row_id,text
0,"Admission Date: [**2136-10-23**] Discharge Date: [**2136-10-24**]
Date of Birth: [**2056-7-14**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80M p/w a large R IPH with intraventricular extension, midline
shift, and hydrocephalus.
The patient was found lying face up in his bathtub after having
shaved. There was no water in the tub and the shower was not
turned on. He was found by a neighbor. [**Name (NI) **] EMS, he was moaning
and there was ""tone in his left arm"" which may have been
consistent with posturing."
1,"He was taken to [**Hospital1 18**] [**Location (un) 620**] and
head
CT was performed, revealing a large intraparenchymal hemorrhage
extending from the lower midbrain into the hypothalamus,
thalamus
and basal ganglia on the right, with significant mass effect,
intraventricular extension with casting of the right ventricle
and some blood product in the posterior [**Doctor Last Name 534**] of the left lateral
ventricle.
[**Hospital1 18**] Neurosurgery was called and on review of imaging and
reported exam- Mannitol 100gm and Decadron 10mg x1 was
recommended and given. He was transferred to [**Hospital1 18**] for a
Neurosurgical evaluation. Dr [**Last Name (STitle) **] discussed and offered
surgical intervention, but this was refused based on
the family's knowledge of his wishes to not prolong life if
incapacitated."
2,"He also had signed a DNR/DNI order. He was clear
that he did not want to be dependent of disabled. The family
asked to maintain his intubation while other family members
arrive from inside and outside [**State 350**]. They offered that
he is an organ donor.
Past Medical History:
- DIABETES TYPE II
- HYPERLIPIDEMIA
- GLAUCOMA
- OSTEOARTHRITIS
- CAROTID STENOSIS left 60-69%, rt 50
- VASOVAGAL SYNCOPE
- BACK PAIN
Family History:
NC
Physical Exam:
No eye opening, pupils 2mm and minimally react. No corneal on
left, minimal corneal on right. Extensor posture with LUE, RUE
attempts to localize, BLE withdraw to noxious stim."
3,"No gag, not
overbreathing the vent. Tone increased in left arm, normal bulk.
Toes are downgoing bilaterally.
Pertinent Results:
FINDINGS: There is a large intraparenchymal basal ganglionic
based hemorrhage. It is multilobulated in nature and at its
greatest extent measures 6.5 x 5.3 cm. This is causing mass
effect and shift of the normally midline structures of
approximately 1.1 cm at the level of the hemorrhage. There is
also intraventricular extension into the ipsilateral and
contralateral lateral ventricles. There is effacement
of the ipsilateral frontal [**Doctor Last Name 534**] of the lateral ventricle
Brief Hospital Course:
Pt was admitted to the neurosurgery service and the ICU. The
organ bank was contact[**Name (NI) **]. [**Name2 (NI) **] was extubated on [**10-24**] without
incident and a morphine drip was started and titrated to
respiratory rate. He passed away on [**10-24**] at 12:55 p.m. The
family declined a post morteum exam.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2136-10-24**]"
4,"Vent 450/12/40%/5.
Review of systems: unable to perform, patient intubated and
sedated
Past Medical History:
SDH with coma for 3 mo about 5 years ago s/p Burr hole
Seizures
Alcoholism
HTN
HLD
chronic cough of unclear etiology (sig second-hand smoke
exposure)
h/o colostomy for unclear reasons
8 pregnancies (G8)
h/o breast bx x 2
foot and ankle fractures
Social History:
Patient lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in [**Hospital1 **]. She has a brother in
law in the area but often spends time with her cousin, [**Name (NI) 553**],
who is local."
5,"The patient showed no signs of
alcohol withdrawl and required only one dose of diazepam on the
CIWA protocol, which was mostly given for insomnia. She was
given thiamine. Neurology was consulted and they performed an
EEG, which showed no epileptiform activity. The day of
discharge, she developed a headache, but a repeat head CT was
normal, and she felt better after Tylenol and ibuprofen so was
discharged to follow-up as an outpatient.
# Chronic cough: the pt had a non-productive cough during your
admission, which has been present for several years, according
to the patient. She had no fevers, chills, oxygen requirement
or leukocytosis, so she was not treated for a pneumonia, and she
felt this was at her baseline."
6,"Furosemide 40 mg PO DAILY
8. Klor-Con *NF* (potassium chloride) 40 mg Oral [**Hospital1 **]
9. risedronate *NF* 35 mg Oral WEEKLY
Discharge Disposition:
Home
Discharge Diagnosis:
Toxic-metabolic encephalopathy of unclear etiology -- resolved
spontaneously
Acute respiratory failure related to above -- resolved
spontaneously
Subdural hematomat with coma for 3 months about 5 years ago
status post Burr hole
Seizures, possibly related to alcoholism in the past
Hypertension
Hyperlipidemia
Chronic cough of unclear etiology (significant second-hand smoke
exposure)
History of colostomy for unclear reasons
8 pregnancies (G8)
History of breast biopsy x 2
Foot and ankle fractures
Discharge Condition:
Mental Status: Clear and coherent."
7,"She is currently disabled. Denies having any
problems with alcohol currently, but did before her stroke.
Drinks 3 glasses of wine a night, no significant beer or liquor,
CAGE negative, denies illicits or tobacco but her ex-husband
(married for 25 years) smoked a lot
Family History:
Mother died of congenital heart condition in her 40s. Brother
died of an MI in his 60s. Otherwise, denies.
Physical Exam:
ADMISSION EXAM
94.5, 73, 97/64. Vent 450/12/40%/5.
General: sedated, non-responsive
HEENT: Sclera anicteric, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anterior lung fields, no wheezes,
rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding"
8,"Amitriptyline 100 mg PO HS
3. Klor-Con *NF* (potassium chloride) 40 mg Oral [**Hospital1 **]
4. Furosemide 40 mg PO DAILY
5. Methocarbamol [**Telephone/Fax (1) 22024**] mg PO Q6H:PRN muscle pain
6. Gabapentin 1200 mg PO TID
7. Fluoxetine 60 mg PO DAILY
8. Topiramate (Topamax) 100 mg PO QAM
9. Topiramate (Topamax) 200 mg PO HS
Discharge Medications:
1. Amitriptyline 100 mg PO HS
2. Fluoxetine 60 mg PO DAILY
3. Gabapentin 1200 mg PO TID
4. Methocarbamol [**Telephone/Fax (1) 22024**] mg PO Q6H:PRN muscle pain
5. Topiramate (Topamax) 100 mg PO QAM
6. Topiramate (Topamax) 200 mg PO HS
7."
9,"Here you were quickly
extubated (taken off the breathing machine) and you
spontaneously improved. The Neurology consult team saw you and
could not explain what had happened. You developed a headache
on the day of discharge, but a repeat head CT was normal, and
you felt better after Tylenol and ibuprofen so were discharged
to follow-up as an outpatient.
Followup Instructions:
Primary Care
Please follow-up with your primary care doctor within the next
few weeks. Dr. [**Last Name (un) **] (your [**Hospital1 18**]-[**Location (un) 86**] discharging
physician) called Dr. [**Last Name (STitle) 1437**], but he was unavailable. After
reviewing your discharge summary, his office will call you with
an appointment. Please be sure to discuss your medications and
possible pulmonary function testing at this appointment.
Neurology
Please follow-up with Dr. [**Last Name (STitle) **] as you had previously planned.
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
Completed by:[**2109-7-31**]"
10,"Blunting of
costophrenic angles could
reflect small effusions or pleural thickening.
No definite pneumonia is appreciated, though in the appropriate
clinical
setting a supervening consolidation would be difficult to
exclude in lower
zones.
Brief Hospital Course:
63 yo F with PMH alcohol abuse with seizures, SDH s/p burr hole
5 years ago admitted with acute change in mental status.
# Acute Respiratory Failure: Patient arrived to the ICU
intubated for respiratory failure in settting of acute
confusional state. The patient's initial ABG was reassuring and
she was deemed able to extubate. She was extubated on the day
of arrival to the ICU and tolerated it well."
11,"I suspect she may have COPD due
to second hand smoke exposure (ex-husband smoked for 25 years
with her). She should have outpatient PFTs done to further
evaluate this.
# Coordination of care: I attempted to speak with the patient's
PCP and Neurologist, but neither were available by phone on the
day of discharge. They will be sent a copy of this summary.
# Inactive issues: The patient was continued on her home
amitriptyline, fluoxetine, furosemide, gabapentin, topiramate,
and methocarbamol.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/CaregiverPharmacy.
1. risedronate *NF* 35 mg Oral WEEKLY
2."
12,"GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated, non-responsive
Pertinent Results:
ADMISSION LABS
[**2109-7-29**] 05:44AM BLOOD WBC-4.7 RBC-3.51* Hgb-11.8* Hct-35.4*
MCV-101* MCH-33.5* MCHC-33.2 RDW-13.7 Plt Ct-104*
[**2109-7-29**] 05:44AM BLOOD PT-11.1 PTT-26.3 INR(PT)-1.0
[**2109-7-29**] 05:44AM BLOOD UreaN-17 Creat-0.6
[**2109-7-30**] 05:20AM BLOOD Glucose-100 UreaN-7 Creat-0.3* Na-139
K-3.1* Cl-110* HCO3-22 AnGap-10
[**2109-7-29**] 05:44AM BLOOD ALT-20 AST-24 LD(LDH)-275* CK(CPK)-138
AlkPhos-81 TotBili-0."
13,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You developed confusion at home, fell and struck your head,
suffering a headache, chipped tooth and sore R shoulder. You
became progressively more confused until you were taken to
[**Hospital1 18**]-[**Hospital1 **] where your evaluation included a head CT, which was
unchanged from your prior (not normal due to your history of
subdural hemorrhage ~5 yrs ago with old R parietal craniotomy,
old R burr hole). Lab testing was unremarkable. You were
intubated (placed on a breathing machine) because your mental
status was so poor and you could not protect your airway and you
were transferred to [**Hospital1 18**]-[**Location (un) 86**]."
14,"Her oxygen
saturation remained in the mid to high 90s on room air. The
etiology of her respiratory was felt to be her toxic-metabolic
encephalopathy as noted below.
# Toxic-metabolic encephalopathy: The patient presented with
acute altered mental status with history of alcohol abuse and
seizures, also with history of SDH s/p craniotomy 5 years ago.
The etiology was unclear, but the differential included alcohol
withdrawal/seizure, toxic metabolic (hepatic encephalopathy),
CVA/ICH, sepsis, wernicke's encephalopathy. UA unremarkable.
Ammonia level normal. Lactic acid WNL. Drug induced possible,
home medications were difficult to clarify (the patient and her
family were poor historians)."
15,"Per OSH records, patient fell the night prior to arrival on
cousin's floor and struck her head; denied LOC, but c/o left
brow pain, heaache, chipped tooth and sore R shoulder. A
preliminary head CT showed no acute intracranial abnormality
with chronic findings (old R parietal craniotomy, old R burr
hole). Labs were notable for lactate 1.2, normal chem 7, normal
CBC, normal UA, ammonia 32 (WNL). Tox negative for ethanol,
salicylates, acetominophen. The patient was intubated for
failure to oxygenate/ventilate and inability to protect airway
(sedation and confusion). CXR showed R mainstem intubation-->
pulled back 1 cm and improved L lung aeration."
16,"Admission Date: [**2109-7-29**] Discharge Date: [**2109-7-31**]
Date of Birth: [**2045-11-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 11220**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation and extubation
History of Present Illness:
[**Hospital Unit Name 153**] Admission Note
Primary Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1437**] ([**Location (un) **])
Neurologist: Dr. [**Last Name (STitle) **] ([**Location (un) **])
Chief Complaint: respiratory failure and altered mental status
Reason for MICU transfer: intubated
History of Present Illness: 63 yo F (real name [**First Name5 (NamePattern1) **] [**Known lastname 11135**])
with PMHx of alcohol abuse with withdrawal seizures, a SDH s/p R
craniotomy, HTN and HL who presents intubated from [**Hospital1 2519**] for confusion."
17,"ET tube is at the carina and should be repositioned.
Bilateral low lung volumes are noted with crowding of
bronchovascular markings. Cardiac silhouette is accentuated by
low lung volumes. Additionally, opacification at the left lung
base and in the retrocardiac region appears concerning for
either pleural effusion versus atelectasis, infectious process
such as pneumonia cannot be completely excluded in the correct
clinical setting.
CXR 8.21
In comparison with the study of [**7-29**], there again are lower lung
volumes. Cardiac silhouette is within upper limits of normal or
slightly
enlarged. Minimal poor definition of pulmonary vessels could
reflect slight
elevation of pulmonary venous pressure."
18,"In the ED, initial VS were: 98.7, 91, 137/78, 21, 99%. Labs
notable for UA with small WBC, Pos nitrite, few bact. ABG
7.33/41/421 on 450/100%. Initially in the ED, she was ""fighting
the vent"" and was making purposeful movements of all 4
extremities to attempt to remove the ETT, she was then heavily
sedated in the ED with fentanyl and midazolam. She received
500mg azithromycin and 1g of ceftriaxone. Neurology was
consulted who recommended EEG.
On arrival to the MICU, patient's VS. 94.5, 73, 97/64. Patient
was intubated and sedated."
19,"4
[**2109-7-30**] 05:20AM BLOOD Calcium-7.0* Phos-2.2* Mg-1.9
[**2109-7-29**] 05:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2109-7-29**] 05:57AM BLOOD Type-ART Tidal V-450 FiO2-100 pO2-421*
pCO2-41 pH-7.33* calTCO2-23 Base XS--4 AADO2-252 REQ O2-49
-ASSIST/CON
[**2109-7-29**] 06:30PM BLOOD Type-ART pO2-83* pCO2-36 pH-7.39
calTCO2-23 Base XS--2 Intubat-NOT INTUBARED
MICRO
IMAGING
CXR 8.20
A feeding tube is noted with tip at the level of the gastric
antrum."
20,"History of Present Illness:
[**First Name9 (NamePattern2) 86978**] [**Known lastname 86979**] is a 65-year-old right-handed woman, with
history
of non-small cell lung cancer. Her neurological problem began in
the summer of [**2119**] when she experienced difficulty seeing her
left side. She also had
vertigo, seeing colored lights in periphery of her visual field.
She experienced headaches at the left occipital region, and it
woke her at night. She had nausea, dry heaves, and decreased
dexerity with impaired ability to open pill bottle with her left
hand. She also had tinnitus in her right ear. She initially
blamed the symptoms on her diabetes but an MRI of the brain
showed a left occipital brain mass with surrounding edema."
21,"She
was started on dexamethasone 4 mg 3 times daily and her headache
disappeared. She was referred to the BTC for evalaution and was
seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
Past Medical History:
Past Medical History: She has a history of type II diabetes
(diagnosed 2 years ago), hypertension, coronary artery disease,
and COPD. She does not have hypercholesterolemia.
Past Surgical History: She had CABG x 1 on [**2118-7-2**],
hysterectomy for fibroids, cholecystectomy, carpal tunnel
surgeries in both hands, and bladder distension surgery.
Social History:
She works in retail sales. She smoked 1.5 packs
of cigarettes per day for 30 years; she stopped smoking since
[**2102**]."
22,"The patient had not had a
post operative bowel movement but was passing flatus and has
baseline constipation. On exam, a visual field cut was no
apprieciated and the patients strength and sensation was full.
Pupils were equal and reactive bilaterally. The surgical
incision was clean dry and intact. The patient was instructed
to begin her Metformin on [**1-15**] hours after her last MRI of
the Brain. She was also instructed to resume her home dosing of
Humalog insulin. The patient will follow up in Brain [**Hospital 341**]
Clinic and with Opthomology. The patient's husband was at her
bedside and the patient was looking forward to her discharge
home."
23,"There has been slight interval decrease in the
adjacent vasogenic edema and slight interval decrease in mass
effect. Study for surgical planning.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2120-1-13**]
5:40 PM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2120-1-13**] 5:40 PM
MR HEAD W & W/O CONTRAST PRELIMINARY RADIOLOGY REPORT 1.
Post-surgical changes in the left occipital surgical resection
cavity, with small areas of linear nodular enhancement within,
which may relate to post-surgical changes/residual tumor or a
combination of both.
2. Areas of decreased diffusion in the periphery of the left
occipital lobe posteriorly and medially, may relate to acute
infarction."
24,"Disp:*30 Tablet(s)* Refills:*0*
9. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*2*
10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every 4-6 hours as needed for pain: do not exceed
4 grams tylenol in 24 hours.
Disp:*50 Tablet(s)* Refills:*0*
11. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 12H
(Every 12 Hours): start this dose [**2120-1-15**].
Disp:*40 Tablet(s)* Refills:*1*
12. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for muscle spasm for 2 weeks: hold for lethargy-
do not drive while on this medication."
25,"Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
You may resume Aspirin one week following your surgery
Please restart your home dose of Metformin on [**2120-1-15**]
(48 hours after your MRI that was performedin the hospital)
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."
26,"Medications on Admission:
Metformin (held [**3-7**] contrast ). paroxetine, decadron, albuterol,
ativan, protonix, albuterol, asa 81mg
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
Disp:*60 Tablet(s)* Refills:*1*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4."
27,"patient is independently
ambulating in the halls, alert, oriented to person, place and
time. strength is full, sensation is full. no pronator drift
noted. occipital incision clean dry and intact sutures closing
the wound. perrl, pupils 5-3mm bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2120-1-11**] 08:38PM WBC-12.6* RBC-4.61 HGB-12.2 HCT-38.2 MCV-83
MCH-26.4* MCHC-31.9 RDW-18.5*
[**2120-1-11**] 08:38PM GLUCOSE-187* UREA N-33* CREAT-1.0 SODIUM-133
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-24 ANION GAP-19
[**2120-1-11**] 08:38PM CALCIUM-7."
28,"albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
Wheezing, SOB.
5. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 1 days: start [**2120-1-14**].
Disp:*4 Tablet(s)* Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety: hold for lethargy."
29,"9* PHOSPHATE-5.1* MAGNESIUM-1.8
dISCHARGE LABS: na 140, GLUCOSE 120, wbc 12.5, PLATLETS 266, hgb
12.4, HCT 39.3, pt 10.1, ptt 19.7, inr .8
IMAGING:
CT Head [**1-11**]: Interval occipital mass resection with
pneumocephalus, but no hemorrhage or midline shift
MR HEAD W/ CONTRAST Study Date of [**2120-1-11**] 6:47 AM
[**Last Name (LF) **],[**First Name3 (LF) **] M. OPT [**2120-1-11**] 6:47 AM
MR HEAD W/ CONTRAST Clip # [**Clip Number (Radiology) 86980**]
Final Report
INDICATION: Left occipital mass.
COMPARISON: [**2119-12-29**] MRI brain from [**Hospital3 3583**] and
scanned into our
PACS system for review."
30,"?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation."
31,"?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**8-12**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**1-29**] at 9:30 am."
32,"She experienced a severe headache and her pain medications were
changed with good post operative pain relief. On exam the
patient ws stable with right field cut noted. A decadron taper
was written.
On [**1-13**], the patient ws seen by physical therapy. She was
noted to ambulate independently but had higher level balance
issues requiring home physical therapy. The patient had her post
operative MRI of the brain which was reviwed by Dr [**Last Name (STitle) **] and
consistent with expected post operative change.
On [**2120-1-14**], the patient was tolerating a regular diet,
ambulating in the halls independently."
33,"Admission Date: [**2120-1-11**] Discharge Date: [**2120-1-14**]
Date of Birth: [**2054-4-29**] Sex: F
Service: NEUROSURGERY
Allergies:
Keflex / Azithromycin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
She experienced difficulty seeing her left side. She also had
vertigo, seeing colored lights in periphery of her visual field.
She experienced headaches at the left occipital region, and it
woke her at night. She had nausea, dry heaves, and decreased
dexerity with impaired ability to open pill bottle with her left
hand. She also had tinnitus in her right ear.
Major Surgical or Invasive Procedure:
[**2120-1-11**] Suboccipital craniotomy for tumor resection"
34,"FINDINGS: The right occipital lobe mass is similar in size to
the [**2119-11-28**] MRI, measuring today 24 x 27 x 26 mm (AP x ML x
SI). The mass has a thick rind of enhancement and a T1
hypointense center.
The adjacent edema has decreased slightly, with slight interval
expansion of the occipital [**Doctor Last Name 534**] and atrium of the left lateral
ventricle and better
definition of adjacent sulci. No new lesions are seen. Major
intracranial
vessels are patent.
IMPRESSION: Left occipital lobe mass, necrotic-appearing. This
can represent a metastasis from the patient's lung cancer or a
primary neoplasm."
35,"Consider followup to assess interval change.
Persistent surrounding vasogenic edema and partial effacement of
the atrium of the left lateral ventricle and the left occipital
[**Doctor Last Name 534**]. Other details as above.
Brief Hospital Course:
Patient presented electively for suboccipital craniotomy for
resection of tumor on [**2120-1-11**]. It was an uncomplicated
procedure, and she was admitted to the ICU for Q1 neurochecks
and Dexamethasone. She had no issues overnight and her pain was
well controlled.
On [**2120-1-12**], the morning of POD #1 she felt well and she had no
acute issues. SHe was transferred out of the ICU to the floor."
36,"She does not drink alcohol or use illicit drugs.
Family History:
She is adopted and she does not know the
biological or medical histories of her parents or siblings. She
has 1 daughter and 3 sons; they are all healthy.
Physical Exam:
PRE OP EXAM:
Temperature is 97.8 F. Her blood pressure
is 142/60. Heart rate is 60. Respiratory rate is 16. Her skin
has full turgor. HEENT examination is unremarkable. Neck is
supple and there is no bruit or lymphadenopathy. Cardiac
examination reveals regular rate and rhythms. Her lungs are
clear. Her abdomen is soft with good bowel sounds."
37,"Her tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: She does not have a drift. Her muscle
strengths are [**6-7**] at all muscle groups. Her muscle tone is
normal. Her reflexes are 2- and symmetric bilaterally. Her
ankle jerks are 2-. Her toes are down going. Sensory
examination is intact to touch and proprioception. Coordination
examination does not reveal dysmetria. Her gait is normal. She
can do tandem gait. She does not have a Romberg.
Exam on the day of discharge: [**2120-1-14**] neurologically intact, no
field cut apprieciated on exam."
38,"Her
extremities do not show clubbing, cyanosis, or edema.
Neurological Examination: Her Karnofsky Performance Score is
90.
She is awake, alert, and oriented times 3. There is no
right-left confusion or finger agnosia. Calculation is intact.
Her language is fluent with good comprehension, naming, and
repetition. Her recent recall is good. Cranial Nerve
Examination: Her pupils are equal and reactive to light, 4 mm
to
2 mm bilaterally. Extraocular movements are full. Visual
fields
are full to confrontation. Funduscopic examination reveals
sharp
disks margins bilaterally. Her face is symmetric. Facial
sensation is intact bilaterally. Her hearing is intact
bilaterally."
39,"The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain
You may resume Aspirin one week following your surgery
Please restart your home dose of Metformin on [**2120-1-15**] (48 hours
after your MRI that was performed in the hospital which was
performed at 6pm [**1-13**])
You will need formal visual field testing performed
with Opthomology before you will be able to drive. This should
be performed in the next 6 weeks. The office number to call for
an appointment is Office Phone:([**Telephone/Fax (1) 5120**],Office Fax:([**Telephone/Fax (1) 22009**]
Office Location:E/TCC-5, [**Location (un) 86**], [**Numeric Identifier 718**]
You may resume your home dose of humalog insulin as
prescribed by your primary care physician.
Completed by:[**2120-1-14**]"
40,"Disp:*20 Tablet(s)* Refills:*0*
13. humalog
please resume your home dose of humalog per your primary care
physician. [**Name10 (NameIs) 357**] continue to check finger sticks 4 times a day
and prior to bed as directed by your primary care physician.
Discharge Disposition:
Home With Service
Facility:
VNA [**Hospital3 **] inc
Discharge Diagnosis:
occipital mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending."
41,"Demographics
Day of intubation:
Day of mechanical ventilation: 2
Ideal body weight: 0 None
Ideal tidal volume: 0 / 0 / 0 mL/kg
Airway
Airway Placement Data
Known difficult intubation: Unknown
Tube Type
ETT:
Position: 22 cm at teeth
Route: Oral
Type: Standard
Size: 7mm
Lung sounds
RLL Lung Sounds: Clear
RUL Lung Sounds: Clear
LUL Lung Sounds: Clear
LLL Lung Sounds: Clear
Comments:
Secretions
Sputum color / consistency: Blood Tinged / Thick
Sputum source/amount: Suctioned / Small
Comments:
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Visual assessment of breathing pattern: Normal quiet breathing;
Comments: Remain on vent support. Will attempt PSV after AM Head CT.
Assessment of breathing comfort: No response (sleeping / sedated)
Invasive ventilation assessment:
Trigger work assessment: Triggering synchronously
Dysynchrony assessment: Frequent alarms (High min. ventilation)
Comments:
Plan
Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;
Comments: Will attempt RSBI once on PSV ^ settled aftyer returning [**Last Name (un) 5215**]
Head CT.
Reason for continuing current ventilatory support: Sedated / Paralyzed,
Hemodynimic instability, Underlying illness not resolved"
42,"Admission Date: [**2134-3-21**] Discharge Date: [**2134-3-26**]
Date of Birth: [**2109-8-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2134-3-21**] Closure of scalp laceration
Washout & closure of left arm laceration
History of Present Illness:
24 year old female who was an unrestrained driver
in a motor vehicle crash. The vehicle reportedly rotated 360 and
was hit twice. The patient was partially ejected from the
vehicle and sustained a
open skull fracture as well as evulsed left arm."
43,"Postoperatively she was taken to the Trauma ICU where she
remained sedated and intubated for several days. She was
eventually extubated without any difficulty.
Neurosurgery was consulted for the epidural/subdural frontal
hemorrhage. She was placed on Dilantin which will continue for a
7 day course as prophylaxis for seizures. Repeat head CT scans
remained stable. Neurologically she is alert and oriented x2 for
the most part; some difficulty intermittently with remembering
where she is. She has been able to follow commands and answer
simple questions appropriately. She was eventually transferred
to the regular nursing unit.
She was evaluated by Plastics for her left metacarpal fracture;
this was managed nonoperative with a ulnar splint and she will
follow up in [**Hospital 3595**] clinic in about a week after discharge."
44,"Orthopedics was consulted for her left clavicle fracture, this
was also managed nonoperative with a sling. She is to remain non
weight bearing on her left arm and will follow up in 2 weeks in
orthopedics clinic.
On HD #5 she was noted to complain of blurred vision with
intermittent diplopia; an Ophthalmology consult was placed and
it was felt that she had a traumatic 6th nerve palsy and no
operative intervention was warranted.
Physical and Occupational therapy were consulted and have
recommended acute rehab after her hospital stay. The screening
process was initiated and discharge plans were underway.
Social work was consulted for coping and emotional support."
45,"7. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
Scalp laceration
Epidural Hematoma
Skull Fracture
Left clavicle fracture
Left metacarpal fracture
Left arm laceration
Traumatic 6th nerve palsy"
46,"Medications on Admission:
OCP's
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 5 days.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours)."
47,"Repeat head CT [**2134-3-23**]
IMPRESSION: Unchanged left frontal hematoma with overlying
frontoparietal
skull fracture and scalp hematoma. Unchanged smaller more
inferior
extra-axial left frontal hematoma.
CT cervical spine [**2134-3-23**]
IMPRESSION:
1. No fracture or subluxation.
2. Extensive soft tissue stranding/hemorrhage in the left
supraclavicular
region which may relate to recent attempt at central venous
access (no
clavicular fracture is seen); correlate clinically.
Brief Hospital Course:
She was admitted to the Trauma service and taken to the
operating room emergently for
incision debridement repair of biceps and soft tissue defect
left upper arm irrigation and debridement closure of open skull
fracture with 12 cm scalp laceration."
48,"0 RBC-3.78* HGB-11.7* HCT-33.3* MCV-88
MCH-30.9 MCHC-35.0 RDW-13.3
[**2134-3-21**] 07:40PM PLT COUNT-230
[**2134-3-21**] 07:40PM PT-14.3* PTT-30.2 INR(PT)-1.2*
[**2134-3-21**] 07:40PM FIBRINOGE-114*
CT Head [**2134-3-22**]
IMPRESSION: There is a left frontal epidural hematoma and a
small associated subdural/epidural hematoma as described above.
Final Attending Comment:
There is a fracture of the left frontal bone and on image 36, a
tiny bony
fragment appears to have been displaced into the brain."
49,"Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
Continue Dilantin until [**2134-3-30**]
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **], Neurosurgery in [**9-29**] days. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that a repeat
non contrast head CT is needed for this appointment.
Follow up in Plastics/Hand clinic next Tuesday [**3-30**], call
[**Telephone/Fax (1) 3009**] for an appointment.
Follow up next Tuesday [**3-30**] with Dr. [**Last Name (STitle) **], Trauma Surgery for
removal of your scalp and left arm staples. Call [**Telephone/Fax (1) 6429**]
for an appoitnment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics for your
clavicle fracture, call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in [**Hospital **] clinic in 2 weeks, call [**Telephone/Fax (1) 253**]
for an appointnment.
Completed by:[**2134-6-9**]"
50,"5 mm fixed, right pupil 2.5 minimally
responsive
III, IV, VI:Extraocular movements- eyes fixed
V, VII,VIII,IX,X,[**Doctor First Name 81**],XII,Motor/Sensation/coordination:unable to
test pt with [**Location (un) 2611**] scale 3
Corneal:absent
Gag: present
Toes downgoing bilaterally
Pertinent Results:
[**2134-3-21**] 09:19PM TYPE-[**Last Name (un) **] PO2-73* PCO2-42 PH-7.25* TOTAL
CO2-19* BASE XS--8 COMMENTS-QUESTION S
[**2134-3-21**] 09:19PM GLUCOSE-179* LACTATE-4.7* NA+-137 K+-3.1*
CL--107
[**2134-3-21**] 09:19PM HGB-11.9* calcHCT-36
[**2134-3-21**] 07:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2134-3-21**] 07:40PM WBC-11."
51,"She was
intubated at the scene with a BP 80/50 and brought to [**Hospital6 23267**] where she received blood and normal saline. She
was then transferred to [**Hospital1 18**] ED. Upon initial presentation she
was moving all
extremities.
Past Medical History:
None
Family History:
Noncontributory
Physical Exam:
Upon admission:
Vital Signs:T: 96.8 BP: 121/83 HR:105 R:20
O2Sats:100
Gen: intubated non-responsive
HEENT: Pupils: left 2.5 mm fixed, right pupil 2.5 minimally
responsive EOMs fixed
Extrem: left arm evulsion fracture, finger with poor circulation
pale blue color
Neuro:
Mental status: intubated , non responsive
Orientation: non responsive
Recall/Language:none
Cranial Nerves:
I: Not tested
II: Pupils equal left 2."
52,"SICU
HPI:
24 yo F unrestrained driver in roll-over MVC. Partial ejection from
car. GCS at scene unknown, but responsive only to pain - intubated at
scene. Non-depressed skull fracture with overlying laceration, and L
arm laceration to bone. At OSH recieved ancef, tetnus and 2 pRBC.
Chief complaint:
PMHx:
none
Current medications:
24 Hour Events:
EXTUBATION - At [**2134-3-22**] 10:56 AM
INVASIVE VENTILATION - STOP [**2134-3-22**] 10:56 AM
intubated in field
MULTI LUMEN - STOP [**2134-3-22**] 04:02 PM
EKG - At [**2134-3-23**] 01:06 AM
peaked T waves noted on EKG, 12 lead EKG obtained
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2134-3-22**] 09:57 AM
Infusions:
Other ICU medications:
Midazolam (Versed) - [**2134-3-22**] 05:30 AM
Propofol - [**2134-3-22**] 05:56 AM
Fentanyl - [**2134-3-22**] 08:01 AM
Dilantin - [**2134-3-22**] 08:09 AM
Famotidine (Pepcid) - [**2134-3-22**] 08:11 AM
Hydromorphone (Dilaudid) - [**2134-3-23**] 12:40 AM
Other medications:
Flowsheet Data as of [**2134-3-23**] 05:16 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**36**] a."
53,"Q1Hr neuro checks. Dilaudid,
percocet, tylenol for pain. repeat head CT in AM
CVS: SBP < 140, prn hydral
PULM: extubated
GI: NPO, H2 blocker
RENAL: Cr stable, continue to follow. Is acidotic with elevated
lactate. continue to follow
HEME: HCT stable, continue to follow
ENDO: RISS
ID: cefzolin
MuskSkel: plastics splinted left wrist, f/u with them in clinic next
Tue, sling on left shoulder for clavicle fx
TLD: foley, LSC triple IJ, piv, aline
IVF: None
CONSULTS: Trauma, NSGY
BILLING DIAGNOSIS: skull fracture
ICU CARE:
GLYCEMIC CONTROL: RISS
PROPHYLAXIS:
DVT - Boots, SQH
STRESS ULCER - H2B
VAP BUNDLE - Yes
COMMUNICATIONS: Parents
ICU Consent: Signed
CODE STATUS: Full
DISPOSITION: transfer to Stepdown
Lines:
20 Gauge - [**2134-3-22**] 05:00 PM
Total time spent: 35 min"
54,"m.
Tmax: 38.1
C (100.5
T current: 37.7
C (99.8
HR: 88 (86 - 119) bpm
BP: 109/55(66) {89/49(60) - 117/71(82)} mmHg
RR: 21 (11 - 28) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 55 kg (admission): 55 kg
Total In:
2,165 mL
30 mL
PO:
140 mL
30 mL
Tube feeding:
IV Fluid:
2,025 mL
Blood products:
Total out:
1,550 mL
1,300 mL
Urine:
1,450 mL
1,300 mL
NG:
100 mL
Stool:
Drains:
Balance:
615 mL
-1,270 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 480 (480 - 528) mL
PS : 8 cmH2O
RR (Set): 16
RR (Spontaneous): 7
PEEP: 5 cmH2O
FiO2: 30%
RSBI: 44
PIP: 13 cmH2O
Plateau: 12 cmH2O
SPO2: 100%
ABG: ///23/
Ve: 5."
55,"5 %
8.6 K/uL
[image002.jpg]
[**2134-3-21**] 09:19 PM
[**2134-3-22**] 12:02 AM
[**2134-3-22**] 12:37 AM
[**2134-3-22**] 04:34 AM
[**2134-3-23**] 01:01 AM
WBC
10.7
8.6
Hct
36
27.5
27
24.5
Plt
177
174
Creatinine
0.8
0.6
TCO2
21
Glucose
179
128
121
Other labs: PT / PTT / INR:14.7/30.9/1.3, Lactic Acid:3.8 mmol/L,
Ca:9.1 mg/dL, Mg:1.9 mg/dL, PO4:3.1 mg/dL
Assessment and Plan
NEURO: Repeat CT shows stable epidural."
56,"7 L/min
Physical Examination
General Appearance: No acute distress
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
174 K/uL
8.8 g/dL
121 mg/dL
0.6 mg/dL
23 mEq/L
3.5 mEq/L
5 mg/dL
108 mEq/L
139 mEq/L
24."
57,"TSICU
HPI:
24 yo F unrestrained driver in roll-over MVC. Partial ejection from
car. GCS at scene unknown, but responsive only to pain - intubated at
scene. Non-depressed skull fracture with overlying laceration, and L
arm laceration to bone. At OSH recieved ancef, tetnus and 2 pRBC.
Chief complaint:
Non-depressed skull fracture , multiple lacerations, and with epidural
hematoma
PMHx:
PMH: None
PSH: None
Current medications:
24 Hour Events:
Post operative day:
[**3-24**] POD 3
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2134-3-22**] 09:57 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2134-3-23**] 08:00 PM
Hydromorphone (Dilaudid) - [**2134-3-24**] 05:15 AM
Other medications:
Flowsheet Data as of [**2134-3-24**] 06:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**36**] a."
58,"0
Plt
177
174
204
Creatinine
0.8
0.6
0.5
TCO2
21
Glucose
179
128
121
122
Other labs: PT / PTT / INR:12.5/25.0/1.1, Lactic Acid:3.8 mmol/L,
Ca:8.4 mg/dL, Mg:2.0 mg/dL, PO4:2.7 mg/dL
Assessment and Plan
ACUTE PAIN, TRAUMA, S/P
Assessment and Plan: 24 yo F in MVC suffering Non-depressed skull
fracture , multiple lacerations, and with epidural hematoma
Neurologic: MVC with non-depressed skull fx and epidural hematoma
stable on CT head x2, no intervention at this point. Neuro check
q1hr."
59,"Incorrect location and date. Unable
to tell year of birthdate
Labs / Radiology
204 K/uL
8.1 g/dL
122 mg/dL
0.5 mg/dL
26 mEq/L
3.7 mEq/L
7 mg/dL
103 mEq/L
138 mEq/L
23.0 %
7.4 K/uL
[image002.jpg]
[**2134-3-21**] 09:19 PM
[**2134-3-22**] 12:02 AM
[**2134-3-22**] 12:37 AM
[**2134-3-22**] 04:34 AM
[**2134-3-23**] 01:01 AM
[**2134-3-24**] 02:00 AM
WBC
10.7
8.6
7.4
Hct
36
27.5
27
24.5
23."
60,"Mental status unchanged. Dilaudid, percocet, tylenol for pain.
C-spine pending clearance by trauma. CT neck ok, but still c/o neck
pain. Trauma to adresst this am. Dilantin for sz proph
Cardiovascular: SBP < 140, prn hydral
Pulmonary: no resp issues, Incentive spirometry
Gastrointestinal / Abdomen: sips, H2 blocker
Nutrition: tolerated clears, advance diet today
Renal: Cr stable, UOP adequate
Hematology: HCT steady decline 33-->27-->24-->23, recheck this pm
Endocrine: RISS
Infectious Disease: monitor wbc, afebrile
Lines / Tubes / Drains: foley, piv
Wounds: c/d/i
Imaging: none
Fluids: KVO
Consults: Neuro surgery, Trauma surgery
Billing Diagnosis: Multiple Trauma
ICU Care
Nutrition: diet
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2134-3-22**] 05:00 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker po
VAP bundle:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 31 minutes"
61,"m.
Tmax: 37.7
C (99.8
T current: 37.2
C (98.9
HR: 80 (78 - 95) bpm
BP: 109/65(77) {99/61(69) - 122/82(92)} mmHg
RR: 17 (12 - 22) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 55.7 kg (admission): 55 kg
Total In:
980 mL
240 mL
PO:
880 mL
240 mL
Tube feeding:
IV Fluid:
100 mL
Blood products:
Total out:
2,299 mL
500 mL
Urine:
2,299 mL
500 mL
NG:
Stool:
Drains:
Balance:
-1,319 mL
-260 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 100%
ABG: ///26/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves
all extremities, Alert to self."
62,"TSICU
HPI:
24 yo F unrestrained driver in roll-over MVC. Partial ejection from
car. GCS at scene unknown, but responsive only to pain - intubated at
scene. Non-depressed skull fracture with overlying laceration, and L
arm laceration to bone. At OSH recieved ancef, tetnus and 2 pRBC.
Chief complaint:
Non-depressed skull fracture , multiple lacerations, and with epidural
hematoma
PMHx:
PMH: None
PSH: None
Current medications:
24 Hour Events:
Post operative day:
[**3-24**] POD 3
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2134-3-22**] 09:57 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2134-3-23**] 08:00 PM
Hydromorphone (Dilaudid) - [**2134-3-24**] 05:15 AM
Other medications:
Flowsheet Data as of [**2134-3-24**] 06:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**36**] a."
63,"0
Plt
177
174
204
Creatinine
0.8
0.6
0.5
TCO2
21
Glucose
179
128
121
122
Other labs: PT / PTT / INR:12.5/25.0/1.1, Lactic Acid:3.8 mmol/L,
Ca:8.4 mg/dL, Mg:2.0 mg/dL, PO4:2.7 mg/dL
Assessment and Plan
ACUTE PAIN, TRAUMA, S/P
Assessment and Plan: 24 yo F in MVC suffering Non-depressed skull
fracture , multiple lacerations, and with epidural hematoma
Neurologic: MVC with non-depressed skull fx and epidural hematoma
stable on CT head x2, no intervention at this point. Neuro check
q1hr."
64,"m.
Tmax: 37.7
C (99.8
T current: 37.2
C (98.9
HR: 80 (78 - 95) bpm
BP: 109/65(77) {99/61(69) - 122/82(92)} mmHg
RR: 17 (12 - 22) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 55.7 kg (admission): 55 kg
Total In:
980 mL
240 mL
PO:
880 mL
240 mL
Tube feeding:
IV Fluid:
100 mL
Blood products:
Total out:
2,299 mL
500 mL
Urine:
2,299 mL
500 mL
NG:
Stool:
Drains:
Balance:
-1,319 mL
-260 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 100%
ABG: ///26/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,
(Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves
all extremities, Alert to self."
65,"Incorrect location and date. Unable
to tell year of birthdate
Labs / Radiology
204 K/uL
8.1 g/dL
122 mg/dL
0.5 mg/dL
26 mEq/L
3.7 mEq/L
7 mg/dL
103 mEq/L
138 mEq/L
23.0 %
7.4 K/uL
[image002.jpg]
[**2134-3-21**] 09:19 PM
[**2134-3-22**] 12:02 AM
[**2134-3-22**] 12:37 AM
[**2134-3-22**] 04:34 AM
[**2134-3-23**] 01:01 AM
[**2134-3-24**] 02:00 AM
WBC
10.7
8.6
7.4
Hct
36
27.5
27
24.5
23."
66,"Mental status unchanged. Dilaudid, percocet, tylenol for pain.
C-spine pending clearance by trauma. Dilantin for sz proph
Cardiovascular: SBP < 140, prn hydral
Pulmonary: no resp issues
Gastrointestinal / Abdomen: sips, H2 blocker
Nutrition:
Renal: Cr stable, UOP adequate
Hematology: HCT steady decline 33-->27-->24-->23
Endocrine: RISS
Infectious Disease: no active issues
Lines / Tubes / Drains: foley, piv
Wounds:
Imaging:
Fluids: KVO
Consults: Neuro surgery, Trauma surgery
Billing Diagnosis:
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2134-3-22**] 05:00 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 23 minutes"
67,"TSICU
HPI:
24 yo F unrestrained driver in roll-over MVC. Partial ejection from
car. GCS at scene unknown, but responsive only to pain - intubated at
scene. Non-depressed skull fracture with overlying laceration, and L
arm laceration to bone. At OSH recieved ancef, tetnus and 2 pRBC.
Chief complaint:
MVA
PMHx:
PMH: None
PSH: None
Current medications:
1. 2. CefazoLIN 3. Famotidine 4. Fentanyl Citrate 5. Heparin 6.
HydrALAzine 7. Midazolam 8. Propofol
9. Sodium Chloride 0.9% Flush
24 Hour Events:
INVASIVE VENTILATION - START [**2134-3-21**] 11:00 PM
intubated in field
MULTI LUMEN - START [**2134-3-21**] 11:24 PM
Allergies:
Last dose of Antibiotics:
Cefazolin - [**2134-3-22**] 02:44 AM
Infusions:
Propofol - 70 mcg/Kg/min
Other ICU medications:
Fentanyl - [**2134-3-22**] 05:30 AM
Midazolam (Versed) - [**2134-3-22**] 05:30 AM
Propofol - [**2134-3-22**] 05:56 AM
Other medications:
Flowsheet Data as of [**2134-3-22**] 06:23 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**36**] a."
68,"Repeat head CT at 9 am for
change in size. Sedation with propfol, versed and fentanyl. Q1/2Hr
neuro checks. SBP < 140. Start Dilantin
CVS: SBP < 140, prn hydral
PULM: Wean to extubation if not to OR
GI: NPO, H2 blocker
RENAL: Cr stable, continue to follow. Is acidotic with decreasing
lactate and hyperchloremic met acidosis. continue to follow
HEME: HCT stable, continue to follow
ENDO: RISS
ID: cefzolin
TLD: ETT, foley, LSC triple IJ, piv, aline
IVF: None
CONSULTS: Trauma, NSGY
Billing Diagnosis: Multiple injuries (Trauma) , Epidural hematoma
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2134-3-21**] 11:24 PM
14 Gauge - [**2134-3-21**] 11:26 PM
18 Gauge - [**2134-3-21**] 11:26 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Family meeting held , ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 31 minutes
Patient is critically ill"
69,"29/42/275/20/-5
Ve: 7.2 L/min
PaO2 / FiO2: 917
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Skin: Multiple abrasions on L arm
Neurologic: Follows simple commands, (Responds to: Verbal stimuli),
Moves all extremities, Sedated
Labs / Radiology
177 K/uL
9.8 g/dL
128 mg/dL
0.8 mg/dL
20 mEq/L
4.0 mEq/L
11 mg/dL
110 mEq/L
141 mEq/L
27
10."
70,"m.
Tmax: 37.8
C (100.1
T current: 37.8
C (100.1
HR: 105 (83 - 111) bpm
BP: 99/58(67) {86/52(60) - 113/65(76)} mmHg
RR: 16 (12 - 17) insp/min
SPO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 55 kg (admission): 55 kg
Total In:
1,615 mL
753 mL
PO:
Tube feeding:
IV Fluid:
1,115 mL
753 mL
Blood products:
500 mL
Total out:
1,020 mL
580 mL
Urine:
60 mL
480 mL
NG:
100 mL
Stool:
Drains:
Balance:
595 mL
173 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 450 (450 - 450) mL
PS : 8 cmH2O
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 30%
RSBI: 44
PIP: 16 cmH2O
Plateau: 14 cmH2O
Compliance: 50 cmH2O/mL
SPO2: 100%
ABG: 7."
71,"7 K/uL
[image002.jpg]
[**2134-3-21**] 09:19 PM
[**2134-3-22**] 12:02 AM
[**2134-3-22**] 12:37 AM
[**2134-3-22**] 04:34 AM
WBC
10.7
Hct
36
27.5
27
Plt
177
Creatinine
0.8
TCO2
21
Glucose
179
128
Other labs: PT / PTT / INR:14.7/30.9/1.3, Lactic Acid:3.8 mmol/L,
Ca:9.0 mg/dL, Mg:1.6 mg/dL, PO4:5.1 mg/dL
Assessment and Plan
Assessment and Plan: 24 F s/p MVA with skull fracture and hematoma.
NEURO: Repeat CT shows epidural hematoma."
72,"TSICU
HPI:
24 yo F unrestrained driver in roll-over MVC. Partial ejection from
car. GCS at scene unknown, but responsive only to pain - intubated at
scene. Non-depressed skull fracture with overlying laceration, and L
arm laceration to bone. At OSH recieved ancef, tetnus and 2 pRBC.
Chief complaint:
MVA
PMHx:
PMH: None
PSH: None
Current medications:
1. 2. CefazoLIN 3. Famotidine 4. Fentanyl Citrate 5. Heparin 6.
HydrALAzine 7. Midazolam 8. Propofol
9. Sodium Chloride 0.9% Flush
24 Hour Events:
INVASIVE VENTILATION - START [**2134-3-21**] 11:00 PM
intubated in field
MULTI LUMEN - START [**2134-3-21**] 11:24 PM
Allergies:
Last dose of Antibiotics:
Cefazolin - [**2134-3-22**] 02:44 AM
Infusions:
Propofol - 70 mcg/Kg/min
Other ICU medications:
Fentanyl - [**2134-3-22**] 05:30 AM
Midazolam (Versed) - [**2134-3-22**] 05:30 AM
Propofol - [**2134-3-22**] 05:56 AM
Other medications:
Flowsheet Data as of [**2134-3-22**] 06:23 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**36**] a."
73,"29/42/275/20/-5
Ve: 7.2 L/min
PaO2 / FiO2: 917
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Skin: Multiple abrasions on L arm
Neurologic: Follows simple commands, (Responds to: Verbal stimuli),
Moves all extremities, Sedated
Labs / Radiology
177 K/uL
9.8 g/dL
128 mg/dL
0.8 mg/dL
20 mEq/L
4.0 mEq/L
11 mg/dL
110 mEq/L
141 mEq/L
27
10."
74,"Repeat head CT at 9 am for ? OR or
not. Sedation with propfol, versed and fentanyl. Q1/2Hr neuro checks.
SBP < 140. Repeat head CT in am.
CVS: SBP < 140, prn hydral
PULM: Ween to extubation
GI: NPO, H2 blocker
RENAL: Cr stable, continue to follow. Is acidotic with elevated
lactate. continue to follow
HEME: HCT stable, continue to follow
ENDO: RISS
ID: cefzolin
TLD: ETT, foley, LSC triple IJ, piv, aline
IVF: None
CONSULTS: Trauma, NSGY
Billing Diagnosis: Multiple injuries (Trauma)
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2134-3-21**] 11:24 PM
14 Gauge - [**2134-3-21**] 11:26 PM
18 Gauge - [**2134-3-21**] 11:26 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Family meeting held , ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 40 minutes
Patient is critically ill"
75,"7 K/uL
[image002.jpg]
[**2134-3-21**] 09:19 PM
[**2134-3-22**] 12:02 AM
[**2134-3-22**] 12:37 AM
[**2134-3-22**] 04:34 AM
WBC
10.7
Hct
36
27.5
27
Plt
177
Creatinine
0.8
TCO2
21
Glucose
179
128
Other labs: PT / PTT / INR:14.7/30.9/1.3, Lactic Acid:3.8 mmol/L,
Ca:9.0 mg/dL, Mg:1.6 mg/dL, PO4:5.1 mg/dL
Assessment and Plan
Assessment and Plan: 24 F s/p MVA with skull fracture and hematoma.
NEURO: Repeat CT shows ? epidural."
76,"m.
Tmax: 37.8
C (100.1
T current: 37.8
C (100.1
HR: 105 (83 - 111) bpm
BP: 99/58(67) {86/52(60) - 113/65(76)} mmHg
RR: 16 (12 - 17) insp/min
SPO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 55 kg (admission): 55 kg
Total In:
1,615 mL
753 mL
PO:
Tube feeding:
IV Fluid:
1,115 mL
753 mL
Blood products:
500 mL
Total out:
1,020 mL
580 mL
Urine:
60 mL
480 mL
NG:
100 mL
Stool:
Drains:
Balance:
595 mL
173 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 450 (450 - 450) mL
PS : 8 cmH2O
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 30%
RSBI: 44
PIP: 16 cmH2O
Plateau: 14 cmH2O
Compliance: 50 cmH2O/mL
SPO2: 100%
ABG: 7."
77,"SICU
HPI:
24 yo F unrestrained driver in roll-over MVC. Partial ejection from
car. GCS at scene unknown, but responsive only to pain - intubated at
scene. Non-depressed skull fracture with overlying laceration, and L
arm laceration to bone. At OSH recieved ancef, tetnus and 2 pRBC.
PMHx:
none
Current medications:
24 Hour Events:
EXTUBATION - At [**2134-3-22**] 10:56 AM
INVASIVE VENTILATION - STOP [**2134-3-22**] 10:56 AM
intubated in field
MULTI LUMEN - STOP [**2134-3-22**] 04:02 PM
EKG - At [**2134-3-23**] 01:06 AM
peaked T waves noted on EKG, 12 lead EKG obtained
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2134-3-22**] 09:57 AM
Infusions:
Other ICU medications:
Midazolam (Versed) - [**2134-3-22**] 05:30 AM
Propofol - [**2134-3-22**] 05:56 AM
Fentanyl - [**2134-3-22**] 08:01 AM
Dilantin - [**2134-3-22**] 08:09 AM
Famotidine (Pepcid) - [**2134-3-22**] 08:11 AM
Hydromorphone (Dilaudid) - [**2134-3-23**] 12:40 AM
Other medications:
Flowsheet Data as of [**2134-3-23**] 05:16 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**36**] a."
78,"7 L/min
Physical Examination
General Appearance: No acute distress
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
174 K/uL
8.8 g/dL
121 mg/dL
0.6 mg/dL
23 mEq/L
3.5 mEq/L
5 mg/dL
108 mEq/L
139 mEq/L
24."
79,"Q1Hr neuro checks. Dilaudid,
percocet for pain. repeat head CT in AM, c/o posterior neck pain
today. I do not see neck films from this hosp admission. Will check
with trauma re: OSH films. Have optho see for left eye ecchymosis
CVS: SBP < 140, prn hydral
PULM: extubated, monitor sats, IS
GI: H2 blocker, advance diet
RENAL: Cr stable, continue to follow UOP, adequate thus far.
HEME: HCT stable, continue to follow
ENDO: RISS
ID: wbc improved, afebrile, ancef off
MuskSkel: plastics splinted left wrist, f/u with them in clinic next
Tue, sling on left shoulder for clavicle fx
TLD: foley, piv
IVF: KVO
CONSULTS: Trauma, NSGY, ortho, plastics, ophtho
BILLING DIAGNOSIS: skull fracture
ICU CARE:
GLYCEMIC CONTROL: RISS
PROPHYLAXIS:
DVT - Boots
STRESS ULCER - H2B
VAP BUNDLE - Yes
COMMUNICATIONS: Parents
ICU Consent: Signed
CODE STATUS: Full
DISPOSITION: transfer to Stepdown
Lines:
20 Gauge - [**2134-3-22**] 05:00 PM
Total time spent: 32 min"
80,"m.
Tmax: 38.1
C (100.5
T current: 37.7
C (99.8
HR: 88 (86 - 119) bpm
BP: 109/55(66) {89/49(60) - 117/71(82)} mmHg
RR: 21 (11 - 28) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 55 kg (admission): 55 kg
Total In:
2,165 mL
30 mL
PO:
140 mL
30 mL
Tube feeding:
IV Fluid:
2,025 mL
Blood products:
Total out:
1,550 mL
1,300 mL
Urine:
1,450 mL
1,300 mL
NG:
100 mL
Stool:
Drains:
Balance:
615 mL
-1,270 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 480 (480 - 528) mL
PS : 8 cmH2O
RR (Set): 16
RR (Spontaneous): 7
PEEP: 5 cmH2O
FiO2: 30%
RSBI: 44
PIP: 13 cmH2O
Plateau: 12 cmH2O
SPO2: 100%
ABG: ///23/
Ve: 5."
81,"5 %
8.6 K/uL
[image002.jpg]
[**2134-3-21**] 09:19 PM
[**2134-3-22**] 12:02 AM
[**2134-3-22**] 12:37 AM
[**2134-3-22**] 04:34 AM
[**2134-3-23**] 01:01 AM
WBC
10.7
8.6
Hct
36
27.5
27
24.5
Plt
177
174
Creatinine
0.8
0.6
TCO2
21
Glucose
179
128
121
Other labs: PT / PTT / INR:14.7/30.9/1.3, Lactic Acid:3.8 mmol/L,
Ca:9.1 mg/dL, Mg:1.9 mg/dL, PO4:3.1 mg/dL
Assessment and Plan
NEURO: Repeat CT shows stable epidural."
82,"TSICU
HPI:
41yo M p/w severe HA, N/V. @OSH, CT showing SAH. Sent to [**Hospital1 1**],
repeat CT showing high attenuation at bifurcation of basilar into
posterior cerbral artery. Neurologically intact.
Chief complaint:
severe HA, n/v
PMHx:
PMH: glaucoma, kidney stone
PSH: lithotripsy, right corneal transplant, multiple R eye [**Doctor First Name **]
Current medications:
24 Hour Events:
Post operative day:
[**3-24**] HD1
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2134-3-22**] 09:57 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2134-3-23**] 08:00 PM
Hydromorphone (Dilaudid) - [**2134-3-24**] 05:15 AM
Other medications:
Flowsheet Data as of [**2134-3-24**] 06:36 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**36**] a."
83,"5/25.0/1.1, Lactic Acid:3.8 mmol/L,
Ca:8.4 mg/dL, Mg:2.0 mg/dL, PO4:2.7 mg/dL
Assessment and Plan
ACUTE PAIN, TRAUMA, S/P
Assessment and Plan: 41yo M p/w SAH at ?bifurcation of basilar into
posterior cerbral artery
Neurologic: SAH, unknown etiology. q1hr neuro checks. Nimodipine 60
mg PO Q4H for spasm proph. goal SBP <140; Pain controlled with fent.
Dilantin for sz proph; possible CTA to find source of bleed, possible
angiogram; h/o right eye glaucoma - to determine home eye gtts
Cardiovascular: goal SBP < 140. Currently at goal w/o NiCARdipine.
Pulmonary: no active issues
Gastrointestinal / Abdomen: NPO, H2B
Nutrition: NPO
Renal: monitor UOP w/ foley
Hematology: no active issues.
Endocrine: RISS
Infectious Disease: no active issue; WBC elevated likely from acute
event.
Lines / Tubes / Drains: A-line, PIV, foley
Wounds:
Imaging:
Fluids: NS20K @ 80
Consults: Neuro surgery
Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2134-3-22**] 05:00 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 23 minutes"
84,"1 g/dL
122 mg/dL
0.5 mg/dL
26 mEq/L
3.7 mEq/L
7 mg/dL
103 mEq/L
138 mEq/L
23.0 %
7.4 K/uL
[image002.jpg]
[**2134-3-21**] 09:19 PM
[**2134-3-22**] 12:02 AM
[**2134-3-22**] 12:37 AM
[**2134-3-22**] 04:34 AM
[**2134-3-23**] 01:01 AM
[**2134-3-24**] 02:00 AM
WBC
10.7
8.6
7.4
Hct
36
27.5
27
24.5
23.0
Plt
177
174
204
Creatinine
0.8
0.6
0.5
TCO2
21
Glucose
179
128
121
122
Other labs: PT / PTT / INR:12."
85,"m.
Tmax: 37.7
C (99.8
T current: 37.2
C (98.9
HR: 80 (78 - 95) bpm
BP: 109/65(77) {99/61(69) - 122/82(92)} mmHg
RR: 17 (12 - 22) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 55.7 kg (admission): 55 kg
Total In:
980 mL
240 mL
PO:
880 mL
240 mL
Tube feeding:
IV Fluid:
100 mL
Blood products:
Total out:
2,299 mL
500 mL
Urine:
2,299 mL
500 mL
NG:
Stool:
Drains:
Balance:
-1,319 mL
-260 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 100%
ABG: ///26/
Physical Examination
General Appearance: No acute distress
HEENT: right eye surgical, left eye reactive
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
204 K/uL
8."
86,"Admission Date: [**2182-4-30**] Discharge Date: [**2182-5-3**]
Date of Birth: [**2158-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bacitracin
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 23 year old male with minimal past medical
history who presented to his PCP for epigastric pain and was
found to have glucose greater than 500. He did not have a prior
diagnosis of diabetes mellitus.
.
On Thursday, [**2182-4-25**], he had a hematoma/abscess on his left
inner thigh that was treated with incision and drainage."
87,"There is no underlying
fat stranding, fluid collection or abscess. The fascial planes
and muscle architecture is well preserved in the thigh. There
are some prominent left inguinal nodes, but they all demonstrate
normal fatty hila. No suspicious lytic or sclerotic osseous
lesion is identified. The visualized portion of the pelvis is
unremarkable.
IMPRESSION: No evidence of abscess.
Brief Hospital Course:
The patient is a 23 year old male with no significant past
medical history who presented to his PCP with epigastric pain
and was found to be in DKA with a new diagnosis of diabetes
mellitus.
# Diabetic Ketoacidosis: He presented in DKA with glucose in the
300s and an anion gap of 27."
88,"# Epigastric Pain: He initially presented with epigastric pain,
most likely due o his DKA. His transaminases, bilirubin, and
lipase were unremarkable on admission. There was no evidence of
a separate abdominal pathology. His abdominal pain had resolved
by the time he arrived at the ICU and never reoccurred.
.
# Left Thigh Abscess: He had an abscess on his left inner thigh
which was treated with surgical I+D on [**2182-4-25**]. He was started
on Cephalexin, which was stopped on [**2182-4-29**]. Reportedly, only
blood was drained from the lesion, without significant
purulence. The patient has been packing the wound according to
instructions."
89,"Directions:
To test blood sugar 4 times a day.
DISP: 1 month supply
refills: 1
Discharge Disposition:
Home
Discharge Diagnosis:
acute likely type 1 diabetes without complication
L.thigh carbuncle/cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with newly diagnosed diabetes. You were
initially in the ICU. You were evaluated by the [**Last Name (un) **] Diabetes
team who have recommended your current insulin regimen. You
received diabetic teaching in terms of diet and how to
administer insulin. Please be sure to check your blood sugars 4
times a day as was being done in the hospital."
90,"Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L
Location: [**Hospital **] MEDICAL-[**Location (un) **]
Address: [**Location (un) 90398**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 31449**]
Phone: [**Telephone/Fax (1) 90399**]
Appt: Please call Dr [**Last Name (STitle) 33854**] on Monday to book a follow up
appt from your hospital stay within one week.
Location: [**Last Name (un) **] Diabetes Center
Address: One [**Last Name (un) **] Place, [**Location (un) 86**], MA 0215
Phone: [**Telephone/Fax (1) 2378**]
Appt: [**5-14**] at 2pm --Eye exam(please arrive at 1:30 for
registration)
Appt: [**5-14**] at 2:30pm--[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**], NP"
91,"9
[**2182-4-30**] 11:22AM BLOOD Lipase-33
[**2182-5-1**] 05:10AM BLOOD CK-MB-3 cTropnT-<0.01
[**2182-4-30**] 11:22AM BLOOD cTropnT-<0.01
[**2182-5-3**] 05:50AM BLOOD Calcium-9.8 Phos-4.7*# Mg-1.9
[**2182-5-2**] 01:25PM BLOOD Calcium-9.9 Phos-3.1 Mg-1.8
[**2182-5-2**] 05:42AM BLOOD Calcium-9.3 Phos-4.3# Mg-1.7
[**2182-5-1**] 05:31PM BLOOD Calcium-9.7 Phos-2.1* Mg-1.8
[**2182-5-1**] 01:49PM BLOOD Calcium-9.4 Phos-2."
92,"He had labs drawn and
the Cephalexin was stopped. He was contact[**Name (NI) **] the next day for a
glucose level in the 500s, and sent in to the ED.
.
In the ED, he continued to have mild epigastric pain, but was
otherwise asymptomatic. Physical exam was unremarkable.
Initial vitals in triage were T 98.2, BP 132/59, HR 103, RR 16,
SpO2 100% on RA. His initial FBG was 268. Labs were drawn and
he was found to be in DKA with initial glucose 302, bicarb 9,
potassium 3.7, anion gap 27, lactate 1.8, ionized calcium 1."
93,"5* Mg-1.7
[**2182-5-1**] 09:04AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8
[**2182-5-1**] 05:10AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.7
[**2182-5-1**] 12:09AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.7
[**2182-4-30**] 08:54PM BLOOD Calcium-7.7* Phos-2.3* Mg-1.9
[**2182-4-30**] 05:28PM BLOOD Calcium-8.0* Phos-1.5* Mg-1.5*
[**2182-4-30**] 02:51PM BLOOD pH-7.26*
[**2182-4-30**] 02:15PM BLOOD pH-7.26* Comment-GREEN TOP
[**2182-4-30**] 11:18AM BLOOD pH-7."
94,"4 Eos-0.7
Baso-1.1
[**2182-5-3**] 05:50AM BLOOD Glucose-192* UreaN-7 Creat-0.8 Na-142
K-3.5 Cl-102 HCO3-31 AnGap-13
[**2182-5-2**] 01:25PM BLOOD Glucose-134* UreaN-7 Creat-0.7 Na-142
K-3.5 Cl-105 HCO3-25 AnGap-16
[**2182-5-2**] 05:42AM BLOOD Glucose-187* UreaN-4* Creat-0.7 Na-140
K-2.9* Cl-102 HCO3-27 AnGap-14
[**2182-5-1**] 05:31PM BLOOD Glucose-135* UreaN-3* Creat-0.8 Na-136
K-3.7 Cl-100 HCO3-24 AnGap-16
[**2182-5-1**] 01:49PM BLOOD Glucose-240* UreaN-3* Creat-0."
95,"Disp:*10 Capsule(s)* Refills:*0*
3. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
Six (36) units Subcutaneous once a day: at breakfast.
Disp:*qs qs* Refills:*1*
4. Humalog 100 unit/mL Cartridge Sig: 0-25 units Subcutaneous
QIDACHS: before each meal and at bedtime. Use according to
sliding scale.
Disp:*qs qs* Refills:*1*
5. glucometer
Please provide glucometer.
DX: insulin dependent diabetes.
Test blood sugar 4 times a day.
6. Insulin Pen Needle 31 Needle Sig: as directed
Miscellaneous QIDACHS.
Disp:*qs qs* Refills:*1*
7. one touch ultra
once touch ultra testing strips."
96,"Reportedly, only blood was present and no purulent material. He
was started on Cephalexin, and instructed to pack the wound. He
was feeling well until Sunday, [**2182-4-28**], when he developed
epigastric discomfort after playing football. He described it
as a gnawing pain that he had not experienced before. He denied
any nausea, vomiting, diarrhea, constipation, or other GI
symptoms. He also felt thirsty and drank water. He ate, took a
nap, and felt much better. He had to urinate several times over
the night and had the same abdominal pain the next morning. He
was concerned that he was having a reaction to the antibiotic
and went in to see his doctor yesterday."
97,"Below is his insulin
scale upon discharge. He will follow with [**Last Name (un) **] after
discharge. Instructed to check finger sticks QIDACHS as he may
experience hypoglycemia as he becomes more active and infection
resolves. Likely type 1 diabetes, but awaiting antibody testing.
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-80 mg/dL 7 Units 7 Units 9 Units 0 Units
81-130 mg/dL 10 Units 10 Units 12 Units 0 Units
131-180 mg/dL 12 Units 12 Units 14 Units 0 Units
181-230 mg/dL 14 Units 14 Units 16 Units 2 Units
231-280 mg/dL 16 Units 16 Units 18 Units 4 Units
281-330 mg/dL 19 Units 19 Units 21 Units 6 Units
331-380 mg/dL 22 Units 22 Units 23 Units 8 Units
381-400 mg/dL 25 Units 25 Units 26 Units 10 Units
."
98,"34,
and ketones on UA. He had Hct 44.8, WBC 6.0, and unremarkable
LFTs. CXR showed no acute process and EKG showed TWI in III and
aVF.
.
He had two PIVs placed, and was given NS boluses for a total of
[**2171**] ml. He was also given 1000 ml of NS with 40 mEq KCl at 250
ml/hr. He was started on an Insulin drip at 6 units/hr, and his
glucose decreased to 280 on fingerstick. His Insulin drip was
temporarily increased to 10 units/hr. Prior to ICU transfer,
his glucose had decreased to 162 and his anion gap had decreased
to 16."
99,"Vital signs on ICU transfer were T 97.6, HR 87, BP
112/72, RR 16, and SpO2 100% on RA.
.
Once in the ICU, he reported that he was no longer thirsty and
that his adbdominal discomfort had resolved. His only complaint
was some slight itching at the site of his I+D. He reports that
he has lost 80 lbs over the last year through diet changes and
exercise. He has been feeling well with no recent illnesses.
He denies any increased thirst or polyuria prior to the last few
days.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denied fever, chills, or night sweats."
100,"Denied headache,
sinus tenderness, rhinorrhea, or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, or
constipation. No recent change in bowel habits. No dysuria.
Denied arthralgias or myalgias. Review of systems was otherwise
negative.
Past Medical History:
# Left Thigh Abscess/Hematoma
-- I+D on [**2182-4-25**] with blood removed
# Frostbite as child
Social History:
He works as an EMT and lives at home with his parents. He has
two older brothers, one who was adopted.
# Tobacco: None
# Alcohol: Occasional alcohol up to [**4-12**] drinks weekly
# Drugs: None
Family History:
Several family members on father's side with diabetes, unclear
whether Type 1 or Type 2."
101,"Father's great uncle had a daughter
who died young from diabetes. No other family history of
autoimmune disease.
Physical Exam:
Gen: Young male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. JVP not elevated. No cervical
lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+."
102,"Early R wave progression. Mild J point and ST segment elevation
in the precordial leads of uncertain significance. No previous
tracing available for comparison. TRACING #1
.
[**4-30**]-Sinus rhythm. Miild inferior and anterior ST segment
elevation of uncertain significance. Since the previous tracing
of earlier same date T wave amplitudes are diminished.
Otherwise, unchanged.
.
CXR [**4-30**]-FINDINGS: The lungs are well expanded and clear. The
mediastinum is unremarkable. The cardiac silhouette is within
normal limits for size. No effusion or pneumothorax is noted.
The visualized osseous structures are unremarkable.
IMPRESSION: No acute pulmonary process
.
CT leg:
FINDINGS: There is minimal skin thickening in the proximal
medial left thigh which is asymmetric compared to the right side
and may represent the area of concern."
103,"8 Na-137
K-3.7 Cl-99 HCO3-26 AnGap-16
[**2182-5-1**] 09:04AM BLOOD Glucose-100 UreaN-4* Creat-0.7 Na-137
K-3.0* Cl-106 HCO3-22 AnGap-12
[**2182-5-1**] 05:10AM BLOOD Glucose-385* UreaN-4* Creat-0.8 Na-133
K-6.0* Cl-107 HCO3-21* AnGap-11
[**2182-5-1**] 12:09AM BLOOD Glucose-335* UreaN-6 Creat-0.8 Na-133
K-4.8 Cl-105 HCO3-19* AnGap-14
[**2182-4-30**] 08:54PM BLOOD Glucose-217* UreaN-7 Creat-0.8 Na-133
K-3."
104,"9 RBC-5.12 Hgb-16.6# Hct-43.8#
MCV-86 MCH-32.3* MCHC-37.8* RDW-12.6 Plt Ct-201
[**2182-5-1**] 05:10AM BLOOD WBC-6.0 RBC-4.12* Hgb-13.4*# Hct-34.7*#
MCV-84 MCH-32.6* MCHC-38.7* RDW-13.8 Plt Ct-181
[**2182-4-30**] 11:22AM BLOOD WBC-6.0 RBC-5.17 Hgb-16.9 Hct-44.8 MCV-87
MCH-32.6* MCHC-37.7* RDW-13.3 Plt Ct-235
[**2182-4-30**] 11:22AM BLOOD Neuts-71.2* Lymphs-21.6 Monos-5."
105,"9 Cl-103 HCO3-17* AnGap-17
[**2182-4-30**] 05:28PM BLOOD Glucose-104* UreaN-9 Creat-0.8 Na-136
K-3.0* Cl-107 HCO3-14* AnGap-18
[**2182-4-30**] 02:45PM BLOOD Glucose-162* UreaN-10 Creat-1.0 Na-137
K-3.4 Cl-106 HCO3-15* AnGap-19
[**2182-4-30**] 02:05PM BLOOD Glucose-673* UreaN-11 Creat-1.0 Na-137
K-8.6* Cl-113* HCO3-11* AnGap-22*
[**2182-4-30**] 11:22AM BLOOD Glucose-331* UreaN-13 Creat-1.1 Na-133
K-4.1 Cl-97 HCO3-9* AnGap-31*
[**2182-5-1**] 05:10AM BLOOD CK(CPK)-81
[**2182-4-30**] 11:22AM BLOOD ALT-22 AST-19 LD(LDH)-274* AlkPhos-80
Amylase-21 TotBili-0."
106,"22*
[**2182-4-30**] 02:51PM BLOOD Glucose-156* Lactate-1.0 Na-138 K-3.3*
Cl-109 calHCO3-14*
[**2182-4-30**] 02:15PM BLOOD Glucose->500 Lactate-0.9 Na-139 K-8.1*
Cl-117* calHCO3-11*
[**2182-4-30**] 11:18AM BLOOD Glucose-302* Lactate-1.8 Na-138 K-3.7
Cl-100 calHCO3-13*
[**2182-4-30**] 02:51PM BLOOD freeCa-1.11*
[**2182-4-30**] 02:15PM BLOOD freeCa-1.08*
[**2182-4-30**] 11:18AM BLOOD freeCa-1.34*
.
[**4-30**]-EKG Sinus rhythm. T wave inversions in leads III and aVF."
107,"It appeared to be indurated with somewhat poor
healing, but no clear evidence of infection. Surgery was
consulted and recommended cephalexin, a CT which was negative
for abscess, and no need for further I+D. Pt was discharged on
cephalexin and doxycycline for cMRSA coverage for 5 more days.
.
#DVT ppx-hep SC TID.
Medications on Admission:
None
Discharge Medications:
1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
2. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 5 days."
108,"He was placed on an insulin drip
and his glucose normalized, with a drop in his AG to 16 prior to
reaching the ICU. He was continued on the insulin drip until his
gap closed. He was supported with NS IVF initially and
transitioned to D5NS, and then discontinued when he was taking
fluids well by mouth. [**Last Name (un) **] was consulted as well as nutrition.
He was transitioned to subq insulin of 36 units glargine and
aggressive SS. On transfer to the floor, his gap was closed and
he was asymptomatic. His electrolytes were repleted
aggressively. He was followed by [**Last Name (un) **] and received diabetic
teaching on insulin and diabetic diet."
109,"Skin: Mildly indurated, but nontender and nonfluctuant lesion on
left inner thigh with scant serosanguinous drainage, about 2 cm
in diameter. No surrounding erythema. No other rashes, ulcers,
or lesions noted.
Neuro: CN II-XII grossly intact. Normal gait. Normal language.
Pertinent Results:
.
Studies:
CT LOW WXT W/C LEFT Study Date of [**2182-5-1**] 9:18 AM
IMPRESSION: No evidence of abscess.
[**2182-5-2**] 05:42AM BLOOD WBC-5.1 RBC-4.68 Hgb-15.0 Hct-40.7 MCV-87
MCH-32.2* MCHC-36.9* RDW-12.9 Plt Ct-175
[**2182-5-1**] 01:49PM BLOOD WBC-5."
110,"Your blood sugars
may change at home as your leg infection improves and your
activity level increases. Please be sure to call the [**Last Name (un) **]
providers if your blood sugars are too high or too low. See
below. Please also be sure to follow a consistent carbohydrate
diet.
.
Medication changes:
1.start glargine (lantus) insulin 36 units at breakfast
2.start humalog sliding scale insulin 7-25 units at meal time
and bedtime as instructed.
3.check your blood sugars before each meal and at bedtime.
4.keflex 500mg four times a day for 5 more days
5.doxycycline 100mg twice a day 5 more days."
111,"Admission Date: [**2172-5-20**] Discharge Date: [**2172-5-27**]
Date of Birth: [**2104-7-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Abnormal stress test
Major Surgical or Invasive Procedure:
[**2172-5-22**] Coronary Artery Bypass Graft x 5 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal, saphenous vein graft to ramus, saphenous vein graft to
obtuse marginal, saphenous vein graft to posterior descending
artery)
History of Present Illness:
60 year old male who underwent cardiac evalutaion due to risk
factors."
112,"Had abnormal stress test and underwent cardiac cath.
Catherization revealed severe coronary disease and he was
transferred to [**Hospital3 **] for surgery.
Past Medical History:
Coronary Artery Disease with history of Myocardial infarction
Hypertension
Diabetes Mellitus
Hyperlipidemia
status post Appendectomy
status post Tonsillectomy
Social History:
Retired custodian. Tobacco history of 2 packs year history as
teenager. No alcohol in last 25 years.
Lives with significant other
Family History:
Non-contributory
Physical Exam:
Vitals: 48 16 148/76
General: No acute distress
Skin: Warm, dry and intact
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Lungs clear bilaterally
Heart: Irregular rhythm with 1/6 systolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Grossly intact"
113,"Following surgery he was transferred to
the CVICU for invasive monitoring. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. Chest
tubes and epicardial pacing wires were removed per protocol. On
post-operative day three he was transferred to the telemetry for
further care. He continued to improve while working with
physical therapy. On hospital day five he was discharged home
with VNA services.
Medications on Admission:
Aspirin 325mg daily, Atenolol 25mg daily, Avandamet 2/1000mg
[**Hospital1 **], Lisinopril 20mg daily, Simvastatin 20mg daily,
Nitroglycerin SL PRN
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day)."
114,"1 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 7 mm Hg < 20 mm Hg
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV
systolic function. Overall normal LVEF (>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter."
115,"Pertinent Results:
[**2172-5-26**] 05:55AM BLOOD WBC-5.8 RBC-3.08* Hgb-9.4* Hct-28.5*
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.5 Plt Ct-135*
[**2172-5-20**] 08:23PM BLOOD WBC-5.7 RBC-3.72* Hgb-11.5* Hct-33.5*
MCV-90 MCH-30.8 MCHC-34.2 RDW-14.6 Plt Ct-154
[**2172-5-26**] 05:55AM BLOOD Plt Ct-135*
[**2172-5-20**] 08:23PM BLOOD PT-12.8 PTT-27.1 INR(PT)-1.1
[**2172-5-20**] 08:23PM BLOOD Plt Ct-154
[**2172-5-26**] 05:55AM BLOOD Glucose-157* UreaN-15 Creat-1."
116,"Blood glucose monitor
Blood glucose strips
Lancets
Alcohol wipes
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p cornary artery bypass graft surgery
Hypertension
Diabetes Mellitus type 2
Hyperlipidemia
Myocardial infarction
status post Appendectomy
status post Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks from date of surgery
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Please monitor blood glucose two to three times a day until
sternal wound healed and if 200 or greater please follow up with
Dr [**Last Name (STitle) 12593**] [**Telephone/Fax (1) 82482**]
Please avoid concentrated sweets
Followup Instructions:
Please call to schedule appointments
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] in [**3-17**] weeks
Dr. [**Last Name (STitle) 12593**] in 1 week [**Telephone/Fax (1) 82482**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2172-5-27**]"
117,"Little change in the
appearance of
the mediastinal silhouette.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2172-5-26**] 4:54 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82481**]
(Complete) Done [**2172-5-22**] at 9:25:27 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2104-7-7**]
Age (years): 67 M Hgt (in): 68
BP (mm Hg): 123/67 Wgt (lb): 183
HR (bpm): 67 BSA (m2): 1."
118,"2. Left ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
6.The mitral valve appears structurally normal with trivial
mitral regurgitation.
7.There is a trivial/physiologic pericardial effusion.
8. Dr [**Last Name (STitle) **] was notified in person of the results on
[**2172-5-22**] at 930am."
119,"Radiology Report CHEST (PA & LAT) Study Date of [**2172-5-26**] 3:07 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2172-5-26**] 3:07 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 82480**]
Reason: f/u atx, effusion
[**Hospital 93**] MEDICAL CONDITION:
67 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
f/u atx, effusion
Final Report
HISTORY: Status post CABG.
FINDINGS: In comparison with study of [**5-24**], the patient has
taken a much
better inspiration and the degree of basilar atelectasis is
decreased. There
is opacification posteriorly heading upward along the chest wall
consistent
with probable bilateral pleural effusion."
120,"Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
8. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11."
121,"Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
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. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler."
122,"Post Bypass
1. Patient is in sinus rhythm and receiving an infusion of
phenylephrine.
2. Biventricular systolic function is unchanged.
3. Aorta intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2172-5-22**] 13:43
[**Known lastname **],[**Known firstname **] [**Medical Record Number 82479**] M 67 [**2104-7-7**]
Cardiology Report ECG Study Date of [**2172-5-22**] 3:32:52 PM
Sinus rhythm with bigeminal atrial premature beats. Compared to
the previous
tracing of [**2172-5-20**] atrial premature beats are not seen on the
current tracing."
123,"Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6."
124,"0 Na-142
K-4.5 Cl-105 HCO3-28 AnGap-14
[**2172-5-20**] 08:23PM BLOOD Glucose-250* UreaN-13 Creat-1.0 Na-141
K-4.1 Cl-107 HCO3-27 AnGap-11
[**2172-5-20**] 08:23PM BLOOD ALT-14 AST-17 LD(LDH)-133 CK(CPK)-42
AlkPhos-44 Amylase-19 TotBili-0.4
[**2172-5-20**] 08:23PM BLOOD Lipase-34
[**2172-5-27**] 06:35AM BLOOD Phos-3.6 Mg-2.1
[**2172-5-20**] 08:23PM BLOOD %HbA1c-7.7*
[**Known lastname **],[**Known firstname **] [**Medical Record Number 82479**] M 67 [**2104-7-7**]"
125,"Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 126 78 390/404 -2 -21 53
Brief Hospital Course:
As mentioned in the history of present illness, Mr. [**Known lastname 67118**]
was transferred from outside hospital to [**Hospital3 **] for
coronary artery bypass surgery. Upon admission he was
appropriately worked up prior to surgical intervention. On [**5-22**]
he was brought to the operating room where he underwent a
coronary artery bypass graft surgery. Please see operative
report for surgical details. He received vancomycin for
perioperative antibiotics because he was in the hospital greater
than twenty four hours."
126,"97 m2
Indication: Intraoperative TEE for CABG. Chest pain. Coronary
artery disease. Left ventricular function. Preoperative
assessment. Right ventricular function.
ICD-9 Codes: 786.05, 786.51, 440.0
Test Information
Date/Time: [**2172-5-22**] at 09:25 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: aw1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1."
127,"6
0.8
TCO2
24
26
22
22
24
19
Glucose
152
136
112
99
98
140
115
Other labs: PT / PTT / INR:14.5/37.4/1.3, Fibrinogen:172 mg/dL, Lactic
Acid:1.2 mmol/L, Ca:8.6 mg/dL, Mg:1.6 mg/dL, PO4:1.5 mg/dL
Imaging: x
Microbiology: x
Assessment and Plan
CORONARY ARTERY BYPASS GRAFT (CABG)
Assessment and Plan:
Neurologic: Neuro checks Q: 4 hr, Pain controlled with percocet and
morphine prn
Cardiovascular: Aspirin, Beta-blocker, Statins
Pulmonary: IS cough and deep breath oob to chair
Gastrointestinal / Abdomen: bowel regimen
Nutrition: Regular diet
Renal: Foley, Adequate UO, no lasix due to autodiuresis
Hematology: stable anemia
Endocrine: RISS, Insulin drip, Lantus (R)
Infectious Disease: vancomycin for periop antibiotics
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Fluids: KVO
Consults: P.T.
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale, Insulin infusion,
Lantus (R) protocol
Lines:
Arterial Line - [**2172-5-22**] 01:30 PM
Cordis/Introducer - [**2172-5-22**] 01:30 PM
20 Gauge - [**2172-5-22**] 01:30 PM
Prophylaxis:
DVT:
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: Transfer to floor"
128,"8 mg/dL
21 mEq/L
4.2 mEq/L
8 mg/dL
110 mEq/L
136 mEq/L
29.8 %
5.8 K/uL
[image002.jpg]
[**2172-5-22**] 12:56 PM
[**2172-5-22**] 01:51 PM
[**2172-5-22**] 01:57 PM
[**2172-5-22**] 03:05 PM
[**2172-5-22**] 04:10 PM
[**2172-5-22**] 05:10 PM
[**2172-5-22**] 06:07 PM
[**2172-5-22**] 06:11 PM
[**2172-5-22**] 08:29 PM
[**2172-5-23**] 02:06 AM
WBC
5.2
5.8
Hct
28
28.3
26.1
29.8
Plt
83
84
Creatinine
0."
129,"42/28/134/21/-4
Ve: 10.4 L/min
PaO2 / FiO2: 134
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), pericardial rub
Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:
Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,
hypoactive
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact), bilateral lower extremities
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
84 K/uL
10.5 g/dL
115 mg/dL
0."
130,"4
C - [**2172-5-22**] 11:00 PM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2172-5-23**] 08:41 AM
Infusions:
Other ICU medications:
Morphine Sulfate - [**2172-5-22**] 05:37 PM
Insulin - Regular - [**2172-5-23**] 01:01 AM
Hydralazine - [**2172-5-23**] 06:38 AM
Other medications:
Flowsheet Data as of [**2172-5-23**] 11:10 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**75**] a.m.
Tmax: 39.1
C (102.4
T current: 37.7
C (99.9
HR: 69 (69 - 105) bpm
BP: 131/51(75) {78/39(52) - 144/76(84)} mmHg
RR: 14 (7 - 23) insp/min
SPO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 90."
131,"3 kg (admission): 82.3 kg
Height: 67 Inch
CVP: 12 (4 - 17) mmHg
PAP: (44 mmHg) / (18 mmHg)
CO/CI (Thermodilution): (6.81 L/min) / (3.5 L/min/m2)
SVR: 693 dynes*sec/cm5
SV: 86 mL
SVI: 44 mL/m2
Total In:
5,393 mL
869 mL
PO:
Tube feeding:
IV Fluid:
5,193 mL
869 mL
Blood products:
Total out:
2,897 mL
1,760 mL
Urine:
2,390 mL
1,370 mL
NG:
Stool:
Drains:
Balance:
2,496 mL
-891 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 495 (444 - 495) mL
PS : 5 cmH2O
RR (Set): 16
RR (Spontaneous): 20
PEEP: 5 cmH2O
FiO2: 100%
PIP: 11 cmH2O
Plateau: 16 cmH2O
SPO2: 97%
ABG: 7."
132,"CVICU
HPI:
HD4
[**5-23**] POD 1
67M s/p CABGx5(LIMA->LAD, SVG->Diag, Ramus, OM, PDA) [**5-22**]
EF 53% Cr 1.1 wt 83.4 kg HgbA1c 7.7
PMH Hypertension, DM type 2, hyperlipidemia, myocardial infarction
[**Last Name (un) **] Aspirin 325', Atenolol 25', Avandamet 2/1000"", lisinopril 20',
simvastatin 20', nitrogylcerin SL prn
Current medications:
Acetaminophen, Albuterol-Ipratropium, Aspirin, Docusate Sodium,
HydrALAzine, insulin, Metoprolol Tartrate, Morphine Sulfate,
Oxycodone-Acetaminophen, Ranitidine, Simvastatin, Vancomycin
24 Hour Events:
Received from OR
Required nitroglycerin for blood pressure management
Extubated without complications
OR RECEIVED - At [**2172-5-22**] 01:27 PM
CABG x5
PA CATHETER - START [**2172-5-22**] 01:30 PM
INVASIVE VENTILATION - START [**2172-5-22**] 01:30 PM
ARTERIAL LINE - START [**2172-5-22**] 01:30 PM
CORDIS/INTRODUCER - START [**2172-5-22**] 01:30 PM
EKG - At [**2172-5-22**] 03:30 PM
INVASIVE VENTILATION - STOP [**2172-5-22**] 08:30 PM
FEVER - 102."
133,"1
Hct
28.3
26.1
29.8
29.9
Plt
83
84
89
Creatinine
0.6
0.8
0.9
TCO2
26
22
22
24
19
Glucose
136
112
99
98
140
115
157
Other labs: PT / PTT / INR:14.5/37.4/1.3, Fibrinogen:172 mg/dL, Lactic
Acid:1.2 mmol/L, Ca:8.6 mg/dL, Mg:2.1 mg/dL, PO4:1.5 mg/dL
Imaging: CXR pending after CT removal
Assessment and Plan
CORONARY ARTERY BYPASS GRAFT (CABG)
Assessment and Plan: Stable. Addressing hyperglycemia w/ Avavadia &
SSI. To floor today.Continue diuresis.
Neurologic:
Cardiovascular: Aspirin, Beta-blocker, Statins
Pulmonary: IS
Gastrointestinal / Abdomen:
Nutrition: Advance diet as tolerated
Renal: Foley
Hematology:
Endocrine: RISS, Avandia
Infectious Disease:
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Imaging: CXR today
Fluids: Other
Consults: P.T.
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale, Comments: Avandia
Lines:
20 Gauge - [**2172-5-23**] 09:16 PM
Prophylaxis:
DVT:
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: Transfer to floor"
134,"CVICU
HPI:
HD5
[**5-23**] POD 1
67M s/p CABGx5(LIMA->LAD, SVG->Diag, Ramus, OM, PDA) [**5-22**]
EF 53% Cr 1.1 wt 83.4 kg HgbA1c 7.7
PMH Hypertension, DM type 2, hyperlipidemia, myocardial infarction
[**Last Name (un) **] Aspirin 325', Atenolol 25', Avandamet 2/1000"", lisinopril 20',
simvastatin 20', nitrogylcerin SL prn
Echo4/9:EF 55%, valves okay. Carotid U/S [**5-21**]:<40% B
Chief complaint:
PMHx:
Current medications:
Acetaminophen . Albuterol-Ipratropium . Aspirin EC . Calcium
Gluconate. Dextrose 50% . Docusate Sodium Insulin . Lisinopril .
Magnesium Sulfate . Metoprolol Tartrate . Metoclopramide . Milk of
Magnesia . Morphine Sulfate . Neutra-Phos ."
135,"Oxycodone-Acetaminophen .
Pneumococcal Vac Polyvalent . Potassium Chloride . . Ranitidine .
Rosiglitazone Maleate . Simvastatin . Vancomycin
24 Hour Events:
PA CATHETER - STOP [**2172-5-23**] 08:00 AM
ARTERIAL LINE - STOP [**2172-5-23**] 11:30 AM
CALLED OUT
Post operative day:
[**5-24**] POD 2 CABG
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2172-5-24**] 08:00 AM
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2172-5-24**] 10:57 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**75**] a.m.
Tmax: 37.6
C (99.6
T current: 37.5
C (99.5
HR: 77 (68 - 82) bpm
BP: 147/55(77) {108/44(63) - 147/86(106)} mmHg
RR: 23 (14 - 23) insp/min
SPO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 90."
136,"3 kg (admission): 82.3 kg
Height: 67 Inch
Total In:
1,288 mL
200 mL
PO:
400 mL
Tube feeding:
IV Fluid:
888 mL
200 mL
Blood products:
Total out:
4,315 mL
1,890 mL
Urine:
3,590 mL
1,765 mL
NG:
Stool:
Drains:
Balance:
-3,027 mL
-1,690 mL
Respiratory support
O2 Delivery Device: None
SPO2: 96%
ABG: ///25/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese
Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),
(Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
89 K/uL
10."
137,"4 g/dL
157 mg/dL
0.9 mg/dL
25 mEq/L
4.1 mEq/L
11 mg/dL
108 mEq/L
139 mEq/L
29.9 %
7.1 K/uL
[image002.jpg]
[**2172-5-22**] 01:51 PM
[**2172-5-22**] 01:57 PM
[**2172-5-22**] 03:05 PM
[**2172-5-22**] 04:10 PM
[**2172-5-22**] 05:10 PM
[**2172-5-22**] 06:07 PM
[**2172-5-22**] 06:11 PM
[**2172-5-22**] 08:29 PM
[**2172-5-23**] 02:06 AM
[**2172-5-24**] 12:42 AM
WBC
5.2
5.8
7."
138,"1 Bas:0.1
Other Hematology
Gran-Ct: [**Numeric Identifier 87757**]
PT: 12.9 PTT: 28.1 INR: 1.1
Brief Hospital Course:
ASSESSMENT:
74 year old male with BPH, s/p R inguinal hernia repair present
with pleuritic abdominal/chest pain found to have a extensive
lymphadenopathy throughout torso and aotocaval large
conglomerate mass with compression of IVC and R common iliac
vein.
.
# Lymphoma- Patient was initially admitted to the medical floor
for expedited evaluation of presumed lymhoproliferative disorder
in the setting of CTA which showed bulky lymphadenopathy and
aortocaval large conglomerate mass with
compression of IVC and right common iliac vein."
139,"Initial labs in
the ED were remarkable for lactic acidosis with HCO3 of 15 and a
lactate of 7.9. On the medical floor, he was found to have a
uric acid of 13.5 and an LDH of 604 in the setting of normal
calcium/ phosphate/ potassium. He was started on allopurinol and
IVF due to concern for TLS. A heme-onc consult was called and an
axillary LN biopsy showed prelimary path c/w aggressive
lymphoma. Bone marrow biopsy eventually showed diffuse large B
cell lymphoma. Patient was noted to have increased work of
breathing with ABG showing worsening acidosis 7."
140,"32/19/111 and
lactate of 11.4. A bicarb drip was initiated and due to concern
for worsening lactic acidosis, patient was transferred to the
ICU. Lactic acidosis was attributed to tumor mass necrosis vs.
infection and patient was started on vanc/zosyn/azithro for
pneumonia visualized on CT chest (see below). He received [**Hospital1 **]
for treatment of his lymphoma and tumor lysis labs were
monitored q6 given his spontaneous tumor lysis syndrome on
admission. He received rasburicase for persistently elevated
uric acid and new renal failure (creatinine 1.3 from 1.0) with
improvement of his symptoms. He became fluid overloaded and was
diuresed with lasix."
141,"Repeat imaging with CT scan showed widespread
peripheral consolidations concerning for an inflammatory
etiology such as eosinophilic pneumonia or organizing pneumonia,
but ultimately attributed to resolving pneumonia in the setting
of a reconstituted immune system as the patient was asymptomatic
and appeared well. Patient will need repeat imaging in [**12-22**] weeks
after discharge to assess progression.
.
# Rash- Patient developed an erythematous papular eruption on
his back as well as a well demarcated erythematous plaque on his
lower L back. Dermatology was consult and attributed the former
to a resolving drug reaction and that latter to a contact
dermatitis. Triamcinolone was applied topically to the plaque
with gradual improvement."
142,".
#. Fluid retention: Patient received fluids as part of his
chemotherapy regimen. His weight increased 10 lbs over several
days secondary to fluid retention. He was diuresed with good
effect and subsequently reaccumulated fluid in his legs with the
second round of chemo. He was restarted on lasix and sent home
to continue diuresis with f/u in the outpatient clinic.
.
#. Headache: Patient complained of mild intermittent R
retro-orbital pain without associated visual changes, diploplia,
or floaters. Was seen by opthalmology who attributed his eye
symptoms to dry eyes. CT head w/ and w/o contrast was negative
for bleeds and metastatic disease."
143,".
# Shingles- Patient complained of continued post herpetic
neuralgia related to his shingles episode six months earlier.
His pain was managed with lidocaine patches and
oxycodone/oxycontin.
.
#. BPH: No active issues. Patient was continued on finasteride
and tamsulosin as his home BPH medications were not on
formulary.
Medications on Admission:
avodart 0.5 mg
uroxatral/alfuzosin alpha 1 blocker 10 mg
Lidoderm patch
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take while you are taking oxycodone.
Disp:*60 Capsule(s)* Refills:*2*
2. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime."
144,"Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
13. alfuzosin 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Diffuse Large B Cell Lymphoma
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent."
145,"Past Medical History:
Enlarged prostate
Shingles - 18 months ago and he is on lyrica
H/o PNA one year ago during which opacities were found, s/p
bronchoscopy. His PNA was diagnosed as part of an evaluation
for weight loss. He did not have fevers, chills or cough
S/p hernia repair in [**9-/2137**]
Social History:
SOCIAL HISTORY/ FUNCTIONAL STATUS:
Son: HCP [**Name (NI) 2491**] [**Name (NI) 87754**]: [**Telephone/Fax (1) 87755**]
Office: [**Telephone/Fax (1) 87756**]
< 65
Cigarettes: [ X] never [ ] ex-smoker [x] current Pack-yrs: 10
quit: ______
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs: none
Occupation: retired engineer
Migrated from [**Country 532**] in [**2115**]
Marital Status: [X ] Married [] Single
Lives: [ ] Alone [X] w/ family [ ] Other:
Received influenza vaccination in the past 12 months [ ]Y [X ]N
Received pneumococcal vaccinationin the past 12 months [ +]Y [
]N"
146,"S1S2, no M/R/G noted
Gastrointestinal: distended, slightly firm. Tender to palpation
in RUQ and LUQ
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: 2+ edema b/l, 2+ radial, DP pulses b/l. R>L edema
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Normal gait
Psychiatric: appropriate
On Discharge:
VS: T98.3 BP 138/74 HR 84 RR 18 O2 sat 95%
Gen: pleasant gentleman sitting in chair in NAD
Skin: resolving erythematous rash on back
HEENT: anicteric sclerae, MMM, slight ulceration under tongue,
no exudates
CV: RRR, no murmurs, rubs, gallops
Pulm: slightly decreased breaths sounds in the right base,
otherwise CTAB
Abd: soft, non tender, non distended; pos BS
Extr: 3+ LE edema b/l
Neuro: A&Ox3, CNII-XII intact, motor and sensation grossly
intact"
147,"In
comparison with the preceding single view examination, it is
possible that these parenchymal densities have progressed
slightly and thus, further followup chest examinations in this
patient with history of lymphoma is recommended.
[**12-4**] CT Chest: 1. Widespread peripheral consolidations which
are new or increasing. These are not entirely specific, but the
striking peripheral character of consolidations is very
suggestive of an inflammator etiology such as eosinophilic
pneumonia or organizing pneumonia, either of which could be
associated with a drug reaction. The appearance would be much
less typical for an infectious etiology or progression of
lymphoma, which has apparently responded overall very well to
treatment."
148,"Your body was retaining fluid so you were
started on a water pill to help remove some of this fluid.
Please continue to take this at home as directed until you
follow up on Friday. Please also weigh yourself daily and call
Dr.[**Name (NI) 14047**] office if your weight increases.
We have made the following changes to your medications:
- START taking filgrastim (injections) as directed for your
blood counts
- START taking fluconazole for prevention of infection
- START taking acyclovir for prevention of infection
- START taking ranitidine for your stomach
- START taking oxycontin for your pain; please take colace and
senna as needed while taking this medication to prevent
constipation; do not drive while taking oxycontin as it is
sedating
- START taking lasix for the fluid in your legs
- START taking potassium as directed while taking lasix
- you may use gelclair as needed for mucositis pain in your
mouth"
149,"There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
[**11-25**] Renal U/S: 1."
150,"Moderate right pleural effusion.
2. Massive conglomerate aortocaval mass with central areas of
necrosis, which compresses the IVC, right common and external
iliac veins, and likely also right proximal ureter. Extensive
mediastinal, hilar, mesenteric, retroperitoneal, and iliac
lymphadenopathy and massive splenomegaly. Overall picture
suggestive of lymphoma/lymphoproliferative disease.
3. Mildly prominent common bile duct. Please correlate with
liver function
test.
4. Diffuse gallbladder mural edema, likely related to systemic
disease,
unlikely due to cholecystitis.
5. Multiple left renal lesions are incompletely evaluated,
including a 12-mm interpolar left renal lesion (3, 301), which
could be further characterized by ultrasound.
[**11-15**] CT Head- 1."
151,"GI: [] All Normal
[ ] Blood in stool [ ] Hematemesis [ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [+] Nausea [] Vomiting [ ] Reflux
[ -] Diarrhea [ -] Constipation [+] Abd pain [ ] Other:
GU: [X] All Normal
[] Dysuria [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
SKIN: [] All Normal
[ +]Scaling rash of R knee [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
[X]all other systems negative except as noted above"
152,"[**11-17**] Immunophenotyping Flow Cytometry: Immunophenotypic finding
consistent with involvement by a kappa-restricted B-cell
lymphoproliferative disorder. Correlation with concurrent bone
marrow biopsy (S10-48307G) is recommended.
DISCHARGE LABS:
142 107 15 85 AGap=12
-------------
3.4 26 0.8
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
Ca: 9.3 Mg: 2.0 P: 2.4
ALT: 35 AP: 226 Tbili: 0.7 Alb: 3.0
AST: 27 LDH: 249 Dbili: TProt:
[**Doctor First Name **]: Lip:
UricA:3.2
20.5 > 8.8 < 186
24.7
N:98.0 L:0.9 M:0.9 E:0."
153,"He was called out to the floor where he
received a round of RCHOP with good effect and no subsequent
tumor lysis. He had some mucositis which was managed with pain
medications and mouth care. He was discharged home on D5 RCHOP
with follow up scheduled in the 7 [**Hospital Ward Name 1826**] outpatient clinic and
a plan to establish care in NY with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25139**]
(appointment tentatively scheduled for [**12-24**]).
# Pneumonia- Patient had chest CT with ground-glass parenchymal
opacity, suggestive of pneumonia. He was started on
vanco/zosyn/azithro and was continued on these antibiotics for 7
days after he was no longer neutropenic per pulmonary
recommendations."
154,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 87754**],
You were admitted to the hospital with chest and abdominal pain.
You had a CT scan of your chest, lymph node and bone marrow
biopsies which showed that you have diffuse large B cell
lymphoma. You received two rounds of chemotherapy while you were
in the hospital. You were also diagnosed with a pneumonia for
which you were treated with antibiotics. You will need to have a
repeat CT of your chest in [**12-22**] weeks to assess the improvement
of this infection."
155,"Pertinent Results:
ADMISSION LABS:
[**2137-11-15**] 06:35PM WBC-8.0 RBC-4.15* HGB-11.9* HCT-33.8* MCV-81*
MCH-28.6 MCHC-35.2* RDW-16.8*
[**2137-11-15**] 06:35PM NEUTS-60 BANDS-5 LYMPHS-12* MONOS-16* EOS-0
BASOS-0 ATYPS-4* METAS-3* MYELOS-0 NUC RBCS-1*
[**2137-11-15**] 06:35PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2137-11-15**] 06:35PM PLT SMR-VERY LOW PLT COUNT-77*
[**2137-11-15**] 06:35PM PT-13.8* PTT-33.0 INR(PT)-1."
156,"Admission Date: [**2137-11-15**] Discharge Date: [**2137-12-11**]
Date of Birth: [**2062-12-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Dysarthria and abdominal pain
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE .
Date:[**2137-11-15**]
PCP:
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 10066**] [**Name (STitle) 87750**] 2202 65th Street [**Location (un) **]
Bay Parkway and West 6th Street [**Telephone/Fax (1) 87751**]
GI: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87752**] [**Telephone/Fax (1) 87753**]
_
________________________________________________________________
HPI:
74M s/p recent L hernia repair on [**2137-10-6**] with chest pain,
+pleuritic x 4 weeks, +n/v x 4 weeks, +intermittent abdominal
pain, question recent aphasic episode [**1-22**] pain per family."
157,">65
ADLS:
Independent of ALL ADLS:
Independent of ALL IADLS:
At baseline walks: [+]independently [ ] with a cane [ ]wutwalker
[ ]wheelchair at baseliine
H/o fall within past year: [+]Y- walking []N
Family History:
Sister died of breast cancer
Brother died of lung cancer
Another sibling died of stomach cancer
Physical Exam:
VS: T = 97 P = 86 BP = 108/62 RR 18 O2Sat = 98% on 2L Wt, ht,
BMI
GENERAL: Elderly male laying in bed
Nourishment: At risk, + temporal wasting
Grooming: good
Mentation: Alert, speaks in full sentences. He feels tired
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: dry MM no lesions noted in OP, poor
dentition
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Decreased BS at R base
Cardiovascular: tachy, nl."
158,"QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2137-11-25**]):
MODERATE GROWTH Commensal Respiratory Flora.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2137-11-24**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
[**12-7**] B glucan- negative
[**12-7**] galactomannan- negative
[**11-19**] IgG 473* IgA 52* IgM 302
STUDIES:
[**11-15**] CTA Chest/Abd/Pelvis:
1. Right upper lobe ground-glass parenchymal opacity, suggestive
of
pneumonia. Multifocal coalescent ground-glass nodules,
predominating upper
lobes but also present in left lower lobe, raise question of
metastatic
involvement."
159,"2. New mild extrahepatic biliary ductal dilatation of uncertain
significance. Correlation with liver function tests is
recommended. If the apppearance may be clinically significant
based on laboratory data or clinical presentation, then MRCP
could be considered or follow-up CT or ultrasound. Extrinsic
compression by lymphadenopathy that is not imaged on this study
is a possible, though somewhat unusual, possibility.
[**12-4**] CT Head: 1. No evidence of intracranial metastatic
disease. MR (if feasible) would be more sensitive than CT for
detection of metastatic lesions. 2. No acute intracranial
process.
[**12-9**] CXR: Heart size is normal. Mediastinal position, contour,
and width are unremarkable and stable."
160,"No acute intracranial hemorrhage or mass
effect. 2. Although there is no CT evidence of large
intracranial mass, MRI with gadolinium is superior in evaluation
of such lesions and can be considered if not contraindicated.
[**11-15**] LENI- No evidence of right lower extremity deep venous
thrombosis.
[**11-15**] EKG: ST at 108 bpm, no other acute changes
[**11-18**] Trans thoracic Echo- The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%)."
161,"The abnormalities
demonstrated on prior chest
radiograph and chest CT appears to be grossly unchanged except
for may be
minimal progression at the level of the left lower lobe and
right upper
superficial area as well as interval development of minimal
amount of pleural effusion on the right. The finding continues
to be nonspecific with the differential diagnosis being broad
including eosinophilic pneumonia, cryptogenic organizing
pneumonia, drug reaction, and less likely infection.
PATHOLOGY:
[**11-17**] Bone marrow biopsy- MARKEDLY HYPERCELLULAR MARROW WITH
EXTENSIVE INVOLVEMENT BY A LYMPHOPROLIFERATIVE DISORDER, MOST
CONSISTENT WITH DIFFUSE LARGE B-CELL LYMPHOMA.
[**11-17**] R axillary lymph node biopsy- DIFFUSE LARGE B CELL
LYMPHOMA, HIGH GRADE."
162,"No evidence of hydronephrosis, with
resolution of the mild hydronephrosis seen on CT [**2137-11-15**]. 2.
Nonvisualization of left renal interpolar region indeterminate
lesion seen on CT scan [**2137-11-15**], due to limited visualization.
For further evaluation,if clinically relevant, an MR could be
performed.
[**12-3**] CXR: The heart size remains normal and no typical
configurational abnormalities is seen. Thoracic aorta, stable
and within normal limits. Position of previously described left
subclavian approach advanced central venous catheter remains
unchanged terminating overlying the SVC at the level of the
carina. No pneumothorax is seen. In comparison with the next
preceding portable examination, the findings have cleared up
markedly."
163,"MICRO:
[**11-15**] Blood cultures- no growth
[**11-15**] Urine cx- no growth
[**2137-11-18**] 9:29 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2137-11-20**]**
GRAM STAIN (Final [**2137-11-18**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2137-11-20**]):
RARE GROWTH Commensal Respiratory Flora.
[**2137-11-23**] 9:05 am SPUTUM Site: EXPECTORATED
ACID FAST CULTURE X 3 TIMES.
GRAM STAIN (Final [**2137-11-23**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
SINGLY AND IN PAIRS."
164,"He
is currently being evaluated by GI for appetite and minimal
weight loss x 3 weeks. + Early satiety. Immediately after
eating he regurgitates solid food. No dysphagia for solids or
liquids or signs of aspiration with eating. Slurred speech x 2
days. No facial asymmetry or focal weakness. Increased weakness
and sweats.
He received ASA and SLNG with some improvement in his pain from
[**9-24**]. R>L asymmetric swelling of the lower extremities
In ER:
Triage Vitals: 8 99 108 108/62 14 99% 4L NC
Meds Given: levoquin 750 mg IV x T
Fluids given: 2L NS
Radiology Studies:
consults called."
165,"You make continue taking your other medications as you were
previously.
It was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
Please come to the 7 [**Hospital Ward Name 1826**] Outpatient Clinic at 10:00AM on
Friday [**12-13**] for tests to check your blood counts and
your chemistries.
Department: BMT/ONCOLOGY UNIT
When: FRIDAY [**2137-12-13**] at 10:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
You will be contact[**Name (NI) **] by Dr."
166,"Disp:*30 Tablet(s)* Refills:*2*
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
4. filgrastim 300 mcg/mL Solution Sig: One (1) injection
Injection Q24H (every 24 hours) for 10 days.
Disp:*10 injections* Refills:*0*
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
6. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation."
167,"Disp:*30 Tablet(s)* Refills:*0*
8. oral wound care products Gel in Packet Sig: One (1)
Packet Mucous membrane TID (3 times a day) as needed for
Mucositis.
Disp:*20 Packet* Refills:*0*
9. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): Do not
drink or drive while taking this medication.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day:
Please take while taking lasix."
168,"In particular the basal bilateral densities strongly
suggestive of bilateral pleural effusions as seen on [**2137-11-21**], have now practically cleared completely, as both lateral
and posterior pleural sinuses are free with the patient in
upright position. Also, the parenchymal densities have
regressed; however, significant residuals remain on both sides.
These consist of lateral located hazy parenchymal densities
close to the pleural space at the level of the third and fourth
rib. On the left side these parenchymal densities are also in
peripheral location but somewhat higher up and overlying the
second and third ribs including the corresponding interspace."
169,"2*
[**2137-11-15**] 06:35PM proBNP-909*
[**2137-11-15**] 06:35PM cTropnT-<0.01
[**2137-11-15**] 06:35PM GLUCOSE-94 UREA N-27* CREAT-1.1 SODIUM-132*
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-15* ANION GAP-25*
[**2137-11-15**] 07:23PM D-DIMER-1103*
[**2137-11-15**] 08:45PM LACTATE-7.9*
[**2137-11-15**] 11:35PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-<=1.005
[**2137-11-15**] 11:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2137-11-15**] 11:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2"
170,"[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25139**] at [**Hospital1 107**] [**Doctor Last Name **]
[**Hospital 87758**] Cancer Center in NY about an appointment on [**12-24**]. If you do not hear from his office regarding the timing of
this appointment please contact him at [**Telephone/Fax (1) 87759**]. In the
meantime, if any issues arise, you have an appointment with Dr.
[**First Name (STitle) **] as below (you can cancel this appointment once your
appointment in NY is finalized):
Department: HEMATOLOGY/BMT
When: MONDAY [**2137-12-23**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2137-12-23**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5778**], 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:[**2137-12-11**]"
171,"VS on transfer HR = 90, BP = 102/58, RR = 16, 98% on 2L
.
PAIN SCALE: 0/10
________________________________________________________________
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[ ] Subjective fever [ ] Chills [ ] Sweats [ ] Fatigue [
] Malaise [ ]Anorexia [ ]Night sweats
[ +] __5___ lbs. weight loss/ over _1____ months
HEENT: [] All Normal
[ ] Blurred vision [ ] Blindness [ ] Photophobia
[ ] Decreased acuity [ +] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ ] Other: [+]occasional
dbl vision when laying down.
RESPIRATORY: [] All Normal
[ -] SOB [ ] DOE [ ] Can't walk 2 flights [+ ] Cough-
occasional yellow phlegm/
[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [++
]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Angina [ ] Palpitations [+ ] Edema [ ] PND
[ ] Orthopnea [+ ] Chest Pain [ ] Other:"
172,"Over the [**Last Name (un) 52**] wire, an 8
French Cook's biliary drainage catheter with extra side holes was placed with
distal tip in the third part of the duodenum .
FINDINGS:
1. Scout image demonstrated indwelling external drainage catheter.
2. Fluoroscopic images demonstrating the AccuStick needle in the residual sac
of the pseudoaneurysm with contrast. More laterally, there is old contrast
noted from prior injection.
3. Tubogram through the indwelling catheter demonstrating the pigtail within
the confluence of the right and left hepatic ducts with no intrahepatic
biliary radicle dilatation. Stricture is noted at the lower end of the CBD.
4. Scout images with wire and catheter demonstrating extrinsic impression on
the CBD and the second and proximal third part of the duodenum.
5. Final scout image demonstrating optimal position of the new internal-
external drainage with pigtail formed beyond the level of the compression in
the junction of the third and fourth part. End holes within the biliary
ductal system.
IMPRESSION:
1. Ultrasound-guided thrombin injection of the SMA pseudoaneurysm
percutaneously.
2. Internalization of the right-sided PTBD using 8.5 French Cook's pigtail
catheter which was modified with extra sideholes."
173,"PROCEDURE IN DETAIL: A written informed consent was obtained explaining the
risks and benefits of the procedure. The patient was brought to the
angiography suite and placed supine on the imaging table. The anesthesiology
service provided general anesthesia. A preprocedure timeout and huddle was
performed. The abdomen was prepped and draped including the indwelling
catheter in the usual sterile fashion.
Pseudoaneurysm Thrombin Injection:Under continuous ultrasound guidance, the
residual sac of the SMA pseudoaneurysm was accessed percutaneously using a
22-gauge AccuStick needle. The intra-sac location of the needle was confirmed
by injecting dilute contrast and also on color doppler."
174,"[**2124-4-13**] 10:03 AM
BILIARY STENT Clip # [**Clip Number (Radiology) 56344**]
Reason: Needs stent advancement past obstruction
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 35
********************************* CPT Codes ********************************
* [**Numeric Identifier 1488**] INTRO PERC TRNASHEPATIC STENT [**Numeric Identifier 1489**] CATH/STENT FOR INT/EXT BILIARY *
* [**Numeric Identifier 4968**] THROMBIN INJ PSEUDOANERYSM RIG GUIDANCE/LOCALIZATION FOR NEEDLE BIO *
* -59 DISTINCT PROCEDURAL SERVICE *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
57 year old man with PTC & stent
REASON FOR THIS EXAMINATION:
Needs stent advancement past obstruction
______________________________________________________________________________
FINAL REPORT
CLINICAL INDICATION: 57-year-old man with status post PTBD for extrinsic
compression of the CBD by a large SMA pseudoaneurysm."
175,"Request for
internalization of the PTBD.
ANESTHESIA: Monitored general anesthesia.
1% buffered lidocaine was used for local anesthesia.
CLINICIANS: Drs. [**First Name8 (NamePattern2) 171**] [**Name (STitle) 172**], [**First Name8 (NamePattern2) 147**] [**Last Name (NamePattern1) 148**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1166**] performed the
procedure. The attending, Dr.[**Last Name (STitle) 1166**] performed the SMA pseudoaneurysm
thrombin injection under ultrasound and fluoroscopic guidance. Dr. [**First Name (STitle) 148**], the
second attending participated and performed the biliary drainage
internalization.
PROCEDURE:
1. Ultrasound-guided thrombin injection into the residual SMA pseudoaneurysm.
2. Placement of a modified internal-external PTBD drainage catheter."
176,"The catheter was cut at its
hub and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 52**] wire was advanced, over which it was gently pulled out. A
long 5 French catheter was then advanced over the wire to cannulate the CBD
distally near the site of stricture. The [**Last Name (un) 52**] wire was then exchanged for
a regular Glidewire which in combination with a Kumpe's catheter was used to
cannulate and navigate through the region of the CBD stenosis and advanced
further into the fourth part of the duodenum. The wire was exchanged for a
[**Last Name (un) 52**] wire and the Kumpe catheter was removed."
177,"Following this, under
continuous ultrasound guidance, thrombin was injected until there was a
satisfactory stasis and nonvisualization of flow. Post-thrombin injection,
Doppler examination of the adjacent vessels was performed to confirm preserved
patency.No significant residual sac was seen.
Internalisation of Biliary catheter:Attention was then directed for
internalization of the indwelling external PTBD. Dilute contrast was injected
(Over)
[**2124-4-13**] 10:03 AM
BILIARY STENT Clip # [**Clip Number (Radiology) 56344**]
Reason: Needs stent advancement past obstruction
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 35
______________________________________________________________________________
FINAL REPORT
(Cont)
through the indwelling external tube which demonstrated the pigtail within the
confluence of the right and left hepatic ducts."
178,"[**2124-4-19**] 2:27 PM
BILIARY CATH CHECK Clip # [**Clip Number (Radiology) 56353**]
Reason: PTC catheter is kinked at entrance into the peritoneum, plea
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 30
********************************* CPT Codes ********************************
* [**Numeric Identifier 56**] CHANGE PERC BILIARY DRAINAGE C -78 RELATED PROCEDURE DURING POSTOPE *
* [**Numeric Identifier 57**] CHANGE PERC TUBE OR CATH W/CON *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
57 year old man with PTC for compression of CBD by pseudoaneurysm now with
rising dbili
REASON FOR THIS EXAMINATION:
PTC catheter is kinked at entrance into the peritoneum, please exchange
catheter
______________________________________________________________________________
FINAL REPORT
MEDICAL HISTORY 57-year-old man with biliary obstruction secondary to SMA
pseudoaneurysm status post right PTBD catheter placement on [**2124-4-13**]."
179,"The patient's biliary catheter is pulled back and kinked in the peritoneal
cavity. A request was placed for biliary catheter check and change.
CLINICIANS: Dr. [**First Name8 (NamePattern2) 547**] [**Name (STitle) 291**], Dr. [**First Name (STitle) 1788**] [**Name (STitle) **] and Dr. [**First Name4 (NamePattern1) 753**] [**Last Name (NamePattern1) 754**]. Dr. [**Last Name (STitle) 754**],
the attending radiologist, was present and supervising throughout.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
200 mcg of fentanyl and 4 mg of Versed throughout the total intra-service time
of 40 minutes during which patient's hemodynamic parameters were continuously
monitored."
180,"It also demonstrated
leakage of contrast into the peritoneal cavity and no drainage was noted into
the duodenum. The catheter was cut distal to the hub and removed over a
[**Last Name (un) 52**] wire. The [**Last Name (un) 52**] wire was advanced further into the proximal jejunum
using a 5 French Kumpe catheter and was exchanged for a Super Stiff Amplatz
wire. Then a 10 French NU stent, modified by cutting side holes proximal and
distal to the renal pigtail and by cutting off the distal pigtail was placed
through a 10 French peel-away sheath and advanced into the duodenum."
181,"The
patient tolerated the procedure well and there were no immediate
complications.
IMPRESSION:
1. Scout image and cholangiogram demonstrated the existing biliary catheter
to have pulled back and kinked in the peritoneal space. There was leakage of
contrast into the peritoneal cavity and no distal drainage of contrast noted
into the bowel.
2. There was moderate dilatation of proximal CBD and main intrahepatic bile
ducts with obstruction of the distal CBD as noted before.
3. The existing biliary catheter was exchanged for a modified 10 French NU
stent to function as an internal/external biliary catheter; the pigtail was
positioned in the duodenum distal to the ampulla and the tip of the catheter
was terminating in the proximal jejunum. The catheter is connected to an
external drainage bag, but can be capped after 24 hours or so, if there is no
clinical contraindication."
182,"The
peel-away sheath and guidewire were then removed. The pigtail of the catheter
was formed in the duodenum, distal to the ampulla and locked. Contrast
injection through the catheter confirmed satisfactory position and free
drainage through the catheter into the duodenum. The catheter was locked and
(Over)
[**2124-4-19**] 2:27 PM
BILIARY CATH CHECK Clip # [**Clip Number (Radiology) 56353**]
Reason: PTC catheter is kinked at entrance into the peritoneum, plea
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 30
______________________________________________________________________________
FINAL REPORT
(Cont)
secured to the skin with 0 silk sutures. The catheter was flushed and
connected to an external drainage bag and sterile dressings were applied."
183,"Local anesthesia with 1% lidocaine and topical lidocaine gel.
PROCEDURE AND FINDINGS: An informed written consent was obtained after
explaining the procedure, benefits, alternatives and risks involved. The
patient was brought to angiography suite and placed supine on the imaging
table. The right upper quadrant including the existing right biliary catheter
were prepped and draped in the usual sterile fashion. Preprocedure huddle and
timeout were performed as per [**Hospital1 51**] protocol.
An initial scout image of the right upper quadrant was obtained demonstrating
the existing biliary catheter to have been pulled back and kinked in the
peritoneal cavity. Contrast injection through the catheter confirmed moderate
dilatation of CBD and main intrahepatic bile ducts."
184,"The
patient was transferred to the ICU for further monitoring with the sheath in
place.
FINDINGS:
1. Large crescentic macrolobulated pseudoaneurysm arising from a jejunal
branch of the SMA.
2. Deployment of multiple GDC coils within the pseudoaneurysm with thrombin
(Over)
[**2124-4-25**] 3:18 PM
MESSENERTIC Clip # [**Clip Number (Radiology) 57369**]
Reason: possible identification of location of GI bleed, possible th
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 300
______________________________________________________________________________
FINAL REPORT
(Cont)
injection.
3. Post-procedure superior mesenteric angiogram again demonstrates the
replaced right hepatic and occlusion and non-filling of the pre-existing
pseudoaneurysm. No active extravasation seen.
4. Aortogram with tips of catheter in the region of the [**Female First Name (un) 85**], inferior
mesenteric and celiac axis demonstrates pronounced atherosclerosis, occlusion
of the common and external iliac on the right, but no active extravasation.
IMPRESSION: Successful embolization using a combination of detachable coils
and thrombin of a large pseudoaneurysm arising from a jejunal branch of the
superior mesenteric artery."
185,"[**2124-4-25**] 3:18 PM
MESSENERTIC Clip # [**Clip Number (Radiology) 57369**]
Reason: possible identification of location of GI bleed, possible th
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 300
********************************* CPT Codes ********************************
* [**Numeric Identifier 39**] EMBO NON NEURO [**Numeric Identifier 4968**] PERC TX EXTREMITY PSA *
* -51 MULTI-PROCEDURE SAME DAY [**Numeric Identifier 285**] 3ED ORDER [**Last Name (un) 286**]/BRACHIOCEPHALIC *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 1042**] EA 1ST ORDER ABD/PEL/LOWER EXT *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 2358**] EXT UNILAT A-GRAM *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 1044**] VISERAL SEL/SUPERSEL A-GRAM *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 822**] F/U STATUS INFUSION/EMBO *
* [**Numeric Identifier 43**] TRANCATHETER EMBOLIZATION *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
57 year old man with pseudoaneurysm, hemobilia, GI bleed
REASON FOR THIS EXAMINATION:
possible identification of location of GI bleed, possible thrombin injection of
pseudoaneurysm
______________________________________________________________________________
FINAL REPORT
INDICATION: 57-year-old man with pseudoaneurysm, hemobilia, GI bleed, for
intervention."
186,"[**2112**] units of thrombin were sequentially injected into the pseudoaneurysm
along with contrast demonstrating a neck and feeding communication to this
jejunal branch of the SMA. At this point, the microcatheter was removed. An
SMA angiogram performed. Next, the catheter was withdrawn into the aorta and
aortograms were performed with the catheter located at L2 and T12. At this
point, with the patient still unstable and requiring transfer back ICU, the
sheath in the brachial artery was sutured in place and sterile dressings
applied for added security. The flush was maintained. The wires and
catheters were removed. The patient tolerated the procedure itself well."
187,"The wire was removed. A 15 mm x 40 cm coil
was deployed.
At this stage, the patient dropped his blood pressure into a systolic of 60s
with elevation of the heart rate into the 120s and was unresponsive. A code
blue was initiated. The patient began mentating and communicating at which
stage the code blue was canceled and with a combination of pressors and fluid
support, the heart rate returned to the 100s and the blood pressure elevated
to systolic in 80s. During this time, a second 15 mm x 40 cm coil was
deployed and two 10 mm x 30 cm coils."
188,"1% lidocaine was used for local pain
control.
TECHNIQUE: After discussion of the risks, benefits, and alternatives to the
procedure, written informed consent was obtained from the patient. Following
this, the patient was brought to the angiography suite and placed supine on
the imaging table. The left upper extremity was prepped and draped in usual
sterile fashion. A preprocedure huddle and timeout were performed per [**Hospital1 51**]
protocol.
Under ultrasound guidance and following administration of local anesthetic,
the left brachial artery was accessed under direct ultrasound guidance with a
(Over)
[**2124-4-25**] 3:18 PM
MESSENERTIC Clip # [**Clip Number (Radiology) 57369**]
Reason: possible identification of location of GI bleed, possible th
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 300
______________________________________________________________________________
FINAL REPORT
(Cont)
micropuncture needle."
189,"035 angled Glidewire, the superior mesenteric artery was selected. An
angiogram was performed. The catheter was exchanged over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 52**] wire for a
5 French straight flush catheter. This was maneuvered more proximally and
angiogram performed. Next, the catheter was exchanged for a Berenstein 5
French catheter which was placed within the SMA. This was loaded with a SL10
90-degree angle tipped [**Company 4055**] catheter loaded with a shaped 0.014
Synchro standard wire. This combination was used to select a superior branch
presumed to supply the pseudoaneurysm. The pseudoaneurysm was entered and the
microcatheter advanced into the proximal portion of the crescentic
macrolobulated pseudoaneurysm."
190,"The access point was over the medial epicondyle of the
humerus. A 0.018 nitinol wire was gently advanced into the brachial artery.
The needle was removed and replaced with a 4.5 French micropuncture sheath.
The inner dilator and nitinol wire were removed and a 0.035 [**Last Name (un) 52**] wire
advanced into the subclavian artery. The micropuncture sheath was removed and
a 5 French vascular sheath was then advanced into the brachial artery. An
arteriogram was performed demonstrating satisfactory location of the brachial
artery sheath. Using a combination of a 5 French vertebral catheter and a
0."
191,"COMPARISON: Angiogram from [**2114-4-22**]; CT from [**2124-4-25**].
PROCEDURES:
1. Left brachial artery access. Superior mesenteric angiogram and
subselective angiogram of jejunal branches supplying pseudoaneurysm.
2. Deployment of GDC coils to pseudoaneurysm.
3. Post-procedure angiogram.
4. Aortograms with catheter positioned at T12 and L2.
OPERATORS: Dr. [**First Name8 (NamePattern2) 1450**] [**Name (STitle) 194**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1057**] (fellow) and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and [**Doctor First Name 1617**] [**First Name8 (NamePattern2) 1562**] [**Doctor Last Name 291**] (attending interventional radiologist) was
present and supervising throughout the entire procedure.
MEDICATIONS: Moderate sedation was provided by administering divided doses of
125 mcg of fentanyl and 3 mg of midazolam throughout the total intraservice
time of 2 hours and 50 minutes during which the patient's hemodynamic
parameters were continuously monitored."
192,"A CT scan performed at the outside hospital
showed a large SMA branch pseudoaneurysm, compressing the CBD.
He was transferred to [**Hospital1 18**] for further evaluation and
management.
Past Medical History:
PMH: laryngeal cancer s/p XRT, hypertension, pancreatitis, TB as
a child
PSH: left knee fracture repair ([**2080**]), excision TB mass from
mandible ([**2077**]), drainage of purulent maxillary sinus
Social History:
Smokes 2 ppd for many years.
H/O 20-30 beers per week, states 1 per week for the past 4
months.
Family History:
Non-contributory.
Physical Exam:
Vitals: T 98.4, P 84, BP 160/82, RR 20, O2 97RA
Gen: AO, NAD, pleasant; obvious jaundice
HEENT: normocephalic, raspy voice, no LAD; CN II-XII intact, +
scleral icterus
Chest: CTAB, no wheeze/rhonchi/rales
CV: RRR, no r/m/g; distal pulses palp
ABD: +BS, S/ND; tender bilateral LQ; RUQ minimally tender with
hepatomegally 5cm below costal margin; not peritoneal, no fluid
wave
Ext: no edema, gross NVI; PT/DP palp; no asterixis."
193,"Vascular surgery, gastroenterology, and interventional
radiology were all consulted and were intimately involved in his
care.
Events:
*HD1 - Vascular surgery consulted for assistance in management.
Taken to endovascular suite for angiography and attempted
definitive management. Unsuccessful due to location and risk of
damage to jejunal blood supply with occlusion.
*HD3 - Percutaneous transhepatic cholecystostomy tube placed by
interventional radiology for biliary decompression.
*HD4 - First ultrasound guided thrombin injection into
pseudoaneurysm by IR.
*HD5 - Second thrombin injection, PTC internalized.
*HD6 - Follow-up ultrasound showed 99% thrombosis of
pseudoaneurysm.
*HD7 - 4-unit GI bleed per rectum; no source identified on CTA;
resuscitated in the ICU without further bleeding
*HD9 - PTC exchanged by IR for larger catheter
*HD10 - Febrile to 101."
194,"He was given TPN for nutrition. Once
stable, he was advanced to a regular diet, which he tolerated
well.
GI: Mr. [**Known lastname 96679**] had several large GI bleeds during his
admission. After investigation, these appear to be due to
hemobilia from biliary instrumentation. He had several CTA's,
none of which demonstrated a bleeding source. An upper
endoscopy showed fresh blood from the ampulla, as well as
significant old blood in the duodenum. He had a PTC drain
placed for biliary decompression, which was kept to drainage
until his bleeding stopped and his bilirubin began to decrease.
The PTC was internalized and he did not have further obstructive
symptoms."
195,"His admission bilirubin was 17.6, and had decreased
to 2.8 at the time of discharge. He will go home with his PTC
capped.
HEME: He had several GI bleeds. He received a total of 14
units of PRBC's and 3 units of FFP. His hematocrit on discharge
was stable at 27.7. He developed a left radial artery occlusion
after an access procedure, and was taken to the operating room
with vascular surgery for a left brachial artery thrombectomy
and repair.
ID: He became bacteremic with E. coli after biliary
instrumentation, and was given a course of zosyn, which he
completed in-house."
196,"amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. 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*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
SMA branch pseudoaneurysm
Hemobilia
Left radial artery occlusion
GI bleed
Discharge Condition:
Mental Status: Clear and coherent."
197,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to Dr.[**Name (NI) 5067**] surgery service for management
of your pseudoaneurysm and bile duct obstruction. You are now
being discharged home with visiting nursing services. Please
follow these instructions to aid in your recovery.
If you have bloody or dark stools, please immediately contact
our office or go directly to the emergency room. This could
represent a very serious condition.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze."
198,"*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 experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication."
199,"Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Catheter care:
Please clean the insertion site of your biliary catheter daily."
200,"PROPHYLAXIS: He was kept on protomix and venodyne boots.
Incentive spirometry and early ambulation were encouraged. He
was not given heparin subcutaneously due to his bleeding.
Medications on Admission:
xanax 0.5mg QID
Discharge Medications:
1. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day) as needed for anxiety.
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
4."
201,"8
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Mr. [**Known lastname 96679**] was admitted to the West 2a surgical service for
evaluation and management of his biliary obstruction and SMA
branch pseudoaneurysm. His hospital course was very
complicated, involving multiple vascular and interventional
radiology procedures, as well as multiple GI bleeds and ICU
transfers. He was ultimately discharged home on hospital day
25."
202,"Please cover the insertion site as needed to prevent catching or
dislodging.
Followup Instructions:
[**2124-5-29**] 02:45p [**Last Name (LF) **],[**First Name3 (LF) **] S.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] SURGICAL SPECIALTIES CC-3
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] (ST-3) GI ROOMS Date/Time:[**2124-5-18**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2124-5-18**] 10:30
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2124-5-19**] 4:00
Completed by:[**2124-5-3**]"
203,"2. Internalization of the right-sided PTBD using 8.5 French
Cook's pigtail catheter which was modified with extra sideholes.
[**2124-4-17**]: Exchange of the PTBD
[**2124-4-19**]: Exchange of PTBD
[**2124-4-21**]: angiography
[**2124-4-25**]: coil embolization of pseudoaneurysm x2
[**2124-4-26**]: left brachial artery thrombectomy
History of Present Illness:
Mr. [**Known lastname 96679**] is a 57M who presented to an outside hospital with
3 weeks of abdominal pain and jaundice. His pain was similar to
previous episodes of alcohol-induced pancreatitis. He
complained of dark urine, acholic stools, and a 15-pound weight
loss over 6 weeks."
204,"Admission Date: [**2124-4-9**] Discharge Date: [**2124-5-3**]
Date of Birth: [**2066-7-8**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
abdominal pain and jaundice
Major Surgical or Invasive Procedure:
[**2124-4-9**]:
1. Ultrasound-guided puncture of the left radial artery.
2. Selective catheterization of the superior mesenteric artery.
3. Selective arteriogram of superior mesenteric artery and its
branches.
[**2124-4-11**]: PTC placement
[**2124-4-12**]: Ultrasound-guided thrombosis of a large pseudoaneurysm
arising off a branch of the superior mesenteric artery
[**2124-4-13**]: 1. Ultrasound-guided thrombin injection of the SMA
pseudoaneurysm percutaneously."
205,"Pertinent Results:
Due to length of hospital stay, please see OMR for specific
laboratory values.
Admission labs:
WBC-7.2 RBC-4.22* Hgb-13.7* Hct-38.9* MCV-92 MCH-32.4*
MCHC-35.1* RDW-14.0 Plt Ct-231
PT-18.9* PTT-25.4 INR(PT)-1.7*
Glucose-126* UreaN-10 Creat-0.8 Na-133 K-3.6 Cl-97 HCO3-29
AnGap-11
ALT-117* AST-78* AlkPhos-712* Amylase-324* TotBili-15.7*
Lipase-352*
Discharge labs:
WBC-7.0 RBC-2.84* Hgb-9.3* Hct-27.4* MCV-97 MCH-32."
206,"7* MCHC-33.9
RDW-16.1* Plt Ct-416
Glucose-95 UreaN-13 Creat-0.6 Na-135 K-4.4 Cl-103 HCO3-27
AnGap-9
ALT-85* AST-71* AlkPhos-544* TotBili-2.8*
Lipase-29
Pertinent Laboratory Trends (admission->discharge)
Hematocrit:
3
8
.
9
-
3
2
.
4
-30.1-25.5-30.6-26.8-31-21.5-28.8-20.9-36.5-22.5-30.2-26-29-27.7
Total bilirubin:
15.7-17.6-10.7-12.1-9.8-14.8-10.2-12.1-7.3-12-5.6-2."
207,"His pain was well-controlled with iv and
oral pain medications.
CV: He was generally hypertensive on the floor, requiring
multiple agents to keep his bp below 140/100. Each time he
bled, his pressure dropped to 80's/40's, and responded quickly
to fluids. During his first ICU admission, he needed a nitro
drip to control his hypertension. He was stabilized on a
regimen of amlodipine and clonidine, on which he was discharged.
RESP: His respiratory status remained stable throughout his
admission. Incentive spirometry was encouraged.
FEN: Mr. [**Known lastname 96679**] was kept NPO until his pseudoaneurysm and
bleeding were stabilized."
208,"7, blood cultures and bile cultures grew
E. coli; zosyn started
*HD11 - PTC exchanged due to kinking of catheter
*HD12 - 5-unit GI bleed per rectum; transferred to ICU for
resuscitation; EGD showed active bleeding through ampulla;
obvious blood in PTC drain; CTA showed no extravasation and
partial reconstitution of the pseudoaneurysm
*HD16 - 5-unit melenic/bloody stool and bloody PTC drain output;
transferred to ICU
*HD17 - Pseudoaneurysm coil-embolized x2 by IR
*HD18 - Left brachial artery thrombectomy and repair by vascular
surgery
*HD22 - Medium melenic stool, no change in hematocrit
NEURO: Mr. [**Known lastname 96680**] mental status remained intact throughout
his hospital stay."
209,"[**2124-4-11**] 6:19 PM
PTBD Clip # [**Clip Number (Radiology) 58488**]
Reason: pls place PTC to decompress biliary tree
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 25
********************************* CPT Codes ********************************
* [**Numeric Identifier 1488**] INTRO PERC TRNASHEPATIC STENT [**Numeric Identifier 1489**] CATH/STENT FOR INT/EXT BILIARY *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
57 year M large pseudoaneurism off SMA compressing CBD
REASON FOR THIS EXAMINATION:
pls place PTC to decompress biliary tree
______________________________________________________________________________
FINAL REPORT
CLINICAL INDICATION: 57-year-old male with large pseudoaneurysm of the SMA
compressing the CBD. Requires PTC for decompression.
CLINICIANS: Drs. [**First Name8 (NamePattern2) 1788**] [**Name (STitle) 1169**], [**First Name8 (NamePattern2) 171**] [**Last Name (un) 172**] and [**First Name8 (NamePattern2) 1562**] [**First Name8 (NamePattern2) 1617**] [**Doctor Last Name 291**] performed the
procedure."
210,"A stiff 0.035 wire was then advanced through the AccuStick sheath and
the sheath was removed. An 8-French biliary drainage catheter was then
advanced over the wire and pigtailed within the confluence of the hepatic
ducts. Dilute contrast was injected to position the side holes within the
intraductal system. The patient withstood the procedure well and had no
immediate complications. The catheter was connected to a bag externally. It
was secured to the skin with 0 silk suture and stat-locked. The patient was
shifted to the PACU in stable condition.
IMPRESSION: Uncomplicated percutaneous transhepatic biliary cholangiogram and
drainage via a right posterior duct. An 8 French external drain is placed
(Over)
[**2124-4-11**] 6:19 PM
PTBD Clip # [**Clip Number (Radiology) 58488**]
Reason: pls place PTC to decompress biliary tree
Admitting Diagnosis: PANCREATIC MASS
Contrast: OPTIRAY Amt: 25
______________________________________________________________________________
FINAL REPORT
(Cont)
which was connected to a bag for drainage."
211,"Dilute contrast was injected to
confirm the intraductal location of the tip of the needle. A 0.016 headliner
wire was advanced through the needle and coiled in the duct over which the
needle was removed and exchanged for AccuStick sheath. After removing the
inner of the AccuStick sheath, contrast was injected to opacify the biliary
ductal system, which demonstrated moderate dilatation of the CBD and
intrahepatic ducts. The CBD does not appear to drain antegrade into the
duodenum. Smooth narrowing is seen at its mid to terminal portion. This is
due to extrinsic compression by the pseudoaneurysm. No filling defects are
noted."
212,"The attending, Dr. [**Last Name (STitle) 291**], was present and supervising during the
entire procedure.
The anesthesia team provided the general anesthesia and monitored the
patient's hemodynamic parameters throughout the procedure. 1% buffered
lidocaine was used for local anesthesia.
PROCEDURE: A written informed consent was obtained explaining the risks and
benefits of the procedure. The patient was brought to the angiography suite
and placed supine on the imaging table. The right side of the abdomen was
prepped and draped in the usual sterile fashion. The anesthesia service
provided general anesthesia after intubating the patient.
Using fluoroscopic and ultrasound guidance, a peripheral right posterior bile
duct was accessed using AccuStick needle."
213,"Admission Date: [**2132-2-10**] Discharge Date: [**2132-2-20**]
Date of Birth: [**2076-4-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Intermittent chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2132-2-14**]
Coronary artery bypass grafting x3 to left internal mammary
artery to left anterior descending artery, bypass from the
ascending aorta to the obtuse marginal branch of the circumflex
artery using reverse
autologous saphenous vein graft and bypass from ascending aorta
to the diagonal artery branch of left anterior descending artery
using reverse autologous saphenous vein graft"
214,"Past Medical History:
hypertension, asthma, GERD
CVA in [**2131-3-20**] - ? residual
Social History:
Race: [**Country **] Rican
Last Dental Exam: edentulous
Lives with: sister
Contact: Phone #
Occupation:disabled (previous forklift driver)
Cigarettes: Smoked no [] yes [x-1 pk every three days since age
11- quite 1 year ago]
Hx:
Other Tobacco use: marijuana -occas. onset age 17 heavy use
until
1 year ago now occasional
ETOH: < 1 drink/week [x] [**3-25**] drinks/week [] >8 drinks/week []
Illicit drug use: marijuana, cocaine-heroine inhaled. Denies
IVDA. Stopped illicit drug use one year ago after CVA.
Family History:
Family History:Premature coronary artery disease
Father MI < 55 [] died of cancer age 60 Mother < 65 [x-MI]"
215,"The remainder of his hospital course was
uneventful, by the time of discharge on POD6*the patient was
ambulating freely, the wound had small amount od bloody drainage
from mid incision, and pain was controlled with oral analgesics.
The patient was discharged home with visiting nurses in good
condition with appropriate follow up instructions.
Medications on Admission:
Lisinopril 10 daily, atenolol 25 daily, HCTZ 25 daily, ASA 325
daily, omeprazole 20 daily, spiriva,
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E."
216,"Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease with worsening angina
Secondary Diagnosis:
hypertension
asthma
GERD
CVA [**2131-3-20**] - ? residual
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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"
217,"Physical Exam:
Physical Exam-Admission
Pulse:58 Resp: 18 O2 sat: 100%
B/P Right:146/93 Left:
Height: 5' 11"" Weight: 69.2 kg
General: NAD
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema -none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: cath site- small hematoma Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2"
218,"There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is in SR, on no inotropes.
Preserved biventricular systolic fxn.
Aorta intact. Trace MR, no AI.
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2132-2-19**]
12:42 PM
REASON FOR THIS EXAMINATION: eval RUL nodule, eval for source of
infection
Wet Read: JKSd [**First Name8 (NamePattern2) **] [**2132-2-19**] 5:10 PM
Final Report
FINDINGS: A 5-mm nodule at the right lung apex (4:37)
corresponds with the
nodule seen on the prior chest x-rays."
219,"A small
calcified granuloma is noted within the right lobe of the liver.
Otherwise, the non-contrast appearance of the upper abdomen is
within normal limits.
BONE WINDOWS: Patient is status post recent sternotomy. There is
no evidence of dehiscence or sternal wire fractures. There is no
erosion of the bone. There are no osseous lesions concerning
for metastatic disease.
IMPRESSION:
1. 5-mm right apical and 3-mm right middle lobe pulmonary
nodules. Six-month followup chest CT is recommended.
2. Moderate paraseptal emphysema with prominent apical bullae.
3. No evidence of pneumonia. Small bilateral pleural effusions
with adjacent atelectasis."
220,"RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS:
Conclusions:
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal."
221,"An additional 3-mm
pulmonary nodule in the right middle lobe is also present
(4:84). There is paraseptal emphysema, predominantly in the
upper lobes bilaterally, with prominent apical bullae.
There are small bilateral pleural effusions with adjacent
atelectasis. There is no evidence of pulmonary infection. Linear
atelectasis is noted within the lingula. The airways are clear.
Patient is status post CABG. There are small retrosternal fluid
collections, many of which contain small air-fluid levels. Other
than expected mild stranding within the subcutaneous fat, the
chest wall subcutaneous fat remains preserved. There is no
presternal fluid collection.
This examination is not tailored for subdiaphragmatic
evaluation."
222,"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. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 10 days."
223,"3
[**2132-2-10**] 07:50PM HCV Ab-POSITIVE*
[**2132-2-10**] 07:50PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
[**2132-2-10**] 07:50PM %HbA1c-5.5 eAG-111
[**2132-2-10**] 07:50PM ALBUMIN-4.5 MAGNESIUM-2.2
[**2132-2-10**] 07:50PM LIPASE-34
[**2132-2-10**] 07:50PM ALT(SGPT)-28 AST(SGOT)-26 ALK PHOS-74
AMYLASE-126* TOT BILI-0.6
[**2132-2-10**] 07:50PM GLUCOSE-92 UREA N-19 CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
[**2132-2-10**] 11:41PM CK-MB-1 cTropnT-<0."
224,"His bypass time
was 76 minutes with a crossclamp time of 62 minutes.
The patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and monitoring. POD 1 found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, phenylephrine
was sucessfully weaned off. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor on POD #1 for
further recovery. Chest tubes and pacing wires were
discontinued per cardiac surgery protocol. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility."
225,"History of Present Illness:
55 year old [**Country **] Rican male who emigrated to US in
[**2099**]-primarily spanish speaking but understands and speaks
english relatively well. He is transferred to [**Hospital1 18**] today from
[**Hospital6 **] after a positive stress test in the
setting of increasing episodes of chest pain over the last month
with minimal activity. The patient has a family history
significant for premature coronary artery disease. The cath was
done with Plavix at LGH. The cath showed that the patient has
left main coronary artery disease. The patient
was subsequently transferred to [**Hospital3 **] Medical Center.
Since the patient had Plavix, a decision was made to postpone
the procedure until the Plavix is washed out."
226,"Slight patchy opacity at the left base is overall unchanged.
Left pleural
effusion is smaller. Doubt CHF.
Again seen is the nodular opacity at the right lung apex,
IMPRESSION:
1. COPD and cardiomegaly.
2. Patchy opacity left base, essentially unchanged.
3. Small nodule at right lung apex again seen. Please see
recommendation for CT, described on prior CXR report.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2-14**] where the patient underwent coronary
artery bypass grafing x3 please see operative report for
details. In summary he had: Coronary artery bypass grafting x3
to left internal mammary artery to left anterior descending
artery, bypass from the ascending aorta to the obtuse marginal
branch of the circumflex artery using reverse
autologous saphenous vein graft and bypass from ascending aorta
to the diagonal artery branch of left anterior descending artery
using reverse autologous saphenous vein graft."
227,"01
[**2132-2-10**] 11:41PM CK(CPK)-102
Labs-Discharge:
[**2132-2-20**] 04:20AM BLOOD WBC-7.6 RBC-3.08* Hgb-10.0* Hct-29.2*
MCV-95 MCH-32.4* MCHC-34.1 RDW-12.6 Plt Ct-292
[**2132-2-20**] 04:20AM BLOOD Plt Ct-292
[**2132-2-20**] 04:20AM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-135
K-4.3 Cl-98 HCO3-27 AnGap-14
[**2132-2-20**] 04:20AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2
[**2132-2-14**] TTE
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA."
228,"Carotid Bruit Right: Left:
Pertinent Results:
Labs-Admission:
[**2132-2-10**] 05:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2132-2-10**] 05:28PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2132-2-10**] 07:50PM PT-11.1 PTT-31.2 INR(PT)-1.0
[**2132-2-10**] 07:50PM PLT COUNT-142*
[**2132-2-10**] 07:50PM WBC-7.1 RBC-4.43* HGB-14.2 HCT-41.5 MCV-94
MCH-32.0 MCHC-34.1 RDW-12."
229,"4. Multiple small retrosternal fluid collections, some with
air-fluid levels, not unexpected in this recently post-surgical
patient. No sternal dehiscence or evidence of sternal wire
fracture. No presternal fluid collection.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2132-2-18**] 2:03
PM
Final Report
The right IJ line has been removed.
The lungs are hyperinflated, suggesting background COPD, with
prominent
bullous change in the upper lobes bilaterally.
There are multiple sternal wires, similar in configuration to
[**2132-2-17**]. No
obvious break in the sternal wires is identified. Mediastinal
clips
consistent with CABG are present. he cardiomediastinal
silhouette is stable compared with one day earlier, with
mild-to-moderate cardiomegaly and an unfolded aorta."
230,"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 CARE CLINIC Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2132-2-26**] 10:30
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2132-3-25**] 1:00
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] on [**2132-3-26**] @ 11:30AM
Please call to schedule appointments with:
Primary Care Dr. [**Last Name (STitle) **] in [**5-22**] weeks [**0-0-**]
***Chest CT w/pulmonary nodules-recommend f/u CT in 6 months***
**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:[**2132-2-20**]"
231,"4 for which she received 325
asprin and was subsequently afebrile. UA at rehab was negative
at rehab. She was given vancomycin for osteomyelitis,
levofloxacin was not given. Pt refused UA, Urine cx, cxr in the
ED. Lactate here was 1.6, no leukocytosis. PICC was pulled, tip
cxs, blood cxs pending. Given hypotension, she was bolused 2 L
NS. Pt was asymptomatic from hypotension and mentating well. She
also got 4 mg morphine for pain.
.
On the floor pt c/o ongoing back pain and is asking for IV
dilaudid. Although aaox3, she is tangential and drowsy.
.
ROS:
(+) Per HPI, + sinus congestion/allergy sxs."
232,"(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No black/bloody or tarry stools. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
-SLE c/b lupus cerebritis
-Chronic low back pain (spinal stenosis)
-Status post [**Location (un) 931**] rods, removed and replaced
-Chronic neck pain; status post C3 and C4 fusion
-Osteoporosis
-Hx hypertension, has been on lisinopril in the past, but not
currently on medications
-Hypercholesterolemia per chart hx, pt states it has resolved
-History of positive purified protein derivative; status
post isoniazid
-Status post resection of basal cell carcinoma on the
left side of nose
-Maxillary sinus incision and drainage
-s/p implantable intrathecal pump
-hx seixures
-pt endorses enlarged lymph nodes in axilla and lungs, states
she says that they need to be biopsied
-intubation for sepsis 1."
233,"6 Na-140
K-3.5 Cl-105 HCO3-25 AnGap-14
[**2134-8-2**] 08:30AM BLOOD Plt Ct-162
[**2134-8-2**] 08:30AM BLOOD WBC-6.2 RBC-3.77* Hgb-8.6* Hct-27.9*
MCV-74* MCH-22.9* MCHC-31.0 RDW-14.1 Plt Ct-162
[**2134-8-3**] 06:22AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2134-8-3**] 06:22AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
ACTIVE DIAGNOSES:
.
#Fever/Chills/Hypotension (Possibly PICC infection, Chronic
Osteomyelitis, or Pneumonia): Pt was recently discharged from
[**Hospital1 2025**] ([**7-23**]) where she was admitted and found to have chronic
osteomyelitis, PICC line infection, and pneumonia."
234,"She was discharged on her home dose
of dilaudid of 2mg PO Q3hrs PRN.
.
# Anemia: This pt states she has anemia likely of chronic
disease as a result of chronic osteomyelitis. She currently does
not have an PCP as she is new to [**Location (un) 86**]. It is important for her
to establish a PCP and undergo workup for her anemia including
colonoscopy and GYN evaluation.
.
#Lupus Cerebritis with related seizure disorder: She remained
stable and exhibited no seizure activity on her home Keppra
dose. We would recommend follow-up with her PCP once established
or her neurologist
.
#GERD: Stable during this admission, continued on her home
prilosec."
235,"12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
- PICC line complication
Secondary:
-Chronic osteomyelitis
-Chronic pain
-GERD
-Lupus cerebritis with related seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 38739**],
You were admitted to [**Hospital1 69**] for
fevers/chills, low blood pressure, and compromise of your PICC
line (it was almost pulled out) in rehab. Your PICC line was
removed, you were treated with fluids, antibiotics, and pain
medications and your condition improved."
236,"5 years ago
-hx MRSA skin infections
-hx anemia, has required blood transfusions in the past.
Colonoscopy attempted but not completed due to back pain.
Social History:
Social History: Pt recently moved from TN with her husband who
is a minister. About a month ago, her husband left for [**Country 5881**] to
do work for the church and left her at a rehab in [**Hospital1 1559**]. She
was subsequently admitted to [**Hospital1 2025**] approx 2 wks ago, treated for
osteomyelitis and discharged to [**Hospital3 **]. Her husband will
be returning from [**Country 5881**] at the end of the month and they plan
on staying in [**Location (un) 86**]."
237,"Multiple surgical scars
EXT: no c/c/e. Several 1-2 cm abrasions on [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: as above
NEURO: AAOx2 (thinks it is still [**Month (only) **]). Cn II-XII intact.
Decreased strength in LEs [**3-3**] pain. No sensory deficits to light
touch appreciated.
DISCHARGE PHYSICAL EXAM:
VS: Temp: 97.6 BP: 100/58 HR: 76 RR: 18 O2sat: 96% RA
GEN: AOx3, comfortable, pleasant
HEENT: anicteric sclera, MMM, OP clear, no supraclavicular or
cervical lymphadenopathy, no jvd. 1-2 cm stable abrasion across
bridge fo nose
CV: RR, S1 and S2 wnl, no m/r/g
RESP: CTAB, no w/r/r exam limited by poor inspiratory effort [**3-3**]
to MSK pain (which is her baseline)
ABD: Soft, NT/ND, normal BS, no organomegaly
EXT: No c/c/e."
238,"Interestingly, following her D/C from [**Hospital1 2025**] She was sent to rehab
with a fresh PICC line with a goal of 6 weeks of IV Vancomycin
and a 1 week course of Levofloxacin which she completed prior to
this adission. She was sent here from [**Hospital3 2558**] rehab for
spiking fevers with chills and hypotension as well as having
pulled her PICC line partway out. It was removed, the tip was
cultured (negative final culture) and blood Cx's were drawn
(NGTD at time of d/c, still pending). She was transferred to the
MICU for concerns of hypotension with BP's in the 90's (which is
about her her baseline according to the patient) where she
became afebrile and her pressures stabilized after fluids."
239,"Few 1-2 cm abrasions on LEs
NEURO: Cn II-XII intact. Decreased strength in LEs [**3-3**] pain. No
sensory deficits to light touch appreciated.
Pertinent Results:
ADMISSION LABS:
[**2134-7-31**] 05:00PM BLOOD WBC-7.3 RBC-3.58* Hgb-8.4*# Hct-26.6*#
MCV-74*# MCH-23.5*# MCHC-31.7 RDW-13.9 Plt Ct-165
[**2134-7-31**] 05:00PM BLOOD Neuts-71.3* Lymphs-20.2 Monos-5.5 Eos-2.5
Baso-0.5
[**2134-7-31**] 05:00PM BLOOD Ret Aut-2.1
[**2134-7-31**] 05:00PM BLOOD Glucose-126* UreaN-14 Creat-0."
240,"Her course was marked by
daily fever spikes (as high as 103 on this admission) including
a spike to 101.3 the morning of the day of discharge which she
described as her baseline for several years when in the
hospital, in rehab, or at home. She indicated on numerous
occasions her desire to avoid further workup and to return to
[**Hospital3 2558**] for rehab despite spiking fevers, even
threatening to leave AMA if need be on several occasions. She
remained hemodynamically stable throughout her admission and
agreed to keep her follow-up appointments at [**Hospital1 2025**] with infectious
disease (Dr."
241,"Discharge Medications:
1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): This medication was
prescribed by Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **],
[**Hospital1 2025**], [**Street Address(2) 38740**] [**Location (un) 86**], [**Numeric Identifier 18228**] [**Telephone/Fax (1) 38741**]
All management questions should be directed to him.
.
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E."
242,"The tip of the PICC line lies within the right atrium and should
be withdrawn into the SVC.
IMPRESSION: PICC line in right atrium.
CXR AP [**2134-8-2**]:
IMPRESSION:
1. Increased opacity in the right perihilar and right
cardiophrenic regions
and minimal increased opacity in the left infrahilar region,
nonspecific. The
differential diagnosis includes infectious and inflammatory
processes and
parenchymal scarring. The markings appear slightly more
pronounced than on
the film from one day earlier. However, doubt overt CHF.
2. Hila are prominent bilaterally.
DISCHARGE LABS:
[**2134-8-3**] 12:51PM BLOOD Vanco-11.1
[**2134-8-2**] 08:30AM BLOOD Glucose-125* UreaN-9 Creat-0."
243,"Pt uses a wheelchair to get around. She
previously worked as a public health nurse and taught nursing,
stopped 4 yrs ago when back problems started. Denies tobacco,
EtOH, drugs.
Family History:
Father with hx of cardiac disease, prostate CA, stomach CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp:98 BP: 121/75 HR:90 RR:12 O2sat: 98% RA
GEN: pleasant, comfortable, NAD, somewhat somnolent and
tangential
HEENT: PERRL, pupils sluggish, EOMI, anicteric, MMM, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd.
2-3 cm abrasion across bridge fo nose
CV: RR, S1 and S2 wnl, no m/r/g
RESP: CTA b/l with good air movement throughout
ABD: nd, +b/s, soft, nt, intrathecal pump palpable on L side of
abdomen."
244,"Admission Date: [**2134-7-31**] Discharge Date: [**2134-8-3**]
Date of Birth: [**2073-6-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Methadone / Tylenol / Penicillins / Oxycodone
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fevers, lost PICC access, hypotension
Major Surgical or Invasive Procedure:
PICC line removal
PICC line placement
History of Present Illness:
HPI: Mrs [**Known lastname 38739**] is a pleasant 61 year old female with hx chronic
neck/back pain s/p multiple laminectomies/fusions complicated by
recurrent L5 osteomyelitis who presents from rehab facility with
fever >102 after having pulled her PICC line halfway out. Pt
states that she has had back pain for the last 4 years c/b
multiple MRSA infections which were thought to have started
while the pt was immunocompromised while on meds for SLE."
245,"TRANSITIONAL ISSUES:
This patient needs to maintain her follow-up appointments with
infectious disease, Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **], who prescribes and manages
her vancomycin and to whom all management questions should be
directed: [**Hospital1 2025**], [**Street Address(2) 38740**] [**Location (un) 86**], [**Numeric Identifier 18228**] [**Telephone/Fax (1) 38741**],
appt on [**8-18**], orthopaedic surgery Dr. [**Last Name (STitle) 38742**] [**Name (STitle) **] at [**Hospital1 2025**], appt
on [**9-8**], and GI for repeat EGD with Dr. [**Last Name (STitle) 38743**] [**Name (STitle) **] at [**Hospital1 2025**] with
her appt on [**9-8**]. She should also establish a PCP for management
of her multiple medical problems including but not limited to
her anemia and seizure disorder."
246,"In
the MICU it was discovered that 4/5 blood cultures from [**Hospital1 2025**] on
[**7-14**] and [**7-15**] were positive for Gordonia species. ID was
consulted and she was re-started on her IV vancomycin. It was
thought that this represented a line infection at [**Hospital1 2025**] and that
the line had been discontinued and that she had recieved at
least 2 weeks of IV vancomycin which is adequate treatment for
such an infection. She refused various elements of the work-up
including a physical exam on transfer to the floor, urine
cultures, echocardiogram to evaluate for possible endocarditis,
bone scan, and other further imaging."
247,"[**2134-8-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2134-7-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2134-7-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY
[**2134-8-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2134-8-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
REPORTS:
CXR AP [**2134-8-1**]:
CLINICAL HISTORY: Left PICC line placed, check position.
The exact position of the PICC line cannot be determined because
of overlying hardware. It is likely that it lies in the right
atrium but somewhat more oblique film would clarify this. The
lung fields are clear.
CXR AP [**2134-8-1**]:
CLINICAL HISTORY: PICC line placed, check position."
248,"She
has been on and off IV abx about 20x for the last 3-4 years,
with the most recent course started 2 wks ago by Dr [**Last Name (STitle) **] at [**Hospital1 2025**].
Pt also with fevers to 103 at rehab, which was worked up
yesterday with CXR (+ for PNA), and UA/cxs (negative). She was
started on levoflox for PNA. Of note, last two doses of
vancomycin for osteo were held at rehab for supratherapeutic
levels.
.
On arrival to our ED, vitals were 98.9 94 91/56 20 94% RA. While
in the ED she had a fever to 100."
249,"[**Last Name (STitle) 38742**] [**Name (STitle) **] on [**8-31**] 10:00am
[**Hospital1 2025**] Yawkey Center, [**Hospital Unit Name **]
[**Street Address(2) 38740**]
[**Location (un) 86**], [**Numeric Identifier 18228**]
[**Telephone/Fax (1) 38744**]
Gastroenterology Follow Up:
Dr. [**Last Name (STitle) 38743**] [**Name (STitle) **] on [**9-8**] at 3pm
[**Doctor Last Name 406**] [**Location (un) **]
[**Street Address(2) 38740**]
[**Location (un) 86**], [**Numeric Identifier 18228**]
[**Telephone/Fax (1) 38744**]
Department: RHEUMATOLOGY
When: THURSDAY [**2134-9-9**] at 2:30 PM
With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], 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
Completed by:[**2134-8-3**]"
250,"7 Na-139
K-3.5 Cl-102 HCO3-26 AnGap-15
[**2134-7-31**] 05:00PM BLOOD Iron-10*
[**2134-8-1**] 04:57AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0
[**2134-7-31**] 05:00PM BLOOD calTIBC-410 Ferritn-16 TRF-315
[**2134-7-31**] 05:00PM BLOOD Vanco-9.9*
[**2134-8-1**] 04:57AM BLOOD Vanco-10.0
[**2134-7-31**] 05:21PM BLOOD Lactate-1.6
MICRO:
[**2134-7-31**] 7:40 pm CATHETER TIP-IV PICC TIP.
**FINAL REPORT [**2134-8-2**]**
WOUND CULTURE (Final [**2134-8-2**]): No significant growth."
251,"C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. gabapentin 600 mg Tablet Sig: Two (2) Tablet PO four times a
day.
7. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
8. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q6H (every 6 hours).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain."
252,"[**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **], who prescribes and manages her
vancomycin and to whom all management questions should be
directed: [**Hospital1 2025**], [**Street Address(2) 38740**] [**Location (un) 86**], [**Numeric Identifier 18228**] [**Telephone/Fax (1) 38741**],
appt on [**8-18**]), orthopaedic surgery (Dr. [**Last Name (STitle) 38742**] [**Name (STitle) **], appt on
[**9-8**]), and GI for repeat EGD (Dr. [**Last Name (STitle) 38743**] [**Name (STitle) **], appt on [**9-8**]).
.
CHRONIC DIAGNOSES:
.
#Chronic Pain: This issue remained stable during her admission.
She was continued on her outpatient pain regimen with the
exception of an increase in her PO dilaudid dose to 4mg PO Q3hrs
PRN for breakthrough pain."
253,"You are being
discharged back to rehab to continue your recovery. At the time
of discharge your PICC line culture was negative and your final
blood culture results were pending.
The following changes have been made to your medications:
-RE-START Vancomycin 1gm IV twice daily
-STOP Furosemide
We wish you the best of luck and a speedy recovery.
Followup Instructions:
Infectious Disease Follow Up:
Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **] on [**8-18**] 10:40AM
[**Street Address(2) 38740**]
[**Location (un) 86**], [**Numeric Identifier 18228**]
[**Doctor Last Name **] building [**Location (un) **]
[**Telephone/Fax (1) 38741**]
Orthopaedic Surgery Follow Up:
Dr."
254,"Medications on Admission:
-multivitamin
-aspirin PRN fever
-lasix 20 mg on [**7-31**] and [**8-1**]
-levaquin 500 mg x7 days (which was completed prior to
admission)
-folic acid 1 mg daily
-dilaudid 2 mg PO q 3 hrs PRN breakthrough pain
-ativan 1 mg [**Hospital1 **]
-prilosec 40 mg PO BID
-senna 2 tabs PO BID
-gabapentin 1200 PO TID
-keppra 750 PO BID
-ms contin 60 mg q 6 hrs
-dulcolax supp 10 mg PR PRN constipation
-Miralax 17 mg PO daily PRN constipation
-Vancomycin-unclear dose and duration from [**Name (NI) **] records, pt states
she started 2 wks ago with intention to complete 6 wk course"
255,"History of Present Illness:
64 y/o female with complex past medical history (see below) who
has had intermittent bouts of dyspnea on exertion and hoarseness
(along with wheezing and dysphagia) over the past several years.
Underwent coronary artery bypass graft x 1 with respiratory
function continuing to decline. Further work-up revealed right
sided arch with aberrant takeoff of left subclavian and dilated
aorta. Also noted to have right mainstem bronchus compression.
Has already underwent 2 surgical procedures with vascular
surgery (Dr. [**Last Name (STitle) **] and now presents for surgical
replacement of her descending aorta.
Past Medical History:
Descending thoracic aortic aneurysm with aberrant left
subclavian artery and Kumeral's diverticulum with aortic sling
compressing the right main stem bronchus, s/p Left Carotid to
Subclavian bypass [**7-7**], s/p Amplatzer plugging of Aberrant left
subclavian [**9-6**], Coronary artery bypass graft x 1 (LIMA to LAD),
Connective tissue disorder with features of Lupus, Sjogren's and
raynaud syndrome, Stroke, Interstitial lung disease,
Hypothyroidism, Gastroesophageal Reflux disease, Right kidney
cyst, s/p cholecystectomy, s/p carcinoid tumor removal during
colonoscopy, s/p right lung resection?"
256,"wedge
Social History:
She is a retired administrative assistant. She quit smoking 15
years ago and has wine daily with dinner. She is currently
living with her husband.
Family History:
She has a noncontributory family history.
Physical Exam:
At Discharge:Expired
Pertinent Results:
[**12-20**] Echo: PREBYPASS: 1. The left atrium is mildly dilated. 2.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal. 4. The descending thoracic aorta is moderately dilated.
The patient has a known right sided arch."
257,"The patient remained intubated and her condition worsened with
the family asking that the patient be made comfort measures
only. The patient was extubated and expired shortly thereafter.
Medications on Admission:
Atenolol 12.5mg qd, Lipitor 10mg qd, Restasis, Plaquenil 400mg
qd, Synthroid 100mcg qd, Protonix 80mg qd, Effexor 75mg qd,
Zolpidem 10mg qd, Spiriva, Advair, Albuterol
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Descending thoracic aortic aneurysm with aberrant left
subclavian artery and Kumeral's diverticulum with aortic sling
compressing the right main stem bronchus s/p Right
posterolateral thoracotomy, replacement of the proximal
descending thoracic aortic aneurysm [**12-20**] and Right Bronchial
Y-stent placement [**12-23**]
Post-op Pneumonia
Post-op Sepsis
Post-op Acute Respiratory Distress Syndrome
Post-op Atrial Fibrillation
Post-op Anemia
PMH: s/p Left Carotid to Subclavian bypass [**7-7**], s/p Amplatzer
plugging of Aberrant left subclavian [**9-6**], Coronary Artery
Disease s/p Coronary artery bypass graft x 1 (LIMA to LAD),
Connective tissue disorder with features of Lupus, Sjogren's and
raynaud syndrome, Stroke, Interstitial lung disease,
Hypothyroidism, Gastroesophageal Reflux disease, Right kidney
cyst, s/p cholecystectomy, s/p carcinoid tumor removal during
colonoscopy, s/p right lung resection?wedge
Acute lung injury and respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2110-1-28**]"
258,"Evaluate for obstruction.
COMPARISON: None.
ABDOMINAL ULTRASOUND: Limited exam as indwelling chest tubes
limits acoustic
windows. The liver is somewhat heterogeneous in appearance. No
focal hepatic
lesion is identified. There is no intra- or extra-hepatic
biliary dilatation.
The common duct measures 5 mm. There is no ascites.
DOPPLER ULTRASOUND: With the exception of the left portal vein,
which could
not be interrogated, the main/right portal veins and hepatic
veins are patent
with appropriate waveforms. The main, right and left hepatic
arteries show
normal flow.
IMPRESSION:
1. Limited exam as patient with indwelling chest tubes which
limits acoustic
windows."
259,"Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
Study Date of [**2109-12-29**] 4:57 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2109-12-29**] SCHED
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL Clip #
[**Clip Number (Radiology) 44359**]
Reason: evaluate flow, increased LFT ? obstruction
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with s/p descending aorta replacement
REASON FOR THIS EXAMINATION:
evaluate flow, increased LFT ? obstruction
Wet Read: KYg SUN [**2109-12-29**] 7:13 PM
limited exam. no e/o bil dil. patent hepatic vasculature.
Final Report
CLINICAL HISTORY: 64-year-old female with lupus, status post
descending aorta
surgery, with increased LFTs."
260,"There is no significant mediastinal hematoma. The
heart and
pulmonary vessels appear unremarkable. Coronary vascular
calcifications are
appreciated.
There are diffuse reticular and ground-glass opacities in both
lungs, left
greater than right, and more pronounced at the lung bases, where
there are
also areas of focal consolidation and air bronchograms
appreciated. The
crowding of vessels and bronchi suggests a component of
atelectasis, and
generalized anasarca indicates that a degree of fluid overload
is also likely
involved. However, an underlying pneumonia cannot be excluded;
dependent
location would suggest aspiration as possible etiology. There is
no
significant pleural effusion on the right."
261,"The feeding tube appears to be coiled within the stomach and
is not
post-pyloric. Remainder of the supporting and monitoring lines
and tubes
appear in adequate position.
2. Bilateral lower lobe focal consolidation with air
bronchograms consistent
with pneumonia. Aspiration should be considered given location.
Further
interstitial and ground-glass opacities likely reflect a
combination of
atelectasis and fluid overload.
3. Ascites and diffuse anasarca suggest fluid overload.
4. Borderline fatty infiltration of the liver, but no biliary
dilatation or
mass lesions to explain patient's liver function test
abnormalities.
5. Status post repair of descending thoracic aortic aneurysm,
without
evidence for immediate complication."
262,"Final Report
HISTORY: 64-year-old female, status post repair of descending
thoracic aortic
aneurysm. Referred for evaluation of persistent fever, elevated
LFTs and INR,
and poor tolerance of tube feedings.
COMPARISON: CT of the chest dated [**2109-5-10**].
TECHNIQUE: MDCT axial imaging of the chest and abdomen was
performed
following the administration of oral but not IV contrast.
Sagittal and
coronal reformatted images were reviewed.
CT CHEST: An endotracheal tube terminates approximately 2.5 cm
from the
carina. Tracheal Y-stent is seen with branches extending into
the right and
left main stem bronchi. Two right-sided central venous lines,
one subclavian
and one internal jugular, terminate in the distal SVC."
263,"No focal hepatic lesion or evidence of biliary
dilatation.
2. Patent hepatic vasculature. The left portal vein was not
interrogated.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: MON [**2109-12-30**] 10:40 AM
Imaging Lab
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit and on [**12-20**] was brought to the
operating room where she underwent a right posterolateral
thoracotomy, replacement of the proximal descending thoracic
aortic aneurysm using a 26-mm Vascutek Dacron interposition tube
graft and bronchoscopy."
264,"Pleural effusion on
the left is
small.
There is no mediastinal lymphadenopathy appreciated. There is no
axillary or
supraclavicular lymphadenopathy.
CT ABDOMEN: Oral contrast is seen in the stomach only.
Evaluation of intra-
abdominal organs is limited in lack of IV contrast. There is
moderate amount
of ascites present. The liver is of somewhat low attenuation,
suggesting
fatty infiltration. Liver is otherwise unremarkable without
focal lesions or
intra-/extra-hepatic biliary dilatation. Patient is status post
cholecystectomy. The pancreas, spleen, and adrenal glands appear
normal. The
left kidney is unremarkable. There is a large 5 x 6 cm cystic
structure
arising from the superior pole of the right kidney and has the
density of
simple fluid and is likely a simple cyst."
265,"Please see operative report for complete
surgical details. Post-surgery bronchoscopy revealed right
mainstem bronchus to still be collapsed. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. On post-op day one she was weaned from sedation,
awoke neurologically intact and extubated. Pulmonary medicine
was consulted for stent placement on post-op day two.
Post-operatively she required several blood transfusions d/t
anemia. Lumbar drain was removed on post-o p day two. Also on
this day she had episode of atrial fibrillation and was treated
appropriately. She continued to have bouts of atrial
fibrillation during post-op course."
266,"There is
an NG tube
terminating in the stomach. A Dobbhoff-type feeding tube is also
seen
extending into the stomach and is coiled extensively, not
extending post-
pylorically. A right-sided chest tube courses along the
posterior margin of
the lung and terminates adjacent to the superior mediastinum.
Right-sided aortic arch is again noted. Patient is status post
repair of
descending thoracic aortic aneurysm, with graft anastomoses seen
at the level
of the arch and inferiorly. The graft appears to extend
approximately 10 cm
in the craniocaudal direction, and has a diameter of 2.9 cm at
the level of
the carina."
267,"On post-op day three she was
brought to the operating room where she underwent Y-stent
placement by interventional pulmonology. Later this day she
required a bronchoscopy which found significant mucus retention
and mucus plug in the lumen of the Y-stent. And had successful
therapeutic aspiration. Later on this day she was again weaned
from sedation and extubated. Aggressive pulmonary therapy/toilet
were performed but she continued to require several
bronchoscopies and increasing oxygen requirements over next
several days. Overnight on post-op day six Mrs. [**Known lastname **] was
progressively getting more dyspneic and was in respiratory
distress the morning of post-op day seven, requiring intubation
and mechanical ventilation."
268,"This is unchanged
compared to [**Month (only) 547**]
of [**2109**]. There is no soft tissue stranding or significant
lymphadenopathy
present. There is no free air. Vascular calcifications are seen
without
aneurysmal dilatation.
IMPRESSION:
1. The feeding tube is coiled in the stomach. The remainder of
the
supportive and monitoring devices appear in adequate position.
2. Status post repair of descending thoracic aortic aneurysm,
with no
evidence for immediate post-surgical complication.
3. Diffuse interstitial and ground glass opacities in the lungs,
left
greater than right, with focal consolidations at the bilateral
bases. While
atelectasis and fluid overload are present, underlying pneumonia
cannot be
excluded."
269,"[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2109-12-31**] SCHED
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # [**Clip Number (Radiology) 44358**]
Reason: elevated lft's, not tolerating tube feeds, elevated INR
not
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman s/p right sided descending aorta repair
REASON FOR THIS EXAMINATION:
elevated lft's, not tolerating tube feeds, elevated INR not
on coumadin. Please
do chest and abdominal CT WITH PO contrast
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: AJy TUE [**2109-12-31**] 6:33 PM
PFI:
1."
270,"The location suggests aspiration as possible etiology.
4. Mild ascites and soft tissue anasarca suggests fluid
overload.
5. Stable large right renal cyst.
6. Borderline fatty infiltration of the liver, without evidence
for focal
liver lesions, biliary dilatation, or masses. Patient is status
post
cholecystectomy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: WED [**2110-1-1**] 10:03 AM
Imaging Lab
[**Known lastname 44356**],[**Known firstname 3049**] [**Age over 90 44357**] F 64 [**2045-2-20**]"
271,"Admission Date: [**2109-12-20**] Discharge Date: [**2110-1-5**]
Date of Birth: [**2045-2-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Quinine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2109-12-20**] Right posterolateral thoracotomy, replacement of the
proximal descending thoracic aortic aneurysm using a 26mm
Vascutek Dacron interposition tube graft
[**2109-12-20**] Diagnostic bronchoscopy pre-aortic reconstruction and
bronchoscopy with toilet aspiration of secretions post aortic
reconstruction
[**2109-12-23**] Right Bronchial Y-stent placement
[**2109-12-23**] Flexible bronchoscopy and Therapeutic aspiration of
secretions
[**2109-12-27**] Flexible bronchoscopy through endotracheal tube,
Therapeutic aspiration of secretions, Bronchoalveolar lavage of
the right middle lobe"
272,"Respiratory distress and hypoxia
seemed to be from developing pneumonia (Chest x-rays were
consistent with pneumonia and acute lung failure with ground
glass opacities) and acute respiratory distress syndrome. Blood
cultures taken on post-op day seven were positive for
Enterobacter Aerogenes and COAG negative Staphylococcus.
Bronchoalveolar Lavage and Urine cultures were positive as well
and she was started on broad-spectrum antibiotics until final
sensitivities were performed. Also on this day she had
increasing metabolic acidosis and hypotension (d/t septic shock)
and required multiple pressor support. She received similar
medical care over the next several days (including multiple
pressors and antibiotics) and infectious disease was consulted
on post-op day 11."
273,"5. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. 6. The mitral valve
appears structurally normal with trivial mitral regurgitation.
7. There is no pericardial effusion. 8. Dr. [**Last Name (STitle) 914**] was notified
in person of the results during the surgical procedure.
POSTBYPASS: Patient is on an phenylephrine infusion and is in
sinus rhythm 1. Biventricular function is preserved. 2.
Descending thoracic graft not clearly appreciated. 3. Other
findings are unchanged.
[**Known lastname 44356**],[**Known firstname 3049**] [**Age over 90 44357**] F 64 [**2045-2-20**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2109-12-31**]
8:43 AM"
274,"Demographics
Day of intubation:
Day of mechanical ventilation: 7
Ideal body weight: 61.2 None
Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg
Airway
Airway Placement Data
Known difficult intubation: No
:
Tube Type
ETT:
Position: 21 cm at teeth
Route: Oral
Type: Standard
Size: 7.5mm
Lung sounds
RLL Lung Sounds: Clear
RUL Lung Sounds: Crackles
LUL Lung Sounds: Clear
LLL Lung Sounds: Diminished
Comments:
Secretions
Sputum color / consistency: Clear / Thin
Sputum source/amount: Suctioned / Scant
Comments:
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Visual assessment of breathing pattern: Supra-sternal retractions,
Accessory muscle use, Tachypneic (RR> 35 b/min); Comments: Patient has
moments of high RR requiring
sedation to make comfortable
Assessment of breathing comfort:
Non-invasive ventilation assessment:
Invasive ventilation assessment:
Trigger work assessment: Abnormal trigger efforts (efforts during
inspiratory)
Dysynchrony assessment:
Comments:
Plan
Next 24-48 hours: Utilize ARDSnet protocol; Comments: Mantain peep and
utilize
esophageal balloon for oxygenation
Reason for continuing current ventilatory support:
Respiratory Care Shift Procedures
Bedside Procedures:
Bronchoscopy (9:00)
Sputum induction
Comments: BAL done
needed to view stent"
275,"CVICU
HPI:
HD4
[**12-23**] POD 3
64F s/p replacement of R-sided desc. thoracic aorta (26mm gelweave
graft)
wt: 64kg Cr: 0.8 EF: 55%
PMH: CAD, bronchus compression, CVA ([**Doctor First Name 1463**] occlusion), CTD w features of
Sjogren's, SLE, raynaud's, interstitial lung dz, hypothyroidism, GERD,
R kidney cyst
PSH: CABGx1 (LIMA>LAD) [**2104**], L carotid-subclavian BP, amplatzer
plugging of aberrant L subclavian, R lung resection (wedge),
ccy/carcinoid tumor removal with colonoscopy
[**Last Name (un) 508**]: synthroid 100', prilosec 20', lipitor 10', atenolol 12.5', effexor
75', spiriva 18mcg', plaquenil 200'', asa 81', advair 250/50'',
albuterol 90'', zolpidem 10', restasis eye gtt, calcium, fiber
capsules
Current medications:
Active Medications [**Known lastname 2396**],[**Known firstname 2397**]
Acetaminophen Albuterol-Ipratropium Aspirin EC Atorvastatin Calcium
Gluconate
Dextrose 50% Docusate Sodium Fluticasone-Salmeterol Diskus (250/50)
HYDROmorphone (Dilaudid) Hydroxychloroquine Sulfate Insulin Influenza
Virus Vaccine
Ketorolac Levothyroxine Sodium Magnesium Sulfate Metoclopramide
Metoprolol Tartrate
Milk of Magnesia Nitroglycerin Omeprazole Potassium Chloride
Venlafaxine
24 Hour Events: weaned off neo gtt
Post operative day:
24 hrs events: Neo gtt weaned to off, episodes off intermittent Afib
Allergies:
Quinine
""pass out
[**Doctor Last Name **]
Last dose of Antibiotics:
Cefazolin - [**2109-12-21**] 11:06 PM
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2109-12-23**] 08:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**13**] a."
276,"6
Hct
24.4
29.4
24.8
28.0
27.5
Plt
101
93
103
85
Creatinine
0.6
0.6
0.5
TCO2
22
26
26
27
29
Glucose
138
112
108
115
109
97
Other labs: PT / PTT / INR:12.6/27.9/1.1, Fibrinogen:183 mg/dL, Lactic
Acid:0.9 mmol/L, Ca:7.8 mg/dL, Mg:2.1 mg/dL, PO4:2.1 mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O AIRWAY OBSTRUCTION,
CENTRAL / UPPER, AORTIC ANEURYSM, THORACIC (TAA), .H/O CORONARY ARTERY
BYPASS GRAFT (CABG)
Assessment and Plan: 64yoW s/p rt thoraco-abdm anerysm repair,
hemodynamically stable."
277,"m.
Tmax: 37.4
C (99.4
T current: 37.2
C (98.9
HR: 101 (83 - 101) bpm
BP: 124/57(81) {91/43(60) - 129/5,749(86)} mmHg
RR: 19 (13 - 25) insp/min
SPO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 73 kg (admission): 63.4 kg
Height: 67 Inch
Total In:
2,040 mL
181 mL
PO:
960 mL
Tube feeding:
IV Fluid:
705 mL
181 mL
Blood products:
375 mL
Total out:
3,095 mL
840 mL
Urine:
2,855 mL
740 mL
NG:
Stool:
Drains:
Balance:
-1,055 mL
-659 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 97%
ABG: 7."
278,"41/44/99.[**Numeric Identifier 433**]/26/2
Physical Examination
General Appearance: No acute distress, Well nourished
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous : right, Diminished: right [**1-30**] way up), clear on left
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact), rt thoracotomy CDI/rt groin-CDI
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli)
Labs / Radiology
85 K/uL
9."
279,"Chest tubes with continued air leak now on
water seal.
Neurologic: Pain controlled, with Dilaudid Toradol and percocet. After
IP places bronchial stent will d/c dilaudid
Cardiovascular: Aspirin, Beta-blocker, Statins
Pulmonary: IS, for bronchial stent with IP today
Gastrointestinal / Abdomen:
Nutrition: NPO, after stent placed will ADAT
Renal: Foley, Adequate UO
Hematology: stable hct, platelets 85K will continue to monitor, will
d/c platelets
Endocrine: RISS, continue synthroid
Infectious Disease: non new data
Lines / Tubes / Drains: Foley, Chest tube - pleural , Aline
Rt IJ cordis
Wounds: Dry dressings
Imaging:
Fluids: KVO
Consults: Vascular surgery, Pulmonology, Thoracic/IP for stent
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines: Aline, cordis, foley, CTx2
Cordis/Introducer - [**2109-12-20**] 02:00 PM
Arterial Line - [**2109-12-20**] 02:30 PM
20 Gauge - [**2109-12-22**] 06:00 AM
18 Gauge - [**2109-12-23**] 06:05 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP bundle:
Comments: OOB today after stent
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU"
280,"8 g/dL
97 mg/dL
0.5 mg/dL
26 mEq/L
3.8 mEq/L
11 mg/dL
108 mEq/L
139 mEq/L
27.5 %
9.6 K/uL
[image002.jpg]
[**2109-12-20**] 11:53 PM
[**2109-12-21**] 01:21 AM
[**2109-12-21**] 04:17 AM
[**2109-12-21**] 08:10 AM
[**2109-12-21**] 09:21 AM
[**2109-12-22**] 03:01 AM
[**2109-12-22**] 12:23 PM
[**2109-12-22**] 12:38 PM
[**2109-12-23**] 03:56 AM
[**2109-12-23**] 04:04 AM
WBC
13.4
12.5
9."
281,"TITLE:
CVICU
HPI:
64 y.o. F POD 8 from replacement of R-sided desc. thoracic aorta (26mm
gelweave graft), POD # 5 from Rt bronchial Y-stent placement,
complicated by RLL and RML pneumonia, ARDS and sepsis
PMHx:
CAD, bronchus compression, CVA ([**Doctor First Name 1463**] occlusion), CTD w features of
Sjogren's, SLE, raynaud's, interstitial lung dz, hypothyroidism, GERD,
R kidney cyst
PSH: CABGx1 (LIMA>LAD) [**2104**], L carotid-subclavian BP, amplatzer
plugging of aberrant L subclavian, R lung resection (wedge),
ccy/carcinoid tumor removal with colonoscopy
Current medications:
24 Hour Events:
UNPLANNED EXTUBATION (PATIENT-INITIATED) - At [**2109-12-27**] 09:00 AM
INTUBATION - At [**2109-12-27**] 09:03 AM
ARTERIAL LINE - START [**2109-12-27**] 09:07 AM
BRONCHOSCOPY - At [**2109-12-27**] 09:10 AM
BLOOD CULTURED - At [**2109-12-27**] 10:00 AM
SPUTUM CULTURE - At [**2109-12-27**] 10:00 AM
URINE CULTURE - At [**2109-12-27**] 10:00 AM
PICC LINE - START [**2109-12-27**] 11:54 AM
Post operative day:
POD#5 - S/P Rigid and flexible bronch with Y stent placement in
mainstem
24 hour events: picc line placed, aline placed, respiratory distress
intubated with difficulty oxygenating, hypotension with increased
pressor requirement
Allergies:
Quinine
""pass out
[**Doctor Last Name **]
Last dose of Antibiotics:
Ciprofloxacin - [**2109-12-27**] 01:01 PM
Vancomycin - [**2109-12-27**] 02:07 PM
Piperacillin/Tazobactam (Zosyn) - [**2109-12-27**] 06:00 PM
Fluconazole - [**2109-12-27**] 08:52 PM
Piperacillin - [**2109-12-28**] 04:26 AM
Infusions:
Midazolam (Versed) - 2 mg/hour
Norepinephrine - 0."
282,"ARDS. Low TV ventilation. Optimal PEEP per esophageal
balloon is 12. wean Fio2 as tolerated
Gastrointestinal / Abdomen: No issues
Nutrition: NPO
Renal: Foley, Oliguria will attempt gentle diuresis with lasix drip -
Goal even to 500ml negative
Hematology: Serial Hct, Stable anemia. Monitor
Endocrine: RISS, Glucose well controlled. Keep < 150
Infectious Disease: Check cultures, RLL and RML pneumonia and (GPC GRN
in BAL), GPC in venopuncture and GNR in urine. On
Vanco/cipro/zosyn/fluconazole for coverage. Vanco level prior to 4^th
dose
Lines / Tubes / Drains: Foley, OGT, ETT, Chest tube - pleural
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: PT, IP
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2109-12-27**] 09:07 AM
20 Gauge - [**2109-12-27**] 11:53 AM
PICC Line - [**2109-12-27**] 11:54 AM
18 Gauge - [**2109-12-27**] 11:22 PM
Multi Lumen - [**2109-12-28**] 08:24 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU"
283,"33/57/107/31/2
Ve: 9.2 L/min
PaO2 / FiO2: 134
Physical Examination
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)
Diastolic), Tachycardia
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
on R-base, Diminished: Throughout)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -
Dorsalis pedis: Diminished)
Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -
Dorsalis pedis: Diminished)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: Sedated, Chemically paralyzed
Labs / Radiology
251 K/uL
8.9 g/dL
92 mg/dL
1.1 mg/dL
31 mEq/L
4.2 mEq/L
31 mg/dL
102 mEq/L
139 mEq/L
29
11."
284,"4 kg
Height: 67 Inch
CVP: 13 (13 - 16) mmHg
Total In:
2,290 mL
873 mL
PO:
Tube feeding:
IV Fluid:
1,290 mL
873 mL
Blood products:
1,000 mL
Total out:
840 mL
129 mL
Urine:
785 mL
129 mL
NG:
Stool:
Drains:
Balance:
1,450 mL
744 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: PCV+Assist
Vt (Set): 330 (330 - 400) mL
Vt (Spontaneous): 299 (299 - 430) mL
PS : 18 cmH2O
RR (Set): 30
RR (Spontaneous): 0
PEEP: 12 cmH2O
FiO2: 100%
RSBI Deferred: PEEP > 10, FiO2 > 60%, Unstable Airway
PIP: 31 cmH2O
Plateau: 30 cmH2O
Compliance: 19 cmH2O/mL
SPO2: 82%
ABG: 7."
285,"6/1.4, ALT / AST:[**11-18**], Alk-Phos / T
bili:62/1.4, Amylase / Lipase:18/, Fibrinogen:183 mg/dL, Lactic
Acid:2.2 mmol/L, Albumin:3.0 g/dL, Ca:7.8 mg/dL, Mg:2.3 mg/dL, PO4:1.7
mg/dL
Assessment and Plan
Neurologic: Neuro checks Q 2 hr, Pain controlled, Fentanyl and versed
drip for sedation, paralyzed due to hypoxia and difficulty oxygenating
Cardiovascular: Aspirin, place [**Last Name (un) **] for hemodynamic monitoring Add
vasopressin and wean Levophed for SBP > 100, then attempt to wean neo
Pulmonary: Cont ETT, (Ventilator mode: Other), improved with PCV with
inverse ratio ?"
286,"0 K/uL
[**2109-12-27**] 07:51 PM
[**2109-12-27**] 10:00 PM
[**2109-12-27**] 10:43 PM
[**2109-12-27**] 11:46 PM
[**2109-12-28**] 01:04 AM
[**2109-12-28**] 01:18 AM
[**2109-12-28**] 03:08 AM
[**2109-12-28**] 04:34 AM
[**2109-12-28**] 06:39 AM
[**2109-12-28**] 09:41 AM
WBC
11.0
Hct
32
32
27.1
29
Plt
251
Creatinine
1.1
TCO2
34
33
34
33
33
32
32
32
31
Glucose
88
116
111
102
92
Other labs: PT / PTT / INR:15.4/33."
287,"14 mcg/Kg/min
Phenylephrine - 1.5 mcg/Kg/min
Fentanyl - 250 mcg/hour
Cisatracurium - 0.14 mg/Kg/hour
Other ICU medications:
Midazolam (Versed) - [**2109-12-27**] 12:30 PM
Fentanyl - [**2109-12-27**] 03:20 PM
Lorazepam (Ativan) - [**2109-12-27**] 03:28 PM
Other medications:
Flowsheet Data as of [**2109-12-28**] 10:16 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**13**] a.m.
Tmax: 38
C (100.4
T current: 38
C (100.4
HR: 111 (84 - 124) bpm
BP: 117/46(64) {78/36(49) - 117/55(74)} mmHg
RR: 30 (21 - 39) insp/min
SPO2: 82%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 73 kg (admission): 63."
288,"Clinician: Nurse
Family arrived @11am. Visited with patient then family requested
withdrawal of care, per HCP-husband [**Name (NI) **] [**Name (NI) **] after catholic priest
was available to pray with family. Pt made CMO and extubated per
family wishes. Placed on morphine gtt for comfort. Pt expired 1555pm
with family at her bedside."
289,"7 mg/dL
Imaging: CXR: elevated hemidiaphragm on the right
Abdominal CT
mulitiple dilated loops of bowel
Assessment and Plan
FEVER
HYPOTENSION
C DIFF COLITIS
LUNG CA
ANEMIA
ACUTE RENAL FAIULRE
COAGULOPATHY
======================
Hemodynamics have improved somewhat overnight. CVP indicates we have
not fully volume resuscitated the patient. Would give additional fluids
and attempt to wean levophed. If unable to do so despite CVP of 12 or
higher, would add vasopressin and consider ACTH stimulation,
particularly with hx of lung cancer. Maintain antibiotics for possible
intra-abdominal source of infection. Oxygenation remains good with only
nasal supplementation.
Creat doubled from baseline."
290,"1 mcg/Kg/min
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2118-7-29**] 09:52 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37
C (98.6
Tcurrent: 37
C (98.6
HR: 92 (87 - 102) bpm
BP: 106/56(68) {87/45(56) - 125/66(74)} mmHg
RR: 17 (10 - 22) insp/min
SpO2: 100%
Heart rhythm: RBBB (Right Bundle Branch Block)
Height: 68 Inch
CVP: 5 (4 - 11)mmHg
CO/CI (Fick): (6."
291,"Probably relates to intravascular volume
depletion and hypotension; possible ATN. Creat down slightly this AM.
Would continue to support with fluids to raise CVP. Replete potassium.
Acid base status acceptable.
Mild anemia, likely related to underlying tumor. No evidence of active
bleeding.
Mild elevation in INR; possibly related to vitamin K deficiency. Will
supplement vitamin K.
ICU Care
Nutrition: Consider NG tube; felt to be at risk for aspiration
Glycemic Control: insulin sliding scale.
Lines:
Multi Lumen - [**2118-7-28**] 11:58 PM
22 Gauge - [**2118-7-29**] 12:01 AM
18 Gauge - [**2118-7-29**] 12:01 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments: Not applicable.
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: DNR / DNI
Disposition :ICU
Total time spent: 40 minutes
Patient is critically ill"
292,"0 g/dL
459 K/uL
153 mg/dL
1.4 mg/dL
23 mEq/L
3.3 mEq/L
36 mg/dL
101 mEq/L
134 mEq/L
30.2 %
14.3 K/uL
[image002.jpg]
[**2118-7-29**] 02:59 AM
WBC
14.3
Hct
30.2
Plt
459
Cr
1.4
Glucose
153
Other labs: PT / PTT / INR:18.0/31.2/1.6, Amylase / Lipase:/9,
Differential-Neuts:60.0 %, Band:16.0 %, Lymph:8.0 %, Mono:13.0 %,
Eos:0.0 %, Lactic Acid:1.0 mmol/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL,
PO4:3."
293,"Chief Complaint: Fever, c diff coliitis, hypotension, lung ca
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
In MICU, patient has continued to have abdominal pain and manifests
some confusion. Blood pressure improved; dopamine stopped. Continues on
levophed. Urine output has been about 30-40 cc/hr.
CVP has been [**6-25**].
24 Hour Events:
MULTI LUMEN - START [**2118-7-28**] 11:58 PM
History obtained from [**Hospital 31**] Medical records
Patient unable to provide history: Language barrier
Allergies:
Augmentin (Oral) (Amox Tr/Potassium Clavulanate)
Rash;
Last dose of Antibiotics:
Metronidazole - [**2118-7-29**] 02:15 AM
Meropenem - [**2118-7-29**] 03:31 AM
Vancomycin - [**2118-7-29**] 08:04 AM
Infusions:
Norepinephrine - 0."
294,"5 L/min) / (3.5 L/min/m2)
Mixed Venous O2% Sat: 73 - 73
Total In:
9 mL
6,960 mL
PO:
TF:
IVF:
9 mL
2,760 mL
Blood products:
Total out:
0 mL
248 mL
Urine:
248 mL
NG:
Stool:
Drains:
Balance:
9 mL
6,712 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ///23/
Physical Examination
General Appearance: Well nourished, No(t) No acute distress, No(t)
Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva
pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)
NG tube, No(t) OG tube, Dry oral mucosa
Cardiovascular: (PMI Normal, Hyperdynamic), (S1: Normal, No(t) Absent),
(S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t)
Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t)
Diastolic)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath
Sounds: Clear : right lung clear (patient lying on left side), No(t)
Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: ,
No(t) Absent : , No(t) Rhonchorous: )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)
Distended, Tender: Mild diffuse, No(t) Obese
Extremities: Right lower extremity edema: 2+ edema, Left lower
extremity edema: 2+, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): Not able to assess - language, Movement:
Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Not assessed
Labs / Radiology
10."
295,"Admission Date: [**2118-7-28**] Discharge Date: [**2118-8-11**]
Date of Birth: [**2040-2-5**] Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. [**Known lastname 78131**] is a 78M with stageIV NSCLC on palliative Tarceva
who presents from his nursing facility with fevers x2d as high
as 103.6F. Per paperwork from rehab, he was given levofloxacin
500mg.
.
Of note, he was recently admitted to the OMED service, having
presented with fevers and discharged on [**7-14**] on cefpodoxime and
azithromycin for suspected pneumonia."
296,"Hypertension
2. Atrial Fibrillation
3. COPD
4. h/o bilateral hernia repair
5. aspiration
.
Oncologic History: (Per OMR note [**2118-6-15**] by Dr. [**Last Name (STitle) **]
1. Stage IIB nonsmall cell lung cancer (adenocarcinoma) s/p
surgical resection and adjuvant chemotherapy.
2. FDG avid left lower [**Last Name (STitle) 3630**] lung nodule with non-malignant
biopsy in [**2117-2-13**].
3. Stage IV nonsmall cell lung cancer (bone and lung
recurrence)diagnosed in [**2118-4-15**].
TREATMENT:
1. Status post right thoracotomy with right lower lobectomy,
mediastinal lymph node sampling in [**2117-4-13**].
2. Status post 4 cycles of carboplatin 5AUC and pemetrexed
500mg/m2 every 21 days of a 3 week cycle today."
297,"Started in
[**2117-6-29**] and last dose was given [**2117-8-31**].
3. Status post 3000 cGy of radiotherapy to left hip lesion
completed in [**2118-5-10**].
4. Started erlotinib 150 mg/day in [**2118-5-24**].
5. h/o mets to sacral spine s/p radiation, on narcotics for pain
control
Social History:
70+ year h/o smoking. Currently at rehab facility.
Family History:
Unknown cause of death of mother or father. The patient does
have siblings that are alive. No recurrent cancers in the
family.
Physical Exam:
On [**Hospital Unit Name 153**] admission:
Vitals 96.3 102 101/58 21 100% on 4L
General Chronically ill appearing man, appears anxious
HEENT Sclera anicteric, dry MMM
Neck supple
Pulm Lungs with few bibasilar rales L>R
CV Tachycardiac regular S1 S1 no m/r/g
Abd Soft +bowel sounds tender to palpation throughout without
rigidity or guarding
Extrem Warm tr bilateral edema palpable distal pulses
Neuro Awake and interactive, oriented to hospital in [**Location (un) 86**],
does not know date
Derm No rash or jaundice
Lines/tubes/drains Foley with yellow urine, RIJ"
298,".
* Hypotension: Patient presented with hypotension concerning for
sepsis. He was briefly on levophed and was taken off of
pressors when SBP 100s-110s. His hypotension was probably due
to hypovolemia from diuresis but severe hypotension in setting
of developing sepsis was also considered. Lactate down to 1.0
from 1.3 on admission with SVO2 73.
On the floors, his SBP's ranged in the 130's to 140's and he was
restarted on his home doses of LASIX WAS HELD FOR THE SEVERAL
DAYS PRIOR TO DISCHARGE BECAUSE HE WAS AUTODIURESING. HE NEEDS
TO BE RE-EVALUATED REGULARLY FOR WHETHER LASIX NEEDS TO BE
RESTARTED."
299,".
* L leg swelling and pain: Patient had lower extremity pain
edema greater on left than right after receiving fluid
resuscitation in the ICU. LENI showed no evidence of DVT. He
was diuresed with lasix until his fluid output was negative. He
was autodiuresing on discharge so his lasix was held. His fluid
status should be reassessed daily to determine if he needs to be
restarted on lasix.
* Hyponatremia: Patient's hyponatremia resolved after
intravenous fluids, which supports hypovolemia as cause on
admission. Review of OMR shows Na's running ~130. At last
discharge, thought to have a component of SIADH."
300,"* Acute renal failure: Patient had creatinine elevated to 1.4
and FeNa was 0.1 on admission. Creatinine has improved to
0.7-0.8 (his baseline). His acute renal failure has resolved and
was likely pre-renal as it improved with IVF.
* Anemia: His hematocrit is down from admission but suspect
this was secondary to hemoconcentration. His anemia is
consistent with baseline.
* NSCLC: Advanced disease, on palliative chemotherapy. Social
work and palliative care were consulted throughout this
hospitalization and discussed goals of care with the family.
Erlotinib will be restarted on [**2118-8-19**] and should be taked every
other day."
301,"He will follow up with Dr. [**Last Name (STitle) **].
* Atrial fibrillation: His sotalol was restarted now that his
hypotension resolved.
# Nutrition ?????? Patient has aspiration risks and is unable to
swallow pills easily. He was evaluated by nutrition and kept on
a pureed diet with TID ensure. He also had an elevated INR
despite not being on anticoagulation which possibly could be due
to malnutrition. INR improved after administration of one dose
of vitamin K.
# Oral thrush: Patient failed nystatin swish and swallow. He was
loaded with 400mg fluconazole and should continue 200mg daily
until [**2118-8-25**].
#Pain control: Patient was maintained on methadone and diluadid
PRN during hospitalization."
302,"25. Erlotinib 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QOD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 4444**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Clostridium difficil colitis
2. Dehydration
3. Hyponatremia
4. Hypotension
SECONDARY DIAGNOSIS:
1. Non Small Cell Lung Cancer
Discharge Condition:
Stable, afebrile [**2-16**] BM's per day.
Discharge Instructions:
You were admitted to the hospital on [**2118-7-28**] with fevers
secondary to clostridium dificile colitis (an infection in your
colon). You are being treated with an antibiotic called flagyl.
You need to continue this antibiotics until [**2118-8-12**].
You should STOP taking lasix (water pill)."
303,"[**7-28**] CT Abd/pelvis:
1. Bibasilar lung consolidations, worse when compared to prior
exam.
Differential diagnosis includes infectious etiologies as well as
a slow
growing lesion such as bronchoalveolar carcinoma. Clinical
correlation is
recommended.
2. No evidence of small bowel obstruction. Colon appears
relatively
featureless with air-fluid levels and possibly pericolonic fat
stranding
versus third spacing. These findings may suggest a colitis.
3. Extensive vascular calcifications.
4. Large prostate.
5. S1 vertebral body fracture with buckling of the superior
cortex, worse
when compared to prior exam.
[**7-30**] Left LENI:
IMPRESSION: No left lower extremity DVT.
[**7-31**] KUB:
FINDINGS:
Small bowel loops containing air are seen without distension."
304,"15. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for fungal rash-groin.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
18. Dilaudid 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every four (4)
hours as needed for pain.
19. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a day as
needed for constipation: Please start taking after diarrhea has
resolved."
305,"You also had thrush in your mouth. Continue to take fluconazole
200mg daily until [**2118-8-25**].
You should restart your erlotinib on [**2118-8-19**] and take it every
other day.
Use miconazole for the fungal rash in your groin. Apply it four
times a day.
Please return to the emergency room if you have worsening
diarrhea >10 BM per day, bloody/black stools, fever>100.4, chest
pain, shortness of breath, or any other symptoms concerning to
you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-17**] weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
Completed by:[**2118-8-11**]"
306,"His methadone should be tapered and
pain reassessed daily while in rehab.
Medications on Admission:
At rehab:
Erlotinib 100mg daily
Simvastatin 10mg daily
Lasix 20mg daily
Sotalol 80mg [**Hospital1 **]
Nifedipine 30mg daily
Methadone 15mg tid
Folate
Lidoderm patch
[**Name (NI) **], [**Name (NI) 78132**], MOM, dulcolax, lactulose, senna, guiafenesin,
colace, tylenol all prn
Zofran prn
Neurontin 300mg q12h
Heparin 5000 units SQ TID
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: One (1)
injection Injection TID (3 times a day).
2. Metronidazole 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every
8 hours): continue util [**2118-8-12**]."
307,"8. Sotalol 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
10. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
11. Nifedipine 30 mg Tablet Sustained Release [**Hospital1 **]: One (1)
Tablet Sustained Release PO DAILY (Daily).
12. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
13. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO
DAILY (Daily).
14. Oral Wound Care Products Gel in Packet [**Hospital1 **]: One (1) ML
Mucous membrane TID (3 times a day) as needed."
308,"20. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
[**Last Name (STitle) **]: One (1) dose PO once a day as needed for constipation:
Please use as needed after diarrhea has resolved.
21. Dulcolax 10 mg Suppository [**Last Name (STitle) **]: One (1) Rectal once a day
as needed for constipation: Please start using as needed after
diarrhea has resolved.
22. Zofran 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8)
hours as needed for nausea.
23. Ambien 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
24. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours): continue until [**2118-8-25**]."
309,"Pertinent Results:
On admission [**2118-7-28**]:
WBC-10.9 RBC-3.71* Hgb-10.3* Hct-32.1* MCV-87 MCH-27.8 MCHC-32.2
RDW-17.1* Plt Ct-410
Neuts-55 Bands-27* Lymphs-6* Monos-10 Eos-0 Baso-0 Atyps-0
Metas-2* Myelos-0
PT-17.9* PTT-33.4 INR(PT)-1.6*
Glucose-143* UreaN-35* Creat-1.6* Na-130* K-4.1 Cl-94* HCO3-26
AnGap-14
ALT-17 AST-34 AlkPhos-60 TotBili-0.7
Albumin-2.6* Calcium-7.6* Phos-3.7 Mg-2.0"
310,".
In the ED, initial vs were T98 P 73 BP 86/51 RR 22 98% on . He
was given vancomycin, cefepime, flagyl, acetaminophen, zofran,
and started on peripheral dopamine. Awake and mentating, making
small amounts of dark urine. CT abdomen done for h/o 1day of
diarrhea, noncontrast showed ?of colitis. Got 5L of saline. BP
remains 70's systolic on 15mcg dopamine and levophed.
.
On the floor, he denies any complaints - though initially
reported some abdominal pain to the RN. Review of systems
otherwise negative, though unclear if patient's history is
reliable.
Past Medical History:
Past Medical History:
1."
311,"[**7-29**] FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA
[**7-28**] EKG: Probable sinus rhythm with low amplitude P waves
(visible in lead V1) versus ectopic atrial rhythm. Right
bundle-branch block. Left anterior fascicular block. Q-T
interval prolongation. Compared to the previous tracing of
[**2118-7-7**] P waves are less apparent. Q-T interval is more
prolonged.
[**7-28**] CXR: 1. Stable post-surgical changes in the right lung from
prior right lower lobectomy and upper [**Month/Year (2) 3630**] wedge resection due
to known non-small cell lung cancer.
2. Hazy opacity in the left lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] reflect atelectasis."
312,"3. Neurontin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO every twelve
(12) hours.
4. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day) as needed for constipation: once diarrhea subsides,
please start taking as standing dose [**Hospital1 **].
5. Methadone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
6. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: no more than 4g in 24 hours."
313,"There is a
paucity of air in the left lower quadrant which might be due to
liquid stool within the descending colon. No free air is seen on
the right lateral decubitus film. The visualized osseous
structures are unremarkable. The right lung base is not well
seen with the dome of the diaghragm being pushed superiorly.
This correlates with the right lower [**Month/Year (2) 3630**] atelactasis on the
corresponding CT.
IMPRESSION: No distended loops of bowel seen.
Brief Hospital Course:
Mr. [**Known lastname 78131**] is a 78M with stage IV NSLC who presents with
fevers from his rehab facility."
314,"HE WILL LIKELY NEED HIS LASIX RESTARTED AT SOME POINT
AT REHAB. His pressures remained stable throughout
hospitalization.
.
* Fever: Patient's fever likely caused by C diff as patient is
toxin positive, although aspiration pneumonia was also
considered a possibility given evidence of dysphagia on prior
video swallow. His underlying pulmonary malignancy predisposes
him to a post-obstructive pneumonia. However the absence of
cough or hypoxia made a pulmonary etiology less compelling.
Blood and urine cultures are negative. His C difficile colitis
was originally treated with PO vancomycin and IV flagyl. Prior
to discharge, as diarrhea began to resolve, he was switched to
PO flagyl alone, to be continued for a two week course (until
[**2118-8-12**])."
315,"Your body has been
eliminating excess fluid well without the lasix. Your doctors
[**Name5 (PTitle) **] [**Name5 (PTitle) 4656**] your fluid status at rehab and decide whether or
not you need lasix in future.
You can continue to take methadone with dilaudid as needed for
breakthrough pain. Your doctors at rehab [**Name5 (PTitle) **] taper your
methadone as needed. Never drive while taking these medications
or perform any activities requiring a fast reaction time. Never
drink alcohol with these medications. Once your diarrhea stops,
you should start taking colace and senna daily to prevent
constipation, which is a common side effect of narcotics."
316,"7 mg/dL
[**7-28**] CXR cardiomegaly with elevated R hemidiaphragm, R effusion vs
consolidation, ?small nodule on L no large infiltrate, otherwise
similar to prior
.
[**7-28**] CT abdomen (noncontrast, prelim dictation)
patchy consolidation R lung base, new from prior study
no SBO. colon with air fluid levels and ?pericolonic fat stranding vs
3rd spacing possibly c/w colitis
BCx, Ucx
pending
CXR
elevated right hemidiaphragm, hazy cardiac borders
Assessment and Plan
Mr. [**Known lastname 7717**] is a 78M with stage IV NSLC who presents with fevers from
his rehab facility.
.
* Hypotension/Septic Shock
Probably due to hypovolemia from diuresis but must consider severe
hypotension in setting of developing sepsis
- Volume resuscitate to CVP 10-12
- Continue pressors MAP>60-65
- Check SVO2
- Follow urine output, goal 0."
317,"5cc/kg/hr
- Repeat lactate
.
* Fever
His history is limited, but abdominal tenderness on exam and diarrhea
point toward a GI source. With his recent antibiotics and stay in
rehab, C difficile colitis is obviously a concern. With evidence of
dysphagia on prior video swallow an aspiration pneumonia is also a
possibility. His underlying pulmonary malignancy predisposes him to a
post-obstructive pneumonia. However the absence of cough or hypoxia
make a pulmonary etiology less compelling.
- continue PO vancomycin and IV flagyl for suspected severe C difficile
colitis
- continue meropenem for ?aspiration pna or non-Cdiff severe
intrabdominal infection
- check LFTs
- f/u blood and urine cultures, stool C diff, CIS
."
318,"3
C (97.3
Tcurrent: 36.3
C (97.3
HR: 91 (87 - 102) bpm
BP: 111/59(71) {87/45(56) - 111/66(73)} mmHg
RR: 19 (10 - 22) insp/min
SpO2: 100%
Heart rhythm: RBBB (Right Bundle Branch Block)
Height: 68 Inch
CVP: 7 (7 - 11)mmHg
CO/CI (Fick): (6.5 L/min) / (3.5 L/min/m2)
Mixed Venous O2% Sat: 73 - 73
Total In:
9 mL
5,800 mL
PO:
TF:
IVF:
9 mL
1,600 mL
Blood products:
Total out:
0 mL
188 mL
Urine:
188 mL
NG:
Stool:
Drains:
Balance:
9 mL
5,612 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ///23/
Physical Examination
General Chronically ill appearing man, appears anxious
HEENT Sclera anicteric, dry MMM
Neck supple
Pulm Lungs with few bibasilar rales L>R
CV Tachycardiac regular S1 S1 no m/r/g
Abd Soft +bowel sounds tender to palpation throughout without rigidity
or guarding
Extrem Warm tr bilateral edema palpable distal pulses
Neuro Awake and interactive, oriented to hospital in [**Location (un) 168**], does not
know date
Derm No rash or jaundice
Lines/tubes/drains Foley with yellow urine, RIJ
Labs / Radiology
459 K/uL
10."
319,"Could consider amiodarone
if needed.
- Not on anticoagulation
.
* HTN
- Hold home antihypertensives given hypotension
.
# Nutrition
patient has aspiration risks, unable to swallow pills
easily. Also has an elevated INR despite not being on anticoagulation,
can possibly be due to malnutrition, lack of Vit K
- Vitamin K 5 mg
- consider NG tube as patient has aspiration risks
ICU Care
Nutrition: thin liquids (see prior speech/swallow recommendations)
Glycemic Control: Blood sugar well controlled
Lines:
Multi Lumen - [**2118-7-28**] 11:58 PM
22 Gauge - [**2118-7-29**] 12:01 AM
18 Gauge - [**2118-7-29**] 12:01 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP: aspiration precautions
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: DNR / DNI
Disposition: ICU"
320,"TITLE:
Chief Complaint:
24 Hour Events:
MULTI LUMEN - START [**2118-7-28**] 11:58 PM
- BP improved overnight, pt now off dopamine, only on levophed
Allergies:
Augmentin (Oral) (Amox Tr/Potassium Clavulanate)
Rash;
Last dose of Antibiotics:
Vancomycin - [**2118-7-29**] 01:30 AM
Metronidazole - [**2118-7-29**] 02:15 AM
Meropenem - [**2118-7-29**] 03:31 AM
Infusions:
Norepinephrine - 0.1 mcg/Kg/min
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2118-7-29**] 07:22 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
321,"0 g/dL
153 mg/dL
1.4 mg/dL
23 mEq/L
3.3 mEq/L
36 mg/dL
101 mEq/L
134 mEq/L
30.2 %
14.3 K/uL
[image002.jpg]
[**2118-7-29**] 02:59 AM
WBC
14.3
Hct
30.2
Plt
459
Cr
1.4
Glucose
153
Other labs: PT / PTT / INR:18.0/31.2/1.6, Amylase / Lipase:/9,
Differential-Neuts:60.0 %, Band:16.0 %, Lymph:8.0 %, Mono:13.0 %,
Eos:0.0 %, Lactic Acid:1.0 mmol/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL,
PO4:3."
322,"* Hyponatremia
Review of OMR shows Na's running ~130. At last discharge, thought to
have a component of SIADH. Suspect he is hypovolemic currently.
- Hold lasix, continue IVF hydration, follow Na
- Check urine osms, lytes
.
* Acute renal failure
Probably due to pre-renal etiology, consider also ATN given hypotension
- IVF as above, follow Cr and urine output, renally doses meds
- Hold ACEI and diuretics
.
* Anemia
- Hct stable follow, maintain active T+S
.
* NSCLC
Advanced disease, on palliative chemotherapy.
- Oncology recs appreciated
- Social work and palliative care, family meeting regarding goals of
care
- Continue outpatient pain meds
.
* Afib
- Hold sotalol in setting of renal failure."
323,"3
10.5
9.0
Hct
30.2
27.9
26.7
Plt
459
396
348
Cr
1.4
1.1
1.0
Glucose
153
122
110
Other labs: PT / PTT / INR:14.3/37.4/1.2, Amylase / Lipase:/9,
Differential-Neuts:79.0 %, Band:2.0 %, Lymph:8.0 %, Mono:9.0 %, Eos:0.0
%, Lactic Acid:1.0 mmol/L, Albumin:2.6 g/dL, Ca++:7.8 mg/dL, Mg++:2.1
mg/dL, PO4:3.0 mg/dL
Assessment and Plan
Septic shock
source likely c.diff. Now stable off pressors. Repeat
lactate 1. Goal MAP 60, CVP 10."
324,"Monitoring Uo.
C.diff colitis
now on p.o. vanc, iv flagyl. Continues to have
diarrhea. Stable, no evidence of perforation.
Hyponatremia
improved w/ volume.
Anemia
no evidence of active bleeding. Guiac stools.
NSCLC
palliative care following
Atrial fibrillation
plan to re-start beta blocker today.
HTN
plan to re-start over the next several days.
LLE
u/s to evaluate for DVT.
ICU Care
Nutrition: Thick liquids. Speech and swallow following.
Glycemic Control:
Lines:
Multi Lumen - [**2118-7-28**] 11:58 PM
22 Gauge - [**2118-7-29**] 12:01 AM
18 Gauge - [**2118-7-29**] 12:01 AM
Prophylaxis:
DVT: sq heparin
Stress ulcer: PPI
Comments:
Communication: Comments:
Code status: DNR / DNI
Disposition : Call out to OMED
Total time spent: 40 min"
325,"Chief Complaint: f/u hypotension
HPI:
78M with a history of stage IV NSCLC a/w fever and hypotension.
Denies respiratory symptoms. Reports that he feels dramatically
improved.
24 Hour Events:
Weaned off levophed.
C. diff toxin positive.
Allergies:
Augmentin (Oral) (Amox Tr/Potassium Clavulanate)
Rash;
Last dose of Antibiotics:
Meropenem - [**2118-7-29**] 03:31 AM
Vancomycin - [**2118-7-30**] 12:49 AM
Metronidazole - [**2118-7-30**] 09:02 AM
Infusions:
Other ICU medications:
Lansoprazole (Prevacid) - [**2118-7-29**] 06:38 PM
Heparin Sodium (Prophylaxis) - [**2118-7-30**] 05:04 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2118-7-30**] 11:52 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
326,"2
C (99
Tcurrent: 35.9
C (96.7
HR: 74 (73 - 92) bpm
BP: 119/69(80) {86/36(49) - 119/75(80)} mmHg
RR: 15 (12 - 27) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 74.7 kg (admission): 74 kg
Height: 68 Inch
CVP: 10 (8 - 10)mmHg
Total In:
8,077 mL
833 mL
PO:
TF:
IVF:
3,817 mL
833 mL
Blood products:
Total out:
613 mL
267 mL
Urine:
613 mL
267 mL
NG:
Stool:
Drains:
Balance:
7,464 mL
566 mL
Respiratory support
O2 Delivery Device: None
SpO2: 100%
ABG: ///22/
Physical Examination
HEENT: OP clr
Neck supple."
327,"CVL site c/d/i
Lungs: Bibasilar rales.
Heart: Irregularly irregular. S1,S2. No m/r/g
Abd: +bs. Soft. ND. Mild TTP in RUQ.
Ext: LLE enlarged compared to R. Mild tenderness to palpation.
Skin: No rashes.
Neurologic: alert and oriented x3.
Labs / Radiology
8.6 g/dL
348 K/uL
110 mg/dL
1.0 mg/dL
22 mEq/L
3.7 mEq/L
37 mg/dL
107 mEq/L
138 mEq/L
26.7 %
9.0 K/uL
[image002.jpg]
[**2118-7-29**] 02:59 AM
[**2118-7-29**] 06:09 PM
[**2118-7-30**] 03:27 AM
WBC
14."
328,"0 %, Lymph:8.0 %, Mono:9.0 %, Eos:0.0
%, Lactic Acid:1.0 mmol/L, Albumin:2.6 g/dL, Ca++:7.8 mg/dL, Mg++:2.1
mg/dL, PO4:3.0 mg/dL
.
corrected Ca 8.72
BCx, Ucx
pending
C diff positive
MRSA screen pending
Assessment and Plan
Mr. [**Known lastname 7717**] is a 78M with stage IV NSLC who presents with fevers from
his rehab facility.
.
* Hypotension/Septic Shock
Probably due to hypovolemia from diuresis but must consider severe
hypotension in setting of developing sepsis
- Volume resuscitate to CVP 10-12
- Goal MAP>60-65
- Check SVO2
- Follow urine output, goal 0."
329,"TITLE:
Chief Complaint:
24 Hour Events:
-Dr. [**Last Name (STitle) 1932**] to see him Monday - will re-start his palliative chemo med
on Monday
-C. diff positive --> D/C'd meropenem. Continued vanco/flagyl
-f/u Palliative care recs in AM
-on levophed drip for hypotension with SBP 110s.--> turned off at 10pm
with SBP 100s. UOP 25cc/hr.
Allergies:
Augmentin (Oral) (Amox Tr/Potassium Clavulanate)
Rash;
Last dose of Antibiotics:
Meropenem - [**2118-7-29**] 03:31 AM
Metronidazole - [**2118-7-29**] 04:39 PM
Vancomycin - [**2118-7-30**] 12:49 AM
Infusions:
Other ICU medications:
Lansoprazole (Prevacid) - [**2118-7-29**] 06:38 PM
Heparin Sodium (Prophylaxis) - [**2118-7-30**] 05:04 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2118-7-30**] 07:42 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
330,"5cc/kg/hr
- Repeat lactate
.
* Fever
His history is limited, but abdominal tenderness on exam and diarrhea
point toward a GI source. With his recent antibiotics and stay in
rehab, C difficile colitis is obviously a concern. With evidence of
dysphagia on prior video swallow an aspiration pneumonia is also a
possibility. His underlying pulmonary malignancy predisposes him to a
post-obstructive pneumonia. However the absence of cough or hypoxia
make a pulmonary etiology less compelling.
- continue PO vancomycin and IV flagyl for suspected severe C difficile
colitis
- continue meropenem for ?aspiration pna or non-Cdiff severe
intrabdominal infection
- check LFTs
- f/u blood and urine cultures, stool C diff, CIS
."
331,"* Hyponatremia
Review of OMR shows Na's running ~130. At last discharge, thought to
have a component of SIADH. Suspect he is hypovolemic currently.
- Hold lasix, continue IVF hydration, follow Na
- Check urine osms, lytes
.
* Acute renal failure
Probably due to pre-renal etiology, consider also ATN given hypotension
- IVF as above, follow Cr and urine output, renally doses meds
- Hold ACEI and diuretics
.
* Anemia
- Hct stable follow, maintain active T+S
.
* NSCLC
Advanced disease, on palliative chemotherapy.
- Oncology recs appreciated
- Social work and palliative care, family meeting regarding goals of
care
- Continue outpatient pain meds
.
* Afib
- Hold sotalol in setting of renal failure."
332,"Could consider amiodarone
if needed.
- Not on anticoagulation
.
* HTN
- Hold home antihypertensives given hypotension
.
# Nutrition
patient has aspiration risks, unable to swallow pills
easily. Also has an elevated INR despite not being on anticoagulation,
can possibly be due to malnutrition, lack of Vit K
- Vitamin K 5 mg
- consider NG tube as patient has aspiration risks
ICU Care
Nutrition: thin liquids (see prior speech/swallow recommendations)
Glycemic Control: monitoring
Lines:
Multi Lumen - [**2118-7-28**] 11:58 PM
22 Gauge - [**2118-7-29**] 12:01 AM
18 Gauge - [**2118-7-29**] 12:01 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP: aspiration precautions
Comments:
Communication: Comments:
Code status: DNR / DNI
Disposition:"
333,"6 g/dL
110 mg/dL
1.0 mg/dL
22 mEq/L
3.7 mEq/L
37 mg/dL
107 mEq/L
138 mEq/L
26.7 %
9.0 K/uL
[image002.jpg]
[**2118-7-29**] 02:59 AM
[**2118-7-29**] 06:09 PM
[**2118-7-30**] 03:27 AM
WBC
14.3
10.5
9.0
Hct
30.2
27.9
26.7
Plt
459
396
348
Cr
1.4
1.1
1.0
Glucose
153
122
110
Other labs: PT / PTT / INR:14.3/37.4/1.2, Amylase / Lipase:/9,
Differential-Neuts:79.0 %, Band:2."
334,"2
C (99
Tcurrent: 36.2
C (97.2
HR: 74 (73 - 92) bpm
BP: 114/53(68) {86/36(49) - 115/75(78)} mmHg
RR: 18 (12 - 27) insp/min
SpO2: 99%
Heart rhythm: RBBB (Right Bundle Branch Block)
Wgt (current): 74.7 kg (admission): 74 kg
Height: 68 Inch
CVP: 10 (5 - 10)mmHg
Total In:
8,077 mL
504 mL
PO:
TF:
IVF:
3,817 mL
504 mL
Blood products:
Total out:
613 mL
177 mL
Urine:
613 mL
177 mL
NG:
Stool:
Drains:
Balance:
7,464 mL
327 mL
Respiratory support
O2 Delivery Device: None
SpO2: 99%
ABG: ///22/
Physical Examination
General Chronically ill appearing man, appears anxious
HEENT Sclera anicteric, dry MMM
Neck supple
Pulm Lungs with few bibasilar rales L>R
CV Tachycardiac regular S1 S1 no m/r/g
Abd Soft +bowel sounds tender to palpation throughout without rigidity
or guarding
Extrem Warm tr bilateral edema palpable distal pulses
Neuro Awake and interactive, oriented to hospital in [**Location (un) 168**], does not
know date
Derm No rash or jaundice
Lines/tubes/drains Foley with yellow urine, RIJ
Labs / Radiology
348 K/uL
8."
335,"Admission Date: [**2186-7-25**] Discharge Date: [**2186-7-27**]
Date of Birth: [**2122-12-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy with placement of 4 cecal clips [**2186-7-26**]
History of Present Illness:
63F with a history of HTN, HLD, and DCIS s/p bilateral
mastectomy who presents with hematochezia x 12 hours, DOE, and
significant malaise. She underwent a screening colonoscopy on
[**2186-7-18**] where she was found to have a 5mm x 10mm sessile polyp
in the cecum, 1 x 2mm sessile polyp in the cecum, and a 4mm
sessile polyp in the sigmoid colon as well as several small
AVMs, mild diverticulosis, and internal hemorrhoids."
336,".
She was consented for ICU care.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denied nausea, vomiting.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. No feelings of depression or
anxiety. All other review of systems negative.
Past Medical History:
- DCIS s/p mastectomy
- Osteopenia
- Hypercholesterolemia
- Vulvodynia
- Hx of BCC and SCC
- Rhinitis
- Constipation
- Sciatica
- Cervicalgia
- HTN
- Osteoarthritis
- Blistering dermatitis NOS"
337,"She was aggressively volume
resuscitated with 5 L of crystalloid and transfused 2 units of
PRBCs after continuning to pass dilute blood with a Golytely
prep, which was then held the first night of the hospitalization
after completing half of the prep. On hospital day 2, she
underwent colonoscopy, which was remarkable for bleeding in the
cecum, the site of 2 of her polypectomies 9 days prior to
admission; 4 clips were placed with adequate hemostasis. Her
volume and hematocrit subsequently remained stable. She was
discharged home in stable condition.
# Tender hepatomegaly: The patient's liver was slightly tender
to palpation on admission, which prompted and abdominal
ultrasound, which subsequently showed that the liver was normal."
338,"# Pancreatic cyst on US: On abdominal ultrasound a pancreatic
cyst was found incidentally described as a 1.3 x 0.6 x 0.6 cm
predominantly hypoechoic lesion in the pancreatic head/neck; it
is likely benign. This will be further evaluated on an
outpatient basis after discharge with an MRCP.
Medications on Admission:
- Simvastatin 60mg PO HS
- HCTZ 12.5mg PO HS
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: Three (3) Tablet PO at bedtime.
Tablet(s)
2. STOPPED: Hydrochlorothiazide 12.5 mg Capsule Sig: One (1)
Capsule PO once a day: Take in mornings; Restart in a week"
339,"Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed from cecal polypectomy site
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a privilege to take care of you in the hospital.
.
You were hospitalized for a bleed in your colon caused by the
re-bleeding of one of your polypectomy sites in your cecum. You
were admitted to the ICU with a low blood count and low blood
pressures when sitting up and standing. We resuscitated your
volume and blood coutns with IV fluids and 2 units of packed red
blood cells. A CT of yoru abdomen did not show the bleeding
source, but a colonoscopy revealed the source, which was stopped
with clips. You also underwent an abdominal ultrasound because
your liver was slightly tender on admission, which showed a
normal liver but an incidental finding of a pancreatic cyst. We
recommend that you have this finding evaluated further as an
outpatient.
.
No changes were made to your home medications.
Followup Instructions:
Please schedule an appointment with Gastroenterology for
evaluation of your pancreas"
340,"4
[**2186-7-25**] 12:30PM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-2.9
MAGNESIUM-1.8 IRON-73
[**2186-7-25**] 12:30PM calTIBC-272 VIT B12-513 FOLATE-10.3
FERRITIN-72 TRF-209
[**2186-7-25**] 12:30PM WBC-7.6 RBC-3.23* HGB-9.8* HCT-28.9* MCV-90
MCH-30.4 MCHC-34.0 RDW-12.7
[**2186-7-25**] 12:30PM NEUTS-79.0* LYMPHS-17.1* MONOS-3.3 EOS-0.5
BASOS-0.2
[**2186-7-25**] 12:30PM PLT COUNT-249
[**2186-7-25**] 12:03PM GLUCOSE-167* UREA N-22* CREAT-0."
341,"For a few
days after her colonoscopy she was feeling somewhat unwell but
denies abdominal pain or cramping, hematochezia, dark stool,
maroon stool, DOE, or orthostatic symptoms. She fully recovered
and felt fine for a week. The evening prior to admission she
suddenly developed crampy lower abdominal pain and an urge to go
to the bathroom. She have 4 bouts of diarrhea of brown stool as
well as bright red blood. She denies blood clots or maroon
stool. She felt weak after the BMs and could barely walk back to
her office. A colleague drove her home. That evening she had DOE
walking in the yard with her dog."
342,"8/28.9 from a baseline
of 14.5/42.8 in 11/[**2184**]. Two 18G PIVs were placed and an ECG
showed no ischemic changed. She received NS 2000mL and was seen
by GI who recommended ICU admission and a PPI. She was
transfered to the ICU for further management.
.
In the [**Hospital Unit Name 153**] she is tired but denies and CP, chest pressure, SOB,
palpitations, or HA. She reports dizziness when she sits up and
some stomach grumbling, but no cramps. She denies any history of
bleeding problems, GIB bleeding, clotting problems, GERD, heart
burn, or jaundice."
343,"8 SODIUM-133
POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13
[**2186-7-25**] 12:03PM estGFR-Using this
CTA-Ab [**2186-7-26**]:
No acute intra-abd or pelvic abnl. Patent mesenteric vasculature
and no e/o
active extravasation.
.
Ab US [**2186-7-25**]
1.3-cm predominantly hypoechoic lesion of the pancreas.
Though likely benign and possibly sequellae of processes such as
pancreatitis,
dedicated MRCP (on a nonemergent basis) of the pancreas
recommended for
further evaluation.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
# Lower GI Bleed: Admitted with a Hct of 29 from baseline 43 and
orthostatic by vital signs."
344,"2 MCHC-33.7 RDW-11.9
[**2186-7-25**] 05:01PM PLT COUNT-277
[**2186-7-25**] 02:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2186-7-25**] 02:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2186-7-25**] 02:40PM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2186-7-25**] 12:30PM GLUCOSE-145* UREA N-23* CREAT-0.8 SODIUM-134
POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-26 ANION GAP-12
[**2186-7-25**] 12:30PM ALT(SGPT)-21 AST(SGOT)-30 LD(LDH)-222 ALK
PHOS-52 TOT BILI-0."
345,"She called the on call service
at [**Location (un) 2274**] and was advised to stay well hydrated and consider
coming to the ED, but refused. The following morning she
conitnued to feel tired and weak. her abdominal cramps returned
and she had 4 more bouts of diarrhea with bright red blood. She
felt so weak she could barely stand and was dizzy with sitting
up. Her son called 911 and she was transported to the ED for
further management.
.
In the ED initial vital signs were 97.9 72 140/90 20 100% on RA.
Initial labs were notable for a H/H of 9."
346,"Pertinent Results:
Labs on Admission:
[**2186-7-25**] 11:51PM GLUCOSE-95 UREA N-11 CREAT-0.7 SODIUM-145
POTASSIUM-3.5 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13
[**2186-7-25**] 11:51PM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-2.3
[**2186-7-25**] 11:51PM WBC-6.6 RBC-2.48* HGB-7.9* HCT-22.8* MCV-92
MCH-31.8 MCHC-34.6 RDW-12.8
[**2186-7-25**] 11:51PM PLT COUNT-216
[**2186-7-25**] 05:01PM WBC-8.2 RBC-3.19* HGB-9.9* HCT-29.5* MCV-93
MCH-31."
347,"Social History:
- Tobacco: Denies
- etOH: Social
- Illicits: Distant marijuana, no IVDU or other illicits
Family History:
- Mother: [**Name (NI) 2481**] dementia
- Father: CAD s/p CABG, melanoma
- Sister: Breast cancer
Physical Exam:
GEN: NAD, pale
VS: 97.0 87 supine: 153/93 sitting 133/88 17 99% on RA
HEENT: MMM, no OP lesions, JVP below the clavicle, neck is
supple, no cervical, supraclavicular, or axillary LAD, normal
geographic tongue
CV: RR, NL S1S2 no S3S4, II/VI low systolic murmur at the LUSB
PULM: CTAB
ABD: BS++, soft, nondistended, liver tender and palpable 3cm
below the costal margin in the mid clavicular line, no stigmata
of chronic liver disease
LIMBS: No LE edema, no tremors or asterixis, no clubbing, no
koilonychia
SKIN: No rashes or skin breakdown
NEURO: Strength 5/5 of the upper and lower extremities, reflexes
2+ of the upper and lower extremities"
348,"SICU
HPI:
65 yo M ON [**2135-9-26**] had an episode of syncope. He was noted to have an
8-point drop in his hematocrit and underwent an endoscopy for further
evaluation. The upper endoscopy performed on [**2135-9-27**] revealed severe
esophagitis at the gastroesophageal junction with some mild bleeding
and a small hiatal hernia. In addition, a 3-mm prepyloric ulcer was
also noted. Biopsy of the inflamed area at the GE junction revealed
invasive moderate to poorly differentiated adenocarcinoma arising in a
background of Barrett's esophagus. Now s/p esophagoscopy, laparoscopic
esophagogastrectomy
Chief complaint:
esophogeal adenocarcinoma
PMHx:
HTN, CVA/TIA, carotid stenosis
Current medications:
20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 2."
349,"250 mL NS 3. Calcium
Gluconate 4. Chlorhexidine Gluconate 0.12% Oral Rinse
5. Dextrose 50% 6. DiphenhydrAMINE 7. Glucagon 8. Heparin 9. 2 10.
Insulin 11. Magnesium Sulfate
12. Metoprolol Tartrate 13. Pneumococcal Vac Polyvalent
24 Hour Events:
-started on TF
-continued epidural for pain managment
-OOB
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2135-12-22**] 05:30 AM
Metronidazole - [**2135-12-22**] 06:00 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2135-12-22**] 08:36 AM
Heparin Sodium (Prophylaxis) - [**2135-12-23**] 12:13 AM
Other medications:
Flowsheet Data as of [**2135-12-23**] 04:49 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**38**] a."
350,"m.
Tmax: 37.9
C (100.2
T current: 37.9
C (100.2
HR: 87 (63 - 89) bpm
BP: 160/66(101) {98/43(64) - 160/66(101)} mmHg
RR: 23 (14 - 23) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
Total In:
3,255 mL
485 mL
PO:
Tube feeding:
180 mL
94 mL
IV Fluid:
3,045 mL
391 mL
Blood products:
Total out:
2,190 mL
490 mL
Urine:
1,275 mL
200 mL
NG:
100 mL
Stool:
Drains:
145 mL
70 mL
Balance:
1,065 mL
-5 mL
Respiratory support
O2 Delivery Device: Aerosol-cool, Face tent
SPO2: 98%
ABG: 7."
351,"7/25.6/1.2, Ca:7.7 mg/dL, Mg:2.0 mg/dL,
PO4:1.9 mg/dL
Assessment and Plan
[**Last Name 9**] PROBLEM - ENTER DESCRIPTION IN COMMENTS
Esophagogastrectomy
Assessment and Plan:
Neurologic: Pain controlled, A & o X3 Pain well controlled with
Epidural Dilaudid & Bupivacaine
Cardiovascular: Hx of HTN HD stable, goal to Keep Map>65. bolus with
IVF or decrease on Epidural rate, no pressors
Pulmonary: IS, continue OOB to chair, requiring face tent to maintain
o2 sats, Chest tube to suction
Gastrointestinal / Abdomen: ngt in place, JP to bulb suction close to
the top of the anastamosis
Nutrition: Tube feeding, nutriton consult for full tube feed recs
Renal: Foley, Adequate UO, required x 1 bolus to maintain UO >30cc/hr
Hematology: Serial Hct, hct stable
Endocrine: RISS, goal bs <150
Infectious Disease:
Lines / Tubes / Drains: Foley, NGT, Surgical drains (hemovac, JP),
Chest tube - pleural
Wounds: Dry dressings
Imaging: CXR today
Fluids: D5 1/2 NS, will KVO when tolerating tf
Consults: CT surgery
Billing Diagnosis:
ICU Care
Nutrition:
Replete (Full) - [**2135-12-22**] 03:00 PM 20 mL/hour
Glycemic Control:
Lines:
Arterial Line - [**2135-12-21**] 07:00 PM
16 Gauge - [**2135-12-21**] 07:36 PM
Prophylaxis:
DVT:
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition: Transfer to floor
Total time spent: 30 minutes"
352,"9 mEq/L
9 mg/dL
103 mEq/L
139 mEq/L
32.9 %
8.4 K/uL
[image002.jpg]
[**2135-12-21**] 07:04 PM
[**2135-12-22**] 02:55 AM
[**2135-12-22**] 03:21 AM
[**2135-12-22**] 05:07 AM
[**2135-12-22**] 03:57 PM
[**2135-12-23**] 03:22 AM
WBC
15.1
9.5
8.4
Hct
38.7
31.8
33.8
34.8
32.9
Plt
154
134
117
Creatinine
1.1
0.8
0.8
0.8
TCO2
30
Glucose
159
97
114
126
Other labs: PT / PTT / INR:13."
353,"40/47/124/33/3
PaO2 / FiO2: 177
Physical Examination
General Appearance: No acute distress, pleasant
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Bowel sounds present, Tender: mild
diffuse
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
117 K/uL
11.1 g/dL
126 mg/dL
0.8 mg/dL
33 mEq/L
3."
354,"Admission Date: [**2135-12-21**] Discharge Date: [**2135-12-28**]
Date of Birth: [**2070-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Esophageal Adenocarcinoma
Major Surgical or Invasive Procedure:
[**2135-12-21**] 1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy.
2. Laparoscopic jejunostomy.
3. Buttressing of intrathoracic anastomosis with thymic
fat.
4. EGD
5. Bronchoscopy
History of Present Illness:
The patient is a 65-year-old gentleman with a T2, N0 cancer of
the gastroesophageal junction. He is being admitted for
esophageal
resection.
Past Medical History:
Hypertension
CVA without residual"
355,"Social History:
He quit smoking 15 years ago. He was also a heavy alcohol user,
but quit 25 years ago. He lives at home with his wife. [**Name (NI) **]
states that he does some yard work, but is not that physically
active.
Family History:
Significant for mother with heart problems, father with a
stroke. Brother with cancer, which she believes is a melanoma.
Physical Exam:
VS: T 98.0 HR: 72 SR BP: 112/66 Sats: 97% RA
General: 65 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: crackles right 1/3 up, left crackles LLL
GI: benign."
356,"Respiratory: Aggressive pulmonary toilet, nebs and IS were
continued. Over the course of his hospitalization the nasal
cannula O2 was titrated off. His room oxygen saturations were
in the high 90's.
Chest-tube: the right chest tube was removed on [**2135-12-27**]
following the esophagus study. The chest tube site required
suturing.
Cardiac: he remained in sinus rhythm 70's. Prophylactic
beta-blocker were continued. Immediately postoperative he
required a fluid challenged for hypovolemia. Once stabilized
his blood pressure remained stable in the 112-130's.
GI: The NGT continued intermittent irrigation to maintain
patency. He had a moderate amount of bilious output."
357,"Neuro: he had no neurological events during this
hospitalization.
Disposition: He was followed by physical therapy who deemed him
safe for home. He continue to make steady progress and was
discharged home with VNA and tube feeds on [**2135-12-28**]
Medications on Admission:
Lipitor 80 mg daily, ASA 325 mg daily, HCTZ 25 mg daily,
lisinopril 5 mg daily, Ascorbic Acid 500 mg daily, MVI daily,
Omega-3 1,000mg daily, Vitamin E 400 unit daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Date Range **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain."
358,"Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**]
If your feeding tube sutures become loose or break: please tape
tube securely.
If your feeding tube falls out, save the tube, call the office
immediately.
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.
Daily weights: keep a log and bring it to your appointment with
Dr. [**First Name (STitle) **]
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**1-10**] 9:30am on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Clinical Center [**Location (un) 24**]. Chest tube suture remvoval at time of
visit
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Completed by:[**2135-12-28**]"
359,"5 Cl-104
HCO3-32
[**2135-12-21**] Glucose-159* UreaN-18 Creat-1.1 Na-140 K-4.2 Cl-103
HCO3-28
[**2135-12-27**] Calcium-8.5 Phos-2.8 Mg-2.1
[**2135-12-27**] Esophagus Study:
1. No evidence of leak.
2. Free flow of barium through to the third part of duodenum.
[**2135-12-27**]: CXR: sm right basilar hydropneumothorax, small
bilateral effusions.
Brief Hospital Course:
Mr. [**Known lastname 3321**] was underwent successful, [**Known lastname 12351**] [**Doctor Last Name **]
esophagectomy, Laparoscopic jejunostomy, Buttressing of
intrathoracic anastomosis with thymic fat, EGD
Bronchoscopy. He transferred to the SICU intubated and
subsequently extubated."
360,"Disp:*400 ML(s)* Refills:*0*
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
3. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2
times a day): while taking narcotics.
4. Osmolite
Osmolite Full strength; Goal rate:110 ml/hr
Cycle: start:3pm Cycle end:9am
5. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
6. Plavix 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day."
361,"J-tube site clean
Incision: Right minimal invasive site clean well approximation
Neuro: non-focal
Pertinent Results:
[**2135-12-26**] WBC-9.4 RBC-3.85* Hgb-12.0* Hct-34.8 Plt Ct-182
[**2135-12-24**] WBC-9.4 RBC-3.69* Hgb-11.3* Hct-33.3 Plt Ct-132
[**2135-12-21**] WBC-15.1 RBC-4.23* Hgb-13.1* Hct-38.7 Plt Ct-154
[**2135-12-27**] Glucose-132* UreaN-19 Creat-0.8 Na-142 K-4.1 Cl-105
HCO3-30
[**2135-12-26**] Glucose-136* UreaN-17 Creat-0.8 Na-142 K-4."
362,"7. Lipitor 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: crush
and take with apple sauce.
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
10. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once
a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Esophageal adenocarcinoma
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent"
363,"It
remained in place until [**2135-12-27**]. J-tube in place. Esophagus
study was done on [**2135-12-27**] which showed passage of contrast into
the small bowel without anastomotic leak.
Nutrition: He was seen by nutrition. The J-tube feeds were
started on [**2135-12-23**] Replete titrated to Goal 110 mL x 18 hrs was
well tolerated.
Pain: well controlled by Bupivacaine/Dilaudid Epidural was
managed by the acute pain service. He was converted to PO
Roxicet once the Chest tube was removed.
Incision: Right minimal invasive incisions were clean margins
well approximated. The anastomotic JP drain was removed on
[**2135-12-27**]."
364,"The
patient also has an element of systolic failure, which could
also be improved with milronone.
On transfer to the floor, the patient reports feeling well.
Past Medical History:
Afib on coumadin
Diastolic heart failure (EF 60-65%)
OSA
Gout
GERD with Barrett's esophagus
Hiatal hernia
Elevated PSA
Erectile dysfunction
s/p cholecystectomy ([**2172**])
s/p right hip replacement ([**2170**])
s/p tailers bunion, fascia release, prosthesis (left foot)
([**2169**])
s/p deviated septum repair ([**2168**])
s/p tailers bunion removal ([**2166**])
s/p multiple laminectomies ([**2164**], [**2151**], [**2148**])
s/p tendon repair right arm ([**2145**])
s/p hemorrhoidectomy ([**2126**])
s/p pilonidal cyst removal ([**2120**])
s/p appendectomy ([**2116**])
s/p bone removal left foot ([**2114**])
s/p tonsillectomy ([**2106**])"
365,"1 Mg-2.3
Blood Culture, Routine (Final [**2178-8-26**]): NO GROWTH.
URINE CULTURE (Final [**2178-8-21**]): NO GROWTH.
KAPPA/LAMDA:
Test Result Reference
Range/Units
FREE KAPPA, SERUM 20.0 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 2.7 L 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 7.41 H 0.26-1.65
Cardiac Cath Report [**8-19**]: Elevated right- and left-sided filling
pressures, moderate pulmonary arterial hypertension in the
setting of left-sided heart failure, large V waves suggestive of
moderate to severe mitral regurgitation. Normal cardiac output
and index."
366,"Assessment: Family and Pt is experiencing difficult adjustment
to
illness and next steps on the best approach for Pt. SW provided
empathic listening, guidance on resources that are available,
and
encouraged Pt and family to continue to utilize clinicians to
help make an informed decision on where Pt should transition to
next.
Brief Hospital Course:
Mr. [**Known lastname 109642**] is 77M with history of atrial fibrillation on
coumadin, systolic and diastolic heart failure, cardiac
amylodosis, and multiple myeloma who initially presented from
OSH with weight gain and need aggressive IV diuresis, requiring
CCU admission for initiation of milrinone drip.
.
# Acute on chronic systolic and diastolic heart failure: Patient
with baseline restrictive disease secondary to his cardiac
amyloid."
367,"He will follow up with Dr. [**Last Name (STitle) **]
in cardiology clinic.
.
[**Last Name (un) **]: Pt developed [**Last Name (un) **] in the setting of aggressive diuresis.
Nephrology was consulted and felt this was likely ATN vs
pre-renal due to hypoperfusion. It was unlikely a sequelae of
MM or amyloid as no protein was found in the urine. After
discontinuing Lasix gtt, he autodiuresed. Upon discharge, his
Creatinine returned to his baseline of 1.7.
.
Community Acquired Pneumonia: Pt developed cough and
leukocytosis with CXR findings of right upper lobe infiltrate.
He was treated with Ciprofloxacin and then Levofloxacin caused
him to have a supratherapeutic INR above 5."
368,"For the remainder
of 10 day abx course, his coumadin was held.
.
# Cardiac amyloidosis with restrictive myopathy: The patient has
history of cardiac amyloidosis confirmed on RV biopsy, and has
resulting restrictive heart disease, with subsequent R sided
dilation and R sided heart failure as above.
.
# Multiple Myeloma: During his last admission, patient was found
to have a monoclonal kappa band and severe hypogammaglobulinemia
on SPEP/UPEP. He underwent bone marrow biopsy which showed 40%
plasma cells. Abdominal fat pad biopsy both performed [**5-28**],
revealed no amyloid but RV cardiac biopsy was positive for
amyloid. He also continued dexamentasone/velcade treatment
while inpatient."
369,"Cycle4 Day8 Velcade administration on [**8-25**].
Will continue treatment with Dr. [**Last Name (STitle) 109643**].
.
# Coronaries: The patient has history of 3VD s/p NSTEMI during
his last admission. Cath from that admission with e/o 50% left
main disease, 50% LAD stenosis. It was decided that the patient
was too high risk for CABG, as well as PCI given his amyloidosis
and was discharge on medical management of his CAD. He was
continued on atorvastatin 80 mg daily, ASA 162 mg daily,
metoprolol 12.5 mg [**Hospital1 **].
.
# Afib: Stable. CHADS score of 2 (age and CHF). He was
continued on coumadin for goal INR of 2."
370,"0-2.5 given for
increased risk of bleeding with amyloid. During the hospital
course, he reached a supratherapeutic INR ~5 after
fluoroquinolones were addded. His coumadin was held for a few
days and restarted to maintain appropriate anticoagulation. He
will continue INR checks and Coumadin management through Dr. [**Name (NI) 109644**] office.
.
# BPH: stable, continued doxazosin
.
# GERD/Barrett's/hiatal hernia: stable, continued omeprazole,
home tums
.
# DEPRESSION/sleep: stable, continued amitriptyline, zolpidem.
.
# GOUT: stable, continued allopurinol, colchine, tramadol prn
.
TRANSITIONAL ISSUES:
-Cycle4 Day8 Velcade administration on [**8-25**]. will f/u with Dr.
[**Last Name (STitle) 3759**]
[**Name (STitle) **] monitored by Dr."
371,"Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 80 mg 1-2 tablets by mouth four times a day Disp
#*120 Tablet Refills:*3
16. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral qAM
17. Nitroglycerin SL 0.3 mg SL PRN CP
18. Allopurinol 100 mg PO QHS
19. Outpatient Lab Work
INR check on [**8-28**] with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 109645**] at
[**Telephone/Fax (1) 21962**]. ICD-9 427.31
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY
-acute on chronic systolic heart failure
-amyloidosis with restrictive myopathy
-multiple myeloma
-community acquired pneumonia
-Hyponatremia
-acute kidney injury
-atrial fibrillation"
372,"However,
the lung volumes have decreased and a small pleural effusion is
unchanged at the right lung base. Unchanged moderate
cardiomegaly. The right PICC line is constant in position.
RENAL ULTRASOUND:
1. No hydronephrosis. Simple bilateral renal cysts.
2. Right pleural effusion and trace of ascites seen in the
right upper
quadrant.
3. Arterial and venous flow is documented within each of the
kidneys,
however, further Doppler analysis cannot be performed as the
patient is unable to hold his breath.
Social Work:
Family has met w/ palliative team and wife expresses that the
conversation is ""premature"". Pt and wife have not signed DNR and
still solidifying long-term plans."
373,"He also
had a bandemia of 9% and was initially treated for a potential
UTI. His CXR showed recurrent right pleural effusion. He was
treated for acute on chronic systolic and diastolic heart
failure with IV lasix but of note this was limited by his BP's.
Weight prior to discharge from [**Location (un) 620**] 105kg.
While on the [**Hospital1 1516**] service, the patient was being diuresed on
Lasix drip 30 mg/hour, with diuresis limited by increasing
creatinine. After discussion with Dr. [**First Name (STitle) 437**], it was thought that
the patient could benefit from milronone drip in the setting of
having a Swan placed to measure his wedge and his CO."
374,"Home services to
assist with this have been set up for you. You also continued
to recieve therapy for your multiple myeloma while and inpatient
and will continue to see Dr. [**Last Name (STitle) 109645**] as an outpatient.
You were discharged on diuretics (torsemide) in order to keep
your weight down. Your discharge weight was 89.1 kg (196 lbs),
you should call Dr.[**Name (NI) 10159**] office at [**Telephone/Fax (1) 9832**] if you
notice your daily weight goes up by more than 3 lbs in a day or
if you notice worsening swelling in your legs, shortness of
breath while walking or any other symptoms that concern you."
375,"Admission Date: [**2178-8-3**] Discharge Date: [**2178-8-26**]
Date of Birth: [**2100-9-20**] Sex: M
Service: MEDICINE
Allergies:
Dilantin Kapseal / Sulfa (Sulfonamide Antibiotics) / Tegretol /
Fentanyl / Thiopental / Succinylcholine / Vecuronium Bromide
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Weight gain
Major Surgical or Invasive Procedure:
PICC line placement
Milrinone infusion
admission to the cardiac intensive care unit
right heart catheterization
History of Present Illness:
Mr. [**Known lastname 109642**] is 77M with h/o systolic and diastolic CHF, a-fib,
cardiac amyloidosis, and multiple myeloma transferred from
[**Hospital1 **] initially for volume overload and need for lasix
drip and chemotherapy.
The patient was recently discharged from [**Hospital1 18**] on [**2178-6-5**], at
which time RV biopsy demonstrated cardiac amyloidosis, as well
as a bone marrow biopsy with e/o multiple myeloma."
376,"DISCHARGE EXAM:
24hr I/O: 1236/1620
87.6 ->88 ->89.1
General: Well NAD,pleasant, well appearing, elderly gentleman in
NAD, laying comfortably in bed
HEENT: EOMI, PERRLA, no cerivcal lymphadenopathy, 12cm JVP
LUNGS: Fine Crackles at right base, no wheezing, rhonchi
HEART - PMI non-displaced, RRR, II/VI systolic murmur at apex,
nl S1-S2,
ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ pitting edema to calves, 2+ peripheral pulses
(radials, DPs), PICC Line in right arm w/o errythema or
tenderness.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-13**] throughout"
377,"Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2178-9-1**] at 2:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], 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: HEMATOLOGY/BMT
When: TUESDAY [**2178-9-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2178-9-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2178-8-30**]"
378,"26 mcg/kg/min
continuous infusion Disp #*1 Mutually Defined Refills:*12
3. Amitriptyline 30 mg PO HS
4. Aspirin 162 mg PO DAILY
5. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;
aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn indigestion
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*3
9. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
10."
379,"Warfarin 4 mg PO DAILY16
RX *warfarin 2 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
11. Zolpidem Tartrate 10 mg PO HS:PRN sleep
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *Milk of Magnesia 400 mg/5 mL 30 mL(s) by mouth every 6 hours
Disp #*1 Bottle Refills:*3
13. Sarna Lotion 1 Appl TP DAILY:PRN itchy
RX *Sarna Anti-Itch 0.5 %-0.5 % apply to itchy skin daily Disp
#*1 Bottle Refills:*3
14. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet
Refills:*3
15."
380,"Pt, wife and [**Name2 (NI) **] are aware of
life expectancy ([**7-21**] mos) and reiterated to SW and physician
that Pt is going to optimize highest level of care and the
priority is to be at home.
Pt and family met w/ infusion home care co. as an option for
next
steps. Physician communicated to pt/family that PT will be
consulted on recommendations for home vs rehab.
Family and Pt are continuing to explore all options and continue
to look into rehab's that can manage current medications however
family has reiterated that going home is their first preference."
381,"DISCHARGE LABS:
[**2178-8-26**] 04:26AM BLOOD WBC-15.9* RBC-3.02* Hgb-9.2* Hct-28.3*
MCV-94 MCH-30.4 MCHC-32.4 RDW-16.1* Plt Ct-233
[**2178-8-25**] 05:32AM BLOOD PT-22.4* PTT-36.2 INR(PT)-2.1*
[**2178-8-26**] 04:26AM BLOOD Glucose-118* UreaN-66* Creat-1.7* Na-131*
K-4.6 Cl-93* HCO3-29 AnGap-14
[**2178-8-15**] 06:40AM BLOOD ALT-22 AST-22 AlkPhos-93 TotBili-0.9
[**2178-8-26**] 04:26AM BLOOD Calcium-8.7 Phos-3."
382,"He diuresed well in the CCU,
was transfered to the floor, but after weaning milrinone, he
required reinitiation of milrinone in the CCU due to drop off in
energy level, urine output an reaccumulation of fluid. He
tolerated reinstitution of milrinone infusion well and was
transferred to the floor. He was also continued spironolactone
and torsemide after period of autodiuresis from [**Last Name (un) **] ended. Over
the course of the hospitalization he lost about 40lbs. His
discharge weight was roughly equivalent to his dry weight at
89.1 kg (196 lbs). He was counseled on the importance of daily
weights and CHF management."
383,"[**Last Name (STitle) 3759**]
[**Name (STitle) 30412**] not amenable to palliative care now
-patient is a full code
-?depression versus adjustment reaction with depression
-Discharge and dry weight 89.1 kg (196 lbs).
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR OSH records.
1. Atenolol 12.5 mg PO DAILY
2. Aspirin 162 mg PO DAILY
3. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral qAM
4. Multivitamins 1 TAB PO DAILY
5. Torsemide 40 mg PO BID
6. Omeprazole 20 mg PO BID
7. Spironolactone 50 mg PO DAILY
8."
384,"Social History:
The patient is married and worked in the import business and
worked for the navy in the shipyards. He never smoked.
Family History:
Positive for hay fever.
Physical Exam:
ADMISSION EXAM:
VS - 97.9 117/63 72 18 98% on RA 105.7kg
GENERAL - chronically ill appearing male in NAD, comfortable,
slightly short of breath while speaking
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVP at 12, no carotid bruits
LUNGS - bibasilar crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 3+ pitting LE edema to upper thighs, 2+
peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-13**] throughout"
385,"ECHO showed
e/o new systolic heart failure on top of preexisting diastolic
heart failure and is s/p cardiac catheterization with e/o 50%
left main disease, 50% LAD stenosis.
Since discharge, the patient reports weight gain, as well as
DOE. He denies orthopnea, PND, palpitations, syncope or
presyncope. He waited until he was seen by Dr. [**Last Name (STitle) **] on [**2178-7-22**]
where he was noted to have elevated JVD and 3+ LE edema. Lasix
was switched to torsemide 40mg [**Hospital1 **] with continued spironolactone
50mg daily.
When he initially presented to [**Hospital1 **], the patient was
noted to have change in mental status that was attributed to
uremia, [**Last Name (un) **], and medication side effect from torsemide."
386,"Pertinent Results:
ADMISSION LABS:
[**2178-8-3**] 11:39PM BLOOD WBC-10.8 RBC-3.43* Hgb-11.1* Hct-35.0*
MCV-102* MCH-32.3* MCHC-31.6 RDW-15.7* Plt Ct-194
[**2178-8-3**] 11:39PM BLOOD Neuts-80.9* Lymphs-8.5* Monos-9.1 Eos-1.0
Baso-0.5
[**2178-8-3**] 11:39PM BLOOD PT-25.4* PTT-37.9* INR(PT)-2.4*
[**2178-8-3**] 11:39PM BLOOD Glucose-119* UreaN-50* Creat-1.6* Na-138
K-4.3 Cl-98 HCO3-30 AnGap-14
[**2178-8-5**] 04:20PM BLOOD CK(CPK)-31*
[**2178-8-5**] 04:20PM BLOOD CK-MB-4 cTropnT-0."
387,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure caring for you while you were at [**Hospital1 18**]. You
were admitted for treatment of your congestive heart failure.
Our testing suggested this was a result of the effects on your
heart from your multiple myeloma. You were started on a
medication called milrinone that helped your heart pump better
and given medications to help you urinate off all the excess
fluid. Your weight was decreased by about 40 pounds. We tried
to stop the milrinone infusion, but your clinical picture
worsened without this medication and it was determined that you
will need it chronically infusing from now on."
388,"Amitriptyline 30 mg PO HS
9. Doxazosin 4 mg PO HS
10. Zolpidem Tartrate 5-10 mg PO HS
11. Allopurinol 100 mg PO QHS
12. Colchicine 0.6 mg PO HS
13. Guaifenesin Dose is Unknown PO Frequency is Unknown
14. Warfarin 5 mg PO DAILY16
15. TraMADOL (Ultram) 50 mg PO QID pain
16. Nitroglycerin SL 0.3 mg SL PRN CP
17. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;
aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn indigestion
Discharge Medications:
1. Hospital Bed
2. Milrinone 0.26 mcg/kg/min IV INFUSION
RX *milrinone in D5W 20 mg/100 mL (200 mcg/mL) 0."
389,"Also with systolic CHF first seen [**5-21**] with RV free
wall hypokinesis. He presented with diffuse peripheral edema,
worsening abdominal distention and JVP elevated to 12 cm,
consistent with right sided failure. He also presented with
right pleural effusion that represented transudate [**3-12**] CHF. He
was initially diuresed with lasix drip and metolazone with good
effect, but was stopped after increasing creatinine. He was
then transferred to the ICU for diuresis with milrinone for
inotropic effect and pulomary vasodilation allowing right sided
unloading. His right heart pressures were monitored by swan-ganz
cath with PA pressure 50 to 40s and wedge pressures of 28 to 19
after administartion of milrinone."
390,"14*
[**2178-8-3**] 11:39PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.4
TRANSFER LABS:
[**2178-8-7**] 03:45PM BLOOD PT-27.2* INR(PT)-2.6*
[**2178-8-7**] 03:10PM BLOOD Glucose-100 UreaN-81* Creat-2.3* Na-135
K-4.0 Cl-91* HCO3-31 AnGap-17
[**2178-8-7**] 03:10PM BLOOD Calcium-8.9 Phos-4.8* Mg-2.6
[**2178-8-6**] 11:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2178-8-6**] 11:19AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
[**2178-8-6**] 11:19AM URINE Hours-RANDOM Creat-37 Na-74 K-38 Cl-88"
391,"EKG [**2178-8-25**]
Atrial fibrillation. Right bundle-branch block. Left axis
deviation. Left
anterior fascicular block. Old inferior myocardial infarction.
Compared to
the previous tracing of [**2178-8-22**] no significant changes are
noted.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 0 148 440/457 0 -70 107
CXR [**2178-8-20**]: As compared to the previous radiograph, the patient
has received a Swan-Ganz catheter. The catheter needs to be
pulled back given that the tip is projecting over distal parts
of the right pulmonary artery. An opacity that pre-existed at
the bases of the right upper lobe is no longer visible."
392,"In light of guiac positive stools, will hold
off on any anticoagulation at this time.
.
5. Metastatic Pancreatic Cancer
Patient has known metastatic pancreatic cancer. He has been offered
palliative chemotherapy and radiation treatment, which he has refused.
He has also had palliative care evaluation which has not been pursued.
Patient's CT scan demonstrates progression of his disease with new
ascites, likely related to his increased burden of hepatic mets.
- will let patient's primary oncologist know that patient is
hospitalized
- palliative care consult
6. Ascites
Patient has developed new ascites which is likely related to his
increased metastatic disease."
393,"2 mEq/L
21 mg/dL
84 mEq/L
113 mEq/L
28.3 %
22.3 K/uL
[image002.jpg]
[**2189-3-30**] 12:31 AM
[**2189-3-30**] 05:30 AM
WBC
22.3
Hct
28.3
Plt
446
Cr
0.7
0.7
Glucose
60
69
Other labs: PT / PTT / INR:15.3/33.4/1.4, ALT / AST:35/96, Alk Phos / T
Bili:496/1.5, Lactic Acid:4.2 mmol/L, Albumin:2.1 g/dL, LDH:765 IU/L,
Ca++:7.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.6 mg/dL
Assessment and Plan
ASSESSMENT / PLAN:
71yo male with history of metastatic pancreatic cancer was admitted
with dyspnea, new ascites, and profound hyponatremia to 103."
394,".
1. Dyspnea
Etiology of his dyspnea is likely multifactorial. Differential
diagnosis includes pneumonia, aspiration, hypoventilation related to
increased ascites, and effusion. Regarding pneumonia, CXR infiltrate
and leukocytosis are suggestive. Regarding hypoventilation, patient may
have increased sensation of dyspnea related to his ascites. Regarding
effusion, patient has evidence of effusion on CXR. Etiology of his
effusion could be secondary to pneumonia or malignancy.
- treat for hospital acquired pneumonia with vancomycin and zosyn
- consider IR-guided paracentesis for evaluation of paracentesis
- consider IR guided thoracentesis for evaluation of his pleural
effusion if his symptoms do not improve with antibiotics
.
2. Hyponatremia
Patient has profound hyponatremia."
395,"NL S1, S2. No murmurs, rubs or gallops
LUNGS: Anterior breath sounds notable for rales at right base and
diminished breath sounds at left base.
ABD: Soft, nl BS, mildly distended, unable to appreciate fluid wave
EXT: 2+ pitting LE edema extending to lower back and 1+ of upper
extremities b/l. 2+ DP pulses BL
SKIN: No lesions
NEURO: Arousable but not oriented. PERRL, unable to elicit rest of
neuro exam as pt not too obtunded
PSYCH: Listens and responds to questions appropriately, pleasant
Labs / Radiology
446 K/uL
9.5 g/dL
69 mg/dL
0.7 mg/dL
19 mEq/L
5."
396,"Patient appears total body
overloaded on exam, although he is likely intravascularly depleted.
This appears likely given his concentrated urine, although it is
somewhat surprising that his creatinine is normal. His hyponatremia is
likely related to an increased ADH related to intravascular volume
depletion. An additional possibility includes SIADH secondary to a
pulmonary process. Given his altered mental status and sodium values,
he likely has symptomatic hyponatremia. Will likely need aggressive
repletion of sodium with increase in sodium concentration of
1-2mEq/hour for the first 3-4 hours and then can slow down to
.5-1mEq/hour after that."
397,"TITLE:
Chief Complaint:
24 Hour Events:
- Continued on vanc/zosyn
- Nasal swab done
Allergies:
Coumadin (Oral) (Warfarin Sodium)
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin - [**2189-3-30**] 02:00 AM
Vancomycin - [**2189-3-30**] 03:00 AM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-3-30**] 07:05 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.3
Tcurrent: 36.8
C (98.3
HR: 79 (75 - 89) bpm
BP: 90/52(62) {90/41(53) - 105/72(78)} mmHg
RR: 15 (14 - 19) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Total In:
811 mL
PO:
TF:
IVF:
811 mL
Blood products:
Total out:
0 mL
260 mL
Urine:
260 mL
NG:
Stool:
Drains:
Balance:
0 mL
551 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 99%
ABG: ///19/
Physical Examination
Gen: Somnolent male difficult to arouse from sleep but in NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate."
398,"- start hypertonic saline at 150mL/hour x 3 hours and check sodium and
make appropriate adjustments after that
- add on urine and serum osm
.
3. Leukocytosis
Etiology of his leukocytosis is unclear. Differential diagnosis
includes most likely infection, with pneumonia being his most likely
source.
- follow-up blood cultures
- send urine cultures
- follow-up final read of CXR
- send sputum gram stain and culture
- continue vancomycin and zosyn for treatment of presumed hospital
acquired pneumonia
.
4. Guaiac positive stools
Patient was found to have guiac positive stools, likely related to his
history of GI cancer and it is unclear if he has any GI tract
involvement of his cancer."
399,"IR guided paracentesis may improve his
subjective symptoms of dyspnea, although this will likely recur quickly
given his metastatic disease.
- consider IR guided paracentesis pending improvement in sodium
7. Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis. Unclear if this
represents a spontaneous thrombosis or is related to tumor invasion.
Patient is certainly a poor candidate for anticoagulation given his
poor PO intake, multiple comorbidities, and reported allergy to
coumadin.
- appreciate GI input
- continue to monitor
ICU Care
Nutrition:
Comments: NPO for now
Glycemic Control:
Lines:
18 Gauge - [**2189-3-30**] 12:54 AM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU"
400,"6, and hyperkalemia to 5.5. He received 1L IVF, vancomycin 1 g IV x
1, and zosyn 4.5g IV x 1.
Allergies:
Coumadin (Oral) (Warfarin Sodium)
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin - [**2189-3-30**] 02:00 AM
Vancomycin - [**2189-3-30**] 03:00 AM
Infusions:
Other ICU medications:
Other medications:
HOME MEDICATIONS: (upon discharge on [**2189-3-20**])
1. Levofloxacin 750mg PO daily x 5 days (4/24-28/09)
2. Docusate 100mg PO bid
.
Past medical history:
Family history:
Social History:
1. Prostate cancer [**2183**] s/p resection
2. Hypertension
3. Atrial fibrillation off coumadin
4."
401,"In light of guiac positive stools, will hold
off on any anticoagulation at this time.
.
5. Metastatic Pancreatic Cancer
Patient has known metastatic pancreatic cancer. He has been offered
palliative chemotherapy and radiation treatment, which he has refused.
He has also had palliative care evaluation which has not been pursued.
Patient's CT scan demonstrates progression of his disease with new
ascites, likely related to his increased burden of hepatic mets.
- will let patient's primary oncologist know that patient is
hospitalized
- palliative care consult
6. Ascites
Patient has developed new ascites which is likely related to his
increased metastatic disease."
402,"Chief Complaint: dyspnea
HPI:
71yo Cantonese and Spanish speaking male with metastatic pancreatic
cancer was admitted from the ED with dyspnea, altered mental status,
and hyponatremia. History was obtained from patient's son and [**Name (NI) 2040**] as
patient could not give complete history.
.
Patient was recently admitted to the OMED service 4/22-24/09 with
tachycardia and hypotension thought related to dehydration. He was
given IVF and 2 units pRBCs with improvement in his blood pressure and
heart rate. He was also treated with a 7-day course of levofloxacin for
presumed community-acquired pneumonia. [**Name (NI) 434**] son reports that his cough
improved, but he gradually developed increasing lower extremity edema
and abdominal swelling."
403,"IR guided paracentesis may improve his
subjective symptoms of dyspnea, although this will likely recur quickly
given his metastatic disease.
- consider IR guided paracentesis pending improvement in sodium
7. Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis. Unclear if this
represents a spontaneous thrombosis or is related to tumor invasion.
Patient is certainly a poor candidate for anticoagulation given his
poor PO intake, multiple comorbidities, and reported allergy to
coumadin.
- appreciate GI input
- continue to monitor
ICU Care
Nutrition:
Comments: NPO for now
Glycemic Control:
Lines:
18 Gauge - [**2189-3-30**] 12:54 AM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU"
404,"7 mEq/L
106 mEq/L
[image002.jpg]
[**2185-11-28**]
2:33 A5/4/[**2188**] 12:31 AM
[**2185-12-2**]
10:20 P
[**2185-12-3**]
1:20 P
[**2185-12-4**]
11:50 P
[**2185-12-5**]
1:20 A
[**2185-12-6**]
7:20 P
1//11/006
1:23 P
[**2185-12-29**]
1:20 P
[**2185-12-29**]
11:20 P
[**2185-12-29**]
4:20 P
Cr
0.7
Glucose
60
Fluid analysis / Other labs: [**2189-3-29**] - 1:40pm
Na 103 / K 6.6 / Cl 73 / CO2 19 / BUN 21 / Cr .8 / BG 65
CK 113 / MB 3 / Trop T < ."
405,"NL S1, S2. No murmurs, rubs or gallops
LUNGS: Anterior breath sounds notable for rales at right base and
diminished breath sounds at left base.
ABD: Soft, nl BS, mildly distended, unable to appreciate fluid wave
EXT: 2+ pitting LE edema extending to lower back and 1+ of upper
extremities b/l. 2+ DP pulses BL
SKIN: No lesions
NEURO: Arousable but not oriented. PERRL, unable to elicit rest of
neuro exam as pt not too obtunded
PSYCH: Listens and responds to questions appropriately, pleasant
Labs / Radiology
60 mg/dL
0.7 mg/dL
21 mg/dL
18 mEq/L
80 mEq/L
5."
406,"Patient appears total body
overloaded on exam, although he is likely intravascularly depleted.
This appears likely given his concentrated urine, although it is
somewhat surprising that his creatinine is normal. His hyponatremia is
likely related to an increased ADH related to intravascular volume
depletion. An additional possibility includes SIADH secondary to a
pulmonary process. Given his altered mental status and sodium values,
he likely has symptomatic hyponatremia. Will likely need aggressive
repletion of sodium with increase in sodium concentration of
1-2mEq/hour for the first 3-4 hours and then can slow down to
.5-1mEq/hour after that."
407,"- start hypertonic saline at 150mL/hour x 3 hours and check sodium and
make appropriate adjustments after that
- add on urine and serum osm
.
3. Leukocytosis
Etiology of his leukocytosis is unclear. Differential diagnosis
includes most likely infection, with pneumonia being his most likely
source.
- follow-up blood cultures
- send urine cultures
- follow-up final read of CXR
- send sputum gram stain and culture
- continue vancomycin and zosyn for treatment of presumed hospital
acquired pneumonia
.
4. Guaiac positive stools
Patient was found to have guiac positive stools, likely related to his
history of GI cancer and it is unclear if he has any GI tract
involvement of his cancer."
408,"Associated symptoms include worsening mental
status and fatigue. On review of systems, he denies fevers, shaking
chills, night sweats, abdominal pain, back pain, chest pain, and sick
contacts.
.
Of note, during his last admission, palliative care was consulted for
assistance with goals of care. Although the patient has refused
palliative chemotherapy and XRT, he has not further discussed or
re-addressed code status. He remains full code.
.
Upon arrival to the ED, temp 98.4, HR 100, BP 122/70, and pulse ox 97%
on 2L. His exam was notable for increased edema and ascites. His labs
were notable for hyponatremia with a sodium of 103, elevated lactate to
6."
409,"01
ALT 41 / AST 147 / Alk Phos 684 / TB 1.4
Lipase 16
BNP 4071
WBC 27.2 / Hct 34.3 / Plt 565
N 88 / Bands 6 / Lymphs 1 / M 4 / E 0 / B 0
Lactate 6
INR 1.3 / PTT 32.6
.
[**2189-3-29**] - 2:23pm
K 5.6 / Lactate 6.6
.
[**2189-3-29**] - 3pm
UA - 1.021, pH 5, negative for urobil, negative bili, trace leuks, neg
bld, neg nitr, tr prot, neg glu, tr ket, 0-2 RBCs, 3-5 WBCs, few
bacteria, no yeast, 0-2 epis
.
[**2189-3-29**] - 8:22pm
Lactate 5."
410,"5
Imaging: - [**2189-3-29**] CT Head - prelim read - no acute intracranial process
- [**2189-3-29**] CT Abd/Pelvis - prelim read - marked interval progression of
disease with increased pancreatic tail mass, and new splenic vein
occlusion. Main, left, and right anterior portal veins patent.
Increased hepatic metastatic lesions, with resulting narrowing of right
posterior portal vein, but it remains patent. New bilateral pleural
effusions. Left adrenal gland further inolved by large primary tumor
mass
- [**2189-3-29**] Portable CXR - Increasing left effusion/consolidation. Please
refer to CT abd/pelvis performed subsequently for further details.
Assessment and Plan
ASSESSMENT / PLAN:
71yo male with history of metastatic pancreatic cancer was admitted
with dyspnea, new ascites, and profound hyponatremia to 103."
411,"3/33.4/1.4, ALT / AST:35/96, Alk Phos / T
Bili:496/1.5, Lactic Acid:4.0 mmol/L, Albumin:2.1 g/dL, LDH:765 IU/L,
Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL
Assessment and Plan
72 yo male with metastatic pancreatic cancer now admitted with
significant altered mental status and hyponatremia.
1)HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)--Combination of SIADH and
excess free water intake leading to severe hyponatremia. Appreciate
renal input and support.
-Continue with free water restriction
-Will need continued free water restriction
2)pancreatic cancer-Extensive spread and including GI tract and with
some evidence of GI bleeding in addition to continued extension into
lung, abdomen."
412,"-NO further corrective intervention specific to be offered
\
3)Pneumonia-
-Continue Cefpodoxime
CANCER (MALIGNANT NEOPLASM), HEPATIC (LIVER)
CANCER (MALIGNANT NEOPLASM), PANCREAS
IMPAIRED SKIN INTEGRITY
IMPAIRED PHYSICAL MOBILITY
ICU Care
Nutrition: po diet as tolerated
Glycemic Control:
Lines:
20 Gauge - [**2189-4-1**] 12:00 AM
Prophylaxis:
DVT:
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments: Will need to continue the discussion with
family in regards to current plan for care and the level of support and
intervention needed going forward. At this point the family has
continued goals for support of the patient which include full code
status and are asking patients
Code status: Full code
Disposition :ICU
Total time spent: 40 minutes"
413,"1
C (98.8
Tcurrent: 36
C (96.8
HR: 114 (96 - 119) bpm
BP: 90/52(61) {74/40(51) - 94/57(63)} mmHg
RR: 16 (15 - 35) insp/min
SpO2: 94%
Heart rhythm: AF (Atrial Fibrillation)
Total In:
1,292 mL
128 mL
PO:
150 mL
25 mL
TF:
IVF:
1,142 mL
103 mL
Blood products:
Total out:
712 mL
160 mL
Urine:
712 mL
160 mL
NG:
Stool:
Drains:
Balance:
580 mL
-32 mL
Respiratory support
O2 Delivery Device: None
SpO2: 94%
ABG: ////
Physical Examination
General Appearance: Thin
Cardiovascular: (S1: Normal), (S2: Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),
(Breath Sounds: Diminished: )
Abdominal: Soft
Extremities: Right: 3+, Left: 3+
Skin: Not assessed
Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
9."
414,"Chief Complaint: Altered Mental Status
Hyponatremia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
Extensive discussion with family and patient concluding with plan for
return home with hospice
History obtained from [**Hospital 15**] Medical records
Allergies:
Coumadin (Oral) (Warfarin Sodium)
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin - [**2189-3-30**] 11:12 PM
Piperacillin/Tazobactam (Zosyn) - [**2189-4-1**] 08:00 AM
Vancomycin - [**2189-4-1**] 08:32 AM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: Fatigue
Flowsheet Data as of [**2189-4-2**] 10:22 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
415,"3 g/dL
458 K/uL
50 mg/dL
0.8 mg/dL
16 mEq/L
4.3 mEq/L
21 mg/dL
98 mEq/L
127 mEq/L
28.2 %
25.5 K/uL
[image002.jpg]
[**2189-3-30**] 12:31 AM
[**2189-3-30**] 05:30 AM
[**2189-3-31**] 04:47 AM
[**2189-3-31**] 08:14 AM
[**2189-4-1**] 05:31 AM
WBC
22.3
21.2
25.5
Hct
28.3
27.3
28.2
Plt
446
490
458
Cr
0.7
0.7
0.7
0.8
Glucose
60
69
44
49
50
Other labs: PT / PTT / INR:15."
416,"Admission Date: [**2189-3-29**] Discharge Date: [**2189-4-2**]
Date of Birth: [**2117-3-31**] Sex: M
Service: MEDICINE
Allergies:
Coumadin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Dyspnea, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 yo Cantonese and Spanish speaking male with metastatic
pancreatic cancer was admitted from the ED with dyspnea, altered
mental status, and hyponatremia. History was obtained from
patient's son and [**Name (NI) **] as patient could not give complete
history.
.
Patient was recently admitted to the OMED service 4/22-24/09
with tachycardia and hypotension thought related to dehydration."
417,"He remains full
code.
.
Upon arrival to the ED, temp 98.4, HR 100, BP 122/70, and pulse
ox 97% on 2L. His exam was notable for increased edema and
ascites. His labs were notable for hyponatremia with a sodium of
103, elevated lactate to 6.6, and hyperkalemia to 5.5. He
received 1L IVF, vancomycin 1 g IV x 1, and zosyn 4.5g IV x 1.
Past Medical History:
1. Prostate cancer [**2183**] s/p resection
2. Hypertension
3. Atrial fibrillation off coumadin
4. Thalaseemia
5. CVA, multiple TIAS
6. Metastatic pancreatic cancer
Social History:
- Home: lives at home with wife and daughter [**Name (NI) **]; moved here
from [**Country 651**] in [**2168**]
- Occupation: worked in hotels and supermarkets
- EtOH: Denies
- Drugs: Denies
- Tobacco: Denies"
418,".
[**2189-3-29**] CT Head: No acute intracranial process. MR is more
sensitive in the
detection of small masses.
Brief Hospital Course:
71 yo man with history of metastatic pancreatic cancer was
admitted with dyspnea, new ascites, and profound hyponatremia.
.
# Hyponatremia: Profound hyponatremia likely etiology of altered
mental status with improvement in lethargy with cautious
correction. Pt initially on hypertonic saline as thought to have
component from dehydration. However, per renal assessment,
appears to have baseline mild SIADH exacerbated by excessive po
fluid intake at home due to diagnosis of dehydration given at
last admission. Pt placed on 800cc to 1L fluid restriction with
improvement to likely baseline of 126-128."
419,".
# Hypotension: Per Renal, likely new baseline in setting of
progressive chronic disease. Ddx hypovolemia given tachycardia
but little response to fluid boluses. Initial concern of
hypoperfusion given elevated lactate but persistence of lactate
likely [**12-29**] to malignancy.
.
# Dyspnea: Infiltrate on CXR initially treated as HAP with vanco
and zosyn. Switched to cefpodoxime prior to discharge as MRSA
screen negative and pseudomonas unlikely given clinical picture.
Legionella negative. Rapid respiratory viral Ag test negative.
Prior to discharge, switched to cefpodoxime as MRSA screen
negative and low clinical suspicion for pseudomonas pneumonia.
Plan to complete 8-day today course of antibiotics, last dose on
[**2189-4-6**]."
420,"Small bilateral effusions on imaging (ddx parapneumonic
v. malignancy) may also have contributed to dyspnea.
.
# Bandemia: Likely [**12-29**] pneumonia, stable to mildly improved. No
other localizing sx. Urine cultures negative with no growth on
blood cultures to date. C. diff toxin test ordered but no sample
sent; unlikely etiology.
.
# Guaiac positive stools: Patient was found to have guiac
positive stools, likely related to his history of GI cancer and
it is unclear if he has any GI tract involvement of his cancer.
In light of guiac positive stools, held off on any
anticoagulation at this time.
.
# Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis."
421,"Unclear if
this represents a spontaneous thrombosis or is related to tumor
invasion. Family made aware of diagnosis, but anticoagulation
held as pt is poor candidate given his poor PO intake, multiple
comorbidities, and reported allergy to coumadin.
.
# Fluid overload: [**Month (only) 116**] be [**12-29**] increased metastatic disease, low
albumin. [**Month (only) 116**] have some diastolic dysfunction not assessed on
prior echo. [**Month (only) 116**] also have third-spacing [**12-29**] hyponatremia.
Nephrotic syndrome unlikely given U/A. ? of new ascites which is
likely related to his increased metastatic disease. Started on
high protein diet.
.
# Metastatic pancreatic Cancer: Evidence of progression of CT
abdomen/pelvis."
422,"Of note, OB positive stool seen in the setting
of known GI malignancy but with relatively stable Hct. He has
been offered palliative chemotherapy and radiation treatment,
which he has declined. Family meeting was held with palliative
care and oncologist Dr. [**Last Name (STitle) **] present. Decision made to discharge
pt home with hospice but to remain full code given hope of
seeing son who will be arriving from [**Location (un) 6847**] in 2 weeks.
.
# Afib: Off coumadin given h/o allergy. Was in RVR during
hospitalization but not rate controlled given low-running BP
although he remained hemodynamically stable.
.
# Nutrition: Speech & swallow and Nutrition recommended high
protein, pureed solids, nectar-thick liquids."
423,"0*
.
[**2189-4-1**] 05:31AM BLOOD WBC-25.5* RBC-4.58* Hgb-9.3* Hct-28.2*
MCV-61* MCH-20.3* MCHC-33.0 RDW-24.6* Plt Ct-458*
[**2189-4-1**] 05:31AM BLOOD Glucose-50* UreaN-21* Creat-0.8 Na-127*
K-4.3 Cl-98 HCO3-16* AnGap-17
[**2189-3-30**] 05:30AM BLOOD ALT-35 AST-96* LD(LDH)-765* AlkPhos-496*
TotBili-1.5
[**2189-4-1**] 05:31AM BLOOD Calcium-7.6* Phos-3.5 Mg-1.9
[**2189-3-31**] 08:14AM BLOOD Osmolal-259*
[**2189-4-1**] 02:04PM BLOOD Lactate-4."
424,"0*
.
[**2189-3-29**] EKG: Atrial fibrillation, ST-T changes are nonspecific,
Since previous tracing of [**2189-3-18**], T wave flattening noted.
.
[**2189-3-29**] CXR: Increasing left effusion/consolidation. Please refer
to CT
abd/pelvis performed subsequently for further details.
.
[**2189-3-29**] CT Abd/Pelvis:
- Marked interval progression of metastatic disease as detailed
above with increased disease burden in the pancreas, liver and
diffuse implants in the abdomen. Please see above for details.
- Stable multiple hypodense lesions in both kidneys.
- Bilateral pleural effusions, moderate, left greater than
right.
- Minimal ascites. Moderate anasarca.
- Small nonobstructing bilateral renal calculi."
425,"You were also found to
have a very low sodium level. This is thought to be due to an
underlying metabolic problem which was exacerbated by too much
water intake at home. You should not drink more than 800 cc of
water daily.
.
Please note that we found a blood clot in your splenic vein.
However, you were not started on blood thinners as the risks
outweighed the benefits.
.
The following changes were made to your medications:
- cefpodoxime - this is an antibiotic to treat your pneumonia.
.
As discussed during the family meeting, you will be sent home
with hospice care. Please seek medical attention if you develop
fevers or chills, increased difficulty breathing, chest pain, or
any other concerning symptoms.
Followup Instructions:
You have the following upcoming appointments already scheduled:
- [**Name6 (MD) **] [**Name8 (MD) **], MD. Phone:[**Telephone/Fax (1) 22**]. Date/Time:[**2189-4-3**] @
1:00pm.
- [**Name6 (MD) **] [**Name8 (MD) **], MD. Phone:[**Telephone/Fax (1) 22**]. Date/Time:[**2189-4-29**] @
1:30pm.
Completed by:[**2189-4-2**]"
426,"6 INR(PT)-1.3*
[**2189-3-29**] 01:40PM BLOOD Glucose-65* UreaN-21* Creat-0.8 Na-103*
K-6.6* Cl-73* HCO3-19* AnGap-18
[**2189-3-29**] 01:40PM BLOOD ALT-41* AST-147* CK(CPK)-113 AlkPhos-684*
TotBili-1.4
[**2189-3-30**] 05:30AM BLOOD Albumin-2.1* Calcium-7.3* Phos-3.6 Mg-1.7
[**2189-3-29**] 01:40PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-4071*
[**2189-3-30**] 05:30AM BLOOD Osmolal-244*
[**2189-3-30**] 10:49AM BLOOD Cortsol-25.2*
[**2189-3-29**] 01:50PM BLOOD Lactate-6."
427,"Maintained on 1L
fluid restriction.
.
# DVT ppx: Pneumoboots.
.
# Code: FULL, as discussed at family mtg.
Medications on Admission:
Levofloxacin 750mg PO daily x 5 days (4/24-28/09) to complete
7-day course
Discharge Medications:
1. Cefpodoxime 100 mg/5 mL Suspension for Reconstitution Sig:
Two Hundred (200) mg PO twice a day for 4 days.
Disp:*1600 mg* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Hyponatremia
- Hospital acquired pneumonia
Secondary
- Metastatic pancreatic cancer
- Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for increasing cough and lethargy. You were
treated for a pneumonia, and we are giving you a prescription to
complete an antibiotic course at home."
428,"He was given IVF and 2 units pRBCs with improvement in his blood
pressure and heart rate. He was also treated with a 7-day course
of levofloxacin for presumed community-acquired pneumonia. [**Name (NI) 1094**]
son reports that his cough improved, but he gradually developed
increasing lower extremity edema and abdominal swelling.
Associated symptoms include worsening mental status and fatigue.
On review of systems, he denies fevers, shaking chills, night
sweats, abdominal pain, back pain, chest pain, and sick
contacts.
.
Of note, during his last admission, palliative care was
consulted for assistance with goals of care. Although the
patient has refused palliative chemotherapy and XRT, he has not
further discussed or re-addressed code status."
429,"Family History:
Denies any history of cancer in the family.
Physical Exam:
T 97.4, HR 82, BP 105/55, RR 19, O2sat 99%RA
Gen: Somnolent male difficult to arouse from sleep but in NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: Anterior breath sounds notable for rales at right base
and diminished breath sounds at left base.
ABD: Soft, nl BS, mildly distended, unable to appreciate fluid
wave
EXT: 2+ pitting LE edema extending to lower back and 1+ of upper
extremities b/l."
430,"2+ DP pulses BL
SKIN: No lesions
NEURO: Arousable but not oriented. PERRL, unable to elicit rest
of neuro exam as pt too obtunded
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2189-3-29**] 01:40PM BLOOD WBC-27.2*# RBC-5.57# Hgb-11.4* Hct-34.3*
MCV-62* MCH-20.4* MCHC-33.1 RDW-23.7* Plt Ct-565*#
[**2189-3-29**] 01:40PM BLOOD Neuts-88* Bands-6* Lymphs-1* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2189-3-29**] 01:40PM BLOOD PT-15.3* PTT-32."
431,"-fluid restrict to 1L
-would avoid add
l IV fluids per Renal, could consider lasix
-appreciate renal recommendations
# Hypotension: DDx intravascular hypovolemia (given tachycardia) versus
new baseline w/ chronic disease
-holding IV fluids for now due to concern of worsening hyponatremia
# Dyspnea, ?pneumonia on CT: Infiltrate on CXR being treated as HAP.
Also with small bilateral effusions, ddx parapneumonic v. malignancy.
