired heart function. These findings
predispose you to future heart problems, including fluid backup
in your lower extremities and lungs.
Please START taking the following medications in addition to
your home medications:
1. Metoprolol - to lower your heart rate, control your blood
pressure and help your heart pump better.
2. Atorvastatin - to lower your cholesterol and prevent future
plaque build-up in your heart's arteries.
3. Plavix - to prevent re-occlusion of your stented arteries or
blockage of the drug-eluting stent that was placed.
4. Aspirin - to prevent platelet blockage of the drug-eluting
stent that was placed.
5. Lisinopril - to control your blood pressure and help your
heart pump better.
6. Nitroglycerin - to alleviate heart-related chest pain. Please
take this medication if you have chest pain at home that is
similar to the chest pain that brought you to the hospital. Take
one tablet, wait 5 minutes, then take another tablet. Please
call 911 if you still have chest pain after 2 tablets, and
please call Dr. [**Last Name (STitle) **] if you use nitroglyerin at all.
It is very important that you are compliant with these
medications, especially Plavix (Clopidogrel) and Aspirin.
Skipping or changing doses of these medications can result in
life-threatening blockage of the arteries that were blocked
during this heart attack. Do not stop unless your cardiologist,
Dr. [**Last Name (STitle) **], tells you that it is ok.
In addition, please:
1. Weigh yourself every morning, and call your primary care
physician if your weight goes up by more than 3 lbs (total).
2. Continue the exercise plan that the physical therapist
discussed with you during this admission.
3. Involve your family and friends in your lifestyle
modifications (including low-salt/low-fat diet, aerobic exercise
and new medication regimen) in order to facilitate the long-term
maintenance of this care.
Thank you for entrusting your health to our staff. Please
contact the [**Name (NI) 91659**] ([**Telephone/Fax (1) 10339**]) if you have chest pain
again or any other concerning symptoms.
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] NP
Location: [**Hospital **] MEDICAL ASSOCIATES, P.C.
Address: [**Street Address(2) 75807**], STES 3A, B, [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 54268**]
Appointment: THURSDAY [**11-4**] AT 10:45AM
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **] MD
Specialty: CARDIOLOGY
Address: [**Street Address(2) 75807**],STE 2C, [**Location (un) **],[**Numeric Identifier 23881**]
Phone: [**Telephone/Fax (1) 44655**]
Appointment: TUESDAY [**11-23**] AT 10:30AM
Department: CARDIAC SERVICES
When: TUESDAY [**2106-12-21**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2106-10-27**] | [
"41401",
"2720",
"4019"
] |
Admission Date: [**2124-12-20**] Discharge Date: [**2124-12-26**]
Date of Birth: [**2046-8-3**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Lasix
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
fever, lethargy, swelling under chin, respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is 78 yo NH resident found to have fever (102.3) for 3 days
and cellulitis of the chin. Presented to the [**Hospital1 18**] ED on
[**2124-12-20**] with the above complaints. Also lethargic. Was
intubated in the ED for stidor and respiratory distress.
Past Medical History:
* Diabetes
* Hypercholesterolemia
* CHF: EF> 60% with LAE, 1+ MR [**First Name (Titles) **] [**Last Name (Titles) **] [**2-8**]; prior admissions
for overload
* hx of sacral decubitus ulcer
* hx of gastric ulcer
* osteomyelitis of the L4-L5 s/p laminectomy
* Cryptogenic Cirrhosis
* osteoarthritis
* Hypertension
* CAD (details unknown)
* h/o spontaneous PTX (with CT placement)
* nutritional deficiency
* hx of MRSA
Social History:
lives in [**Location **] x 3 years, daughter and son visit everyday. Former
25 pack-year smoking hx. No alcohol. Retired [**Last Name (un) 104638**] in
schools.
Family History:
Sister and Daughter with cryptogenic cirrhosis
Physical Exam:
100.1, 97.8, 65, 91/38, 12 99% intubated
Vent AC FiO2 50% PEEOP 5
CTA
RRR
Abd: soft, NT, ND
Neck: Swollen, erythematous, no crepitous
HEENT: MMM, no obvious abscess or cellulitis
Pertinent Results:
[**2124-12-20**] 10:50AM BLOOD WBC-8.6 RBC-2.82* Hgb-9.8* Hct-27.4*
MCV-97 MCH-34.9*# MCHC-35.9*# RDW-13.6 Plt Ct-106*
[**2124-12-20**] 10:50AM BLOOD Neuts-80* Bands-2 Lymphs-6* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2124-12-20**] 10:50AM BLOOD PT-14.0* PTT-24.8 INR(PT)-1.3
[**2124-12-20**] 10:50AM BLOOD Glucose-212* UreaN-16 Creat-0.7 Na-134
K-4.6 Cl-100 HCO3-20* AnGap-19
[**2124-12-20**] 10:50AM BLOOD ALT-26 AST-41* CK(CPK)-32 AlkPhos-139*
Amylase-45 TotBili-2.5*
[**2124-12-20**] 10:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
.
RADIOLOGY Final Report
CT NECK W/CONTRAST (EG:PAROTIDS) [**2124-12-20**] 1:02 PM
CT OF THE NECK WITH CONTRAST: The subcutaneous soft tissues of
the anterior neck are swollen with diffuse fat stranding
thickening and ill defined imaging of the fasical planes. The
process extends from the level of the clavicular heads to the
angle of mandible, and is more prominent on the right side.
Blurring of the fat planes between the anterior strap muscles
with increased asymmetric soft tissue infiltration both anterior
and posterior to the hyoid bone is noted, again largely right
sided Some suggestion of small ~1 cm fluid collections posterior
to the right submandibular gland and adjacent to the right
portion of the hyoid bone are found. Soft tissue stranding
extends to the right carotid sheath, blurring the fat plane.
However, both the internal jugular and carotid vasculature
within the neck enhance normally, with no evidence of filling
defects or irregularity.
The patient is intubated, likely accounting for a large amount
of fluid secretions within the nasopharynx, oropharynx, nasal
cavity, and right inferior maxillary sinus.
The base of the brain is unremarkable. No suspicious bone
lesions are found. Lung apices are clear.
IMPRESSION: Marked edema and stranding of the soft tissues of
the anterior neck as described, more prominent on the right
side, most consistent with cellulitis/fasciitis in light of the
provided history of infectious signs and symptoms. Possible
small, early fluid loculations adjacent to the right
submandiblaur gland and right portion of the hyoid bone.
.
RADIOLOGY Final Report
NECK,SOFT TISSUE US PORT [**2124-12-21**] 12:48 PM
COMPARISON: CT scan from [**2124-12-10**].
ULTRASOUND OF THE SOFT TISSUES OF THE NECK: There is edema of
the strap muscles, which is slightly more conspicuous deep neck
soft tissues above the hyoid, without any discrete fluid
collections.
IMPRESSION: Edematous changes within the strap muscles in the
soft tissues of the right neck, without any discrete fluid
collections. Results were discussed with the covering resident
after the study was performed.
.
Brief Hospital Course:
The patient was admited to the General Surgery service under Dr.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and placed in the SICU. IV Antibiotics were started
(Vanco, Zosyn, Clindamycin). ENT was consulted who agreed with
IV Abx and following the patient wihtout surgery if unless her
condition worsened. ON HD 2 the cellulitis was improved and
vent weaning began. On [**12-22**] decadron was started to help with
laryngeal swelling per the reccommendation of ENT; NG tube
placement was unsuccessful. There continued to be improvement in
the neck swelling/erythema and airwayu swelling. Pt was
extubated on [**12-23**] without event. On [**2124-12-24**] the patient was
started on a full liquid diet and transfered to the floor with
continued improvement of her clinical course. The antibiotics
were continued. A PICC line was placed on [**2124-12-24**]. The
morning of [**2124-12-25**] the patient was found to be in rate
controlled AFib. Given her rate control, multiple
comorbidities, and return to NSR, we opted not to anticoagulate.
There was worsening of the patients baseline anemia (HCT lowest
22.4). This anemia of acute disease was observed; given no
signs of hypovolemia, we opted not to transfuse.
On [**2124-12-26**] the patient was tolerating a regular diet, was
afebrile, and had no signs of cellulitis. She was discharged to
back to her Nursing Home to finish a 14-day course of
Vanco/Zosyn. Clindamycin was stopped [**2124-12-25**] per ID
recommendations.
Medications on Admission:
Tylenol, aldactone, insulin, doxepin, benadryl, nirtofuratone,
protonix, reglan, albuterol
Discharge Medications:
1. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 8 days.
Disp:*24 Recon Soln(s)* Refills:*0*
2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 8 days.
Disp:*8 1gm/200ml* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 10283**] Center - [**Location (un) **]
Discharge Diagnosis:
neck cellulitis
Discharge Condition:
good
Discharge Instructions:
Restart you home medications as usual. Regular diet. You may
resume activity as tolerated.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Return of erythema/swelling of neck
* Other symptoms concerning to you
Followup Instructions:
Call Dr.[**Name (NI) 22019**] office for a follow-up appointment ([**Telephone/Fax (1) 25089**]
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
| [
"4280",
"4240",
"42731",
"5990",
"2875",
"4019",
"2720",
"2859"
] |
Admission Date: [**2131-10-2**] Discharge Date: [**2131-10-12**]
Date of Birth: [**2074-8-16**] Sex: M
Service: SURGERY
Allergies:
Cellcept
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Trauma- MVC
Major Surgical or Invasive Procedure:
1. Intubation
2. Open reduction internal fixation right distal radius
History of Present Illness:
PI: The patient is a 57 yo male s/p renal transplant, HTN, IDDM
who was airlifted from OSH following MVA. History mainly
obtained
from records as patient was intubated.
Earlier tonight patient had MVA car versus tree accident with
moderate damage. He was unrestrained, airbag worked. According
to
the notes, he was able to ambulate at the scene and it is not
clear whether the patient lost consiousness. FSBS at scene was
52, for which he received an amp of D50.
He was brought to OSH. He had laceraration to his head and
periorbital ecchymoses. A CT head showed small SAH (R-frontal
and
temporal) and focal, punctate hemorrhage in R basal ganglia as
well as small vessel disease.
He was transferred to [**Hospital1 18**], where he was intubated in the OR
with fiberoptics as he had a raspy voice (according to his
daughter this is his baseline). Injuries include L-rib fractures
([**2-17**]), C1 fracture (minimally displaced), widened mediastinum. A
head CT was repeated.
Past Medical History:
1. Insulin dependent diabetes mellitus
2. Cerebral vascular event
3. Hypertension
4. Laproscopic cholecystectomy
5. Renal transplant x 2
Social History:
n/a
Family History:
n/a
Physical Exam:
A&Ox2
PERRLA left 2-->1mm
Right periorbital hematoma and multiple lacerations
CTA bilaterally
RRR
Abd soft, ntnd, foley in place
Rectal nml tone, heme negative
C spine ttp, no step off
Pertinent Results:
[**2131-10-2**] 10:47PM BLOOD WBC-16.9* RBC-4.09* Hgb-13.3* Hct-37.9*
MCV-93 MCH-32.5* MCHC-35.1* RDW-14.1 Plt Ct-147*
[**2131-10-3**] 02:50AM BLOOD WBC-11.1* RBC-3.44* Hgb-10.9* Hct-31.7*
MCV-92 MCH-31.7 MCHC-34.5 RDW-14.1 Plt Ct-136*
[**2131-10-3**] 04:13PM BLOOD WBC-14.2* RBC-3.16* Hgb-10.4* Hct-29.6*
MCV-94 MCH-33.0* MCHC-35.2* RDW-14.2 Plt Ct-127*
[**2131-10-4**] 01:53AM BLOOD WBC-13.4* RBC-3.03* Hgb-9.7* Hct-28.7*
MCV-95 MCH-31.8 MCHC-33.6 RDW-14.3 Plt Ct-137*
[**2131-10-5**] 02:09AM BLOOD WBC-10.4 RBC-2.77* Hgb-8.8* Hct-25.5*
MCV-92 MCH-31.9 MCHC-34.7 RDW-14.0 Plt Ct-120*
[**2131-10-5**] 11:10AM BLOOD WBC-11.5* RBC-2.82* Hgb-9.1* Hct-26.1*
MCV-93 MCH-32.4* MCHC-34.9 RDW-14.0 Plt Ct-121*
[**2131-10-6**] 02:46AM BLOOD WBC-11.5* RBC-2.91* Hgb-9.1* Hct-26.7*
MCV-92 MCH-31.3 MCHC-34.1 RDW-13.8 Plt Ct-173
[**2131-10-7**] 03:09AM BLOOD WBC-7.9 RBC-2.68* Hgb-8.6* Hct-24.2*
MCV-90 MCH-32.1* MCHC-35.7* RDW-13.8 Plt Ct-170
[**2131-10-11**] 04:55AM BLOOD WBC-7.6 RBC-3.28* Hgb-10.2* Hct-29.9*
MCV-91 MCH-31.2 MCHC-34.2 RDW-14.0 Plt Ct-530*
[**2131-10-2**] 10:47PM BLOOD PT-13.6* PTT-20.8* INR(PT)-1.2
[**2131-10-2**] 10:47PM BLOOD Plt Ct-147*
[**2131-10-3**] 02:50AM BLOOD PT-13.8* PTT-23.6 INR(PT)-1.3
[**2131-10-3**] 02:50AM BLOOD Plt Ct-136*
[**2131-10-3**] 04:13PM BLOOD Plt Ct-127*
[**2131-10-5**] 02:09AM BLOOD Plt Ct-120*
[**2131-10-5**] 11:10AM BLOOD Plt Ct-121*
[**2131-10-6**] 02:46AM BLOOD Plt Ct-173
[**2131-10-10**] 01:52AM BLOOD Plt Ct-423#
[**2131-10-11**] 04:55AM BLOOD Plt Ct-530*
[**2131-10-2**] 10:47PM BLOOD Fibrino-369
[**2131-10-6**] 10:50AM BLOOD Parst S-NEGATIVE
[**2131-10-3**] 02:50AM BLOOD Glucose-230* UreaN-17 Creat-0.8 Na-138
K-4.4 Cl-105 HCO3-26 AnGap-11
[**2131-10-3**] 04:13PM BLOOD Glucose-142* UreaN-16 Creat-0.8 Na-137
K-4.4 Cl-104 HCO3-26 AnGap-11
[**2131-10-4**] 01:53AM BLOOD Glucose-210* UreaN-15 Creat-0.8 Na-138
K-4.5 Cl-106 HCO3-24 AnGap-13
[**2131-10-5**] 02:09AM BLOOD Glucose-68* UreaN-11 Creat-0.8 Na-141
K-3.9 Cl-108 HCO3-26 AnGap-11
[**2131-10-5**] 11:10AM BLOOD Glucose-181* UreaN-15 Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-24 AnGap-14
[**2131-10-7**] 03:09AM BLOOD Glucose-141* UreaN-19 Creat-0.8 Na-136
K-4.3 Cl-103 HCO3-25 AnGap-12
[**2131-10-8**] 01:52AM BLOOD Glucose-229* UreaN-21* Creat-0.8 Na-137
K-4.4 Cl-104 HCO3-25 AnGap-12
[**2131-10-11**] 04:55AM BLOOD Glucose-51* UreaN-16 Creat-0.9 Na-136
K-5.0 Cl-103 HCO3-21* AnGap-17
[**2131-10-2**] 10:47PM BLOOD Amylase-71
[**2131-10-3**] 02:50AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.5*
[**2131-10-11**] 04:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
[**2131-10-7**] 08:57AM BLOOD Vanco-6.7*
[**2131-10-4**] 01:53AM BLOOD Phenyto-9.0*
[**2131-10-5**] 02:09AM BLOOD Phenyto-7.0*
[**2131-10-2**] 10:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-10-5**] 12:14PM BLOOD FK506-LESS THAN
[**2131-10-6**] 02:46AM BLOOD FK506-7.8
[**2131-10-11**] 10:03AM BLOOD FK506-PND
[**2131-10-3**] 12:16AM BLOOD Type-ART pO2-166* pCO2-42 pH-7.41
calHCO3-28 Base XS-2
[**2131-10-7**] 07:21PM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-129*
pCO2-38 pH-7.46* calHCO3-28 Base XS-3
Brief Hospital Course:
Admitted to trauma service T-SICU. Intubated and sedated. Seen
by orthopedics for radius fracture and unltimately ORIF ([**10-5**])
of radius without complication. Evaluated by Orthopedic spine
service- recommended continued hard cervical collar. Transplant
nephrology followed throughout his hopsitalization. Patient was
febrile through his stay in the SICU and treated with Vancomycin
and Zosyn empirically.
Video swallow study on HD6 revealed mild oral and mild to
moderate pharyngeal dysphagia [**1-17**] tongue weakness. This
resulted in recommendation for ground consistency diet with thin
liquids
Patient extubated on HD 4 ([**10-4**])
HD 11: Patient with continued waxing and [**Doctor Last Name 688**] baseline
confusion (oriented to person and intermittently to time).
Repeat Head CT revealed decreased intracranial bleed. CT Sinus
revealed nondisplaced posterior wall fracture of the maxillary
sinus with fluid ni the left maxillary and bilateral ethmoid
sinuses. CT cervical spine revealed know right C1 lateral mass
fracture. Continued on immunosuppressive therapy for
transplant.
Medications on Admission:
See admission H & P
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
Disp:*30 Tablet(s)* Refills:*0*
3. Albuterol Sulfate 0.083 % Solution Sig: [**12-17**] Inhalation Q6H
(every 6 hours) as needed.
Disp:*1 1* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Prednisone 5 mg Tablet Sig: 1.5 tabs Tablets PO at bedtime:
TOTAL DOSE 7.5 mg PO QD.
Disp:*60 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Azathioprine 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*20 * Refills:*2*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. Right subarachnoid hemorrhage
2. Thalamic contusion
3. 1st cervical vertebrae lateral mass fracture
4. Right distal radius fracture
5. Left sided rib fractures (Rib 1, [**2-20**])
6. Pulmonary contusion
Discharge Condition:
Stable
Discharge Instructions:
1. Wear cervical collar at ALL TIMES
2. Physical therapy, occupational therapy, speech therapy
3. Neuro rehab per protocols of accepting facility
4. Follow daily tacrolimus (FK05) levels
Followup Instructions:
1. Trauma clinic in 2 weeks [**Telephone/Fax (1) 24689**]
2. [**Hospital **] clinic [**Telephone/Fax (1) 9769**]
3. Orthopedic spine clinic in 6 weeks. Call [**Telephone/Fax (1) 54028**]
4. Follow up with your transplant doctor within 1-2 weeks
| [
"4019",
"25000",
"V5867"
] |
Admission Date: [**2200-11-27**] Discharge Date: [**2201-2-10**]
Date of Birth: [**2142-2-13**] Sex: M
Service: MEDICINE
Allergies:
Dofetilide / Lipitor / Haldol / Reglan
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
multiple ET intubation during 3 MICU admissions (now extubated)
right IJ [**2200-12-10**] (removed)
right PICC line placement [**2201-1-5**] (removed)
NGT placement [**2201-1-7**] (removed)
left PICC line placement [**2201-1-27**] (still in place)
NGT placement [**2201-1-30**] (removed)
2 units of pRBC transfusion ([**2201-1-31**] and [**2200-12-24**])
1 unit of plate transfusion ([**2201-1-30**])
History of Present Illness:
The patient is a 58 year old male with severe cardiomyopathy (EF
~20%) who was seen in ED in [**Month (only) **] and treated for a pneumonia. He
now presents with progressive symptoms including sinus pain,
cough, rhinorrhea, headache and mild shortness of breath. He
describes his cough as productive of pink sputum. He denies any
lower extremity edema. The patient first presented to the ED
on [**2200-11-5**] and was evaluated in the emergency department and
found to have a RML pneumonia. He was discharged with a Z-pack
but this was later changed to levofloxacin given concern for a
possible interaction with amiodarone. He completed a 7 day
course of levofloxacin with great improvement in his symptoms.
Approximately six days prior to this presentation, he began to
have recurrence of his symptoms. He took three days of
amoxicillin 500 mg, which he had left over from a previous
dental procedure. This has made him feel somewhat better. On
[**11-24**], he presented to his PCP. [**Name10 (NameIs) **] that time a repeat CXR
showed "probable partial resolution of a right-sided pneumonia."
His symptoms continued to worsen over the next three days and
his PCP ultimately advised him to come to the emergency
department.
.
In the ED, vital signs were T 100.5, HR 69, BP 98/66, RR 20, O2
sat 97%. He received 500 mg levofloxacin and was admitted to the
floor.
Past Medical History:
1. Dilated cardiomyopathy of unclear etiology (EF=20 percent)
2. 3+ MR (s/p repair [**8-29**] at [**Hospital1 112**])
3. AF (s/p maze procedure [**8-29**], AV paced, on coumadin and
amiodarone)
4. COPD: PFT [**5-30**](FVC=2.86, FEV1=2.28, MMF=2.09, FEV1/FVC=80)
5. Hypercholesterolemia
6. AICD with pacer placement in [**12-28**] following an episode of
NSVT
7. Polymorphic ventricular tachycardia [**2-27**] dofetilide therapy
8. CAD s/p IMI in [**2189**] LAD stent in [**12-28**] (patent on cath [**8-29**]),
s/p SVG to OM1
9. Depression/anxiety
Social History:
He has a 20pk/yr smoking history but quit over 10yr ago. Denies
any intravenous drug use or alcohol use. Lives in [**Hospital1 392**] w/ his
girlfriend and has a 11yr old son who does not live with him.
Does not work but used to work for a security company and a
catering company.
Family History:
Noncontributory
Physical Exam:
VS - T 100.5, BP 106/69, HR 69, RR 20, O2 sat 93% on RA
GEN - well appearing male, lying in bed in NAD, occastionally
coughing
HEENT - no LAD, sclera anicteric, no conjunctival palor
CV - rrr, III-IV/VI systolic murmur, best heard at apex with
radiation to axilla
PULM - crackles at left base and right middle areas; good
inspiratory effort
ABD - soft, non-tender, non-distended
EXT - warm, no edema
Pertinent Results:
Admission Labs:
[**2200-11-27**] 02:07PM LACTATE-2.2*
[**2200-11-27**] 02:00PM UREA N-13 CREAT-1.1 SODIUM-138 POTASSIUM-5.0
CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
[**2200-11-27**] 02:00PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-2.0
[**2200-11-27**] 02:00PM WBC-13.0* RBC-4.41* HGB-14.3 HCT-45.4
MCV-103* MCH-32.5* MCHC-31.6 RDW-13.7
[**2200-11-27**] 02:00PM NEUTS-83.1* LYMPHS-9.5* MONOS-6.3 EOS-0.4
BASOS-0.8
[**2200-11-27**] 02:00PM PLT COUNT-161
[**2200-11-27**] 02:00PM PT-21.0* PTT-29.3 INR(PT)-2.0*
MICU Admission Labs:
[**2200-11-30**] 01:59PM BLOOD WBC-23.8*# RBC-4.24* Hgb-14.4 Hct-44.0
MCV-104* MCH-34.0* MCHC-32.7 RDW-14.1 Plt Ct-147*
[**2200-11-30**] 05:30AM BLOOD Neuts-76* Bands-2 Lymphs-9* Monos-5
Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2200-12-2**] 11:50AM BLOOD PT-53.5* PTT-42.9* INR(PT)-6.4*
[**2200-12-2**] 11:50AM BLOOD Fibrino-746* D-Dimer-3362*
[**2200-11-30**] 01:59PM BLOOD Glucose-138* UreaN-44* Creat-2.5* Na-134
K-5.4* Cl-97 HCO3-16* AnGap-26*
[**2200-11-30**] 01:59PM BLOOD ALT-50* AST-110* LD(LDH)-848* CK(CPK)-49
AlkPhos-74
[**2200-11-30**] 05:30AM BLOOD proBNP-6548*
[**2200-12-1**] 03:17PM BLOOD Cortsol-27.0*
[**2200-12-1**] 05:29PM BLOOD Cortsol-36.9*
[**2200-12-2**] 11:50AM BLOOD ANCA-NEGATIVE B
[**2200-11-30**] 02:09PM BLOOD Lactate-10.9* K-5.3
[**2200-11-30**] 04:00PM BLOOD O2 Sat-74
.
Discharge labs:
[**2201-2-10**] 06:04AM BLOOD WBC-10.0 RBC-2.71* Hgb-9.2* Hct-29.7*
MCV-110* MCH-33.9* MCHC-30.8* RDW-21.5* Plt Ct-67*
[**2201-2-10**] 06:04AM BLOOD PT-11.4 PTT-26.5 INR(PT)-1.0
[**2201-2-10**] 06:04AM BLOOD Glucose-119* UreaN-36* Creat-0.3* Na-143
K-3.8 Cl-112* HCO3-25 AnGap-10
[**2201-2-10**] 06:04AM BLOOD ALT-75* AST-49* LD(LDH)-546* CK(CPK)-25*
AlkPhos-325* TotBili-2.3*
[**2201-2-10**] 06:04AM BLOOD Albumin-1.9* Calcium-7.9* Phos-3.0 Mg-2.1
Other Labs:
[**2200-12-2**] 11:50AM BLOOD ESR-66*
[**2200-12-24**] 03:36AM BLOOD Parst S-NEG
[**2201-1-3**] 04:34AM BLOOD LAP-154*
[**2200-11-30**] 01:59PM BLOOD CK-MB-3 cTropnT-0.05*
[**2200-11-30**] 10:49PM BLOOD CK-MB-5 cTropnT-0.08*
[**2200-12-1**] 04:23AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2200-12-22**] 03:28PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2200-12-23**] 02:45AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2201-1-24**] 09:40PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2201-2-6**] 02:54PM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2201-2-7**] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2201-2-7**] 07:09AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2201-2-9**] 06:36AM BLOOD CK-MB-7 cTropnT-0.06*
[**2201-2-9**] 12:08PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2201-2-10**] 06:04AM BLOOD cTropnT-0.08*
[**2201-1-20**] 03:59AM BLOOD Triglyc-539*
[**2201-2-8**] 08:26AM BLOOD Triglyc-278* HDL-17 CHOL/HD-12.7
LDLcalc-143*
[**2200-12-22**] 03:28PM BLOOD T3-125 Free T4-GREATER TH
[**2200-12-23**] 02:45AM BLOOD T4-22.2* calcTBG-0.31* TUptake-3.23*
T4Index-71.7*
[**2200-12-24**] 03:36AM BLOOD T4-20.2* T3-105 Free T4-6.2*
[**2200-12-25**] 03:50AM BLOOD T4-20.8* T3-97 Free T4-7.3*
[**2200-12-26**] 04:20AM BLOOD T4-20.4* T3-93 Free T4-6.1*
[**2200-12-27**] 04:56AM BLOOD T4-18.5* T3-88
[**2200-12-28**] 02:57AM BLOOD T4-15.7* T3-82
[**2200-12-29**] 03:23AM BLOOD T4-13.5* T3-74*
[**2200-12-29**] 10:31AM BLOOD T4-16.0* calcTBG-0.53* TUptake-1.89*
T4Index-30.2*
[**2200-12-30**] 05:15AM BLOOD T4-15.2* T3-69*
[**2201-1-6**] 05:13AM BLOOD T4-19.3* T3-99 Free T4-6.2*
[**2201-1-7**] 04:15PM BLOOD T4-GREATER TH T3-116 calcTBG-0.31*
TUptake-3.23*
[**2201-1-9**] 05:34AM BLOOD T4-24.6* T3-115 calcTBG-0.28*
TUptake-3.57* T4Index-87.8*
[**2201-1-11**] 04:30AM BLOOD T4-24.3* T3-113 calcTBG-0.33*
TUptake-3.03* T4Index-73.6*
[**2201-1-13**] 05:41AM BLOOD T4-18.4* T3-88 calcTBG-0.48*
TUptake-2.08* T4Index-38.3*
[**2201-1-21**] 03:08AM BLOOD T4-11.4 T3-47* calcTBG-0.72*
TUptake-1.39* T4Index-15.8*
[**2201-2-3**] 03:29AM BLOOD T4-7.9 T3-45* Free T4-1.7
.
Microbiology:
[**2200-11-28**] Urine Legionella - negative
[**2200-11-29**] Blood cultures - NGTD
[**2200-11-30**] Viral antigen panel - negative, cultures pending
[**2200-11-30**] Urine culture - negative
[**2200-11-30**] BAL - 4+ polys, gram stain negative, PCP neg, AFB neg,
cultures negative
[**2200-12-1**] Blood cultures, urine cultures - negative
[**2200-12-3**] Blood cultures, urine cultures - negative
[**2200-12-3**] Sputum cultures - 2+ yeast
[**2200-12-3**] Stool - C. diff negative
[**2200-12-5**] Blood, urine cultures - NGTD
[**2200-12-5**] Sputum cultures - yeast
[**2200-12-7**] Blood, urine cultures - NGTD
[**2200-12-8**] Stool - C. diff negative
[**2200-12-9**] Blood, urine cultures - NGTD
.
Imaging and studies:
CXR ([**2200-11-27**]) Comparison is made with the prior chest x-ray of
[**11-24**]. Since that time, there has been increase in density
in the right mid zone. The heart remains enlarged. The
costophrenic angles are sharp. These findings suggest [**Month (only) 9140**]
of the right-sided pneumonia which probably lies in the apical
segment of the right lower [**Month (only) 3630**].
.
TTE [**2200-12-1**]: The left atrium is moderately dilated. No definite
intracardiac shunt identified. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated
with severe global hypokinesis and septal dysynchrony. Right
ventricular chamber size is normal with moderate global free
wall hypokinesis. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened with mildly restrained leaflets. The annuloplasty
ring is well seated but with increased gradient c/w mild
functional mitral stenosis. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is an anterior space which most likely
represents a fat pad. Compared with the prior study (images
reviewed) of [**2200-9-11**], the severity of mitral regurgitation is
lower (may be related to acoustic shadowing). The transmitral
gradient has increased (previously 5mmHg mean) and the estimated
mitral valve area is smaller (prior P1/2 time 95ms). Left
ventricular systolic function is more depressed (global) -EF
20%.
CXR [**1-24**]:
[**Month/Year (2) **] air space disease bilaterally, right greater than
left. Complement of superimposed failure may be present but lack
of distention of the pulmonary vessels and persistent sharp
features of the costophrenic sulci suggest otherwise.
.
Thyroid U/s ([**2200-12-11**])
IMPRESSION: This is a normal EEG recording during stage II
sleep. No
epileptiform features or focal slowing were noted. However, only
a very
brief period of wakefulness was recorded, precluding a full
evaluation
for possible encephalopathy. If clinical suspicion for
encephalopathy
remains, a repeat study during wakefulness could be considered.
.
[**Month/Day/Year **] ([**2200-12-29**])
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is moderately dilated with
moderate
regional systolic dysfunction with near akinesis of the inferior
and
inferolateral walls and mild hypokinesis of remaining segments.
Right
ventricular cavity size is normal with mild global free wall
hypokinesis.
There is abnormal septal motion/position. The aortic valve
leaflets appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. A mitral valve annuloplasty
ring is present. There is a minimally increased gradient
consistent with trivial mitral stenosis. Trivial mitral
regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be quanitified.There is no pericardial
[**Month/Day/Year 17838**].
.
EEG ([**2201-1-18**])
IMPRESSION: This is a normal EEG recording during stage II
sleep. No
epileptiform features or focal slowing were noted. However, only
a very
brief period of wakefulness was recorded, precluding a full
evaluation
for possible encephalopathy. If clinical suspicion for
encephalopathy
remains, a repeat study during wakefulness could be considered.
CT [**1-22**]:
1. Abnormal markedly distended urinary bladder with mild
hydroureter and hydronephrosis bilaterally in the setting of
well positioned Foley catheter. This likely is due to
obstruction of the catheter system and flushing or replacement
is recommended. No other cause for lower quadrant intraabdominal
pain identified.
2. Nonspecific opacities within the right middle [**Month/Year (2) 3630**] and left
lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] represent resolving pneumonia, however acute
infectious process or chronic interstitial process (especially
within the lower [**First Name3 (LF) 3630**]) cannot be excluded. Moderate right-sided
pleural [**First Name3 (LF) 17838**] and compression atelectasis.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Simple right renal cyst.
5. Mild amount of intraabdominal and pelvic free fluid.
.
Abd U/S ([**2201-1-31**]):
RIGHT UPPER QUADRANT ULTRASOUND: Limited evaluation of the
liver shows no evidence of biliary ductal dilatation. A
gallstone is noted in the fundus of the gallbladder. The
gallbladder wall is normal with no gallbladder distention or
pericholecystic fluid. There is no extrahepatic biliary ductal
dilatation with the common duct measuring 4 mm.
IMPRESSION: Cholelithiasis, without evidence of biliary ductal
obstruction or cholecystitis.
.
CXR ([**2201-2-1**])
The previously seen Dobbhoff tube in the right mainstem bronchus
has been removed. There is a feeding tube with the distal tip
beyond the pylorus. There is a left-sided AICD, unchanged.
There are again noted diffuse airspace opacities bilaterally
with relative sparing in the left upper lung zone. This may be
secondary to underlying pulmonary edema versus multifocal
pneumonia. There are streaky densities at the left base
consistent with subsegmental
atelectasis. There is a small right-sided pleural [**Month/Day/Year 17838**].
.
CT abd ([**2201-2-7**])
IMPRESSION:
1. Persistent linear opacities at the left lung base. Interval
change in
configuration of opacities in the right middle [**Month/Day/Year 3630**] with an
appearance of
nodular density. Decrease in size of right-sided pleural
[**Month/Day/Year 17838**] with
persistent compression atelectasis.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Multiple hypoattenuating lesions in both kidneys, most of
which are too
small to characterize.
4. Slightly increased amount of the pelvic ascites.
5. Resolution of abnormally distended urinary bladder and
hydroureter.
.
CXR ([**2201-2-8**])
There has been interval removal of the feeding tube. The left
AICD is
unchanged. Sternal wires are unchanged. Again noted are
diffuse interstitial
infiltrates with more focal infiltrate in the left lower [**Month/Day/Year 3630**].
This left
lower [**Month/Day/Year 3630**] infiltrate is slightly more confluent than on the
film from the
prior week.
Brief Hospital Course:
The patient is a 58 year old male with dilated cardiomyopathy
who presents with cough, fevers and increased shortness of
breath after a recent course of antibiotics for a pneumonia.
Breif summary:
[**11-27**] - [**11-30**]: admitted to the medicine service for pneumonia
[**11-30**] - [**1-4**]: admitted to the MICU for respiratry failure,
intubated until [**12-31**].
[**1-4**] - [**1-13**]: transferred to the floor, medicine
[**1-13**] - [**1-21**]: readmitted to the MICU for repeat resp distress
[**1-21**] - [**1-25**]: readmitted to the floor
[**1-25**] - [**2-3**]: readmitted to the MICU with CHF excerbation
[**2-3**]: transferred to the floor.
58 year old gentleman with atrial fibrillation, iCMP (EF of
20%), h/o VT on amiodarone, s/p pacemaker, CAD s/p CABG, COPD,
who was initially admitted for pneumonia, but has had a complex
hospital course included 3 MICU admissions, hypoxic respiratory
failure secondary to pneumonia/CHF exacerbation,
amiodarone-related thyrotoxicosis, ARF (resolved Cr peaked at
2.4, now resolved 0.4 today)leukocytosis, and thrombocytopenia,
vocal cord paralysis.
.
the patient was originally admitted to medicine on [**11-27**] for
pneumonia. On [**11-30**] the patient developed hypotension and
hypoxic respiratory failure, was intubated, placed on triple
pressors and transferred to MICU. He was on levaquin on
admission, started on broad spectrum antibiotic course on MICU
transfer which included azithromycin, ceftriaxone, and
vancomycin. Pt also received flagyl course empirically for c.
diff. MICU stay was prolonged and difficult. Pt was weaned off
pressors by [**12-8**] but could not be extubated until [**12-31**]
secondary to pneumonia and pulmonary edema related to
decompensated cardiomyopathy that was difficult to manage in the
setting of sepsis. The patient was also persistently febrile
until [**12-31**]. No source could definitively be identified. Chest
x-ray did reveal bilateral air space opacities. Numerous blood,
urine and sputum cultures were not revealing of a source. BAL
lavage was also unrevealing. DFA, viral cultures and legionella
were negative.
.
The patients stay was further complicated by amiodarone related
thyrotoxicosis, type II. Pt was started on steroids for this
reason. Tapazole was briefly given but discontinued for
secondary rise in LFT's and belief that this was type II.
Thyrotoxicosis did not resolve. In addition, the pt had
persistently elevated WBC--elevated LAP score pointed to
leukemoid reaction.
.
The patient was transferred to the general medical floor on
[**1-4**]. By that point his fevers had resolved and his respiratory
status were satisfactory. Notably his mental status remained
poor since his extubation. On the floor he was persistently
delirious. His WBC remained elevated and he was intermittently
tachycardic. His thyrotoxicosis did not resolve despite
increased dosing of decadron. From [**1-12**] to [**1-13**] the pt
developed diarrhea. On [**1-13**], the pt developed a fever to 103.9
and became tachycardic to the 140's. Vancomycin and zosyn was
empirically started. It was also believed the mental status was
somewhat worse. Laboratories revealed WBC of 24.5 from 21.6 and
lactate of 2.6. Urinalysis and CXR was unrevealing. Pt was
transferred to MICU given septic physiology.
.
While in the MICU patient improved. He had an NGT placed as he
failed speech and swallow. In terms of thyrotoxicosis patient
followed with endocrine, continued on steroids and
Cholestyramine which was stopped on [**1-21**]. Patient was also
noted to have thrombocytopenia so HIT Ab was sent which was
negative. Antibiotics were stopped on [**1-17**]. Patient was called
out to the floor on [**1-21**].
.
Patient was maintained on 6L of shovel mask until [**1-25**], when he
was noted to be more hypoxic. He pulled off his FM in the AM and
O2 sats were 68% on RA transiently. His sats, which had been in
the mid 90s over the past few days dropped to the low 90s on 10L
mask. Pt had progressively [**Month/Day (4) 9140**] tachypnea and increasing O2
requirement on [**1-25**]. His ABG on a facemask was 7.55/30/49. He
was placed on a 100% NRB. He was given 20 of IV lasix at 5 pm
and put out 1 L in 2 hours. CXR done in the morning shows
[**Month/Day (4) 9140**] bilateral airspace disease and possible component of
pulmonary edema. He was again admitted to MICU for hypoxia and
pulmonary edema on [**1-25**].
.
While at the MICU for the 3rd time, he was treated for CHF
exacerbation with IV lasix which he responded and his pulmonary
status gradually improved; it was noted that he had melena on
[**2201-1-31**] and drop in HCT with Hct nadired on [**2201-1-29**] at 23.6; GI
was consulted, given pt HD stable and responded well to
transfusion (1 unit during this MICU admission), EGD was held
for now, and conservative management unless acute bleeding.
Given his complicated hospital course, a family meeting was held
on [**2201-2-2**] at which time pt was made DNR/DNI, no PEG placement,
and he expressed wishs to be made comfortable; His defibrilator
was turned off by EP per pt's request on [**2201-2-3**], and his pacer
was left in place; Given his vocal cord paralysis, PEG has been
recommended, however, pt currently refusing replacement of
Dobhoff or feeding device, and prefered to eat by PO with
understanding that po puts pt at very high risk for aspiration.
he is being called to the floor on [**2201-2-3**] for further discussion
of long term goal of his care.
On the floor, he remained afebrile, and his SBP remained
80-100s, with transient drop of SBP to 68-72s and responded to
fluid bolus IVNS 500cc; goals of care were readdress with the
patient and his guardian (please see goals of care note by Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 12879**], and pt expressed wishes to give IV TPN,
PT and reahab a try, but goals of care needs to be readdress if
siutation arises that he needs to be transferred to the MICU or
coming back to the hospital after being discharged to rehab.