[**Month (only) 51**] also have hypoventilation related to increased ascites.
-vanco and Zosyn stopped yesterday; will continue cefpodoxime for 8-day
course (today is d4/8)
# Bandemia: Likely [**12-29**] pneumonia, stable to mildly improved. No other
localizing sx."
432,"-continue to monitor
# Fluid overload: [**Month (only) 51**] be [**12-29**] increased metastatic disease, low albumin.
[**Month (only) 51**] have some diastolic dysfunction not assessed on prior echo. [**Month (only) 51**]
also have third-spacing [**12-29**] hyponatremia. Nephrotic syndrome unlikely
given U/A. ? of new ascites which is likely related to metastatic
disease.
-high protein diet, could consider lasix per renal recs
# Metastatic pancreatic cancer: Evidence of progression on CT
abdomen/pelvis. He declined palliative chemo and/or radiation therapy.
Goals of care meeting [**4-1**] addressed home hospice, which patient would
like to try.
ICU Care
Nutrition: High protein, pureed/nectar-thick
Glycemic Control:
Lines:
18 Gauge - [**2189-3-30**] 12:54 AM
20 Gauge - [**2189-4-1**] 12:00 AM
Prophylaxis:
DVT: pneumoboots
Stress ulcer: eating
VAP:
Comments:
Communication:
Code status: FULL code (per patient and family mtg on [**4-1**]
Disposition: Home w/ hospice"
433,"TITLE:
Chief Complaint: hyponatremia, altered MS
24 Hour Events:
-Family mtg: D/c home with hospice, full code.
-Renal: Cont fluid restrict
-Abx changed to cefpodoxime for dispo as MRSA screen negative and
pseudomonas unlikely
[**Hospital 7395**] hospice bed
Allergies:
Coumadin (Oral) (Warfarin Sodium)
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin - [**2189-3-30**] 11:12 PM
Piperacillin/Tazobactam (Zosyn) - [**2189-4-1**] 08:00 AM
Vancomycin - [**2189-4-1**] 08:32 AM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-4-2**] 06:51 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
434,"1
C (98.8
Tcurrent: 37.1
C (98.8
HR: 119 (93 - 119) bpm
BP: 91/44(55) {74/40(51) - 97/57(63)} mmHg
RR: 35 (15 - 35) insp/min
SpO2: 94%
Heart rhythm: AF (Atrial Fibrillation)
Total In:
1,291 mL
64 mL
PO:
150 mL
TF:
IVF:
1,141 mL
64 mL
Blood products:
Total out:
712 mL
115 mL
Urine:
712 mL
115 mL
NG:
Stool:
Drains:
Balance:
579 mL
-51 mL
Respiratory support
O2 Delivery Device: None
SpO2: 94%
ABG: ////
Physical Examination
Gen:
Neck:
CV:
Lungs:
[**Last Name (un) 61**]:
Extre:
Neuro:
Labs / Radiology
458 K/uL
9."
435,"3 g/dL
50 mg/dL
0.8 mg/dL
16 mEq/L
4.3 mEq/L
21 mg/dL
98 mEq/L
127 mEq/L
28.2 %
25.5 K/uL
[image002.jpg]
[**2189-3-30**] 12:31 AM
[**2189-3-30**] 05:30 AM
[**2189-3-31**] 04:47 AM
[**2189-3-31**] 08:14 AM
[**2189-4-1**] 05:31 AM
WBC
22.3
21.2
25.5
Hct
28.3
27.3
28.2
Plt
446
490
458
Cr
0.7
0.7
0.7
0.8
Glucose
60
69
44
49
50
Other labs: PT / PTT / INR:15."
436,"3/33.4/1.4, ALT / AST:35/96, Alk Phos / T
Bili:496/1.5, Lactic Acid:4.0 mmol/L, Albumin:2.1 g/dL, LDH:765 IU/L,
Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL
Assessment and Plan
71 yo man with history of metastatic pancreatic cancer was admitted
with dyspnea, new ascites, and profound hyponatremia.
# Hyponatremia: Likely etiology of altered mental status. Has improved
with hypertonic saline and restriction of free water intake. Underlying
mild SIADH and hyponatremia was likely exacerbated by excessive free
water intake at home given recent admission for
dehydration."
437,"Blood cultures negative. Respiratory viral screen, MRSA
swab both negative. Urine legionella and urine culture negative. Still
awaiting stool sample for c. diff
-continue cefpodoxime for pna, 8-day course
-f/u cultures
-awaiting stool for C. diff
# Guaiac positive stools: Patient was found to have guiac positive
stools, likely related to metastatic pancreatic cancer. In light of
guiac positive stools, will hold off on any anticoagulation at this
time.
-hematocrit stable, will continue to follow
# Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis. Unclear if this
represents a spontaneous thrombosis or is related to tumor invasion.
Patient is certainly a poor candidate for anticoagulation given his
poor PO intake, multiple comorbidities, and reported allergy to
coumadin."
438,"3/33.4/1.4, ALT / AST:35/96, Alk Phos / T
Bili:496/1.5, Lactic Acid:4.2 mmol/L, Albumin:2.1 g/dL, LDH:765 IU/L,
Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL
Assessment and Plan
72 yo male with metastatic pancreatic CA and SIADH now admitted with
significant hyponatremia in the setting of excess free water intake.
1) HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY)-
-Free water restrict as possible
goal 1 liter
-Follow Na+ daily
2)Hypotension
Had a component of hypovolemia perhaps but has not had
durable response to IVF bolus and his urine Na+ is >21."
439,"The issue is
he has hypotension, tachycardia, poor urine output and small AG
acidosis.
-Vanco/Zosyn to continue for possible sepsis
-Will repeat Lactate
-For today will consider patient likely euvolemic but do have concerns
above
-Fluid bolus for symptomatic hypotension
3)Pancreatic Cancer-
-Thrombosis not to be treated given risk of GI bleeding
-Will need to consider goals of care in light of current progression of
decline
CANCER (MALIGNANT NEOPLASM), HEPATIC (LIVER)
CANCER (MALIGNANT NEOPLASM), PANCREAS
IMPAIRED SKIN INTEGRITY
IMPAIRED PHYSICAL MOBILITY
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2189-3-30**] 12:54 AM
20 Gauge - [**2189-4-1**] 12:00 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :Transfer to floor
Total time spent: 40 minutes"
440,"Chief Complaint: Hyponatremia
Altered Mental Status
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
Na+ with further improvement.
Renal consult much appreciated with better understanding of home H2O
intake and role of SIADH in generating hyponatremia.
Allergies:
Coumadin (Oral) (Warfarin Sodium)
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin - [**2189-3-30**] 11:12 PM
Vancomycin - [**2189-3-31**] 08:56 PM
Piperacillin/Tazobactam (Zosyn) - [**2189-4-1**] 08:00 AM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-4-1**] 11:34 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
441,"3 g/dL
458 K/uL
50 mg/dL
0.8 mg/dL
16 mEq/L
4.3 mEq/L
21 mg/dL
98 mEq/L
127 mEq/L
28.2 %
25.5 K/uL
[image002.jpg]
[**2189-3-30**] 12:31 AM
[**2189-3-30**] 05:30 AM
[**2189-3-31**] 04:47 AM
[**2189-3-31**] 08:14 AM
[**2189-4-1**] 05:31 AM
WBC
22.3
21.2
25.5
Hct
28.3
27.3
28.2
Plt
446
490
458
Cr
0.7
0.7
0.7
0.8
Glucose
60
69
44
49
50
Other labs: PT / PTT / INR:15."
442,"9
C (98.5
Tcurrent: 36.3
C (97.4
HR: 105 (90 - 119) bpm
BP: 86/40(52) {82/37(49) - 100/57(66)} mmHg
RR: 19 (15 - 21) insp/min
SpO2: 95%
Heart rhythm: AF (Atrial Fibrillation)
Total In:
3,020 mL
916 mL
PO:
360 mL
100 mL
TF:
IVF:
2,660 mL
816 mL
Blood products:
Total out:
1,052 mL
295 mL
Urine:
1,052 mL
295 mL
NG:
Stool:
Drains:
Balance:
1,968 mL
621 mL
Respiratory support
O2 Delivery Device: None
SpO2: 95%
ABG: ///16/
Physical Examination
General Appearance: Thin
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),
(Breath Sounds: Diminished: )
Abdominal: Soft, No(t) Non-tender, Tender: Mild
Skin: Not assessed
Neurologic: Follows simple commands, Responds to: Verbal stimuli,
Movement: Not assessed, Tone: Not assessed
Labs / Radiology
9."
443,"Admission Date: [**2146-3-10**] Discharge Date: [**2146-4-27**]
Date of Birth: [**2117-12-8**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents / Dilaudid
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, tachycardia.
Major Surgical or Invasive Procedure:
[**2146-3-10**]: Ultrasound-guided pancreatic pseudocyst drainage with
drain placement.
.
[**2146-3-18**]: CT-guided drainage of upper abdominal pseudocyst
.
[**2146-4-14**]: Ultrasound-guided fluid aspiration of a left flank
collection.
.
[**2146-4-14**]: Ultrasound-guided placement of left pleural pigtail
catheter.
.
[**2146-4-21**]: Ultrasound-guided left flank fluid collection
drainage with placement of a 8-French [**Last Name (un) 2823**] pigtail catheter."
444,"He rated this as
an [**9-6**] though currently [**7-7**]. He states that he was able to eat
dinner (grilled chicken) without difficulty. He was eating
breakfast this morning and became nauseated while eating grapes.
He had several episodes of non-bilious emesis and was brought to
[**Hospital1 18**] for further care given increased abdominal pain and
tachycardia.
Past Medical History:
PMH: Gallstone pancreatitis as above, obesity, congenital
blindness in right eye, left common iliac DVT .
PSH: Laparoscopic cholecystectomy [**1-5**]
Social History:
Recently married. He lives with his wife and their dog. No kids.
Works as an investment manager."
445,"He also repeatedly spiked temperatures.
.
Given his history of a left lower extremity acute deep venous
thrombosis, Vascular Surgery was consulted. In lieu of planned
surgical intervention on [**2146-4-5**] for treatment of the above
pseudocyst with adhesions, the patient underwent placement of a
Bard G2 inferior vena cava filter, which went without
complication. Then on [**2146-4-5**], the patient underwent external
drainage of pancreatic pseudocyst and extended adhesiolysis,
which also went well without complication (see Operative Note).
After a brief, uneventful stay in the PACU, the patient was
returned to the floor NPO with an NG tube, on IV fluids and TPN,
with a foley catheter and two JP drains in place (one in the
pseudocyst and one in the abdomen to drain ascites), he was
continued on a Fentanyl patch and was given a Morphine PCA with
good effect."
446,"Discharge Diagnosis:
1. Necrotizing gallstone pancreatitis.
2. Multiple pancreatic pseudocysts.
3. Non-occlusive thrombus in the left common femoral vein.
4. Left Pleural effusion
5. Anemia
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 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 [**6-6**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions."
447,"When
not NPO for procedures, his diet was advanced back to low fat
regular with good tolerability and intake. When the foley
catheter was removed after surgery, he was able to void without
problem. Patient's intake and output were closely monitored, and
IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
.
GI: Admission liver and pancreatic enzymes were elevated.
Shortly after admission, the patient underwent ultrasound-guided
pseudocyst drainage measuring 1.7 liters of fluid with a
drainage catheter left in place to gravity on [**2146-3-10**]. Liver
and pancreatic enzymes began trending down."
448,"He was discharged
home with VNA and PT services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash."
449,"C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Hospital1 **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*11*
5. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO every 4-6 hours as
needed for pain.
[**Hospital1 **]:*120 Tablet(s)* Refills:*0*
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain.
[**Hospital1 **]:*10 Patch 72 hr(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
8."
450,"How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,"
451,"Able to
wean off supplemental oxygen. CXR on [**3-17**] revealed still
extremely low lung volumes. Hazy opacification at the left base
is consistent with pleural fluid. Obscuration of the
hemidiaphragm suggests volume loss in the left lower lobe. The
right lung was essentially clear and there was no evidence of
pulmonary vascular congestion.
Starting on [**4-12**], he spiked a temperature to 103 PO and his WBC
increased from 13 to 23,000. He had a CT abdomen performed
which demonstrated a left pleural effusion
on the upper cuts of the abdomen. Thoracic surgery was consulted
for management of the pleural effusion."
452,"2
.
IMAGING:
[**2146-3-10**] AP CXR: Low lung volumes with LLL consolidation, could
reflect atelectasis, however, pneumonia cannot be excluded.
.
[**2146-3-10**] CTA CHEST W&W/O C&RECONS, ABD/PELVIC CT W/CONTRAST:
1. Minimal interval increase in size of right upper quadrant
pancreatic pseudocyst. Interval decrease in size of remaining
loculated fluid collections.
2. No pulmonary embolism present. Large bilateral pleural
effusions with associated compression atelectasis.
3. Increased amount of abdominal and pelvic free fluid.
.
[**2146-3-11**] BILAT LOWER EXT VEINS:
1. Persistent non-occlusive thrombus in the left common femoral
vein.
2. No right lower extremity DVT."
453,"ACID FAST CULTURE (Preliminary):
.
[**2146-4-5**] SWAB GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC
CULTURE-FINAL:
[**2146-4-5**] 3:09 pm SWAB PSEUDO CYST FLUID.
**FINAL REPORT [**2146-4-11**]**
GRAM STAIN (Final [**2146-4-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2146-4-7**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-4-11**]): NO GROWTH.
.
[**2146-3-28**] 9:25 am PERITONEAL FLUID
**FINAL REPORT [**2146-4-1**]**
GRAM STAIN (Final [**2146-3-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count."
454,"The drained collection has significantly decreased
in size.
2. Increase in pleural effusions: Left moderate and right
minimal size, findings are accompanied by compressive
atelectasis.
3. Minimal residual of the left common femoral vein and left
external iliac vein thrombus.
.
[**2146-3-17**] AP CXR:
In comparison with the study of [**3-15**], there is still extremely
low lung volumes. Hazy opacification at the left base is
consistent with pleural fluid. Obscuration of the hemidiaphragm
suggests volume loss in the left lower lobe. The right lung is
essentially clear and there is no evidence of pulmonary vascular
congestion. The tip of the right IJ catheter is difficult to see
but appears to be in the mid-to-lower portion of the SVC."
455,"He was again converted back to
Coumadin prior to discharge, at which time the INR was
therapeutic at 3.2 on a Coumadin dose of 2.5mg daily. INR goal
2.5 with a therapeutic range of [**3-2**].
.
MOBILITY: The patient worked with Physical and Occupation
therapy extensively. By discharge, he was able to ambulate
independently. He was discharge home with PT and OT services.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with minimal assistance, voiding without
assistance, and pain was well controlled."
456,"2. A small fluid collection adjacent to the inferior edge of
right lobe of liver measuring 4.9 x 3.2 x 2.0 cm, is new since
the prior study.
3. Unchanged left femoral vein thrombosis. Infrarenal IVC filter
in place.
4. Mild interval improvement in the small-to-moderate left
pleural effusion. Compressive atelectasis of the left lower
lobe is unchanged.
.
[**2146-4-15**] CXR:
Status after withdrawal of a left-sided chest tube. Minimal
apical and lateral basal pneumothorax without evidence of
tension. Unchanged minimal atelectasis at the left lung base. No
other changes. Normal cardiac silhouette."
457,"Respiratory toilet, incentive spirrometry, and frequent
ambulation was encouraged.
.
GU/FEN: On admission, the patient was made NPO and he received
vigorous IV fluid rescusitation. A foley catheter was placed.
Allowed clears on [**3-11**] and [**3-12**], but an NG tube was placed on
[**3-13**] for increased abdominal distension and emesis resulting
with 1400mL bilious output. After successful clamp trial
overnight, the NG tube was discontinued on [**3-15**] in the morning.
Given persistent problems with tolerating oral intake, a PICC
was placed, and TPN was started on [**2146-3-14**]. With the decision
to proceed to surgery, TPN was continued through [**2146-4-12**]."
458,"2. He did not require any further
blood products after this date. At discharge, his HCT was 23.7.
.
PROPHYLAXIS: History left common iliac DVT and HITs. Repeat
duplex ultra-sound on admission confirmed persistent
non-occlusive thrombus in the left common femoral vein; no right
DVT was seen. Chest CTA did not reveal a PE. On admission,
Coumadin stopped, and Agatroban started. After the drainage of
the collection on [**3-10**], Agatroban was stopped, and Coumadin
restarted. Coumadin also restarted after reversal for second
collection drainage. After the surgery on [**2146-4-5**], the patient
was restarted on Argatroban."
459,"Persistent marked attenuation of the
splenic vein. Smaller splenic infarcts.
3. Unchanged bilateral pleural effusions and associated
compressive atelectasis.
4. Unchanged thrombus within the left external iliac and common
iliac veins.
.
[**2146-3-28**] CXR:
Stable size of left pleural effusion with associated
consolidation which likely represents atelectasis but
superimposed infection cannot be excluded.
.
[**2146-4-13**] ABD/PELVI CT W/CONTRAST:
1. In this patient with known history of necrotizing
pancreatitis, there is enhancement of the distal body and tail
of the pancreas with non visualization of the remainder of the
pancreas. Multiple extensive peripancreatic fluid collections
have decreased in size since the prior study."
460,"O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: Slightly decreased at bases, otherwise clear.
COR: RRR
ABD: Protuberant. (L) LQ abdominal JP drain (into pancreatic
pseudocyst) patent/intact. (L)flank drain patent/intact. Both
drains with scant output. Prior sub-umbilical drain site clean,
healed without drainage. BSx4. Soft/NT/ND.
EXTREM: WWP; mild LE edema, no cyanosis, clubbing.
NEURO: A+Ox3. Very deconditioned. Requires assistance with gait.
Pertinent Results:
On Admission:
[**2146-3-10**] 08:28PM TYPE-ART PO2-138* PCO2-42 PH-7.55* TOTAL
CO2-38* BASE XS-13 INTUBATED-NOT INTUBA
[**2146-3-10**] 08:28PM freeCa-0."
461,"[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
13. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 14 days.
[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO daily in the
evening or as directed by PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO As directed by
PCP: **This Prescription should only be used if advised by your
PCP.**.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] homecare VNA"
462,"Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
JP Drain Care:
*Please look at the site 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.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water."
463,"Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD (Hematology).
Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2146-5-18**] 2:00."
464,"To date, these
pseudocyts have been managed largely with percutaneous catheter
drainage of the pseudocysts. Initially, during this admission,
this was the approach to managing the patient's recurring
pseudocyts. The patient underwent drainage of pancreatic
pseudocysts on [**2146-3-10**] and [**2146-3-18**], Ultrasound and CT-guided,
respectively. However, he developed an accumulating posterior
retroperitoneal cyst, which continued to progress, and there was
evidence of a disconnected pancreatic remnant within it. The
recent drainages of the other satellite lesions have dried them
up. The main retroperitoneal cyst continued to grow in size, and
became symptomatic for him. He was unable to eat full meals and
has a diminished capacity to keep food down, as well as a poor
appetite."
465,"[**2146-4-15**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-14**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-12**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-28**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-28**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-23**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-23**] URINE CULTURE-FINAL: NO GROWTH.
[**2146-3-23**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-19**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-19**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-18**] FLUID CULTURE: NO GROWTH - FINAL.
[**2146-3-17**] BLOOD CULTURE: NO GROWTH - FINAL."
466,"Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form."
467,"HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0."
468,"6* PTT-33.6 INR(PT)-2.1*
[**2146-3-10**] 07:29AM WBC-30.7*# RBC-4.67# HGB-11.7*# HCT-39.7*#
MCV-85 MCH-25.0* MCHC-29.4* RDW-17.4*
[**2146-3-10**] 07:29AM NEUTS-89* BANDS-3 LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2146-3-10**] 07:29AM PLT SMR-VERY HIGH PLT COUNT-818*#
[**2146-3-10**] 05:46AM GLUCOSE-149* LACTATE-2.5* NA+-136 K+-4.6
CL--99* TCO2-17*
.
Prior to Discharge:
[**2146-4-27**] PT/INR: 31.9/3."
469,"Admission abdominal/pelvic CT revealed minimal
interval increase in size of right upper quadrant pancreatic
pseudocyst, but decrease in size of remaining loculated fluid
collections. Large bilateral pleural effusions with associated
compression atelectasis were noted, as well as increased amount
of abdominal and pelvic free fluid. He was admitted to the SICU,
made NPO, started on vigorous IV fluid rescusitation, a foley
was placed, and he received IV pain medication with good effect.
He had a very long, and complicated hospital course.
.
In the process of repairing his florid necrotizing pancreatitis
secondary to his history of severe gallstone pancreatitis, he
ultimately developed recurrent pseudocyts, which have plagued
him throughtout his hospital stays since [**48**]/[**2145**]."
470,"11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for btp.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Adjust dose according to INR. .
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust daily dose according to INR."
471,"He did not require exogenous insulin.
.
HEMATOLOGY: Upon admission, Coumadin was stopped, and the
patient received 5 untis of Fresh Frozen Plasma (FFPs) prior to
fluid collection drainage in Intervention Radiology. On [**3-17**],
FFPs were again administered in preparation for IR drainage of a
large anterior abdominal fluid collection, but was stopped after
the patient experienced severe lower back pain after initiation
of the second unit of FFP. On [**3-18**], he received a total of 4
units of FFPs prior to IR drainage of the aforementioned
collection. Prior to [**2146-4-5**] surgery, the patient received 2
units of PRBCs for a HCT of 22."
472,"5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever.
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
7. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for back pain.
8. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. Methadone 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
10. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
sliding scale Subcutaneous ASDIR (AS DIRECTED)."
473,"NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2146-3-27**]):
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 [**2146-3-28**]): NO ANAEROBES ISOLATED.
.
[**2146-3-10**] FLUID,OTHER GRAM STAIN-FINAL; WOUND CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL:
GRAM STAIN (Final [**2146-3-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2146-3-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-3-16**]): NO GROWTH.
.
BLOOD & URINE CULTURES:
[**2146-4-18**] BLOOD CULTURE: NO GROWTH - FINAL."
474,"Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2146-4-25**]): NO ANAEROBES ISOLATED.
.
[**2146-4-16**] 4:30 pm FLUID,OTHER LEFT JP DRAIN FLUID.
**FINAL REPORT [**2146-4-19**]**
GRAM STAIN (Final [**2146-4-16**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 10PM [**2146-4-16**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES."
475,".
[**2146-4-18**] CXR:
1. Low lung volumes with left basilar subsegmental atelectasis,
likely related to the recent abdominal surgery and ongoing
intra-abdominal process.
2. No appreciable residual left pneumothorax.
3. Left-sided PICC likely at the junction of that axillary and
subclavian vein; this may need to be advanced into a more
central vein, depending on the indication for its use.
.
[**2146-4-20**] ABD/PELVIC CT W/O CONTRAST:
1. Slightly decreased size of dominant central abdominal fluid
collection with left drain in satisfactory position. Right
catheter has been removed.
2. Other fluid collections are little changed [**2146-4-13**]."
476,"[**2146-3-17**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-10**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-10**] BLOOD CULTURE: NO GROWTH - FINAL.
.
RESPIRATORY/OTHER CULTURES:
[**2146-4-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL:
Upper respiratory contamination.
[**2146-4-13**] CATHETER TIP-IV WOUND CULTURE-FINAL: NO SIGNIFICANT
GROWTH.
[**2146-4-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL:
Upper Respiratory Contamination.
[**2146-3-10**] MRSA SCREEN MRSA: NEGATIVE.
Brief Hospital Course:
The patient was re-admitted on [**2146-3-10**] back to the General
Surgical Service for evaluation and treatment of abdominal pain
and tachycardia."
477,"On [**2146-4-14**], he underwent
ultrasound-guided thorocentesis and placement of left pleural
pigtail catheter. Plural fluid for culture, gram stain,
cytology, chemistries, and AFB was sent. The pleural pigtail
catheter was removed on [**4-15**]; post-removal CXR revealed minimal
apical and lateral basal pneumothorax without evidence of
tension. Unchanged minimal atelectasis at the left lung base. A
follow-up CXR on [**2146-4-18**] showed continued low lung volumes with
left basilar subsegmental atelectasis, likely related to the
recent abdominal surgery and ongoing intra-abdominal process. No
appreciable residual left pneumothorax was seen. The patient
remained stable from a pulmonary standpoitn thereafter."
478,"98*
[**2146-3-10**] 05:10PM OTHER BODY FLUID AMYLASE-[**Numeric Identifier **]
[**2146-3-10**] 05:10PM PT-20.2* INR(PT)-1.9*
[**2146-3-10**] 02:50PM WBC-22.5* RBC-3.31*# HGB-8.5*# HCT-28.0*#
MCV-85 MCH-25.7* MCHC-30.4* RDW-18.2*
[**2146-3-10**] 02:50PM PLT COUNT-511*
[**2146-3-10**] 02:07PM GLUCOSE-196* UREA N-19 CREAT-1.3* SODIUM-134
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-30 ANION GAP-15
[**2146-3-10**] 02:07PM CALCIUM-7.7* PHOSPHATE-6.2* MAGNESIUM-1.5*
[**2146-3-10**] 01:52PM PT-22."
479,"However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin?"
480,"He was hemodynamically stable.
.
NEURO: Upon admission, the patient received IV pain medication
PRN transitioned to a Morphine PCA with good effect and adequate
pain control. When tolerating oral intake, he was transitioned
to oral pain medications. After the surgery on [**2146-4-5**], the
Chronic Pain Service was consulted. His pain was controlled once
the Fentanyl dose was increased to 75mcg/72Hr plus the Morphine
PCA. When again tolerating a diet post-operatively, the PCA was
discontinued, and he was started on oral pain medication in
addition to the Fentanyl patch with continued good effect. He
remained neurologically intact."
481,"The patient had been started on empiric IV
Vancomycin, Ciprofloxacin, and Flagyl when he spiked a
temperature on [**4-14**]. Fluconazole for empiric coverage after the
thorocentesis was started on [**4-15**]. Flagyl, Cipro, and
Fluconazole were discontinued on [**4-16**]. Cipro restarted on [**4-21**].
Infectious Disease was consulted for discharge antibiotic
recommendations; their input was greatly appreciated. Cipro was
discomntinued, and oral Levofloxacin and Flagyl started on [**4-26**]
with Vancomycin continued. At discharge, the patient was sent
home on a two week course oral Linezolid, and a total of four
weeks of oral Levofloxacin and Flagyl.
.
ENDOCRINE: The patient's blood sugar was monitored throughout
his stay when he was on TPN; sliding scale insulin was
administered accordingly."
482,"severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin."
483,".
FLUID CULTURE (Final [**2146-4-1**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6976**] @ 1:20 PM ON [**2146-3-29**].
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..
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
RARE GROWTH OF THREE COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2146-4-1**]): NO ANAEROBES ISOLATED.
.
[**2146-3-23**] 10:43 pm FLUID,OTHER DRAIN FLUID.
**FINAL REPORT [**2146-3-28**]**
GRAM STAIN (Final [**2146-3-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES."
484,"4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final [**2146-4-19**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH."
485,"Follow-up
abdominal/pelvic CT on [**3-16**] demonstrated enlargement of the
previously seen fluid collection and appearance of the numerous
new large collections in the peritoneum. The drained collection
had significantly decreased in size. On [**3-18**], the patient
returned to Interventional Radiology for drainage of an anterior
collection, and placement of a new drainage catheter to gravity.
The previous drain was removed, and upper abdominal pseudocyst
was succesfully drained with a catheter left in place to
gravity. Unfortunately, as noted above, he developed an
accumulating posterior retroperitoneal cyst, which continued to
progress, and there was evidence of a disconnected pancreatic
remnant within it."
486,"5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2146-4-18**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2146-4-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
.
[**2146-4-14**] 9:57 am PLEURAL FLUID
GRAM STAIN (Final [**2146-4-14**]):
3+ (5-10 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 [**2146-4-17**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-4-20**]): NO GROWTH.
ACID FAST SMEAR (Final [**2146-4-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR."
487,"SICU
HPI:
28M s/p lap chole [**1-5**] for gallstone panc, c/b DVT, resp failure
(requiring mechanical ventilation ~ 3weeks), ARF (requiring CVVHD ~
1.5weeks), panc necrosis (requiring perc drain), d/c-ed to rehab [**3-9**].
Returns [**3-10**] with abd pain, tachycardia, after session with PT. Pain
[**2146-9-2**]. Episodes of non-bilious emesis morning of admission. Pt brought
to [**Hospital1 5**] for further eval. In [**Name (NI) **], pt had CT Chest/Abd/Pelv which was
negative for PE, and showed increased size of pancreatic pseudocyst.
Received 3L crystalloids. Admitted to SICU
Chief complaint:
abdominal pain, tachycardia
PMHx:
gallstone pancreatitis, s/p lap chol [**1-5**], obesity, congenital
blindness R, DVT L common iliac/femoral/popliteal
Current medications:
Albuterol 0."
488,"7
T current: 36.7
C (98.1
HR: 115 (99 - 119) bpm
BP: 153/93(106) {129/72(84) - 170/101(117)} mmHg
RR: 20 (17 - 34) insp/min
SPO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 97.5 kg (admission): 96.2 kg
Height: 68 Inch
CVP: 9 (5 - 17) mmHg
Total In:
2,710 mL
748 mL
PO:
Tube feeding:
IV Fluid:
2,710 mL
748 mL
Blood products:
Total out:
2,885 mL
1,100 mL
Urine:
1,375 mL
500 mL
NG:
1,450 mL
600 mL
Stool:
Drains:
60 mL
Balance:
-175 mL
-352 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 97%
ABG: ///27/
Physical Examination
General Appearance: Anxious, Overweight / Obese
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), tachycardic, sinus
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),
(Breath Sounds: CTA bilateral : ), short, shallow breaths
Abdominal: Soft, Non-distended, No(t) Non-tender, Bowel sounds present,
Tender: mild tender epigastrium
Left Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm), (Pulse
- Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
239 K/uL
7."
489,"4
Hct
28.0
29.1
27.7
25.9
25.3
24.9
Plt
[**Telephone/Fax (2) 11555**]
Creatinine
1.3
0.9
0.9
0.8
0.7
0.6
0.6
TCO2
38
Glucose
196
122
119
115
100
94
99
Other labs: PT / PTT / INR:24.8/29.8/2.4, ALT / AST:34/15, Alk-Phos / T
bili:111/0.7, Amylase / Lipase:180/101, Lactic Acid:1.2 mmol/L,
Albumin:2.0 g/dL, LDH:167 IU/L, Ca:7.3 mg/dL, Mg:2.0 mg/dL, PO4:4.0
mg/dL
Assessment and Plan
PANCREATIC PSEUDOCYST
Assessment and Plan: 28M s/p lap chole [**1-5**] for necrotizing gallstone
panc, p/w incr abd pain and tachycardia
Neurologic: Pain controlled
Cardiovascular: -- tachycardic - Beta-block; Lopressor 50 TID
Pulmonary: sating >90% on 4-5L NC
Gastrointestinal / Abdomen: NGT in place
-- LFT
s, amylase/lipase trending down
-- enlarged pancreatic pseudocyst s/p perc drain; cx neg to date
Nutrition: NPO
Renal: Adequate UO
Hematology: Hct stable
f/u INR, on coumadin
Endocrine: RISS
Infectious Disease: Check cultures, elevated WBC (trending down) 30.7
-> 22.5 -> 21.9-> 14
cx NGTD
Lines / Tubes / Drains: NGT
Wounds:
Imaging:
Fluids: D5NS
Consults: General surgery
Billing Diagnosis: Pancreatitis, Other: SIRS
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2146-3-10**] 02:52 PM
Prophylaxis:
DVT: Boots (Systemic anticoagulation: Coumadin (R))
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , Family
meeting planning, Family meeting held , ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 35 minutes
Patient is critically ill"
490,"7 g/dL
99 mg/dL
0.6 mg/dL
27 mEq/L
3.5 mEq/L
12 mg/dL
97 mEq/L
134 mEq/L
24.9 %
14.4 K/uL
[image002.jpg]
[**2146-3-10**] 02:07 PM
[**2146-3-10**] 02:50 PM
[**2146-3-10**] 08:28 PM
[**2146-3-11**] 01:55 AM
[**2146-3-11**] 04:20 PM
[**2146-3-12**] 03:24 AM
[**2146-3-13**] 03:22 AM
[**2146-3-13**] 03:22 PM
[**2146-3-14**] 02:15 AM
WBC
22.5
21.9
20.9
16.9
14.6
14."
491,"083% Neb Soln, Docusate Sodium, Insulin, Ipratropium
Bromide Neb, Magnesium Sulfate, Metoprolol Tartrate, Morphine Sulfate,
Pantoprazole, Senna, Warfarin
24 Hour Events:
BLOOD CULTURED - At [**2146-3-13**] 10:38 AM
Post operative day:
PPD 4 s/p Perc drain pancreatic pseudocyst
Allergies:
Heparin Agents
HIT;
Heparin Agents
HIT;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2146-3-14**] 12:00 AM
Morphine Sulfate - [**2146-3-14**] 02:15 AM
Other medications:
Flowsheet Data as of [**2146-3-14**] 06:34 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**48**] a.m.
Tmax: 37.6
C (99."
492,"Admission Date: [**2172-9-24**] Discharge Date: [**2172-10-5**]
Date of Birth: [**2103-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2172-9-24**] cardiac catheterization
[**2172-9-25**] IABP
[**2172-9-25**] CABG x3(LIMA-LAD, SVG-OM, SVG-PDA)
History of Present Illness:
60 year old male complains of noticing mild dyspnea with
exertion, more noticeable as compared to last year. He also
describes occasional chest pain that is responsive to SL
nitroglycerin. This typically occurs after a large meal, but may
also happen with exertion."
493,"The LCX
had
minimal irregularities. The RCA had a proximal 100% stenosis
with distal
vessel filling via right to right collaterals.
2. Due to differential blood pressure in both arms, left
subclavian
angiogram was performed. It was widely patent.
3. Left ventriculography was defferred.
4. Limited resting hemodynamics revealed normal systemic
systolic and
diastolic pressures. (106/60 mmHg)
FINAL DIAGNOSIS:
1. Left Main and one vessel coronary artery disease.
disease.
Carotid US: [**2172-9-24**]
IMPRESSION: 40-59% stenosis in the right internal carotid artery
and no
evidence of significant carotid artery stenosis in the left
internal carotid artery
[**2172-10-4**] 04:13AM BLOOD WBC-9."
494,"He had further angina the night before surgery so
an IABP was placed. He was brought to the operating room on
[**2172-9-25**] for coronary bypass grafting, please see operative report
for details. In summary he had: coronary bypass grafting x3 with
left internal mammary artery to left anterior descending artery,
reverse saphenous vein graft to obtuse marginal artery and
reverse saphenous vein graft to posterior descending artery. His
bypass time was 81 minutes with a crossclamp time of 59 minutes.
He tolerated the operation well and was transferred to the
cardiac surgery ICU in stable condition. He was transfused
multiple units of packed red blood cells for bleeding in the
immediate post-op period."
495,"He initially required hemodynamic
support with IABP, Levophed and Vasopressin. Drips and IABP
were weaned and the patient was extubated on POD 2. He
developed post-op a-fib and was started on amiodarone. He has a
history of thrombus and coumadin was resumed. He was noted to
have a small amount of sternal drainage and was started on
Kefzol. Drainage resolved and he will not be discharged on
antibiotics.
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."
496,"spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
10. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
s/p coronary bypass grafting x3
PMHx: Hypertension, Hyperlipidemia, [**2167**]: presumed CAD by ETT
(RCA ischemia), LV mural thrombus consistent with MI, on
Coumadin, Type 2 Diabetes Mellitus, Osteoarthritis, Obesity,
Glaucoma s/p surgery bilaterally, Bilateral cataract surgery
with lens implants, s/p tonsillectomy
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage."
497,"General:
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 [] grade ______
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 [x]
Pulses:
Femoral Right: Left:
DP Right2+: Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit none pulses Right: 2+ Left:2+
Pertinent Results:
Admission Labs:
[**2172-9-24**] 03:16PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1."
498,"3*
[**2172-10-4**] 04:13AM BLOOD PT-42.1* INR(PT)-4.3*
[**2172-10-3**] 11:49AM BLOOD PT-51.0* INR(PT)-5.4*
[**2172-10-3**] 04:05AM BLOOD PT-48.1* PTT-36.7* INR(PT)-5.1*
[**2172-10-2**] 04:07AM BLOOD PT-37.8* INR(PT)-3.8*
[**2172-10-1**] 04:34AM BLOOD PT-23.6* INR(PT)-2.2*
[**2172-9-30**] 04:21AM BLOOD PT-16.8* PTT-30.3 INR(PT)-1.5*
[**2172-9-29**] 03:54AM BLOOD PT-17.2* PTT-29.1 INR(PT)-1."
499,"4 mg Tablet, Sublingual - 1
Tablet(s)
sublingually every five minutes for chest discomfort. Call 911
if
pain persists longer than 15 minutes
SIMVASTATIN 80 mg Tablet - 1 Tablet(s) by mouth every evening
SPIRONOLACTONE 25 mg Tablet - 1 Tablet(s) by mouth every morning
WARFARIN 2.5 mg Tablet - 2 Tablet(s) by mouth daily as directed
by [**Location (un) 2274**] coumadin clinic. Last dose [**2172-9-19**] pre cath/ICD
Medications - OTC
ASPIRIN 325 mg Tablet - 1 Tablet(s) by mouth every morning
MULTIVITAMIN Dosage uncertain
--------------- --------------- --------------- ---------------
Plavix - last dose:None
Coumadin: Last dose [**2172-9-20**]
Discharge Medications:
1."
500,"Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]"
501,"3 RBC-3.33* Hgb-11.3* Hct-31.8*
MCV-96 MCH-33.9* MCHC-35.4* RDW-16.3* Plt Ct-245
[**2172-10-3**] 04:05AM BLOOD WBC-11.0 RBC-3.49* Hgb-11.8* Hct-32.8*
MCV-94 MCH-33.7* MCHC-35.9* RDW-17.6* Plt Ct-223
[**2172-10-2**] 04:07AM BLOOD WBC-9.7 RBC-3.53* Hgb-12.0* Hct-33.0*
MCV-93 MCH-34.0* MCHC-36.4* RDW-17.4* Plt Ct-194
[**2172-10-5**] 03:57AM BLOOD PT-33.1* INR(PT)-3."
502,"Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication
Goal INR 2-2.5
First draw [**2172-10-6**]
Results to phone [**Telephone/Fax (1) 90848**], [**Hospital 2274**] [**Hospital **] clinic- [**Doctor First Name **] for
Dr. [**Last Name (STitle) 6512**]
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
[**Hospital 2274**] [**Hospital **] clinic to manage for goal INR 2-2."
503,"5.
Disp:*30 Tablet(s)* Refills:*2*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily.
Disp:*120 Tablet(s)* Refills:*2*
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9."
504,"5*
[**2172-9-28**] 02:48AM BLOOD PT-16.2* PTT-31.8 INR(PT)-1.4*
[**2172-10-5**] 03:57AM BLOOD UreaN-26* Creat-1.1 Na-139 K-4.2 Cl-104
[**2172-10-4**] 04:13AM BLOOD UreaN-27* Creat-1.2 Na-136 K-3.4 Cl-100
[**2172-10-3**] 04:05AM BLOOD Glucose-105* UreaN-30* Creat-1.2 Na-141
K-4.1 Cl-103 HCO3-27 AnGap-15
Brief Hospital Course:
Mr [**Known lastname **] was admitted for cardiac catheterization and found to
have left main and right coronary artery disease. Cardiac
surgery was consulted and he was scheduled for surgery the
following day."
505,"The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 10 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with VNA in good condition with
appropriate follow up instructions. [**Location (un) 2274**] Post Office Square
will continue to follow coumadin.
Medications on Admission:
ATENOLOL 50 mg Tablet - 1 Tablet(s) by mouth daily (AM)
GLIPIZIDE 5 mg Tablet - 1/2-1 Tablet(s) by mouth every morning
LISINOPRIL 10 mg Tablet - 1 Tablet(s) by mouth every morning
NITROGLYCERIN [NITROSTAT] 0."
506,"Social History:
Race:Caucasian
Last Dental Exam: 1 year ago, upper dentures, bottom native
teeth
Lives with: wife who has [**Name (NI) 2481**], diagnosed in her early
60's
Contact: [**Name (NI) **](son) cell: [**Telephone/Fax (1) 90847**]
Occupation: retired post office worker
Cigarettes: Smoked no [x] Other Tobacco use:denies
ETOH: < 1 drink/week [x]
Illicit drug use:denies
Family History:
Family History: Premature coronary artery disease- Father died
from an MI at age 75. Mother died from a stroke at age 74.
Physical Exam:
Pulse:64 Resp:16 O2 sat:100/RA
B/P Right:96/64 Left:120/56
Height:5'[**72**]"" Weight:228 lbs"
507,"He has used [**3-20**] nitro over the past
four months. He was referred for left heart catheterization.
He was found to have left main disease and was referred for
cardiac surgery. On the night before going to the operating room
for revascularization he experienced further chest pain with EKG
changes and an IABP was placed.
Past Medical History:
Past Medical History:
Hypertension
Hyperlipidemia
[**2167**]: presumed CAD by ETT (RCA ischemia)
LV mural thrombus consistent with MI, on Coumadin
Type 2 Diabetes Mellitus
Osteoarthritis
Obesity
Glaucoma s/p surgery bilaterally
Bilateral cataract surgery with lens implants
Past Surgical History:
s/p tonsillectomy"
508,"5 RBC-4.19* HGB-14.5 HCT-39.9* MCV-95
MCH-34.6* MCHC-36.4* RDW-13.2
[**2172-9-24**] 02:20PM PLT COUNT-160
[**2172-9-24**] 02:20PM PT-15.1* PTT-23.5 INR(PT)-1.3*
[**2172-9-24**] 10:45AM GLUCOSE-111* UREA N-17 CREAT-0.9 SODIUM-137
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14
Cardiac Catheterization: [**2172-9-24**]
1. Coronary angiography in this right dominant system
demonstrated left
main and 1 vessel disease. The LMCA had a 95% distal stenosis.
The LAD
had minimal luminal irregularities, and D1 40% stenosis."
509,"**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 CARE appt, [**Last Name (NamePattern1) 439**], 2A Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2172-10-13**] 11:00
Surgeon:[**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2172-10-28**] at 1:45
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6512**] on [**10-16**] at 9:50am
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 639**],[**First Name3 (LF) 640**] N. [**Telephone/Fax (1) 644**] in [**4-21**] 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**
Labs: PT/INR for Coumadin ?????? indication
Goal INR 2-2.5
First draw [**2172-10-6**]
Results to phone [**Telephone/Fax (1) 90848**], [**Hospital 2274**] [**Hospital **] clinic- [**Doctor First Name **] for
Dr. [**Last Name (STitle) 6512**]
Completed by:[**2172-10-5**]"
510,"032
[**2172-9-24**] 03:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-7.5 LEUK-NEG
[**2172-9-24**] 02:20PM GLUCOSE-100 UREA N-17 CREAT-1.0 SODIUM-137
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
[**2172-9-24**] 02:20PM ALT(SGPT)-17 AST(SGOT)-18 LD(LDH)-193 ALK
PHOS-43 AMYLASE-37 TOT BILI-2.3*
[**2172-9-24**] 02:20PM LIPASE-28
[**2172-9-24**] 02:20PM ALBUMIN-3.6
[**2172-9-24**] 02:20PM %HbA1c-6.2* eAG-131*
[**2172-9-24**] 02:20PM WBC-6."
511,"During
this time, he reports increasing somnolence, also endorsing
dreams and hallucinations during the day. People with whom he
lives have become increasingly concerned in the last several
days and today advised him to come the emergency room for
evaluation. On review of systems, he denies cough or sputum
production. He denies chest pain or pressure, but he does
endorse increasing dyspnea during the last several weeks.
.
Initial vital signs in the ED were T 98.3, HR 109, sat 95% on
4L. Patient reportedly fell asleep while talking to ED
physicians and was noted to snore loudly. An EKG showed sinus
tachycardia with a RBBB that is unchanged from prior."
512,"Vitals at time of admission were sat 99% on 4L, T 99.6, BP
136/73, HR 103.
Past Medical History:
1) HIV - diagnosed [**2167**]. complicated by HIV encephalopathy
2) Bipolar disorder - SA at 19yo by OD on aspirin
3) Peripheral neuropathy - ?[**2-13**] B12 def vs HIV
4) Lipodystrophy
5) Hypertriglyceridemia
6) OSA - not on CPAP (sleep study [**1-/2177**] AHI 59.9)
7) GERD
8) Asthma - PFTS normal [**7-16**]
9) Seborrheic dermatitis
10) Rotator cuff tendinitis, Bicep tendinitis
11) LBP, chronic neck pain/spasm s/p MVA
12) Erectile Dysfunction
13) Renal cysts (seen on ultrasound)
14) Evidence of prior HBV (neg HBsAg, pos HBsAb, pos HBcAb)
15) Arthritis
16) Colonic polyps
17) Deviated septum surgery
[**95**]) Excision of perianal papilloma ([**2176-8-29**])."
513,"Normal anal pap
smear [**2-17**].
19) Tonsillectomy
20) Low testosterone
21) Scrotal abscess [**2-/2183**]
22) Fatty liver by Ultrasound
23) Vitamin B12 deficiency
24) Verrucous hyperkeratosis
Social History:
Per OMR Born in [**Location (un) **], MA. Previously worked as pharmacy
technician and bus driver. Now on disability and lives [**Location (un) 111723**]Apartment Program x past 11 years. Father[**Name (NI) **] one child,
not involved in his care. Has two [**Name (NI) 1685**] sisters, [**Name (NI) **] and
[**Name2 (NI) **]. Both his mother and twin sister are deceased.
Tobacco - 60 pack year history, no longer smokes
Alcohol - denies
Drugs - denies."
514,"2
[**2187-5-18**] 10:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-5-18**] 10:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Brief Hospital Course:
59 y/o man h/o HIV on HAART (well-controlled), morbid obesity,
OSA presents with worsening shortness of breath and somnolence.
.
# Dyspnea/somnolence. Likely secondary to hypercarbia/hypoxemia
from worsening obstructive sleep apnea in the setting of poor
compliance with home CPAP. There was no evidence of pulmonary
infection, CHF or drug intoxication (serum/urine tox negative).
Pt reports severe leak from his BiPAP mask at home and having to
adjust it >6x per night."
515,"Pt was placed on home BiPAP and mental
status was much improved by the morning. Pt is on complex
medication regimen and would benefit from medication
reconciliation and simplification with psychiatry as outpatient.
.
# HIV: continue home HAART regimen.
.
# Bipolar disorder with anxiety and significant depression s/p
ECT in [**2187-1-12**]. Pt was reporting hallucinations on
presentation and was taking Pramiprexole TID. This was
decreased to qhs only to prevent dopaminergic side effects.
Otherwise, he was continued on his home psych regimen. We
recommend psych follow up for simplication of his regimen and
changing to meds that are more weight neutral
."
516,"# Hypertension: poorly controlled, increased amlodipine to 10mg
daily
.
# Nephrogenic DI: On day 2 of admission, Na rose to 150 and
corrects easily when patient is alert and has adequate access to
fluids. Na came down to 146 and pt should be continued on low
sodium and low protein diet in addition to 5L of fluid intake
per day
.
# FEN. Low-sodium diet.
.
# Prophylaxis. Heparin subcutanous, Tylenol prn, bowel regimen.
.
# Access. PIVs.
.
# Communication. [**Name (NI) **] [**Name (NI) **] (sister): [**Telephone/Fax (1) 111724**].
.
# Code status. DNR but intubation okay.
Medications on Admission:
ABACAVIR-LAMIVUDINE [EPZICOM] - 600 mg-300 mg Tablet - 1
Tablet(s) by mouth daily
ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - [**1-13**] Tablet(s) by
mouth every four (4) hours as needed for back pain Do not drive
or drink alcohol on this medication
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth Qday
AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL XR] - 15 mg Capsule,
Sust."
517,"18. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Somnolence secondarily to Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for being very sleepy and having
hallucinations. Initially there was concern about your breathing
so you were admitted to the ICU. In here we started you on BiPAP
with your home settings and a new mask and worked beautifully
for you."
518,"Release 24 hr - 1 Capsule(s) by mouth qam
CITALOPRAM - 40 mg Tablet - 2 Tablet(s) by mouth qam
ESZOPICLONE [LUNESTA] - 3 mg Tablet - 1 Tablet(s) by mouth at
bedtime
ETRAVIRINE [INTELENCE] - 100 mg Tablet - two Tablet(s) by mouth
twice daily In place of Fosamprenavir
FAMOTIDINE - 20 mg Tablet - 1 Tablet(s) by mouth HS
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - 1
Tablet(s) by mouth Daily
HYDROCORTISONE - 2.5 % Cream - Apply thin layer to affected area
2-3 times per day
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - Daily WASH FACE, HAIR AND
CHEST LEAVE ON FOR 2 MIN EVERY DAY
LAMOTRIGINE - 150 mg Tablet - 2 Tablet(s) by mouth at bedtime
LORAZEPAM - 1 mg Tablet - 2 Tablet(s) by mouth at bedtime
LORAZEPAM [ATIVAN] - 2 mg Tablet - 1 Tablet(s) by mouth x 1 1
hour before MRI
MIRTAZAPINE - 30 mg Tablet - 2 Tablet(s) by mouth at bedtime
OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - 1 gram Capsule - 2
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - 2
Tablet(s) by mouth every 6 hours as needed for pain
PRAMIPEXOLE [MIRAPEX] - 0."
519,"Admission Date: [**2187-5-18**] Discharge Date: [**2187-5-20**]
Date of Birth: [**2128-2-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
dypsnea and somonolence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59 y/o man h/o HIV on HAART (last CD4 868, vL <48 in [**2187-5-16**])
who presented to the ED tonight with increasing shortness of
breath for 1-2 months. He reports that his CPAP machine broke
recently and he therefore has not been using it at home."
520,"[**2-13**] venous stasis disease
Neurological: moving all extremities, AAOx3, concentration
intact
.
Pertinent Results:
[**2187-5-19**] 12:49AM BLOOD WBC-8.8 RBC-3.69* Hgb-13.8* Hct-42.1
MCV-114* MCH-37.4* MCHC-32.8 RDW-17.7* Plt Ct-329
[**2187-5-18**] 10:40AM BLOOD Glucose-137* UreaN-23* Creat-1.4* Na-145
K-4.5 Cl-103 HCO3-31 AnGap-16
[**2187-5-19**] 01:11PM BLOOD Na-146* K-3.7
[**2187-5-18**] 10:40AM BLOOD D-Dimer-915*
[**2187-5-18**] 10:40AM BLOOD TSH-0.55
[**2187-5-18**] 10:40AM BLOOD Calcium-10."
521,"No past history of IVDU
.
Family History:
Per OMR, grandmother received ECT; father had schizophrenia.
Mother and [**Name2 (NI) 1685**] sister with bipolar disorder. Otherwise,
denies sudden cardiac death, coronary artery disease.
Physical Exam:
T 99.9, BP 132/79, HR 97, RR 27, sat 99% venti-mask FiO2 40%
General: obese, middle-aged man, slightly diaphoretic, becomes
dyspneic with minimal exertion in bed
HEENT: posterior oropharynx poorly visualized secondary to large
tongue
Neck: large diameter, supple
Lungs: poor air movement in posterior fields, no focal wheezes
Heart: distant s1/s2
Abdomen: obese, soft, non-tender
Extremities: 1+ pitting edema in lower extremities, pink skin
?"
522,"125 mg Tablet - 1 Tablet(s) by mouth
three times a day
RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - One Tablet(s) by mouth
twice daily This is to replace Tenofovir
STAVUDINE - 40 mg Capsule - 1 Capsule(s) by mouth twice a day
UREA [CARMOL 40] - 40 % Cream - Apply to the feet once to twice
per day
.
Medications - OTC
CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s)
by
mouth Daily
VITAMIN E - 400 unit Capsule - 1 Capsule(s) by mouth four times
a
day
Discharge Medications:
1. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2."
523,"Labs were
remarkable for normal CBC with white count of 9.6 (70% polys).
BMP was also normal (creatinine at baseline 1.4), with normal
LFTs and lipase. His pro-BNP was 169 and troponin was flat. A
d-dimer came back elevated at 915 and so CTA was done that
showed no evidence of PE or other acute process. Urine and serum
toxicology screens were negative. ABG showed 7.35/57/46. Blood
cultures were taken. Patient given Levo, ceftriaxone, Flagyl for
treatment of possible pneumonia. He was a admitted to the ICU
for somnolence and need for positive pressure ventilation."
524,".
It is important that you lose weight watching your diet. If you
lose more than [**10-26**] pounds call your pulmonologist for a new
mask. Losing weight will improve your sleep.
Followup Instructions:
You need to follow up with your psychiatry next Thursday and
tell him about your hallucinations and the change in the
medication we did (Pramepixole).
.
You need to follow up with your PCP within the next two weeks.
.
If you have problems with your mask call your
Pulmonologist/Sleep doctor: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD at ([**Telephone/Fax (1) 513**] and
he can help you with your mask.
Appointments indicated below:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2187-5-21**] 10:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-5-21**]
8:35
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2187-5-24**] 2:00"
525,"You were able to have a good night sleep and you woke
up, probably after your CO2 level improved with the pressure of
the machine. We ruled you out for a heart attack. changed
Pramipexole to qhs only given that you were having
hallucinations and those improved.
.
You need to follow up with your psychiatry next Thursday and
tell him about your hallucinations and the change in the
medication we did (Pramepixole).
.
You need to follow up with your PCP within the next two weeks.
.
If you have problems with your mask call your
Pulmonologist/Sleep doctor: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD at ([**Telephone/Fax (1) 513**] and
he can help you with your mask."
526,"10. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
11. Lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. Mirtazapine 30 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Stavudine 20 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
16. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO QID (4
times a day)."
527,"Amphetamine-Dextroamphetamine 5 mg Capsule, Sust. Release 24
hr Sig: Three (3) Capsule, Sust. Release 24 hr PO qAM ().
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs ().
7. Etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Lunesta 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime))."
528,"0 Phos-3.8 Mg-2.4
[**2187-5-18**] 10:40AM BLOOD cTropnT-<0.01
[**2187-5-19**] 12:49AM BLOOD CK-MB-9 cTropnT-<0.01
[**2187-5-19**] 12:49AM BLOOD CK(CPK)-291
[**2187-5-18**] 01:53PM BLOOD Type-ART O2 Flow-5 pO2-46* pCO2-57*
pH-7.35 calTCO2-33* Base XS-3 Intubat-NOT INTUBA Comment-NC
[**2187-5-18**] 08:46PM BLOOD Type-ART pO2-86 pCO2-47* pH-7.43
calTCO2-32* Base XS-5
[**2187-5-18**] 10:46AM BLOOD Lactate-1.4
[**2187-5-18**] 08:46PM BLOOD Lactate-1."
529,"Pain controlled well per patient, although complains of hip pain with
moving.
- f/u ortho recs
- OOB with PT when able, WBAT BLE
- cefazolin x2 doses
- lovenox for ppx PE
.
# Cardiac Ischemia/EKG changes: has new ST changes on admission EKG to
the MICU. Not complaining of chest pain, no fluid overloaded on exam
so not clinically in failure. On admission on [**7-15**] had troponin leak
and TWI in V2 that was concerning for demand ischemia.
- cycle CEs
- discuss EKGs with cardiology
- continue atorvastatin, BB IV while NPO
- change ASA 81 to ASA 325
- echo in AM
.
# Low urine output: likely hypovolemia post-op."
530,"No
information was available to her regarding her birth father. She has
several step siblings. Her daughter is healthy.
Occupation: retired
Drugs: none
Tobacco: none
Alcohol: none
Other: lives alone; daughter involved; difficult to get a hold of
Review of systems:
Constitutional: Fatigue
Cardiovascular: troponin leak
Nutritional Support: NPO
Respiratory: No(t) Dyspnea, No(t) Tachypnea
Genitourinary: Foley
Musculoskeletal: Joint pain, R hip fracture; hx of RA
Heme / Lymph: Anemia
Psychiatric / Sleep: Daytime somnolence
Pain: Unable to answer
Flowsheet Data as of [**2128-2-16**] 08:28 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**29**] AM
Tmax: 37."
531,"Responded well to bipap. Has known underlying
lung disease and has had baseline O2 requirement on the floor. Has O2
at home to wear at night. Most likely etiology of hypoxia is from
oversedation due to anesthesia. Other etiologies could include PE or
aspiration pneumonia, although less likely. CXR did not show an
infiltrate and hemodynamics stable without PE changes on EKG. Received
substantial doses of narcotics intra and post-operatively.
- hold sedating meds overnight
- continue bipap and do serial ABGs
- wean as tolerated to nasal canula
- CXR in AM
.
# AMS: is not at baseline, intermittently alert and oriented now,
although mostly somnolent."
532,"3. Lung apices suggestive of edema, inflammatory, or small airways
disease, vs infectious process.
4. 6mm peripherally calcified right thyroid nodule for which further
evaluation with ultrasound.
.
[**2-13**] CT Abd/Pelvis:
1. Right subcapital hip fracture.
2. Fibroid uterus.
3. Distended bladder with mild left pelvic fullness.
4. Bilateral adrenal gland thickening, left greater than right.
.
[**2-13**] CXR:
FINDINGS: Cardiomediastinal contours are within normal limits. There is
no focal consolidation, pleural effusion, or pneumothorax. Vague
nodular opacity at the left upper lung is stable when compared to exam
dating back to [**2122-8-1**] and may represent vascular shadows versus benign
lesion."
533,"# RA:
- hold methotrexate for now (given weekly)
- manage pain with tylenol and prn morphine
.
# Depression: dx with mild depression
- Effexor 150 mg Daily
.
# Dementia: unclear circumstances of diagnosis, per record patient
reporting forgetfulness, psych testing showing mild attention deficits
- hold aricept for now
.
# FEN:
- IVF as above
- replete electrolytes
- regular diet for now, NPO until MS improves
.
# Prophylaxis: pneumoboots; lovenox starting in AM
# Access: peripherals
# Communication: Patient for now, have attempted to call daughter three
times but appears to be the wrong number
# [**Serial Number 11359**] (pending further discussion with patient)
# Disposition: ICU pending clinical improvement
.
.
[**First Name8 (NamePattern2) 4445**] [**Last Name (NamePattern1) 1130**], PGY 2
pg [**Numeric Identifier 11404**]
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2128-2-16**] 05:51 PM
20 Gauge - [**2128-2-16**] 05:51 PM
Prophylaxis:
DVT: Boots, LMW Heparin
Stress ulcer:
VAP:
Comments:
Communication: Comments: Talked with daughter, patient full code; ICU
consent still needs to be signed
Code status: Full code
Disposition: ICU"
534,"The ventricles and sulci are prominent consistent
with age-related atrophy. The basilar cisterns are preserved. There is
no evidence of hydrocephalus. There is normal [**Doctor Last Name 988**]-white matter
differentiation. Bony exostosis/osteoma arising from the inner table of
the left frontal bone (2, 21) is stable. Hyperdensity in the right
superior frontal lobe subcortical white matter is unchanged. There is
no acute major vascular territorial infarct. The visualized paranasal
sinuses are clear except mild
mucosal thickening.
IMPRESSION: No acute intracranial hemorrhage.
.
[**2-13**] CT C Spine:
1. No evidence of acute fracture.
2. Multilevel degenerative changes as described above."
535,"Chief Complaint: hypoxia post-op
HPI:
73 year old woman with past medical history of IDDM, seizure disorder
and breast cancer who lives alone presenting with right-sided hip, leg
and low back pain after slipping off her toilet the morning of
admission. Patient does not remember any other details at this time.
There were no witnesses, and it is not clear how long she was down
for. She was initially admitted to the MICU for ARF, troponin leak and
nonspecific EKG changes.
.
See MICU admission note for complete admission details. Of note, the
patient did have intermittent desats while in the MICU, associated
mostly with transfusions or fluid."
536,"There is no evidence of displaced rib fractures identified.
IMPRESSION: No acute cardiopulmonary process.
Microbiology: [**2-13**] urine - <1000 GNRs
Assessment and Plan
HYPOXEMIA
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
.H/O DIABETES MELLITUS (DM), TYPE I
.H/O FRACTURE, OTHER
.H/O ELECTROLYTE & FLUID DISORDER, OTHER
THROMBOCYTOPENIA, CHRONIC
.
.
.
73F PMHx of IDDM, seizure disorder and breast cancer presenting with R
hip fx s/p fall and admitted to the ICU initially with ARF and troponin
leak; now s/p ORIF of R hip with post-op hypoxia.
.
# Hypoxia: patient with post-op hypoxia based on ABGs as above as pleth
difficult to obtain."
537,"Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. 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.
Patient admitted from: [**Hospital1 1**] OR / PACU
History obtained from Patient, Family / [**Hospital 380**] Medical records
Patient unable to provide history: Sedated
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Metoprolol - [**2128-2-16**] 06:30 PM
Other medications:
Past medical history:
Family history:
Social History:
Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat [**Name (NI) 11403**]
mother died at 47 in surgery (possibly during a hysterectomy)."
538,"Most likely secondary to hypoxia and
narcotic use intra-op. Could be metabolic encephalopathy but
electrolytes normal and no asterixis on exam. No focal deficits so
less likely CVA or intracranial hemorrhage. Could be infectious. Has
skin tear on her back but does not appear infected on exam. Low grade
fever post op. Has hx of seizure disorder and tegretol being held, but
patient does not appear to be seizing and does not appear to be
post-ictal.
- hold sedating meds
- correct hypercarbia as above with bipap
- urine and blood cultures to rule out infection.
.
# Right Hip Fracture s/p Fall: s/p ORIF today; ortho following along."
539,"8
C (100.1
Tcurrent: 37.4
C (99.4
HR: 89 (84 - 102) bpm
BP: 117/68(84) {110/68(82) - 148/80(100)} mmHg
RR: 18 (14 - 28) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 54.8 kg (admission): 54.9 kg
Total In:
2,077 mL
PO:
TF:
IVF:
2,077 mL
Blood products:
Total out:
0 mL
285 mL
Urine:
35 mL
NG:
Stool:
Drains:
Balance:
0 mL
1,792 mL
Respiratory
O2 Delivery Device: Bipap mask
SpO2: 100%
ABG: 7.37/35/146/22/-3
Physical Examination
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, bipap mask on, comfortable, no
leaks
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
fine at bases, Diminished: at bilateral bases), no wheezes, rhonchi
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
167 K/uL
12."
540,"Admission Date: [**2128-2-13**] Discharge Date: [**2128-2-19**]
Date of Birth: [**2054-3-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
s/p fall with right hip pain and fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation right valgus impacted femoral
neck fracture with 7.3 mm screws x3.
History of Present Illness:
73 year old woman with past medical history of IDDM, seizure
disorder and breast cancer who lives alone presenting with
right-sided hip, leg and low back pain after slipping off her
toilet this morning."
541,"A CT abdomen and pelvis showed urinary retention and a
foley catheter was placed. Perceived to have a somewhat altered
mental status although unclear baseline.
Past Medical History:
Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
.
Of note, neuropsych evaluation in [**2125**] commented that ""her
marked attentional impairments raises concerns around her
safety, medication compliance, and other areas of functional
vulnerability.""
Social History:
Social History: Lives alone. Ambulatory at baseline.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
Family History: mother died at 47 in surgery (possibly during a
hysterectomy)."
542,"Some
residual areas of opacification are seen at the right base
laterally and at the left base. These most likely represent
residual aspiration or possible atelectasis.
.
[**2128-2-18**] EKG
Normal sinus rhythm with Q waves in the right precordial leads
consistent with anterior wall myocardial infarction. Q waves in
the inferior leads consistent with inferior myocardial
infarction. Compared to tracing #2 there is no change.
Brief Hospital Course:
73F PMHx of DM, seizure disorder and breast cancer, found down
on her floor with R hip fx s/p fall, admitted to the ICU with
hip fx, ARF, NSTEMI, and hypoxia."
543,"She
commenced PT POD#1, and was significantly limited by pain, but
this improved by POD#3 (ay of d/c). She did receive narcotics
around the time of PT to aid in progress. Pain was also managed
with tylenol. She was discharged on lovenox 40mg sQ daily for
DVT ppx, and with orthopedic followup.
# Pancyopenia: Presented with acute on chronic anemia with
baseline in low 30s, as well as thrombocytopenia with nadir
platelets in the 40s, and leukopenia to a nadir of 2.1 Felt
likely [**1-13**] methotrexate use with questionable use of folate
(marrow suppressive process). She was transfused 3 units in the
ICU and on HD#2 had a stable Hct to 32."
544,"8. DDAVP was given for
low platelets. Her methotrexate was held, she received
supplemental folic acid, and all cell lines recovered to normal
by discharge. She will followup with erh rheumatologist for ?
resumption of methotrexate.
# Acute Kidney Injury: Baseline creatinine = 1.3, but she
presented with creatinine 1.8 -> max of 2.2 in setting of fall.
Normal CKs made rhabdo unlikely. Felt likely [**1-13**] hypoperfusion
and prerenal state. Pt. was given IVF boluses and Cr decreased
to 1.3 by discharge.
# Transaminitis: Had elevations of ALT, AST and Alk Phos without
elevation in bilis. Unclear etiology, felt [**1-13**] mild ischemic
liver in setting of hypotension."
545,"Further syncope
workup included monitoring on telemetry without significant
arryhtmia, sending a tegretol level (normal), repeating EKGs
(developed signs of MI), and carotid ultrasounds which were
normal. Head CT and Cspine Ct in ED were negative.
# Hypoxia - pt still had minimal O2 requirement on d/c. Has
known OSA per prior sleep evaluations. Also received many liters
of IVF and 3 units of blood during her hospital course, so ?
some element of hypervolemia, but phsical exam did not support
this. Echo performed this admission revealed preserved EF of
60-65% but markedly dilated RV with severe global free wall
hypokinesis."
546,"There was abnormal diastolic septal motion/position
consistent with right ventricular volume overload. There was
moderate pulmonary artery systolic hypertension. This was
thought to possible represent sequelae from her MI. Pulmonary
embolism was on the differential but given her acute on chronic
renal failure, a CT-A was deferred, and the patient was allowed
to autodiurese and recover from the imediate postoperative
period and wean off of narcotics. If persistent, this could be
further worked up as an outpatient.
# RA: methotrexate was held during admission given pancytopenia
above.
# Depression: dx with mild depression - Effexor therapy was
continued
# Dementia/Delerium: unclear circumstances of diagnosis, per
record patient reporting forgetfulness, psych testing showing
mild attention deficits."
547,"13. Metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
14. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every [**5-18**]
hours as needed for pain: HOLD for any CNS or respiratory
depression (RR <12). Can be given prior to physical therapy
sessions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
- Right valgus impacted femoral neck fracture.
- NSTEMI vs. demand ischemia
- shock liver
- Pancytopenia likely due to methotrexate
- Right heart failure
Secondary:
- Rheumatoid arthritis
- Hypertension
- Depression
- Seizure disorder
- Diabetes mellitus type II
- Obstructive sleep apnea
- Dementia
- H/O breast cancer"
548,"Patient does not remember any other details
at this time. There were no witnesses, and it is not clear how
long she was down for.
.
In the ED, the intitial VS t 96.6 hr 109 bp 138/83 rr 15 and
pain was [**9-19**]. Physical exam showed pain with active and
passive R hip rotation. She was given 1g tylenol, 2mg IV
morphine and 2L NS. Evaluated by ortho. Imaging showed
subcapital femoral neck fx. Guaiac negative, cr 1.8 from b/l of
1.3. K+ 5.8->5.6, EKG notable for new T wave inversions in
V1-V4."
549,"You will need a course of rehabilitation
and aggressive physical therapy to regain your previous level of
function.
.
We also discovered that the right side of your heart is not
working well, which will need to be worked up further by your
PCP. [**Name10 (NameIs) **] the meantime we did discharge you with some supplemental
oxygen to keep your oxygen levels at a healthy level.
.
Some changes were made to your medications, as follows:
1) Your methotrexate was STOPPED, since it might have been
lowering your blood cell counts when you came to the hospital.
The blood counts revcovered nicely when you were taken off
methotrexate."
550,"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:
Dear Ms. [**Known lastname **],
You were admitted to the hospital after falling at home. You
were found after being down on the floor for a prolonged time.
As a result of the fall, you suffered a fractured right hip, as
well as low blood pressure which caused major stress to your
heart and liver. Your hip fracture was surgically repaired, and
as you were given IV fluids, the damage to your heart and liver
improved substantially."
551,"You can determine when to restart this when you
see Dr. [**Last Name (STitle) 6426**] in followup.
2) Your lipitor was increased to 80mg daily
3) You will be receiving daily injections of lovenox, a blood
thinner, to prevent blood clots after your hip surgery, for the
next 25 days
4) START calcium and vitamin D supplements to help with bone
healing
5) START metoprolol 12.5mg [**Hospital1 **] to protect the heart
6) START a baby aspirin every day to protect the heart
Followup Instructions:
Orthopedics:
Tuesday [**3-2**] at 11:20 with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Location (un) 8661**]
Building, [**Location (un) **])
.
Cognitive Neurology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2128-3-2**] 10:30
.
Primary Care:
Thursday, [**2130-4-9**]:20 with Dr. [**First Name (STitle) **]
.
Rheumatology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2128-3-4**] 11:30"
552,"Hospital course by problem:
# Elevated Cardiac Enzymes and EKG Changes: Had elevated
troponins in the setting of [**Last Name (un) **] and new TWI both in the setting
of anemia. [**Hospital **] medical regimen included ASA 81mg, statin
80mg daily, and beta blocker. ACE-I was held given recent acute
on chronic renal failure and preserved EF as seen on echo (see
below).
.
# Right Hip Fracture s/p Fall. Pt was evaluated by orthopedics
who planned for
minimally invasive pinning procedure pending medical clearance,
which was provided by daughter, [**Name (NI) 1785**], as pt was delirious.
Went to OR on [**2128-2-16**], no complications intra-op, but did go back
ot the ICU for overnight monitoring as she had some hypoxia
postoperatively (had received a larga amount of morphine)."
553,"Her methotrexate was also held.
LFTs had entirely normalized by discharge.
# IDDM: well-controlled by A1c. FS were checked every 4 hours
and she was placed on an insuling sliding scale. Her lisinopril
was held. On discharge,her metformin was continued, but
lisinopril was still held in setting of recent acute renal
failure.
# Fall: unclear etiology in pt with h/o seizure d/o and multiple
CAD risk factors.
Her cardiac enzymes were followed and Trop was trended from
0.16-->0.22-->0.22, so an MI could be the etiology but this
could also have been a conseqeunce of her fall."
554,".
CT ABD/PELVIS [**2128-2-13**]
IMPRESSION:
1. Right subcapital hip fracture.
2. Fibroid uterus.
3. Distended bladder with mild left pelvic fullness.
4. Bilateral adrenal gland thickening, left greater than right.
.
CT HEAD [**2128-2-13**]
IMPRESSION: No acute intracranial hemorrhage.
.
CT C-SPINE [**2128-2-13**]
IMPRESSION:
1. No evidence of acute fracture.
2. Multilevel degenerative changes as described above.
3. Lung apices suggestive of edema, inflammatory, or small
airways disease, vs infectious process.
4. 6mm peripherally calcified right thyroid nodule for which
further
evaluation with ultrasound.
.
EKG [**2128-2-13**]
Sinus rhythm. The P-R interval is prolonged."
555,"5 mg weekly
Effexor 150 mg Daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 25 days: LAST DAY OF THERAPY IS
[**2128-3-14**].
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day)."
556,"6. Recommend repeat swallowing evaluation at rehab prior to
upgrading diet.
# Prophylaxis: will be on lovenox 40mg sQ daily until ealry
[**Month (only) 547**] for DVT ppx, also d/c'ed on bowel regimen
# Communication: with patient and daughter [**Name (NI) **] HCP
[**Name (NI) 1785**] [**Name (NI) 1356**]
[**PO Box 103136**]
[**Location (un) 2268**], [**Numeric Identifier 103137**]
Home: [**Telephone/Fax (1) 103138**]
Cell: [**Telephone/Fax (1) 103139**]
Work: [**Telephone/Fax (1) 103140**]
# Code: Full
# Dispo:
To [**Hospital3 **]
Medications on Admission:
Lipitor 20 mg daily
Tegretol 200 mg TID
Aricept 10 mg daily
Lisinopril 5 mg daily
Meloxicam 15 mg daily
Metformin 500 mg daily
Methotrexate 12."
557,"There is a late
transition with Q waves and ST-T wave changes in the anterior
leads consistent with probable prior anterior myocardial
infarction. There are tiny R waves in the inferior leads
consistent with possible prior inferior myocardial infarction.
Compared to the previous tracing ST segment changes are new.
.
CXR [**2128-2-13**]
IMPRESSION: No acute cardiopulmonary process.
.
R HIP FILMS [**2128-2-16**]
FINDINGS: In comparison with study of [**2-13**], views from the
operating suite show placement of three metallic screws across
the previously described fracture of the femur.
.
[**2128-2-16**] ECHO:
The left atrium is normal in size."
558,"No information was available to her regarding her
birth father. She has several step siblings. Her daughter is
healthy.
Physical Exam:
PE on Admission to MICU:
Vitals: T 96.8 BP 111/50 P 84 RR 16 O2 99ra
General: Alert, oriented to place, year and ethnicity but not
name of the current president; calm but in visible pain
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Chest: right prosthetic breast
GU: foley
Ext: cold and pale bilaterally with weak but palpable distal
pulses bilaterally"
559,"5# RBC-4.50 Hgb-14.1 Hct-41.6
MCV-93 MCH-31.3 MCHC-33.8 RDW-18.7* Plt Ct-222
[**2128-2-18**] 06:50AM BLOOD Glucose-155* UreaN-37* Creat-1.3* Na-138
K-4.9 Cl-108 HCO3-21* AnGap-14
[**2128-2-18**] 06:50AM BLOOD ALT-30 AST-31 LD(LDH)-597* AlkPhos-147*
TotBili-0.5
.
CARDIAC ENZYME TREND:
[**2128-2-13**] 12:00PM BLOOD CK 108 CK-MB-10 MB Indx-9.3*
cTropnT-0.16*
[**2128-2-13**] 06:45PM BLOOD CK 147 CK-MB-13* MB Indx-8."
560,"Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is markedly dilated with severe global free wall
hypokinesis. There is abnormal diastolic septal motion/position
consistent with right ventricular volume overload. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse."
561,"Pertinent Results:
ADMISSION LABS:
[**2128-2-14**] 12:40PM BLOOD WBC-3.1* RBC-3.70* Hgb-11.5* Hct-32.8*
MCV-88 MCH-31.1 MCHC-35.2* RDW-19.1* Plt Ct-66*
[**2128-2-13**] 06:45PM BLOOD Neuts-72.0* Lymphs-20.1 Monos-6.4 Eos-0.9
Baso-0.7
[**2128-2-14**] 01:50AM BLOOD PT-12.9 PTT-25.7 INR(PT)-1.1
[**2128-2-14**] 12:40PM BLOOD Glucose-90 UreaN-47* Creat-1.8* Na-143
K-4.6 Cl-112* HCO3-22 AnGap-14
.
DISCHARGE LABS:
[**2128-2-18**] 06:50AM BLOOD WBC-5."
562,"6. Vitamin D 400 unit Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day)."
563,"No mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Markedly dilated right ventricle with severe global
hypokinesis. At least moderate pulmonary hypertension. Small
left ventricular cavity size with preserved systolic function.
.
[**2038-2-16**] CAROTID ULTRASOUNDS
IMPRESSION: There is less than 40% stenosis within the internal
carotid
arteries bilaterally.
.
[**2128-2-17**] CXR
FINDINGS: In comparison with the study of [**2-16**], there has been a
substantial decrease in the bilateral opacification, which had
been more prominent on the left and could have represented
either asymmetric pulmonary edema or diffuse aspiration."
564,"8*
cTropnT-0.22*
[**2128-2-14**] 01:50AM BLOOD CK 119 CK-MB-10 MB Indx-8.4*
cTropnT-0.22*
[**2128-2-16**] 06:37PM BLOOD CK 72 CK-MB-NotDone cTropnT-0.18*
[**2128-2-16**] 11:45PM BLOOD CK 49 CK-MB-NotDone cTropnT-0.16*
.
RADIOLOGY:
R Hip Films: [**2128-2-13**]
FINDINGS: There is a nondisplaced, slightly impacted right
subcapital hip
fracture. No other fractures are identified. Mild degenerative
changes
involving the SI joints and lumbar spine are noted. There is a
normal bowel
gas pattern.
IMPRESSION: Right subcapital hip fracture as described above."
565,"She was continued on Aricept. She did
experience significant delirium during her hospitalization which
had improved by her discharge, but was still present in a waxing
and [**Doctor Last Name 688**] nature but easily treated with reorientation and
discontinuation of foley catheter, telemetry, and hydration. She
does have followup scheduled with her cognitive neurologist.
# FEN:
pt was seen by speech and swallow who recommended:
1. Continue current diet of thin liquids and puree.
2. Pills whole or crushed with puree.
3. 1:1 supervision for all POs.
4. Give POs ONLY when patient is most awake and alert.
5. Nutrition consult."
566,"Hard to synthesize her other issues but possibly cardiac event leading
to hypotension, fall and hip fx, ATN, shock liver. Alternatively,
cardiac event may have been consequence of hypotension from blood
loss. Renal failure most suggestive of ATN but her distended bladder
and CT showing pelvic dilation raise ? of component of obstruction. We
are transfusing, giving DDAVP for uremic plts, holding on plt tx,
checking Una and UA, renally dosing all meds, r/o for MI, checking
cardiac echo in am, following LFT
s. Would defer surgery until more
stable medically if that is possible. Attempting to contact daughter.
Time spent 75 min
Critically ill"
567,"TITLE: CRITICAL CARE
Present for the key portions of the resident
s history and exam. Agree
substantially with assessment and plan as outlined in resident
s note
above. Briefly, 73 yo woman with DM, neurocognitive dysfxn, sz
disorder found on floor at home with hip fx. Reports she was rising
from toilet when
slid down
. Unclear if LOC and no clear recollection
of event, of how long she was on floor. In ED evidence of hip fx. ECG
ant t-wave inversion new from [**2121**], pos trop, hct down from baseline,
new thrombocytopenia, wbc down, incr transaminases, and incr creat."
568,"Bladder
1L when Foley inserted
96.7 83 108/54
Somnolent but arousable
Mouth dry
Follows commands but limited recall of events
Chest rare crackles at bases
CV 2/6 SEM
Abd soft
Hct 23
WBC 2.6
Plt 80
Creat 2.2
Hip fx in need of repair. Situation complicated by falling hct,
evidence of marrow suppression (WBC, plt), hepatic inj with incr
AST/ALT, renal failure with rising creat, pos trop with ECG changes of
?able duration. Hct drop seems likely due to blood loss in hip. Other
lines, however, seem most c/w marrow suppression possibly from meds."
569,"cannot
rule out pancytopenia from tegretol or other marrow suppressive
process.
.
# Pancytopenia:
.
# ARF:
.
# Seizure Disorder:
.
# Transaminitis: mild elevation of ALT, AST and Alk Phos without
elevation in bilis. Unclear etiology, plausible mild ischemic liver in
setting of hypotension
- trend LFTs
- hold tylenol
.
# IDDM: well-controlled by A1c
- FS q4 hours w/ISS
- hold metformin
- hold lisinopril
.
# Fall: unclear etiology in pt with h/o seizure d/o and multiple CAD
risk factors.
- ROMI, repeat EKGs
- check tegretol level
- follow CK
.
# Pain Control:
- morphine, 1mg q4 prn
- no tylenol given elevated LFTs
.
# RA:
- hold methotrexate for now (given weekly)
- manage pain with tylenol and prn morphine
."
570,"No
information was available to her regarding her birth father. She has
several step siblings. Her daughter is healthy.
Occupation: retired
Drugs: none
Tobacco: none
Alcohol: none
Other: lives alone; daughter involved; difficult to get a hold of
Review of systems:
Constitutional: Fatigue
Cardiovascular: troponin leak
Nutritional Support: NPO
Respiratory: No(t) Dyspnea, No(t) Tachypnea
Genitourinary: Foley
Musculoskeletal: Joint pain, R hip fracture; hx of RA
Heme / Lymph: Anemia
Psychiatric / Sleep: Daytime somnolence
Pain: Unable to answer
Flowsheet Data as of [**2128-2-16**] 08:28 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**29**] AM
Tmax: 37."
571,"1
3.1
2.9
Hct
29.9
32.8
37.5
Plt
73
66
167
Cr
2.0
1.8
1.2
TropT
0.22
TC02
21
Glucose
177
90
137
Other labs: PT / PTT / INR:12.4/27.0/1.0, CK / CKMB /
Troponin-T:119/10/0.22, ALT / AST:121/188, Alk Phos / T Bili:108/1.2,
Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:564 IU/L, Ca++:8.3 mg/dL,
Mg++:1.8 mg/dL, PO4:2.2 mg/dL
Fluid analysis / Other labs: none
Imaging: Images:
[**2-13**] CT Head:
FINDINGS: There is no evidence of acute hemorrhage or shift of normally
midline structures."
572,"There is no evidence of displaced rib fractures identified.
IMPRESSION: No acute cardiopulmonary process.
Microbiology: [**2-13**] urine - <1000 GNRs
Assessment and Plan
HYPOXEMIA
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
.H/O DIABETES MELLITUS (DM), TYPE I
.H/O FRACTURE, OTHER
.H/O ELECTROLYTE & FLUID DISORDER, OTHER
THROMBOCYTOPENIA, CHRONIC
.
.
.
73F PMHx of IDDM, seizure disorder and breast cancer presenting with R
hip fx s/p fall and admitted to the ICU initially with ARF and troponin
leak; now s/p ORIF of R hip with post-op hypoxia.
.
# Hypoxia:
.
# Right Hip Fracture s/p Fall
.
# Cardiac Ischemia:
.
# Anemia: acute on chronic with baseline in low 30s; acute component
likely blood loss into hip +/- dilutional component; chronic component
likely [**1-13**] methotrexate use with questionable use of folate."
573,"# Depression: dx with mild depression
- Effexor 150 mg Daily
.
# Dementia: unclear circumstances of diagnosis, per record patient
reporting forgetfulness, psych testing showing mild attention deficits
- hold aricept for now
.
# FEN:
- IVF as above
- replete electrolytes
- regular diet for now, NPO at midnight
.
# Prophylaxis: pneumoboots
# Access: peripherals
# Communication: Patient for now, have attempted to call daughter three
times but appears to be the wrong number
# [**Serial Number 11359**] (pending further discussion with patient)
# Disposition: ICU pending clinical improvement
.
.
[**First Name8 (NamePattern2) 4445**] [**Last Name (NamePattern1) 1130**], PGY 2
pg [**Numeric Identifier 11404**]
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2128-2-16**] 05:51 PM
20 Gauge - [**2128-2-16**] 05:51 PM
Prophylaxis:
DVT: Boots, LMW Heparin
Stress ulcer:
VAP:
Comments:
Communication: Comments: Talked with daughter, patient full code; ICU
consent still needs to be signed
Code status: Full code
Disposition: ICU"
574,"Chief Complaint: hypoxia post-op
HPI:
73 year old woman with past medical history of IDDM, seizure disorder
and breast cancer who lives alone presenting with right-sided hip, leg
and low back pain after slipping off her toilet the morning of
admission. Patient does not remember any other details at this time.
There were no witnesses, and it is not clear how long she was down
for. She was initially admitted to the MICU for ARF, troponin leak and
nonspecific EKG changes.
.
See MICU admission note for complete admission details. Of note, the
patient did have intermittent desats while in the MICU, associated
mostly with transfusions or fluid."
575,"Post op, they continued to have a difficult time getting a pleth and an
ABG was obtained showing 7.34/43/36. She was lethargic. She was
started on bipap and her next gas was 7.39/74. She had received 2 mg
IV morphine, __ fentanyl, and then 6 mg IV morphine post-op. She was
moaning to movement and would follow commands, moving all extremities
and squeezing.
.
On arrival to the ICU, she is more alert, has no complaints of pain and
is tolerating the bipap mask well.
.
Review of systems:
(+) Per HPI
(-) (per floor team) Denies fever, chills, night sweats, recent weight
loss or gain."
576,"The ventricles and sulci are prominent consistent
with age-related atrophy. The basilar cisterns are preserved. There is
no evidence of hydrocephalus. There is normal [**Doctor Last Name 988**]-white matter
differentiation. Bony exostosis/osteoma arising from the inner table of
the left frontal bone (2, 21) is stable. Hyperdensity in the right
superior frontal lobe subcortical white matter is unchanged. There is
no acute major vascular territorial infarct. The visualized paranasal
sinuses are clear except mild
mucosal thickening.
IMPRESSION: No acute intracranial hemorrhage.
.
[**2-13**] CT C Spine:
1. No evidence of acute fracture.
2. Multilevel degenerative changes as described above."
577,"CXR did not show infiltrates and no
treatment for infection was initiated. She was diuresed as needed and
tolerated it well with only nasal canula supplemental oxygen. She
received 3 u PRBCs pre-op for anemia (guiac negative) and responded
appropriately. Goal hct was 30 due to her troponin leak.
.
She was transferred to the floor where she did well. She was on 4L
nasal canula at the time. Today, she had an ORIF of her R hip.
Intraoperatively, they had a difficult time assessing her O2 sat due to
poor pleth. She has also hypotensive and on neo for a short time."
578,"3. Lung apices suggestive of edema, inflammatory, or small airways
disease, vs infectious process.
4. 6mm peripherally calcified right thyroid nodule for which further
evaluation with ultrasound.
.
[**2-13**] CT Abd/Pelvis:
1. Right subcapital hip fracture.
2. Fibroid uterus.
3. Distended bladder with mild left pelvic fullness.
4. Bilateral adrenal gland thickening, left greater than right.
.
[**2-13**] CXR:
FINDINGS: Cardiomediastinal contours are within normal limits. There is
no focal consolidation, pleural effusion, or pneumothorax. Vague
nodular opacity at the left upper lung is stable when compared to exam
dating back to [**2122-8-1**] and may represent vascular shadows versus benign
lesion."
579,"8
C (100.1
Tcurrent: 37.4
C (99.4
HR: 89 (84 - 102) bpm
BP: 117/68(84) {110/68(82) - 148/80(100)} mmHg
RR: 18 (14 - 28) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 54.8 kg (admission): 54.9 kg
Total In:
2,077 mL
PO:
TF:
IVF:
2,077 mL
Blood products:
Total out:
0 mL
285 mL
Urine:
35 mL
NG:
Stool:
Drains:
Balance:
0 mL
1,792 mL
Respiratory
O2 Delivery Device: Bipap mask
SpO2: 100%
ABG: 7.37/35/146/22/-3
Physical Examination
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, bipap mask on, comfortable, no
leaks
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
fine at bases, Diminished: at bilateral bases), no wheezes, rhonchi
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
167 K/uL
12."
580,"Chief Complaint: right hip pain s/p fall
HPI:
73 year old woman with past medical history of IDDM, seizure disorder
and breast cancer who lives alone presenting with right-sided hip, leg
and low back pain after slipping off her toilet this morning. Patient
does not remember any other details at this time. There were no
witnesses, and it is not clear how long she was down for.
In the ED, the intitial VS t 96.6 hr 109 bp 138/83 rr 15 and pain was
[**9-19**]. Physical exam showed pain with active and passive R hip
rotation."
581,"- ROMI, repeat EKGs
- check tegretol level
- follow CK
# Pain Controll
- morphine, 1mg q4 prn
- no tylenol given elevated LFTs
# RA:
- hold methotrexate for now (given weekly)
- manage pain with tylenol and prn morphine
# Hyperkalemia: [**1-13**] [**Last Name (un) 2406**]
- IVF as above
- [**Hospital1 **] lytes
- kayexelate if needed
# Depression: dx with mild depression
- Effexor 150 mg Daily
# Dementia: unclear circumstances of diagnosis, per record patient
reporting forgetfulness, psych testing showing mild attention deficits
- hold aricept for now
# FEN:
- IVF as above
- replete electrolytes
- regular diet for now, NPO at midnight
# Prophylaxis: pneumoboots
# Access: peripherals
# Communication: Patient for now, have attempted to call daughter three
times but appears to be the wrong number
# [**Serial Number 11359**] (pending further discussion with patient)
# Disposition: ICU pending clinical improvement
ICU Care
Nutrition: NPO for procedure
Glycemic Control: q4 FS with ISS
Lines:
18 Gauge - [**2128-2-13**] 09:07 PM
Prophylaxis:
DVT: pneumoboots
Stress ulcer: rotation
VAP: N/A
Comments:
Communication: patient, trying to reach daughter
[**Name (NI) 129**] status:
Disposition: likely to ortho service"
582,"6 24 2.2
2.6 > 7.7 / 23.6 < 80
N:72.0 L:20.1 M:6.4 E:0.9 Bas:0.7
PT: 12.2 PTT: 24.6 INR: 1.0
12:00p cr 1.8 hct 23.6
IMAGING:
CT Abdomen and pelvis w/o Contrast: slightly impacted right subcapital
hip fracture. old rib fx on the right. left adrenal gland thickening.
Distended bladder and mild fullness of left renal pelvis.
.
CT C-Spine W/O Contrast: severe djd. no fx
CT Head W/O Contrast: no bleed
.
EKG: NSR, normal axis, normal intervals, no ST segment changes, TWI in
V1-V4 compared to [**2121**] (none since)
Other labs: PT / PTT / INR:13."
583,"""
Occupation: nurse (retired)
Drugs: none
Tobacco: none
Alcohol: none
Other: Lives alone. Ambulatory at baseline.
Review of systems:
Flowsheet Data as of [**2128-2-14**] 01:29 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**29**] AM
Tmax: 36.1
C (97
Tcurrent: 36.1
C (97
HR: 83 (83 - 88) bpm
BP: 115/59(72) {90/50(60) - 115/60(72)} mmHg
RR: 14 (12 - 30) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
664 mL
534 mL
PO:
TF:
IVF:
364 mL
208 mL
Blood products:
300 mL
327 mL
Total out:
345 mL
25 mL
Urine:
345 mL
25 mL
NG:
Stool:
Drains:
Balance:
319 mL
509 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 100%
Physical Examination
Vitals: T 96."
584,"Review of systems was negative for recent fever, chills, cough,
shortness of breath or chest pain, nausea or vomiting.
Patient admitted from: [**Hospital1 1**] ER
History obtained from Medical records
Patient unable to provide history: Sedated
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
HOME MEDICATIONS:
Lipitor 20 mg daily
Tegretol 200 mg TID
Aricept 10 mg daily
Lisinopril 5 mg daily
Meloxicam 15 mg daily
Metformin 500 mg daily
Methotrexate 12.5 mg weekly
Effexor 150 mg Daily
Past medical history:
Family history:
Social History:
Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
Of note, neuropsych evaluation in [**2125**] commented that ""her marked
attentional impairments raises concerns around her safety, medication
compliance, and other areas of functional vulnerability."
585,"cannot
rule out pancytopenia from tegretol or other marrow suppressive
process.
- q6 hct checks for now
- transfuse 3 units, goal hct > 30
- check DIC labs
- DDAVP given PLT
- folate IV given methotrexate use with ? folate compliance
# [**Last Name (un) 2406**]: creatinine 1.8 -> 2.2 in ED vs baseline 1.3 in setting of fall
but with normal CK. Likely hypoperfusion.
- IVF @ 150 overnight
- urine lytes
- recheck creatinine in morning
# Transaminitis: mild elevation of ALT, AST and Alk Phos without
elevation in bilis. Unclear etiology, plausible mild ischemic liver in
setting of hypotension
- trend LFTs
- hold tylenol
# Right Hip Fracture s/p Fall
- ortho planning for minimally invasive pinning procedure pending
medical clearance
- ortho advised that not cleared for the OR until further evaluation
in the morning; agreed waiting 1-2 days will not significantly reduce
expected functional outcomes
- pain management as below
- repeat EKG in morning
# IDDM: well-controlled by A1c
- FS q4 hours w/ISS
- hold metformin
- hold lisinopril
# Fall: unclear etiology in pt with h/o seizure d/o and multiple CAD
risk factors."
586,"She was given 1g tylenol, 2mg IV morphine and 2L NS.
Evaluated by ortho. Imaging showed subcapital femoral neck fx. Guiac
negative, cr 1.8 from b/l of 1.3. K+ 5.8->5.6, EKG notable for new T
wave inversions in V1-V4. A CT abdomen and pelvis showed urinary
retention and a foley catheter was placed. Perceived to have a somewhat
altered mental status although unclear baseline.
Most recent vitals at the time of transfer to the MICU were t 97 hr 90
bp 100/54 rr 16 sat 100% on RA. On arrival to the ICU she was calm but
visibly in pain."
587,"0/26.2/1.1
Assessment and Plan
73F PMHx of IDDM, seizure disorder and breast cancer presenting with R
hip fx s/p fall and admitted to the ICU with [**Last Name (un) 2406**] and concern for ACS in
the setting of expected surgical repair of fracture.
# Elevated Cardiac Enzymes and EKG Changes: mildly elevated troponins
in the setting of [**Last Name (un) 2406**] and new TWI both in the setting of anemia.
- repeat EKG in morning
- trend troponins
- cont statin
- no perioperative BB
# Anemia: acute on chronic with baseline in low 30s; acute component
likely blood loss into hip +/- dilutional component; chronic component
likely [**1-13**] methotrexate use with questionable use of folate."
588,"8 BP 111/50 P 84 RR 16 O2 99ra
General: Alert, oriented to place, year and ethnicity but not name of
the current president; calm but in visible pain
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Chest: right prosthetic breast
GU: foley
Ext: cold and pale bilaterally with weak but palpable distal pulses
bilaterally
Labs / Radiology
140 104 49 315
5."
589,"Admission Date: [**2161-3-29**] Discharge Date: [**2161-4-1**]
Date of Birth: [**2111-10-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Tetanus Toxoid,Adsorbed
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall. Struck right forehead on ground.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49F who presented to [**Hospital3 1280**] Hospital via EMS after
sustaining a blunt head injury on [**3-29**]. She was reportedly
sitting on a stool at a resturant, when she turned and tripped
over the stool falling and striking the right side of her head.
She lost conciousness for approximately 3-5 minutes."
590,"The events
are stated per her friend who accompanied her, as the patient's
recollection of the events are poor.
Past Medical History:
Hypotension, s/p Lt knee surgeries x2
Social History:
Single, unemployed on Workman's Compensation for a left knee
injury sustained. No children. +Tobacco use. One sister who is
presently travelling in [**Country 651**]. Pts friend [**Name (NI) 501**] who
accompanies her.
Family History:
Non-contributory
Physical Exam:
On Admission:
T:97.3 BP: 126/86 HR: 114 R 22 O2Sats 95%
Gen: WD/WN, Agitated, combative, requiring pharmacologic and
leather restraints.
HEENT: Rt forhead laceration with bandage."
591,"Discharge Disposition:
Home
Discharge Diagnosis:
Bifrontal contusions,Right frontal Intraparenchymal hemorrhage,
Left frontal Subdural hemorrhage.
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING"
592,"Imaging:
CT C-Spine [**3-29**]:
IMPRESSION:
1. No fracture or malalignment of the cervical spine.
2. Posterior osteophytes at C5-6 and C6-7 contact the thecal
sac. MRI is
more sensitive for evaluation of the thecal sac and its
contents.
Head CT [**3-29**]:
TECHNIQUE: Contiguous axial images were obtained through the
brain. No
contrast was administered. Multiplanar reformatted images were
generated.
FINDINGS: Hyperdense material is seen within the subdural space
overlying the left frontoparietal cortex. This acute left
subdural hemorrhage has increased slightly in extent compared to
the prior CT. Hemorrhage measures
approximately 5 mm in depth, and now extends slightly further
posteriorly, now overlying the left parietal cortex (2:19)."
593,"2* Lymphs-19.4 Monos-2.8 Eos-0.3
Baso-0.3
[**2161-3-29**] 12:51AM BLOOD PT-14.9* PTT-24.2 INR(PT)-1.3*
[**2161-3-29**] 12:51AM BLOOD Glucose-102 UreaN-10 Creat-0.5 Na-142
K-4.0 Cl-106 HCO3-25 AnGap-15
[**2161-3-29**] 12:51AM BLOOD ALT-10 AST-16 AlkPhos-94 TotBili-0.2
[**2161-3-29**] 12:51AM BLOOD TotProt-7.0 Albumin-4.6 Globuln-2.4
Calcium-8.9 Phos-4.0 Mg-2.2
[**2161-3-29**] 12:51AM BLOOD ASA-NEG Ethanol-333* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG"
594,"Paranasal sinuses demonstrate complete
opacification of the right maxillary sinus with low-density
material, as well as erosion of the medial wall of the right
maxillary sinus with opacification of the adjacent nasal cavity
and neighboring right ethmoid air cells. The sphenoid and
mastoid air cells are well aerated. The frontal sinuses are only
minimally pneumatized, with a small amount of soft tissue
material extending anteriorly from the right ethmoid air cells.
Soft tissues reveal a small scalp hematoma overlying the right
inferior frontal bone just above the orbit.
IMPRESSIONS:
1. Left frontoparietal subdural hematoma, slightly increased in
size compared to the prior study of approximately three hours
earlier."
595,"Inferiorly in the right frontal lobe, there is a small focus of
hyperdense material, likely reflecting a hemorrhagic contusion.
This spans a region of less than 1 cm, and is largely unchanged
from the prior CT. There are no other foci of intracranial
hemorrhage. There is no edema, shift of normally midline
structures or evidence of major vascular territorial infarct.
Adjacent to the left subdural hematoma, sulci are not effaced
and there is no mass effect. Ventricles and sulci are normal in
size and configuration. The basilar cisterns are patent. The
[**Doctor Last Name 352**]-white differentiation is preserved.
There is no fracture."
596,"Sm. lac above right
eyebrow with Dermabond or like closure. Pupils: 3mm to 2mm bil.
with brisk reaction. EOMs full. Follows this examiner around
room.
Neck: Supple. No Bruits or JVD
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, initially cooperative with exam,
labile affect. Cooperation alternating with agitation. Poor
historian. Unable to recall events of this evening consistently.
Poor decision making displayed regarding medical care.
Orientation: Oriented to person, place, and date and the current
President of the U.S.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5"
597,"She was
evaluated by physical and occupational therapy who determined
that she was physically safe for discharge to home. Psychiatry
was consulted who recommended Haldol PRN while in the hospital
and they agreed with the CIWA scale. Social work was also
consulted to assess home safety and patient coping. The patient
expressed interest in attempting to quit drinking. Social work
gave her some resources to use for when she goes home. The
patient was discharged home on [**2161-4-1**].
Medications on Admission:
Vicodin prn
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days."
598,"No underlying sulcal effacement or mass effect. No
herniation.
2. Small hemorrhagic contusion of the right inferior frontal
lobe, unchanged from the prior exam.
3. No fractures.
4. Small scalp hematoma overlying right inferior frontal bone.
5. Severe sinus disease, with complete opacification of the
right maxillary
sinus and erosion of right maxillary sinus medial wall.
Brief Hospital Course:
The patient was admitted on [**3-29**] following a fall while
intoxicated, striking her head. She was admitted to the ICU for
24 hour monitoring. On [**3-30**], after an uneventful night, she was
transferred to the neurosurgery floor. Head CT done prior to
transfer showed stable intracranial contusions."
599,"?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2161-4-1**]"
600,"Sensation: Intact to light touch, propioception, pinprick and
bilaterally.
Reflexes: B T Br Pa Ac
Right +2 +2 +2 +2 +2
Left +2 +2 +2 NT +2
Propioception intact
Toes downgoing bilaterally
On Discharge:
Alert, oriented with full strength throughout upper and lower
extremities. Pupils are equal and reactive to light. The is
right orbital ecchymosis.
Pertinent Results:
Labs on Admission:
[**2161-3-29**] 12:51AM BLOOD WBC-10.9 RBC-3.79* Hgb-13.5 Hct-38.9
MCV-103* MCH-35.6* MCHC-34.7 RDW-14.6 Plt Ct-446*
[**2161-3-29**] 12:51AM BLOOD Neuts-77."
601,"Disp:*21 Capsule(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours:
No driving while on narcotics.
Disp:*20 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
10 days.
Disp:*20 Capsule(s)* Refills:*0*
7. Counseling
We recommend that you seek outpatient counseling for
discontiuing alcohol use."
602,"H/O ALCOHOL ABUSE, SUBDURAL HEMORRHAGE (SDH)
Assessment and Plan: 49F w EtOH s/p fall and L SDH
Neurologic: Q1 hr neuro checks, repeat CT performed this AM, read
pending, Ativan Q4 PRN; patient should have social work/substance abuse
consult during admission
Cardiovascular: HD stable, mild tachy
Pulmonary: stable
Gastrointestinal / Abdomen: no issues
Nutrition: clears ADAT
Renal: normal creat, good UOP d/c foley
Hematology: INR 1.2, mild anemia, plts wnl
Endocrine: no active issues
Infectious Disease: stable
Lines / Tubes / Drains: PIV, foley
Wounds: R head lac C/D/I
Imaging:
Fluids: NS @ 85
Consults: Neuro surgery, Etoh counseling
Billing Diagnosis: (Hemorrhage, NOS: Subdural)
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2161-3-29**] 04:46 AM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle:
Communication:
Code status: Full
Disposition: to Floor
Total time spent: 31min"
603,"m.
Tmax: 37.8
C (100.1
T current: 37.6
C (99.6
HR: 83 (82 - 102) bpm
BP: 109/66(75) {91/48(60) - 119/66(77)} mmHg
RR: 15 (14 - 29) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
2,212 mL
815 mL
PO:
480 mL
240 mL
Tube feeding:
IV Fluid:
1,732 mL
575 mL
Blood products:
Total out:
962 mL
490 mL
Urine:
962 mL
490 mL
NG:
Stool:
Drains:
Balance:
1,250 mL
325 mL
Respiratory support
SPO2: 98%
ABG: ///27/
Physical Examination
General Appearance: No acute distress, Overweight / Obese
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
307 K/uL
10."
604,"1 g/dL
94 mg/dL
0.4 mg/dL
27 mEq/L
3.2 mEq/L
4 mg/dL
102 mEq/L
135 mEq/L
29.4 %
6.0 K/uL
[image002.jpg]
[**2161-3-29**] 04:55 AM
[**2161-3-30**] 03:59 AM
WBC
9.4
6.0
Hct
31.4
29.4
Plt
350
307
Creatinine
0.4
0.4
Glucose
96
94
Other labs: PT / PTT / INR:13.4/26.3/1.2, Albumin:3.5 g/dL, Ca:8.2
mg/dL, Mg:1.7 mg/dL, PO4:2.9 mg/dL
Imaging: [**3-29**] CT head: Left frontoparietal subdural hematoma; Small
hemorrhagic contusion of the right inferior frontal lobe; Severe sinus
disease, with complete opacification of the right maxillary sinus and
erosion of right maxillary sinus medial wall
[**3-29**] CT C-spine: No fracture or malalignment of the cervical spine;
Microbiology: [**3-29**] MRSA screen: pending
[**3-29**] UCx: pending
Assessment and Plan
."
605,"SICU
HPI:
49 yo female who presented to OSH via EMS after sustaining a blunt head
injury. Pt was reported as drinking wine this evening with her friend.
She was sitting on a stool and while turning on the stool, the stool
tipped over and the pt then fell to floor striking her right forehead.
3-5min LOC. Now w L SDH
Chief complaint:
LEFT SDH
PMHx:
Lt ACL repair x2, Mult. falls
Current medications:
Acetaminophen, Bisacodyl, Docusate Sodium, Famotidine, FoLIC Acid,
Lorazepam, Metoprolol, Senna, Thiamine
24 Hour Events:
Allergies:
Tetanus Toxoid
Adsorbed
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2161-3-29**] 08:37 PM
Lorazepam (Ativan) - [**2161-3-30**] 04:21 AM
Metoprolol - [**2161-3-30**] 05:22 AM
Other medications:
Flowsheet Data as of [**2161-3-30**] 06:46 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**64**] a."
606,"Admission Date: [**2118-12-11**] Discharge Date: [**2118-12-16**]
Date of Birth: [**2033-5-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
hematemesis, melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
85 y/o male with h/o bladder cancer s/p urostomy, HTN, HLD, and
h/o GIB who presents from [**Hospital **] Hospital ED with concern for
upper GI bleed in the setting of dark-colored stools and
hematemesis. Three days prior to admission, the patient
developed the sudden onset of dark-colored stools."
607,"A CXR did not reveal any evidence of aspiration and was
otherwise clear, and NGT was noted to be appropriately placed.
He was continued on the Protonix gtt and given 2 L NS. He was
T&S for 2 units. A GI consult was called prior to transfer to
the MICU and they plan on EGD in the am. VS on transfer were
96.4, P: 65, BP: 105/36, RR: 20, 99% on 2L NC.
.
Currently, he is without complaint and states he is feeling
better.
Past Medical History:
1. Bladder CA s/p urostomy
2. Hypertension
3. Hyperlipidemia
4."
608,"4
Brief Hospital Course:
Patient is a 85 y/o male with h/o bladder cancer s/p urostomy,
HTN, HLD, SIADH who presents with upper GI bleed in the setting
of recent NSAID use.
.
#. Upper GI bleed: Patient admitted with hematemesis and melena
consistent with upper GI bleed. Given his recent use of NSAIDS
and aspirin, gastritis or ulcer were the most likely etiology.
He remained hemodynamically stable. He was initally placed on a
PPI drip and transitioned to high dose PPI IV BID. He underwent
EGD; a peptic ulcer was found in the distal bulb, and this was
clipped."
609,"He was transferred to the floor and remained stable.
His PPI was made PO and his home medicines were restarted. We
held his Aspirin and his NSAID pain medicine. He should avoid
NSAIDs in the future. He will need to have his ASA started at
the discretion of his PCP.
.
#. Leukocytosis: UA suggestive of UTI, although he has chronic
indwelling urostomy and no symptoms of infection. [**Month (only) 116**] also be
secondary to stress reaction in setting of probable GIB. CXR
without infiltrate c/f pneumonia. Urine culture was negative.
Leukocytosis resolved and was likley due to acute bleed.
. .
#. Positive Urinalysis/Asymptomatic Bacteriuria: Patient s/p
bladder cancer with urostomy so has chronic indwelling biofilm
so UA likely to be persistently positive."
610,"Culture was negative.
No antibiotics were given.
.
#. Hypertension, benign: amlodipine and nadolol were held on
admission. His BP normalized and his home anti-hypertensives
were restarted.
.
# Night time oxygen desaturations; Patient had several nighttime
SaO2 values of 75% while sleeping. He was asymptomatic during
these events. He did not endorse symptoms to suggest sleep
apnea. Sleep was consulted and felt he did have evidence however
an urgent inptaint sleep study was not warrented. He will be
discharged on night time home oxygen therapy and will follow up
with the sleep clinic in early [**Month (only) 404**]. In the mean time he will
need assistence in setting up an outpatient sleep study."
611,"His PCP
was called and this was communicated to him directly.
.
+++++++++++++++++
Transitional issues:
1) Consider restarting Aspirin 81 after follow up visit with
PCP, [**Name10 (NameIs) **] there is no recurrent bleeding.
2) Will need CBC and Chem 7 checked on Monday following
discharge by PCP (office aware). Hct 29.3 and Creatinine 1.6 on
last check here.
3) Will need to have Outpatient sleep study set up, preferably
at [**Hospital **] hospital.
4) He was advised to avoid NSAIDs.
.
Medications on Admission:
demeclocycline 150 mg po BID
simvastatin 10 mg po daily
nadolol 20 mg po once a daily
amlodipine 10 mg po daily
Aricept 10 mg Once Daily
Aspirin- 81 mg po daily (started 1 week ago)
Arthrotec 75/200 1 tab [**Hospital1 **] (diclofenac/ misoprostol)"
612,"nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. Outpatient Lab Work
please draw CBC, Sodium, Potassium, Chloride, Bicarb, BUN and Cr
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
Duodenal ulcer
Sleep apnea"
613,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] because you had a bleeding ulcer in
your stomach. This was a result of the anti-inflammatory
medications you were taking for your knee. The GI doctors placed
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] across the bleeding and it has stopped. You will need to
follow up with your PCP as listed below.
.
You also were found to have a condition known as sleep apnea.
You will need to have a sleep study soon after being discharged
from the hospital."
614,"[**Name (NI) 92610**] office. You will be given an oreder to take with you
that will let them know what tests to order.
.
You will be called by Dr.[**Name (NI) 92611**] office to have a follow up
appointment sheduled. If you have not heard from them in 1 week
you shoudl call them ASAP to set up a follow up appointment.
.
You will need to see the sleep physicians for a follow up
appointment on Tuesday [**2119-1-17**] at 9am. Please call ([**Telephone/Fax (1) 514**] to set up the details of your appointment. They will
help to schedule your sleep study for you."
615,"He gradually
developed nausea and vomiting with four episodes of
coffee-ground emesis. With regards to his prior GIB, the source
is unknown as the family is unaware of whether the patient had
an EGD or colonoscopy. He was recently started on an NSAID [**3-11**]
weeks ago for a joint effusion. He developed GI upset and the
dosing was decreased from daily to [**Hospital1 **]. He was also started on
aspirin 81 mg po daily one week ago. He has no history of
alcohol abuse, liver disorders and is not on any
anti-coagulation. Patient reports ongoing nausea but denies any
fevers, chills, abdominal pain, chest pain, SOB, or dysuria."
616,"Discharge Medications:
1. Home O2
Patient requires night time home oxygen. Documented
desaturations to <78% on room air while sleeping. Corrects fully
with oxygen. Saturations remain above 90% on RA while awake.
Please start at 2L/min nasal cannula and titrate to SaO2 >95%
2. simvastatin 10 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 Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. demeclocycline 150 mg Tablet Sig: One (1) Tablet PO bid ().
5."
617,"SIADH
Social History:
Patient lives by himself with the help of 2 home health aides.
He denies ever drinking alcohol, smoking or using illicit drugs.
Family History:
patient unsure but denies a history of cancer.
Physical Exam:
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, sl dry MM, OP
clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - crackles at RLL, otherwise CTAB, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - urostomy in place in RLQ, NABS, soft/NT/ND, no masses
or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)"
618,"SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-12**] throughout, sensation grossly intact throughout, gait
deferred
Pertinent Results:
[**2118-12-11**] 08:45PM BLOOD WBC-15.9* RBC-2.92* Hgb-9.6* Hct-28.2*
MCV-97 MCH-32.8* MCHC-33.9 RDW-12.5 Plt Ct-338
[**2118-12-12**] 05:25AM BLOOD WBC-9.9 RBC-2.85* Hgb-9.0* Hct-27.3*
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.7 Plt Ct-288
[**2118-12-13**] 10:14AM BLOOD WBC-7."
619,"He
denies any dizziness or presyncope.
.
The patient initially presented to [**Hospital **] Hospital ED. He was
given an Octreotide bolus, Protonix bolus and was started on a
Protonix drip. An NGT was placed which revealed coffee-ground
emesis which cleared with NG lavage. His hemoglobin at [**Hospital **]
Hospital was 10.1, which is noted to be his baseline. On arrival
to the [**Hospital3 **] ED, his initial VS were 96.4, 60 113/49, 14,
99% RA. His repeat CBC revealed a hemoglobin of 9.6 and a
leukocytosis of 15.6 with a left-shift (PMNs 84.9%) with no
bands."
620,"You will need to discuss this with your PCP
and have this set up at [**Hospital **] hospital when you see him in
follow up. In the meantime you will need to wear Oxygen while
you sleep.
.
While you were here we made the following changes to yoru
medications.
We STOPPED your arthrotec
We STOPPED your aspirin - you will need to talk about when to
restart this with your PCP
We STARTED you on Pantoprazole
We STARTED you on Senna
We STARTED you on colace
.
You should continue to take your other emdications as directed.
Followup Instructions:
You will have need to have your blood drawn this monday at Dr."
621,"5 RBC-2.85* Hgb-8.9* Hct-26.3*
MCV-92 MCH-31.2 MCHC-33.8 RDW-15.9* Plt Ct-235
[**2118-12-11**] 08:45PM BLOOD Neuts-84.9* Lymphs-12.8* Monos-1.7*
Eos-0.2 Baso-0.4
[**2118-12-13**] 04:32AM BLOOD PT-12.3 PTT-72.5* INR(PT)-1.1
[**2118-12-13**] 04:32AM BLOOD Glucose-80 UreaN-41* Creat-1.6* Na-141
K-3.4 Cl-111* HCO3-24 AnGap-9
[**2118-12-11**] 08:45PM BLOOD ALT-26 AST-31 LD(LDH)-231 AlkPhos-74
TotBili-0."
622,"Admission Date: [**2105-7-4**] Discharge Date: [**2105-7-12**]
Date of Birth: [**2043-5-24**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62M w/HCV and EtOH cirrhosis, s/p liver [**First Name3 (LF) **] [**2104-11-30**],
now presenting with fever and hypotension with pressor
requirement after HD today. Mr. [**Known lastname **] has had a complex course
since his [**Known lastname **], including wash-out for intra-abdominal
hemorrhage, ESRD requiring dialysis, recurrent HCV, pneumonia
with right empyema, and C."
623,"Past Medical History:
recurrent hepatitis C with the suspicion of fibrosing
cholestatic hepatitis
s/p ERCP on [**2105-2-24**] with biliary stent placement
HCV; VL on [**2104-12-15**] was 32.6 million
HCV/ETOH cirrhosis w/ hepatorenal syndrome s/p OLT [**2104-11-30**]
Intra-abdominal hemorrhage
Malnutrition
VRE UTI
Social History:
ETOH history 5-6 years ago > 14 drinks/week secondary to
brothers death at age 50. Last drink [**2104-5-20**], Tobacco [**12-22**] pack
x 20 years (quit in [**5-29**]), remote marijuana, no IVDU.
Family History:
Mom survived MI age 35, Father died age 59 of alcoholic
cirrhosis."
624,"Brief Hospital Course:
Patient was admitted to the [**Year (4 digits) **] surgery service with the
bacteremia and sepsis. He was admitted to the ICU.
Neuro: Since the time of admission patient was arousable and
responded to commands. He remained at his baseline until the day
he decompensated when his metal status has worsened and upon
intubation, required no sedation. He received minimal pain
medications for abdominal pain/discomfort.
CV: The patient was initially stable from a cardiovascular
standpoint. He required vasopressors upon admission, in the next
48 hours he was weaned of the pressors. He developed vasopressor
requirement and became hemodynamically unstable approximately 48
hour prior to his demise."
625,"Following the aspiration event on the
floor level of care on [**7-10**], patient was transferred to ICU,
where he drooped his systolic blood pressure shortly after. He
was on one vasopressor for the 24 hours, later on 2 pressors,
yet his sbp was in 70s. The family made a decision to withdraw
life support including vasopressors on [**7-12**] in the early
mid-afternoon. Patient expired several hours after.
Pulmonary: The patient remained stable from a pulmonary
standpoint initially. On [**7-10**] he vomited and aspirated. His
oxygen saturation dropped and he was transferred to the ICU. His
oxygen saturation was low, his mental status worsened, thus he
was intubated."
626,"He remained intubated until he expired.
GI/GU/FEN: Patient was found to have C. difficile colitis. He
was fed via TPN. The electrolytes was initially repleated. The
hyperkalemia was treated with kayaxylate. Patient also [**Month/Year (2) 1834**]
CVVH. The CVVH no longer continued after [**7-10**], when patient was
intubated, due to family wishes. Patient had diagnostis
paracenthesis, which did not show SBP.
ID: He was treated for C. difficile colitis initially with PO
vancomycin and IV flagyl as well as tigacycine. The Klebsiella
bacteremia was treated with meropenem. Prior to the cultures
becoming available, patient also recieved amikacin and cefepime."
627,"He was afebrile for most of the hospital stay.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay.
As patient status declined rapidly on [**7-10**] following the
aspiration event, family made a well thought out decision to
minimize the patient's suffering as his prognosis was not
favorable. Patient was initially made DNR status for about 24
hours. Next, the family made the patient CMO with continued
ventilation on [**7-12**]."
628,"Patient expired one to hours after all the
vasopressors were stopped. He was started on morphine gtt. He
expired comfortable, with no agonal breaths observed. The
medical examiner as well as the family refused an autopsy.
Medications on Admission:
tylenol 500'''' prn fever, darbepoetin alpha 40 qweek, folic
acid, HSQ, lispro sliding scale, reglan 5 iv q8, mycophenolate
180"", nepro TF 45/hr, nystatin swish/swallow"""", zofran prn,
promod syrup 10ml q8, protonix 40"", bactrim', tacrolimus
0.5/0.5,
ursodiol 300"", renal vitamin
Discharge Medications:
patient was CMO:
- morphine gtt
Discharge Disposition:
Expired
Discharge Diagnosis:
multiorgan system failure
cardiac arrest
Discharge Condition:
death
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
Completed by:[**2105-7-13**]"
629,"One brother died age 50 of ?mesothelioma. Sister had
[**Location (un) 38204**] 12 yrs ago. Other four sibs are alive and well.
One niece survived ruptured brain aneurism in her 30s. No other
family h/o liver disease, heart disease, or cancer.
Physical Exam:
PE on admission:
Vitals: T 99.5, HR 128, BP 89/46, RR 16, O2 100%
Gen: sleepy but arousable, oriented x3; sclerae anicteric
CV: tachycardic, no appreciable murmur
Resp: right-sided crackles and decreased breath sounds at base,
dullness to percussion right base; left lung cta
Abd: soft, non-tender, moderately distended, +fluid wave;
incisions well-healed; - [**Doctor Last Name **] sign
Extr: warm, 1+ pulses
DRE: no gross blood, guaiac negative"
630,"Diffuse colitis, nonspecific in appearance but certainly
could be related to patient's known C. diff infection.
[**2105-7-10**] CXR
Large bilateral pleural effusions and right basal atelectasis
unchanged
acutely. No pneumothorax. A feeding tube and a nasogastric tube
ends in the upper stomach. Right jugular line tip projects over
the low SVC. Heart is not enlarged. No pneumothorax.
laboratory:
[**2105-7-3**] 07:30PM BLOOD WBC-17.0*# RBC-2.70* Hgb-9.1* Hct-30.8*
MCV-114*# MCH-33.8* MCHC-29.6* RDW-18.3* Plt Ct-80*
[**2105-7-4**] 06:36PM BLOOD WBC-34."
631,"6* RBC-2.53* Hgb-8.7* Hct-26.7*
MCV-105* MCH-34.5* MCHC-32.8 RDW-19.2* Plt Ct-88*
[**2105-7-6**] 01:52AM BLOOD WBC-13.5*# RBC-2.90* Hgb-9.6* Hct-28.2*
MCV-97 MCH-33.2* MCHC-34.2 RDW-19.3* Plt Ct-68*
[**2105-7-7**] 01:42AM BLOOD WBC-9.8 RBC-3.54* Hgb-11.4* Hct-33.0*
MCV-93 MCH-32.2* MCHC-34.6 RDW-19.4* Plt Ct-53*
[**2105-7-10**] 09:27AM BLOOD WBC-12.4* RBC-3.21* Hgb-10."
632,"2* Cl-92* HCO3-18* AnGap-16
[**2105-7-4**] 02:16AM BLOOD Glucose-72 UreaN-22* Creat-2.9* Na-135
K-3.4 Cl-99 HCO3-15* AnGap-24*
[**2105-7-4**] 01:37PM BLOOD Glucose-43* UreaN-25* Creat-3.4* Na-133
K-4.0 Cl-97 HCO3-12* AnGap-28*
[**2105-7-7**] 01:42AM BLOOD Glucose-89 UreaN-42* Creat-4.7* Na-129*
K-3.1* Cl-99 HCO3-16* AnGap-17
[**2105-7-7**] 04:45PM BLOOD Glucose-93 UreaN-19 Creat-2.6*# Na-136
K-3.7 Cl-102 HCO3-26 AnGap-12
[**2105-7-10**] 01:33AM BLOOD Glucose-133* UreaN-23* Creat-2."
633,"diff colitis. He was most recently
discharged from [**Hospital1 18**] on [**2105-6-23**] for his c.diff infection. He
was
doing well at rehab, and had HD today, which went without
incident. After completion, they noted that he was hypotensive
to the 80's and febrile to 103, and he was brought to our ED for
evaluation. His wife reports his stools are still loose, but
are
decreased in amount and the character is improved since
completing c. diff treatment. History is obtained from the
patient's wife and [**Name (NI) **], as the patient is a very poor historian
and is mostly non-verbal currently"
634,"PE on discharge:
- no vital signs, no resppirtaion, no pulse, no heart sounds, no
pupillary reflexes
Pertinent Results:
imaging:
[**2105-7-3**] Dupplex abdomen
1. Patent portal and hepatic veins and hepatic arteries with
normal systolic upstroke.
2. Coarsened liver with echogenic area in the left lobe
compatible with a
resolving hematoma or complex fluid collection. Simple hepatic
cyst also
seen.
3. Moderate-to-large amount of ascites.
[**2105-7-4**] CT abdomen/pelvis
1. Bilateral pleural effusions with compressive atelectasis.
2. Dobbhoff tube curled twice, once in the stomach, once in the
esophagus.
3. Moderate to extensive ascites.
4."
635,"5* Hct-31.7*
MCV-99* MCH-32.6* MCHC-33.0 RDW-19.8* Plt Ct-33*
[**2105-7-3**] 07:30PM BLOOD PT-22.9* PTT-48.2* INR(PT)-2.1*
[**2105-7-4**] 01:37PM BLOOD Plt Ct-92*
[**2105-7-6**] 01:52AM BLOOD PT-38.1* PTT->150* INR(PT)-3.9*
[**2105-7-10**] 09:27AM BLOOD PT-51.0* PTT-88.0* INR(PT)-5.4*
[**2105-7-10**] 09:27AM BLOOD Plt Smr-VERY LOW Plt Ct-33*
[**2105-7-3**] 07:30PM BLOOD Glucose-553* UreaN-18 Creat-2.5*# Na-123*
K-3."
636,"4* Na-137
K-3.7 Cl-104 HCO3-25 AnGap-12
[**2105-7-10**] 09:27AM BLOOD Glucose-145* UreaN-25* Creat-2.7* Na-138
K-4.7 Cl-104 HCO3-27 AnGap-12
[**2105-7-3**] 07:30PM BLOOD ALT-79* AST-172* AlkPhos-214*
TotBili-5.4*
[**2105-7-4**] 02:16AM BLOOD ALT-104* AST-239* AlkPhos-188* Amylase-73
TotBili-5.5*
[**2105-7-7**] 01:42AM BLOOD ALT-134* AST-197* AlkPhos-162*
TotBili-13.0*
[**2105-7-10**] 01:33AM BLOOD ALT-63* AST-83* AlkPhos-181*
TotBili-21.3*
[**2105-7-10**] 09:27AM BLOOD ALT-60* AST-76* AlkPhos-181*
TotBili-22."
637,"35 calTCO2-27 Base XS-0 Intubat-NOT INTUBA
[**2105-7-10**] 12:50PM BLOOD Type-ART pO2-160* pCO2-38 pH-7.39
calTCO2-24 Base XS--1
microbiology:
[**2105-7-3**] blood culture
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
326-4714B
[**2105-7-3**].
[**2105-7-5**] blood culture
LACTOBACILLUS SPECIES.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final [**2105-7-7**]):
Reported to and read back by [**First Name9 (NamePattern2) 85588**] [**Last Name (un) 6977**] @ 1810 ON
[**7-7**] - CC6C.
GRAM POSITIVE ROD(S).
IN CHAINS.
[**2105-7-8**] Bclx - pend
[**2105-7-9**] Bclx - pend
[**2105-7-10**] Bclx - pend"
638,"0*
[**2105-7-3**] 07:30PM BLOOD Albumin-1.8* Calcium-6.3* Phos-1.3*
Mg-1.6
[**2105-7-8**] 03:03AM BLOOD Albumin-2.4* Calcium-8.1* Phos-2.8 Mg-1.9
[**2105-7-10**] 09:27AM BLOOD Albumin-2.5* Calcium-8.3* Phos-3.9#
Mg-2.3
[**2105-7-3**] 07:41PM BLOOD pH-7.31*
[**2105-7-4**] 02:41AM BLOOD Type-ART pO2-118* pCO2-29* pH-7.35
calTCO2-17* Base XS--7
[**2105-7-10**] 08:58AM BLOOD Type-ART Temp-36.4 pO2-50* pCO2-47*
pH-7."
639,"Admission Date: [**2172-12-8**] Discharge Date: [**2172-12-14**]
Date of Birth: [**2095-2-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2172-12-8**]
1. Aortic valve replacement with a 27 mm [**Company 1543**] Mosaic
Ultra aortic valve bioprosthesis model number 305,
serial number [**Serial Number 92202**].
2. Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary
artery; reverse saphenous vein single graft from aorta
to the ramus intermedius coronary artery; reverse
saphenous vein single graft from the aorta to the distal
right coronary artery."
640,"3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
77 year old male presented to ED today after found to have
abnormal stress test. On day prior to admission, he reported
left anterior chest, shoulder and upper arm
pain/pressure/numbness for 9 hours. He reports chest pain
started while he was working at his computer and persisted until
he went to bed that evening. He also says that over last few
months he has had occasional dyspnea on exertion. He saw his PCP
who recommended that he undergo an ETT. His exercise stress test
showed ST depressions in inferior and lateral leads."
641,"He was placed on
Beta-blocker and oral Amiodarone. Anticoagulation with Coumadin
was initiated. His INR went from 1.0->2.4->3.2 and he was given
0 mg Coumadin on [**2172-12-14**] with repeat INR on [**2172-12-15**] scheduled.
INR goal 2.0-3.0 - [**Hospital 2274**] [**Hospital3 271**] to provide
further Coumadin instructions. On [**2172-12-13**] he was transfused
with 2 units of PRBC for HCT of 21.8 which increased to Hct of
27.2. He was given Folic acid, iron and Vitamin C for post op
anemia. He continue to progress and on POD 6 he was cleared for
discharge to home with VNA services."
642,"Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Severe critical aortic stenosis/Severe 3-vessel coronary
disease.
s/p AVR/CABG
Atrial Flutter
Secondary:
Dyslipidemia
Hypertension
Mild aortic stenosis
Anemia, vitamin B12 deficiency
Erectile Dysfunction
seborrheic keratosis
ocular hypertension
GERD
hypothyroidism
CKD (baseline Creat 1.3-1.5)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon."
643,"[**Last Name (STitle) 914**]. Please see operative report for
further details.CARDIOPULMONARY BYPASS TIME: 144
minutes.CROSSCLAMP TIME: 123 minutes. He tolerated the
procedure well and transferred to the CVICU intubated and
sedated. He awoke neurologically intact and was extubated. He
weaned off pressor support and initially Beta-blocker was held
due to nodal rhythm. Statin/Aspirin and diuresis were
initiatited. All lines and drains were discontinued per
protocol. POD#1 he was transferred to the step down unit for
further monitoring. Physical Therapy was consulted for
evaluation of strength and mobility. POD#3 he went into rate
controlled atrial fibrillation/flutter."
644,"07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *17 < 15
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *44 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 19 mm Hg
Aortic Valve - LVOT VTI: 27
Aortic Valve - LVOT diam: 1.9 cm
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 1."
645,"1 m/sec
Mitral Valve - E/A ratio: 1.09
Mitral Valve - E Wave deceleration time: *291 ms 140-250 ms
TR Gradient (+ RA = PASP): 25 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2172-12-1**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels."
646,"3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 77 ml/beat
Left Ventricle - Cardiac Output: 4.67 L/min
Left Ventricle - Cardiac Index: 2.67 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 7 mm Hg <= 10 mm
Hg
Left Ventricle - Lateral Peak E': *0."
647,"Disp:*60 Tablet(s)* Refills:*0*
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 2 months.
Disp:*60 Tablet(s)* Refills:*0*
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 months.
Disp:*60 Tablet(s)* Refills:*0*
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed for goal INR 2.0-3.0 - Take NO Coumadin on [**2172-12-14**].
Disp:*60 Tablet(s)* Refills:*2*"
648,"Disp:*60 Capsule(s)* Refills:*2*
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200 [**Hospital1 **] x 2 weeks then 200 mg daily x 1 month or seen by
cardiologist."
649,"Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
650,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] - the office will call you with an
appointment for 1 month
[**Location (un) 2274**] office to call with appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2920**] or Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**University/College **] [**Location (un) 2274**] Center for the next [**1-16**]
weeks
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2172-12-17**] at 10:00
in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 17528**],[**First Name3 (LF) 17529**] [**Telephone/Fax (1) 17530**] in [**3-18**] 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**
Coumadin for Atrial Flutter: INR Goal 2.0-3.0
[**Hospital 2274**] [**Hospital3 **] to call with further Coumadin
instructions
Next INR draw Tuesday [**2172-12-15**]
Phone: [**Telephone/Fax (1) 17530**]
Fax: [**Telephone/Fax (1) 6808**]
Completed by:[**2172-12-14**]"
651,"9 INR(PT)-1.2*
[**2172-12-12**] 05:52AM BLOOD Glucose-108* UreaN-39* Creat-1.7* Na-132*
K-5.1 Cl-100 HCO3-27 AnGap-10
[**2172-12-8**] 02:30PM BLOOD UreaN-28* Creat-1.3* Na-139 K-4.9 Cl-110*
HCO3-24
[**2172-12-14**] 04:32AM BLOOD Hct-27.2*
[**2172-12-13**] 04:57AM BLOOD WBC-7.7 RBC-2.39* Hgb-7.4* Hct-21.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.4 Plt Ct-269
[**2172-12-14**] 04:32AM BLOOD UreaN-36* Creat-1."
652,"Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis leaflets appear to move normally. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Increased left ventricular filling pressure.
Well-seated, normally functioning aortic valve bioprosthesis
with borderline-elevated transaortic valvular mean pressure
gradients (19 mmHg)."
653,"All follow up appintments
were advised.
Medications on Admission:
Lisinopril 20 mg daily
Levothyroxine 50mcg po daily
Omeprazole 20mg po daily
Vitamin B12 1000mcg po daily
HCTZ 25mg po daily (sometimes halved dose or did not take)
Fish oil
Red yeast rice extract
Discharge Medications:
1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Delayed Release (E.C."
654,"6* Na-136 K-4.8 Cl-102
[**2172-12-13**] 04:57AM BLOOD Glucose-91 UreaN-38* Creat-1.6* Na-135
K-4.5 Cl-103 HCO3-27 AnGap-10
[**2172-12-14**] 04:32AM BLOOD PT-24.8* INR(PT)-2.4*
[**2172-12-13**] 04:57AM BLOOD PT-11.1 INR(PT)-1.0
[**2172-12-9**] 02:07AM BLOOD PT-11.1 PTT-26.8 INR(PT)-1.0
[**2172-12-8**] 02:30PM BLOOD PT-12.6* PTT-33.0 INR(PT)-1.2*
Echocardiographic: [**2172-12-10**]
Left Atrium - Long Axis Dimension: *4."
655,"Family History:
Father had pacemaker placed when 60.
Mother with hx of HTN and CVA
family hx also notable for colon cancer and diabetse
No additional family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admission Physical Exam
Pulse:58 Resp:20 O2 sat:100/RA
B/P Right:182/72 Left:201/63
Height:6'2"" Weight:170 lbs
General:
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 [III/VI]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none - muscle
bulge on right mid shin (present x 60 years)
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+"
656,"Normal pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of [**2172-12-1**], a
bioprosthetic aortic valve is now present. The pulmonary artery
systolic pressure has normalized.
CXR: IMPRESSION: [**2172-12-13**] Right apical pneumothorax is tiny and
unchanged. Small bilateral pleural effusions are stable and
bibasilar atelectasis has improved. Heart size is normal. Right
jugular line ends low in the SVC. No pulmonary edema.
Brief Hospital Course:
On [**2172-12-8**] Mr.[**Known lastname 23903**] was taken to the operating room and
underwent Aortic valve replacement(#27 mm [**Company 1543**] Mosaic Ultra
aortic valve bioprosthesis)/Coronary artery bypass grafting x3
(left internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein single graft from aorta
to the ramus intermedius coronary artery; reverse saphenous vein
single graft from the aorta to the distal right coronary
artery) with Dr."
657,"He was then
referred to [**Hospital1 18**] for a cardiac catheterization. He was found to
have aortic stenosis and coronary artery disease and is now
being referred to cardiac surgery for revascularization and an
aortic valve replacement.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Mild aortic stenosis
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Anemia, vitamin B12 deficiency
Erectile Dysfunction
seborrheic keratosis
ocular hypertension
GERD
hypothyroidism
CKD
Social History:
Lives with significant other. Previously worked in
sales/marketing.
-Tobacco history: never smoked
-ETOH: occasional
-Illicit drugs: denies"
658,"No 2D or Doppler evidence of distal arch coarctation.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
leaflets move normally. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR. Prolonged (>250ms) transmitral E-wave decel time.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg)."
659,"Carotid Bruit Right/Left:transmitted murmur B/L
Pertinent Results:
[**2172-12-12**] 05:52AM BLOOD WBC-9.4 RBC-2.50* Hgb-7.8* Hct-22.4*
MCV-90 MCH-31.2 MCHC-34.9 RDW-13.2 Plt Ct-244
[**2172-12-8**] 02:30PM BLOOD WBC-12.1*# RBC-3.52* Hgb-10.6* Hct-31.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.3 Plt Ct-177
[**2172-12-9**] 02:07AM BLOOD PT-11.1 PTT-26.8 INR(PT)-1.0
[**2172-12-8**] 01:30PM BLOOD PT-12.9* PTT-32."
660,") Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN/TEMP.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)."
661,"Admission Date: [**2163-9-5**] Discharge Date: [**2163-9-7**]
Date of Birth: [**2144-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 18 year old male with past medical history
significant for depression who presents today after an
intentional overdose in the setting of recently breaking up with
his girlfriend of 1.5 years and worsening depression. He
initially presented to the [**Hospital6 **] on [**2163-8-25**]
feeling unsafe. He was able to contract for safety and was
discharged with close followup."
662,"His
transaminases were monitored and showed no elevation. His INR
rose slightly to 1.5 and then trended down to 1.2. He was seen
by psychiatry who recommended 1:1 sitter and transfer to
psychiatry once medically stable for further management.
On transfer to the floor he has no complaints. Specifically he
denies fevers, chills, confusion, lightheadedness, dizziness,
chest pain, difficulty breathing, nausea, vomiting, abdominal
pain, diarrhea, constipation, dysuria, hematuria, leg pain or
swelling. All other review of systems is negative in detail.
Past Medical History:
Depression
Social History:
Born in [**State 760**]. Currently, he is a sophomore at BU in
Biomed engineering."
663,"4
Toxicology:
[**2163-9-5**] 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-167*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-9-6**] 08:59PM BLOOD Acetmnp-NEG
[**2163-9-6**] 05:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
This is an 18 year old male with past medical history
significant for depression who presented after an intentional
overdose in the setting of recently breaking up with
his girlfriend of 1.5 years and worsening depression.
Intentional Overdose/Tylenol Toxicity: Patient reported
ingesting significant quantities of ativan, motrin, nyquil,and
excedrin pm at approximately 2 pm on Monday [**9-5**]."
664,"Suicide Attempt/Depression: Patient was transferred on section
12 after a serious suicide attempt. On arrival he had a
flattened affect. He was seen by social work and psychiatry who
recommended 1:1 sitter and ultimate transfer to inpatient
psychiatry facility for further management of his depression.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Depression
Overdose
Discharge Condition:
Stable. Ambulating without assistance. No evidence of hepatic
damage.
Discharge Instructions:
You were seen and evaluated for your overdose. You were found
to have an elevated tylenol level and were treated with
n-acetylcysteine for liver protection."
665,"8 Na-141
K-4.3 Cl-104 HCO3-28 AnGap-13
[**2163-9-7**] 06:15AM BLOOD Calcium-9.9 Phos-3.2 Mg-1.8
Transaminases:
[**2163-9-5**] 09:15PM BLOOD ALT-14 AST-21 LD(LDH)-190 AlkPhos-63
TotBili-0.2
[**2163-9-6**] 05:30AM BLOOD ALT-10 AST-13 LD(LDH)-134 AlkPhos-46
TotBili-0.4
[**2163-9-6**] 01:05PM BLOOD ALT-12 AST-18 LD(LDH)-170 AlkPhos-53
TotBili-0.6
[**2163-9-6**] 08:59PM BLOOD ALT-10 AST-15 AlkPhos-50 TotBili-0.3
[**2163-9-7**] 06:15AM BLOOD ALT-12 AST-18 AlkPhos-53 TotBili-0."
666,"Discharge Exam:
Unchanged
Pertinent Results:
Hematology:
[**2163-9-7**] 06:15AM BLOOD WBC-5.8 RBC-4.72 Hgb-13.9* Hct-40.5
MCV-86 MCH-29.4 MCHC-34.3 RDW-12.8 Plt Ct-224
[**2163-9-6**] 05:30AM BLOOD WBC-7.6 RBC-4.57* Hgb-13.2* Hct-39.0*
MCV-85 MCH-28.9 MCHC-33.9 RDW-12.8 Plt Ct-212
[**2163-9-5**] 09:15PM BLOOD WBC-5.7 RBC-5.41 Hgb-15.3 Hct-45.1 MCV-83
MCH-28.2 MCHC-33.9 RDW-13.3 Plt Ct-306"
667,"Seven hours
later his tylenol level on presentation to the emergency room
was 167 which is within potential range for hepatotoxicity. He
was started on n-acetylcysteine for treatment of tylenol
toxicity and admitted to the MICU. He was monitored on
telemetry with no arrhythmias. His transaminases were monitored
and did not increase. His INR increased slightly from 1.2 to
1.5 but subsequently normalized. He showed no signs of liver
damage. He completed a 21 hour course of n-acetylcysteine. No
further medical therapy is needed for treatment of his overdose
and he is medically stable for transfer for psychiatry."
668,"3 P 98 BP 126/76 R16 O2 sat 100% on RA.
Patient was slightly lethargic appearing but was conversant. He
reported taking 3 mg lorazepam, [**12-2**] ibuprofen, 1 shot [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5261**], and an unclear amount of Nyquil and excederine PM.
Initially laboratories were notable for normal chemistries and
transaminases but a serum tylenol level of 167 at approximately
7 hours after ingestion. His toxicology screen was otherwise
negative. Given that this is within the window for potential
hepatic toxicity he was started on a n-acetylcysteine drip and
transferred to the ICU.
In the ICU he was monitored on telemetry with no events."
669,"You were monitored
initially in the ICU and then on the floor for evidence of liver
damage which you did not develop.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please do not take any tylenol products for one month
Please keep all your follow up appointments as scheduled.
Please seek immediate medical attention if you experience any
fevers, lightheadedness, chest pain, difficulty breathing,
abdominal pain, yellowing of your skin or any other concerning
symptoms.
Followup Instructions:
Please follow up with your primary care physician within one
week of discharge from psychiatry. If you do not have a primary
care physician, [**Name10 (NameIs) **] are welcome to establish primary care here
at [**Hospital3 **]. The office phone number is [**Telephone/Fax (1) 250**]."
670,"He then presented to BU Mental
Health feeling unsafe and was section 12 and transferred to
[**Hospital1 18**] but he was felt to be safe for discharge and released to
the care of his family. He subsequently ingested unknown
quantities of ativan, motrin, nyquil, and excedrin pm
approximately 2 pm on Monday [**9-5**]. He went [**Location (un) 84770**] and wanted to jump in front of a car but couldn't bring
himself to do it. He ultimately sought medical attention about
7 yours later on Monday evening, after friends found him
lethargic and vomiting.
In the ED,vs were: T98."
671,"Occasional EtOH, no tobacco or illicits.
Has used marijuana on two occassions in the past.
Family History:
Alcohol abuse in his father
Physical Exam:
Initial Physical Exam:
Vitals: T: 98.3 P: 98 BP: 126/76 R: 16 O2sat: 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Cardiac: 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
Extremities: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema"
672,"Coagulation Profiles:
[**2163-9-5**] 10:30PM BLOOD PT-13.9* PTT-21.4* INR(PT)-1.2*
[**2163-9-6**] 05:30AM BLOOD PT-16.8* PTT-26.8 INR(PT)-1.5*
[**2163-9-7**] 06:15AM BLOOD PT-14.1* PTT-28.6 INR(PT)-1.2*
Chemistries:
[**2163-9-5**] 09:15PM BLOOD Glucose-116* UreaN-15 Creat-1.3* Na-143
K-3.7 Cl-99 HCO3-28 AnGap-20
[**2163-9-6**] 01:05PM BLOOD Glucose-91 UreaN-9 Creat-0.9 Na-140 K-3.7
Cl-106 HCO3-24 AnGap-14
[**2163-9-7**] 06:15AM BLOOD Glucose-80 UreaN-11 Creat-0."
673,"Chief Complaint: Acetaminophen overdose
HPI:
This is an 18 year old male with past medical history significant for
depression who presents today after an acetaminophen overdose. The
patient has been having problems recently with a break up with his
girlfriend and in the context of this relationship ending he has been
dealing with worsened depression and suicidal ideation. Per notes he
intially presented to the [**Hospital6 **] Emergency Department on
[**2163-8-25**] due to feeling unsafe. After eventually being able to contract
for safety he was discharged with follow up. In between that emergency
department visit and his follow up he once again presented to the BU
[**Hospital 9116**] Health Center complaining of feeling unsafe and thoughts of
self harm including a plan."
674,"1) Acetaminophen Overdose: Patient's acetaminophen level at seven hours
after toxic ingestion is within range of possible liver toxicity and
not completely reliable regarding time of ingestion. Therefore, we
have initiated NAC protocol. Currently, INR and LFT's relatively
normal
-Continue NAC
-Recheck labs in AM
-F/U tox reccs
2) Suicide Attempt/Depression: Patient has flattened affect and serious
attempts suggest depression though given clear situational precipitant
also possible adjustment disorder. Very serious attempt after multiple
calls for help is concerning. Likely will need inpatient psych
admission after medicine discharge.
-1:1 sitter
-f/u psych reccs
-Social work re: coping
3) Other ingestions: Other ingested substances (lorazepam,
diphenhydramine, ibuprofen) unlikely to cause end organ damage and
would mostly be managed supportively."
675,"I agree with
the note above, including the assessment and plan. To that I would add
the following:
This is an 18 yo man who presented to ED today with ingestion of
Excedrin PM (acetaminophen, diphenhydramine), Ativan, Motrin, nyquil,
and whiskey in context of suicidal ideation/intent. Has had multiple
ED visits over last week with suicidal ideation after breaking up with
his girlfriend. Acetaminophen level 167 approx 7 hrs post-ingestion.
Started on iv NAC protocol in ED and transferred to MICU.
Plan on continuing iv NAC for acetaminophen overdose. Supportive care
for other substances ingested; pt arousable and conversant with
housestaff team.
Pt is critically ill. Time spent 33 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 1776**] [**Name8 (MD) **], MD
on:[**2163-9-6**] 03:01 ------"
676,"Occupation: [**Name2 (NI) 9117**] at BU
Drugs: None
Tobacco: None
Alcohol: Rare
Other:
Review of systems:
Constitutional: No(t) Fever
Eyes: No(t) Blurry vision
Gastrointestinal: No(t) Abdominal pain
Flowsheet Data as of [**2163-9-6**] 02:40 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37
C (98.6
Tcurrent: 37
C (98.6
HR: 86 (79 - 88) bpm
BP: 115/65(71) {115/65(71) - 115/65(77)} mmHg
RR: 21 (16 - 21) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
1,045 mL
PO:
TF:
IVF:
1,045 mL
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
1,045 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 100%
Physical Examination
General Appearance: Well nourished, No acute distress, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),
(Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): Person, place, and time, Movement: Purposeful,
Tone: Normal
Labs / Radiology
306
15."
677,"3
116
1.3
15
28
99
3.7
143
45.1
5.7
[image002.jpg]
Other labs: PT / PTT / INR:13.9/21.4/1.2, ALT / AST:14/21, Alk Phos / T
Bili:63/0.2, Amylase / Lipase:/31, Differential-Neuts:63.2, Lymph:30.9,
Mono:4.2, Eos:1.4
Fluid analysis / Other labs: Serum APAP: 167
Serum ASA, EtOH, [**Last Name (LF) 1556**], [**First Name3 (LF) **], Tricyclic: Negative
ECG: Sinus rhythm at rate of 96, normal axis and intervals (QTc of
431). No concerning ST or T wave changes
Assessment and Plan
This is an 18 year old male with a history of depression presenting
after an acetaminophen overdose."
678,"-Monitory
4) PPx: Pneumoboots and ambulate for DVT, will start H2 blocker given
large NSAID dose
5) FEN: Regular diet, replete lytes PRN
6) Code: Full
7) Access: PIV's
8) Contact: patient doesn't wish for anyone to be called tonight, we
will contact family in AM
9) Dispo: ICU pending stable LFT's
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2163-9-6**] 01:09 AM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
------ Protected Section ------
I saw and examined the patient, and was physically present with the ICU
resident for the key portions of the services provided."
679,"A friend called
911. [**Name2 (NI) **] is unclear whether he still wants to die. He reports his
ingestion was at about 2:00 PM.
In the ED,vs were: T098.3 P 98 BP 126/76 R16 O2 sat 100% on RA.
Patient was slightly altered and seemed drugged but otherwise benign
exam and was cooperative. APAP level of 167. Admitted to medicine for
further management.
Currently, he feels depressed but denies any physical complaints.
Patient admitted from: [**Hospital1 5**] ER
History obtained from Patient
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
-s/p ORIF R arm
EtOH abuse in father."
680,"He was transferred to [**Hospital1 5**] ED on a
section 12 and had been a plan to admit until family showed up and
offered to support and observe patient. Therefore, he was released to
their supervision. In the interim he had been somewhat stable and had
been seeing behavioral health at BU. This afternoon, he spoke to his
ex-girlfriend on the phone and became upset with her. Therefore, he
decided he wanted to die and decided the least painful way was with
medications. He took a small amount of [**First Name4 (NamePattern1) 1384**] [**Last Name (NamePattern1) 3268**], 3 mg of
lorazepam, 15-20 ibuprofen, excedrin PM, and nyquil."
681,"Admission Date: [**2173-8-3**] Discharge Date: [**2173-8-8**]
Date of Birth: [**2114-1-5**] Sex: M
Service: MEDICINE
Allergies:
clindamycin HCl
Attending:[**First Name3 (LF) 23497**]
Chief Complaint:
Weakness and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59M w/pmhx CHF (last EF 55-60%), afib, elevated LFTs, chronic LE
wounds (recent admission for cellulitis on [**6-14**]), hx of PE and
atrial thrombus, presented to clinic today for F/U. Pt had hx of
multiple missed appointments and F/U labs were drawn today.
Reported losing ~20lbs within the past month. Pt appeared
euvolemic and had extensive chronic LE ulcerations (pt was seen
in vascular clinic immediately prior to general medicine
appointment and was started on Keflex)."
682,"An EKG
showed afib @ 115, NA, lateral minimal stdep likely demand
related. no STE. He recieved 1L NS and was restarted on his
metorolol and diltiazem. His digoxin was held.
Past Medical History:
CARDIAC HISTORY:
- Afib - noted first during admission [**1-/2171**]; initial TEE CV
aborted due to left atrial thrombus; s/p DCCV [**2171-4-11**].
- Systolic CHF/nonischemic dilated cardiomyopathy - thought due
to tachymyopathy. Recent EF 40% ([**3-/2171**])
- PFO (noted on TEE)
- HTN
Other Past History:
- Pulmonary embolus (noted on CT [**1-/2171**])
- Anxiety
- S/p hernia repair, pt describes complicated course of what
sounds like dehiscence and redo x2 with mesh placement, last in
12/[**2168**]."
683,"6*
MCV-97 MCH-31.9 MCHC-33.0 RDW-15.2 Plt Ct-252
[**2173-8-8**] 06:10AM BLOOD Glucose-99 UreaN-16 Creat-0.9 Na-134
K-4.2 Cl-97 HCO3-27 AnGap-14
[**2173-8-8**] 06:10AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.6
[**2173-8-8**] 06:10AM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.4*
Brief Hospital Course:
59 year old male with a past medical history of systolic
congestive heart failure (last EF 55-60%), atrial fibrillation
on coumadin, transaminitis secondary to cirrhosis, chronic lower
extremity stasis dermatitis (recent admission for cellulitis on
[**2173-6-14**]), history of pulmonary embolus and atrial thrombus who
presented from clinic with with a significant hyponatremia,
elevated lactate, and acute kidney injury."
684,"#. HYPONATREMIA: Etiology was likely hypovolemic hyponatremia in
the setting of over-aggressive diuretic use and decreased
dietary intake of sodium. Patient had started dieting, eating
less salt and drinking more water. He presented with
hypotension and tachycardia. Patient also presented with acute
kidney injury, elevated lactate, fractional excretion of sodium
less than 1, low urine sodium, and elevated creatinine and BUN
all suggesting hypovolemic hyponatremia as the etiology. While
in the MICU his sodium was corrected with normal saline and his
urine and serum sodium trended. Once his sodium was trending
upward he was transferred to the medicine floor. His torsemide
was held and then restarted on [**8-7**] on an every other day dosing
schedule, and he should follow up with his PCP for repeat lab
testing."
685,"# HYPOTENSION / TACHYCARDIA - Though initially concerned for
SIRS/sepsis because of leukocytosis on admission, and possible
source of infection being cellulitis from chronic venous stasis
ulcers. CXR, UA, blood cultures were all negative for signs of
infection. He did not have fever of systemic signs of
infection. Initially he met systemic inflammatory response
syndrome criteria with a possible source. He was started on
vancomycin and unasyn empirically. On re-evaluation he remained
afebrile with no constitutional symptoms concerning for sepsis.
His vancomycin and unysin was discontinued and keflex was kept
on per his vascular physicians prescription. Hypotension was
likely a result of extracellular volume depletion in the setting
of overdiuresis and salt restriction as above, with a reactive
tachycardia."
686,"Metoprolol, digoxin, and diltiazem were held for
hypotension but restarted as his pressures tolerated them. He
was monitored on telemetry and was not shown to have any atrial
fibrillation with RVR. However, he had asymptomatic sinus
tachycardia to the 130-160s during physical therapy. This was
likely because his home medications were held, and his
tachycardia improved upon restarting digoxin, metoprolol, and
diltiazem at his home doses. Torsemide was restarted on an
every other day dosing schedule.
#. ATRIAL FIBRILLATION: Chronic issue. On coumadin, metoprolol,
diltizem, and digoxin at home. In the MICU, he became mildly
hypotensive (sbp in 90s, not requiring pressors) so his
metoprolol and diltiazem were reduced in dose."
687,"Upon trasnfer to
floor, blood pressure was stable after resuming home meidcations
and metoprolol was uptitrates in setting of tachycardia,
particularly with exertion with PT. He should follow up with his
PCP regarding titration of his rate control. His INR was
subtherapeutic, so his warfarin was increased to 6mg. Digoxin
was continued and level was not toxic.
#. Acute kidney injury: Likely prerenal and related to
hypoperfusion in the setting of hypotension. creatinine improved
with holding torsemide and administration of IVF. His creatine
and BUN were trended and his creatine trended downward with IV
fluids.
#. STASIS DERMATITIS WITH POSSIBLE SUPER IMPOSED CELLULITIS:
While in the MICU he did not spike a fever or appear overtly
septic by exam or review of systems."
688,"His leukocytosis
normalized. The decision was made to leave him on his outpatient
dose of keflex however pending follow-up with his vascular
physician.
#. CIRRHOSIS: This is a diagnosis that is currently undergoing
outpatient workup. He did not appear hypervolemic and this was
not likely related to the etiology of his hyponatremia. He
denies alcohol abuse and is reportedly planning on undergoing a
liver biopsy to further characterize his liver disease. His
liver function was monitored while in the MICU and remained
stable, and no further management of his possible cirrhosis was
performed.
TRANSITIONAL ISSUES:
-Vascular, renal, and hepatic follow-up."
689,"Warfarin 6 mg PO DAILY16
8. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Diltiazem Extended-Release 180 mg PO DAILY
10. Outpatient Lab Work
Please check INR [**2173-8-9**] and send results to [**Company 191**] [**Hospital 3052**]. Phone [**Telephone/Fax (1) 2173**].
Discharge Disposition:
Home With Service
Facility:
Allcare VNA
Discharge Diagnosis:
Primary: Hyponatremia, acute kidney injury
Secondary: Atrial fibrillation, chronic systolic congestive
heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)."
690,"- Seasonal allergies
Social History:
He is single and lives alone. He worked as a painter at [**Hospital1 **]
[**Location (un) 620**], still out of work. He is a lifetime nonsmoker and
denies illicit drug use. he does drink approximately [**12-28**] bottle
of wine about 3 times weekly and ""a few beers"" from time to time
with friends.
Family History:
Father: h/o CVA
Mother: h/o heart disease, arrythmia and had a pacer. Deceased
82yo.
Physical Exam:
ADMIT EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, 2+ pulses, no clubbing, s/p DP amutation of left
great toe, venous stasis dermatitis with possible super
infection bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred."
691,"Please have your INR checked on Tuesday [**2173-8-10**]. You may need
adjustment in your coumadin dose. For now, you should take 6 mg
per day as your INR is low.
Please keep the appointments listed below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2173-8-13**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage"
692,"Discharge Instructions:
Dear Mr. [**Known lastname 10840**],
You were treated at [**Hospital1 18**] for low sodium and decreased kidney
function. Your low sodium and decreased kidney function were
likely caused by a combination of not eating and drinking as
much as you used to, as well as your torsemide diuretic. As we
gave you fluid and discontinued your torsemide, your sodium
level improved. Please restart your torsemide, but at a lower
dose. Take 20 mg every other day until you see your
cardiologist and primary care doctor. You should take your next
dose on Monday [**2173-8-9**].
Your kidney function also improved with IV fluids, and is now
normal."
693,"3
[**2173-8-3**] 05:13AM BLOOD Plt Ct-224
[**2173-8-3**] 12:25AM BLOOD Glucose-104* UreaN-58* Creat-3.0* Na-118*
K-4.6 Cl-85* HCO3-20* AnGap-18
[**2173-8-3**] 05:13AM BLOOD Glucose-91 UreaN-55* Creat-2.5* Na-119*
K-4.5 Cl-86* HCO3-24 AnGap-14
[**2173-8-3**] 07:00AM BLOOD Glucose-132* UreaN-58* Creat-2.8* Na-120*
K-4.0 Cl-85* HCO3-22 AnGap-17
[**2173-8-3**] 02:00PM BLOOD Glucose-131* UreaN-55* Creat-2.3* Na-124*
K-4.1 Cl-89* HCO3-23 AnGap-16
[**2173-8-3**] 07:53PM BLOOD Glucose-136* UreaN-52* Creat-2."
694,"Referred to ED due to hyponatremia/[**Last Name (un) **] found on labs.
On presentation to the emergency Department the patient reports
that he has had occasional exertional shortness of breath,
reports no symptoms at rest. He denies chest pain at any point.
He reports that due to neuropathy he hasn't felt any pain in his
leg ulcers but notices that they are significantly more
erythematous and draining more fluid. Additionally he reports
that he has not taken any of his A. fib medications for several
days.
In the ED his initial vitals were 98.4 130 90/52 18 100."
695,"0* Na-123*
K-5.6* Cl-91* HCO3-22 AnGap-16
[**2173-8-3**] 12:25AM BLOOD ALT-33 AST-35 LD(LDH)-333* AlkPhos-163*
TotBili-0.8
[**2173-8-3**] 05:13AM BLOOD ALT-29 AST-32 LD(LDH)-283* AlkPhos-146*
TotBili-0.9
[**2173-8-3**] 02:00PM BLOOD ALT-25 AST-25 LD(LDH)-265* AlkPhos-137*
TotBili-0.7
[**2173-8-3**] 12:25AM BLOOD proBNP-1588*
[**2173-8-3**] 02:00PM BLOOD proBNP-1666*
[**2173-8-3**] 12:25AM BLOOD ALT-33 AST-35 LD(LDH)-333* AlkPhos-163*
TotBili-0.8
[**2173-8-3**] 05:13AM BLOOD ALT-29 AST-32 LD(LDH)-283* AlkPhos-146*
TotBili-0."
696,"Metoprolol Succinate XL 50 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
6. Diltiazem Extended-Release 180 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Cephalexin 500 mg PO Q6H
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
2. Digoxin 0.125 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
5. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
6. Torsemide 20 mg PO EVERY OTHER DAY
please hold for SBP <100
RX *Demadex 20 mg 1 tablet(s) by mouth every other day Disp #*15
Tablet Refills:*0
7."
697,"DISCHARGE EXAM:
VS: 99.7 112/62 100 18 96% RA
Gen: awake, alert, resting comfortably in chair, NAD
HEENT: sclera anicteric, MMM
CV: RRR
Lungs: CTAB, no wheezes/rales/rhonchi
Abd: bowel sounds present, soft, NT, ND
Ext: bilateral pedal edema, venous stasis changes, legs wrapped
in ACE bandages
Pertinent Results:
IMAGING:
CXR [**2173-8-3**] -
FINDINGS AND IMPRESSION: The lungs are clear. No pleural
effusion, pulmonary
edema or pneumothorax is present. Mild cardiomegaly is
unchanged.
MICRO/PATH:
[**2173-8-3**] BLOOD CULTURES X 2 - no growth to date after 5 days.
ADMIT LABS:
[**2173-8-2**] 04:15PM BLOOD WBC-15."
698,"Department: VASCULAR SURGERY
When: MONDAY [**2173-9-13**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20205**], MD [**Telephone/Fax (1) 20206**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2173-8-18**] at 1:30 PM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] in the [**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Notes: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Completed by:[**2173-8-8**]"
699,"9
[**2173-8-3**] 02:00PM BLOOD ALT-25 AST-25 LD(LDH)-265* AlkPhos-137*
TotBili-0.7
[**2173-8-3**] 12:25AM BLOOD proBNP-1588*
[**2173-8-3**] 02:00PM BLOOD proBNP-1666*
[**2173-8-3**] 07:00AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.5*
[**2173-8-3**] 02:00PM BLOOD Albumin-3.2* Calcium-8.0* Phos-3.6 Mg-2.6
[**2173-8-3**] 07:53PM BLOOD Calcium-8.0* Phos-3.6 Mg-2.5
DISCHARGE LABS:
[**2173-8-8**] 06:10AM BLOOD WBC-10.0 RBC-2.65* Hgb-8.4* Hct-25."
700,"9
[**2173-8-2**] 04:15PM BLOOD Albumin-3.6 Calcium-9.1 Cholest-141
RELEVANT LABS:
[**2173-8-3**] 12:25AM BLOOD WBC-12.7* RBC-3.08* Hgb-10.0* Hct-28.8*
MCV-94 MCH-32.5* MCHC-34.7 RDW-15.8* Plt Ct-272
[**2173-8-3**] 05:13AM BLOOD WBC-10.7 RBC-2.99* Hgb-10.0* Hct-28.1*
MCV-94 MCH-33.3* MCHC-35.5* RDW-15.7* Plt Ct-224
[**2173-8-3**] 12:25AM BLOOD Neuts-82.3* Lymphs-10.2* Monos-6.3
Eos-0.9 Baso-0."
701,"1* RBC-3.29* Hgb-10.5* Hct-30.6*
MCV-93 MCH-31.9 MCHC-34.2 RDW-15.6* Plt Ct-289
[**2173-8-2**] 04:15PM BLOOD Neuts-93* Bands-0 Lymphs-5* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-8-2**] 04:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2173-8-2**] 12:30PM BLOOD PT-15.7* INR(PT)-1.5*
[**2173-8-2**] 04:15PM BLOOD UreaN-60* Creat-3.4*# Na-120* K-4.6
Cl-80* HCO3-24 AnGap-21*
[**2173-8-2**] 04:15PM BLOOD Glucose-102*
[**2173-8-2**] 04:15PM BLOOD ALT-33 AST-36 CK(CPK)-46* AlkPhos-162*
TotBili-0."
702,"-Should f/u with PCP regarding torsemide dosing which was
decreased to every other day. He should be evaluated for less
aggressive diuresis if has bump in creatinine.
-He should follow up with his PCP and cardiology regarding
titration of his metoprolol and diltiazem for rate control.
-Warfarin increased to 6mg at discharge as his INR was 1.4
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Month/Year (2) 581**].
1. Warfarin 2 mg PO DAILY16
2. Torsemide 50 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
4."
703,"Admission Date: [**2120-11-26**] Discharge Date: [**2120-12-3**]
Date of Birth: [**2090-10-22**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreatitis, ETOH overdose, severe acidosis, ETOH hepatitis,
substance abuse, UGIB
Major Surgical or Invasive Procedure:
[**2120-11-26**]: Intubation, CVL and axillary [**Last Name (un) **] monitor placment
[**2120-12-2**]: UGI:
History of Present Illness:
30F w active EtOH abuse and alcoholic hepatitis p/w altered
mental status and report of hematemesis. Of note, HPI is per
report/documentation as pt intubated/sedated at time of
consultation."
704,"Pt has hx EtOH abuse/binge drinking w multiple
EtOH related admits/ED visits for withdraw, escalating in
frequency in recent months. Presents today in setting of
reported 2.5 day EtOH abstention with altered mental status,
nausea and vomiting. Intubated on arrival for
confusion/hematemesis and inability to protect airway. Reported
episodes of hematemesis at this time though quality/quantity of
blood in emesis unclear. Started on pressors w massive
resuscitation for hypotension/ tachycardia. Laboratories
reflected dehydration, known EtOH hepatitis and lipase 100
suggestive of acute pancreatitis. CT scan showed severe
pancreatitis and GB with edematous wall filled w sludge vs
blood."
705,"Reported episodes of hematemesis
prior to arrival prompted Protonix and Octreotide drips. IN the
Ed patient was started on Levophed w 12L resuscitation for
hypotension/ tachycardia in the ED. She was admitted to the ICU
with suspected EtOH hepatitis, acute pancreatitis with lipase
100, severe acidosis with lactate 22, ph 6.9. Sh was
hypernatremic to 150 qith acute renal failure Cr 2.3. Liver
function tests significant for ALT: 230 AP: 180 Tbili: 1.2 Alb:
AST: 485 Serum ASA, Acetaminophen, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
CT scan showed severe pancreatitis and GB with edematous wall
filled w sludge vs blood."
706,"She had Elevated BPs 150-160's
overnight. Also started clonidine patch.
[**11-28**]: She was changed to Precedex gtt. IR attempt to make
Dobbhoff post pyloric unsuccessful so tube remained as NG.
[**11-29**] Extubated. A&Ox3. She was advanced to a regular diet.
Overnight pt with hallucinations (Visual/auditory) and she was
agitated requiring Valium. CIWA protocol was initiated. She was
also noted to have a drop in her platelets to the 69s, Her HSQ
was discontinued and HITT panel sent.
[**11-30**]: Patient was transferred to floor; psych and social work
c/s ordered to help facilitate substance abuse counseling."
707,"Patient's abdominal pain slowly resolving.
[**12-1**]: After psychiatry and SW recommended 30 day substance
abuse rehab upon dc. GI consult recomended inpatient endoscopy
to evaluate the source of patient's reported UGIB. Recheck of
platelets showed recovery to 125 without intervention.
[**12-2**]: Upper Endoscopy. HITT pending. In the am pt complained of
mild SOB prompting a CXR.
[**12-3**]: CXR was negative for PNA. EGD demonstrated erythema in
the stomach body compatible with gastritis and mucosa suggestive
of Barrett's esophagus, biopsy were taken. Patient's diet was
advanced to regular and she was discharge home in stable
condition."
708,"Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. EtOH induced pancreatitis
2. Alcohol abuse
3. Alcohol withdrawal
4. Metabolic acidosis
5. Upper gastrointestinal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
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."
709,"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 is 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.
Followup Instructions:
Please call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2998**] if you have any
questions.
.
Please follow up with [**Doctor Last Name 634**], PA (PCP) in 1 week after
discharge
.
Call [**Telephone/Fax (1) 13545**] in one week for the biopsy (EGD) results
Completed by:[**2120-12-3**]"
710,"0
[**12-2**]:
7.4>----<125
36.1
142 101 5 aGap=11
-------------<118
3.3 33 1.0
Ca: 9.2 Mg: 1.3 P: 2.0
ALT: 51 AP: 78 Tbili: 0.8
AST: 62 LDH: 430
[**Doctor First Name **]: 146 Lip: 206
IMAGING:
CT A/P [**11-26**]: Noncontrast CT due to elevated creatinine, limiting
assessment. Peripancreatic inflammation, c/w pancreatitis.
Cannot assess parenchymal enhancement or vascular complications.
But no obvious large pseudocyst or abscess. Diffusely fatty
liver. Gallbladder with diffuse mural thickening and distended
with hyperdense material. No free air. Free fluid in pelvis.
[**12-3**] CXR:
As compared to the previous radiograph, all monitoring and
support
devices have been removed."
711,"Pertinent Results:
Labs at time of admission:
15.7>-14.8/48.1-<393
N:86.4 L:11.2 M:1.2 E:0.7 Bas:0.5
PT: 11.0 PTT: 31.8 INR: 1.0
150 91 13
-------------< 93 AGap=58
4.7 6 2.8 ∆
ALT: 230 AP: 180 Tbili: 1.2
AST: 485 Lip: 100
Serum EtOH 255
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
8AM:
pH 6.93 pCO2 33 pO2 124 HCO3 8 BaseXS -26
Type:Art; Intubated; FiO2%:50; Rate:/16; TV:500;
Mode:Assist/Control
Lactate:12."
712,"0 P: 134 BP: 110/57 RR: 20 O2sat: 100
CMV 0.5; 20x500; 5
GEN: WD, WN F intubated/sedated
HEENT: NCAT, PERRLA, anicteric
CV: RRR; tachy
PULM: CTA B/L w no W/R/R, intubated
ABD: firmly distended, unable to assess tenderness [**1-24**] sedation
EXT: WWP, no CCE, 2+ B/L radial/DP/PT
NEURO: moves all 4 extremities; sedated
On Discharge:
VS:
GEN; Pleasant with NAD
CV: RRR
Lungs: Diminished breath sounds bilateraly on bases
Abd: NT/ND, soft
Extr: Warm, no c/c/e
Neuro: AAO x 3, Cranial nerves II-XII grossly intact"
713,"Her PCP was [**Name (NI) 653**] prior discharge, and message
was left explaining patient's needs for prompt follow up with
PCP.
Medications on Admission:
[**Last Name (un) 1724**]: folic acid 1', thiamine 100', fluoxetine 10', MVI,
naltrexone 50'
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. naltrexone 50 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks: Please do not drink alcohol while taking this
medication."
714,"There are persistent opacities at
both lung bases, right more than left, that are exaggerated by
relatively [**Name2 (NI) 15410**] breast tissue.
The changes could reflect minimal fluid overload or layering
pleural
effusions. No circumscribed focal parenchymal opacity suggesting
pneumonia.
No cardiomegaly. No lung nodules or masses.
[**12-3**] EGD:
Impression:
1. Erythema in the stomach body compatible with gastritis
(biopsy)
2. Mucosa suggestive of Barrett's esophagus (biopsy)
Brief Hospital Course:
[**11-26**]- Admitted to the TSICU after a reported 2.5 day EtOH
abstention ( ETOH level 255) with altered mental status, nausea
and vomiting. Intubated on arrival for confusion/hematemesis and
inability to protect airway."
715,"In the ICU an Axillary line and [**Last Name (un) 18821**]
monitor were placed, as well as a central line in the R IJ. A
Bicarb drip for PH 6.9 that was later stopped in the pm.
Thiamine and folate where repleted. Toxicology , general
surgery and Gi were consulted. Bladder pressure were checked for
evidence of compartment syndrome. With aggressive management she
improved overnight. Cardiac ECHO showed no evidence of
infarction.
[**11-27**]: By the am her ventilator was weaned to [**4-25**]. Fentanyl dc'd
and she was started on 3mg IV Ativan for intermittent agitation
and question of withdrawal."
716,"Surgery consult obtained for pancreatitis, UGIB.
Past Medical History:
EtOH abuse with several inpatient detox stays
Social History:
The patient is originally from [**Location (un) 11177**], [**State 4565**]. She is
currently on dental student on a leave of absence. She reports a
history of binge drinking, typically [**3-26**] ""strong"" drinks at a
time. She reports a history of multiple inpateint detox stays
without success. She denies tobacco or IVDU
Family History:
Maternal grandfather with alcoholism
Maternal uncle with drug problem
Paternal aunt with alcoholism
Physical Exam:
At time of admission:
P/E:
Levo: 0.12, Protonix: 8; Versed: 18
VS: T: 97."
717,"Admission Date: [**2132-2-14**] Discharge Date: [**2132-2-14**]
Date of Birth: [**2073-11-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
facial and laryngeal swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 58 year-old male with a history of hyperlipidemia who
presents with laryngeal edema after endoscopy. The patient
reports that throughtout his life he would have episodes of
swelling during viral or other illness. These would include
swelling of the lip, throat, hand, arm or leg. He was able to
take benadryl and his symptoms would resolved."
718,".
Past Medical History:
Hyperlipidemia
GERD/ Ulcers
Social History:
Lives in [**Location 620**] with wife and son.
[**Name (NI) 1139**]: neg
EtOH: socially, ~2/week
Denies drugs
Family History:
Brother: recurrent angioedema
Strong h/o autoimmune disorders
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, slight swelling of the lower lip, tongue is
mildy enlarged; able to clearly visualize the airway. Improved
vocal hoarseness
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, improved expiratory wheeze, no R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time."
719,"Patient received a total of epi-pen x2, IV
methylprednisone 125mg x2, benadryl x3, famotidine with
improvement in breathing and near complete resolution of
swelling. Patient discharged on 5 day prednisone taper as well
as Pepcid [**Hospital1 **] for 5 days for further treatment of edema as well
as instruction to discontinue Augmentin. Prescribed epi-pen x2
in case of emergency. C1 inhibitor level, complement levels,
ESR, CRP as well as tryptase levels were drawn. ESR mildly
elevated, CRP wnl. Remaining labs pending at time of discharge.
Patient will follow-up with PCP and from there be referred to an
allergist for further work-up of what appears to be recurrent
angioedema."
720,".
# Transaminitis. On admission ALT/AST found to be mildly
elevated at ; unknown baseline. Patient without h/o liver
disease of heavy EtOH use. Patient has been on current statin
therapy at current dose for years. Patient does endorse recent
URI therefore strong possibility mild abnl is secondary to viral
illness.
Will follow as outpatient.
#. Hyperlipidemia: Continued home statin
.
#. Dispo: Patient discharged to from from the ICU after near
complete resolution of symptoms. He will plan to follow-up with
PCP [**Last Name (NamePattern4) **] 1 week.
Medications on Admission:
MVI
Prilosec
Pravastatin
ASA 81
MVI
Calcium supplementation
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day)."
721,"Discharge Diagnosis:
Primary:
Laryngeal edema
.
Secondary
Gastric Ulcers
Discharge Condition:
Mental status: clear and coherent
Ambulates without assistance
Discharge Instructions:
Dear Mr [**Known lastname 49965**] it was a pleasure taking care of you.
.
You were admitted to [**Hospital1 18**] for treatment and evaluation of your
upper airway and facial swelling after endoscopy. You received
IV steroids as well as benadryl and pepcid. You facial swelling
lessened, your breathing and swallowing improved. Tests were
sent off to determine a cause of your recurrent swelling. These
were pending at time of discharge. It will be important to
follow-up these results with both your primary care physician as
well as an allergist."
722,".
#. Laryngeal Edema: The patient with a history of prior episodes
of swelling which typically occur in setting of viral illness.
[**Name (NI) **] brother also with similar episodes raising the
possibility to of an hereditary angioedema. This last episode,
incurred after endoscopy, has been the most severe and caused
significant laryngeal edema and airway compromise. It is likely
that the endoscopy caused irritation that lead to the edema
though it has been reported that oral-pharyngeal
trauma/manipulation can precipitate episodes of hereditay
angioedema, such as C1 esterase inhibitor. Also question if
recent medication, such as Augmentin, may have spurred allergic
reaction."
723,".
CHANGES TO YOUR MEDICATIONS
- Stop taking Augmentin as it is unclear if this medication
contributed to your episode of swelling
To treat your swelling start taking:
- Prednisone - this medication will be administered on a taper
for 5 days: 60mg day one, 50mg day 2, 40mg day 3, 30mg day 4,
20mg day 5
- Pepcid 20mg twice daily for 5 days.
- Epi-pen prescription to be used as needed
.
Again it was a pleasure taking care of you. Please do not
hesitate to contact with any questions or concerns
Followup Instructions:
Please follow-up with your PCP in next week.
Your PCP will arrange allergy follow-up for you.
Completed by:[**2132-2-14**]"
724,"CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2132-2-14**] 02:14AM WBC-8.0 RBC-4.46* HGB-13.6* HCT-38.9* MCV-87
MCH-30.5 MCHC-34.9 RDW-13.7
[**2132-2-14**] 02:14AM PLT COUNT-255
[**2132-2-14**] 02:14AM NEUTS-91.4* LYMPHS-7.4* MONOS-0.7* EOS-0.2
BASOS-0.3
[**2132-2-14**] 02:14AM GLUCOSE-153* UREA N-17 CREAT-1."
725,"Disp:*10 Tablet(s)* Refills:*0*
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO daily ().
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) ML
Intramuscular PRN (as needed) as needed for angiedema.
Disp:*2 ML(s)* Refills:*0*
5. Prilosec Oral
6. prednisone 10 mg Tablet Sig: per taper Tablet PO once a day
for 5 days: Taper:
Day 1: 60mg; Day2: 50mg; Day 3: 40mg, Day 4: 30mg; Day 5: 20mg.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home"
726,"He has never
been hospitalized or intubated for these episodes.
Interestingly, the patients twin brother also has similar
symptoms. The patient was in his usual state of health when he
went for an outpatient endoscopy to follow-up prior ulcers. He
states that after the procedure he noticed his eyes swelling and
on the car ride home he could feel his neck and throat swelling.
They presented to the [**Location (un) 620**] ED in respiratory distress and
was having difficulty handling his secreations. He was given
125mg solumedrol, 50mg benadryl, pepcid 20mg, and epi-pen x2.
He was also evaluated by ENT who saw significant laryngeal
edema."
727,"1 SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14
[**2132-2-14**] 02:14AM ALT(SGPT)-135* AST(SGOT)-55* LD(LDH)-160 ALK
PHOS-89 TOT BILI-0.4
[**2132-2-14**] 02:14AM ALBUMIN-4.7
[**2132-2-14**] 02:14AM CRP-3.0
[**2132-2-14**] 02:14AM C3-172 C4-48*
[**2132-2-14**] 02:14AM SED RATE-28*
ALT: 135 AP: 89 Tbili: 0.4 Alb: 4.7
C3: 172
C4: 48
[**2132-2-14**] C1 ESTERASE INHIBITOR, FUNCTIONAL ASSAY: pending
[**2132-2-14**] TRYPTASE: pending
Brief Hospital Course:
This is a 58 year-old male with a history of recurrent
angioedema who presents with facial swelling."
728,"His symptoms improved after the 2 epi-pens, but was
transferred to [**Hospital1 18**] for further management.
.
In the ED, 96.8 159/107 95 20 94% 2L. He was given 1L NS and
transferred to the ICU for closer monitoring.
.
On arrival to the ICU the patient continues to have hoarse
voice, but reports that his breathing is more comfortable.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes."
729,"Admission Date: [**2176-11-26**] Discharge Date: [**2176-12-9**]
Date of Birth: [**2146-7-19**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
traumatic left ankle/foot amputation and degloving below the
knee
Major Surgical or Invasive Procedure:
1. left above the knee amputation
2. irrigation and debridement of left lower extremity wound.
3. muscle flap advancement for closure of abdominal wound.
4. full-thickness skin graft measuring 40 x 9 cm.
5. split-thickness skin graft measuring 20 x 8 cm.
6. Local tissue rearrangement of proximally based
fasciocutaneous flap."
730,"7. irrigation and debridement of left lower extremity wound
and nonviable tissues.
8. split-thickness skin graft coverage of wound measuring
26 x 19 cm.
History of Present Illness:
30yo male who reports riding a backhoe at work and was hit by a
car at a high speed while working on the highway. Per patient
he may have gotten out of the backhoe and been walking when he
was hit, but the details are unclear. [**Name2 (NI) **] was found to have a L
ankle amputation with degloving distal to the knee. His tissue
was recovered at the seen and was bagged and iced."
731,"He was
transported by air to [**Hospital1 18**]. Patient complaining of back pain
and left lower extremity pain.
Past Medical History:
3 prior back surgeries
chronic pain
Social History:
works in construction, + tobacco use, occasional alcohol use,
denies other drug use.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM [**2176-11-26**]:
99.0 118 125/76 24 100% NRB --> 2L NC
Gen: Pt. lying on stretcher, in acute pain
HEENT: PERRL
CV: RRR
PULM: CTAB
ABD: protuberant, soft NT/ND, pelvis is stable on exam by
trauma
team, normal rectal exam by trauma team.
EXT: LLE with ankle amputation and degloving below the knee with
large laceration proximal to the knee joint."
732,"Cephalexin
was discontinued on POD#13. The patient's temperature was
closely watched for signs of infection.
.
Musculoskeletal: Patient was noted to have a left non-displaced
ulnar styloid fracture on x-ray and was placed in an ulnar
gutter splint.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
At the time of discharge on POD#14, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Methadone 80 mg QD"
733,"Discharge Medications:
1. Wheelchair Device Sig: One (1) unit Miscellaneous for
patient mobility: wheelchair with elevating leg rests.
Disp:*1 wheelchair* Refills:*0*
2. commode Sig: One (1) unit for patient use.
Disp:*1 unit* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation."
734,"left non-displaced ulnar styloid fracture
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Activity: non-weight beaing left lower extremity and non-weight
bearing left wrist
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you."
735,"If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
FOLLOW-UP APPOINTMENT:
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
.
You may page Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by going through the Page
Operator at ([**Telephone/Fax (1) 83886**], with any questions or concerns.
Followup Instructions:
please call [**Telephone/Fax (1) 5343**] to schedule a follow-up appointment
with plastic surgery (Dr [**First Name (STitle) **] as well as follow-up x-ray for
your left wrist
please call vascular surgery (Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 2625**]
as needed
Completed by:[**2176-12-9**]"
736,"3* Hct-27.1*
MCV-85 MCH-29.0 MCHC-34.3 RDW-15.0 Plt Ct-261
[**2176-11-30**] 08:30AM BLOOD Neuts-74.2* Lymphs-20.1 Monos-4.6 Eos-0.9
Baso-0.2
[**2176-12-4**] 07:15AM BLOOD WBC-15.0* RBC-3.46* Hgb-9.7* Hct-29.9*
MCV-87 MCH-28.0 MCHC-32.4 RDW-14.5 Plt Ct-424#
.
COAGS
[**2176-11-26**] 11:45AM BLOOD PT-12.5 PTT-21.6* INR(PT)-1.1
[**2176-11-29**] 06:00AM BLOOD Plt Ct-174
[**2176-11-30**] 08:30AM BLOOD Plt Ct-261
[**2176-12-4**] 07:15AM BLOOD Plt Ct-424#
."
737,"The patient was initially
admitted to the Trauma service on [**2176-11-26**] and then transferred
to the plastic surgery service on [**2176-11-28**]. On [**2176-11-26**], he
underwent an above the left knee amputation by the Vascular
service and then had a full-thickness skin graft measuring 40 x
9 cm, a Split-thickness skin graft measuring 20 x 8 cm, and
local tissue rearrangement of proximally based fasciocutaneous
flap by Plastic Surgery. A wound vac was applied to skin graft
sites per protocol. The patient tolerated the procedure well
and was transferred to the PACU for post-operative recovery and
then to the Trauma SICU for close monitoring."
738,"Question possible underlying trauma to
the left
renal artery, however, the kidneys enhance symmetrically with
normal
excretion. Followup is recommended to evaluate renal artery for
trauamtic
dissection after acute presentation resolves.
.
X-ray left wrist ([**12-8**])
IMPRESSION:
lucency and cortical distruption at the base of ulnar styloid
process likely representing non-displaced ulnar styloid
fracture.
.
BLOOD WORK:
CBC
[**2176-11-26**] 11:45AM BLOOD WBC-37.0* RBC-4.60 Hgb-13.4* Hct-38.9*
MCV-85 MCH-29.2 MCHC-34.5 RDW-13.5 Plt Ct-467*
[**2176-11-26**] 01:58PM BLOOD WBC-27.4* RBC-3."
739,"Most of the soft
tissue below the knee is gone leaving only tibia. Painful
sensation of the proximal thigh. Pulses intact on right lower
extremity, sensation intact right lower extremity. Bleeding
controlled after tourniquet released.
Pertinent Results:
RADIOLOGY [**2176-11-26**]:
.
CT SPINE
IMPRESSION: No evidence of fractures or abnormal alignment at
the cervical
spine.
.
CT HEAD
IMPRESSION:
1. No acute intracranial traumatic injury.
2. Small linear nondisplaced fracture at the right zygomatic
bone, of
indeterminate age. Clinical correlation is indicated.
.
CT TORSO
IMPRESSION:
Mild fat stranding in the left renal hilum, which may indicate
hematoma,
related to acute injury."
740,"Disp:*500 ML(s)* Refills:*4*
7. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO Q6H (every 6 hours) as needed for pain.
Disp:*120 Tablet, Soluble(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
9. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
1. left lower extremity trauma with traumatic amputation of left
ankle/foot and below the knee degloving
2."
741,"These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
Limit strenuous activity for 6 weeks.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing.
.
WOUND CARE:
daily dressing changes with xeroform and kerlix to amputation
site
keep skin graft donor skin clean and dry.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery."
742,"95* Hgb-11.7* Hct-32.4*
MCV-82 MCH-29.7 MCHC-36.1* RDW-13.4 Plt Ct-356
[**2176-11-27**] 02:20AM BLOOD WBC-14.9* RBC-3.10* Hgb-9.1* Hct-25.9*
MCV-83 MCH-29.3 MCHC-35.1* RDW-14.3 Plt Ct-283
[**2176-11-27**] 03:35PM BLOOD WBC-13.0* RBC-2.56* Hgb-7.5* Hct-21.5*
MCV-84 MCH-29.3 MCHC-34.9 RDW-14.4 Plt Ct-209
[**2176-11-28**] 02:17AM BLOOD WBC-12.3* RBC-2.24* Hgb-6.4* Hct-18."
743,"APS also started the patient PO
methadone. Patient's pain escalated on [**2176-11-27**] dilaudid PCA was
increased and APS added neurontin and tizanidine to his pain
regimen. On [**2176-11-28**], APS discontinued the tizanidine, and
decreased neurontin and dilaudid dosages for episodes of
increased sedation. Bupivicaine catheters infusions and
Dilaudid PCA were discontinued on [**2176-11-30**]. The patient was
started on PO Dilaudid and his Neurontin was increased to 600 mg
TID. Patient maintained on Methadone 40 mg Q6h. This regimen
was very effective until patient returned to OR on [**2176-12-2**] for
skin grafting to left stump sites."
744,".
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation."
745,"Skin graft donor sites were
very painful for patient and he felt they were 'on fire'. A
dilaudid PCA was re-started to provide relief in the setting of
acute pain. This PCA was discontinued on [**2176-12-8**] per Chronic
Pain Service recommendations and he was given a home analgesia
regimen prior to discharge consisting of oral dilaudid,
methadone, and neurontin.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake."
746,"4*
MCV-82 MCH-28.5 MCHC-34.8 RDW-13.6 Plt Ct-187
[**2176-11-28**] 07:22AM BLOOD WBC-12.2* RBC-2.59* Hgb-7.6* Hct-21.2*
MCV-82 MCH-29.2 MCHC-35.6* RDW-13.7 Plt Ct-182
[**2176-11-28**] 12:45PM BLOOD Hct-20.8*
[**2176-11-29**] 06:00AM BLOOD WBC-13.2* RBC-3.08* Hgb-9.0* Hct-25.8*
MCV-84 MCH-29.3 MCHC-34.9 RDW-14.5 Plt Ct-174
[**2176-11-30**] 08:30AM BLOOD WBC-11.5* RBC-3.20* Hgb-9."
747,"CHEMISTRIES
[**2176-11-26**] 11:45AM BLOOD UreaN-14 Creat-1.1
[**2176-11-26**] 01:58PM BLOOD Glucose-128* UreaN-13 Creat-0.8 Na-140
K-4.0 Cl-109* HCO3-21* AnGap-14
[**2176-11-26**] 01:58PM BLOOD Calcium-8.1* Phos-2.4* Mg-1.7
[**2176-11-27**] 02:20AM BLOOD Glucose-142* UreaN-11 Creat-0.7 Na-137
K-4.7 Cl-107 HCO3-22 AnGap-13
[**2176-11-27**] 02:20AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.6
[**2176-11-28**] 02:17AM BLOOD Glucose-111* UreaN-11 Creat-0."
748,"4# Mg-2.3
.
BLOOD GASES
[**2176-11-26**] 06:09PM BLOOD Type-ART Temp-37.6 pO2-197* pCO2-33*
pH-7.41 calTCO2-22 Base XS--2
[**2176-11-28**] 02:44AM BLOOD Type-ART pO2-96 pCO2-37 pH-7.48*
calTCO2-28 Base XS-3
Brief Hospital Course:
The patient was transported to [**Hospital1 18**] via [**Location (un) 7622**]. In the
Emergency Room he was thoroughly evaluated by the Trauma team,
Vascular surgery, and Plastic surgery. He underwent CT imaging
of the head, neck, and torso. After review of these films
patient was cleared to go to the OR."
749,"8 Na-132*
K-4.3 Cl-101 HCO3-26 AnGap-9
[**2176-11-28**] 02:17AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.0
[**2176-11-29**] 06:00AM BLOOD Glucose-83 UreaN-9 Creat-0.7 Na-141 K-4.0
Cl-103 HCO3-29 AnGap-13
[**2176-11-29**] 06:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.3
[**2176-12-4**] 07:15AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-136
K-4.5 Cl-99 HCO3-30 AnGap-12
[**2176-12-4**] 07:15AM BLOOD Calcium-9.1 Phos-4."
750,"On POD#2, the
patient was transferred out of the Trauma SICU and onto the
floor on telemetry monitoring. On [**2176-12-2**], patient returned to
OR for irrigation and debridement of left lower extremity wound
and nonviable tissues. a split-thickness skin graft was taken
from left lower extremity upper thigh area to cover stump wound
measuring 26 x 19 cm.
.
Neuro: In the ED, pain was controlled with IV Fentanyl, Dilaudid
and Methadone. Post-operatively, the patient was evaluated by
the Acute Pain Service (APS) and started on Bupivacaine sciatic
catheter infusion and Bupivacaine femoral catheter infusion as
well as a dilaudid PCA."
751,"* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
This information provided is designed as a guideline to assist
you in a speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions."
752,"His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley catheter was removed on
POD#2. Intake and output were closely monitored. CT Torso on
[**2176-11-26**] showed mild fat stranding in the left renal hilum,
indicating question of hematoma and question of trauma to left
renal artery. Patient continued with good urine output, stable
Creatinine, and normal blood pressures so Vascular felt there
was no need for further intervention.
.
ID: Patient was given IV Gentamcin and Cefazolin upon arrival to
the ED. Post-operatively, the patient was started on IV
cefazolin, then switched to PO cephalexin on POD#2."
753,"Dial 911 if you have any medical emergency.
.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting.
.
No driving until cleared by your surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
1. Redness in or drainage from your leg wound(s).
2. Watch for signs and symptoms of infection."
754,"8 w/o tx so temp may have been
spurious.
stable. Given 1 unit PRBCs for Hct 18.
Post operative day:
POD#2 - left AKA
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Gentamicin - [**2176-11-26**] 02:12 PM
Cefazolin - [**2176-11-28**] 04:00 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2176-11-27**] 08:50 AM
Heparin Sodium (Prophylaxis) - [**2176-11-28**] 06:00 AM
Other medications:
Flowsheet Data as of [**2176-11-28**] 06:29 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**78**] a.m.
Tmax: 39
C (102.2
T current: 37
C (98."
755,"5%), neurontin 600 TID, tizanidine. f/u pain recs, may
consider toradol.
Cardiovascular: Tachycardia decreased with pain control, HTN w/family
visits and pain
Pulmonary: Extubated, Stable, needs IS
Gastrointestinal / Abdomen: Regular diet
Nutrition: Regular diet
Renal: Adequate UO
Hematology: Trending Hct 38.9->32.4->26->21.5->18.4, 1 unit rbcs given
([**11-27**]) with bump to 21. Will follow serial Hcts until stable, no e/o
active bleeding at this time.
Endocrine: RISS, adequate control.
Infectious Disease: Cefazolin, VAC needs to be changed by plastics,
then plan for tx to floor
Lines / Tubes / Drains: PIV X 2, fem/sciatic catheters, VAC
Wounds: Wound vacuum
Imaging: None
Fluids: KVO
Consults: Trauma surgery, Plastics
Billing Diagnosis:
ICU Care
Nutrition:
Glycemic Control:
Lines:
16 Gauge - [**2176-11-26**] 01:26 PM
Arterial Line - [**2176-11-26**] 09:30 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: n/a
Comments:
Communication: Comments:
Code status: Full code
Disposition: Transfer to floor later this AM if Hct stable
Total time spent: 31 min"
756,"4 g/dL
111 mg/dL
0.8 mg/dL
26 mEq/L
4.3 mEq/L
11 mg/dL
101 mEq/L
132 mEq/L
18.4 %
12.3 K/uL
[image002.jpg]
[**2176-11-26**] 01:58 PM
[**2176-11-26**] 06:09 PM
[**2176-11-27**] 02:20 AM
[**2176-11-27**] 03:35 PM
[**2176-11-28**] 02:17 AM
[**2176-11-28**] 02:44 AM
WBC
27.4
14.9
13.0
12.3
Hct
32.4
28
25.9
21.5
18.4
Plt
356
283
209
187
Creatinine
0.8
0.7
0."
757,"SICU
HPI:
33M with traumatic left foot amputation (after being thrown off a
backhoe when it struck a car), for Left AKA with skin graft closure.
([**11-26**])
Chief complaint:
traumatic left leg amputation
PMHx:
PMH: Chronic back pain
PSH: Back surgery X 3
Current medications:
1. Acetaminophen
2. Bupivacaine 0.25%
3. Calcium Carbonate
4. CefazoLIN
5. Famotidine
6. Gabapentin
7. HYDROmorphone (Dilaudid)
8. Heparin
9. Magnesium Oxide
10. Methadone
11. Multivitamins
12. Phosphorus
13. Senna
14. Tizanidine
24 Hour Events:
FEVER - 102.2
F - [**2176-11-28**] 12:00 AM
not cultured, when rechecked
1 hour later w/o intervention was 100."
758,"6
HR: 86 (86 - 116) bpm
BP: 127/71(84) {127/62(78) - 131/71(84)} mmHg
RR: 14 (13 - 48) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 67 Inch
Total In:
2,856 mL
1,612 mL
PO:
1,160 mL
930 mL
Tube feeding:
IV Fluid:
1,696 mL
332 mL
Blood products:
350 mL
Total out:
2,650 mL
1,225 mL
Urine:
2,570 mL
1,225 mL
NG:
Stool:
Drains:
80 mL
Balance:
206 mL
387 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 100%
ABG: 7.48/37/95.[**Numeric Identifier 253**]/26/3
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Skin: Wound vac
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
187 K/uL
6."
759,"8
TCO2
22
28
Glucose
128
129
142
111
Other labs: PT / PTT / INR:13.1/22.7/1.1, Lactic Acid:0.9 mmol/L,
Ca:7.8 mg/dL, Mg:2.0 mg/dL, PO4:2.4 mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), TRAUMA, S/P accident
Assessment and Plan: 33M with traumatic left foot amputation (after
being thrown off a backhoe when it struck a car). Left AKA with skin
graft closure. ([**11-26**])
Neurologic: C-spine cleared by Trauma.
Neuro checks Q shift.
Pain: Dilaudid PCA @ 0.5; methadone 80TID, infusion catheters X 2 with
bupivacaine (2."
760,"TSICU
HPI:
33M with traumatic left foot amputation (after being thrown off a
backhoe when it struck a car). Tourniquet placed distal thigh above
knee, C-collar, ? LOC. Taken to ED after arrival to [**Hospital1 5**] for Left AKA
with skin graft closure. ([**11-26**])
Chief complaint:
Left foot amputation with degloving injury
PMHx:
PMH: Chronic back pain
PSH: Back surgery X 3
[**Last Name (un) **]: Methadone 80' qAM 20-40 qPM
Current medications:
1. 1000 mL LR
Continuous at 120 ml/hr Order date: [**11-27**] @ 0023 8. Heparin 5000 UNIT
SC TID Order date: [**11-26**] @ 2211
2."
761,"Bupivacaine 0.1% 8 mL/hr PERIPHNERVE INFUSION
For SCIATIC catheter. Infusion to be managed by acute pain service.
Order date: [**11-26**] @ 2156 9. Lorazepam 1 mg PO/NG ONCE Duration: 1 Doses
Order date: [**11-27**] @ 0055
3. Bupivacaine 0.1% 11 mL/hr PERIPHNERVE INFUSION
For FEMORAL catheter. Infusion to be managed by acute pain service.
Order date: [**11-26**] @ 2156 10. Magnesium Sulfate 2 gm IV ONCE Duration: 1
Doses Order date: [**11-27**] @ 0328
4. CefazoLIN 2 g IV Q8H Order date: [**11-26**] @ 2148 11. Methadone 80 mg
PO/NG QAM Order date: [**11-27**] @ 0400
5."
762,"m.
Tmax: 37.6
C (99.7
T current: 37.4
C (99.3
HR: 105 (93 - 119) bpm
BP: 135/72(86) {125/69(84) - 135/77(90)} mmHg
RR: 24 (16 - 27) insp/min
SPO2: 99%
Heart rhythm: ST (Sinus Tachycardia)
Height: 67 Inch
Total In:
6,496 mL
1,382 mL
PO:
1,440 mL
480 mL
Tube feeding:
IV Fluid:
5,056 mL
902 mL
Blood products:
Total out:
2,515 mL
805 mL
Urine:
745 mL
805 mL
NG:
Stool:
Drains:
Balance:
3,981 mL
577 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 99%
ABG: 7."
763,"7 mg/dL
22 mEq/L
4.7 mEq/L
11 mg/dL
107 mEq/L
137 mEq/L
25.9 %
14.9 K/uL
[image002.jpg]
[**2176-11-26**] 01:58 PM
[**2176-11-26**] 06:09 PM
[**2176-11-27**] 02:20 AM
WBC
27.4
14.9
Hct
32.4
28
25.9
Plt
356
283
Creatinine
0.8
0.7
TCO2
22
Glucose
128
129
142
Other labs: PT / PTT / INR:13.1/22.7/1.1, Lactic Acid:3.6 mmol/L,
Ca:8.2 mg/dL, Mg:1.6 mg/dL, PO4:3.8 mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), TRAUMA, S/P
33M with chronic back pain, methadone user s/p left traumatic foot
amputation with significant degloving injury to knee s/p Left AKA with
skin graft closure."
764,"Diazepam 5 mg PO/NG ONCE Duration: 1 Doses Order date: [**11-27**] @ 0711
12. Methadone 40 mg PO/NG QPM Order date: [**11-27**] @ 0400
6. Famotidine 20 mg PO/NG [**Hospital1 **] Order date: [**11-26**] @ 2148 13.
Multivitamins 1 TAB PO/NG DAILY Order date: [**11-27**] @ 0023
7. HYDROmorphone (Dilaudid) 1 mg IVPCA Lockout Interval: 6 minutes
Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 10 mg(s) Order date: [**11-27**] @
0400 14. Senna 1 TAB PO BID:PRN Constipation Order date: [**11-26**] @ 2148
24 Hour Events:
Significant pain after surgery. APS called, Methadone PO given and
Dilaudid PCA increased."
765,"Pt currently comfortable. Catheters still
infusing bupivacaine. AKA stump had areas of ecchymosis, suction
turned down to 90-100. Back cleared by trauma surgery.
Post operative day:
POD#1 - left AKA
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Gentamicin - [**2176-11-26**] 02:12 PM
Cefazolin - [**2176-11-27**] 04:30 AM
Infusions:
Other ICU medications:
Hydromorphone (Dilaudid) - [**2176-11-26**] 01:40 PM
Fentanyl - [**2176-11-26**] 02:35 PM
Famotidine (Pepcid) - [**2176-11-26**] 10:00 PM
Methadone Hydrochloride - [**2176-11-26**] 11:00 PM
Lorazepam (Ativan) - [**2176-11-27**] 02:15 AM
Heparin Sodium (Prophylaxis) - [**2176-11-27**] 06:00 AM
Other medications:
Flowsheet Data as of [**2176-11-27**] 07:22 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**78**] a."
766,"41/33/197/22/-2
PaO2 / FiO2: 197
Physical Examination
General Appearance: No acute distress, pain well controlled
HEENT: PERRL, Right scalp hematoma-stable
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), AKA stump site
c/d/I, some areas of eechymosis, VAC dressings in place on wall suction
Right Extremities: (Edema: Absent), (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities, [**Location (un) 408**] J collar on.
Labs / Radiology
283 K/uL
9.1 g/dL
142 mg/dL
0."
767,"PULM: Extubated, Stable, needs IS.
GI: sips
adat
RENAL: Foley, KVO fluids
HEME: Trending Hct 38.9->32.4->26, T/C X 2 units
MSK: Wound closed with native skin flap, PRS following. VAC in place.
ENDO: SSI, adequate control
ID: Cefazolin, VAC to wall suction @ 90-100, PRS will manage wound vac.
TLD: Foley, PIV X 2, infusion catheter X 2, VAC
IVF: KVO
CONSULTS: Vascular, Ortho, Plastics, Social Work c/s
BILLING DIAGNOSIS:
ICU Care
Nutrition: ADAT
Glycemic Control: Regular insulin sliding scale
Lines:
16 Gauge - [**2176-11-26**] 01:26 PM
18 Gauge - [**2176-11-26**] 01:26 PM
Arterial Line - [**2176-11-26**] 09:30 PM
Prophylaxis:
DVT: Boot x 1, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: n/a
Comments:
Communication: Comments:
Code status: Full code
Disposition: Transfer to floor, on Plastics service
Total time spent: 33 min"
768,"NEURO: [**Location (un) 408**] J collar on, no obvious bony injury on CT scan, will
assess for ligamentous injury after OR, until then keep [**Location (un) 408**] J on.
Trauma surgery to clear C-spine now that pain is better controlled.
Back cleared by trauma surgery. Neuro checks Q shift
Pain: Dilaudid PCA @ 1.0; methadone 80 mg QAM and 40 QPM per CPS,
infusion catheters X 2 with bupivacaine, f/u pain recs this AM, will
see if toradol ok as long as hct is stable. Increase Methadone to 100
[**Hospital1 **], add Neurontin and Flexeril (appreciate pain recs).
CVS: Tachycardia decreased with pain control."
769,"jpg]
Assessment and Plan
NEURO: [**Location (un) 408**] J collar on, no obvious bony injury on CT scan, will
assess for ligamentous injury after OR, until then keep [**Location (un) 408**] J on.
Pain: Fent PRN, may need dilaudid as well
CVS: Tachycardic [**1-29**] pain and hypovolemia
pain control, LR + banana
bag
PULM: Stable
GI: NPO
RENAL: Foley, LR @ 120, Banana Bag X 1
HEME: Trending Hct
ENDO: SSI
ID: Cefazolin/Gent
Dispo: To OR for left AKA
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
16 Gauge - [**2176-11-26**] 01:26 PM
18 Gauge - [**2176-11-26**] 01:26 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: H2 blocker
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
Total time spent:"
770,"7
C (96.2
Tcurrent: 35.7
C (96.2
HR: 112 (112 - 112) bpm
BP: 125/69(84) {125/69(84) - 125/69(84)} mmHg
RR: 20 (20 - 26) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
1,016 mL
PO:
TF:
IVF:
1,016 mL
Blood products:
Total out:
0 mL
800 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
216 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ////
Physical Examination
General Appearance: Well nourished, Thin, Anxious, Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), tachycardic
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Absent)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Significant left degloving injury to knee, Left foot
amputated, exposed tibia
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): X 3, Movement: Not assessed, Tone: Not
assessed
Labs / Radiology
[image002."
771,"Chief Complaint: Traumatic Left Foot Amputation with degloving injury
HPI:
33M s/p traumatic left foot amputation after being thrown off a
backhoe when it struck a car. Tourniquet placed distal thigh above
knee, C-collar, ? LOC. [**Location (un) **] into [**Hospital1 5**]. In ED recieved 1 PRBC
(hct 39), no obvious bleeding but clearly vasoconstricted. Tachycardic
110-120s with response to pain meds, BP 120's systolic.
Injuries:
Left ankle amputation with degloving up to knee
R Zygomatic non-displaced fx
Post operative day:
Allergies:
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Fentanyl - [**2176-11-26**] 01:27 PM
Hydromorphone (Dilaudid) - [**2176-11-26**] 01:40 PM
Other medications:
Past medical history:
Family / Social history:
PMH: Chronic back pain
PSH: Back surgery X 3
10+ pack year smoker, occassional ETOH, denies IVDU, on methadone for
chronic pain
Flowsheet Data as of [**2176-11-26**] 01:51 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 35."
772,"He
further denied any nausea, vomiting, constipation or diarrhea.
.
In the ER, VS were T 98.5, BP 125/70, HR 120, but his HR came
down to 90, RR 20 and saturations to 95% after the patient was
placed on 3L of O2 by nasal canula. A CXR was performed that was
concerning for bilateral pleural effusions.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- began to have fatigue, dizziness and flu symptoms in [**Month (only) 404**]
[**2180**]
- on routine visit in [**Month (only) 116**], found to have RUQ mass
- CT abd/pelvis on [**2180-6-24**] showed a large exophytic mass in R
kidney, 9."
773,"6 x 9.3 cm, with associated abdominal lymphadenopathy
and pulmonary metastasis
- CT chest showed diffuse pulmonary metastases
- CT guided needle biopsy of the kidney on [**2180-7-17**] showed high
grade carcinoma, favoring renal cell cancer, with necrosis
- enrolled in protocol 04-117: Tumor/DC fusion in patients with
Renal Cell Carcinoma on [**2180-8-16**]
- s/p R laparoscopic radical nephrectomy on [**2180-9-5**]
- path showed clear cell renal cell carcinoma with sarcomatoid
features (60%), [**Last Name (un) 19076**] grade [**5-14**], with extension into
perinephric fat (T3a, N0, M1); margins clear, LVI indeterminate
- post-surgical CT showed rapid disease progression and he was
taken off study on [**2180-10-9**]
- Completed recent two week course of Sutent and is currently
taking two weeks off
."
774,"PAST MEDICAL HISTORY:
# Hypercholesterolemia
# Bilateral shoulder and hand surgery
Social History:
He is divorced, lives and works on [**Hospital3 **] as an electrician.
He quit smoking at age 51, one pack per week x15 years.
Previously drank 1-2 drinks several times per week, but none in
last 1-2 weeks due to feeling ill. No recreational drug use.
Family History:
Negative for kidney, prostate or bladder cancer. Father has CAD,
but is alive and well.
Physical Exam:
At admission:
VS: T 96.4, BP 130/72, HR 104, R 18, sats 95% on 2L
GEN: uncomfortable appearing, laboring to breath but NAD
HEENT: sclera anicteric, dry mucus membranes, no nasal flaring
NECK: no cervical LAD, no JVD
CV: tachycardic, regular rhythm, normal S1, S2, no m/r/g
LUNGS: decreased breath sounds at the bases bilaterally, left
worse than right, dullness to percussion
ABD: S/NT/ND, BS+
EXT: warm, well-perfused, no palpable cords, no TTP
NEURO: CN II-XII grossly intact, moving all extremities,
sensation to light touch in tact"
775,"Enlargement of the cardiac silhouette persists and
there is mediastinal widening reflecting diffuse adenopathy.
Brief Hospital Course:
Mr. [**Known lastname 4711**] is a 51 year old male with stage IV clear cell
renal carcinoma with known lung mets who presented with
worsening shortness of breath and hypoxia.
# Dyspnea, Hypoxia - Patient initially required 2L O2 to
maintain O2 sats 94%. CTA chest on admission was negative for
PE. By hospital day two he required 4L by nasal canula. A
thoracentesis was attempted, but there was insufficient fluid to
tap. On hospital day 3 he triggered for O2 sat of 86% on 4L
nasal canula and was increased to 6L nasal canula and then
transferred to the ICU for closer monitoring and placed on a
face tent."
776,"It is unclear if he is continuing to
derive benefit from this medication so consideration to stopping
this medication can be given. As he has been on this medication
for almost a month, it will need to be tapered before stopping
completely. He has stage 4 disease with poor prognosis. There
are no further treatment options per the patient's oncologist.
After discussion with his oncologist following transfer to the
ICU the patient changed his code status to DNR/DNI. Palliative
care was consulted and made [**Known lastname 7219**] for symptom
management including dyspnea, nausea, and insomnia. He is being
discharged to inpatient hospice for further symptom management
and due to his high oxygen requirement."
777,"#. Hypercalcemia: Patient was noted to have elevated calcium on
presentation. He was given IVF and lasix and calcium remained
elevated. He was also treated with a dose of pamidronate and
calcitonin.
# Hyperkalemia: The patient had intermittently elevated serum
potassiums that peaked at 5.2. Etiology is unclear but may be
secondary to dexamethasone or tumor burden causing increased
lactate due to increased metabolic demand. There was no
evidence of renal failure or acidemia.
#. Contact: friend and HCP [**Name (NI) **] [**Name (NI) 85654**] [**Telephone/Fax (1) 85655**] or
[**Telephone/Fax (1) 85656**]
Medications on Admission:
MEDICATIONS (per patient):
Dexamethasone 2 mg PO BID
Pantoprazole 40 mg PO daily
Sunitinib 12."
778,"Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospice
Discharge Diagnosis:
Primary:
Dyspnea and hypoxia
Renal cell carcinoma metastatic to lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Requires 50% face tent to maintain O2 sats > 93%
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of shortness of breath. While you were here, you had
imaging which showed that the cancer in your lungs has
progressed and is likely what is causing your symptoms. There
is no further treatment available for your cancer at this time."
779,"2* Calcium-10.9* Phos-2.6*
Mg-1.8
[**2180-12-3**] 02:06PM BLOOD Type-ART pO2-84* pCO2-46* pH-7.43
calTCO2-32* Base XS-4
[**2180-12-2**] 01:34AM BLOOD Lactate-2.5*
[**2180-12-2**] 01:36AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
On Discharge:
[**2180-12-7**] 05:46AM BLOOD WBC-4.8 RBC-3.26* Hgb-10.2* Hct-29.3*
MCV-90 MCH-31.4 MCHC-34.9 RDW-18.8* Plt Ct-326
[**2180-12-7**] 05:46AM BLOOD Glucose-90 UreaN-23* Creat-0."
780,"Admission Date: [**2180-12-2**] Discharge Date: [**2180-12-7**]
Date of Birth: [**2129-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
attempted thoracentesis [**12-3**]
History of Present Illness:
Mr. [**Known lastname 4711**] is a 51yo male with stage IV clear cell renal
carcinoma s/p R laparoscopic nephrostomy on [**2180-9-5**], who
presented with shortness of breath worsening over the last 48
hours. The patient was recently admission for hypercalcemia,
acute renal failure and a large left pleural effusion."
781,"You were seen by the palliative care doctors who made
[**Name5 (PTitle) 7219**] for helping to manage your symptoms.
While you were here some of your medications were changed.
-You were started on morphine and nebulized albuterol and
ipratroprium to help alleviate your shortness of breath.
-You were also given zofran and compazine as needed to treat
your nausea.
-You were given benzonatate and guiafenesin with codeine for
your cough.
-You were given lorazepam as needed for anxiety.
-You were given trazodone as needed for insomnia.
Followup Instructions:
Please follow-up with your primary care doctor,
[**Last Name (LF) **],[**First Name3 (LF) 85657**], as needed ([**Telephone/Fax (1) 85658**])"
782,"Chest x-ray demonstrated worsening bilateral patchy
opacities. He was treated with broad spectrum antibiotics for
48 hours (vancomycin, levofloxacin, cefepime, and bactrim),
however, his respiratory status failed to improve and cultures
remained negative so antibiotics were stopped. He did not
tolerate oral bactrim due to nausea. His hypoxia and dyspnea
are most likely secondary to his widespread pulmonary metastatic
disease. He was given morphine and nebs to treat his dyspnea
and guiafenesin with codeine and benzonatate for cough.
#. Metastatic Renal Cell Carcinoma: He recently completed a
cycle of Sutent. The patient was continued on dexamethasone per
his outpatient regimen which was initiated at the time of his
whole brain radiation."
783,"10. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
eight (8) hours as needed for nausea.
11. morphine in 0.9 % NaCl 2 mg/mL (1 mL) Syringe Sig: 1-4 mg
Intravenous Q2H as needed for shortness of breath or pain.
Disp:*50 mL* Refills:*0*
12. Prochlorperazine 10 mg IV Q6H:PRN nausea
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): If stopped, this medication will need to be tapered
off.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)."
784,"9 Na-131*
K-5.2* Cl-96 HCO3-27 AnGap-13
[**2180-12-7**] 05:46AM BLOOD Calcium-9.9 Phos-2.1* Mg-2.0
Blood cultures 10/23, no growth as of [**12-7**]
CTA chest [**12-2**]
IMPRESSION:
1. Progression of multiple bilateral pulmonary metastatic
lesions.
2. No evidence of pulmonary embolism.
3. Progression of right adrenal, likely metastatic lesion.
[**12-5**] AP CXR - FINDINGS: In comparison with the study of [**12-4**],
there is little overall change in the diffuse bilateral
pulmonary opacifications consistent with multiple pulmonary
metastases apparently complicated by a pulmonary edema or
hemorrhage."
785,"Pertinent Results:
At admission:
[**2180-12-2**] 01:20AM BLOOD WBC-5.5 RBC-4.05* Hgb-12.6* Hct-36.5*
MCV-90 MCH-31.2 MCHC-34.6 RDW-19.6* Plt Ct-248#
[**2180-12-2**] 01:20AM BLOOD Neuts-80* Bands-4 Lymphs-12* Monos-3
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2180-12-2**] 01:20AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0
[**2180-12-2**] 01:20AM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-136
K-4.8 Cl-103 HCO3-24 AnGap-14
[**2180-12-2**] 01:20AM BLOOD Albumin-3."
786,"5. morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime) as needed for shortness of
breath.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath.
9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath."
787,"A Pleurex
catheter was placed during that admission but was removed prior
to discharge. The patient stated that he was home from rehab for
approximately one week and felt as if he was getting his
strength back. Two days prior to admission the patient stated
that he began to feel short of breath when working with his
physical therapist. He remained home until the next evening when
a friend took him to [**Hospital2 **] [**Hospital3 **] because he felt he could no
longer catch his breath. He was immediately transferred here. He
denied any recent fevers or chills, chest pain or dizziness."
788,"5 mg PO daily for two weeks, then two weeks off
Lorazepam 0.5 mg PO daily Q8H
Senna 8.6 mg, 1-2 tabs PO daily as needed
.
ALLERGIES: NKDA
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea or anxiety.
Disp:*60 Tablet(s)* Refills:*0*
4. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough."
789,"Admission Date: [**2136-11-1**] Discharge Date: [**2136-11-8**]
Date of Birth: [**2057-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1. Intra-aortic balloon pump placement
2. Cardiac catheterization with left main coronary artery bare
metal stent placement
History of Present Illness:
The patient is a 79-year-old male with history of prior CVA,
hypertension, cirrhosis and prior NSTEMI which was treated
medically in [**2136-10-24**] who presents now as a transfer from OSH with a new NSTEMI.
He has been complaining of epigastric pain and ""heart burn"" for
5 days leading up to this admission."
790,"Aditional review of his EKG at
[**Hospital1 18**] revealed normal sinus rhythm but prominent ST segment
depressions in I, II, aVL, V5-V6
and ST segment elevations in leads aVR and V1. After admission,
the patient was observed on telemetry in preparation for a
cardiac catheterization. He was given ongoing therapy with
[**Last Name (LF) 4532**], [**First Name3 (LF) **], Statin, beta-blocker, and IV heparin. Overnight, he
triggered for hypotension and was given fluid bolus of 500cc x2.
He remained chest pain free initially but had recurrent chest
pain in the early morning hours requiring IV morphine.
In the cardiac cath lab, a right heart catheterization
demonstrated RA Pressure of 19 mmHg,RVEDP 21 mm Hg, PASP 51 with
a mean of 39 mm Hg and PCWP 34 mm Hg."
791,"Fluids were discontinued
and Mr. [**Known lastname **] was given 40mg IV lasix. On left heart
catheterization, the LMCA had a distal 90% stenosis at the
trifurcation of the ramus intermedius, LAD, and LCX. The LAD had
mild diffuse disease with a large D1. The LCX had an OM1 with
diffuse 90% proximal stenosis. The RCA was totally occluded
proximally with faint left-right collaterals. Resting
hemodynamics revealed elevated right and left-sided filling
pressures consistent with cardiogenic shock. The cardiac output
was 4.2 l/min with an index of 2.0 l/min/m2 and left
ventriculography was deferred with plan to stabilize patient
with IABP and consider stent or CABG at later time."
792,"Ultimately,
the patient underwent stent placement on [**2136-11-2**] with stent
placed across LAD to distal left main coronary artery. Outcome
showed an improvement to 30% obstruction at trifurcation vs.
prior 90% blockage, with a TIMI 3 result.
.
On arrival to CCU, patient was chest pain free and had no
shortness of breath. He was lying flat in bed on 4L NC. He
denied any back, groin pain, LE pain. On review of systems, he
denied any prior history of deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, hemoptysis, black stools or red stools."
793,"He denied
exertional buttock or calf pain. All of the other review of
systems were negative.
Past Medical History:
NSTEMI ([**1-31**])
CVA
Gout
Cirrhosis - alcoholic, no biopsy, no known h/o varices or
complications from his liver disease.
Dementia
HTN
OSA
macular degeneration
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
Cardiac History: NSTEMI
Prior percutaneous coronary intervention: none
Pacemaker/ICD:None
Social History:
The patient lives in [**Location **] and is dependent in ADL's and IADL's and
is cognitively very intact. He denies any history of smoking,
current etoh use or any history of drug use.
Family History:
No premature cardiac disease in family, noncontributory family
history."
794,".
RHYTHM : The patient was monitored throughout his stay and per
telemetry he remained predominantly in normal sinus rhythm after
his PCI procedure with very limited PVCs.
.
ANTICOAGULATION: The patient's most recent ECHO revealed
moderate global left ventricular hypokinesis (LVEF =35-40 %)and
the right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. Thus, he was started on IV heparin and
bridged while starting coumadin therapy to reduce his risk of
thrombus and CVAs. The end INR goal being [**2-26**]. At time of
discharge the patient's INR was slightly supratherapeutic at 3.5
and his evening warfarin dose was held prior to his discharge."
795,".
ACUTE ON CHRONIC RENAL FAILURE : The patient's initial CRF
history was further challenged by his relative hypoperfusion in
the setting of his ACS/NSTEMI and during his cardiogenic shock.
Based on limited OSH records it is unclear what the patient's
true BUN/Cr baseline is. His Cr peaked at 2.4 and came down to
1.6/1.7 by time of discharge. He was given mucomyst pre and
post-procedure and IVFs were given sparingly due to the
patient's CHF/cardiogenic shock.
.
CIRRHOSIS : The patient had a GI consult for pre-op risk
stratification. Unclear if patient has true underlying cirrhosis
but ultrasound revealed a nodular liver."
796,"Follow-up urine cultures were negative. He was through 4/7 days
therapy at time of discharge and had no complaints of dysuria or
frequency.
FLUIDS AND ELECTROLYTES: The patients magnesium and potassium
were repleted on an as needed basis during his hospital stay and
daily electrolytes were monitored. He was started on a full
cardiac diet once he stabilized and he did very well with his
oral input and had a good appetite. IVF were used sparingly in
the setting of CHF.
.
SACRAL DECUBITUS: The patient's sacral stage 1 buttock sore
remained in tact and he had protective cream applied to avoid
any breakdown."
797,"Medications on Admission:
Home Medications on arrival:
Reglaid
Flonase
Sudafed
Celexa
Colchine
[**Date Range **]
Lopressor
Allopurinol
Aricept
Recently completed levaquin for PNA
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Acute Systolic Congestive Heart Failure
Urinary Tract Infection
Acute Renal Failure
Discharge Condition:
Stable
Creat: 1.6
BUN: 47
K: 4.2
Hct: 27.9
Stage 1 sacral ulcer
Discharge Instructions:
You had a heart attack and required a bare metal stent to open
one of your heart arteries. You will need to take [**Location (un) **] every
day for the rest of your life."
798,"Successful PTCA and placement
of a 3.0x15mm Vision stent in the distal LMCA and origin LAD
were performed. The stent was postdilated proximally using a
4.5x8mm Quantum Maverick balloon and distally using a 3.5x12mm
Quantum Maverick balloon. Final angiography showed normal flow,
no apparent dissection, and a 30% residual stenosis at the
trifurcation site. (See PTCA comments.)
2. Left femoral arteriotomy closure was performed using an 8
French
Angioseal VIP. FINAL DIAGNOSIS:PTCA and placement of a
bare-metal stent in the distal LMCA to origin LAD.
.
[**2136-11-3**] ECHO :
The left atrium is moderately dilated."
799,"Patient stable at time of discharge and will plan
to follow-up with his PCP regarding further monitoring.
.
PROPHYLAXIS: The patient was on anticoagulation for NSTEMI and
thrombus coverage in the setting of his hypokinetic heart and
was therefore covered for DVT prophylaxis as well. PT also
helped the patient to do exercises during his stay to maintain a
fair level of mobility. He was also given 40mg PO daily
Protonix for GI prophylaxis.
.
The patient was maintained as a full code
status for the entirety of his hospital stay. He was asked to
please return to the emergency room or call his primary
cardiologist or PCP as soon as possible if he had any worsening
shortness of breath, chest pain, dizziness or lightheadedness
after discharge."
800,"0 Leuks-TR
[**2136-11-5**] 04:14PM URINE RBC-10* WBC-9* Bacteri-FEW Yeast-NONE
Epi-0
Brief Hospital Course:
In summary, the patient is a 79-year-old male with history of
hypertension, s/p NSTEMI [**1-/2136**] who was transferred from OSH
after presenting with 5 days of unstable angina with associated
dyspepsia and found to have NSTEMI with transient ST elevations
in AVR and ST depressions inferolaterally concerning for
significant left
main/proximal LAD disease with relative hypotension.
:
CORONARY ARTERY DISEASE/NSTEMI and CARDIOGENIC SHOCK: The
patient presented to OSH and was found to have elevated
Troponins to 2."
801,"At time of discharge
he had WBC count of 8.1 and was afebrile. Mr. [**Known lastname **] did have
leukocytosis to 19 at OSH but only mildly elevated WBC to 12
here and CXR clear other than mild effusions initially which had
improved to near resolution by time of discharge.
.
DEMENTIA : For the patient's mild dementia he was continued on
his daily Donepezil therapy.
.
URINARY TRACT INFECTION: On [**2136-11-5**] the patient had a routine
UA which revealed bacteria and WBCs and labs were consistent
with a UTI so he was started on Doxycycline for a 7 day regimen."
802,"Moderate (2+) mitral regurgitation
is seen. The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
pMIBI at OSH [**1-/2136**]: left ventricular dialtion with diffuse
hypokinesis and reduced EF to 35%. non-transmural inferior wall
perfusion defect on post-stress images. subendocarial ishemia
[**2136-11-1**] 10:42PM PTT-58.0*
LABS PRIOR TO DISCHARGE:
[**2136-11-8**] 05:55AM BLOOD WBC-8.1 RBC-3.14* Hgb-9.3* Hct-28.2*
MCV-90 MCH-29.7 MCHC-33."
803,"The patient was cleared
for surgery and he had LFTs within normal limits at the time of
discharge. Per GI records the patient had a classification of
Child Class B w/ 30% cirrhosis secondary to alcohol history. He
had no appreciable RUQ tenderness, jaundice, HSM on exam and he
will plan to follow-up with his usual PCP after discharge
regarding his GI management. Hepatitis B/C panels were done and
were all negative.
RECENT PNA : The patient was noted to have had a fever at OSH
and he had recently completed treatment for PNA. He had no
dullness to percusssion on exam and he had no significant cough
or productive sputum during his CCU course."
804,"0 with CK of 103. The patient was treated as an
NSTEMI protocol with heparin, [**Year (4 digits) **], [**Year (4 digits) 4532**] load and he was then
transferred to [**Hospital1 18**] for further management. Aditional review of
his EKG at [**Hospital1 18**] revealed normal sinus rhythm but prominent ST
segment depressions in I, II, aVL, V5-V6 and ST segment
elevations in leads aVR and V1. CK peaked peaked at 400. Patient
continued [**Last Name (LF) 4532**], [**First Name3 (LF) **], statin and heparin therapy. Patient's
beta blocker held in the setting of severe cardiogenic shock on
admission to CCU."
805,"After discussion
with family and patient he elected to undergo an attempt at PCI.
He underwent PTCA and placement of a bare-metal stent in the
distal LMCA to origin of LAD and recovered well with no notable
complications post-procedure.
.
PUMP FUNCTION: ECHO revealed LVEF of 35%. The patient had
initial elevation in BNP of [**Numeric Identifier 79816**] given his acute NSTEMI and CHF
with poor cardiac output. He received post catheterization
diuresis with Lasix and his CXRs showed improvement in his
pulmonary edema throughout his hospital course. The patient's
oxygen saturations were improved to 96 % on room air by time of
discharge and he had no clinical complaints of shortness of
breath and only trace lower extremity edema which had improved
from his initial presentation."
806,"He had associated chest
pain radiating to his jaw and bilateral arms for several days,
almost continuously but waxing and [**Doctor Last Name 688**] in intensity. He
states that he felt better with burping, and his pain worsened
after eating food. He denies any shortness of breath, chills, or
sweats. The patient presented to OSH and was found to have
elevated Troponins to 2.0 with CK of 103. CXR showing mild
pulmonary edema. The patient was treated as an NSTEMI protocol
with heparin, [**Doctor Last Name **], [**Doctor Last Name 4532**] load and he was then transferred to
[**Hospital1 18**] for further management."
807,"Admission TTE/ECHO [**2136-11-1**] showed moderate
global left ventricular hypokinesis (LVEF = 40 %) and Grade
III/IV (severe) LV diastolic dysfunction. The right ventricle
was mildly dilated with mild global hypokinesis as well. The
patient was stabilized with the assistance of a intra-aortic
balloon pump to help augment BP. The patient was initially
placed on IABP 1:1 and gentle diuresis was given with lasix.
Diagnostic coronary angiography showed 2 vessel and left main
coronary artery disease as patient was found to have 90% L-main
occlusion. Due to significant comorbidities, there was
reluctance to offer CABG as reasonable option."
808,"1 RDW-14.6 Plt Ct-252
[**2136-11-8**] 05:55AM BLOOD Glucose-113* UreaN-45* Creat-1.7* Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
[**2136-11-5**] 07:00AM BLOOD ALT-26 AST-25 AlkPhos-73 TotBili-0.4
[**2136-11-8**] 05:55AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
[**2136-11-2**] 01:00AM BLOOD CK-MB-48* MB Indx-11.4* cTropnT-4.06*
proBNP-[**Numeric Identifier 79816**]*
[**2136-11-5**] 04:14PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2136-11-5**] 04:14PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5."
809,"CTA
anteriorly, decreased b/s at bases.
Abd: Soft, NTND. No HSM or tenderness. Abdominal aorta not
enlarged by palpation.
Ext: Slightly cool lower extemities with 1+ pedal pulses
bilaterally, no edema. No femoral bruits, R-groin w/o hematoma
or ecchymoses, IABP in place.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: dopplerable DP pulses, faintly dopplerable PT pulses
b/l.
Pertinent Results:
[**2136-11-1**] Admission EKG: sinus rhythm with nml axis, nml
intervals, ST depressions in V4-V6, I, AVL and ST elevation in
AVR. Borderline ST elevation in V1.
.
[**2136-11-2**] Cardiac Cath Report: 1."
810,"You had some damage to your heart
muscle and now your heart is weak. Because of this, you will
need to follow a low salt diet, weigh your self every day and
call the doctor if you gain more than 3 pounds in 1 day or 6
pounds in 3 days. We changed some of your medicines.
Continue daily [**Location (un) **] to keep the cardiac stent open. Continue
doxycycline for 3 remaining days of therapy for a urinary tract
infection and continue daily Warfarin as prescribed to avoid
blood clots and to decrease stroke risk.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Cardiology: Pt will need follow-up with a cardiologist in [**2-27**]
weeks as a new pt.
Completed by:[**2136-11-8**]"
811,"The right atrium is
moderately dilated. The estimated right atrial pressure is
10-15mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is
moderate global left ventricular hypokinesis (LVEF = 40 %).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. There
is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen."
812,"Physical Exam:
VS - afebrile, T 98.4, IABP Augmented Diastolic BP 105/50, HR
82, SaO2 95% 4L NC, RR 20
Gen: No acute distress, well-developed and well-appearing middle
aged male. Alert and oriented to person, place and time. Mood,
affect appropriate. Speech mildly slurred (without dentures) .
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma. PERRL, EOMI.
Neck: Thick neck, supine, 8cm JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, balloon pump on 1:1.
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use."
813,"5/ 45.0/1.3, CK / CKMB /
Troponin-T:116/17/9.02, ALT / AST:29/58, Alk Phos / T Bili:78/0.5,
Albumin:2.9 g/dL, LDH:507 IU/L, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:4.4
mg/dL
Assessment and Plan
79 M p/w STEMI from OSH, found to have 90% L-main, 100% RCA and w/
cardiogenic shock requiring IABP. Patient had stent placed to L-main.
Was deemed non-operable candidate.
#. Cardiogenic Shock: Patient weaned off IABP and tolerating well.
Captopril 6.25 mg PO TID for afterload reduction."
814,"- hold beta-blocker
.
#. CAD: CAD peaked at 400. Continue [**Last Name (LF) **], [**First Name3 (LF) 119**], Statin and Heparin.
.
#. Pump: EF 35% on OSH MIBI. elevated BNP now, may be in some acute CHF
with poor cardiac output.
- ECHO report pending
- diuresis goal
.
#. Rhythm: NSR
.
# Acute on Chronic RF: cr elevation likely [**2-25**] to poor cardiac output
- unclear baseline.
- mucomyst post-procedure
- hold IVF's given recent cardiogenic shock
.
# Cirrhosis: Decreased albumin, increased AST. LDH increased most
likely secondary to ischemia.
.
# LE PT Pulses - follow Vascular recs.
- Vascular eval - will likely need ABI's and peripheral procedure down
the road if persists."
815,"Chief Complaint: 79 M p/w STEMI from OSH, found to have 90% L-main,
100% RCA and w/ cardiogenic shock requiring IABP.
24 Hour Events:
TRANSTHORACIC ECHO - At [**2136-11-3**] 09:30 AM
IABP LINE - STOP [**2136-11-3**] 01:20 PM
SHEATH - STOP [**2136-11-3**] 02:00 PM
Allergies:
Penicillins
Rash;
Last dose of Antibiotics:
Infusions:
Heparin Sodium - 1,200 units/hour
Other ICU medications:
Pantoprazole (Protonix) - [**2136-11-3**] 10:00 AM
Other medications:
Captopril 6.25 mg PO TID
Acetaminophen 325-650 mg PO Q8H:PRN back pain
Clopidogrel 75 mg PO DAILY
Allopurinol 100 mg PO DAILY
Donepezil 5 mg PO HS
Fexofenadine 60 mg PO BID
Citalopram Hydrobromide 10 mg PO
Fluticasone Propionate NASAL 1 SPRY NU
Morphine Sulfate 1-4 mg IV Q6H:PRN chest pain
Pantoprazole 40 mg PO Q24H
Aluminum-Magnesium Hydrox."
816,"1 g/dL
136 mg/dL
2.2 mg/dL
24 mEq/L
4.8 mEq/L
55 mg/dL
108 mEq/L
140 mEq/L
29.7 %
9.1 K/uL
[image002.jpg]
[**2136-11-2**] 02:47 PM
[**2136-11-3**] 12:00 AM
[**2136-11-3**] 10:48 AM
[**2136-11-4**] 01:06 AM
WBC
12.6
13.2
10.5
9.1
Hct
33.4
29.5
29.7
29.7
Plt
183
246
232
238
Cr
2.2
2.2
2.1
2.2
TropT
9.02
Glucose
127
168
161
136
Other labs: PT / PTT / INR:14."
817,"-Simethicone 15-30 mL PO QID:PRN
Atorvastatin 80 mg PO DAILY
Aspirin 325 mg PO DAILY
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2136-11-4**] 06:32 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.2
Tcurrent: 36.8
C (98.2
HR: 86 (85 - 99) bpm
BP: 98/56(65) {91/36(54) - 110/65(75)} mmHg
RR: 21 (16 - 29) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 68 Inch
Total In:
877 mL
231 mL
PO:
560 mL
160 mL
TF:
IVF:
317 mL
71 mL
Blood products:
Total out:
1,260 mL
280 mL
Urine:
1,260 mL
280 mL
NG:
Stool:
Drains:
Balance:
-383 mL
-49 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///24/
Physical Examination
General Appearance: No acute distress
Cardiovascular: (S1: Normal), (S2: Normal, Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), coarse upper airway sounds
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: no cyanosis or clubbing
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
238 K/uL
10."
818,"- Will follow post - procedure.
.
# Fever at OSH: recently completed tx for PNA. No PNA on exam. afibrile
here. Did have leukocytosis to 19 at OSH but only mildly elevated WBC
to 12 [**Last Name (un) 1700**] and CXR clear. Likely [**2-25**] to MI.
- further w/u PRN.
.
#.mild dementia
- cont aricept
.
#. FEN: Follow and replete electrolytes. Cardiac diet.
.
#. Sacral Decubitus Ulcer: unable to examine with IABP in place
- wound consult post-operative
.
#. Access: PIVx2
.
#. PPx:
.
#. Code: full
.
#. Dispo: Pending Clinical above. PT consult.
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2136-11-2**] 11:00 AM
20 Gauge - [**2136-11-2**] 11:00 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
819,"No evidence
of active bleeding. Unable to perform polypectomy at the time of urgent
scope. Pt presenting with likely slow bleeding given time frame of
symptoms of dyspnea. Had colonoscopy in [**2134**] demonstrating only
internal hemorrhoids, source of bleed most likely secondary to
ulcerated polyp
- Plan for repeat EGD with polypectomy, possible utilizatoin of EUS
- Will transfuse a total of 3U PRBC tonight
- Trend HCT Q8
- Continue IV PPI [**Hospital1 7**]
- Clear diet, NPO in am for possible procedure
.
# Iron Deficiency Anemia - Patient has a history of menorrhagia and now
found to have upper GI bleed source
- will hold po iron supplementation
- transfuse PRBC
- can restart iron on discharge
.
# FEN: monitor electrolytes, clear liquids overnight
.
ICU Care
Nutrition:
Comments: Clear liquids
Glycemic Control:
Lines:
Comments: 2 18 guage PIV
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: ICU"
820,"3 BP: 112/62 P: 86 R: 13 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
.
Labs / Radiology
211
6.8
87
0.8
20
25
108
3.7
141
20.4
5.5
[image002.jpg] AST 20 ALT 13 AP 57
Endoscopy [**8-12**] - A single 2."
821,"Review of systems:
Constitutional: Fatigue
Respiratory: Dyspnea
Flowsheet Data as of [**2137-8-12**] 10:31 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.3
Tcurrent: 36.7
C (98.1
HR: 72 (72 - 102) bpm
BP: 102/63(67) {93/50(62) - 117/69(80)} mmHg
RR: 12 (12 - 18) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
408 mL
PO:
TF:
IVF:
35 mL
Blood products:
373 mL
Total out:
0 mL
300 mL
Urine:
300 mL
NG:
Stool:
Drains:
Balance:
0 mL
108 mL
Respiratory
O2 Delivery Device: None
SpO2: 98%
Physical Examination
Vitals: T: 98."
822,"Chief Complaint: GIB
HPI:
The patient is a 54y/o F with a PMH of H. pylori and depression
admitted with DOE and anemia with HCT of 19. The patient noted onset of
DOE over the past two days, with worsening so that she was unable to
ambulate without significant difficultly over the past 24 hours. She
noted black stools yesterday. Denies previous recent history of
bleeding. She underwent a routine screening colonoscopy in [**2134**] which
demonstrated grade 1 internal hemorrhoids.
.
In the ED, initial vitals T 98.2, HR 80, BP 119/75, RR 16, O2 100% RA.
On exam she was found to have dark, guaiac + stools."
823,"2mm non-bleeding polyp of benign appearance
was found in the second part of the duodenum on wall opposite ampulla.
The top of the polyp was ulcerated. Impression: Polyp in the second
part of the duodenum on wall opposite ampulla
Otherwise normal EGD to third part of the duodenum
Assessment and Plan
Assessment and Plan: This is a 54y/o F with a PMH of H. pylori and
depression presenting with DOE and found to have GIB with HCT of 18.9.
Urgent endoscopy demonstrated evidence of an ulcerated duodenal polyp
with no evidence of active bleeding
.
# Upper GI bleed secondary to ulcerated duodenal polyp - Pt found to
have an ulcerated polyp in the second part of the duodenum."
824,"5 mg Tablet one half to one Tablet(s) by mouth @ hs no more
than 3 nights per week
Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 7**]
Multivitamin Tablet 1 Tablet(s) by mouth daily (OTC)
Past medical history:
Family history:
Social History:
Melanoma in-situ, lentigo maligna type - L cheeck [**2133**]
Depression
H. Pylori
Nephew with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9372**] deficiency
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: The patient is married and has one teenage son. She runs the
Gift Shop at [**Hospital1 19**]. The patient denies tobacco, EtOH, IVDU. Denies over
the counter herbal supplements."
825,"NG lavage
negative. 2 18 guage PIV were placed. She was transfused 1U PRBC.
.
On arrival to the MICU, the patient is resting comfortably, in NAD.
Denies current CP/SOB. The GI performed an upper endoscopy on arrival
to the MICU which demonstrated a large polyp with no evidence of
current bleeding. Intervention was deferred overnight for planned
excision and biopsy with EUS.
Patient admitted from: [**Hospital1 19**] ER
History obtained from Patient, Family / [**Hospital 75**] Medical records
Allergies:
Iodine
Anaphylaxis;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Midazolam (Versed) - [**2137-8-12**] 09:20 PM
Fentanyl - [**2137-8-12**] 09:20 PM
Pantoprazole (Protonix) - [**2137-8-12**] 10:00 PM
Other medications:
Home Medications: Bupropion HCl 200 mg Tablet SR daily
Citalopram 20 mg Tablet daily
Lorazepam 0."
826,"Denies previous recent history of
bleeding. She underwent a routine screening colonoscopy in [**2134**]
which demonstrated grade 1 internal hemorrhoids. She denies any
other bleeding (urine, gums). She denies weight changes, fevers,
chills, night sweats. She has nto had any bowel movements since
admission.
In the ED, initial vitals T 98.2, HR 80, BP 119/75, RR 16, O2
100% RA. On exam she was found to have dark, guaiac + stools. NG
lavage negative. 2 18 guage PIV were placed. She was transfused
1U PRBC.
On arrival to the MICU, the patient is resting comfortably, in
NAD. Denies current CP/SOB."
827,"The GI performed an upper endoscopy
on arrival to the MICU which demonstrated a large polyp with no
evidence of current bleeding. Intervention was deferred
overnight for planned excision and biopsy with EUS. She was
transfused 3 units PRBC's with appropriate improvement in her
hct and has been hemodynamically stable in the ICU.
10 point review of systems otherwise negative except as noted
above.
Past Medical History:
Melanoma in-situ, lentigo maligna type - L cheeck [**2133**]
Depression
H. Pylori
Social History:
The patient is married and has one teenage son. She runs the
Gift Shop at [**Hospital1 18**]. The patient denies tobacco, EtOH, IVDU."
828,"6 LYMPHS-24.2 MONOS-8.8 EOS-1.9
BASOS-0.5
[**2137-8-12**] 01:46PM PLT COUNT-177
[**2137-8-12**] 01:46PM PT-11.9 PTT-23.5 INR(PT)-1.0
[**2137-8-12**] 01:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2137-8-12**] 01:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
EGD [**2137-8-12**]: Impression: Polyp in the second part of the
duodenum on wall opposite ampulla Otherwise normal EGD to third
part of the duodenum
Recommendations: Patient will require polypectomy of this polyp."
829,"We do not have the equipment to perform this as an emergency
procedure. Can have clear liquids. give Protonix 40 mg twice
daily.
Colonoscopy [**2137-8-12**]: Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
This is a 54y/o woman with a h/o H. pylori and depression with
acute blood loss anemia, GIB, duodenal polyp.
1. Acute blood loss anemia due to GI bleeding: She presented
with blood loss anemia, secondary to slow GI bleed. She had an
emergent EGD which showed a duodenal polyp. She improved with
transfusion of 3 units of blood with stable hematocrit."
830,"She
will need to restart an [**Month/Day/Year **] supplement on discharge.
.
2. Duodenal polyp: Underwent EUS on [**8-15**] for evaluation of polyp
found on initial EGD. EUS showed 3 cm pedunculated polyp in the
second part of the duodenum. The ampulla was identified and was
separate from the mass. The ampulla appeared normal.
On EUS, this lesion appeared as a pedunculated polyp. No
extension of the lesion beyond the submucosa was noted. The
muscularis was clearly identified and was intact. She went for
removal on [**2137-8-16**]. During that EGD, EGD on she was found to
have angioectasia in the stomach (treated with thermal therapy),
a polyp in the second part of the duodenum (treated with
polypectomy, endoclip, and otherwise normal EGD to third part of
the duodenum."
831,"Discharge Diagnosis:
Upper GI bleed
Acute blood loss anemia
Duodenal polyp
Depression
Discharge Condition:
Stable, hematocrit 31.5, no active bleeding, ambulating without
shortness of breath
Discharge Instructions:
You were admitted with anemia, due to blood loss. The most
likely cause was the polyp in your duodenum, which was slowly
oozing. You improved with transfusions with a stable blood
count throughout your stay after the transfusion. You had the
polyp removed on the day before discharge.
.
No aspirin, or NSAIDs. You do not need to take protonix.
.
Return to the ED if you get short of breath or dizzy. Your
stool will probably turn black from the [**Last Name (LF) **], [**First Name3 (LF) **] that is
expected.
.
Start eating solid food tonight. Stay well hydrated in the next
few days.
Followup Instructions:
Call the GI department to make an appointment with [**Doctor First Name 4370**] [**Doctor Last Name **] in
the next 2-3 weeks. The phone number is [**Telephone/Fax (1) 9557**]. They
will give you the results of your polyp removal.
.
Provider: [**Name10 (NameIs) **] [**Name6 (MD) **] [**Name8 (MD) 19840**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2137-9-3**] 3:00 (resident working with Dr. [**Last Name (STitle) 5263**]
.
Blood count check next week."
832,"3 PTT-21.8* INR(PT)-0.9
[**2137-8-12**] 01:46PM GLUCOSE-95
[**2137-8-12**] 01:46PM UREA N-23* CREAT-0.8 SODIUM-141 POTASSIUM-4.4
CHLORIDE-109* TOTAL CO2-29 ANION GAP-7*
[**2137-8-12**] 01:46PM estGFR-Using this
[**2137-8-12**] 01:46PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-57 TOT
BILI-0.2
[**2137-8-12**] 01:46PM WBC-3.9* RBC-2.13*# HGB-6.4*# HCT-18.9*#
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.1
[**2137-8-12**] 01:46PM NEUTS-64."
833,"Admission Date: [**2137-8-12**] Discharge Date: [**2137-8-16**]
Date of Birth: [**2083-1-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a 54y/o woman with a PMH of H. pylori and
depression admitted with DOE and anemia with HCT of 19. The
patient noted onset of DOE 2 days prior to presentation, with
worsening so that she was unable to ambulate without significant
difficultly over the past 24 hours. She noted black stools 24
hours prior to presentation."
834,"Pertinent Results:
[**2137-8-12**] 05:57PM COMMENTS-GREEN TOP
[**2137-8-12**] 05:57PM HGB-7.8* calcHCT-23
[**2137-8-12**] 05:50PM GLUCOSE-87 UREA N-20 CREAT-0.8 SODIUM-141
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12
[**2137-8-12**] 05:50PM WBC-5.5 RBC-2.22* HGB-6.8* HCT-20.4* MCV-92
MCH-30.8 MCHC-33.4 RDW-14.0
[**2137-8-12**] 05:50PM NEUTS-68.4 LYMPHS-24.4 MONOS-5.5 EOS-1.4
BASOS-0.2
[**2137-8-12**] 05:50PM PLT COUNT-211
[**2137-8-12**] 05:50PM PT-11."
835,"Denies over the counter herbal supplements.
Family History:
Nephew with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19839**] deficiency
Physical Exam:
VS: T 97.3 HR 59 BP 102/69 RR 18 Sat 99% RA
Gen: wll appearing woman in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates,
conjunctiva pink
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, asterixis absent, speech fluent,
DTR's 2+ patellar, achilles, biceps, triceps, brachioradialis
bilaterally, babinski down-going bilaterally
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD"
836,"She was discharged home after the polypectomy,
with advise to return in the event of pain, hematemesis, or
worsening melena. She will have a CBC approximately 5 days post
discharge, results to her PCP.
.
3. Depression: continuee wellbutrin and celexa.
.
OUTSTANDING TESTS:
Polyp, pathology pending
Medications on Admission:
On Admission:
Bupropion HCl 200 mg Tablet SR daily
Citalopram 20 mg Tablet daily
Lorazepam 0.5 mg Tablet one half to one Tablet(s) by mouth @ hs
no more than 3 nights per week
Ferrous Sulfate 325 mg (65 mg [**Date Range **]) Tablet [**Hospital1 **]
Multivitamin Tablet 1 Tablet(s) by mouth daily (OTC)"
837,"On transfer:
BuPROPion (Sustained Release) 200 mg PO QAM
Citalopram Hydrobromide 20 mg PO DAILY
Pantoprazole 40 mg IV Q12H
Discharge Medications:
1. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. [**Hospital1 **] (Ferrous Sulfate) 325 mg (65 mg [**Hospital1 **]) Tablet Sig: One
(1) Tablet PO once a day.
4. Outpatient Lab Work
CBC, [**2137-8-21**]. Results to Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] phone
[**Telephone/Fax (1) 250**].
Discharge Disposition:
Home"
838,"Demographics
Day of intubation: 1
Day of mechanical ventilation: 1
Ideal body weight: 0 None
Ideal tidal volume: 0 / 0 / 0 mL/kg
Airway
Airway Placement Data
Known difficult intubation: Unknown
Procedure location: Outside hospital
Reason: Emergent (1st time)
Tube Type
ETT:
Position: 22 cm at teeth
Route: Oral
Type: Standard
Size: 7mm
Cuff Management:
Vol/Press:
Cuff pressure: 28 cmH2O
Cuff volume: 6 mL / Air
Lung sounds
RLL Lung Sounds: Diminished
RUL Lung Sounds: Rhonchi
LUL Lung Sounds: Rhonchi
LLL Lung Sounds: Diminished
Secretions
Sputum color / consistency: Blood Tinged / Thick
Sputum source/amount: Suctioned / Moderate
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Visual assessment of breathing pattern: Normal quiet breathing
Assessment of breathing comfort: No response (sleeping / sedated)
Invasive ventilation assessment:
Trigger work assessment: Not triggering
Plan
Next 24-48 hours:
Reason for continuing current ventilatory support: Hemodynimic
instability
Respiratory Care Shift Procedures
Transports:
Destination (R/T)
Time
Complications
Comments
CT
2330
Transported to CT scan and back without incident."
839,"SICU
HPI:
82 yo F h/o Afib found down at home with speech difficulty, right sided
weakness. Found to have left MCA stroke with some hemorrhagic
conversion, not TPA candidate.
Chief complaint:
right hemiplegia
PMHx:
SAH/intraventricular bleed after mechanical fall [**1-/2154**], Parkinson's
disease, atrial fibrillation/flutter (not on coumadin because of
falls), arthritis, CAD (inferolateral reversible defect per MIBI in
[**2146**]), asthma, hypothyroidism, TIA [**2140**], osteoporosis, HTN, hiatal
hernia
Current medications:
1. IV access: Peripheral line Order date: [**5-5**] @ 1730
12. Magnesium Sulfate IV Sliding Scale Order date: [**5-6**] @ 0419
2. 40 mEq Potassium Chloride / 1000 mL NS
Continuous at 70 ml/hr Order date: [**5-6**] @ 0420
13."
840,"56/36/494/33/10
Ve: 5.8 L/min
PaO2 / FiO2: 988
Physical Examination
General Appearance: intubated, sedated
HEENT: surgical pupil right, left pupil dilated and fixed
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : , Diminished: right base)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Neurologic: Sedated, intubated, withdraws extremities to nailbed stim,
+corneal, +cough
Labs / Radiology
186 K/uL
11.1 g/dL
97 mg/dL
0.6 mg/dL
33 mEq/L
2.6 mEq/L
16 mg/dL
102 mEq/L
143 mEq/L
32."
841,"Continue to watch.
Endocrine: RISS, Follow FS. Continue levothyroxine.
Infectious Disease: WBC 10.9. Afebrile, no indication for abx
Lines / Tubes / Drains: Foley, NGT, ETT, PIV
Wounds:
Imaging:
Fluids: NS, Potassium Chloride, 70 cc/hr
Consults: Neuro surgery, Neurology
Billing Diagnosis: (Hemorrhage, NOS), CVA, (Respiratory distress:
Failure)
ICU Care
Nutrition:
Comments: NPO for now, consider TFs.
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2154-5-5**] 08:00 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds , Family
meeting planning Comments: To have family meeting when pt's relative
returns from [**Country 6757**].
Code status: Full code
Disposition: ICU
Total time spent: 32 minutes
Patient is critically ill"
842,"Simvastatin 10 mg PO DAILY Order date: [**5-5**] @ 1730
9. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**5-5**] @ 1730
20. 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.
Order date: [**5-5**] @ 1730
10. Levothyroxine Sodium 175 mcg PO DAILY Order date: [**5-5**] @ 1730
21. Vitamin D 400 UNIT PO DAILY Order date: [**5-5**] @ 2314
11. Mannitol 25 g IV ONCE Duration: 1 Doses Order date: [**5-6**] @ 0006
24 Hour Events:
- change in left pupil -> head CT showing large area of hemorrhage
- no intervention per nsurg, likely unsalvageable
Post operative day:
HD #2
Allergies:
Penicillins
Hives;
Sulfa (Sulfonamides)
Hives;
Risperidone
Confusion/Delir
Oxycodone
Confusion/Delir
Dilaudid (Oral) (Hydromorphone Hcl)
Confusion/Delir
Codeine
Nausea/Vomiting
Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Mannitol
Other ICU medications:
Other medications:
Flowsheet Data as of [**2154-5-6**] 05:44 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**56**] a."
843,"Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>65. Order
date: [**5-6**] @ 0541
6. Calcium Carbonate 1500 mg PO DAILY Order date: [**5-5**] @ 2314
17. Potassium Chloride PO Sliding Scale Duration: 24 Hours
Hold for K > Order date: [**5-6**] @ 0419
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**5-5**] @
2307
18. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO adequate sedation
Order date: [**5-5**] @ 2307
8. Docusate Sodium 100 mg PO BID Order date: [**5-5**] @ 1730
19."
844,"5 %
10.9 K/uL
[image002.jpg]
[**2154-5-5**] 11:21 PM
[**2154-5-6**] 02:51 AM
WBC
10.9
Hct
32.5
Plt
186
Creatinine
0.6
Troponin T
0.05
TCO2
33
Glucose
97
Other labs: CK / CK-MB / Troponin T:178/5/0.05, Ca:8.7 mg/dL, Mg:1.6
mg/dL, PO4:2.4 mg/dL
Assessment and Plan
CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC
Assessment and Plan: 82 yo F h/o Afib with left MCA stroke with
hemorrhagic conversion.
Neurologic: Neuro checks Q: 2 hr, Left MCA stroke -> large hemorrhage,
likely unsalvageable."
845,"Continue mannitol 25 q6 to temporize until
family arrives.
Cardiovascular: Hemodynamically stable, keep SBP<180. ?TTE today to
eval for embolic source. Continue lopressor 25 tid, statin
Pulmonary: Cont ETT, (Ventilator mode: CMV), Wean vent as tolerated,
likely will not be able to extubate.
Gastrointestinal / Abdomen: NPO for now, NGT in place. Consider
starting TF's.
Nutrition: NPO
Renal: Foley, Adequate UO, Creat stable 0.6. Follow Na/osm q6 while on
mannitol. Repleted K/Mg
Hematology: Hct 32.5 down from 37.7, cont to follow. No obvious source
of bleed other than intracranial, possibly hemodilution [**1-7**] IV fluids."
846,"Mannitol 25 g IV Q6H
Hold for serum osmol >320 and serum Na >145. Order date: [**5-6**] @ 0543
3. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain Order date: [**5-5**] @
1730
14. Metoprolol Tartrate 25 mg PO TID
Hold for SBP<110, HR<55 Order date: [**5-5**] @ 2054
4. Carbidopa-Levodopa (25-100) 2 TAB PO BID
At noontime and at midnight. Order date: [**5-5**] @ 2054
15. Omeprazole 40 mg PO DAILY Order date: [**5-5**] @ 1730
5. Carbidopa-Levodopa (25-100) 3 TAB PO BID
At 6 am and at 6pm. Order date: [**5-5**] @ 2054
16."
847,"m.
Tmax: 37.7
C (99.8
T current: 37
C (98.6
HR: 57 (53 - 60) bpm
BP: 100/54(65) {100/54(65) - 189/84(107)} mmHg
RR: 14 (14 - 21) insp/min
SPO2: 98%
Heart rhythm: SB (Sinus Bradycardia)
Total In:
531 mL
916 mL
PO:
Tube feeding:
IV Fluid:
471 mL
736 mL
Blood products:
Total out:
620 mL
690 mL
Urine:
620 mL
690 mL
NG:
Stool:
Drains:
Balance:
-89 mL
226 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 450 (450 - 450) mL
RR (Set): 14
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
RSBI Deferred: No Spon Resp
PIP: 29 cmH2O
Plateau: 23 cmH2O
Compliance: 25 cmH2O/mL
SPO2: 98%
ABG: 7."
848,"Admission Date: [**2154-5-5**] Discharge Date: [**2154-5-7**]
Date of Birth: [**2071-6-2**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamides) / Risperidone / Oxycodone /
Dilaudid / Codeine / Vicodin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
R sided weakness and trouble speaking
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
82 yo RH woman with h/o Afib (not on coumadin [**1-7**] multiple
falls), HTN, PD, CAD, recent IVH [**1-7**] fall who presents after
being found down. She was speaking to her son-in-law this am
~9am who found her initially to be speaking normally (although
conversation was brief but able to ask about her daughter who is
out of the country) - incidentally she called him."
849,"Incidentally, the patient's children describe her as having
gradual worsening of her language with worsening word finding
difficulties over the past year. After a recent admission for
IVH, she has also had a tendency to sit with her eyes close
(although awake) per their report.
Per family, patient with h/o TIA with dysarthria and L hand
""shaking"" lasting minutes. they don't recall results of workup
from [**2140**].
ROS:
Gen: pt unable to relate. but per family, no recent illness, no
complaints of HA, no other previous weakness, vision changes,
sensory symptoms.
Past Medical History:
Atrial fibrillation-diagnosed [**12-11**] (on Coumadin)
Arthritis
CAD (inferolateral reversible defect per MIBI in [**2146**])
Zoster
Asthma
Arthroscopic surgery to knees (bilat)
Wrist [**Doctor First Name **]
TAH
CCY
Hypothyroidism
TIA in [**2140**] (self limited with no residual defecits)
Osteoporosis
Parkinson's disease
Hypertension
Hiatal hernia"
850,"On [**5-7**] after a family meeting with bother
daughters, son-in-law, [**Name (NI) 18198**], and other family members
care was withdrawn and she was made comfort measures only. She
passed away shortly after extubation.
Medications on Admission:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
QID (4 times a day).
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): in one week (starting [**2154-1-24**], dose should be
incresed to 750 mg [**Hospital1 **] foe one week, then (on [**2154-1-31**]), dose
should be increased to 1000 mg [**Hospital1 **], as long as pt."
851,"Discharge Disposition:
Expired
Discharge Diagnosis:
Massive hemorrhagic conversion of a left MCA territory infarct
with local mass effect, including effacement of the left lateral
ventricle including near complete effacement of the left lateral
ventricle, as well as significant subfalcine and left uncal
herniation
Atrial Fibrillation
Discharge Condition:
Expired
Discharge Instructions:
The patient was admitted with a large left MCA infarct with
large hemorrhagic conversion and subfalcine and left uncal
herniation. The patient was made CMO, and expired with her
family at the bedside.
Followup Instructions:
None
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2154-5-10**]"
852,"s mental
status remains clear. If there are questions about this,
contact pt.s primary care MD, Dr. [**Last Name (STitle) 2204**] at [**Telephone/Fax (1) 20792**].
Tablet(s)
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: Two (2) Capsule PO at bedtime."
853,"Social History:
Lives alone in an apartment. Her daughters are involved. She
denies alcohol, tobacco and illicit drugs.
Family History:
No significant
Physical Exam:
VS: T 97.3 HR 62 BP 154/94 RR 18 Sat 100% RA
PE:
HEENT AT/NC, MMM no lesions
Neck Supple, no bruits
Chest CTA B
CVS irregularly irregular
ABD soft, NTND, + BS
SKIN
NEUROLOGICAL
MS: intubated, sedated on propofol. when taken off, BPs into
200s
eyes closed, not following commands, no spont eye opening or eye
movements. spont movements of all extremities except RUE.
CN: surgical pupils bilaterally, + corneal reflexes Bilaterally,
no OCRs, no gag, no grimace noted."
854,"pt with ETT taped onto R NLF
Motor: tone: increased tone throughout. moving extremities
except for RUE spontaneously. With noxious to RUE, localizes
with left, but no movement noted on R. LLE moving greater than
RLE, but RLE is easily antigravity.
[**Last Name (un) **]: all extremities save for RUE withdraw to mild stim
Reflex: 2+ bilaterally, except for ankles 0. toe on L is up. toe
on R is mute.
Pertinent Results:
[**2154-5-5**] 03:11PM GLUCOSE-116* LACTATE-2.2* NA+-143 K+-3.5
CL--95* TCO2-31*
[**2154-5-5**] 02:55PM GLUCOSE-122* UREA N-21* CREAT-0."
855,"8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
Discharge Medications:
None, pt passed away"
856,"1* LYMPHS-11.1* MONOS-4.5 EOS-0.7
BASOS-0.6
[**2154-5-5**] 02:55PM PLT COUNT-235
[**2154-5-5**] 02:55PM PT-13.7* PTT-27.1 INR(PT)-1.2*
[**2154-5-5**] 04:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2154-5-5**] 04:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2154-5-5**] 11:21PM TYPE-ART PO2-494* PCO2-36 PH-7.56* TOTAL
CO2-33* BASE XS-10
[**5-5**] CT head: Large hypodense area concerning for acute ischemia
in distribution
of left MCA, with foci of blood products."
857,"However,
soon
after the call, he was answering a question and then noted no
response on the other end of the telephone. He called her name,
but heard no response. A friend had been planning to pick her
up
at 10 am, so he figured the phone was having technical
difficulties and that he would be contact[**Name (NI) **]/seen by the people
she was supposed to meet. He didn't hear anything and presumed
that things were ok. ~12:30, her daughter in law came by her
apt
to see how she was doing. When she knocked, she heard someone
(the pt) trying to say something but not really saying anything
clearly."
858,"8 SODIUM-140
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-28 ANION GAP-18
[**2154-5-5**] 02:55PM CK(CPK)-106
[**2154-5-5**] 02:55PM CK-MB-7
[**2154-5-5**] 02:55PM cTropnT-0.01
[**2154-5-5**] 02:55PM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2154-5-5**] 02:55PM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2154-5-5**] 02:55PM WBC-8.3 RBC-3.89* HGB-12.5 HCT-37.7 MCV-97
MCH-32.2* MCHC-33.3 RDW-14.4
[**2154-5-5**] 02:55PM NEUTS-83."
859,"Some mild interval
dilatation of the
right lateral ventricle atrium should be monitored on followup
examinations.
Brief Hospital Course:
Mrs [**Known lastname **] was admitted to the ICU with large LMCA infarction. No
intervention was indicated as she was outside the window.
Overnight she had a change in her pupilary exam and stat repeat
head CT was ordered. She was found to have massive hemorrhagic
conversion of her stroke. She was not on any anti-platlet or
anticoagulants at the time. Full medical management was
maintainted until [**5-7**] when her daughter [**Name (NI) **] was able to arrive
home from [**Country 84997**]."
860,"MRI is recommended for
further
evaluation, and neurology consult. Findings were discussed with
Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 780**] at 4:10 p.m. on [**2154-5-5**] and posted on the ED dashboard.
2. Scattered area of low attenuation in the subcortical white
matter on the
right, likely consistent with chronic small vessel ischemic
changes.
3. No evidence of fracture.
[**5-5**] CT head after change in exam:
1. Massive hemorrhagic conversion of a left MCA territory
infarct with local
mass effect, including effacement of the left lateral ventricle
including near
complete effacement of the left lateral ventricle, as well as
significant
subfalcine and left uncal herniation."
861,"She called 911 and the fire dept responded, broke open
the door and found the patient dressed (ready to go out per
children), unable to communicate - not making word salad, but
only word that was understandable was ""no"" with r sided
weakness.
As a result, she was brought to [**Hospital1 18**] ED where she was SBPs in
150. she could follow simple commands, but was not moving her
RUE. she also appeared to have trouble getting words out per ED
staff. She was then intubated for airway protection. CTH was
attained which revealed hypodensity involving LMCA territory
with
small amount of hemorrhage concerning for hemorrhagic conversion
of infarction and neurology service was contact[**Name (NI) **]."
862,"Admission Date: [**2134-11-26**] Discharge Date: [**2134-12-10**]
Date of Birth: [**2051-9-1**] Sex: F
Service: MEDICINE
Allergies:
Peanut / Chocolate Flavor / Codeine
Attending:[**First Name3 (LF) 9965**]
Chief Complaint:
CC:[**CC Contact Info 95464**].
Reason for MICU transfer: respiratory distress/COPD exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 2564**] is an 83 y/o F with HTN, COPD and RA who presented
to the ED with developing LLE erythema over 3 days duration.
Presented to PCP who suggested she go to the ED for further
eval. Denied any associated Sx including fever/chills or pain."
863,"She was placed on a NRB with saturations in
the 90% and transfered to the MICU for further management of her
respiratory distress.
Past Medical History:
- Osteoporosis with T8-9 compression fracture
- RA
- COPD (no PFTs in OMR)
- HTN
Social History:
Not presently employed. Lives independently. Has a niece who is
[**Name8 (MD) **] RN. No EtOH, tobacco or other drug use.
Family History:
Father with [**Name2 (NI) **]
Physical Exam:
On Admission:
VS: afebrile, BP 114/70, HR 150s, RR 30s, O2sats 93-99% NRB
GA: AOx3, severe increased work of breathing with use of
abdominal muscles for respiration, no sentence dyspnea
HEENT: JVP elevated to 10-12 cm
Cards: irregularly irregular, S1 and S2, +[**1-31**] murmur best heard
over apex
Pulm: intermittent inspiratory stridor, expiratory wheezes
bilaterally, no crackles
Abd: soft, NT, +BS."
864,"no g/rt. neg HSM.
Extremities: erythema and flaking on skin over left tibia
extending down to foot. RLE with e/o venous statis changes.
On Discharge:
VS: 97.0 121/77 86 22 94%2L
Gen: Severely kyphotic, elderly female in NAD. Oriented x3.
Mood, affect appropriate.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi. Does have rhoncorous upper
airway sounds.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. Digital cap refill <2 sec. No C/C/E."
865,"4* Mg-2.1
Studies:
.
[**11-30**] TTE: IMPRESSION: Aortic valve mass, probably a vegetation.
No associated aortic regurgitation. Moderate mitral and
tricuspid regurgitation
.
[**12-1**] TEE Esophagus was successfully intubated with TEE probe.
Prior to the acquisition of any pictures the patient developed
stridorous breathing which resolved fully following removal of
the TEE probe. The procedure was aborted at that time. The
patient was closely monitored in the TEE room until sedation
wore off and she fully recovered back to baseline. There was no
further stridor noted.
.
[**12-4**] CT Head: IMPRESSION: No acute intracranial process; exam
limited by exclusion of the superior-most aspect of the brain."
866,".
# Strep viridans bacteremia - The patient initially presented
with cellulitis of her left leg and was treated with oral
antibiotics. On Day #3 of therapy, [**12-29**] blood cultures drawn at
admission returned (+) for Strep Viridans. She was started on IV
ceftriaxone on [**2134-11-29**]. The patient underwent TTE which
revealed an aoritc valve vegitation. Plan was for TEE however,
during the procedure, the patient became stridorous (as
described in detail below) and required intubation and MICU
transfer. In the MICU, the patient underwent TEE which again
demonstrated the aortic valve vegitation. On [**2134-12-8**], the
patient was HD stable and was able to return to the medicine
floor from the MICU."
867,"Was also started on methylpred
60 mg q8h. Imaging showed a mild left effusion and atelectasis.
Extubated on MICU day #1 without event. During her ICU course,
the patient would intermittently develop respiratory distress
and stridor, with saturations dipping into the low 80s. She
underwent BiPAP intermittently overnight, then was changed to
nasal BiPAP after her respiratory status improved. On the floor,
the patient self-discontinued BiPAP due to discomfort. Seen by
ENT who scoped to the level of the vocal cords but found no
abnormality. Etiology of respiratory decompensation is unclear
although is believed to be related to possible upper airway
edema exacerbated by TEE/intubation."
868,"meloxicam 15 mg Tablet Sig: One (1) Tablet PO once a day.
9. azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
10. Flovent Diskus 100 mcg/Actuation Disk with Device Sig: Two
(2) Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Cellulitis, Atrial Fibrillation, respiratory failure
Cellulitis, Atrial Fibrillation, Endocarditis
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 with a skin infection of your leg."
869,"3
[**2134-11-27**] 06:00AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
On Discharge:
[**2134-12-10**] 05:45AM BLOOD WBC-10.4 RBC-3.35* Hgb-10.6* Hct-32.4*
MCV-97 MCH-31.5 MCHC-32.6 RDW-13.6 Plt Ct-236
[**2134-12-9**] 05:50AM BLOOD PT-14.5* PTT-30.7 INR(PT)-1.4*
[**2134-12-10**] 05:45AM BLOOD Glucose-102* UreaN-16 Creat-0.4 Na-139
K-4.0 Cl-100 HCO3-36* AnGap-7*
[**2134-12-10**] 05:45AM BLOOD Calcium-8.4 Phos-2."
870,"Is
writted for alendronate, vitamin D, and calcium at home although
reports not reliably taking the alendronate. She was maintained
on calcium and vitamin D in house. Received Alendronate on
Mondays per home schedule. She never complained of pain related
to compression fractures.
.
# COPD - The patient carries a history of COPD. This may have
contributed to respiratory decompensation described above. In
house she was continued on standing nebulizer therapy. Prior to
discharge, the patient continued to have a dry, hacking cough
and an increased oxygen requirement (2L NC to maintain sats
~94%). Given relatively clear imaging, a COPD exacerbation was
suspected and the patient was discharged with plans to complete
a steroid taper and a 5 day course of azithromycin."
871,"In the
emergency room you were also found to have an abnormal heart
rhythym called atrial fibrillation. You were treated with
antibiotics for the skin infection with improvement. You were
also treated with a medication to slow your heart rate and were
started on a blood thinning medication to prevent stroke.
Additionally, you were found to have an infection of your
bloodstream and of your heart valve. For this you will be
discharged on a 4 week course of intravenous antibiotics.
See below for changes to your home medication regimen:
1) Please START Metoprolol 200mg once daily
2) Please START Warfarin 0."
872,".
[**12-5**] CT Chest: IMPRESSION: 1. No pneumonia. 2. Mild pulmonary
edema. Moderate right and small left pleural effusions,
moderately severe bibasilar atelectasis. New moderate
cardiomegaly. 3. New severe multilevel thoracic vertebral
compression fractures.
.
[**12-9**] CXR: PFI: Improved appearance of right lung with residual
right cardiophrenic consolidation with trace right pleural
effusion; unchanged retrocardiac consolidation with small left
pleural effusion.
Brief Hospital Course:
Assessment and Plan: Ms. [**Known lastname 2564**] is an 83 y/o F with HTN, COPD
and RA who presented with cellulitis and afib with RVR in the
ED. Found to be bacteremic on the floor and found to have aortic
valve vegitation."
873,"5mg in the evening. You will
follow-up with the [**State **] Square-[**Hospital1 18**] office
[**Hospital 2786**] clinic for further changes to your dosing
3) Please CONTINUE Ceftriaxone until otherwise instructed by the
infectious disease clinic
4) Please START Aspirin 81mg DAilY
5) Please STOP Atenolol
6) Please CONTINUE Prednisone 4 pills daily for 3 days. Then 3
pills daily for 3 days then 2 pills daily for 3 days then STOP.
7) Please CONTINUE Azithromycin 250mg daily for 3 additional
days to complete a 5 day course
8) Please STOP Roxicet
See below for instructions regarding follow-up care:
Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2134-12-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please follow-up with your primary care phsyician ([**Doctor Last Name 2204**],
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**Telephone/Fax (1) 2205**]) within 7 days of discharge from your
rehabilitation facility.
Completed by:[**2134-12-13**]"
874,"A midline was placed for long term
antibiotic therapy. The patient will be discharged to a rehab
center where she will continue antibiotic therapy for 1 month
and follow-up with ID as an outpatient.
.
# Respiratory distress: On [**2134-12-1**] a TEE was attempted
however had to be abandoned as the patient became stridorous
during the procedure. Following this event, the patient was
stable on the floor until ~6pm when she began to develop
respiratory distress. Despite agressive measures including IV
steroids, nebs, O2, lasix, and racemic epi the patient required
intubation and was transferred to the MICU. In the MICU the
patient was diuresed further and continued on
albuterol/ipratropium for COPD."
875,"Also has poor reserve with
underlying COPD and severe kyphosis.
.
# Afib with RVR - The patient was noted to be in afib with RVR
while in the ED. No known h/o afib. In the hospital she was
initially controlled with IV metoprolol and loaded with orals.
Oral metoprolol titrated to 200mg daily and converted to long
acting. Given CHADS2 score of 2, anti-coagulation was
recommended and the patient was agreeable. Started on warfarin
without bridge and will continue warfarin on an outpatient
basis. Goal INR [**1-28**].
.
# Osteoporosis - In house, the patient was incidentally found to
have a number of new compression fractures on imaging."
876,"5. ceftriaxone 1 gram Recon Soln Sig: One (1) Intravenous once
a day: Please continue on Ceftriaxone until instructed otherwise
at your infectious disease clinic follow-up.
6. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day:
Continue 4 pills daily for 3 days. Then 3 pills daily for 3 days
then 2 pills daily for 3 days then STOP.
Disp:*28 Tablet(s)* Refills:*0*
7. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8."
877,"5 mL IH ONCE x2
Furosemide 20 mg IV ONCE
Senna 2 TAB PO/NG HS
Guaifenesin [**5-4**] mL PO/NG Q4H:PRN cough
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Monday.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime:
Please follow up with your [**Hospital 2786**] clinic for further
management of your dosing.
Disp:*30 Tablet(s)* Refills:*1*
4. multivitamin Tablet Sig: One (1) Tablet PO once a day."
878,"Medications on Admission:
MEDICATIONS: (at home)
ALENDRONATE - 70 mg Tablet Weekly
ATENOLOL - 25 mg Daily
FLUTICASONE [FLOVENT DISKUS]
meloxicam 15 mg Tablet Daily
OXYCODONE-ACETAMINOPHEN [ROXICET] - 1 tab Q6H;PRN for pain
MULTIVITAMIN
.
MEDICATIONS: (on transfer)
Ipratropium Neb 1 NEB IH Q6H:PRN SOB/Wheezing
Acetaminophen 325-650 mg PO/NG Q4H:PRN pain or fever
Albuterol Inhaler [**12-27**] PUFF IH Q4H:PRN wheezing/shortness of
breath MethylPREDNISolone Sodium Succ 125 mg x1
Aspirin 81 mg PO/NG DAILY
Metoprolol Succinate XL 200 mg PO DAILY
Alendronate Sodium 70 mg PO QMON
Metoprolol Tartrate 5 mg IV x2
Metoprolol Tartrate 25 mg PO/NG ONCE
Benzonatate 100 mg PO TID
Magnesium Sulfate 2 gm IV ONCE
CeftriaXONE 1 gm IV Q24H day 1 [**11-26**]
MethylPREDNISolone Sodium Succ 125 mg IV Q6H start [**12-2**]
Docusate Sodium 100 mg PO BID
PredniSONE 40 mg PO/NG DAILY
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Racepinephrine 0."
879,"Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: venous stasis changes in lower extremity; cellulitis is
significantly improved
Pertinent Results:
On Admission:
[**2134-11-26**] 04:15PM BLOOD WBC-6.9 RBC-4.03* Hgb-12.6 Hct-38.9
MCV-97 MCH-31.3 MCHC-32.4 RDW-12.5 Plt Ct-428
[**2134-11-28**] 08:10AM BLOOD PT-12.2 PTT-22.6* INR(PT)-1.1
[**2134-11-26**] 03:30PM BLOOD Glucose-97 UreaN-13 Creat-0.6 Na-145
K-3.5 Cl-105 HCO3-32 AnGap-12
[**2134-12-4**] 08:32AM BLOOD ALT-28 AST-24 LD(LDH)-158 AlkPhos-80
TotBili-0."
880,".
# HTN - The patient has a h/o HTN and was on atenolol at home.
This was changed to metoprolol in house and she will be
discharged with plans to continue metoprolol.
.
# RA - Has a history of what is apparently rather severe RA. Not
on any medications to control disease at home. Attempted to
contact the patient's rheumatologist although he has apparently
recently retired.
.
# Transitional Issues:
1) Continue Ceftriaxone to complete a 1 month course and
follow-up with infectious disease clinic as scheduled.
2) Recommend referral to see a new rheumatologist (former
rheumatologist retired) and a pulmonologist.
3) Continue Metoprolol 200mg daily for atrial fibrillation
4) Continue coumadin daily and follow-up with [**State 95465**] [**Hospital 2786**] clinic
5) Complete steroid taper and course of azithromycin"
881,"Does describe weeping from the lesion. In the ED she developed
afib with RVR and was treated with IV and oral metoprolol and
admitted to medicine for further work-up of new afib.
.
On the floor, she was continued on metoprolol for afib. She was
treated with ceftriaxone for cellulitis but blood cultures
turned positive for strep viridans. Thus, a TTE was ordered
which showed possible aortic valve vegetation. A TEE was
performed today to better characterize the vegetation but during
the procedure she became stridorous.
.
She was treated with nebulizers and IV steroids for presumed
COPD exacerbation. She also had magnesium, furosemide x1, and
metoprolol IV x 2."
882,"CVICU
HPI:
HD3 POD 1-CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
Ejection Fraction:30
Hempglobin A1c:5.3
Pre-Op Weight:190.26 lbs 86.3 kgs
Baseline Creatinine:0.9
PMHx:
PMH: Dyslipidemia, Hypertension, +ETT, Peripheral vascular disease- b/l
lower extremities, depression, +tob
MEDS: simvastatin 40', candesartan 32', doxycycline 20', Imdur 30',
chlorthalidone 25', fluoxetine 40', dicyclomine 10', NTG-sl .4/prn,
[**Last Name (LF) 9543**], [**First Name3 (LF) **] 81', Paxil 40'
Current medications:
. Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6. CefazoLIN 8.
Docusate Sodium 9. Furosemide 10. Insulin 11. Ketorolac . Magnesium
Sulfate 14."
883,"2/31.3/1.0, CK / CK-MB / Troponin
T:176//0.04, Fibrinogen:202 mg/dL, Lactic Acid:1.2 mmol/L, Ca:9.1
mg/dL, Mg:1.8 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
KNOWLEDGE DEFICIT, CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART
DISEASE), PERIPHERAL VASCULAR DISEASE (PVD) WITHOUT CRITICAL LIMB
ISCHEMIA
Assessment and Plan: 59yo man s/p CABGx4. Preop IABP removed
post-operatively. Hemodynamically stable
Neurologic: Pain controlled, percocet and Toradol for pain control
Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,
wean Epi infusion to off. Then start BBlockers and titrate to BP/HR
Pulmonary: IS, OOB-today
Gastrointestinal / Abdomen:
Nutrition: Regular diet, Advance diet as tolerated
Renal: Foley, begin diuretics to make net negative 1-1."
884,"37/37/106/24/-3
Ve: 9.3 L/min
PaO2 / FiO2: 212
Physical Examination
General Appearance: No acute distress, Well nourished
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -
Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)
Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -
Posterior tibial: Diminished)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
147 K/uL
11.2 g/dL
127
0."
885,"Metoclopramide 15. Milk of Magnesia 16. Morphine Sulfate
17. Nitroglycerin 18. Oxycodone-Acetaminophen 19. Paroxetine 20.
Phenylephrine 21. Potassium Chloride 22. Ranitidine 23. Simvastatin
24 Hour Events:
NASAL SWAB - At [**2124-8-1**] 12:19 PM
OR RECEIVED - At [**2124-8-1**] 12:19 PM
INVASIVE VENTILATION - START [**2124-8-1**] 12:19 PM
IABP LINE - START [**2124-8-1**] 01:06 PM
ARTERIAL LINE - START [**2124-8-1**] 01:08 PM
SHEATH - START [**2124-8-1**] 01:10 PM
arterial
PA CATHETER - START [**2124-8-1**] 01:12 PM
CORDIS/INTRODUCER - START [**2124-8-1**] 01:13 PM
SHEATH - STOP [**2124-8-1**] 01:54 PM
arterial
EKG - At [**2124-8-1**] 02:21 PM
IABP LINE - STOP [**2124-8-1**] 03:55 PM
EXTUBATION - At [**2124-8-2**] 06:35 AM
Post operative day:
[**8-2**] HD3 POD 1-CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2124-8-1**] 11:55 PM
Infusions:
Epinephrine - 0."
886,"6 mg/dL
24 mEq/L
3.8 mEq/L
5 mg/dL
104 mEq/L
131 mEq/L
32.8 %
8.0 K/uL
[image002.jpg]
[**2124-8-2**] 12:02 AM
[**2124-8-2**] 01:00 AM
[**2124-8-2**] 02:00 AM
[**2124-8-2**] 03:00 AM
[**2124-8-2**] 03:10 AM
[**2124-8-2**] 04:00 AM
[**2124-8-2**] 05:00 AM
[**2124-8-2**] 05:20 AM
[**2124-8-2**] 05:51 AM
[**2124-8-2**] 06:00 AM
WBC
8.0
Hct
32.8
Plt
147
Creatinine
0.6
TCO2
22
23
23
22
Glucose
111
110
103
104
76
127
Other labs: PT / PTT / INR:12."
887,"01 mcg/Kg/min
Phenylephrine - 0.5 mcg/Kg/min
Insulin - Regular - 2 units/hour
Other ICU medications:
Insulin - Regular - [**2124-8-1**] 04:41 PM
Sodium Bicarbonate 8.4% (Amp) - [**2124-8-1**] 05:30 PM
Ranitidine (Prophylaxis) - [**2124-8-1**] 06:01 PM
Morphine Sulfate - [**2124-8-2**] 06:46 AM
Flowsheet Data as of [**2124-8-2**] 07:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**26**] a.m.
Tmax: 38
C (100.4
T current: 37.8
C (100
HR: 86 (52 - 118) bpm
BP: 96/54(69) {79/42(60) - 125/70(90)} mmHg
RR: 19 (11 - 25) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 99 kg (admission): 88."
888,"3 kg
Height: 65 Inch
CVP: 5 (5 - 17) mmHg
PAP: (25 mmHg) / (10 mmHg)
CO/CI (Thermodilution): (5.18 L/min) / (3.4 L/min/m2)
CO/CI (Fick): (6.8 L/min) / (3.5 L/min/m2)
SVR: 798 dynes*sec/cm5
Mixed Venous O2% sat: 78 - 78
SV: 78 mL
SVI: 40 mL/m2
Total In:
9,982 mL
665 mL
PO:
Tube feeding:
IV Fluid:
9,607 mL
665 mL
Blood products:
375 mL
Total out:
3,470 mL
830 mL
Urine:
3,170 mL
660 mL
NG:
Stool:
Drains:
Balance:
6,512 mL
-165 mL
Respiratory support
O2 Delivery Device: Face tent
Ventilator mode: SIMV/PSV/AutoFlow
Vt (Set): 600 (600 - 600) mL
Vt (Spontaneous): 574 (574 - 628) mL
PS : 5 cmH2O
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
RSBI: 64
PIP: 26 cmH2O
Plateau: 18 cmH2O
SPO2: 100%
ABG: 7."
889,"5 liters/day
Monitor BUN/Cr
post-op acidosis improved after volume resuscitation
Hematology: stable hct
Endocrine: Insulin drip, convert to lantus/RISS
Infectious Disease: No active issues
Afebrile, normal WBC
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Imaging: CXR today, after chest tubes removed
Consults: CT surgery, P.T., Nutrition
ICU Care
Nutrition: cardiac diet/ADAT
Glycemic Control: Lantus (R) protocol
Lines:
Arterial Line - [**2124-8-1**] 01:08 PM
PA Catheter - [**2124-8-1**] 01:12 PM
Cordis/Introducer - [**2124-8-1**] 01:13 PM
16 Gauge - [**2124-8-1**] 01:16 PM
20 Gauge - [**2124-8-1**] 07:25 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care
Communication: Patient discussed on interdisciplinary rounds , ICU
consent signed:
Code status: Full code
Disposition: ICU"
890,"Cath showed 3VD. Intra-aortic balloon
placed to improved coronary flow. Upon admission to floor,
nitro gtt was restarted. Heparin IV as well as IABP heparin
protocol started. He had residual pain that resolved upon
resuming nitro gtt. EKG initially showed isolated STE in V2
with T-wave inversion in avL and V3. Enzymes trended. Denied
any chest pain overnight. Was seen and evaluated by CT [**Doctor First Name **].
Mr. [**Known lastname 2816**] was taken to the OR for CABG x4 (LIMA-LAD, SVG-diag,
SVG-OM, SVG-PDA)on [**8-1**]. IABP was removed post-opeeratively.
Immediately after surgery Mr."
891,"Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease
dyslipidemia
peripheral vascular disease depression
hypertension
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]"
892,"Dr. [**Last Name (STitle) **] 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] 1 week
Dr. [**Last Name (STitle) **] [**1-18**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Sternal Precautions
No lifting greater than 10 pounds for 10 weeks
No driving for 1 month and off narcotics
Cardipulmonary Assessment
Wound Care
Medication Compliance
Follow up appointment compliance
[**Hospital1 **] INSTRUCTIONS:
Dr. [**Last Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) **] 3 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name (STitle) **],THEVERTHUDIYIL K. [**Telephone/Fax (1) 82904**] in 1 week
Dr. [**Last Name (STitle) 911**] in [**1-18**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2124-8-5**]"
893,"CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Slightly cool to palpation. Right cooler than left
Pulses dopplerable. No signs of erythema, ulcers. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Popliteal 2+ DP/PT Doppler
[**Name (NI) 2325**]: Carotid 2+ Popliteal 2+ DP/PT Doppler
Pertinent Results:
[**2124-7-31**] 02:15PM BLOOD %HbA1c-5.3
[**2124-7-31**] 02:15PM BLOOD Triglyc-162* HDL-69 CHOL/HD-3.1
LDLcalc-111
CARDIAC CATH: [**2124-7-31**]
LAD: ostial 95%."
894,"3 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: 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. Moderately
dilated LV cavity. Moderate regional LV systolic dysfunction.
Moderately depressed LVEF.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Focal calcifications in aortic root."
895,"Heavy Calcium mid vessel 95%, distal 50%, D1
and D2 with origin 50%.
LCX: mid vessel 50%. OM2 has total occlusion with collaterals
from LAD filling the distal vessel. LPLV has proximal 20%
stenosis.
RCA: Total occlusion with collaterals from LCA.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82902**] (Complete)
Done [**2124-8-1**] at 9:09:21 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2065-2-23**]
Age (years): 59 M Hgt (in): 66
BP (mm Hg): / Wgt (lb): 190
HR (bpm): BSA (m2): 1."
896,"At this time, he
is not having any chest pain.
.
Admitted to CCU with plans to undergo CABG on [**8-1**].
.
On review of systems, 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. Hhe denies recent fevers, chills or
rigors. He reports denies exertional buttock and calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain
at present, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope."
897,"[**Known lastname 2816**] was admitted to the CVICU
intubated, sedated and on epi and levo. Mr. [**Known lastname 2816**] was
extubated on POD#1 and epi and levo were weaned off. Chest tubes
were removed and Mr. [**Known lastname 2816**] was transferred to the floor on
POD#2. He was started on diuresis, betablockade and stain
therapy. Pacing wires were removed on POD#3. He was evaluated by
physical therapy and cleared for d/c home on POD#4.
Medications on Admission:
simvastatin 40', candesartan 32', doxycycline 20', Imdur 30',
chlorthalidone 25', fluoxetine 40', dicyclomine 10', NTG-sl
.4/prn,
[**Last Name (LF) 82903**], [**First Name3 (LF) **] 81', Paxil 40'"
898,"There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion. An intra-aortic balloon (IAB) is seen with
its tip at the level of the distal aortic arch/proximal
descending aortic transition area. Dr. [**Last Name (STitle) 914**] was notified in
person of the results in the operating room at the time of the
study.
POST BYPASS The patient is receiving epinephrine by infusion."
899,"Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
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."
900,".
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
-CABG: Planned for [**8-1**]
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
-Positive stress test
3. OTHER PAST MEDICAL HISTORY:
Peripheral vascular disease- b/l lower extremities
Social History:
He is currently laid off, but he used to work inmodification of
vehicles for people with disabilities.
Functional activity, he continues to go to the gym doing mostly
weight training because his claudication prevents him from doing
walking, running, or other aerobics. Intentionally lost 30
pounds and 3 inches of his waist line over the past three years."
901,"Normal ascending
aorta diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm."
902,"Admission Date: [**2124-7-31**] Discharge Date: [**2124-8-5**]
Date of Birth: [**2065-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cath- [**7-31**]
CABG- [**8-1**]
History of Present Illness:
Patient is a 59yo male with multiple cardiac risk factors
presenting with chest pain during cath procedure today. Balloon
pump placed and pain resolved. Currently is asymptomatic and
stable.
.
He reports recent worsening of this ""chest sensation"" in the
last month. Said in the last week, he has used his nitro
4-5x/day."
903,"He follows a low-fat diet.
Family History:
His mother died at age 85. His father is 88 with heart disease
and lung cancer. Father had a CABG in his 70s
Physical Exam:
GENERAL: WDWN man 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 no JVP.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4. difficult to auscultate given balloon pump
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use."