He was started on IV TPN on [**2201-2-6**] and PT started working with
the patient over the weekend of [**2201-2-7**] to get patient
ready for rehab placement.
Some of the other issues not addressed above are listed below:
Acute Renal Failure: On the morning of [**2200-11-30**] the patient's
creatinine was noted to have increased from 1.0 to 2.5 and
ultimately peaked at 3.0 with associated decreased urine output.
His renal failure occured in the setting of increased NSAID
use, hypotension and new onset peripheral eosinophilia at 8%.
Urine electrolytes revealed a FENA of 1.2 % in the setting of
lasix use. Urinalysis showed many WBCs but no eosinophils.
Urine did not contain muddy brown casts. The differential
diagnosis for his acute renal failure included both prerenal
azotemia, acute tubular necrosis and acute interstitial
nephritis. He received IV fluids and pressure support to
maintain his renal perfusion. NSAIDS were immediately
discontinued. Ceftriaxone was also discontinued given concern
for AIN. His renal function quickly improved with return to
baseline creatinine by MICU day 8. On floor, renal function
remained NL, w/Cr 0.3-0.4.
.
Thryotoxicosis: The patient was found to have elevated T4 and T3
levels and undetectable TSH on the [**11-21**], three weeks
into his hospital course. He was treated with Methamizol and
Dexamethasone. Methamizole was subsequently discontinued because
of LFT elevation. Dexamethasone was tapered. TFT were trending
down. Endocrinology was following. As the patient is dependent
on Amiodaron for prevention of VT/Vfib it was continued. If the
patient has recurrent problems due to thyroid hyperactivity,
radioablation of the thyroid has to be considered. T4/T3 levels
continued to trend down on the floor, but not to the point that
steroids could be tapered. pt needs to continued for 2-3 months
on IV methylpredinosolone 40mg, then continued a slow taper
after than by for the next month. He needs to have his Thyroid
function test checked weekely after discharge;
.
Thrombocytopenia: Pt. with falling platelet count starting
[**1-9**]. Reached nadir oof 23 on [**2201-1-23**], then plateaued.
Unclear etiology, but possibilities include amiodarone,
methamazole. HIT seems less likely given negative HIT antibody
x2. As plt count continued to decline on floor, hematology was
consulted; he received a total of 1 unit of platelets during
this admission and currently on steroids for amiodorone induced
thyrotoxicosis. His Plateletes remained stable in the 50,0000s
at the time of discharge.
.
Dilated cardiomyopathy: [**Date Range 461**] was performed on [**2200-12-1**]
and [**12-31**] revealed severe LV global hypokinesis with an ejection
fraction of 20%. Given his intial hypotension his outpatient
cardiac regimen was held. Once his blood pressure had
stabilized off pressors he was restarted on his outpatient
eplerenone, ace-inhibitor and beta blocker; He was found to be
in thyroid storm which is likely partly repsonsible for his
worsened cardiac function. However, his meds were d/c'ed except
metoprolol given his low BP at baseline prior to discharge.
.
Mitral Regurgitation: The patient has known 3+ MR status post
mitral valve repair in [**2198**]. Repeat [**Year (4 digits) 113**] on this admission
revealed 1+ mitral regurgitation. It was felt that this issue
was stable throughout this admission.
.
Atrial Fibrillation: The patient is status post maze procedure
in [**2198**]. The patient is also status post AICD placement for
NSVT and throughout this hospitalization he was noted to be in
either an atrial or ventricularly paced rhythm. Given initial
concern that amiodarone might be contributing to his [**Year (4 digits) 9140**]
pulmonary function his amiodarone was held for the majority of
his hospitalization, but was then reintroduced when his
pulmonary process became more clearly pulmonary edema. He went
into a run of VT/Vfib with very frequent shocks and was reloaded
with amiodarone drip x 1 day and was transitioned to amiodarone
200daily. EP changed his pacer settings to shock for VT with
rate>183 and for VF. When he was discovered to have
thyrotoxicosis he was started on an esmolol drip which improved
his ectopy. He was then transitioned back to oral beta
blockers. On the floor, pt had HR in 70's-90's, and was in
sinus rhythm on telemetry. During his 3rd MICU admissions, pt
decided to deactivate his AICD, and we continue to hold off his
amiodorone given his pulm toxicity.
.
Cardiac: The patient is status post inferior MI in [**2189**] and
stent placement in [**2197**]. His EKG was unchanged during this
admission. Cardiac enzymes were unremarkable on admission to
the MICU, which was rechecked while he was called to the floor
as pt had multiple chest pain complaints (ECGs were paced, CE
unremarkable); He had two [**Year (4 digits) 113**] done during this admission which
remained poor EF 20%; However, ASA were stopped due to
thrombocytopenia, melena with Hct drop; After he was kept on
beta blocker (although didn't get much due to aspiration and
hypotensive episodes by either mouth or IV), and all other
Cardiac meds were d/c'ed prior to discharge due to low BP; He
was to follow up with cardiology to address whether his cardiac
meds need to be restarted;
Depression/anxiety: Was continued on lexapro, then this was
stopped when he was not taking POs. Pt became very depressed and
psych was consulted. we restarted him on lexapro on [**2-3**] ( 5mg
qday x 1 week, then increase to 10mg qday after that); see goals
of care/code status below.
Nutrition: The patient required a short course of TPN during his
MICU course and otherwise received tube feeds while intubated
for his nutritional needs. On the floor, he was reevaluated by
speech and swallow and found to be completely unable to swallow
any fluids without aspiration. Initially, he was amenable to a
PEG tube, but this was been delayed in setting of
thrombocytopenia. However, on transfer to the floor on [**2-3**], he
was interested in the Dauboff out and no PEG placed. He
understands that he may aspirated and die by making this
decision; intially on the floor he expressed no interested of
TPN or PEG, but on [**2201-2-6**] agreed to IV TPN for nutritional
support, he was made NPO, but agreed to give small amounts of
apple sauce, ice chips, small amounts of water, and small
amounts of pureed foods for comfort, but remained for full
aspiration precautions.
Goals of care/Code: Initially he was full Code. However, after
the prolonged hospital course, he voiced sentiments of being
CMO. A family meeting with the MICU team and his guardian
decided goals of care. The paitent was changed to DNR/DNI after
this meeting on [**2-2**]. In congruence with this decision, the ICD
were inactivated on [**2-3**] and his Dauboff was removed. If
situation arises (any fever, chill, chest pain, SOB, or any
concerning symptoms), please contact patient's gaudian ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 108846**] home [**Telephone/Fax (1) 108847**], cell [**Telephone/Fax (1) 108848**] work [**Telephone/Fax (1) 108849**]),
goals of care needs to be readdressed at that point.
Guardianship: [**Name (NI) 108850**] obtained this hospitalization after
the long intubation period in [**Month (only) **]. patient's gaudian ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 108846**] home [**Telephone/Fax (1) 108847**], cell [**Telephone/Fax (1) 108848**] work [**Telephone/Fax (1) 108849**]),
Medications on Admission:
1. Amiodarone 200 mg daily
2. Atrovent TID
3. ASA 81 mg daily
4. Beclomethasone (NASAL) 2 puffs each nostril [**Hospital1 **]
5. Clonazepam 1 mg TID
6. Coumadin 3 mg--one to two tablet(s) by mouth as directed by
[**Company **]
coumadin clinic
7. Eplerenon 25 mg daily
8. Lexapro 20 mg daily
9. Lisinoprol 5 mg daily
10. Lorazepam 1 mg daily PRN
11. Nasonex 50 mgc two sprays each nostril every day
12. Protonix 40mg daily
13. Senna
14. Toprol XL 25 mg
15. Triamcinolone 0.05 %--apply 2ml [**Hospital1 **]
16. Zocor 10 mg daily
Discharge Medications:
1. TPN
Day 3 Central standard TPN 3 in 1 with fat based on 80kg weight,
total TPN Volume [**2194**], Amino Acid(g/d)340, Dextrose(g/d) 120,
Fat(g/d) 40, Kcal/day [**2194**];
with trace elements and standard vitamin added; with 50 meqNaAc;
20 meq NaPO4; 10 meq KAc; 40 meq KPO4; 10 meq MgSO4, 12 meq
CaGluc, 20 units insulin added to the TPN
2. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): please swab around inside mouth with this
solution - cannot take swish/swallow as he aspirates but may
have thrush .
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane TID (3 times a day) as needed for mouth hygiene:
please swab around inside mouth with this solution - cannot take
swish/swallow as he aspirates but may have thrush .
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. sliding scale insulin
please continue sliding scale insulin and check FS qid while pt
is on TPN
8. Pantoprazole 40 mg IV Q24H
if unable to tolerate PO protonix
9. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed for Nausea.
10. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q6H (every 6 hours): hold for SBP<90 and HR<55.
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime):
hold for oversedation.
12. Methylprednisolone Sodium Succ 40 mg Recon Soln Sig: One (1)
Recon Soln Injection Q24H (every 24 hours) for 2 months: after 2
months, please continue a slower taper for the next mongh,
decrease the dosage by 10mg per week; Please also make sure that
you check weekly thyroid function tests including (T4, free T4,
and T3) .
13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed.
14. PICC line
PICC line care per rehab protocol
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift. .
16. Lorazepam 2 mg/mL Syringe Sig: 0.5 ml Injection Q4H (every
4 hours) as needed for anxiety.
17. Morphine 10 mg/mL Solution Sig: 0.5 ml Intravenous every
4-6 hours as needed for pain: hold for oversedation or RR<12.
18. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO once a day:
full aspiration precaustions, please crush meds and give with
apple sauce.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
Pneumonia
Congestive heart failure (exacerbation) responded to lasix
Vocal cord dysfunction due to intubation
thyroid toxicosis from amiodorone (improved)
depression
hyponatremia resolved
Thrombocytopenia (platelets in the 50,000 and stable)
Melena (responded to pRBC transfusion, and Hct remained stable)
-------
Secondary diagnosis:
Dilated cardiomyopathy (EF 20%)
3+ Mitral regurgitation (s/p repair [**8-29**] at [**Hospital1 112**])
Atrial fibrillation (s/p maze procedure [**8-29**], AV paced, on
coumadin and amiodarone) both coumadin and amiodorone were
stopped during this admission and AICD deactivated)
COPD PFT [**5-30**](FVC=2.86, FEV1=2.28, MMF=2.09, FEV1/FVC=80)
Hyperlipidemia
Coronary artery disease s/p IMI in [**2189**] LAD stent in [**12-28**]
(patent on cath [**8-29**]), s/p SVG to OM1
Discharge Condition:
afebrile, VSS (SBP baseline upper 80-90s), with full aspiration
precautions
Discharge Instructions:
Full aspiration precautions: Pt should remain NPO, and only
offer PO for comfort (apple sauce, ice chips, small amounts of
water, and small
amounts of pureed foods); Patient is aware and understand the
risks of aspiration when taking POs, and he is willing to accept
these risks for comfort.
.
There were entensive discussion during this prolonged
hospitalization; Given multiple medical problems, see goals of
care discussion notes from Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 12879**] (attached);
pt is DNR/ DNI, and expressing wishes to be comfort measure only
at some point during his hospitalization, but now, he is willing
to accept IV TPN and willing to work with PT;
.
If situation arises (any fever, chill, chest pain, SOB, or any
concerning symptoms), please contact patient's gaudian ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 108846**] home [**Telephone/Fax (1) 108847**], cell [**Telephone/Fax (1) 108848**] work [**Telephone/Fax (1) 108849**]),
goals of care needs to be readdressed at that point.
.
Other instructions:
1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
2. Adhere to 2 gm sodium diet
.
Please take all your medications as prescribed.
.
Please follow up all of your appointments
Followup Instructions:
Please follow up with your PCP 1-2 weeks after discharge in
addition to the following appointments:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2201-2-27**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2201-2-27**] 3:40
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2201-3-24**] 1:00
You will also need to follow up with otolaryngology (Ear, Nose,
& Throat) for further evaluation of your vocal cords and throat.
Call [**Telephone/Fax (1) 31733**] to make an appointment. Tell them you were
seen by the ENT resident while you were in the hospital and were
told to schedule a follow-up appointment.
Completed by:[**2201-2-11**] | [
"486",
"51881",
"42731",
"496",
"5849",
"0389",
"99592",
"4280",
"4240",
"2761",
"412",
"V4582",
"V4581",
"5070"
] |
Admission Date: [**2169-11-18**] Discharge Date: [**2169-11-29**]
Date of Birth: [**2098-11-18**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Cipro / Augmentin / Vicodin
Attending:[**First Name3 (LF) 9965**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71F with RA/CREST on prednisone, possible COPD and recent workup
for possible lung neoplasm who presents with 2 days of worsening
dyspnea and cough productive of yellow sputum. The patient was
in her USOH including being able to walk across the room without
becoming SOB or stopping until approx. 2 days ago. She reports
progressive dyspnea on exertion and now dyspnea at rest over the
last 2 days. She is now unable to walk across the room without
becoming SOB. She has also had a chronic cough for the last
thirty years that is usually non-productive but has become
productive of thick yellow sputum over the last 2 days. Denies
hemoptysis. Denies fevers or chills at home. She denies CP, N/V,
dysuria, urgency, frequency, HA, neck stiffness. No sick
contacts. She received the influenza vaccine this year. She
endorses a 10lb unintentional weight loss over the last month
[**1-25**] poor appetite. She also endorses severe back pain that has
been progressive over the last 3-4 weeks and was initially
intermittent but is now constant. The pain is pleuritic in
nature. She denies a h/o falls or trauma to the back. She has
had back pain in the past but nothing similar to this. She
denies other bony pain besides in the back. She endorses night
sweats for the last ten days or so. She also has intermittent
colitis flares, and has had one recently with no abdominal pain
but [**3-28**] watery or loose BMs/day. She denies melena or
hematochezia. She underwent colonoscopy in [**2169-4-23**] and reports
that polyps removed had no evidence of cancer on pathology.
.
Regarding the patient's RLL mass, it was incidentally discovered
on a CXR in [**2169-7-24**] after her chronic cough of 30 years
intensified this summer. Her outside pulmonologist recommended
CT scan and on CT there was a peripherally located, broad based
RLL lesion. She was prescribed Augmentin but was only able to
complete 3 days [**1-25**] GI upset. Repeat CT scan 1 month later was
unchanged and decision was made to seek further investigation at
[**Hospital1 18**]. On [**2169-10-25**] she underwent flexible bronchoscopy by IP
service with normal airway surveillance. "Radial EBUS via the R
basilar posterior segment showed a mass at 4cm from entrance
from such subsegment". Brushings and washings were taken and BAL
was done. She reports her cough has been worse since her
bronchoscopy. Initial pathology on brushings/washings were
positive for malignancy but after review this was equivocal and
it was recommended to obtain more tissue. She was seen by Dr.
[**Last Name (STitle) **] in thoracic surgery on [**11-7**] who recommended
CT-guided core needly biopsy which was to be done on [**2169-11-20**].
.
At the OSH, initial VS 98 108 120/54 16 94% 2L NC. Labs notable
for WBC 25.9 with 30% bands, Cr 0.97.CXR showed RLL infiltrate.
She was given a Duoneb and transferred to [**Hospital1 18**] for further
management.
.
In the [**Hospital1 18**] ED, initial vs were: 99.8 96 102/42 19 94% 2L NC.
CXR showed RLL infiltrate consistent with pnemonia. EKG showed
sinus tachycardia with non specific ST changes anteriorly. Labs
notable for WBC 22.9 with 88%N and 7% bands, Hct 33.5 (most
recent 36), BUN 32, Cr 1.3, Mg 1.3, Phos 2.4, trop neg x1. Blood
cultures and sputum culture was drawn and Foley was placed.
Patient was given vancomycin, Zosyn. She was given codeine and
benzonatate for cough, Tylenol 1 gram for fever, Mag sulfate for
repletion, hydrocortisone 50mg given known chronic prednisone
use. Initial lactate was 5.5, she was given 5L NS, repeat
lactate 2.5 with subjective improvement in symptoms. She was
seen by thoracic surgery who recommended MICU admission and they
will follow along. VS at transfer: 99.4 94 109/50 16 97% 4L NC.
.
Upon arrival to the ICU, the patient reports feeling much better
overall since presentation. She denies any SOB and says the
codeine helped her back pain and cough tremendously.
Past Medical History:
?COPD
RLL lung mass found on CXR [**7-/2169**]
Rheumatoid arthritis with CREST overlap syndrome with features
of
inflammatory polyarthritis, Raynaud's, reflux, sclerodactyly, on
prednisone, followed by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3057**]
HTN
Diverticulosis
Hemorrhoids
R knee surgery for benign mass
R ovarian surgery many years ago for benign mass
h/o shingles infection 4 yrs ago
Chronic rhinitis
Osteoarthritis s/p right hip replacement
Social History:
Smoked 1-2ppd x 45 years, quit <10 years ago. Denies EtOH or
illicits. Lives in [**Hospital1 1562**] with her husband who is a
pharmacist. Worked as property manager for affordable housing.
Daughter is pulmonologist at [**University/College **]. No recent travel.
Family History:
Father and PGM died of colon cancer in late 40s/early 50s. No
known FH of lung disease/malignancy, autoimmune disease.
Physical Exam:
On Admission:
Vitals: T: 98.7 BP: 153/55 P: 87 R: 23 O2: 92% 4L NC
General: Alert, oriented, no acute distress, thin
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diminished BS on the right 2/3 up from the bases with
inspiratory and expiratory crackles, pleural friction rub and
egophony present, otherwise Clear without wheezes
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 with pale yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, answering questions appropriately, moving all
extremities.
.
On Discharge:
Vitals - 98.9 (afebrile since 0735 on [**11-22**]) 142/64 92 24 92%2L
General - Lying in bed in NAD. NC in place on 2L.
CV - RRR, S1 and S2, no m/r/g
Lung - CTA on left. Breath sounds remained decreased on right.
Abdomen - Soft, NT/ND, BSx4
Ext- PICC line in place on left
Neuro- Awake, alert and oriented. Moving all extremeties.
Pertinent Results:
Admission labs:
[**2169-11-18**] 02:26PM WBC-22.9*# RBC-3.67* HGB-10.2* HCT-33.5*
MCV-91 MCH-27.8 MCHC-30.5* RDW-17.8*
[**2169-11-18**] 02:26PM NEUTS-88* BANDS-7* LYMPHS-0 MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2169-11-18**] 02:26PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-1+
[**2169-11-18**] 02:26PM PLT SMR-NORMAL PLT COUNT-404
[**2169-11-18**] 02:26PM PT-14.0* PTT-26.8 INR(PT)-1.2*
[**2169-11-18**] 02:26PM GLUCOSE-137* UREA N-32* CREAT-1.3* SODIUM-145
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-22 ANION GAP-20
[**2169-11-18**] 02:26PM ALT(SGPT)-21 AST(SGOT)-30 ALK PHOS-124* TOT
BILI-0.3
[**2169-11-18**] 02:26PM cTropnT-<0.01
AP CXR: Worsening consolidative opacification within the right
lung base concerning for pneumonia.
CTA chest: IMPRESSION:
1. Rapid interval progression of a consolidative process
involving the right lower lobe and posterior aspect of the right
upper lobe since the [**2169-11-13**] PET-CT, with obscuration
of previously seen mass-like lesions at posterior aspect of the
right lower lobe. Findings are most compatible with worsening
pneumonia. An underlying co-existent neoplasm may also be
present, but is obscured by this pneumonia. Right lower lobe
bronchi appear impacted.
2. New small right pleural effusion.
3. 11-mm thyroid isthmus nodule. Comparison with prior
ultrasound examinations or a non-emergent ultrasound evaluation
is recommended when
clinical stable.
4. Moderate to severe emphysema.
EKG: ST 105, LAD, TWF I, aVL, V5-V6, II, III, aVF, low voltage
limb leads, no ST depressions/elevations
[**11-22**] ECHO: IMPRESSION: Mild mitral valve prolapse with moderate
mitral regurgitation. Normal global and regional biventricular
systolic function. Late saline contrast in left heart after
injection of agitated saline suggesting intrapulmonary shunting.
[**2169-11-24**] CT Chest:
1. Persistent right lower lobe consolidation and parapneumonic
effusion with new cavitary changes, concerning for necrotizing
pneumonia. Underlying mass cannot be excluded and followup CT is
recommended after resolution of pneumonia for evaluation for
pulmonary mass. Discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 25139**] by phone by
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**] at 19:42 on [**2169-11-24**].
2. Increased trace left pleural effusion.
3. Increased right hilar and subcarinal lymphadenopathy, which
is likely
reactive given the time course of development, but metastasis
cannot be
excluded and could be further evaluated after resolution of
infection.
4. 11-mm thyroid isthmus nodule for which ultrasound could be
performed for further evaluation if not done previously
Brief Hospital Course:
Ms. [**Known lastname **] is a 71 y/o F with RA on chronic prednisone,
chronic cough and recent workup for possible lung neoplasm who
presented with 2 days of worsening productive cough and dyspnea
and was found to have a pneumonia.
.
# Pneumonia - The patient presented to an OSH where she was
found to have an elevated WBC with a left shift. CXR showed a
RLL PNA. Transferred to [**Hospital1 18**] where she was HD stable although
was saturating 94% on 2L. Lactate noted to be 5.5 which improved
following ~5L of IVF. CTA was performed that showed rapid
interval progression of a consolidative process involving the
right lower lobe and posterior aspect of the right upper lobe.
Started on vanc zosyn and admitted to the MICU for further
management. In the MICU the patient remained hemodynamically
stable although continued to spike fevers up to 102.1.
Transferred to the floor on HOD #1. On the floor the patient was
intermittently febrile although continued to subjective improve.
Continued on cefepime/vancomycin/azithro. Pulmonary and
interventional pulmonary consulted. An ultrasound of the lung
showed no fluid amenable to thoracentesis. A PICC line was
placed for continued antibiotic therapy on [**2169-11-22**] and an
xray showed good line placement. Also revealed significant
interval improvement in the pleural effusion. There was some
concern that her fevers were related to her antibiotics and her
antibiotics were ultimately switched to meropenem from
vancomycin/cefepime. The patient continued to have fevers on
the day of discharge although frequency and severity were
markedly improved. She clinically appeared well, was breathing
comfortably on room air, subjectively better and lung sounds
markedly improved. One urine legionella was sent at the time of
discharge and will be followed by ID. Her last dose of
meropenem will be on [**2169-12-2**].
.
# ?Lung Malignancy: BAL brushings from [**10/2169**] were suspicious
for adenocarcinoma although definitive biopsy deferred while
patient was hospitalized. The patient will follow-up with
thoracic surgery for further evaluation and likely biopsy.
.
# Anemia: The patient has a chronic anemia with hematocrit
baseline ~36. Iron studies during this admission are c/w anemia
of chronic disease. Throughout the patient's stay here her hct
has been ~30. Acute on chronic anemia thought to be a
combination of repeated blood draws and immunosupression for
underlying malignancy and infection. Reitc count of 0.4 is
supportive of this. No e/o hemolysis or active bleeding. There
was some concern for medication induced marrow suppression and
her cefepime was changed to meropenem. With this change in her
meds, her anemia stabilized. She did require 1 unit of pRBC
while on cefepime.
.
# RA/CREST: Chronic, on low dose prednisone. Managed by Dr.
[**Last Name (STitle) 3057**]. Prednisone was initially held in-house although
re-started on transfer to the floor. Hydroxychloroquine held
during active infection although will re-start after discharge.
Methotrexate on Saturday per home dosing.
.
# HTN: Held diltiazem initially although will restart on
discharge.
.
# Chronic rhinitis: Stable. Continued home fluticasone.
# Incidental findings:
11-mm thyroid isthmus nodule. Comparison with prior ultrasound
examinations or a non-emergent ultrasound evaluation is
recommended when clinical stable.
# Transitional Issues:
1) Continue meropenem for 8 additional days to complete 10 day
treatment course (last day [**2169-12-7**])
2) Will need to re-address need for lung biopsy at upcomming
thoracic surgery visit
3) F/u thoracic nodule as above
4) Repeat CBC at PCP appointment which should be within 1 week
of discharge from rehab
Medications on Admission:
DILTIAZEM HCL - 240 mg Capsule,Ext Release Degradable - 1
Capsule(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts nasal once a
day
HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth twice
a day except one on Wed. and Sat.
IRON POLYSACCH COMPLEX-B12-FA [NIFEREX-150 FORTE] - 150 mg-25
mcg-1 mg Capsule - 1 Capsule(s) by mouth once a day
KAPRIDEX - (Prescribed by Other Provider; PPI) - Dosage
uncertain
METHOTREXATE SODIUM - 2.5 mg Tablet - 8 Tablet(s) by mouth EVERY
SATURDAY
NABUMETONE - 500 mg Tablet - 1 Tablet(s) by mouth [**12-25**] qd pc as
needed for prn pain
OXAZEPAM [SERAX] - 15 mg Capsule - 1 Capsule(s) by mouth 1 po an
hour prior to MRI or long air flights
PREDNISONE - 1-5MG PO DAILY, usually takes 2-3mg daily, 3mg
recently
ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (OTC) - 500 mg Tablet
- 2 (Two) Tablet(s) by mouth as needed
ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg Tablet - 1 (One)
Tablet(s) by mouth once a day
CALCIUM CARBONATE-VIT D3-MIN - (OTC) - Dosage uncertain
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (OTC) - 100 mcg
Tablet - 1 (One) Tablet(s) by mouth once a day
LORATADINE [CLARITIN] - (Prescribed by Other Provider; OTC) -
Dosage uncertain
MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth
once a day
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (OTC) - 1,000 mg
Capsule - 1 (One) Capsule(s) by mouth once a day
Discharge Medications:
1. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. Niferex-150 Forte 150-25-1 mg-mcg-mg Capsule Sig: One (1)
Capsule PO once a day.
4. nabumetone 500 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
5. prednisone 1 mg Tablet Sig: Three (3) Tablet PO once a day.
6. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for fever or pain.
7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO once a day.
9. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
10. multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
12. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
13. codeine sulfate 30 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every
4 hours) as needed for cough.
Disp:*30 Tablet(s)* Refills:*0*
14. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-2**]
MLs PO Q6H (every 6 hours).
Disp:*200 ML(s)* Refills:*0*
15. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every six (6) hours for 4 days.
16. Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection every
eight (8) hours.
17. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous
every eight (8) hours.
18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] care and rehab
Discharge Diagnosis:
Primary: Pneumonia, Pleural effusion
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 at [**Hospital1 18**]!
You were admitted due to shortness of breath and cough. While in
the hospital you were found to have a pneumonia and fluid
surrounding your lung. During your stay you were treated with
antibiotics and your condition has significantly improved. You
are now ready to be discharged to a rehabilitation facility for
continuation of your care.
See below for changes to your home medication regimen:
1) Please CONTINUE Meropenem 500mg IV every 6 hours for an
additional 4 days to complete a 14 day course on [**2169-12-2**]
2) Please STOP Methotrexate until otherwise instructed
3) Please STOP hydroxychloroquine until you see Dr. [**Last Name (STitle) 3057**]
next
.
See below for instructions regarding follow-up care:
Followup Instructions:
**Please follow-up with your Primary Care Physician,
[**Name10 (NameIs) **],[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 33278**]), within 1 week of
discharge from your rehabilitation facility**
****Please call Dr. [**Last Name (STitle) **]
[**Location (un) 830**], [**Hospital Ward Name 23**] 9
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3020**]
Fax: [**Telephone/Fax (1) 89999**]
To schedule an appt for biopsy of your RLL lung mass
.
Department: RHEUMATOLOGY
When: FRIDAY [**2170-3-9**] at 1 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2169-12-15**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2169-11-30**] | [
"0389",
"486",
"5119",
"2762",
"2760",
"41401",
"4019",
"496"
] |
Admission Date: [**2147-11-8**] Discharge Date: [**2147-11-26**]
Date of Birth: [**2147-11-8**] Sex: M
Service: NBB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 74435**] is the
former 2.345 kg product of a 34 and [**3-15**] week gestation
pregnancy born to a 34 year-old, G2, P1 now 2 woman. Prenatal
screens: Blood type AB positive, antibody negative, Rubella
immune, RPR nonreactive. Hepatitis B surface antigen
negative. Group beta strep status unknown. Mother's
obstetrical history was notable for a Cesarean section at 36
weeks due to breech presentation. This pregnancy was
uncomplicated. She presented in preterm labor and was taken
to elective repeat Cesarean section. This infant emerged
with spontaneous respirations, required blow-by oxygen, in
the delivery room had Apgars of 8 at 1 minute and 8 at 5
minutes. He was admitted to the NICU for treatment of
prematurity. The intrapartum sepsis risk factors were a
temperature of 99.6 degrees Fahrenheit. Rupture of membranes
occurred at delivery. There was no intrapartum antibiotic
treatment. The infant had a prenatal amniocentesis performed
showing chromosomes of 46XY.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, anthropometric measurements revealed a
weight of 2.345 kg, length 44 cm, head circumference 32 cm,
all 50th percentile for gestational age. Physical examination
upon discharge: Weight 2.765 kg. Length 48 cm, head
circumference 33 cm. General: Alert, active infant in room
air. Skin warm and dry. Color pink. Diaper rash. Head,
eyes, ears, nose and throat: Anterior fontanel open and flat.
Sutures apposed. Positive red reflex bilaterally. Neck
supple. Chest: Breath sounds clear and equal, easy
respirations. Cardiovascular: Regular rate and rhythm, no
murmur. Normal S1 and S2. Femoral pulses +2. Abdomen soft,
nontender, nondistended. No masses. Cord on and drying.
Genitourinary: Normal male phallus. Testes palpable
bilaterally, high in the canal. Patent anus.
Musculoskeletal: Spine straight, normal sacrum. Hips stable.
Moves all extremities. Neuro: Alert, nonfocal, symmetric
tone and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: System 1: Respiratory. This infant required
treatment with oxygen and continuous positive airway
pressure. After admission to the NICU, a chest x-ray was
remarkable for 9 rib expansion, some streaking perihilar
densities, consistent with transient tachypnea of the
newborn. He was able to wean off of C-pap to room air by day
of life. He continued in room air for the rest of his
Neonatal Intensive Care Unit admission. He did not have any
episodes of spontaneous apnea and bradycardia. At the time
of discharge, he is breathing comfortably in room air with a
respiratory rate of 40 to 60 breaths per minute with oxygen
saturations greater than 97%.
System 2: Cardiovascular: This infant has maintained normal
heart rates and blood pressures. A soft intermittent murmur
was noted during admission but was not audible at the time of
discharge. Baseline heart rate is 140 to 160 beats per minute
with a recent blood pressure of 72/31 mmHg, mean arterial
pressure of 46 mmHg.
System 3: Fluids, electrolytes and nutrition. The infant
was initially n.p.o. and maintained on IV fluids. Enteral
feeds were started on day of life one. On day of life 2, he
was noted to have thick, bilious green aspirate with
abdominal distention and an abdominal x-ray showing dilated
bowel loops. He was transferred to [**Hospital3 1810**] where
he underwent upper gastrointestinal and enema studies. These
were normal and he was returned to the [**Hospital1 **]
Hospital and feedings were resumed. He has tolerated feedings
well since that time. At the time of discharge, he is taking
a minimum of 130 mm/kg per day of Enfamil 24 calorie per
ounce formula all by mouth. Weight on the day of discharge
is 2.765 kg. Serum electrolytes were sent 3 times in the
first week of life and were all within normal limits.
System 4: Infectious disease. Due to the unknown etiology
of preterm labor and unknown group beta strep status of his
mother, this infant was evaluated for sepsis upon admission
to the Neonatal Intensive Care Unit. 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.
System 5: Hematological. Hematocrit at birth was 49.4%.
This infant did not receive any transfusions of blood
products.
System 6: Gastrointestinal. As previously mentioned, this
infant had upper gastrointestinal and enema contrast studies
done at [**Hospital3 1810**]. Both studies were within normal
limits. The infant had not passed stool prior to the enema
but has maintained normal stooling patterns since that time.
Enteral feeds have been well tolerated. The peak serum
bilirubin was noted on day of life #5, total of 11.2 mg/dl.
A recheck level on [**2147-11-15**] was 9 mg/dl. He did not require
any treatment. This infant will require follow-up with
pediatric surgery 2 to 3 weeks after discharge.
System 7: Endocrine. This infant was noted to have
undescended testes bilaterally upon admission to the Neonatal
Intensive Care Unit. He was evaluated by the urology team
from [**Hospital3 1810**]. An abdominal ultrasound was
performed on [**2147-11-10**] and the testes were not visualized.
At the recommendation of the consult service, a serum
testosterone level was sent and was 151 ng/dl and well above
the normal range. During his admission, both testes have
been noted high in the canals and are undescended but
palpable at the time of discharge. This infant should follow-
up with urology consult team with the attending Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 64463**] 4 to 6 weeks after discharge.
System 8: Neurology. This infant has maintained a normal
neurologic examination and there are no neurologic concerns
at the time of discharge.
System 10: Sensory
Audiology: Hearing screening was performed with automated
auditory brain stem responses. This infant passed in both
ears.
System 11: Psychosocial. [**Hospital1 188**] social work has been involved with this family. The
contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**] and she can be
reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY CARE PHYSICIAN: [**First Name8 (NamePattern2) 40133**] [**Last Name (NamePattern1) 311**], [**Apartment Address(1) 76003**], [**Location (un) **], [**Numeric Identifier 68635**], telephone number [**Telephone/Fax (1) 76004**].
CARE AND RECOMMENDATIONS:
1. Feeding ad lib: Enfamil 24 calorie per ounce formula
with a minimum of 130 ml/kg per day intake.
2. No medications.
3. 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.
4. Car seat position screening was performed. This infant
was evaluated in his car seat for 90 minutes without any
episodes of desaturation or bradycardia.
5. State newborn screens were sent on [**11-11**] and [**2147-11-26**]
with no notification of abnormal results to date.
6. Immunizations: Hepatitis B vaccine was administered on
[**2147-11-24**].
7. Immunizations recommended:
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.
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.
This infant has not received ROTA virus 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:
1. Pediatric surgery with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], 2 to 3 weeks
after discharge. Phone number [**Telephone/Fax (1) 76005**].
2. Pediatric urology: Attending [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 64463**] 4 to 6 weeks
after discharge. Phone number [**Telephone/Fax (1) 45268**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 3/7 weeks gestation.
2. Respiratory distress, consistent with transient
tachypnea of the newborn.
3. Suspicion for sepsis ruled out.
4. Undescended testicles.
5. Suspicion for bowel obstruction ruled out.
[**First Name8 (NamePattern2) 73452**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 73453**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2147-11-26**] 00:49:42
T: [**2147-11-26**] 15:28:59
Job#: [**Job Number 76006**]
| [
"V053",
"V290"
] |
Admission Date: [**2177-12-18**] Discharge Date: [**2177-12-23**]
Date of Birth: [**2126-9-8**] Sex: M
Service: Trauma Surgery
CHIEF COMPLAINT: Stabbing to left upper quadrant.
HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old male,
who presented to the ED following a stabbing to the left
upper abdomen with a reported significant blood loss at the
scene. Hematocrit on arrival in the ED was 12 with a blood
alcohol of 31, systolic blood pressure of 110, and a heart
rate of 115. The patient was taken emergently to the
operating room for an exploratory laparotomy.
PAST MEDICAL HISTORY: Hypertension, otherwise unknown.
PAST SURGICAL HISTORY: Unknown.
MEDICATIONS: Aspirin, otherwise unknown.
ALLERGIES: Unknown.
PHYSICAL EXAMINATION: The patient's first set of vital signs
at 7:20 a.m. were recorded as heart rate 100, blood pressure
160/palp, respiratory rate 20, saturations were 100%. The
patient was not intubated at the time. Patient's physical
exam was notable for a stab wound to the left upper quadrant
below the costal margin and anterior to the anterior axillary
line with tenderness to palpation greater on the left
than on the right. The abdomen was distended and had guarding to
palpation. was distended. Patient's rectal examination was
guaiac
negative with normal tone.
LABORATORIES: The patient's hemoglobin was 4.5, hematocrit
was 14, platelets 203. Coags revealed an INR of 1.1, PT of
13, PTT of 21.1, lactate was 2.9, fibrinogen 261. Blood gas
was 7.46/28/269/21/-1. Blood alcohol was 31.
Peripheral IV access was established in the ED and blood
transfusion immediately initiated. A left
subclavian central line was placed, and the patient was
emergently taken to the operating room. Intraoperatively,
the patient was noted to have a transverse colonic stab
injury with minimal soilage. The injury was repaired primarily.
Exploration of his abdomen revealed no further injury. The wound
was only closed at the fascial level and otherwise, the skin was
left open. The patient received 5,000 mL of crystalloid, and 4
units of packed red blood cells intraoperatively. Estimated
blood loss was 150 cc, which included some clot.
Hematocrit at the end of the case was 29 following 4 units of
red blood cells infused in total. The patient was left
intubated on transfer to the Intensive Care Unit. The
patient was extubated without complication on postoperative
day #1. Patient had an epigastric tube in place. The
patient had an uncomplicated ICU course and was transferred
out to the floor on postoperative day #3. The patient had
been started on triple antibiotics of ampicillin, Levaquin,
and Flagyl. This was continued on transfer to the floor.
The patient's hematocrit remained stable. The patient was
alert and oriented with pain well controlled following
extubation.
Patient was started on clear liquids as a diet on
postoperative day #4, and started on medications by mouth.
His midline incision was noted to have some slight erythema
in the superior pole. This was unchanged by
postoperative day #5. By postoperative day #5, the patient
was ambulating comfortably and had a bowel movement. He was
tolerating a regular diet. He was discharged home on
Levaquin and Flagyl for one week, and instructions on wound
care. He was to keep the wound covered with dry gauze.
The patient's Left upper quadrant was clean, dry with no
evidence of infection and was covered with a Vaseline gauze
and a gauze dressing.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Metoprolol 50 mg p.o. b.i.d.
2. Aspirin 81 mg p.o. q.d.
3. Levaquin 500 mg p.o. q.d. x7 days.
4. Flagyl 500 mg p.o. t.i.d. x7 days.
5. Dilaudid 2-4 mg p.o. q.4h.
FOLLOWUP: The patient was to followup in
the Trauma Clinic in one week.
MISCELLANEOUS: The patient was to receive visiting nurse
care for dressing changes to his stab wound as well as his
midline incision to be changed once a day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 14131**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2177-12-24**] 12:50
T: [**2177-12-29**] 05:19
JOB#: [**Job Number 100472**]
| [
"4019"
] |
Admission Date: [**2161-3-2**] Discharge Date: [**2161-3-8**]
Date of Birth: [**2089-11-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
s/p suboccipital craniotomy for tumor resection and biopsy
History of Present Illness:
71F with NSCLC, HTN, hypercholesterolemia, admitted with
refractory nausea/vomitting since starting Tarceva. She denies
abdominal/chest pain, SOB, diarrhea/constipation or problems
w/bladder incontinence. She does have unsteadiness of gait as
well as trouble using her right hand.
Past Medical History:
1. NSCLC: prior w/u at [**Hospital1 112**]/[**Company 2860**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3273**])- lung
nodules found on preop CXR [**6-14**], CT showed RLL nodule c/w
primary lung cancer and multifocal bronchoalveolar carcinoma,
PET/CT showed FDG-avid R lung nodule and mediastinal/pericardial
LAD, s/p bronch/mediastinoscopy with mediastinal LN dissection
with path showing NSCLC-adenoca; sought 2nd opinion at [**Hospital1 18**]
([**Doctor Last Name 3274**]/[**Doctor Last Name 1058**]), s/p 2 cycles of Taxol and carboplatin from
[**Date range (1) 3275**], s/p 4 cycles Navelbine on [**2165-9-14**], CT chest [**2-16**]
showed interval worsening of lung metastases and LAD, started
Tarceva ?[**2-20**]
2. Hypertension
3. Hypercholesterolemia
4. Degenerative joint disease
Social History:
She is a former smoker of half to one pack a day
for 20 to 30 years, but she quit about 20 years ago. She does
not have significant amount of passive smoking exposure, no
asbestos exposure, and rare social drinking.
Family History:
Positive for cardiac or vascular disease, but no
cancer. She has a possible history of amoxicillin allergy,
although it is not clear whether this was poor tolerance, and
she
has taken penicillin in the past without difficulty. She has a
daughter who is a physician and who comes with her to the visit
along with her son-in-law. She worked as a bookkeeper in an
electrical company in the past.
Physical Exam:
T:96.9 BP:140/78 HR:64 RR:20 O2Sats:95% RA
Gen: WD/WN, comfortable, NAD.
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, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-13**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, heel to shin
(+) Romberg
Pertinent Results:
[**2161-3-2**] 09:10PM WBC-11.9* RBC-5.25 HGB-15.3 HCT-44.5 MCV-85
MCH-29.2 MCHC-34.4 RDW-16.7*
[**2161-3-2**] 09:10PM NEUTS-70.0 LYMPHS-24.3 MONOS-4.0 EOS-1.3
BASOS-0.5
[**2161-3-2**] 09:10PM ANISOCYT-1+ MICROCYT-1+
[**2161-3-2**] 09:10PM PLT COUNT-406
[**2161-3-2**] 09:10PM GLUCOSE-97 UREA N-34* CREAT-0.8 SODIUM-133
POTASSIUM-7.7* CHLORIDE-98 TOTAL CO2-26 ANION GAP-17
[**2161-3-2**] 09:10PM estGFR-Using this
[**2161-3-2**] 09:10PM ALT(SGPT)-33 AST(SGOT)-97* ALK PHOS-109
AMYLASE-111* TOT BILI-0.6
[**2161-3-2**] 09:10PM LIPASE-81*
[**2161-3-2**] 09:10PM CALCIUM-9.6 PHOSPHATE-4.4 MAGNESIUM-2.4
MRI head:
1. Enhancing mass in the right cerebellar hemisphere, with mass
effect as described above, most consistent with a metastatic
lesion. No additional mass/abnormal enhancement.
2. Old lacune in the left caudate nucleus and a nonspecific T2
hyperintensity in the right frontal lobe, likely post-traumatic
or chronic small vessel ischemic change.
3. Mucosal changes in the right sphenoid sinus.
CT abdomen/pelvis:
1. No evidence of intra-abdominal metastatic disease.
2. A 9-mm hypoattenuating liver lesion is likely a cyst but
should be
monitored closely on followup exams.
3. New small bilateral pleural effusions with adjacent
atelectasis.
4. Large paraesophageal hernia.
5. Stable pericardial lymph node.
Brief Hospital Course:
# Nausea and vomiting: Concerning presentation for brain
metastasis. Tarceva d/c'd on thursday of last week w/continued
N/V as well as unsteadiness of gait
# NSCLC: further treatment plans per Dr. [**Last Name (STitle) 3274**] and [**Doctor Last Name 1058**]
- hold Tarceva
- CT head as above
# Code status: DNR/DNI
On [**3-4**], the patient came from the [**Hospital Ward Name **] to the SICU on
the west. She underwent preop evaluation and surgery was
scheduled for [**3-5**] with Dr. [**Last Name (STitle) 548**]. She had a very successful
surgery with no reported complications. Please see the
operative note for full details. She went back to the ICU for
24 hours and then came to the floor. Physical therapy saw her
and had no major issues with her progression. She plans to say
with her daughter for several days to recuperate. The patient
will see neuro oncology and Dr. [**Last Name (STitle) 548**] next week and will be on a
course of steroids for the unforeseeable future.
Medications on Admission:
[**Doctor First Name **] 60MG [**Hospital1 **]
FLONASE 50 mcg 2 sprays ou qd
LIPITOR 10 MG qd
PRILOSEC 40 mg qd
Discharge Medications:
1. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) for 2 days.
Disp:*12 Tablet(s)* Refills:*0*
2. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO twice a
day for 2 days: Start this dose after taking 3mg TID.
Disp:*8 Tablet(s)* Refills:*0*
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day:
Once you have finished taking 3mg [**Hospital1 **], take 2mg [**Hospital1 **] until
directed by MD otherwise.
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: Please take this medication as long as
you are taking percocet. .
Disp:*60 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
cerebellar mass
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? Have a 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,
excessive bending
* Please continue all of your preadmission medications that you
were on before coming into the hospital.
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? 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, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Need to follow-up with oncologist for 9-mm hypoattenuating liver
lesion which is likely a cyst but needs to be watched.
PLEASE RETURN TO THE OFFICE IN 7 DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) 548**] TO BE SEEN IN 1 WEEK.
YOU WILL NOT NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT
CONTRAST
Completed by:[**2161-3-8**] | [
"4019",
"2720",
"V1582"
] |
Admission Date: [**2198-3-13**] Discharge Date: [**2198-3-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Bloody bowel movements
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 86 y/o F with PMH of diverticulosis, hepatic cyst
s/p resection, and HTN who presents to the ED with BRBPR X 3 at
home. Patient was feeling well today until 1430 pm when she had
a large loose bowel movement with bright blood. This occurred X
2 more and patient presented to the ED. Of note, she has a known
history of diverticular bleed requiring ICU admission and
transfusion of 4 U PRBCs in 9/[**2196**]. She denies abdominal pain
throughout. She denies chest pain, shortness of breath, and
dizziness/lightheadedness today.
In the ED, the patient's initial vitals were HR 67, BP 127/64.
BP remained in 110s-130s systolic. She received 2 L normal
saline. Her hematocrit demonstrated decrease to 29.7 from 31-32
(2 weeks ago); repeat Hct at [**2190**] pm (four hours after
presentation) demonstrated further drop to 24.4 (no interval
transfusion but did receive IVF). Two large-bore peripheral IVs
were placed, and the patient was transfused 1 U PRBCs (still
running when she arrived on the floor). She remained
asymptomatic throughout. GI was [**Year (4 digits) 653**] and recommended
observation in the ICU and tagged RBC scan if bloody BMs
continued.
In the MICU she received one unit of pRBC. She stabilized, and
was hemodynamically stable. She had two small episoded of BRBPR.
GI evaluated and deferred scope at this time as she likely has
diverticular bleed and no easy intervention.
She feels well on transfer to the floor, without any complaints
of pain.
Past Medical History:
1. Hypothyroidism
2. H/O E. Coli Sepsis ([**4-/2194**])
3. HTN
4. H/O Bronchitis
5. Hepatic Cystadenoma S/P Resection ([**2184**])
6. Cholangitis S/P Stenting
7. PUD (Duodenum)
8. TAH/BSO
9. DJD
10. CAD (2VD s/p DES to D1)
11. Osteoarthritis of the knees
12. Diverticulosis
13. Neuropathy
14. Spinal stenosis
Social History:
Lives at an [**Hospital3 **] facility in [**Location (un) 583**], moved to U.S.
from rural [**Country 651**] 40 years ago. Denies smoking, alcohol, and
drug use. Lives alone in [**Hospital3 4634**] with family near by.
Previously worked in laundering/ironing.
Family History:
No known liver, gall bladder, lung or heart disease. No known
cancers.
Physical Exam:
VS: 98.6, BP 133/62, HR 81, O2Sat 98 RA, RR 20
GEN: pleasant, comfortable, elderly female in NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, supple
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: slighlty distended with prior midline & right-sided scars,
+b/s, soft, nontender to palpation, no masses or
hepatosplenomegaly
EXT: trace anterior tibial edema, extremities warm
SKIN: no rashes/no jaundice
NEURO: AAOx3. face symmetric & speaking clearly in full
sentences. moving all extremities without difficulty.
Pertinent Results:
[**2198-3-13**] 04:20PM WBC-6.8 RBC-3.76* HGB-10.1* HCT-29.7* MCV-79*
MCH-26.9* MCHC-34.1 RDW-14.0 PLT COUNT-344 NEUTS-78.0*
LYMPHS-14.2* MONOS-5.4 EOS-2.0 BASOS-0.3
[**2198-3-13**] 08:09PM BLOOD Hgb-8.1* Hct-24.4*
[**2198-3-14**] 07:51AM BLOOD WBC-7.3 RBC-3.57* Hgb-9.6* Hct-27.8*
MCV-78* MCH-26.7* MCHC-34.3 RDW-14.9 Plt Ct-284
[**2198-3-15**] 05:35AM BLOOD WBC-6.3 RBC-3.33* Hgb-9.0* Hct-26.7*
MCV-80* MCH-26.9* MCHC-33.6 RDW-14.6 Plt Ct-245
[**2198-3-16**] 06:00AM BLOOD WBC-6.5 RBC-3.51* Hgb-9.5* Hct-27.7*
MCV-79* MCH-27.0 MCHC-34.2 RDW-15.6* Plt Ct-257
[**2198-3-13**] 04:20PM GLUCOSE-115* UREA N-21* CREAT-1.3* SODIUM-136
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
EKG
Sinus rhythm and occasional atrial ectopy. Compared to the
previous tracing of [**2198-2-28**] the atrial morphology has changed
and the rate has slowed. Atrial ectopy has appeared. Otherwise,
no diagnotic interim change.
Intervals Axes
Rate PR QRS QT/QTc P
68 200 88 390/404 0
Brief Hospital Course:
86 year old female with known history of diverticulosis presents
with BRBPR and drop in hematocrit.
# GI bleeding: Likely diverticular bleed given history of
diverticula and clinical presentation. Hemodynamically stable
with minimal bloody bowel movements since second day of
admission. Coagulation studies were checked and found to be
within normal limits. During her admission she received 1 unit
of PRBC and HCT then remained stable. The GI service was
consulted on admission and thought there was no role for
colonoscopy for now as this likely represented a diverticular
bleed. Her family, who are her primary caregivers, were
[**Name (NI) 653**] to discuss the nature of diverticular bleeding and
that very little intervention can be done via colonoscopy.
Given that her HCT remained stable for three days post-initial
transfusion, she was discharged home with follow-up.
Specifically, she will have a HCT check by VNA 3 days
post-discharge and will be seen by her PCP 6 days
post-discharge.
# Acute Renal Failure: Likely related to hypovolemia from
diarrhea/blood loss. Resolved after hydration.
# Hypothyroidism: Continued Levothyroxine.
# History of choledocholithiasis: Continued ursodiol at home
dose.
# Hypertension: Anti-hypertensives were initially held given
concern for potential hemodynamic instability. While in ICU,
she was restarted on Amlodipine at her home dose. During the
remainder of her inpatient stay, Metoprolol and Cozaar were both
restarted. Thus, she was discharged on her prior outpatient
regimen.
Medications on Admission:
amlodipine 5 mg daily
actigall 300 mg [**Hospital1 **]
cozaar 25 mg daily
levothyroxine 75 mcg daily
meloxicam 15 mg once daily - patient self-d/c
metoprolol 50 mg [**Hospital1 **]
prilosec 20 mg daily
darvocet prn
calcium/vitamin D
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Calcium 600 + D 600-400 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
8. Outpatient Physical Therapy
To evaluate and treat in home as needed.
9. Outpatient Lab Work
VNA to continue outpatient services. Additionally, a CBC should
be drawn [**2198-3-19**] and results should be faxed to Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 16691**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Gastrointestinal bleeding, likely due to diverticuli
Secondary: Hypertension, hypothyroidism
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
You were admitted with blood in your stool and black stools.
You were found to have bleeding from your intestines, likely
from diverticuli as you've had this in the past. You were
transfused one unit of blood and your blood levels have been
stable since. Thus, you're being discharged with outpatient
follow-up and physical therapy at home for continued recovery.
Take all medications as prescribed. Your medications have not
been changed while you were in the hospital.
Please keep all outpatient appointments.
Return to the hospital or seek medical advice if you notice
fever, chills, difficulty breathing, chest pain, bloody stools,
black stools, bloody vomit or for any other symptom which is
concerning to you.
Followup Instructions:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2198-3-22**] 12:40
Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2198-4-4**] 11:30
| [
"5849",
"2851",
"4019",
"2449"
] |
Admission Date: [**2129-10-14**] Discharge Date: [**2129-10-17**]
Date of Birth: [**2070-7-27**] Sex: M
Service: Neurosurgery
HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old
gentleman who has a past medical history of hypertension and
a subarachnoid hemorrhage for a ruptured basilar tip aneurysm
which was treated using coil embolization in [**2129-5-5**]. He
returns now for stent placement and coil embolization of the
residual basilar tip aneurysm.
HOSPITAL COURSE: The patient underwent the procedure on
[**2129-10-14**] with placement of a stent and coiling of the
remainder of the aneurysm without intraprocedural
complication. The patient was monitored in the PACU, doing
well without complaints. No pain, confusion, chest pain,
shortness of breath, or nausea or vomiting. He had no
apparent anesthesia complications. Postoperatively, he was
awake, alert, without complications, moving everything well,
lying flat, oriented times three, speech was clear. The
pupils were equal, round, and reactive to light. EOMs were
full. No diplopia. No nystagmus. Right groin sheath was
removed with some oozing but no hematoma, good pedal pulses.
The patient was out of bed ambulating, tolerating a regular
diet, transferred to the regular floor. He was continued on
Plavix and aspirin.
He was discharged to home on postprocedure day number three
in stable condition, neurologically intact with follow-up
with Dr. [**Last Name (STitle) 1132**] in one month for repeat angiogram at that
time. Continue on Plavix for one week and aspirin
indefinitely.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg p.o. q.d.
2. Percocet one to two tablets p.o. q. four hours for pain.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2129-10-17**] 10:53
T: [**2129-10-17**] 14:48
JOB#: [**Job Number 47665**]
| [
"4019",
"53081"
] |
Admission Date: [**2152-9-29**] Discharge Date: [**2152-10-4**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
CC:[**CC Contact Info 41404**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 female w/ breast ca briefly on tamoxifen, paroxysmal afib,
presumed diastolic dysfunction, ?COPD now being eval for resp
distress. Per daughter, [**Name (NI) 41405**] until increased sob/tachypnea x [**12-31**]
days treated w/ levaquin for ?pna and diuretics for volume
overload. On day of admission, initially improved following
additional lasix but then w/ episode of shaking, diaphoresis
followed by reported unresponsiveness and then lethargy.
Transferred to ED where afebrile, hypertensive to systolic 170's
but 86% ra w/ abg7.35/74/59. Started on bipap, diuresed w/ 60 iv
lasix and 1200 cc urine output. Repeat gas on 100 fio2
7.25/99/257. In MICU Pt was placed on Bipap with target O2 sat
90-92%, diuresed, and abx tx continued with vanc + ceftaz. MICU
achieved 95-97% O2 sat weaned off BIPAP to 3L NC. Transferred
to medical floor.
Past Medical History:
COPD (1L O2 baseline, Sat not reported)
Breast Ca (tamoxifen)
Paroxysmal AFIB ??????no coumadin (fall risk)
Diastolic Dysfunction (CHF)
Hypothyroidism
HTN
UTI (previous proteus enterococcus, both susceptible to levo.
Per [**Hospital1 18**] records).
s/p R hip ORIF [**2152-7-7**]
Social History:
Resides at [**Location (un) 2716**] Point (extend care). Per record, quit
smoking 30 years ago, 3 cigs qd. Retired teacher.
Family History:
Not reported in records. Son ([**Telephone/Fax (1) 41406**]) is MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]
Diabetes Center.
Physical Exam:
T:98.1 97.9 BP: 120-130/30-40 HR 90 (70-110) RR:20
O2Sat:95(92-97) 3LNC
Gen: Pt. is awake, and alert but disoriented. According to
home health aide (present) pt. is at baseline today.
Skin: Nl. Skin turgor. Small well healed surgical scar on
neck base.
HEENT: EOMI. Sclera anicteric.
Heart: Irreg. Irreg. On auscultation. No murmurs noted. No
rubs or gallop. S1 S2 JVP < 10cm.
Lungs: Distant breath sounds. Bibasilar rales B/L (R>L), no
wheezes, no rhonchi.
Abd: Soft, obese, nontender to palpation, nondistended, no
[**Doctor Last Name **]??????s sign. Normal bowel sounds.
Extrem: Strength 4/5 flexion & extension UE b/l. Strength
4-/5 LLE raise, [**4-3**] LLE extension, Strength 2/5 RLE raise, [**2-3**]
RLE extension. Plantarflexion and dorsiflexion 4-/5 b/l. 1+
edema b/l.
Pertinent Results:
[**2152-9-29**] 01:25PM BLOOD WBC-7.2 RBC-3.94* Hgb-11.6* Hct-36.6
MCV-93 MCH-29.4 MCHC-31.6 RDW-13.5 Plt Ct-250
[**2152-9-29**] 01:25PM BLOOD PT-12.1 PTT-24.6 INR(PT)-0.9
[**2152-9-29**] 01:25PM BLOOD Glucose-141* UreaN-17 Creat-0.8 Na-141
K-4.4 Cl-93* HCO3-39* AnGap-13
[**2152-9-29**] 01:25PM BLOOD Acetone-NEG
[**2152-9-29**] 01:25PM BLOOD TSH-3.6
[**2152-9-29**] 01:38PM BLOOD Type-ART pO2-59* pCO2-74* pH-7.35
calHCO3-43* Base XS-10
[**2152-9-29**] 04:51PM BLOOD Lactate-0.6
[**2152-9-29**] 04:51PM BLOOD freeCa-1.11*
[**2152-9-30**] PORTABLE CHEST: Comparison is made from film from one
day earlier. The patient has made a slightly improved
inspiratory effort on the current film. The cardiac and
mediastinal contours are unchanged, with prominence of the left
hilum again noted. Previously noted pulmonary edema persists
without change. There is some improved aeration in the left
base.
[**2152-10-2**] SWALLOWING EVAL RECOMMENDATIONS:
1.Advance to regular consistency po diet.
2.Should pt develop s/s aspiration, worsening pna, or
difficulty with upper airway secretions, please reconsult
for a video swallow study.
[**2152-9-29**] EKG:
Sinus arrhythmia
Normal ECG
No change from previous
Brief Hospital Course:
1. COPD: Patient was observed at her Nursing Home ([**Location (un) 2716**]
Point) to have increased SOB for two days and was seen by PCP [**Last Name (NamePattern4) **]
[**2152-9-29**]. She was noted to have oxygen saturation of 80% RA,
thought potentially secondary to CHF exac vs. PNA. She was
treated with levofloxacin and lasix with some improvement in her
oxygen saturation to 85% RA, but BP incr. 160s. IV nitro was
started at her nursing home, antibiotics were switched to
azithro + ceftaz, and she was transferred to the [**Hospital1 18**] ED.
On arrival to the ED, she was diaphoretic, shaky and
unresponsive. Her temperature was 99.6 and pt was hypertensive
to 160-170/60, with oxygen saturation of 86% RA. An ABG was
7.25/99/257 suggesting CO2 retention. Per MICU note, daughter
reported [**Name2 (NI) **], no recent F/C/N/V, no CP mild SOB over the last
couple of weeks, no PND , no orthopnea. Daughter reports
increased LE edema and some weight gain (undocumented) over [**2-1**]
weeks, but no urinary Sx.
In MICU, pt was placed on BIPAP with target O2 sat 90-92%,
diuresed, and abx tx continued with vanc + ceftaz. MICU
achieved 95-97% O2 sat weaned off BIPAP to 3L NC. Transferred
to medical floor and we continued to wean O2, continued steroids
(prednisone taper) and continued ipratropium neb, added
albuterol neb. 48 hours later, patient was weaned from 3L NC 02
with 90-95% sats to RA and >95% sats with mild crackles at base.
She was d/ced in this condition.
2. CHANGE IN MS: Pt. was found unresponsive and brought to the
ED diaphoretic, acidotic, with low O2 Sat. Was confused and
disoriented, not at baseline per home attendant. In Unit,
palced on BiPAP with improving sats but hypercarbic, retaining.
Still poor mental status. As BiPAP was weaned and on day of
transfer to floor, pt was much closer to baseline per home
health aide. At d.c from medicine floor, home health aid
reports that patient is at baseline mentation. Although still
not oriented, her thoughts are organized and she is vocal.
3. ID: Pt's COPD and CXR with infiltrate are worrisome for PNA
+ COPD exac. Txed inpatient with Vanc+ceftaz, transferred to
floor and continued on ceftaz, then converted to
azithro+ceftriax. Will d/c with wbc 5.4 crit 33.1 plat 228, abx
10d of cefpodoxime 200 [**Hospital1 **] and azithro 250 QD.
4. Atrial fibrillation: Per PCP, [**Name10 (NameIs) **] patient is a fall risk, and
PCP does not recommend coumadin or lovenox given risk. Her beta
blocker dose was titrated up for improved rate control.
5. Hypothyroidism: The patient's TSH was checked on admission
and was within normal limits. On discharge it was midly elev at
5.0. Her levothyroxine was continued at her present dose. PCP
should consider TSH level in 2wks to determine if current
levoxyl dose is adequate.
6. Documented desat during sleep ? sleep apnea. Pt. was
observed for 15 min on 02 sat during sleep. awake o2 sat 90-92%
RA, pt desats to low 80s high 70s after 30 sec apneic events
during sleep, then sats rise to high 80s. We will d/c on
nocturnal 02 2L, but may wish to consider sleep apnea w/u as
o.p.
6. C/o R eyelid pain. On [**10-4**] pt c.o mild R eye discomfort -
she and home health aid admit to chronic R eye
dryness/discomfornt. No exudate, scleara clear, no obvious
foreign body, no erythema, no edema. Txed with artificial
tears. No clinical indication on exam of pathologic process.
Medications on Admission:
ON ADMIT:
zyprexa 2.5 qhs, levoxyl 125 qd, neurontin 100 tid, donezepil 10
qhs, trazodone 50 qhs, atrovent neb qid
FROM MICU:
Famotidine 20 mg IV
Ipratropium Bromide Neb 1 NEB Q6H
Levothyroxine 125 mcg PO
Aspirin 81 mg PO
Heparin 5000 UNIT SC TID
Ceftazidime 1 gm IV
Vancomycin HCl 1000 mg IV Q24H
Nitroglycerin 0.05 mcg/kg/min IV DRIP TITRATE TO sbp
under
Olanzapine 2.5 mg PO
Methylprednis. Succ 60 mg IV Q8Hx3d Metoprolol 25 mg PO BID
hold for sbp<100 or hr<60
Olanzapine 2.5 mg PO TID PRN
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation every eight (8) hours.
2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO TID PRN ().
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day): Taper from day 1 ([**2152-10-3**]):40,40,40,20,20,20,10,10,10,10.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
8. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 10 days.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) for 10 days.
11. Nocturnal 02 2L nasal can.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2716**] [**Last Name (un) **] - [**Location (un) 55**]
Discharge Diagnosis:
COPD exacerbation + PNA
1. COPD exacerbation + PNA
2. Dementia
3. Hypothyroidism
4. Diastolic dysfunction
5. Depression
Discharge Condition:
fair.
Discharge Instructions:
Please return to the ED if you experience increasing shortness
of breath, increased oxygen requirement, shortness of breath and
[**Location (un) **], fever, chest pain.
Followup Instructions:
Please follow up with your primary care physician within the
next 2 weeks.
| [
"486",
"51881",
"4280",
"2859"
] |
Admission Date: [**2103-9-20**] Discharge Date: [**2103-9-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7708**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
[**2103-9-24**] Colonoscopy
History of Present Illness:
Ms. [**Known lastname 72724**] is a [**Age over 90 **] y/oF with history of remote colon ca s/p
resection ~23 years ago, and mild hypertension who is admitted
night of [**2103-10-21**] with BRBPR. She has noticed some change in her
stools for the last few days, but brought to her daughter??????s
attention last night with maroon stool in the toilet. She had
another episode of red blood this morning, moderate quantity.
She has not had this problem before. She has no abdominal pain,
but has had occasional nausea but no vomiting. Her only other
change in bowel habits was a few days earlier, when she ahd some
constipation and had to use her finger to aid in evacuation of
stool. She has no history of hemorrhoids.
.
She has DJD and had been taking more naproxen PRN, and more of
one analgesic more recently, that the daughter thinks is
Tylenol.
.
In the ED: her initial vitals were T 97.6, HR 72, BP 127/48 RR
18 Sat 98% 2L. She received 2L of normal saline. She had an
episode of BRBPR in the ED of about 500cc. Vitals however
remained stable without tachycardia or hypotension. Her rectal
exam was frankly bloody, but no hemorrhoids appreciated. She was
seen by GI with decision to not scope immediately and see if
this clears, with back-up plan of IR scan/embolism likely
preceded by endoscopy.
.
In the ICU: She presented with a Hct of 27.4, but dropped to
24.7 that same night. She subseqently received 2 units on [**9-20**],
and 1 unit PRBC on [**9-21**]. Her Hct has remained stable in the 30s
since then.
Past Medical History:
- Colon Ca s/p resection 23 years ago in [**Last Name (un) 51768**], FL
- Hypertension
- Depression
- Degenerative Joint Disease
Social History:
lives at home with daughter and son-in-law, denies etoh, smoking
Family History:
NC
Physical Exam:
Vitals: 96.8, 121/48, 65, 18, 98%RA
HEENT: NC/AT, clear oropharynx, MMM
Neck: supple, no LAD
CV: RRR s m/g/r
Chest: CTAB
Abd: +BS NT/ND, soft
Ext: no c/c/e
Skin: no rashes, lesions, or jaundice
Neuro: A&Ox3
Pertinent Results:
LABS:
[**2103-9-20**] WBC-8.8 RBC-3.05* HGB-9.0*# HCT-27.4*# MCV-90 MCH-29.6
MCHC-33.0 RDW-13.4
[**2103-9-20**] 02:50PM CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.1
[**2103-9-20**] 02:50PM cTropnT-0.02*
[**2103-9-20**] 02:50PM CK(CPK)-94
[**2103-9-20**] 02:50PM GLUCOSE-117* UREA N-47* CREAT-1.0 SODIUM-140
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-30 ANION GAP-12
[**2103-9-20**] 03:35PM URINE RBC-0-2 WBC-<1 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2103-9-20**] 03:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2103-9-20**] 07:47PM WBC-7.8 RBC-2.76* HGB-8.6* HCT-24.7* MCV-89
MCH-31.1 MCHC-34.8 RDW-13.5
[**9-21**] 5:18pm - Hct 30.2
[**9-22**] 1:35pm - Hct 30.7
[**2103-9-23**] 03:02PM BLOOD Hct-32.1*
[**2103-9-24**] 05:25AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.3* Hct-30.7*
MCV-89 MCH-30.1 MCHC-33.7 RDW-13.9 Plt Ct-249
[**2103-9-25**] 05:15AM BLOOD WBC-8.5 RBC-3.39* Hgb-10.4* Hct-30.3*
MCV-90 MCH-30.7 MCHC-34.2 RDW-13.8 Plt Ct-263
[**2103-9-25**] 05:15AM BLOOD Glucose-105 UreaN-12 Creat-0.9 Na-139
K-3.8 Cl-104 HCO3-28 AnGap-11
.
Imaging: CXR: no acute CP process
ECG: Sinus 1:1 at 70 bpm, normal axis, intervals. No e/o
ischemia
Colonoscopy: Diverticulosis of the sigmoid colon and descending
colon
Two small polyps in the sigmoid and ascending colon
1.5 cm penduculated polyp in the sigmoid colon. (polypectomy)
Erythema and petechiae on several colonic folds in the sigmoid
colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
[**Age over 90 **] y/oM with remote h/o semi-colectomy for colon ca a/w likely
lower GI bleed in the absence of abdominal pain.
# GIB: Patient reported painless hematochezia and maroon stools
x 2-3 days prior to admmission and then BRBPR on morning of
admission. Differential included diverticulosis, AVM, colon CA,
or colonic ischemia. Pt's Hct nadired to 24.7. She received 3
units PRBC in ICU. She remained hemodynamically stable during
floor hospital course. For the remainder of her hospital course
and she did not require any further transfusions after [**2103-9-21**].
The day after [**Hospital **] transfer to floor she reported two bloody
bowel movements and [**Hospital1 **] hematocrit checks were continued but HCT
remained stable around 30. She reported no further bloody or
maroon bowel movements. She had a colonoscopy on [**2103-9-24**] which
showed diverticulosis as well as polyps. She had a polypectomy
and pathology is pending. Although initially started empirically
on IV PPI [**Hospital1 **], this was changed to PO daily dosing prior to
discharge.
# HTN- Norvasc initially held but restarted prior to discharge
at home dose 5 mg daily.
# [**Name (NI) 1068**] Pt Remained stable on zoloft.
# Code: Full
Medications on Admission:
Allergies: NKDA
Home medications:
Zoloft 50mg PO daily
Norvasc 5mg PO daily
Naproxen PRN
Tylenol PRN
Aspirin PRN
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis
1. Gastrointestinal Bleed
2. Diverticulosis
3. Sigmoid/Colon Polyps. Biopsy reports pending
Secondary Diagnosis
1. Depression
2. Osteoarthritis
3. Hypertension
Discharge Condition:
Hemodynamically stable, stable hematocrit x 3 days, afebrile
Discharge Instructions:
You were admitted to the hospital with maroon colored stools and
bleeding from your gastrointestinal tract. Your blood counts
were initially low so you were transfused 3 units of blood.
After this, your blood counts remained stable and you did not
have any further bleeding. You had a colonoscopy on [**2103-9-24**]
which showed diverticulosis, which are small outpouchings in the
colon, and polyps. One polyp was removed and a biopsy was sent
for pathology. The results of the biopsy were pending at the
time of discharge.
We made the following changes to your medications
1. We added Pantoprazole 40mg by mouth daily
Please take all medications as prescribed and follow up with
your primary care doctor as below.
Please return to the ED or call your primary care physician if
you develop bloody, maroon or dark tarry stools or notice
bleeding from you rectum. Also call if you develop nausea,
vomiting, lightheadedness, dizziness, chest pain, shortness of
breath or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on
Thursday [**10-4**] at 5:15pm. Call [**Telephone/Fax (1) 14825**] if you have
any questions regarding your appointment.
A repeat hematocrit should also be checked at this time.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**] MD [**MD Number(1) 7715**]
| [
"2851",
"4019",
"311"
] |
Admission Date: [**2118-5-7**] Discharge Date: [**2118-5-12**]
Date of Birth: [**2070-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
Radiofrequency ablation of liver lesions
History of Present Illness:
47 yo man with h/o etoh/HCC cirrhosis, esophageal varices with
melena with black emesis and dark tarry stools [**5-6**]. He states
the melena started [**5-5**]. He also had some lightheadedness. He
notes some abdominal pain during the ambulance ride that
improved with zofran. His partner encouraged him to go to the
[**Name (NI) **]. At [**Doctor First Name 8125**] hct 37.2.
In the ED VS: 98.7 76 117/75 18 99% on 2L NC. He 2L NS. 2
Melenic, guaiac + stools. HR 80, SBP 120, hemodynamically
stable. Was initially to go to floor, housestaff uncomfortable.
ROS: no wt change, change in abdominal girth, fevers, chills,
head ache, chest pain, sob, palpitations, sob, dysuria,
hematuria, confusion, rash.
Past Medical History:
- Etoh/HCV cirrhosis with varices, ascites, and previous
episodes of encephalopathy, Last viral load 7,340 IU/mL [**2117-2-26**].
The patient has not had a liver biopsy nor has the patient had
any treatment to date for his hepatitis C followed by Dr. [**Last Name (STitle) 497**]
(last seen [**4-11**]). EGD [**2115-12-23**] revealing varices at the lower
third of the esophagus, with two bands placed, and portal
gastropathy. Grade 3 esophageal varices with multiple admissions
for GIB, banding in past; last EGD [**9-11**] varices too small to
band.
- Ethanol abuse with history of DTs: + hallucinations in the
past but no intubations or seizures.
- h/o Nephrolithiasis.
- MVA [**2113-5-4**] with two fractured lumbar vertebrae, torn
rotator cuff, and humeral head fracture.
- h/o coagulopathy, anemia (baseline Hct ~30), thrombocytopenia
- foot surgery
- facial reconstruction as a child
- leg cramps
- asthma
- Hep B SAg/sAb negative ; Hep A immune
- HIV negative [**2115-7-5**]
- AFP 1.81 [**2117-2-4**], U/S [**2117-2-25**] with 1.1cm echogenic focus
in left lobe, f/u MRI limited
Social History:
He has a long history of alcohol abuse (since high school).
currently drinking a pint of vodka per day with some mixed
drinks, last drink [**5-6**] am. He has a history of DTs, no seizures
or intubations for this but + hallucinations. He currently
smokes less than a pack per day and has smoked 30+ years. He is
unemployed but used to work as a carpenter. He has a history of
IVDU (cocaine and heroin) but last use 15 years ago. He has a
history of incarceration in the past.
Family History:
He does not know of any liver disease or colon cancer. Father
with a history of alcoholism
Physical Exam:
VS: T 97.9 HR 89 BP 129/82 RR 24 Sat 93% on RA
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: protuberant, soft, NT, ND, + BS, no obvious HSM on
percusion, ? small fluid wave, no caput
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
Skin: spider angiomas on chest, scattered [**Last Name (LF) 94195**], [**First Name3 (LF) **] damage
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
asterixis.
PSYCH: appropriate affect, no anxiety, tremulousness,
diaphoresis
Pertinent Results:
Admission labs:
[**Age over 90 **]|105|10
-----------<128
3.7|25|0.6
Ca: 7.5 Mg: 1.3 P: 2.6
ALT: 38 AP: 124 Tbili: 4.9 Alb: 2.3
AST: 111
.
11.8
7.5>--<152
33.9
PT: 19.6 PTT: 35.6 INR: 1.8
Fibrinogen: 256 D
EGD: no actively bleeding vessels (please see full report in OMR
for further details)
Radiofrequency ablation:
1. Successful radiofrequency ablation of the patient's liver
tumor.
[**2118-5-12**] 05:45AM BLOOD WBC-6.0 RBC-2.72* Hgb-10.1* Hct-28.6*
MCV-105* MCH-37.1* MCHC-35.2* RDW-17.0* Plt Ct-91*
[**2118-5-12**] 05:45AM BLOOD Plt Ct-91*
[**2118-5-12**] 05:45AM BLOOD Glucose-169* UreaN-8 Creat-0.6 Na-130*
K-3.4 Cl-96 HCO3-29 AnGap-8
[**2118-5-12**] 05:45AM BLOOD ALT-29 AST-92* LD(LDH)-276* AlkPhos-107
TotBili-3.6*
[**2118-5-12**] 05:45AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.4*
Brief Hospital Course:
46 yo man with alcoholic cirrhosis, known esophageal varices
admitted with melena and emesis. The patient was
hemodynamically stable throughout his admission. He had no
further episodes of melena during this hospital course. The
patient was initially maintained with two large bore IVs with a
plan to transfuse for a hematocrit less than 28. He had an EGD
which did not demonstrate any actively bleeding lesions.
The patient was actively drinking prior to admission. Although
he denied a history of withdrawal seizures he was tachycardic,
hypertensive and nauseated on admission. He was maintained on a
q2 hour CIWA scale, with decreasing benzo requirements
throughout his admission. The patient was also maintained on
thiamine, folate and a multivitamin. His clonidine was
discontinued on admission and restarted once the patient was
called out to the floor.
The patient has a coagulopathy secondary to his chronic
cirrhosis. His disease is secondary to ETOH with HCC, and he is
followed by Dr. [**Last Name (STitle) 497**]. His disease is complicated by portal
hypertension, hypertensive gastropathy, esophageal varices s/p
banding and melena in the past, as well as ascites,
thrombocytopenia, anemia, and coagulopathy. His medications
were initially held but once it was clear the patient was not
actively bleeding, his nadolol, furosemide, spironolactone and
lactulose were restarted.
The patient had a stable thrombocytopenia. He did receive FFP
prior to a planned RFA for three liver lesions. The procedure
went well and the patient was discharged the following day.
The patient was continued on his outpatient pain regimen of
Neurontin and a lidocaine patch.
He also had a chronic stable anemia which was macrocytic, likely
multifactorial given GIB, EtOH use and liver disease. Vitamin
B12 1787 [**4-12**], folate 11.8 [**4-12**].
The patient was a full code throughout this admission.
Communication was as follow: mother [**Name (NI) **] (HCP) [**Telephone/Fax (1) 94196**],
Partner [**Name (NI) **] (h) [**Telephone/Fax (1) 94197**], (c) [**Telephone/Fax (1) 94198**].
Medications on Admission:
Pt poor historian, unable to verify meds
Clonidine 0.1 mg PO TID
Fluticasone 50 mcg/Actuation Nasal [**Hospital1 **]
Folic Acid 1 mg PO DAILY
Furosemide 40 mg PO DAILY
Gabapentin 300 mg PO Q8H
Lactulose 10 gram/15 mL ThirtyML PO four times a day - only
takes when constipated
Nadolol 40 mg PO DAILY
Pantoprazole 40 mg PO Q24H - states [**Hospital1 **]
Ferrous Sulfate 325 mg PO DAILY
Hexavitamin PO DAILY - not likely taking
Thiamine HCl 100 mg PO DAILY
Lidocaine 5 %(700 mg/patch) Topical DAILY
Spironolactone 100 mg PO DAILY
Nicotine 21 mg/24 hr Transdermal DAILY
Discharge Medications:
1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
7. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for
12, off for 12 hours.
12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Alcoholic cirrhosis
GI bleed
Secondary:
HCV
Liver lesions
Asthma
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with concern for
gastrointestinal bleeding. While you were in the hospital, you
had an EGD which did not demonstrate any actively bleeding
vessels.
You also had radiofrequency ablation of the lesions in your
liver. Your blood counts have been stable since your admission
to the hospital.
Please take all of your medications as prescribed. Please call
your physician or come to the emergency room with anyfevers,
vomiting, blood in your stool or your vomit, confusion or other
symptoms you find concerning.
Followup Instructions:
Please call [**Telephone/Fax (1) 250**] to schedule an [**Telephone/Fax (1) 648**] with your
primary care doctor to follow up after discharge.
Please call the Liver Center at ([**Telephone/Fax (1) 1582**] to set up an
[**Telephone/Fax (1) 648**] with Dr. [**Last Name (STitle) 497**] within several weeks of discharge.
| [
"2875",
"3051",
"49390"
] |
Admission Date: [**2155-8-10**] Discharge Date: [**2155-8-27**]
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 80-year-old white
female with a past medical history significant for non-Q-wave
MI on 6/[**2155**]. The patient was transferred to [**Hospital1 346**] from [**Hospital6 33**] with a
question of small-bowel obstruction. The patient was in her
a bowel movement. Prior to admission she felt bloated,
although she did not have any nausea or vomiting, but had
stopped passing gas approximately two days prior to
admission. The patient was brought to [**Hospital6 33**]
on [**8-9**] secondary to increased abdominal pain, which was
diffuse across the lower abdomen, mostly crampy. She was
admitted and fluid resuscitated at [**Hospital6 33**]. NG
[**Hospital **] Hospital showed dilated loops of small bowel with an
air-fluid level.
PAST MEDICAL HISTORY:
1, The patient was found to have small-bowel obstruction and
she was transferred to the [**Hospital1 188**] for exploratory laparotomy and lysis of adhesions.
Past medical history is significant for non-Q-wave MI in
[**2155-6-21**], at which time approximately four cardiac stents
were placed.
2. Chronic obstructive pulmonary disease.
3. Hypertension.
PAST SURGICAL HISTORY: The patient had a colectomy
approximately 30 years ago and vaginal hysterectomy.
ALLERGIES: The patient has no known allergies to
medications.
HOME MEDICATIONS:
1. Serevent two puffs q.h.s.
2. Combivent 2 puffs q.i.d.p.r.n.
3. Albuterol and Atrovent 25/500 q.i.d.
4. Zantac 50.
5. Ativan 2 mg q.4h. to 6h. for anxiety.
6. Morphine for pain.
7. Hydralazine 2 mg IV q.8h. for blood pressure control.
SOCIAL HISTORY: The patient is a long-term smoker.