904,"Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with mid-distal anterior, anteroseptal and
apical severe hypokinesis/akinesis. No apical thrombus is seen.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-35%%). The right ventricle displays
borderline normal free wall function."
905,"96 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 440.0, 410.92
Test Information
Date/Time: [**2124-8-1**] at 09:09 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Ascending: 3."
906,"Up until one month ago, he ""never"" used his nitro.
Reports some additional anxiety since he got the stress test
results back and thinks that is contributing to his increased
use of nitro. Denies having any chest pressure, just this
sensation which is described as follows: starts with a tightened
sensation in his throat that progresses down to his heart. Does
not occur at rest. Denies any radiation of pain, jaw
claudication, syncope, shortness of breath, diaphoresis, or
palpitations. Says this is the same sensation he had while in
the cath lab today and when he got to the CCU."
907,"There is normal right ventricular systolic function. The focal
abnormalities of the apical, anterior, and anteropseptal walls
noted in the pre-bypass study are improved and now display mild
hypokinesis. The left ventricular systolic function is now in
the 40 to 45% range. Valvular function is unchanged. The
thoracic aorta appears intact. The IAB remains as noted in the
pre-bypass study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2124-8-1**] 13:39
Brief Hospital Course:
Angina- Patient experienced angina while undergoing cath
procedure on [**7-31**]."
908,"C.)(s)* Refills:*2*
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. [**First Name3 (LF) 82903**] Oral
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching."
909,"38///25/
Physical Examination
General Appearance: No acute distress, Overweight / Obese
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, No(t)
Obese
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
105 K/uL
9.8 g/dL
129 mg/dL
0."
910,"2 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2124-8-2**] 08:05 PM
Flowsheet Data as of [**2124-8-3**] 09:24 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**26**] a.m.
Tmax: 37.4
C (99.3
T current: 37
C (98.6
HR: 85 (77 - 92) bpm
BP: 111/70(80) {0/0(0) - 116/78(87)} mmHg
RR: 26 (16 - 30) insp/min
SPO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 99 kg (admission): 88.3 kg
Height: 65 Inch
CVP: 11 (11 - 11) mmHg
PAP: (39 mmHg) / (17 mmHg)
Total In:
1,954 mL
292 mL
PO:
480 mL
Tube feeding:
IV Fluid:
1,474 mL
292 mL
Blood products:
Total out:
3,545 mL
360 mL
Urine:
2,955 mL
320 mL
NG:
Stool:
Drains:
Balance:
-1,591 mL
-68 mL
Respiratory support
O2 Delivery Device: None
SPO2: 94%
ABG: 7."
911,"7 mg/dL
25 mEq/L
3.2 mEq/L
7 mg/dL
100 mEq/L
131 mEq/L
28.2 %
9.1 K/uL
[**2124-8-2**] 01:00 AM
[**2124-8-2**] 02:00 AM
[**2124-8-2**] 03:00 AM
[**2124-8-2**] 03:10 AM
[**2124-8-2**] 04:00 AM
[**2124-8-2**] 05:00 AM
[**2124-8-2**] 05:20 AM
[**2124-8-2**] 05:51 AM
[**2124-8-2**] 06:00 AM
[**2124-8-3**] 01:11 AM
WBC
8.0
9.1
Hct
32.8
28.2
Plt
147
105
Creatinine
0."
912,"TITLE: Intensivist
Surgical Critical Care Note
CVICU
HPI:
HD4 POD 2-CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
Ejection Fraction:30
Hempglobin A1c:5.3
Pre-Op Weight:190.26 lbs 86.3 kgs
Baseline Creatinine:0.9
[**Last Name (LF) 9543**], [**First Name3 (LF) **] 81', Paxil 40'
Assessment:59yoM s/p CABG X$(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)[**8-1**]
PMHx:
PMH: Dyslipidemia, Hypertension, +ETT, Peripheral vascular disease- b/l
lower extremities, depression, +tob
MEDS: simvastatin 40', candesartan 32', doxycycline 20', Imdur 30',
chlorthalidone 25', fluoxetine 40', dicyclomine 10', NTG-sl .4/prn,
Current medications:
Acetaminophen 4."
913,"Aspirin EC 5. Calcium Gluconate 6. Carvedilol 7.
Dextrose 50% 8. DiphenhydrAMINE 9. Docusate Sodium 10. Furosemide 11.
Hydrocodone-Acetaminophen 12. Insulin 13. Ketorolac 14. Magnesium
Sulfate 15. Metoclopramide 16. Milk of Magnesia 17. Morphine Sulfate
18. Paroxetine Potassium Chloride 21. Ranitidine 22. Simvastatin 23.
Sodium Chloride 0.9% Flush
24 Hour Events:
PA CATHETER - STOP [**2124-8-2**] 10:13 AM
ARTERIAL LINE - STOP [**2124-8-3**] 01:30 AM
Weaned Neo infusion
Post operative day:
[**8-3**] HD4 POD 2-CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
Allergies:
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
Itching;
Last dose of Antibiotics:
Cefazolin - [**2124-8-2**] 04:00 PM
Infusions:
Phenylephrine - 0."
914,"Neurologic: Pain controlled, pain control with Vicodan and toradol
fluoxetine resumed
Cardiovascular: Aspirin, Statins, start B-blockers today
Pulmonary: IS, Discontinue chest tube(s), OOB-ambulate
Gastrointestinal / Abdomen:
Nutrition: Regular diet
Renal: Lasix to keep net negative 1-1.5 liters/day. Hyponatremia preop
with some resolution postop. Borderline serum hypoosmolarity. Low uric
acid. Free water restriction to 500cc/day
Monitor BUN/Cr
Hematology: stable anemia
Endocrine: RISS
Infectious Disease: no active issues
afebrile, normal wbc
Lines / Tubes / Drains: Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Imaging: CXR today, after chest tubes removed
Fluids:
Consults: CT surgery, P.T., Nutrition
ICU Care
Nutrition: cardiac diet
Glycemic Control: RISS
Lines: Cordis/Introducer - [**2124-8-1**] 01:13 PM
20 Gauge - [**2124-8-1**] 07:25 PM
Prophylaxis:
DVT: (ambulate today)
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: Transfer to floor Time spent : 31 min"
915,"6
0.7
TCO2
23
23
22
Glucose
111
110
103
104
76
127
129
Other labs: PT / PTT / INR:12.2/31.3/1.0, CK / CK-MB / Troponin
T:176//0.04, Fibrinogen:202 mg/dL, Lactic Acid:1.2 mmol/L, Ca:9.1
mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), KNOWLEDGE DEFICIT, CORONARY
ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE), PERIPHERAL VASCULAR
DISEASE (PVD) WITHOUT CRITICAL LIMB ISCHEMIA
Assessment and Plan: 59yo man s/p CABG x4, hypotension requiring
Neosynephrine infusion on POD1 now weaned off."
916,"LPLV has proximal 20% stenosis.
RCA: Total occlusion with collaterals from LCA.
Assessment and Plan
ASSESSMENT AND PLAN
.
# CORONARIES: Cath showed 3VD. patient now reports increased frequency
of his angina in the last week (using nitro [**3-19**]/day). EKG showed
isolated ST-elevation in V2. Currently asymptomatic on nitro gtt.
- nitro gtt
- hold home PO nitro
- simvastatin 40mg daily
- aspirin 81mg daily
- CT [**Doctor First Name 213**] following
- CABG- hopefully tomorrow
- NPO after midnight
- carotid ultrasound
- trend enzymes given new ekg changes s/p cath.
.
# PUMP: IABP placed in cath lab. Holding canbdesartan given marginal
blood pressures. Will not add beta blocker given marginal blood
pressure on balloon pump.
- continue IABP
- check platelets
- on heparin IABP protocol
- monitor pressures
.
# RHYTHM: Sinus rhythm with rate in the 80s, frequent PVC's.
.
# Anxiety: continue paroxetine, ativan prn.
.
# Impacted Wisdom tooth. Will continue home dose doxycycline.
.
FEN: NPO past midnight. heart healthy diet otherwise.
.
ACCESS: PIV's
.
PROPHYLAXIS:
-DVT ppx with IV heparin
-Pain management with
-Bowel regimen with colace, senna
.
CODE: full
.
COMM: [**Name (NI) 946**] [**Name (NI) 9507**] (brother)- [**Telephone/Fax (1) 9508**]
[**Name (NI) 8**] [**Name (NI) 9509**] (girlfriend)- [**Telephone/Fax (1) 9510**]
.
DISPO: CCU for now"
917,"All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain at
present, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Review of Systems
Organ system ROS normal
Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,
Hematology / Lymphatic, Genitourinary, Musculoskeletal, Integumentary,
Neurological, Psychiatric, Allergy / Immune
Signs and symptoms absent
Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,
Bleeding during surgery, Joint pains, Myalgias
Social History
Social history details: He is currently laid off, but he used to work
inmodification of vehicles for people with disabilities.
Functional activity, he continues to go to the gym doing mostly
weight training because his claudication prevents him from doing
walking, running, or other aerobics."
918,"sublingual nitroglycerin 0.4 mg
8. Chantix
9. aspirin 81 mg daily
10. Prilosec 1 one tablet daily.
Cardiovascular ROS
Cardiovascular ROS Signs and Symptoms Present
Chest pain, Claudication
Cardiovascular ROS Signs and Symptoms Absent
Murmur, Rheumatic fever, SOB, DOE, PND, Orthopnea, Edema, Palpitations,
Syncope, Presyncope, Lightheadedness, TIA / CVA, DVT, Exertional
buttock pain, Exertional calf pain
Cardiovascular ROS Details: On review of systems, 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. Hhe denies recent fevers,
chills or rigors. He reports denies exertional buttock and calf pain."
919,"CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
difficult to auscultate given balloon pump
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were
unlabored, no accessory muscle use. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: Slightly cool to palpation. Right cooler than left Pulses
dopplerable. No signs of erythema, ulcers. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Popliteal 2+ DP/PT Doppler
[**Name (NI) **]: Carotid 2+ Popliteal 2+ DP/PT Doppler
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and
palette: WNL)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Jugular veins: JVP, 8cm)
Back / Musculoskeletal: (Chest wall structure: WNL)
Respiratory: (Effort: WNL), (Auscultation: WNL)
Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:
WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (WNL)
Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:
No bruit)
Extremities / Musculoskeletal: (Gait and station: WNL), (Muscle
strength and tone: WNL)
Skin: ( WNL)
Labs
146
12."
920,"Denies having any
chest pressure, just this sensation which is described as follows:
starts with a tightened sensation in his throat that progresses down to
his heart. Does not occur at rest. Denies any radiation of pain, jaw
claudication, syncope, shortness of breath, diaphoresis, or
palpitations. Says this is the same sensation he had while in the cath
lab today and when he got to the CCU. At this time, he is not having
any chest pain.
.
Admitted to CCU with plans to undergo CABG on [**8-1**].
Past medical history: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)
Dyslipidemia, (+) Hypertension
2. CARDIAC HISTORY:
-CABG: Planned for [**8-1**]
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
-Positive stress test
3."
921,"PVCs. left axis. T-wave inversion in avL and V3
Echocardiogram: (Date: [**7-17**]), STRESS ECHOCARDIOGRAM: Non-specific ECG
changes with 2D echocardiographic evidence of prior myocardial
infarction without inducible ischemia to achieved workload. Hypotensive
response to dobutamine.
.
Dobutamine infusion terminated secondary to symptomatic
hypotensive blood pressure response with probable anginal symptoms in
the absence of ischemic ST segment changes. Echo report sent
separately.
Cardiac Cath: (Date: [**7-31**]), LAD: ostial 95%. Heavy Calcium mid vessel
95%, distal 50%, D1 and D2 with origin 50%.
LCX: mid vessel 50%. OM2 has total occlusion with collaterals from LAD
filling the distal vessel."
922,"Intentionally lost 30 pounds and
3 inches of his waist line over the past three years. He follows a
low-fat diet.
.
-Tobacco history: Quit one week ago (1ppd x 30 years)
-ETOH: 4 glasses of wine/week
-Illicit drugs: None
Physical Exam
Height: 65 Inch, 165 cm
Vital sign details: VS: T= 97.7 BP= 107/64 HR= 78 RR= 12 O2 sat= 99% on
2L
GENERAL: WDWN man 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 no JVP."
923,"OTHER PAST MEDICAL HISTORY:
Peripheral vascular disease- b/l lower extremities
CAD Risk Factors
CAD Risk Factors Present
Dyslipidemia, Hypertension
CAD Risk Factors Absent
Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death
(Tobacco: Yes), (Quit: Yes), (Cigarettes: .5 packs / day x 30 yrs),
(Discontinue tobacco: yes)
Cardiovascular Procedural History
There is no history of:
PCI
CABG
Pacemaker / ICD
Allergies: NKDA
No Known Drug Allergies
Current medications: 1. simvastatin 40 mg daily
2. candesartan 32 mg daily
3. doxycycline 20 mg daily
4. chlorthalidone 25 mg daily
5. fluoxetine 40 mg daily
6. dicyclomine 10 mg daily
7."
924,"2
89
0.9
29
3.0
12
93
130
34.6
5.1
[image002.jpg]
[**2124-7-31**] 04:39 PM
Na+
130
K + (Serum)
3.0
Cl
93
HCO3
29
BUN
12
Creatinine
0.9
Glucose
89
CK
74
ABG: / / / 29 / Values as of [**2124-7-31**] 04:39 PM
Tests
ECG: (Date: [**7-31**]), EKG: Pre-cath [**7-31**] 10:26am- sinus rhythm, no
ischemic changes. rate of 78. left axis, normal intervals. No LVH,
BBB. T-wave inversion in aVL, V1-V5
Post-cath [**7-31**]- 15:25- isolated STE in V2. sinus rhythm, normal
intervals."
925,"Date of service: [**2124-7-31**]
Initial visit, Cardiology service: CCU
Presenting complaint: Chest pain, Claudication
History of present illness: Patient is a 59yo male with multiple
cardiac risk factors presenting with chest pain during cath procedure
today. Balloon pump placed and pain resolved. Currently is
asymptomatic and stable.
.
He reports recent worsening of this ""chest sensation"" in the last
month. Said in the last week, he has used his nitro 4-5x/day. Up
until one month ago, he ""never"" used his nitro. Reports some
additional anxiety since he got the stress test results back and thinks
that is contributing to his increased use of nitro."
926,"Intentionally lost 30 pounds and
3 inches of his waist line over the past three years. He follows a
low-fat diet.
.
-Tobacco history: Quit one week ago (1ppd x 30 years)
-ETOH: 4 glasses of wine/week
-Illicit drugs: None
Physical Exam
Height: 65 Inch, 165 cm
Vital sign details: VS: T= 97.7 BP= 107/64 HR= 78 RR= 12 O2 sat= 99% on
2L
GENERAL: WDWN man 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 no JVP."
927,"- continue IABP
- check platelets
- on heparin IABP protocol
- monitor pressures
.
# RHYTHM: Sinus rhythm with rate in the 80s, frequent PVC's.
.
#Hyponatremia: euvolemic on exam. Differential includes SIADH,
hypothyroid, adrenal insufficiency.
-U lytes
-serum osm
.
# Anxiety: continue paroxetine, ativan prn.
.
# Impacted Wisdom tooth. Will continue home dose doxycycline.
.
FEN: NPO past midnight. heart healthy diet otherwise.
.
ACCESS: PIV's
.
PROPHYLAXIS:
-DVT ppx with IV heparin
-Pain management with
-Bowel regimen with colace, senna
.
CODE: full
.
COMM: [**Name (NI) 946**] [**Name (NI) 9507**] (brother)- [**Telephone/Fax (1) 9508**]
[**Name (NI) 8**] [**Name (NI) 9509**] (girlfriend)- [**Telephone/Fax (1) 9510**]
.
DISPO: CCU for now
------ Protected Section ------
Attending
s Note
Reviewed data,clinical presentation and cath findings.
Examined pt.
Agree with present treatment and need for urgent CABG
Spent 45mins on case
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6658**]
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Name (NI) 6658**]
on:[**2124-7-31**] 18:18 ------"
928,"Denies having any
chest pressure, just this sensation which is described as follows:
starts with a tightened sensation in his throat that progresses down to
his heart. Does not occur at rest. Denies any radiation of pain, jaw
claudication, syncope, shortness of breath, diaphoresis, or
palpitations. Says this is the same sensation he had while in the cath
lab today and when he got to the CCU. At this time, he is not having
any chest pain.
.
Admitted to CCU with plans to undergo CABG on [**8-1**].
Past medical history: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)
Dyslipidemia, (+) Hypertension
2. CARDIAC HISTORY:
-CABG: Planned for [**8-1**]
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
-Positive stress test
3."
929,"PVCs. left axis. T-wave inversion in avL and V3
Echocardiogram: (Date: [**7-17**]), STRESS ECHOCARDIOGRAM: Non-specific ECG
changes with 2D echocardiographic evidence of prior myocardial
infarction without inducible ischemia to achieved workload. Hypotensive
response to dobutamine.
.
Dobutamine infusion terminated secondary to symptomatic
hypotensive blood pressure response with probable anginal symptoms in
the absence of ischemic ST segment changes. Echo report sent
separately.
Cardiac Cath: (Date: [**7-31**]), LAD: ostial 95%. Heavy Calcium mid vessel
95%, distal 50%, D1 and D2 with origin 50%.
LCX: mid vessel 50%. OM2 has total occlusion with collaterals from LAD
filling the distal vessel."
930,"OTHER PAST MEDICAL HISTORY:
Peripheral vascular disease- b/l lower extremities
CAD Risk Factors
CAD Risk Factors Present
Dyslipidemia, Hypertension
CAD Risk Factors Absent
Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death
(Tobacco: Yes), (Quit: Yes), (Cigarettes: .5 packs / day x 30 yrs),
(Discontinue tobacco: yes)
Cardiovascular Procedural History
There is no history of:
PCI
CABG
Pacemaker / ICD
Allergies: NKDA
No Known Drug Allergies
Current medications: 1. simvastatin 40 mg daily
2. candesartan 32 mg daily
3. doxycycline 20 mg daily
4. chlorthalidone 25 mg daily
5. fluoxetine 40 mg daily
6. dicyclomine 10 mg daily
7."
931,"Date of service: [**2124-7-31**]
Initial visit, Cardiology service: CCU
Presenting complaint: Chest pain, Claudication
History of present illness: Patient is a 59yo male with multiple
cardiac risk factors presenting with chest pain during cath procedure
today. Balloon pump placed and pain resolved. Currently is
asymptomatic and stable.
.
He reports recent worsening of this ""chest sensation"" in the last
month. Said in the last week, he has used his nitro 4-5x/day. Up
until one month ago, he ""never"" used his nitro. Reports some
additional anxiety since he got the stress test results back and thinks
that is contributing to his increased use of nitro."
932,"CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
difficult to auscultate given balloon pump
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were
unlabored, no accessory muscle use. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: Slightly cool to palpation. Right cooler than left Pulses
dopplerable. No signs of erythema, ulcers. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Popliteal 2+ DP/PT Doppler
[**Name (NI) **]: Carotid 2+ Popliteal 2+ DP/PT Doppler
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and
palette: WNL)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Jugular veins: JVP, 8cm)
Back / Musculoskeletal: (Chest wall structure: WNL)
Respiratory: (Effort: WNL), (Auscultation: WNL)
Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:
WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (WNL)
Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:
No bruit)
Extremities / Musculoskeletal: (Gait and station: WNL), (Muscle
strength and tone: WNL)
Skin: ( WNL)
Labs
146
12."
933,"2
89
0.9
29
3.0
12
93
130
34.6
5.1
[image002.jpg]
[**2124-7-31**] 04:39 PM
Na+
130
K + (Serum)
3.0
Cl
93
HCO3
29
BUN
12
Creatinine
0.9
Glucose
89
CK
74
ABG: / / / 29 / Values as of [**2124-7-31**] 04:39 PM
Tests
ECG: (Date: [**7-31**]), EKG: Pre-cath [**7-31**] 10:26am- sinus rhythm, no
ischemic changes. rate of 78. left axis, normal intervals. No LVH,
BBB. T-wave inversion in aVL, V1-V5
Post-cath [**7-31**]- 15:25- isolated STE in V2. sinus rhythm, normal
intervals."
934,"sublingual nitroglycerin 0.4 mg
8. Chantix
9. aspirin 81 mg daily
10. Prilosec 1 one tablet daily.
Cardiovascular ROS
Cardiovascular ROS Signs and Symptoms Present
Chest pain, Claudication
Cardiovascular ROS Signs and Symptoms Absent
Murmur, Rheumatic fever, SOB, DOE, PND, Orthopnea, Edema, Palpitations,
Syncope, Presyncope, Lightheadedness, TIA / CVA, DVT, Exertional
buttock pain, Exertional calf pain
Cardiovascular ROS Details: On review of systems, 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. Hhe denies recent fevers,
chills or rigors. He reports denies exertional buttock and calf pain."
935,"LPLV has proximal 20% stenosis.
RCA: Total occlusion with collaterals from LCA.
Assessment and Plan
ASSESSMENT AND PLAN
.
# CORONARIES: Cath showed 3VD. patient now reports increased frequency
of his angina in the last week (using nitro [**3-19**]/day). EKG showed
isolated ST-elevation in V2. Currently asymptomatic on nitro gtt.
- nitro gtt
- hold home PO nitro
- simvastatin 40mg daily
- aspirin 81mg daily
- CT [**Doctor First Name 213**] following
- CABG- hopefully tomorrow
- NPO after midnight
- carotid ultrasound
- trend enzymes given new ekg changes s/p cath.
.
# PUMP: IABP placed in cath lab. Holding canbdesartan given marginal
blood pressures. Will not add beta blocker given marginal blood
pressure on balloon pump."
936,"All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain at
present, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Review of Systems
Organ system ROS normal
Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,
Hematology / Lymphatic, Genitourinary, Musculoskeletal, Integumentary,
Neurological, Psychiatric, Allergy / Immune
Signs and symptoms absent
Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,
Bleeding during surgery, Joint pains, Myalgias
Social History
Social history details: He is currently laid off, but he used to work
inmodification of vehicles for people with disabilities.
Functional activity, he continues to go to the gym doing mostly
weight training because his claudication prevents him from doing
walking, running, or other aerobics."
937,"Then start B-Blocker and titrate to BP/HR
Pulmonary: IS, OOB-today
Gastrointestinal / Abdomen: no issues
Nutrition: Regular diet, Advance diet as tolerated
Renal: Foley, begin diuretics to make net negative 1-1.5 liters/day
Monitor BUN/Cr
post-op acidosis improved after volume resuscitation O/N
Hematology: stable hct
Endocrine: Insulin drip, convert to lantus/RISS, postop hyponatremia
managed with NS. Partially resolved
Infectious Disease: No active issues
Afebrile, normal WBC
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube
mediastinal follow output. Pacing wires
Wounds: Dry dressings
Imaging: CXR today, after chest tubes removed
Consults: CT surgery, P.T., Nutrition
ICU Care
Nutrition: cardiac diet/ADAT
Glycemic Control: Lantus (R) protocol
Lines:
Arterial Line - [**2124-8-1**] 01:08 PM
PA Catheter - [**2124-8-1**] 01:12 PM
Cordis/Introducer - [**2124-8-1**] 01:13 PM
16 Gauge - [**2124-8-1**] 01:16 PM
20 Gauge - [**2124-8-1**] 07:25 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care
Communication: Patient discussed on interdisciplinary rounds , ICU
consent signed:
Code status: Full code
Disposition: ICU"
938,"37/37/106/24/-3
Ve: 9.3 L/min
PaO2 / FiO2: 212
Physical Examination
General Appearance: No acute distress, Well nourished
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -
Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)
Right Extremities: (Edema: Trace), (Temperature: Cool), (Pulse -
Posterior tibial: Diminished)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
147 K/uL
11.2 g/dL
127
0."
939,"2/31.3/1.0, CK / CK-MB / Troponin
T:176//0.04, Fibrinogen:202 mg/dL, Lactic Acid:1.2 mmol/L, Ca:9.1
mg/dL, Mg:1.8 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
KNOWLEDGE DEFICIT, CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART
DISEASE), PERIPHERAL VASCULAR DISEASE (PVD) WITHOUT CRITICAL LIMB
ISCHEMIA
Assessment and Plan: 59yo man s/p CABGx4. Preop IABP removed
post-operatively R LE color improved. Hemodynamically stable.
Neurologic: Pain controlled, percocet and Toradol for pain control
Cardiovascular: 1. toleraged d/c of IABP 2. Aspirin, Beta-blocker,
Statins, Discontinue PA monitor, wean Epi first then Neo infusion to
off."
940,"Ketorolac . Magnesium
Sulfate 14. Metoclopramide 15. Milk of Magnesia 16. Morphine Sulfate
17. Nitroglycerin 18. Oxycodone-Acetaminophen 19. Paroxetine 20.
Phenylephrine 21. Potassium Chloride 22. Ranitidine 23. Simvastatin
24 Hour Events:
NASAL SWAB - At [**2124-8-1**] 12:19 PM
OR RECEIVED - At [**2124-8-1**] 12:19 PM
INVASIVE VENTILATION - START [**2124-8-1**] 12:19 PM
IABP LINE - START [**2124-8-1**] 01:06 PM
ARTERIAL LINE - START [**2124-8-1**] 01:08 PM
SHEATH - START [**2124-8-1**] 01:10 PM
arterial
PA CATHETER - START [**2124-8-1**] 01:12 PM
CORDIS/INTRODUCER - START [**2124-8-1**] 01:13 PM
SHEATH - STOP [**2124-8-1**] 01:54 PM
arterial
EKG - At [**2124-8-1**] 02:21 PM
IABP LINE - STOP [**2124-8-1**] 03:55 PM
EXTUBATION - At [**2124-8-2**] 06:35 AM
Post operative day:
[**8-2**] HD3 POD 1-CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2124-8-1**] 11:55 PM
Infusions:
Epinephrine - 0."
941,"6 mg/dL
24 mEq/L
3.8 mEq/L
5 mg/dL
104 mEq/L
131 mEq/L
32.8 %
8.0 K/uL
[**2124-8-2**] 12:02 AM
[**2124-8-2**] 01:00 AM
[**2124-8-2**] 02:00 AM
[**2124-8-2**] 03:00 AM
[**2124-8-2**] 03:10 AM
[**2124-8-2**] 04:00 AM
[**2124-8-2**] 05:00 AM
[**2124-8-2**] 05:20 AM
[**2124-8-2**] 05:51 AM
[**2124-8-2**] 06:00 AM
WBC
8.0
Hct
32.8
Plt
147
Creatinine
0.6
TCO2
22
23
23
22
Glucose
111
110
103
104
76
127
Other labs: PT / PTT / INR:12."
942,"3 kg
Height: 65 Inch
CVP: 5 (5 - 17) mmHg
PAP: (25 mmHg) / (10 mmHg)
CO/CI (Thermodilution): (5.18 L/min) / (3.4 L/min/m2)
CO/CI (Fick): (6.8 L/min) / (3.5 L/min/m2)
SVR: 798 dynes*sec/cm5
Mixed Venous O2% sat: 78 - 78
SV: 78 mL
SVI: 40 mL/m2
Total In:
9,982 mL
665 mL
PO:
Tube feeding:
IV Fluid:
9,607 mL
665 mL
Blood products:
375 mL
Total out:
3,470 mL
830 mL
Urine:
3,170 mL
660 mL
NG:
Stool:
Drains:
Balance:
6,512 mL
-165 mL
Respiratory support
O2 Delivery Device: Face tent
Ventilator mode: SIMV/PSV/AutoFlow
Vt (Set): 600 (600 - 600) mL
Vt (Spontaneous): 574 (574 - 628) mL
PS : 5 cmH2O
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
RSBI: 64
PIP: 26 cmH2O
Plateau: 18 cmH2O
SPO2: 100%
ABG: 7."
943,"TITLE: Intensivist
Surgical Critical Care
CVICU
HPI:
HD3 POD 1-CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
Ejection Fraction:30
Hempglobin A1c:5.3
Pre-Op Weight:190.26 lbs 86.3 kgs
Baseline Creatinine:0.9
PMHx:
PMH: Dyslipidemia, Hypertension, +ETT, Peripheral vascular disease- b/l
lower extremities, depression, +tob
MEDS: simvastatin 40', candesartan 32', doxycycline 20', Imdur 30',
chlorthalidone 25', fluoxetine 40', dicyclomine 10', NTG-sl .4/prn,
[**Last Name (LF) 9543**], [**First Name3 (LF) **] 81', Paxil 40'
Current medications:
. Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6. CefazoLIN 8.
Docusate Sodium 9. Furosemide 10. Insulin 11."
944,"01 mcg/Kg/min
Phenylephrine - 0.5 mcg/Kg/min
Insulin - Regular - 2 units/hour
Other ICU medications:
Insulin - Regular - [**2124-8-1**] 04:41 PM
Sodium Bicarbonate 8.4% (Amp) - [**2124-8-1**] 05:30 PM
Ranitidine (Prophylaxis) - [**2124-8-1**] 06:01 PM
Morphine Sulfate - [**2124-8-2**] 06:46 AM
Flowsheet Data as of [**2124-8-2**] 07:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**26**] a.m.
Tmax: 38
C (100.4
T current: 37.8
C (100
HR: 86 (52 - 118) bpm
BP: 96/54(69) {79/42(60) - 125/70(90)} mmHg
RR: 19 (11 - 25) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 99 kg (admission): 88."
945,"TITLE:
Please see resident H+P for full details. 59 M with HTN, smoker, PAD,
HL, FH (dad CABG in 60s), p/w 1 mo worsening exertional angina, +stress
test, cath showing severe 3vd with proximal 95% LAD stenosis. Baseline
EKG suggests possible anterior NSTEMI in the LAD territory sometime in
past. EF of 40% on stress supports that. Pt developed further pain
during cath a/w EKG changes in V1-2 (STE, TWI) and IABP was thus
placed. Pain resolved with nitro gtt. Plan for CABG tomorrow. Cont
balloon pump, nitro gtt, heparin gtt, judicious BB. If further pain,
will call surgeon to expedite CABG."
946,"TITLE: Intensivist
Surgical Critical Care Note
CVICU
HPI:
HD4 POD 2-CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
Ejection Fraction:30
Hempglobin A1c:5.3
Pre-Op Weight:190.26 lbs 86.3 kgs
Baseline Creatinine:0.9
[**Last Name (LF) 9543**], [**First Name3 (LF) **] 81', Paxil 40'
Assessment:59yoM s/p CABG X$(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)[**8-1**]
PMHx:
PMH: Dyslipidemia, Hypertension, +ETT, Peripheral vascular disease- b/l
lower extremities, depression, +tob
MEDS: simvastatin 40', candesartan 32', doxycycline 20', Imdur 30',
chlorthalidone 25', fluoxetine 40', dicyclomine 10', NTG-sl .4/prn,
Current medications:
Acetaminophen 4."
947,"Neurologic: Pain controlled, pain control with Vicodan and toradol
fluoxetine resumed
Cardiovascular: Aspirin, Statins, start B-blockers today
Pulmonary: IS, Discontinue chest tube(s), OOB-ambulate
Gastrointestinal / Abdomen:
Nutrition: Regular diet
Renal: Lasix to keep net negative 1-1.5 liters/day. Hyponatremia preop
with some resolution postop. Borderline serum hypoosmolarity. Low uric
acid. Free water restriction to 1000cc/day
Monitor BUN/Cr
Hematology: stable anemia
Endocrine: RISS
Infectious Disease: no active issues
afebrile, normal wbc
Lines / Tubes / Drains: Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Imaging: CXR today, after chest tubes removed
Fluids:
Consults: CT surgery, P.T., Nutrition
ICU Care
Nutrition: cardiac diet
Glycemic Control: RISS
Lines: Cordis/Introducer - [**2124-8-1**] 01:13 PM
20 Gauge - [**2124-8-1**] 07:25 PM
Prophylaxis:
DVT: (ambulate today)
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: Transfer to floor Time spent : 31 min Post op
hypotension, post-op resp insufficiency"
948,"6
0.7
TCO2
23
23
22
Glucose
111
110
103
104
76
127
129
Other labs: PT / PTT / INR:12.2/31.3/1.0, CK / CK-MB / Troponin
T:176//0.04, Fibrinogen:202 mg/dL, Lactic Acid:1.2 mmol/L, Ca:9.1
mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), KNOWLEDGE DEFICIT, CORONARY
ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE), PERIPHERAL VASCULAR
DISEASE (PVD) WITHOUT CRITICAL LIMB ISCHEMIA
Assessment and Plan: 59yo man s/p CABG x4, hypotension requiring
Neosynephrine infusion on POD1 now weaned off."
949,"38///25/
Physical Examination
General Appearance: No acute distress, Overweight / Obese
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, No(t)
Obese
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
105 K/uL
9.8 g/dL
129 mg/dL
0."
950,"2 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2124-8-2**] 08:05 PM
Flowsheet Data as of [**2124-8-3**] 09:24 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**26**] a.m.
Tmax: 37.4
C (99.3
T current: 37
C (98.6
HR: 85 (77 - 92) bpm
BP: 111/70(80) {0/0(0) - 116/78(87)} mmHg
RR: 26 (16 - 30) insp/min
SPO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 99 kg (admission): 88.3 kg
Height: 65 Inch
CVP: 11 (11 - 11) mmHg
PAP: (39 mmHg) / (17 mmHg)
Total In:
1,954 mL
292 mL
PO:
480 mL
Tube feeding:
IV Fluid:
1,474 mL
292 mL
Blood products:
Total out:
3,545 mL
360 mL
Urine:
2,955 mL
320 mL
NG:
Stool:
Drains:
Balance:
-1,591 mL
-68 mL
Respiratory support
O2 Delivery Device: None
SPO2: 94%
ABG: 7."
951,"7 mg/dL
25 mEq/L
3.2 mEq/L
7 mg/dL
100 mEq/L
131 mEq/L
28.2 %
9.1 K/uL
[**2124-8-2**] 01:00 AM
[**2124-8-2**] 02:00 AM
[**2124-8-2**] 03:00 AM
[**2124-8-2**] 03:10 AM
[**2124-8-2**] 04:00 AM
[**2124-8-2**] 05:00 AM
[**2124-8-2**] 05:20 AM
[**2124-8-2**] 05:51 AM
[**2124-8-2**] 06:00 AM
[**2124-8-3**] 01:11 AM
WBC
8.0
9.1
Hct
32.8
28.2
Plt
147
105
Creatinine
0."
952,"Aspirin EC 5. Calcium Gluconate 6. Carvedilol 7.
Dextrose 50% 8. DiphenhydrAMINE 9. Docusate Sodium 10. Furosemide 11.
Hydrocodone-Acetaminophen 12. Insulin 13. Ketorolac 14. Magnesium
Sulfate 15. Metoclopramide 16. Milk of Magnesia 17. Morphine Sulfate
18. Paroxetine Potassium Chloride 21. Ranitidine 22. Simvastatin 23.
Sodium Chloride 0.9% Flush
24 Hour Events:
PA CATHETER - STOP [**2124-8-2**] 10:13 AM
ARTERIAL LINE - STOP [**2124-8-3**] 01:30 AM
Weaned Neo infusion
Post operative day:
[**8-3**] HD4 POD 2-CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
Allergies:
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
Itching;
Last dose of Antibiotics:
Cefazolin - [**2124-8-2**] 04:00 PM
Infusions:
Phenylephrine - 0."
953,"EMS was called and found him looking pale and
lethargic. While EMS was assessing, he became unresponsive with
eyes rolling back in head with 20 second convulsions for
approximately 20 seconds before returning to normal
consciousness. Denied chest pain. A telemetry monitor was
placed and was noted to be in 3rd degree heart block with rates
10-30 beats per minute. A transcutaneous pacer was placed on
route.
Past Medical History:
-coronary disease s/p stent placement
-diabetes mellitus
-hypertension
-hyperlipidemia
-gout
-type II diabetes
-sleep apnea
-osteoarthritis
-depression
Social History:
occasional EtOH use
Family History:
n/c
Physical Exam:
BP 118/71, HR 80, RR 16, SpO2 100% on assist control PEEP 5 FiO2
50%
Gen: Sedated, intubated, in no apparent distress
Cardiac: Nl s1/s2, regular rate and rhythm, no murmurs
appreciable, no s3/s4
Resp: lungs clear in anterior lung fields
Abd: soft and nontender, +BS
Ext: 1+ lower extremity edema, pulses 1+ distally, warm and
well-perfused"
954,"Brief Hospital Course:
This is a 75 year old male with a known history of CAD with
prior inferior wall MI who now presents with syncope likely
secondary to complete heart block
.
# Syncope/Symptomatic Bradycardia: Episode secondary to complete
heart block noted on telemetry at time of event. Patient was
intubated for airway protection and a temporary transcutaneous
pacer was placed. Cardiac enzymes were negative and TSH normal.
A head CT was done to rule out CNS bleed. An echocardiogram was
also done that showed mild regional systolic dysfunction, c/w
CAD, mild MR, EF 45%. [**6-16**] patient was extubated."
955,"A permanent
[**Company **] pacemaker was placed on this admission.
.
# CAD: Cardiac markers were negative on admission. Echo showed,
mild regional systolic dysfunction c/w CAD. Once head bleed was
ruled out he was continued on aspirin, plavix. His
ace-inhibitor was continued. Nodal agents were initially held,
given the heart block. Post-pacemaker placement, he was
restarted on amlodipine. He was switched from atenolol to
carvedilol.
.
# Diabetes mellitus: Patient continued on ISS. He currently
takes no medicines at home for glucose control.
.
# Hyperlipidemia: Continuec statin
.
# Gout: Patient complained on knee pain consistent w/ his prior
history of gout. He was treated with a short course of
prednisone."
956,".
# HTN: PCP confirmed that patient was supposed to switched from
HCTZ to chlorthalidone. This was held given his suspected gout
flare. He was treated with ace-i, ccb, and atenolol switched to
carvedilol (see above).
.
# Chronic Renal Insufficiency: Based on atrius records, patient
noted to have renal complications of diabetes with a Creatine of
1.7 for the past several years. His Cr at [**Hospital1 18**] ranged from
1.5-1.8.
.
# Anemia: No obvious signs of bleeding. Pt has not had a BM here
and rectal exam negative for impaction with negative guiaic.
Iron studies show mild Fe deficiency."
957,"Ferrous sulfate started at
discharge with instructions for repeat CBC on [**6-23**]. His PCP
was made aware of plan.
Medications on Admission:
-chlorthalidone 12.5 mg daily
-simvastatin 40 mg qhs
-flomax 0.4 mg PO daily
-allopurinol 100 mg PO BID
-hydrochlorothiazide 25 mg daily
-isosorbide dinitrate 10 mg PO BID
-plavix 75 mg daily
-atenolol 50 mg po daily
-atenolol 25 mg po qpm
-amlodipine/benzapril 10 / 20 mg daily
-lorazepam 0.5 mg [**Hospital1 **] PRN anxiety
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)."
958,"Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Please check Chem-7 and CBC on Friday [**6-23**] with results to
Dr. [**Last Name (STitle) **]
17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily). Tablet(s)
18. Polyethylene Glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO DAILY (Daily).
19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Complete Heart Block status post Pacemaker
Coronary Artery Disease
Gout
Hypertension
Hyperlipidemia
Anemia
Chronic Kidney Disease"
959,"No
lifting your left arm over your head or lifting more than 5
pounds for 6 weeks. No driving until after your device clinic
appt. Please see the pacemaker booklet for further instructions.
You were found to have some anemia but your blood counts are
stable today. Please get labs checked on Friday [**6-23**] and
take iron to help your blood counts improve.
.
Medication changes:
1.Start Prednisone to treat a gout flare for a total of 5 days.
2. Start Keflex, an antibiotic to prevent an infection at the
pacer site.
3. Start Oxycodone for your knee pain and Tylenol if you have
pain at the pacer site."
960,"3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day)."
961,"9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Amlodipine-Benazepril 10-20 mg Capsule Sig: One (1) Capsule
PO once a day.
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
15."
962,"8 Phos-3.2 Mg-1.9
[**2131-6-16**] 03:55PM BLOOD TSH-2.0
.
Cardiac Enzymes:
[**2131-6-16**] 03:55PM BLOOD CK-MB-3 cTropnT-<0.01
[**2131-6-17**] 04:00AM BLOOD CK-MB-3 cTropnT-LESS THAN
.
Discharge labs:
[**2131-6-20**] 01:20PM BLOOD WBC-9.4 RBC-3.79* Hgb-10.8* Hct-33.2*
MCV-88 MCH-28.5 MCHC-32.6 RDW-16.1* Plt Ct-165
[**2131-6-20**] 06:55AM BLOOD Glucose-128* UreaN-53* Creat-1.8* Na-137
K-4.7 Cl-103 HCO3-25 AnGap-14
[**2131-6-20**] 06:55AM BLOOD Mg-2."
963,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had complete heart block which is due to a deterioration of
the electrical system of your heart. This caused a very slow
heart rate and you received a pacemaker to keep your heart rate
at a normal level. You will need to avoid showers for 3 days and
keep the pacer site dry. On Saturday you can take the dressing
off and take a shower, pat the area dry. You will be seen in the
[**Hospital1 **] Device clinic in 1 week to check the pacer."
964,"Admission Date: [**2131-6-16**] Discharge Date: [**2131-6-20**]
Date of Birth: [**2056-3-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
s/p dual chamber [**Company 1543**] Adapta PM via left cephalic
History of Present Illness:
This is a 75 year old male with a history of CAD with stents
placed in [**2127**] at [**Hospital6 **],
Per family, Mr [**Known lastname **] was having chest pain while sitting in the
chair, as well as feeling lightheaded. He then passed out for
10-20 seconds."
965,"Mild mitral
regurgitation.
.
[**2131-6-16**] CT head:
No acute intracranial hemorrhage or mass effect.
.
[**2131-6-16**] CXR:
There is moderate cardiomegaly. ET tube tip is 4.3 cm above the
carina.
Pacer tip is in the right ventricle. There is no evident
pneumothorax or
pleural effusions. Aside from minimal atelectasis in the left
base, the lungs are clear. There is marked distention of the
stomach.
.
[**2131-6-18**] CXR:
The external pacer terminates in the right ventricle.
Cardiomediastinal
silhouette is stable. There is overall improvement of the basal
aeration.
The upper lungs are also unremarkable. No appreciable pleural
effusion is
demonstrated as well as no definitive evidence of pneumothorax
is present."
966,"Pertinent Results:
Admission labs:
[**2131-6-16**] 03:55PM BLOOD WBC-7.8 RBC-4.06* Hgb-11.4* Hct-35.4*
MCV-87 MCH-28.0 MCHC-32.1 RDW-16.2* Plt Ct-154
[**2131-6-16**] 03:55PM BLOOD Neuts-76.5* Lymphs-17.9* Monos-4.4
Eos-0.8 Baso-0.3
[**2131-6-16**] 03:55PM BLOOD PT-12.7 PTT-30.2 INR(PT)-1.1
[**2131-6-16**] 03:55PM BLOOD Glucose-91 UreaN-41* Creat-1.5* Na-144
K-6.0* Cl-112* HCO3-24 AnGap-14
[**2131-6-16**] 03:55PM BLOOD Calcium-8."
967,"4. Stop chlorthalidone
5. Stop Atenolol, start Carvedilol at 12.5 mg twice daily for
your blood pressure.
6. Start Ferrous sulfate to help your anemia. You will need to
take colace, a stool softener, and Miralax if you get
constipated. These all are over the counter medicines.
Followup Instructions:
DEVICE CLINIC: [**Hospital1 **] office will call you with an
appt for next week.
.
Cardiology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 2258**] Date/Time:
[**Hospital1 **] office will call you with an appt.
Primary Care:
[**Last Name (LF) 41941**],[**First Name3 (LF) **] J. Phone: [**Telephone/Fax (1) 31019**] Please call Dr [**Last Name (STitle) **] when you
get home to schedule an appt in 2 weeks.
Completed by:[**2131-6-20**]"
968,"3
.
[**2131-6-16**] Echo:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with inferolateral hypokinesis.
The remaining segments contract normally (LVEF = 45%). The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction, c/w CAD."
969,"Admission Date: [**2189-12-6**] Discharge Date: [**2189-12-31**]
Date of Birth: [**2128-3-31**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids / Lisinopril / Celebrex / Rofecoxib / Tegaderm
/ Ciprofloxacin / Allopurinol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Pre-TACE hydration
Reason for Transfer to [**Hospital Unit Name 153**]: Hypoxemia
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy
Left radial arterial line
History of Present Illness:
61F with pancreatic neuroendocrine CA metastatic to the liver
s/p CBD stent and chronic diastolic CHF admitted to OMED [**12-6**]
for hydration prior to TACE on [**12-7**]. Started on zosyn [**12-6**],
followed by vanc/cefepime/flagyl on [**12-9**] for possible
aspiration pneumonia."
970,"On routine vitals found to have O2sat 88%5L (had been on 5L NC
since [**12-14**]) - improved to 92-94%8L FM. Given lasix 20 mg IV
with 300 UOP. ABG on NRB 7.45/47/72/34. CXR showed extensive
right-sided airspace disease. Vital signs prior to transfer 97.3
102/59 95 22 98%NRB.
Past Medical History:
Oncologic History (from Dr.[**Name (NI) 52983**] [**9-16**] note)
[**1-6**]: Had UGI bleeding, EGD revealed gastric ulcer (official
report unavailable)
[**2-7**]: Developed chronic fatigue and anorexia soon after
returning home from let hip and knee surgery."
971,"2. Colonoscopy [**12-6**] --> polyp, repeat from [**1-6**] --> normal
3. Arthritis
-Hip replacement [**2183**] and revision in [**2184**].
-Hip debridement in [**2-7**]
-Left knee torn cartilage repair in [**2-7**].
4. Hysterectomy for fibroids
5. Mitral valve prolapse
6. Obstructive sleep apnea
7. Asthma
8. Coronary artery ""spasms"" based on cath in [**2162**] and [**2179**]
9. Diabetes mellitus, type II
10. Hypertension
11. Hyperlipidemia
12. Obesity
13. Chronic diastolic CHF
14. Depression
Social History:
Widow, husband murdered in [**2162**]. Lives with daughter and her
family in [**Name (NI) **], MA. Has two healthy children and 3 healthy
grandchildren. Previously worked as lab technician in hospital."
972,"The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2189-12-11**],
left ventricular systolic function is more dynamic and the heart
rate is higher. The estimated pulmonary artery systolic pressure
is now higher.
[**2189-12-23**]
- CT Chest
Brief Hospital Course:
61 y/o with metastatic neuroendocrine CA admitted for hydration
prior to TACE on [**12-7**], presented to the ICU with hypoxemic
respiratory failure due to what was thought to be
hospital-acquired pneumonia vs acute on chronic diastolic CHF vs
pneumonitis secondary to a portosystemic shunt communicating
from her TACE procedure."
973,"Ms. [**Name14 (STitle) 52984**] had a prolonged course in
the ICU, requiring ventilatory assitance
# Hypoxemic respiratory failure/Lung infiltrates. Patient was
transferred from oncology service after her TACE for increased
respiratory distress with a subacute decompensation, which was
initially thought to be from acute on chronic diastolic heart
failure, pneumonia, aspiration, hemorrhage or VTE with a small
component of portosystemic shunt. She was intubated for
increased work of breathing on [**2189-12-16**]. However, subsequent
bronchoscopy did not suggest an infectious or hemorrhagic
etiology as BAL was negative and bronchoscopy showed mostly
clear aspirate. She was continued on vancomycin which was
started prior to her transfer to ICU, and she was started also
on meropenem so that both would cover for HAP as well as
levofloxacin to cover atypical pneumonia."
974,"As her sepsis improved, she was able to tolerate
intermittent dose of lasix to diurese the presumed pulmonary
edema as her total length of state fluid balance was positive.
Family meeting was held to discuss her respiratory status, and
patient was made CMO. Patient was extubated on the night of
[**12-30**] and she passed away shortly therafter.
# Shock, liekly [**3-3**] distributive/sepsis with SvO2 78% and
initial SVV [**5-17**]. Patient initially required Levophed support
as well as fluid boluses to maintain her MAP and urine output.
The likely source for the sepsis is pulmonary
infection/inflammation based on radiographical evidence as her
other culture data have been negative."
975,"No evidence of adrenal
insufficiency, thyroid toxicosis, PE. She was able to be weaned
off pressors.
# Acute Renal insufficiency, likely from pre-renal azotemia
secondary to sepsis. This was noted as her Crt trended up to 1.5
from baseline 0.6-0.8. FeUrea was found to be < 35% and FENa <
1%. She initially required pressors and IVF boluses for the low
urine output. Her SVO2 and SVV were monitored closely to help
guide therapy. She gradually improved and was able to be weaned
off of pressors and tolerate diuresis with improved and stable
Crt.
# Hypernatremia. Free water deficit initially about 3."
976,"8L. She
was treated with D5W fluid bolus then maintenance with the
likely goal of starting free water flushes into her tube feed.
# Acute on Chronic Diastolic CHF, likely with some component of
pulmonary edema which contributes some to the respiratory
function. Initial echocardiogram showed LVEF of 50-55%. Diovan
and diltiazem were soon held after her arrival to the [**Hospital Unit Name 153**]
secondary to hypotension and requirement of pressor, Levophed.
Her repeat echocardiogram showed hyperdynamic ventricular
function, correlating to her distributive shock picture. As she
was weaned off pressor on [**2189-12-21**]. She was able to tolerate
intermittent low dose of furosemide for diuresis given that
patient's length of stay fluid balance was positive."
977,"#Pancytopenia, likely [**3-3**] recent chemotherapy. Her CBC was
monitored on a daily basis. Her white count, anemia, and
thrombocytopenia were stably low. She did not have episodes of
acute bleeding. Active type and screen were maintained.
# Neuroendocrine cancer. Patient was admitted to the hospital
for TACE. Her LFT was elevated after TACE, but gradually
trended downward during her stay in the ICU.
# Diabetes Mellitus. Patient was placed on an insulin sliding
scale with 70/30 and regular finger stick blood sugar
monitoring.
# Goals of Care. Full code, confirmed on [**2189-12-16**]. However,
prior to intubation, patient voiced that she would not want to
be on the ventilator for a prolonged period of time, and she
would give herself 4-6 weeks on the ventilator only if she was
unable to be successfully extubated."
978,"She stated that she would
not want to have a trach or a PEG prior to [**2189-12-16**]. Her
health care proxy is her daughter, [**Name (NI) **] [**Name (NI) 16745**] [**Telephone/Fax (1) 52985**].
A fmily meeting was held on [**2189-12-30**]. At that point Ms. [**Known lastname 52986**]
family decided that in light of her continued deterioration and
in respect for her clear wish not to have prolonged life
supporting care if her lung function was not improving to make
comfort the sole goal and will discontinue any therapy not
directed at comfort. She passed away that evening.
Medications on Admission:
Deceased.
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2190-1-1**]"
979,"The stomach, duodenum, and intra-abdominal loops
of small and large bowel are
normal in caliber and configuration. There is no bowel
distention or bowel wall thickening. There is no free fluid or
free air identified.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions
identified.
IMPRESSION:
1. Extensive Ethiodol uptake within the left lobe of the liver,
most
concentrated at the site of previously noted
arterially-enhancing lesions seen on [**2189-11-13**].
2. Hyperdensity at the lung bases is most compatible with
Ethiodol, likely secondary to a small intrahepatic
porto-systemic shunt. There is no further evidence of
extrahepatic Ethiodol uptake."
980,"Other than the aforementioned
hyperdensity at the lung bases, there is no definite evidence of
extrahepatic Ethiodol uptake. Hyperdense material dependently
within stomach appears intraluminal, most likely reflecting
ingested medication. The spleen, adrenal glands, and kidneys
remain unremarkable. Contrast in the collecting system reflects
recent angiography. There are no contour-altering renal mass
lesions. The pancreatic tail is again noted to be atrophic. The
known pancreatic head mass is not well appreciated without
intravenous contrast. Stranding inferior to the pancreatic head
is noted, possibly reflecting the sequelae of prior
pancreatitis. There is a metallic common bile duct stent in
standard position, with left lobe pneumobilia compatible with
stent patency."
981,"[**3-10**]: Presented to PCP with [**Name9 (PRE) 5283**] pain and worsening jaundice for
2 weeks. RUQ US demonstrated pancreatic head mass and multiple
liver nodules suspicious for metastasis. Admitted to [**Hospital **]
hospital, where CT scan confirmed US findings. ERCP at [**Hospital1 18**]
demonstrated duodenal invasion (with stigmata of recent
bleeding,) and extrinsic compression of CBD, which was stented.
Duodenal biopsy returned poorly differentiated neuroendocrine
carcinoma. MRCP demonstrated numerous hepatic metastases.
US-guided biopsy of one hepatic lesion revealed same findings as
duodenal biopsy. The picture was consistent was metastatic,
poorly differentiated neuroendocrine carcinoma.
.
Other PMH:
1. Chronic anemia, underwent EGD and diagnosed with bleeding
ulcer in [**11/2186**] and 12/[**2187**]."
982,"5
[**2189-12-6**] 01:26AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0
[**2189-12-8**] 08:50PM BLOOD ALT-236* AST-562* LD(LDH)-722*
AlkPhos-269* TotBili-1.2
[**2189-12-8**] 06:45AM BLOOD Lipase-7
[**2189-12-9**] 06:40AM BLOOD proBNP-1324*
[**2189-12-7**] 07:05AM BLOOD CEA-7.2* AFP-2.1
[**2189-12-16**] 06:04AM BLOOD Digoxin-<0.2*
[**2189-12-16**] 06:34AM BLOOD Type-ART pO2-72* pCO2-47* pH-7.45
calTCO2-34* Base XS-7
[**2189-12-16**] 03:39PM BLOOD Lactate-1.4
[**2189-12-16**] 03:08PM BLOOD B-GLUCAN- < 31 pg/mL negative
[**2189-12-16**] 03:08PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0."
983,"The airways are patent to
the subsegmental level. There is interval development of diffuse
ground-glass airspace opacities, most severely involving the
upper lobes. These findings are new compared to a CT Torso from
[**2189-9-30**]. The previously seen hyperdense foci within the lower
lobes suggestive of extra-hepatic Ethiodol are less apparent on
this study. The previously seen dense consolidation of the lower
lobes are also improved. There is no pleural or pericardial
effusion. This examination is not tailored for subdiaphragmatic
evaluation. Extensive Ethiodol uptake within the left lobe of
the liver is again noted. Osseous structures reveal no
suspicious lesion."
984,"There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and low normal global left ventricular systolic
function.
[**2189-12-14**]
- The heart is normal in size. Mitral annular calcifications are
noted.
Atherosclerotic calcifications of the aortic arch are present.
Low attenuation of the intracardiac blood pool suggests
underlying anemia. There is a right central venous catheter,
with tip terminating within the SVC. A right paratracheal lymph
node is mildly enlarged measuring 15 mm, which is larger from
prior study, and is likely reactive."
985,"She completed a 5 day
course of levofloxain and 12 day course of vancomycin.
Meropenem was kept for pseudomonal coverage for a planned course
of 14 days. Methylprednisolone was initiated at 20 mg q8h for
possible pneumonitis as patient's hypoxic respiratory failure
persists despite antibiotics treatments. Her respiratory status
continued to be without progress on the steroid, requiring FiO2
of 50-60%. Thoracic surgery was consulted for possible VATS
biopsy to obtain a more definitive diagnosis to patient's
parenchy infiltrates seen on CXR and CT. However, no VATS is
possible given her clinical status, and the risk outweighs the
benefit for patient to undergo open thoracotomy for tissue
biopsy."
986,"Tob: smoked for six months in [**2149**]; none current
EtOH: none
Family History:
Half sister died from uterine cancer in her 40s
Paternal half sister - uterine cancer
Paternal brother -- esophageal cancer in 50s
Maternal cousin died of renal cancer at 46
Maternal cousin died of lung cancer at 46.
Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: T 97.6 HR 93 BP 100/48 RR 20 O2sat 93%NRB
GEN: Cachectic, appears comfortable, resp nonlabored
HEENT: pale OP clear dry MM
NECK: JVP 10 cm H20
CV: reg rate nl S1S2 no m/r/g
PULM: coarse rales [**3-4**] right lung field and at left base no
wheeze
ABD: soft NTND
EXT: warm, dry +PP tr pedal edema no calf tenderness
NEURO: awake, alert, conversing appropriately"
987,"Notably, CT chest [**12-11**] showed ethiodol
uptake in the lung, concerning for a portosystemic shunt.
Azithromycin was added [**12-15**], and cefepime was stopped in favor
of levo/[**Last Name (un) 2830**] on [**12-15**]. She has also been treated with bolus
diuresis for acute diastolic CHF. She states that she felt as if
she was improving on treatment as of yesterday but then became
more short of breath with minimal exertion, with a cough
productive of yellow-light green sputum. She endorses orthopnea
but denies PND. No fever, chills, sweats, chest pain,
palpitations, nausea, vomiting, diarrhea, or calf pain."
988,"===================
MICROBIOLOGY
===================
[**2189-12-15**]
- urine legionella antigen- negative
[**2189-12-16**]
- MRSA screen- negative
- BAL: No polys seen. No microbes seen. Respiratory cultures
negative. Legionella culture negative. Negative PCP. [**Name10 (NameIs) **]
fungal (prelim). AFB negative. AFB culture negative (prelim).
Viral culture negative (prelim)
- Urine cx- negative
- Blood cx- negative
[**2189-12-17**]
- Blood cx- negative
[**2189-12-18**]
- Blood cx [**3-3**]- pending
- Rapid respiratory viral screen & culture: negative
- sputum: moderate growth of yeast
- Urine cx- negative
[**2189-12-19**]
- Blood cx- pending
- Urine cx- negative
[**2189-12-20**]
- Blood cx- pending
- C. diff toxin- negative
===============
INTERNVETION
===============
[**2189-12-7**]
- Common hepatic artery and left hepatic artery arteriogram."
989,"IMPRESSION:
1. Interval development of diffuse ground-glass opacities
throughout the lungs, most severe within the upper lobes
bilaterally. The differential diagnosis includes infection
(including atypical infections from PCP or fungal if the patient
is immunocompromised), pulmonary edema, and pulmonary
hemorrhage.
2. Previously seen hyperdense foci in the lung bases felt to
represent extra-hepatic Ethiodol are less apparent on this
study.
3. Extensive Ethiodol uptake within the left lobe of the liver.
[**2189-12-16**]
- LENIS: The deep veins of bilateral lower extremity, namely the
common femoral vein, the superficial femoral vein, the popliteal
vein, the peroneal and the posterior tibial veins proximally in
the calf region are patent, show normal caliber,
compressibility, and phasicity."
990,"- Transarterial chemoembolization of the left lobe of liver.
- Angio-Seal closure device deployment to the right common
femoral artery
access site.
FINDINGS:
1. There is conventional celiac axis anatomy as demonstrated on
previous
arteriograms.
2. Common hepatic artery arteriogram demonstrates multiple
arterially
enhancing masses throughout both lobes of liver.
3. The left hepatic artery arteriogram confirmed large enhancing
masses in the left lobe of liver, which was successfully
targeted with the
chemotherapeutic [**Doctor Last Name 360**], with 60 mg of doxorubicin, 20 mL of
lipoidol, and 20 mL of intra-arterial lidocaine, and one and a
half vials of 100-300 micron Embospheres administered."
991,"On spectral wave Doppler, good
augmentation and phasicity waves are noted. There is no evidence
of acute or chronic thrombus at this time .
IMPRESSION: No evidence of deep venous thrombosis in the
bilateral lower
extremity deep veins on the available images at the time of the
study.
[**2189-12-19**]
- CXR: Pulmonary consolidation has been severe in the right lung
since [**12-13**]. Today, it has progressed dramatically in the
left upper lobe. Whether this is pneumonia or pulmonary
hemorrhage is radiographically indeterminate. Sparing of left
lower lobe suggests that it is not edema. Severe cardiomegaly
persists along with mediastinal and hilar vascular engorgement."
992,"1,
negative
[**2189-12-18**] 08:03AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2189-12-18**] 08:03AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2189-12-18**] 08:03AM URINE RBC-9* WBC-0 Bacteri-MOD Yeast-NONE Epi-0
[**2189-12-18**] 08:03AM URINE AmorphX-MANY
[**2189-12-18**] 08:03AM URINE Eos-NEGATIVE
[**2189-12-18**] 08:03AM URINE Hours-RANDOM UreaN-533 Creat-142 Na-<10
K-45 Cl-<10
[**2189-12-18**] 08:03AM URINE Osmolal-363"
993,"3. Common bile duct stent in standard position. Left lobe
pneumobilia is
compatible with stent patency. Known pancreatic head mass is not
well
appreciated given lack of intravenous contrast.
[**2189-12-11**]
- Echo: The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal."
994,"Pertinent Results:
[**2189-12-6**] 01:26AM BLOOD WBC-3.9* RBC-3.24* Hgb-10.2* Hct-32.6*
MCV-100* MCH-31.6 MCHC-31.5 RDW-15.4 Plt Ct-128*
[**2189-12-6**] 01:26AM BLOOD Neuts-67.4 Lymphs-22.6 Monos-6.6 Eos-2.7
Baso-0.7
[**2189-12-6**] 01:26AM BLOOD PT-17.8* PTT-33.3 INR(PT)-1.6*
[**2189-12-6**] 01:26AM BLOOD Glucose-118* UreaN-5* Creat-0.7 Na-141
K-3.9 Cl-106 HCO3-29 AnGap-10
[**2189-12-6**] 01:26AM BLOOD ALT-34 AST-54* LD(LDH)-143 AlkPhos-191*
TotBili-0."
995,"IMPRESSION: Satisfactory left hepatic artery chemoembolization
======================
IMAGING
======================
[**2189-12-8**]
- CT Abdomen/Pelvis: There is dependent atelectasis at the
bilateral lung bases without effusion or focal consolidation to
suggest pneumonia. Some hyperdensity is newly seen at the lung
bases, which most likely reflects systemic ethiodol distribution
secondary to small intrahepatic portosystemic shunt. Coronary
calcifications are noted. Hyperdense material within multiple
right lobe liver lesions is stable from [**2189-11-13**],
compatible with sequelae of prior chemoembolization.
Additionally, there is newly noted extensive hyperdense material
within the left lobe of the liver and caudate lobe, most
concentrated at the sites of previously noted
arterially-enhancing lesions, compatible with recent left
hepatic artery chemoembolization."
996,"Tip of the endotracheal tube is above the upper margin of the
clavicles, no less than 3 cm from the carina. No pneumothorax.
[**2189-12-21**]
- Echo: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is high
(>4.0L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. No aortic regurgitation
is seen."
997,"6 mg/dL
24 mEq/L
4.1 mEq/L
12 mg/dL
112 mEq/L
144 mEq/L
32.0 %
16.7 K/uL
[image002.jpg]
[**2151-2-19**] 06:01 PM
[**2151-2-19**] 06:05 PM
[**2151-2-20**] 03:24 AM
WBC
17.7
16.7
Hct
30.8
32.0
Plt
245
212
Creatinine
0.6
TCO2
27
Glucose
108
Other labs: PT / PTT / INR:11.8/19.5/1.0, Ca:8.8 mg/dL, Mg:2.3 mg/dL,
PO4:3.1 mg/dL
Assessment and Plan
[**Last Name **] PROBLEM - ENTER DESCRIPTION IN COMMENTS
Assessment and Plan: 78F s/p drainage of B frontal brain abscesses
Neurologic: Keppra for seizure prophylaxis, continue antibiotics for
brain abscesses and f/u cultures, f/[**Location 471**] MRI read today
Neuro checks Q:1
Pain: morphine PRN with good effect
Cardiovascular: Hemodynamically stable, will likely need TEE to r/o
endocarditis, cardiology is consulted
Pulmonary: Wean to extubate, possible abscess in right lung - discussed
w IP and will see the patient today regarding recommendations vs
possible drainage
Gastrointestinal / Abdomen: NPO
Nutrition: NPO
Renal: normal creatinine with good urine output, will check lytes and
replete as necessary
Hematology: stable anemia, coags normal
Endocrine: RISS
Infectious Disease: Currently w/o fevers."
998,"TSICU
HPI:
78 F recently treated for BOOP w prednisone, now admitted to [**Hospital1 **] w/
AMS, confusion. Found to have large intracranial masses (left and
right frontal lobe) - abscesses. s/p open drainage [**2-18**] of first
abscess, and now s/p stereotactic drainage [**2-19**] of second abscess.
Chief complaint:
mental status changes
PMHx:
COPD, BOOP (dx by CT bx), PNA ([**1-22**]), glaucoma, lipids, anxiety
Current medications:
LeVETiracetam 500 mg IV BID, MetRONIDAZOLE (FLagyl) 500 mg IV Q8H,
Ampicillin 2 g IV Q4H, CeftazIDIME 2 g IV Q8H, Chlorhexidine Gluconate
0.12% Oral Rinse 15 ml ORAL [**Hospital1 **], Dexamethasone 4 mg IV Q6H, Propofol
5-20 mcg/kg/min IV DRIP, Famotidine 20 mg IV Q12H, Insulin SC
24 Hour Events:
INTUBATION - At [**2151-2-19**] 05:28 PM
INVASIVE VENTILATION - START [**2151-2-19**] 05:31 PM
ARTERIAL LINE - START [**2151-2-19**] 07:22 PM
ARTERIAL LINE - STOP [**2151-2-19**] 09:10 PM
MAGNETIC RESONANCE IMAGING - At [**2151-2-20**] 01:27 AM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2151-2-19**] 08:18 PM
Metronidazole - [**2151-2-19**] 11:34 PM
Ceftazidime - [**2151-2-20**] 02:57 AM
Ampicillin - [**2151-2-20**] 03:44 AM
Infusions:
Propofol - 15 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2151-2-19**] 09:33 PM
Other medications:
Flowsheet Data as of [**2151-2-20**] 04:15 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**54**] a."
999,"41/41/198/24/1
Ve: 7.2 L/min
PaO2 / FiO2: 396
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)
Diastolic)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: Follows simple commands, (Responds to: Verbal stimuli),
Moves all extremities
Labs / Radiology
212 K/uL
10.5 g/dL
108 mg/dL
0."
1000,"m.
Tmax: 36.1
C (97
T current: 35.8
C (96.5
HR: 46 (46 - 71) bpm
BP: 113/40(60) {101/39(59) - 141/72(85)} mmHg
RR: 14 (12 - 16) insp/min
SPO2: 99%
Heart rhythm: SB (Sinus Bradycardia)
Total In:
1,249 mL
352 mL
PO:
Tube feeding:
IV Fluid:
1,249 mL
352 mL
Blood products:
Total out:
293 mL
158 mL
Urine:
293 mL
158 mL
NG:
Stool:
Drains:
Balance:
956 mL
194 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 14
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
PIP: 31 cmH2O
Plateau: 23 cmH2O
SPO2: 99%
ABG: 7."
1001,"Antibiotics - Flagyl, vanc,
unasyn, and ceftazidime. ID following, will follow-up continued recs
today. f/u OR cultures, now w GPCs from brain abscesses.
Lines / Tubes / Drains: PIV, Foley, a-line, ETT
Wounds: craniotomy wounds clean/dry/intact
Imaging: MRI
Fluids: NS @ 100
Consults: neurosurg, ID, IP, cardiology
Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2151-2-19**] 07:22 PM
20 Gauge - [**2151-2-19**] 08:36 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent:"
1002,"She was loaded with
dilantin. She was admitted to medicine for further workup.
Past Medical History:
1. COPD
2. BOOP- diagnosed 3 weeks ago by CT guided biopsy
3. Pneumonia ([**1-22**]) 3 days admission- [**Hospital1 **]
4. Glaucoma
5. Anxiety
6. Bipolar D/O -- well controlled x 20 years
7. Cataract
8. fluid retention
9. Neuropathy
10. hyperlipidemia
Social History:
Lives at home with daughter, completes most ADLs. Smoked 3ppd
for many years, quit over 20 years ago. No EtOH.
Family History:
Father- lung ca, CAD
Physical Exam:
Gen: NAD
HEENT: MMM. PERRL, EOMI.
CV: RRR
Pulm: CTA, minimal fine crackles at bases
Abd: obese, soft, NT/ND
LE: warm, no edema
Neuro: alert, oriented to person and place."
1003,"2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 80584**] @ 00:08A [**2151-2-19**].
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final [**2151-2-25**]):
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
NOT VIABLE FOR SENSITIVITIES.
VIRIDANS STREPTOCOCCI. RARE GROWTH. SECOND MORPHOLOGY.
NOT VIABLE FOR SENSITIVITIES.
ANAEROBIC CULTURE (Final [**2151-2-25**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2151-2-19**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Brief Hospital Course:
## Brain Abscess: Pt was admitted to [**Hospital1 18**] from an outside
hospital following her history of altered mental status as well
evidence of frontal bilateral masses."
1004,"Pt underwent a CT scan and
MRI which showed the appearance of cystic lesion. Pt was started
on IV steroids and neurosurgery were consult. On the night of
admission pt underwent an open bone flap and drainage to assess
whether lesion was metastatic versus an infection. Pus was noted
and drained noted to have brain abscess on biopsy/drainage
performed on [**2-18**]. Pt was then admitted and observed in the
Neurosurgical ICU where she underwent a second procedure to
remove her remaining rt sided lesion. Streptococcus Viridans was
cultured and pt was started on a course of Vancomycin and then
transitioned to Ceftriaxone per Infectious disease
recommendations 2gm IV q 12hrs on [**2-26**]."
1005,"Pt underwent a TTE that did not show any endocarditis. TEE was
deferred as it would not change management and was felt to be a
high risk
procedure per our cardiology team. The most likely etiology of
her brain abscesses is seeding from her lung infection (see
below) or from endocarditis.
## Lung Lesion: Pt underwent a biopsy of lung mass recently that
was positive for BOOP. As the possibility of malignancy still
existed the pt's RUL mass went to the bronchoscopy suite where
she underwent 6 biopsies, BAL, brush examination. Biopsies
showed alveolar and peribronchial tissue with mixed inflammatory
infiltrate, suggestive of acute pneumonia."
1006,"## Leukocytosis: Pt's WBC was noted to trend up and then down
prior to discharge. Pt noted to have thrush as well as yeast in
her urine. Pt was started on a 14 day course of oral
Fluconazole.
- continue total 14 days Course of Fluconazole
## Endometrial thickening: On CAT scan pt's endometrial lining.
Recommend pt undergo a transvaginal U/S to evaluate endometrial
thickening as an outpatient.
## FEN: pt underwent bedside and swallow evaluation. Per speech
and swallow recommendations pt was started and tolerated a soft
diet with thin liquids.
## Psych: Pt has history of bipolar disorder, for which she
usually takes Thoridazine."
1007,"After discussion with Neurosurgery it
was decided that the Thoridazine would have a potential to
interfere with the pt's neurological examination. Pt will be
re-evaluated by Dr. [**Last Name (STitle) **] on [**3-23**], at that time a decision
will be made whether Thoridazine can be restarted.
- Recommend discussing with Dr. [**Last Name (STitle) **] on [**3-23**] whether pt can
start her Thoridazine again.
## COPD: Pt noted intermittently to be wheezing on examination
during the first days of admission. Pt was discharged on
Tiotropium Bromide.
## Code status: FULL CODE
Medications on Admission:
Prednisone 20 mg Daily (Started [**2151-2-13**])
Gabapentin 300 mg TID
HCTZ 25 mg Daily
Simvistatin 20 mg Daily
Spiriva 18 mg Daily
Albuterol
Betaxolol Ophth Susp 0."
1008,"12. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 13 doses: Please follow taper.
[**Date range (3) 80586**] Please take 15mg of Prednisone once a day.
[**Date range (1) 80587**] Please take 10mg of Prednisone once a day.
[**Date range (1) 52680**] Please take 5mg of Prednisone once a day.
[**Date range (1) 80588**] Please take 2.5mg of Prednisone once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Bilateral Brain Abscesses
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital after it was found that you
had two brain abscesses."
1009,"7* RBC-3.86* Hgb-11.9* Hct-35.4*
MCV-92 MCH-30.8 MCHC-33.5 RDW-16.2* Plt Ct-163
[**2151-2-27**] 05:29AM BLOOD WBC-14.9* RBC-3.87* Hgb-11.7* Hct-35.0*
MCV-91 MCH-30.2 MCHC-33.4 RDW-16.3* Plt Ct-171
[**2151-2-26**] 05:40AM BLOOD WBC-14.0* RBC-3.67* Hgb-11.1* Hct-33.2*
MCV-91 MCH-30.3 MCHC-33.4 RDW-15.7* Plt Ct-163
[**2151-2-28**] 06:54AM BLOOD Neuts-64 Bands-0 Lymphs-21 Monos-7 Eos-5*
Baso-0 Atyps-2* Metas-1* Myelos-0
[**2151-3-2**] 06:10AM BLOOD Glucose-86 UreaN-14 Creat-0."
1010,"speech is slow,
mostly limited to yes and no responses. seems to have some
wordfinding difficulty. cranial nerves grossly intact. moves all
4 ext with good strength, no gross sensory deficits.
Pertinent Results:
[**2151-3-2**] 06:10AM BLOOD WBC-13.2* RBC-3.62* Hgb-11.2* Hct-33.2*
MCV-92 MCH-31.1 MCHC-33.8 RDW-16.5* Plt Ct-135*
[**2151-3-1**] 05:49AM BLOOD WBC-14.0* RBC-3.62* Hgb-11.1* Hct-33.2*
MCV-92 MCH-30.5 MCHC-33.3 RDW-16.2* Plt Ct-143*
[**2151-2-28**] 06:54AM BLOOD WBC-19."
1011,"Bronchial mucosa with
mildly increased goblet cells and focal acute inflammation. No
malignancy was identified. Pt was discharged with a 7 day
steroid taper per Interventional Pulmonary. Pt will f/u with a
repeat CT chest with contrast scan on [**2151-4-9**] 1030 to check the
RUL mass. Results will be faxed to Dr. [**Name (NI) 80585**], pt will follow
up with Dr. [**Last Name (STitle) 80585**] on [**2151-4-15**] 17:15.
##. Mobility: Pt had bone flap removed for abscess drainage. She
will need to wear the helmet whenever she is mobile. She will
later need a graft however this will not be performed until
several months from now."
1012,"Transferred to [**Hospital1 18**] for neurosurg eval.
The patient developed what was thought to be ""the flu"" in
[**Month (only) 359**]; this then developed into pneumonia in [**Month (only) 1096**]. The
pneumonia did not go away despite a few rounds of antibiotics. A
biopsy was performed [**2151-2-5**] which showed ""metaplastic alveolar
epithelial cells, fibroblasts and rare inflammatory cells""
thought to be consistant with BOOP. She was started Prednisone 4
days prior to admission.
She has not had a colonoscopy. She has yearly mammograms that
have been fine. Her daughter is not sure about her [**Name (NI) **] history.
In the [**Hospital1 18**] ED: Neurosurgery was consulted."
1013,"You were taken to the operating room by
the Neurosurgeons who drained your abscesses. The abscesses were
positive for a bacteria called Streptococcus Viridans. We
checked your blood cultures, performed an echo of yor heart
check for a source of the infection, all were negative. We
consulted the infectious disease specialists who recommended a
minimum 4 weeks of antibiotics. They will see you as an
outpatient to see whether you will need more antibiotics.
Prior to leaving the hospital you were fitted for a helmet which
you will need to wear whenever you are walking as a part of you
skull was removed for the abscess drainage."
1014,"25%
Thioridazine 40 mg qHS
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily)."
1015,"Per Neurosurgery
recommendations pt was started on Keppra for seizure
prophylaxis. Pt currently has two sutures in place at time of
discharge, the largest will dissolve, the second will need to be
removed during a follow up visit to Dr.[**Name (NI) 12757**] office on
[**2151-3-8**] 11:30. Pt will need a repeat CT scan as an outpatient
which has been scheduled for [**2151-3-23**] 2:00, after CT head scan
pt will see Dr. [**Last Name (STitle) **]. Pt will need a minimum of a 4 week
course of Ceftriaxone 2gm IV q12hrs. Pt will have, during this
duration, a follow up Infectious Disease Clinic appointment
where they will decide whether she needs additional treatment."
1016,"[**Last Name (STitle) 80585**] and us.
The results will be faxed to Dr. [**Last Name (STitle) 80585**]. It is scheduled for
[**2151-4-9**] 10:30 and it will be on the [**Location (un) **] of the [**Hospital Ward Name 23**]
building.
If you experienced any seizures, fevers, chills, difficulty
breathing please call your doctor or return to the ED.
Followup Instructions:
You will continue to receive antibiotics for a total of 4 weeks.
You can call [**Telephone/Fax (1) **] to reach the infectious disease
doctors [**First Name (Titles) **] [**Hospital1 **] for any questions.
SUTURE REMOVAL APPOINTMENT: (DR.[**Doctor Last Name **] OFFICE) [**2151-3-8**] 11:30
OFFICE Located aT [**Doctor First Name **]"
1017,"[**2151-2-17**]: Bld Culture x 1 Negative
[**2151-2-17**]: Urine Cx x 1 negative
[**2151-2-18**]: Tissue Cx Left Frontal Brain Abscess Wall: PMN
Leukocytes 2+, no micro-organisms.
[**2151-2-23**] BAL: PMN Leukocytes, no microorganisms, no Fungus, No
AFBs
[**2151-2-23**] RUL Tissue (during bronchoscopy)
GRAM STAIN: POLYMORPHONUCLEAR LEUKOCYTES, NO MICROORGANISMS
SEEN. NO GRWOTH
ANAEROBIC CULTURE: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2151-2-18**] BRAIN ABSCESS DRAINAGE
GRAM STAIN (Final [**2151-2-19**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES."
1018,"Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-3-23**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12760**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2151-3-23**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2151-4-2**]
11:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-4-9**] 10:30
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Date/Time: [**2151-4-15**] 17:15
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]"
1019,"Please take your medications as prescribed:
You will be on a Prednisone taper:-
[**Date range (3) 80586**] Please take 15mg of Prednisone once a day.
[**Date range (1) 80587**] Please take 10mg of Prednisone once a day.
[**Date range (1) 52680**] Please take 5mg of Prednisone once a day.
[**Date range (1) 80588**] Please take 2.5mg of Prednisone once a day.
You were also started on two antibiotics:
1. Ceftriaxone 2gm IV every 12 hours, your last dose currently
will be given on [**2151-4-3**].
2. Fluconazole for the yeast in your urine and oral thrush.
Please take 100mg Fluconazole once a day day."
1020,"Admission Date: [**2151-2-17**] Discharge Date: [**2151-3-2**]
Date of Birth: [**2072-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Brain Abscess drainage
Bronchoscopy with biopsy
History of Present Illness:
78 F presents from [**Hospital3 **] for acute mental status
changes and bilateral frontal mass lesions. She began prednisone
therapy for 4 days ago for BOOP. She complained of a headache on
over the weekend, which was unusual for her. Her family noted
increasing confusion x a few days, then yesterday she was noted
to have some slurred speech and then this morning she couldn't
speak - could only say ""[**Last Name (un) 46536**]."
1021,"5 Na-143
K-4.2 Cl-105 HCO3-33* AnGap-9
[**2151-3-1**] 05:49AM BLOOD Glucose-80 UreaN-14 Creat-0.6 Na-143
K-4.2 Cl-104 HCO3-33* AnGap-10
[**2151-2-28**] 06:54AM BLOOD Glucose-67* UreaN-14 Creat-0.6 Na-145
K-4.0 Cl-104 HCO3-31 AnGap-14
[**2151-2-27**] 05:29AM BLOOD Glucose-105 UreaN-12 Creat-0.5 Na-139
K-4.0 Cl-102 HCO3-32 AnGap-9
[**2151-2-27**] 05:29AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1
==========================================================
MICROBIOLOGY:"
1022,"Your last dose
will be [**2151-3-29**].
Please follow up with all of your appointments.
You have been scheduled for 2 CAT scans.
Your first scan is of your head and will be followed by Dr.
[**Last Name (STitle) **], This is to check the progression of your abscesses and
if they have come back. It is scheduled for [**2151-3-23**] 14:00 and
it will be on the [**Location (un) **] of [**Hospital Ward Name 23**].
The second CAT scan is of your chest to see the progression of
the mass in your chest that was biopsied by Dr."
1023,".."" and ""no."" She was not able to
bathe herself this AM as she forgot what to do. She normally
cares for herself and is high functioning. She was taken to her
PCP (Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 80583**]), where a mini mental was given, she could only
do about half the items on the test -- this is a dramatic change
for her. Therefore, she was sent to the [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4117**] ED. CT
revealed 2.4 cm lesion in the L frontoparietal region and a 20
mm lesion in the Right frontal lobe. At OSH ED given decadron 24
mg x1."
1024,"7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours) for 33 days: Your
last day of antibiotics will be on [**2151-4-3**].
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
11. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 28 days: Your last dose will be [**2151-3-29**]."
1025,"Demographics
Day of intubation: 2
Day of mechanical ventilation: 2
Ideal body weight: 0 None
Ideal tidal volume: 0 / 0 / 0 mL/kg
Airway
Airway Placement Data
Known difficult intubation: No
Procedure location: ICU
Reason: Re-intubation
Tube Type
ETT:
Position: 21 cm at teeth
Route: Oral
Type: Standard
Size: 7mm
Tracheostomy tube:
Type:
Manufacturer:
Size:
PMV:
Cuff Management:
Vol/Press:
Cuff pressure: cmH2O
Cuff volume: mL /
Airway problems:
Comments:
Lung sounds
RLL Lung Sounds: Diminished
RUL Lung Sounds: Clear
LUL Lung Sounds: Clear
LLL Lung Sounds: Diminished
Comments:
Secretions
Sputum color / consistency: Tan / Thick
Sputum source/amount: Suctioned / Scant
Comments:
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Visual assessment of breathing pattern: no breathing efforts
Assessment of breathing comfort: No response (sleeping / sedated)
Non-invasive ventilation assessment:
Invasive ventilation assessment:
Trigger work assessment: Not triggering
Dysynchrony assessment:
Comments:
Plan
Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated
Reason for continuing current ventilatory support:
Respiratory Care Shift Procedures
Transports:
Destination (R/T)
Time
Complications
Comments
Bedside Procedures:
Comments:
[**Name (NI) 2739**] pt status on rounds"
1026,"Admission Date: [**2185-4-4**] Discharge Date: [**2185-4-6**]
Date of Birth: [**2102-9-13**] Sex: M
Service: NEUROLOGY
Allergies:
Latanoprost
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is an 82 year old man (unknown handedness) with
a history of Parkinson's disease, hypercholesterolemia, and
right
hip fracture s/p fall [**2-2**] s/p ORIF who presents with altered
mental status for whom neurology was consulted when head CT
showed a right MCA infarct.
The following history is taken from a nurse ([**Doctor Last Name **] [**Telephone/Fax (1) 7233**])
from the [**Hospital3 2558**]."
1027,"There have been no recent
medication changes in the past 2 weeks. Of note, he was listed
on
a mechanical soft diet with nectar thickened liquids. He has
been
non-weightbearing since his [**Hospital3 **] discharge on [**2185-2-16**] to
just 2 days ago (was set to start PT today).
Per the patient's ex-wife, he has been coughing a lot more than
usual since Friday.
Past Medical History:
Parkinson's disease, followed by Dr. [**Last Name (STitle) 65301**] at [**Hospital 882**]
Hospital
Dementia
Right hip fracture s/p fall and ORIF with trochanteric nail:
admitted to [**Last Name (un) 1724**] [**Date range (1) 86884**]
Hypercholesterolemia
Bilateral shoulder fracture
Glaucoma
Impulse control disorder
BPH
Positive PPD
Obsessive-compulsive personality trait
Right 5th metacarpal fracture"
1028,".
HOSPITAL COURSE BY SYSTEM:
.
#Neuro -
A non-contrast CT of the head done to evaluate altered mental
status revealed a large infarct in the right Middle Cerebral
Artery territory. The stroke was thought to be secondary to a
large embolic event, possibly in the context of prolonged
immobilization and a patent foramen ovale. Initial plans were
to obtain a CTA of the head and neck in addition to an
echocardiogram. However, these tests were not ultimately
performed as goals of care were transitioned to comfort in the
setting of a poor prognosis.
.
#Resp -
On admission the patient was noted to be in significant
respiratory distress, requiring a non-rebreather to maintain
oxygen saturation."
1029,"13, as well as signs of right heart strain on EKG. This was
thought to be secondary to the large pulmonary embolism.
.
#Goals of Care -
Extensive discussions were held with the patient's ex-wife, who
was in communication with his daughter and health care proxy.
[**Name (NI) 227**] the patient's overall poor prognosis, the decision was
made to transition goals of care from cure to comfort. He was
transferred to the floor on [**4-5**]. Members of the palliative
care team participated in his care. On [**2185-4-6**], he died.
Medications on Admission:
Carbidopa-Levodopa 25/100: 1."
1030,"5 tabs PO q6AM and 10 am; 1 tab q2
pm and 6 pm
Comtan 200 mg PO q6 am, 10 am, 2 pm, 6 pm
Namenda 10 mg [**Hospital1 **]
Prozac 40 mg qAM
Seroquel 25 mg qhs
Remeron 30 mg qhs
Tylenol 650 mg qid
Colace [**Hospital1 **]
Timoptic 0.5% OU daily
Xalatan 0.005% drop OU qhs
Vitamin D3 50,000 U qweekly (last dose 4/8)
Calcium carbonate 600 mg [**Hospital1 **]
Natural tears prn
Oxycodone 5-10 mg q4 hr prn
Milk of magnesia prn
Discharge Medications:
- none
Discharge Disposition:
Expired
Discharge Diagnosis:
Stroke Right Middle Cerebral Artery Territory
Bilateral Pulmonary Emboli
Discharge Condition:
Expired
Discharge Instructions:
Not Applicable
Followup Instructions:
Not Applicable
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]"
1031,"Withdraws his right>left leg to nailbed
pressure.
Reflexes: 2+ right biceps, brachioradialis, triceps, knees; 1+
in
right ankle. Trace left biceps, 1+ left brachioradialis and
triceps, 3+ left knee, 2+ left ankle. Toes upgoing bilaterally.
Pertinent Results:
Admission Labs:
147 | 106 | 22
---------------< 144
3.6 | 25 | 0.7
14.1
14.3 >-----< 235
41.2
CK-MB-NotDone cTropnT-0.13*
PT-13.1 PTT-29.9 INR(PT)-1.1
.
URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
.
IMAGING
.
CT Head ([**2185-4-4**])
IMPRESSION: Findings consistent with acute right MCA territory
ischemic
infarction with hyperdense thrombus in the right MCA."
1032,"Social History:
He has been in the [**Hospital3 2558**] x2 months after
a right hip fracture (and he has been weight bearing only over
the past 2 days). He is a former professor and chair in English
and theology at [**Hospital1 3278**], and has written 42 books on literary
history. His ex-wife, [**Name (NI) **] [**Name (NI) **], is active in his healthcare,
but his HCP is his daughter [**Name (NI) 794**] ([**Name2 (NI) 3235**]) [**Last Name (un) 86885**] in
[**Name (NI) **].
His PCP is [**Last Name (NamePattern4) **]. [**First Name (STitle) **] at [**Last Name (un) 10526**] [**Hospital1 **].
Family History:
Unable to obtain."
1033,"Intubation was discussed but not ultimately
pursued given the patient's overall poor prognosis. He was
started on broad spectrum antibiotics for presumed pneumonia,
and underwent a chest CT to evaluate for possible pulmonary
embolism. CT showed large multiple bilateral emboli. However,
given the large cerebral infarct, he would have been at
significant risk for hemorrhagic conversion were he to undergo
anticoagulation. An IVC filter was briefly discussed. Since a
filter would not address the significant clot burden or
associated heart strain already present, it was not pursued.
.
#CV -
On admission Mr. [**Known lastname **] was noted to have an elevated troponin of
0."
1034,"Yesterday, the patient coughed up a
large mucus plug, and was tired ever since then. It was not
documented when the patient went to bed last night. At 6:00 am,
he was able to take his medications normally. At 8:00 am, the
patient wasn't able to take his medications due to difficulty
swallowing and had a productive cough. The charge nurse saw the
patient, and he was still tired but was able to squeeze hand on
the right on cue (but the left hand was not checked) and open
his
eyes, saying a few words (""yes/no"")."
1035,"Does not show 2 fingers or his
thumb on the right.
Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. Does not move the left side of his face as
well
when he groans.
Motor/Sensation: Pill-rolling tremor of his right hand, worse
with noxious stimulus. Decreased tone in his left arm, cogwheel
rigidity in his right arm. Increased tone in his bilateral legs.
No observed myoclonus. Does not keep his bilateral arms or legs
lifted against gravity. Briskly withdraws his right arm to
nailbed pressure, only slightly flexes his left forearm to
nailbed pressure."
1036,"No
intracranial
hemorrhage.
.
CTA Chest ([**2185-4-4**]):
IMPRESSION:
1. Extensive bilateral pulmonary embolus with resulting
hypoperfusion/developing infarction at lung bases.
2. Early right heart strain.
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname **] was an 82 year old man (unknown handedness)
with a history of Parkinson's disease, hypercholesterolemia, and
right hip fracture s/p fall [**2-2**] s/p
ORIF who presented to the [**Hospital1 18**] with altered mental status and
was found to have a right MCA infarct. He was admitted to the
stroke service from [**2185-4-4**] to the time of his death on [**2185-4-6**]."
1037,"Physical Exam:
PHYSICAL EXAM AT ADMISSION
VS: temp 102.2, HR 101, bp 111/52, RR 32, SaO2 92% on NRB
Genl: Eyes closed, NRB in place, does not open eyes to sternal
rub
HEENT: Sclerae anicteric, no conjunctival injection
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: Tachypnic, right basilar crackles, no wheezes or rhonchi
Abd: Increased BS, soft, NTND abdomen
Neurologic examination:
Mental status: Eyes closed. Does not open eyes on command or to
sternal rub, only briefly groans to nailbed pressure. Squeezes
right hand and wiggles right toes on command, does not move the
left hand or toes on command."
1038,"Vitals were bp 138/70, HR
86, RR 18, FSBG 136, SaO2 88% on RA so was placed on 2L NC which
improved to 91%. Over a 3 hour period, he became less responsive
and wasn't talking as much, and had a low grade temp to 99.9
axillary so labs were ordered given concern for aspiration. They
did not notice any focalities or asymmetry. Per the ED staff,
Narcan was given without response. The ambulance was called and
came at 11:15 pm, and by that time he was completely
unresponsive.
At baseline, speaks in complete sentences slowly and can be
difficult to understand, tries to get out of bed, oriented x2
(not always sure where he is)."
1039,".
Cardiac review of systems is notable for dyspnea on exertion,
negative for paroxysmal nocturnal dyspnea, negative for
orthopnea, ankle edema, palpitations.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes type 2 +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY:
- CABG: Per report, CABG with AVR in [**4-/2121**] (90% distal left
main extending to LAD and ostium of LCX with 80% mid-RCA)
- PERCUTANEOUS CORONARY INTERVENTIONS: C. Cath [**9-/2122**] with
clean grafts per report at [**Hospital1 1774**]
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
HTN
HLD
DM2
R total hip replacement
Social History:
Married, works as carpenter. Denies drugs, alcohol, smoking."
1040,"A catheter overlies the left upper quadrant,
and is likely external to the patient. Again noted is dense
calcification of the aorta and iliac vessels. A left total hip
arthroplasty is unchanged.
IMPRESSION:
Interval increasing dilation of air-filled loops of small bowel
loops raises concern for ischemia.
Brief Hospital Course:
Mr. [**Known lastname 91160**] is a 61M transferred from [**Hospital3 26615**] hospital with
CAD s/p 3V CABG and AVR in [**2120**], NSTEMI, s/p DDD pacer implant
for intermittent complete heart block in [**9-/2122**] transferred
from OSH for evaluation and management of VT with HD instability
requiring defibrillation."
1041,".
# Septic shock/endocarditis with aortic valve dehiscence: The
patient underwent pacemaker placement [**2122-10-2**]. He was febrile
on admission with elevated wbc count and described weeks of
shaking chills. Blood cultures grew coag negative staph and he
was started on Vancomycin. His blood pressure decreased to the
SBPs in the 80-90s. He was started on cefepime in addition to
vancomycin. A TEE showed aortic valve dehiscence with flow from
the aorta to the right atrium and possible vegetations. He later
went into PEA briefly then his pulse returned but because of
hypotension and poor O2 saturation he was intubated and put on
pressors."
1042,"His blood pressure continued to fall and he was
requiring 4 pressors and large volumes of IVF. A dialysis
catheter was placed to try to remove some volume and manage his
potassium. However, after this was placed his BP would not
tolerate dialysis. Shortly after he went into asystole and
passed away.
.
# VT/rhythm: In [**Month (only) 359**] he had a syncopal event thought to be
related to heart block so a pacemaker was placed. He was
transferred to [**Hospital1 18**] from an OSH after he had pulseless VT
requiring defibrillation. He was not in VT when he arrived at
[**Hospital1 18**]."
1043,"He was planned to have an EP procedure and prior to the
procedure he was started on atenolol to prevent VT. However,
before he could undergo any procedure he developed septic shock
and aortic valve dehiscence and then expired as above.
.
Medications on Admission:
HOME MEDICATIONS:
ASA 81 mg daily
metformin 1000 mg qam
Vitamin D 1000 u daily
Coumadin
simvastatin 80 mg
lisinopril 10 mg daily (stopped taking)
metoprolol 50 mg daily (stopped taking)
.
Medications on transfer:
atenolol 25 mg daily
ASA 325 daily
atorvastatin 40 mg daily
NG
heparin drip
ISS
bisacodyl
docusate
milk of magnesia
Simethacone
guafenesin
acetaminophen
metformin 1000 mg
amiodarone infusion
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic Shock
Presumed Endocarditis
Mechanical Disruption of aortic valve
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a"
1044,"No aortic regurgitation is
seen through this area. There is trivial valvular aortic
regurgitation (normal for this prosthesis). The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen.
IMPRESSION: Partially posterior aortic valve prosthesis
dehiscence with flow from the aorta into the right atrium.
Vegetations vs. suture vs. tissue in the area.Moderate to severe
tricuspid regurgitation.
.
RUQ US [**2122-11-2**]
IMPRESSION:
1. Mildly coarsened hepatic echotexture. No frank biliary
dilatation.
2. A few peripheral echogenic foci in the liver likely represent
small portal branches; however, portal venous gas cannot be
entirely excluded."
1045,"He
was transferred to the ICU and transferred to [**Hospital1 18**] for further
evaluation and treatment.
.
On the floor he describes shaking chills occasionally over the
past 3 weeks after having his pacemaker placed although he
denies frank fevers. He also denies pain, redness, or drainage
from the site of his pacemaker. He also describes having a cough
over the past week but states it is non-productive.
.
On review of systems, 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."
1046,"3 MCHC-35.0 RDW-14.1
[**2122-10-31**] 05:56PM NEUTS-90.7* LYMPHS-5.0* MONOS-3.9 EOS-0.2
BASOS-0.1
[**2122-10-31**] 05:56PM PLT COUNT-429
[**2122-10-31**] 05:56PM PT-29.0* PTT-45.8* INR(PT)-2.8*
[**2122-10-31**] 05:56PM CRP-143.7*
[**2122-10-31**] 05:56PM SED RATE-62*
.
MICRO:
4/4 bottles positive for coagulase negative staph
.
ECHO [**2122-11-2**]
No atrial septal defect is seen by 2D or color Doppler. Two
pacemaker leads are seen entering the right atrium from the SVC,
without definite associated vegetations."
1047,"Overall left
ventricular systolic function is normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. A mechanical
aortic valve prosthesis is present. The anterior attachment of
the prosthesis is normal. The posterior half of the prosthesis
appears hypermobile/partial dehiscence extending nearly [**12-14**] way
around the prosthesis (clip [**Clip Number (Radiology) **]). An echolucent space is seen
posteriorly with systolic flow into this space which is then
contiguous with the right atrium with continus flow (aorta to
right atrial fistula). There are mobile echodensities (clip [**Clip Number (Radiology) **],
84) seen at the posterior attachment site of the prosthesis c/w
tissue, sutures and/or vegetations."
1048,"He was
started on ASA 325, given lovenox 1mg/kg SQ.
.
Then rapid response was called at 3am today at OSH for VT with
HR to 280 with pt found to be diaphoretic and dyspneic but then
uresponsive for 5 seconds. VT self-teriminated after 2 minutes
and pt started on amiodarone drip @ 3:30AM, crit found to be 26
(stable from admission)and rec'd 1u pRBCs and trop drawn and
found to be 0.14. Later went into monomorphic VT with rate in
the 250's @ 11:45AM, shocked x 1 with return to paced rate of 88
and was apparently neurologically intact and AOx3 following."
1049,"No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+
PT 2+
Neuro: CN 2-12 grossly intact, normal strength and sensation
throughout
Pertinent Results:
ADMISSION LABS:
[**2122-10-31**] 05:56PM GLUCOSE-142* UREA N-11 CREAT-0.8 SODIUM-133
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-13
[**2122-10-31**] 05:56PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2122-10-31**] 05:56PM WBC-15.0* RBC-3.35* HGB-9.8* HCT-28.1* MCV-84
MCH-29."
1050,"If there is clinical concern for ischemic
bowel, further assessment should be performed with CT.
3. Diffuse gallbladder wall thickening.
4. Splenomegaly to 15 cm.
.
KUB [**2122-11-1**]
FINDINGS: Two supine and one left lateral decubitus image show
no evidence of free air. There are air-filled loops of
nondilated small bowel. There is air and stool seen within the
colon extending into the sigmoid and rectum. There is no
evidence of obstruction or ileus. Patient is status post a total
left hip arthroplasty with no evidence of loosening. There are
degenerative changes of L4 and L5 in the right hip."
1051,"He
was admitted to OSH after being started back on metoprolol which
caused him symptoms of light-headedness, lethargy, and mental
slowing (which he had previously experienced leading him to stop
taking metoprolol and lisinopril). He stopped the medication
himself and began to feel better but became extremely SOB when
walking up stairs and ended up lying on the floor due to his
inability to catch his breath which prompted him to call 911 and
present to OSH. He was assessed has possibly having ACS and
underwent ROMI with trops <0.03 -> 0.16 -> 0.12, negative MB's
throughout and EKG with pacer rhythm and 100% capture."
1052,"The bases of
the lungs are clear. Sternotomy wires and pacemaker wires are
seen within the chest.
IMPRESSION: No evidence of obstruction or ileus.
.
KUB [**2122-11-2**]
FINDINGS: Three supine frontal images of the abdomen show newly
dilated loops of small bowel measuring up to 3.4 cm in the left
upper quadrant. Given history of recent arrest, the dilation may
be secondary to ischemia. Could also consider the possibility of
an early or partial small-bowel obstruction. There is no obvious
free air, although exam is somewhat limited due to supine
positioning. There has been interval placement of a femoral line
on the right groin."
1053,"Admission Date: [**2122-10-31**] Discharge Date: [**2122-11-2**]
Date of Birth: [**2061-9-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
-Central Venous Line Placement
-Dialysis Line Placement
History of Present Illness:
61M transferred from [**Hospital3 26615**] hospital with CAD s/p 3V CABG
and AVR @ [**Hospital3 2358**] [**4-/2121**] (90% distal left main extending to
LAD and ostium of LCX with 80% mid-RCA) for NSTEMI, s/p DDD
pacer implant for intermittent complete heart block @ [**Hospital1 3343**] [**9-/2122**] transferred from OSH for evaluation and
management of VT with HD instability requiring shocks x 1."
1054,"Family History:
father with CAD, brother with carotid vascular disease, paternal
grandfather with CAD
Physical Exam:
ADMISSION EXAM:
VS: 100.9 98 127/62 14 98% on 2L
GENERAL: NAD, sleeping comfortably in bed
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP not appreciated
CHEST: pacemaker pocket-no erythema, no discharge, no tenderness
to palpation
CARDIAC: RRR, normal S1, S2, + mechanical click, no
murmurs/rubs/gallops appreciated
LUNGS: anterior lung fields clear to auscultation, patient
refused to sit up for posterior lung exam
ABDOMEN: soft, nontender, nondistended, +BS
EXTREMITIES: No c/c/e."
1055,"ECHO from [**4-10**] similar to last ECHO [**2-27**].
-hold home furosemide
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2182-4-10**] 03:50 AM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition:
------ Protected Section ------
I have seen and examined the patient with the resident and agree
substantially with the assessment and plan with the following
modifications/emphasis:
Overnight, hematocrit remained stable and no new problems
T 36.4 P 84 BP: 120/50 RR 16 SpO2: 95%
Gen: Awake, alert NAD
Chest: CTA bilaterally
Heart: S1 S2 reg
Abd: Soft NT ND
Ext: No edema
Labs reviewed
Assessment:
1) GI Bleed
2) Diverticulitis
3) Acute renal failure
4) CAD
5) CHF
25%, Aortic Stenosis
Plan:
1) Continue serial hcts
2) Endoscopy tomorrow
3) Holding asa/plavix
4) Transfer to floor
Time Spent: 25 minutes
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **], MD
on:[**2182-4-11**] 16:39 ------"
1056,"Chief Complaint:
24 Hour Events:
TRANSTHORACIC ECHO - At [**2182-4-10**] 02:22 PM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Dextrose 50% - [**2182-4-10**] 06:12 PM
Pantoprazole (Protonix) - [**2182-4-10**] 08:00 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2182-4-11**] 07:07 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**84**] AM
Tmax: 36.4
C (97.5
Tcurrent: 35.3
C (95.6
HR: 84 (75 - 97) bpm
BP: 120/50(69) {80/45(58) - 124/84(94)} mmHg
RR: 16 (16 - 29) insp/min
SpO2: 91%
Heart rhythm: SR (Sinus Rhythm)
Total In:
1,461 mL
403 mL
PO:
TF:
IVF:
146 mL
193 mL
Blood products:
865 mL
210 mL
Total out:
3,175 mL
1,100 mL
Urine:
2,925 mL
1,100 mL
NG:
Stool:
Drains:
Balance:
-1,714 mL
-698 mL
Respiratory support
O2 Delivery Device: None
SpO2: 91%
ABG: ///23/
Physical Examination
HEENT: MMM
CARDIAC: RRR, [**2-23**] mid peaking crescendo decrescendo murmur at the USB
with radiation to the precordium and the carotids, good carotid
pulsations."
1057,"LUNG: CTAB
ABDOMEN: soft, NT, ND, no masses or organomegaly
EXT: WWP, no c/c/e
NEURO: AOx3, grossly normal
Labs / Radiology
173 K/uL
10.3 g/dL
75 mg/dL
2.0 mg/dL
23 mEq/L
5.2 mEq/L
116 mg/dL
112 mEq/L
144 mEq/L
29.6 %
6.1 K/uL
[image002.jpg]
[**2182-4-10**] 04:32 AM
[**2182-4-10**] 12:40 PM
[**2182-4-10**] 03:39 PM
[**2182-4-10**] 06:07 PM
[**2182-4-11**] 03:51 AM
WBC
6.1
Hct
22.4
24.8
25.8
29."
1058,"6
Plt
173
Cr
2.7
2.3
2.0
Glucose
55
75
Other labs: PT / PTT / INR:12.9/29.3/1.1, ALT / AST:79/36, Alk Phos / T
Bili:57/0.6, Albumin:3.4 g/dL, LDH:177 IU/L, Ca++:8.3 mg/dL, Mg++:2.4
mg/dL, PO4:4.0 mg/dL
Assessment and Plan
The patient is an 89 yoM w/ CAD, systolic CHF EF 25-30%, moderate AS,
on aspirin and plavix presents with severe anemia and melena.
.
# GI bleed: melena c/w upper GI bleed. Likely source is gastritis /
PUD."
1059,"No e/o active bleeding since admission.
-plan for EGD tomorrow [**4-12**] with anesthesia on the [**Hospital Ward Name **]
-hct stable, continue to hold ASA / plavix, cardiology has been
consulted regarding this as well as risk assessment (intermediate risk
for a low risk procedure)
-clear liquids and NPO after MN
-Q8hr hct
-[**Hospital1 **] PPI
# Acute renal failure: baseline Cr around 2.0, currently at baseline
# Hyperkalemia: mild hyperkalemia, continue to monitor
# CAD:
-hold ACEi and beta blocker given possible hemodynamic instability
-holding ASA/plavix
-transfuse for Hct<30
# chronic systolic heart failure: EF of 25-30% most recently, ischemic
etiology."
1060,"Admission Date: [**2182-4-10**] Discharge Date: [**2182-4-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89yM with CAD, systolic CHF EF 25-30%, moderate AS, on aspirin
and [**First Name3 (LF) **] presenting with severe anemia and melena. 3-4 days of
melena, [**3-21**] stools per day. Stool foul smelling, sticky, black.
No red blood. No abdominal pain, no nausea or vomiting. No EtOH
or NSAIDs, just ASA and [**Month/Day (3) **]. No additional ASA."
1061,"No history of
GI bleeding and no EGD in th epast. Has NYHA class III CHF
symptoms at baseline, no angina at baseline. He gets short of
breath while walking in the part, does okay around the house. No
orthopnea, PND, or pedal edema. Weighed 177lbs on admission, 175
baseline. No other symptoms. No fevers/chills. In ED, had 2 PIV,
got 1L IVF, 40mg IV Protonix, and 1 unit pRBC's.
Past Medical History:
Diabetes
Dyslipidemia
CAD s/p PCA in [**1-/2182**]
Moderate Aortic Stenosis
Anemia
CKD (baseline creatinine 2.1)
Gout
CHF, EF 25-30%
Social History:
Lives in [**Location 1268**] with wife."
1062,"The left ventricular ejection
fraction may have been slightly underestimated in the prior
report. . Estimated valve area is slightly higher in the current
report.
Chest X-ray [**2182-4-10**]: IMPRESSION: No evidence for pulmonary
edema. Suspected tiny or small pleural effusion on the left.
Chest X-ray [**2182-4-16**]: IMPRESSION: Unchanged mild cardiomegaly
and small bilateral effusions.
Brief Hospital Course:
89yM with CAD and systolic CHF, moderate AS, on aspirin and
[**Year (4 digits) **], admitted with severe anemia and melena.
# GI Bleeding. Hct on admission 22; baseline 30-32. Thought
secondary to UGIB (gastritis, PUD). ASA/[**Year (4 digits) **] stopped on
admission."
1063,"Seen by GI; given multiple cardiac problems, any
procedure would need to be done by [**Last Name (LF) **], [**First Name3 (LF) **] deferred. Hematocrit
stabilized off ASA/[**First Name3 (LF) **]; GI bleeding thought secondary to
[**Last Name (LF) **], [**First Name3 (LF) **] this should be permanently discontinued. Metoprolol,
lisinopril, and torsemide held in setting of GI bleeding.
Hematocrit after [**4-12**] was stable, ranging from 25-30%. Received
a total of 5 units pRBC's during admission (last on [**4-16**]);
hematocrit at discharge 28%. No bowel movement in 3 days at time
of discharge. Discharged on pantoprazole [**Hospital1 **].
# Acute on chronic renal failure."
1064,"Creatinine 2.7 at time of
admission (baseline 2.0-2.2). Creatinine was as low as 1.7
during the admission. Bumped from 1.7 to 2.2 when lisinopril
initially restarted; this medication was discontinued again and
should be restarted as an outpatient. Torsemide to be restarted
on discharge.
# Coronary artery disease. [**Hospital1 **] discontinued. Aspirin
restarted three days prior to discharge with subsequent stable
hematocrit. Statin continued. Metoprolol restarted two days
prior to discharge, and lisinopril to be restarted as
outpatient.
# Chronic systolic heart failure. Well-compensated throughout
the admission. Change in x-ray demonstrated accumulation of mild
bilateral pulmonary effusions (diuresis was held during the
admission)."
1065,"I's/O's closely monitored, and he remained euvolemic
throughout the admission. Beta blocker restarted during
admission, torsemide to start as outpatient, and lisinopril to
be restarted within one week of discharge.
# Delirium. Noted to have reversed sleep/wake cycles during the
admission, with subsequent confusion. Improved with trazodone,
to be continued on discharge.
# Gout flare. On [**5-6**], patient had low-grade fever and
bilateral great toe pain. Given one dose of colchicine with
resolution of fever and pain.
# Hyperlipidemia. Continued statin.
# Hypernatremia. Did develop hypernatremia during
hospitalization. Resolved with increased PO fluid intake.
# Full Code, confirmed with patient."
1066,"Medications on Admission:
Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Lisinopril 10mg daily
[**Date Range **] 75mg daily
Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
Torsemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**4-23**]
hours as needed for pain.
Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day
Zantac 75mg [**Hospital1 **]"
1067,"C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**4-23**]
hours as needed for pain.
9. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1) GI bleed
2) Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent, with cane/walker
Discharge Instructions:
You were admitted with bleeding in your GI tract."
1068,"There is
moderate global left ventricular hypokinesis (LVEF = 35-40 %).
The aortic valve leaflets are severely thickened/deformed. There
is moderate to severe aortic valve stenosis (valve area
1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2182-3-16**],
the heart fate is higher and left ventricular systolic function
is slightly more vigorous."
1069,"DISCHARGE EXAM:
98.2F, BP 102/64, 862, 96%RA
No JVD
RRR, 2/6 systolic murmur
Lungs clear to auscultation bilaterally
Abdomen benign
No peripheral edema
A&O x 3
Pertinent Results:
[**2182-4-9**] 11:30PM PT-12.8 PTT-29.3 INR(PT)-1.1
[**2182-4-9**] 11:30PM PLT COUNT-233
[**2182-4-9**] 11:30PM NEUTS-68.5 LYMPHS-17.4* MONOS-6.1 EOS-7.3*
BASOS-0.6
[**2182-4-9**] 11:30PM WBC-5.0 RBC-2.32*# HGB-7.5*# HCT-22.1*#
MCV-96 MCH-32.2* MCHC-33."
1070,"Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E."
1071,"[**Name (NI) **] 2 daughters and a son.
[**Name (NI) **] was born in [**Country 4754**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3
children and 9 grandchildren.
-Tobacco history: Denies
-ETOH: Occasional
-Illicit drugs: Denies
Family History:
No know FH of cardiac disease, diabetes, no colon/proste/breast
cancer. Parents lived to 70s to 80s with no known medical
problems. Children in good health. Brother had heart disease.
Physical Exam:
Vitals 97,0F, BP 98/51, HR 77, RR 14, O2 sat 97%RA
General: NAD, A&O x 3
HEENT: MM slightly dry, JVP 8cm
Cardiac: RRR, [**2-23**] mid peaking systolic crescendo decrescendo
murmur at the USB with radiation to the precordium and the
carotids, good carotid pulsations
Lung: CTAB
Abdomen: Soft, NT, ND, no masses or organomegaly
Rectal: minimal melnea in rectal vault, no red blood, no rectal
masses
Neuro: A&O x3, grossly normal"
1072,"[**Last Name (STitle) 131**]; please discuss this medication with him when you see him
on [**2182-4-24**]
- Trazodone: This is a medication for sleep.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**]
Specialty: Internal Medicine-Primary Care
Date/ Time: [**2182-4-24**] 10:30am
Location: [**Street Address(2) 3375**] [**Location (un) 858**], [**Location (un) **] MA
Phone number: [**Telephone/Fax (1) 133**]
Special instructions for patient:
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7965**]
Specialty: Cardiology
Date/ Time:
Location:
Phone number: [**Telephone/Fax (1) 62**]
Special instructions for patient: The office will call you with
an appointment. If you do not hear or have any questions please
call the office. Thanks."
1073,"7 RDW-13.6
[**2182-4-9**] 11:30PM cTropnT-0.05*
[**2182-4-9**] 11:30PM CK(CPK)-81
[**2182-4-9**] 11:30PM GLUCOSE-195* UREA N-163* CREAT-2.9*
SODIUM-132* POTASSIUM-6.3* CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
[**2182-4-10**] 04:32AM PT-12.9 PTT-29.3 INR(PT)-1.1
[**2182-4-10**] 04:32AM HCT-22.4*
[**2182-4-10**] 04:32AM ALBUMIN-3.4* CALCIUM-8.3* PHOSPHATE-4.0
MAGNESIUM-2.8*
[**2182-4-10**] 04:32AM ALT(SGPT)-79* AST(SGOT)-36 LD(LDH)-177 ALK
PHOS-57 TOT BILI-0."
1074,"This was most
likely due to your medication, [**Hospital **], that you recently started
taking. Please do not take your [**Hospital **]. Your aspirin was
restarted, and you had no further bleeding; you should continue
to take this medication.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Please take all of your medications as prescribed
and keep all follow up appointments.
The following changes are made to your medication list:
- [**Name8 (MD) **]: DO NOT TAKE THIS MEDICATION, as it likely contributed
to your episode of bleeding from your GI tract
- Pantoprazole: this is an anti-acid medication that you are
prescribed to help prevent bleeding from your GI tract
- Lisinopril: This medication will likely be restarted by Dr."
1075,"6
[**2182-4-10**] 04:32AM GLUCOSE-55* UREA N-158* CREAT-2.7* SODIUM-136
POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
[**2182-4-10**] 12:40PM HCT-24.8*
[**2182-4-10**] 12:40PM POTASSIUM-5.2*
[**2182-4-10**] 03:39PM HCT-25.8*
[**2182-4-10**] 06:07PM MAGNESIUM-2.4
[**2182-4-10**] 06:07PM estGFR-Using this
[**2182-4-10**] 06:07PM UREA N-134* CREAT-2.3* POTASSIUM-5.3*
Echo [**2182-4-10**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal for the patient's body size."
1076,"No stents placed- procedure aborted due to severe
agitation
LCx 40% prox, 60% ramus
RCA non dominant and no disease
moderate AS with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 549**] of 1.0cm and a mean gradient of 24mmHg
Assessment and Plan
GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)
The patient is an 89 yoM w/ CAD, systolic CHF EF 25-30%, moderate AS,
on aspirin and plavix presents with severe anemia and melena.
# GI bleed: melena c/w upper GI bleed. Likely source is gastritis /
PUD.
-add on LFTs
-he is consented and type and crossmatched
-2 PIV x 18g
-Protonix 80mg IV bolus then 8mg/hr
-GI consult
-NG lavage negative and rectal without red [**Last Name (LF) 1056**], [**First Name3 (LF) 124**] need urgent EGD
-hold ASA and plavix for now
# Acute renal failure: baseline Cr around 2."
1077,"Patient admitted from: [**Hospital1 5**] ER
History obtained from Patient
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Pantoprazole (Protonix) - 8 mg/hour
Other ICU medications:
Pantoprazole (Protonix) - [**2182-4-10**] 05:19 AM
Other medications:
Atorvastatin 80 mg po daily
Plavix 75mg daily
ASA 81mg daily
Metoprolol 12.5mg po bid
Ferrous Sulfate 300 mg (60 mg Iron) po daily
Docusate Sodium 100 mg po bid
Lisinopril 10 mg po dailly
Nitroglycerin 0.4 mg SL prn
Glipizide 10 mg po daily
Zantac 75mg po bid
Tylenol prn
Torsemide 40mg po daily
Past medical history:
Family history:
Social History:
Diabetes
Dyslipidemia
Hypertension
CAD
Anemia
Chronic Kidney Disease (Baseline Cre 2."
1078,"1
C (97
Tcurrent: 36.1
C (97
HR: 83 (79 - 83) bpm
BP: 95/40(53) {95/40(53) - 107/48(62)} mmHg
RR: 20 (20 - 20) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Total In:
362 mL
PO:
TF:
IVF:
12 mL
[**Year (2 digits) **] products:
Total out:
0 mL
750 mL
Urine:
500 mL
NG:
Stool:
Drains:
Balance:
0 mL
-388 mL
Respiratory
O2 Delivery Device: None
SpO2: 99%
ABG: ///24/
Physical Examination
Vitals - T: 97.0 BP: 98/51 HR: 77 RR: 14 02 sat: 97% on RA.
GENERAL: NAD, AOx3
HEENT: MM slightly dry, JVP 8cm
CARDIAC: RRR, [**2-23**] mid peaking crescendo decrescendo murmur at the USB
with radiation to the precordium and the carotids, good carotid
pulsations."
1079,"No orthopnea, PND or pedal edema. He weighs 177
today, baseline weight is 175. No other symptoms. No F/C.
In the ED, initial VS: T 98.2 HR 71 BP 96/40 RR 18 O2 sat: 100% on
RA. His hct 3 weeks prior was 36, down to 22 on presentation to the
ER. He has 2 PIV - 18g x 2. He rec'd 1L IVF, 40mg IV protonix and 1
uPRBC. He rec'd 1 amp of bicarb, 10uIV insulin, and an amp of D50.
EKG without any changes c/w hyperkalemia. Prior to transfer to the
floor his HR was 70 and BP 115/74."
1080,"0, recently has been
2.7-2.9, currently 2.7. likely related to hypovolemia, trend as the
patient is transfused and returns to euvolemia.
-if does not continue to improve will send urine lytes.
# Hyperkalemia: repeat p.m. K at 3 p.m., no hyperkalemic changes on
EKG. Possibly from worsening creatinine.
# CAD: The patient has a baseline history of CAD, with a cath in [**1-27**]
with 2 vessel CAD and s/p atherectomy but no stenting. On aspirin and
plavix, at this point given a life threatening bleed will have to hold
both aspirin and plavix and re-asess in the future."
1081,"4
Cr
2.7
Glucose
55
Other labs: PT / PTT / INR:12.9/29.3/1.1, Ca++:8.3 mg/dL, Mg++:2.8
mg/dL, PO4:4.0 mg/dL
ECG: EKG: NSR rate of 66, AV conduction delay, RBBB, slight STD in V4
and V5 unchanged from prior.
ECHO TTE [**2-27**]: 25-30% (with regional akinesis of inf wall and apex),
mild symmetric LVH. Severe AS valve area 0.8-1.0cm2 but mean gradient
of 15mmHg. 2+ TR, 1+ MR. moderate pulm HTN.
Cath [**2182-1-24**]: 2VD
LMCA normal
LAD prox 80%, 90% mid, 70% distal --> rotational atherectomy and PTCA
of prox and mid LAD."
1082,"Chief Complaint: Melena
HPI:
89 yoM w/ CAD, systolic CHF EF 25-30%, moderate AS, on aspirin and
plavix presents with severe anemia and melena. 3-4 days of melena, [**3-21**]
stools per day. The stool has been foul smelling, sticky and black. No
red [**Month/Day (3) 1056**]. No abdominal pain, no nausea or vomiting. No ETOH or
NSAIDs, just ASA and plavix. No additional ASA. No h/o GI bleed and
no EGD in the past.
The patient has NYHA class II CHF symptoms at baseline, no angina at
baseline. He gets short of breath while walking in the park, does okay
around the house."
1083,"LUNG: CTAB
ABDOMEN: soft, NT, ND, no masses or organomegaly
RECTAL: minimal melena in rectal vault, no red [**Month/Day (4) 1056**], no rectal masses
EXT: WWP, no c/c/e
NEURO: AOx3, grossly normal
Labs / Radiology
55 mg/dL
2.7 mg/dL
158 mg/dL
24 mEq/L
104 mEq/L
5.3 mEq/L
136 mEq/L
22.4 %
[image002.jpg]
[**2178-1-19**]
2:33 A3/24/[**2182**] 04:32 AM
[**2178-1-23**]
10:20 P
[**2178-1-24**]
1:20 P
[**2178-1-25**]
11:50 P
[**2178-1-26**]
1:20 A
[**2178-1-27**]
7:20 P
1//11/006
1:23 P
[**2178-2-19**]
1:20 P
[**2178-2-19**]
11:20 P
[**2178-2-19**]
4:20 P
Hct
22."
1084,"1)
Gout
No know FH of cardiac disease, diabetes, no colon/proste/breast cancer.
Parents lived to 70s to 80s with no known medical problems. Children in
good health. Brother had heart disease.
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Lives in [**Location 4320**] with wife. [**Name (NI) 6**] 2 daughters and a son.
[**Name (NI) **] was born in [**Country 5802**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3 children
and 9 grandchildren.
-Tobacco history: Denies
-ETOH: Occasional
-Illicit drugs: Denies
Review of systems:
Flowsheet Data as of [**2182-4-10**] 05:33 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**84**] AM
Tmax: 36."
1085,"-hold ACEi and beta blocker given possible hemodynamic instability
# CHF: chronic systolic heart failure with an EF of 25-30% most
recently, ischemic etiology. In addition moderate AS on cath [**1-26**].
-lasix with [**Month/Year (2) 1056**] transfusion, will use 40mg IV
# FEN: IVFs / replete lytes prn / NPO
# PPX: PPI, pneumoboots
# ACCESS: PIV
# CODE: FULL CODE
# CONTACT: Wife
# ICU CONSENT: Patient would like to discuss with his wife prior to
signing the consent form
# DISPO: ICU
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2182-4-10**] 03:50 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU"
1086,"0, recently has been
2.7-2.9, currently 2.7. likely related to hypovolemia, trend as the
patient is transfused and returns to euvolemia.
-if does not continue to improve will send urine lytes.
# Hyperkalemia: repeat p.m. K at 3 p.m., no hyperkalemic changes on
EKG. Possibly from worsening creatinine.
# CAD: The patient has a baseline history of CAD, with a cath in [**1-27**]
with 2 vessel CAD and s/p atherectomy but no stenting. On aspirin and
plavix, at this point given a life threatening bleed will have to hold
both aspirin and plavix and re-asess in the future."
1087,"4
Cr
2.7
Glucose
55
Other labs: PT / PTT / INR:12.9/29.3/1.1, Ca++:8.3 mg/dL, Mg++:2.8
mg/dL, PO4:4.0 mg/dL
ECG: EKG: NSR rate of 66, AV conduction delay, RBBB, slight STD in V4
and V5 unchanged from prior.
ECHO TTE [**2-27**]: 25-30% (with regional akinesis of inf wall and apex),
mild symmetric LVH. Severe AS valve area 0.8-1.0cm2 but mean gradient
of 15mmHg. 2+ TR, 1+ MR. moderate pulm HTN.
Cath [**2182-1-24**]: 2VD
LMCA normal
LAD prox 80%, 90% mid, 70% distal --> rotational atherectomy and PTCA
of prox and mid LAD."
1088,"Patient admitted from: [**Hospital1 5**] ER
History obtained from Patient
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Pantoprazole (Protonix) - 8 mg/hour
Other ICU medications:
Pantoprazole (Protonix) - [**2182-4-10**] 05:19 AM
Other medications:
Atorvastatin 80 mg po daily
Plavix 75mg daily
ASA 81mg daily
Metoprolol 12.5mg po bid
Ferrous Sulfate 300 mg (60 mg Iron) po daily
Docusate Sodium 100 mg po bid
Lisinopril 10 mg po dailly
Nitroglycerin 0.4 mg SL prn
Glipizide 10 mg po daily
Zantac 75mg po bid
Tylenol prn
Torsemide 40mg po daily
Past medical history:
Family history:
Social History:
Diabetes
Dyslipidemia
Hypertension
CAD
Anemia
Chronic Kidney Disease (Baseline Cre 2."
1089,"1)
Gout
No know FH of cardiac disease, diabetes, no colon/proste/breast cancer.
Parents lived to 70s to 80s with no known medical problems. Children in
good health. Brother had heart disease.
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Lives in [**Location 4320**] with wife. [**Name (NI) 6**] 2 daughters and a son.
[**Name (NI) **] was born in [**Country 5802**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3 children
and 9 grandchildren.
-Tobacco history: Denies
-ETOH: Occasional
-Illicit drugs: Denies
Review of systems:
Flowsheet Data as of [**2182-4-10**] 05:33 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**84**] AM
Tmax: 36."
1090,"LUNG: CTAB
ABDOMEN: soft, NT, ND, no masses or organomegaly
RECTAL: minimal melena in rectal vault, no red [**Month/Day (4) 1056**], no rectal masses
EXT: WWP, no c/c/e
NEURO: AOx3, grossly normal
Labs / Radiology
55 mg/dL
2.7 mg/dL
158 mg/dL
24 mEq/L
104 mEq/L
5.3 mEq/L
136 mEq/L
22.4 %
[image002.jpg]
[**2178-1-19**]
2:33 A3/24/[**2182**] 04:32 AM
[**2178-1-23**]
10:20 P
[**2178-1-24**]
1:20 P
[**2178-1-25**]
11:50 P
[**2178-1-26**]
1:20 A
[**2178-1-27**]
7:20 P
1//11/006
1:23 P
[**2178-2-19**]
1:20 P
[**2178-2-19**]
11:20 P
[**2178-2-19**]
4:20 P
Hct
22."
1091,"No orthopnea, PND or pedal edema. He weighs 177
today, baseline weight is 175. No other symptoms. No F/C.
In the ED, initial VS: T 98.2 HR 71 BP 96/40 RR 18 O2 sat: 100% on
RA. His hct 3 weeks prior was 36, down to 22 on presentation to the
ER. He has 2 PIV - 18g x 2. He rec'd 1L IVF, 40mg IV protonix and 1
uPRBC. He rec'd 1 amp of bicarb, 10uIV insulin, and an amp of D50.
EKG without any changes c/w hyperkalemia. Prior to transfer to the
floor his HR was 70 and BP 115/74."
1092,"-hold ACEi and beta blocker given possible hemodynamic instability
# CHF: chronic systolic heart failure with an EF of 25-30% most
recently, ischemic etiology. In addition moderate AS on cath [**1-26**].
-lasix with [**Month/Year (2) 1056**] transfusion, will use 40mg IV
# FEN: IVFs / replete lytes prn / NPO
# PPX: PPI, pneumoboots
# ACCESS: PIV
# CODE: FULL CODE
# CONTACT: Wife
# ICU CONSENT: Patient would like to discuss with his wife prior to
signing the consent form
# DISPO: ICU
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2182-4-10**] 03:50 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
------ Protected Section ------
GI Bleed: s/p 2 units PRBSc. No further melena. GI planning to hold off
on EGD today given melena ceased.
--c/s cards for pre-EGD risk assessment
--f/u post-transfusion Hct
-- Q6 Hcts, goal hct>25
--DC PPI gtt and change to [**Hospital1 **] PPI
.
Hypotension: goal maps >65
.
Hypoglycemia: hold glyburide. Monitor serum glucose closely
.
CAD: No CP or SOB. CEs flat
--getting cards c/s as per above
--hold anti-hypertensives
.
DISPO: ICU for now
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) 7030**], MD
on:[**2182-4-10**] 11:05 ------"
1093,"Chief Complaint: Melena
HPI:
89 yoM w/ CAD, systolic CHF EF 25-30%, moderate AS, on aspirin and
plavix presents with severe anemia and melena. 3-4 days of melena, [**3-21**]
stools per day. The stool has been foul smelling, sticky and black. No
red [**Month/Day (3) 1056**]. No abdominal pain, no nausea or vomiting. No ETOH or
NSAIDs, just ASA and plavix. No additional ASA. No h/o GI bleed and
no EGD in the past.
The patient has NYHA class II CHF symptoms at baseline, no angina at
baseline. He gets short of breath while walking in the park, does okay
around the house."
1094,"No stents placed- procedure aborted due to severe
agitation
LCx 40% prox, 60% ramus
RCA non dominant and no disease
moderate AS with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 549**] of 1.0cm and a mean gradient of 24mmHg
Assessment and Plan
GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)
The patient is an 89 yoM w/ CAD, systolic CHF EF 25-30%, moderate AS,
on aspirin and plavix presents with severe anemia and melena.
# GI bleed: melena c/w upper GI bleed. Likely source is gastritis /
PUD.
-add on LFTs
-he is consented and type and crossmatched
-2 PIV x 18g
-Protonix 80mg IV bolus then 8mg/hr
-GI consult
-NG lavage negative and rectal without red [**Last Name (LF) 1056**], [**First Name3 (LF) 124**] need urgent EGD
-hold ASA and plavix for now
# Acute renal failure: baseline Cr around 2."
1095,"1
C (97
Tcurrent: 36.1
C (97
HR: 83 (79 - 83) bpm
BP: 95/40(53) {95/40(53) - 107/48(62)} mmHg
RR: 20 (20 - 20) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Total In:
362 mL
PO:
TF:
IVF:
12 mL
[**Year (2 digits) **] products:
Total out:
0 mL
750 mL
Urine:
500 mL
NG:
Stool:
Drains:
Balance:
0 mL
-388 mL
Respiratory
O2 Delivery Device: None
SpO2: 99%
ABG: ///24/
Physical Examination
Vitals - T: 97.0 BP: 98/51 HR: 77 RR: 14 02 sat: 97% on RA.
GENERAL: NAD, AOx3
HEENT: MM slightly dry, JVP 8cm
CARDIAC: RRR, [**2-23**] mid peaking crescendo decrescendo murmur at the USB
with radiation to the precordium and the carotids, good carotid
pulsations."
1096,"No stents placed- procedure aborted due to severe
agitation
LCx 40% prox, 60% ramus
RCA non dominant and no disease
moderate AS with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 549**] of 1.0cm and a mean gradient of 24mmHg
Assessment and Plan
GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)
The patient is an 89 yoM w/ CAD, systolic CHF EF 25-30%, moderate AS,
on aspirin and plavix presents with severe anemia and melena.
# GI bleed: melena c/w upper GI bleed. Likely source is gastritis /
PUD.
-add on LFTs
-he is consented and type and crossmatched
-2 PIV x 18g
-Protonix 80mg IV bolus then 8mg/hr
-GI consult
-NG lavage negative and rectal without red [**Last Name (LF) 1056**], [**First Name3 (LF) 124**] need urgent EGD
-hold ASA and plavix for now
# Acute renal failure: baseline Cr around 2."
1097,"0, recently has been
2.7-2.9, currently 2.7. likely related to hypovolemia, trend as the
patient is transfused and returns to euvolemia.
-if does not continue to improve will send urine lytes.
# Hyperkalemia: repeat p.m. K at 3 p.m., no hyperkalemic changes on
EKG. Possibly from worsening creatinine.
# CAD: The patient has a baseline history of CAD, with a cath in [**1-27**]
with 2 vessel CAD and s/p atherectomy but no stenting. On aspirin and
plavix, at this point given a life threatening bleed will have to hold
both aspirin and plavix and re-asess in the future."
1098,"No further melena. GI planning to hold off
on EGD today given melena ceased.
--c/s cards for pre-EGD risk assessment
--f/u post-transfusion Hct
-- Q6 Hcts, goal hct>25
--DC PPI gtt and change to [**Hospital1 **] PPI
.
Hypotension: goal maps >65
.
Hypoglycemia: hold glyburide. Monitor serum glucose closely
.
CAD: No CP or SOB. CEs flat
--getting cards c/s as per above
--hold anti-hypertensives
.
DISPO: ICU for now
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) 7030**], MD
on:[**2182-4-10**] 11:05 ------
I have seen and examined the patient with the fellow and agree
substantially with the assessment and plan as above with the following
modifications/emphasis:
Year resented to the ED."
1099,"No orthopnea, PND or pedal edema. He weighs 177
today, baseline weight is 175. No other symptoms. No F/C.
In the ED, initial VS: T 98.2 HR 71 BP 96/40 RR 18 O2 sat: 100% on
RA. His hct 3 weeks prior was 36, down to 22 on presentation to the
ER. He has 2 PIV - 18g x 2. He rec'd 1L IVF, 40mg IV protonix and 1
uPRBC. He rec'd 1 amp of bicarb, 10uIV insulin, and an amp of D50.
EKG without any changes c/w hyperkalemia. Prior to transfer to the
floor his HR was 70 and BP 115/74."
1100,"Chief Complaint: Melena
HPI:
89 yoM w/ CAD, systolic CHF EF 25-30%, moderate AS, on aspirin and
plavix presents with severe anemia and melena. 3-4 days of melena, [**3-21**]
stools per day. The stool has been foul smelling, sticky and black. No
red [**Month/Day (3) 1056**]. No abdominal pain, no nausea or vomiting. No ETOH or
NSAIDs, just ASA and plavix. No additional ASA. No h/o GI bleed and
no EGD in the past.
The patient has NYHA class II CHF symptoms at baseline, no angina at
baseline. He gets short of breath while walking in the park, does okay
around the house."
1101,"-hold ACEi and beta blocker given possible hemodynamic instability
# CHF: chronic systolic heart failure with an EF of 25-30% most
recently, ischemic etiology. In addition moderate AS on cath [**1-26**].
-lasix with [**Month/Year (2) 1056**] transfusion, will use 40mg IV
# FEN: IVFs / replete lytes prn / NPO
# PPX: PPI, pneumoboots
# ACCESS: PIV
# CODE: FULL CODE
# CONTACT: Wife
# ICU CONSENT: Patient would like to discuss with his wife prior to
signing the consent form
# DISPO: ICU
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2182-4-10**] 03:50 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
------ Protected Section ------
GI Bleed: s/p 2 units PRBSc."
1102,"1)
Gout
No know FH of cardiac disease, diabetes, no colon/proste/breast cancer.
Parents lived to 70s to 80s with no known medical problems. Children in
good health. Brother had heart disease.
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Lives in [**Location 4320**] with wife. [**Name (NI) 6**] 2 daughters and a son.
[**Name (NI) **] was born in [**Country 5802**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3 children
and 9 grandchildren.
-Tobacco history: Denies
-ETOH: Occasional
-Illicit drugs: Denies
Review of systems:
Flowsheet Data as of [**2182-4-10**] 05:33 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**84**] AM
Tmax: 36."
1103,"Has received a total of 3 Units of PRBCs
Tm: 97 P: 89 BP:103/56 RR 18 Oxygen Saturation: 98%
General: Intubated, sedated
Chest: CTA bilaterally
Heart: S1 S2
Abd: Soft, NT ND
Ext: No edema or cyanosis
Labs: reviewed and as above
Hct 22% -> 22% (after 1 Unit) -> 2 Units
Negative NG lavage
Assessment:
1) GI bleed -
2) Aortic Stenosis and 2-vessel CAD
Plan:
1) GI consult
2) 2 Large-bore IVs
3) Serial hct
4) Repeat ECHO and cardiology consult
Time Spent: 30 minutes
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **], MD
on:[**2182-4-10**] 06:57 PM ------"
1104,"4
Cr
2.7
Glucose
55
Other labs: PT / PTT / INR:12.9/29.3/1.1, Ca++:8.3 mg/dL, Mg++:2.8
mg/dL, PO4:4.0 mg/dL
ECG: EKG: NSR rate of 66, AV conduction delay, RBBB, slight STD in V4
and V5 unchanged from prior.
ECHO TTE [**2-27**]: 25-30% (with regional akinesis of inf wall and apex),
mild symmetric LVH. Severe AS valve area 0.8-1.0cm2 but mean gradient
of 15mmHg. 2+ TR, 1+ MR. moderate pulm HTN.
Cath [**2182-1-24**]: 2VD
LMCA normal
LAD prox 80%, 90% mid, 70% distal --> rotational atherectomy and PTCA
of prox and mid LAD."
1105,"Patient admitted from: [**Hospital1 5**] ER
History obtained from Patient
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Pantoprazole (Protonix) - 8 mg/hour
Other ICU medications:
Pantoprazole (Protonix) - [**2182-4-10**] 05:19 AM
Other medications:
Atorvastatin 80 mg po daily
Plavix 75mg daily
ASA 81mg daily
Metoprolol 12.5mg po bid
Ferrous Sulfate 300 mg (60 mg Iron) po daily
Docusate Sodium 100 mg po bid
Lisinopril 10 mg po dailly
Nitroglycerin 0.4 mg SL prn
Glipizide 10 mg po daily
Zantac 75mg po bid
Tylenol prn
Torsemide 40mg po daily
Past medical history:
Family history:
Social History:
Diabetes
Dyslipidemia
Hypertension
CAD
Anemia
Chronic Kidney Disease (Baseline Cre 2."
1106,"1
C (97
Tcurrent: 36.1
C (97
HR: 83 (79 - 83) bpm
BP: 95/40(53) {95/40(53) - 107/48(62)} mmHg
RR: 20 (20 - 20) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Total In:
362 mL
PO:
TF:
IVF:
12 mL
[**Year (2 digits) **] products:
Total out:
0 mL
750 mL
Urine:
500 mL
NG:
Stool:
Drains:
Balance:
0 mL
-388 mL
Respiratory
O2 Delivery Device: None
SpO2: 99%
ABG: ///24/
Physical Examination
Vitals - T: 97.0 BP: 98/51 HR: 77 RR: 14 02 sat: 97% on RA.
GENERAL: NAD, AOx3
HEENT: MM slightly dry, JVP 8cm
CARDIAC: RRR, [**2-23**] mid peaking crescendo decrescendo murmur at the USB
with radiation to the precordium and the carotids, good carotid
pulsations."
1107,"LUNG: CTAB
ABDOMEN: soft, NT, ND, no masses or organomegaly
RECTAL: minimal melena in rectal vault, no red [**Month/Day (4) 1056**], no rectal masses
EXT: WWP, no c/c/e
NEURO: AOx3, grossly normal
Labs / Radiology
55 mg/dL
2.7 mg/dL
158 mg/dL
24 mEq/L
104 mEq/L
5.3 mEq/L
136 mEq/L
22.4 %
[image002.jpg]
[**2178-1-19**]
2:33 A3/24/[**2182**] 04:32 AM
[**2178-1-23**]
10:20 P
[**2178-1-24**]
1:20 P
[**2178-1-25**]
11:50 P
[**2178-1-26**]
1:20 A
[**2178-1-27**]
7:20 P
1//11/006
1:23 P
[**2178-2-19**]
1:20 P
[**2178-2-19**]
11:20 P
[**2178-2-19**]
4:20 P
Hct
22."
1108,"Admission Date: [**2184-3-27**] Discharge Date: [**2184-3-28**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88yo woman with PMH CAD on plavix was found down by her
daughter at 7AM today. Initially she was arousable and
complained
of headache. She was taken to OSH by ambulance where she
reportedly decompensated in the ED requiring intubation. BP was
recorded as 184/84. Head CT revealed large posterior fossa IPH.
She was life flighted to [**Hospital1 18**] and Neurosurgery consultation was
requested."
1109,"Past Medical History:
Celiac Disease
CAD
DM
Pacemaker
Hysterectomy
MI s/p stents and plasty. most recently in [**2179**] @ [**Hospital1 2025**]
Social History:
married, lives with husband and daughter. no e/t/d
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
GCS: E-3 V-1 M-6
O: BP: 184/84 HR: 83 R 14 O2Sats 100%
Gen: Intubated and sedated (prop held for exam)
HEENT: Pupils: 3mm sluggish b/l. + corneals, + gag
Neck: hard collar
Extrem: Warm and well-perfused
Neuro:
Mental status: EO to voice
Cranial Nerves:
II: Pupils equally round and reactive to light 3mm, very
sluggish
mm bilaterally."
1110,"She wished to make her mother DNR. She
was told the risk of developing hydrocephalus and need for EVD
placement. She said she would think about this but was not sure
if she would want to proceed with it.
Overnight on [**3-27**] - [**3-28**] the patient became less responsive. A
head CT was obtained which revealed developing hydrocephalus.
The daughter was [**Name (NI) 653**] and said that she did not want to
proceed with the EVD. The patient was made CMO at that time and
extubated at approximately 6AM.
The daughter [**Name (NI) 653**] the ICU later in the morning and
requested that the patient be transferred to [**Hospital3 15402**] so that
she would be closer to home."
1111,"The bed facilitator was [**Hospital3 653**]
and once transport was arranged she was discharged.
Medications on Admission:
Medications prior to admission:
Nitroglycerine
Plavix
glucophage
metoprolol
gemfibrozil
alprazolam
isosorbide mononitrate
flagyl
Discharge Medications:
1. morphine (PF) in D5W 100 mg/100 mL (1 mg/mL) Parenteral
Solution Sig: 5-20 mg Intravenous TITRATE TO (titrate to desired
clinical effect (please specify)).
2. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
3. midazolam in 0.9 % NaCl 1 mg/mL Solution Sig: 5-20 mg
Intravenous TITRATE TO (titrate to desired clinical effect
(please specify)).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
cerebellar hemorhage, hydrocephelus
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.
Discharge Instructions:
Pt is DNR/DNI and CMO. Transfer to [**Hospital3 15402**] per family's
request.
Followup Instructions:
N/A
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2184-3-28**]"
1112,"Motor: MAE's. B/L UE's antigravity to command
On Discharge:
No [**Last Name (LF) **], [**First Name3 (LF) 2995**] to noxious
Pertinent Results:
[**2184-3-27**] 03:00PM PLT COUNT-226
[**2184-3-27**] 03:00PM PT-13.8* PTT-18.8* INR(PT)-1.2*
[**2184-3-27**] 03:00PM NEUTS-92.9* LYMPHS-4.2* MONOS-1.9* EOS-0.6
BASOS-0.4
[**2184-3-27**] 03:00PM WBC-10.3 RBC-3.86* HGB-12.2 HCT-35.5* MCV-92
MCH-31.5 MCHC-34.3 RDW-13.6
[**2184-3-27**] 03:00PM CALCIUM-9."
1113,"! WET READ !!
No evidence of aneuryms. However, reformats which are necessary
for
interpretation are still pending.
CT HEAD W/O CONTRAST Study Date of [**2184-3-27**] 11:12 PM
Findings compatible with rapidly-evolving obstructive
hydrocephalus due to extensive intraventricular hemorrhage,
predominately in the fourth ventricle, with extension into
prepontine cisterns and occipital horns. Focal hemorrhage may
also be present in the left cerebellum. Left parietal and left
supratentorial subdural hemorrhage are not well seen on
preceding outside exam.
Brief Hospital Course:
Pt was admitted to the neurosurgery service for close
observation. Upon admission a discussion was held with the
daughter (official HCP)."