PHYSICAL EXAMINATION: Physical examination on admission
revealed the following: VITAL SIGNS: Temperature 97.4,
blood pressure 150/20, pulse 82, respiratory rate 16,
saturation 93% on room air. HEAD AND NECK: Head and neck
examination: Pupils equal, round, and reactive to light.
Extraocular muscles are intact. Mucous membranes moist.
RESPIRATORY: The patient is clear to auscultation
bilaterally. She is moving air well. CARDIAC: Examination
showed regular rate and rhythm, normal S1 and S2 without
murmurs, rubs, or gallops. ABDOMEN: Abdomen was noted to be
soft, distended, with mild tenderness diffusely. There is no
guarding or rebound. EXTREMITIES: Without edema, stools
were guaiac negative at that time.
LABORATORY DATA: Prior to admission, labs drawn at [**Hospital6 3622**] revealed the white count of 11.0, hematocrit
37.1, platelet count 346,000, sodium 136, potassium 3.5, BUN
25, creatinine 1.3, glucose 132, calcium 10.5, magnesium 1.9,
LFTs and ALT 1125, AST 21, amylase 20, lipase 22.
On [**2155-8-11**], the patient received a CT scan of the abdomen,
which demonstrated multiple loops of small bowel with a
region of narrowing in the right lower quadrant and iliac
fossa consistent with mechanical small-bowel obstruction,
single low attenuation cyst in the liver, tiny gallstone
without evidence of cholecystitis, scattered sigmoid
diverticula without diverticulitis, extensive vascular
calcification in the region of the mesenteric artery.
HOSPITAL COURSE: Given the patient's CT findings, it was
decided that the patient would be taken to the operating room
for emergent exploratory laparotomy and lysis of adhesions.
On [**2155-8-11**], the patient had the exploratory laparotomy and
she tolerated the operation well. Approximate blood loss was
200 cc. She was transfused intraoperatively with six units
of platelets, 800 cc crystalloid.
Intraoperative central line was placed,
and a chest film was obtained to confirm placement
The patient was transferred from the operating room to the
Post Anesthesia Care Unit. From there, she was transferred
to the Surgical Intensive Care Unit for observation and
monitoring after laparotomy given her history of non-Q-wave
MI and chronic obstructive pulmonary disease.
In the Post Anesthesia Care Unit, the patient was evaluated
by the Cardiology Service, where she was noted to have
transient right bundle branch block and the Post Anesthesia
Care Unit decided to resume her Aspirin.
Overnight, from postoperative day #0 to postoperative day #1,
the patient did not have any major events. She was continued
to be monitored in the Surgical Intensive Care Unit. In the
Intensive Care Unit it was decided to diurese the patient.
She was transfused with one unit of packed red blood cells.
The hematocrit was noted to increase to 29.7. Overnight,
from postoperative day #1 to postoperative day #2, the
patient was noted to have low urine output. While in the
ICU, the patient was kept NPO. She was noted to have an
increasing hematocrit after infusion of one unit of packed
red blood cells. On [**2155-8-12**] the patient received a
transthoracic echocardiogram, which demonstrated preserved
left ventricular ejection fraction. It was decided to start
Lopressor on the patient for rate and pressure control.
From postoperative day #2 to postoperative day #3, the
patient continued to do well without major events. The NG
tube was noted to be draining 350 cc from postoperative day
#2 to postoperative day #3. Again, the patient was noted to
have a low hematocrit of 27.7 on [**2155-8-13**]. The patient
continued to do well, although she did have one episode of
anxiety. It was decided on [**2155-8-13**] to change the patient
from a pCO2, regular morphine prn. She was found to be
stable on Lopressor and IV Vasotec. She was transfused again
with one unit of packed red blood cells.
During the evening of [**2155-8-13**], the patient was transferred
from the Intensive Care Unit to the floor, where she was
noted to be doing well with no overnight events from [**8-13**] to
[**8-14**]. Overnight, from [**8-13**] to [**8-14**], the patient's NG tube
put out approximately 150 cc. She was still not passing
flatus.
On postoperative day #4 to postoperative day #5, [**2155-8-14**] to
[**2155-8-5**] the patient continued to do well. She had
decreased abdominal pain, and she was able to ambulate. The
patient remained without flatus. The patient was diuresed
3.5, which was repleted. At this point, total parenteral
nutrition was started for the patient. The patient tolerated
TPN well and she was advanced to goal total parenteral
nutrition on [**2155-8-15**].
On [**2155-8-16**], the patient was evaluated by rehabilitation
services and physical therapy. The patient was noted to be
making progress with ambulatory ability.
Overnight, from [**2155-8-16**] to [**2155-8-17**] the patient noticed
increased amounts of flatus. She was able to pass flatus at
this point. She remained on TPN on [**2155-8-17**]. The NG tube
was noted to put approximately 250 cc out on [**2155-8-16**].
On [**2155-8-17**] to [**2155-8-18**] the patient continued to do well.
On [**2155-8-17**], the patient had the NG tube pulled. She is to
be taking small sips. TPN was continued, IV fluids were not.
On [**2155-8-18**], the Dermatology Service was consulted for a
facial rash. Their impression was that she was an
80-year-old female with onset of malar rash after treatment
for small-bowel obstruction. They prescribed hydrocortisone
1% cream for the patient, which seemed to help with the
contact dermatitis.
Overnight, [**2155-8-18**] to [**2155-8-19**], the patient complained of
some shortness of breath to approximately 4 in the morning,
which was relieved with nebulizers.
LABORATORY DATA: The patient was found to have a hematocrit
of 26. TPN was continued through [**2155-8-19**]. On [**2155-8-19**],
the Pulmonary Service was consulted because of the patient's
complaint of dyspnea. Their impression was that she was an
80-year-old female with known chronic obstructive pulmonary
disease status post myocardial infarction and recent
abdominal surgery with the differential diagnosis for
episodes of dyspnea were mostly multifactorial with chronic
obstructive pulmonary disease exacerbation. They recommended
increasing Atrovent to four puffs b.i.d.; restarting Flovent
and checking for PFTs. Also, the differential diagnosis of
bronchitis with increased amounts of sputum and increased
shortness of breath. However, the patient was without any
clear chest x-ray or infiltrate. The patient was treated
with Azithromycin for possible tracheobronchitis for a total
course of five days. The differential diagnosis was
pulmonary edema and deconditioning given prolonged hospital
course. It was decided to treat the patient with
approximately five days of Azithromycin and to adjust her
MDIs and nebulizers according to the recommendations.
On [**2155-8-20**], the patient was transfused with one unit of
packed red blood cells. The hematocrit improved from 26 to
33. The patient continued to do well. She was ambulating.
However, overnight from [**2155-8-19**] to [**2155-8-20**], the patient
started to vomit twice. The nasogastric tube was replaced,
it drained approximately 100 cc from the stomach.
The Dermatology Department followed the patient. The patient
was given an increase in the Hydrocortisone ointment from 1%
to 2.5% b.i.d. for the worsening facial rash.
Overnight, from [**2155-8-20**] to [**2155-8-21**], the patient had no
complaints. She felt that her respiratory status was better
in the morning. She was without nausea or vomiting after the
NG tube was replaced. Overnight, the NG was noted to put out
approximately 350 cc. The hematocrit was stable at 33.8 from
33.9 the day before.
Overnight, from [**2155-8-21**] to [**2155-8-22**], the patient did well.
The nasogastric tube was noted to have put out only 650 cc of
fluid the previous day. The hematocrit was stable at 33.2.
The blood pressure medications at this time were IV Lopressor
Enalapril, and Hydralazine. The patient tolerated these well
with good pressures and rate. She was maintained on
telemetry.
The patient was diuresed with 2 mg of Lasix on [**2155-8-21**]. On
[**2155-8-22**], it was decided that the patient was passing flatus
and was able to have a bowel movement. At this point, the
nasogastric tube was taken out. The patient was noted to
tolerate about 630 PO ice chips on [**2155-8-22**].
Overnight, from [**2155-8-22**] to [**2155-8-23**], the patient continued
to do well with the nasogastric tube discontinued and she had
no complaints of nausea, vomiting, or abdominal pain. The
TPN was continued. At this point, the patient decided that
the best course of action would be to go to acute
rehabilitation prior to leaving for home in [**State 760**].
Overnight, from [**2155-8-23**] to [**2155-8-24**], the patient continued
to do well. She began tolerating a clear liquid diet. She
continued to pass flatus. The labs were noted to be stable.
She was diuresed again with 10 mg of Lasix on [**2155-8-24**].
Overnight, from [**2155-8-24**] to [**2155-8-25**], the patient continued
to do well. She was able to tolerated her clear liquid diet
throughout the day without nausea or vomiting. The
hematocrit was noted to be stable at 32.8.
Overnight, from [**2155-8-25**] to [**2155-8-26**] the patient continued to
do well. She felt a slight amount of nausea with soft diet.
She was diuresed with approximately 20 mg of Lasix from
[**2155-8-25**] to [**2155-8-26**] given the positive fluid balance over
the course of the past two days, weight was noted to be 75.8,
which was fairly close to her known dry weight. The patient,
however, did not have emesis with her soft diet. It was
decided to continue the soft diet. At this point, it was
decided to stop the patient's TPN; discontinued the central
line; switch her from the IV cardiac medications to PO
cardiac medications; and take her off telemetry.
Overnight, from [**2155-8-26**] to [**2155-8-27**], the patient continued
to do well. It was decided at this point that she be
transferred to an acute rehabilitation facility here in
[**State 350**], prior to her going her to [**State 760**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Small-bowel obstruction, status post exploratory
laparotomy.
2. Non-Q-wave myocardial infarction.
3. Chronic obstructive pulmonary disease.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg PO q.d.
2. Enalapril 5 mg PO b.i.d.
3. Metoprolol 12.5 mg PO b.i.d.
4. Enteric aspirin 325 mg PO q.d.
5. Ativan 0.5 mg
6. Colace 10 mg PO b.i.d.
7. Ipratropium bromide 4 puffs q.i.d.
8. Flovent 110 mcg two puffs b.i.d.
9. Albuterol nebulizers one nebulizer q.6h.p.r.n.
bronchospasm.
10. Albuterol one to two puffs q.4h. to 6h.p.r.n.
bronchospasm.
11. Salmeterol two puffs b.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Name8 (MD) 16207**]
MEDQUIST36
D: [**2155-8-27**] 04:56
T: [**2155-8-27**] 10:02
JOB#: [**Job Number 43770**]
| [
"4280",
"53081",
"4019",
"V4582"
] |
Admission Date: [**2161-8-27**] Discharge Date: [**2161-9-3**]
Date of Birth: [**2121-2-5**] Sex: M
Service: MED
Allergies:
Bactrim
Attending:[**First Name3 (LF) 15241**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 15225**] is a 40 year old man with AIDS (criteria of CD-4 counts
and opportunistic infections) who is being admitted for dyspnea,
fevers, and hypoxia.
Mr. [**Known lastname 15225**] says that he was in his usual state of (chronically
poor) health until about 3 days ago when he began to have more
fatigue than usual. He then began to have fevers up to
99.0-100.0
and yesterday started to develop left sided chest pain that came
on with deep breaths and coughing, and fevers up to 103 degrees
with chills but no rigors. He is coughing up scant, thick yellow
sputum, without any blood in the sputum.
He came to the Infectious Disease Outpatient Clinic this morning
and was found to have a temp of 102 degrees, and an oxygen
saturation after walking down the hallway that was 71.%. He was
brought to the Emergency Room and admitted from there.
He was last hospitalized here from [**6-29**] -> [**2161-7-6**] for persistent
pain from a right-sided kidney stone. During the hospital-
ization, he had a stent placed into the right kidney to help
remove the stone. The stent was removed prior to his discharge.
A chest X ray during that admission revealed a faint opacity in
the left lower lobe that obscured the left hemidiaphragm on the
lateral view. He was, therefore, put on cefpodixime for 7 days."
In ER VSS were temp of 101.7 HR of 99 BP 112/72 R24, 74% on RA,
99% on 2L. Cxray notable for LLL infiltrate. EKG notable for
sinus tach at 92, negative axis, R wave transition in v3, flat T
waves V5-V6, q3T3, q in [**12-30**]/avf (no change from baseline). INR
was 0.9. Cr of 1.6. Blood cultures were sent. In ed received
tylenol, ceftriaxone 2mg iv, MS contin and heparin IV.
40 M w/AIDS (CD4 count of 9 on [**2161-4-23**]) admitted [**8-27**] for
dyspnea, fevers to 103, and hypoxia. (In [**Hospital **] clinic with
temperature of 102 degrees and ambulatory o2 sat of 71%. Please
see ID admit note in OMR for complete HPI/history.) In short,
patient was in his usual state of health until three days prior
to admission when he experienced more fatigue, fevers up to
99.0-100.0, pleuritic chest pain and cough. (Patient was last
hospitalized at [**Hospital1 18**] from [**6-29**] to [**2161-7-6**] for persistent pain
from a right-sided kidney stone, a stent was placed and
removed.)
In ER on admission: VSS were temp of 101.7 HR of 99 BP 112/72
R24, 74% on RA, 99% on 2L. Chest xray was notable for LLL
infiltrate. EKG notable for sinus tach at 92, negative axis, R
wave transition in v3, flat T waves V5-V6, q3T3, q in [**12-30**]/avf
(no change from baseline). INR was 0.9. Cr of 1.6. In the ed the
patient received tylenol, ceftriaxone 2mg IV, MS contin and
heparin IV.
ROS: Man with HIV/AIDS last CD4 count of 9. On transfer to the
[**Hospital Ward Name **] patient continues to express sharp chest pain in
left sternal area radiating to left shoulder [**5-7**] in intensity
worse with inspiration, patient also reports not some SOB.
Patient reports intermittent hematuria. He denies abdominal
pain, diarrhea, melena, headache, sore throat, dysuria, lower
extremity swelling or pain, orthopnea.
Past Medical History:
1. AIDS dx [**2142**]: [**5-1**] VL 23K; [**3-31**] CD4 1 VL 47K- initially on
monotherapy starting in [**2144**], now with variable degrees of
resistance to HAART.
2. PCP x5: [**2146**](intubated) c/b perirectal HSV and pancreatitis
from pentamidine and/or steroids, [**1-/2155**] c/b LUE axillary vein
thrombosis, [**5-/2155**], [**7-/2155**], [**3-/2157**]
3. Disseminated MAC bacteremia [**2148**]
4. Didanosine associated pancreatitis [**6-/2150**]
5. Aseptic meningitis [**1-/2154**] secondary to TMP/SMX
6. Cerebral MAC (diff from [**2148**] organism) c/b seizures [**3-/2157**]
7. Necrotic HSV L chest wall lesion resistant to acyclovir and
ganciclovir and treated with Foscarnet [**3-30**]
8. Acyclovir resitant HSV R chest wall lesion [**5-1**] treated with
Foscarnet (to stop [**2161-7-2**])
9. Neurosurgical drainage of a R sided subdural fluid collection
[**11-27**] c/b post-op seizure and intubation for airway protection
10. HTN
11. Chronic peripheral neuropathy (legs>arms)
12. Systolic CHF (Echo [**9-30**] EF 50% w/ 1+AR, [**11-28**]+MR, 1+ TR)
13. Coagulopathy [**12-29**] lupus anticoagulant c/b DVT/PE [**4-28**] and
[**9-30**], on anticoagulation with IVC filter in place
14. IMI [**4-28**] (presumed [**12-29**] hypercoagulable state) s/p RCA
stenting
15. Aflutter s/p ablation [**12-31**]
16. Thrush-resistant to fluconazole (now tx w/ voriconazole)
17. Asthma
18. Chronic renal failure
19. Hyperkalemia
Social History:
-Divorced; contracted HIV from his ex-wife after their child
died of AIDS. They were subsequently tested and found to both be
HIV+ and wife admitted to IVDU. She has since died.-Lives alone
with dog, [**Month/Year (2) 15233**]. Lives in studio apt rented from his
mother.-Smoked 1 ppd x 2 years (on job). Quit 5 mths ago when he
stopped working as a an operations manager in scrap metal.
-EtOH- occas wine; Marijuana occas for nausea; Exercises
5x/wk-H/o asbestos exposure
Family History:
Mom-mild HTN and hypercholesterolemia; brother- asthma, HTN. 3
sisters-alive and healthy
Physical Exam:
OBJ: T 99.9 BP 142/104 HR 97 R 20 98% on 1.5 L
GEN: emaciated gentleman, in mild respiratory distress
HEENT: OP clear, no evidence of thrush, no cervical
lymphadenopathy
CV: RRR with systolic murmur
LUNG: crackles auscultated on Left base
ABD: +BS/NT/ND, no organomegally, no rebound, no guard
EXT: no edema/cyanosis/pulses intact, skin dorsum of hands is
red-purple in color right greater than left
NEURO:[**1-8**] intact, upper extremity, lower extremity strength
symmetric and intact
Skin: normal skin tone, no erythema/rashes
Pertinent Results:
[**2161-8-27**] 01:15PM POTASSIUM-4.4
[**2161-8-27**] 12:55PM PT-12.0 PTT-18.2* INR(PT)-0.9
[**2161-8-27**] 11:56AM LACTATE-1.9
[**2161-8-27**] 11:54AM GLUCOSE-92 UREA N-23* CREAT-1.6* SODIUM-135
POTASSIUM-6.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-18
[**2161-8-27**] 11:54AM ALT(SGPT)-15 AST(SGOT)-43* ALK PHOS-73
AMYLASE-31 TOT BILI-1.3
[**2161-8-27**] 11:54AM ALBUMIN-3.8
[**2161-8-27**] 11:54AM WBC-3.1* RBC-3.36* HGB-11.3* HCT-35.6*
MCV-106* MCH-33.7* MCHC-31.8 RDW-16.2*
[**2161-8-27**] 11:54AM NEUTS-71.6* LYMPHS-11.6* MONOS-12.3* EOS-3.6
BASOS-0.7
[**2161-8-27**] 11:54AM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-3+
[**2161-8-27**] 11:54AM PLT COUNT-223
renal u/s ([**2161-8-5**]): IPRESSION:
1. Diffuse echogenicity of bilateral kidneys consistent with
the patient's
history of HIV.
2. Simple cyst in upper pole of right kidney which is slightly
smaller than
on prior examination.
3. No evidence of hydronephrosis, stones or masses bilaterally.
Ct abdomen: [**2161-6-17**] IMPRESSION: 6-mm partially obstructing
calculus within the proximal right ureter, with acute forniceal
rupture.
EKG: EKG notable for sinus tach at 92, negative axis, R wave
transition in v3, flat T waves V5-V6, q3T3, q in [**12-30**]/avf (no
change from baseline).
cath [**5-28**]: FINAL DIAGNOSIS:
1. Patent RCA stents.
2. Normal biventricular filling pressures.
3. Mild LV systolic dysfunction with dopamine infusion.
CXRAY ([**2161-8-27**]): IMPRESSION: Patchy bibasilar opacities
consistent with pneumonia.
Lower extremity u/s:IMPRESSION: Chronic deep venous thrombosis
extending from the proximal left superficial femoral vein to the
left popliteal vein, with multiple collaterals.
Brief Hospital Course:
40 M w/ AIDS (CD4 of 9), multiple medical problems presents with
dypnea and fever.
SOB - On the floor antibiotic was changed to cefipime. One day
following admission, patient developed additional chest pain and
hypoxia initially read in o2 sat of 70s requiring 10L of O2 at
which patient was 93% (abg was 7.35/34/90 on 10L face-mask),
patient's systolic blood pressure was also in 100s compared to
baseline of 130s. Unclear if relative hypotension was secondary
to pain medications, dehydration, developing heart failure from
possible PE, verus worsening PNA, therefore patient was
transferred to unit.
In [**Hospital Unit Name 153**] supportive measures were continued. The patient was
provided with IV fluid. Empiric treatment for PCP [**Name Initial (PRE) **]
(primaquine) but then discontinued. CT on [**8-29**] showed: LLL
PNA, effusion, enlargement of nodule at left lung apex and new
nodule in the medial LUL nodule, possibly representing
differences in slice selection compared to [**9-30**]. Patient will
need to follow up with Dr. [**Last Name (STitle) 2148**] regarding further work-up of
these findings. (A contrast CT was not performed secondary to
the patient's CRI.) Labs on [**8-31**] notable for HCT 25.5, Retic
0.7, LDH normal, INR of 1.6, Cr at 1.6 (down from elevated 1.9
on admission), of note Trop maximum at 0.83 and an echo was
performed on [**8-29**] which demonstrated normal systolic function,
therefore felt to represent possible RV strain. Patient's
respiratory status improved on antibiotics and patients
transferred out of unit. Of note cryptococcal antigen was
negative. Nasopharyngeal culture for ADENO,PARAINFLUENZA 1,2,3
INFLUENZA A,B AND RSV was negative. CMV DNA was negative.
Patient o2 sat was 94% while ambulating on discharged but with
subjective feeling of intermittent dyspnea we discharge with
oxygen. Patient will also be discharged on Lovenox SC, until
INR is therapeutic. A picc line was placed on discharge for
outpatient cefipime.
2. Fever - Patient with AIDS, history of fever and chest
xray/chest CT notable for PNA. Blood cultures / urine cultures
in-house were negative. Patient without diarrhea. Reticulocyte
low, LDH normal, D bili was slightly elevated.
3. CRI/Hematuria - Patient with a history of renal stones,
recent admission for kidney stone and urthethral stent presents
with elevated CR compared to baseline. The etiology was likely
prerenal as patient responded to fluids. On discharge CR was 1.3
(baseline 1.3-1.8).
4. Cardiac/CAD - Of note patient with a history of RCA stent,
IMI in past, q waves on inferior leads on EKG. Patient is not
maintained on cardiac medications secondary to concerns
regarding drug interactions (discussed with attending). Patient
experienced elevated troponins during episodes of chest pain. An
echo demonstrated intact systolic function. Patient discharged
on aspirin.
5. HIV - Patient on antiretroviral medications tonofovir,
stavudine, ritonavir, Fuzeon, Emtricitabine, Atazanavir. Patient
is on empiric AIDS coverage with cipro, azithro, acyclovir.
6. Neurology/History of seizure - Maintain on kepra. Seizure
thought to be due to a focus from scar of a prior brain abscess.
Patient reports using gabapentin for neuropathic pain.
7. Anemia - Patient presented with a hematocrit of 34, wide
variation in baseline (34-44). Throughout hospitalization
hematocrit went down to 25 but stabilized. This decrease likely
reprented fluid shifts from hydration. The differential for
anemia includes low production given anemia of chronic disease,
low reticulocyte count. Iron studies demonstrated low iron, low
b12. Therefore b12 was provided. Patient has history of procrit
use which will be resumed on discharge.
10. Code - DNR/DNI.
Medications on Admission:
(per OMR on [**2161-8-4**])
ACYCLOVIR 400MG--One capsule by mouth twice a day
ALBUTEROL 90MCG--2 puffs every 4 hours as needed for coughing
not relieved by serevent.
ATAZANAVIR 150 MG--Two capsules (300 mg) by mouth once (one
time) daily.
AZITHROMYCIN 250MG--One capsule by mouth twice a day
CIPROFLOXACIN HCL ORAL 500 MG TABLET 500MG--One tablet by mouth
twice a day
COUMADIN 5MG--Take 7.5 mg/day until further notice.
DILAUDID 2MG--One tablet every 3 hours as needed for pain not
controlled with morphine contin.
EFFEXOR XR 75MG--One capsule daily.
EMTRICITABINE 200 MG--One capsule by mouth daily.
ETHAMBUTOL HCL 400MG--One tablet by mouth three times a day
FLONASE 50MCG--Two sprays each nostril twice a day
FUSEON 90 MG--Inject one vial (90 mg) sq [**Hospital1 **].
ITRACONAZOLE 10MG/ML--20 cc (200 mg) swish and swallow daily.
KEPPRA 500MG--One tablet by mouth twice a day for suppression of
seizures
LOVENOX 120MG/.8ML--One injection sq daily.
NEUPOGEN 300MCG/0.5--Inject one cc every other week (every 2
weeks).
NEURONTIN 100MG--Two capsules three times a day with two of the
400 mg capsules for 1000 mg by mouth three times a day for
control of discomfort from peripheral neuropathy.
OPIUM 10%--One cc by mouth four times a day as needed for
diarrhea
OXANDROLONE 10MG--One tablet (10 mg) by mouth twice a day for
weight loss.
PENTAMIDINE ISETHIONATE 300MG--Given by aerosol monthly
PERCOCET 5-325MG--One to two tablets every 4 hours as needed for
pain not controlled by morphine contin.
PROCRIT [**Numeric Identifier **] U/ML--One cc every other week (every 2 weeks).
RITONAVIR 100MG--One capsule once daily, with two capsules of
atazanavir (reyetaz).
SEREVENT DISKUS 50MCG--Two puffs [**Hospital1 **].
STAVUDINE 15MG--One capsule by mouth twice a day
SYRINGE/SAFETY GLIDE 25GX0.625"--Use one cc 25 g x 0.625"
syringes for procrit and g-csf injections.
TENOVOFIR 300 MG--One tablet daily
ULTRASE MT 18 59-18-59--Two capsules by mouth with each meal
ZOFRAN 4MG--One tablet by mouth q 6 hours as needed for nausea /
vomiting
MEGACE 40MG--One tablet daily, for enhancement of appetite.
-per patient he does not take albuterol/dilaudid/itraconazole
-he does take gabapentin and amphotericin
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*1 30* Refills:*0*
2. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO
QD (once a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
5. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO QAM (once a day (in the
morning)).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
6. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO qd ().
Disp:*30 Capsule(s)* Refills:*2*
7. Ethambutol HCl 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [**Hospital1 **] (2
times a day): 90 mg SC injection.
Disp:*60 Kit(s)* Refills:*2*
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Morphine Sulfate 15 mg Tablet Sustained Release Sig: Three
(3) Tablet Sustained Release PO Q8H (every 8 hours).
Disp:*4 Tablet Sustained Release(s)* Refills:*2*
11. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Oxandrolone 2.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
Disp:*240 Tablet(s)* Refills:*2*
13. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QD (once a
day).
Disp:*30 Capsule(s)* Refills:*2*
14. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours): (50 mcg)
2 INH IH Q12H
.
Disp:*60 Disk with Device(s)* Refills:*2*
15. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
16. Stavudine 30 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
17. Amphotericin B 50 mg Recon Soln Sig: One (1) Recon Soln
Injection QID (4 times a day): DOSE: 20 mg.
Disp:*120 Recon Soln(s)* Refills:*2*
18. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
20. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
Disp:*1 30* Refills:*2*
21. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
22. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
23. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
Disp:*15 ML(s)* Refills:*0*
24. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO at bedtime.
Disp:*45 Tablet(s)* Refills:*2*
25. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1)
injection of 0.8 ML Subcutaneous Q12H (every 12 hours) for 4
days.
Disp:*8 injection of 0.8 ML* Refills:*0*
26. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO four times a day as
needed for pain for 7 days.
Disp:*20 Tablet(s)* Refills:*0*
27. Outpatient Lab Work
Please obtain INR value on [**2161-9-6**]
28. Cefepime HCl 2 g Piggyback Sig: One (1) Piggyback
Intravenous Q12H (every 12 hours) for 10 days.
Disp:*20 Piggyback(s)* Refills:*0*
29. Other
Please continue procrit administration as prior to
hospitalization. Normally given every other Tuesday.
30. instruction
Please take pentamadine as prior to hospitalization.
(dose provided in the hospital on [**8-28**])
31. Outpatient Lab Work
Please obtain INR as an outpatient.
Please send results to Dr. [**Last Name (STitle) 2148**]
32. Oxygen
Oxygen 2L via nasal cannual
PRN dyspnea
33. oxygen
2 liters continuous
Discharge Disposition:
Home With Service
Facility:
Staff Builders-TLC-[**Location (un) 1456**]
Discharge Diagnosis:
PNA
Discharge Condition:
stable
Discharge Instructions:
Please return if you experience increasing shortness of breath,
chest pain or pressure
Please continue procrit and pentamadine as prior to
hospitalization.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 2148**] within 2 weeks. ([**Telephone/Fax (1) 457**])
Appointment made Tuesday at 3:00 pm.
Provider UROLOGY UNIT Where: [**Hospital6 29**] SURGICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2161-9-23**] 9:00
Provider [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2161-9-28**] 1:15
[**Name6 (MD) **] [**Last Name (NamePattern4) 15242**] MD, [**MD Number(3) 15243**]
| [
"486",
"40391",
"4280",
"5849"
] |
Admission Date: [**2108-3-8**] Discharge Date: [**2108-3-16**]
Date of Birth: [**2047-10-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
CP and fatigue
Major Surgical or Invasive Procedure:
s/p CABGx3(LIMA->LAD, SVG->OM, PDA) [**2108-3-12**]
History of Present Illness:
This 60 y/o WF has had exertional angina and it has increased to
having it at rest. She underwent cardiac cath at [**Hospital3 6101**] on [**2108-3-8**] which revealed 50-60% LM stenosis, 100% RCA
and she was transferred on [**3-8**] for cardiac surgery.
Past Medical History:
CAD
s/p MI
PVD
OA
s/p cardiac thrombus
obesity
s/p carotid->carotid bypass
s/p TAH
^chol.
Social History:
Lives with husband.
[**Name (NI) 1403**] as a computer operator.
Cigs: 20-30 pk. yr., quit in [**2094**]
ETOH: denies
Family History:
F died of MI at age 53, brother +CAD
Physical Exam:
WDWNWF in NAD
AVSS
HEENT: NC/AT, PERLA, oropharynx benign
Neck: FROM, supple, carotids without bruit
Lungs: Clear to A+P
CV: RRR without R/G/M
Abd: +BS, soft, nontender, without masses or hepatosplenomegaly,
obese
Ext: without C/C/E, pulses Fem: 2+ bil., DP: 1+ bil., PT: 1+
bil., Rad: 2+ bil.
Neuro: nonfocal
Pertinent Results:
[**2108-3-16**] 03:27AM BLOOD WBC-8.3 RBC-3.38* Hgb-10.3* Hct-30.4*
MCV-90 MCH-30.4 MCHC-33.9 RDW-13.7 Plt Ct-144*
[**2108-3-15**] 08:44PM BLOOD PT-12.9 PTT-29.8 INR(PT)-1.1
[**2108-3-16**] 03:27AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-29 AnGap-12
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2108-3-13**] 4:17 PM
CHEST (PORTABLE AP)
Reason: eval ptx s/p ct d/c
[**Hospital 93**] MEDICAL CONDITION:
60 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
eval ptx s/p ct d/c
CHEST, AP PORTABLE SINGLE VIEW
INDICATION: Status post bypass surgery. Discontinued lines and
extubated. Evaluate for pneumothorax.
FINDINGS: AP single view of the chest obtained with patient in
sitting semi-upright position is analyzed in direct comparison
with the next preceding chest examination of [**2108-3-12**].
During the interval, the patient has been extubated, and the NG
tube has been removed. The same holds for the Swan-Ganz catheter
and the sheath which has been replaced with a central venous
line seen to terminate overlying the SVC at the level 2 cm below
the carina. No pneumothorax has developed, and no new
infiltrates are seen. _____ on previous examinations, the noted
parenchymal densities in the upper lobe areas have resolved.
They were interpreted as representing edema.
IMPRESSION: Satisfactory chest findings after instrument
removal, no evidence of pneumothorax.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 6102**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 6103**] (Complete)
Done [**2108-3-12**] at 1:31:43 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2047-10-22**]
Age (years): 60 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Chest pain. Coronary artery disease.
Shortness of breath.
ICD-9 Codes: 786.05, 786.51, 440.0
Test Information
Date/Time: [**2108-3-12**] at 13:31 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% to 55% >= 55%
Aorta - Ascending: 3.1 cm <= 3.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection
velocity. Cannot exclude LAA thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Mild regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in ascending aorta. Simple atheroma in
aortic arch. Complex (>4mm) atheroma in the descending thoracic
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
Conclusions
PRE-CPB:1. The left atrium is mildly dilated. A left atrial
appendage thrombus cannot be excluded. No atrial septal defect
is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with anterior mid and apical
hypokinesis.
3. . Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of phenylephrine. Episode of transient RV
dysfunction secondary to air visible in RCA. Epi 8-10 mcg given
with prompt resolution. Preserved biventricular systolic
function. Trace MR. Aortic contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2108-3-12**] 16:17
Brief Hospital Course:
The patient was transferred from [**Hospital6 5016**] on [**3-8**].
She had a preop vascular evaluation regarding her previous
carotid surgery and she was cleared. Carotid doppler showed a
patent graft. On [**2108-3-12**] she underwent CABGx3(LIMA->LAD,
SVG->OM, PDA). The cross-clamp time was 50 mins., total bypas
time was 66 mins. She tolerated the procedure well and was
transferred to the CVICU in stable condition on Neo and
Propofol. She was extubated on the post op night and continued
to progress. She was on neo and eventually weaned off. Her
chest tubes were d/c'd on POD#1 and wires were d/c'd on POD#3.
She continued to progress and was discharged to home in stable
condition on POD#4.
Medications on Admission:
Metformin 1000 mg PO BID
Avandia 4 mg PO daily
Fosamax 70 mg PO q week
Verapamil SR 240 mg PO BID
Lipitor 80 mg PO daily
Isordil 140 mg PO TID
Toprol XL 25 mg PO daily
Lisinopril 10 mg PO daily
Folic acid 1 mg PO daily
ASA 81 ng PO daily
Nitro spray PRN
Discharge Medications:
1. 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*
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).
Disp:*60 Capsule(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Rosiglitazone 8 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Disp:*4 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD
PVD
OA
s/p MI
s/p cardiac thrombus
obesity
^chol.
Discharge Condition:
Good
Discharge Instructions:
Follow medications in 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 creams, lotions, or powders on wounds.
Call our office with sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 6104**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 4783**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Wound check on [**Hospital Ward Name 121**] 6 on [**3-26**] at 11AM. Call [**Telephone/Fax (1) **] with
any changes.
Completed by:[**2108-3-16**] | [
"41401",
"412",
"2720",
"25000",
"4019",
"2859",
"V1582"
] |
Admission Date: [**2143-7-6**] Discharge Date: [**2143-7-20**]
Date of Birth: [**2073-7-21**] Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Shortness of breath, nausea
Major Surgical or Invasive Procedure:
cardiac cath [**2143-7-15**]
cardiac cath [**2143-7-18**]
cardiac biopsy [**2143-7-18**]
History of Present Illness:
69 y/o w/ HTN, CAD (Lcx 99%, 40% mLAD, 40% r PDA), systolic CHF
EF 30-35% w/ significant LVH, recent NSTEMI, presented with
generalized weakness, mild confusion, nausea and vomitting. She
was just discharged from [**Hospital 26580**] hospital where she was admitted
from [**Date range (3) 54882**]. Per obtained discharge summary, she
presented with progressive SOB and LE edema and ruled in for
NSTEMI with trop 0.38, 0.48, 0.98. She subsequently had cardiac
cath completed on [**2143-7-1**] which showed mid LAD 40% stenosis, mid
Lcx 99% unfavorable total occlusion, rPDA 40% stenosis,
pulmonary hypertension, mod-severe MR, depressed LVEF ~45% and
LVH. She then had TEE to better evaluate MR on [**2143-7-2**] which
showed 3+ MR [**First Name (Titles) 15015**] [**Last Name (Titles) **] hitting back wall with probably mild
mitral stenosis and LVEF 30-35% with dilated atria b/l, elevated
wedge pressure and significant LVH. She was diuresed with lasix
(-10L per patient), and started on metoprolol and losartan. She
was discharged on lasix 100mg [**Hospital1 **] and she reports improvement in
SOB and edema with diuresis throughout hospital stay.
.
Upon discharge home, she was initially feeling well, but then
became weak, more SOB and LE persisted and may have slightly
worsened. No reported weight gain. No PND, +orthopnea (sleeps w/
2 pillows nightly). The morning of admission she became nauseous
and vomitted ~5 times (bilious w/ food non-bloody), was unable
to take POs and thus re-presented to [**Hospital1 46**]. Per her
cardiologist Dr. [**Last Name (STitle) 3321**], she was transferred to [**Hospital1 18**] for
cardiac MRI and evaluation for MV repair/replacement.
.
At OSH, she was A&O x3, vitals prior to transfer were afebrile,
HR 74 BP 86/61, 20 99% 4L. Upon arrival to the floor she has
mild SOB and c/o LE edema. Nausea/vomitting much improved. Was
feeling "spacy" earlier, but now feels lucid. Feels generalized
weakness. Denies F/C, HA, vision changes, cough, CP,
palpitations, abd pain, diarrhea, constipation, melena,
hematochezia, dysuria or hematuria.
Past Medical History:
Recent NSTEMI admitted [**Hospital 26580**] hosp [**Date range (1) 54883**]
CATH: [**2143-7-1**]: LMCA normal, mid LAD 40% stenosis, mid Lcx 99%
unfavorable total occlusion, rPDA 40% stenosis, pulmonary
hypertension, mod-severe MR, depressed EF ~45%
CABG: none
HTN
DM2
systolic and diastolic CHF
Peripheral vascular disease
COPD - not on home O2
B12 deficiency
Hypothyroidism
H/o DVT [**2142-10-8**] - on coumadin
Insominia
Osteoporosis
cholecystectomy
hysterectomy
appendectomy
h/o thyroidectomy and parathyroidectomy
exploratory laporotomy [**2142-10-8**] (for possible gut ischemia but
none seen)
h/o diverticulitis s/p partial colectomy w/ temp colostomy and
reanastamosis
Social History:
lives w/ husband, independent in all ADL and iADLs, recently
walking on treadmill at cardiac rehab, h/o 45 pack years quit
tob 10 years ago, no ETOH or IVDA.
Family History:
mother w/ CVA, no known MI, HTN, malignancy or DM.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 98.4 100/66 85 16 98% RA 55.3kg
GENERAL: NAD, A&Ox3
HEENT: PERRLA, EOMI, sclerae anicteric, oral MM dry, no OP
lesions.
NECK: Supple, no thyroid gland, JVP 13cm
HEART: RRR, nl S1, nl S2, cannot appreciate murmurs
LUNGS: mild crackles bilateral bases R>L, no rh/wh, resp
unlabored.
ABDOMEN: Soft/NT/ND, no rebound/guarding, +BS.
EXTREMITIES: 2+ pitting edema to knee b/l w/ venous stasis skin
changes, decreased sensation in feet b/l, callus (? non-healing
ulcer) left foot plantar surface, pulses diminished DP/PT b/l,
2+ peripheral pulses in UE b/l
Pertinent Results:
ADMISSION LABS:
[**2143-7-7**] 06:24AM BLOOD WBC-7.2 RBC-5.83*# Hgb-15.8# Hct-50.0*#
MCV-86# MCH-27.1# MCHC-31.6# RDW-19.1* Plt Ct-231
[**2143-7-7**] 06:24AM BLOOD Neuts-70.2* Lymphs-19.8 Monos-7.4 Eos-1.8
Baso-0.8
[**2143-7-7**] 08:40AM BLOOD PT-14.4* PTT-31.0 INR(PT)-1.2*
[**2143-7-7**] 06:24AM BLOOD Glucose-98 UreaN-43* Creat-1.6* Na-137
K-4.0 Cl-97 HCO3-23 AnGap-21*
[**2143-7-7**] 06:24AM BLOOD ALT-39 AST-50* LD(LDH)-364* CK(CPK)-41
AlkPhos-108* TotBili-1.1
[**2143-7-7**] 06:24AM BLOOD TotProt-6.6 Albumin-3.9 Globuln-2.7
Calcium-9.2 Phos-5.3*# Mg-2.4 Iron-PND
[**2143-7-7**] 06:24AM BLOOD CK-MB-4 cTropnT-0.30*
[**2143-7-19**] 01:55AM BLOOD WBC-12.1*# RBC-5.63* Hgb-15.3 Hct-47.1
MCV-84 MCH-27.1 MCHC-32.4 RDW-19.4* Plt Ct-190
[**2143-7-19**] 10:45AM BLOOD PT-16.8* PTT-115.7* INR(PT)-1.5*
[**2143-7-19**] 01:55AM BLOOD Glucose-119* UreaN-51* Creat-1.8* Na-130*
K-4.1 Cl-91* HCO3-23 AnGap-20
[**2143-7-19**] 01:55AM BLOOD Calcium-9.2 Phos-5.8*# Mg-2.3
[**2143-7-20**] 03:15AM BLOOD WBC-22.5*# RBC-5.99* Hgb-16.2* Hct-51.5*
MCV-86 MCH-27.0 MCHC-31.4 RDW-19.7* Plt Ct-292#
[**2143-7-20**] 03:15AM BLOOD Neuts-90* Bands-0 Lymphs-3* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2143-7-20**] 03:15AM BLOOD PT-19.3* PTT-90.8* INR(PT)-1.7*
[**2143-7-20**] 03:15AM BLOOD Glucose-77 UreaN-66* Creat-3.0*# Na-131*
K-4.8 Cl-87* HCO3-21* AnGap-28*
[**2143-7-20**] 03:15AM BLOOD Calcium-9.5 Phos-7.0* Mg-2.3
Pertinent studies:
Cardiac MRI ([**2143-7-8**])-
1. Normal left ventricular cavity size with segmental wall
motion
abnormalities (see above) and mildly reduced systolic function
with the LVEF of 41%. The effective forward LVEF was severely
depressed at 19%. There are multiple areas of hyperenhancement
as described above consistent with myocardial infarction/scar.
2. Moderately to severely increased LV wall thickness.
3. Severely increased LV mass index.
4. Normal right ventricular cavity size with abnormal global
systolic
function. The RVEF was moderately depressed at 23%.
5. Severe mitral regurgitation. There is leaflet tethering
consistent with
"ischemic" (post-infarction) mitral regurgitation.
6. The indexed diameters of the ascending and descending
thoracic aorta were normal. The indexed diameter of the main
pulmonary artery was mildly enlarged.
7. Mild right and left atrial enlargement.
8. Normal coronary artery origins with no evidence of anomalous
coronary
arteries.
9. A note is made of moderate to severe right pleural effusion
and small left pleural effusion.
CXR ([**2143-7-10**])- Interval increase in a now moderate right effusion
with associated atelectasis. New small left effusion.
Spirometry ([**2143-7-11**])- Mild restrictive ventilatory defect with a
severe gas exchange defect. The DLCO is reduced out of
proportion to the reduction in TLC which is consistent with an
interstitial or pulmonary vascular process. The reduced FEV1/SVC
ratio (62.4, 87% of predicted) indicates a coexisting
obstructive ventilatory defect. There are no prior studies
available for comparison.
TEE ([**2143-7-11**])- No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is low normal (LVEF
50-55%). There is borderline normal free wall function of the
right ventricle. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened with no aortic valve stenosis or regurgitation.
The mitral valve leaflets are structurally normal with mild (1+)
mitral regurgitation. The tricuspid valve leaflets are mildly
thickened. There is a small pericardial effusion with no
echocardiographic signs of tamponade.
Dobutamine stress echo ([**2143-7-12**])- Resting images were acquired at
a heart rate of 85 bpm and a blood pressure of 84/60 mmHg. These
demonstrated near-akinesis of the inferior wall with mild
hypokinesis elsewhere (EF 35%). There is a small pericardial
effusion. Doppler demonstrated mild mitral regurgitation with no
aortic stenosis, aortic regurgitation or significant resting
LVOT gradient. At low dose dobutamine [5mcg/kg/min; heart rate
84 bpm, blood pressure 84/58 mmHg), there was failure to augment
systolic function of the inferior wall, with mild augmentation
of all other segments. At mid-dose dobutamine [10 mcg/kg/min;
heart rate 88 bpm, blood pressure 76/50 mmHg), there was failure
to augment systolic function of the inferior wall, with mild
augmentation of all other segments.
.
Cardiac cath ([**2143-7-15**])-
1. Two vessel coronary artery disease.
2. Moderate diastolic ventricular dysfunction.
3. Moderate pulmonary hypertension.
4. Successful PTCA and stenting of the distal Cx with a BMS.
.
Right Heart cardiac cath ([**2143-7-18**])
1. Moderately elevated biventricular pressures.
2. Severe pulmonary hypertension.
3. Depressed cardiac index.
4. Successful RV biopsy.
.
Cardiac biopsy [**2143-7-18**]:
Myocardial tissue with extensive amyloid deposition (confirmed
with [**Country **] red stains) primarily subendocardial and associated
with blood vessels.
Urine culture [**2143-7-20**]:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS
Blood culture [**2143-7-20**]:
Blood Culture, Routine (Final [**2143-7-26**]): NO GROWTH.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 69 yo w/ HTN, CAD (Lcx 99%, 40% mLAD, 40% r
PDA), systolic CHF EF 30-35% w/ significant LVH, ruled in for
NSTEMI, 3+ MR, LVEF 30-35% with dilated atria b/l, elevated
wedge pressure and significant [**Hospital 54884**] transferred to [**Hospital1 18**] for
cardiac MRI and evaluation for MV repair/replacement, but only
mild MR on repeat TEE, now s/p BMS of LCx, and cardiac biopsy
positive for cardiac amyloidosis.
--For a summary of her hospital course, please refer to accept
note dated [**2143-7-19**].
After Pt was transferred to [**Hospital1 1516**], she had SBP in 80s/50s,
remained asymptomatic, but at ~9pm, had one measurement to
60s/40s, although remeasurement was high 70s/50s. Pt was
completely asymptomatic, even when sitting up, and remained
talkative and was joking with MDs. The 60s/40s was felt to be
due to measurement error due to Pt's very thin body habitus,
even when using small adult cuff. Cardiology fellow and resident
were both consulted, who felt that Pt was very stable. Pt
remained afebrile and HR was in 70s-80s throughout. Pt did not
have any discomfort or pain and was not dyspnic. She had O2 sat
~97% on 2L nc.
The following morning ([**7-20**]) at 0700, Pt was found to tachypnic
to 25 but still sat 95% on 2L nc. She was working harder to
breathe but stated that she did not feel short of breath when
questioned. When morning lab results returned at ~0830, Pt was
noted to have leukocytosis to ~22k and Cr jumped to 3.0 from 1.8
the day prior. Stat blood cultures, urine analysis, and urine
cultures, and chest XR were send. Her foley cath was
discontinued. She was started on IV vancomycin and cefepime. Pt
was never febrile, though she had one oral temp to 35.5C at ~
midnight that was ~36.1C four hours later. Pt was never
tachycardic and her BP remained in 80s/50s, consistent with her
prior BPs on the floor. Pt began to feel very short of breath at
this time (0830), was tachypnic to 30s-40s, and put on
non-rebreather mask. She looked very and her family was notified
to come to the hospital given her rapidly deteriorating state.
After the arrival of family and in discussion with the Pt, who
was still lucid, Pt decided to be made comfort measures only
with the exception of antibiotics, declined intubation and
declined transfer to the CCU. Pt was given lorazepam and
morphine to help with dyspnea, which was initially difficult to
control. Palliative care was consulted who recommended IV
morphine, which was provided, and Pt appeared to respond. Pt
became less and less responsive by 1300, received Eucharist at
1400 and expired at 1440.
Pt's family consented to autopsy.
------------
#Acute on chronic congestive heart failure: Mrs. [**Known lastname **] was
admitted for CHF most likley due to MR but possibly secondary to
ischemic cardiomyopathy versus infiltrative cardiomyopathy. She
has evidence of diffuse coronary disease, but only significant
single vessel disease (Lcx 99% stenosed) that likely does not
explain her global hypokinesis. Additional contributing factors
include MR (see below) and diastolic dysfunction (significant
LVH seen) raising suspicion for potential infiltrative
cardiomyopathy as well. Infiltrative etiologies to consider
include amyloid, multiple myeloma, sarcoid, hemachromotosis, HIV
or myocarditis, but have so far been negative. In the workup so
far, serum protein electrophoresis, ACE, TSH, and iron levels,
were all normal. Infiltrative disease was further supported by
echo findings and a cardiac MRI. Given the negative work-up thus
far this was highly concerning for specific cardiac amyloid
without systemic involvement. Therefore the patient underwent a
endocardial biopsy on [**2143-7-18**]. Results of the biopsy were
consistent with cardiac amyloidosis ([**Country **] red stainin
positive). Final stains and studies are still pending.
Symptomatically, she initially had lower extremity edema, a
stable right lower lobe pleural effusion, inspiratory crackles
on exam and dyspnea. She initially responded well to diuresis
with furosemide up to 80mg IV BID which was then decreased to 80
daily. However she continued to dyspnea and chest xray findings
consistent with volume overload in the setting of low blood
pressure which made further diuresis difficult. On HD8, patient
had a right sided catheterization which showed elevated PA and
PCWP pressures consistent with class II pulmonary artery
hypertension resulting form left ventricular overload.
Following cardiac catheterization with placement of BMS to the
LCx, the patient was transferred to the CCU for diuresis with
lasix gtt with pressure support initially with dopamine gtt.
She did not have a good response to diuresis and was changed
from dopamine to milrinone with improvement in urine output.
Additionally, metolazone was added to augment diuresis. In the
CCU she was diuresed 3 L in 4 days with improvement in her
respiratory status. Milrinone was stopped with inital
maintenance of blood pressure. Repeat right heart catherization
on [**2143-7-18**], done for endocardial biopsy, showed continued
elevation of right heart pressures as well as a persistent low
cardiac index of 1.28. Though she was still volume overloaded
lasix gtt was stopped due to hypotension and rising creatinine
with improvement in blood pressure. The plan was to establish
her on a home oral regimen as her congestive heart failure is
end stage and the patient has expressed desire to go home. She
was transferred to [**Hospital1 1516**].
.
On further review of EKG and echocardiogram, it was noted that
patient had a left bundle branch block causing a dyssynchronous
rhythm. It was felt that cardiac output may improve with BiV
pacing. However in further evaluation of the echocardiogram it
was felt that BiV pacing would likely not be helpful as the
patients right heart dysfunction was more significant than her
left heart dysfunction.
#Acute Respiratory Distress: see above
.
#Mitral regurgitation: On her outside hospital TEE, Pt was
thought to have moderate to severe mitral regurgitation. Pt was
transferred here for a cardiac MRI, which showed a normal left
ventricular cavity size with segmental wall motion abnormalities
and mildly reduced systolic function with the LVEF of 41% with a
severely depressed calculated effective forward LVEF of 19%.
Multiple areas of hyperenhancement were observed and interpreted
as being consistent with myocardial infarction/scar. She also
had moderately to severely increased LV wall thickness, severely
increased LV mass index, a normal right ventricular cavity size
with abnormal global systolic function and moderately depressed
RVEF at 23%. Also observed on the cardiac MRI was severe mitral
regurgitation with leaflet tethering consistent with "ischemic"
(post-infarction) mitral regurgitation. Given these findings,
cardiac surgery was consulted regarding the possiblility of
mitral repair versus replacement and suggested a repeat TEE at
[**Hospital1 18**], which surprisingly showed mild symmetric left ventricular
hypertrophy, an overall low normal left ventricular systolic
function is (LVEF 50-55%) and structurally normal mitral valve
leaflets with only mild (1+) mitral regurgitation. Complex
(>4mm) atheroma in the descending thoracic aorta were also
observed. The Pt therefore did not require surgery, and
attention re-centered on the known left circumflex stenosis (see
below).
.
#Coronary artery disease: Pt had a diagnostic cardiac cath
performed by Dr. [**Last Name (STitle) 3321**] just prior to admission showing
stenosis of the Lcx 99%, 40% mLAD, 40% r PDA of unknown age,
with no intervention at the time. To determine whether any of
the affected areas were salvagable, the patient had a dobutamine
viability echo, which showed minimal viability in the inferior
wall but apparently-viable myocardium elsewhere. She was taken
to cardiac cath on [**2143-7-15**] and a bare metal stent was placed in
the left circumflex artery. Catherization also showed elevated
filling pressures, pulmonary HTN and a cardiac index of 1.23.
Following the procedure, patient was started on aspirin, plavix
and heparin. Her catheterization site was c/d/i and no bruits
or hematomas were appreciated. Right heart catherization for on
[**7-18**] demonstrated continued poor cardiac index.
.
#Acute kidney injury: On admission her creatinine was noted to
be 1.6 (1.0 on discharge two days before). This was thought to
be pre-renal from poor kidney persusion from CHF, poor PO intake
and nausea, and she had recently started losartan on her prior
admission. Losartan was held during this admission. Because she
was still volume overloaded she was gently diuresed. As above
the patient did require additional diuresis with inotropic
support. She was started on a lasix gtt with resultant increase
in her creatinine. Furosemide was held due to decreased kidney
function.
.
# Atrial Fibrillation: On HD # 8 the patient was noted to be in
atrial fibrillation with RVR associated with nausea and
vomiting. She was initally rate controlled with metoprolol.
However, during her endocardial biopsy she was noted to have HR
to the 130s and a drop in her systolic blood pressure to the
70s. She was given IV metoprolol and fluids with spontaneous
conversion to sinus rhythm. She was then given a PO amiodarone
load and started on a heparin drip. Given her CHADS2 score of 3
she was started on warfarin. This was discontinued on [**Hospital1 1516**].
.
# RLL infiltrate: Patient noted to have possible RLL infiltrate
vs atelectasis on chest xray and white count to 12. She
remained afebrile and noted only a scant sputum. X ray also
showed a R sided pleural effusion. Therefore it was felt
changes likely represented atelectasis and antibiotics were not
started.
.
#Nausea: Pt was reported significant nausea and vomiting on
admission, was given PO zofran PRN which effectively controlled
her nausea and she had only one episode of vomiting throughout
the remainder of her hospital course. Nausea was always
associated with volume overload or atrial fibrillation.
.
# Code Status: The poor prognosis of both her poor cardiac
function and cardiac amyloid was discussed in depth with the
patient and her family. She expressed understanding that her
congestive heart disease was likely end stage. She additionally
decided that she would not want intubation or CPR and was made
DNR/DNI. Pt was made comfort measures only on [**7-20**] and expired
at 1440 (see above).
# COPD: no evidence of acute exacerbation. Pt was continued on
her home albuterol and tiotropium.
.
# Diabetes: well controlled, on sliding scale
# Hypothyroidism: stable on home levothyroxine, TSH normal
# peripheral neuropathy: stable, vicodin PRN pain
Medications on Admission:
albuterol 1puff q4H PRN
aspirin 81mg daily
conjugated estrogens 1 vag application PRN
furosemide 100mg [**Hospital1 **]
hydrocodone/acetaminophen 5/500 1-2 tabs q4H PRN
levothyroxine 75mcg daily
oxazepam 15-30mg qHS PRN
tiotropium 18mcg daily
vitamin B12 IM
coumadin 1mg daily
zoledronic acid administered in clinic
zolpidem 10mg qHS
losartan 25mg daily
metoprolol succinate 25mg daily
KCL 20meQ daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Cardiac amyloidosis
Congestive heart failure
Coronary artery disease
Secondary Diagnoses:
Mild mitral regurgitation
Hypothyroidism
Diabetes mellitus, type 2
Chronic obstructive pulmonary disease (COPD)
Discharge Condition:
Pt expired on [**2143-7-20**].
Completed by:[**2143-7-28**] | [
"5849",
"496",
"9971",
"5180",
"4168",
"42731",
"41401",
"4280",
"4240",
"25000",
"4019",
"V5861"
] |
Admission Date: [**2172-12-5**] Discharge Date: [**2172-12-18**]
Date of Birth: [**2090-8-9**] Sex: F
Service: SURGERY
Allergies:
Cephalexin Hcl
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
abdominal pain, SBO
Major Surgical or Invasive Procedure:
[**2172-12-6**]
1. Exploratory laparotomy.
2. Small-bowel resection.
3. Ileocolic anastomosis.
4. Abdominal washout.
5. Closure abdominal wall defect.
6. post op ileus
History of Present Illness:
82-year-old female who underwent laparoscopic robot assisted
TAHBSO, LOA for endometrial cancer and reduction of hernia on
[**2172-11-17**]. She was seen by the Acute Care service afterwards
for a small bowel obstruction which resolved with conservative
management. She has had a RLQ ventral hernia for the past nine
years since her right hip replacement. This was reduced during
her surgery but became reincarcerated post-operatively and was
thought to be the likely source of her obstruction. She was
ultimately discharged to home on [**2172-11-27**]. She returned to the
[**Hospital1 18**] ED after presenting to an OSH with an acute abdomen.
Past Medical History:
Past Medical History: asthma, HTN, chronic sinusitis, LE
edema/cellulitis, laparoscopic robot assisted TAHBSO, LOA for
endometrial cancer ([**2172-11-17**])
Past Surgical History: right hip replacement ([**2163**]), bladder
neck suspension, open appy, ovarian cystectomy,
cytoscele/rectocele repair, thyroid surgery
Social History:
Denies smoking, alcohol, or drug abuse. She is a 20-pack-year
smoker who quit over 20 years ago.
Family History:
Two sisters had breast cancer. Uterine cancer in her youngest
daughter. [**Name (NI) **] history of ovarian or colon cancer.
Physical Exam:
In the ED:
98.7 99 122/50 18 97RA
GEN: A&O, NAD, NGT in place
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: large R sided ventral hernia, minimally tender to
palpation,
feels firm and indurated, rest of abdomen is soft, minimally
distended, no rebound or guarding
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
CT Abd/Pelvis [**2172-12-5**] :
1. New/increased fluid in the right lower quadrant hernia sac
with ill-defined small bowel loops and mesenteric edema within
the sac, as well as increased intermesenteric fluid in the
peritoneal cavity, raises concern for bowel ischemia.
Extraluminal gas in the hernia sac, while seen previously, it is
now more remote from patient's surgery, and perforation can not
be excluded.
2. Relative caliber change of small bowel at the hernia neck,
but only mildy dilated proximal bowel loops, may be due to
early/partial obstruction.
3. Increased/new pelvic fluid which appears to be organizing and
with peritoneal enhancement; while findings may be reactive with
peritonitis, underlying infection is not excluded.
4. Unchanged postsurgical soft tissue densities between the
urethra and the rectum and between the right ischial tuberosity
and the anus.
5. Small right renal hypodensity, too small to further
characterize on this study, but which could be further evaluated
on non-urgent ultrasound.
[**2172-12-5**] 07:40PM WBC-20.6*# RBC-3.79* HGB-11.5* HCT-34.5*
MCV-91 MCH-30.4 MCHC-33.3 RDW-12.9
[**2172-12-5**] 07:40PM NEUTS-56 BANDS-38* LYMPHS-0 MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2172-12-5**] 07:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-1+
[**2172-12-5**] 07:40PM PLT SMR-NORMAL PLT COUNT-290
[**2172-12-5**] 07:40PM PT-15.7* PTT-25.9 INR(PT)-1.4*
[**2172-12-5**] 07:40PM GLUCOSE-129* UREA N-30* CREAT-2.2*#
SODIUM-140 POTASSIUM-5.5* CHLORIDE-108 TOTAL CO2-20* ANION
GAP-18
[**2172-12-5**] 07:45PM LACTATE-2.1*
[**2172-12-6**] 12:28 am PERITONEAL FLUID
GRAM STAIN (Final [**2172-12-6**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83986**] @ 5:41A [**2172-12-6**].
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2172-12-10**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2172-12-10**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2172-12-7**]):
Test cancelled by laboratory.
PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Brief Hospital Course:
Mrs. [**Known lastname 101374**] was evaluated by the Acute Care service in the
Emergency Room as well as the GYN service given her recent
surgery. She had a WBC of 20K and her CT scan demonstrated an
incarcerated hernia with evidence of ischemia on exam. She was
admitted to the ICU for vigorous fluid resuscitation and broad
spectrum antibiotics.
On [**2172-12-6**] she was taken to the Operating Room and underwent an
exploratory laparotomy with repair of a strangulated, perforated
ventral hernia. She tolerated the procedure well and returned
to the ICU in stable condition. She maintained stable
hemodynamics and her pain was well controlled with IV Dilaudid.
She remained intubated overnight and was successfully weaned and
extubated on post op day #1. Due to her extensive surgery her
nasogastric tube remained in for decompression until her bowel
function returned.
Following transfer to the Surgical floor on [**2172-12-9**] she remained
stable but her nasogastric tube was removed. She was taking only
a small amount of liquids over the next few days and she became
more distended and tympanic on exam. She stopped passing flatus
and her KUB showed a dilated large bowel. She was treated with
Methylnaltrexone which was immediately effective. She was
passing flatus and had a normal bowel movement. Her narcotics
were discontinued and her pain was effectively managed with
Tylenol. Her diet was advanced to regular but her appetite was
only fair. Eventually she improved with Carnation Instant
Breakfast supplements along with the addition of Megace.
The Physical Therapy service evaluated her on numerous occasions
and due to her prolonged hospitalization and decreased mobility
a short term rehab was recommended prior to her return home. She
was dischargaed on [**2172-12-18**].
Medications on Admission:
diovan 160', prevacid 30', lasix 20', ibuprofen,
percocet
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO BID (2 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
Q6H (every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] home
Discharge Diagnosis:
Strangulated, perforated ventral hernia.
.
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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down 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 experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-18**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
* Your staples will be removed at rehab.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-12**] weeks.
Completed by:[**2172-12-18**] | [
"0389",
"51881",
"99592",
"49390",
"4019",
"53081",
"2724",
"V1582"
] |
Admission Date: [**2126-9-15**] Discharge Date: [**2126-9-17**]
Date of Birth: [**2094-11-20**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Conventional Cerebral Angiogram
History of Present Illness:
The pt is a 31 year-old right-handed woman G3P3 post-partum
day 7, who presents with sudden onset of severe headache
starting
at 3am. She reports that her most recent pregnancy was
complicated by being GBS positive, and developing a temperature
of 100.8. According to her husband, there was some concern
about
the baby's HR, so she was induced at that time. No excessive
bleeding, and otherwise uncomplicated delivery on [**9-6**]. On [**9-10**]
she reports developing a sore throat with mild exudate on her
tonsils. She saw her PCP [**Last Name (NamePattern4) **] [**9-11**], and reportedly tested
negative
for strep. Her symptoms of sore throat improved, and she was
feeling better until 3am on [**9-14**]. She reports that she awoke
with
a headache, initially [**6-23**], that escalated to [**11-23**] within 30
minutes. This was accompanied by photo and phonophobia, as well
as nausea and vomiting. She notes that movement tended to make
her symptoms worse. She took Motrin and 2 Excedrin with no
relief, and around 9:30am called her PCP. [**Name10 (NameIs) **] was told to try
caffeine, to see if that improved her symptoms, and if not, to
come to the ED for further evaluation. In the ED she was given
Dilaudid and Compazine, which improved her symptoms, and
hydralazine for elevated blood pressure.
As an adult, she has had headaches every few months described as
throbbing. Usually the headaches are behind her left eye. Does
not have nausea, vomiting, photophobia, or phonophobia, or
autonomic symptoms with her headaches. HA start gradually. They
respond well to Motrin or Excedrin. She has a first cousin with
migraines but no other family member has migraines. [**Known firstname 26317**] had
one headache during her second trimester that was throbbing and
associated with photophobia.
She notes increased frequency of headaches during her
pregnancies but they were not as severe as the one described
above during her second trimester.
She denies any neck stiffness, rash, or confusion.
No diplopia or blurred vision. She reports that she has been
able to produce a small amount of milk, but has primarily been
giving her child formula. This is similar to how things were
during her prior pregnancies.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Hypothyroidism
- Anemia
Social History:
The patient lives in [**Location 2251**] with her husband and
children. She currently is a stay-at-home Mom, but used to work
as director of Multicultural affairs at a local [**Location (un) **]. No
EtOH, smoking or illicits.
Family History:
Heart disease on maternal side, DM on paternal side.
Physical Exam:
Vitals: P:52 R: 16 BP:164/62 SaO2: 95% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**4-16**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
Admission Labs:
PT-11.8 PTT-29.9 INR(PT)-1.0
PLT COUNT-354
NEUTS-56.8 LYMPHS-38.5 MONOS-3.3 EOS-0.6 BASOS-0.7
WBC-5.9 RBC-4.88 HGB-12.2 HCT-39.4 MCV-81* MCH-25.0* MCHC-31.0
RDW-14.4
URIC ACID-6.3*
ALT(SGPT)-167* AST(SGOT)-89* ALK PHOS-102 TOT BILI-0.3
GLUCOSE-83 UREA N-10 CREAT-1.0 SODIUM-144 POTASSIUM-4.4
CHLORIDE-106 TOTAL CO2-25 ANION GAP-17
ALT(SGPT)-128* AST(SGOT)-49* ALK PHOS-92
[**2126-9-14**] 03:00PM URINE
RBC-[**4-18**]* WBC-[**4-18**] BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2
BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM COLOR-Straw
APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2126-9-15**] 12:57AM
CEREBROSPINAL FLUID (CSF) WBC-17 RBC-[**Numeric Identifier 47655**]* POLYS-83 LYMPHS-14
MONOS-3
CEREBROSPINAL FLUID (CSF) WBC-4 RBC-[**Numeric Identifier **]* POLYS-60 LYMPHS-34
MONOS-4 ATYPS-2
CEREBROSPINAL FLUID (CSF) PROTEIN-253* GLUCOSE-74
ALBUMIN-3.9
LIPASE-76*
CT HEAD W/O CONTRAST Study Date of [**2126-9-14**] 2:52 PM
Diffuse sulcal effacement involving the right posterior frontal
and parietal regions. Differential considerations include
subacute subarachnoid hemorrhage or focal meningitis. MRI is
recommended for further assessment.
MR HEAD W & W/O CONTRAST Study Date of [**2126-9-14**] 8:46 PM
1. Areas of negative susceptibility with enhancement in the
cerebral sulci in the right frontal and the parietal lobes,
raises the possibility of
hemorrhage, with or without superimposed inflammation/infection
related to
cerebritis or meningitis. No acute infarction.
2. Associated cerebral edema involving the right cerebral
hemisphere as
described above.
3. No mass effect.
4. Patent major intracranial arteries without obvious evidence
of aneurysm.
5. Consultation with interventional neuroradiology/neurosurgery,
for further evaluation if necessary, by conventional angiogram
can be considered, after performing a non-contrast CT head
study, to document the presence of hemorrhage.
6. Patent major dural venous sinuses. Evaluation for cortical
veins is
limited on the present study. Correlation with clinical
neurological
examination and LP can also be considered given the imaging
findings above.
CTA HEAD W&W/O C & RECONS Study Date of [**2126-9-15**] 2:50 AM
1. Evidence of high attenuation in the right-sided cerebral
sulci, which can relate to hemorrhage or enhancement from prior
gadolinium administration, which may relate to leptomeningeal
enhancement related to cerebritis or meningitis. Effacement of
the cerebral sulci with associated edema on the right side, as
seen on the prior study.
2. Patent major intra- and extra-cranial arteries without focal
flow-limiting stenosis, occlusion, or aneurysm.
3 Prominent nasopharyngeal soft tissues, and tonsils, which can
be correlated with direct visualization, with narrowing of the
oropharynx. Mild right maxillary sinus disease.
4. Heterogeneous thyroid- non-emergent ultraosund can be
considered.
Conventional Angiogram on [**9-16**]: (prelim impression by Dr.
[**Last Name (STitle) **]
Mild beading of multiple distal vessels in the right MCA
territory. No aneurysm or dissection or other vascular
malformation seen.
Brief Hospital Course:
Ms. [**Known lastname **] is a 31 year-old G3P3 woman with a history of
hypothyroidism who delievered her baby on [**9-6**] and then on
[**9-14**] had onset of a severe bifrontal headache, associated
with photo- and phonophobia, nausea and vomiting, over a period
of 30 minutes.
On arrival, the patient's exam was notable for hypertension.
She was felt to have normal cognition, mild photophobia, and no
meningismus. Laboratory results were remarkable for elevated
LFTs (normal on [**9-3**]),
with normal platelets. CT brain was suggestive of a small right
frontal, parietal, temporal subarachnoid hemorrhage. LP was
consistent with subarachnoid hemorrhage ([**Numeric Identifier **] RBCs in Tube 4).
She was initially admitted to the ICU/Neurosurgery service for
monitoring. She underwent conventional angiogram which did not
show an aneurysm or AVM. She was hemodynamically and
neurologically stable and therefore transferred to the
neurology floor. Given the improvement in symptoms and lack of
findings on neurologic exam, she was discharged with plans for
follow-up in the stroke clinic. It was felt that the patient's
presentation was most consistent with post partum cerebral
angiopathy (otherwise known as Call [**Doctor Last Name 8271**] syndrome). Much less
likely would be thrombosis of a small cortical vein then leading
to right-sided subarachnoid hemorrhage. She was started on
verapamil SR 180mg daily to prevent vasospasm from the SAH. She
was given Keppra 500mg [**Hospital1 **] for seven days, then Keppra 500mg
daily for three days, and then instructed to stop [**Doctor Last Name (ambig) 13401**]. [**Known firstname 26317**]
was told not to drive, bath in a tub by herself, bath her
children in a tub by herself, or climb for the next month. She
was instructed to refrain from strenuous physical activity for
three months (should not lift objects more than 20lbs.)
At the time of discharge, RF, CRP, ESR as well as ANCA, [**Doctor First Name **],
Homocystine, Protein C, S and ACA was pending.
Medications on Admission:
- Levothyroxine
- Iron
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*5 Tablet(s)* Refills:*0*
3. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*3*
4. Over the counter fiber supplement
for constipation. Use as directed.
5. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: take two tablets each day for seven days, then take one
tablet daily for three days, then off.
Disp:*17 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Post-partum cerebral angiopathy (Call-[**Doctor Last Name 8271**] Syndrome)
Subarachnoid hemorrhage
Migraine headaches.
Discharge Condition:
Normal neurological examination
Discharge Instructions:
You were admitted for a severe headache and found to have a
small amount of bleeding on top of your brain in the
subarachnoid space. This was likely due to abnormal narrowing of
your blood vessels related to pregnancy and your history of
migraines. You have a normal neurological examination. Your
condition is expected to improve while taking verapamil as
indicated.
You should refrain from strenuous physical activity for three
months. Please avoid any driving, tub bathing, swimming alone or
any other activity where you may injure yourself or others
should you suddenly lose consciousness for two weeks.
Please return to the emergency room if you experience any new or
different nature of your headaches. Difficulty speaking, visual
loss, numbness, tingling or weakness or any other concerning
symptoms.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] on Wednesday, [**2126-10-2**] at 4pm in
the stroke neurology division at [**Hospital1 **]. Office
is located on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building, [**Location (un) 858**].
Completed by:[**2126-9-17**] | [
"2449",
"2859"
] |
Admission Date: [**2130-3-26**] Discharge Date: [**2130-4-4**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2130-3-29**]
1. Coronary artery bypass grafting x5 with the left
internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery and sequential reverse saphenous vein
graft to the first and second obtuse marginal artery and
a reverse saphenous vein graft to the diagonal artery
which is Y-grafted to the sequential vein graft.
2. Aortic valve replacement with a 23-mm St. [**Male First Name (un) 923**] Epic
tissue valve.
3. Left atrial appendage resection.
[**2130-3-30**] re-exploration mediastinum
History of Present Illness:
88 year old male admitted to [**Hospital 5279**] Hospital with ACS from
[**Date range (1) 85977**]. Cardiac catheterization at that time revealed
coronary artery and mitral regurgitation. He was transferred to
[**Hospital1 69**] for surgical evaluation.
Past Medical History:
Atrial fibrillation
NSTEMI [**2-15**]
Vertebral fx([**2063**])
Macular degeneration/legally blind
[**Doctor Last Name 9376**] syndrome
Benign Prostatic Hypertrophy
Hypertension
Bilateral knee arthritis
Social History:
Lives alone
Occupation: retired dairy farmer and historic house restorer
Tobacco: remote-quit many years ago, previously smoked 1ppd
ETOH:[**1-11**] glasses of wine/week
Family History:
Brother-afib and heart failure;
father and sister CVA
Physical Exam:
Pulse: 65 Resp: 14 O2 sat:
B/P Right: 130/60
Height: 5'6" Weight:163lbs.
General:
Skin: Dry [x] intact [x] Old well-healed incision across left
abdomen
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur II/VI SEM across
pre-cordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:[x]
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2130-4-4**] 05:50AM BLOOD WBC-10.5 RBC-3.43* Hgb-10.4* Hct-30.6*
MCV-89 MCH-30.3 MCHC-34.0 RDW-15.4 Plt Ct-162
[**2130-3-26**] 02:43PM BLOOD WBC-6.6 RBC-3.78* Hgb-11.7* Hct-33.9*
MCV-90 MCH-30.8 MCHC-34.4 RDW-13.9 Plt Ct-218
[**2130-4-4**] 05:50AM BLOOD Plt Ct-162
[**2130-4-4**] 05:50AM BLOOD PT-17.8* INR(PT)-1.6*
[**2130-3-26**] 02:43PM BLOOD Plt Ct-218
[**2130-3-26**] 02:43PM BLOOD PT-18.3* PTT-40.7* INR(PT)-1.7*
[**2130-4-4**] 05:50AM BLOOD Glucose-104* UreaN-35* Creat-1.0 Na-140
K-4.0 Cl-103 HCO3-28 AnGap-13
[**2130-3-26**] 02:43PM BLOOD Glucose-91 UreaN-25* Creat-1.2 Na-136
K-4.3 Cl-96 HCO3-29 AnGap-15
[**2130-3-26**] 02:43PM BLOOD ALT-21 AST-20 LD(LDH)-225 CK(CPK)-189
AlkPhos-101 Amylase-62 TotBili-1.3
[**2130-3-26**] 02:43PM BLOOD Lipase-29
[**2130-3-26**] 02:43PM BLOOD cTropnT-0.04*
[**2130-4-4**] 05:50AM BLOOD Mg-2.1
[**2130-4-1**] 02:52AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1
[**2130-3-27**] 02:52AM BLOOD %HbA1c-5.9 eAG-123
Final Report
CHEST RADIOGRAPH
INDICATION: Status post CABG, evaluation for interval change.
COMPARISON: [**2130-4-1**].
FINDINGS: As compared to the previous radiograph, the lung
volumes have
increased. Small bilateral pleural effusions. Moderate
cardiomegaly. No
pulmonary edema. The right venous introduction sheath has been
removed.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: SUN [**2130-4-2**] 4:40 PM
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.5 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *8.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.1 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Left Ventricle - Stroke Volume: 72 ml/beat
Left Ventricle - Cardiac Output: 4.99 L/min
Left Ventricle - Cardiac Index: 2.72 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.16 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 10 < 15
Aorta - Sinus Level: 2.5 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - E Wave deceleration time: 170 ms 140-250 ms
TR Gradient (+ RA = PASP): *39 to 41 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Marked LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Mildly dilated aortic arch.
AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened
aortic valve leaflets. Moderate AS (area 1.0-1.2cm2)
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is markedly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic arch is
mildly dilated. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate aortic stenosis. Preserved regional and
global biventricular systolic function. Moderate to severe
tricuspid regurgitation. Moderate pulmonary hypertension.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2130-3-28**] 16:54
Brief Hospital Course:
Transferred in from [**Doctor First Name 5279**] in NH on [**3-26**] for surgery. He
required IV heparin and NTG pre-operatively. Pre-operative
workup completed and he underwent surgery on [**3-29**] with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
epinephrine, phenylephrine, and propofol drips. Had developed
tamponade and returned to the OR for re-exploration on the
following morning [**3-30**]. Extubated later that afternoon without
complications. Coumadin restarted for Atrial fibrillation.
Transferred to the floor on POD #3 to begin increasing his
activity level. Chest tubes and pacing wires removed per
protocol. Gently diuresed toward his preop weight. He had
urinary retention which required foley reinsertion and being
discharged with foley to rehab on ampicillin until foley
removed. He was ready for discharge to rehab [**4-4**]. He was
discharged to rehab at Pleasantview in [**Location (un) **] [**Location (un) 3844**].
Medications on Admission:
Aspirin 81 daily
Lasix 40 daily
Lisinopril 10 daily
Metoprolol XL 50 daily
Ocuvite
Macrobid 100 daily
Simvastatin 20 daily
Flomax 0.4 QHS
Nitroglycerin-prn
Coumadin
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: due
for INR check [**4-6**] - goal INR 2.0-2.5 dose to be adjusted based
on lab results .
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) for 5 days: or until foley removed .
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): continue twice a day for 10 days then decrease to once a
day .
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours): twice a day with lasix for 10 days then decrease to once
a day .
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Outpatient Lab Work
please check cr/bun, potassium, magnesium twice a week while on
twice a day lasix
Discharge Disposition:
Extended Care
Facility:
Pleasant View
Discharge Diagnosis:
aortic stenosis
coronary artery disease
PMH:
Afib(coumadin), Vertebral fx([**2063**]), Macular
degeneration/legally blind, [**Doctor Last Name 9376**] syndrome, Benign Prostatic
Hypertrophy, Coronary Artery Disease, Hypertension, Bilat knee
arthritis
Discharge Condition:
Alert and oriented x3 nonfocal
gait ***
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*** Target INR 2.0-2.5 for A Fib; first blood draw at rehab
after transfer please.
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Wed [**4-19**] @ 1:15 PM- please
reschedule from rehab if still receiving high-level care
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] F. [**Telephone/Fax (1) 85978**] in 6 weeks
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 55499**] in 4 weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2130-4-4**] | [
"41401",
"5990",
"4241",
"42731",
"4019",
"4168",
"V5861"
] |
Admission Date: [**2126-5-31**] Discharge Date: [**2126-6-7**]
Date of Birth: [**2046-7-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
right pelvic/femur fracture
Major Surgical or Invasive Procedure:
[**2126-5-31**] ORIF of right subtrochanteric hip fracture with
intramedullary nail
History of Present Illness:
Ms. [**Known lastname 48639**] is a 79 year-old lady with developmental delay who
is transferred from group home were she was attending day care
(lives primarily with brother, [**Doctor First Name **] due to hip pain and was
found to have right pelvic/femur fracture.
Initially it had been reported that she was "found down" but
after further history was gathered it seems that she was found
seated at a table, poorly interactive, screaming/crying, and
tremulous (versus shaking). The patient's brother corroborates
this by saying he was told she may have had a seizure - he was
unaware of a fall report.
She was brought to an outside hospital first where CT head was
negative and a pelvic x-ray showed a pubic ramus fracture. She
was unable to give a good history. She denied pain. At that
point, the OSH transferred her to [**Hospital1 18**] for orthopedic
evaluation.
In the ED, initial vs were 5 98.1 80 98/52 18 98% 2L Nasal
Cannula. Trauma exam included rectal exam without blood. CT
torso showed no other signs of trauma but had "evidence of
aspiration" so she was given Levofloxacin/Metronidazole. She
was admitted to Medicine for further management. On transfer to
the floor, VS were 99.1, 97, 24, 121/62, 100%.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
All other 10-system review negative in detail.
Past Medical History:
developmental delay
HTN
arthritis
Social History:
Lives with brother [**Name (NI) **] in [**Location (un) 5503**], MA
Attends day care at group home
No smoking, alcohol or illicits
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM
VS: 98.5, 114/62, 99, 20, 99% 2L NC
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: Good aeration, CTAB no wheezes, rales, ronchi
CV: RRR normal S1/S2, no mrg
ABD: soft NT ND normoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: no ulcers or lesions
.
DISCHARGE EXAM
VS: 98.9-99.4, 118-123/63-66, 65-71, 18, 98-99%RA
BM: none
I/Os: poor PO intake, UOP not recorded as incontinent
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: Good aeration, CTAB no wheezes, rales, ronchi
CV: RRR normal S1/S2, no mrg
ABD: soft NT ND normoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable b/l, dressing over right lateral
thigh/pelvis - c/d/i, non-tender to palpation, patient on left
hip with legs slightly bent, but asking for legs to be
straightened.