1114,"6 PHOSPHATE-3.1 MAGNESIUM-1.3*
[**2184-3-27**] 03:00PM CK-MB-3 cTropnT-<0.01
[**2184-3-27**] 03:00PM CK(CPK)-48
[**2184-3-27**] 03:00PM estGFR-Using this
[**2184-3-27**] 03:00PM GLUCOSE-186* UREA N-20 CREAT-1.0 SODIUM-136
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18
[**2184-3-27**] 03:08PM GLUCOSE-181* LACTATE-3.1* K+-4.7
[**2184-3-27**] 03:45PM TYPE-ART PO2-252* PCO2-38 PH-7.38 TOTAL
CO2-23 BASE XS--1 INTUBATED-INTUBATED
[**2184-3-27**] 05:40PM URINE MUCOUS-RARE
[**2184-3-27**] 05:40PM URINE RBC-1 WBC-125* BACTERIA-FEW YEAST-NONE
EPI-<1 RENAL EPI-<1
[**2184-3-27**] 05:40PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5."
1115,"5
LEUK-LG
[**2184-3-27**] 05:40PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.026
CHEST (PORTABLE AP) Study Date of [**2184-3-27**] 2:50 PM FINDINGS:
Endotracheal tube ends 3.0 cm above the carina. An NG tube
passes beyond the GE junction into the antrum of the stomach.
There are low lung volumes but no evidence of pleural effusion
or pneumothorax. Mild left retrocardiac opacity likely
represents atelectasis.
IMPRESSION:
1. ET tube ends 3 cm above the carina.
2. Left basilar opacity, likely atelectasis, but aspiration is
not excluded.
CTA HEAD W&W/O C & RECONS Study Date of [**2184-3-27**] 3:38 PM
Preliminary Report !"
1116,"On arrival to the MICU, patient appears in no acute distress.
Stated that he felt well. Denied prior episodes. Was hungry.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- ADD
- L sided weakness from mild anoxia at birth
- Only has a R sided kidney
- nephrolithiasis
Social History:
- Tobacco history: denies
- ETOH: quite > 1 year ago, previous drank approx 10 ETOH/ week
- Illicit drugs: denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals- Temp: 38."
1117,"0*
Cl-109*
[**2118-7-7**] 04:49PM BLOOD O2 Sat-99
[**2118-6-27**]: CTA abdomen:
IMPRESSION:
1. No active extravasation to identify the source of bleeding.
Possible AVM in the descending colon.
2. Moderate sigmoid and descending colon diverticulosis without
diverticulitis
[**2118-6-27**]: chest x-ray:
FINDINGS: In comparison with the study of [**2117-12-28**], there is
little interval change. The suspected opacification at the left
base has cleared. No pneumonia, vascular congestion, or pleural
effusion.
[**2118-6-30**]: GI bleeding study:
IMPRESSION: No evidence of active GI bleeding. Findings were
discussed with Dr. [**First Name (STitle) **] at 10pm on [**2118-6-30**] via telephone
by Dr."
1118,"Brief Hospital Course:
The patient was admitted to the hospital with rectal bleeding.
Prior to admission, he was reported to be hypotensive and
required 2 units of packed red blood cells. Upon arrival to the
hospital, he was hemodynamically stable despite having bright
red blood/maroon blood per rectum with a stable hematocrit. His
vital signs and hematocrit were closely monitored. He was
reported to have a decreased hematocrit to 25 and received 1
unit of packed red blood cells.
On hospital day #2, he underwent a colonoscopy which did not
visualized any bleeding source. He continued to bleed and was
transfused 1 unit of blood."
1119,"On HD #11, he was taken to the operating room for an extended
left hemicolectomy with mobilization of the splenic flexure.
The operative course was stable. He had a 400cc blood loss and
required 275cc of platelets. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed in the
left retroperitoneum. He was extubated after the procedure and
monitored in the recovery room.
His post-operative course has been stable. On POD #1, his
[**Last Name (un) **]-gastric tube and Foley catheter were removed. During this
time, he had an isolated episode of decreased oxygenation to 82%
on room air. The patient was encouraged to use the incentive
spirometer and his oxygen level gradually improved."
1120,"He reported
nausea with emesis on POD #3 and he was made NPO and had the
[**Last Name (un) **]-gastric tube inserted. He was also reported to have an
isolated episode of hematuria which was though to be related to
manipulation of the Foley catheter. His abdominal distention
gradually resolved and his and the [**Last Name (un) **]-gastric was removed on
POD #6 as well as his Hemovac. He was introduced to clear
liquids with advancement to a regular diet. The regular diet
progressed well until POD #8, when the patient had a recurrence
of nausea and vomiting. A x-ray of the abdomen was done which
showed dilated loops of small bowel suggestive of an ileus."
1121,"His pain has been controlled
with oral analgesics. His hematocrit has stabilized at 27. His
Plavix was resumed on POD #7. His prior anti-platelet
medication,Prasugrel was discontinued. Aspirin was resumed on
POD #8. He was discharged to home with instructions to
follow-up with the acute care surgery clinic, Cardiology, and
Gastroenterology.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Prasugrel 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Fluoxetine 40 mg PO DAILY
5. Nitroglycerin SL Dose is Unknown SL PRN chest pain
6."
1122,"Nitroglycerin SL 0.4 mg SL PRN chest pain
take 1 TABLET EVERY 5 MINS. X 3 ....PLEASE NOTIFY YOUR PCP OR
call for ride to emergency [**Apartment Address(1) 91781**]. Docusate Sodium 100 mg PO BID
hold for diarrhea
17. Senna 1 TAB PO BID:PRN constipation
18. Metoclopramide 10 mg PO QIDACHS
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with rectal bleeding. You were
given several blood transfusions to maintain your blood level."
1123,"After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Month (only) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as ""soreness"".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
[**Name2 (NI) **] to take by mouth."
1124,"It is important to take this [**Name2 (NI) **]
as directied. Do not take it more frequently than prescribed. Do
not take more [**Name2 (NI) **] at one time than prescribed.
Your pain [**Name2 (NI) **] will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain [**Name2 (NI) **]. Please don't take any other pain
[**Name2 (NI) **], including non-prescription pain [**Name2 (NI) **], unless your
[**Name2 (NI) 5059**] has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain [**Name2 (NI) **]."
1125,"Admission Date: [**2118-6-27**] Discharge Date: [**2118-7-18**]
Date of Birth: [**2052-9-12**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
[**2118-6-28**] Colonoscopy
[**2118-7-7**] Left Colectomy,Mobilization of Splenic Flexure
History of Present Illness:
65yoM with h/o CAD with IMI s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 2, ADD who initially
presented to [**Hospital1 **]-N on [**6-26**] with bloody diarrhea. Patient was in
USOH until [**6-26**] when he developed diarrhea. On 5th or 6th BM, he
noticed bright red blood."
1126,"Don't lift more than 20-25 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise."
1127,"8 Plt Ct-139*
[**2118-6-30**] 07:15AM BLOOD Neuts-61.0 Lymphs-29.5 Monos-6.6 Eos-2.6
Baso-0.3
[**2118-7-13**] 05:34AM BLOOD Plt Ct-349
[**2118-7-13**] 05:34AM BLOOD Glucose-102* UreaN-9 Creat-0.7 Na-138
K-3.3 Cl-101 HCO3-28 AnGap-12
[**2118-6-28**] 04:28AM BLOOD ALT-19 AST-16 AlkPhos-45 TotBili-0.3
[**2118-7-13**] 05:34AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.2
[**2118-7-7**] 04:49PM BLOOD Glucose-142* Lactate-1.5 Na-141 K-3."
1128,"States that it was solely blood with
clots and no brown or tarry stool. Was otherwise asymptomatic.
Specifically denied dizziness, LH, CP, SOB, abdominal pain,
nausea, vomiting, fevers, chills, recent travel or food
exposure. Given his symptoms he presented to [**Hospital1 **]-N for
evaluation.
At [**Hospital1 **]-N, initial Hct was 37. NGL was negative blood. Patient
continued to have BRBPR (~100cc per BM). Serial Hct drifted
downward to 29. Patient was given 2L GoLYTEly for preparation of
colonoscopy. Patient was transfused 2 units of pRBCs. SBPs
trended downward to 90s and decision was made to transfer
patient to [**Hospital1 18**] for further management."
1129,"You underwent several tests to determine the cause of your
bleeding [**Doctor First Name **] you were found to have bleeding in the descending
colon. You were taken to the operating room where you part of
your left colon removed. You are slowly recovering from your
surgery. Your vital signs and blood work have been normal. You
are preparing for discharge home with the following
instructions:
ACTIVITY:
Do not drive until you have stopped taking pain [**Doctor First Name **] and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Doctor First Name 5059**] at your next visit."
1130,"rate <10
RX *hydromorphone 2 mg 1 tablet(s) by mouth EVERY 3 HOURS Disp
#*40 Tablet Refills:*0
6. BuPROPion (Sustained Release) 150 mg PO QAM
7. Fluoxetine 40 mg PO DAILY
8. methylphenidate *NF* 18 mg Oral qday
9. Multivitamins 1 TAB PO DAILY
10. Pravastatin 80 mg PO DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Ascorbic Acid 1000 mg PO DAILY
14. TraMADOL (Ultram) 50 mg PO QID
RX *tramadol 50 mg 1 tablet(s) by mouth four times a day Disp
#*30 Tablet Refills:*0
15."
1131,"Remember to use your ""cough pillow"" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication."
1132,"This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your [**Month (only) 5059**]."
1133,"Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD
Specialty: CARDIOLOGY
Location: [**Hospital1 **]-[**Location (un) **]
Address: [**Street Address(2) **] [**Location (un) **], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
Appointment: Thursday [**7-28**] at 1pm
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 88349**], MD
Specialty: Primary Care
When: Wednesday [**8-3**] at 3:50p
Location: [**Location (un) **] [**University/College **] FAMILY [**University/College 662**] PC
Address: [**Street Address(2) **]., [**Apartment Address(1) 35387**], [**Location (un) 35388**],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 17203**]
You do not need to follow up with the GI service here, but if
you develop any further problems, such as recurrence of
bleeding. Please feel free to schedule an appointment with the
GI service by calling # [**Telephone/Fax (1) 682**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2118-7-20**]"
1134,"You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of [**Month (only) **] such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**]."
1135,"A
[**Last Name (un) **]-gastric tube was inserted, and motility agents added to his
medical regimen.
Over the course of the next 1-2 days his symptoms improved and
the ng tube was removed. His diet was slowly advanced and he was
able to tolerate this without any difficulties. At time of
discharge he was also having bowel movements.
During his hospital course, he was evaluated by physical therapy
because of his long hospitalization and deconditioning. After
evaluation, recommendations were made for discharge home.
His vital signs have been stable and he has been afebrile. He
has been tolerated a regular diet."
1136,"HOW YOU [**Month (only) **] FEEL:
You may feel weak or ""washed out"" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples."
1137,"Metoprolol Succinate XL 50 mg PO DAILY
7. methylphenidate *NF* 18 mg Oral qday
8. Pravastatin 80 mg PO DAILY
9. Ascorbic Acid 1000 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*21
Tablet Refills:*0
5. HYDROmorphone (Dilaudid) 2-6 mg PO Q3H:PRN pain
hold for increased sedation, resp."
1138,"A tagged RBC scan was performed,
which was also unsuccessful in appreciating any bleed. Multiple
units of packed red blood cells were transfused over the next
couple days as his hematocrit continued to drop and rebound post
infusion. His bleeding increased from 600cc to 1000cc daily. A
left descending colon bleed was discovered during the latest
test and the patient was scheduled for IR embolization the
following day. Unfortunately the patients bleeding decreased
over the evening prior to surgery and the IR team was unable to
visualize or fix the bleed. Bleeding resumed the following day
and the acute care service was notified."
1139,"6, HR: 60, BP: 104/71, RR: 25, O2sat: 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Rectal: mostly empty rectal vault with specks of BRB mixed with
brown stool.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2118-7-13**] 05:34AM BLOOD WBC-5."
1140,"If you have any questions about what [**Name2 (NI) **] to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
When: Tuesday [**7-26**] at 3pm
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage"
1141,"[**Last Name (STitle) **]
[**2118-7-4**]: GI bleeding study:
IMPRESSION: Moderately brisk bleeding over a short interval in
the region of the descending colon
[**2118-7-5**]: IR study:
IMPRESSION: Selective inferior mesenteric as well as superior
mesenteric
angiographies with no evidence of active bleeding, vascular
malformation or dysplasia
[**2118-7-5**]: angio:
IMPRESSION: Selective inferior mesenteric as well as superior
mesenteric
angiographies with no evidence of active bleeding, vascular
malformation or dysplasia
[**2118-7-5**]: lower abdominal pelvis, abd. angio:
IMPRESSION: Selective inferior mesenteric as well as superior
mesenteric
angiographies with no evidence of active bleeding, vascular
malformation or dysplasia"
1142,"4 RBC-2.98* Hgb-8.7* Hct-26.6*
MCV-89 MCH-29.2 MCHC-32.7 RDW-14.7 Plt Ct-349
[**2118-7-12**] 06:00AM BLOOD WBC-5.3 RBC-2.90* Hgb-8.6* Hct-25.9*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.3 Plt Ct-341#
[**2118-6-29**] 12:10PM BLOOD Hct-25.0*
[**2118-6-28**] 09:00AM BLOOD Hct-24.9*
[**2118-6-27**] 08:08AM BLOOD WBC-4.1 RBC-3.67* Hgb-11.0* Hct-32.9*
MCV-90 MCH-29.9 MCHC-33.4 RDW-13."
1143,"Admission Date: [**2137-4-18**] Discharge Date: [**2137-4-22**]
Date of Birth: [**2076-12-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2137-4-18**]
1. Coronary artery bypass grafts x3, left internal mammary
artery to left anterior descending artery and saphenous
vein grafts to right coronary artery and obtuse marginal
arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
60 year old female for the past two years she has been
experiencing shortness of breath and dyspnea with exertion."
1144,"This
occurs after walking approximately 10 minutes starts in her
epigastric area and radiates up to her upper chest.
It resolves with rest. She had been trying to lose weight
recently and was using a treadmill and was experiencing
shortness of breath and chest pain. She underwent a stress test
which was abnormal. She was referred for a cardiac
catheterization and was found to have coronary artery disease.
She was referred to cardiac surgery for revascularization.
Past Medical History:
Coronary Artery Disease
PMH:
Paroxysmal Atrial Fibrillation, reported PAF or palpitations
since [**2133**]
Depression/Anxiety
Vitamin D Deficiency
Chronic bilateral Leg/Joint pain
Dyslipidemia
Frequent Headaches
Past Surgical History:
Tonsillectomy
Appendectomy"
1145,"Social History:
Lives with:Husband
Contact:[**Name (NI) **] (daughter) Phone# [**Telephone/Fax (1) 92267**]
Occupation:skin care specialist
Cigarettes: Smoked no [] yes [x]Hx: quit 6 years ago, smoked
<1ppd x13-15 years
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-26**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Mother had MI
at 65, Sister died at 60 with HTN and ?MI
Physical Exam:
Pulse:65 Resp:13 O2 sat:98/RA
B/P Right:120/72 Left:127/68
Height:5'1"" Weight:186 lbs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp"
1146,"5 Na-135
K-4.0 Cl-105 HCO3-23 AnGap-11
Brief Hospital Course:
The patient was brought to the Operating Room on [**2137-4-18**] where
the patient underwent CABG x 3 with Dr. [**First Name (STitle) **]. Initial attempt
at endoscopic approach was aborted and converted to open CABG.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Left sided
chest tube was placed for pleural effusion via endoscopic port
site on post operative night before extubation. POD 1 found the
patient extubated, alert and oriented and breathing comfortably."
1147,"By the time
of discharge on POD 4 the patient was ambulating freely, she was
hemodynamically stable in sinus rhythm, the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged home with VNA services in good condition with
appropriate follow up instructions.
Medications on Admission:
ASPIRIN 81 mg Daily
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
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 BID (2
times a day) for 1 months."
1148,"Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease
PMH:
Paroxysmal Atrial Fibrillation, reported PAF or palpitations
since [**2133**]
Depression/Anxiety
Vitamin D Deficiency
Chronic bilateral Leg/Joint pain
Dyslipidemia
Frequent Headaches
Past Surgical History:
Tonsillectomy
Appendectomy
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**]."
1149,"bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**1-21**]
Puffs Inhalation Q6H (every 6 hours) as needed for sob,
wheezing.
Disp:*1 1* Refills:*0*
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-26**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days."
1150,"The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. POD 1 OR
chest tubes were removed and left chest tube remained in place.
She has paroxysmal atrial fibrillation which she had
preoperatively but was in sinus rhtyhm at the time of discharge
and was not anticoagulated. Beta blocker was initiated at a low
dose with SBP 90's and the patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Left Chest tube was
removed at this time and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility."
1151,"Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2137-4-30**]
at 10:15a
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2137-5-28**] at 1:00p
Cardiologist Dr. [**Last Name (STitle) 3357**] on [**2137-5-3**] at 11:30
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 92268**],[**First Name3 (LF) **] V. [**Telephone/Fax (1) 26774**] in [**4-25**] 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:[**2137-4-22**]"
1152,"Carotid Bruit Right: none Left: none
Pertinent Results:
Intra-op TEE [**2137-4-18**]
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta."
1153,"Disp:*60 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8."
1154,"9*
MCV-95 MCH-29.3 MCHC-31.0 RDW-13.8 Plt Ct-287
[**2137-4-21**] 04:52AM BLOOD Hct-26.2*
[**2137-4-20**] 11:26PM BLOOD Hct-25.9*
[**2137-4-22**] 04:17AM BLOOD Glucose-97 UreaN-14 Creat-0.8 Na-137
K-4.3 Cl-103 HCO3-29 AnGap-9
[**2137-4-21**] 04:52AM BLOOD UreaN-15 Creat-0.8
[**2137-4-20**] 02:51AM BLOOD Glucose-122* UreaN-11 Creat-0.9 Na-138
K-4.4 Cl-105 HCO3-25 AnGap-12
[**2137-4-19**] 02:52AM BLOOD Glucose-118* UreaN-9 Creat-0."
1155,"There are three
aortic valve leaflets. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results at time of surgery.
POST-BYPASS: The patient is A paced. The patient is on a
phenylephrine infusion. Biventricular function is unchanged.
Mitral regurgitation is unchanged. Tricuspid regurgitation is
moderate (2+). The aorta is intact post-decannulation.
[**2137-4-22**] 04:17AM BLOOD WBC-9.2 RBC-2.84* Hgb-8.3* Hct-26."
1156,"Admission Date: [**2189-8-31**] Discharge Date: [**2189-10-23**]
Date of Birth: [**2150-9-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
s/p fall ~ 30 feet
Major Surgical or Invasive Procedure:
T5-T11 posterior fusion with CSF leak repair
Lumbar drain
History of Present Illness:
38 year old male portugese speaking s/p fall ~30 feet landed on
stomach. No LOC at scene- Unable to move feet, loss of LE
sensation/+step-offs.
Past Medical History:
None
Social History:
Nonsmoker, family lives in [**Location 4194**]"
1157,"Family History:
None
Physical Exam:
PHYSICAL EXAM upon admission:
Gen: AOx3, NAD
HEENT: multiple facial lacerations, right periorbital ecchymosis
Pupils: 3>2 bilateral EOMs full and intact
Neck: in cervical collar
Lungs: not examined
Cardiac: not examined
Abd: not examined
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 0 0 0 0 0 0
L 5 5 5 5 5 0 0 0 0 0 0"
1158,"Several rib
fractures are demonstrated and seen to better detail on recent
CT of [**2189-8-31**].
LENI [**9-7**]
IMPRESSION: No evidence of deep vein thrombosis of the right or
left lower
extremity.
thoracic spine xrays [**9-8**]:
FINDINGS: There is again seen a burst fracture involving the T8
vertebral
body with loss of approximately 40% of the anterior height.
There is again
seen anterolisthesis of T7 over T8, but the alignment is
improved since the initial study. There is a posterior
stabilizing hardware spanning T5 to T12 with pedicle screws
within the T5, T7, T10, T11, and T12."
1159,"Abdomen [**9-9**]
No evidence of ileus, obstruction or fecal impaction seen.
R wrist [**9-9**]
IMPRESSION: No evidence of fracture. Normal right wrist.
Brief Hospital Course:
Patient is a 38 year old Protugese speaking male s/p fall ~30
feet landed on stomach. No LOC noted at sceen. Patient was
found to have comminuted vertebral fracture at T8 with
retropulsion of multiple bony fragments into the central spinal
canal with cord transection demonstrated. Neurosurgery was
consulted in the trauma unit. The patient was admitted to the
TICU and stabilized. Upon clearance of the C-spine the patients
c-collar was removed."
1160,"The patient was then transfered to the
floor and on [**9-2**] the patient was taken to the operating room
with Neurosurgery for repair of his injuries and was transfered
to the Neurosurgery service for continued care.He underwent
posterior instrumented fusion T5-11 with repair of dura, right
iliac crest bone harvest and placement of lumbar drain all done
under general anesthesia. There was estimated 1 liter of blood
loss during the procedure and the patient recieved 2 units of
packed red blood cells in the OR. He tolerated this proceure
well, was extubated in TICU. Lumbar drain was functioning and
drained 5-10cc/hr."
1161,"The patient continues to be seen
by Rehab medicine during his hospital stay.
On [**9-17**] he had some mild dehiscence of the upper 1/3rd of his
incision. There was scant drainage. Wound care consult was
requested. The wound adequately healed in time. On [**9-18**] he was
instructed how to straight cath himself. On [**9-19**] he was found to
have mild diabetes, diet controlled and also started on emycin
for conjuctivitis. On [**9-24**] he received wrist brace for transfer.
On [**2189-10-19**] he was found to have foul smelling urine with
negative urinalysis but culture showing MSSA and he was started
on 7d course of cipro on [**2189-10-22**]."
1162,"Disp:*14 Tablet(s)* Refills:*0*
9. Outpatient Physical Therapy
s/p thoracic instrumented fusion
please treat and evaluate
Discharge Disposition:
Home
Discharge Diagnosis:
spinal cord injury
abdominal distention
fever of unknown origin
conjuctivitis
Discharge Condition:
stable,paraplegic
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
* Do not smoke
* Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
* Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. until after [**12-1**].
* Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
* The following places are where you can get urinary
catheters:
[**Hospital 43292**] Medical Supply [**Telephone/Fax (1) 51271**] and [**Hospital3 **] Medical Supply
[**Telephone/Fax (1) 82811**]"
1163,"ID consult was obtained but pt remained afebrile after
lumbar drain removed and ancef stopped. He was also begun on
bowel regimen and remained with foley. Urine cultures showed
no growth. Blood and CSF cultures were all negative.Wound was
clean and dry. He required enemas and suppositories for bowels,
had foley for bladder. On [**9-9**], the patient developed right
wrist pain. The wrist xray was negative for fracture. He
experienced reported chest pain and his EKG was negative. His
abdomen was distended and a KUB xray was performed which showed
no ileus or obstruction or fecal impaction. [**9-10**] stool was sent
for C-Diff which was negative."
1164,"0
LEUK-NEG
[**2189-8-31**] 09:25AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
CT C-spine [**8-31**]:
IMPRESSION:
1. No acute fracture or malalignment involving the cervical
spine.
2. Old T1 spinous process.
3. Biapical lung scarring, likely sequelae of prior
TB/granulomatous
exposure.
CT CAP [**8-31**]:
IMPRESSION:
1. Comminuted vertebral fracture at T8 with retropulsion of
multiple bony
fragments into the central spinal canal concerning for
transection. There is associated paravertebral hematoma.
2. Posterior mediastinal hematoma adjacent to the distal
esophagus and
descending aorta which may reflect tracking of hematoma from
paraspinal hematoma."
1165,"CALL IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
*The following clinic services free care patients. Please call
and arrange for appointment to establish a primary care
physician for general care: [**Location (un) 3786**] Family Medicine Center (part
of the [**Hospital6 12736**]) [**Street Address(2) 82812**], [**Location (un) 3786**] MA
[**Telephone/Fax (1) 25050**].
*Please follow up with Spinal Cord Injury Specialist [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 805**], MD, [**Telephone/Fax (1) 82813**], [**Last Name (NamePattern1) **] [**Location (un) 442**] [**Location (un) 20473**]
Family Building at [**Hospital6 **] on [**10-30**] at 1:30
PM.
*Follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks, you will need xrays at
this appt. Please call [**Telephone/Fax (1) 2992**] to schedule.
Completed by:[**2189-10-23**]"
1166,"8 MCV-83
MCH-29.3 MCHC-35.1* RDW-14.5
[**2189-8-31**] 08:59AM PLT COUNT-236
[**2189-8-31**] 08:59AM PT-13.2 PTT-21.2* INR(PT)-1.1
[**2189-8-31**] 08:59AM FIBRINOGE-378
[**2189-8-31**] 08:59AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-8-31**] 09:14AM GLUCOSE-147* LACTATE-3.0* NA+-142 K+-3.6
CL--100 TCO2-25
[**2189-8-31**] 09:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5."
1167,"Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QAM (once a day (in the morning)).
Disp:*60 Suppository(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*120 Tablet(s)* Refills:*2*
6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever,pain.
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*120 Capsule(s)* Refills:*2*
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days."
1168,"Diet was advanced, medication changed to PO.
He was transferred to the floor on [**9-3**]. His activity was
advanced with help of PT and [**Doctor Last Name 2598**] lift, he tolerated being
upright. The patient had fevers beginning on [**9-3**] and again on
[**9-6**] with workup all being negative(CXR, cultures,abdominal
US,LENIs) though this was during time he was being covered with
ancef while lumbar drain was in place. The lumbar drain was
clamped on [**9-7**]. Lumbar drain was removed [**9-8**] with wound being
dry. Good placement of operative hardware noted on thoracic
Xray."
1169,"The
patient is now proficient in self cath and bowel care. His PPD
was read as negative for tuberculosis. He was discharged to
apartment with community support on [**2189-10-23**].
Medications on Admission:
None
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 2 weeks.
Disp:*28 * Refills:*3*
2. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 months.
Disp:*90 Tablet(s)* Refills:*0*
4."
1170,"There are no signs of
hardware-related complications.
Abdominal US [**9-8**]
IMPRESSION: Sludge in gallbladder without other signs of
cholecystitis.
[**Doctor Last Name 515**] sign is negative. No specific US signs of acute
cholecystitis.
CXR [**9-8**]
IMPRESSION:
AP chest compared to [**9-6**]:
Lateral aspect of the right lower chest is excluded from the
examination. The imaged pleural surfaces are normal. The region
of chronic right lower costal pleural thickening is not
examined. Lungs are grossly clear. Heart size normal. Spinal
stabilization device and skin staples project over the
thoracic and upper lumbar spine. Stomach is at least moderately
distended
with air."
1171,"Sensation: Intact to light touch in upper extremities and on
trunk superior to xiphoid process bilaterally, no sensation to
light touch on trunk distal to xiphoid process and in lower
extremities bilaterally.
Rectal Tone: reported intact by General Surgery Trauma service
on
their exam
Reflexes: B T Br Pa Ac
Right 1+ 1+ 1+ absent
Left 1+ 1+ 1+ absent
Toes neutral on Babinski, no clonus
Exam upon discharge:
[**6-2**] UE
0/5 LE
no sensation T8 distal
wound well healed
Pertinent Results:
[**2189-8-31**] 08:59AM WBC-9.2 RBC-5.26 HGB-15.4 HCT-43."
1172,"Howevre, esophageal injury cannot be
entirely excluded.
Recommend correlation with esophagram if needed. No definite
evidence for
aortic injury, though follow-up recommended if there is clinical
concern
given the hematoma adjacent to the descending thoracic aorta at
the level of the spinal fractures.
3. Retrosternal hematoma along the anterior aspect of the heart
without
identifiable sternal fracture. Findings may be secondary to
blunt trauma and cardiac contusion cannot be excluded. Clinical
correlation is advised.
4. Biapical lung scarring suggestive of prior TB with areas of
ground-glass
opacity in the peripheral aspect of the right middle lobe,
unclear etiology, may reflect chronic interstitial lung disease,
less likely contusion."
1173,"Weekly case management meetings have been taking place with the
patient, his pastor, friends, the neurosurgery team, case
management, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and nursing throughout his prolonged
hospital stay. The meetings have explored all options of rehab
(he is unable to go to due to no insurance), medical shelters
(denied due to no longer follow term care), going back to [**Country 4194**]
and apartments in the local area. Dr [**Last Name (STitle) **] has set up free care
at [**Hospital6 **] with a spinal cord specialist. Free
medications have been set up through our free care pharmacy. A
reconditioned wheelchair was obtain, a commode and a slider
board, and cath equipment were all given to the patient."
1174,"5. Multiple rib fractures, multiple transverse process
fractures.
CT sinus/mandible [**8-31**]:
IMPRESSION:
1. Right lamina papyracea fracture with small extraconal
hematoma and air
locules in the medial right orbit.
2. Right nasal bone fracture.
3. Pansinus mucosal thickening.
4. No other fractures identified.
5. Mucosal thickening involving the paranasal sinuses. Recommend
clinical
correlation for sinusitis.
MRI T-spine [**2189-8-31**]:
IMPRESSION:
1. Acute compression fracture of the T8 vertebral body with
Grade II
anterolisthesis of T7 on T8 and retropulsion of fracture
fragments posteriorly and superiorly causing severe spinal cord
compression and possible spinal cord transection. Additional
punctate T2 hyperintense focus within the spinal cord at T10 may
represent a small post traumatic syrinx."
1175,"2. Large prevertebral soft tissue hematoma.
3. Large bilateral pleural effusions with a probable right
hemothorax.
Cardiology Report ECG [**2189-9-1**] 10:59:58 AM
Sinus rhythm. No diagnostic abnormalities. No previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
97 116 80 [**Telephone/Fax (2) 82810**] 44
[**9-6**] CXR:
FINDINGS: Interval surgery for thoracic spine fracture with
[**Location (un) 931**] rods
in place. Cardiomediastinal contours are within normal limits.
Moderate
layering right pleural effusion with adjacent retrocardiac
opacity, probably atelectasis, although infection is not
excluded. Nonspecific fibronodular opacities at the lung apices,
potentially due to scarring, although active disease is not
excluded without older studies for comparison."
1176,"3
9.5
12.3
Hct
38.3
30.4
30.3
Plt
182
169
184
Creatinine
1.0
0.8
0.7
Glucose
191
172
184
[**Telephone/Fax (3) 8155**]
216
178
Other labs: Differential-Neuts:82.5 %, Lymph:13.6 %, Mono:3.3 %,
Eos:0.4 %, Ca:7.9 mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL
Assessment and Plan
THORACIC / LUMBAR / SACRAL FRACTURE (TLS WITH SPINAL CORD INJURY), RIB
FRACTURE
Assessment and Plan: ASSESSMENT AND PLAN:
38 yo m s/p fall from ladder suffered T [**8-5**] SCI., S/p spinal fixation
T5-T11
NEURO: Neuro checks q2, Dilaudid q2prn pain
CVS: HD stable, 1L blood loss, transfused 2U intra-op am hct
PULM: Extubated; pulm toilet, IS, sit upright
GI: npo
RENAL: Foley; follow uop
HEME: hct 30."
1177,"4 check in am
ENDO: ssi
ID: cefazolin x6 doses
TLD: A-line, Foley, PIV
IVF: NS@80
CONSULTS: Trauma, Neurosurg
BILLING DIAGNOSIS:
ICU CARE:
GLYCEMIC CONTROL:
PROPHYLAXIS:
DVT - boots
STRESS ULCER - famotidine
VAP BUNDLE +
COMMUNICATIONS:
ICU Consent: yes
CODE STATUS: full
DISPOSITION: floor
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
14 Gauge - [**2189-9-2**] 05:49 PM
Arterial Line - [**2189-9-2**] 05:50 PM
18 Gauge - [**2189-9-2**] 05:51 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: Transfer to floor
Total time spent:"
1178,"m.
Tmax: 38.4
C (101.2
T current: 37.6
C (99.7
HR: 96 (94 - 106) bpm
BP: 157/68(91) {120/64(79) - 166/80(101)} mmHg
RR: 15 (12 - 32) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
3,677 mL
291 mL
PO:
Tube feeding:
IV Fluid:
3,677 mL
291 mL
Blood products:
Total out:
2,815 mL
380 mL
Urine:
375 mL
380 mL
NG:
Stool:
Drains:
Balance:
862 mL
-89 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 824 (824 - 824) mL
PS : 5 cmH2O
RR (Spontaneous): 15
PEEP: 5 cmH2O
FiO2: 70%
PIP: 11 cmH2O
SPO2: 100%
ABG: ///24/
Ve: 10."
1179,"TSICU
HPI:
38 y/o male portuges speaking s/p fall ~30 feet landed on stomach. No
LOC at sceen- Unable to move feet, loss of LE sensation/+step-offs
Chief complaint:
s/p fall, t8 spinal cord transection
PMHx:
PMH: none
PSH: none
Soc: none
Current medications:
none
24 Hour Events:
s/p fixation T5-T11; extubate in T/SICU
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2189-9-2**] 09:37 PM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2189-9-2**] 07:47 PM
Metoprolol - [**2189-9-3**] 01:15 AM
Hydromorphone (Dilaudid) - [**2189-9-3**] 02:10 AM
Other medications:
Flowsheet Data as of [**2189-9-3**] 03:42 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**92**] a."
1180,"5 L/min
Physical Examination
General Appearance: No acute distress
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Trace), (Temperature: Warm)
Right Extremities: (Edema: Trace), (Temperature: Warm)
Skin: dressings c/d/i - lumbar drain clamped
Neurologic: (Awake / Alert / Oriented: x 3)
Labs / Radiology
184 K/uL
10.0 g/dL
178 mg/dL
0.7 mg/dL
24 mEq/L
4.5 mEq/L
13 mg/dL
105 mEq/L
138 mEq/L
30.3 %
12.3 K/uL
[image002.jpg]
[**2189-8-31**] 03:00 PM
[**2189-8-31**] 08:00 PM
[**2189-9-1**] 01:49 AM
[**2189-9-1**] 02:00 AM
[**2189-9-1**] 08:00 AM
[**2189-9-1**] 02:00 PM
[**2189-9-2**] 06:19 PM
[**2189-9-3**] 01:50 AM
WBC
12."
1181,"Admission Date: [**2112-9-15**] Discharge Date: [**2112-10-5**]
Date of Birth: [**2051-5-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Right arm pain/swelling.
Major Surgical or Invasive Procedure:
Left IJ line insertion [**2112-9-20**]
History of Present Illness:
61M with HCC, HCV cirrhosis, CHF, DM, history of CVA with left
sided weakness, PVD, asthma, presenting with one week of RUE
swelling and pain. He and his VNA first noticed RUE swelling
about one week ago, and feels this has been getting gradually
worse over the course of the week."
1182,"- Pontine stroke in [**2109**] with some residual left arm, left leg
weakness. The patient also reports that some emotional
dysregulation in that his laughter, anger and sadness responses
are sometimes inappropriate.
- PVD, status post right BKA.
- History of osteomyelitis, s/p left foot debridement, 10/[**2111**].
- Hypertension.
- Chronic back pain, spinal stenosis, takes morphine, baclofen
and gabapentin.
- GERD.
- Asthma. Multiple inhalers.
- Hx potassium dysregulation in the setting of diuretics.
- Anemia.
- Proteinuria and microscopic hematuria. Presumed [**3-9**] DM.
- Cholecystectomy, [**2099**].
- Right wrist ganglion removal in [**2080**].
- Left eye laser surgery in [**2111**] for retinal detachment.
- Contrast induced renal insufficiency
Social History:
Lives in an apartment by himself with 2 PCAs in floors above and
below him."
1183,"H/o 20 PY tob use -quit in [**2109-9-6**]. He has a
remote history of alcohol and drugs, but has been sober for the
last 15-20 years. He is on disability, he does not work.
Originally from [**State **], lived in [**Location 86**] since [**2068**].
Family History:
DM, HTN.
Physical Exam:
ADMISSION EXAM:
T97.9, 102/64, HR 70, R20, 99% on RA
General: obese male with general anasarca, no respiratory
distress.
HEENT: PERRL, anicteric. No obvious ptosis, conjunctival
injection, or periorbital swelling. Mild general sense of
increased fullness/lack of symmetry with enlargement of R side
of face."
1184,"Tender with excessive touch
of skin. No sense of tautness of skin relative to other side.
Joint ROM preserved without significant tenderness with passive
motion at each joint. LLE also with 1-2+ pitting edema, less
painful. Some chronic venous stasis changes.
Neuro: alert, oriented. CN II-XII intact. LUE weak with
limited active movement at elbow and shoulder with some
contracture and muscle atrophy. RUE with 5/5 strength at each
site except weak finger abduction. Able to move LLE but with
minimal strength.
DISCHARGE EXAM:
VS - 98.1 136/80 70 18 94%
GEN - morbidly obese, no acute distress
CV - RRR no m/r/g
LUNGS - CTA b/l
ABD - soft NT ND
EXT - no CCE, right AKA, left [**Hospital Ward Name **] cyst
SKIN - warm and dry"
1185,"2*
[**2112-10-5**] 05:00AM BLOOD Glucose-228* UreaN-48* Creat-2.1* Na-137
K-4.0 Cl-103 HCO3-26 AnGap-12
[**2112-10-4**] 05:30AM BLOOD ALT-18 AST-27 AlkPhos-62 TotBili-0.3
Brief Hospital Course:
Primary Reason for Hospitalization:
61yo man with hepatocellular CA, CHF, HTN, DM, hep C cirrhosis,
PVD, hx of CVA, admitted for RUE cellulitis. He was started on
ampicillin/sulbactam. CXR was negative. You were also started
on bacitracin/polymyxin ointment for a right-eye conjunctivitis.
Active Diagnoses:
# Somnolence: Ddx included hepatic encephelopathy vs. uremia vs.
hypercarbia vs."
1186,"Per
hepatology consult on the day of ICU transfer, patient appears
to have hepatorenal syndrome, so he was given albumin 25 q8h and
diuresis was held. He received albumin before arriving to MICU
and in MICU was started on midodrine/ocreotide for possible
hepatorenal syndome. Hepatology and renal followed in MICU and
he received bedside HD. Pt was then transitioned to UF as
mentioned above. Anasarca resolved and pt's creatine improved
to 1.8 on discharge. He will be set up for outpatient UF 3x
weekly.
# [**Last Name (un) **]: History of CKD w/ baseline creatinine around 1.6. Recent
history of contrast nephropathy with creatinine as high as 3."
1187,"7.
Currently rising from 1.6 on admission to 2.6 today. Likely
secondary to poor forward flow in setting of intravascular
depletion with a component of hepatorenal syndrome. Gave albumin
and held diuresis in the setting of likely hepatorenal syndrome.
As above, he was started on midodrine and octreotide in MICU in
addition to, HD line placed by IR and bedside HD initiated.
Tunneled line was placed and used for UF as above.
# RUE cellulitis: Unclear whether this was a true infection in
setting of significant swelling, likely secondary to anasarca.
UENI negative for DVT. On exam, arm does not appear erythematous
or particularly tender."
1188,"No CXR findings to suspect SVC syndrome.
Started ampicillin/sulbactam for cellulitis in a diabetic on
[**2112-9-16**] and showed significant improvement. Seen by ID, who
recommended 7-10 days of abx, switched to vancomycin on [**2112-9-19**].
Pt was treated until day of discharge with vanco and at this
point cellulitis had resolved.
# Right-eye bacterial conjunctivitis: Treated with
bacitracin/polymixin eye ointment.
# Anemia: Unclear etiology. Pt has had recent EGD ([**5-16**]) w/o
evidence of varices. Pt has had a colonscopy x 4 years ago (no
report) and will need to d/w PCP. [**Name10 (NameIs) **] transfused 1 unit on [**9-18**]
with appropriate bump."
1189,"Remained stable when on floor.
# Pain: Held baclofen, gabapentin, and MSContin in the setting
of increased somnolence. As his MS improved he was restarted on
baclofen and given po oxycodone PRN for pain.
# Hepatocellular CA: Recent CT scan showed stable disease.
Given multiple comorbidities, he was not a candidate for
therapy. He aslo developed contrast nephropathy last CT scan
and will be followed by AFP and U/S. Pt's disease is currently
end stage. Palliative care consulted and pt had good
understanding of prognosis of disease. He was discharged with
transition to hospice care.
# Chronic diastolic CHF: Continued carvedilol, hydralazine,
amlodipine."
1190,"# PVD: Continued aspirin and statin.
.
# LLE ulcer: Wound care consulted.
.
# DM: Continued outpatient insulin glargine and sliding scale.
.
# Elevated uric acid: Has had elevated levels in the past.
Checked CPK level. Started allopurinol.
.
# Asthma: Continued fluticasone and tioptropium.
.
# Hypoalbuminemia: Nutrition consulted. Checked urine protein.
Transitional Issues:
- transition to hospice care when disease worsens, for now will
go for UF 3x weekly.
Medications on Admission:
1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY.
3. albuterol sulfate 2.5mg/3mL (0.083%) Nebulization [**2-7**] Inh Q4H
PRN dyspnea."
1191,"20. MS Contin 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO every 6-8 hours as needed for pain: do not
drink alcohol or drive with this medication.
21. insulin glargine 100 unit/mL Cartridge Sig: Twenty Eight
(28) Units Subcutaneous twice a day.
22. insulin lispro 100 unit/mL Insulin Pen Sig: per sliding
scale Subcutaneous per sliding scale: please administer
according to sliding scale.
Disp:*30 pen* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
[**Last Name (un) **] requiring dialysis and ultrafiltration
Hypervolemia requiring ultrafiltration
Right arm cellulitis (skin infection)."
1192,"Right eye conjunctivitis (infection).
Health Care Acquired Pneumonia
End stage HCC and liver cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 4542**],
It was a pleasure taking care of you during this
hospitalization. You were initially admitted to the hospital
for right arm swelling and found to have a skin infection of
that arm (cellulitis). You were started on antibiotics and
slowly responded to this. Doppler ultrasound did not show a
blood clot. Your eye was also found to have an infection
(conjunctivitis), so you were given an antibiotic eye ointment."
1193,"13. Insulin Sliding Scale insulin lispro [Humalog] per home
sliding scale [**Hospital1 **].
14. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
1 neb q6hrs.
15. lactulose 10 gram Packet Sig: One (1) packet PO at bedtime.
16. simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS.
17. omeprazole 20 mg Capsule PO DAILY.
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID.
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY.
20. Spiriva with HandiHaler 18 mcg Capsule 1 Inhalation once a
day.
21. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO BID."
1194,"Noted [**5-/2112**] to have a 4.7 x 4.3 cm right hepatic lobe mass
displaying imaging characteristics consistent with HCC. Biopsy
showed well-to-moderately differentiated HCC. Further imaging
studies have been limited due to history of contrast nephropathy
requiring hydration (which is further limited by cardiac
concerns). Discussions of chemoembolization, RFA-sorafenib, ans
sorafenib systemic chemo.
.
OTHER PMH:
- HCV cirrhosis, viral load 10/11/[**2111**]=9,619,847 IU/mL. EGD
normal [**5-/2112**]
- Acute and chronic diastolic CHF, LVEF 50% in [**12/2109**] and 55%
on most recent [**5-/2112**] admission. Hx fluid overload.
- Diabetes mellitus for 36 years, on insulin."
1195,"# Hypoxemia: A-a gradient <10 making hypoxemia is suggestive of
hypoventilation, likely secondary to obesity
hypoventilation/sleep apnea. Hypercarbia appears to be somewhat
chronic in nature given pH of 7.34 and pCO2 of 54 (if acute
change, would expect pH of 7.28 or so). Pt denies recent
worsening of cough or dyspnea. Has been afebrile. He was
encouraged to use BIPAP while asleep for obesity
hypoventilation. A CXR was obtained to assess for any acute
process. He was admitted to MICU for worsening respiratory
distress, given his anasarca pulmonary edema was the focared
diagnosis, though aspiration pneumonitis and PNA were also
considered."
1196,"2 MAGNESIUM-2.4
OSMOLAL-312*
LACTATE-1.3
CBC, chems at relative baseline
.
[**2112-9-16**] CXR: IMPRESSION: Lungs are fully expanded and clear.
There is no apical mass. Pleural surfaces are smooth. No
pneumothorax. Heart is top normal size. Interval increase in
caliber of the upper mediastinum could be due to differences in
patient position or adenopathy, and not necessarily a change. If
there is serious concern for vascular patency, then direct
imaging of the vein should be performed.
.
[**2112-9-15**] RUE DOPPLER U/S: IMPRESSION: No evidence of DVT in the
right upper extremity including the right internal jugular vein
and visualized portions of the subclavian vein."
1197,"3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q6H (every 6 hours).
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for itching.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily)."
1198,"It also became painful and
feels somewhat tight and stiff to move. There has not been
weakness. His VNA may have noted redness. No fevers or chills.
There was also potentially concern fo swelling on the right
side of the face with some symptoms of eye irritation as well
(watery eye, itching, no blurred vision). He had a presentation
in [**2112-7-6**] with swelling that involved the left arm, but he
felt this was more limited to the L elbow at that time, however
- not involving hand or shoulder. He had ultrasounds, bone
scan, ortho evaluation, rheum evaluation, all unrevealing."
1199,"We have made the following changes to your home medications:
STOP: hydralazine
STOP: gabapentin
CHANGE: lasix from 40mg daily to 40mg twice daily
CHANGE: insulin sliding scale
START: Metolozone 2.5 mg daily
START: potassium chloride 40meq twice daily
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: LIVER CENTER
When: TUESDAY [**2112-10-18**] at 11:45 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2112-10-14**] at 10:10 AM
With: DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/[**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up"
1200,"22. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID PRN
constipation.
23. multivitamin Tablet Sig: One (1) Tablet PO DAILY
24. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY.
25. baclofen 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
26. MS Contin 15 mg Tablet Extended Release PO 2-3 times per
day.
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation."
1201,"He was treated with Vancomycin/Zosyn empirically and
he received bedside hemodialysis to remove excess fluid. In MICU
his repiratory status improved with HD, empiric therapy and
patient began auto-diuresing. On floor was continued on UF 3x
weekly and his sats remained in the high 90s.
# Anasarca- Likely secondary to hypoalbuminemia from cirrhotic
disease and progressive renal failure (renal protein wasting
though not nephrotic range proteinuria). Also, was off of lasix
and spironolactone since prior discharge on [**8-30**] and was just
restarted on [**9-16**] (40 mg IV) and [**9-18**] (60 mg) w/ poor response.
Has become oliguric in response to recent lasix challenges."
1202,"medication effect (was on gabapentin, baclofen,
MSContin, oxycodone) vs. hypoventilation/OSA. Less likely
etiologies include CVA, more likely hemispheric than brainstem.
Patient has some degree of cirrhosis, but normal EGD in [**Month (only) 547**]
[**2112**], no peripheral stigmata on exam, and synthetic function not
terribly depressed (normal coags, though admission albumin 2.5).
Renal function steadily deteriorating and BUN climbing so this
could likely be a contributing etiology. TSH wnl. Infection also
in ddx, though afebrile, WBC not high at this time, UA negative,
and has been on abx for cellulitis. We increased the frequency
of lactulose to treat potential hepatic encephelopathy,
titrating to [**4-8**] BM/day."
1203,"During your admission you were also found to have a pneumonia
which required a short stay in the ICU. We treated you with IV
antibiotics and your pneumonia improved.
While you were here, you also had an acute kidney injury. This
resulted in volume overload to the point where it became
difficult for you to breath. We determined that your kidneys
were not able to remove the extra fluid by themselves, so we
started you on dialysis. Your kidney function improved after
dialysis, so we started you on a different type of dialysis
called ultra-filtration. We have arranged for outpatient
dialysis for you, which will happen three times a week."
1204,"9. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-7**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for dry nasal passages.
14. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*20 Tablet(s)* Refills:*2*
15."
1205,"Painless. Normal facial muscle strength and
sensation. OP clear.
Neck: obese. JVD elevation difficult to appreciate.
Heart: regular, S1 S2, [**3-13**] SM best at RUSB. No heave.
Chest: Limited by poor bed mobility. Preserved air entry
bilaterally without obvious wheezes or crackles, but posterior
exam limited.
Abdomen: obese, +BS, soft, NT, ND. +pitting abdominal wall and
sacral edema.
Extrem: R arm grossly larger than left both proximal/distal.
Relative increase in both pitting and nonpitting edema. Pitting
edema most notable in dependent areas. No obvious erythema
except small area on medial upper arm, which has some increased
tenderness relative to elsewhere."
1206,"potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO twice a day.
Disp:*120 Tablet, ER Particles/Crystals(s)* Refills:*0*
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H
(every 2 hours) as needed for constipation.
18. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day."
1207,"Possible that this was CRPS, and he was treated with lidocaine
patches. He denies headache, chest pain, dyspnea, cough,
abdominal pain, N/V/D, change in urination, poor glucose
control. He does endorse weight gain of 40# ""in fluid weight""
in the past 6 months, maybe 20# since last admission which he
thinks is due to kidney stress and needs to have him fluids at
that time.
.
In the ED, afebrile with normal HR/BP/O2 sats. UENIs without
evidence of proximal/distal clot on R. Received 12 units
insulin for glucose >400. Admitted for further workup.
Past Medical History:
ONC HISTORY:
Biopsy-proven HCV cirrhosis since [**2101**]."
1208,"Extensive soft
tissue edema. Evaluation of the left upper extremity was limited
given inability to properly position the arm. No evidence of
thrombus in the visualized left internal jugular, subclavian,
and cephalic veins.
.
DISCHARGE LABS:
[**2112-10-4**] 05:30AM BLOOD WBC-7.4 RBC-2.95* Hgb-8.4* Hct-25.1*
MCV-85 MCH-28.4 MCHC-33.3 RDW-14.0 Plt Ct-201
[**2112-9-27**] 05:30AM BLOOD Neuts-65.5 Lymphs-24.2 Monos-7.0 Eos-2.9
Baso-0.3
[**2112-10-4**] 05:30AM BLOOD PT-14.4* PTT-35.8* INR(PT)-1."
1209,"Pertinent Results:
ADMISSION LABS:
[**2112-9-15**] 04:00PM
WBC-5.7 RBC-2.85* HGB-8.3* HCT-24.8* MCV-87 MCH-29.1 MCHC-33.4
RDW-13.5
NEUTS-61.2 LYMPHS-28.6 MONOS-6.6 EOS-3.1 BASOS-0.5
PLT COUNT-102*
PT-14.5* PTT-34.6 INR(PT)-1.3*
GLUCOSE-294* UREA N-41* CREAT-1.6* SODIUM-139 POTASSIUM-3.7
CHLORIDE-105 TOTAL CO2-27 ANION GAP-11
ALT(SGPT)-26 AST(SGOT)-38 ALK PHOS-97 TOT BILI-0.2 LIPASE-19
CALCIUM-8.2* PHOSPHATE-4."
1210,"4. ammonium lactate 12 % Lotion ASDIR as needed for once daily.
5. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]: to arm.
6. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **].
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY.
8. fluticasone 50 mcg/Actuation 1 Spray Nasal DAILY.
9. gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H.
11. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Insulin insulin glargine [Lantus] 100 unit/mL Solution 26U
[**Hospital1 **]."
1211,"He was encouraged to use BIPAP
overnight for obesity hypoventilation in case hypercapnia was
contributing to his somnolence, but this seems more chronic in
nature. He was cultured to rule out toxic/metabolic causes of
encephalopathy. Cultures were negative. Cr increased despite
octreotide, midodrine and pt became volume overloaded, leading
to need for dialysis. Dialysis was initiated and pt's MS
improved to baseline indicating uremia was likely contributing
to AMS. However around the same time pt was also started on
lactulose, so could have had a level of HE. Pt's hypoxic
episodes could have been contributory to AMS as well."
1212,"1/115.9/1.3, CK / CK-MB / Troponin
T:114/7/0.03, Lactic Acid:4.5 mmol/L, Ca:7.9 mg/dL, Mg:1.4 mg/dL,
PO4:5.5 mg/dL
Assessment and Plan
Minimize sedation.
Follow Urine output, CVP and ABG/Lactate to assess volume status, may
need more crystalloid.
If Lactic acidosis and urine output improve, wean vent to Pressure
support ventilation.
Cont H2-Blocker and Pneumoboots for prophylaxis.
ICU Care
Nutrition:
Glycemic Control:
Lines:
Arterial Line - [**2109-9-15**] 04:23 AM
Multi Lumen - [**2109-9-15**] 04:25 AM
18 Gauge - [**2109-9-15**] 04:26 AM"
1213,"CVICU
HPI: POD#0 s/p L axillary aplasty, covered stent, L brachial artery
cutdown with vein patch aplasty [**9-15**]
66F s/p fall with L arm in anterior extension, development of
axillary/chest wall hematoma. At OSH, surgeon unroofed the clot to
exposed a posterior branch of axillary artery, couldn't gain control.
24 Hour Events:
INVASIVE VENTILATION - START [**2109-9-15**] 04:18 AM
ARTERIAL LINE - START [**2109-9-15**] 04:23 AM
MULTI LUMEN - START [**2109-9-15**] 04:25 AM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Phenylephrine - 2 mcg/Kg/min
Propofol - 30 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2109-9-15**] 06:00 AM
Other medications:
Flowsheet Data as of [**2109-9-15**] 07:37 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**12**] a."
1214,"m.
Tmax: 36.2
C (97.1
T current: 36.2
C (97.1
HR: 91 (82 - 104) bpm
BP: 94/56(67) {86/49(59) - 112/64(77)} mmHg
RR: 0 (0 - 27) insp/min
SPO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Height: 62 Inch
Total In:
7,486 mL
PO:
Tube feeding:
IV Fluid:
5,386 mL
Blood products:
2,100 mL
Total out:
0 mL
2,090 mL
Urine:
90 mL
NG:
Stool:
Drains:
Balance:
0 mL
5,396 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 18
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
PIP: 28 cmH2O
Plateau: 24 cmH2O
Compliance: 26."
1215,"3 cmH2O/mL
SPO2: 95%
ABG: 7.34/37/196/20/-5
Ve: 7.4 L/min
PaO2 / FiO2: 392
Labs / Radiology
102 K/uL
13.0 g/dL
218 mg/dL
0.5 mg/dL
20 mEq/L
5.6 mEq/L
19 mg/dL
109 mEq/L
138 mEq/L
36.0 %
18.3 K/uL
[image002.jpg]
[**2109-9-15**] 02:27 AM
[**2109-9-15**] 04:35 AM
[**2109-9-15**] 04:44 AM
[**2109-9-15**] 06:32 AM
WBC
18.3
Hct
34
36.0
Plt
102
Creatinine
0.5
Troponin T
0.03
TCO2
23
22
21
Glucose
[**Telephone/Fax (3) 2631**]18
Other labs: PT / PTT / INR:15."
1216,"Admission Date: [**2109-9-15**] Discharge Date: [**2109-9-18**]
Date of Birth: [**2042-10-23**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Lacerated axillary artery
Major Surgical or Invasive Procedure:
Ultrasound-guided access for vascular access,
first order axillary and extremity arteriography, covered
stent the left axillary artery followed by repair of axillary
artery and vein patch angioplasty of left brachial artery
after a brachial cutdown.
History of Present Illness:
66 F emergent transfer from OSH for axillary artery hemorrhage.
Patient fell down at 3:00 p."
1217,"Estimated
blood loss intraoperatively was one liter with additional two
liters from the OSH. She had received 4 units of packed red
blood cells and 2 units of FFP. At the completion of the case,
the patient had a palpable brachial pulse and a palpable radial
pulse. Her hand looks markedly improved compared to
preoperatively. She was taken intubated to the intensive care
unit in guarded condition. Plesse see dictated operative note
for more detail.
.
POD1, patient required neo pressors and fluids for hemodynamic
support. She was awoken briefly for routine vascular and neuro
exams to check left upper extremity."
1218,"Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Laceration or Right axillary artery
Discharge Condition:
VSS, ambulating, pain well controlled with Po pain meds,
hematocrit stable
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day; you may walk and you may go up and down
stairs
??????Increase your activities as you can tolerate- do not do too
much right away!"
1219,"2. It is normal to have swelling of the arm you were operated
on:
?????? Elevate your arm above the level of your heart (use [**1-6**]
pillows) every 2-3 hours throughout the day and at night
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication"
1220,"Pertinent Results:
AP shoulder: Three views of the left shoulder were reviewed. The
patient is after surgery of the left upper chest/area of axilla.
Vascular stent is noted. No evidence of fracture is present. No
evidence of dislocation is seen.
[**2109-9-15**] 01:20AM BLOOD WBC-12.9* RBC-3.31* Hgb-10.6* Hct-29.7*
MCV-90 MCH-31.9 MCHC-35.6* RDW-15.2 Plt Ct-121*
[**2109-9-15**] 04:35AM BLOOD WBC-18.3* RBC-4.09* Hgb-13.0 Hct-36.0
MCV-88 MCH-31.8 MCHC-36.2* RDW-15."
1221,"2*
[**2109-9-15**] 04:35AM BLOOD PT-15.1* PTT-115.9* INR(PT)-1.3*
[**2109-9-16**] 04:40AM BLOOD PT-11.9 PTT-24.9 INR(PT)-1.0
[**2109-9-17**] 03:39AM BLOOD PT-12.0 PTT-25.0 INR(PT)-1.0
[**2109-9-15**] 04:35AM BLOOD Glucose-240* UreaN-19 Creat-0.5 Na-138
K-5.1 Cl-109* HCO3-20* AnGap-14
[**2109-9-15**] 10:35AM BLOOD Glucose-158* K-4.7
[**2109-9-16**] 04:40AM BLOOD Glucose-107* UreaN-16 Creat-0.5 Na-134
K-4."
1222,"0 Cl-105 HCO3-25 AnGap-8
[**2109-9-17**] 03:40AM BLOOD Glucose-100 UreaN-9 Creat-0.4 Na-139
K-3.7 Cl-109*
[**2109-9-15**] 01:36AM BLOOD Type-ART pO2-92 pCO2-62* pH-7.16*
calTCO2-23 Base XS--7
[**2109-9-15**] 02:27AM BLOOD Type-ART pO2-330* pCO2-46* pH-7.28*
calTCO2-23 Base XS--4
[**2109-9-15**] 04:44AM BLOOD Type-ART pO2-178* pCO2-44 pH-7.28*
calTCO2-22 Base XS--5
[**2109-9-15**] 06:32AM BLOOD Type-ART pO2-196* pCO2-37 pH-7."
1223,"????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your arm or the
ability to feel your arm
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 2625**] Follow-up
appointment should be in 2 weeks"
1224,"What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?"
1225,"0 Plt Ct-102*
[**2109-9-15**] 10:35AM BLOOD Hgb-10.5* Hct-28.1*
[**2109-9-16**] 02:58PM BLOOD Hct-27.5*
[**2109-9-17**] 03:40AM BLOOD WBC-6.3 RBC-2.70* Hgb-8.9* Hct-24.0*
MCV-89 MCH-33.0* MCHC-37.2* RDW-15.7* Plt Ct-71*
[**2109-9-18**] 06:30AM BLOOD WBC-4.3 RBC-2.90* Hgb-9.3* Hct-26.1*
MCV-90 MCH-32.2* MCHC-35.7* RDW-15.8* Plt Ct-91*
[**2109-9-15**] 02:00AM BLOOD PT-22.8* PTT-150* INR(PT)-2."
1226,"Pulses remained palpable
throughout his postoperative course. Ortho asked to follow for
question of possible brachial plexus injury or nerve impingement
by hematoma. Question of acute thrombocytopenia with platelets
dropping to 77 from 100's. Anticoagulation held and HIT panel
antibodies sent. Results are pending. She was weaned to extubate
from the ventilator without any respiratory complications.
.
POD2, she was transfused 1u pRBC for Hct of 24. Hct responded to
27.5 and remained stable during remained of hospital course.
Occupational therapy consulted for evaluation. On discharge, she
continues to have decreased coordination, grasping and
sensation, strength and functional use of her left upper
extremity."
1227,"She will be discharged home with outpatient
occupational therapy to follow for strengthening and
conditioning.
.
POD3, patient discharged home with services. She will follow
occupational therapy as outpatient. Her vitals signs are stable.
She is tolerating regular food. Hct remained stable at 26.1. She
will follow up with Dr. [**Last Name (STitle) **] in clinic in [**12-5**] weeks for
postoperative follow up. She is to continue her aspirin and
plavix as well.
Medications on Admission:
None
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 28 days.
Disp:*30 Tablet(s)* Refills:*0*
2."
1228,"34*
calTCO2-21 Base XS--5
[**2109-9-15**] 09:33AM BLOOD Type-ART pO2-224* pCO2-38 pH-7.40
calTCO2-24 Base XS-0
[**2109-9-15**] 11:48AM BLOOD Type-ART pO2-74* pCO2-37 pH-7.40
calTCO2-24 Base XS-0
Brief Hospital Course:
Patient was transferred via [**Location (un) 7622**] to [**Hospital1 18**] and taken
directly to the OR by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**2109-9-15**] for L
axillary arterioplasty, covered stent, L brachial artery cutdown
with vein patch arterioplasty. During transportation, patient
was intubaed and remained hemodynamically stable."
1229,"She arrived intubated
and hemodynamically stable.
Past Medical History:
L shoulder dislocation 2 months ago
Vaginal hysterectomy in [**2102**]
Social History:
Drinks socially
Denies tobacco and IVDU
Family History:
mother with arthritis, father with brain tumor (unclear
pathology)
Physical Exam:
Tmax 97, Tc 97, HR 91, BP 117/76, RR 19, SaO2 100%, CMV/AC (FiO2
0.5, Peep 5, TV 500, RR 18), Neo 1.3, Prop 20
Gen: intubated, sedated
CV: RRR
Pulm: CTA BS
Abd: soft, NT, ND, act BS
L ext - dopplerable ulnar, radial, brachial
R ext - dopplerable ulnar, radial
Ext: no clubbing, cyanosis, gross edema"
1230,"m. today and developed a hematoma of
her left chest but had no shoulder dislocation. Due to
neurologic symptoms in her left hand, the patient was taken
urgently to the operating room despite no active extravasation
of contrast on the chest CT. In the operating room from OSH, the
surgeon's exposed
the artery but found massive bleeding and decided to transport
the patient to [**Hospital1 69**] by med
flight. The surgeon came in the helicopter with manual pressure
being held on the artery and the patient was brought emergently
to the endovascular room. At this point, the patient had artery
had already lost 2 liters of blood and received 4 units of
packed red blood cells and 2 units of FFP."
1231,"Demographics
Day of intubation:
Day of mechanical ventilation: 1
Ideal body weight: 49.9 None
Ideal tidal volume: 199.6 / 299.4 / 399.2 mL/kg
Airway
Airway Placement Data
Known difficult intubation: Unknown
Procedure location: Outside hospital
Tube Type
ETT:
Position: 22 cm at teeth
Route: Oral
Type: Standard
Size: 7mm
:
Lung sounds
RLL Lung Sounds: Rhonchi
RUL Lung Sounds: Rhonchi
LUL Lung Sounds: Rhonchi
LLL Lung Sounds: Rhonchi
Comments:
Secretions
Sputum color / consistency: /
Sputum source/amount: Suctioned / None
Comments:
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Invasive ventilation assessment:
Trigger work assessment: Triggering synchronously
Plan
Next 24-48 hours:
Reason for continuing current ventilatory support: Sedated /
Comments: Pt. admitted from OR intubated . Placed on A/C. RR ^ 18 due
to resp. acidosis. Plan extubation when pt. awake."
1232,"Admission Date: [**2146-11-2**] Discharge Date: [**2146-11-23**]
Date of Birth: [**2094-10-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2146-11-14**] embedded stent removal and tracheostomy.
History of Present Illness:
52F with dwarfism, asthma, CHF, COPD, OSA on CPAP and severe
tracheobronchomalacia s/p tracheal stent x2 and Left main
bronchial stent x1 on [**2146-10-28**]. On [**2146-10-31**] She was
hospitalized
at [**Hospital1 2025**] for respiratory distress with increased dyspnea and
fever,
diagnosed with pneumonia and CHF started empiric treatment with
Vancomycin, Cefepime and Levofloxacin, cultures postive for
staph, plus diuresis."
1233,"On [**2146-11-1**] Left main bronchus stent was
removed. Patient was transferred to [**Hospital1 **] for further evaluation
and management. A rigid bronchoscopy was performed on
[**2146-11-9**]. The metal stents were visualized in the trachea but
were unable to be removed as extensive granulation tissue was
present and the stents were embedded. Thoracic surgery is
consulted for stent removal and possible tracheoplasty.
Past Medical History:
Dwarfism syndrome, Glaucoma, Asthma, COPD, CHF, OSA on CPAP 13
cm
of H2O, Osteoporosis
Social History:
Lives in [**Location 18317**] with her husband.
Occupation attorney
Smoking history quit 4-5 years ago after ~15-20 pack"
1234,"13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day: take only while
taking lasix. may need adjustment based on potassium and lasix
dosing.
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
day.
16. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Tracheobronchomalacia
Dwarfism Syndrome
Asthma
obstructive sleep apnea
COPD
CHF
glaucoma
CHF"
1235,"Discharge Condition:
stable
Discharge Instructions:
Walk three times a day.
Call if fevers, chills, difficulties breathing, or any
questions.
CPAP at night, trach collar during day- wean to trach collar and
off ventilator, aggressively.
Followup Instructions:
On [**2146-12-6**] in CDC [**Hospital Ward Name **] [**Hospital1 18**] you have an appointment
with Dr. [**Last Name (STitle) **] 10:30, Dr. [**Last Name (STitle) **] 11:00, followed by
bronchoscopy. Call if you have questions: [**Telephone/Fax (1) 10084**].
Do not eat or drink after midnight prior to seeing us, for your
bronchoscopy.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2146-11-23**]"
1236,"Cal counts recommended. The patient should have 3 ensure cans a
day for nutrition.
CV: Hx CHF, however unknown LVEF. no echo done inhouse, and no
outside reports available. Stable cardiac rhythm. lasix/Kcl per
home dosing. no edema. will need rehab lyte monitoring.
Abd: refused dobhoff. see HEENT. having normal BM- last on date
of transfer
ID: no active ID issues. Completed 7 day course of levofloxacin
for PNA. OHS cx showed + s.aureus sensitivy to all but PCN. Also
completed 7 day course of acyclovir for gluteus herpes.
Line: right PICC placed [**11-2**]. Does not need PICC after arrival,
but kept for ACLS transport."
1237,"The patient
was taken to the SICU for further recovery. Her future goals are
for tracheoplasty scheduled [**2146-11-14**], however she is being
transfered as cleared by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] to
[**Hospital1 **] on [**2146-11-23**] for vent rehab and weaning to prepare for
surgery. Below is her systems hospital course:
Neuro: A and O x 4. Had issues with anxiety due to airway
secretion management and spasms. Psychiatry was heavily involved
and recommended fluoxetine 40 mg daily and prn ativan for
anxiety. The patient is currently controlled on this regime.
Respiratory: Completed a seven day course of levofloxacin for
PNA."
1238,"Family History:
Father and son with the same syndrome
Physical Exam:
VS: Temp: 99.1, BP 93/51, Pulse 100-110 ST reg RR 30 97% on 50%
TC
PE:
Gen: pleasant resting in her hospital bed in NAD
Lungs: wheezed and rales t/o bilaterally
CV: RRR S1, S2, no MRG
Abd: Soft, NT, ND
Ext: warm, no edema
IV: right PICC intact without redness, purulence or drg
Pertinent Results:
CXR on [**2146-11-21**]
1. Bilateral parenchymal opacity most likely pneumonia,
increased on the
right side and improved on the left.
2. Airless appearance of the trachea and bronchi most likely
related to
underlying tracheobronchomalacia as well as postoperative
edema-secretions."
1239,"Sputum cx on [**2146-11-18**] were negative despite some radiologic
concern for PNA. The patient has been afebrile without WBC
elevation. Trach collar 45% during day and CPAP at night to
rest, only required 2 hrs of CPAP [**11-22**] [**2146-11-21**] night. The
patient should have lower CPAP pressures in rehab.
The patient had a bronchoscopy [**2146-11-16**] showing distally, there
were thin secretions in both bronchial trees and these were
aspirated.
HEENT: Speech and swallow evaluated the patient recommending
electrolarynx for communication but no passey muir valve. The
patient can eat soft solids and thin liquids with cuff deflated."
1240,"Please dc on arrival. thanks.
Discharge Medications:
1. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation Q4H (every 4 hours).
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
unit Injection TID (3 times a day): subcutaneous.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
5. Lidocaine (PF) 10 mg/mL (1 %) Solution Sig: 2.5 MLs Injection
Q4H (every 4 hours) as needed for spasm.
6."
1241,"Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lorazepam 1 mg Tablet Sig: 0.5-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
9. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
12. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO
Q6H (every 6 hours) as needed for pain."
1242,"[**2146-11-23**] 01:56AM BLOOD WBC-5.8 RBC-3.38* Hgb-9.8* Hct-30.2*
MCV-89 MCH-29.0 MCHC-32.4 RDW-15.0 Plt Ct-411
[**2146-11-23**] 01:56AM BLOOD Glucose-117* UreaN-12 Creat-0.6 Na-142
K-3.9 Cl-101 HCO3-35* AnGap-10
Brief Hospital Course:
Mrs. [**Known lastname 84405**] was transferred from [**Hospital1 2025**] to [**Hospital1 18**] where she
underwent bronchoscopy which revealed embedded stents. The
patient was taken to the operating room on [**2146-11-14**] and had
stents removed with tracheostomy by Dr. [**Last Name (STitle) **]."
1243,"Sputum also showed [**Female First Name (un) 444**].
[**11-2**] UCX - no growth
[**11-4**] UCX - mixed bacterial flora c/w skin/genital contamination
[**11-6**] Sputum Cx - sparse growth Commensal Respiratory Flora. sparse
growth yeast.
[**11-7**] Sputum Cx - extensive contamination with upper respiratory
secretions
Assessment and Plan
TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), ANXIETY
Assessment and Plan: 52yF with TBM s/p metal stenting and subsequent
PNA admitted to TSICU with significant respiratory distress.
Respiratory status improved and pt transferred to floors. Pt to OR
[**2146-11-14**] for tracheostomy, bronch and stent removal and admitted to
TICU postop management.
Neurologic: Ativan 1-2mg q2h prn for anxiety."
1244,"9 g/dL
105 mg/dL
0.4 mg/dL
27 mEq/L
3.4 mEq/L
10 mg/dL
109 mEq/L
146 mEq/L
27.3 %
5.5 K/uL
[image002.jpg]
[**2146-11-15**] 08:00 AM
[**2146-11-15**] 12:57 PM
[**2146-11-15**] 02:00 PM
[**2146-11-15**] 06:00 PM
[**2146-11-15**] 08:00 PM
[**2146-11-16**] 02:00 AM
[**2146-11-16**] 02:08 AM
[**2146-11-17**] 02:20 AM
[**2146-11-18**] 02:00 AM
[**2146-11-18**] 02:38 AM
WBC
7.1
7.2
5."
1245,"[**11-6**] CXR - little to no change from previous
[**11-7**] CXR - persistant L sided opacity - pna vs atelectasis
[**11-12**] CT ABD/PEL - No renal calculi or renal masses. No evidence of
hydronephrosis. Thickening of the wall of urinary bladder may be due to
underdistension and the urinary catheter seen in situ.
[**11-14**] CXR - R>L interstitial prominence, vascular redistribution most
likely asymmetric pulmonary edema.
[**11-15**] CXR - Left sided opacity - PNA vs. LLL collapse
[**11-17**] CXR - Ill-defined opacity in RUL
Microbiology: [**11-1**] Sputum ([**Hospital1 49**]) - staph aureus Res to PCN G, otherwise
pan-sensitive including: cipro, levo, mox, clinda, tmx, methacillin,
vanco, Bactrim, linezolid."
1246,"5
Hct
29.5
26.9
27.3
Plt
[**Telephone/Fax (3) 9652**]
Creatinine
0.6
0.5
0.4
TCO2
28
27
30
Glucose
103
103
112
115
101
101
105
Other labs: Lactic Acid:1.0 mmol/L, Ca:8.4 mg/dL, Mg:2.2 mg/dL, PO4:2.7
mg/dL
Imaging: [**11-3**] CXR - L retrocardiac opacity, pneumomediastinum (postop
changes)
[**11-4**] CXR - There is mild linear radiolucency projected over the left
cardiac silhouette are unchanged representing pneumomediastinum or
pneumopericardium. This is stable. Bibasilar opacities, left greater
than right, are unchanged from prior study, the ill-defined appearance
favors pneumonia over atelectasis."
1247,"Pt discharged, however, on [**2146-10-31**], pt with with increased SOB,
worsening cough, sore throat, and febrile to 105 F. EMS called, SBP
230's, given lasix and SL nitro and placed on nonreabrether. Pt taken
to [**Hospital1 49**] where she was bronched with removal of stent in left main
bronchus. Pt also with WBC 17 and found to have pneumonia (?aspiration
PNA as pt was witnessed to aspirate with liquids when taking po meds).
Pt started on ABX vanco/cefepime/l evaquin and on lasix for CHF like
symptoms. Transferred to [**Hospital1 1**] TICU [**2146-11-2**] for further management."
1248,"Restarted fluoxetine 40mg
qd. dilaudid prn. Ask Psych to revisit mood, husband request..
Cardiovascular: Hemodynamically stable. Hx of CHF, on lasix 20mg PO QD.
Pulmonary: Trach, IS, Pt admitted with PNA and completed 7 day course
of levofloxacin. Tracheobronchomalacia s/p 3 stents and removal of 2
stents and Tracheostomy placed [**2146-11-14**]. On trach collar, desaturated,
occasional coughing fits and spasms with min desaturation. Cont xopenex
nebs, atrovent nebs. Restarted singulair. Longterm plan includes
tracheobronchoplasty in few weeks.
Gastrointestinal / Abdomen: Video swallow [**11-18**], Dobhoff placed [**11-17**].
Replete w/fiber (per nutrition), goal 50
Nutrition: Tube feeding, Speech and Swallow eval
Renal: Foley, cont Foley while on Lasix."
1249,"Hematuria since time of
admission - likely secondary to foley trauma to bladder, will remove
when able.
Hematology: stable
Endocrine: RISS
Infectious Disease: Currently not on ABX. Afebrile. S/p 10 day course
of levofloxacin for PNA. OSH cultures showed S.Areus sensitive to all
abx except PCN, as well as [**Female First Name (un) 444**]. S/p 7 day course of acyclovir for
herpes on gluteus. WBC decreased but low grade temp overnight. If CXR
worsens or spikes fever, will need abx coverage.
Lines / Tubes / Drains: Foley, Dobhoff, Trach, PICC, aline
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: CT surgery, Pulmonology, Urology
Billing Diagnosis: Other: Respiratory Distress, Tracheobronchomalacia
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2146-11-17**] 11:06 PM 40 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2146-11-14**] 06:39 PM
PICC Line - [**2146-11-14**] 06:50 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: HOB elevation
Comments:
Communication: Patient discussed on interdisciplinary rounds , Family
meeting held , ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 31 min"
1250,"5 kg (admission): 71.9 kg
Total In:
870 mL
259 mL
PO:
Tube feeding:
57 mL
187 mL
IV Fluid:
783 mL
72 mL
Blood products:
Total out:
1,135 mL
140 mL
Urine:
1,135 mL
140 mL
NG:
Stool:
Drains:
Balance:
-265 mL
119 mL
Respiratory support
O2 Delivery Device: Aerosol-cool, Trach mask
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 297 (297 - 297) mL
PS : 8 cmH2O
RR (Spontaneous): 30
PEEP: 5 cmH2O
FiO2: 50%
PIP: 14 cmH2O
SPO2: 91%
ABG: 7.40/46/107/27/2
Ve: 10.8 L/min
PaO2 / FiO2: 214
Physical Examination
General Appearance: No acute distress, occasional distress with
anxiety, coughing episodes
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :
bilateral, inspiratory and expiratory), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, Obese
Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:
Present)
Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
277 K/uL
8."
1251,"Allergies:
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Furosemide (Lasix) - [**2146-11-17**] 08:05 AM
Heparin Sodium (Prophylaxis) - [**2146-11-17**] 02:02 PM
Lorazepam (Ativan) - [**2146-11-18**] 06:02 AM
Hydromorphone (Dilaudid) - [**2146-11-18**] 06:02 AM
Other medications:
Flowsheet Data as of [**2146-11-18**] 06:46 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**48**] a.m.
Tmax: 37.9
C (100.3
T current: 36.9
C (98.4
HR: 133 (91 - 141) bpm
BP: 204/112(147) {93/50(65) - 204/163(181)} mmHg
RR: 41 (23 - 47) insp/min
SPO2: 91%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 68."
1252,"Chief complaint:
tracheobronchomalacia
PMHx:
dwarfism, glaucoma, asthma, CHF, COPD, OSA on CPAP 13cm H2O,
osteoporosis, severe TBM
Current medications:
Calcium Gluconate 3. Chlorhexidine Gluconate 0.12% Oral Rinse 4.
Dextrose 50% 5. Famotidine
6. Fentanyl Citrate 7. Fluoxetine 8. Furosemide 9. Glucagon 10.
HYDROmorphone (Dilaudid) 11. Heparin Flush (10 units/ml)
12. Heparin 13. 14. Insulin 15. Ipratropium Bromide Neb 16. Lidocaine
1% 17. Lorazepam 18. Lorazepam
19. Magnesium Sulfate 20. Montelukast Sodium 21. Potassium Chloride 22.
Potassium Phosphate 23. Sodium Chloride 0.9% Flush
24. Xopenex Neb
24 Hour Events:
MULTI LUMEN - STOP [**2146-11-17**] 02:28 PM
Post operative day:
POD#4 - s/p flex bronch w/ stent removal and tracheostomy ."
1253,"TSICU
HPI:
52y F with PMHx dwarfism, asthma, COPD, OSA on CPAP presents with c/o
chronic dry cough, wheezing and dyspnea with moderate activities,
intermitted dysphagia. Pt was found to have TBM on outpt eval in
[**Location (un) 2339**], and presents to [**Hospital1 1**] on [**2146-10-24**] for further eval and
potential stent trial. S/p flexible bronchoscopy [**2146-10-24**] which showed
severe tracheobronchomalacia that involved all of the traceha, right
mainstem, bronchus intermedius and left mainstem. S/p rigid bronch
[**2146-10-28**] with placement of 3 metal stents (2 in trachea, 1 in left
main)."
1254,"Pt discharged, however, on [**2146-10-31**], pt with with increased SOB,
worsening cough, sore throat, and febrile to 105 F. EMS called, SBP
230's, given lasix and SL nitro and placed on nonreabrether. Pt taken
to [**Hospital1 49**] where she was bronched with removal of stent in left main
bronchus. Pt also with WBC 17 and found to have pneumonia (?aspiration
PNA as pt was witnessed to aspirate with liquids when taking po meds).
Pt started on ABX vanco/cefepime/l evaquin and on lasix for CHF like
symptoms. Transferred to [**Hospital1 1**] TICU [**2146-11-2**] for further management."
1255,"[**Hospital **] rehab screening.
Gastrointestinal / Abdomen: Video swallow [**11-18**] ok thin liquids, soft
solids ([**11-21**] no need to repeat), Dobhoff placed [**11-17**]. Cycling TF at
night to stimulate PO intake during the day; Nutr recs d/c'ing Tfs if
pt tolerated 3 cans Ensure + food.
Nutrition: Tube feeding, Regular diet, Speech and Swallow eval
Renal: Adequate UO, On home dose of lasix. Keep dry.
Hematology: Hct stable. Monitor Daily.
Endocrine: RISS
Infectious Disease: Currently not on ABX. Afebrile.
S/p 10 day course of levofloxacin for PNA. OSH cultures showed S.Areus
sensitive to all abx except PCN, as well as [**Female First Name (un) 444**]. S/p 7 day course
of acyclovir for herpes on gluteus.
Lines / Tubes / Drains: PICC (placed [**11-2**]), Trach, Dobhoff
Wounds:
Imaging:
Fluids: KVO
Consults: Interventional Pulm, Thoracic, Urology
Billing Diagnosis: (Respiratory distress), Other: Respiratory Distress,
Tracheobronchomalacia
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2146-11-14**] 06:50 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: Not indicated
VAP bundle: HOB elevation, Mouth care
Comments:
Communication: Patient discussed on interdisciplinary rounds , Family
meeting held , ICU consent signed Comments:
Code status: Full code
Disposition: Transfer to rehab / long term facility
Total time spent:"
1256,"5
10.5
6.5
6.1
7.2
Hct
29.5
26.9
27.3
31.5
28.6
28.7
29.7
Plt
[**Telephone/Fax (3) 9718**]
390
Creatinine
0.6
0.5
0.4
0.5
0.5
0.5
0.5
TCO2
30
Glucose
115
101
101
105
122
127
137
110
146
Other labs: PT / PTT / INR:12.9/41.0/1.1, Lactic Acid:1.0 mmol/L,
Ca:9.8 mg/dL, Mg:2.2 mg/dL, PO4:4.4 mg/dL
Imaging: [**11-3**] CXR - L retrocardiac opacity, pneumomediastinum (postop
changes)
[**11-4**] CXR - unchanged pneumomediastinum."
1257,"7 g/dL
146 mg/dL
0.5 mg/dL
36 mEq/L
4.2 mEq/L
15 mg/dL
101 mEq/L
142 mEq/L
29.7 %
7.2 K/uL
[image002.jpg]
[**2146-11-16**] 02:00 AM
[**2146-11-16**] 02:08 AM
[**2146-11-17**] 02:20 AM
[**2146-11-18**] 02:00 AM
[**2146-11-18**] 02:38 AM
[**2146-11-19**] 02:51 AM
[**2146-11-19**] 02:00 PM
[**2146-11-20**] 02:04 AM
[**2146-11-21**] 02:42 AM
[**2146-11-22**] 02:03 AM
WBC
7.1
7.2
5."
1258,"9 kg
Height: 55 Inch
Total In:
1,585 mL
518 mL
PO:
600 mL
Tube feeding:
495 mL
338 mL
IV Fluid:
100 mL
Blood products:
Total out:
1,025 mL
250 mL
Urine:
1,025 mL
250 mL
NG:
Stool:
Drains:
Balance:
560 mL
268 mL
Respiratory support
O2 Delivery Device: Trach mask
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 339 (339 - 339) mL
PS : 12 cmH2O
RR (Spontaneous): 19
PEEP: 8 cmH2O
FiO2: 60%
PIP: 21 cmH2O
SPO2: 99%
ABG: ///36/
Ve: 9.4 L/min
Physical Examination
General Appearance: No acute distress, Anxious, Well nourished
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
390 K/uL
9."
1259,"[**11-18**] CXR - Improved R suprahilar opacity, stable LLL atelectasis versus
infection.
[**11-19**] CXR - LLL atelectasis
[**11-20**] CXR - ill-defined RUL opacity persists, w/small focus laterally in
mid lung. suggests PNA. Opacity @R base c/w volume loss and pleural
effusion. possibility of another focus of consolidation in this region.
[**11-21**] CXR - B/l parenchymal opacity most likely PNA, incr on R &improved
on L.
Microbiology: [**11-1**] Sputum ([**Hospital1 49**]) - staph aureus Res to PCN G, otherwise
pan-sensitive including: cipro, levo, mox, clinda, tmx, methacillin,
vanco, Bactrim, linezolid. Sputum also showed [**Female First Name (un) 444**]."
1260,"Nutr recs d/c'ing Tfs if pt tolerated 3 cans Ensure +
food. Insomnia o/n-trazodone ordered.
Post operative day:
POD#8 - s/p flex bronch w/ stent removal and tracheostomy .
Allergies:
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2146-11-21**] 08:00 PM
Other medications:
Flowsheet Data as of [**2146-11-22**] 06:50 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**48**] a.m.
Tmax: 37.6
C (99.7
T current: 36.9
C (98.5
HR: 99 (79 - 123) bpm
BP: 103/42(56) {89/40(54) - 134/85(88)} mmHg
RR: 23 (20 - 51) insp/min
SPO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 67 kg (admission): 71."
1261,"Seen by
psych on this admission, may consider repeat visit. Restarted
fluoxetine 40mg qd.
Neuro checks Q: shift
Pain: Roxicet prn.
Cardiovascular: Hemodynamically stable. Hx of CHF, on lasix 20mg PO
QD. Intermittent tachycardia to 120s, pt refusing Ativan [**11-21**] day.
Pulmonary: Trach, Pt admitted with PNA and completed 7 day course of
levofloxacin. TBM s/p 3 stents and removal of 2 stents and Tracheostomy
placed [**2146-11-14**]. On trach collar, occasional coughing fits and spasms
with min desaturation. Placed back on CPAP at night. Cont xopenex nebs,
atrovent nebs, &tessalon perles prn. Restarted singulair. Longterm plan
includes tracheobronchoplasty in few weeks."
1262,"TSICU
HPI:
52y F with PMHx dwarfism, asthma, COPD, OSA on CPAP presents with c/o
chronic dry cough, wheezing and dyspnea with moderate activities,
intermitted dysphagia. Pt was found to have TBM on outpt eval in
[**Location (un) 2339**], and presents to [**Hospital1 1**] on [**2146-10-24**] for further eval and
potential stent trial. S/p flexible bronchoscopy [**2146-10-24**] which showed
severe tracheobronchomalacia that involved all of the traceha, right
mainstem, bronchus intermedius and left mainstem. S/p rigid bronch
[**2146-10-28**] with placement of 3 metal stents (2 in trachea, 1 in left
main)."
1263,"Chief complaint:
difficulty breathing
PMHx:
dwarfism, glaucoma, asthma, CHF, COPD, OSA on CPAP 13cm H2O,
osteoporosis, severe TBM
Current medications:
Acetaminophen (Liquid) 3. Benzonatate 4. Calcium Gluconate 5.
Chlorhexidine Gluconate 0.12% Oral Rinse
6. Dextrose 50% 7. Fluoxetine 8. Furosemide 9. Glucagon 10. Heparin
Flush (10 units/ml) 11. Heparin
12. 13. Insulin 14. Ipratropium Bromide Neb 15. Lidocaine 1% 16.
Lorazepam 17. Magnesium Sulfate
18. Montelukast Sodium 19. OxycoDONE-Acetaminophen Elixir 20. Potassium
Chloride 21. Potassium Phosphate
22. Sodium Chloride 0.9% Flush 23. Xopenex Neb 24. traZODONE
24 Hour Events:
INVASIVE VENTILATION - STOP [**2146-11-21**] 08:01 AM
INVASIVE VENTILATION - START [**2146-11-21**] 09:45 PM
INVASIVE VENTILATION - STOP [**2146-11-22**] 02:01 AM
[**11-21**] - vent rehab screening, S&S re-eval (no need for video swallow),
regular diet."
1264,"Bibasilar opacities L>R,
unchanged: PNA vs. atelectasis.
[**11-6**] CXR - little to no change
[**11-7**] CXR - persistant L sided opacity - pna vs atelectasis
[**11-12**] CT ABD/PEL - No renal calculi or renal masses. No hydronephrosis.
Thickening of urinary bladder wall may be due to underdistension and
the urinary catheter seen in situ.
[**11-14**] CXR - R>L interstitial prominence, vascular redistribution most
likely asymmetric pulmonary edema.
[**11-15**] CXR - L sided opacity - PNA vs. LLL collapse
[**11-17**] CXR - Ill-defined opacity in RUL
[**11-18**] CXR - The Dobbhoff catheter in distal stomach. R suprahilar
opacity stable and RUL density, most likely atelectasis unchanged."
1265,"[**11-2**] UCX - no growth
[**11-4**] UCX - mixed bacterial flora c/w skin/genital contamination
[**11-6**] Sputum Cx - sparse growth Commensal Respiratory Flora. sparse
growth yeast.
[**11-7**] Sputum Cx - extensive contamination with upper respiratory
secretions
[**11-18**] Sputum - no growth
Assessment and Plan
TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), ANXIETY
Assessment and Plan: 52yF with TBM s/p metal stenting and subsequent
PNA admitted to TSICU with significant respiratory distress.
Respiratory status improved and pt transferred to floors. Pt to OR
[**2146-11-14**] for tracheostomy, bronch and stent removal and admitted to
TICU postop management.
Neurologic: Pain controlled, Ativan 1-2mg q2h prn for anxiety."
1266,"Chief complaint:
TBM
PMHx:
dwarfism ,glaucoma, asthma, CHF, COPD, OSA on CPAP 13cm H2O,
osteoporosis
Current medications:
1. IV access: PICC, heparin dependent Order date: [**11-14**] @ 1803 13.
HYDROmorphone (Dilaudid) 0.25-1 mg IV Q4H:PRN pain Order date: [**11-15**] @
1003
2. IV access: Temporary central access (ICU) Location: Right Internal
Jugular, Date inserted: [**2146-11-14**] Order date: [**11-14**] @ 1803 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. Order date: [**11-14**] @ 1803
3."
1267,"1 kg (admission): 71.9 kg
Total In:
657 mL
92 mL
PO:
Tube feeding:
IV Fluid:
657 mL
92 mL
Blood products:
Total out:
1,832 mL
158 mL
Urine:
1,832 mL
158 mL
NG:
Stool:
Drains:
Balance:
-1,175 mL
-66 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 420 (279 - 475) mL
PS : 5 cmH2O
RR (Spontaneous): 18
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 65
PIP: 15 cmH2O
SPO2: 97%
ABG: 7.38/44/178/27/0
Ve: 9.8 L/min
PaO2 / FiO2: 445
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: 1+), (Temperature: Warm)
Right Extremities: (Edema: 1+), (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
242 K/uL
9."
1268,"8 g/dL
101 mg/dL
0.6 mg/dL
27 mEq/L
3.7 mEq/L
10 mg/dL
104 mEq/L
141 mEq/L
29.5 %
7.1 K/uL
[image002.jpg]
[**2146-11-14**] 10:36 PM
[**2146-11-15**] 01:49 AM
[**2146-11-15**] 02:22 AM
[**2146-11-15**] 08:00 AM
[**2146-11-15**] 12:57 PM
[**2146-11-15**] 02:00 PM
[**2146-11-15**] 06:00 PM
[**2146-11-15**] 08:00 PM
[**2146-11-16**] 02:00 AM
[**2146-11-16**] 02:08 AM
WBC
9.7
7.1
Hct
29."
1269,"Pt discharged, however, on [**2146-10-31**], pt with with increased SOB,
worsening cough, sore throat, and febrile to 105 F. EMS called, SBP
230's, given lasix and SL nitro and placed on nonreabrether. Pt taken
to [**Hospital1 49**] where she was bronched with removal of stent in left main
bronchus. Pt also with WBC 17 and found to have pneumonia (?aspiration
PNA as pt was witnessed to aspirate with liquids when taking po meds).
Pt started on ABX vanco/cefepime/l evaquin and on lasix for CHF like
symptoms. Transferred to [**Hospital1 1**] TICU [**2146-11-2**] for further management."
1270,"Allergies:
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2146-11-15**] 08:00 PM
Furosemide (Lasix) - [**2146-11-15**] 08:00 PM
Heparin Sodium (Prophylaxis) - [**2146-11-15**] 10:00 PM
Hydromorphone (Dilaudid) - [**2146-11-16**] 06:00 AM
Lorazepam (Ativan) - [**2146-11-16**] 08:20 AM
Other medications:
Flowsheet Data as of [**2146-11-16**] 08:29 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**48**] a.m.
Tmax: 37.7
C (99.8
T current: 36.9
C (98.5
HR: 100 (92 - 112) bpm
BP: 116/60(79) {94/51(65) - 142/76(97)} mmHg
RR: 19 (15 - 35) insp/min
SPO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 70."
1271,"Will need video speech and swallow eval.
RENAL: cont Foley while on Lasix. Hematuria since time of admission -
likely secondary to foley trauma to bladder. Urology consulted.
HEME: Hct stable. Monitor Daily.
ENDO: RISS
ID: S/p 10 day course of levofloxacin for PNA. OSH cultures showed
S.Areus sensitive to all abx except PCN, as well as [**Female First Name (un) 444**]. S/p 7 day
course of acyclovir for herpes on gluteus. Currently not on ABX.
Afebrile.
TLD: PICC (placed [**11-2**]), ALine (placed [**11-14**]), Right IJ (placed
[**11-14**]), Trach, foley
IVF: -
CONSULTS: Interventional Pulm, Thoracic, Urology
BILLING DIAGNOSIS: Respiratory Distress, Tracheobronchomalacia
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2146-11-14**] 06:37 PM
Arterial Line - [**2146-11-14**] 06:39 PM
PICC Line - [**2146-11-14**] 06:50 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent:"
1272,"Acetylcysteine 20% 3-5 mL NEB Q6H:PRN SOB
please give via trach instead of nebulized Order date: [**11-15**] @ 1044
15. Heparin 5000 UNIT SC TID Order date: [**11-14**] @ 1807
4. Alteplase 1mg/2mL ( Clearance ie. PICC, tunneled access line ) 1 mg
IV ONCE Duration: 1 Doses Order date: [**11-15**] @ 1755 16. Insulin SC (per
Insulin Flowsheet)
Sliding Scale Order date: [**11-14**] @ 1855
5. Calcium Gluconate IV Sliding Scale Order date: [**11-14**] @ 1855 17.
Ipratropium Bromide MDI 4 PUFF IH Q4H Order date: [**11-14**] @ [**2093**]
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation."
1273,"Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**11-14**] @ 1855
11. Furosemide 10 mg IV BID Start: In am
hold for sbp<100 Order date: [**11-14**] @ 1803 23. Sodium Chloride 0.9%
Flush 10 mL IV PRN line flush Order date: [**11-14**] @ 1803
12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:
[**11-14**] @ 1855 24. Xopenex Neb *NF* 3 mL IH Q4H Start: [**2146-11-5**] Order
date: [**11-14**] @ 1803
24 Hour Events:
Successfully weaned to PSV 5/5.
Post operative day:
POD#2 - s/p flex bronch w/ stent removal and tracheostomy ."
1274,"4
29.5
Plt
258
242
Creatinine
0.5
0.6
TCO2
29
29
28
27
Glucose
104
105
103
103
112
115
101
Other labs: Ca:8.2 mg/dL, Mg:2.2 mg/dL, PO4:3.3 mg/dL
Assessment and Plan
TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), ANXIETY
52yF with TBM s/p metal stenting and subsequent PNA admitted to TSICU
with significant respiratory distress. Respiratory status improved and
pt transferred to floors. Pt to OR [**2146-11-14**] for tracheostomy, bronch
and stent removal and admitted to TICU postop for further management.
NEURO.. Baseline AOx3. Moves all 4 extremites."
1275,"TSICU
HPI:
52y F with PMHx dwarfism, asthma, COPD, OSA on CPAP presents with c/o
chronic dry cough, wheezing and dyspnea with moderate activities,
intermitted dysphagia. Pt was found to have TBM on outpt eval in
[**Location (un) 2339**], and presents to [**Hospital1 1**] on [**2146-10-24**] for further eval and
potential stent trial. S/p flexible bronchoscopy [**2146-10-24**] which showed
severe tracheobronchomalacia that involved all of the traceha, right
mainstem, bronchus intermedius and left mainstem. S/p rigid bronch
[**2146-10-28**] with placement of 3 metal stents (2 in trachea, 1 in left
main)."
1276,"PERLL. Ativan 1-2mg q4h
prn for anxiety. Seen by psych on this admission. Restart fluoxetine
40mg qd when able.
Neuro checks Q: shift
Pain: dilaudid prn.
CVS: Hemodynamically stable. Hx of CHF, on lasix 10mg IV BID.
PULM: Pt admitted with PNA and completed 7 day course of levofloxacin.
Tracheobronchomalacia s/p 3 stents and removal of 2 stents and
Tracheostomy placed [**2146-11-14**]. Currently on CPAP 40% PSV 5 PEEP 5. Plan
to wean off vent to trach collar. Cont xopenex nebs, atrovent nebs.
Restart singulair once awake. Longterm plan includes
tracheobronchoplasty in few weeks.
GI: NPO for now."
1277,"Respiratory status improved and pt transferred to floors. Pt to OR
[**2146-11-14**] for tracheostomy, bronch and stent removal and admitted to
TICU postop management.
Neurologic: AOx3. Moves all 4 extremities. PERLL. Ativan 1-2mg q2h prn
for anxiety. Restarted fluoxetine 40mg qd. Neuro checks Q: shift Pain:
Roxicet prn.
Cardiovascular: Hemodynamically stable. Hx of CHF, on lasix 20mg PO QD.
Pulmonary: Pt admitted with PNA and completed 7 day course of
levofloxacin. TBM s/p 3 stents and removal of 2 stents and Tracheostomy
placed [**2146-11-14**]. On trach collar, occasional coughing fits and spasms
with min desaturation."
1278,"m.
Tmax: 37.2
C (99
T current: 36.9
C (98.4
HR: 84 (79 - 116) bpm
BP: 104/65(72) {86/49(57) - 156/92(102)} mmHg
RR: 26 (19 - 51) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 67.7 kg (admission): 71.9 kg
Total In:
1,269 mL
330 mL
PO:
420 mL
Tube feeding:
459 mL
210 mL
IV Fluid:
100 mL
Blood products:
Total out:
700 mL
0 mL
Urine:
700 mL
NG:
Stool:
Drains:
Balance:
569 mL
330 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 312 (312 - 1,801) mL
PS : 12 cmH2O
RR (Spontaneous): 21
PEEP: 8 cmH2O
FiO2: 60%
PIP: 21 cmH2O
SPO2: 100%
ABG: ///32/
Ve: 7."
1279,"Areus sensitive to all
abx except PCN, as well as [**Female First Name (un) 444**]. S/p 7 day course of acyclovir for
herpes on gluteus.
Lines / Tubes / Drains: PICC (placed [**11-2**]), Trach, Dobhoff
Wounds:
Imaging: CXR today
Fluids: KVO
Consults: CT surgery, Pulmonology
Billing Diagnosis:
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2146-11-20**] 09:30 PM 50 mL/hour
Glycemic Control:
Lines:
PICC Line - [**2146-11-14**] 06:50 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: Not indicated
VAP bundle: HOB elevation, Mouth care
Comments:
Communication: ICU consent signed Comments: [**Hospital **] rehab screening today
Code status: Full code
Disposition: ICU
Total time spent: 31 min"
1280,"TSICU
HPI:
52yF with TBM s/p metal stenting and subsequent PNA admitted to TSICU
with significant respiratory distress. Respiratory status improved and
pt transferred to floors. Pt to OR [**2146-11-14**] for tracheostomy, bronch
and stent removal and admitted to TICU postop management.
Chief complaint:
TBM
PMHx:
dwarfism, glaucoma, asthma, CHF, COPD, OSA on CPAP 13cm H2O,
osteoporosis, severe TBM
PSH: TBM stented s/p trach stent removal and tracheostomy [**11-14**]
Current medications:
1. Benzonatate 2. Calcium Gluconate 3. Chlorhexidine Gluconate 0.12%
Oral Rinse 4. Dextrose 50% 5. Fluoxetine 6. Furosemide 7. Glucagon 8.
Heparin Flush (10 units/ml) 9."
1281,"Placed back on CPAP at night. Cont xopenex nebs,
atrovent nebs. tessalon perles prn. Restarted singulair. Longterm plan
includes tracheobronchoplasty in few weeks.
Gastrointestinal / Abdomen: Video swallow [**11-18**] ok thin liquids, soft
solids, Dobhoff placed [**11-17**]. Pt c/o of trouble swallowing, S&S
reconsulted. Cycling TF at night to stimulate PO intake during the day.
Nutrition: Tube feeding at goal.
Renal: On home dose of lasix. Keep dry.
Hematology: Hct stable. Monitor Daily.
Endocrine: RISS, adequate control.
Infectious Disease: Currently not on ABX. Afebrile. S/p 10 day course
of levofloxacin for PNA. OSH cultures showed S."
1282,"Heparin 10. Insulin 11. Ipratropium
Bromide Neb 12. Lidocaine 1% 13. Lorazepam 14. Magnesium Sulfate 15.
Montelukast Sodium
16. OxycoDONE-Acetaminophen Elixir 17. Potassium Chloride 18. Potassium
Phosphate 19. Sodium Chloride 0.9% Flush 20. Xopenex Neb
24 Hour Events:
INVASIVE VENTILATION - START [**2146-11-20**] 05:10 PM
TM during day, CPAP in afternoon.
Post operative day:
POD#7 - s/p flex bronch w/ stent removal and tracheostomy .
Allergies:
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Hydromorphone (Dilaudid) - [**2146-11-20**] 06:15 AM
Heparin Sodium (Prophylaxis) - [**2146-11-20**] 08:00 PM
Other medications:
Flowsheet Data as of [**2146-11-21**] 04:20 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**48**] a."
1283,"1
7.2
5.5
10.5
6.5
6.1
Hct
29.5
26.9
27.3
31.5
28.6
28.7
Plt
[**Telephone/Fax (3) 9718**]
Creatinine
0.6
0.5
0.4
0.5
0.5
0.5
TCO2
30
Glucose
112
115
101
101
105
122
127
137
110
Other labs: PT / PTT / INR:12.9/41.0/1.1, Lactic Acid:1.0 mmol/L,
Ca:9.2 mg/dL, Mg:2.2 mg/dL, PO4:4.9 mg/dL
Assessment and Plan
TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), ANXIETY
Assessment and Plan: 52yF with TBM s/p metal stenting and subsequent
PNA admitted to TSICU with significant respiratory distress."
1284,"2 L/min
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :
bilateral)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Temperature: Warm)
Right Extremities: (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities
Labs / Radiology
326 K/uL
9.4 g/dL
110 mg/dL
0.5 mg/dL
32 mEq/L
3.8 mEq/L
16 mg/dL
101 mEq/L
141 mEq/L
28.7 %
6.1 K/uL
[image002.jpg]
[**2146-11-15**] 08:00 PM
[**2146-11-16**] 02:00 AM
[**2146-11-16**] 02:08 AM
[**2146-11-17**] 02:20 AM
[**2146-11-18**] 02:00 AM
[**2146-11-18**] 02:38 AM
[**2146-11-19**] 02:51 AM
[**2146-11-19**] 02:00 PM
[**2146-11-20**] 02:04 AM
[**2146-11-21**] 02:42 AM
WBC
7."
1285,"Admission Date: [**2183-3-17**] Discharge Date: [**2183-3-20**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 8238**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo F h/o alzheimers dementia, COPD, bipolar disorder who
presents from her [**Female First Name (un) **]-psych facility with fever, tachycardia,
tachypneic to the mid-20s. For the past few days has been
somnolent at her facility, and was recently diagnosed with a
UTI, and started nitrofurantoin. In speaking with her case
manager, she has been feeling unwell for several days with
stomach distension, increased leg swelling and redness of which
lasix was started recently."
1286,"On arrival to the MICU, the patient states she is comfortable
without pain or shortness of breath. She states she is in a
hospital, but is not clear why she is here. She states she came
from home.
.
Review of systems: unable to obtain accurate review
Past Medical History:
Per the records, and health care proxy:
Breast cancer, s/p mastectomy
Alzheimer's dementia
Bipolar Disorder
Orthostatic Hypotension and Syncope
COPD
Osteoporosis
Hyperlipidemia
Bifascicular block
Borderline Diabetes
Social History:
Previously sociology professor [**First Name (Titles) **] [**Last Name (Titles) 3278**], retired. Never married.
No current tobacco. Occasional alcohol. Resident ot [**Last Name (un) 35689**]
House in JP, due to recent aggressive behaviour, she was
sectioned and staying at [**Hospital 1191**] Hospital"
1287,"As a
consequence, the lung volumes have decreased. Borderline size of
the cardiac silhouette. No overt pulmonary edema. No evidence of
pneumonia or pleural effusions. Retrocardiac atelectasis. No
pneumothorax.
CT abd/pelv [**2183-3-17**]: IMPRESSION:
1. No acute intra-abdominal or pelvic process.
2. Incompletely characterized 15 x 11 mm splenic hypodensity. In
the absence of a history of malignancy, incidental splenic
lesions are typically benign.
3. Pancreatic calcifications, some may be vascular, but raising
concern for chronic pancreatitis. No CT evidence of acute
pancreatitis.
Brief Hospital Course:
89 yo F h/o alzheimers dementia, COPD, Bipolar d/o presenting
with fever, tachycardia, and an elevated lactate."
1288,".
Sepsis: With fever, tachycardia and elevated lactate and
possible PNA and cellulitis consistent with sepsis. Patient was
started on vancomycin and cefepime. She was switched to
bactrim/doxycycline PO. Her blood pressure was low on night of
admission and received a total of 8 liters of IVFs over
approximately 16 hours. Her blood pressure then normalized after
this intervention. Patient was called out of the MICU within 24
hours of admission. On arrival to the medicine floor, patient's
antibiotics were switched to augmentin/bactrim for cellulitis
and azithromycin for questionable atypical pneumonia. Knowing
that patient had recent urinary tract infection, urine culture
results were obtained form [**Doctor First Name 1191**] which showed sensitivity to
nitrofurantoin, which patient had been treated with prior to
admission."
1289,"AVSS throughout stay on medicine floor.
Her rash was not classic for cellulitis given the
vesiculo-pustular appearance and symmetry; it appeared more like
a contact dermatitis, although without known exposure. We
unroofed a vesicle and sent for HSV/VZV DFA which is pending at
time of discharge. Also would consider medium potency topical
steroid cream.
Patient will be continued on augmentin/bactrim x 5 more days and
azithromycin x 3 more days.
.
Goals of Care: ICU attending held discussion with HCP regarding
goals of care and it was decided that patient would not benefit
from escalation of care. This included NO central line or
pressors."
1290,"Patient would likely benefit from DNH (do not
hospitalize) order.
.
[**Last Name (un) **]: Elevated at 1.7 from baseline near 1.0. After IVFs, patient
CR decreased to 1.5 and stabilized at 1.3. PO fluid intake was
encouraged throughout the hospital stay.
.
COPD: Currently not on any inhalers, however has been in the
past, ordered combivent nebs prn. Did not require any PRNs
while in house.
.
Dementia: Reportedly due to alzheimers and with recent
aggressive behavior. Continued donepezil 10 mg daily. Patient
did not require PRN medications and remained calm and oriented
throughout her stay on the medicine floor
."
1291,"Bipolar d/o: Recent medication adjustment at [**Hospital 1191**] Hospital.
Continued [**Hospital3 4107**] regimen of Seroquel 12.5 prn,
citalopram 20 mg daily, Divalproex and gabapentin as well.
Patient did not require any PRN medications for agitation while
on the medicine floor
.
Anemia: Stable. No transfusions in the MICU. Remained stable on
emdicine floor
.
Splenic hypodensity: CT scan showed splenic hypondensity, given
history of malignancy, could be followed up with further
evaluation although may not be compatible w/ goals of care.
.
Code: DNR/DNI
.
Transitional issues - HSV/VZV DFA pending at time of discharge;
topical steroid cream not yet started"
1292,"Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] of [**Location (un) 55**]
Discharge Diagnosis:
Cellulitis
pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 1655**],
You were admitted to the hospital with fevers and confusion
concerning for a serious infection. You were admitted to the
intensive care unit and stabilized and then observed on the
floor. Your fever was likely caused by a skin infection on your
legs. You were started on two antibiotics for this, augmentin
and bactrim, and will need to take both two times per day for an
additional 5 days. A chest x-ray was concerning for a
developing pneumonia and you were started on a separate
antibiotic for this. You will need to take this antibiotic,
azithromycin, one time daily for another 3 days total.
We have made the following changes to your medications:
# ADD: augmentin [**Hospital1 **] for 5 days
# ADD: bactrim [**Hospital1 **] for 5 days
# ADD: azithromyicin daily for 3 days
Please continue all of your other medications as prescribed
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week
Completed by:[**2183-3-20**]"
1293,"Medications on Admission:
Medications: Per [**Doctor First Name 1191**] [**Month (only) 16**]
Citalopram 20 mg Once Daily
docusate sodium 100 mg at bedtime
donepezil 10 mg qhs
MVI
Omeprazole 20 mg daily
Simvastatin 20 mg daily
Gabapentin 100 mg TID
Divalproex 125 mg [**Hospital1 **] (0900 and 1400)
Divalproex 250 mg qhs
Nitrofurantoin 100 mg [**Hospital1 **]
Saliva Substitute 2 mL QID after meals and HS
Fluocinolone acetonide [**Hospital1 **]
Acetaminophen 650 daily
Maalox q4H prn
MgOH daily prn
Quetiapine 12.5 mg q6h PRN and 25 mg q6H prn
Albuterol prn
bisacodyl 10 mg PRN
Lasix 60 mg daily
Discharge Medications:
1."
1294,"C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day)."
1295,"Some
underlying edema. No sloughing of skin, no tenderness, no
drainage. No rash on other parts of body. No mucosal rash.
Pertinent Results:
Admission Labs:
[**2183-3-17**] 12:50PM BLOOD WBC-8.7# RBC-3.15* Hgb-10.4* Hct-31.8*
MCV-101* MCH-33.1* MCHC-32.8 RDW-12.8 Plt Ct-194
[**2183-3-17**] 12:50PM BLOOD Neuts-78.9* Lymphs-14.3* Monos-2.8
Eos-3.9 Baso-0.2
[**2183-3-17**] 12:50PM BLOOD Glucose-114* UreaN-25* Creat-1.7* Na-137
K-4.8 Cl-101 HCO3-24 AnGap-17
[**2183-3-17**] 12:50PM BLOOD ALT-15 AST-19 LD(LDH)-226 AlkPhos-57
TotBili-0."
1296,"3
[**2183-3-18**] 12:42AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
[**2183-3-18**] 12:42AM BLOOD VitB12-498 Folate-GREATER TH
[**2183-3-17**] 11:55PM BLOOD Type-ART pO2-89 pCO2-46* pH-7.41
calTCO2-30 Base XS-3 Intubat-NOT INTUBA
[**2183-3-17**] 01:47PM BLOOD Lactate-5.1*
[**2183-3-17**] 11:55PM BLOOD Lactate-0.8
[**2183-3-17**] 11:55PM BLOOD freeCa-1.14
[**2183-3-20**] 08:00AM BLOOD WBC-4.7 RBC-2.74* Hgb-9.1* Hct-27.7*
MCV-101* MCH-33.1* MCHC-32."
1297,"Family History:
NC
Physical Exam:
Vitals: T:99.8 BP: P:107 R: 23 O2: 97%
General: Alert, oriented to person, no acute distress
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremeties
DISCHARGE EXAM:
Skin- bilateral medial shins/calves have an erythematous rash
with multiple vesicles/papules/pustules overlying."
1298,"citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO BID (2 times a day).
7. divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO HS (at bedtime).
8. omeprazole 20 mg Capsule, Delayed Release(E."
1299,"Due to fever, tachycardia and cough
this morning, the patient was transferred to [**Hospital1 18**] for further
management.
.
In the ED, initial VS were: 101.2 96 117/60 18 98% 2L nc. c/o
sob. BLE new swelling/erythematous and excoriations c/f
cellulitis. Labs notable for Cr 1.7 (baseline around 1.0),
lactate of 5.1 which improved to 2.0 with 3 liters NS. CT scan
of abdomen showed no acute process. CXR: can't rule out PNA.
Received 1 gram of tylenol, Vancomycin and zosyn. Access: 2
PIVs. VS prior to transfer 101.8 122 117/68 20 96% 2L
."
1300,"7 RDW-12.5 Plt Ct-197
[**2183-3-19**] 10:45AM BLOOD Neuts-70.8* Lymphs-16.6* Monos-4.9
Eos-7.2* Baso-0.4
[**2183-3-20**] 08:00AM BLOOD Plt Ct-197
[**2183-3-20**] 08:00AM BLOOD Glucose-112* UreaN-21* Creat-1.3* Na-145
K-4.9 Cl-114* HCO3-22 AnGap-14
[**2183-3-20**] 08:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.3
Diagnostics:
CXR [**2183-3-17**]: IMPRESSION: Interstitial prominence which could
reflect edema or atypical infection. Correlate clinically
CXR [**2183-3-18**]: FINDINGS: As compared to the previous radiograph,
the patient has made a lesser inspiratory effort."
1301,"Admission Date: [**2161-1-29**] Discharge Date: [**2161-2-7**]
Date of Birth: [**2076-8-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Mitral valve replacement with a [**Street Address(2) 12523**]. [**Hospital 923**] Medical Biocor
Epic tissue valve.
History of Present Illness:
83 year old male with recent dyspnea with exertion and edema
lower extremities that has improved with lasix. Referred for
cardiac catheterization due to mitral regurgitation found on
echocardiogram, in preparation for cardiac
surgery.
Past Medical History:
Hypertension
Hyperlipidemia
Severe mitral regurgitation/prolapse
Atrial fibrillation, on Coumadin; last dose WED [**12-31**]
Diabetes type II
Prostate cancer- elevated PSA (not treated)
Colon polyps s/p polypectomy
Bilateral Inguinal hernia repair
remote trauma to leg involving pitchfork"
1302,"Carotid Bruit: left/right: referred cardiac murmur
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 89503**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 89504**] (Complete)
Done [**2161-2-2**] at 1:19:08 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2076-8-2**]
Age (years): 84 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for MV Repair vs replacement
ICD-9 Codes: 428.0, 427.31, 424.0, 424.2
Test Information
Date/Time: [**2161-2-2**] at 13:19 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW4-: Machine: U/S 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1."
1303,"5. warfarin 1 mg Tablet Sig: [**Name8 (MD) **] MD Tablet PO DAILY (Daily):
INR goal=>2, indication; Atrial Fibrillation.
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
10. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever."
1304,"RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. 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. Mildly
dilated LV cavity. Normal regional LV systolic function. Mildly
depressed LVEF. [Intrinsic LV systolic function likely depressed
given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Dilated RV cavity. Moderate global RV free wall
hypokinesis.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Simple
atheroma in aortic arch. Focal calcifications in aortic arch."
1305,"The rest of the LV segments are glbally,
moderately depressed. Overall left ventricular ejection fraction
is approximately 35%. There is a bioprosthesis located in the
mitral position. It appears well seated. The leaflets have
normal motion. There is trace valvular mitral regurgitation. The
maximum gradient through the valve was 6 mmHg with a mean of 2
mmHg at a cardiac output of 3.5 liters/minute. The thoracic
aorta is intact after decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2161-2-2**] 16:09"
1306,"Carotid Bruit: left/right: referred cardiac murmur
Pertinent Results:
[**2161-2-7**] 06:40AM BLOOD WBC-6.2 RBC-4.18* Hgb-13.7* Hct-40.1
MCV-96 MCH-32.7* MCHC-34.0 RDW-14.6 Plt Ct-134*
[**2161-2-7**] 06:40AM BLOOD PT-19.1* PTT-38.3* INR(PT)-1.7*
[**2161-1-29**] 04:13PM BLOOD PT-15.5* PTT-28.9 INR(PT)-1.4*
[**2161-2-7**] 06:40AM BLOOD Glucose-98 UreaN-31* Creat-1.0 Na-135
K-4.6 Cl-96 HCO3-31 AnGap-13
[**2161-1-29**] 04:13PM BLOOD Glucose-294* UreaN-33* Creat-1."
1307,"He awoke neurologically intact,
although slow to wake and was extubated on POD#2. He was weaned
off inotropes and pressors and was started on
Beta-blocker/Statin/Aspirin and diuresis. All lines and drains
were discontinued in a timely fashion. Mr.[**Known lastname **] was confused on
POD#2 and narcotics were discontinued. His mental status
improved to baseline. He continued to progress and was
transferred to the step down unit for further monitoring.
Physical Therapy was consulted for evaluation of strength and
mobility. On POD# 4 an unwitnessed slip vs.fall occurred and Mr.
[**Known lastname **] was not able to fully weight bare immediately thereafter."
1308,"Discharge Instructions:
Please shower daily including washing puncture sites in groins
with mild soap, no baths or swimming for 1 week until groin
sites are healed.
Please NO lotions, cream, powder, or ointments to puncture sites
in your groins
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 one month, will be discussed at follow up
appointment
No lifting or pulling more than 10 pounds for 1 week, and then
continue to take it easy for 1 month
Please call with any questions or concerns [**Telephone/Fax (1) 170**]"
1309,"**Please call Integrated Aortic valve clinic in 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
Surgeon:Dr.[**Last Name (STitle) **] #[**Telephone/Fax (1) 170**] on [**2-26**] at 1:15pm
Cardiologist:Dr [**Last Name (STitle) 7526**] on [**3-4**] at 11am.
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] S. # [**Telephone/Fax (1) 28262**] in [**11-23**] weeks
**Please call Integrated Aortic valve clinic in cardiac surgery
office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering
service will contact on call person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR :>2
First draw:[**2161-2-8**]
Completed by:[**2161-2-7**]"
1310,"Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth daliy
GLUCOSAMINE SULFATE [GLUCOSAMINE] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day)."
1311,"Orthpeadics was consulted and a CT scan was performed. Per Ortho
Mr.[**Known lastname **] was cleared for discharge with partial weight baring
on his left lower extremity until follow up in [**11-23**] weeks with
Dr.[**First Name (STitle) 4223**] in orthopeadic oncology. On POD# 5 Mr.[**Known lastname **] was
cleared for discharge to [**Hospital 1514**] Health Care Center in Ma. All
follow up appointments were advised.
Medications on Admission:
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
GLYBURIDE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth twice a day
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth daily
WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 3
Tablet(s) by mouth once a day as directed per coumadin clinic"
1312,"Social History:
Last Dental Exam: > 1 year
Lives with:alone
Occupation:retired mechanic shop owner
Tobacco:denies
ETOH:denies
Family History:
non contributory
Physical Exam:
Pulse: 78 Resp: 18 O2 sat: 100%
B/P Right: 133/59 Left: 156/80
Height: 6' Weight: 160#
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: systolic ejection murmur
best heart at the left sternal border radiating to both
carotids.
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + []
Extremities: Warm [x], well-perfused [x]
no Edema; has bilateral varicosities
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 0 Left: 0
Radial Right: 2+ Left: +"
1313,"12. warfarin 3 mg Tablet Sig: One (1) Tablet PO once for 1
doses.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Mitral valve replacement with a [**Street Address(2) 12523**]. [**Hospital 923**] Medical Biocor
Epic tissue valve.
Secondary:
Hypertension
Hyperlipidemia
Severe mitral regurgitation/prolapse
Atrial fibrillation, on Coumadin; last dose WED [**12-31**]
Diabetes type II
Prostate cancer- elevated PSA (not treated)
Colon polyps s/p polypectomy
Bilateral Inguinal hernia repair
remote trauma to leg involving pitchfork
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Groin pain managed with tylenol
Left groin - no erythema or drainage
Right groin - no erythema or drainage
Bilateral Lower extremity with no/trace edema"
1314,"0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.2 cm
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast in the
body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Mild
spontaneous echo contrast in the LAA. Depressed LAA emptying
velocity (<0.2m/s) All four pulmonary veins identified and enter
the left atrium."
1315,"Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Myxomatous mitral valve leaflets. Moderate/severe MVP. Partial
mitral leaflet flail. Moderate mitral annular calcification.
Calcified tips of papillary muscles. No MS. Eccentric MR jet.
Severe (4+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild to
moderate [[**11-23**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
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."
1316,"The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient. Bilateral pleural effusions.
Conclusions
PRE BYPASS The left atrium is dilated. No spontaneous echo
contrast is seen in the body of the left atrium. No
mass/thrombus is seen in the left atrium or left atrial
appendage. Mild spontaneous echo contrast is present in the left
atrial appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). The right atrium is dilated. No atrial
septal defect is seen by 2D or color Doppler."
1317,"?????? [**2152**] CareGroup IS. All rights reserved.
Brief Hospital Course:
83 year old with worsening symptoms of heart failure and found
to have severe
mitral regurgitation presenting for mitral valve replacement.
His preoperative work up consisted of dental consult and OMFS
for root extraction. [**2161-2-1**] Mr. [**Known lastname **] was taken to the
operating room and underwent Mitral valve replacement with a [**Street Address(2) 89505**]. [**Hospital 923**] Medical Biocor Epic tissue valve with Dr.[**Last Name (STitle) **].
Please refer to operative note for further surgical details. He
tolerated the procedure well and was transferred to the CVICU in
critical but stable condition."
1318,"Left ventricular
wall thicknesses are normal. The left ventricular cavity is
mildly dilated. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-45 %). [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is dilated with
moderate global free wall hypokinesis. There are simple atheroma
in the aortic arch. There are focal calcifications in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen."
1319,"The mitral valve leaflets are moderately thickened. The
mitral valve leaflets are myxomatous. There is bileaflet
prolapse with a flail P2 segment and potentislly some A2 partial
flail. An eccentric, anteriorly directed jet of severe (4+)
mitral regurgitation is seen. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is receiving milrinone and
norepinephrine by infusion. The right ventricle displays normal
systolic function. The left ventricle displays septal dyskinesis
versus severe dysynchronous contraction which is new from the
pre-bypass study."
1320,"1 Na-138
K-5.0 Cl-104 HCO3-27 AnGap-12
[**2161-1-29**] 04:13PM BLOOD ALT-17 AST-31 LD(LDH)-224 AlkPhos-112
Amylase-41 TotBili-1.0
Pulse: 78 Resp: 18 O2 sat: 100%
B/P Right: 133/59 Left: 156/80
Height: 6' Weight: 160#
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: systolic ejection murmur
best heart at the left sternal border radiating to both
carotids.
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + []
Extremities: Warm [x], well-perfused [x]
no Edema; has bilateral varicosities
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 0 Left: 0
Radial Right: 2+ Left: +"
1321,"CVICU
HPI:
HD3
72F readmit with sternal wound infection S/P CABG x4 (LIMA>LAD, SVG>D1,
SVG>OM, SVG>RCA) MV repair (28mm [**Company 1994**] 30mm ring) [**1-14**]
EF: 35% Wt: 108kg Cr:1.2-1.9 (preop) Hgb A1C:6.4
PMH DM, CAD MIx3, BMS [**10-25**], HTN, pulm HTN, MR, HTN, PVD s/p bilat LE
stenting, MRSA, s/p psoas abscess repair, s/p chol, s/p appy
Chief complaint:
PMHx:
Current medications:
Albuterol-Ipratropium , Amiodarone , Aspirin , Ciprofloxacin HCl,
Clopidogrel , Docusate Sodium , Heparin Flush (10 units/ml) , Heparin ,
Heparin Flush (10 units/ml) , Insulin , Lisinopril , Metoprolol
Succinate XL , Omeprazole, Oxycodone-Acetaminophen, Rosuvastatin
Calcium , Vancomycin
24 Hour Events:
BLOOD CULTURED - At [**2189-1-30**] 11:15 PM
Allergies:
Iodine; Iodine Containing
lips and tongue
Lipitor (Oral) (Atorvastatin Calcium)
leg cramps;
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Vancomycin - [**2189-1-31**] 09:45 AM
Infusions:
Other ICU medications:
Insulin - Regular - [**2189-1-30**] 07:00 PM
Heparin Sodium (Prophylaxis) - [**2189-1-31**] 08:00 AM
Omeprazole (Prilosec) - [**2189-1-31**] 08:00 AM
Other medications:
Flowsheet Data as of [**2189-1-31**] 02:47 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**91**] a."
1322,"1 g/dL
104
1.4 mg/dL
32 mEq/L
4.7 mEq/L
42 mg/dL
95 mEq/L
134 mEq/L
29.3 %
13.2 K/uL
[image002.jpg]
[**2189-1-30**] 11:40 PM
[**2189-1-31**] 03:31 AM
[**2189-1-31**] 04:01 AM
[**2189-1-31**] 05:00 AM
[**2189-1-31**] 06:00 AM
WBC
13.2
Hct
29.3
Plt
475
Creatinine
1.4
Glucose
114
104
99
110
104
Other labs: Ca:10.6 mg/dL, Mg:1.8 mg/dL, PO4:3.5 mg/dL
Imaging: CT scan negative
Microbiology: all neg
Assessment and Plan
HYPERGLYCEMIA, WOUND INFECTION
Assessment and Plan: Pt. doing very well. Blood sugar under control.
PICC placed today. Tx to floor.
Neurologic:
Cardiovascular: Aspirin, Beta-blocker, Statins
Pulmonary: IS
Gastrointestinal / Abdomen:
Nutrition: Regular diet
Renal:
Hematology:
Endocrine: RISS
Infectious Disease: all neg
Lines / Tubes / Drains:
Wounds: Wet / Dry dressings, Sternum
Imaging:
Fluids:
Consults: P.T.
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2189-1-31**] 09:30 AM
Prophylaxis:
DVT:
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: Transfer to floor"
1323,"m.
Tmax: 37.3
C (99.1
T current: 36.2
C (97.1
HR: 69 (54 - 69) bpm
BP: 120/51(70) {102/38(54) - 134/99(108)} mmHg
RR: 16 (14 - 19) insp/min
SPO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
Total In:
403 mL
219 mL
PO:
360 mL
Tube feeding:
IV Fluid:
43 mL
219 mL
Blood products:
Total out:
0 mL
1,300 mL
Urine:
1,300 mL
NG:
Stool:
Drains:
Balance:
403 mL
-1,081 mL
Respiratory support
O2 Delivery Device: None
SPO2: 96%
Physical Examination
General Appearance: No acute distress
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable ), superficial sound improving
Abdominal: Soft
Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 3)
Labs / Radiology
475 K/uL
10."
1324,"She was admitted to
[**Hospital1 69**] for debridement and
intravenous antibiotics.
Past Medical History:
s/p CABG x4/MVr (on [**2189-1-14**])
Coronary artery disease with unstable angina
chronic systolic heart failure
mitral regurgitatiuon
obesity
insulin dependent diabetes mellitus
s/p coronary angioplasty
pulmonary hypertension
hypertension
peripheral vascular disease-s/p stenting lower extremities
s/p cholecystectomy
s/p appendectomy
s/p psoas abcess
gastritis
Social History:
Heavy smoker up to 2 PPD for 50 years, quit in [**10-25**]. Denies
etOH or IVDU. Pt is a retired x-ray technician. She lives with
her husband and two grandchildren in [**Name (NI) 67740**], She is the
caregiver for her sister with [**Name (NI) 309**] body dementia and her husband
as well as her two grandchildren."
1325,"She was advised to call with any signs or
symptoms of worsening infection, and to follow up with
Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **] for wound visit in 1 week.
Medications on Admission:
plavix 75mg
omeprazole 20mg [**Hospital1 **]
Insulin NPH 36 units in the morning and evening
Insulin Lispro 4 units in the morning and evening
atrovent
xenopex
[**Hospital1 21177**] 10mg
metolazone 5mg [**Hospital1 **]
colace
zocor 40mg
aspirin 81mg
percocet
amiodarone 400mg
lopressor 75mg
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E."
1326,"Disp:*180 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Rosuvastatin 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. [**Hospital1 **] 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-21**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*1 * Refills:*0*
10. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): x 10 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
superficial sternal wound infection
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
No creams, lotions, powders, or ointments to incisions
**Wound dressing changes, wet to dry, twice daily
Followup Instructions:
See Dr. [**Last Name (STitle) **] in 1week
Call for appointment [**Telephone/Fax (1) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2189-2-2**]"
1327,"2 RBC-3.77* Hgb-11.2* Hct-34.2*
MCV-91 MCH-29.7 MCHC-32.7 RDW-13.5 Plt Ct-495*#
[**2189-2-2**] 05:59AM BLOOD WBC-10.4
[**2189-1-30**] 04:19PM BLOOD Glucose-338* UreaN-40* Creat-1.5* Na-133
K-6.0* Cl-94* HCO3-31 AnGap-14
[**2189-2-2**] 05:59AM BLOOD UreaN-31* Creat-1.1
[**2189-1-29**] 6:22 pm SWAB Source: mediastinum.
GRAM STAIN (Final [**2189-1-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS."
1328,"Family History:
No family history of CAD or premature death, DM, HTN, HLD.
Mother with PD. Sister with [**Name (NI) 309**] body dementia. Sister with lung
CA.
Physical Exam:
At admission Ms. [**Known lastname 67738**] was noted to be in no acute distress.
She was hemodynamically stable and afebrile. Her lungs were
clear to auscultation bilaterally and her heart was of regular
rate and rhythm. Her abdomen was soft, non-tender, and
non-distended. Her mediastinal incision was intact at the
superior pole, but inferiorly a 3 cm long by 2 cm wide area of
eschar.
Pertinent Results:
[**2189-1-30**] 04:19PM BLOOD WBC-10."
1329,"1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final [**2189-2-1**]):
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 (Preliminary): RESULTS PENDING.
Brief Hospital Course:
Ms. [**Known lastname 67738**] was admitted and her wound cultured. She was placed
on Vancomycin and her wound was debrided. Superficial eschar
was removed and vascularized healthy tissue was discovered just
below it. No pus was expressed. A peripherally inserted central
catheter was placed for access."
1330,"Admission Date: [**2189-1-29**] Discharge Date: [**2189-2-2**]
Date of Birth: [**2116-1-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Lipitor / Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
superficial sternal wound infection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 67738**] is a 73 year old woman who [**Known lastname 1834**] a coronary
artery bypass grafting times four and mitral valve repair on
[**2189-1-14**]. She subsequently was discharged to a rehab facility.
Once home, her visiting nurse described her sternal wound to be
erythematous with foul smelling eschar."
1331,"She remained afebrile with a
normal white blood cell count. Her wound on discharge was
superficial without erythema or drainage. Her sternum was stable
with no [**Doctor Last Name **] or click. Wound swab culture from [**1-29**] showed mixed
bacteria. As per Dr.[**Last Name (STitle) **], Vanco and Cipro was
discontinued and Ms.[**Known lastname 67738**] was placed on oral antibiotic course:
Keflex 500 mg every 6 hours x ten days. A visiting nurse has
been arranged for wound checks at home and Ms.[**Known lastname 67738**] has been
instructed on dressing changes as well so that the wound can be
dressd twice daily."
1332,"C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily)."
1333,"Admission Date: [**2189-12-20**] Discharge Date: [**2189-12-25**]
Date of Birth: [**2140-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Suicide Attempt by ingestion
Major Surgical or Invasive Procedure:
CT head
MRI brain
History of Present Illness:
This is a 49 year-old female with a history of Bipolar disorder,
prior history of SI who presents after being found by family and
admitting to EMTs that she took 50+ pills of ambien and
benztropine. Patient was found by EMS to be sitting at scene,
but lethargic."
1334,"3 Phos-4.3 Mg-2.0
[**2189-12-21**] 01:00AM BLOOD VitB12-510 Folate-10.1
[**2189-12-21**] 01:00AM BLOOD TSH-1.8
[**2189-12-21**] 01:00AM BLOOD Lithium-0.2* Valproa-<3.0*
[**2189-12-21**] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-12-21**] 03:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
Brief Hospital Course:
A/P: 49 year-old female with a history of bipolar and prior
suicide attempt who presents after she took 50+ pills of ambien
and benztropine in apparent suicide attempt."
1335,"1. Sucide attempt with toxic ingestion: Monitored in ICU since
[**12-21**] and other than delirium, vitals have remained stable.
-Pt evaluated by psych and cannot leave the hospital
-Will need 1:1 sitter at all times
-Pt not in delirium anymore, just restless and anxious. Is
medically cleared to go to psych
-Per psych haldol discontinued and on seroquel tid and prn for
restlessness, agitation
2. Delirium - likely [**3-21**] to residual effects of recent
ingestion. WBC trending down. Afebrile, stalbe vitals, all cx no
growth so far. Head CT in ICU unable to be performed, so got one
yesterday."
1336,"3. Leukocytosis - likely [**3-21**] leukomoid rxn from stress. Afebrile
w negative urine/blood cx, neg cxr. WBC downtrending
.FEN - Regular
.DVT pro - SQ heparin
.Dispo - to psych inpt service
Medications on Admission:
Home medications unclear.
[**Name2 (NI) **] had empty bottles found at the scene including:
- Zolipiden Tartate 10 mg PO once at night for insomnia
([**2189-12-1**])
- Benztropine 0.5 mg PO 1-2 times daily PRN ([**2189-11-25**])
.
Per Osco Pharmacy ([**Street Address(2) 31090**]. [**Location 1268**] [**Numeric Identifier **]) at
([**Telephone/Fax (1) 31091**]) she has been prescribed the following drugs by
Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]:
- Lamotrigine 25 mg [**2-18**] daily ([**2189-12-11**])
- Ambien 10mg PO once at night PRN insomnia ([**2189-12-11**])
- Benztropine 0."
1337,"5 mg PO 1-2 times daily PRN ([**2189-11-25**])
- Topamax 200 mg 1 daily ([**2189-11-10**])
- Risperdal 2 mg twice daily ([**2189-11-10**])
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
2. Quetiapine 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Suicide attempt
Coccaine abuse
Bipolar do
Discharge Condition:
Good
Discharge Instructions:
To inpatient psych service
You were admitted unresponsive after a suicide attempt with
ingestion of many pills of ambein and cogentin."
1338,"No bleed or cva but did show some white matter
lesions for which MRI was recommended. MRI shows those lesions,
which per neurology, can be seen in coccaine use and the
treatment is for pt to stop using cocaine.
-Pt was staffed by Neuro attending after transfer to Psych [**Hospital1 **]
and attending recommended repeat MRI w appropriate sequencing to
r/o MS and an LP to look for oligoclonal bands. While this does
not need to happen urgently, neuro would like to have this done
during hospitalization as pt is at risk to being lost to
followup. This will be conveyed by neuro team to psych service."
1339,"Per EMT's no evidence of EtOH intoxication.
Arrived at ED around 8:00 PM and EMTs relayed that pt took pills
""some time while it was dark"".
.
Patient was taken to [**Hospital 882**] Hospital ED, where initial vitals
were T 96, P 80, R 12, BP 100/69, 97% RA. Patient somnolent but
arousable to verbal and physical stimuli. She responded in
grunts and moans, no reason for taking pills. Given 1 L NS and
transfered to [**Hospital1 18**] as there were no ICU beds at [**Hospital1 882**].
.
Currently, patient is unable to converse, but withdraws to
painful stimuli."
1340,"HEENT: NC/AT, Pupils 5mm ERRL, sclera anicteric, no epistaxis or
rhinorrhea, MM dry, OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, +BS, no HSM, no masses Mid-line scar.
EXT: No C/C/E, no palpable cords
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
Admission labs:
[**2189-12-21**] 01:00AM BLOOD WBC-8.4 RBC-4.13* Hgb-13.2 Hct-37.8
MCV-92 MCH-32.0 MCHC-35."
1341,"0 RDW-12.4 Plt Ct-335
[**2189-12-21**] 01:00AM BLOOD Neuts-64.7 Lymphs-28.0 Monos-6.2 Eos-0.9
Baso-0.3
[**2189-12-21**] 01:00AM BLOOD PT-14.3* PTT-25.5 INR(PT)-1.2*
[**2189-12-21**] 01:00AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-141 K-4.1
Cl-108 HCO3-25 AnGap-12
[**2189-12-21**] 01:00AM BLOOD ALT-14 AST-13 LD(LDH)-148 CK(CPK)-89
AlkPhos-80 TotBili-0.5
[**2189-12-21**] 01:00AM BLOOD Albumin-3.9 Calcium-9."
1342,"your urine also
showed coccaine. Initially you were confused from the overdose
but improved. We did a head CT and MRI which showed changes in
your brain due to coccaine use. Please stop using coccaine. You
will need a repeat scan and outpatient follow up with neurology,
unless they repeat the scan before you leave. Please call the
neurology clinic after you are discharged from psychiatry to set
up follow up appt
You are being transferred to the inpatient psych service for
further help with your management. Please follow up with your
pcp at discharge
Followup Instructions:
1. PcP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 31092**] [**Last Name (NamePattern1) 31093**], ph: [**Telephone/Fax (1) 9347**]. Please make a
follow up appt in [**2-18**] weeks after discharge from psych service
2. [**Hospital 878**] clinic, ph: [**Telephone/Fax (1) 8302**], please call and make appt
in clinic after discharge from psychiatry"
1343,"She is divorced, without children,
by her initiation after she found her husband
cheating on her ~ 2 years ago. sister, [**Name (NI) 16883**] [**Name (NI) **], ph:
[**Telephone/Fax (1) 31089**] for more information
.
Substance Abuse Hx:
Patient denies alcohol dependence/abuse and IVDU as does mother.
Cocaine use for several years per mother; patient denies use,
although fiance states this is her drug of choice for which she
recently graduate a treatment program for. Intermittent
marijuana
use.
Family History:
Pt unable to give at this time.
Physical Exam:
Vitals: T: 96.1 BP: 110/60 HR: 86 RR: 26 O2Sat: 100% 2L
GEN: No acute distress, Moving all extremities equally,
Withdraws from painful stimuli, but not arousable or conversant."
1344,"No family could be reached as only phone
number is out of service.
.
ROS: Unable to obtain as patient is only arousable to pain and
non-conversant.
.
Past Medical History:
Bipolar disorder
Prior Suicide attempt
Endometriosis s/p supracervical hysterectomy
Social History:
Patient lives alone in an apartment in [**Location 1268**] paid for by
both her mother and [**Name (NI) **]. She graduated from high school and
attended beauty school but now works intermittently at a packing
facility. Her main support is her mother and her fiance/friend
whom she recently met at SOAR treatment program. The patient has
questionably stressful relationship with sister and could not
otherwise name any supports."
1345,"Chief Complaint:
24 Hour Events:
- Haloperidol 2mg and Ativan 2mg given (x3 each) for agitation and
anxiety
- Advanced diet
- Psych states she can
t leave AMA, likely will need inpatient psych
Allergies:
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Haloperidol (Haldol) - [**2189-12-22**] 12:00 AM
Lorazepam (Ativan) - [**2189-12-22**] 01:50 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-12-22**] 06:30 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
1346,"Cocaine was positive on
tox screen, however, patient is does not show other signs of cocaine
intoxication.
- 1:1 sitter
- Hold off on Head CT given current agitation
- Supportive care (O2, cardiac monitoring, IVF as needed) until
inpatient Psych.
.
# Bipolar disorder: Unable to obtain acurate history or medications.
.
# FEN: regular, aspiration precautions when sedated.
.
# Access: PIV
.
# PPx: Heparin SQ.
.
# Code: Presumed Full
.
# Dispo: ICU until more alert.
.
# Comm: Attempt to contact family/PCP
ICU [**Name9 (PRE) 151**]
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2189-12-21**] 03:33 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU"
1347,"3
C (97.3
Tcurrent: 36.3
C (97.3
HR: 90 (60 - 91) bpm
BP: 97/67(75) {88/36(52) - 139/119(124)} mmHg
RR: 20 (14 - 32) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
1,785 mL
125 mL
Urine:
1,785 mL
125 mL
NG:
Stool:
Drains:
Balance:
-1,785 mL
-125 mL
Respiratory support
O2 Delivery Device: None
SpO2: 93%
ABG: ////
Physical Examination
Gen: NAD, Alert
CV: RRR, no M/R/G
Pulm: CTAB
Abd: Soft, NT/ND, BS +
Extr: no edema, LE with dry skin, ?"
1348,"vericose vein on R ankle
Labs / Radiology
335 K/uL
13.2 g/dL
92 mg/dL
0.6 mg/dL
25 mEq/L
4.1 mEq/L
8 mg/dL
108 mEq/L
141 mEq/L
37.8 %
8.4 K/uL
[image002.jpg]
[**2189-12-21**] 01:00 AM
WBC
8.4
Hct
37.8
Plt
335
Cr
0.6
TropT
<0.01
Glucose
92
Other labs: PT / PTT / INR:14.3/25.5/1.2, CK / CKMB /
Troponin-T:89/2/<0.01, ALT / AST:14/13, Alk Phos / T Bili:80/0.5,
Differential-Neuts:64."
1349,"7 %, Lymph:28.0 %, Mono:6.2 %, Eos:0.9 %,
Albumin:3.9 g/dL, LDH:148 IU/L, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.3
mg/dL
Assessment and Plan
POISONING / OVERDOSE, OTHER
49 year-old female with a history of bipolar and prior suicide attempt
who presents after she took 50+ pills of ambien and benztropine in
apparent suicide attempt.
.
Plan:
# Toxic ingestion: Patient currently with stable vitals, more
responsive today. Primarily sounds like Ambien and benztropine
overdose and clinical picutre fits with sedatives. Reason for patient
to have benztropine prescription is unknown."
1350,"Admission Date: [**2141-12-31**] Discharge Date: [**2142-1-9**]
Date of Birth: [**2065-5-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, transfer for STEMI
Major Surgical or Invasive Procedure:
[**2142-1-1**] Cardiac Cath
[**2142-1-4**] Coronary artery bypass grafting x4, with the left
internal mammary artery to the left anterior descending artery
and reversed saphenous vein grafts to the posterior descending
artery and first and second diagonal arteries.
History of Present Illness:
76 year old male who presented to OSH for ED with sudden onset
of [**9-19**] chest pressure, similar to prior chest pain."
1351,"Attempted
to fall asleep however could not and so called EMS who brought
him to [**Hospital3 **]. At OSH, EKG revealed ST elevations in
anterior leads. Pt was started heparin gtt and transferred to
[**Hospital1 18**] emergently for further evaluation. Code STEMI was called
after EKG showed ~2mm ST elevations in V3-V4. Labs were
significant for mild troponin of 0.09. He was found to have two
vessel disease and he is now being referred to cardiac surgery
for revascularization.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
2 stents at [**Hospital1 3278**] in [**2129**] (not on plavix because of CVA)
Atrial fibrillation not on Coumadin because of CVA
MCA stroke with hemorrhagic conversion s/p craniectomy in [**2132**]
at Southshore
B12 deficiency
BPH
s/p craniectomy in [**2132**]"
1352,"Social History:
Race:Caucasian
Last Dental Exam:>1 year ago
Lives with:wife, Wheelchair bound. Wife is primary caretaker
Contact: [**Name (NI) 18380**] (wife) Phone #[**Telephone/Fax (1) 85652**]
Occupation:retired business man
Cigarettes: Smoked no [] yes [x] Hx:quit 20 years ago, has a
greater than 20 pack year history of smoking
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-16**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
No premature coronary artery disease- Father had an MI at age 70
Physical Exam:
Pulse:97 Resp:26 O2 sat:96/2L
B/P 109/66
Height:65"" Weight:83kgs"
1353,"Fib. No spontaneous
echo contrast is seen in the left atrial appendage. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricular cavity is mildly dilated with mild global free
wall hypokinesis. The ascending aorta is mildly dilated. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is moderate aortic valve stenosis (valve area 1.0-1.2cm2). In
the face of more modest peak and mean gradients across the
valve, a discussion led to the decision to not replace it. Dr.