Pertinent Results:
ADMISSION LABS:
[**2126-5-31**] 02:50AM BLOOD WBC-12.9* RBC-4.34 Hgb-12.5 Hct-37.1
MCV-86 MCH-28.8 MCHC-33.7 RDW-14.0 Plt Ct-125*
[**2126-5-31**] 02:50AM BLOOD Neuts-91.5* Lymphs-6.0* Monos-1.9*
Eos-0.3 Baso-0.2
[**2126-5-31**] 02:50AM BLOOD PT-13.7* PTT-26.7 INR(PT)-1.3*
[**2126-5-31**] 02:50AM BLOOD Glucose-215* UreaN-19 Creat-0.8 Na-142
K-4.1 Cl-104 HCO3-20* AnGap-22*
[**2126-5-31**] 02:50AM BLOOD ALT-26 AST-42* AlkPhos-110* TotBili-0.5
[**2126-5-31**] 02:50AM BLOOD Albumin-3.8
[**2126-6-1**] 05:01AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.7
DISCHARGE LABS:
[**2126-6-5**] 06:22AM BLOOD WBC-6.8 RBC-3.68* Hgb-11.0* Hct-32.8*
MCV-89 MCH-30.0 MCHC-33.7 RDW-15.6* Plt Ct-160#
[**2126-6-4**] 07:30AM BLOOD Glucose-88 UreaN-12 Creat-0.5 Na-139
K-4.0 Cl-107 HCO3-27 AnGap-9
PERTINENT LABS:
[**2126-5-31**] 06:24AM BLOOD Lactate-6.2*
[**2126-5-31**] 06:47AM BLOOD Lactate-7.7*
[**2126-5-31**] 07:18AM BLOOD Lactate-4.8*
[**2126-5-31**] 11:57PM BLOOD Lactate-3.6*
[**2126-5-31**] 02:50AM BLOOD cTropnT-<0.01
[**2126-5-31**] 11:35PM BLOOD cTropnT-<0.01
[**2126-6-1**] 05:01AM BLOOD cTropnT-<0.01
MICRO DATA:
[**2126-5-31**] 05:55AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050*
[**2126-5-31**] 05:55AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2126-5-31**] 05:55AM URINE RBC-5* WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2126-6-2**] BLOOD CULTURE x2 NEGATIVE
[**2126-6-2**] URINE CULTURE - NEGATIVE
[**2126-5-31**] BLOOD CULTURE x2 [FINAL RESULT PENDING]
[**2126-5-31**] URINE CULTURE - NEGATIVE
EKG [**2126-5-31**]:
Sinus rhythm. Possible right ventricular hypertrophy. Modest
ST-T wave
changes are non-specific. No previous tracing available for
comparison.
CT C-SPINE W/O CONTRAST [**2126-5-31**]:
No fractures. Multilevel degenerative changes.
CT ABD/PELVIS W/CONTRAST [**2126-5-31**]:
1. Comminuted right intertrochanteric, left acetabular, left
ischial, and left sacral fractures.
2. Mixed density right upper lobe nodule. Recommend 6-month
followup chest CT.
3. Probable pulmonary hypertension.
4. Probable cystitis, correlate with urinalysis.
5. 2.6-cm right adnexal cyst. Recommend non-emergent pelvic
ultrasound for further evaluation.
6. Nonspecific liver and renal hypodensities. Recommend
non-emergent
abdominal ultrasound.
CXR [**2126-5-31**]:
No acute intrathoracic process or radiographic evidence of
injury. Please refer to subsequent CT torso for further
details, including small right apical lung nodules.
BILATERAL HIP X-RAYS [**2126-5-31**]:
1. Comminuted right intertrochanteric fracture.
2. Fractures of the left acetabulum and ischium.
3. Severe bilateral hip and right knee osteoarthritis.
LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.
[**2126-5-31**]:
Images show placement of a metallic fixation device about the
fracture of the proximal femur. Further information can be
gathered from the operative report.
HIP UNILAT MIN 2 VIEWS RIGHT IN O.R. [**2126-5-31**]:
Images show placement of a metallic fixation device about the
fracture of the proximal femur. Further information can be
gathered from the operative report.
EKG [**2126-6-1**]:
Sinus rhythm. Short P-R interval. Left axis deviation, consider
left anterior fascicular block. Intraventricular conduction
delay of right bundle-branch block type. Since the previous
tracing of [**2126-5-31**], the rate is faster, ST-T wave abnormalities
are more prominent.
RUQ ULTRASOUND [**2126-6-4**]:
Focal liver lesions seen on recent CT correspond to simple
hepatic cysts. The liver is otherwise normal in appearance
showing no signs of cirrhosis or splenomegaly. The extrahepatic
common bile duct dilatation is also noted, which could be
age-related ectasia, but clinical correlation is recommended.
CT HEAD W/O CONTRAST [**2126-6-4**]:
1. No acute intracranial process.
2. Ventriculomegaly with dilation of the occipital horns is
likely due to atrophy.
3. Chronic small vessel ischemic disease.
MR HEAD [**2126-6-5**]:
No acute infarct seen. Ventriculomegaly out of proportion for
sulci could be due to normal pressure hydrocephalus in proper
clinical setting. Small vessel disease. Limited study due to
motion.
MR [**Name13 (STitle) **] [**2126-6-5**]:
1. Somewhat motion limited axial images.
2. No evidence of ligamentous disruption of marrow edema within
the vertebral bodies to suggest acute trauma.
3. Multilevel degenerative changes with disc bulging at multiple
levels and minimal extrinsic indentation on the spinal cord by
disc bulging at C3-4 level.
4. No evidence of intrinsic spinal cord signal abnormalities.
EEG [**2126-6-4**]:
This is an abnormal awake and sleep EEG because of intermittent
generalized frontally dominant bursts of slowing with admixed
sharp features. These findings are indicative of mild to
moderate diffuse encephalopathy most likely related to patient's
history of static encephalopathy. No electrographic seizures are
present. If clinical concern for seizures is high, a 24 hour
bedside EEG telemetry study is recommended.
Brief Hospital Course:
Ms. [**Known lastname 48639**] is a 79 y/o lady w/ developmental delay who
presented from her group home for a right pelvic and femur
fracture. Her stay was complicated by a brief MICU stay for
post-operative tachycardia and hypotension (possibly due to
blood loss) that resolved. She also underwent workup for
possibe seizure given the history obtained by providers at her
group home. She was discharged to rehab.
# Right pelvic and femur fracture: s/p surgery [**2126-5-31**].
She had a comminuted right intertrochanteric fracture, and a
fracture of the left acetabulum and ischium. Now s/p ORIF of
right subtrochanteric hip fracture with intramedullary nail on
[**5-31**]. Pain well controlled with Tylenol and low-dose narcotics
(which were not needed by the time of discharge). She was
started on enoxaparin prophylaxis on [**5-31**] which should continue
for 4 weeks (end day [**6-28**]). She is touch-down weight-bearing
only on the right leg. She will f/u with Ortho in clinic on
[**2126-6-18**].
# Mechanism of fracture: unclear, possibly a seizure.
Though it was first believed that she had a fall, it was later
clarified by group home staff that she was actually found seated
at a table shaking (still unclear if tremulous/crying or if
shaking/seizing). Patient was unable to describe the event.
Since there was no fall, the fracture was initially suspicious
for very severe osteoporosis in the setting of seizure versus
possible elder abuse. Social Work has ongoing investigations
regarding any elder abuse at the group home though it is felt to
be unlikely. With regards to the cause, seizure was
investigated due to her presentation. EEG and MR imaging of the
head was performed and was not very suggestive of a seizure, but
Neurology consult felt that a seizure is highly likely and
probable given the history obtained. Seizure could explain her
high lactate on presentation (~7). It was fellt that risks of
antiepileptics outweighed the benefits so she was not started on
one this admission. Tramadol was stopped due to risk of
decreasing seizure threshold. She will follow up with Neurology
on [**2126-7-15**].
# Osteoporosis: clinically diagnosed.
Has not had a BMD scan (she has a clinical diagnosis of
osteoporosis given this fracture). She was started on calcium
and vitamin D; she might benefit from bisphosphonate therapy as
an outpatient. No inpatient imaging indicated.
# Post-operative tachycardia/hypotension: requiring MICU stay,
resolved.
After the operation on [**5-31**] she was noted to go into a fast
heart rhythm (HR 140's); no EKG was done. Labs revealed a Hct
drop from 37.1 to 26.4. She was given Metoprolol 5mg IV. Also
over the next few hours, she received a few liters of IV fluids
and 2 units of blood. Her tachycardia persisted and in the
evening she developed hypotension to the 80's so she was
observed in the MICU overnight. With time her tachycardia and
hypotension resolved and she was able to return to the medical
floor the next day. Estimated blood loss was 200cc but it is
possible that this was underestimated and that this was from
hypovolemia. Alternately, this could be related to the fact
that she did not receive her home Metoprolol prior to the
procedure causing tachycardia. Finally, other etiologies that
were considered peri-operative MI but this was ruled out by EKG
and serial troponins. She was normotensive (on antihypertensive
meds) and did not have any more tachycardia for the duration of
her stay. She was able to be continued on her antihypertensive
medication (Lisinopril) and also Metoprolol.
# Acute anemia: likely from blood loss, now Hct stable.
She was s/p surgery with only 200cc blood loss, however did have
pelvic/femur fractures which can bleed extensively. On [**5-31**],
Hct fell from 37.1 to 26.4, then received 2u pRBC with repeat
Hct 31.8. The next day ([**6-1**]) she was noted to have Hct 25 so
she received 2u pRBC with Hct increasing to 33.9. Hct was
stable by the time of discharge, and she did not require any
more transfusions. Hct was 32.8 on [**6-5**]. No need for further
Hct checks unless any clinical concern for bleeding.
# Thrombocytopenia: unclear etiology.
Four T score of 2 makes HIT unlikely. No obvious signs of
cirrhosis or hypersplenism. No h/o ITP. No signs or symptoms
to suggest TTP. Though her plt dropped from 125 to 75, platelet
level stabilized with plt 160 at the time of discharge.
# Leukocytosis: resolved, low suspicion for infection.
WBC 12.9 on presentation (neutrophil predominance, no bands) but
no signs and symptoms of infection (negative urinalysis and
urine cultures, blood cultures with no growth to date, and clear
CXR). No antibiotics were continued once she was admitted, and
her leukocytosis resolved (WBC 6.8 at discharge). Initial
leukocytosis might have represented a stress response from her
fracture.
# Hypertension: controlled.
Besides her episode of hypotension (see above) she did require
her antihypertensive medications and her blood pressure was
reasonably controlled. She was continued on her Lisinopril and
Metoprolol.
# Developmental delay: stable, guardianship extension in
progress.
Mental status at baseline is alert and interactive, answering
questions. Her family felt that she has derived great benefit
from her adult day program. Has good family support (especially
from brother [**Doctor First Name **]. She continues on Donepezil. Guardianship
required an extension from the courts during this admission as
[**Doctor First Name **] legal guardianship of [**Name (NI) **] did not include a [**Name (NI) 1501**] admission
clause due to the date it was originally attained on. Legal
paperwork is being processed and information will be shared with
her rehab hospital.
# Mixed density right upper lobe nodule: incidental finding on
CT.
6-month followup chest CT was recommended. She should have this
as an outpatient.
# 2.6cm right adnexal cyst: incidental finding on CT.
Non-emergent pelvic ultrasound was recommended for further
evaluation. She should have this done as an outpatient.
# Nonspecific liver and renal hypodensities: incidental finding
on CT.
Non-emergent abdominal ultrasound was recommended, and was done
while she was an inpatient. This revealed several simple hepatic
cysts and mild dilation of the extrahepatic bile duct.
# Transitional issues
-Code status: Full Code
-Emergency Contact: [**Name (NI) **] [**Name (NI) 48639**] (brother): [**Telephone/Fax (1) 112245**]
-Guardianship extension: paperwork submitted, and awaiting court
date currently
-Dispo: to rehab hospital per PT evaluation
-Ongoing investigation into question of elder abuse at group
home
-Pending at the time of discharge: final result of blood
cultures from [**6-2**]
-Incidental findings requiring follow-up (see above): RUL lung
nodule, right adnexal cyst
-Lovenox duration: [**Date range (1) 94218**]
-Patient might benefit from bisphosphonate therapy
-Follow-up: with Ortho on [**2126-6-18**] and Neurology on [**2126-7-15**]
Medications on Admission:
(confirmed with [**Doctor First Name **], patient's brother)
Donepezil 10mg daily
Lisinopril 40mg daily
Tramadol 50mg daily
Metoprolol tartrate 100mg twice a day
Colace [**Hospital1 **]
Miralax 3350 1 packet PRN
Discharge Medications:
1. Donepezil 10 mg PO HS
2. Lisinopril 40 mg PO DAILY
hold for sbp < 100 or map < 60
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
hod for sedation or rr < 10.
4. Metoprolol Tartrate 100 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Senna 2 TAB PO DAILY:PRN constipation
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Acetaminophen 650 mg PO Q6H:PRN pain/fever
9. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral twice a day
10. Morphine Sulfate IR 5-10 mg PO Q8H:PRN pain
Hold for sedation or RR < 12.
11. Enoxaparin Sodium 30 mg SC Q12H
planned duration: weeks post-op ([**Date range (3) 112246**])
12. Miconazole Powder 2% 1 Appl TP TID:PRN rash
apply to affected area
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
comminuted right intertrochanteric fracture
fracture of the left acetabulum and ischium
thrombocytopenia
anemia
SECONDARY:
developmental delay
osteoporosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted due to a right pelvis and femur fracture. You
underwent surgery for this and are now being discharged to rehab
with plans to follow-up with Orthopedic Surgery (appointment
listed below).
Note that during your stay, you were worked up for possible
seizure and you will follow up with Neurology (appointment
listed below).
We made the following changes to your medications:
-START Lovenox (Enoxaparin) injections to prevent blood clots
(from [**Date range (1) 94218**])
-START Tylenol as needed for pain
-START Morphine as needed for pain
-START Calcium/Vitamin D for osteoporosis
-STOP Tramadol (this could predispose you to having seizures)
Followup Instructions:
ORTHOPEDICS
When: TUESDAY [**2126-6-18**] at 10:20 AM
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
ORTHOPEDICS
When: TUESDAY [**2126-6-18**] at 10:40 AM
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
NEUROLOGY
When: MONDAY [**2126-7-15**] at 4:00 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD [**Telephone/Fax (1) 541**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| [
"2851",
"2875",
"42731"
] |
Admission Date: [**2175-11-6**] Discharge Date: [**2175-11-13**]
Service: .
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old man
with a history of coronary artery disease status post
coronary artery bypass graft surgery, severe aortic stenosis
and a recent non-ST elevation myocardial infarction the week
prior to admission, which was complicated by congestive heart
failure with the ejection fraction in the 30s. At that time,
his aortic valve area was noted to be 0.5 cm squared. The
patient initially refused cardiac catheterization, pacemaker
and anti-coagulation at the outside hospital and was
discharged to home to return the next day with shortness of
breath at rest. He was noted to have a systolic blood
pressure in the 80s; temperature 100.6 F., with a right lower
lobe infiltrate found on chest x-ray.
He again ruled in for myocardial infarction and was started
treatment with antibiotics, heparin drip and Natrecor. He
was transferred to [**Hospital1 69**],
initially admitted to the [**Hospital Unit Name 196**] Service and taken for cardiac
catheterization.
Catheterization revealed severe three vessel disease and
severe biventricular diastolic dysfunction with patent graft.
The patient also had critical aortic stenosis, severe
pulmonary hypertension and a successful balloon valvuloplasty
bringing the aortic valve area from 0.5 cm squared to 0.7 cm
squared. The patient was started on Dobutamine in the
catheterization laboratory and was transferred to the Cardiac
Care Unit.
Cardiac output on dobutamine was 2.88 and did not
significantly change after the dobutamine was stopped.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft in [**2167**] with left internal mammary artery to the
left anterior descending, saphenous vein graft to the left
circumflex and obtuse marginal ramus, and saphenous vein
graft to the right coronary artery.
2. Severe aortic stenosis with a valve area of 0.5 cm
squared.
3. Tachycardia / Bradycardia syndrome.
4. Atrial fibrillation.
5. Recent non-ST elevation myocardial infarction.
6. Asthma.
7. Congestive heart failure with an ejection fraction of
30%.
8. Hypertension.
9. Chronic renal insufficiency.
10. Hyperlipidemia.
11. Diabetes mellitus type 2.
12. History of urinary tract infection.
13. Status post transurethral resection of the prostate.
14. Benign prostatic hypertrophy.
MEDICATIONS AT HOME:
1. Captopril 6.25 mg twice a day.
2. Augmentin twice a day.
3. Lasix 60 mg p.o. twice a day.
4. Digoxin 0.125 mg p.o. q. day.
5. Coreg 3.125 mg p.o. twice a day.
6. Aspirin 325 mg p.o. q. day.
7. Pravachol 60 mg p.o. q. day.
8. Atrovent and Albuterol inhalers.
9. Flovent inhaler.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives at home; denies alcohol or
tobacco use.
PHYSICAL EXAMINATION: On admission, temperature 100.4 F.;
pulse 69; blood pressure 105/38; respiratory rate 22;
saturation of 99% on a non-rebreather. Generally, the
patient is confused, moving around in bed. He had a jugular
venous pressure of 7 cm with a II/VI systolic ejection murmur
heard at the right upper sternal border. On lung examination
he had diffuse wheezes and crackles at bases. The rest of
his examination was unremarkable.
LABORATORY: On admission showed a BUN and creatinine of 48
and 1.9. Troponin T was 2.38 and CK 40.
EKG pre-cath showed atrial fibrillation at a rate of 60 beats
per minute, left axis deviation, right bundle branch block
with ST depressions in V1 through V6.
SUMMARY OF HOSPITAL COURSE: The patient was transferred post
catheterization to the Cardiac Intensive Care Unit.
[**Unit Number **]. CORONARY ARTERY DISEASE: Catheterization revealed severe
three vessel disease with patent graft. The patient was
status post two recent non-ST elevation myocardial
infarctions. To continue on aspirin and Pravachol.
Initially, his beta blocker was held secondary to hypotension
and presumed cardiogenic shock, however, his beta blocker,
ACE inhibitor and digoxin were started prior to discharge
without complications.
2. CONGESTIVE HEART FAILURE: The patient was shown to have
an ejection fraction of 30% with severe biventricular
diastolic dysfunction and a very low cardiac output. He was
resumed on his home Lasix dose as well as his home ACE
inhibitor and beta blocker and was felt to be euvolemic by
the time of discharge.
3. SICK SINUS SYNDROME: The patient continues to refuse a
pacemaker and while in-house he became bradycardic at times,
but was otherwise in regular rate in his atrial fibrillation.
4. ATRIAL FIBRILLATION: The patient continues to refuse
anti-coagulation and remained in atrial fibrillation. He is
continued on Carvedilol for multiple indications, one of
which is for rate control.
5. ASTHMA / QUESTION OF CHRONIC OBSTRUCTIVE PULMONARY
DISEASE: The patient was continued on oxygen via nasal
cannula. He continued to saturate well throughout his
admission as long as he was on two or three liters which he
states is his home dose of oxygen. He was also continued on
Atrovent and Albuterol nebulizers and transitioned over to
inhalers by the end of his hospital stay as well as his
Flovent inhaler.
6. PNEUMONIA: The patient had been treated with Levaquin
for two days followed by Caveats and Clindamycin for two days
at the outside hospital. He was continued on Ceftriaxone
while here for a total of a ten day course. He appeared to
improve in his oxygen saturation and his sputum production
decreased by the time of discharge with no complications.
7. DIABETES MELLITUS: The patient was initially started on
a Regular insulin sliding scale, however, his blood sugar
remained less than 150 at all times, so the Regular insulin
sliding scale was stopped prior to discharge.
8. CODE STATUS: The patient remained "DO NOT RESUSCITATE"
and "DO NOT INTUBATE" throughout his hospital stay.
9. MENTAL STATUS: On admission, the patient appeared
confused and continued to do so throughout his hospital stay.
Likely that this patient has a baseline dementia, however,
due to this, he is having difficulty swallowing. He was
evaluated by the Speech and Swallow Team on the day of
discharge who recommended that the patient not take anything
by mouth until his mental status clears. If this does not
happen, then he should be started on tube feeds and a PEG
tube should be considered as he is a very high aspiration
risk.
DISCHARGE MEDICATIONS:
1. Digoxin 0.125 mg p.o. q. day.
2. Carbuterol 3.125 mg p.o. twice a day.
3. Lasix 60 mg p.o. twice a day.
4. Captopril 6.25 mg p.o. three times a day.
5. Lipitor 10 mg p.o. q. h.s.
6. Aspirin 325 mg p.o. q. day.
7. Flovent two puffs twice a day.
8. Risperidone 0.5 mg p.o. twice a day p.r.n.
9. Atrovent nebulizers q. six hours.
10. Albuterol nebulizers q. six hours.
11. Colace 100 mg p.o. twice a day.
12. Senokot one to two tablets p.o. q. day p.r.n.
13. Heparin subcutaneously 5000 units q. eight hours until
ambulating.
14. Protonix 40 mg p.o. q. day.
15. Guaifenesin p.r.n.
DISPOSITION: The patient will be discharged to a
rehabilitation facility.
DISCHARGE STATUS: Stable; the patient denied chest pain
throughout this entire admission.
DISCHARGE INSTRUCTIONS: Follow-up appointments to be
determined.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 2543**]
MEDQUIST36
D: [**2175-11-13**] 13:46
T: [**2175-11-13**] 14:33
JOB#: [**Job Number 53887**]
| [
"4241",
"4280",
"42731",
"4168",
"25000",
"4019",
"2720",
"41401"
] |
Admission Date: [**2149-7-29**] Discharge Date: [**2149-8-4**]
Date of Birth: [**2117-7-23**] Sex: M
Service: CARDIAC SURGERY
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 31 year-old gentleman
with a known history of bicuspid aortic valve with severe
aortic regurgitation who has been experiencing increasing
dyspnea on exertion over the last three months. The patient
was seen by Dr. [**Last Name (Prefixes) **] and admitted [**7-29**] for elective
aortic valve replacement. Cardiac catheterization in [**2149-10-6**] showed a left ventricular ejection fraction at 52%,
severe aortic regurgitation with mild aortic stenosis, mild
left ventricular diastolic dysfunction, normal coronary
arteries. Echocardiogram from [**2149-1-5**] showed moderate
to severe aortic regurgitation, left ventricular ejection
fraction of 55%, normal left ventricular function, dilated
aortic root and bicuspid aortic valve.
PAST MEDICAL HISTORY: Bicuspid aortic valve.
MEDICATIONS: Zestril 10 mg po q.d.
ALLERGIES: Fava beans.
SOCIAL HISTORY: The patient lives with his parents. He
denies tobacco use. Occasional ETOH use.
HO[**Last Name (STitle) **] COURSE: The patient was admitted [**2149-7-29**] and was
taken to the Operating Room with Dr. [**Last Name (Prefixes) **] where he
underwent an aortic valve replacement with a 25 mm Carbomedic
valve. The patient originally was scheduled for a Bentall
procedure, but upon examination by transesophageal
echocardiogram in the Operating Room it was found that there
was no dilation of the proximal ascending aorta or
sinotubular junction, so it was elected to proceed with a
aortic valve replacement. Ejection fraction in the Operating
Room was 50%. Please see 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 his first postoperative night. The
patient was consistently tachycardic with heart rates in the
1 teens to 120s sinus tachycardia, responded to intravenous
Lopressor. The patient remained hemodynamically stable with
minimal chest tube drainage. On postoperative day number one
the patient began ambulating in the hallway. The patient
remained in the Intensive Care Unit due to lack of bed
availability on the floor. On postoperative day number two
the patient was transferred out of the Intensive Care Unit to
the regular floor in stable condition. The patient continued
to have sinus tachycardia rates into the 1 teens on
increasing doses of Lopressor. There was a question of
whether or not the tachycardia was due to poor pain control.
The patient's pain medications were switched to Dilaudid and
the patient was started on around the clock Motrin, which
seemed to improve the patient's pain control, but did not
change the sinus tachycardia. Labetalol was added to the
patient's regimen of Lopressor, which did improve the
tachycardia and heart rate decreased into the 90s to low
100s. On postoperative day number two the patient was started
on Coumadin for the patient's mechanical aortic valve.
The patient began working with physical therapy and the
patient's pacing wires were removed on postoperative day
number three. The Labetalol was increased on postoperative
day number three for continued tachycardia. On postoperative
day number four the patient completed a level five with
physical therapy walking 500 feet and climbing one flight of
stairs. The patient remained in the hospital for continued
titration of his Coumadin therapy. On postoperative day
number five the patient's INR rose to 2.0 and on
postoperative day number six the patient was cleared for
discharge to home.
CONDITION ON DISCHARGE: Temperature max 99.1, pulse 99 sinus
rhythm, blood pressure 118/70, respiratory rate 16, room air
oxygen saturation 95%. The patient's weight on [**8-4**] was
104 kilograms. The patient weighed 109 kilograms
preoperatively. Neurologically the patient is awake, alert
and oriented times three, nonfocal. Cardiovascular regular
rate and rhythm. No murmur or rub, sharp valve click. Lungs
breath sounds are clear bilaterally. No rales, wheezes or
rhonchi. Gastrointestinal positive bowel wounds, obese,
nontender, nondistended. Extremities 2+ pitting edema.
Sternal incision is clean and dry. Sternum is intact. There
is no erythema or drainage.
LABORATORY DATA: White blood cell count 11.3, hematocrit
34.1, platelets count 342, sodium 138, potassium 4.5,
chloride 101, bicarb 24, BUN 21, creatinine 0.9 and glucose
145. PT 20.8, INR 2.9.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg po b.i.d.
2. Lasix 20 mg po b.i.d. times seven days.
3. K-Ciel 20 milliequivalents po b.i.d. times seven days.
4. Colace 100 mg po b.i.d.
5. Zantac 150 mg po b.i.d.
6. Labetalol 40 mg po b.i.d.
7. Percocet 5/325 one to two tablets po q 4 hours prn.
8. Ibuprofen 600 mg po q 6 hours prn.
9. Coumadin 3 mg po on [**8-4**]. Blood is to be drawn on [**8-5**]
and the results are to be faxed to his primary care physician
[**Last Name (NamePattern4) **].[**Name (NI) 14088**] office who will determine further Coumadin
dosing.
DISCHARGE DIAGNOSES:
1. Aortic regurgitation.
2. Status post aortic valve replacement.
Th[**Last Name (STitle) 1050**] is to follow up with his primary care physician
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in one to two weeks and by phone on [**8-5**] for a
Coumadin dose. The patient is to follow up with Dr. [**Last Name (STitle) 120**]
his cardiologist in one to two weeks. The patient is to
follow up with Dr. [**Last Name (Prefixes) **] in four weeks. The patient is
to be discharged to home in stable condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2149-8-4**] 11:23
T: [**2149-8-4**] 11:36
JOB#: [**Job Number 14089**]
| [
"9971",
"42789",
"V5861"
] |
Admission Date: [**2185-5-15**] Discharge Date: [**2185-5-23**]
Date of Birth: [**2129-2-10**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Prednisone
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
-Right internal jugular central access line placed [**5-15**] and
removed [**5-19**]
-Peripheral arterial line placement
History of Present Illness:
Mr. [**Known lastname 24078**] is a 56-year old male with a history of pulmonary
sarcoidosis, obstructive sleep apnea and asthma who presents
from home with one day of chills, myalgias, cough productive of
yellow sputum tinged with blood and right sided chest pain. Of
note he was previously diagnosed with community acquired
pneumonia in [**Month (only) 956**] and treated with azithromycin with
complete resolution of symptoms. He was feeling well until one
day prior to presentation when these symptoms developed
suddenly. The pain is primarily in the right side of his chest
and worsens with deep inspiration. He is unable to take a deep
breath secondary to pain. His breathing is worse when lying flat
or on his left side. He has had myalgias and chills but has not
taken his temperature at home. He has had mild nausea but no
vomiting, abdominal pain, diarrhea or constipation. He has had
blood tinged sputum for one day. He has been taking normal PO
intake and had normal urine output without dysuria. He denies
lower extremity edema. He denies any recent travel or sick
contacts. [**Name (NI) **] has not been on recent steroids or other
immunosuppresants. He is not a smoker. All other review of
systems negative.
.
In the ED, initial vs were: T: 98.7 P: 116 BP: 73/45 R: 16 O2
sat: 88% on RA. He had a chest CT with contrast which showed no
pulmonary embolism but showed a severe right middle and right
lower lobe pneumonia. He received 5 liters of normal saline. His
blood pressure ranged from the 70s to 90s systolic and he
subsequently had a right sided sepsis catheter placed and was
started on levophed which was soon stopped. He received
levofloxacin, vancomycin, aspirin 325 mg and morphine 4 mg IV x
1, tylenol 1000 mg PO x 1. He had an EKG which showed sinus
tachycardia, normal axis, normal intervals, isolated 1 mm STE in
lead III which resolved on subsequent EKGs. He was admitted to
the MICU for further management.
.
Past Medical History:
Sarcoidosis complicated by uveitis
Hyperglycemia
Hypercholesterolemia
Obstructive Sleep Apnea
Anxiety
Depression
Benign Prostatic Hypertrophy
Exercise Induced Asthma
Social History:
He denies a history of smoking, alcohol or illicit drug use. He
lives with his wife and his dog. No recent travel or sick
contacts.
.
Family History:
No family history of sarcoidosis or other lung disorders.
Physical Exam:
INITIAL ADMISSION PHYSICAL EXAM ON [**2185-5-15**]:
Vitals: T: 97.4 BP: 95/56 P: 96 R: 27 O2: 93% on 100% NRB
General: Alert, oriented, tachypneic, not using accessory
muscles
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Left side with coarse breath sounds, right with
inspiratory and expiratory ronchi, dullness to percussion on the
right, egophony on the right
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neurologic: Alert and oriented x 3, strength 5/5 throughout,
sensation intact to light touch across all dermatomes
.
.
PHYSICAL EXAM ON TRANSFER TO THE MEDICAL FLOOR FROM ICU ON
[**2185-5-19**]:
Vital Signs: Tmax [**Age over 90 **]F, BP 142/81, HR 77, RR 18, Oxygen Sat 97%
on room air
General: Alert & oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Right sided basilat decreased breath sounds and rhonchi
with expiration/inspiration, left side with decreased aeroation
at bases.
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema bilaterally noted (R=L)
Neuro: CNs [**3-10**] grossly in tact, PERRLA, EOMI, no focal
deficits. Gait assessment deferred.
Pertinent Results:
ADMISSION LABS:
[**2185-5-15**] 11:00AM GLUCOSE-158* UREA N-25* CREAT-1.6* SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16
[**2185-5-15**] 11:00AM ALT(SGPT)-31 AST(SGOT)-21 CK(CPK)-46 ALK
PHOS-64 TOT BILI-1.5, LIPASE-17
[**2185-5-15**] 11:01AM LACTATE-2.4*
[**2185-5-15**] 11:00AM TOT PROT-6.4 ALBUMIN-4.0 GLOBULIN-2.4
CALCIUM-9.1 PHOSPHATE-1.9* MAGNESIUM-1.5*
[**2185-5-15**] 11:00AM CORTISOL-45.6*
[**2185-5-15**] 11:00AM CRP-89.2*
[**2185-5-15**] 11:00AM WBC-10.6# RBC-5.22 HGB-14.1 HCT-41.1 MCV-79*
MCH-27.0 MCHC-34.4 RDW-13.9
[**2185-5-15**] 11:00AM NEUTS-71* BANDS-18* LYMPHS-6* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2185-5-15**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2185-5-15**] 11:00AM PLT SMR-NORMAL PLT COUNT-183
[**2185-5-15**] 11:00AM PT-14.1* PTT-25.0 INR(PT)-1.2*
.
.
CARDIAC ENZYMES:
[**2185-5-15**] 06:16PM CK(CPK)-72
[**2185-5-15**] 06:16PM CK-MB-NotDone cTropnT-<0.01
[**2185-5-15**] 11:00AM cTropnT-<0.01
[**2185-5-15**] 11:00AM CK-MB-NotDone
.
ABGs:
[**2185-5-15**] 06:28PM TYPE-ART TEMP-36.3 PO2-88 PCO2-28* PH-7.42
TOTAL CO2-19* BASE XS--4, LACTATE-1.4
.
URINE STUDIES:
[**2185-5-15**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2185-5-15**] 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
.
IMAGING STUDIES:
[**2185-5-15**] PORTABLE CXR -Findings consistent with right lower lobe
atelectasis.Superimposed infection cannot be excluded. Document
resolution upon treatment to exclude an underlying obstructive
process.
.
[**2185-5-15**] CTA:
1. Severe right middle lobe pneumonia with involvement of
portions of the
right lower lobe, right upper lobe and lingula. No evidence of
aortic
dissection or pulmonary embolism.
2. Unchanged sequelae of known underlying sarcoidosis.
3. Unchanged non-obstructive left renal calculi.
.
[**2185-5-19**] CHEST XRAY, PA AND LATERAL: Since [**5-18**],
consolidation in the right middle and lower lobes is improved.
Moderate-to-severe left mid and upper pulmonary edema is
unchanged. Left-sided pleural effusion is slightly increased
from [**2185-5-17**]. Atelectatsis in the right lower lobe is
stable. The right central line has been removed. The remainder
of the exam is unchanged.
IMPRESSION:
1. Improving pneumonia in the right middle and lower lobes.
2. Persistent moderate edema, despite decreased central venous
pressure.
3. Slight increase in left side pleural effusion.
.
MICROBIOLOGY:
[**2185-5-15**] Blood Culture, Routine (Final [**2185-5-21**]): NO GROWTH.
[**2185-5-16**] Sputum Culture results-->
**FINAL REPORT [**2185-5-18**]**
GRAM STAIN (Final [**2185-5-16**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2185-5-18**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
.
[**2185-5-15**] 5:35 pm URINE Source: CVS.
**FINAL REPORT [**2185-5-16**]**
Legionella Urinary Antigen (Final [**2185-5-16**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
EKGs [**2185-5-15**] -[**2185-5-16**]: Sinus tachycardia, normal axis, normal
intervals, isolated 1 mm STE in lead III which resolved on
subsequent EKGs
.
DISCHARGE LABS:
Brief Hospital Course:
In summary, this is a 56-year-old male with sarcoidosis, OSA,
anxiety/depression, and hyperlipidemia who presented with
shortness of breath, right sided chest pain and fevers and he
was found to have multifocal right sided PNA per chest CT
imaging. Admitted to ICU for sepsis concerns in setting of
hypotension to systolic range in 70s with mild tachycardia.
Resuscitated with generous IVFs and given IV antibiotics,
supportive oxygen and briefly on Levophed for blood pressure
stabilization. Patient hemodynamically stabilized well over [**1-28**]
days in ICU and never required any intubation. He was
transferred to general medical floor on [**2185-5-19**]. For more
detailed hospital course please see below:
.
#Multifocal PNA: Patient's initial presentation was concerning
for septic shock as he became tachycardic to 120s range and
hypotensive to systolic 70s in the emergency room on [**2185-5-15**].
Blood pressures improved with generous IVFs and he only required
brief pressor support with Levophed. CTA chest done at admission
on [**2185-5-15**] showed right sided multi-focal PNA. Of note, Mr.
[**Known lastname 24078**] has pre-existing poor pulmonary reserve at baseline from
his sarcoidosis and asthma. He also endured 2 previous bouts of
pneumonia over the past year. He was initially started on triple
coverage in the ED with Levaquin, and IV Vancomycin & Zosyn.
This was continued in the ICU up until [**5-18**] when he was switched
to IV Ceftriaxone with continuance of Levaquin. He arrived on
the general medical floor on [**5-19**] but appeared to have more
labored breathing later in the afternoon so a repeat CXR done
and team decided to place him back on his prior Vancomycin and
Zosyn regimen and CTX and Levaquin were discontinued. The CXR
done [**2185-5-19**] showed mild effusions but overall improving
pneumonia in the right middle and lower lobes. He continued to
have improved shortness of breath and decreasing oxygen
requirements and his cough was persistent but phlegm production
lessened. Fevers gradually defervesced. Initial blood cultures
were negative. Sputum gram stain showed >25 PMNs and 3+ gram
positive cocci in pairs and chains and 2+ gram negative rods
also identified. Sputum culture only showed
sparse growth of oropharyngeal flora. Patient developed drug
rash, leukocytosis and eosinophilia, Zosyn was discontined.
Placed only on PO levoquin high-dose. To complete total of 14
day course.
asked to follow-up as an outpatient with his pulmonologist, Dr.
[**Last Name (STitle) **], over the next few weeks.
.
#Sarcoidosis: Mr. [**Known lastname 24078**] has both pulmonary sarcoidosis and
extrapulmonary manifestations of sarcoid in the form of prior
uveitis flare-ups. He does not typically take any home oral
steroids on an ongoing basis for his sarcoid and on chest CT on
this admission his sarcoid disease appeared to be stable as
compared with prior films. Given his acute infection there was
no role for any additional steroids on this admission. Moreover,
his dyspnea and respiratory congestion seemed to gradually
improve on antibiotics and supportive oxygen alone. He was,
however, continued on his usual inhaled steroids with ongoing
Advair and Albuterol nebulizers.
.
#Obstructive Sleep Apnea: He was continued on his usual home
nightly CPAP regimen while inpatient.
.
#Hypercholesterolemia: Daily cholestyramine was continued. Mr.
[**Known lastname 24078**] had also been enrolled to participate in a research study
which included daily administration of possible statin (vs.
placebo) and this protocol was completed on [**5-21**].
.
#Depression: During his hospital course he had occasional
apparent depressed moods at times but denied any suicidal
ideation and he maintained an appropriate affect after he was
transferred to the general medical floor. He was continued on
his usual Effexor and daily clonazepam was continued for his
concomitant anxiety.
.
#Benign Prostatic Hypertrophy: He was given his usual home
finasteride therapy and at time of discharge he will return to
his usual Flomax as well. He reported no difficulty with
urination during his hospital course.
.
#Exercise Induced Asthma: He was continued on his usual daily
Advair and monteleukast. In place of his PRN albuterol inhaler
he was given nebulizer treatments on an as-need basis q4-6
hours.
.
#GERD: He was continued on a PPI regimen for his severe GERD
history.
.
#Hyperglycemia / Pre-diabetes: He had not been on any home
standing medications for his mild to moderate hyperglycemic
tendency. He had QID fingersticks and a sliding scale insulin
regimen with meals and QHS. Fasting and post-prandial glucose
levels were predominantly normal to borderline normal for
hospital course. No additional standing insulin or oral
medications were added to his medications.
.
# Fluids, Electrolytes and Nutrition: He had several liters of
IVFs over the initial 48 hours of his hospital stay and then
once he had good PO intake IVFs were tapered. Electrolytes were
monitored and repleted as needed and he was continued on a
regular diet.
.
# Prophylaxis: Subcutaneous heparin was given TID for DVT
prevention, PPI for GERD as above, and a bowel regimen with
Colace and Senna was continued.
.
# Code Status: Patient was maintained as a full code status for
entire hospital course ; confirmed directly with patient.
Medications on Admission:
Albuterol 90 mcg 1-2 puffs q4-6H:PRN
Cholestyramine-Aspartame 2 grams daily
Clonazepam 0.5 mg PO daily:PRN
Fexofenadine 60 mg Tablet [**Hospital1 **]
Finasteride 5 mg PO daily [Proscar]
Flomax 0.4 mg daily
Fluticasone nasal 50 mcg 2 sprays daily
Fluticasone-Salmeterol 500 mcg-50 mcg 1 puff [**Hospital1 **]
Montelukast 10 mg PO QHS
Omeprazole 40 mg [**Hospital1 **]
Ranitidine HCl 300 mg daily
Venlafaxine 100 mg TID
Aspirin 81 mg q 3 days
Bismuth Subsalicylate [Pepto-Bismol] 1 tablet QID:PRN
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-28**] Inhalation every
4-6 hours as needed for shortness of breath or wheezing.