[**Last Name (STitle) 4901**] offered his opinion also."
1354,"If any there are small bilateral pleural effusions.
The sternal wires are aligned.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 47059**] was transferred from
outside hospital with an ST-elevation myocardial infarction. He
underwent a cardiac cath on [**1-1**] which revealed severe three
vessel coronary artery disease. He then underwent appropriate
surgical work-up while awaiting Plavix to wash-out. On [**1-4**] he
was brought to the operating room where he underwent a coronary
artery bypass graft x 4. Please see operative note for surgical
details. Following surgery he was transferred to the CIVCU for
invasive monitoring in stable condition."
1355,"His
Foley was removed and a condom cath was placed for incontinence.
He was bladder scanned for 300. He continued to make good
progress while working with physical therapy. On post-op day 5
he was discharged to rehab with the appropriate medications and
follow-up appointments.
Medications on Admission:
Medications at home:
metoprolol tartarte 50mg [**Hospital1 **]
lisinopril 10mg daily
simvastatin 20mg daily
tamsulosin 0.4mg daily
escitalopram 20mg daily
finasteride 4mg
senna-docunsate 1 tab TID
NPH/Novolin 10 units SC daily
NPH 15 units SC at dinner
ascorbic acid 500mg daily
folic acid-vit b2-vit b6-vit b 1 tab [**Hospital1 **]
ergocalciferol 1000 units daily
trazodone 50mg daily
aspirin 81mg daily"
1356,"Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Diabetes
Dyslipidemia
Hypertension
2 stents at [**Hospital1 3278**] in [**2129**] (not on plavix because of CVA)
atrial fibrillation not on Coumadin because of CVA
MCA stroke with hemorrhagic conversion s/p craniectomy in [**2132**]
at
Southshore
B12 deficiency
BPH
s/p craniectomy in [**2132**]
Discharge Condition:
Alert and oriented with Left Hemi-paresis
Ambulating with Max assist
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage."
1357,"Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation."
1358,"Trace aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion. Post-CPB: The patient is on an AV-Pacer, though there
is no atrial response. No inotropes. Preserved biventricular
systolic fxn. 1+MR, trace AI. Aorta intact.
.
[**2142-1-9**] WBC-10.4 RBC-3.14* Hgb-9.3* Hct-27.7* MCV-89 MCH-29.6
MCHC-33.5 RDW-13.9 Plt Ct-308
[**2141-12-31**] WBC-11.5* RBC-4.95 Hgb-14.6 Hct-43.0 MCV-87 MCH-29.6
MCHC-34."
1359,"0 RDW-13.0 Plt Ct-205
[**2142-1-9**] Glucose-136* UreaN-23* Creat-1.0 Na-140 K-4.5 Cl-103
HCO3-32
[**2141-12-31**] Glucose-172* UreaN-21* Creat-0.9 Na-141 K-4.4 Cl-106
HCO3-22
[**2142-1-3**] ALT-27 AST-29 LD(LDH)-260* AlkPhos-61 TotBili-0.4
Micro:
[**2142-1-3**] URINE CULTURE (Final [**2142-1-4**]): <10,000
organisms/ml.
MRSA SCREEN NASAL SWAB. MRSA SCREEN (Final [**2142-1-6**]): No MRSA
isolated
PICC line [**2141-1-7**]:
Right jugular line has been removed. Tip of the new right PIC
line is in the right atrium."
1360,"S2 no murmur
Resp: diminished breath sounds bilateral with fine crackles
right 1/4 up, no wheezes
GI: obese, bowel sounds positive, abdomen soft
Extr: warm no edema
Incision: sternal and left lower extremity clean, dry margins
well approximated with no erythema
Skin: ecchymosis right hip, Left papula rash left upper, lower
and groin region.
Neuro: awake, alert, oriented to person, place and time. Mild
left facial droop
Strengths R 3-3/4, Left 0-/4 (old CVA)
Pertinent Results:
[**2142-1-1**] Cardiac Cath: 1. Selective coronary angiography in this
right dominant system demonstrated two vessel CAD. The LMCA was
patent."
1361,"General:
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x] Contracted left knee
Neuro: Grossly intact []
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Discharge Exam:
VS: T: 97.6 HR: 65-100 SR BP: 105-125/60-70 Sats: 96% RA
General: 76 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,."
1362,"It should be withdrawn 3.5 cm to
position it low in the SVC.
Mild pulmonary edema has developed, most readily appreciated in
the right
lower lung. Severe cardiomegaly is longstanding, but mediastinal
and hilar
vascular engorgements have worsened. There is greater
consolidation at the
left lung base, presumably atelectasis though pneumonia is not
excluded, and an increase in small-to-moderate left pleural
effusion. There is no
pneumothorax.
CXR: [**2142-1-6**] There is a questionable tiny left pneumothorax.
The pulmonary edema has almost resolved. There are persistent
low lung volumes with bibasilar atelectasis. Cardiomediastinal
silhouette is unchanged. Right IJ catheter remains low in the
right atrium and can be withdrawn 3-4 cm for more standard
position."
1363,"Disp:*50 Tablet(s)* Refills:*0*
14. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 7 days
then 400 mg daily x 7 days then 200 mg daily.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash: apply to rash.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for PAIN/TEMP.
18. PICC Line
Non-Heparin: FLUSH with 10 mL of Normal Saline"
1364,"The PL has 70-80% ostially but overall
this is a small diffusely diseased vessel. The R-PDA is patent.
2. Limited resting hemodynamics revealed moderately elevated
systemic arterial systolic pressures with an SBP of 150 mmHg. 3.
Abdominal aortography was performed using a pigtail catheter via
power injection and showed diffuse plaquing in the infra-renal
aorta, possible moderate L renal artery stenosis, calcific right
common iliac artery stenosis (difficulty passing the wire
through the common iliac into the aorta).
.
[**2142-1-3**] Carotid U/S: Right ICA <40% stenosis. Left ICA no
stenosis.
.
[**2142-1-4**] Echo: Pre-CPB: The patient is in A."
1365,"The LAD had diffuse plaquing throughout and tapers to
90% beyond the patent proximal to mid LAD stent and the D2
takeoff. The D2 is diffusely diseased with 40% at ostium and 50%
proximally. The D1 is a substantive bifricating vessel with 70%
ostial stenosis (partially jailed by the LAD stent). The LCx had
mild plaquing throughout. The proximal OM1 and mid OM2 (both
small vessels) have focal 70% stenosis with normal flow. The RCA
was subselectively engaged due to ostial stent and
calcifications. The ostial stent was patent with instent
restenosis (mild, nonflow-limiting). Serial focal stenosis (1st
65-70%) just beyond the acute marginal takeoff and second (90%)
about 2 cm downstream."
1366,"Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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 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
Surgeon: Dr. [**Last Name (STitle) **] on [**2142-2-8**] at 1:15PM in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) 10357**] [**Hospital Unit Name **]
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**] [**2142-1-22**] 12:00
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2142-1-9**]"
1367,"Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one he was started on beta-blockers and diuretics
and diuresed towards his pre-op weight. On post-op day two he
was transferred to the telemetry floor for further care. Chest
tubes and epicardial pacing wires were removed per protocol. On
post-op day three he had episode of rapid atrial fibrillation
IV/PO amiodarone was started. He converted to sinus rhythm
(pre-op history of AF but not on Coumadin d/t hemorrhagic
stroke). A Non-heparin PICC line was placed for IV access."
1368,"7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours).
11. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q6H (every 6 hours).
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain."
1369,"Admission Date: [**2112-10-10**] Discharge Date: [**2112-10-16**]
Date of Birth: [**2041-10-20**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Ace Inhibitors
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
N/V/D
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old man with h/o CAD, dilated
ischemic cardiomyopathy (EF 10%), aflutter on Dabigatran, BiV
ICD, DM, HTN, HLD, CKD, R 4th toe amputation with debridement in
[**2112-6-3**], s/p 6 weeks of Vanc/Ctx for osteomyelitis, who
presents with N/V/D x4 days.
Patient has been having nausea, vomiting, and diarrhea for the
past 4 days."
1370,"CAD, multiple MIs, CABG ([**2101**]) ([**2101**]): SVG-PL, SVG-Diagonal
and LIMA-LAD. He had a PTCA only of the mid Cx with an Apex OTW
2.25x15 mm
2. Dilated ischemic cardiomyopathy with LVEF of 10%.
3. Atrial flutter, status post cardioversion [**2110-11-28**].
4. BiV ICD pacemaker.
5. Diabetes.
6. Dyslipidemia.
7. Hypertension.
8. Stage III chronic kidney disease secondary to hypertension
and diabetes.
9. Retinopathy, neuropathy, and nephropathy from diabetes.
10. Left hip fracture with attempted surgery, which resulted in
a cardiac arrest.
11. History of substance abuse.
12. History of pancreatitis.
13. GERD.
14. Colonic polyps."
1371,"15. [**6-6**] Right fourth toe amputation.
16. [**5-/2111**] ORIF left hip with persistent nonunion of his
subtrochanteric femur fracture
17. Left eye vitrectomy
18. [**2112-7-1**]: RLE Balloon angioplasty of tibioperoneal trunk,
Balloon angioplasty of the anterior tibialis artery.
19. [**2112-7-5**]: Debridement of wound down through subcutaneous
tissue and including bone with placement of vacuum-assisted
closure dressing.
20. R foot osteomyelitis, s/p 6 weeks Vanc/Ctx, finished
[**2112-9-11**]
Social History:
- Previously employed as cab driver, now retired. Lives at home
with his wife.
- Tobacco history: 40-50 pack year history, quit 15 years ago
- ETOH: heavy use until [**2090**]
- Illicit drugs: previous heroin/cocaine use"
1372,"The patient was transitioned to
inpatient hospice on the medical floor. He expired on [**2112-10-16**].
Medications on Admission:
ASA 81mg PO daily
Atorvastatin 40mg PO qhs
Dabigatran 150mg PO BID
Digoxin 0.125mg PO daily
Metoprolol XL 50mg PO daily
Imdur 30mg PO daily
NTG 0.4mg SL q5min prn
Valsartan 80mg PO daily
Spironolactone 25mg PO daily
Torsemide 60mg PO daily
Gabapentin 100mg PO TID
Oxycontin 10mg PO BID
Percocet 2tabs PO q4-6h prn
Oxycodone 5mg PO BID prn
Lorazepam 0.5mg PO q6h prn
Trazodone 25mg PO BID
NPH
Humalog
Ascorbic acid 250mg PO BID
Colace 100mg PO BID
Ferrous sulfate 325mg PO BID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
MRSA sepsis
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2112-10-18**]"
1373,"2*#
Na-132* K-4.4 Cl-104 HCO3-9* AnGap-23*
[**2112-10-10**] 04:40AM BLOOD ALT-32 AST-37 AlkPhos-330* TotBili-1.4
[**2112-10-10**] 04:40AM BLOOD Lipase-17
[**2112-10-10**] 09:36AM BLOOD CK-MB-4
[**2112-10-10**] 09:36AM BLOOD Calcium-8.7 Phos-4.4# Mg-2.0
[**2112-10-11**] 05:59AM BLOOD CRP-161.1*
[**2112-10-10**] 06:00PM BLOOD Digoxin-1.0
[**2112-10-10**] 08:08AM BLOOD pO2-62* pCO2-38 pH-7.21* calTCO2-16* Base
XS--12 Comment-GREENTOP
[**2112-10-10**] 04:41AM BLOOD Lactate-2."
1374,"The severity of tricuspid regurgitation is
slightly increased.
[**2112-10-10**] RUQ U/S:
1. Nondistended gallbladder filled with sludge, negative
son[**Name (NI) 493**] [**Name2 (NI) 515**] sign, and minimal gallbladder wall edema
and pericholecystic fluid. Findings likely due to chronic liver
disease.
2. Mild perihepatic ascites and small left pleural effusion.
3. Normal common bile duct diameter measuring 3 mm.
4. Homogeneous echogenicity of the liver without focal lesion.
[**2112-10-11**] L Knee XR:
1. Incompletely seen intramedullary rod with distal interlocking
screw, with ossification surrounding the head of the screw and
distal lateral femur. No signs of orthopedic hardware loosening."
1375,"MICRO:
[**2112-10-10**] BCx: MRSA
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2112-10-10**] UCx: negative
STUDIES:
[**2112-10-10**] ECHO:
Left ventricular hypertrophy with cavity dilatation and severe
global biventricular hypokinesis c/w diffuse process
(multivessel CAD, toxin, metabolic, etc.) Severe pulmlonary
artery hypertension. Tricuspid regurgitation. Mild-moderate
mitral regurgitation.
Compared with the prior study (images reviewed) of [**2110-12-1**],
global and regional left ventricular systolic function is now
more depressed."
1376,"5L) and started on
broad-spectrum antibiotics for concern for sepsis. Patient was
altered in the AM, but became more alert in the afternoon. He
was refusing VS and lab draws at times. Lactate and anion gap
improved initially, but then worsened in the early evening.
Given concern for worsening labs, patient was transferred to the
ICU for closer monitoring.
In the ICU, the patient is currently not complaining of nausea,
vomiting, or abdominal pain. He has had no episodes of diarrhea
today. He is c/o L knee pain, new from a few weeks ago.
Past Medical History:
1."
1377,"7*
[**2112-10-10**] 06:07PM BLOOD O2 Sat-68
[**2112-10-10**] 11:50AM BLOOD freeCa-1.13
URINE:
[**2112-10-10**] 10:45PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2112-10-10**] 10:45PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2112-10-10**] 10:45PM URINE RBC-36* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
[**2112-10-10**] 10:45PM URINE WBC Clm-FEW
[**2112-10-10**] 10:45PM URINE Hours-RANDOM UreaN-92 Creat-124 Na-91
K-25 Cl-63
[**2112-10-10**] 10:45PM URINE Osmolal-312"
1378,"2. No definite acute fracture or dislocation.
3. Extensive vascular calcified atherosclerotic disease at the
left knee soft tissues.
4. Trace knee joint effusion
[**2112-10-12**] CXR:
Left pectoral CCD with defibrillator leads leading to the right
ventricle and other two leads each terminating into the right
atrium and left ventricle are unchanged in position. Patient is
status post median sternotomy and has intact sternal sutures.
Moderate-to-large cardiomegaly and mediastinal and hilar
contours are stable. Bilateral lung volumes remain low with mild
improvement in the pulmonary edema. No pleural effusion. No
discrete opacities concerning for pneumonia.
Brief Hospital Course:
Mr."
1379,"[**Known lastname **] is a 70 year old man with h/o CAD, sCHF (EF <20%),
DM, HTN, CKD, s/p R 4th toe amputation and recent Abx, who was
admitted with N/V/D x 4days. He was transferred from the medical
floor to the ICU for sepsis, found to have MRSA bacteremia.
Likely source is from his R foot, where he recently had a toe
amputation and osteomyelitis. Despite treatment with
broad-spectrum antibiotics (Linezolid and Zosyn), the patient
declined rapidly and had multi-system organ failure. The patient
and family declined further invasive lines and treatments. The
family and medical team decided to make the patient comfort
measures only on [**2112-10-13**]."
1380,"Family History:
Mother and father died in 70's-80s of cancer. Denies any family
history of cardiac disease. No family history of early MI.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.8 BP: 92/55 P: 87 R: 20 O2: 98% RA
General: Alert, orientedx2, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild ttp in RLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool to touch, palpable/dopplerable distal pulses, no
edema, R 4th toe amputated with dry gauze overlying ulcer, L
knee with effusion, no warmth/erythema, mild tenderness
Neuro: grossly intact"
1381,"Diarrhea is watery stool, nonbloody. No recent
travel or sick contacts. [**Name (NI) **] abdominal pain. +subjective fevers
and chills. Of note, patient finished 6 week course of Vanc/Ctx
for R foot osteomyelitis on [**2112-9-11**].
In the ED, initial VS were stable. Patient was given Dilaudid
for chronic LE pain, 250cc NS, and Zofran. RUQ U/S with sludge,
negative [**Doctor Last Name 515**], no wall edema. Labs notable for lactate 2.7,
anion gap 19, Cr 2.2, HCO3 9. pH was 7.21 on VBG. Patient has
been relatively hypotensive, SBP 90s. On the Medicine floor, the
patient was treated with IVF boluses (1."
1382,"Pertinent Results:
ADMISSION LABS:
[**2112-10-10**] 04:30AM BLOOD WBC-12.8*# RBC-3.88*# Hgb-9.3*#
Hct-30.2*# MCV-78* MCH-24.0*# MCHC-30.9* RDW-16.0* Plt Ct-256
[**2112-10-10**] 04:30AM BLOOD Neuts-91.3* Lymphs-4.5* Monos-3.4 Eos-0.6
Baso-0.2
[**2112-10-10**] 09:36AM BLOOD PT-21.5* PTT-40.6* INR(PT)-2.0*
[**2112-10-11**] 03:04PM BLOOD Fibrino-556*#
[**2112-10-11**] 03:04PM BLOOD ESR-35*
[**2112-10-10**] 04:30AM BLOOD Glucose-156* UreaN-47* Creat-2."
1383,"Name: [**Known lastname 15075**],[**Known firstname 240**] J Unit No: [**Numeric Identifier 15076**]
Admission Date: [**2112-10-10**] Discharge Date: [**2112-10-16**]
Date of Birth: [**2041-10-20**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Ace Inhibitors
Attending:[**First Name3 (LF) 1991**]
Addendum:
After being called out to the medical floor from the ICU,
another family meeting was held to again explain Mr. [**Known lastname 15091**]
dire medical condition, and that the medical therapies that we
had to offer were highly unlikely to allow the patient to
recover a meaningful quality of life. Given this information,
the patient's wife [**Name (NI) 3053**] and son [**Name (NI) **] at that time reaffirmed his
desire not to go forward with potentially life sustaining
therapies and rather have comfort focused care."
1384,"Later on [**2112-10-14**], the patient's other sons and daughters
arrived, and requested that we consult the renal team concerning
the possibility of dialysis or CVVH. The renal team came and
saw the patient and discussed with the family what the potential
benefits and harms of dialysis, in particular the benefits that
could be realized for Mr. [**Known lastname **] at the current stage of his
disease. After further discussion amongst the family, the HCPs
([**Name (NI) 3053**] and [**Name (NI) **]) reaffirmed the decision to have comfort focused
care. The patient expired on [**2112-10-16**].
Discharge Disposition:
Expired
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 1992**] MD [**MD Number(2) 1993**]
Completed by:[**2112-10-18**]"
1385,"At OSH, pt
had non-contrast head CT showing sentinel bleed in basilar area
and pt was transferred to [**Hospital1 18**] for further management. Pt
states that she did have some dizziness and double vision from
her left eye 4 days ago. She denies focal numbness or weakness
and has been going to work.
Past Medical History:
s/p left elbow surgery
Social History:
Social Hx: Pt smokes [**1-20**] pack per day. Occasional EtOH. Sells
software, lives with husband.
Family History:
Family Hx: Father with coronary artery disease.
Physical Exam:
On Admission:
T 99.9 P 71 BP 145/90 R 18 SaO2 100%"
1386,"Medications on Admission:
None
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for HA.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use while on Percocet.
Disp:*40 Capsule(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QHS (once a day (at bedtime)) for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Basilar subarachnoid hemorrhage-nonaneurysmal
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions"
1387,"Exam on Discharge:
XXXXXXXXXXXXXXXXXX
Pertinent Results:
Labs on Admission;
[**2141-9-28**] 07:05PM BLOOD WBC-8.2 RBC-4.10* Hgb-12.1 Hct-37.5
MCV-92 MCH-29.6 MCHC-32.3 RDW-12.2 Plt Ct-232
[**2141-9-28**] 07:05PM BLOOD Neuts-77.4* Lymphs-18.1 Monos-3.5 Eos-0.7
Baso-0.4
[**2141-9-28**] 07:05PM BLOOD PT-10.9 PTT-25.6 INR(PT)-0.9
[**2141-9-28**] 07:05PM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-139
K-3.9 Cl-104 HCO3-26 AnGap-13
[**2141-9-29**] 03:59AM BLOOD Albumin-3."
1388,"The posterior cerebral arteries are normal.
IMPRESSION:
1. Similar volume of localized hemorrhage within the
interpeduncular and
prepontine cistern with minimal volume of subarachnoid blood
near the vertex without additional hemorrhage.
2. No aneurysm is identified, and the findings suggest the
possibility for
perimesencephalic hemorrhage, though an occult aneurysm is not
fully excluded.
Brief Hospital Course:
The patient was admitted to the ICU for close neurological
monitoring.She was started on Dilantin for seizure prophylaxis.
Within a few hours she underwent a cerebral angiogram which
showed no source of bleeding. Later on her first hospitalization
day she was transferred to the floor."
1389,"7 Calcium-8.7 Phos-4.3 Mg-1.9
[**2141-9-29**] 03:59AM BLOOD Phenyto-13.1
Labs on Discharge:
XXXXXXXXXXXXXXXX
-------------------
IMAGING:
-------------------
CTA Head [**9-29**]:
FINDINGS: Initial non-contrast images demonstrate subarachnoid
hemorrhage
layering within the interpeduncular cistern as well as a small
volume at the vertex to the left of midline. No findings of
infarct are evident by CT.
CTA: The intracranial internal carotid arteries are normal, as
are the middle and anterior cerebral arteries. Minimal
atherosclerotic disease is present within the cavernous segments
of the internal carotid arteries bilaterally. There is left
vertebral artery dominance and both vertebral arteries
contribute the formation of a normal-appearing basilar artery."
1390,"Mental status: alert and oriented x 3, responds to commands,
conversant, appropriate
Cranial Nerves:
I: Not tested
II: Pupils equal round and reactive to light, 4mm-2 bilaterally.
III, IV, VI: extraocular movements intact
V, VII: Corneal reflex intact bilaterally, face symmetric, no
facial weakness or numbness
IX, X: Gag intact
[**Doctor First Name 81**]: shoulder shrug [**5-23**]
XII: tongue protrusion midline
MOTOR:
B T WE WF IP Q AT [**Last Name (un) 938**] G
No pronator drift
finger to nose intact
Sensory: sensation to light touch intact throughout
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2"
1391,"?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP?"
1392,"Admission Date: [**2141-9-28**] Discharge Date: [**2141-10-2**]
Date of Birth: [**2091-8-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2141-9-29**] Diagnostic Angiogram
History of Present Illness:
50 y/o F who presents with worst headache of her life. Headache
is in frontal area and started suddenly 4 days prior to
admission. Pain is sharp and initially was [**10-28**] in severity.
Pain did get somewhat better over the next few days, however
worsened again today causing pt to present to OSH."
1393,"?????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
?????? You will have an angiogram on [**2141-10-11**] show time 0900 to
[**Hospital Ward Name 121**] 1 Daycare. If you have any questions please call ([**Telephone/Fax (1) 18865**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen
in 4 weeks.
Completed by:[**2141-10-2**]"
1394,"She underwent both a MRA/I
of her Brain and C-Spine which showed no source for bleeding.
The patient was monitored for 48 hours with improvement in her
symptoms she was neurologically intact. On her day of discharge
she underwent a CTA which showed a small cluster of vascular
channels noted in the midline frontal region which could
represent a venous aneurysm with associated DVA. It was
recommend that Ms [**Known lastname 1140**] would have a follow up angiogram on [**10-11**] she will be returning for a angiogram. She was aware to
return if she developed any new or worsening symptoms."
1395,"SICU
HPI:
50 y/o F with small subarachnoid hemorrhage in basilar area, no
aneurysm seen on head CTA. Severe frontal HA since [**9-24**] with
photophobia/stiff neck/blurred vision/dizziness. Pt attributed to new
onset migraines. Presented [**2141-9-28**] to OSH and found small basilar
SAH. [**9-28**] followup scan at [**Hospital1 1**] stable, CTA showed no aneurysm.
Pt reports improving HA, denies visual or balance changes. Denies
weakness/numbness/tingling. No N/V. No syncope. No CP or SOB.
Chief complaint:
HA
PMHx:
Dyslipidemia
.
PSH: Childhood left elbow surgery
Current medications:
1. 20 mEq Potassium Chloride / 1000 mL NS
Continuous at 75 ml/hr Order date: [**9-28**] @ [**2141**]
6."
1396,"NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO SBP<140. Order date:
[**9-28**] @ [**2141**]
2. Famotidine 20 mg PO BID Order date: [**9-28**] @ [**2141**]
7. Ondansetron 4 mg IV Q8H:PRN nausea or pruritis Order date: [**9-29**] @
0304
3. HydrALAzine 10 mg IV Q6H:PRN SBP>140. Order date: [**9-28**] @ [**2141**]
8. Oxycodone-Acetaminophen [**1-20**] TAB PO Q4H:PRN HA Order date: [**9-29**] @
0112
4. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**9-29**] @ 0136
9. Phenytoin 100 mg IV Q8H Order date: [**9-28**] @ [**2141**]
5. Nimodipine 60 mg PO Q4H
Hold for SBP<100, P<60."
1397,"Hemorrhage in the interpeduncular cistern
unchanged from prior.
Assessment and Plan
SUBARACHNOID HEMORRHAGE (SAH)
Assessment and Plan: 50 y/o F with small subarachnoid hemorrhage in
basilar area, no aneurysm seen on head CTA. Neurologically intact.
Neurologic: Neuro checks Q: 1 hr, Phenytoin - therapeutic, Angiogram
[**9-29**]. Nicardipine. Dilantin bolused and prophylactic dosing Phenytoin
100 mg IV Q8H. Check dilanitn level.
Cardiovascular: Hydralizine prn HTN, Nipride if needed, Nicardipine for
SBP goal 120-140.
Pulmonary: Pt planning to quit smoking.
Gastrointestinal / Abdomen: NPO for angio, likely advance diet pending
scan.
Nutrition: likely advance diet pending scan.
FEN: NS 20KCL 75cc/h
Renal: Foley, No issues.
Hematology: Hct stable.
Endocrine: RISS
Infectious Disease: No issues.
Lines / Tubes / Drains: PIV
Wounds: Dry dressings
Imaging:
Fluids: NS 20KCL 75cc/h
Consults: Neuro surgery
Billing Diagnosis:
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2141-9-28**] 10:34 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle: HOB elevation
Comments:
Communication: Comments:
Code status: Full code
Disposition:
Total time spent:"
1398,"Labs / Radiology
196 K/uL
11.3 g/dL
118 mg/dL
0.7 mg/dL
26 mEq/L
4.2 mEq/L
6 mg/dL
106 mEq/L
138 mEq/L
35.8 %
6.9 K/uL
[image002.jpg]
[**2141-9-29**] 03:59 AM
WBC
6.9
Hct
35.8
Plt
196
Creatinine
0.7
Glucose
118
Other labs: PT / PTT / INR:11.6/26.9/1.0, Differential-Neuts:74.8 %,
Lymph:20.4 %, Mono:3.7 %, Eos:0.6 %, Ca:8.7 mg/dL, Mg:1.9 mg/dL,
PO4:4.3 mg/dL
Imaging: [**2141-9-28**] CTA: 2 mm aneurysm arising from the Acom may be
present (402b image 18)."
1399,"Order date: [**9-28**] @ [**2141**]
10. Phenytoin 1000 mg IV STAT Duration: 1 Doses Order date: [**9-28**] @
[**2141**]
24 Hour Events:
EKG - At [**2141-9-28**] 11:16 PM
Tylenol, Excedrin PM since [**2141-9-24**].
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2141-9-29**] 05:34 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**44**] a.m.
Tmax: 37.4
C (99.3
T current: 37.4
C (99.3
HR: 56 (56 - 75) bpm
BP: 113/65(76) {104/60(74) - 122/85(89)} mmHg
RR: 16 (13 - 17) insp/min
SPO2: 95%
Heart rhythm: SB (Sinus Bradycardia)
Height: 67 Inch
Total In:
828 mL
584 mL
PO:
Tube feeding:
IV Fluid:
228 mL
584 mL
Blood products:
Total out:
200 mL
600 mL
Urine:
200 mL
600 mL
NG:
Stool:
Drains:
Balance:
628 mL
-16 mL
Respiratory support
O2 Delivery Device: None
SPO2: 95%
ABG: ///26/
Physical Examination
General Appearance: No acute distress, Alert, pleasant
HEENT: PERRL, EOMI, CN II-XII grossly intact
Cardiovascular: (Rhythm: Regular), No appreciable M/R/G
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities, Fully alert with
[**5-23**] UE and LE strength bilat."
1400,"TITLE: CCU Fellow Admit Note
83M with HTN, HL admitted with complete heart block. Was watching TV
with wife, then went downstairs and wife went to bed. Felt LH, called
daughter and had apparent syncopal episode while talking to daughter.
EMS called, found to be in ventricular escape in the 20s, given
atropine and brought to ED. Given atropine x 1 in ED, initially
hypertensive then became progressively hypotensive. RIJ cordis placed
then, pt became briefly asystolic. A temp wire was emergently placed,
the pt was paced, and he was intubated for airway protection.
VS:
Gen: sedated
CV: s1/s2, rrr, distant
Chest: CTA anteriorly
Abd: soft, nt/nd, +bs
Ext: cool, 2+dp, no c/c/e
Labs: reviewed in OMR
ECG #1: ventricular escape in the 20s, RBBB morphology with RAD
ECG #2: V-paced, 80, no retrograde conduction
Prior ECG: RBBB, LAD
A/P: 83M with HTN, HL admitted with complete heart block.
-temp wire in place, threshold 1mA -> set at 5mA
-permanent pacemaker tomorrow
-cont to trend CE
-SBT in AM
Discussed with EP attending, Dr. [**Last Name (STitle) **]."
1401,"# PUMP: The patient had an echo in [**2101-1-7**] which did not show
evidence of systolic dysfunction, EF > 55%, regional wall motion
abnormalities or significant valvular disease. Given risk of possible
ischemia, would consider echo in AM to evaluate for change in systolic
function or wall motion abnormalities.
- Monitor I/Os and daily weights
- Maintain even fluid balance
- TTE as above
.
# History of Alcohol Abuse: CIWA scale with ativan as needed if the
patient starts to demonstrate signs of withdrawal including agitation
and hypertension.
.
# History of Diverticulitis: S/P Hemicolectomy. Continue bowel
regimen including colace and senna.
.
# Hypertension: Not on medical management as an outpatient."
1402,"CARDIAC RISK FACTORS: (+) Dyslipidemia, (+) Hypertension
2. CARDIAC HISTORY: left anterior fascicular block and right bundle
branch block on recent EKG
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Obesity, central
- History of alcohol abuse.
- Status post ruptured rotator cuff: Injured shoulder 50 years
ago when he slipped on ice. Specialists have told him he needs
it replaced
- History of diverticulitis - s/p hemi-colectomy in [**5-16**]
No family history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Occupation:
Drugs: none
Tobacco: quit smoking 20+ years ago
Alcohol: Drinks roughly 12 alcoholic drinks per week,
Other: Lives at home with his wife."
1403,"[**Name (NI) 3749**] in real estate part time with
son and son-in-law.
Review of systems:
Unable to obtain secondary to sedation/intubation
Flowsheet Data as of [**2102-10-2**] 01:26 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
0 mL
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 550 (550 - 550) mL
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 100%
PIP: 14 cmH2O
Ve: 11."
1404,"However, this may also be generalized AV nodal
dysfunction.
- Temp pacer wire, PPM in AM
- Cycle cardiac enzymes
- Avoid nodal agents
- Atropine at the bedside
- Follow EP recs
.
# CORONARIES: No history of coronary artery disease, but significant
risk factors of hyperlipidemia and hypertension, not treated
previously. The patient had a normal stress echocardiogram in [**Month (only) **] of
[**2100**]. Will cycle cardiac enzymes to evaluate for ischemia as cause of
heart block, although first set negative. The patient may need a
cardiac catherization to evaluate for reversible cause of heart block.
- Cycle enzymes
- Continue aspirin 325mg
- Consider statin therapy after lipid panel in AM
- TTE in AM to eval for wall motion abnormalities
."
1405,"Monitor
and start antihypertensives PRN.
.
# Hyperlipidemia: Not on medical management as an outpatient.
Consider statin therapy as above.
.
# Respiratory: No acute respiratory process. Intubated for airway
protection only. Will attempt to wean sedation as tolerated.
.
FEN: NPO for now in anticipation of possible PPM placement in AM
.
ACCESS: R IJ placed in ED
.
PROPHYLAXIS:
-DVT ppx with heparin SC TID
-Pain management with tylenol PRN
-Bowel regimen with colace and senna
.
CODE: Presumed full
.
COMM: [**Name (NI) **] [**Name (NI) 11008**] (Wife) [**Telephone/Fax (1) 11009**]
.
DISPO: CCU for now
ICU Care
Nutrition:
Glycemic Control:
Lines:
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Comments:
Code status:
Disposition:
------ Protected Section ------
EP Fellow Addendum:
Pt seen and examined, data reviewed."
1406,"Right
ventricular free wall motion is normal. Doppler demonstrated no aortic
stenosis, aortic regurgitation or significant mitral regurgitation or
resting LVOT gradient. Echo images were acquired within 33 seconds
after peak stress at heart rates of 110 - 87 bpm. These demonstrated
appropriate augmentation of all left ventricular segments with slight
decrease in cavity size. There was augmentation of right ventricular
free wall motion.
IMPRESSION: Fair functional exercise capacity. No ECG or 2D
echocardiographic evidence of inducible ischemia to achieved workload.
Resting hypertension with normal hemodynamic response to exercise.
.
ETT: [**2101-11-18**] This 82 yo man was referred to the lab for evaluation of
worsening dypsnea on exertion."
1407,"Briefly, pt is an 83 year old male with h/o bifascicular block p/w
syncope and CHB. Pt was found down by EMS after having syncope while
on the phone with his daughter, who called EMS. He was found to be in
CHB with SR 100, ventricular escape in 20
s from LAF. Temporary pacing
initiated in ER, pt intubated due to instability at the time.
PE:
BP 150/60 HR 80 paced O2 sat 100% temp wire threshold 1mA
Intubated, sedated
RIJ in place
CTA B/L
RRR, nml S1 and S2
Soft, NTND
WWP, no edema
CXR: RV wire in good position
ECG: V paced with LBBB morphology
Data reviewed and discussed with housestaff.
A/P:
83 yo M with bifascicular block p/w infranodal CHB s/p temp wire.
-NPO for PPM
-Keep intubated until am
-Temp wire in place
D/W Dr. [**Last Name (STitle) **]. Rest of plan per housestaff.
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) 10843**], MD
on:[**2102-10-2**] 08:03 ------"
1408,"0, HR 30, BP 140/60, RR18, o2 100%
on NRB. He was found to be in third degree heart block with a
continued ventricular rate in the 30s. He was given atropine again.
He sustained a brief episode of asystole and a temporary pacer wire was
placed. He had appropriate capture and was paced at a rate of 80bpm.
He was intubated for airway protection, given fentanyl and midazolam
for sedation, then changed to propofol prior to transfer.
.
Unable to obtain review of systems secondary to sedation.
Patient admitted from: [**Hospital1 19**] ER
History obtained from Medical records
Patient unable to provide history: Sedated
Allergies:
Penicillins
Unknown;
Quinolones
Rash;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Aspirin 81mg QAM
Pregabalin 75mg [**Hospital1 7**]
Zyrtec 10mg QAM
Omeprazole 20mg QAM
Colace PRN
Senna PRN
Tylenol PRN
Percocet PRN
Past medical history:
Family history:
Social History:
1."
1409,"5 METS) reaching a peak heart rate of 117 bpm and a peak
blood pressure of 190/82 mmHg. The test was stopped because of fatigue.
This level of exercise represents a fair exercise tolerance for age. In
response to stress, the ECG showed no ST-T wave changes (see exercise
report for details). There is resting hypertension with There were
normal blood pressure response and a slightly blunted heart rate
response to stress. Resting images were acquired at a heart rate of 86
bpm and a blood pressure of 152/84 mmHg. These demonstrated normal
regional and global left ventricular systolic function."
1410,"The patient completed 9 minutes on a
modified [**Doctor Last Name 10270**] protocol and was stopped at his request due to fatigue
and shortness of breath (~3.5 METS). This represents a fair exercise
capacity for his age. The patient denied any chest, back, arm, or neck
discomforts throughout the study. No significant ST segment changes
were noted during exercise or in recovery. The rhythm was sinus with
one VPB in recovery. Resting hypertension (152/84) with an appropriate
blood pressure response to exercise.
IMPRESSION: No ischemic EKG changes or anginal symptoms. Echo report
sent separately.
. [image002.jpg]
Assessment and Plan
83 yo male with history of hypertension, hyperlipidemia and
bifascicular block presents with syncope secondary to third degree
heart block."
1411,"No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: 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+
Labs / Radiology
EKG: On admission to the ED, third degree heart block with a sinus
rate of 110 bpm, and ventricular escape rhythm at 22bpm with right
bundle branch morphology, right-[**Hospital1 **] axis. On admission to the CCU,
pacer dependent at a rate of 80bpm.
.
TELEMETRY: pacer dependent at a rate 80bpm.
.
ECHO: [**1-15**] The left atrium is normal in size."
1412,"Admission Date: [**2102-10-1**] Discharge Date: [**2102-10-3**]
Date of Birth: [**2019-8-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Quinolones
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] pacemaker placement
History of Present Illness:
83 yo male with history of hyperlipidema, hypertension,
bifascicular block on previous EKG presented to the ED with
syncope. The patient was feeling lightheaded this evening. He
called his daughter to discuss his symptoms. While he was on
the phone, the line went dead for approx 3min. He reports he
lost consciousness during that time."
1413,"His daughter called EMS.
He denied falling during the episode of LOC. When EMS arrived,
he was found to be in complete heart block with a ventricular
rate in the 20s. He was given atropine en route to the ED.
.
In the ED, initial vitals were T99.0, HR 30, BP 140/60, RR18, o2
100% on NRB. He was found to be in third degree heart block
with a continued ventricular rate in the 30s. He was given
atropine again. He sustained a brief episode of asystole and a
temporary pacer wire was placed. He had appropriate capture and
was paced at a rate of 80bpm."
1414,"Social History:
Lives at home with his wife. [**Name (NI) 1403**] in real estate part time with
son and son-in-law.
-Tobacco history: quit smoking 20+ years ago
-ETOH: Drinks roughly 12 alcoholic drinks per week,
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: intubated, sedated.
HEENT: NCAT. Sclera anicteric. Right pupil is tear drop shaped,
minimally reactive appears post surgical, left pupil is
reactive. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
NECK: Supple with flat JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line."
1415,"CXR:
FINDINGS: Left-sided dual-chamber pacemaker has been inserted,
with leads
intact and in standard positions, ending in the right atrium and
right
ventricle. There is no pneumothorax, focal consolidation,
pleural effusion or pulmonary edema. Degenerative changes are
noted in the thoracic spine.
IMPRESSION: New left-sided pacemaker with leads in standard
positions without evidence of pneumothorax.
Brief Hospital Course:
# Complete Heart Block: The patient had a know history of RBBB
and LAFB. His current presentation was likely degenerative
conduction disease, finally losing his posterior fasicle. He had
no evidence of active ischemia. A TTE showed no focal wall
motion abnormalities, cardiac biomarkers were flat, and ECGs
showed no signs of ischemia."
1416,"He was initially emergently
intubated and tranvenously paced. He rapidly extubated and
eventually had a PPM placed with little complication. He
tolerated the procedure well and was discharged home on PO
clindamycin. He will follow up with EP and the device clinic. He
was started on 81mg of aspirin for primary prevention.
#HTN: Not previously on medical management and remained
normotensive in house. No medications started.
#Hyperlipidemia: Lipid profile at goal when checked in house. No
medications started.
#Prophylaxis: HSC
#Code: Full confirmed
COMM: [**Name (NI) 1404**] [**Name (NI) 14**] (Wife) [**Telephone/Fax (1) 1405**]
Medications on Admission:
Aspirin 81mg QAM
Pregabalin 75mg [**Hospital1 **]
Zyrtec 10mg QAM
Omeprazole 20mg QAM
Colace PRN
Senna PRN
Tylenol PRN
Percocet PRN"
1417,"You did not have a
heart attack. Your echocardiogram showed no significant change
or abnormality. This is a preliminary [**Location (un) 1131**] and will be
reviewed by the attending cardiologist later in the day.
.
Medication changes:
1. Take a baby aspirin 81 mg daily.
2. Take Clindamycin for 3 days, this is an antibiotic that will
prevent an infection at the pacer site.
3. Vicodin: to take for pain at the pacer site or shoulders
.
No lifting more than 5 pounds with your left arm or lifting you
left arm over your head for 6 weeks. Keep the dressing dry, no
showers or baths for 1 week. Do not change the pacer dressing
unless it is damp.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2102-10-10**]
2:00.
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. [**Hospital Ward Name 516**], [**Hospital1 18**].
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**11-10**]
at 3:20 pm.
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. [**Hospital Ward Name 516**], [**Hospital1 18**]."
1418,"7 RBC-4.13* Hgb-11.9* Hct-37.7*
MCV-91 MCH-28.9 MCHC-31.6 RDW-16.5* Plt Ct-260
[**2102-10-3**] 07:00AM BLOOD WBC-6.9 RBC-3.87* Hgb-11.4* Hct-34.6*
MCV-90 MCH-29.6 MCHC-33.1 RDW-17.2* Plt Ct-206
[**2102-10-1**] 10:05PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1
[**2102-10-1**] 10:05PM BLOOD Glucose-186* UreaN-29* Creat-1.0 Na-141
K-4.4 Cl-106 HCO3-22 AnGap-17
[**2102-10-3**] 07:00AM BLOOD Glucose-85 UreaN-19 Creat-0."
1419,"Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
3. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Complete Heart Block
Discharge Condition:
stable.
Discharge Instructions:
You had a rhythm problem with your heart called complete heart
block. This was treated with a pacemaker that will regulate the
electrical system of your heart from now on."
1420,"RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: midline scar, soft, NTND. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: 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:
[**2102-10-1**] 10:05PM BLOOD WBC-10."
1421,"On
admission to the CCU, pacer dependent at a rate of 80bpm.
ECG:
High degree A-V block. Again, given the inconsistent
relationship between
P waves and QRS complexes tracing is suggestive of complete
heart block with ventricular or aberrantly conducted nodal
escape rhythm. There is also a rightward axis deviation. Right
bundle-branch block and non-specific ST-T wave abnormalities.
Compared to the previous tracing #2 evidence for complete heart
block is more clearly seen.
TTE [**2102-10-3**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded."
1422,"He was intubated for airway
protection, given fentanyl and midazolam for sedation, then
changed to propofol prior to transfer.
.
Unable to obtain review of systems secondary to sedation.
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Dyslipidemia, (+) Hypertension
2. CARDIAC HISTORY: left anterior fascicular block and right
bundle branch block on recent EKG
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Obesity, central
- History of alcohol abuse.
- Status post ruptured rotator cuff: Injured shoulder 50 years
ago when he slipped on ice. Specialists have told him he needs
it replaced
- History of diverticulitis - s/p hemi-colectomy in [**5-16**]"
1423,"8 Na-143
K-4.7 Cl-109* HCO3-25 AnGap-14
[**2102-10-1**] 10:05PM BLOOD CK(CPK)-40
[**2102-10-2**] 05:00AM BLOOD CK(CPK)-44
[**2102-10-1**] 10:05PM BLOOD cTropnT-0.02*
[**2102-10-2**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2102-10-1**] 10:05PM BLOOD Calcium-8.3* Phos-5.8* Mg-2.1
[**2102-10-2**] 05:00AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.9 LDLcalc-82
EKG: On admission to the ED, third degree heart block with a
sinus rate of 110 bpm, and ventricular escape rhythm at 22bpm
with right bundle branch morphology, right-[**Hospital1 **] axis."
1424,"Overall left ventricular systolic function is normal (LVEF
60-70%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The aortic valve is not well seen. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2101-2-3**], no
major change is evident."
1425,"Demographics
Day of intubation:
Day of mechanical ventilation: 0
Ideal body weight: 0 None
Ideal tidal volume: 0 / 0 / 0 mL/kg
Airway
Airway Placement Data
Known difficult intubation: No
Tube Type
ETT:
Type: Standard
Size: 7.5mm
Cuff Management:
Vol/Press:
Cuff pressure: cmH2O
Lung sounds
RLL Lung Sounds: Diminished
RUL Lung Sounds: Clear
LUL Lung Sounds: Clear
LLL Lung Sounds: Diminished
Comments:
Secretions
Sputum color / consistency: /
Sputum source/amount: Suctioned / None
Comments:
Ventilation Assessment
Level of breathing assistance:
Visual assessment of breathing pattern: Normal quiet breathing
Invasive ventilation assessment:
Trigger work assessment: Triggering synchronously
Plan
Next 24-48 hours:
Reason for continuing current ventilatory support: Pending procedure /
OR; Comments: going for pacemaker placement in am.
Respiratory Care Shift Procedures
Pt on present settings, will be going for pacemaker placement in am.
Possible wean later as patient was intubated for airway protection."
1426,".
He was diagnosed with cirrhosis in [**4-/2173**] and was unaware of his
liver disease prior to then. Per patient report, he has had
paracentesis about twice monthly since then with volumes of [**7-16**]
L. He reports failing diuretic therapy due to symptomatic
hypotension. He also reports that he has had endoscopy showing
mild varices and denies ever having upper or lower GI bleeding.
.
Per the patient, he has needed recurrent paracentesis over the
past few months despite being on Furosemide and Spironolactone.
His hepatologist suggested a TIPS procedure to relieve the
recurrent ascites and hepatic hydrothorax which he has had over
the past year."
1427,"The patient states that he initially went to
[**Hospital1 **] to have the TIPS procedure done, but later requested a
transfer since he wanted one of the [**Hospital1 18**] IR physicians to do
the procedure.
.
Per the transfer summary he was admitted to [**Hospital3 **] on
[**2173-9-18**] for increasing ascites and hypotension. The transfer
summary is confusing but it appears as if there was a concern
for SBP. He was given an albumin infusion which was later
discontinued due to pleural effusion. He was then seen by
Pulmonary who noted his cirrhosis, ascites, and a large pleural
effusion. They decided to observe him, and offered thoracentesis
for to help with dyspnea."
1428,"He is married and his wife
is supportive.
# Smoking: Quit over 15 years ago
# Alcohol: Stopped drinking over 10 years ago
# Drugs: No recreational drug use
Family History:
Noncontributory
Physical Exam:
VS: T 97.4(96.9-97.4), BP 106/65(100-115/58-71), HR 81(77-88)
....RR 22(20-22), SpO2 96(96-100) on RA
Gen: NAD. Alert and oriented x3. Mood and affect appropriate.
Pleasant and cooperative. Resting in bed.
HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
CV: RRR. Normal S1, S2. No M/R/G appreciated."
1429,"4. Interval decrease in size to now moderate right pleural
effusion which is also of slightly higher density than before
and may have a component of blood within it. A very small
anterior right pneumothorax is also noted, not unexpected given
the recent pleural catheter removal.
.
.
Brief Hospital Course:
The patient is a 64 year old male with alcoholic cirrhosis c/b
portal hypertension, ascites, and varices who presented as a
transfer from OSH for TIPS evaluation. He has had two failed
TIPS placement attempts with hepatic artery puncture on the
second attempt.
.
# TIPS Placement Attempts: He was sent from OSH for TIPS
evaluation and placement."
1430,"His
transaminases were significantly elevated after the second
procedure, but were trending down rapidly at the time of
discharge. Per IR, further TIPS placement attempts would be
technically possible, but will be deferred until a later time.
.
# Creatinine Elevation: His Cr increased to 1.3 after his second
TIPS attempt. CT scan on [**2173-10-12**] showed findings concerning for
contrast-induced nephropathy/ATN. His Cr remained stable at 1.3
for the last three days. A prerenal etiology may also have been
contributing given his limited PO intake and recent fluid
losses. He will likely need aggressive hydration and
Acetylcysteine with any future contrast loads."
1431,"His MELD
score on admission was 11, so TIPS was not contraindicated. He
denied any prior episodes of hepatic encephalopathy or GI
bleeding. He was continued on a regimen of Lactulose and
Rifaximin. His Rifaximin dosing was changed to 400 mg TID so
that he could take smaller pills. MELD labs were checked daily
and his score remained stable around 11, but acutely increased
to 15 after his second TIPS attempt.
.
# Nutrition: On admission he appeared cachectic and chronically
ill, reporting a significant weight loss over the last few
months. His PO intake was poor during his admission. Nutrition
consult felt that he would clearly benefit from additional
nutrition through tube feeds."
1432,"A Dobhoff tube was placed on
[**2173-10-15**] and tube feeds were initiated. Nutrition recommended
Nutren 2.0 at 70 ml/hr. Continued PO intake was encouraged and
he was provided Ensure and Beneprotein supplements with each
meal.
.
# Hypotension: He has a history of symptomatic hypotension. His
TSH was mildly elevated at 7.8 and his morning cortisol was 8.3,
which is WNL but on the low side. He will need followup of his
TSH as an outpatient. Further workup of his cortisol level is
probably not necessary at this time. He remained
hemodynamically stable with SBP in the 90s to 100s after
admission mild diuretic treatments, paracentesis, and
thoracentesis."
1433,"Diuretic treatment was discontinued pending
TIPS. He was given Albumin (5%) 25 g on several occasions for
volume repletion.
.
# [**Last Name (un) 4584**]-[**Location (un) **] Syndrome: He had an episode of GBS in [**2169**] which
resolved and a second episode which started several months ago.
He is currently wheelchair bound due to LE weakness. He was
seen by PT and was able to stand with a walker but not ambulate.
He will require additional PT after discharge.
.
# Anemia: He has a slightly macrocytic anemia with a hematocrit
stable around 30. His WBC count and platelets are also low,
suggesting a component of marrow suppression."
1434,"6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Hold for sedation, RR<12, or signs of
encephalopathy.
8. Tube feeds
Nutren 2.0 Full strength;
Starting rate:10 ml/hr; Advance rate by 10 ml Q4H;
Goal rate:70 ml/hr;
Flush with 50 ml water Q6H
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
Alcoholic cirrhosis complicated by ascites
Right hepatohydrothorax
Ascites"
1435,".
[**2173-10-5**] 5:35 pm SEROLOGY/BLOOD CONSENT RECEIVED.
RAPID PLASMA REAGIN TEST (Final [**2173-10-6**]): NONREACTIVE.
.
.
TTE (Complete) Done [**2173-10-5**] at 3:50:26 PM
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). There is no left ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation."
1436,"Iron studies show
an moderately elevated ferritin, low TIBC, and low serum iron
consistent with chronic inflammation. His B12 and folate levels
were normal. His hematocrit was monitored closely, and he
showed no signs of GI bleeding.
.
# DVT Prophylaxis: Provided with Heparin 5000 units SC TID.
.
# MICU Course [**2173-4-8**]:
Patient was admitted to the MICU after puncture of hepatic
artery during TIPS procedure for hemodynamic monitoring. Patient
remained stable and serial hematocrits were stable. A CT scan
was completed showing: No significant hematoma, with decreased
ascites, with some blood mixed in (likely oozing from the TIPS
procedure attempts)."
1437,"The micropuncture sheath
was removed and the venotomy site dilated with an 8 French
dilator. The sheath was then advanced to the level of the origin
of the hepatic veins and a 035 Glidewire advanced into the right
hepatic vein. The sheath was advanced over the wire to lie in
the mid portion of the right hepatic vein. Pressure gradients
were obtained at this time. Following this, a 5 French 035
occlusive balloon was advanced into the distal right hepatic
vein branch and CO2 portography was performed to evaluate the
position of the right and left main portal vein. AP and lateral
projections were obtained."
1438,"BONE WINDOWS: No malignant-appearing osseous lesions are
identified.
IMPRESSION:
1. No significant retroperitoneal or subcapsular hematoma
identified. While the amount of intra-abdominal/pelvic ascites
has significantly decreased from prior [**2173-9-22**] exam
the fluid is of slightly higher density suggesting that it is a
mixture of underlying ascites and blood likely related to oozing
from capsular puncture during TIPS attempt.
2. Abnormal appearance to the inferior right hepatic lobe
parenchyma distal to site of known embolization. This may
reflect underlying parenchyma infarction.
3. Persistent corticomedullary differentiation of the kidneys
with contrast within the collecting systems. This suggests
underlying contrast-induced nephropathy/ATN and should be
correlated with serial creatinine values."
1439,"Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to [**3-11**] bowel movements per day.
2. rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation."
1440,"Chest: Respiration unlabored. Decreased breath sounds on right.
No wheezes, rhonchi, or rales.
Abd: BS present. Soft, NT, ND. Ascites present but not tense.
Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap
refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+.
Neuro: CN II-XII grossly intact. LE strength hip flexion [**4-12**],
knee flexion and extension [**4-12**], dorsiflexion and plantarflexion
[**3-12**]. UE strength intact.
Pertinent Results:
Labs on Admission:
[**2173-10-5**] 12:50AM BLOOD WBC-2.4* RBC-3.10* Hgb-10.3* Hct-30.4*
MCV-98 MCH-33.2* MCHC-33."
1441,"The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
.
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2173-10-5**] 10:22 AM
FINDINGS: The liver is nodular and shrunken in appearance but no
solid liver lesion is identified. A simple cyst is seen at the
dome of the right lobe measuring 1.0 cm and a simple cyst is
seen at the dome of the left lobe also measuring 1.0 cm.
No biliary dilatation is seen and the common duct measures 0."
1442,"There has been interval
decrease in the amount of ascites when compared to the prior
outside imaging; however, the fluid is now more mixed density
with Hounsfield values measuring 20-30, suggestive of a mixture
of underlying ascites hemorrhage likely related to some oozing
after capsular puncture on TIPS attempt. Contrast is noted
within the gallbladder and there is streak artifact from the
indwelling coils and Amplatz occluder devices in the right
hepatic artery. Distal to these devices, the hepatic parenchyma
displays abnormal low attenuation, which may suggest underlying
infarction given the poor flow noted on the post-embolization
angiogram images to this region."
1443,"8 RDW-14.6 Plt Ct-136*
[**2173-10-5**] 12:50AM BLOOD PT-16.2* PTT-28.7 INR(PT)-1.4*
[**2173-10-5**] 12:50AM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-136
K-5.2* Cl-103 HCO3-29 AnGap-9
[**2173-10-5**] 12:50AM BLOOD ALT-15 AST-22 AlkPhos-82 TotBili-1.2
[**2173-10-5**] 12:50AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.4 Mg-2.3
.
Thoracentesis:
[**2173-10-6**] 11:48AM PLEURAL WBC-23* RBC-428* Polys-11* Lymphs-51*
Monos-10* Meso-4* Macro-24*
[**2173-10-6**] 11:48AM PLEURAL TotProt-2."
1444,"3 LD(LDH)-68 Albumin-1.6
.
Other Relevant Labs:
[**2173-10-6**] 05:25AM BLOOD VitB12-761 Folate-18.9
[**2173-10-5**] 05:35PM BLOOD calTIBC-114* Ferritn-558* TRF-88*
[**2173-10-5**] 05:35PM BLOOD Iron-35*
.
[**2173-10-14**] 05:05AM BLOOD Triglyc-63 HDL-25 CHOL/HD-3.0 LDLcalc-37
[**2173-10-5**] 06:10AM BLOOD TSH-7.8*
[**2173-10-5**] 06:10AM BLOOD Cortsol-8.3
.
[**2173-10-14**] 05:05AM BLOOD HAV Ab-POSITIVE
[**2173-10-5**] 05:35PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
[**2173-10-5**] 05:35PM BLOOD HCV Ab-NEGATIVE
[**2173-10-5**] 05:35PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2173-10-5**] 05:35PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2173-10-14**] 05:05AM BLOOD CEA-4."
1445,"The peritoneal
drainage catheter was removed over a wire and a sterile dressing
applied. A 7 French right pleural drain was left in situ to
continue pleural drainage and lung expansion. The catheter was
attached to an underwater seal. The referring clinician, Dr.
[**Last Name (STitle) **], was contact[**Name (NI) **] at the time of procedure. There were no
early complications and the patient was extubated in the
angiography suite and transferred to the anesthesia care unit.
FINDINGS: Ultrasound demonstrated large volume right-sided
pleural effusion and ascites. There was uncomplicated placement
of right pleural and right peritoneal drainage catheter. Portal
venography demonstrated a markedly narrowed right hepatic vein."
1446,"Evaluate for subcapsular or retroperitoneal bleed.
COMPARISON: Outside CT [**2173-9-22**], as well as angiogram
images from [**2173-10-11**].
CT ABDOMEN WITHOUT CONTRAST
Limited evaluation of the included lung bases displays
normal-appearing left lung. The right lung displays significant
interval decrease in size to a now slightly high-attenuation
small-to-moderate pleural effusion with persistent adjacent
compressive atelectasis involving portions of the right lower
lobe as well as the small locule of air noted posterior to the
sternum and a small anterior pneumothorax present.
Unenhanced images of the abdomen display no large
retroperitoneal or subcapsular hematoma."
1447,"CXR, echocardiogram, and duplex US of
liver were completed and no contraindication to the procedure
was identified on this imaging. Viral and autoimmune hepatitis
assays were negative. Imaging from the OSH was uploaded and
reviewed by IR. TIPS placement was attempted on [**2173-10-8**], but
the shunt could not be passed through his liver tissue. He had
a second attempt on [**2173-10-11**], which was also not successful. The
hepatic artery was punctured during the procedure and repaired
without blood loss or significant hemodynamic instability. He
had a brief stay in the MICU and returned to the floor."
1448,"You are scheduled to see
Dr. [**Name (NI) **], a liver specialist, for this and further
management of your liver disease.
A feeding tube was also placed to aid with your nutrition.
During the hospitalization you also worked with physical
therapy; improvement in your strength was noted.
Your medication regimen has changed. Please review the
medication list closely.
Followup Instructions:
Please be sure to keep the following appointment with the liver
center.
Department: TRANSPLANT
When: FRIDAY [**2173-10-29**] at 8:40 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT SOCIAL WORK
When: FRIDAY [**2173-10-29**] at 10:00 AM [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please also schedule an appointment to see your primary care
doctor within 1-2 weeks of discharge from the rehabilitation
facility.
During this hospital course you were noted to have a slightly
elevated TSH, which is a marker of thyroid function. This
should be rechecked as an outpatient, particularly after you
start feeling better. Please discuss this with your primary
care doctor."
1449,"4 cm, which may suggest some mild underlying
ileus with no findings of obstruction. Scattered mesenteric and
retroperitoneal lymph nodes are better appreciated on prior
contrast-enhanced CT.
CT OF THE PELVIS WITHOUT INTRAVENOUS OR ORAL CONTRAST:
Significant interval decrease in amount of free fluid within the
pelvis is identified, although the fluid is noted to be slightly
higher in attenuation as compared to the prior outside exam with
Hounsfield value of approximately 20. A large fecal ball is
noted within the rectal vault, with the intrapelvic bowel
appearing otherwise unremarkable. Contrast is noted within the
bladder from prior procedure."
1450,"It also demonstrated possible kidney damage
secondary to contrast nephropathy so patient's creatinine needs
to be monitored clinically. Patient was transferred back to the
floor after 24 hour monitoring.
.
# Followup:
-- Appointment scheduled in 2 weeks with Dr [**Name (NI) **] to begin
transplant evaluation process
-- Pending results: CA [**82**]-9 and Vitamin D assays
Medications on Admission:
Home Medications:
Heparin 5,000 units daily
Lactinex 1 packet [**Hospital1 **]
Lactulose 30 ml TID
Lorazepam 1 mg QHS
Lorazepam PRN
Colace 100 mg [**Hospital1 **]
Senna
Lactobacillus
MVI daily
.
Discharge Medications:
Morphine Sulfate 2 mg Q6H PRN
Heparin SC 5,000 units [**Hospital1 **]
Lactulose 30 ml TID
Rifaxamin 400 mg [**Hospital1 **]
Nasal Spray 1 spray each nostril TID
Lorazepam 2 mg Q6H PRN
Lorazepam 1 mg QHS
Colace 100 mg [**Hospital1 **]
Senna 2 tabs QHS
Lactobacillus 1 mg PO BID
MVI daily
."
1451,"However, a large amount of pleural fluid remains.
The left lung is clear and there is no evidence of pneumothorax.
.
.
Cytology Report PLEURAL FLUID Procedure Date of [**2173-10-6**]
REPORT APPROVED DATE: [**2173-10-8**]
SPECIMEN RECEIVED: [**2173-10-7**] [**-1/3452**] PLEURAL FLUID
SPECIMEN DESCRIPTION: Received 2000ml cloudy yellow fluid.
Prepared 1 ThinPrep slide.
DIAGNOSIS: Pleural Fluid:
NEGATIVE FOR MALIGNANT CELLS.
Macrophages, mesothelial cells, and inflammatory cells.
.
.
Radiology Report TIPS Study Date of [**2173-10-8**] 8:26 AM
PROCEDURE:
1. Abdominal paracentesis.
2. Right pleural thoracocentesis.
3. Hepatic venography via right internal jugular vein approach.
4. Unsuccessful transhepatic cannulation of the portal vein."
1452,"A negative result generally indicates lack of immunity.
.
[**2173-10-5**] 5:35 pm Blood (EBV)
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2173-10-7**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2173-10-7**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2173-10-7**]): NEGATIVE <1:10
BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
.
[**2173-10-5**] 5:35 pm Blood (CMV AB)
CMV IgG ANTIBODY (Final [**2173-10-8**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA. < 4 AU/ML."
1453,"HISTORY: 64-year-old man with cirrhosis and intractable ascites,
requires TIPS for control of ascites and recurrent right-sided
hydrothorax.
ANESTHESIA: General anesthesia was provided by the
anesthesiology service. In addition, 1% lidocaine was
administered to the skin around the internal jugular vein
puncture, thoracocentesis and paracentesis site.
RADIOLOGIST: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4401**], Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12166**] performed the procedure. Dr. [**Last Name (STitle) 12166**], the
attending radiologist, was present throughout the procedure.
PROCEDURE: Informed consent was obtained outlining the risks and
benefits of the procedure involved."
1454,"Admission Date: [**2173-10-4**] Discharge Date: [**2173-10-16**]
Date of Birth: [**2109-5-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hydrothorax
Major Surgical or Invasive Procedure:
TIPS Placement (Failed x2)
History of Present Illness:
[**Known firstname 85376**] [**Known lastname 174**] is a 64 year old male with alcoholic cirrhosis c/b
portal hypertension, ascites, and varices who presented as a
transfer from [**Hospital1 **] for TIPS evaluation. Of note, he has
Guillain-[**Location (un) **] syndrome and is currently wheelchair bound due to
lower extremity weakness."
1455,".
# Ascites: His outpatient hepatologist was contact[**Name (NI) **] for more
information regarding his prior diuresis, recurrent ascites, and
hydrothorax. He was previously taking Furosemide and
Spironolactone, but developed hypotension with use of the
diuretics and continued to have significant hydrothorax and
recurrent ascites requiring large volume paracentesis. During
his stay at [**Hospital1 18**], he was kept on a low sodium diet and fluid
restriction of 1500 ml. Strict I/Os and daily weights were
monitored. He did not require additional paracentesis after 4 L
of fluid were removed during his first TIPS attempt.
.
# Alcholic Cirrhosis: The indications for TIPS include recurrent
ascites, hepatic hydrothorax, or variceal bleeding."
1456,".
# Pain Control: He has significant pain from immobility due to
[**Last Name (un) 4584**]-[**Location (un) **] Syndrome, which was made worse by chest tube
placement during his first TIPS attempt. He was much more
comfortable after the chest tube was removed. He was started on
Oxycodone 5 mg PO with close monitoring. He did not show any
signs of hepatic encephalopathy or sedation. He was switched to
Q6H PRN dosing on [**2173-10-13**], which worked well for the patient.
.
# Hydrothorax: He has a history of recurrent hepatic
hydrothorax. His CXR on admission showed a large pleural
effusion / hydrothorax with complete whiteout of the right
hemithorax."
1457,"4
cm. Several shadowing gallstones are seen within the lumen of
the gallbladder. The pancreas and midline structures are
obscured from view by overlying bowel. The spleen is enlarged
measuring 19.7 cm. No hydronephrosis is seen. The right kidney
measures 9.4 cm and the left kidney measures 10.8 cm. A moderate
amount of ascites is seen within the abdomen. A large right
pleural effusion is identified.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were obtained. The main, right and left portal veins are patent
with hepatopetal flow. Appropriate flow is seen in the IVC, the
hepatic veins, and the hepatic arteries."
1458,"Secondary:
Guillain-[**Location (un) **] Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2173-10-4**] to have an evaluation for a TIPS procedure. Two
attempts were made and unsuccessful. You also had a chest tube
placed temporarily for fluid in your right lungs; this was
removed several days prior to your discharge. During this
hospitalization we discussed undergoing evaluation for a liver
transplant; many tests were done in the hospital, and the workup
will continue on an outpatient basis."
1459,"Following this, the patient
was brought to the angiography suite where general anesthesia
was induced. The right neck and right-sided chest and upper
abdomen were prepped and draped in the usual sterile fashion. A
preprocedure huddle and timeout were performed as per [**Hospital1 18**]
protocol. Ultrasound of the right side demonstrates a large
right-sided pleural effusion and a large volume of ascites.
Under ultrasound guidance, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11097**] centesis needle was positioned
within the peritoneal space and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire advanced under
fluoroscopic guidance. A 5 French OmniFlush catheter was then
advanced over the wire and attached to a suction drainage
device."
1460,"Following this, the Roshida needle
was used to attempt to access the portal vein from the right
hepatic vein approach. Despite multiple needle passes in
multiple orientations, it was not possible to enter the portal
vein and advance a wire. In addition, an attempt was made to by
the portal vein via a right flank percutaneous transhepatic
approach. Again despite multiple wire passes, we were unable to
sufficiently opacify the portal vein. Following a total
procedure time of 6 hours and a fluoroscopic time of 80 minutes,
a decision was made to abort the procedure. The internal jugular
vein access sheath was removed and manual pressure was applied
for 10 minutes, ensuring good hemostasis."
1461,"IMPRESSION:
1. Nodular shrunken liver with two small simple cysts but no
solid liver lesion identified.
2. Large right pleural effusion and ascites.
3. Splenomegaly.
4. Cholelithiasis.
.
.
CHEST (PA & LAT) Study Date of [**2173-10-5**] 2:52 PM
FINDINGS: A large right pleural effusion causes collapse of the
right lung. The left lung and cardiac size are normal.
IMPRESSION: Extensive right pleural effusion with associated
right pulmonary collapse.
.
.
CHEST (PORTABLE AP) Study Date of [**2173-10-6**] 11:58 AM
FINDINGS: In comparison with the study of [**10-5**], there has been
removal of a substantial amount of fluid from the right
hemithorax."
1462,"ANAEROBIC CULTURE (Final [**2173-10-12**]): NO GROWTH.
ACID FAST SMEAR (Final [**2173-10-7**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
.
[**2173-10-14**] 5:05 am Blood (Toxo)
TOXOPLASMA IgG ANTIBODY (Final [**2173-10-15**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML.
.
[**2173-10-14**] 5:05 am SEROLOGY/BLOOD
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2173-10-15**]): POSITIVE BY EIA.
A positive IgG result generally indicates past exposure and/or
immunity.
.
[**2173-10-14**] 5:05 am SEROLOGY/BLOOD
Rubella IgG/IgM Antibody (Final [**2173-10-14**]):
NEGATIVE by Latex Agglutination."
1463,"Again under ultrasound guidance and following
administration of 1% lidocaine, a 7 French all purpose drainage
catheter was advanced into the right pleural space and again
attached to a underwater seal on suction drainage. Both drainage
catheters were secured.
Attention was then turned to access the right internal jugular
vein. 1% lidocaine was administered to the skin overlying the
internal jugular vein and under direct ultrasound guidance, a
micropuncture needle advanced into the right internal jugular
vein. A 4.5 French micropuncture sheath was advanced over an 018
nitinol wire. The 018 wire and inner dilator were removed and an
035 [**Last Name (un) 7648**] wire advanced into the IVC."
1464,"Some residual air is noted
within the liver parenchyma likely related to a recent
procedure. Multiple small hypoattenuating lesions in the liver
are again seen, likely hepatic cysts and there is unchanged
configuration to known underlying cirrhosis with sequelae of
portal hypertension including splenomegaly, massive
esophageal/paraesophageal varices, and intra-abdominal
collateral vessels. Limited unenhanced evaluation of the
remaining solid organs within the abdomen including the pancreas
and adrenal glands are normal. Kidneys displays persistent
corticomedullary differentiation involving the kidneys
suggestive of underlying renal dysfunction from prior contrast
administration one day prior. There are some prominent
air-filled loops of small and large bowel with the small bowel
measuring up to 3."
1465,"The patient declined thoracentesis.
According to the patient, he received [**4-12**] large volume
paracentesis taps ranging from 8-9 L a tap. He states that
during his hospitalization his diuretic therapy was stopped
because he was hypotensive and required albumin infusions.
.
ROS was otherwise essentially negative. The patient denied
recent fevers, night sweats, chills, hematemesis, coffee-ground
emesis, nausea, vomiting, melena, hematochezia. He does have
significant lower extremity weakness due to his ongoing
Guillain-[**Location (un) **] syndrome.
.
Past Medical History:
Guillain-[**Location (un) **] Syndrome
Alcoholic Cirrhosis
Portal Hypertension
Postural Hypotension
Anemia
Anxiety
Gait disorder
Social History:
He previously worked as a dentist."
1466,"2* PSA-0.4 AFP-1.5
[**2173-10-5**] 05:35PM BLOOD IgG-898 IgA-422* IgM-33*
.
.
[**2173-10-5**] 17:35
Test Result Reference
Range/Units
ALPHA-1-ANTITRYPSIN QN 177 83-199 mg/dL
.
.
[**2173-10-5**] 17:35
Test Result Reference
Range/Units
CERULOPLASMIN 18 18-36 mg/dL
.
.
[**2173-10-6**] 11:48 am PLEURAL FLUID
GRAM STAIN (Final [**2173-10-6**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
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 [**2173-10-9**]): NO GROWTH."
1467,"He was asymptomatic and maintaining good oxygen
saturation. He had thoracentesis with removal of 2 L of fluid.
He tolerated the procedure well, with only some mild coughing.
The fluid was transudative based on Light's criteria, with no
evidence of infection. During his TIPS procedure on [**2173-10-8**], he
had 3.5 L of fluid drained and a chest tube was placed. The
chest tube drained large amounts of fluid over the days
following its placement. The chest tube was removed at the time
of his repeat TIPS attempt on [**2173-10-11**]. Patient has oxygen
saturation 98% on room air at time of discharge."
1468,"In addition, CO2 portography demonstrated a small right portal
vein branch. Given the overall anatomy and severe background
ascites added to the difficulty in accessing the portal vein
transhepatically.
CONCLUSION: Successful right-sided thoracocentesis and abdominal
paracentesis. Hepatic venography and pressure measurements. The
right atrial pressure was measured at 8 mmHg. The hepatic wedge
pressure was measured at 20 mmHg. The staff radiologist, Dr.
[**Last Name (STitle) 12166**], has reviewed the report.
.
.
CT PELVIS W/O CONTRAST Study Date of [**2173-10-12**] 1:03 PM
HISTORY: Alcoholic cirrhosis with known portal hypertension,
status post attempted TIPS procedure x2, most recent complicated
by hepatic venous arterial fistula and subsequent embolization."
1469,"TITLE:
Clinician: Nurse
Late note: pt had witnessed vtach/vfib arrest at 0420 , cpr
initiated,code blue called, patent airway, shock 1 x at 200j, no drugs
pushed. On exam of monitor strip R on T from sinus. return to sinus
brady with cont. of cpr. pulse reestablish after defib. post exam pt.
at basline, able to nod to questions, mae, stated ""chest hurt.
amiodorone 150 mgm IV given in bolus with subsequest gtt started for 6
hrs at 1 mgm then decrease to .5mgm for added 18 hrs. Magnesium
repleted, labs showed no need to repelete potassium. wife and mother
at bedside with pt.
Total time spent: 15 minutes
Patient is critically ill."
1470,"TITLE: Critical Care
Present for key portions of resident
s history and exam. Agree with
assessment and plan as above. TEE yesterday
mild-mod MR, no
vegetations. Bronch with BAL
polys but no organisms. All cx remain
neg. Creat is stable at 1.8. Remains febrile to 103. Bronchial BS
over L chest.
Several things suggest improvement
declining WBC, stable creat and
increasing UO, declining need for pressors, decreased O2 requirement.
Yet his temp is increased, CT showed worsening infiltrate L > R, temp
is higher.
We have not had a single pos culture and I favor stopping abx. I have
increased concern this is a non-infectious process, possibly now with a
drug fever. No eosinophilia but absence of incr WBC and declining
pressor need makes it unlikely this is sepsis. We are lightening
sedation, stopping abx, trying again to diurese, and trying to lighten
sedation.
Time spent
50 min
Critically ill"
1471,"TITLE: Critical Care
Present for key portions of resident
s history and exam. Agree
substantially with assessment and plan above. He had an eventful
weekend. Episode of VT requiring CPR, T increasing
103 today, Hct
down to 22, and troponin increasing after CPR.
For VT
EP consult, monitor electrolytes
have all been in reasonable
range, holding meds that might increase QT (although QT was normal,
loaded with amiodarone, TEE today
Fever
all cx remain neg. Plan for TEE, bronch with BAL, Rheum
consult for non-infectious process asso with fever, surgery re lymph
node bx. If bronch neg would be inclined to D/C abx and recx as could
have drug fever
Respiratory failure
oxygenation improved with drainage of effusion.
He is better sedated and passive on vent. Will hold on current settings
with low Vt ventilation
Time spent
55 min
Patient is critically ill"
1472,"Clinician: Attending
Patient with polymorphic VT. Telemetry show R on T twice followed by
polymorphic VT consistent with Torsades. Had CPR initiated and
defibrillation X1 with return of pulse. Post-arrest patient was
following commands. On exam, patient currently tachycardic, but no
pericardial rub. Rhoncherous lung exam. Labs show no hypomagnesemia
or hypokalemia. EKG with QTc about 380 which was unchanged from
pre-arrest. Does have ST depressions in precordial leads that are
improving over subsequent EKGs. Meds include reglan and cipro.
Unclear what precipitated this polymorphic VT. QTc is not prolonged.
Loaded on amiodarone. Reglan and cipro can cause Torsades, but
unsusual in that QTc is not prolonged. Will get cardiology input and
echo today. Hold reglan.
Total time spent: 45 minutes
Patient is critically ill."
1473,"5 hr car ride yesterday).
.
On ROS, he notes that he has occasional night sweats (had to
change his nightclothes X 2) and a [**4-24**] pound weight loss. His
wife notes that he has been more tired recently.
Past Medical History:
1. +1 MR, +1 TR, borderline pulmonary HTN
2. Testicular rhabdomyosarcoma, age 4, s/p orchiectomy and LN
dissection
3. Thyroid nodule, age 33, s/p surgical removal
4. ?Excess rib cartilage ~8th grade, s/p excision c/b pleural
effusion
5. Pectus excavatum
6. Recently diagnosed BCC
Social History:
Lives with wife, [**Name (NI) 8526**]. Attorney. EtOH [**2-20**] drinks/wk
(although in past has had ""a couple"" of drinks per day)."
1474,".
# Hypoxic respiratory failure: Based on initial CXR, etiology
seemed most consistent with multifocal PNA and ARDS. Initially
PE was considered and the patient was started on heparin drip
briefly, however determined to be unlikely based on septic
physiology. Unlikely cardiogenic pulmonary edema as initial
mixed venous sat was in the 80s. However, a repeat mixed venous
sat the following day was 46. A TTE was done at the bedside to
evaluate for cardiogenic cause of respiratory failure, and found
to have a globally decreased EF, consistent with septic
physiology. The patient had worsening tachypnea and hypoxia on
the floor, was transferred to the ICU the night of admission and
was intubated within hours."
1475,"The descision was made
to do a diagnostic thoracentesis. Dark yellow, thick fluid with
[**Last Name (un) 15936**] was expressed from the pleura on the right side. A chest
tube was placed for continuous drainage. The fluid was found to
be exudative with a large number of WBC however no organisms
grew from this fluid, however it was thought to be a complicated
parapneumonic fluid. The patient was unable to be weaned from
the ventilator, had two episodes of cardiac arrest separated by
days, and was unable to be resuscitated from the second, see
below.
.
# Shock: The patient had bandemia of 41%, fever, tachypnea, and
elevated lactate
on admission with evidence of a pulmonary source on CXR, however
blood cultures were not drawn on admission."
1476,"The patient recovered from the code
and was thought to be improving. He was tolerating lasix for
volume removal and eventually weaned off of pressors for
intermittent periods. However, on [**2139-12-31**] the patient coded
again, initally started as hypotension, then progressed to
bradycardia and eventually PEA. The patient was given atropine
and vasopression. Defibrillation was attempted with no return
of spontaneous circulation. He was given calcium and magnesium.
His bedside US did not show evidence of a pericardial effusion,
his labs were unremarkable. The patient was pronounced dead
after 40min of resuscitation without spontaneous return of
circulation.
.
# Acute renal failure: ATN from septic shock."
1477,"Renal was
consulted. CVVH line was placed, CVVH started. Volume was
removed by CVVH. Renal function did not return to normal, the
patient was unable to be taken off CVVH.
.
# Transaminitis: Secondary to shock liver/hepatic congestion
after excluding other possible sources. Hepatitis serologies
were negative. Abdominal US unremarkable, aside from distended
gall bladder, which IR declined to drain given no other signs of
cholecystitis or cholelithiasis.
.
# Back pain: R-sided, was tender to palpation over R mid-back.
Per his wife he had had some intermittent scapular pain for the
past 4 months. Most likely this pain was the only symptom he
had of the developing pneumonia."
1478,".
# Hypothyroid: TSH was elevated at 14. The patient was treated
with levothyroxine 50 mcg IV daily.
.
# Thrombocytopenia: Thought to be related to bone marrow
suppression secondary to overwhelming sepsis. Heme/Onc was
consulted, agreed with above. Eventually the thrombocytopenia
developed into a thrombocytosis likely secondary to infection as
well.
.
# Conjunctival edema: likely from volume overload.
Ophthalmology consulted and recommended diuresis and lacrilube
ointment applied to the eyes.
.
# FEN: IVF as above, replete electrolytes, tube feeds
.
# Prophylaxis: pneumoboots
.
# Access: RIJ placed [**12-15**], R femoral art line placed [**12-17**]
Medications on Admission:
Levothyroxine 100 mcg daily
Lisinopril 5 mg daily
ASA 325mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Underlying diagnosis unknown at time of death, sepsis of unknown
cause
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2140-1-12**]"
1479,"0# RBC-4.85 HGB-14.0 HCT-41.4 MCV-85
MCH-28.9 MCHC-33.9 RDW-13.8
[**2139-12-16**] 09:50AM NEUTS-48* BANDS-41* LYMPHS-5* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2139-12-16**] 09:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2139-12-16**] 09:50AM PLT SMR-NORMAL PLT COUNT-214
[**2139-12-15**] 11:50AM URINE GR HOLD-HOLD
[**2139-12-15**] 11:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2139-12-15**] 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5."
1480,"Echogenic appearance of the kidneys, suggestive of possible
parenchymal
renal disease.
Portable CXR [**2139-12-30**]:
The ET tube tip is 3.7 cm above the carina. The NG tube tip is
in the
stomach. The right internal jugular line is at the proximal
right atrium.
The pigtail catheter inserted in the right basal hemithorax is
unchanged in position. There is no interval change in the
widespread consolidations mostly involving left lung but also
seen in the right lung base. The surgical clips projecting over
the abdomen are unchanged.
Microbiology:
No growth on several blood, urine, stool, lavaged samples.
Brief Hospital Course:
41 year old man with a history significant for rhabdomyosarcoma
testicular cancer as a child s/p resection, chemotherapy and
radiation who presented with back pain, admitted to the ICU for
septic shock."
1481,"5, 109, 114/57, 36, 92%. Labs showed
WBC 11, Band 41, Cr 2.4. Received 3L IVF, ceftriaxone 1gm and
azithromycin 500mg, as well as ibuprofen, percocet, valium, and
toradol and was admitted to the medical floor. On the floor, he
was hypoxic to the 70s on RA. He stated that he felt weak,
fatigued, with poor appetite. He noted that his pain causes him
to feel nauseated and shake occasionally. Also c/o SOB due to
his pain. Denies f/c/n, cough, sputum, hemoptysis, abd pain,
diarrhea, dysuria, hematuria, frequency, urgency, leg pain,
weakness, numbness, tingling. No sick contacts or foreign travel
(only notes 2."
1482,"Denies
tob. Uses pot occasionally. Was HIV neg 1.5 yrs ago with no new
partners since.
Family History:
His mother was just diagnosed w/ diabetes and HTN.
Physical Exam:
Admission Exam:
Vitals: T: 99.4 axillary BP: 137/66 P: 122 R: AC 400X 14 100%
FiO2 and 5 of PEEP. O2 Sat 100%.
General: Sleepy, oriented X 3, prior to intubation was toxic
appearing, thin, tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear, seemed to have
some trismus
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
1483,"6* MAGNESIUM-2.6
[**2139-12-16**] 07:56PM CALCIUM-6.5* PHOSPHATE-4.0 MAGNESIUM-2.1
[**2139-12-16**] 07:56PM WBC-4.5# RBC-4.62 HGB-14.0 HCT-39.9* MCV-87
MCH-30.4 MCHC-35.1* RDW-14.1
[**2139-12-16**] 07:56PM WBC-2.1*# RBC-4.60 HGB-13.6* HCT-39.4* MCV-86
MCH-29.6 MCHC-34.6 RDW-13.9
[**2139-12-16**] 07:56PM PLT COUNT-247
[**2139-12-16**] 07:56PM PT-16.7* PTT-91.8* INR(PT)-1.5*
[**2139-12-16**] 07:56PM PLT COUNT-191
[**2139-12-16**] 07:56PM PT-28."
1484,"5* PTT-150* INR(PT)-2.9*
[**2139-12-16**] 07:06PM TYPE-ART PO2-92 PCO2-38 PH-7.34* TOTAL CO2-21
BASE XS--4
[**2139-12-16**] 07:06PM LACTATE-2.3*
[**2139-12-16**] 04:38PM D-DIMER-1662*
[**2139-12-16**] 04:38PM D-DIMER-As of [**11-16**]
[**2139-12-16**] 03:29PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2139-12-16**] 03:00PM GLUCOSE-100 UREA N-41* CREAT-2.0* SODIUM-133
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-17* ANION GAP-20
[**2139-12-16**] 03:00PM ALT(SGPT)-64* AST(SGOT)-121* LD(LDH)-312* ALK
PHOS-53 TOT BILI-0."
1485,"After ID
consultation, the patient was started on clindamycin for
possible toxin mediated process given the rapidity of the
progression. The patient continued to require pressors, renal
function continued to worsen, and continued to spike fevers.
On [**2139-12-26**] at 4:30am the patient underwent a run of
pulseless polymorphic ventricular tachycardia. Chest
compressions were started, he was shocked once and spontaneous
circulation returned. At that time, his electrolytes were
within normal limits. He was started on an amiodarone drip.
Cardiology was consulted, and thought that the arrhythmia was
secondary to his metabolic derrangement. Cardiology recommended
continuing oral amiodarone."
1486,".
He states that he awoke suddenly [**12-14**] am with 8/10 nonradiating
R sided pain over his posterior lower ribs, worse with
inspiration. He went to [**Hospital1 18**] for evaluation, and was discharged
with dx of muscle strain from playing Wii bowling. His pain
improved with the oxycodone, ibuprofen 600mg, and valium he was
rx'd at the ED. The following am (day of admission), he again
awoke with 8/10 pain. He took his temp as advised by the ED
(although had no subj fever) and noted T 101. Returned to [**Hospital1 18**]
ED, where vitals were T 100."
1487,"Admission Date: [**2139-12-16**] Discharge Date: [**2139-12-31**]
Date of Birth: [**2098-5-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypoxia, Tachypnea
Major Surgical or Invasive Procedure:
Intubation
R chest tube
History of Present Illness:
41 yo M with remote pmh of testicular cancer at age 4
transferred to the MICU in the setting of hypoxia, tachypnea,
evolving bilateral pulmonary infiltrates and acute renal
failure. On arrival to the MICU, he was intubated for increased
work of breathing. He was transiently hypotensive
peri-intubation but his blood pressure stabilized."
1488,"0
LEUK-NEG
Relevant Imaging:
Torso CT with Contrast: [**2139-12-26**] IMPRESSIONS:
1. New pulmonary consolidation and ground- glass opacities, left
greater than
right, consistent with interval development of pneumonia since
[**2139-12-18**].
2. Unchanged moderate left, and increased large right pleural
effusions, with
adjacent compressive atelectasis.
3. Peripheral, wedge-shaped areas of low attenuation in the
spleen and kidney
are concerning for infection or infarction, possibly due to
embolic
phenomenon.
4. Anasarca with trace perihepatic and trace pelvic fluid.
5. Similarly distended gallbladder compared to eight days prior,
without CT
evidence for cholecystitis.
6. Status post right orchiectomy and retroperitoneal
lymphadenectomy, with
new increased axillary adenopathy."
1489,"Pertinent Results:
Admission Labs:
[**2139-12-16**] 10:47PM LACTATE-3.5*
[**2139-12-16**] 10:42PM TYPE-CENTRAL VE TEMP-38.3 RATES-14/ TIDAL
VOL-400 PEEP-5 O2-100 PO2-61* PCO2-61* PH-7.20* TOTAL CO2-25
BASE XS--4 AADO2-585 REQ O2-97 -ASSIST/CON INTUBATED-INTUBATED
[**2139-12-16**] 10:42PM LACTATE-3.4* K+-5.4*
[**2139-12-16**] 10:42PM O2 SAT-84
[**2139-12-16**] 09:47PM URINE HOURS-RANDOM CREAT-135 SODIUM-52
[**2139-12-16**] 09:47PM URINE HOURS-RANDOM
[**2139-12-16**] 09:47PM URINE OSMOLAL-564
[**2139-12-16**] 09:47PM URINE GR HOLD-HOLD
[**2139-12-16**] 09:47PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-12-16**] 07:56PM GLUCOSE-185* UREA N-38* CREAT-1."
1490,"6*
SODIUM-132* POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-23 ANION
GAP-14
[**2139-12-16**] 07:56PM GLUCOSE-178* UREA N-38* CREAT-1.8*
SODIUM-132* POTASSIUM-6.5* CHLORIDE-104 TOTAL CO2-16* ANION
GAP-19
[**2139-12-16**] 07:56PM ALT(SGPT)-134* AST(SGOT)-229* LD(LDH)-299*
ALK PHOS-61 AMYLASE-55 TOT BILI-0.5
[**2139-12-16**] 07:56PM ALT(SGPT)-96* AST(SGOT)-180* LD(LDH)-558* ALK
PHOS-46 TOT BILI-0.4
[**2139-12-16**] 07:56PM LIPASE-19
[**2139-12-16**] 07:56PM CALCIUM-6.9* PHOSPHATE-4."
1491,"The patient was treated with ARDS
net protocol, with increased PEEP and decreased tidal volumes.
The patient was unable to be weaned from the ventilator despite
being treated with broad spectrum antibiotics for bilateral
pneumonia and volume removal with CVVH after aggressive volume
resuscitation. Patient underwent bronchoscopy and BAL which
were unrevealing to cause. As the patient became more difficult
to ventilate and CXRs showed progression of bilateral
infiltrates despite volume removal and antibiotics, a contrast
CT scan was done which showed large bilateral pleural effusions,
worse on the right than left, ground glass infiltrates and
airbronchograms especially on the left."
1492,"Other sources
considered were endocarditis, osteomyelitis, pancreatitis, and
other intra-abdominal process, however pneumonia was thought to
be the source after thorough evaluation of other possibilities.
After intubation the patient experienced hypotension, requiring
aggressive volume resuscitation and ultimately the use of
pressors. Over the course of his hospitalization, the patient
required the use of pressors, at times multiple pressors, to
maintain adequate blood pressure. Multiple cultures were sent
from sputum, blood, urine, pleural fluid, BALs however all
following the administration of IV antibiotics and all found to
be negative. The patient was initially started on levofloxacin,
vancomycin and zosyn for broad antibiotic coverage."
1493,"7. Small aorta, measuring 7 mm proximal to bifurcation, of
uncertain
etiology, although finding could relate to prior radiation
therapy, if the
patient has had such.
8. Findings in the proximal femurs suggesting prior slipped
capital femoral epiphyses with bilateral hip degenerative
change.
Abdominal U/S [**2139-12-25**]:
IMPRESSION:
1. Tiny hepatic cyst, otherwise normal appearance of the liver.
2. Stable gallbladder distension, containing sludge which is
becoming
tumefactive. No gallbladder wall thickening or edema,
pericholecystic fluid, or focal tenderness over the gallbladder
during the examination is seen. No specific sign of
cholecystitis.
3. Large pleural effusions bilaterally.
4."
1494,"4
[**2139-12-16**] 03:29PM LACTATE-3.2*
[**2139-12-16**] 03:00PM TSH-14*
[**2139-12-16**] 03:00PM ASA-NEG ACETMNPHN-5.4 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2139-12-16**] 12:15PM COMMENTS-GREEN TOP
[**2139-12-16**] 12:15PM LACTATE-2.5* K+-4.6
[**2139-12-16**] 10:40AM URINE HOURS-RANDOM
[**2139-12-16**] 10:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2139-12-16**] 09:50AM GLUCOSE-116* UREA N-41* CREAT-2.4*#
SODIUM-132* POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-26 ANION GAP-16
[**2139-12-16**] 09:50AM estGFR-Using this
[**2139-12-16**] 09:50AM WBC-11."
1495,"Demographics
Day of intubation: [**12-15**]
Day of mechanical ventilation: 9
Ideal body weight: 48.1 None
Ideal tidal volume: 192.4 / 288.6 / 384.8 mL/kg
Airway
Airway Placement Data
Known difficult intubation: No
Reason: Hypoxic respiratory failure
Tube Type
ETT:
Position: 21 cm at teeth
Route: Oral
Type: Standard
Size: 7.5mm
:
Cuff Management:
Vol/Press:
Cuff pressure: 25 cmH2O
Cuff volume: mL /
Lung sounds
RLL Lung Sounds: Diminished
RUL Lung Sounds: Clear
LUL Lung Sounds: Clear
LLL Lung Sounds: Clear
Secretions
Sputum color / consistency: White / Thick
Sputum source/amount: Suctioned / Small
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Visual assessment of breathing pattern: Normal quiet breathing;
Comments: Pt placed on PSV during the day and remains comfortable
overnight and tolerating well. Vt slightly higer but RR and PIP
decreased.
Assessment of breathing comfort: No response (sleeping / sedated)
Plan
Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;
Comments: ARDS net
Reason for continuing current ventilatory support:"
1496,"excess rib cartilage removed, pectus deformity.
Meds at home:
Lisinopril
ASA
levoxyl
mother: HTN and DM
Occupation:
Drugs: no IVDU, occasional marijuana
Tobacco: none
Alcohol: [**2-20**]/wk
Other: HIV negative 1.5 years ago, no new partners since
Review of systems:
Constitutional: Fever
Cardiovascular: No(t) Chest pain
Respiratory: Dyspnea
Gastrointestinal: Nausea
Genitourinary: Foley
Musculoskeletal: some right upper back pain
Psychiatric / Sleep: No(t) Agitated
Pain: No pain / appears comfortable
Flowsheet Data as of [**2139-12-17**] 02:15 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37.7
C (99.8
Tcurrent: 37."
1497,"6 mg/dL
38 mg/dL
23 mEq/L
100 mEq/L
5.4 mEq/L
132 mEq/L
4.5 K/uL
[image002.jpg]
[**2139-12-16**] 07:56 PM
WBC
4.5
Hct
39.9
Plt
247
Cr
1.6
Glucose
185
Other labs: PT / PTT / INR:16.7/91.8/1.5, ALT / AST:134/229, Alk Phos /
T Bili:61/0.5, Lactic Acid:3.5 mmol/L, LDH:299 IU/L, Ca++:6.9 mg/dL,
Mg++:2.6 mg/dL, PO4:4.6 mg/dL
Assessment and Plan
Respiratory failure: hypoxemic with infiltrates consistent with
pneumonia."
1498,"Chief Complaint: abdominal pain, septic shock
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
41 yo man two days ago ([**12-14**]) presented to ER with severe right upper
back pain. CXR was unremarkable. Dx with musculoskeletal pain and
sent home. At home had fever so returned. In ER Oxygen sat 92%, CXR
with b/l multifocal PNA. Got CTX and azithro. Admitted to floor where
he was found to be hypoxemic to 70s. EKG with S1, Q3, T3, started on
heparin and given HCO3 in preparation for CTA."
1499,"Got tachypneic,
desatted, transferred to MICU where he was intubated for RR in 50s.
Patient admitted from: [**Hospital1 19**] [**Hospital1 158**]
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2139-12-16**] 11:00 PM
Piperacillin/Tazobactam (Zosyn) - [**2139-12-17**] 12:43 AM
Levofloxacin - [**2139-12-17**] 01:20 AM
Infusions:
Fentanyl - 25 mcg/hour
Midazolam (Versed) - 2 mg/hour
Phenylephrine - 4 mcg/Kg/min
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
1+ MR, 1+ TR, borderline pulm HTN in [**2137**]
Thyroid nodule removed not cancerous
rhabdomyosarcoma of testes at age 4."
1500,"Consider atypicals including legionella. Wean FiO2 as
tolerated. Doubt PE given infiltrates with bandemia.
Shock: Most likely septic given high mixed venous SvO2, fever,
bandemia suggest infection. Possibilities include PNA, endocarditis
with abscess of spine resulting in back pain. Other causes of
abdominal pain include pancreatitis, cholangitis.
- diagnostically echo would be useful. Obtain sputum
sample and legionella urine antigen.
- check pancreatic enzymes, abdominal CT if
stabilizes.
Acute renal failure: Likely due to septic shock. Improved with
hydration. Follow urine output.
Abnormal liver function test: could be from shock. Or specific
infections such as mycoplasma, underlying hepatitis. No signficant
ETOH history.
Hypothyroid: empiric levoxyl.
ICU Care
Nutrition:
Glycemic Control:
Lines / Intubation:
20 Gauge - [**2139-12-16**] 08:30 PM
Multi Lumen - [**2139-12-16**] 10:40 PM
Arterial Line - [**2139-12-17**] 01:38 AM
Comments:
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent: 60 minutes
Patient is critically ill"
1501,"7
C (99.8
HR: 108 (107 - 138) bpm
BP: 66/48(51) {66/43(50) - 152/81(93)} mmHg
RR: 16 (6 - 44) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Height: 60 Inch
CVP: 20 (8 - 20)mmHg
Total In:
588 mL
1,015 mL
PO:
TF:
IVF:
588 mL
1,015 mL
Blood products:
Total out:
820 mL
140 mL
Urine:
520 mL
90 mL
NG:
300 mL
50 mL
Stool:
Drains:
Balance:
-232 mL
875 mL
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 400 (400 - 400) mL
RR (Set): 14
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 100%
PIP: 23 cmH2O
Plateau: 20 cmH2O
Compliance: 26."
1502,"7 cmH2O/mL
SpO2: 100%
ABG: 7.21/45/117
Ve: 10.6 L/min
Physical Examination
General Appearance: Thin
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: Crackles : b/l, Bronchial: right
base)
Abdominal: Soft, Non-tender
Extremities: Right: Absent, Left: Absent
Musculoskeletal: point tenderness in back over rib
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
247 K/uL
39.9 %
14.0 g/dL
185 mg/dL
1."
1503,"4
5.4
7.2
Hct
39.3
33.7
32.1
Plt
266
169
108
Cr
2.0
2.2
2.6
2.5
TCO2
11
16
17
19
21
19
Glucose
139
126
113
55
86
87
Other labs: PT / PTT / INR:18.5/70.1/1.7, ALT / AST:[**Telephone/Fax (1) 4746**], Alk Phos
/ T Bili:117/1.3, Amylase / Lipase:55/19, Lactic Acid:3.2 mmol/L,
LDH:864 IU/L, Ca++:7.8 mg/dL, Mg++:2.0 mg/dL, PO4:5.1 mg/dL
Assessment and Plan
ELECTROLYTE & FLUID DISORDER, OTHER
SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)
PNEUMONIA, OTHER
ICU Care
Nutrition: tf
Glycemic Control:
Lines:
Multi Lumen - [**2139-12-16**] 10:40 PM
Arterial Line - [**2139-12-17**] 01:38 AM
Prophylaxis:
DVT: sc hep
Stress ulcer: ppi
VAP: HOB chlorhex
Communication: with wife
[**Name (NI) 36**] status: Full code
Disposition :ICU
Total time spent: 45 minutes
Patient is critically ill"
1504,"40/29/99.[**Numeric Identifier 508**]/18/-4
Ve: 8.8 L/min
PaO2 / FiO2: 250
Physical Examination
Gen: intubated and sedated
HEENT: scleral edema, ETT OGT
CV: RR
Chest: bilat dense rhonci at bases
Abd: well healed clam shell scar, distended but soft
Ext: cool hands and feet, no edema
Neuro: opens eyes to voice
Labs / Radiology
11.3 g/dL
108 K/uL
87 mg/dL
2.5 mg/dL
18 mEq/L
4.9 mEq/L
45 mg/dL
107 mEq/L
136 mEq/L
32.1 %
7.2 K/uL
[image002.jpg]
[**2139-12-17**] 06:21 AM
[**2139-12-17**] 07:00 AM
[**2139-12-17**] 11:18 AM
[**2139-12-17**] 12:59 PM
[**2139-12-17**] 01:20 PM
[**2139-12-17**] 05:31 PM
[**2139-12-17**] 09:23 PM
[**2139-12-18**] 03:15 AM
[**2139-12-18**] 03:30 AM
[**2139-12-18**] 06:29 AM
WBC
8."
1505,"Chief Complaint: septic shock
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
EKG - At [**2139-12-17**] 09:00 AM
BRONCHOSCOPY - At [**2139-12-17**] 12:15 PM
TRANSTHORACIC ECHO - At [**2139-12-17**] 02:30 PM
ID consulted
SCvO2 trending up
Aggressive IVF
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Levofloxacin - [**2139-12-17**] 01:20 AM
Vancomycin - [**2139-12-17**] 11:10 PM
Piperacillin/Tazobactam (Zosyn) - [**2139-12-18**] 12:10 AM
Clindamycin - [**2139-12-18**] 04:11 AM
Infusions:
Fentanyl - 50 mcg/hour
Midazolam (Versed) - 2 mg/hour
Norepinephrine - 0."
1506,"2 mcg/Kg/min
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2139-12-18**] 12:12 AM
Famotidine (Pepcid) - [**2139-12-18**] 04:11 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2139-12-18**] 08:51 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.4
C (99.4
Tcurrent: 36.4
C (97.6
HR: 81 (81 - 105) bpm
BP: 99/54(72) {82/43(59) - 125/63(86)} mmHg
RR: 20 (20 - 30) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 60 Inch
CVP: 10 (8 - 14)mmHg
Mixed Venous O2% Sat: 63 - 70
Total In:
6,930 mL
2,573 mL
PO:
TF:
IVF:
6,790 mL
2,573 mL
Blood products:
Total out:
741 mL
287 mL
Urine:
686 mL
287 mL
NG:
55 mL
Stool:
Drains:
Balance:
6,189 mL
2,286 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 450 (450 - 450) mL
RR (Set): 20
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI Deferred: No Spon Resp
PIP: 29 cmH2O
Plateau: 23 cmH2O
SpO2: 97%
ABG: 7."
1507,"Pt
s TPN is at
goal, which provides 100% estimated needs: 25kcals/kg and 1.2g aa/kg.
Team wishes to concentrate TPN if possible; will be able to decrease
volume to ~1150mL. Noted outside Phos and Mag repletions. Pt needs
his TG to be checked, to ensure that they are <400 (requirement for
safely giving lipids in TPN).
Medical Nutrition Therapy Plan - Recommend the Following
1) Rec TPN goal of 1150mL (220dex/ 60aa/ 30fat) = 1288kcal.
2) Please check TG
s, if >400, lipid will need to be removed from
TPN.
3) Monitor lytes per daily chem. 10, adj as needed in TPN.
4) Monitor lytes and hydration with TPN and CVVH running.
Please page with?
s #[**Numeric Identifier 2337**]"
1508,"8 mg/dL
[**2139-12-22**] 03:02 AM
WBC
18.8 K/uL
[**2139-12-23**] 07:54 AM
Hgb
9.2 g/dL
[**2139-12-23**] 07:54 AM
Hematocrit
26.2 %
[**2139-12-23**] 07:54 AM
Current diet order / nutrition support: TPN: 1400mL (220dex/ 60aa/
30fat) = 1288kcals
GI: abd firm, negative bowel sounds, + BM
Assessment of Nutritional Status
41 y.o. M adm with hypoxia, ARF, now in septic shock still of unclear
etiology. Pt has been on CVVH since
for fluid removal and acidosis.
Pt is receiving TPN for nutrition support while it is unsafe to use
pt
s gut [**1-18**] unstable BP and unclear source of sepsis."
1509,"[**Numeric Identifier 176**] mm Hg
[**2139-12-23**] 08:36 AM
PCO2 (arterial)
57 mm Hg
[**2139-12-23**] 08:36 AM
pH (arterial)
7.34 units
[**2139-12-23**] 08:36 AM
pH (urine)
5.5 units
[**2139-12-22**] 12:46 PM
CO2 (Calc) arterial
32 mEq/L
[**2139-12-23**] 08:36 AM
Calcium non-ionized
7.3 mg/dL
[**2139-12-23**] 07:54 AM
Phosphorus
2.3 mg/dL
[**2139-12-23**] 07:54 AM
Ionized Calcium
0.97 mmol/L
[**2139-12-23**] 08:36 AM
Magnesium
1.6 mg/dL
[**2139-12-23**] 07:54 AM
ALT
850 IU/L
[**2139-12-22**] 03:02 AM
Alkaline Phosphate
188 IU/L
[**2139-12-22**] 03:02 AM
AST
727 IU/L
[**2139-12-22**] 03:02 AM
Amylase
55 IU/L
[**2139-12-16**] 07:56 PM
Total Bilirubin
0."
1510,"Objective
Pertinent medications: Fentanyl, Norepinephrine, Versed, HISS, Abx,
NaPhos repletion, MagSO4 repletions, others noted
Labs:
Value
Date
Glucose
126 mg/dL
[**2139-12-23**] 07:54 AM
Glucose Finger Stick
137
[**2139-12-23**] 10:00 AM
BUN
21 mg/dL
[**2139-12-23**] 07:54 AM
Creatinine
1.1 mg/dL
[**2139-12-23**] 07:54 AM
Sodium
137 mEq/L
[**2139-12-23**] 07:54 AM
Potassium
3.5 mEq/L
[**2139-12-23**] 07:54 AM
Chloride
97 mEq/L
[**2139-12-23**] 07:54 AM
TCO2
30 mEq/L
[**2139-12-23**] 07:54 AM
PO2 (arterial)
80."
1511,"Demographics
Day of intubation:
Day of mechanical ventilation: 11
Ideal body weight: 48.1 None
Ideal tidal volume: 192.4 / 288.6 / 384.8 mL/kg
Airway
Airway Placement Data
Known difficult intubation: No
Procedure location:
Reason:
Tube Type
ETT:
Position: 23 cm at teeth
Route: Oral
Type: Standard
Size: 7.5mm
Tracheostomy tube:
Type:
Manufacturer:
Size:
PMV:
Cuff Management:
Vol/Press:
Cuff pressure: 25 cmH2O
Cuff volume: mL /
Airway problems:
Comments:
Lung sounds
RLL Lung Sounds: Diminished
RUL Lung Sounds: Rhonchi
LUL Lung Sounds: Rhonchi
LLL Lung Sounds: Rhonchi
Comments:
Secretions
Sputum color / consistency: Yellow / Thick
Sputum source/amount: Suctioned / Small
Comments:
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Visual assessment of breathing pattern: Normal quiet breathing;
Comments: placed on paralytic prior to change of shift this AM 2to vent
dissynchrony w/ gd effect.
Assessment of breathing comfort: No response (sleeping / sedated);
Comments: paralyzed/sedated/ resting comf
Non-invasive ventilation assessment:
Invasive ventilation assessment:
Trigger work assessment: Not triggering
Dysynchrony assessment:
Comments: occassionally does trigger. MD [**First Name (Titles) **] [**Last Name (Titles) **] aware.
Plan
Next 24-48 hours: Reduce PEEP as tolerated; Comments: slow PEEP wean
following thoracenthesis.
Reason for continuing current ventilatory support: Underlying illness
not resolved
Respiratory Care Shift Procedures
Transports:
Destination (R/T)
Time
Complications
Comments
Bedside Procedures:
Comments: thoracenthesis to R side done by IP. Lg amt drainage to chest
tube.
15:25"
1512,"Chief Complaint: GI Bleed, Blood loss anemia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
79 yo man who had recent total hip replacment last month with
subsequent GI bleed at rehab necessitating admission to [**Hospital1 19**] ICU. Had
EGD on [**9-6**] that showed GE junction ulceration as well as a visible
bleeding ulcer in duodenem that was felt to be source of bleeding.
Bleeding controlled with clips and injection. Pt recieved 13 units
pRBC at that time for ongoing blood loss and hypotension."
1513,"Was
stablilized and transferred back to rehab on [**9-14**]. Had been doing
weel until yesterday when he started to feel weak. At an ortho
appointment today, had a large bowel movement of melena and red blood
--> noted also to have greyish pallor and sent to ED. HR in 100s, BP
in 60s initiatially --> recieved 2L of saline with normalization. Seen
by GI who will plan to scope. Admitted to MICU for furter management.
Current off of Coumadin, ASA, NSAIDs - though had been getting these
around time of prior bleed. Hct 28 --> 22.3.
Patient admitted from: [**Hospital1 19**] ER
History obtained from [**Hospital 15**] Medical records
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
per ICU resident note
Past medical history:
Family history:
Social History:
UGIB earlier this month as above
Chronic LBP
HTN
Chronic L Hip pain
s/p R TKA
Achilles tendon repair
Rotator Cuff repair
Tonsillectomy
Post-op narcotic related ileus
Appendectomy
non-contributory for GI Bleed
Occupation:
Drugs:
Tobacco: [**12-2**] PPD
Alcohol: 1-2 drinks 3x per week
Other:
Review of systems:
Constitutional: No(t) Fever
Ear, Nose, Throat: OG / NG tube
Cardiovascular: No(t) Chest pain
Nutritional Support: NPO
Respiratory: No(t) Dyspnea
Gastrointestinal: No(t) Abdominal pain
Genitourinary: Foley
Integumentary (skin): No(t) Jaundice
Heme / Lymph: Anemia
Psychiatric / Sleep: No(t) Agitated
Pain: No pain / appears comfortable
Flowsheet Data as of [**2102-9-18**] 04:16 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36."
1514,"3
106
1.2
27
28
106
4.7 mEq/L
142
19.4
[image002.jpg]
Other labs: PT / PTT / INR:13/26.5/1.1, Lactic Acid:1.8 mmol/L
Fluid analysis / Other labs:
Assessment and Plan
79 yo man with GI Bleed, Blood loss anemia. Likely that source is same
duodenal bleeding vessel as previous GI Bleed. No coagulopathic
currently and on no anti-coagulant/at-platelt agents.
-3 peripheral ivs
-Being seen by GI with likely plan to do EGD
-Gastric lavage negative
-PPI drip
-Transfuse 2 units now
-Serial Hct checks
Remainder of issues per ICU team.
ICU Care
Nutrition:
Glycemic Control:
Lines / Intubation:
Comments:
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent: 35 minutes
Patient is critically ill"
1515,"6
C (97.8
Tcurrent: 36.6
C (97.8
HR: 88 (88 - 91) bpm
BP: 113/48(62) {113/44(62) - 121/48(65)} mmHg
RR: 16 (13 - 16) insp/min
SpO2: 97%
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
0 mL
Respiratory
SpO2: 97%
ABG: ////
Physical Examination
General Appearance: No acute distress
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed, pleasant,
conversive
Labs / Radiology
536
22."
1516,"Admission Date: [**2102-9-18**] Discharge Date: [**2102-9-23**]
Date of Birth: [**2023-2-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
-Upper endoscopy on [**2102-9-18**]
-NG lavage on [**2102-9-18**]
-Colonoscopy [**2102-9-21**]
History of Present Illness:
79-year old gentleman s/p recent hip replacement surgery ([**8-29**]
at NEBH), with post op complicated by severe GI bleed in the
setting of NSAIDs, Coumadin, ASA, requiring MICU admission. Pt
found to have duodenal bleed but could not be fully accessed due
to its location and surrounding area was injected with epi and
clipped."
1517,"In the ED initial vitals: HR103 BP66/40 O298%RA. Pt appeared
pale, diaphoretic, rectal revealed dark blood in vault. Pt had 3
PIVs placed: 16G, 18G, 20G. Pt received 40mg IV Protonix and a
total of 3L NS, awaiting blood crossing.
Pt was seen by GI and recommended NGL and semiemergent scope.
Most recent vitals: 75, 91/47, 15, 100% 2L.
Ortho recommended Keflex 500mg TID for wound erythema.
Past Medical History:
Chronic LBP
HTN
Chronic L Hip pain
s/p R TKA
Achilles tendon repair
Rotator Cuff repair
Tonsillectomy
Post-op ileus [**1-2**] narcotics
Appendectomy
Social History:
Previous heavy smoker up to 1."
1518,"5 packs per day for 20 years. Now
only smokers rarely. Previously was an alcoholic but quit in the
[**2062**]. Now has an occassional glass of wine with dinner. Denies
illicit drug use.
Family History:
No history of bleeding disorders or gastrointestinal ulcers.
Physical Exam:
Physical Exam on the medical floor:
Vitals: T: 98.6 BP: 133/69 P: 76 R: 18 O2: 96% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds
hyperactive, no rebound tenderness or guarding, no organomegaly"
1519,"No previous
tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
101 152 88 346/417 32 60 64
Brief Hospital Course:
79 yo M with recent THA, and severe UGIB, presents with
recurrent GI bleed.
#. Gastrointestinal bleed: The patient was initially
hypotensive in the 60s which quickly rose to the 120s after 4
liters of normal saline and 4 units of pRBCs. An IV PPI was
started which was later switched to oral on the floor. The
patient had a negative NG lavage and endoscopy revealed no
suspected bleeding at the previous bleeding site. Since there
was no evidence of upper GI bleeding, a colonoscopy was
performed next."
1520,"The colonoscopy revealed diverticulosis, but no
areas of active bleeding. The gastroenterologist recommended a
capsule study to evaluate the GI tract. The patient underwent
the capsule study and the results will be available after
discharge. After the initial fluid resusitation and
transfusions, the patient remained hemodynamically stable. He
had no episodes of GI bleeding and stable hematocrits. The
patient was advised to continuing taking his PPI. His aspirin
was stopped on his previous admission and restarting it should
be addressed as an outpatient. His discharge hematocrit was
33.3.
.
# Cellulitis on left hip: The patient was started on Vancomycin
and the erythema decreased significantly."
1521,"The patient was then
switched to Augmentin for a total 7 day course of treatment that
ends on [**9-27**].
.
# Leukocytosis: The patinet had a moderate leukocytosis while in
the hospital. It might have been due to his GIB or the
cellulitis. On previous admission, the primary team found out
that the patient had a high WBC at baseline and recommended
outpatient followup. On discharge, the WBC count was 11.9.
.
#Acute Renal Insufficiency: The patient presented with acute
renal failure, likely pre-renal in the setting of acute GI
bleed. With fluid resusitation, the creatinine returned to
baseline.
Outpatient followup:
1."
1522,"7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Rehab
Discharge Diagnosis:
Primary
-lower gastrointestinal bleed
.
Secondary
-cellulitis LLE (surgical wound)
-hypertension
Discharge Condition:
Stable. Patient ambulating with walker, on room air.
Discharge Instructions:
You came to the hospital after feeling lightheaded and low blood
pressure following a bloody bowel movement. You had an endoscopy
and colonoscopy which showed no bleeding. A capsule study was
performed and the results are pending.
.
Your aspirin was stopped on last admission. You should speak
with your primary doctor on when to start the aspirin."
1523,"Pt discharged to rehab where he was feeling well,
working with PT. At ortho f/u today for wound erythema developed
nausea and had black/red large BM with presyncopal symptoms.
Denied CP, palpitations.
At prior admission pt had been exposed to NSAIDs, ASA and
Coumadin. EGD showed ""Erythema and granularity in the
gastroesophageal, junction compatible with esophagitis, Ulcers
in the gastroesophageal junction, Schatzski ring noted in the
distal, esophagus, with hiatal hernia. Blood in the stomach,
Blood in the duodenum, Otherwise normal EGD to second part of
the duodenum"". Pt received a total of 15pRBCs, 5FFP, 1
platelets, and 1 Cryo and Hct on discharge was 36."
1524,"4 Lipase-44
[**2102-9-18**] Glucose-106* UreaN-27* Creat-1.2 Na-142 K-5.4* Cl-106
HCO3-28 AnGap-13 Calcium-8.3* Phos-3.5 Mg-2.1
U/A:
[**2102-9-18**] 01:51PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2102-9-18**] 01:51PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-LG Urobiln-1 pH-7.5 Leuks-TR
[**2102-9-18**] 01:51PM URINE CastHy-[**5-10**]*
EKG ([**9-18**]): Sinus tachycardia with frequent premature atrial
contractions. Non-specific ST-T wave abnormalities."
1525,"hematocrit, WBC
2. restarting aspirin
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H as needed for pain.
2. Lisinopril 10 mg PO DAILY.
3. Pantoprazole 40 mg PO Q12H.
4. Zolpidem 5 mg PO HS as needed for insomnia.
5. Docusate Sodium 100mg PO BID.
6. Senna 8.6 mg PO BID as needed for constipation.
7. Trimethoprim-Sulfamethoxazole 160-800 mg PO BID (2 times a
day) for 3 days: last day of treatment = [**9-17**].
8. Bisacodyl 10 mg PO DAILY (Daily) as needed for constipation.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C."
1526,") Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 4 days: Last day of treatment: [**9-27**]."
1527,"Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema to knees bilaterally. Left hip wound without purulence or
drainage, area of erythema along lower border without warmth
Pertinent Results:
Admission laboratories:
[**2102-9-18**] WBC-19.4*# RBC-2.96* Hgb-8.8* Hct-28.0* MCV-95 MCH-29.7
MCHC-31.4 RDW-15.0 Plt Ct-536*
[**2102-9-18**] Neuts-88.6* Lymphs-7.5* Monos-3.1 Eos-0.5 Baso-0.2
[**2102-9-18**] PT-13.0 PTT-26.5 INR(PT)-1.1
[**2102-9-18**] ALT-36 AST-23 AlkPhos-73 TotBili-0."
1528,".
You should call your primary doctor or come back to the hospital
if you have blood in your bowel movement, continue to have black
stools, or feel short of breath, lightheaded or dizzy.
Followup Instructions:
You should followup with your primary care doctor when you leave
rehab.
.
You have an appointment with the gastroenterologist in
[**Hospital1 6687**]: Dr. [**First Name (STitle) 572**] on [**2102-10-10**]. The gastrogenterology fellow,
Dr. [**Last Name (STitle) **], arranged this appointment for you.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 63560**]
Date/Time:[**2102-10-10**] 4:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]"
1529,"6. Senna 8.6 mg PO BID as needed for constipation.
7. Trimethoprim-Sulfamethoxazole 160-800 mg PO BID (2 times a day) for
3 days: last day of treatment = [**9-17**].
8. Bisacodyl 10 mg PO DAILY (Daily) as needed for constipation.
Past medical history:
Family history:
Social History:
Recent UGIB
Chronic LBP
HTN
Chronic L Hip pain
s/p R TKA
Achilles tendon repair
Rotator Cuff repair
Tonsillectomy
Post-op narcotic related ileus
Appendectomy
Noncontributory
Pt smokes [**12-2**] ppd, has [**12-2**] EtoH drinks 3 days a week. Denies any
recreational drug use.
Review of systems:
As per HPI
Flowsheet Data as of [**2102-9-18**] 04:58 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36."
1530,"- q4 hr Hct
- another 1L NS now
- active type and cross
- NGL negative for blood
- 1U pRBCs for now
- GI consulted, plan on scope today
- 3 large bore peripheral IVs
- no need for central access at this time, seems pressors will be
avoidable at this time. If requires will place transfusion line.
- holding BP meds.
- PPI drip
.
#. Hyperkalemia: repeated at 5.4 without EKG changes. Resolved with
multiple liters of IVF.
.
#. Acute Renal Insufficiency: Baseline Cr 0.7-0.8, now at 1.2.
Presumabely prerenal given hypotension and concurrent elevated lactic
acid.
- Continue to monitor with IVF and pRBC resuscitation
- dose meds renally
- avoid nephrotoxins
.
# Wound erythema. No abscess noted.
- treat cellulitis with Keflex as recommended by Ortho
.
#. Hypertension. Not active issue. Holding home lisinopril given GIB.
.
#. Recent UTI. Completed course of Bactrim last week. UA neg today
.
FEN: NPO for now, IVF prn above, lytes prn
.
PPX:
-DVT ppx with pneumoboots
-Bowel regimen colace/senna
-Pain management with tylenol
.
ACCESS: PIVs x2
.
CODE STATUS: Confirmed full
.
EMERGENCY CONTACT: Wife [**Name (NI) 10853**], [**Telephone/Fax (1) 10552**]
.
DISPOSITION: ICU
."
1531,"EGD showed ""Erythema and granularity in the gastroesophageal, junction
compatible with esophagitis, Ulcers in the gastroesophageal junction,
Schatzski ring noted in the distal, esophagus, with hiatal hernia.
Blood in the stomach, Blood in the duodenum, Otherwise normal EGD to
second part of the duodenum"". Pt received a total of 15pRBCs, 5FFP, 1
platelets, and 1 Cryo and Hct on discharge was 36.
.
In the ED initial vitals: HR103 BP66/40 O298%RA. Pt appeared pale,
diaphoretic, rectal revealed dark blood in vault. Pt had 3 PIVs placed:
16G, 18G, 20G. Pt received 40mg IV Protonix and a total of 3L NS,
awaiting blood crossing."
1532,"3
Other labs: Lactic Acid:1.8 mmol/L
Assessment and Plan
79 yo M with recent THA, and severe UGIB, presents with recurrent GI
bleed.
#. GIB: Per history unclear if upper or lower source given black and
red stools. Suspect possible rebleed at site of prior bleeding. Pt
without prior risk factors of NSAIDs, ASA, Coumadin but was meanwhile
on Bactrim which may have elevated INR. INR today 1.1. Pt intially
hypotensive to 60s, came up quickly to 120s with 3L IVF. Also with
acute renal failure and elevated lactic acidosis. Type and cross sent
but blood not given given Hct 28, which is 8 point drop from recent
discharge."
1533,"Normal S1, S2. No murmurs, rubs
or [**Last Name (un) 1011**]. JVP=
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial
pulses.
SKIN: No rashes/lesions, ecchymoses. Slight erythema at base of hip
incision, otherwise healing well. No warmth, fluctuance or draining.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Labs / Radiology
4.7 mEq/L
22.3 %
[image002.jpg]
[**2098-12-1**]
2:33 A10/19/[**2101**] 03:36 PM
[**2098-12-5**]
10:20 P
[**2098-12-6**]
1:20 P
[**2098-12-7**]
11:50 P
[**2098-12-8**]
1:20 A
[**2098-12-9**]
7:20 P
1//11/006
1:23 P
[**2099-1-1**]
1:20 P
[**2099-1-1**]
11:20 P
[**2099-1-1**]
4:20 P
Hct
22."
1534,"TITLE:
Chief Complaint: GI bleed
HPI:
79-year old gentleman s/p recent hip replacement surgery ([**8-29**] at
NEBH), with post op complicated by severe GI bleed in the setting of
NSAIDs, Coumadin, ASA, requiring MICU admission. Pt found to have
duodenal bleed but could not be fully accessed due to its location and
surrounding area was injected with epi and clipped. Pt discharged to
rehab where he was feeling well, working with PT. At ortho f/u today
for wound erythema developed nausea and had black/red large BM with
presyncopal symptoms. Denied CP, palpitations.
.
At prior admission pt had been exposed to NSAIDs, ASA and Coumadin."
1535,"labs significant for WBC 19.4, Hct 28, Plt 536, Cr 1.2, K 5.4, INR 1.1.
Pt was seen by GI and recommended NGL and semiemergent scope. Most
recent vitals: 75, 91/47, 15, 100% 2L.
.
Ortho recommended Keflex 500mg TID for wound erythema.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Pantoprazole (Protonix) - 10 mg/hour
Home Meds:
1. Acetaminophen 650 mg PO Q6H as needed for pain.
2. Lisinopril 10 mg PO DAILY.
3. Pantoprazole 40 mg PO Q12H.
4. Zolpidem 5 mg PO HS as needed for insomnia.
5. Docusate Sodium 100mg PO BID."
1536,"6
C (97.8
Tcurrent: 36.6
C (97.8
HR: 91 (88 - 91) bpm
BP: 109/52(67) {109/44(62) - 121/52(67)} mmHg
RR: 13 (13 - 16) insp/min
SpO2: 97%
Total In:
1,357 mL
PO:
TF:
IVF:
1,015 mL
Blood products:
342 mL
Total out:
0 mL
480 mL
Urine:
480 mL
NG:
Stool:
Drains:
Balance:
0 mL
877 mL
Physical Examination
GENERAL: Pleasant, well appearing white elderly male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral
icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, normal rate."
1537,"8 mmol/L, Ca++:8.3 mg/dL, Mg++:2.1
mg/dL, PO4:3.5 mg/dL
Assessment and Plan
79 yo M with recent THA, and severe UGIB, presents with recurrent GI
bleed.
#. GIB: Evaluation for upper GI bleed negative, suspect source in
lower GI tract. Pt without prior risk factors of NSAIDs, ASA, Coumadin
but was meanwhile on Bactrim which may have elevated INR. INR today
1.0. Pt intially hypotensive to 60s, came up quickly to 120s with 4L
IVF s/p 4U hct. Also with acute renal failure and elevated lactic
acidosis. 8 point drop from recent discharge to Hct 28 -> 4L IVF ->
22."
1538,"2 g/dL
88 mg/dL
0.8 mg/dL
28 mEq/L
4.6 mEq/L
22 mg/dL
107 mEq/L
140 mEq/L
30.3 %
16.7 K/uL
[image002.jpg]
[**2102-9-18**] 03:36 PM
[**2102-9-18**] 05:29 PM
[**2102-9-18**] 11:25 PM
[**2102-9-19**] 04:38 AM
WBC
16.7
Hct
22.3
26.2
29.4
30.3
Plt
390
Cr
0.8
TropT
0.01
Glucose
88
Other labs: PT / PTT / INR:12.1/27.5/1.0, CK / CKMB /
Troponin-T:/4/0.01, Lactic Acid:1."
1539,"#. Hypertension. Not active issue. Holding home lisinopril given GIB.
#. Recent UTI. Completed course of Bactrim last week. UA neg today
#. FEN: NPO for now, IVF prn above, lytes prn
#. PPX:
-DVT ppx with pneumoboots
-Bowel regimen colace/senna
-Pain management with tylenol
#. ACCESS: PIVs x2
#. CODE STATUS: Confirmed full
#. EMERGENCY CONTACT: Wife [**Name (NI) 10853**], [**Telephone/Fax (1) 10552**]
#. DISPOSITION: ICU, call out today if Hct stable
ICU Care
Nutrition:
Glycemic Control:
Lines:
16 Gauge - [**2102-9-18**] 02:54 PM
18 Gauge - [**2102-9-18**] 04:54 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:"
1540,"Chief Complaint:
24 Hour Events:
- NG lavage negative
- GI with negative upper endoscopy, replaced clips over previous site,
rec: stabilize overnight, transfuse to hct >30, will scope when can
tolerate prep, if negative for capsule, if continued bleeding, need
tagged RBC scan
- Given 4L fluid Hct 28 -> 22.3, given 2U PRBC Hct 26.2, given 1U PRBC
Hct 29.4, getting 1 more unit, recheck am hct
- Surgical c/s given prior GIB difficult to access
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Pantoprazole (Protonix) - 10 mg/hour
Other ICU medications:
Midazolam (Versed) - [**2102-9-18**] 06:38 PM
Fentanyl - [**2102-9-18**] 06:38 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2102-9-19**] 07:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
1541,"6
C (99.7
Tcurrent: 36.7
C (98.1
HR: 72 (69 - 103) bpm
BP: 125/52(68) {103/35(55) - 154/75(93)} mmHg
RR: 13 (12 - 29) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Total In:
5,410 mL
603 mL
PO:
TF:
IVF:
1,255 mL
333 mL
Blood products:
1,155 mL
270 mL
Total out:
875 mL
950 mL
Urine:
875 mL
950 mL
NG:
Stool:
Drains:
Balance:
4,535 mL
-347 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 96%
ABG: ///28/
Physical Examination
Awake, alert, appropriate
RRR, cta b/l
Abd soft, nontender
2+ pulses
Labs / Radiology
390 K/uL
10."
1542,"3, given 2U PRBC Hct 26.2, given 2U PRBC Hct 30
- GI recs: stabilize overnight, transfuse to hct >30, will scope when
can tolerate prep, if negative for capsule, if continued bleeding, need
tagged RBC scan
- surgery to follow
- q4 hr Hct
- maintain active type and cross
- 3 large bore peripheral IVs
- holding BP meds.
- continue PPI drip
#. Acute Renal Insufficiency: At baseline Cr 0.7-0.8. Probably was
prerenal given improvement with fluids.
- Monitor daily
# Wound erythema. No abscess noted.
- treat cellulitis with Keflex as recommended by Ortho
#. Hyperkalemia: 5.4 -> 4.6 without EKG changes. Resolved with multiple
liters of IVF."
1543,"Chief Complaint: GI Bleed, Blood Loss Anemia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
No complaints this AM except feeling bloated, passed significant gas
overnight
24 Hour Events:
ENDOSCOPY - At [**2102-9-18**] 05:51 PM - no active bleedin seen on EGD
Transfused 4 units of pRBCs overnight to Hct > 30
Hemodynamically stable overnight
History obtained from [**Hospital 15**] Medical records, icu team
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Midazolam (Versed) - [**2102-9-18**] 06:38 PM
Fentanyl - [**2102-9-18**] 06:38 PM
Other medications:
per ICU resident note
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: No(t) Fever
Ear, Nose, Throat: OG / NG tube
Nutritional Support: NPO
Gastrointestinal: No(t) Abdominal pain
Heme / Lymph: Anemia
Pain: No pain / appears comfortable
Flowsheet Data as of [**2102-9-19**] 09:19 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
1544,"01, Lactic Acid:1.8 mmol/L, Ca++:8.3 mg/dL, Mg++:2.1
mg/dL, PO4:3.5 mg/dL
Assessment and Plan
GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)
PAIN CONTROL
79 yo man with recent GI Bleed from bleeding duodenal vessel, in MICU
with new GI Bleed, blood loss anemia. EGD yesterday without
significant active bleeding source.
-Will need colonoscopy - will discuss with GI if prep today
appropriate. If colonoscopy negative will bleed capsule study
-PPI
-Okay to call out to the floor
-Serial Hcts
-Continue to hold anti-hypertensives
-Cr improved
Remainder of issues per ICU team
ICU Care
Nutrition:
Glycemic Control:
Lines:
16 Gauge - [**2102-9-18**] 02:54 PM
18 Gauge - [**2102-9-18**] 04:54 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :Transfer to floor
Total time spent:"
1545,"2 g/dL
390 K/uL
88 mg/dL
0.8 mg/dL
28 mEq/L
4.6 mEq/L
22 mg/dL
107 mEq/L
140 mEq/L
30.3 %
16.7 K/uL
[image002.jpg]
[**2102-9-18**] 03:36 PM
[**2102-9-18**] 05:29 PM
[**2102-9-18**] 11:25 PM
[**2102-9-19**] 04:38 AM
WBC
16.7
Hct
22.3
26.2
29.4
30.3
Plt
390
Cr
0.8
TropT
0.01
Glucose
88
Other labs: PT / PTT / INR:12.1/27.5/1.0, CK / CKMB /
Troponin-T:/4/0."
1546,"6
C (99.7
Tcurrent: 36.7
C (98.1
HR: 68 (68 - 103) bpm
BP: 118/49(65) {103/35(55) - 154/75(93)} mmHg
RR: 13 (12 - 29) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Total In:
5,410 mL
723 mL
PO:
TF:
IVF:
1,255 mL
453 mL
Blood products:
1,155 mL
270 mL
Total out:
875 mL
1,350 mL
Urine:
875 mL
1,350 mL
NG:
Stool:
Drains:
Balance:
4,535 mL
-627 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 97%
ABG: ///28/
Physical Examination
General Appearance: No acute distress
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed, conversive,
appropriate
Labs / Radiology
10."
1547,"Demographics
Day of intubation:
Day of mechanical ventilation: 2
Ideal body weight: 67.1 None
Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg
Airway
Airway Placement Data
Known difficult intubation: No
Tube Type
ETT:
Position: 24 cm at teeth
Route: Oral
Type: Standard
Size: 8mm
Cuff Management:
Vol/Press:
Cuff pressure: 25
cmH2O
Lung sounds
RLL Lung Sounds: Diminished
RUL Lung Sounds: Clear
LUL Lung Sounds: Clear
LLL Lung Sounds: Diminished
Secretions
Sputum color / consistency: Blood Tinged / Thin
Sputum source/amount: Suctioned / Small
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Visual assessment of breathing pattern: Normal quiet breathing
Assessment of breathing comfort: No response (sleeping / sedated)
Trigger work assessment: Triggering synchronously
Plan
Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated
Reason for continuing current ventilatory support: Underlying illness
not resolved"
1548,"Admission Date: [**2105-2-19**] Discharge Date: [**2105-2-26**]
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / Terazosin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
88 M admitted to [**Hospital1 **] [**Location (un) 620**] with CAP and atrial fibrillation
with RVR on [**2-16**]. He was treated with levaquin and then changed
to CTX/azithro/flagyl and subsequently transferred to ICU for
hypoxia thought to be due to acute heart failure. TTE showed
preserved systolic function but did show moderate RV dilation so
a CTA chest was done which was negative for PE."
1549,"Remained hypoxic
and placed on BIPAP which fell on his head causing laceration,
has had 2 CTH which were unrevealing for ICH. Has been on
diltiazem gtt for rate control and VSS at time of transfer wre
90s on NRB and stable BP and HR.
Upon arrival to the ICU patient comfortable and in no acute
distress, speaking in full sentences with clear sensorium. No
complaints.
Patient then became difficult to mantain adequate oxygenation on
NRB and subsequently on BIPAP with saturations in the 90s,
patient became progressively delirious and intubation was
undertaken.
Past Medical History:
atrial fibrillation
atrial flutter
CAD s/p CABG
history of PFO
ulcerative colitis
glaucoma
hypertension
BPH s/p TURP"
1550,"Social History:
Lives at home. Prior smoker quit several years ago
Family History:
unremarkable.
Physical Exam:
General Appearance: Intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: Irregular
Respiratory / Chest: Rhonchi bilaterally up to [**1-25**]
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: No lower extremity edema
Skin: Warm
Neurologic: Intubated, sedated
Pertinent Results:
Labs on Admission:
[**2105-2-19**] 07:34PM BLOOD WBC-25.3*# RBC-3.02* Hgb-9.8* Hct-29.7*
MCV-98 MCH-32.3* MCHC-32.9 RDW-13.9 Plt Ct-308
[**2105-2-19**] 07:34PM BLOOD Neuts-90."
1551,"There is no appreciable pleural effusion. ET tube is
in standard placement. Nasogastric tube ends in the stomach. No
pneumothorax.
CXR ([**2-23**]): In comparison with the study of [**2-22**], there is
continued elevation of pulmonary venous pressure with
atelectasis at the left base medially.
Video swallow study ([**2-24**]): ****
Brief Hospital Course:
88 year old male with CAD s/p CABG, remote smoking history,
atrial fibrillation, [**Hospital **] transferred from [**Hospital1 **] [**Location (un) 620**] with
hypoxia after being treated for a CAP
.
# Hypoxia: Initially intubated given difficulty with
oxygenation. TTE revealed regional akinesis and hypokinesis, as
well as LVEF 35%, possibly attributable to acute heart failure."
1552,"He was placed on furosemide gtt but was intermittently held for
hypotension. Was placed on empiric antibiotics for CAP. Was
evaluated by Speech & Swallow therapy, and was believed to be
aspirating as well has collecting significant pharyngeal
residue, to which he was insensate. This was potentially
secondary to irritation of his oropharynx from his brief
intubation. His hypoxia improved greatly, and it was felt that
his swallow would likely recover over time. A dobhoff was
placed for temporary nutrition and med administration. ****
.
# Atrial fibrillation with RVR: Placed on diltiazem gtt for rate
control. Amiodarone was initially held for concern for
amiodarone-induced pneumonitis, but this was eventually
restarted."
1553,"Warfarin was restarted on [**2-21**]. Dilt was switched
over to PO and increased to 60qd with good rate control. At
dishcarge his home dose of verapamil SR was restarted.
.
# CAD s/p CABG/CHF: Added lisinopril to home regimen.****
.
# HTN: Well controlled on home regimen.
Medications on Admission:
Amiodarone 200 mg daily.
Accupril 5 mg daily.
Ursodiol 300 mg t.i.d.
Levothyroxine 25 mcg daily.
Sulfadiazine 100 mg b.i.d.
Coumadin.
Verapamil SR 180 mg daily.
Xalatan eye drops.
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Metipranolol 0."
1554,"Discharge Diagnosis:
Multifocal Pneumonia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were transferred to [**Hospital3 **] for better managment of your
low oxgyen levels which had required intubation at the outside
hospital. It was determined that you had a complicated
pneumonia, which responded well to antibiotics. It was
determined that you need tube feeds to temporarily protect your
wind pipe while your swallowing is not strong.
The following changes were made to your outpatient regimen:
Your warfarin was changed to 2mg per day.
Followup Instructions:
As needed with Rehab Facility MD
Provider [**Name9 (PRE) 161**] [**Name8 (MD) 6476**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2105-7-2**]
11:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2105-3-1**]"
1555,"3 % Drops Sig: One (1) drop Ophthalmic qd ().
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Accupril 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO three times a
day.
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. Verapamil SR 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU"
1556,"Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-24**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. Severe
pulmonic regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w LAD disease. Mild to moderate mitral
regurgitation. Mild pulmonary hypertension.
CXR ([**2-21**]): Asymmetrically distributed pulmonary edema improved
substantially between [**2-19**] and [**2-20**] and heart size decreased.
Allowing for lower lung volumes, there has been no subsequent
change. Since 8:10 p.m. on [**2-20**] more confluent areas of
pulmonary abnormality in the axillary subsegments of the right
upper lobe and right lung base posteriorly, could be pneumonia
but could also be asymmetric edema and atelectasis, particularly
the latter."
1557,"4 Phos-2.8 Mg-2.6
[**2105-2-19**] 08:18PM BLOOD Type-[**Last Name (un) **] pO2-57* pCO2-55* pH-7.38
calTCO2-34* Base XS-5 Comment-GREEN TOP
[**2105-2-19**] 09:09PM BLOOD Lactate-2.1*
Labs on Discharge:
Micro:
Studies:
ECHO ([**2-20**]): The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with mid- to
distal anterior and anteroseptal hypokinesis. The remaining
segments contract normally (LVEF = 35%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present."
1558,"1* Lymphs-6.8* Monos-2.7 Eos-0.3
Baso-0.1
[**2105-2-19**] 07:34PM BLOOD PT-15.6* PTT-27.7 INR(PT)-1.4*
[**2105-2-19**] 07:34PM BLOOD Glucose-125* UreaN-40* Creat-1.0 Na-150*
K-3.9 Cl-107 HCO3-32 AnGap-15
[**2105-2-19**] 07:34PM BLOOD CK(CPK)-309
[**2105-2-19**] 07:34PM BLOOD CK-MB-11* MB Indx-3.6 cTropnT-0.54*
[**2105-2-20**] 03:52AM BLOOD CK-MB-5 cTropnT-0.54*
[**2105-2-20**] 05:27PM BLOOD cTropnT-0.45*
[**2105-2-19**] 07:34PM BLOOD Calcium-9."
1559,"Also with afib/RVR
1. Respiratory Failure
-Cont CTX/azithro empirically pending cx results
-Cont diuresis
-SBT - assess for possibility of extubation
-weaning sedation - following commands
2. Afib/RVR
-Rate well controlled
-able to wean dilt gtt
-cont amiodarone
3. Hypertension
4. Hypernatremia resolved with fH20
5. Access - place PICC
6. Mental status
-improving with sedation wean
7. Met alkalosis
-? Contraction from diuresis
-has compensatory mild resp acidosis
Remainder of issues per ICU team.
ICU Care
Nutrition:
Glycemic Control:
Lines:
22 Gauge - [**2105-2-19**] 06:36 PM
Arterial Line - [**2105-2-19**] 11:28 PM
20 Gauge - [**2105-2-21**] 09:55 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :
Total time spent: 35 minutes
Patient is critically ill"
1560,"1
Plt
[**Telephone/Fax (3) 11219**]
Cr
1.0
1.2
1.1
1.1
TropT
0.54
0.54
0.45
TCO2
32
32
34
35
35
37
Glucose
125
164
124
104
Other labs: PT / PTT / INR:15.9/29.6/1.4, CK / CKMB /
Troponin-T:377/5/0.45, Differential-Neuts:80.1 %, Band:0.0 %,
Lymph:15.0 %, Mono:3.1 %, Eos:1.3 %, Lactic Acid:1.8 mmol/L, Ca++:8.7
mg/dL, Mg++:1.8 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
88 yo man with hypoxemic respiratory failure due likely combination of
pneumonia and diastolic CHF."
1561,"44/53/143/31/10
Ve: 9.6 L/min
PaO2 / FiO2: 286
Physical Examination
General Appearance: Thin
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (S1: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :
anteriorly)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower extremity
edema: Trace
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
9.7 g/dL
309 K/uL
104 mg/dL
1."
1562,"TITLE:
Chief Complaint: resp failure, CAP, afib RVR
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
-progress weaning vent
-diuresed
History obtained from [**Hospital 19**] Medical records
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Unknown;
Terazosin
Unknown;
Last dose of Antibiotics:
Ceftriaxone - [**2105-2-21**] 08:15 AM
Azithromycin - [**2105-2-21**] 09:00 AM
Infusions:
Midazolam (Versed) - 0.5 mg/hour
Fentanyl (Concentrate) - 25 mcg/hour
Furosemide (Lasix) - 5 mg/hour
Other ICU medications:
Fentanyl - [**2105-2-20**] 12:30 PM
Midazolam (Versed) - [**2105-2-20**] 12:30 PM
Famotidine (Pepcid) - [**2105-2-21**] 08:00 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2105-2-21**] 11:28 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**07**] AM
Tmax: 37."
1563,"1 mg/dL
31 mEq/L
3.7 mEq/L
42 mg/dL
106 mEq/L
146 mEq/L
29.1 %
13.3 K/uL
[image002.jpg]
[**2105-2-19**] 07:34 PM
[**2105-2-19**] 09:09 PM
[**2105-2-19**] 11:51 PM
[**2105-2-20**] 03:52 AM
[**2105-2-20**] 04:35 AM
[**2105-2-20**] 05:27 PM
[**2105-2-20**] 05:47 PM
[**2105-2-21**] 03:35 AM
[**2105-2-21**] 03:50 AM
[**2105-2-21**] 08:49 AM
WBC
25.3
15.8
13.3
Hct
29.7
28.6
29."
1564,"8
C (100.1
Tcurrent: 36.7
C (98
HR: 94 (76 - 103) bpm
BP: 116/64(85) {82/48(61) - 135/69(95)} mmHg
RR: 17 (15 - 28) insp/min
SpO2: 96%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 58 kg (admission): 55.9 kg
Height: 67 Inch
Total In:
2,606 mL
494 mL
PO:
TF:
IVF:
2,506 mL
434 mL
Blood products:
Total out:
1,555 mL
1,060 mL
Urine:
1,555 mL
1,060 mL
NG:
Stool:
Drains:
Balance:
1,051 mL
-566 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: PSV/SBT
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 520 (471 - 520) mL
PS : 5 cmH2O
RR (Set): 16
RR (Spontaneous): 19
PEEP: 0 cmH2O
FiO2: 50%
RSBI: 53
PIP: 6 cmH2O
Plateau: 17 cmH2O
SpO2: 96%
ABG: 7."
1565,"5
12.6
Hct
29.8
30.1
31.4
Plt
[**Telephone/Fax (3) 11277**]
Cr
1.0
0.8
0.7
0.6
0.7
0.8
TCO2
35
37
38
26
36
Glucose
98
109
131
117
118
108
Other labs: PT / PTT / INR:20.8/33.5/1.9, CK / CKMB /
Troponin-T:377/5/0.45, Differential-Neuts:80.1 %, Band:0.0 %,
Lymph:15.0 %, Mono:3.1 %, Eos:1.3 %, Lactic Acid:1.8 mmol/L, Ca++:8.7
mg/dL, Mg++:1.9 mg/dL, PO4:3.7 mg/dL
Assessment and Plan
PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)
ATRIAL FIBRILLATION (AFIB)
ASPIRATION
CAD, S/P CABG
INCR Na
Feels well but weak."