2. Cholestyramine-Sucrose 4 gram Packet Sig: 0.5 Packet PO DAILY
(Daily).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. Ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO once a
day.
12. Venlafaxine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QMOWEFR (Monday -Wednesday-Friday).
14. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1)
Tablet PO QID (4 times a day) as needed.
15. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
16. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for Itch for 7 days: Do not drive
as this is a sedating medication.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Pneumonia
-Respiratory distress
.
Secondary:
-Sarcoidosis
-Hyperglycemia
-Hypercholesterolemia
-Obstructive Sleep Apnea
-Anxiety
-Depression
-Benign Prostatic Hypertrophy
-Exercise Induced Asthma
Discharge Condition:
Clinically stable. No apparent distress and normal vital signs
at time of discharge.
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted with fevers, a cough
and shortness of breath. Additional imaging studies revealed
that you had a right sided pneumonia. You were initially taken
care of in the intensive care unit where you were given IV
antibiotics, IV fluids and supportive oxygen therapy to help
with your breathing.
.
Once you had clinically stabilized and your symptoms improved
you were transferred to the general medical wards. You were
continued on supportive oxygen which was slowly weaned and
antibiotics were continued. Chest physical therapy was also
provided to help you recuperate faster.
.
It is very important that you follow-up with your appointments
as listed below. Also, please continue to take all of your
listed medications as prescribed and outlined below.
.
If you experience any new fevers, chills, bloody sputum, worse
cough, worse shortness of breath, dizziness, lightheadedness,
chest pains, heart palpitations or any other concerning symptoms
then please return to the emergency room or call your primary
care physician.
Followup Instructions:
1) Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**]
[**Last Name (NamePattern1) **] on [**6-8**] at 8:45am. Phone:[**Telephone/Fax (1) 9347**]
.
2) Please call #[**Telephone/Fax (1) 612**] to set up a follow-up appointment
with your pulmonologist, Dr. [**Last Name (STitle) **] over the next 1-2 weeks
time.
.
Completed by:[**2185-5-23**] | [
"0389",
"5849",
"486",
"99592",
"32723",
"49390",
"2720",
"53081"
] |
Admission Date: [**2111-7-1**] Discharge Date: [**2111-7-2**]
Service: MED
Allergies:
Macrobid
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
bradycardia, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82F w/ PMH sig for HTN, Fe deficiency anemia, cardiomegaly now
p/w [**12-26**] mth h/o increasing gait unsteadiness, falls, dysphagia,
nonproductive cough, DOE, bilat ankle edema, generalized
weakness. Around 9:30pm 1 day PTA, pt's daughter noted her to
be pale, cool to the touch, with slurred speech and increased
gait unsteadiness. At the time, her PO temp was noted to by 94
degrees w/ SBP in the 90s (baseline 130s), but the patient's
daughter did not seek medical attention. Over the course of the
day today, the pt was noted to become progressively more
lethargic, 'slumping down multiple times' and was thus brought
to the ED by her daughter for further eval. ROS also notable
for 2 days of subjective chills, constipation, and abdominal
pain en route to the ED.
Past Medical History:
HTN
CVA '[**81**]
"large heart"
no hx MI
AI
osteoporosis
hyperchol
L hip pinning
TAH/BSO
Fe def anemia
Social History:
lives w/ dtr at home
no tob, no EtOH, no OTC/illicit drug use
uses wheelchair but independent in all her ADLS
Family History:
noncontributory
Physical Exam:
T92.8 BP92/60 P66 RR20 100% sat on AC 550 x 20, peep
5, 100% FiO2
Gen - pale, intubated & sedated
[**Year (2 digits) **] - PERRL, OP clear, MM dry
Neck - RIJ site ok, no JVP/LAD
Lungs - [**Month (only) **] at L base o/w clear
CV - RRR, no R/M/G
Abd - soft, NT/ND, NABS, no masses, no rebound/guarding
Ext - 1+ LE edema bilat, warm, no rashes, 1+ pedal pulses
Neuro - moves all 4 ext spont, symmetric DTRs, normal muscle
tone
Pertinent Results:
[**2111-7-1**] 08:15PM WBC-25.5*# RBC-3.02* HGB-8.5* HCT-26.9*
MCV-89 MCH-28.0 MCHC-31.4 RDW-14.0 PLT COUNT-135*
[**2111-7-1**] 08:23PM GLUCOSE-125* LACTATE-10.1* NA+-135 K+-6.2*
CL--101 TCO2-15*
UREA N-44* CREAT-3.4*# CALCIUM-8.4 PHOSPHATE-5.6*#
MAGNESIUM-1.7
[**2111-7-1**] 08:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2111-7-1**] 08:26PM PO2-274* PCO2-14* PH-7.46* TOTAL CO2-10* BASE
XS--9 INTUBATED-INTUBATED O2 SAT-90
[**2111-7-1**] [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG
amphetmn-NEG mthdone-NEG
Brief Hospital Course:
Upon arrival to the ED, the patient was noted by triage nurses
to be unresponsive, 'cold & clammy,' with heart rate in the 30s,
no palpable pulse, and breathing agonally. No improvement with
1 mg each of atropine, epinephrine, or glucagon, so she was
externally paced, intubated, and started on levophed. She was
given broad spectrum antibiotic coverage for presumed sepsis
(levo/flagyl/vanc), along w/ agressive fluid recussitation and
subsequently transferred to the MICU for further management.
Unfortunately, despite agressive pressor and fluid therapy, the
patient's clinical condition continued to rapidly deteriorate
over the next 12 hours. She continued to display signs and
symptoms of vasodilatory shock, including hypothermia, a rising
lactate, leukocytosis, and hypotension refractory to fluid and
maximum dosages of 3 simultaneous pressors. It was decided
based on her grave clinical condition and poor prognosis that
CPR would not be medically indicated, and the patient passed
away at 7am [**2111-7-2**]. Her family was notified, but an autopsy was
not granted.
Medications on Admission:
vitamin d3 400 daily
calcium carbonate 500 q6hrs
lipitor 10 daily
lisinopril 40 daily
hctz 25 daily
procardia XL 90 daily
atenolol 100 daily
[**Month/Day/Year **] 325 daily
actonel 30 once a week
iron 325 twice a day
percocent/ambien/[**Last Name (un) **] #3/ativan/trazadone PRN
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Likely Septic/Vasodilatory Shock
Discharge Condition:
expired
Completed by:[**0-0-0**] | [
"0389",
"5849",
"51881",
"2875",
"99592"
] |
Admission Date: [**2198-5-27**] Discharge Date: [**2198-6-5**]
Date of Birth: [**2144-10-19**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
AMS, hypothermia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 53yo male with PMH of Cerebral palsy, mental
retardation, and seizures who presents via EMS for hypothermia
and altered mental status. This AM, his caretaker noticed he was
not responding like he normally does and was gurgling. He was
found to be hypothermic to 32C. Last night was his normal self
with no cough, [**First Name3 (LF) **], abd pain. His caretaker states he presents
this way when he has infections. He recently had a uti 3 weeks
ago, and completed an abx course. He also went to [**Hospital1 **] 3 days
ago for a seizure. He is on keppra, dilantin, and lamictal.
In the ED, initial VS were: BP80/55 HR52 RR13 O2sat:100% RA
Temp31.5. He received 2LNS with improvment in SBP to 100, which
then dropped to 80's systolic again at which point he was
started on norepinephrine gtt. A CVL was placed and he received
another 500cc. An EKG showed sinus brady 43 qtc 505. Head CT
showed no acute process and CXR showed bowel above the liver and
no pneumonia. Labs showed WBC count of 2.8 and clean UA. FS 78,
and he was started on D5 IVF with the levophen gtt. A dilantin
level was 18.2. He was given hydrocortisone 100iv and vancomycin
1gm and zosyn 4.5g for question sepsis. Vital signs prior to
transfer were Current VS 64 98% RA 33.7F 109/61 off levophed.
For access he has an 18 and a 20g IV.
.
On arrival to the MICU, his vital signs were T34.6C, HR77,
BP136/101, RR18, O2sat:98%. He is noted to have a right sided
fat deposit in his right neck near the central line noted in ED.
There is no ecchymosis associated with it or stridor
appreciated. He is calm and obeys commands intermittantly.
.
Review of systems: Unable to obtain secondary to altered mental
status
Past Medical History:
Cerebral palsy
mental retardation
seizures
lower extremity edema thought to be secondary to venous
insufficiency
seasonal allergies
contact dermatitis
status-post treatment bowel and bladder incontinence,
aspiration
pneumonia in [**2196**]
UTI and aspiration pneumonia in [**2197**]
Social History:
He lives with his caretaker [**Name (NI) 123**], phone number
is [**Telephone/Fax (1) 93387**]. No immediate family is still alive. He goes
to
daily daycare. His current guardian is [**Name (NI) **] [**Name (NI) 93392**] and the
phone number is [**Telephone/Fax (1) 93393**]. At baseline, pt appears to be
quite interactive, is able to respond meaningfully.
Family History:
His aunt passed away 3 years ago from lung
cancer. Both parents have passed away. His mother died of heart
condition. It is unclear what his father passed away of.
Physical Exam:
Physical Exam on Admission:
Vitals: T34.6C, HR77, BP136/101, RR18, O2sat:98%General: Alert,
oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: full ROM, right IJ in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: no wheezes or rales, positive for upper airway 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: moves all 4 limbs to command, unable to otherwise
participate in neuro exam
******************
At discharge:
Neuro: awake, alert. Mumbles, typically not able to be
understood by anyone who doesn't know him well. Does not follow
commands. Looks around room. Moves RUE > others spontaneously,
but moves all extremities at least antigravity in response to
light touch.
Pertinent Results:
Lab Results on Admission:
[**2198-5-27**] 10:45AM BLOOD WBC-2.3* RBC-4.72 Hgb-14.9 Hct-46.6
MCV-99* MCH-31.7 MCHC-32.1 RDW-14.4 Plt Ct-167
[**2198-5-27**] 10:45AM BLOOD Neuts-56.7 Lymphs-31.3 Monos-4.7 Eos-3.8
Baso-3.6*
[**2198-5-27**] 10:45AM BLOOD Glucose-190* UreaN-12 Creat-0.6 Na-145
K-4.7 Cl-110* HCO3-29 AnGap-11
[**2198-5-27**] 10:45AM BLOOD ALT-25 AST-36 AlkPhos-128 TotBili-0.2
[**2198-5-27**] 10:45AM BLOOD cTropnT-<0.01
[**2198-5-27**] 10:45AM BLOOD Albumin-4.0
[**2198-5-28**] 03:52AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.6
[**2198-5-30**] 06:10AM BLOOD Cortsol-8.6
[**2198-5-29**] 03:10AM BLOOD TSH-2.0
[**2198-5-27**] 10:45AM BLOOD Phenyto-18.2
[**2198-5-28**] 03:52AM BLOOD Phenyto-20.2*
[**2198-5-27**] 10:53AM BLOOD Lactate-1.4
[**2198-5-27**] 10:53AM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2198-5-27**] 11:14AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2198-5-27**] 11:14AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Discharge labs:
[**2198-6-5**] 04:30AM BLOOD WBC-10.8 RBC-4.42* Hgb-14.8 Hct-42.6
MCV-96 MCH-33.4* MCHC-34.7 RDW-13.8 Plt Ct-227
[**2198-6-5**] 04:30AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-139
K-4.4 Cl-100 HCO3-28 AnGap-15
[**2198-6-5**] 04:30AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1
[**2198-6-4**] 05:25AM BLOOD Phenyto-20.0
[**2198-5-30**] 12:29 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2198-5-31**]**
C. difficile DNA amplification assay (Final [**2198-5-31**]):
This test was cancelled because a FORMED stool specimen
was received,
and is NOT acceptable for the C. difficle DNA
amplification testing..
PATIENT CREDITED.
Studies:
Cardiovascular Report ECG Study Date of [**2198-5-27**] 10:46:20 AM
Marked sinus bradycardia at 43 beats per minute. Q-T interval is
prolonged. Cannot rule out inferoposterior myocardial infarction
of indeterminate age. Compared to the previous tracing of
[**2198-4-30**] there is no significant change
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2198-5-27**]
10:41 AM
IMPRESSION:
1. No acute hemorrhage or intracranial process.
2. Chronic developmental abnormalities .
Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-5-27**]
10:51 AM
IMPRESSION: No acute intrathoracic process within the
limitations of this
study.
Radiology Report -77 BY DIFFERENT PHYSICIAN [**Name9 (PRE) 2221**] Date of
[**2198-5-27**] 1:33 PM
FINDINGS: Tip of right internal jugular central venous catheter
terminates in the expected location of the body of the right
atrium and could be withdrawn several centimeters for standard
positioning. There is no visible pneumothorax. Lung volumes
remain low, accentuating the cardiac silhouette and
bronchovascular structures. Even allowing for this factor,
there is likely mild pulmonary vascular congestion present.
Patchy areas of atelectasis have developed at both bases.
Questionable small left pleural effusion.
Radiology Report -76 BY SAME PHYSICIAN [**Name9 (PRE) 2221**] Date of [**2198-5-27**]
2:34 PM
FINDINGS: Tip of right internal jugular central venous catheter
may have been withdrawn slightly, but continues to terminate in
the expected location of the body of the right atrium below the
cavoatrial junction. Otherwise, no significant change in the
appearance of the chest since the recent radiograph performed
about one hour earlier.
Neurophysiology Report EEG Study Date of [**2198-5-28**]
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of the presence of a moderately diffuse encephalopathy with
extremely
active epileptiform features that are both multifocal and
generalized in
their appearance. Additionally, there were two sustained
electrographic
seizures recorded and are reported above.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-5-28**]
11:35 AM
IMPRESSION: Nasogastric tube in the stomach
The preliminary impression that the tube could have folded back
on itself in the gastro-esophageal junction was communicated
with Dr. [**Last Name (STitle) **] at 2 p.m by phone at [**2198-5-28**]. After
subsequent confirmatory radiograph, final positioning was
communicated via page at 3 pm.
Radiology Report PORTABLE ABDOMEN Study Date of [**2198-5-28**] 11:35
AM
IMPRESSION: No radiographic evidence for obstruction.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-5-28**] 2:21
PM
IMPRESSION: Nasoenteric tube projects over the expected
position of the
stomach.
Neurophysiology Report EEG:
[**2198-5-29**]
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of the presence of a mild to moderate diffuse encephalopathy
with
extremely active paroxysmal multifocal independent interictal
discharges
and frequent runs of generalized rhythmic epileptiform activity.
These
bursts and discharges did not appear to have an obvious clinical
accompaniment. In comparison to the previous day's tracing,
there
were no symptomatic electrographic/clinical seizures.
[**5-30**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of mild diffuse encephalopathy with perhaps some subtle left
hemisphere
predominance. There is extremely active multifocal and
generalized
epileptiform activity. Some of the latter activity appeared to
be
sustained but not associated with any clear clinical
accompaniment.
[**5-31**]:
IMPRESSION: This is an abnormal video EEG monitoring session
because of
a prolonged electrographic seizure accompanied by clinical
features as
described under pushbutton activations. Also, in the second half
of the
recording, there were 10-15 seconds runs of epileptic discharges
and one
of these that lasted 20 seconds had minor left arm tonic
extension and
likely represented a brief seizure. In addition, there were
frequent
generalized polyspikes and abundant multifocal epileptic
discharges.
These findings are indicative of diffuse cortical irritability
with
epileptogenicity. In addition, background activity was diffusely
slow
and disorganized with intermittent runs of further slowing
indicative of
moderate diffuse encephalopathy consistent with patient's
history of
static encephalopathy. Compared to the prior day's recording,
this
study was worse due to significant increased in epileptiform
activity
and two electrographic seizures.
[**6-1**]:
IMPRESSION: This is an abnormal video-EEG monitoring
session due to frequent generalized polyspikes and abundant
multifocal
epileptic discharges. These findings are indicative of diffuse
cortical
irritability with potential epileptogenicity. Additionally,
background
activity was disorganized and diffusely slow indicative of
moderate
diffuse encephalopathy consistent with patients history of
static
encephalopathy. Compared to the prior day's recording, this
study was
significantly improved due to absence of electrographic
seizures.
[**6-2**]:
IMPRESSION: This is an abnormal video-EEG monitoring session
because of
frequent generalized polyspikes and abundant multifocal
epileptic
discharges. These findings are suggestive of wide spread
cortical
irritability with potential epileptogenicity. In addtion,
background
activity was diffusely slow and disorganized signifying moderate
diffuse
encephalopathy consistent with patients history of static
encephalopathy. Compared to the prior day's recording, this
study was
unchanged.
[**6-3**]:
IMPRESSION: This is an abnormal video-EEG monitoring session
because of
two electrographic and clinical seizures lasting less than one
minute.
These seizures are described earlier under pushbutton
activations and
seizure detection programs. In addition there were abundant
multifocal
epileptic discharges and frequent generalized polyspike
discharges.
These findings are indicative of wide spread cortical
irritability with
potential epileptogenicity. Furthermore, background activity was
disorganized and diffusely slow indicative of a moderate diffuse
encephalopathy consistent with patients history of static
encephalopathy. Compared to the prior day's recording, this
study was
worse due to two brief electrographic seizures.
[**6-4**]:
[**6-5**]: pending
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 53yo male with
PMH of Cerebral palsy, mental retardation, and seizures who
presented via EMS for hypothermia and altered mental status. He
was treated recently for UTI 3 weeks prior to admission and had
completed a course of antibiotics. On presentation to the ED he
became hypotensive, and recovered his blood pressure with IVF
and hydrocortisone. He was admitted to the ICU where he was
rewarmed with the bair hugger and maintained blood pressure
without aggressive fluid resuscitationa or pressors after
initial resuscitation. He experienced several short-lasting
seizures in the unit and was transferred to the floor with
hypothermia and shock picture resolved and no infectious source
indentified. He was transferred to the neurology epilepsy
monitoring unit.
.
# Hypothermia: Patient had temperature reportedly at 32C at home
and recorded at 31.5C in the ED. It recovered with bair hiffer
but dropped again to 34C on [**5-29**] with recovery on bair hugger
again. He was not hypotensive following the initial
resuscitation. Potential etiologies of hypothermia include
hypothalamic dysfunction vs. hypopituitarism vs. medications,
infection, post-ictal state. TSH found to be normal along with
AM cortisol. After cultures, exam, and monitoring, no infectious
source was identified. Vancomycin and Zosyn were started on
admission but discontinued after [**Month/Year (2) **] curve and WBC returned to
[**Location 213**] with no source on culture data.
.
2. Seizure Disorder: Patient has baseline seizure disorder on 3
different anti-epileptics. He has had recent dose adjustments at
home and a presentation for seizure 3 days PTA at OSH. Overnight
on [**4-11**], patient had another cluster of 3 brief
tonic-clonic seizures and was given 1mg lorazepam. EEG from [**5-28**]
showed epileptiform discharges and brief organized seizures. The
EEG from [**5-29**] showed no organized seizure activity. He was
continued on levetiracetam, phenytoin, and lamotrigine via NGT.
Antibiotics were discontinued when no infectious source was
identified and it was felt that the antibiotics were lowering
the seizure threshold. During his monitoring, he had several
more seizure including 1 prolonged (45min) clonic seizure that
involved 1-2 min of right arm extention followed by agitated
behavior. His antiepileptics were increased as follows:
MEDICATION INCREASES:
Lamictal 300mg by mouth twice daily
Levetiracetam (Keppra) 2000mg by mouth twice daily
CONTINUED:
phenytoin (Dilantin) 100mg by mouth twice daily
He was at his typically seizure baseline prior to discharge.
.
3. Shock: Patient had hypotension, hypothermia, and WBC count
<4000 on admission, meeting criteria for shock. Underlying
infection was suspected but no infectious source was identified.
He rceived Fluid resuscitation and pressors resolved patient's
hypotension in the first night and he required no further
resuscitation following.
.
# Altered mental status: Patient remained more somnolent than
baseline on admission. He presented with acute change in
behavior from his baseline interactiveness to minimal
responsiveness. He reportedly has presented like this with
infections in the past. Differential includes infection,
seizure, or toxic/metabolic encephalopathy. TSH checked and
normal, as was cortisol. He was seen to have organized seizure
activity on EEG monitoring and his AEDs were adjusted as
mentioned above. He returned to his normal mental baseline (per
caregiver) prior to discharge.
.
# Gurgling in throat: Patient's caregiver reports that he has a
new gurgling sound in his throat. This is likely secretions from
URI but may represtent aspiration, especially considering he is
being treated for potential infection. Speech and swallow saw
patient and found him to be safe to swallow with no aspiration.
.
#Hct drop: Patient??????s Hct dropped from 46.6 to 37.2 overnight
[**5-27**], then slowly downtrending from there to 36.9. Possibly from
fluid boluses and hospitalization. Patient was hemodynamically
stable and has no obvious sign of bleed, and Hct stabilized and
then returned to baseline without intervention.
Medications on Admission:
hydrocortisone 2.5% cream apply to areas of redness twice daily
as needed
lamotrigine 250mg PO BID
levetiracetam 500mg tabs. Take 3 tabs by mouth at 6am and 4 tabs
by mouth at 9pm
dilantin 200mg PO once daily????
timolol maleate 0.5% solution. 1 gtt to the right eye QAM
MVI one capsule daily
loratadine 10mg PO daily
senna 8.6 mg PO BID prn constipation
potassium chloride 10meq PO daily
bisacodyl 10mg PR daily prn constipation
thiamine 100mg PO daily
carbamide peroxide 6.5%drops, one dropper full each day as
needed for ear wax
Discharge Medications:
1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
2. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO twice a
day.
Disp:*180 Tablet(s)* Refills:*2*
3. loratadine 10 mg Tablet Sig: One (1) Tablet PO daily ().
4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day): hold for loose stool.
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
9. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO twice a day.
10. levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
viral infection
epilepsy
generalized clonic seizures
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro: awake, alert. Mumbles, typically not able to be
understood by anyone who doesn't know him well. Does not follow
commands. Looks around room. Moves RUE > others spontaneously,
but moves all extremities at least antigravity in response to
light touch.
Discharge Instructions:
Dear Mr. [**Known lastname 26010**] and your caregiver,
[**Name (NI) **] were admitted to the hospital for evaluation of seizures and
hypothermia. We did an infection evaluation that did not show
any specific source for infection, likely indicating a viral
illness as a cause of your temperature changes and seizure
frequency. While you were here we saw a long seizure that
started with the right arm going out straight, followed by
agitated behavior. We increased two of your seizure medications,
Lamictal and and levetiracetam (Keppra). We increased these
medications as listed below, and your caregiver felt that you
were at your baseline prior to discharge. Please continue on the
same phenytoin (Dilantin) dose as you were previously was
taking.
MEDICATION INCREASES:
Lamictal 300mg by mouth twice daily
Levetiracetam (Keppra) 2000mg by mouth twice daily
CONTINUE:
phenytoin (Dilantin) 100mg by mouth twice daily
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2442**] in the [**Hospital 875**] clinic as
follows:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2198-8-21**] 9:00
Please follow up at your previously scheduled appointments:
Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 1112**], MD Phone:[**Telephone/Fax (1) 2010**]
Date/Time:[**2198-6-6**] 1:45
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2199-5-7**] 9:45
| [
"0389",
"78552",
"2760",
"99592",
"42789"
] |
Admission Date: [**2146-9-19**] Discharge Date: [**2146-9-27**]
Date of Birth: [**2074-12-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Aortic stenosis
Major Surgical or Invasive Procedure:
[**2146-9-22**]: Aortic valve replacement with a size 21-mm [**Doctor Last Name **]
Magna tissue valve.
History of Present Illness:
71 year old male who has been experiencing mild chest pressure
dizziness, fatigue and SOB over the past several months. He
presented to [**Hospital 11560**] [**Hospital3 **] [**9-15**] with worsenig SOB
and chest pain that extended into his left hand. He also notes
dyspnea on exertion when climbing stairs. He was admitted and
ruled out for myocardial infarction. His echocardiogram revealed
significant aortic stenosis. Cardiac cath revealed no sigificant
CAD and carotids were clear. Of note during this admission he
was noted to have thrombocytopenia with platelet counts around
70,000 and was seen by Hematology who felt that he had
idiopathic thrombocytopenic purpura. They ok's him to receive
ASA and to proceed with the cath. He was transferred to [**Hospital1 18**]
for surgical evaluation for an aortic valve replacement.
Past Medical History:
Aortic Stenosis
Benign Prostatic Hyperplasia
Thrombocytopneia I ITP
Past Surgical History:
Tonsillectomy
herniorrhaphy
Social History:
Race:Caucasian
Last Dental Exam:
Lives with: wife, has 3 daughters
Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 112498**]
Occupation:
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-8**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Father died at 65 in sleep
Mother died at 90 with Diabetes
Sister had breast cancer
Brother had stomach cancer at 62
Physical Exam:
Physical Exam
Pulse:63 Resp:18 O2 sat:97/RA
B/P Right:134/81 Left:128/84
Height: 5'8" Weight:205 lbs
General:
Skin: Warm [x] Dry [x] intact [xX]
HEENT: NCAT [X] PERRLA [X] EOMI [x]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade [**4-8**] HSM______
Abdomen: Round Soft [X] non-distended [X] non-tender [X] bowel
sounds + []
Extremities: Warm [X], well-perfused [X] Edema [] _____
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit: Right: referred Left:Referred
Pertinent Results:
Echocardgiogram [**2146-9-22**]
PREBYPASS: Normal LV wall motion and systolic function with LVEF
> 55%. Mild to moderated LVH. Right ventricular chamber size and
free wall motion are normal. The number of aortic valve leaflets
cannot be determined because of the level of calcification, but
it is functionally bicuspid.. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). The mitral valve appears
structurally normal with trivial mitral regurgitation. Normal TV
and PV. No clot in LAA. Intact interatrial septum with no PFO
seen. The descending thoracic aorta has mild diffuse
atherosclerotic plaque. The coronary sinus appears normal.
Normal transmitral diastolic inflow velocity spectral profile (E
> A)and pulmonary venous spectral Doppler profile (S >D) With e'
= 6-8 cm/sec indicating perhaps either normal diastolic function
or a mild decrease in active relaxation. There is no pericardial
effusion.
POSTBYPASS: Normallly functioning bioprosthetic AV with no
significant AS or AI. LVEF > 60%, Otherwise unchanged
Spleen Ultrasound [**2146-9-21**]: Transverse and sagittal images were
obtained of the spleen. There is borderline splenomegaly and
the spleen measures 13.3 cm in length. IMPRESSION: Borderline
splenomegaly.
Chest CT [**2146-9-20**]:
FINDINGS: Cardiac size is normal. The aorta is normal in
caliber. The
ascending aorta measures up to 3.4 cm. There is a tiny area of
calcification in the proximal medial ascending aorta. There is
also two small calcifications in the arch. The descending aorta
is normal in caliber. Mediastinal lymph nodes do not meet CT
criteria for pathologic enlargement. There is calcification of
the aortic valve. There is no pleural or pericardial effusion
Peripheral Blood Smear:
Normal RBC and WBC morphology, big platelets and rare
megakaryocyte fragments.
.
[**2146-9-27**] 06:10AM BLOOD WBC-6.5 RBC-3.37* Hgb-10.4* Hct-30.4*
MCV-90 MCH-30.9 MCHC-34.2 RDW-14.3 Plt Ct-132*
[**2146-9-26**] 05:22AM BLOOD WBC-5.4 RBC-3.30* Hgb-10.3* Hct-29.2*
MCV-89 MCH-31.2 MCHC-35.2* RDW-14.2 Plt Ct-113*
[**2146-9-25**] 04:54AM BLOOD WBC-6.4 RBC-3.19* Hgb-9.8* Hct-28.2*
MCV-88 MCH-30.8 MCHC-34.9 RDW-14.5 Plt Ct-85*
[**2146-9-24**] 01:31AM BLOOD WBC-7.9 RBC-3.54* Hgb-10.9* Hct-30.9*
MCV-87 MCH-30.8 MCHC-35.3* RDW-14.5 Plt Ct-120*
[**2146-9-27**] 06:10AM BLOOD PT-13.0* PTT-25.3 INR(PT)-1.2*
[**2146-9-24**] 01:31AM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.3*
[**2146-9-27**] 06:10AM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-137
K-4.4 Cl-102 HCO3-30 AnGap-9
[**2146-9-26**] 05:22AM BLOOD Glucose-102* UreaN-20 Creat-0.7 Na-136
K-3.8 Cl-99 HCO3-32 AnGap-9
[**2146-9-25**] 04:54AM BLOOD Glucose-105* UreaN-16 Creat-0.8 Na-138
K-3.9 Cl-101 HCO3-30 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] was transfer from [**Hospital6 3105**] for
surgical evaluation for an aortic valve replacement. Hematology
was consulted for his underlying cause of
thrombocytopenia, which is unclear. Splenic Ultrasound showed
Borderline splenomegaly. Given the range of his current
platelet count it would be safe for him to undergo heart surgery
with the appropriate anticoagulation.
The patient was brought to the Operating Room on [**2146-9-22**] where
the patient underwent Aortic valve replacement with a size 21-mm
[**Doctor Last Name **] Magna tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 5 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home with services in good condition
with appropriate follow up instructions.
Medications on Admission:
None
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
if extubated
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Atorvastatin 10 mg PO DAILY
RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
4. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*7 Packet Refills:*0
5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg [**1-3**] tablet(s) by mouth every
four (4) hours Disp #*40 Tablet Refills:*0
6. Metoprolol Tartrate 25 mg PO TID
hold for hr less than 60 and sbp less than 100
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
Care Tenders
Discharge Diagnosis:
Aortic Stenosis
Benign Prostatic Hyperplasia
Thrombocytopneia I ITP
? MRSA UTI, Tonsillectomy
herniorrhaphy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2146-10-4**]
10:45
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2146-10-25**] 1:30
Cardiologist Dr. [**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**] [**2146-10-20**] at 1:00pm ( Address:
[**Doctor Last Name **] [**Hospital1 3597**], NH Phone: [**Telephone/Fax (1) 37284**])
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],RAOUF [**Telephone/Fax (1) 112499**] in [**4-7**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2146-9-27**] | [
"4241"
] |
Admission Date: [**2169-6-9**] Discharge Date: [**2169-6-13**]
Date of Birth: [**2103-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66M with no known PMH, but suspected HTN and DM, who presents
with shortness of breath and increased LE edema. The patient has
not followed up with doctors, and is a somewhat difficult
historian, but essentially reports 2-3 weeks of increased
difficulty breathing, with LE edema and difficulty ambulating at
home with a fall this AM. He reports having to sleep sitting in
a chair for the past year and a half. Denies any chest pain at
rest or with exertion; no LH, palpitations, URI sx, F/C. Reports
an occasional cough, non-productive. Was seen in ED about a year
ago for a fall on the job, where he was noted to have elevated
sugars and hypertension, and was seen in follow up not at [**Hospital1 18**]
(uncertain where), and was told to start metformin although he
did not take it. Reports today that he woke from sleep and
"couldn't get a deep breath." Tried to walk around, but felt
unsteady and apparently fell, although he did not hit his head.
No LOC or presyncope
Past Medical History:
?Hyperglycemia, HTN. s/p injury from fall about 1 year ago--seen
in [**Hospital1 18**] ED.
Social History:
Retired appliance technician and mechanic, retired since injury
last year. Lives in [**Location 86**] with wife, son here as well. Smoked
1-2ppd over 30+ years, quit about 20 years ago. ETOH: about 3
pints of whisky a week, with heavier use in younger years (about
1.5 gallons a week). Denies cocaine or IVDU.
Family History:
No significant CAD, HTN, DM
Physical Exam:
per Dr. [**Last Name (STitle) **]:
VS: T 97.5 BP 146/88 HR 107 RR 28 O2 95% 2LNC
Gen: Obese male, NAD. Slightly dyspneic.
HEENT: NCAT. Sclera anicteric. Dry MM.
Neck: Supple with JVD to ear. Thick neck.
CV: Irregularly irregular, normal S1, S2. P2 tap on palpation.
No m/r/g appreciated. No S3 or S4.
Chest: BS BL, diminished at bases. No appreciable crackles,
wheezes.
Abd: Distended. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: Skin changes c/w venous stasis. 3+ pitting edema.
Skin: Acanthosis nigricans on neck. Venous stasis changes as
above.
Pertinent Results:
Admit EKG: Atypical flutter vs Afib at 122. Low voltage. NL
axis/intervals. QS in V1V2 concerning for prior anterior MI.
Nonspecific TW flattening in inferior-lateral leads. No prior
available for comparison.
.
Admit CXR: Cardiac size cannot be evaluated. Large bilateral
pleural effusions are present. Some upper zone redistribution is
seen. Appearances are most suggestive of cardiac failure.
Infiltrates in both lower lobes cannot be excluded.
IMPRESSION: Evidence of failure with bilateral effusions.
.
Admit labs:
Trop-T: 0.01 to 0.02
CK: 214 to 146
MB: 5 to 4
136 97 8
--------------< 331
4.2 34 1.0
ALT: 38 AP: 79 Tbili: 0.4 Alb: 3.6
AST: 29 LDH: Dbili: TProt:
TSH:2.8
Cholesterol:149
Triglyc: 79
HDL: 65
LDLcalc: 68
proBNP: 1730
.
14.2
6.5 >----< 230
43.6
N:63.7 L:26.7 M:7.8 E:1.7 Bas:0.1
.
Discharge labs:
WBC-5.1 RBC-4.78 Hgb-13.3* Hct-41.4 Plt Ct-222
PT-13.8* PTT-53.1* INR(PT)-1.2*
Glucose-150* UreaN-11 Creat-0.9 Na-141 K-4.2 Cl-100 HCO3-36*
AnGap-9
.
Radiology
[**6-11**]: Echo: The left atrium is mildly dilated. The right atrium
is moderately dilated. The estimated right atrial pressure is
16-20 mmHg. There is moderate symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is low
normal (LVEF 50%). The right ventricular cavity is moderately
dilated with free wall hypokinesis. 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. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. The main
pulmonary artery is dilated. There is no pericardial effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokinesis, pulmonary artery dilation and moderate pulmonary
artery systolic hypertension. This constellation of findings is
suggestive of a primary pulmonary process. Prominent left
ventricular hypertrophy with low normal systolic function. In
the absence of a history of systemic hypertension, an
infiltrative process (e.g., amyloid) should be considered.
.
[**6-12**]: DVT scan: negative
Brief Hospital Course:
66M with likely PMH DM, HTN, and COPD, who p/w progressive LE
edema and shortness of breath in the setting of taking no
medications. He was also found to be in atrial fibrillation.
Hospital course by problem:
.
#) CHF: diastolic dysfunction and predominantly right sided
heart failure. The patient likely had untreated CHF and a
progressive decline. The etiology was likely [**2-10**] 1) untreated
HTN leading to diastolic dysfunction, 2) OSA leading to right
heart failure, and 3) atrial fib leading to mild systolic
dysfunction. We aggressively diuresed initially to IV lasix (pt
responds to 40 IV) with goal 2-3 L negative per day. We
diuresed 11L with improvement in his O2 requirement to RA and
improvement in his leg edema. He also initially was treated
with a nitro gtt but this was weaned off in the setting of
starting the ACEi, aldactone, lasix PO, and BB. The patient had
an echo as above which supported these conclusions. Upon
discharge, he was on RA and ambulating. We also counseled him
on the importance of low Na diet and monitoring weight closely.
** discharge weight is 136 kilograms **
.
# Cards Ischemic: There was no evidence of ischemia which
prompted the above exacerbation. EKG and echo as above. We
started ASA, checked lipids, treated with BB. He will need
close followup with PCP and NP as outpt for management.
.
# Cards Rhythm: patient presented in AFib with unknown
chronicity. We treated with increasing doses of metoprolol for
rate control. We also treated with heparin gtt and bridged with
coumadin for three days. His INR remained subtherapeutic at
d/c. He received coumadin 5mg qhs x3 doses. Per [**Company 191**] anticoag
nurses, we discharged him on 7.5mg qhs x1 then back to 5mg qhs
thereafter. He has an INR check scheduled for [**6-15**] at [**Company 191**].
-We recommend he followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] for echo and
potential DCCV in [**1-10**] months if he is documented properly
anticoagulated for >1 month time. We are concerned he will not
be a good candidate for longterm anticoagulation given poor med
compliance in the past. TSH normal.
.
# DM: A1c was checked and pending. We treated with ISS and
temporarily with glargine. We held metformin on dispo given his
heart failure. We started glyburide 5 daily with followup in
[**Last Name (un) **]. If he becomes hypoglycemic, please d/c glyburide.
.
# OSA: patient with witnessed desats and apneic episodes at
night. Has thick neck. We were unable to get BiPap trial in
house [**2-10**] patient refusal. He will benefit from outpt sleep
study. This was strongly conveyed to patient and wife.
.
# HTN: ACEI, aldactone, and BB as above, titrated up to current
doses
.
# Dysuria: U/A neg, resolved. received one dose of cipro but
this was stopped.
.
# FEN: DM/Low Na/Cardiac diet. Lytes need to be checked later
this week then again several weeks later to ensure that K and
Creatinine are stable.
.
# Code: Full
.
# Contact/social: family very involved. patient had not
received medical care in the past. He will need frequent
followup and encouragement. Without his wife present, he can
get somewhat agitated but redirected easily.
.
# Dispo: we strongly recommended rehab but the patient refused.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. GlyBURIDE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 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*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
please have your INR and electrolytes checked on [**6-15**]. Your
goal INR is [**2-11**] and your coumadin may need to be adjusted. Your
potassium needs to be monitored and your cardiac meds adjusted
as needed.
8. Warfarin 2.5 mg Tablet Sig: variable Tablet PO at bedtime: **
take 3 tabs (7.5mg) the night of [**6-13**], then 2 tabs (5mg) the
following night. then have your INR checked on [**6-15**] and the [**Company 191**]
nurses will make further adjustments.
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
- CHF exacerbation: right sided failure, mild systolic
dysfunction, diastolic dysfunction.
- DMII
- HTN
- Atrial fibrillation (unknown duration)
- likely obstructive sleep apnea
Secondary:
- hyperlipidemia
Discharge Condition:
fair
Discharge Instructions:
You were admitted with shortness of breath. You had atrial
fibrillation and congestive heart failure. You also have
diabetes, high blood pressure, high cholesterol, and obstructive
sleep apnea. We treated you for all of these conditions.
.
You came in with no medications. We started multiple
medications and it is very important for you to take them all as
instructed.
.
You need to keep your followup appointments as scheduled. It is
important for you to have your coumadin level checked regularly.
You should also have your electrolytes and INR checked within
three days
.
Please weigh yourself daily. Please adhere to a low sodium
diet. Your weight on discharge was 136 kilograms. If you gain
more than 2 pounds in a day, please contact your PCP.
.
Please contact your PCP or return to the emergency department if
you experience shortness of breath, chest pain, worsening leg
swelling, abdominal pain, dizziness, severe headache.
.
We recommended that you go to rehab for a short stay to improve
your physical and medical health. You refused despite our
request.
Followup Instructions:
*** Please contact [**Name (NI) 191**] at [**Telephone/Fax (1) **] TONIGHT or TOMORROW to
confirm your registration info. *****
Please followup with Dr. [**Last Name (STitle) **] at [**Company 191**] on [**6-15**] at 4:10 pm.
His number is [**Telephone/Fax (1) **]. His office is located on [**Hospital Ward Name 23**]
[**Location (un) **] in the central suite. Please have lab work performed
at this time.
.
Please followup with Dr. [**First Name8 (NamePattern2) 48991**] [**Name (STitle) 19868**] on [**7-19**] at 2pm. His
office is located in the [**Hospital 191**] clinic on [**Hospital Ward Name 23**] 6, at [**Hospital1 18**] [**Hospital Ward Name **]. Phone number [**Telephone/Fax (1) **].
.
Please followup in the [**Hospital **] Clinic. They are located at 1
[**Last Name (un) **] Way. Phone number: ([**Telephone/Fax (1) 4847**]. Thursday [**6-22**]
at 2pm.
.
Please followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in one month. His number
is ([**Telephone/Fax (1) 1987**]. Please contact his office for an
appointment.
.
Please have a sleep study performed. The phone number is ([**Telephone/Fax (1) 48992**]. Please contact them for an appointment
.
The coumadin clinic at the [**Company 191**] center will monitor your coumadin
level for you.
| [
"42731",
"25000",
"4280",
"32723",
"2720"
] |
Admission Date: [**2104-9-14**] Discharge Date: [**2104-9-28**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 21990**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
[**Age over 90 **]M h/o CAD/CABG, Dementia, who presented to [**Hospital1 18**] ED with fever
(101.5) and mild decr of OS (93%) with CXR demonstrating LLL
infiltrate. He also had RLE erythema consistent with cellulitis.
Pt was given IV levaquin, flagyl, and ancef and was DCed back to
NH on PO levaquin/flagyl/keflex. Once at the NH, he had
rigors/shaking, hypoxia (OS74%) and he promptly returned to the
ED. He received Benzos en transit to the ED for empiric seizure
Rx.
In the ED, he was lethargic, T104.6, HR110, BP160/100, RR14 and
OS100%. He was intubated emergently for airway protection and
was placed on the sepsis protocol. He received ceftriaxone 1 gm
IV , vancomycin 1 gm IV, and IVF (total of 5L NS). A CK was
1012, MB 72 (MBI 7.1) and troponin was 1.31. EKG showed only an
old RBBB. Health care proxy met with cardiologist, decided that
pt should be DNR and is not cath candidate, but they decided to
keep pt intubated. Later in ED, had recurrence of possible
seizure activity. He was seen by Neuro: head CT was negative, LP
with thousands RBCs (but reported traumatic tap). Pt was started
on empiric acyclovir for possible HSV Meningitis. Pt was then
sent to [**Hospital Unit Name 153**].
Past Medical History:
Dementia, CAD S/P CABG ([**2086**]) S/P NSTEMI ([**9-13**]), CHF (EF43% -
'[**02**]), 2+ MR, Chronic Venous Stasis, HTN, Glaucoma
Social History:
Pt is demented, but is reportedly functional at baseline in his
nursing home. He converses with all the other residents, is
quite social, and can feed himself. He is continent of stool and
urine. No tobacco/EtOH.
Family History:
Unknown.
Physical Exam:
T99.7 BP120/57 HR84 RR28 OS97%RA
GEN: Awake and Alert. Conversing (wants to go home).
SKIN: Warm and dry. RLE erythema now absent.
CV: RRR. II/VI SEM LSB/Apex Rad to Axilla.
Lungs: Mild end-expiratory wheezes at R base. Dim BS at L base.
ABD: Mildly distended. S/NT. Pos BS.
Ext: No C/C/E. 1+ DPs.
Pertinent Results:
[**2104-9-25**] 03:30AM BLOOD WBC-16.1* RBC-3.50* Hgb-10.3* Hct-32.0*
MCV-91 MCH-29.4 MCHC-32.2 RDW-13.8 Plt Ct-322
[**2104-9-24**] 04:18AM BLOOD WBC-14.7* RBC-3.25* Hgb-9.8* Hct-29.3*
MCV-90 MCH-30.1 MCHC-33.4 RDW-14.5 Plt Ct-293
[**2104-9-23**] 04:15AM BLOOD WBC-18.0* RBC-3.29* Hgb-9.6* Hct-29.8*
MCV-91 MCH-29.1 MCHC-32.1 RDW-14.0 Plt Ct-260
[**2104-9-22**] 05:36PM BLOOD WBC-21.2*# RBC-3.52* Hgb-10.6* Hct-32.1*
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.4 Plt Ct-306
[**2104-9-22**] 06:34AM BLOOD WBC-13.9* RBC-3.59* Hgb-10.7* Hct-32.2*
MCV-90 MCH-29.8 MCHC-33.3 RDW-14.4 Plt Ct-305
[**2104-9-21**] 05:00AM BLOOD WBC-12.4* RBC-3.92* Hgb-11.6* Hct-34.6*
MCV-88 MCH-29.7 MCHC-33.7 RDW-13.8 Plt Ct-322
[**2104-9-20**] 05:49AM BLOOD WBC-9.7 RBC-3.62* Hgb-10.8* Hct-32.2*
MCV-89 MCH-29.7 MCHC-33.4 RDW-13.9 Plt Ct-256
[**2104-9-19**] 04:28AM BLOOD WBC-7.6 RBC-3.45* Hgb-10.5* Hct-30.0*
MCV-87 MCH-30.6 MCHC-35.1* RDW-14.4 Plt Ct-227
[**2104-9-18**] 03:57AM BLOOD WBC-8.1 RBC-3.39* Hgb-10.2* Hct-29.7*
MCV-87 MCH-30.0 MCHC-34.3 RDW-14.0 Plt Ct-183
[**2104-9-17**] 05:00AM BLOOD WBC-8.1 RBC-3.48* Hgb-10.6* Hct-30.7*
MCV-88 MCH-30.4 MCHC-34.4 RDW-14.7 Plt Ct-171
[**2104-9-16**] 05:15AM BLOOD WBC-7.5 RBC-3.36* Hgb-10.1* Hct-29.5*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.0 Plt Ct-159
[**2104-9-15**] 11:56AM BLOOD WBC-7.3 RBC-3.76* Hgb-11.2* Hct-33.0*
MCV-88 MCH-29.8 MCHC-33.9 RDW-14.5 Plt Ct-160
[**2104-9-15**] 05:12AM BLOOD WBC-7.1 RBC-3.54* Hgb-10.8* Hct-30.9*
MCV-88 MCH-30.4 MCHC-34.7 RDW-14.3 Plt Ct-147*
[**2104-9-14**] 05:00PM BLOOD WBC-9.9 RBC-4.04* Hgb-12.2* Hct-36.8*
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.7 Plt Ct-186
[**2104-9-14**] 04:30AM BLOOD WBC-6.8 RBC-4.22* Hgb-12.5* Hct-36.5*
MCV-86 MCH-29.5 MCHC-34.2 RDW-13.6 Plt Ct-191
[**2104-9-25**] 03:30AM BLOOD Plt Ct-322
[**2104-9-24**] 04:18AM BLOOD Plt Ct-293
[**2104-9-24**] 04:18AM BLOOD PT-13.0 PTT-41.4* INR(PT)-1.1
[**2104-9-23**] 04:15AM BLOOD PT-13.2 PTT-56.8* INR(PT)-1.1
[**2104-9-22**] 06:34AM BLOOD PT-13.0 PTT-41.0* INR(PT)-1.1
[**2104-9-18**] 03:57AM BLOOD PT-13.5 PTT-53.1* INR(PT)-1.2
[**2104-9-15**] 06:54AM BLOOD PT-13.7* PTT-65.2* INR(PT)-1.2
[**2104-9-14**] 05:00PM BLOOD PT-13.7* PTT-42.2* INR(PT)-1.2
[**2104-9-14**] 04:30AM BLOOD PT-13.3 PTT-43.3* INR(PT)-1.1
[**2104-9-25**] 03:30AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-141
K-4.1 Cl-104 HCO3-24 AnGap-17
[**2104-9-24**] 04:18AM BLOOD Glucose-95 UreaN-36* Creat-0.9 Na-139
K-4.3 Cl-104 HCO3-27 AnGap-12
[**2104-9-22**] 05:36PM BLOOD Glucose-159* UreaN-44* Creat-1.2 Na-139
K-3.7 Cl-101 HCO3-25 AnGap-17
[**2104-9-21**] 05:00AM BLOOD Glucose-118* UreaN-31* Creat-0.9 Na-143
K-4.1 Cl-102 HCO3-31* AnGap-14
[**2104-9-20**] 08:25PM BLOOD K-4.1
[**2104-9-20**] 05:49AM BLOOD Glucose-97 UreaN-25* Creat-1.0 Na-142
K-4.2 Cl-107 HCO3-30* AnGap-9
[**2104-9-19**] 04:28AM BLOOD Glucose-116* UreaN-26* Creat-0.9 Na-144
K-4.3 Cl-112* HCO3-25 AnGap-11
[**2104-9-18**] 03:57AM BLOOD Glucose-100 UreaN-26* Creat-1.1 Na-141
K-3.3 Cl-110* HCO3-24 AnGap-10
[**2104-9-17**] 05:00AM BLOOD Glucose-99 UreaN-28* Creat-1.0 Na-140
K-3.8 Cl-111* HCO3-20* AnGap-13
[**2104-9-16**] 05:15AM BLOOD Glucose-93 UreaN-28* Creat-1.2 Na-139
K-4.2 Cl-113* HCO3-20* AnGap-10
[**2104-9-15**] 05:16PM BLOOD Glucose-92 UreaN-29* Creat-1.1 Na-141
K-3.8 Cl-112* HCO3-20* AnGap-13
[**2104-9-15**] 11:56AM BLOOD Glucose-85 UreaN-29* Creat-1.1 Na-140
K-4.5 Cl-110* HCO3-20* AnGap-15
[**2104-9-15**] 05:12AM BLOOD Glucose-94 UreaN-29* Creat-1.1 Na-141
K-3.3 Cl-111* HCO3-21* AnGap-12
[**2104-9-14**] 11:37PM BLOOD Glucose-116* UreaN-30* Creat-1.1 Na-141
K-3.6 Cl-111* HCO3-21* AnGap-13
[**2104-9-14**] 05:00PM BLOOD Glucose-184* UreaN-37* Creat-1.6* Na-139
K-4.6 Cl-101 HCO3-15* AnGap-28*
[**2104-9-14**] 04:30AM BLOOD Glucose-120* UreaN-37* Creat-1.3* Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
[**2104-9-21**] 05:00AM BLOOD CK(CPK)-127
[**2104-9-20**] 05:49AM BLOOD CK(CPK)-140
[**2104-9-19**] 04:28AM BLOOD CK(CPK)-104
[**2104-9-18**] 03:57AM BLOOD CK(CPK)-194*
[**2104-9-17**] 12:35PM BLOOD CK(CPK)-249*
[**2104-9-17**] 05:00AM BLOOD CK(CPK)-308*
[**2104-9-15**] 11:56AM BLOOD CK(CPK)-794*
[**2104-9-15**] 05:12AM BLOOD CK(CPK)-858*
[**2104-9-14**] 05:00PM BLOOD ALT-28 AST-116* LD(LDH)-426*
CK(CPK)-1012* AlkPhos-104 TotBili-0.6
[**2104-9-21**] 05:00AM BLOOD CK-MB-3 cTropnT-2.01*
[**2104-9-20**] 05:49AM BLOOD CK-MB-4 cTropnT-2.75*
[**2104-9-19**] 04:28AM BLOOD CK-MB-5 cTropnT-3.33*
[**2104-9-18**] 03:57AM BLOOD CK-MB-8 cTropnT-3.64*
[**2104-9-17**] 12:35PM BLOOD CK-MB-11* MB Indx-4.4 cTropnT-2.54*
[**2104-9-17**] 05:00AM BLOOD cTropnT-2.60*
[**2104-9-15**] 11:56AM BLOOD CK-MB-50* MB Indx-6.3* cTropnT-1.73*
[**2104-9-15**] 05:12AM BLOOD CK-MB-56* MB Indx-6.5* cTropnT-1.60*
[**2104-9-14**] 05:00PM BLOOD CK-MB-72* MB Indx-7.1*
[**2104-9-14**] 05:00PM BLOOD cTropnT-1.31*
[**2104-9-25**] 03:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.2
[**2104-9-17**] 12:35PM BLOOD Triglyc-145 HDL-31 CHOL/HD-4.5 LDLcalc-81
[**2104-9-14**] 05:00PM BLOOD Cortsol-54.2*
[**2104-9-22**] 10:55PM BLOOD Type-ART pO2-105 pCO2-35 pH-7.49*
calHCO3-27 Base XS-3 Intubat-INTUBATED
[**2104-9-21**] 05:42PM BLOOD Type-ART pO2-413* pCO2-43 pH-7.43
calHCO3-29 Base XS-4
[**2104-9-21**] 06:33AM BLOOD Type-ART pO2-108* pCO2-44 pH-7.46*
calHCO3-32* Base XS-6
[**2104-9-20**] 02:42PM BLOOD Type-ART Temp-36.6 pO2-120* pCO2-28*
pH-7.48* calHCO3-21 Base XS-0
[**2104-9-18**] 11:13AM BLOOD Type-ART pO2-144* pCO2-38 pH-7.39
calHCO3-24 Base XS--1 Intubat-INTUBATED
[**2104-9-16**] 05:25PM BLOOD Type-ART pO2-167* pCO2-30* pH-7.37
calHCO3-18* Base XS--6
[**2104-9-15**] 10:56AM BLOOD Type-ART PEEP-5 O2-50 pO2-125* pCO2-30*
pH-7.40 calHCO3-19* Base XS--4 Intubat-INTUBATED Vent-CONTROLLED
[**2104-9-15**] 12:05AM BLOOD Type-ART pO2-380* pCO2-30* pH-7.41
calHCO3-20* Base XS--3
[**2104-9-21**] 05:42PM BLOOD Lactate-2.1*
[**2104-9-14**] 06:46PM BLOOD Lactate-3.0*
[**2104-9-14**] 05:26PM BLOOD Lactate-15.2*
[**2104-9-14**] 04:35AM BLOOD Lactate-1.7
Brief Hospital Course:
1. Pulmonary: The pt was intubated in the ED for airway
protection. He did have a LLL infiltrate on CXR that was not
overwhelmingly impressive. While in the ICU, he did well on the
vent and was on pressure support at minimal settings for most of
the time. His RSBIs were often elevated >100 [**2-11**] agitation, and
during a spontaneous breathing trial on [**9-22**], he became
tachypneic, tachycardic, and was pulling on his tube (he did at
that time manage to pull out his OGT.) He also began having
more secretions suctioned from his tube around that time. Later
that day, while being turned, he turned [**Doctor Last Name 352**] and became hypoxic
to the 80s, with some generalized tonic-clonic activity. A
large mucous plug was suctioned from his tube and his sats began
to rise. On [**9-24**], it was decided to extubate him, as it
appeared that his mental status was not going to tolerate being
on the vent without sedation, meaning that he would never have a
great RSBI or spontaneous breathing trial. After a long
discussion with his health care proxy, [**Name (NI) **] [**Name (NI) **], it was decided
that we would extubate Mr. [**Known lastname 6930**] and would not reintubate him
if he failed extubation. He tolerated extubation well and for
the remainder of his stay in the ICU had O2 sats greater than
96% on RA. His infiltrates slowly improved on CXR.
2. Cardiovascular: On admission, Mr. [**Known lastname 6930**] had an elevated
troponin and CKs. It was decided by his cardiologist/PCP that
he was not a candidate for cath and that he would be managed
medically. During the first few days of his hospitalization,
his CK and MB declined as expected, but his troponins continued
to rise, peaking at 3.64 on HD#5. Cardiology was consulted, as
he had no EKG changes to suggest ongoing ischemia and his CKs
were at that time flat. They did not have an explanation for
the rising troponins, and it eventually trended downward. For
his rhythm, he was in and out of atrial fibrillation and also
had a wandering atrial pacemaker at time. His blood pressure
was labile while he was here, and at times he had systolics in
the 90s. Eventually, his pressure came back to a normal range
and he was started on a beta-blocker and an ACE, as well as
continued on an ASA. He also had a lipid panel checked and it
was normal. A statin was not started [**2-11**] elevated ALT at
baseline.
3. GI: He developed diarrhea during his admission, and a C diff
toxin was positive. He was begun on Flagyl 500 mg po tid for a
total of a 14 day course.
4. Infectious Disease: He never grew any bacteria from his
sputum, blood, or urine cx. He was treated with ceftaz for a
total of 14 days. He was initially treated with vancomycin
given that he appeared septic and had a cellulitis. That was
d/c'ed after approximately 5 days as the cellulitis did not
appear to be that impressive, but he began spiking fevers to 102
after it was stopped and so it was restarted. It was
discontinued again after the CDiff returned positive, as we felt
that had caused the fevers. However, he spiked another fever
and had a leukocytosis after the vanc was stopped, and so
finally it was restarted so that he would have a total of 14
days of vancomycin.
5. Neuro: On presentation there was concern that he had had a
seizure, although with a temp of 104 it seemed much more c/w
rigors. He was evaluated by Neuro in the ED and had a normal
head CT. An LP was done as well, which didn't reveal a
leukocytosis but he did have quite a few red cells, and so HSV
PCR was sent and he was begun on acyclovir. It was later felt
that the tap was bloody (the ED resident said that he had hit an
artery) and so the acyclovir was discontinued. Later in his
admission, during his aforementioned episode with the hypoxia
and mucous plug, it was felt he again had seizure activity with
tonic clonic jerking. He was again evaluated by Neuro, who felt
that it was likely due to hypoxia and not an actual seizure
disorder. He had an EEG that revealed generalized mild
encephalopathy but no frank epileptiform discharges. Once he
was extubated, his mental status quickly returned to his
baseline (per his PCP), which is a mild dementia.
6. Heme: On [**9-26**], the pt had a hematocrit drop from 32 to 27.
This stabilized to a Hct of 29 on day of discharge without
intervention. Iron studies are consistent with anemia of
chronic disease.
7. Code Status: DNR/DNI
Medications on Admission:
ASA 81 mg po qd
Metoprolol 25 mg po bid
Risperdal 0.25 mg po bid
MVT
Brimonidine eye drops
NTG sl prn
Discharge Medications:
1. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic
Q8H (every 8 hours).
Disp:*1 bottle* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
Disp:*33 Tablet(s)* Refills:*0*
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: One
(1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 inh* Refills:*5*
8. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous every twelve (12) hours for 5 days.
Disp:*10 grams* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Dx: Pneumonia
Secondary Dx: Clostridium Dificile Colitis, Hypoxia-Induced
Seizures, Non ST-Elevation Myocardial Infarction, Anemia of
Chronic Disease.
Discharge Condition:
Fair.
Discharge Instructions:
1) If you have any fevers, chills, pain, shortness of breath,
diarrhea, or any other concerning symptoms, please contact your
doctor or return to the ER.
2) Take your medications as instructed.
3) Please have your doctor evaulate your liver enzymes. If they
become normal, you may benefit from statin therapy to decrease
your LDL and raise your HDL cholesterol levels.
Followup Instructions:
1) Please see your primary doctor in the next 1-2 weeks
([**Last Name (LF) **],[**First Name3 (LF) **] N. [**Telephone/Fax (1) 719**]).
| [
"0389",
"78552",
"51881",
"486",
"4280"
] |
Admission Date: [**2178-11-3**] Discharge Date: [**2178-11-4**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is an 82-year-old female
with a past medical history significant for
non-insulin-dependent diabetes mellitus, gastric cancer,
status post an upper gastrointestinal bleed treated with
radiation therapy, hypertension. She is an 82-year-old
female that is status post an inferior wall myocardial
infarction with post infarction ventricular septal defect
changes who was transferred her with an intra-aortic balloon
pump in place on Neo-Synephrine and dopamine with a systolic
blood pressure of around 80. She had large ST elevations in
the inferior leads. She was anuric with a lactic acid of
8.5.
Cardiac catheterization revealed ventricular septal defect
changes. She arrived in gravely ill condition.
ALLERGIES: She has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Her vital signs on
admission were temperature of 95.2, heart rate 183, in atrial
fibrillation, blood pressure 123/81, respirations 14, satting
at 97%; arterial blood gas 7.28/23/180/111. The physical
examination was deferred by the family.
LABORATORY DATA ON PRESENTATION: Her laboratories were white
blood cell count of 18.1, hematocrit 37.9, and platelets
of 240. Magnesium of 2.5. Her ALT was 33, AST 53, alkaline
phosphatase 145. Creatine kinase was 216. Troponin I
of 37.7. Total bilirubin 0.6.
HOSPITAL COURSE: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] discussed the
possibility of surgery with the patient's family, and given
the very low (if not zero) chance of survival the family
whished to not proceed with the surgery and to stop support.
On [**2178-11-4**], on hospital day two, the drips were
discontinued earlier during the day. Systolic blood pressure
dropped to 50s and then 40s. The patient was maintained on a
morphine drip at 10 mg per hour. She became asystolic
without vital signs at 1:35 a.m., and she was pronounced dead
at this time. Dr. [**Last Name (STitle) 70**] was notified. The medical
examiner's office was notified but declined autopsy. The
patient wished to proceed with autopsy.
DIAGNOSIS AT TIME OF DEATH: Post infarction
ventricular septal defect.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 15735**]
MEDQUIST36
D: [**2178-11-13**] 13:22
T: [**2178-11-17**] 08:37
JOB#: [**Job Number 29579**]
| [
"41401",
"25000",
"4019"
] |
Admission Date: [**2125-8-9**] Discharge Date: [**2125-8-19**]
Date of Birth: [**2069-9-23**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Back pain, RUQ pain, dyspnea
Major Surgical or Invasive Procedure:
Right arterial line
History of Present Illness:
55 yo F w/history of metastatic renal cell carcinoma in the
setting of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau syndrome presented to clinic [**8-8**]
she appeared ill and complained of three weeks worsening right
lower quadrant and back pain, nausea/vomiting,
weakness, fatigue, and inability to rise from a chair. She
reported a subjective 20lb weight loss. She also had two
episodes of bladder incontinence during over the past two days.
ED COURSE: Initial vitals 89/62, HR 60 SR an 97% on RA. BP inc
to 110/72 after 1 liter NS bolus. she was found to have a K of
6.2 and a Ca of 13.3. For her hyperkalemia she was given 10
units insulin with 1 amp D50, 1 amp calcium gluconate, 30mg
kayecelate. For her neurological symptoms, she was given 10 mg
decadron and head CT, and thoracolumbar MRI were performed to
rule out CNS involvement and cord compression respectively. A UA
was also sent. Ms. [**Known lastname **] was then trasferred to the OMED service
for further care.
FLOOR COURSE: Ms. [**Known lastname **] arrived to the floor with a K of 6.2 and a
Ca of 11.5. The patient was having difficulty with word finding
and was very sleepy after receiving narcotics. History was
therefore obtained from chart. Per these reports, she noted
shortness of breath, dyspnea with exertion preventing her from
carrying out activities of daily living, diffuse body aches,
diarrhea and fecal incontinence.
.
Given the incontinence and thoracic pain, she had a neurologic
work up for ?cord compression, and subsequently an c, t, l spine
MRI which was notable for metastatic disease diffusely and
evidence of epidural disease at the L5 vertebral body level, but
no compression. The patient received lasix, insulin, glucose and
bicarb as well as kayexalate for electrolyte management, and
also received a total of 3L of NS for acute pancreatitis. Her
total uop on the floor in response to the lasix was 720cc. She
had a progressive O2 requirement with tachypnea and on the
morning of transfer to the [**Hospital Unit Name 153**] was satting 93% on 5L by nasal
cannula. She doesn't admit to increased shortness of breath
overnight but notes that in general, her dyspnea has been
worsening over the last few days. She complains of severe
abdominal pain, and admits to LH. She denies chest pain,
headache, weakness, but notes that she has severe chronic pain
related to spinal metastasis. She was transferred to the [**Hospital Unit Name 153**]
for hypoxia and volume management.
Past Medical History:
Past Oncological History:
Initially presented at age 9 with vision changes secondary to
hypertensive emergency. She was diagnosed with a
pheochromocytoma and underwent left adrenalectomy. She underwent
right adrenalectomy in [**2088**] after being diagnosed with a second
pheochromocytoma. In [**2111**], she underwent a hysterectomy which
was complicated by postoperative bleeding. An ultrasound noted
renal cysts leading to a biopsy of the right kidney, which was
reported as normal. She then did well until [**2120**] when she was
diagnosed with an L2 vertebral hemangioma after presenting with
back pain with radicular symptoms. One year prior, her daughter
had been diagnosed with a brain tumor, which was likely a
hemangioma, and through testing was found to have [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 21344**]-Lindau disease.
-Nexivar was discontinued in [**2125-5-29**] following progression of
disease to her liver. She was seen at [**Hospital1 18**] [**2125-6-27**], and at
that time options for treatment with Sutent vs enrollment in a
trial on perifosine were discussed. She has remained off
therapy and returned to [**Hospital1 18**] with anticipation of enrollment on
perifosine.
-In [**2121-5-29**], Ms. [**Known lastname **] developed left flank pain and hematuria.
Left radical nephrectomy on [**2121-6-2**] revealed a polycystic
kidney with five clear cell type renal cell carcinomas ranging
in size from 0.6 cm to 9 cm. There was no tumor invasion of the
renal capsule, perinephritic adipose tissue, or large renal
veins, and margins were negative. No lymph nodes were recovered
in the specimen. Her TNM stage was T2 Nx Mx.
-Ms. [**Known lastname **] was subsequently followed with MRIs every six months.
MRI in [**3-/2124**] was notable for polycystic kidney disease in the
right kidney and gradually increasing size of a lesion in the
caudate lobe of the liver. Biopsy of this liver lesion on
[**2124-6-29**] revealed metastatic clear cell renal cell carcinoma. In
[**2124-7-29**], she was started on sorafenib (Nexavar). Because of
some confusion, she was taking 200 mg p.o. b.i.d. MRI on
[**2125-4-11**] showed growth of the liver lesion to 6 cm. In
addition, in the polycystic right kidney, there was a 5 cm mass
with enhancement in the peripheral margins and septations,
raising concern for a slowly growing cystic neoplasm. The
patient went off Nexavar because of progression in the liver and
the development of a probable new tumor in the remaining right
kidney.
.
PRIOR TREATMENT:
1. Left adrenalectomy at age 9 and right adrenalectomy at age 18
for pheochromocytomas.
2. Left nephrectomy for renal cell carcinoma (5 independent
tumors noted) in [**2121-5-29**].
3. Biopsy-documented metastatic disease in the caudate lobe of
the liver in [**2124-3-29**], after which the patient was started on
sorafenib.
4. Development of progressive disease in the liver and a
probable new renal primary (or metastases) in the right kidney
in the setting of polycystic disease.
.
Past Medical History: Ms. [**Known lastname **] has never been officially
diagnosed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**]-Lindau disease, but her daughter was
diagnosed with it and her personal and family history makes us
fairly certain that she has it. She also has hypertension.
.
Past Surgical History:
- L nephrectomy [**5-31**]
- Bilat adrenalectomy [**3-2**] pheochromocytoma
- TAH/BSO for benign ovarian abnormalities,
- appendectomy in [**2088**]
- right knee surgery for a ligament tear
- resection of a hemangioma in [**2121**].
Social History:
-Lives with husband in [**State 2748**]
- Remote tobacco use
- No EtoH or drug use
Family History:
- Pt's daughter has been diagnosed with [**Name (NI) **] [**Last Name (NamePattern1) 21354**], she
has a hx of benign brain tumors, pheochromocytomas, & bilateral
renal cell carcinoma
- A brother died from a brain tumor in [**2103**]
- Her mother died of renal failure at age 47
- A sister was diagnosed in her late 40s with breast CA
- Another sister has diabetes mellitus, diabetic nephropathy &
is s/p renal transplant
- A brother died of myocardial infarction at age 58
- Maternal grandmother had hx of kidney problems
Physical Exam:
Vitals: T 97 HR 84 BP 98/60 R 22 Sat 93% on 5L by nasal
cannula
Gen: 55 yo F, very pale, ill-appearing, round face, no obvious
respiratory distress, no accessory muscle use.
HEENT: conjunctival pallor, anicteric, PERRL/EOMI, MM dry, op
clear.
Neck: JVD flat, supple
CV - RRR, no MRG
Resp: CTAB with faint bibasilar rales
ABD - hypoactive BS, with mild distention and marked tenderness
to palpation diffusely, but especially in the epigastrium, no
rebound/guarding.
Skin - pale, dry but warm and well perfused.
EXT - no c/c/e, tender to touch
Neuro - sleepy but arousable to voice. oriented x 3. Nonfocal
exam, but limited secondary to pain.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt Ct
[**2125-8-17**] 04:05AM 37.3* 3.71* 8.9* 29.0* 78* 23.9* 30.5*
22.0* 178
[**2125-8-16**] 04:38AM 27.1* 3.54* 8.7* 27.3* 77* 24.7* 32.0
21.8* 211
[**2125-8-15**] 04:38AM 20.2*1 3.99* 9.5* 30.7* 77* 23.8* 30.9*
21.5* 270
.
[**2125-8-11**] 05:00AM 15.1* 3.00* 6.4* 22.6* 75* 21.3* 28.3*
21.8* 363
[**2125-8-9**] 01:00PM 12.7* 3.14* 6.8* 24.2* 77* 21.6* 28.1*
21.5* 484*
[**2125-8-8**] 01:35PM 9.1 3.27* 6.9* 24.5* 75* 21.0* 28.0*
21.7* 596*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2125-8-17**] 04:05AM 121* 79* 2.1* 143 3.3 105 17* 24*
[**2125-8-16**] 04:01PM 124* 72* 2.1* 138 3.1* 103 16* 22*
[**2125-8-15**] 02:52PM 119* 73* 2.3* 139 3.2* 100 19* 23*
[**2125-8-13**] 08:28PM 80 79* 3.0* 136 4.6 101 12* 28*
.
[**2125-8-10**] 05:15AM 119* 49* 2.1* 140 5.0 108 19* 18
[**2125-8-9**] 01:00PM 107* 48* 2.1* 135 6.7 107 17* 18
.
Alb Calcium Phos Mg
[**2125-8-17**] 04:05AM 1.9* 8.8 4.4 2.2
[**2125-8-14**] 07:58PM 10.0 6.2* 2.5
[**2125-8-11**] 05:00AM 2.3* 4.0* 3.5 1.6
[**2125-8-8**] 01:35PM 3.3* 13.3* 3.8 2.5
.
ENZYMES & BILIRUBIN
- ALT & AST remained WNL during admission
- LDH increased from 120's to peak of 870, then was trending
down prior to
death
- Alk Phos at 601 & Amylase was 1789 on admission & continued to
trend
down during admission to 169 & 78 respectively.
.
Lactate
[**2125-8-17**] 09:05AM 1.6
.
MICRO:
URINE CULTURE (Final [**2125-8-13**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
VANCOMYCIN SENSITIVITY CONFIRMED BY ETEST.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
.
BLOOD CULTURES X8-NGTD
STOOL: C-DIFF X2-Negative
VRE-Swab: negative
.
IMAGING:
.
Chest xray:
- [**2125-8-16**]: Essentially unchanged chest radiograph with left
atelectasis and pleural effusion.
.
- [**2125-8-15**]: AP chest compared to [**8-13**] through 17:
Mild pulmonary edema is new. Left lower lobe atelectasis has
worsened, and right infrahilar atelectasis is new. Moderate
cardiac enlargement persists. Small left pleural effusion may be
present, not changed appreciably. No pneumothorax. Nasogastric
tube ends in the distal stomach. No pneumothorax.
.
- [**2125-8-8**]: 1. Enlarged cardiac silhouette. 2. No evidence of
acute congestive heart failure or consolidation
.
CT HEAD:
- [**2125-8-16**]: There is no significant interval change compared to
prior examination from [**2125-8-8**]. However, due to motion
artifact, the study is limited and a subtle lesion cannot be
entirely excluded.
.
[**2125-8-8**]: 1. No acute abnormality including no intracranial
hemorrhage is detected. 2. Although no obvious intracranial
metastasis was identified, small isodense metastasis cannot be
excluded on this non contrast study. MRI of the brain is
recommended for further characterization. Small hypodense area
in the right frontal [**Doctor Last Name 534**] might represent a metastasis although
it is not a proper location for brain metastasis.
.
CT ABDOMEN & PELVIS:
- [**2125-8-16**]: 1. Somewhat limited examination due to the lack of
IV contrast however no evidence for abscess. Extensive phlegmon
involving the peripancreatic soft tissues and the mesentery. 2.
Liver metastases and bone metastases unchanged, pericardial
effusion, left pleural effusion stable.3. Multiple cysts in the
right kidney with complex lesion in the right lower pole
unchanged.
.
- [**2125-8-9**]: 1. Compared to prior study, there is increased
stranding surrounding the pancreas, tracking to the left
paracolic space, with mild wall thickening seen in the
descending colon. Findings are concerning for acute
pancreatitis.
.
[**2125-8-13**] ECHOCARDIOGRAM:
PERICARDIUM: Small pericardial effusion. Effusion echo dense,
c/w blood,
inflammation or other cellular elements. No RV diastolic
collapse.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures. Significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, c/w impaired ventricular filling. Left ventricular
systolic function is hyperdynamic (EF>75%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal.
Small pericardial effusion without overt tamponade.
.
[**2125-8-13**] RUQ Ultrasound: 1. No evidence of cholelithiasis. A
mildly distended gallbladder lumen with moderate amount of
sludge is not uncommon in an ICU patient. If high clinical
suspicion for acute cholecystitis, can consider correlation with
HIDA scan. 2. Reidentification of known hepatic metastatic
lesions and complex right renal cysts.
Brief Hospital Course:
A/P: 55 yo F with metastatic RCC in the setting of VHL who
presented with acute pancreatitis from hypercalcemia, ARF,
mental status changes, respiratory distress and significant back
pain.
.
#. Respiratory Distress: Mild hypoxemia on 3L NC she was
initially placed in a NRB and her O2 sats improved. In the
setting of severe pancreatitis we were concerned about ARDS,
however, she never required intubation for airway protection.
Her CXRs on multiple occassions were clear without evidence of a
consolidation. However, she remained hypoxic most likely caused
by continued severe LLL atelectasis + small
pleural/pericardial effusions, as well as a depressed mental
status. She was not diuresed due to pancreatitis, her narcotic
regimen was initially held to help improve her mental status,
which did not clear. She remained on supplemental O2 throughout
her hospital course and was not intubated.
.
#. Acute Renal Failure: Baseline creatinine unknown admitted
with Cr 2.1, likely compromised by L nephrectomy thus single
kidney with polycystic kidney disease in the setting of VHL,
>5cm RCC mass in R kidney. Also in the setting of poor PO intake
possibly pre-renal.
- Continued anion gap metabolic acidosis likely due to chronic
renal failure as pt
had low lactate levels.
- Multiple electrolyte abnormalities during admission including
hyperphosphatemia &
hypocalcemia requiring therapy; Initially admitted with
hyperkalemia &
hypercalcemia which resolved. She initially received one dose
of Calcitonin on the floor which is possible cause of
hypocalcemia. Another possibility of severe hypocalcemia was her
pancreatitis. Repleted calcium IV with calcium drip.
- Had required bicarbonate repletion, however this was
discontinued as pt's bicarb
levels improved.
- The renal service was consulted, provided recommendations for
therapy during
admission.
.
#. Infection/inflammation w/increasing WBC and left shift
- Had low grade fevers, however on steroids, at first stress
dose then slowly titrated to down, however due to elevated WBC
she was remained on stress dose levels. When pt was made CMO her
steroids were d/c'd alltogether.
- Known enterococcus UTI, not VRE colonized; unlikely source of
infection. Other
sources of infection included pancreatitis phlegmon &
pneumonia/atelectasis. Abd CT showed large peripancreatic
phelgmon with increased fat stranding likely resulting in
considerable intra-abdominal inflammation. She was started on
broad spectrum abx with vanco and zosyn, then switched to
ampicillin for entoroccus UTI. Her Vanco was then switched to
Meropenem for an abdominal source as noted below. All abx were
d/c'd when pt made CMO as noted below.
.
#. Coagulopathy. likely from decreased nutritional status and
antibiotics
- INR improved from max 2.9 ->to 1.5 [**8-16**] after vitamin K x1.
- Did not actively have any bleeding during admission, but there
was concern
especially given known hemangiomas.
.
#. Acute Pancreatitis: Potentially [**3-2**] cyst from VHL complex or
metastasis.
- Although admitted with elevated amylase, lipase, LDH & alk
phos,ALT & AST remained nml. Initially pt was not given
aggressive IVF due to her tenous respiratory status. Her T bili
trended up to 4.4 on [**8-17**]. She had Increased fat stranding and
phlegmon suggests inflammation and likely infection. Her
pancreatitis was resolving but she had persistent abdominal pain
with a very large 10cm liver mass. An U/S was done c/w biliary
sludge, however no cholelithiasis. She was started on Meropenem
for an intra-abdominal source of infection on [**8-17**]. Her pain was
managed with dilaudid prn as her renal failure prevented use of
morphine. However, Morphine drip was started when pt. was made
CMO.
.
#. Cardiovascular dysfunction:
-->Pump: Non-contributory pericardial effusion, but appears
bloody/cellular/inflammatory on ECHO. EF >75%, mild diastolic
dysfunction.
-->Rhythm: Continued sinus tach (100-120) with frequent APBs,
likely due to pain and
infection. Also with a h/o pheochromocytoma on norvasc,
labetolol and valsartan, which were all initially held due to
hypotension. During her course she became tachycardic HR 150s
most likely MAT. She was started on lopressor 5mg TID and
titrated to control her HR. HR also controlled with pain
control.
-->Ischemia: No wall motion abnormalities or signs of ischemic
dysfunction
.
#. Adrenal insufficiency in the setting of bilateral
adrenalectomy, home steroid dependence, prednisone 5mg daily.
Pt. was placed on stress dose steriods due to hypotension and
infection. steroids were d/c'ed once pt was made CMO.
.
#. Metastatic RCC: CT scans negative for cord compression,
however, 10cm liver metastasis, abundant evidence of probable
VHL hemangiomas in the cervical, lumbar and thoracic spine. Heme
Onc followed pt. & discussed the possibility of treatment with
Sutent when pt was stable for d/c to a medicine floor. She was
too tenuous throughout her [**Hospital Unit Name 153**] course to receive sutent. Pt's
pain was controlled with aggressive pain medication. Palliative
care was consulted for pain control and help with goals of care
when her clinical status deteriorated. she was managed with a
morphine drip once made CMO.
.
#. MS changes: Pt was drowsy and sedated, but appeared to be in
pain with movement.
MS changes likely combination of pain, uremia, ICU delerium,
inflammation/ infection.
She underwent 2 head CTs which did not show an acute process,
however due to movement, and a limited study, a subtle lesion
could not be entirely excluded. Despite no narcotics for several
days she was not interactive or responsive.
.
#. Code status: Initially full code then made DNR/DNI, and CMO
prior to death with help from Palliative care and [**Hospital Unit Name 153**] team as
clinical status persistently deteriorated.
.
#. Goals of care. Ms. [**Known lastname **] had known advanced metastatic RCC with
diffuse liver metastases in the setting of severe acute
pancreatitis with a rising white count and continued MS changes
despite electrolyte normalization and being off sedation.
- A family meeting with spouse addressing concerns of worsening
status including
resp distress, an elevated WBC despite abx, & metastatic RCC,
resulted in change of code status to DNR/DNI and shifting care
to comfort only.
- A morphine drip was initiated to ease pain & make her
comfortable; prior to CMO
she had adequate pain control via standing pain medications.
- Palliative care was following the pt since [**8-10**].
.
Pt expired on morning of [**8-19**] at 11am. Per pt's request her
organs were donated to NDRI in coordination with our pathology
department. Her husband agreed to an autopsy.
Medications on Admission:
Prednisone 5 mg p.o.daily
Norvasc 10 mg p.o. b.i.d.
Trandate 200 mg p.o. b.i.d.,
Diovan 160 mg p.o. daily.
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
| [
"5849",
"2767",
"2761",
"5990",
"2762",
"4019"
] |