1566,"7
C (99.9
Tcurrent: 35.9
C (96.7
HR: 100 (99 - 107) bpm
BP: 153/138(146) {104/42(80) - 162/140(295)} mmHg
RR: 26 (12 - 31) insp/min
SpO2: 100%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 55.6 kg (admission): 55.9 kg
Height: 67 Inch
Total In:
454 mL
220 mL
PO:
30 mL
30 mL
TF:
IVF:
424 mL
190 mL
Blood products:
Total out:
1,580 mL
345 mL
Urine:
1,580 mL
345 mL
NG:
Stool:
Drains:
Balance:
-1,126 mL
-125 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ///34/
Physical Examination
General Appearance: No(t) Well nourished, No(t) No acute distress,
No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva
pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)
Endotracheal tube, No(t) NG tube, No(t) OG tube
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)
Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,
No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)
Diastolic), 2/6 SEM
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),
(Breath Sounds: No(t) Clear : , Crackles : bilat lower mid insp, No(t)
Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,
No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,
No(t) Tender: , No(t) Obese
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: Muscle wasting, Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): x3, Movement: Purposeful, No(t) Sedated, No(t)
Paralyzed, Tone: Not assessed
Labs / Radiology
10."
1567,"Chief Complaint: Respiratory failure
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
Comfortable. Swallow study - major aspiration - does not sense bolus
24 Hour Events:
History obtained from [**Hospital 19**] Medical records
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Unknown;
Terazosin
Unknown;
Last dose of Antibiotics:
Azithromycin - [**2105-2-23**] 08:30 AM
Ceftriaxone - [**2105-2-24**] 12:05 PM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2105-2-24**] 12:06 PM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: Fatigue, Fever, No(t) Weight loss
Eyes: No(t) Blurry vision, No(t) Conjunctival edema
Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube
Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,
No(t) Tachycardia, No(t) Orthopnea
Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition
Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,
No(t) Diarrhea, No(t) Constipation
Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis
Musculoskeletal: No(t) Joint pain, No(t) Myalgias
Integumentary (skin): No(t) Jaundice, No(t) Rash
Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease
Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy, coumadin
Neurologic: Numbness / tingling, No(t) Headache, No(t) Seizure
Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,
No(t) Daytime somnolence
Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine
Pain: No pain / appears comfortable
Flowsheet Data as of [**2105-2-24**] 12:41 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**07**] AM
Tmax: 37."
1568,"Aspirating on swallow study. Would be inclined
to give him meds in soft solids and see if he can tolerate as he is not
a great candidate for feeding tube with anticoagulation. Suspect some
of swallowing difficulty will improve as he gets away from intubation.
UO is somewhat low but adequate - may be somewhat dry so will give IVF
if urine drops off
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2105-2-19**] 11:28 PM
20 Gauge - [**2105-2-21**] 05:00 PM
PICC Line - [**2105-2-22**] 09:00 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: H2 blocker
VAP:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition :Transfer to floor
Total time spent: 35 minutes"
1569,"0 g/dL
359 K/uL
108 mg/dL
0.8 mg/dL
34 mEq/L
3.8 mEq/L
24 mg/dL
105 mEq/L
145 mEq/L
31.4 %
12.6 K/uL
[image002.jpg]
[**2105-2-21**] 11:24 AM
[**2105-2-21**] 12:37 PM
[**2105-2-21**] 01:16 PM
[**2105-2-22**] 03:14 AM
[**2105-2-22**] 03:41 AM
[**2105-2-22**] 11:32 AM
[**2105-2-22**] 04:00 PM
[**2105-2-23**] 02:50 AM
[**2105-2-23**] 05:05 PM
[**2105-2-24**] 03:21 AM
WBC
14.4
13."
1570,"6 %
[**2105-2-20**] 03:52 AM
Current diet order / nutrition support: Diet: NPO
GI: abd soft, hypoactive bowel sounds
Assessment of Nutritional Status
Malnourished
Patient at risk due to: Malnourished due to 4% wt loss over past week,
minimal caloric intake for 5 days, low baseline wt, advanced age
Estimated Nutritional Needs
Calories: 1462-1755 (25-30 cal/kg)
Protein: 58-70 (1-1.2 g/kg)
Fluid: per team
Calculations based on: Usual body weight
Estimation of previous intake: Inadequate
Estimation of current intake: Inadequate
Specifics:
88 y.o. Male admitted with hypoxemic respiratory failure due to likely
combination of PNA and diastolic CHF."
1571,"Patient is currently intubated
and sedated. Recommend starting enteral nutrition within the next
24-48hrs, as patient has had minimal nutrition for 5 days and had a low
body wt at baseline. Recommend a low carbohydrate formula given
hyperglycemia with IV fluids. Noted IV fluids at 100mL/hr to help
rehydrate patient and correct hypernatremia.
Medical Nutrition Therapy Plan - Recommend the Following
Recommend tube feeding goal of Boost Glucose Control @
57mL/hr (1450kcals, 79g protein). Start at 15mL/hr and advance rate by
10mL q4hrs as tolerated to goal.
Adjust H20 flushes to help keep patient hydrated but not
fluid overloaded.
Multivitamin / Mineral supplement: via tube feeds
Following - #[**Numeric Identifier 1312**]"
1572,"2 mg/dL
[**2105-2-20**] 03:52 AM
Sodium
150 mEq/L
[**2105-2-20**] 03:52 AM
Potassium
3.4 mEq/L
[**2105-2-20**] 03:52 AM
Chloride
109 mEq/L
[**2105-2-20**] 03:52 AM
TCO2
32 mEq/L
[**2105-2-20**] 03:52 AM
PO2 (arterial)
67 mm Hg
[**2105-2-20**] 04:35 AM
PO2 (venous)
57 mm Hg
[**2105-2-19**] 08:18 PM
PCO2 (arterial)
50 mm Hg
[**2105-2-20**] 04:35 AM
PCO2 (venous)
55 mm Hg
[**2105-2-19**] 08:18 PM
pH (arterial)
7.43 units
[**2105-2-20**] 04:35 AM
pH (venous)
7."
1573,"38 units
[**2105-2-19**] 08:18 PM
pH (urine)
5.0 units
[**2105-2-19**] 09:44 PM
CO2 (Calc) arterial
34 mEq/L
[**2105-2-20**] 04:35 AM
CO2 (Calc) venous
34 mEq/L
[**2105-2-19**] 08:18 PM
Calcium non-ionized
8.5 mg/dL
[**2105-2-20**] 03:52 AM
Phosphorus
3.5 mg/dL
[**2105-2-20**] 03:52 AM
Magnesium
2.4 mg/dL
[**2105-2-20**] 03:52 AM
WBC
15.8 K/uL
[**2105-2-20**] 03:52 AM
Hgb
9.2 g/dL
[**2105-2-20**] 03:52 AM
Hematocrit
28."
1574,"Subjective: Per patient
s wife, patient usually eats very well, is
very careful to eat low fat and low sugar due to h/o multiple CABG
Patient also works out 30-45 minutes per day.
Objective
Height
Admit weight
Daily weight
Weight change
BMI
170 cm
55.9 kg
19.3
Ideal body weight
% Ideal body weight
Adjusted weight
Usual body weight
% Usual body weight
67.1 kg
83%
58.5 kg
96%
Diagnosis: PNA
PMHx: atrial fibrillation, atrial flutter, CAD s/p CABG, history of
PFO, ulcerative colitis, glaucoma, hypertension, BPH s/p TURP
Food allergies and intolerances: none
Pertinent medications: Fentanyl, Versed, dextrose 5% @ 100mL/hr, ABx,
Pepcid, Heparin, others noted
Labs:
Value
Date
Glucose
164 mg/dL
[**2105-2-20**] 03:52 AM
Glucose Finger Stick
201
[**2105-2-20**] 10:00 AM
BUN
47 mg/dL
[**2105-2-20**] 03:52 AM
Creatinine
1."
1575,"Admission Date: [**2197-3-31**] Discharge Date: [**2197-4-2**]
Date of Birth: [**2120-5-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Paraesophageal Hernia
Major Surgical or Invasive Procedure:
[**2197-3-31**] Parasesophageal hernia repair
History of Present Illness:
Mr. [**Known lastname **] is a 76 year old male with multiple medical problems
who was referred to Dr. [**First Name (STitle) **] by his PCP [**Name Initial (PRE) **] 2 reasons. He has a
large paraesophageal hernia by CT scan and exhibits symptoms of
occasional regurgitation. He has no nausea or vomiting."
1576,"He is
able to eat all foods. His weight is down 10 lbs over the last
year and he was also recently diagnosed with prostate cancer.
His second issue is that of a thoracoabdominal aneurysym 4 cm at
its greatest diameter and he was also referred for possible
stent placement. His main complaint is of a sore throat for the
past 3 weeks. He occasionally coughs up thin phlegm, denies SOB
or wheezing.
Past Medical History:
1. Hypertension
2. Diabetes
3. Gout
4. Arthritis
5. Prostate cancer
6. Thoracoabdominal aneurysm
1. S/P APPY
2. S/P RIH
3. S/P right ear tumor excision years"
1577,"Social History:
Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:> 80
pk years__
quit: _1998_____
ETOH: [ ] No [x] Yes drinks/day: __occasional
beer___
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation:
Marital Status: [x] Married [ ] Single
Lives: [ ] Alone [x] w/ family [ ] Other:
Family History:
Non contributory
Physical Exam:
VS:98.6 71 147/68 18 94% on room air
Gen: AOx3 NAD
Cor: RRR
Res: CTAB
Abd: Soft, NT/ND
Wounds: Lap port sites C/D/I
Ext: WWP without edema
Pertinent Results:
[**2197-4-1**] 02:38AM BLOOD WBC-13.3*# RBC-3.68* Hgb-11.8* Hct-33."
1578,"Please see the
dictated operative note for further details of the patient's
procedure. Postoperatively he required reintubation for
agitation and was kept in the surgical intensive care unit
overnight. He was subsequently extubated on POD1. He had some
pain control issues initially which was accompanied by some
hypertension and SVT, however with good pain control these
symptoms resolved. He had an upper GI study which demonstrated
good flow with no leak hence he was started on sips and advanced
to a soft liquid diet. His pain was well controlled with oral
oxycodone elixir. His vital signs were stable within normal
limits."
1579,"Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. oxycodone 5 mg/5 mL Solution Sig: 5-10 Mg PO Q4H (every 4
hours) as needed for pain.
Disp:*200 ml* Refills:*0*
5. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-23**]
Drops Ophthalmic TID (3 times a day).
6. Allopurinol, 300mg PO daily
7. Metformin, 500mg PO Daily
Discharge Disposition:
Home
Discharge Diagnosis:
S/P paraesophageal hernia repair"
1580,"5*
MCV-91 MCH-32.0 MCHC-35.1* RDW-13.6 Plt Ct-211
[**2197-4-1**] 02:38AM BLOOD Glucose-147* UreaN-23* Creat-0.8 Na-137
K-4.0 Cl-106 HCO3-23 AnGap-12
[**2197-3-31**] 10:43PM BLOOD Type-ART pO2-177* pCO2-27* pH-7.50*
calTCO2-22 Base XS-0
[**2197-3-31**] 10:43PM BLOOD Lactate-1.6
[**2197-3-31**] 03:50PM BLOOD Hgb-12.9* calcHCT-39
[**2197-3-31**] 03:50PM BLOOD freeCa-1.18
Brief Hospital Course:
The patient was admitted to the Thoracic Surgical Service
following a repair of a paraesophageal hernia."
1581,"Discharge Condition:
Mental status is clear and coherent at the patient's baseline.
Ambulating and voiding without difficulty.
Tolerating full liquid diet.
Pain is controlled.
Discharge Instructions:
You were admitted to the hospital for a paraesophageal hernia
repair.
Pain
-Acetaminophen 650 mg every 6 hours as needed for pain
-Oxycodone 5-10 mg every 4 hours as needed for pain, you may
take this less often if you are able.
-Take stool softners with narcotics
-No driving while taking narcotics
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Diet:
Please stay on a full liquid diet for several days.
Eat small frequent meals. Sit in chair for all meals. Remain
sitting up for 30-45 minutes after all meals
NO CARBONATED DRINKS
Followup Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] to schedule a follow up
appointment.
Completed by:[**2197-4-2**]"
1582,"He was ambulating and voiding, and was judged to be
doign sufficiently well for discharge.
Medications on Admission:
1. ALLOPURINOL - (Prescribed by Other Provider) - 300 mg Tablet
- 1
Tablet(s) by mouth once a day
2. AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet -
1
Tablet(s) by mouth once a day
3. ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth once a day
4. METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet -
1
Tablet(s) by mouth once a day
5. SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet
- 1
Tablet(s) by mouth once a day"
1583,"Admission Date: [**2110-4-4**] Discharge Date: [**2110-4-7**]
Service: MEDICINE
Allergies:
sodium pentothal
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
cardiac catheterization with Drug eluting stent to the mid Left
anterior descending artery.
History of Present Illness:
88 year old woman with coronary artery disease (diagnosed by
stress testing [**2106**]), type 2 diabetes mellitus, hypertension,
GERD, paroxysmal atrial fibrillation on coumadin and sotalol
(INR 1.84 today and currently in sinus rhythm) who was
transferred from an OSH for management of an NSTEMI.
.
The patient was admitted [**2110-4-3**] to [**Hospital3 **] with chest
pressure."
1584,"She had been feeling well until overnight she
developed s/o CP, without diaphoresis, nausea, radiation or
dyspnea. Believing it was dyspepsia, the patient waited until
morning before calling EMS. An EKG was significant for SR w/ 1st
degree atrioventricular block and poor R wave progression which
was different from prior. Vitals were 102/60, 72. She
ultimately ruled in for an NSTEMI with Troponin I 14.96 this
morning, given aspirin 325mg, loaded with plavix, started on
heparin gtt and nitro paste and kept NPO. She was transferred to
[**Hospital1 18**] for cardiac catheterization, chest pain free.
Incidentally, a foley catheter had been placed for urinary
retention prior to transfer."
1585,"CARDIAC RISK FACTORS:
Diabetes(+),Dyslipidemia(+),Hypertension(+)
2. CARDIAC HISTORY:
- Atrial fibrillation: on coumadin, sotalol (now in sinus
rhythm). Initially unsuccessfully cardioverted, on digoxin and
atenolol.
- Hypertension: H/o labile pressures, now better on lisinopril
3. OTHER PAST MEDICAL HISTORY:
- Diabetes Type 2: Hmg A1c 6.5 in [**9-/2099**]
- Spinal stenosis, lower back pain
- Squamous cell carcinoma s/p excision (nose)
- Tonsillectomy
- Bunion surgery
- Open right thumb comminuted fracture s/p fall ([**1-/2109**])
- D&C
- Bakers Cyst on R knee
- Osteoarthritis
- Hypothyroid
- GERD w/ cough, patulous hiatus
- Nasal Polyps (s/p resection [**2099**])
- G4P6 (two sets of twins)
- Bunions/hammertoes (operated [**2097**])
- Macular degeneration, bilaterally"
1586,"Social History:
Widowed since [**2093**], fairly active (able to walk quarter mile
daily). Lives alone, with involved family. Retired lunch room
monitor. Interested in cardiac rehab.
- Tobacco history: Quit at age 60
- ETOH: Occasional
- Illicit drugs: Denies
Family History:
Heart diease, throat/tonsil/stomach cancers
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP not elevated.
CARDIAC: distant heart sonds, soft systolic murmur loudest at
upper sternal borders, no radiation to carotids.
LUNGS: No chest wall deformities, scoliosis or kyphosis."
1587,"There
was no gradient across the aortic valve on pullback from the LV
to the Aorta.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease. Poor targets for
bypass in the
left coronary system.
2. Left ventricular diastolic heart failure.
3. Systemic systolic arterial hypertension.
.
TTE [**2110-4-5**]:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with mid to distal antero-septal, anterior
and apical akinesis."
1588,"The right ventricular cavity is mildly
dilated with borderline normal free wall function. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**2-9**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Brief Hospital Course:
HOSPITAL COURSE
88 year old woman with coronary artery disease, type 2 diabetes
mellitus, hypertension, GERD, paroxysmal atrial fibrillation on
coumadin and sotalol who was admitted to the CCU status post DES
to LAD for post catheter monitoring after three minutes of
severe non-reflow to LAD observed during cath."
1589,"She was started on
atorvastatin 80mg daily. As above, her LDL was 88. Her TSH was
3.5.
.
# SPINAL STENOSIS: Currently on celebrex for pain management.
Held during admission given increased risk of adverse
cardiovascular events and side effect of hypertension. In
future, if restart, note to important to co-administer w/
aspirin for mitigating effect.
.
# URINARY RETENTION: Episode of urinary retention occurred at
OSH with placement of foley catheter and drainage of 700 cc
fluid. Urinalysis consistent with uncomplicated urinary tract
infection as symptom onset occurred before foley cath placement.
She was started on ciprofloxacin for total 3 day course."
1590,"Urine culture showed gram negative rods.
.
# HYPERBILIRUBINEMIA: Isolated hyperbilirubinemia on admission
in absence of right upper quadrant tenderness. Fractionated
bilirubin demonstrated t. bili 2.0 and direct bili 0.5 which
trended down to normal without intervention.
Medications on Admission:
HOME MEDICATIONS:
1. Nitroglycerin 0.4mg sublingual tablets, use as needed
2. Spironolactone 25 mg tablet 1 tablet qdaily
3. Isosorbide Mononitrate 60mg ER tablets take 1 tablet qAM PRN
4. Metoclopramide 20mg tablet qHS
5. Glyburide 10mg tablet qdaily
6. Warfarin 2.5 mg take 2 tablets everyday except Sundays, take
1 tab
7. Lisinopril 5mg qdaily
8. Lipitor 5 mg daily
9."
1591,"Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day)."
1592,"Sotalol 80 mg daily
10. Preservision eye vitamin 120 soft gel
11. Metformin 1000 mg tablet [**Hospital1 **]
12. Prilosec 1 tab qdaily
13. Vitamen D3 1000 1 U
14. Levothyroxine 25 mg qdaily
15. Celebrex 200 mg capsule take 1 qdaily
.
TRANSFER MEDICATIONS:
1. metoclopramide 20mg qhs
2. sotalol 80mg [**Hospital1 **]
3. lisinopril 5mg daily
4. spironolactone 25 mg daily
5. levothyroxine 25 mcg daily
6. lipitor 80mg daily
7. nitro gtt one inch q8hrs
8. multivitamen one tablet qdaily
9. B12 500 mcg daily
10. protonix 40mg daily
11. heparin gtt
12. nitroglycerin SL 0.4
13. Tylenol 650 mg q4hrs"
1593,".
# TYPE 2 DIABETES MELLITUS: History of DM2 on glyburide and
metformin. Most recent known A1c from [**2099**] and 6.5. Oral
diabetic agents in setting of cath and restarted 48 hours post
catheterization on discharge. Gluocose control managemed with
insulin sliding scale. A1c was 8.4.
.
# HYPERTENSION: History of labile pressures in the past with
improved control while on lisinopril, spironolactone, sotalol
regimen. Spironolactone and lisinopril held in setting of
catherization and restarted the following morning. Imdur was
held given prn dosing at home and was stopped at discharge.
.
# HYPERLIPIDEMIA: History of hyperlipidemia on low dose lipitor
at home. Unknown recent lipid panel."
1594,".
Cardiac catheterization showed twin LAD systems with severe
stenosis. Distal LAD stenosis also observed but not intervened
on. PCI was done to true LAD with Promus DES placed, initially
resulting in severe non-reflow X 3 minutes. The flow gradually
improved with administration of adenosine, diltiazem and
nicardipine. Right femoral arterial manual pull was performed.
Some ST elevations were noted transiently during cardiac
catheterization. Plan is for return to cath lab for stenting of
her right coronary artery in ~two weeks.
.
REVIEW OF SYSTEMS
(+) chronic peripheral edema, hearing loss, rhinorrhea,
nocturia, fatigue
(-) orthopnea, PND, dyspnea, palpitations, stroke, bleeding
disorder
Past Medical History:
1."
1595,"Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi on anterior exam. (lying flat post cath)
ABDOMEN: Soft, NTND. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Good distal DP and TP pulses dopplarable bilaterally,
femoral pulses ausculatated without femoral bruits
FEMORAL WOUND: Hematoma appears to be improving within outline.
No femoral bruits, or masses palpated. Intact distal pulses and
sensation. No bleeding into wound gauze.
Pertinent Results:
Hematology:
[**2110-4-7**] 07:45AM BLOOD WBC-6.6 RBC-3.76* Hgb-11.1* Hct-32."
1596,"5
.
STUDIES:
CARDIAC CATHERIZATION [**2110-4-4**]
1. Selective coronary angiography of this right-dominant system
demonstrated 3 vessel coronary artery disease. The LMCA had 30%
distal stenosis. The LAD had 90% mid-vessel stenosis. The
distal LAD was diffusely diseased and occluded at the apex.
There was in intramyocardial large spetal with 90% origin
stenosis. The LCx had 60% stenosis at mid-segment with 80% OM1
disease. The RCA had 80% stenosis in the distal segment with
60% stenosis of the RPL.
2. Limited resting hemodynamics revealed elevated left-sided
filling pressure with an LVEDP of 27 mmHg. There was systemic
systolic arterial hypertension with an SBP of 158 mmHg."
1597,"5* IndBili-1.5
[**2110-4-4**] 08:14PM BLOOD ALT-19 AST-85* LD(LDH)-405* CK(CPK)-495*
AlkPhos-78 TotBili-1.9*
Cardiac:
[**2110-4-5**] 05:31AM BLOOD CK-MB-22* MB Indx-6.2* cTropnT-1.63*
[**2110-4-4**] 08:14PM BLOOD CK-MB-37* MB Indx-7.5* cTropnT-1.77*
Other:
[**2110-4-5**] 05:31AM BLOOD Hapto-194
[**2110-4-4**] 11:14PM BLOOD %HbA1c-8.4* eAG-194*
[**2110-4-5**] 05:31AM BLOOD Triglyc-146 HDL-28 CHOL/HD-5.2 LDLcalc-88
[**2110-4-5**] 05:31AM BLOOD TSH-3."
1598,"14. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 [**Month (only) 4319**]: take in the evening [**4-7**]. .
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Hypertension
Atrial Fibrillation
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
YOu had a heart attack and was transferred to [**Hospital1 **] for a cardiac catheterization. This showed 3 blockages
in your coronary arteries. One was fixed with a drug eluting
stent and you will need to return to have the other 2 blockages
fixed in about 2 weeks."
1599,"Plan for staged
intevention of septal LAD and RCA lesions in several weeks.
.
ACTIVE ISSUES
# CORONARY ARTERY DISEASE: The patient is status post DES to
LAD with plan for staged intervention to septal LAD and RCA in
several weeks. Admitted to CCU for monitoring after 3 minutes
of severe non reflow that was relieved with adenosine, diltiazem
and nicardipine. Cardiac risk factors include dyslipidemia,
diabetes and hypertension with a reported postive stress test in
[**2106**]. She was started on full dose aspirin and plavix. Home dose
of lisinopril held post cath and started the following day. She
was started on atorvastatin 80mg daily."
1600,"You will need to take Clopidogrel
(Plavix) every day for at least one year and possibly longer. Do
not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 10543**] tells
you to. Stopping Plavix may cause the artery to get blocked
again and may cause a fatal heart attack.
You will get a call from the cardiac intake nurses at [**Hospital1 **] to
schedule the cardiac catheterization. Please call Dr. [**Last Name (STitle) 10543**] or
911 if you have any further chest pain.
.
We made the following changes to your medications:
1. Stop taking Warfarin, Imdur and Celebrex
2. Start taking Aspirin and Plavix (clopidogrel) every day for
at least one year and possibly longer.
3. Start taking tylenol for your arthritis.
5. Increase Lipitor to 80 mg for one to two months.
Followup Instructions:
Dr. [**Last Name (STitle) 10543**]: Friday [**4-11**] at 3:15pm."
1601,"9 Na-138
K-4.1 Cl-103 HCO3-26 AnGap-13
[**2110-4-4**] 08:14PM BLOOD Glucose-103* UreaN-15 Creat-0.7 Na-140
K-3.8 Cl-106 HCO3-22 AnGap-16
[**2110-4-7**] 07:45AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8
[**2110-4-4**] 08:14PM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7
LFTS:
[**2110-4-6**] 06:55AM BLOOD TotBili-1.4 DirBili-0.3 IndBili-1.1
[**2110-4-5**] 05:31AM BLOOD ALT-16 AST-74* CK(CPK)-357* AlkPhos-80
TotBili-2.0* DirBili-0."
1602,"7*
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.2 Plt Ct-152
[**2110-4-4**] 08:14PM BLOOD WBC-8.4 RBC-4.03* Hgb-11.8* Hct-34.5*
MCV-86 MCH-29.4 MCHC-34.3 RDW-14.1 Plt Ct-146*
Coags:
[**2110-4-7**] 07:45AM BLOOD PT-14.3* PTT-31.2 INR(PT)-1.2*
[**2110-4-6**] 06:55AM BLOOD PT-15.2* PTT-32.1 INR(PT)-1.3*
[**2110-4-4**] 08:14PM BLOOD PT-17.0* PTT-57.5* INR(PT)-1.5*
Chemistries:
[**2110-4-7**] 07:45AM BLOOD Glucose-177* UreaN-24* Creat-0."
1603,"Lipid panel showed LDL
88, and A1c was 8.4. TTE demonstrated EF 40%, mild to moderate
regional left ventricular systolic dysfunction with mid to
distal antero-septal, anterior and apical akinesis.
.
# RHYTHM/ATRIAL FIBRILLATION: History of atrial fibrillation on
coumadin at home. Now in sinus rhythm. Now status post DES to
LAD, the patient will require plavix and aspirin for one year.
Decision made to discontinue coumadin in setting of sinus rhythm
on admission and significant risk of bleeding if on triple
therapy. CHADS2 score is 3 (age, hypertension, diabetes). She
was continued on sotalol at her home dose."
1604,"7. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
8. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
11. glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day: Please start taking on Tuesday [**4-8**]."
1605,"Admission Date: [**2196-10-13**] Discharge Date: [**2196-10-21**]
Date of Birth: [**2145-4-30**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
worst headache of life
Major Surgical or Invasive Procedure:
[**2196-10-14**]: DIAGNOSTIC CEREBRAL ANGIOGRAM
[**2196-10-20**]: DIAGNOSTIC CEREBRAL ANGIOGRAM
History of Present Illness:
51 y/o female who presents a history of being at the gym today
around 5pm doing weighted hip lifts when she developed a sudden
onset severe headache and nausea. She was unable to rise from
the
floor, EMS was called, she was transported to [**First Name8 (NamePattern2) 745**] [**Last Name (NamePattern1) **]
Hospital and subsequently transferred here after a head CT
revealed SAH."
1606,"She was
taken to for a cerebral angiogram for confirmation and was
negative for aneurysm or other vascular anomalies.
On [**10-15**] a MRI/A of the cervical spine was performed to rule out
a vascular anomaly and was negative. Patient remained in the
ICU.
On [**10-17**] A CTA of the head was performed to r/o vasospasm which
was negative. She was subsequently transferred to the SD unit.
She did well on the floor, but mostly had difficulties with
lower back pain which ultimately responded to a combination of
NSAIDs and valium. Her headaches were controlled with fioricet-
and similar agents."
1607,"Disp:*40 Tablet(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*1*
5. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
SUBARACHNOID HEAMORRHAGE
HEADACHE
THYROID LESION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable."
1608,"????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?"
1609,"She received aprox. 9mg of Morphine and several anti-emetics
prior to transfer and was re medicated for nausea in our ER.
Past Medical History:
None
Social History:
Denies Tobacco, ETOH socially, Married, Lives at home with
husband and two kids.
Family History:
NC
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 2 GCS E: 3 V:5 Motor 6
O: T: 97.6 BP:126 /69 HR: 84 R15 O2Sats 100
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT,
Extrem: Warm and well-perfused."
1610,"Cerebral Angiogram [**2196-10-14**]:
Negative for aneurysm
MRI/A C-spine [**2196-10-15**]:
No evidence of arteriovenous fistula or malformation seen in the
cervical region. No abnormal signal seen within the spinal cord.
Mild
degenerative changes. No abnormal enhancement.
Brief Hospital Course:
51 y/o F s/p WHOL after working out at the gym. She was taken to
OSH where head CT revealed a perimesincephalic SAH. She was
transferred to [**Hospital1 18**] for further neurosurgical evaluation. Once
at the [**Hospital1 **], patient had a CTA of the head that showed no
aneurysm. Patient remained neurologically intact. On [**10-14**],
repeat head CT showed stable SAH with no hydrocephalus."
1611,"No C/C/E.
Neuro:
Mental status: Lethargic but alert, presents complete history,
cooperative with exam
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. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength intact and symmetric, decrease
sensation
right cheek.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally."
1612,"Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during this
hospitalization. You were admitted to the Neurosurgery Service
of the [**Hospital1 69**] for an evaluation of
your headache which was associated with a ""subarachnoid
hemorrhage"", which is a collection of blood just outside the
brain that can be very serious and dangerous. You received
multiple procedures to search for an ""aneurysm"", which is an
outpouching of a blood vessel that can be prone to easy rupture.
- Your restrictions are that you should not work x 4 weeks
- do not lift > 15 lbs
- you may exercise as tolerated
- It is important that you take your medications as prescribed
below."
1613,"- Please do not hesitate to contact us if you experience further
symptoms or have questions.
- Please follow up with your PCP as well as Dr. [**First Name (STitle) **] from the
Neurosurgery Department.
Medications:
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?"
1614,"XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-21**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2196-10-13**]
1. Stable bilateral supratentorial subarachnoid blood as well as
stable
hemorrhage in the 4th ventricle, and in the prepontine,
premedullary and right lateral medullary cisterns.
2. No evidence of cerebral aneurysm or AVM, or vertebral or
other cervical
arterial dissection.
3. 1.1 cm and a 1 cm bilateral hypodense thyroid lesions. If not
previously done elsewhere, ultrasound is suggested if clinically
warranted."
1615,"????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
PLEASE FOLLOW-UP WITH DR [**First Name (STitle) **] IN 1 month. PLEASE CALL
[**Telephone/Fax (1) 4296**] TO MAKE THIS APPOINTMENT.
PLEASE FOLLOW-UP WITH YOUR PCP REGARDING THE THYROID LESION
NOTED ON IMAGING. [PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 10505**]]
Completed by:[**2196-10-21**]"
1616,"Following a repeat angiogram on [**10-20**] which was normal, she
was discharged to home the next day with instructions to follow
up in one month with Dr. [**First Name (STitle) **]. A referral was placed for the
patient to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in clinic.
Medications on Admission:
None
Discharge Medications:
1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every six (6) hours as needed for Headache.
Disp:*40 Tablet(s)* Refills:*0*
2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain/spasm."
1617,"Possibly recent PUD vs anastomotic site vs [**2-26**] colon ca vs
diverticulosis. Hct currently stable at 24, AM Hct pending.
- plan for EGD
- q 6hr HCTs
- IVF boluses for low UO or hypotension
- IV PPI [**Hospital1 **]
- F/U GI recs
- Type and crossmatch 2U [**Last Name (LF) 825**], [**First Name3 (LF) 116**] transfuse if Hct cont to drop
- NPO
- Previous discussed PEG placement with GI on [**10-17**]
will follow up
with GI regarding plan
.
Alzheimer's: pt with baseline dementia. Pt oriented to self, but not
time or place.
- continue namenda and aricept
- will speak with family regarding baseline dementia
.
FEN: NPO, replete lytes PRN, IVFs
.
PPX: IV PPI, bowel regimen
.
ACCESS: PIV, L EJ
.
CODE: FULL
.
CONTACT: [**Name (NI) **], [**Name (NI) **] [**Name (NI) 177**] C [**Telephone/Fax (1) 957**]
.
DISPO: ICU level care for now
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2124-10-24**] 09:40 PM
18 Gauge - [**2124-10-24**] 10:30 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:"
1618,"3
C (99.2
Tcurrent: 37.3
C (99.2
HR: 69 (64 - 78) bpm
BP: 150/73(91) {128/39(65) - 150/99(103)} mmHg
RR: 16 (16 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
2,375 mL
1,020 mL
PO:
100 mL
TF:
IVF:
275 mL
1,020 mL
Blood products:
Total out:
55 mL
1,150 mL
Urine:
55 mL
1,150 mL
NG:
Stool:
Drains:
Balance:
2,320 mL
-130 mL
Respiratory support
O2 Delivery Device: None
SpO2: 100%
ABG: ////
Physical Examination
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), RRR
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender: ,
healing colectomy scar, no erythema, tenderness, bleeding, oozing."
1619,"Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): only new year and thought he was at [**Hospital1 966**],
Movement: Purposeful, Tone: Normal
Labs / Radiology
593 K/uL
7.4 g/dL
24.0 %
9.7 K/uL
[image002.jpg]
[**2124-10-24**] 11:35 PM
WBC
9.7
Hct
24.0
Plt
593
Other labs: PT / PTT / INR:14.4/27.2/1.3
Assessment and Plan
A/P: 85 yo M with PMH of colon CA s/p resection now presenting with
black stools and HCT drop.
.
GI bleed: NG lavage was negative in ED, however, pt with duodenal ulcer
on EGD [**8-1**]."
1620,"Chief Complaint: 85y/o m w/ hx AD, diverticulosis, recently dx colon ca
s.p hemicolectomy (91/15/08) p/w dark stools and dropping Hct (30
-->26-->23).
24 Hour Events:
No sig events overnight
History obtained from Patient
Allergies:
History obtained from PatientTetanus Antitoxin
Unknown;
Aspirin
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Pt denied light-headness, dizziness, CP, SOB, abdominal pain,
F/C/N/V/D.
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: No(t) Fever
Cardiovascular: No(t) Chest pain, No(t) Palpitations
Respiratory: No(t) Cough, No(t) Dyspnea
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,
No(t) Diarrhea, No(t) Constipation
Flowsheet Data as of [**2124-10-25**] 07:28 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
1621,"Admission Date: [**2124-10-24**] Discharge Date: [**2124-10-31**]
Service: MEDICINE
Allergies:
Tetanus Antitoxin / Aspirin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
GI bleed and decreased po intake
Major Surgical or Invasive Procedure:
Percutaneous G- tube placement
History of Present Illness:
85 yo m w/ hx AD, diverticulosis, recently diagnosed colon CA,
status post hemicolectomy on [**2124-10-9**] presents with dark stools.
HCTs have trended down from 30 at NH --> 26--> 23.
In the ED, VS: T 99.2 HR 67 BP 146/69 RR 18 99% RA. NG lavage
was negative. Patient was transferred to [**Hospital Unit Name 153**] for further
monitoring with plan for EGD in AM."
1622,"Past Medical History:
1) Colon ca s/p r colectomy [**2124-10-9**] - mucinous adenocarcinoma
with 1 out of three lymph nodes positive
2) diverticulosis
3) right knee and shoulder surgery
4) benign prostatic hypertrophy s/p TURP with history of ARF
attributed to post-obstructive uropathy, requiring transient
indwelling Foley
5) nephrolithiasis
6) Alzheimer's
7) Chronic anemia
8) Depression
Social History:
Lives in [**Location 2299**] Nursing House. No smoking. Minimal alcohol use.
Formerly in the Navy, worked as a tailgunner during WW2.
Family History:
2 brothers died of lung cancer, one brother died of colon cancer
Physical Exam:
VS: Afebrile, HR 70, BP 140/76, 98%RA
GEN: Elderly man, pleasant, in NAD
HEENT: EOMI, PERRL
NECK: Supple, JVP at clavicle
CV: RRR, S1S2, no m/r/g
ABD: Soft/ NT/ ND, +BS
EXT: warm, no cyanosis or edema
SKIN: no rashes
NEURO: AAO x 2: [**Hospital **] hospital ([**Hospital1 756**]); CN ii-Xii intact"
1623,"A 20FR percutaneous gastrostomy tube (PEG) was placed
successfully using standard techniques at the stomach body.
Impression: Atrophy in the antrum
Low risk ulcers and duodenitis in the duodenal bulb
Successful PEG placement (PEG)
Question of small submucosal mass in duodenal bulb.
Otherwise normal EGD to third part of the duodenum
Recommendations: High dose protonix 40 mg twice a day
Please check H. Pylori serology and treat if positive
No further intervention for now for question of submucosal mass
unless symptomatic or further bleeding.
[**Month (only) 116**] use tube for essential meds if needed tonight. Can start
tube feeding tomorrow."
1624,"Duodenitis and ulcer may have accounted for slow hct decline.
Brief Hospital Course:
Mr. [**Known lastname **] is a 85 year old man with a history of Alzheimer's,
diverticulosis, recently diagnosed colon CA, status post
hemicolectomy on [**2124-10-9**] presented with dark stools and acute
blood loss anemia and malnutrition from The [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
In the [**Last Name (LF) **], [**First Name3 (LF) **] NG lavage was negative by report. He was
initially admitted to the Medical ICU, and given 2 Units of
PRBCs. He was hemodynamically stable and underwent EGD,
revealing: ""Atrophy in the antrum, Low risk ulcers and
duodenitis in the duodenal bulb, Successful PEG placement (PEG),
Question of small submucosal mass in duodenal bulb, Otherwise
normal EGD to third part of the duodenum."
1625,"6. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 10 days.
7. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 10 days.
8. Protonix 40 mg Susp,Delayed Release for Recon Sig: Forty (40)
mg PO twice a day.
9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Three
Hundred (300) mg PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1) Acute Blood Loss Anemia - likely secondary to duodenal
ulcerations, H. pylori Ab positive
2) Malnutrition, s/p G tube placement"
1626,"Secondary:
--Adenocarcinoma s/p hemicolectomy in [**2124-9-25**], metastatic
to 1 out of three lymph nodes, CT report from this admission,
showed ""Small retroperitoneal nodes are seen adjacent to the IVC
measuring up to about 7 cm size (2:36). These are not markedly
changed from the prior examination.""
--Alzheimer's Dementia
--Possible depression
--history of renal failure secondary to obstructive uropathy
[**2122**]
Discharge Condition:
good
Discharge Instructions:
Please [**Name8 (MD) 138**] MD if Mr. [**Known lastname **] is unable to tolerate his Tube
Feeds, develops respiratory distress, pain, fever, or other
concerning symptoms.
Followup Instructions:
Please ensure patient has transporation to see his Urologist,
DR. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2124-11-16**] 10:30
Please ensure patient has transportation to see his Colonic
Surgeon
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2124-11-23**] 11:15
Consider Oncologic evaluation for adjuvant therapy for his
advanced mucinous adenocarcinoma"
1627,"
TECHNIQUE: Contiguous axial images from the mid chest through
the abdomen
were obtained without IV contrast. Coronal and sagittal
reformatted images
were generated.
PRELIMINARY REPORT: Gastrostomy tube terminates in the
esophagus,
repositioning is recommended. Filling defect in the mid
esophagus. Bilateral pleural effusions, right greater than left.
Small right lung base consolidation. Large bilateral renal
cysts. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
CT ABDOMEN WITHOUT IV CONTRAST: There is a moderate right
pleural effusion
and small left pleural effusion, simple in attenuation. There is
adjacent
atelectasis and/or consolidation within a portion of the
posterior right lung base."
1628,"
Alzheimer's Dementia and Depression: Pt oriented to self, but
not place or time. He was continued on Namenda and Aricept per
home regimen. He was continued on his mirtazapine and his TSH
was normal.
Submucosal Mass seen on EGD: Unclear if this requires
follow-up. See EGD report attached.
Remaining open surgical wound: minimal opening, excellent
granulation tissue, no evidence for infection, appears to be
healing well. Continue conservative care as directed.
Mucinous Adenocarcinoma with 1/3 positive lymph nodes,
adenopathy seen on CT scan: Consider outpatient follow up with
GI oncology if patient/family desire."
1629,"
IMPRESSION:
1. The gastrostomy tube has been placed percutaneously into the
gastric
antrum, but the tube is oriented cephalad, with the tip in the
lowermost
esophagus. Oral contrast is seen within the lower half of the
esophagus, and a rounded structure within the lumen of the mid
esophagus at the level of the carina likely represents retained
food.
2. Increased size of bilateral pleural effusions, right greater
than left,
and there is a small pericardial effusion.
3. Diffuse atherosclerotic disease as described.
Findings reviewed with the GI fellow on [**2124-10-30**].
The study and the report were reviewed by the staff radiologist."
1630,"DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4346**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2124-10-31**] 2:44 AM
EGD from admission:
Findings: Esophagus: Normal esophagus.
Stomach: Mucosa: Atrophy of the mucosa was noted in the antrum.
Duodenum: Protruding Lesions There was a question of a small
sub-mucosal mass of benign appearance at the duodenal bulb.
Excavated Lesions A few ulcers were found in the duodenal bulb
as well as duodenitis. These were considered low risk for
bleeding. Other procedures: As ulcers and duodenitis were
considered low risk, decision was made to proceed with PEG
placement."
1631,""" It was felt these
ulcers were likely accounting for the blood loss and occult
blood positive stools. H. pylori Ab was positive and he was
started on antimicrobial therapy as well as twice daily PPI
treatment.
Mr. [**Known lastname **] was called out of the unit to the general medical
floor. Once on the General Medical Floor, he had trouble
tolerating his TFs initially with emesis and nausea. CT scan
revealed the G tube curled up proximally into the esophagus.
The GI Fellow pulled the tube back and abdominal x-ray showed it
no longer in the esophagus. TFs were resumed and the patient
had no difficuties thereafter."
1632,"Pertinent Results:
[**2124-10-31**] 10:30AM BLOOD WBC-9.0 RBC-4.12* Hgb-10.6* Hct-33.4*
MCV-81* MCH-25.8* MCHC-31.7 RDW-17.1* Plt Ct-474*
[**2124-10-31**] 10:30AM BLOOD Glucose-115* UreaN-6 Creat-0.8 Na-144
K-4.0 Cl-112* HCO3-24 AnGap-12
[**2124-10-29**] 12:15AM BLOOD ALT-8 AST-19 AlkPhos-73 Amylase-81
TotBili-0.5
[**2124-10-31**] 10:30AM BLOOD TSH-1.5
CT ABDOMEN
INDICATION: Recent percutaneous gastrostomy placement. Evaluate
placement.
COMPARISON: CT torso of [**2124-9-13**] and abdomen radiograph of
[**2124-10-29**]."
1633,"I personally discussed
the above findings and recommendations with the patient's HCP
and son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 99269**] and his questions were
answered to his apparent satisfaction.
During the patient's admission, he was a FULL CODE. You may
consider readdressing this in the future.
Please note, the patient may have some dark stools given his
recent GI bleed, but this should resolve over time. You may
consider checking a Hct if you are concerned that he is bleeding
again, though the suspicion that his duodenal ulcers will bleed
any more is small as he is on treatment for H."
1634,"pylori and a high
dose PPI.
Medications on Admission:
Remeron 15mg qHS
Omeprazole 20 mg PO bid
Celexa 20mg daily
Aricept 10mg daily
Namenda 10mg daily
Senna
Ferrous sulfate
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed: hold for loose stools.
4. Acetaminophen 500 mg Capsule Sig: [**1-26**] Capsules PO Q 8 hours
as needed.
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime)."
1635,"
The abdominal aorta is normal in caliber, with moderately-severe
atherosclerotic calcification, particularly involving the origin
of the SMA.
The patient is post-right hemicolectomy. Oral contrast opacifies
the remaining portion of the colon, or several diverticula are
seen. Visualized small bowel loops also contains some oral
contrast, but are otherwise unremarkable. There is no free air
in the abdomen. There is no free fluid. Small retroperitoneal
nodes are seen adjacent to the IVC measuring up to about 7 cm
size (2:36). These are not markedly changed from the prior
examination.
No concerning osseous lesions are seen."
1636,"There is a small pericardial
effusion. All effusions are increased since [**2124-8-25**]. There
are coarse coronary artery calcifications, particularly
involving the LAD.
In the epigastric region, a percutaneous gastrostomy has been
placed into the gastric antrum. The tube courses cephalad
through the body of the stomach, through the gastroesophageal
junction, and with the tip into the lowermost esophagus. Oral
contrast has been administered via the gastrostomy tube, which
opacifies the lower esophagus. Within the lumen of the uppermost
imaged esophagus (at the level of the carina), there is a round
soft tissue attenuation structure with air, which may represent
retained food."
1637,"Small amounts of oral contrast are seen within
the gastric lumen.
The non-contrast appearance of the liver is unremarkable except
for the
occasional calcified granuloma. Minimal high-density material is
seen
dependently within the gallbladder, possibly representing
layering stones.
Multiple calcified granulomas are seen in the spleen. A splenule
is noted.
The non-contrast appearance of the pancreas is unremarkable. The
adrenal
glands are minimally bulky, without a focal mass lesion,
unchanged. There is no hydronephrosis of the kidneys. Bilateral
renal cysts are noted, which are unchanged in appearance. The
previously described hyperenhancing focus in the lower pole of
the right kidney is not apparent on non-contrast imaging."
1638,".
GI bleed: Likely lower GI bleed as NG lavage was negative. Possibly
recent anastomotic site vs [**2-26**] colon ca vs PUD vs diverticulosis.
- q 6hr HCTs
- IVF boluses for low UO or hypotension
- IV PPI [**Hospital1 **]
- F/U GI recs
- Type and crossmatch 2U PRBCs
.
Alzheimer's:
- continue namenda and aricept
.
FEN: NPO, replete lytes PRN, IVFs
.
PPX: IV PPI, bowel regimen
.
ACCESS: PIV, L EJ
.
CODE: FULL
.
CONTACT: [**Name (NI) **], [**Name (NI) **] [**Name (NI) 177**] C [**Telephone/Fax (1) 957**]
.
DISPO: ICU level care for now
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2124-10-24**] 09:40 PM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU"
1639,"No smoking. Minimal alcohol use.
Review of systems:
Constitutional: Fatigue
Flowsheet Data as of [**2124-10-24**] 11:03 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37.3
C (99.2
Tcurrent: 37.3
C (99.2
HR: 71 (68 - 71) bpm
BP: 143/76(92) {138/62(81) - 143/76(92)} mmHg
RR: 19 (19 - 23) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
2,175 mL
PO:
TF:
IVF:
175 mL
Blood products:
Total out:
0 mL
35 mL
Urine:
35 mL
NG:
Stool:
Drains:
Balance:
0 mL
2,140 mL
Respiratory
O2 Delivery Device: None
SpO2: 98%
Physical Examination
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): person, hospital, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
[image002."
1640,"Chief Complaint: GI bleed
HPI:
85 yo m w/ hx AD, diverticulosis, recently diagnosed colon CA, status
post hemicolectomy on [**2124-10-9**] presents with dark stools. HCts have
trended down from 30 at NH --> 26--> 23.
.
In the ED, VS: T99.2 HR 67 BP 146/69 RR 18 99% RA. NG lavage was
negative. Patient was transferred to [**Hospital Unit Name 10**] for further monitoring with
plan for EGD in AM.
Patient admitted from: [**Hospital1 1**] ER
History obtained from Medical records
Allergies:
Tetanus Antitoxin
Unknown;
Aspirin
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
Colon ca s/p r colectomy [**2124-10-9**]
diverticulosis
right knee and shoulder surgery
benign prostatic hypertrophy s/p TURP
nephrolithiasis
Alzheimer's
Chronic anemia
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Lives in [**Location 956**] Nursing House."
1641,"jpg]
Fluid analysis / Other labs: 138 104 8 105 AGap=10
3.3 27 0.7
CK: 19 MB: Notdone Trop-T: <0.01
Ca: 9.1 Mg: 1.8 P: 2.2
ALT: 7 AP: 63 Tbili: 0.2 Alb:
AST: 17 LDH: Dbili: TProt:
[**Doctor First Name 92**]: Lip: 17
8.3 7.4 352
23.6
Imaging: EGD [**8-24**]:
Normal mucosa in the esophagus
Atrophy in the stomach compatible with atrophic gastritis
Ulcers in the duodenum (ligation)
Erythema, friability and ulceration in the duodenum
Stenosis of the pylorus
Colonoscopy [**8-24**]:
Polyp in the transverse colon 10 cm distal to the mass
Diverticulosis of the sigmoid colon and descending colon
Mass in the colon
Assessment and Plan
A/P: 85 yo M with PMH of colon CA s/p resection now presenting with
black stools and HCT drop."
1642,"TITLE: Addendum to Dr. [**Last Name (STitle) 816**]
s note
MICU ATTENDING ADDENDUM
I saw and examined the patient, and was physically present with the ICU
team for the key portions of the services provided. I agree with the
note above, including the assessment and plan. I would emphasize and
add the following points:
85M with alzhiemers, h/o colon ca
right colectomy 2 weeks ago,
duodenal ulcers ligated [**8-1**]. Now with falling hemotocrit and melena at
nursing home, stable BP. Brought to ER. NG lavage negative. Transferred
to ICU for possible EGD in AM.
Exam notable for T normal HR 70 BP 140/76 RR 16 with 98% sat on
RA
No distress, no complaints, no JVD, RRR, benign abdomen, guaiac
positive
Labs notable for WBC 8.3 K, HCT 24 , Na 138 ,K+ 3.3 , HCO3 27 ,Cr .7 ,
coags pending
Imaging: none
Problems:
GI bleed
blood loss anemia
Recent colon surgery
Alzheimers
Agree with plan to maintain adequate IV access, follow Hct, type and
cross, EGD in AM, PPI
Remainder of plan as outlined above.
Patient is critically ill.
Total time: 36 min"
1643,"Admission Date: [**2121-8-28**] Discharge Date: [**2121-8-29**]
Date of Birth: [**2045-1-14**] Sex: F
Service: MEDICINE
Allergies:
Valsartan / Tikosyn
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
increased shortness of breath leading to an elective right and
left heart catheterization with aortic valvuloplasty and
echocardiogram during procedure
Major Surgical or Invasive Procedure:
Cardiac catheterization
Aortic balloon valvuloplasty
History of Present Illness:
76F with severe aortic stenosis, biventricular heart failure,
atrial fibrillation on warfarin and s/p dual-chamber pacemaker,
and dilated cardiomyapathy who presents to the CCU after having
a right and left heart catheterizaton with aortic valvuloplasty
in the setting in increased SOB."
1644,"The patient is s/p aortic
valvuloplasty in [**2117**] after she was not felt to be a candidate
for cardiac surgery. She also has dilated cardiomyopathy with an
EF of 20%. She is s/p biventricular ICD placement in [**2117**] with
recent generator change performed [**2121-7-8**]. She has been
experiencing increased shortness of breath with minimal exertion
and recently underwent right and left heart catheterization by
Dr. [**Last Name (STitle) **] [**2121-7-9**] which demonstrated low gradient/low flow
aortic stenosis, severe pulmonary hypertension with an elevated
PCWP(=36 mmHg), and acute on chronic systolic and diastolic
heart failure."
1645,").
.
On arrival to the floor, patient was feeling well and denied
chest pain or SOB. She had mild pain at her ICD and mild pain
att the femoral catheter site.
Past Medical History:
- Hyperlipidemia
- Hypertension
- Diabetes Mellitus on insulin
- Dilated cardiomyopathy
- Aortic stenosis s/p csurg evaluation by Dr. [**Last Name (STitle) **] [**2117**]; not
a surgical candidate
- S/P aortic valvuloplasty [**5-/2118**]
- Cath [**2120**]: non-obstructive/non-significant CAD
- BIV/ICD placed [**2117**] and [**Company 1543**] generator change [**2121-7-8**]
- Open reduction/internal fixation of right femur after
mechanical fall
- Chronic kidney disease
- Thyroid disease
- S/P shingles
- Short term memory issues"
1646,"The mitral regurgitation appears significantly reduced,
although the aortic regurgitation is increased.
.
.
Cardiac Catheterization [**2121-8-28**]:
The right and left heart pressures were elevated (mean PAP 35,
PCWP 26). The heart was 86 bpm, the CO was 2.65 L/min, mean
gradient 38.25 mmHg, and the aortic valve area was 0.38 cm2.
.
Interventional details
During test rapid ventricular pacing, the patient developed
ventricular tachycardia that degenerated into ventricular
fibrillation. She was cardioverted to paced rhythm with return
in her BP following a Neo infusion.
.
The aortic valve was dilated without rapid ventricular pacing
using a 20 mm Hg and a 22 mm Hg x 6 cm valvuloplasty balloons."
1647,"Patient has device clinic follow-up
in a few weeks.
Brief Hospital Course:
76F with severe aortic stenosis, biventricular diastolic heart
failure, atrial fibrillation on warfarin and s/p dual-chamber
pacemaker, and dilated cardiomyapathy who presents to the CCU
after having a right and left heart catheterizaton with aortic
valvuloplasty in the setting in increased SOB.
.
# Aortic Stenosis: Pt was turned down for cardiac surgery in
[**2117**] and had an aortic valvuloplasty at that time. Recently had
worsening SOB and presented for elective valvuloplasty; the
valvuloplasty increased her aortic area by 50% and decreased the
gradient from 38 to 28."
1648,"Given the risk of serious complications
following her procedure, she was admitted to the CCU for 24
hours of monitoring. She did well in the CCU after the
valvuloplasty. She did not complain of SOB or chest pain and
had no bleeding from the femoral catheter insertion site.
Post-cath labs were reassuring. She was discharged with follow
up with her PCP (Dr. [**Name (NI) 23019**]), her primary cardiologist
(Dr. [**Last Name (STitle) **], and the interventional cardiologist Dr. [**Last Name (STitle) **]. She
also has an appointment with Dr. [**Last Name (STitle) **], who has been
following her for her ICD.
.
# Biventricular ICD/Rhythm: s/p successful generator change in
[**Month (only) 205**] with hematoma since this procedure, which is slowly
resolving according to the patient and her significant other."
1649,"Her
warfarin was held prior to the cardiac cath, but it was
restarted in the CCU. She will follow up with her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
for INR/warfarin monitoring and adjustments.
.
# Chronic Systolic and Diastolic Heart Failure: Pt has dilated
cardiomyopathy, EF 20%, and currently with PCWP of 26 and PAPs
in the 70s systolic (mean 30s). The patient was continued on
her home digoxin, losartan, metoprolol, and aspirin. We
diuresed her with IV Lasix given her elevated PCWP. She was
sent home on her regular torsemide and metolazone.
.
# Chronic Kidney Disease: Pre-procedure the pt's Cr was 2."
1650,"5, and
the pt received a small amount of contrast in the procedure.
Patient's B/L Cr is 1.5-2.2. Unclear reason for increase,
perhaps worsening cardiac function or hypovolemia in setting of
decreased PO intake. The patient's medications were renally
dosed, and her creatinine was followed, which remained in the
2.5-2.6 range. She will follow up with her PCP.
.
# HTN: Chronic problem, but pt not currently hypertensive. The
patient's losartan and metoprolol were continued.
.
# DM: FSBG post procedure was 155. Patient was put on glargine
insulin [**Hospital1 **] and humalog SS QID during the brief hospitalization."
1651,"Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care Services
Discharge Diagnosis:
Aortic stenosis
Acute on chronic systolic congestive heart failure
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:
Ms. [**Known lastname 20774**],
You were admitted to the hospital for evaluation and treatment
of your aortic stenosis. You had a cardiac catheterization and
a balloon valvuloplasty, where a balloon was temporarily
inflated to open up your aortic valve and improve the aortic
stenosis. Your heart went into a rhythm called ventricular
tachycardia for about 20 seconds during the procedure."
1652,"[**2121-7-10**] Echo: left ventricular EF 20% (severe global systolic
dysfunction), left atrium moderately dilated, left ventricle
moderately dilated, right ventricle size normal with NML free
wall motion, critical aortical valve area (<0.8), mild (1+)
aortic regurg, moderate to severe (3+) mitral regurg, 2+
tricuspid regerg, moderate pulm systolic HTN
.
[**5-/2121**]: PASP 43mmHg. Mean gradient 33mmHg.
.
In the cath lab, initial vitals were 70, 93/49, 23, 98% (on RA).
Though the patient has an ICD, a temporary pacing wire was
inserted via catheter in order to rapidly pace her heart in
order to empty out the left ventricle prior to valvuloplasty."
1653,"Programming changes (details):
With threshold testing the patient noted diaphragmatic pacing
with LV lead amplitudes > 1.5 V @ 1.0 ms, and intermitant
diaphragmatic pacing with LV lead amplitudes between 1.25 - 1.5
V @ 1.0 ms. The measured LV threshold was 0.5 V @ 1.0 ms. The
patient's LV amplitude was previously set at 1.25V @ 1.0 ms, so
the LV amplitude was decreased to 1.0 V @ 1.0 ms [**First Name (Titles) **] [**Last Name (Titles) **] her
symptoms.
.
Summary (normal / abnormal device function):
Normally functioning biventricular ICD. Intermittent
diaphragmatic pacing due to high LV thresholds which where were
decreased as noted above."
1654,"17 V
.
RA lead
Intrinsic amplitude: 1.6 mV
Pacing impedance: 475 ohms
Pacing threshold: 0.75 V @ 0.4 ms
.
RV lead
Intrinsic amplitude: 6.3 mV
Pacing impedance: 418 ohms
Pacing threshold: 1.375 V @ 0.4 ms
.
LV lead
Intrinsic amplitude: N/A
Pacing impedance: 418 ohms
Pacing threshold: 0.5 V @ 1.0 ms
.
Defib Coil impedance: 42/43 ohms
.
Pacing:
AS-VS: <0.1%
AS-VP: 0.2%
AP-VS: 0.1%
AP-VP: 99.7%
.
Diagnostic information: High rate, Mode switch:
2 episodes of NSVT
1 episode of VT in the monitor zone x 35 sec
No ICD therapies needed
."
1655,"There is no mitral
valve prolapse. There is moderate thickening of the mitral valve
chordae. Mild to moderate ([**12-23**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. [Due to acoustic shadowing, the
severity of tricuspid regurgitation may be significantly
UNDERestimated.] Significant pulmonic regurgitation is seen.
There is no pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2121-7-10**], the transaortic valvular pressure gradients are
similar, but the left ventricular stroke volume is higher.
Therefore, the aortic valve orifice area is increased, although
it could not be calculated with vertainty due to technical
factors."
1656,"[**Last Name (STitle) **] if your weight goes
up more than 3 lbs in a day or more than 5 lbs in 3 days.
A physical therapist saw you while you were in the CCU and
recommended that you get physical therapy as an outpatient. You
will have a physical therapist and visiting nurse when you leave
the hospital.
There have been no changes in your medications. However, please
ask Dr. [**Name (NI) 23019**] if you should adjust your Namenda dose or
any of your other medications due to your renal function.
Followup Instructions:
Name: [**Doctor Last Name **]-[**Last Name (LF) **],[**First Name3 (LF) **] Z."
1657,"4* PTT-53.8* INR(PT)-1.8*
[**2121-8-28**] 10:00AM PLT COUNT-239
[**2121-8-28**] 10:00AM WBC-10.4 RBC-4.06*# HGB-14.4# HCT-44.1#
MCV-109* MCH-35.5* MCHC-32.7 RDW-15.9*
[**2121-8-28**] 10:00AM estGFR-Using this
[**2121-8-28**] 10:00AM GLUCOSE-106* UREA N-111* CREAT-2.5*
SODIUM-140 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-32 ANION GAP-17
[**2121-8-28**] 10:50PM CALCIUM-9.7 PHOSPHATE-4.2 MAGNESIUM-2.1
[**2121-8-28**] 10:50PM GLUCOSE-202* UREA N-103* CREAT-2."
1658,".
After balloon valvuloplasty, the heart was 79 bpm, the CO was
2.65 L/min, mean gradient 27.27 mmHg, and the aortic valve area
was 0.56 cm2.
.
Assessment & Recommendations
1. Critical aortic stenosis
2. s/p successful balloon aortic valvuloplasty up to 22 mm
balloon with > 50% in the aortic valve area but residual severe
aortic stenosis
3. To CCU overnight
.
.
EKG [**2121-8-28**]: AV paced, regular, rate ~70, small p waves, wide QRS
.
.
PPM Interrogation [**2121-8-29**] (PRELIMINARY REPORT):
Device Brand: [**Company 1543**]
Model: [**Name6 (MD) 39503**] XT CRT-D D314TRG
Presenting rhythm: A-biV sequentially paced
Intrinsic Rhythm: Junctional bradycardia at ~ 30 bpm
Programmed Mode: DDDR
Battery Voltage: 3."
1659,"Dr. [**Last Name (STitle) **] has been following this in the outpatient setting.
The patient has known a fib and is on warfarin (was held this
week prior to procedure). She had a brief episode of v tach in
the setting of rapid pacing in the cath lab, but she had not
such episodes afterwards. While in the CCU, the patient
complained of a sensation of a beat in her epigastrum that was
concerning for diaphragmatic pacing. Her device was
interrrogated and adjusted (see results section), and she will
follow up with Dr. [**Last Name (STitle) **] next week. She was continued on her
home amiodarone and metoprolol during her hospital stay."
1660,"Family History:
SON s/p MI at AGE 49, DAUGHTER WITH DILATED CARDIOMYOPATHY,
MOTHER WITH CAD AND MIs- died age 79.
Physical Exam:
VS: T=97.7, BP=116/53 (69), HR=73, RR=13, O2 sat=97% on 2L by NC
GENERAL: cachectic, frail, 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, JVP difficult to assess as patient is supine.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No r/g. [**2-25**] cresendo/decresendo murmur
best heard at sternal border."
1661,"Torsemide 40 mg PO BID
16. Vitamin D 1200 UNIT PO DAILY
17. Warfarin 3 mg PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA)
Tues, Thurs, Sat, Sun
18. Warfarin 2 mg PO 3X/WEEK (MO,WE,FR)
19. Losartan Potassium 12.5 mg PO DAILY
20. Metolazone 2.5 mg PO QTUTHUR (TU,TH) Duration: 1 Doses
21. Potassium Chloride 15 cc PO DAILY
10% oral liquid
22. Cetirizine *NF* 10 mg Oral daily
23. Ditropan XL *NF* (oxybutynin chloride) 5 mg Oral daily
24. Levemir 22 Units Breakfast
Levemir 4 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin"
1662,"No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly, no
crackles, wheezes or rhonchi. ICD is surrounded by edema, mild
TTP (pt reports that for months there has been a hematoma in ICD
pocket, now slowly resolving).
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/only trace edema at ankles. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP and PT dopplerable
Left: DP 1+ PT 1+
Pertinent Results:
[**2121-8-28**] 10:00AM PT-19."
1663,"5*
SODIUM-135 POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-30 ANION GAP-14
.
.
ECHO [**2121-8-28**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is severely depressed
(LVEF = 25 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. Significant aortic stenosis is present (not
quantified). Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened."
1664,"A shock
was administered and resolved this rhythm, and you had no other
issues during or after the procedure.
Because of the risk of complications in the hours immediately
following this procedure, you were admitted to the CCU (the
cardiac intensive care unit) for monitoring. You were continued
on most of your regular medications, and there was no evidence
of complications from the procedure.
Upon discharge, please resume taking all your regular
medications. Please follow up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 5076**], and
Dr. [**Last Name (un) **] at the times listed below. Please weigh
yourself every morning, and call Dr."
1665,"She resumed her home insulim regimen on discharge.
.
Transitional Issues
# CODE: Confirmed full
# Health Care Proxy: daughter [**Name (NI) **] [**Name (NI) 20774**] ([**Telephone/Fax (1) 45875**])
# Contact: [**Name (NI) 892**] (caregiver and significant other) ([**Telephone/Fax (1) 45876**])
# INR: Was subtherapeutic on the day of discharge at 1.7. PCP
[**Last Name (NamePattern4) **]. [**Name (NI) 45877**] will follow up with the patient in 3 days.
# Heart Failure Management: Future caregivers may wish to
consider starting spironolactone if there is no
contraindication.
# Home Services: The patient was evaluated by physical therapy,
who recommended home PT. She will also get a home skilled
nursing visit."
1666,"Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
We are working on a follow up appointment with your primary care
physician within [**Name Initial (PRE) **] week. The office will contact you at home
with an appointment. If you have not heard from the office
within 2 business days please call them at [**Telephone/Fax (1) 45878**].
Department: CARDIAC SERVICES
When: WEDNESDAY [**2121-9-3**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 488**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital **] MEDICAL GROUP-[**Location (un) 8720**] CARDIOLOGY
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY, [**Location 8723**],[**Numeric Identifier 18655**]
Phone: [**Telephone/Fax (1) 8725**]
**APPOINTMENT Tuesday [**2121-9-9**] 2:00pm***"
1667,"Discharge Medications:
1. Allopurinol 300 mg PO DAILY
2. Amiodarone 100 mg PO BID
3. Aspirin 81 mg PO DAILY
4. BuPROPion (Sustained Release) 150 mg PO QPM
5. Calcium Carbonate 500 mg PO Q 8H
6. Digoxin 0.125 mg PO EVERY OTHER DAY
7. Donepezil 10 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Memantine 10 mg PO BID
12. Metoprolol Tartrate 12.5 mg PO BID
13. Omeprazole 20 mg PO Q 8H
14. Oxazepam 10 mg PO HS
15."
1668,"Patient is on warfarin which was stopped [**2121-8-23**]
per Dr.[**Name (NI) 32659**] instructions. Patient is now referred for right
and left heart catheterization with aortic valvuloplasty and
echocardiogram during the procedure.
.
The patient does not have any chest pain or PND. She has 2
pillow orthopnea. Occassional lower extremity edema. No
dizziness. She walks at home with a cane, but her ambulation is
limited, more by pain in her leg than by dyspnea. She had a
mechanical fall in [**2120-9-21**] leading to ORIF for a right
supracondylar femur fracture. She does feel fatigued and SOB
with minimal activity, such as dressing herself."
1669,"However, the rapid pacing caused the patient to go into V tach.
Chest compressions were started (for 20 sec), and she was
shocked, which resolved the arrythmia. She was briefly on Neo
and dopamine during the procedure, but these were taken off soon
after the catheterization with SBPs in the 110s and MAPs in the
60s. Valvuloplasty was performed with 3-4 inflations of a 23mm
balloon. The gradient was decreased from 38 to 28, and the valve
area was increased from 0.38cm2 to 0.56cm2. PCWP was measured to
be 26. The sheaths were removed.
.
Vitals on transfer to the CCU were 70, 114/49, 20, and 99% (on
2L by NC?"
1670,"Her boyfriend
[**Name (NI) 12239**] is also her caretaker and ensures that she takes all her
medications every day. She has had no falls in [**2120**], but the
year prior she had the mechanical fall leading to the femur
fracture, as well as 4 episodes of syncope/LOC attributed to
Tikosyn, which has since been stopped.
.
Prior Diagnostics:
[**2121-7-9**]: Cardiac Cath
-Low gradient (31), low flow aortic stenosis (valve area 0.52)
-Insignificant coronary artery disease (30% stenosis in mid LAD
second diagonal branch, and RCA proximal)
-Severe pulmonary hypertension with an elevated PCWP(=36 mmHg),
RA pressure of 17, PA 73/28 (45)
-Acute on chronic systolic and diastolic heart failure
."
1671,"Medications on Admission:
allopurinol 300 mg daily
amiodarone 100 mg [**Hospital1 **]
bupropion HCl SR 150 mg daily in PM
digoxin 125 mcg every other day
donepezil 10 mg daily
folic acid 1 mg daily
Novolog 100 unit/mL Sub-Q sliding scale with meals four times
daily
Levemir 100 unit/mL Sub-Q 22 units in the am; 4 units in the PM
Levothroid 112 mcg tablet daily
losartan 12.5 mg daily
Namenda 10 mg tablet [**Hospital1 **]
metolazone 2.5 mg on Tuesday and Thursday
metoprolol tartrate 12.5 mg [**Hospital1 **]
omeprazole delayed release 20 mg TID
oxazepam 10 mg daily
Ditropan XL 5 mg daily
potassium chloride 10 % Oral Liquid 15 cc by mouth daily
torsemide 40 mg [**Hospital1 **]
warfarin 3 mg tues thurs sat sun, 2mg mwf
aspirin 81 mg daily
calcium carbonate-vitamin D3 500 mg(1,250 mg)-400 unit TID
cetirizine 10 mg daily
ferrous sulfate 325 mg (65 mg iron) daily"
1672,"Admission Date: [**2118-3-2**] Discharge Date: [**2118-3-7**]
Date of Birth: [**2047-10-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Adhesive Tape / Cholinesterase
Inhibitor(Carbamate) / Bactrim DS / Iodine-Iodine Containing /
Pravachol / Lipitor / Betadine / Sulfa (Sulfonamide Antibiotics)
/ Anectine / Magnesium Citrate / Crestor / Niacin / Zetia /
Pregabalin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional dyspnea, recent sycope
Major Surgical or Invasive Procedure:
[**2118-3-3**] Aortic valve replacement (#19mm [**Doctor Last Name **] pericardial)/
Myomectomy
[**2118-3-2**] Cardiac cath
History of Present Illness:
This is a 70 year old female with multiple medical issues who
has known aortic stenosis which has been followed by serial
echocardiograms for the past several years."
1673,"Early this [**Month (only) 956**]
she had a syncopal episode. She was admitted and on telemetry
for 48 hours which showed no arrythmias and she ruled out for
myocardial infarction. Her last echocardiogram in [**2117-4-21**]
showed severe aortic stenosis with a peak velocity of 3.8m/s.
Currently her symptoms include exertional dyspnea, poor exercise
tolerance and fatigue. Given her recent sycopal episode and
known severe aortic stenosis, she has been referred for surgical
evaluation.
Past Medical History:
1. Aortic stensosis
2. Hypertension
3. Hyperlipidemia
4. Osteoarthritis - currently awaiting left hip replacement
5. Diabetes mellitus type II
6."
1674,"Sj??????grens syndrome
7. Obstructive sleep apnea
8. Fibromyalgia/Nocturnal Leg Cramping/Restless Leg Syndrome
9. Burning tongue syndrome
10. Stress incontinence
11. de Quervain's tendinitis
12. Venous Stasis with spider veins
13. GERD
14. Allergic rhinitis, history of sinusitis
15. Stable left lung nodule
16. Depression/Anxiety
17. Carpal tunnel syndrome
18. Adie's pupil
19. Hearing loss - bilateral hearing aids
20. Back pain
21. Lactose intolerance
22. Actinic keratosis
23. Raynauds Disease
24. History of Kidney Stones
25. History of Fatty Liver - prior liver biopsy
26. Constipation
27. Pseudocholinesterase Deficiency
Past Surgical History:
1. Tonsillectomy [**2066**]
2."
1675,"Total knee replacement right, [**2113-3-21**]
17. Right knee revision, [**2114-8-27**]
18. Venous closure and phlebectomy for varicose veins - Dr.
[**Last Name (STitle) **]
19. Right wrist first dorsal compartment release and a right
wrist arthroscopy. [**3-/2117**], Dr. [**Last Name (STitle) 98016**]
20. Laminetomy L2-3 [**7-2**], Dr. [**Last Name (STitle) 98017**]
Social History:
Race: Caucasian
Last Dental Exam: dental clearance obtained [**2118-1-28**]
Lives with: Husband
Occupation: Retired
Cigarettes: 6 PYH. Quit over 30 years ago.
ETOH: social, denies history of ETOH abuse
Illicit drug use: Denies
Family History:
Father CABG in his 60's, died at age 72 of myocardial
infarction."
1676,"C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection achs: per sliding scale.
12. metformin 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain."
1677,"Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is moderate thickening of the mitral valve chordae. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
POST CPB: 1. Preserverd [**Hospital1 **]-ventricular systolci function."
1678,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Name (NI) 5572**] office will contact you to arrange an
appointment
DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2118-3-29**] 11:00
Provider [**Name9 (PRE) 2788**] [**Hospital **] CLINIC Phone:[**Telephone/Fax (1) 7773**]
Date/Time:[**2118-5-3**] 10:15
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 7773**]
Date/Time:[**2118-5-20**] 12:20
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3306**] in [**2-24**] 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**
Completed by:[**2118-3-7**]"
1679,"Disp:*40 Tablet(s)* Refills:*0*
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Aortic stensosis s/p Aortic valve replacement
Past medical history:
Hypertension
Hyperlipidemia
Osteoarthritis - currently awaiting left hip replacement
Diabetes mellitus type II
Sj??????grens syndrome
Obstructive sleep apnea
Fibromyalgia/Nocturnal Leg Cramping/Restless Leg Syndrome
Burning tongue syndrome
Stress incontinence
de Quervain's tendinitis
Venous Stasis with spider veins
GERD
Allergic rhinitis, history of sinusitis
Stable left lung nodule
Depression/Anxiety
Carpal tunnel syndrome
Adie's pupil
Hearing loss - bilateral hearing aids
Back pain
Lactose intolerance
Actinic keratosis
Raynauds Disease
History of Kidney Stones
History of Fatty Liver - prior liver biopsy
Constipation
Pseudocholinesterase Deficiency"
1680,"myomectomy. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring in stable condition. Later this day she was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one she was started on beta-blockers and
diuretics and gently diuresed towards her pre-op weight. POD#2
she was transferred to the step-down floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. She remained hemodynamically stable in sinus rhythm.
With aggressive pulmonary toilet and ambulation she titrated off
oxygen. Her pain was well controlled with Ultram and NSAIDS."
1681,") Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. aspirin 81 mg Tablet, Delayed Release (E."
1682,"5* PTT-35.8 INR(PT)-1.4*
[**2118-3-7**] 06:18AM BLOOD Glucose-113* UreaN-19 Creat-0.5 Na-138
K-4.4 Cl-101 HCO3-32 AnGap-9
[**2118-3-2**] 05:30PM BLOOD Glucose-125* UreaN-21* Creat-0.5 Na-140
K-3.6 Cl-104 HCO3-25 AnGap-15
Brief Hospital Course:
Mrs. [**Known lastname 47958**] was admitted on [**3-2**] following her cardiac cath
which revealed no coronary artery disease. She underwent further
testing this day for preparation of surgery the following day.
On [**3-3**] she was brought to the operating room where she
underwent an aortic valve replacement (#19mm [**Doctor Last Name **]
pericardial)?"
1683,"Physical Exam:
Pulse: 84 Resp: 16 O2 sat: 100% room air
B/P Right: 138/80 Left:
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 [x] grade 3/6 SEM radiating
to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: Spider veins present. No gross varicosities noted.
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: soft transmitted murmur noted bilaterally"
1684,"Nasal surgery [**2067**]
3. Cholecystectomy [**2071**]
4. Laminectomy L4-5-[**2079**]
5. TAH/BSO-[**2089**]- question raised whether supracervical
procedure-cervix was found on exam and Pap smear obtained.
6. Bladder suspension, [**2092**]
7. Right rotator cuff surgery-[**2101**]
8. Cervical diskectomy [**2105-2-19**]
9. Sinus surgery, [**2105**]
10. Left knee arthroscopy? [**2107-4-22**]
11. Left knee-arthroscopy? [**2108-1-20**]
12. Spinal fusion L4-S1, [**2110-11-22**]
13. Right tibial plateau for a status post two screws and
fusion, [**2111-10-22**]
14. Sinus surgery, [**2112-3-21**]
15. Right carpal tunnel release [**2112-11-21**]
16."
1685,"2.
Bioprosthetic valve in aortic position. Wewll seated and stable
with good leaflet excursion. PG + 28 mm hg. 3. Chordal [**Male First Name (un) **] with
trivial MR. 4. No other change.
.
[**2118-3-7**] 06:18AM BLOOD WBC-7.9 RBC-2.72* Hgb-7.5* Hct-24.2*
MCV-89 MCH-27.6 MCHC-30.9* RDW-13.5 Plt Ct-195#
[**2118-3-2**] 05:30PM BLOOD WBC-12.8* RBC-4.12* Hgb-11.9* Hct-37.6
MCV-91 MCH-28.8 MCHC-31.5 RDW-13.4 Plt Ct-300
[**2118-3-5**] 02:28AM BLOOD PT-14."
1686,"Medications - OTC
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth qd with
meal
CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider) -
600 mg calcium (1,500 mg)-400 unit Tablet - Tablet(s) by mouth
once a day
LANCETS [LANCETS,THIN] - Misc - test three times a day
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (OTC) - Dosage
uncertain
Discharge Medications:
1. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO qhs, prn ()
as needed for RLS.
2. fluvastatin 40 mg Capsule Sig: Two (2) Capsule PO twice a
day.
3. omeprazole 20 mg Capsule, Delayed Release(E.C."
1687,"She was evaluated by by physical therapy. The remainder of her
postoperative course was essentially uneventful. She continued
to make steady progress and was discharged to [**Hospital6 **]
in [**Location (un) 246**] on POD# 4. All follow up appointmets were advised.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**11-22**] qid prn
AZELASTINE [ASTELIN] - 137 mcg (0.1 %) Aerosol, Spray - 1
spray/nostril(s) twice a day as needed for seasonal allergies
CLONAZEPAM - 2 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
at bedtime
DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
FLUVASTATIN [LESCOL XL] - 80 mg Tablet Extended Release 24 hr -
1 Tablet(s) by mouth 3-4times/week
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METFORMIN - 500 mg Tablet Extended Rel 24 hr - 1 Tab(s) by mouth
once a day
OMEPRAZOLE - 20MG Capsule, Delayed Release(E."
1688,"Pertinent Results:
[**2118-3-2**] Cardiac cath: 1. Selective coronary angiography of this
LEFT dominant system demonstrated no angiographically-apparent
coronary artery disease. The LMCA, LAD, dominant LCx, and RCA
were all free of any obstructive disease. 2. Limited resting
hemodynamics revealed normal systemic arterial pressures, with a
central aortic pressure of 121/61, mean 88 mmHg.
.
[**2118-3-2**] Carotid U/S: Right ICA no stenosis. Left ICA no
stenosis.
.
[**2118-3-3**] Echo: PRE-BYPASS: The left atrium is moderately dilated.
At least one pulmonary vein may be entering the right atrium. No
atrial septal defect is seen by 2D or color Doppler."
1689,"Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram and NSAIDs
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
1690,"C.) - ONE EVERY
MORNING
ONE TOUCH ULTRASMART TEST STRIPS - - test four times a day
PRAMIPEXOLE - 0.5 mg Tablet - 1 Tablet(s) by mouth hs prn RLS
PREDNISONE - (Prescribed by Other Provider) - 20 mg Tablet - 2
Tablet(s) by mouth take 40mg TUES [**3-1**] pm, 40mg WED4/11 AM.
premedications for dye allergy called into pt's pharmacy per Dr.
[**Last Name (STitle) **]
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet
- 1 Tablet(s) by mouth take 1 tablet TUES [**3-1**] pm, 1 tablet wed
[**3-2**] AM premed for contrast allergy
ZOLPIDEM - (On Hold from [**2117-12-30**] to unknown for trial off) -
10 mg Tablet - 1 Tablet(s) by mouth at bedtime"
1691,"No
dysmetria on FNF and foot tapping rhythmic bilaterally.
-Gait: not assessed.
Pertinent Results:
[**2188-6-6**] 02:54AM BLOOD %HbA1c-7.9* eAG-180*
[**2188-6-10**] 04:45AM BLOOD Calcium-8.9 Phos-2.2* Mg-1.8
CT head
1. 12 x 10 mm hemorrhagic focus in the left basal ganglia,
without
significant mass effect, midline shift, intraventricular
extension or
subarachnoid hemorrhage. Most likely etiology is hypertension.
2. Global atrophy with mild chronic microvascular ischemic
disease.
Brief Hospital Course:
84-year old man with complex past medical history including
cardiac disease status-post pacemaker, porcine aortic valve
replacement, diabetes, hypertension, hypercholesterolemia
presenting with onset of right leg weakness and right facial
droop with subsequent non-word speech and possibly right leg
tingling now with symptoms improving, exam notable for right
word-finding difficulties and low-frequency naming difficulty,
right facial droop, and trace right pronator drift but no
obvious
weakness."
1692,"Patients Phos was noted to be 2.2 and was given 1
packet of neutro phos.
DM:
patient was restarted on his metformin w. insulin sliding scale
coverage.
HTN:
Patients BP was controlled with Atenolol and Lisinopril 5 mg PO
daily was started.
Adrenal insufficiency:
Patient was continued on home doses of prednisone and
fludrocortisone.
DVT prophylaxis. was kept on pneumoboots before restarting
subcutaneous heparin
dispo: patient was re-evaluated by PT who stated that patient
was capable of going home with only minor deficits remaining.
****spoke with patient's wife on the phone and made her aware of
all the medication changes that were made."
1693,"Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 325 mg PO daily
8. Lisinopril 5 mg PO daily
Discharge Disposition:
Home With Service
Facility:
Diversified VNA and hospice
Discharge Diagnosis:
12 x 10 mm hemorrhagic stroke in the left basal ganglia.
High blood pressure
Diabetes
Hyperlipidemia
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)."
1694,"Lisinopril was
called into pharmacy at [**Telephone/Fax (1) 85048**]. Patient also made aware
to cont. on Aspirin and to follow up with PCP early next week.
Medications on Admission:
Alendronate 70 mg qweek
Metformin 500 mg [**Hospital1 **]
Prednisone 2.5 mg daily
Aspiring 325 mg daily
Atenolol 50 mg daily
Fludrocortisone 0.1 mg daily
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Tablet(s)
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4."
1695,"He was noted to have
elevated blood pressure with SBP around 180, but since he was
improving neurologically, they did not lower it. Otherwise, upon
questioning he endorses possibly right leg tingling but denies
headache, right arm weakness.
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes mellitus type 2
Adrenal insufficiency/Addison's disease - needs stress dose
steroids 100 mg is his crisis dose
Cardiac disease - pacemaker, aortic valve porcine replacement,
apparently was on plavix up until 1-2 weeks ago, discontinued
and
replaced with 325 mg aspirin--unknown why
Pacemaker recently interrogated and atrial fibrillation noted
Social History:
Lives with wife, former television and antenna repairman
EtOH: [**12-8**] drink daily (increased recently as his wife pours
more now)
tobacco: denies
drugs: denies"
1696,"Family History:
denies family history of neurologic disease, early
stroke, clotting or bleeding disorder
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, 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 with
OCCASIONAL WORD-FINDING DIFFICULTY."
1697,"Subtle
pronator drift on right.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0 0 0 1 0 Flexor
R 0 0 0 1 0 Flexor
-Sensory: REPORTS DECREASED COLD SENSATION ON RLE TO KNEE;
decreased vibratory sense bilaterally distally, intact to light
touch, pinprick, and no extinction
-Coordination: No intention tremor, dysdiadochokinesia noted."
1698,"CT head from OSH reveals right basal ganglia bleed
differential diagnosis includes amyloid, unlikely because not
lobar, tumor, or arteriovenous malformation, but far more likely
hypertensive given known history of hypertension and classic
location of bleed. Not a candidate for MRI given pacer.
Neuro:
patient was admitted to neuro ICU, attending [**Doctor Last Name **] a SBP < 160
was maintained using emolol. patient's ASA and sc heparin were
initially held until day 3. Patient progressed well. on
discharge patient's weakness was limited only to a fine R
protonator drift and 4+ strength in biceps. Cardiac enzymes
were negative. LDL was found to be 165 was started on Zocor 40
mg PO qHS."
1699,"Patient reports that he was
gardening with his wife at 11:30, and he almost fell due to
right
leg weakness. He went into the house to sit down and was
initially feeling a bit better, but his wife was very concerned,
so she took him to his PCP. [**Name10 (NameIs) **] also apparently told him that
his face looked asymmetric. He noted that as he was waiting to
see his primary care physician he continued to have mild
difficulty walking and right leg weakness. In addition, while
at
the PCP he reports that for a few hours he was unable to speak
properly."
1700,"Admission Date: [**2188-6-5**] Discharge Date: [**2188-6-10**]
Date of Birth: [**2103-7-29**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
84-year old man presenting with onset of right leg weakness and
right facial droop with subsequent non-word speech and possibly
right leg
tingling now with symptoms improving, exam notable for right
word-finding difficulties and low-frequency naming difficulty,
right facial droop, and trace right pronator drift but no
obvious weakness.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84-year old man with history of recently noted atrial
fibrillation, cardiac disease status-post pacemaker and porcine
aortic valve replacement, hypertension, hyperlipidemia, and
diabetes presents with new onset right leg weakness, difficulty
speaking, and right facial droop."
1701,"It is noted in the medical record that he was
answering questions appropriately but then at times repeating
non-word answers. His speech also seemed slurred to them as
well
as the patient. He denies any difficulty understanding
questions. In addition to his speech, language, and weakness
issues he also notes that in the past he has had long-standing
issues with discoordination possibly due to a ""mini-stroke,"" and
this was also worse today while in general it had been improving
over the past few years. His PCP was concerned regarding a
stroke, so sent him to the emergency room where a CT scan was
obtained revealing a right basal ganglia hemorrhage about 1x1
and
2 cm in the craniocaudal direction."
1702,"Inpatient PT noted pt. has walker at home for use and
that patient would benefit from home PT for home safety eval and
to progress mobility.
Mental Status: Confused - sometimes.
Discharge Instructions:
You suffered a 12 x 10 mm hemorrhagic focus in the left basal
ganglia portion of the brain, without significant mass effect,
midline shift, intraventricular extension or subarachnoid
hemorrhage. It was thought that this was most likely related to
your high blood pressure. You were also found to have
uncontrolled diabetes and cholesterol. You were started on
Simvastatin for cholesterol. You will need to follow up with
your primary doctor regarding your diabetes management. You
were initially stopped on your Aspirin secondary to bleed in
your brain.
Followup Instructions:
Follow up with your Primary care physician for further
management.
Follow up with Dr [**Last Name (STitle) **] for neurology. Please call [**Telephone/Fax (1) 657**]
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2188-6-10**]"
1703,"Attentive, able to name DOW
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name high BUT NOT LOW
FREQUENCY. Speech was not dysarthric. Able to follow both
midline
and appendicular commands. Pt. was able to register 3 objects
and
RECALL [**12-9**] at 5 minutes (but 1 hour later still recalled [**1-9**]).
There was no evidence of apraxia or neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally, fundi
normal
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: RIGHT FACIAL DROOP IN UPPER MOTOR NEURON PATTERN
VIII: hears finger rub bilaterally , but slightly decreased to
voice
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-9**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; no asterixis or myoclonus."
1704,"7: [**6-22**], fentanyl prn
Cardiovascular: normotensive. goal SBP <160, on metoprolol 50''',
labetolol prn, statin, no ASA
Pulmonary: currently on CPAP, attempt to wean, diuresis - goal >=1L neg
Gastrointestinal / Abdomen: TF at goal.
Nutrition: TF@goal
Renal: Foley, adequate UOP, Cr stable, DC diamox. lasix prn overnight.
Hematology: anemia. Hct stable 28
Endocrine: mild hyperglycemia. RISS, goal FS<150
Infectious Disease: afebrile, WBC 6.2>6.0
Lines / Tubes / Drains: Foley, RIJ CVL, trach, PEG, a-line
Wounds: dry dressings
Imaging:
Fluids: KVO
Consults: Neuro surgery, Cardiology, Neurology
Billing Diagnosis:
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2107-6-22**] 06:26 AM 55 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2107-6-16**] 06:00 PM
20 Gauge - [**2107-6-19**] 06:00 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: DNR (do not resuscitate)
Disposition: ICU
Total time spent: 31mins.
Patient is critically ill"
1705,"1
6.2
6.0
Hct
25.0
25.0
28.0
Plt
[**Telephone/Fax (3) 7793**]
Creatinine
0.6
0.5
0.6
TCO2
34
31
31
27
29
26
Glucose
162
100
131
147
Other labs: PT / PTT / INR:13.0/28.4/1.1, CK / CK-MB / Troponin
T:47/16/<0.01, ALT / AST:20/28, Alk-Phos / T bili:67/0.5, Lactic
Acid:0.6 mmol/L, Albumin:3.1 g/dL, LDH:226 IU/L, Ca:8.3 mg/dL, Mg:2.2
mg/dL, PO4:4.1 mg/dL
Assessment and Plan
AIRWAY CLEARANCE, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE,
IMPAIRED, MOTOR FUNCTION, IMPAIRED, RESPIRATION / GAS EXCHANGE,
IMPAIRED, SUBARACHNOID HEMORRHAGE (SAH), [**Last Name 12**] PROBLEM - ENTER
DESCRIPTION IN COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH)
Assessment and Plan: 81F c/o headache, neck pain found to have SAH,
cardiac arrest at OSH, s/p EVD, s/p trach/PEG, c/b new cerebellar
stroke [**6-12**] s/p aneursym clipping [**6-16**], s/p angio [**6-17**]
Neurologic: q2 neurochecks, Dilantin -> 14."
1706,"41/39/139/21/0
Ve: 9.2 L/min
PaO2 / FiO2: 348
Physical Examination
General Appearance: No acute distress
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: Diminished: )
Abdominal: Soft, No(t) Non-distended, Non-tender
Left Extremities: (Edema: Trace), (Temperature: Warm)
Right Extremities: (Edema: Trace), (Temperature: Warm)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Responds to: Noxious stimuli), L hemiparesis
Labs / Radiology
278 K/uL
8.8 g/dL
147
0.6 mg/dL
21 mEq/L
3.8 mEq/L
19 mg/dL
105 mEq/L
137 mEq/L
28.0 %
6.0 K/uL
[image002.jpg]
[**2107-6-19**] 12:18 PM
[**2107-6-20**] 02:57 AM
[**2107-6-20**] 08:38 AM
[**2107-6-21**] 02:44 AM
[**2107-6-21**] 02:55 AM
[**2107-6-21**] 07:46 AM
[**2107-6-21**] 09:10 AM
[**2107-6-22**] 02:37 AM
[**2107-6-22**] 02:50 AM
[**2107-6-22**] 04:00 AM
WBC
7."
1707,"Phenytoin (Suspension) 17. Pneumococcal Vac Polyvalent 18. Potassium
Chloride 19. Potassium Chloride 20. Senna 21. Simvastatin 22. Sodium
Chloride 0.9% Flush 23. Spironolactone
24 Hour Events:
[**6-21**]: CXR: small b/l effusions confirmed w/US at bedside, diuresis
w/goal >= 1L neg, new L hemiplegia - no angio per NSurg
Post operative day:
POD#5 - aneurysm clipping
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2107-6-21**] 09:18 AM
Heparin Sodium (Prophylaxis) - [**2107-6-22**] 12:00 AM
Other medications:
Flowsheet Data as of [**2107-6-22**] 07:47 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a."
1708,"m.
Tmax: 37.7
C (99.9
T current: 37.1
C (98.7
HR: 72 (65 - 77) bpm
BP: 78/53(67) {69/43(63) - 159/100(107)} mmHg
RR: 28 (22 - 33) insp/min
SPO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 94.3 kg (admission): 91 kg
Height: 65 Inch
Total In:
1,620 mL
454 mL
PO:
Tube feeding:
1,320 mL
424 mL
IV Fluid:
Blood products:
Total out:
3,885 mL
1,200 mL
Urine:
3,885 mL
1,200 mL
NG:
Stool:
Drains:
Balance:
-2,265 mL
-746 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 290 (249 - 330) mL
PS : 5 cmH2O
RR (Spontaneous): 29
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 88
PIP: 11 cmH2O
SPO2: 97%
ABG: 7."
1709,"SICU
HPI:
81F c/o headache, neck pain found to have SAH, cardiac arrest at OSH,
s/p EVD, s/p trach/PEG, c/b new cerebellar stroke [**6-12**] s/p aneursym
clipping [**6-16**], s/p angio [**6-17**]
Chief complaint:
neck pain
PMHx:
PMH: CAD s/p CABG, HTN, high cholesterol
PSH: CABG, hysterectomy, cholecystectomy
Current medications:
1. 2. 3. Acetaminophen 4. AcetaZOLamide 5. Bisacodyl 6. Calcium
Gluconate 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Famotidine 9.
Fentanyl Citrate 10. Heparin 11. Insulin 12. Labetalol 13. Magnesium
Sulfate 14. Metoprolol Tartrate 15. Nystatin Oral Suspension 16."
1710,"7
Endocrine: RISS, fs goal< 150, currently 161
Infectious Disease: cefazolin while EVD in place, WBC 13.9
likely
reactive
Lines / Tubes / Drains: Foley, OGT, ETT, Surgical drains (hemovac, JP),
aline, RIJ CVL, EVDx2
Wounds: Dry dressings
Imaging:
Fluids: KVO
Consults: Neuro surgery, Cardiology
Billing Diagnosis: Cardiac arrest, CVA
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2107-6-5**] 12:04 AM 55 mL/hour
Glycemic Control: Regular insulin sliding scale, Comments: tighten up
sliding scale
Lines:
Arterial Line - [**2107-5-29**] 04:47 PM
Multi Lumen - [**2107-5-29**] 04:48 PM
ICP Catheter - [**2107-5-29**] 05:00 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds , Family
meeting planning, ICU consent signed Comments:
Code status: DNR (do not resuscitate)
Disposition: ICU
Total time spent: 40 minutes
Patient is critically ill"
1711,"Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, ICP monitor,
Ventriculostomy, Pain controlled, EVD at 15cm above tragus, nimodipine,
dilantin, ?clip aneurysm on Monday, fentanyl prn
Cardiovascular: Beta-blocker, Statins, keep SBP 100-140, on metoprolol
50'''/lisinopril 10'/hydral/ nicardipine drip (wean), no ASA
Pulmonary: Cont ETT, (Ventilator mode: CMV), wean as tolerated, pt
breathing above vent, decrease PEEP today
Gastrointestinal / Abdomen: Place NGT, NPO, on tube feeds
Nutrition: Tube feeding, tube feeds at goal
Renal: Foley, Adequate UO, diurese with lasix drip, goal of euvolemia,
fluid balance -300, BUN stable, goal 500 negative today
Hematology: Serial Hct, Hct stable at 29."
1712,"8
Hct
30.2
29.7
29.7
Plt
263
277
296
Creatinine
1.1
1.1
1.0
Troponin T
0.23
TCO2
18
24
20
23
Glucose
165
185
160
182
161
161
Other labs: PT / PTT / INR:13.0/26.4/1.1, CK / CK-MB / Troponin
T:32/16/0.23, ALT / AST:20/28, Alk-Phos / T bili:67/0.5, Lactic
Acid:1.2 mmol/L, Albumin:2.9 g/dL, LDH:226 IU/L, Ca:8.3 mg/dL, Mg:2.4
mg/dL, PO4:3.7 mg/dL
Assessment and Plan
[**Last Name 12**] PROBLEM - ENTER DESCRIPTION IN COMMENTS, TACHYCARDIA, OTHER,
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 11**]), INTRACEREBRAL HEMORRHAGE
(ICH)
Assessment and Plan: 81F c/o headache, neck pain found to have SAH,
cardiac arrest at OSH."
1713,"8 cmH2O/mL
SPO2: 98%
ABG: 7.50/28/121/21/0
Ve: 12 L/min
PaO2 / FiO2: 242
Physical Examination
General Appearance: No acute distress, intubated, not sedated
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: at bilateral bases)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Diminished), (Pulse - Posterior tibial: Diminished)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Diminished), (Pulse - Posterior tibial: Diminished)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Responds to: Noxious stimuli), No(t) Moves all
extremities, (RUE: Weakness), (LUE: Weakness), (RLE: Weakness), (LLE:
Weakness), opens eyes spontaneously
Labs / Radiology
296 K/uL
9."
1714,"SICU
HPI:
81F c/o headache, neck pain found to have SAH, cardiac arrest at OSH.
Chief complaint:
subarachnoid hemorrhage, myocardial infarction
PMHx:
PMH: CAD s/p CABG, HTN, high cholesterol
PSH: CABG, hysterectomy, cholecystectomy
Current medications:
1. 2. Acetaminophen 3. Albuterol Inhaler 4. Bisacodyl 5. Calcium
Gluconate 6. CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse
8. Famotidine 9. Fentanyl Citrate 10. Furosemide 11. Heparin 12.
HydrALAzine 13. Insulin 14. Labetalol
15. Lisinopril 16. Magnesium Sulfate 17. Metoprolol Tartrate 18.
Nimodipine 19. NiCARdipine 20. Nystatin Oral Suspension
21. Phenytoin 22. Phenylephrine 23. Pneumococcal Vac Polyvalent 24.
Potassium Chloride 25."
1715,"8
C (100.1
HR: 91 (70 - 96) bpm
BP: 140/51(76) {115/35(60) - 146/55(80)} mmHg
RR: 22 (19 - 28) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 101.4 kg (admission): 91 kg
Height: 65 Inch
CVP: 22 (8 - 22) mmHg
ICP: 12 (7 - 13) mmHg
Total In:
2,566 mL
414 mL
PO:
Tube feeding:
1,328 mL
249 mL
IV Fluid:
1,058 mL
105 mL
Blood products:
Total out:
2,893 mL
1,143 mL
Urine:
2,695 mL
1,100 mL
NG:
5 mL
Stool:
Drains:
193 mL
43 mL
Balance:
-327 mL
-729 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST
Vt (Set): 500 (500 - 500) mL
RR (Set): 14
PEEP: 10 cmH2O
FiO2: 50%
RSBI Deferred: PEEP > 10
PIP: 33 cmH2O
Plateau: 28 cmH2O
Compliance: 27."
1716,"9 g/dL
161 mg/dL
1.0 mg/dL
21 mEq/L
3.9 mEq/L
47 mg/dL
113 mEq/L
144 mEq/L
29.7 %
13.8 K/uL
[image002.jpg]
[**2107-6-3**] 04:26 AM
[**2107-6-3**] 01:58 PM
[**2107-6-3**] 03:04 PM
[**2107-6-3**] 03:23 PM
[**2107-6-4**] 03:13 AM
[**2107-6-4**] 03:26 AM
[**2107-6-4**] 02:13 PM
[**2107-6-4**] 04:00 PM
[**2107-6-5**] 03:00 AM
[**2107-6-5**] 03:17 AM
WBC
11.8
12.5
13."
1717,"Potassium Phosphate
26. Propofol 27. Senna 28. Simvastatin
24 Hour Events:
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2107-6-4**] 10:16 PM
Infusions:
Furosemide (Lasix) - 2 mg/hour
Nicardipine - 2 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2107-6-4**] 07:56 PM
Heparin Sodium (Prophylaxis) - [**2107-6-5**] 12:18 AM
Dilantin - [**2107-6-5**] 02:25 AM
Hydralazine - [**2107-6-5**] 04:29 AM
Other medications:
Flowsheet Data as of [**2107-6-5**] 04:42 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a.m.
Tmax: 38.3
C (101
T current: 37."
1718,"38/48/121/26/2
Ve: 7.1 L/min
PaO2 / FiO2: 303
Physical Examination
General Appearance: No acute distress, Overweight / Obese
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous : bilateral bases)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Diminished), (Pulse - Posterior tibial: Diminished)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Diminished), (Pulse - Posterior tibial: Diminished)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: Follows simple commands, (Responds to: Verbal stimuli,
Tactile stimuli), Moves all extremities
Labs / Radiology
280 K/uL
9.0 g/dL
118 mg/dL
0."
1719,"9
T current: 36.7
C (98.1
HR: 79 (67 - 82) bpm
BP: 133/45(66) {116/42(59) - 151/62(82)} mmHg
RR: 28 (19 - 37) insp/min
SPO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 88.4 kg (admission): 91 kg
Height: 65 Inch
Total In:
1,400 mL
407 mL
PO:
Tube feeding:
1,320 mL
347 mL
IV Fluid:
Blood products:
Total out:
2,980 mL
1,010 mL
Urine:
2,980 mL
1,010 mL
NG:
Stool:
Drains:
Balance:
-1,580 mL
-603 mL
Respiratory support
O2 Delivery Device: Trach mask
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 340 (340 - 340) mL
PS : 5 cmH2O
RR (Spontaneous): 28
PEEP: 5 cmH2O
FiO2: 40%
PIP: 10 cmH2O
SPO2: 99%
ABG: 7."
1720,"Insulin
11. Labetalol 12. Magnesium Sulfate
13. Metoprolol Tartrate 14. Nystatin Oral Suspension 15. Pneumococcal
Vac Polyvalent 16. Potassium Chloride
17. Senna 18. Simvastatin 19. Sodium Chloride 0.9% Flush 20.
Spironolactone
24 Hour Events:
ARTERIAL LINE - STOP [**2107-6-24**] 04:06 AM
Post operative day:
POD#7 - aneurysm clipping
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2107-6-24**] 12:00 AM
Other medications:
Flowsheet Data as of [**2107-6-24**] 06:25 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a.m.
Tmax: 37.2
C (98."
1721,"SICU
HPI:
81F c/o headache, neck pain found to have SAH, cardiac arrest at OSH,
s/p EVD, s/p trach/PEG, c/b new cerebellar stroke [**6-12**] s/p aneursym
clipping [**6-16**], s/p angio [**6-17**].
Chief complaint:
SAH, NSTEMI, mental status change
PMHx:
PMH: CAD s/p CABG, HTN, high cholesterol
PSH: CABG, hysterectomy, cholecystectomy
[**Last Name (un) **]: Diovan, Vytorin 10/40, metoprolol 12.5"", ASA 325', MVI,
glucosoamine, calcium
Current medications:
Acetaminophen 4. Bisacodyl 5. Calcium Gluconate 6. Chlorhexidine
Gluconate 0.12% Oral Rinse
7. Docusate Sodium (Liquid) 8. Fentanyl Citrate 9. Heparin 10."
1722,"Neurologic: Neuro checks Q: 2 hr, Pain controlled without medications
Cardiovascular: Beta-blocker, Statins, goal SBP <160, on metoprolol
50''', labetolol prn, statin, no ASA
Pulmonary: Trach, keep pt on TC as long as she can tolerate
Gastrointestinal / Abdomen: TF@goal
Nutrition: Tube feeding
Renal: Foley, adequate UOP, Cr-0.6 stable, autodiuresing, Lasix prn,
goal ~1L neg
Hematology: Serial Hct, Hct-25.9<27.2 stable
Endocrine: RISS, goal FS<150, well controlled
Infectious Disease: afebrile, WBC WNL
Lines / Tubes / Drains: Foley, trach, PEG, a-line
Wounds: Dry dressings
Imaging:
Fluids: KVO
Consults: Neuro surgery
Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory
distress: Insufficiency / Post-op)
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2107-6-24**] 03:29 AM 55 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2107-6-24**] 04:12 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer:
VAP bundle: HOB elevation, Mouth care
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: [**Hospital 1025**] Transfer to rehab / long term facility
Total time spent: 40 minutes
Patient is critically ill"
1723,"2
Plt
[**Telephone/Fax (3) 7838**]
Creatinine
0.6
0.6
0.6
TCO2
31
27
29
26
23
29
Glucose
131
147
128
118
Other labs: PT / PTT / INR:13.0/28.4/1.1, CK / CK-MB / Troponin
T:47/16/<0.01, ALT / AST:20/28, Alk-Phos / T bili:67/0.5, Lactic
Acid:0.6 mmol/L, Albumin:3.1 g/dL, LDH:226 IU/L, Ca:8.6 mg/dL, Mg:2.2
mg/dL, PO4:4.2 mg/dL
Assessment and Plan
AIRWAY CLEARANCE, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE,
IMPAIRED, MOTOR FUNCTION, IMPAIRED, RESPIRATION / GAS EXCHANGE,
IMPAIRED, SUBARACHNOID HEMORRHAGE (SAH)
Assessment and Plan: 81F c/o headache, neck pain found to have SAH,
cardiac arrest at OSH, s/p EVD, s/p trach/PEG, c/b new cerebellar
stroke [**6-12**] s/p aneursym clipping [**6-16**], s/p angio [**6-17**]."
1724,"6 mg/dL
26 mEq/L
4.3 mEq/L
19 mg/dL
105 mEq/L
140 mEq/L
27.2 %
5.8 K/uL
[image002.jpg]
[**2107-6-21**] 02:55 AM
[**2107-6-21**] 07:46 AM
[**2107-6-21**] 09:10 AM
[**2107-6-22**] 02:37 AM
[**2107-6-22**] 02:50 AM
[**2107-6-22**] 04:00 AM
[**2107-6-23**] 02:32 AM
[**2107-6-23**] 02:50 AM
[**2107-6-24**] 02:26 AM
[**2107-6-24**] 02:35 AM
WBC
6.0
6.0
5.8
Hct
28.0
25.9
27."
1725,"5
mg/dL, PO4:3.3 mg/dL
Assessment and Plan
SUBARACHNOID HEMORRHAGE (SAH), [**Last Name 12**] PROBLEM - ENTER DESCRIPTION IN
COMMENTS, TACHYCARDIA, OTHER, RESPIRATORY FAILURE, ACUTE (NOT
ARDS/[**Doctor Last Name 11**]), INTRACEREBRAL HEMORRHAGE (ICH)
Assessment and Plan: 81F c/o headache, neck pain found to have SAH,
cardiac arrest at OSH, s/p EVD, s/p trach/PEG
Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain
controlled, EVD 20cm tragus, nimodipine, dilantin, fentanyl prn,
aneurysm clipping on tue.
Cardiovascular: HTN controlled on Beta-blocker, keep SBP 100-180, on
metoprolol 75'''/lisinopril 20'/hydral, statin, no ASA
Pulmonary: Trach, (Ventilator mode: CPAP + PS), Trach mask as tolerated
Gastrointestinal / Abdomen: TF; NPO
Nutrition: Tube feeding at goal."
1726,"2 L/min
Physical Examination
General Appearance: No acute distress
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: 2+), (Temperature: Warm)
Right Extremities: (Edema: 2+), (Temperature: Warm)
Neurologic: Follows simple commands, Moves all extremities.
Labs / Radiology
353 K/uL
8.3 g/dL
144 mg/dL
0.7 mg/dL
23 mEq/L
3.9 mEq/L
28 mg/dL
114 mEq/L
144 mEq/L
26.1 %
12.2 K/uL
[image002.jpg]
[**2107-6-9**] 02:20 AM
[**2107-6-9**] 02:37 AM
[**2107-6-9**] 11:16 PM
[**2107-6-10**] 05:29 AM
[**2107-6-10**] 05:43 AM
[**2107-6-10**] 04:32 PM
[**2107-6-11**] 12:30 AM
[**2107-6-11**] 02:26 AM
[**2107-6-11**] 02:45 PM
[**2107-6-12**] 02:42 AM
WBC
13."
1727,"SICU
HPI:
81F c/o headache, neck pain found to have SAH, cardiac arrest at OSH,
s/p EVD, s/p trach/PEG
Chief complaint:
headache, neck pain
PMHx:
PMH: CAD s/p CABG, HTN, high cholesterol
PSH: CABG, hysterectomy, cholecystectomy
Current medications:
1. IV access: None Order date: [**5-29**] @ 1356
15. Lisinopril 20 mg PO DAILY htn Order date: [**6-11**] @ 0802
2. 1000 mL 1/2NS
Continuous at 10 ml/hr
kvo Order date: [**6-10**] @ 2229
16. Magnesium Sulfate IV Sliding Scale Order date: [**5-29**] @ 2036
3. Acetaminophen 650 mg PO/PR Q6H:PRN fever pain Order date: [**5-29**] @
1356
17."
1728,"CefazoLIN 2 g IV Q8H while evd in place Order date: [**5-29**] @ 1356
21. Phenytoin 100 mg IV Q8H
start at noon Order date: [**6-3**] @ 0810
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 7**]
Use only if patient is on mechanical ventilation. Order date: [**5-29**] @
1758
22. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO sbp>110 Order
date: [**6-3**] @ 1846
9. Famotidine 20 mg IV Q12H Order date: [**5-29**] @ 1356
23. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**5-29**] @
1350
10. Fentanyl Citrate 25-50 mcg IV Q4H:PRN pain Order date: [**6-4**] @
0907
24."
1729,"Renal: Foley, Adequate UO, Continue to diurese. Volume overload
Lasix
[**Hospital1 **] to be neg 1.5L by am.
Hematology: stable anemia. Hct 26.1
Endocrine: mild hyperglycemia. RISS
Infectious Disease: Check cultures, Afebrile, cefazolin while EVD in
place, WBC 12.2, stable
Lines / Tubes / Drains: Foley, G-tube, Trach
Wounds:
Imaging:
Fluids: KVO
Consults: Neuro surgery
Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory
distress: Failure)
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2107-6-11**] 10:17 AM 55 mL/hour
Glycemic Control:
Lines:
Arterial Line - [**2107-5-29**] 04:47 PM
Multi Lumen - [**2107-5-29**] 04:48 PM
ICP Catheter - [**2107-5-29**] 05:00 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: DNR (do not resuscitate)
Disposition: ICU
Total time spent: 31 minutes"
1730,"m.
Tmax: 37.3
C (99.1
T current: 36.8
C (98.3
HR: 67 (63 - 78) bpm
BP: 143/43(69) {128/39(63) - 175/58(94)} mmHg
RR: 25 (23 - 33) insp/min
SPO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 98.5 kg (admission): 91 kg
Height: 65 Inch
CVP: 9 (9 - 18) mmHg
ICP: 11 (7 - 13) mmHg
Total In:
1,933 mL
253 mL
PO:
Tube feeding:
330 mL
203 mL
IV Fluid:
473 mL
50 mL
Blood products:
Total out:
2,412 mL
363 mL
Urine:
2,190 mL
360 mL
NG:
100 mL
Stool:
Drains:
122 mL
3 mL
Balance:
-479 mL
-110 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 378 (308 - 378) mL
PS : 10 cmH2O
RR (Spontaneous): 26
PEEP: 5 cmH2O
FiO2: 50%
RSBI: 61
PIP: 16 cmH2O
SPO2: 96%
ABG: ///23/
Ve: 8."
1731,"Potassium Chloride PO Sliding Scale Duration: 24 Hours
Hold for K > Order date: [**6-11**] @ 1720
11. Heparin 5000 UNIT SC TID
Please hold am dose on [**2107-6-10**] Order date: [**6-9**] @ 1540
25. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Order date:
[**5-29**] @ [**2016**]
12. HydrALAzine 20 mg PO Q6H Order date: [**6-11**] @ 0802
26. Senna 1 TAB PO BID Order date: [**5-29**] @ 1356
13. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**5-30**] @ 0934
27. Simvastatin 10 mg PO DAILY Order date: [**6-1**] @ 1005
14. Labetalol 10 mg IV Q2H:PRN sbp>180mmHg Order date: [**6-11**] @ 1148
24 Hour Events:
Free water decreased, Lasix 20, Hydralazine and Lisinopril increased
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2107-6-11**] 09:02 PM
Infusions:
Other ICU medications:
Labetalol - [**2107-6-11**] 05:04 AM
Heparin Sodium (Prophylaxis) - [**2107-6-11**] 08:17 AM
Furosemide (Lasix) - [**2107-6-11**] 08:44 AM
Fentanyl - [**2107-6-11**] 02:36 PM
Famotidine (Pepcid) - [**2107-6-11**] 10:00 PM
Other medications:
Flowsheet Data as of [**2107-6-12**] 05:08 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a."
1732,"2
12.1
12.8
12.2
Hct
27.5
27.1
26.4
26.1
Plt
[**Telephone/Fax (3) 7584**]53
Creatinine
1.0
0.8
0.9
0.8
0.7
Troponin T
<0.01
<0.01
TCO2
23
22
23
Glucose
141
126
116
131
144
Other labs: PT / PTT / INR:13.7/28.0/1.2, CK / CK-MB / Troponin
T:47/16/<0.01, ALT / AST:20/28, Alk-Phos / T bili:67/0.5, Lactic
Acid:1.2 mmol/L, Albumin:2.6 g/dL, LDH:226 IU/L, Ca:7.7 mg/dL, Mg:2."
1733,"Metoprolol Tartrate 75 mg PO/NG TID
Hold for SBP<100, HR<60 Order date: [**6-7**] @ 0816
4. Albuterol Inhaler [**3-4**] PUFF IH Q4H:PRN wheezing Order date: [**6-1**] @
2103
18. Nimodipine 60 mg PO Q4H vasospasm prophylaxis
hold for sys bp <110 Order date: [**5-29**] @ 1356
5. Bisacodyl 10 mg PO/PR DAILY Order date: [**5-29**] @ 1356
19. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO sbp<180 Order date:
[**6-11**] @ 1148
6. Calcium Gluconate IV Sliding Scale Order date: [**5-29**] @ 2036
20. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
swish and swallow Order date: [**6-4**] @ 0933
7."
1734,"8
0.8
1.0
TCO2
20
17
20
20
20
21
18
Glucose
138
149
131
146
144
177
Other labs: PT / PTT / INR:12.7/24.3/1.1, CK / CK-MB / Troponin
T:116/16/0.55, ALT / AST:20/28, Alk-Phos / T bili:67/0.5, Lactic
Acid:2.2 mmol/L, Albumin:3.0 g/dL, LDH:226 IU/L, Ca:8.2 mg/dL, Mg:2.5
mg/dL, PO4:1.9 mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 11**]), INTRACEREBRAL HEMORRHAGE
(ICH)
Assessment and Plan: 81F c/o headache, neck pain found to have SAH,
cardiac arrest at OSH."
1735,"SICU
HPI:
81F c/o headache, neck pain found to have SAH, cardiac arrest at OSH.
Chief complaint:
PMHx:
PMH: CAD s/p CABG, HTN, high cholesterol
PSH: CABG, hysterectomy, cholecystectomy
Current medications:
1. 2. Acetaminophen 3. Albuterol Inhaler 4. Bisacodyl 5. Calcium
Gluconate 6. CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8.
Famotidine 9. Fentanyl Citrate 10. Furosemide 11. Furosemide 12.
Heparin 13. HydrALAzine 14. Insulin 15. Labetalol 16. Lisinopril 17.
Magnesium Sulfate 18. Metoprolol Tartrate 19. Nimodipine 20.
NiCARdipine 21. Phenytoin 22. Pneumococcal Vac Polyvalent 23. Potassium
Chloride 24. Potassium Phosphate 25. Propofol
26. Senna 27. Simvastatin
24 Hour Events:
- continuing to hold Dilantin
- increased lisinopril
- fentanyl gtt started
- diuresis with lasix 10 mg x1, 20 mg x1 (weight increasing, increasing
vent requirements)
- made DNR
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2107-6-2**] 02:26 PM
Infusions:
Fentanyl - 50 mcg/hour
Nicardipine - 0."
1736,"1 mEq/L
42 mg/dL
116 mEq/L
143 mEq/L
28.6 %
12.5 K/uL
[image002.jpg]
[**2107-5-31**] 03:28 AM
[**2107-6-1**] 02:47 AM
[**2107-6-1**] 03:04 AM
[**2107-6-1**] 06:20 AM
[**2107-6-1**] 02:14 PM
[**2107-6-2**] 03:36 AM
[**2107-6-2**] 06:20 PM
[**2107-6-2**] 09:28 PM
[**2107-6-3**] 04:14 AM
[**2107-6-3**] 04:26 AM
WBC
14.9
14.6
12.5
Hct
31.1
30.1
28.6
Plt
249
244
260
Creatinine
0."
1737,"Hematology: daily HCT
Endocrine: SSI
Infectious Disease: Cefazolin while drains in. WBC trending down.
Lines / Tubes / Drains: Foley, OGT, ETT, A-line, RIJ central line, EVD
x2
Wounds: c/d/i
Imaging: CXR today
Fluids: KVO
Consults: Neuro surgery
Billing Diagnosis: Cardiac arrest, Acute MI / Ischemia, (Hemorrhage,
NOS: Sub-arachnoid), (Respiratory distress: Failure)
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2107-6-3**] 04:58 AM 55 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2107-5-29**] 04:47 PM
Multi Lumen - [**2107-5-29**] 04:48 PM
ICP Catheter - [**2107-5-29**] 05:00 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 32 minutes
Patient is critically ill"
1738,"7 kg (admission): 91 kg
Height: 65 Inch
CVP: 20 (14 - 22) mmHg
ICP: 6 (4 - 9) mmHg
Total In:
2,617 mL
364 mL
PO:
Tube feeding:
1,256 mL
279 mL
IV Fluid:
1,181 mL
55 mL
Blood products:
Total out:
1,433 mL
286 mL
Urine:
1,262 mL
245 mL
NG:
Stool:
Drains:
171 mL
41 mL
Balance:
1,184 mL
78 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 435 (435 - 435) mL
PS : 10 cmH2O
RR (Spontaneous): 29
PEEP: 8 cmH2O
FiO2: 50%
PIP: 15 cmH2O
SPO2: 95%
ABG: 7."
1739,"49/23/77/18/-2
Ve: 13 L/min
PaO2 / FiO2: 154
Physical Examination
General Appearance: No acute distress, intubated, sedated
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)
Right Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)
Neurologic: (Responds to: Noxious stimuli), No(t) Moves all
extremities, (RUE: No movement), (LUE: Weakness), (RLE: No movement),
(LLE: No movement), Sedated
Labs / Radiology
260 K/uL
9.5 g/dL
177 mg/dL
1.0 mg/dL
18 mEq/L
4."
1740,"8 mcg/Kg/min
Other ICU medications:
Labetalol - [**2107-6-2**] 02:00 PM
Furosemide (Lasix) - [**2107-6-2**] 08:52 PM
Heparin Sodium (Prophylaxis) - [**2107-6-3**] 12:00 AM
Hydralazine - [**2107-6-3**] 04:00 AM
Other medications:
Flowsheet Data as of [**2107-6-3**] 05:33 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a.m.
Tmax: 37.9
C (100.3
T current: 37.9
C (100.3
HR: 85 (73 - 87) bpm
BP: 138/53(77) {109/38(60) - 151/61(90)} mmHg
RR: 30 (21 - 31) insp/min
SPO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 99."
1741,"Neurologic: Neuro checks Q: 1 hr, ICP monitor, Pain controlled, EVD at
10cm above tragus, continue nimodipine, recheck dilantin level today
-?clip aneurysm on Monday vs. CMO
neurosurgery discussing with
family, fentanyl gtt
Cardiovascular: Beta-blocker, Statins, Keep SBP 100-140, on metoprolol
37.5'''/lisinopril 10'/hydral/ nicardipine drip (wean as tolerated), no
ASA. Will start lasix
Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), needing increased
PEEP, will diurese today lasix
Gastrointestinal / Abdomen: NPO, TF.bowel regimen
Nutrition: Tube feeding, NPO
Renal: Foley, Adequate UO, Likely needs diuresis - weight increasing,
increasing vent requirements. Goal 1-2 liters negative today with lasix
gtt for gentle diuresis."
1742,"Found to have new
cerebellar stroke 5/17pm s/p aneursym clipping [**6-16**], s/p angio [**6-17**].
Neurologic: neurochecks q2h, nicardipine, nimodipine, dilantin,
fentanyl prn, new cerebellar stroke, s/p aneurysm clipping, to angio
revealed good clip placement with mild vasospasm
Cardiovascular: goal SBP <160, on metoprolol 75'''/lisinopril
20'/hydral, statin, no ASA
Pulmonary: Trach, currently on CPAP, attempt to wean to trach mask
Gastrointestinal / Abdomen: s/p PEG, TF@goal
Nutrition: Tube feeding
Renal: Foley, adequate UOP, Cr 0.6, aldactone, follow ABGs
Hematology: Hct 28.6, stable
Endocrine: RISS, goal FS<150
Infectious Disease: Afebrile, WBC 7."
1743,"6 %
12.0 K/uL
[image002.jpg]
[**2107-6-14**] 01:56 PM
[**2107-6-14**] 02:04 PM
[**2107-6-15**] 03:06 AM
[**2107-6-15**] 03:36 PM
[**2107-6-16**] 02:10 AM
[**2107-6-16**] 09:47 PM
[**2107-6-17**] 03:56 AM
[**2107-6-17**] 04:18 AM
[**2107-6-17**] 07:38 AM
[**2107-6-18**] 02:03 AM
WBC
6.8
7.8
7.5
12.0
Hct
24.6
24.8
29
29.4
28.6
Plt
378
384
371
370
Creatinine
0.6
0.6
0.6
0.7
0."
1744,"Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Order date:
[**6-17**] @ 0011
10. Furosemide 1-5 mg/hr IV DRIP INFUSION
Bolus with 10mg. Goal diuresis 2 liters Order date: [**6-17**] @ 0002
24. Senna 1 TAB PO BID Order date: [**6-17**] @ 0002
11. Heparin 5000 UNIT SC TID Order date: [**6-17**] @ 1732
25. Simvastatin 10 mg PO DAILY Order date: [**6-17**] @ 0002
12. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**6-17**] @ 0002
26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN."
1745,"Nimodipine 60 mg PO Q4H vasospasm prophylaxis
hold for sys bp <110 Order date: [**6-17**] @ 0002
3. 1000 mL D5 1/2NS
Continuous at 80 ml/hr Order date: [**6-17**] @ 0002
17. NiCARdipine 1-3 mcg/kg/min IV DRIP TITRATE TO sbp<160 Order date:
[**6-17**] @ 0002
4. Acetaminophen 650 mg PO/PR Q6H:PRN fever pain Order date: [**6-17**] @
0002
18. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
swish and swallow Order date: [**6-17**] @ 0002
5. Bisacodyl 10 mg PO/PR DAILY Order date: [**6-17**] @ 0002
19. Phenytoin 100 mg IV Q8H
start at noon Order date: [**6-17**] @ 0002
6."
1746,"6
TCO2
31
33
34
32
38
Glucose
127
135
128
129
141
161
Other labs: PT / PTT / INR:14.0/24.6/1.2, CK / CK-MB / Troponin
T:47/16/<0.01, ALT / AST:20/28, Alk-Phos / T bili:67/0.5, Lactic
Acid:1.0 mmol/L, Albumin:3.1 g/dL, LDH:226 IU/L, Ca:8.6 mg/dL, Mg:2.1
mg/dL, PO4:4.3 mg/dL
Imaging: [**6-12**] CT head: New R cerebellar infarct in the PICA
distribution
[**6-13**] TTE: LV fxn nml. no AS/AR, 1+MR, 2+TR, PA sys htn
[**6-13**] CTA head: R PICA infarct, 2mm aneurysm R PICA, unchanged SAH/IVH
[**6-14**] CT Head: No hydrocephalus, stable SAH/IVH
[**6-16**] CT Head: postsurgical changes, no new ICH
Microbiology: [**5-29**] urine: neg
[**5-29**] blood x2: neg
[**6-5**] urine: neg
[**6-5**] bld x 2: neg
[**6-5**] sputum: contam
[**6-6**] sputum: neg
[**6-7**] CSF: neg
[**6-11**] Cdiff: neg
Assessment and Plan
SUBARACHNOID HEMORRHAGE (SAH), [**Last Name 12**] PROBLEM - ENTER DESCRIPTION IN
COMMENTS, INTRACEREBRAL HEMORRHAGE (ICH)
Assessment and Plan: 81F c/o headache, neck pain found to have SAH,
cardiac arrest at OSH, s/p EVD, s/p trach/PEG."
1747,"8 -> 12
Lines / Tubes / Drains: Foley, RIJ CVL, trach, PEG
Wounds: Dry dressings
Imaging:
Fluids: KVO
Consults: Neuro surgery
Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2107-6-18**] 03:00 AM 55 mL/hour
Glycemic Control:
Lines:
Multi Lumen - [**2107-5-29**] 04:48 PM
Arterial Line - [**2107-6-16**] 06:00 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: DNR (do not resuscitate)
Disposition: ICU
Total time spent: 31 minutes"
1748,"m.
Tmax: 37.8
C (100.1
T current: 37.8
C (100.1
HR: 85 (70 - 90) bpm
BP: 138/50(78) {60/50(57) - 166/98(113)} mmHg
RR: 21 (12 - 23) insp/min
SPO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 94.3 kg (admission): 91 kg
Height: 65 Inch
Total In:
2,797 mL
476 mL
PO:
Tube feeding:
334 mL
277 mL
IV Fluid:
2,103 mL
139 mL
Blood products:
Total out:
3,555 mL
180 mL
Urine:
3,555 mL
180 mL
NG:
Stool:
Drains:
Balance:
-758 mL
296 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 468 (369 - 585) mL
PS : 14 cmH2O
RR (Set): 10
RR (Spontaneous): 19
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 97
PIP: 20 cmH2O
Plateau: 18 cmH2O
SPO2: 97%
ABG: 7."
1749,"Calcium Gluconate IV Sliding Scale Order date: [**6-17**] @ 0002
20. Phenytoin 200 mg IV ONCE Duration: 1 Doses
please give in addition to daily dosing Order date: [**6-17**] @ 0808
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 7**]
Use only if patient is on mechanical ventilation. Order date: [**6-17**] @
0002
21. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**5-29**] @
1350
8. Famotidine 20 mg IV Q12H Order date: [**6-17**] @ 0002
22. Potassium Chloride IV Sliding Scale Order date: [**6-17**] @ 0002
9. Fentanyl Citrate 25-50 mcg IV Q4H:PRN pain Order date: [**6-17**] @ 0002
23."
1750,"SICU
HPI:
81F c/o headache, neck pain found to have SAH, cardiac arrest at OSH,
s/p EVD, s/p trach/PEG. Found to have new cerebellar stroke 5/17pm s/p
aneursym clipping [**6-16**], s/p angio [**6-17**].
Chief complaint:
headache
PMHx:
PMH: CAD s/p CABG, HTN, high cholesterol
PSH: CABG, hysterectomy, cholecystectomy
Current medications:
1. IV access: None Order date: [**6-17**] @ 0002
15. Metoprolol Tartrate 50 mg PO/NG TID
Hold for SBP<100, HR<60 Order date: [**6-17**] @ 0002
2. IV access: Temporary central access (ICU) Order date: [**6-17**] @ 0002
16."
1751,"49/48/95.[**Numeric Identifier 143**]/28/11
Ve: 7.4 L/min
PaO2 / FiO2: 240
Physical Examination
General Appearance: No acute distress
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: 1+), (Temperature: Warm)
Right Extremities: (Edema: 1+), (Temperature: Warm)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
370 K/uL
9.4 g/dL
161 mg/dL
0.6 mg/dL
28 mEq/L
3.9 mEq/L
15 mg/dL
100 mEq/L
138 mEq/L
28."
1752,"Order date: [**6-17**] @ 0002
13. Labetalol 10 mg IV Q2H:PRN sbp>160mmHg Order date: [**6-17**] @ 0002
27. Spironolactone 25 mg PO DAILY Order date: [**6-17**] @ 0002
14. Magnesium Sulfate IV Sliding Scale Order date: [**6-17**] @ 0002
24 Hour Events:
angio - good clip placement with mild vasospasm
Post operative day:
POD#1 - aneurysm clipping
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2107-6-15**] 06:05 AM
Infusions:
Nicardipine - 1.5 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2107-6-17**] 08:20 AM
Dilantin - [**2107-6-18**] 04:30 AM
Other medications:
Flowsheet Data as of [**2107-6-18**] 05:07 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a."
1753,"Subjective: Per patient
s sister and husband, patient usually has a
great appetite.
Objective
Height
Admit weight
Daily weight
Weight change
BMI
165 cm
91 kg
95.6 kg ([**2107-5-31**] 12:00 AM)
33.3
Ideal body weight
% Ideal body weight
Adjusted weight
Usual body weight
% Usual body weight
56.7 kg
160%
65kg
87kg
103%
Diagnosis: ICH
PMH : CAD s/p CABG, HTN, high cholesterol, CABG, hysterectomy,
cholecystectomy
Food allergies and intolerances: no known food allergies
Pertinent medications: NaCl 0.9% with KCl @75cc/hr, RISS, Pepcid,
Heparin, Bisacodyl, Senna, others noted
Labs:
Value
Date
Glucose
146 mg/dL
[**2107-6-1**] 06:20 AM
Glucose Finger Stick
169
[**2107-6-1**] 10:00 AM
BUN
19 mg/dL
[**2107-6-1**] 02:47 AM
Creatinine
0."
1754,"1 %
[**2107-6-1**] 02:47 AM
Current diet order / nutrition support: Tube Feed: Replete with Fiber @
95cc/hr (2280kcals, 141g protein)
GI: abd soft, obese, +bowel sounds
Assessment of Nutritional Status
Obese
Estimated Nutritional Needs
Calories: 1300-1625 (BEE x or / 20-25 cal/kg)
Protein: 65-84 (1-1.3 g/kg)
Fluid: per team
Estimation of previous intake: Adequate
Estimation of current intake: Excessive
Specifics:
81 y.o. Female admitted s/p NSTEMI and with SAH due to aneurysm. A B/L
vent drain was placed, which is draining small amounts. Patient with
NGT; tube feeds were started last night, currently at 40cc/hr."
1755,"Current
tube feed goal will significantly overfeed calories and protein, thus
recommend changing tube feed goal to more appropriately meet patient
needs.
Medical Nutrition Therapy Plan - Recommend the Following
1) Recommend changing tube feed goal to Nutren Pulmonary @40cc/hr
(1440kcals, 65g protein) to meet 100% of estimated nutritional needs.
2) Monitor lytes and BG with tube feed advancement.
3) Will follow progress/plan.
Please page with any questions. #[**Numeric Identifier 2337**]
------ Protected Section ------
Tube feeding goal could also be Replete with Fiber @ 55cc/hr
(1320kcals, 82g protein) to meet 100% of estimated needs.
------ Protected Section Addendum Entered By:[**Name (NI) 2118**] [**Last Name (NamePattern1) 5392**], RD, [**Name (NI) 287**]
on:[**2107-6-1**] 11:36 ------"
1756,"9 mg/dL
[**2107-6-1**] 02:47 AM
Phosphorus
2.4 mg/dL
[**2107-6-1**] 02:47 AM
Ionized Calcium
1.14 mmol/L
[**2107-6-1**] 06:20 AM
Magnesium
2.5 mg/dL
[**2107-6-1**] 02:47 AM
ALT
166 IU/L
[**2107-5-29**] 04:54 PM
Alkaline Phosphate
59 IU/L
[**2107-5-29**] 04:54 PM
AST
179 IU/L
[**2107-5-29**] 04:54 PM
Phenytoin (Dilantin)
17.7 ug/mL
[**2107-5-31**] 03:07 AM
WBC
14.9 K/uL
[**2107-6-1**] 02:47 AM
Hgb
10.4 g/dL
[**2107-6-1**] 02:47 AM
Hematocrit
31."
1757,"8 mg/dL
[**2107-6-1**] 02:47 AM
Sodium
141 mEq/L
[**2107-6-1**] 02:47 AM
Potassium
4.3 mEq/L
[**2107-6-1**] 06:20 AM
Chloride
116 mEq/L
[**2107-6-1**] 02:47 AM
TCO2
18 mEq/L
[**2107-6-1**] 02:47 AM
PO2 (arterial)
172 mm Hg
[**2107-6-1**] 06:20 AM
PCO2 (arterial)
31 mm Hg
[**2107-6-1**] 06:20 AM
pH (arterial)
7.40 units
[**2107-6-1**] 06:20 AM
CO2 (Calc) arterial
20 mEq/L
[**2107-6-1**] 06:20 AM
Albumin
3.0 g/dL
[**2107-6-1**] 02:47 AM
Calcium non-ionized
7."
1758,"Family
reports pt in her usual state of health yesterday and this am
until she c/o of pain in her head and neck this am and they
called EMS. They deny c/o CP or SOB. No trauma in history. Pt
was intubated by report at OSH.
Past Medical History:
CABG x 2 / [**2103**], HTN, hysterectomy (remote), Cholecystectomy
(remote), no recent hospitalizatin or illness per family
Social History:
Social Hx: unknown at present
Family History:
Family Hx:has a twin sister/present
Physical Exam:
on arrival
PHYSICAL EXAM:
O: T:AF BP:77/70 HR:74 R vented O2Sats100%
Gen: WD/WN, intubated, no obvious trauma noted
HEENT: NC/AT Pupils: 2mm non reactive at present, +trace
corneals, conjugate gaze."
1759,"Heart size is top normal. Leftward
mediastinal shift and
opacification at the left lung base suggest left lower lobe
collapse, present since at least [**6-6**]. Tracheostomy tube in
standard placement. No
pneumothorax.
Brief Hospital Course:
Pt was received to the ED from OSH after c/o headache and neck
pain at home. Accorrding to EMS records she required
resucitation. IN the ED she was severly hypotensive and
required fluid resucitation.
CT scan reveled SAH with IVH and HCP. She was taken emergently
to the OR for placment of bilateral EVD's. After the OR she had
an emergent CTA of the brain which did not reveal a source of
the SAH."
1760,"She was transfered to the SICU and monitored closely. Nimodipine
and dilantin were started. Cardilogy consult was initiated in
the ED for elevated troponins. She underwent a TTE which the
results are in the results section of this summary.
A Cerebral angiogram was performed on [**2107-5-31**]. It revealed a
Right PICA aneurysm.
MRI did not show any infarcts. Pt was medically managed as she
was not able to be coiled. A decision was made monitor her exam
for a few more days to see if she improved before considering an
open craniotomy.
On [**6-5**] pt began opening eys and able to stick tongue out on
command."
1761,"On [**6-7**] she began withdrawing her lower extremities to
stimulation and nodding head to simple questions. Her L EVD was
dc'd without difficulty.
Her neurological exam vastly improved to following commands by
nodding head appropriately to questions correctly and lifting
all extremeties off the bed to command. She received a trach
placed on [**6-7**]. She underwent an attempted coiling on [**6-10**] of
her right vertebral artery but it was unable to be accessed.
On [**6-12**], patient had a right cerbellar infact that was not
previously seen on CT. Neuro suspected that the infarct may have
occluded the PICA and the aneurysm."
1762,"12. Calcium Gluconate in D5W 2 gram/100 mL Solution Sig: One (1)
Intravenous ASDIR (AS DIRECTED).
13. Magnesium Sulfate 4 % Solution Sig: One (1) Injection PRN
(as needed).
14. Fentanyl Citrate 25-50 mcg IV Q4H:PRN pain
15. Potassium Chloride Intravenous
16. Labetalol 10 mg IV Q2H:PRN sbp>160mmHg
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Health Network
Discharge Diagnosis:
Intraventricular Hemorrhage, subarachnoid hemorrhage, cerebral
aneurysm(Rt PICA)
NSTEMI; depressed cardiac function (EF 35%, global hypokinesis)"
1763,"High-density material also
layers along the tentorium cerebelli. There are no other foci of
intracranial hemorrhage. There is no edema, shift of normally
midline structures or evidence of major vascular territorial
infarct. There is no large mass effect associated with
intraventricular and subarachnoid bleeding. There is no other
evidence of herniation. There is no fracture. Mastoid air cells
are well aerated. There is fluid within scattered ethmoid air
cells, but the sphenoid, maxillary and frontal air cells are
well aerated.
IMPRESSIONS:
1. Diffuse subarachnoid hemorrhage along the base of the brain,
and
collecting within the ventricles, predominantly within the third
and fourth ventricles, but also layering dependently in the
lateral ventricles."
1764,"No new aneurysms are identified. 5 mg of Verapamil
were infused via slow infusion.
A right common carotid artery arteriogram was performed
secondary to moderate plaque at the origin of the right internal
carotid artery. Mild vasospasm was noted. 5 mg of Verapamil were
infused IV via slow infusion.
Moderate sedation was provided by administering divided doses of
Fentanyl
throughout the total intraservice time of 1 hour and 15 minutes
during which the patient's hemodynamic parameters were
continuously monitored.
CHEST (PORTABLE AP) Study Date of [**2107-6-23**] 4:01 AM
Small bilateral pleural effusions and mild pulmonary edema have
improved since [**6-21**]."
1765,"No
contrast was administered. Multiplanar reformatted images were
generated.
FINDINGS: There is an extensive amount of high-density material
tracking
around the cerebellum, as well as through the basilar cisterns.
Overall, this is consistent with subarachnoid hemorrhage. There
is no obvious area of greatest density to indicate a source for
the bleeding. Hyperdense material also layers dependently within
the occipital horns of the lateral ventricles, and collects in
the third and fourth ventricles. Lateral ventricles are not
enlarged, although comparison with the prior study is not
possible at the time of dictation. However, there is no large
ventricular outlet obstruction."
1766,"She tolerated the procedure
well and her post-op head CT show no new hemorrhage however she
did have further evolution or R cerebellar infarct.
On [**6-17**], angiogram showed good clip placement with mild
vasospasm. She was able to still follow commands and open her
eyes spontaneoulsy. She was not moving her upper extremities.
She was also placed on nimodipine 60mg Q4H for vasospasm.
On the 23rd and 24th, patient's physical exam improved, she was
able to move both upper and lower extremities, but UE55%)."
1770,"IMPRESSION:
Diffuse subarachnoid hemorrhage including right
perimesencephalic cistern
and fourth intraventricular hemorrhage. 2.5 mm likely tiny
aneurysm at the origin of the right posterior inferior
cerebellar artery. Further evaluation with cerebral angiography
is recommended, as clinically relevant.
ECHOCARDIOGRAPHY REPORT [**2107-5-30**] at 9:45:40 AM
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is moderate global left
ventricular hypokinesis (LVEF = 35%). No masses or thrombi are
seen in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg)."
1771,"No evidence of outlet obstruction at this
time, although a comparison with prior CT would be useful to
determine interval change. No mass effect or herniation at this
time.
2. No other foci of hemorrhage.
3. Opacification of scattered ethmoid air cells.
CTA HEAD W&W/O C & RECONS [**2107-5-29**] 2:36 PM
SCAN FINDINGS: Non-contrast CT of the head demonstrates diffuse
cerebral
subarachnoid hemorrhage including blood products within the
lateral
ventricles, third ventricles and filling the fourth ventricle
extending
through the foramen of Luschka with subarachnoid hemorrhage in
the right
perimesencephalic cistern. There is no significant shift of
midline
structures."
1772,"5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day)."
1773,"No cardiac source of embolism
identified.
CTA HEAD W&W/O C & RECONS Study Date of [**2107-6-13**] 11:51
1. Unchanged appearance of the right posterior inferior
cerebellar artery
territory infarction.
2. 2 mm aneurysm at the origin of the right posterior inferior
cerebellar
artery is again seen. The posterior inferior cerebellar artery
remains
patent.
3. Unchanged subarachnoid and intraventricular hemorrhage
CT HEAD W/O CONTRAST Study Date of [**2107-6-14**] 5:31
1. Interval removal of right frontal ventriculostomy catheter
with slight
interval increase in lateral ventricle size. Close follow-up
recommended.
2. Stable residual subarachnoid and intraventricular hemorrhage."
1774,"No hemotympanum, battles sign or
raccoons sign, no csf rhinorrhea or otorrhea.
Neck: no cervical collar in place
Abd: Soft
Extrem: Warm.
Neuro:
Mental status: No eye opening to voice or noxious, currently off
sedation and gagging vs pre-emesis. No commands, +
localization
with RUE, w/d's LUE and LE's B/L.fect.
PR equivocal
ON DISCHARGE:
A&O x 3, mouthing words, following commands
Pupils: PERRL 4-3mm bilaterally
EOMs: intact
Face symmetrical
Motor:
UE: Right-grasp [**3-31**], biceps, triceps, and deltoids- 4-
Left- no movement
LE: Right- antigravity, bends knees, wiggles toes
Left-bends knees, wiggles toes"
1775,"Patient mouthing words, A&O
x3, moves all extremites to command. [**6-13**], CTA showed patency of
PICA and planning for open coiling or clipping of PICA aneurysm
started. CTA will be repeated on [**6-15**] to recheck patency of
PICA. EVD ""fell"" out and stat CT showed stable SAH.
On [**6-15**], patient A&O x3 and following commands. Her repeat head
CT shows slight increase in lateral ventricle size, but stable.
Patient will be sent to OR for open clipping of PICA aneurysm.
On [**6-16**] patient was brought to the OR where she underwent a
clipping of her R pica aneurysm."
1776,"Pertinent Results:
Cardiology Report ECG Study Date of [**2107-5-29**] 10:51:26 AM
Sinus rhythm Nonspecific intraventricular conduction delay
Possible anterior infarct - age undetermined Nonspecific ST-T
wave changes
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 152 102 438/467 83 43 174
Imaging:
CT HEAD W/O CONTRAST [**2107-5-29**] 10:59 AM
Final Addendum
ADDENDUM: Findings of subarachnoid hemorrhage and
intraventricular hemorrhage discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from
neurosurgery at the time of subsequent CTA head examination.
TECHNIQUE: Contiguous axial images were obtained through the
brain."
1777,"She will be
discharged to a rehab facility with ventilator.
Medications on Admission:
diovan, vytorin 10/40, metoprolol 12.5 [**Hospital1 **], asa 325 daily, MVI,
glucosoamine, calcium.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever pain .
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day)."
1778,"Admission Date: [**2107-5-29**] Discharge Date: [**2107-6-24**]
Date of Birth: [**2025-12-28**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
WHOL and neck pain at home / ems was called / pt intubated on
arrival
Major Surgical or Invasive Procedure:
Bilateral external ventricular drains [**2107-5-29**]
cerebral angiogram [**2107-5-31**]
History of Present Illness:
Asked to see this 81 year old white female who was transfered
from OSH for SAH. By EMS reports, pt reported CP and SOB and
family called 911. On their arrival pt required CPR."
1779,"?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status."
1780,"Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc."
1781,"3. Expected evolution of right cerebellar infarction.
TRANSCATH THERAPY Study Date of [**2107-6-17**] 10:51 AM
Evaluation of the right vertebral artery showed moderate
stenosis
at the origin. The arteriogram demonstrated mild vasospasm. The
aneurysm
appeared well clipped. 5 mg of Verapamil were given IV via slow
infusion,
secondary to the vasospasm. No new aneurysms, regions of
flow-limiting
stenosis or occlusions were identified.
The left internal carotid artery arteriogram demonstrated
minimal vasospasm in the left lenticulostriate and MCA branches.
No new aneurysm is identified. 5mg of Verapamil were infused via
slow infusion.
The left vertebral artery arteriogram demonstrated minimal
vasospasm."
1782,"CTA OF THE HEAD: CTA of the head demonstrates a tiny 2.5-mm
outpouching at
the origin of the right posterior inferior cerebellar artery
suggestive of a tiny aneurysm. 2.5 mm indicates the patent
lumen. The location of this
aneurysm would be consistent with the pattern of subarachnoid
hemorrhage.
The right vertebral artery terminates in the PICA. The remaining
intracranial circulation demonstrates no evidence of
hemodynamically significant stenosis, aneurysm or occlusion. The
right vertebral artery, basilar artery as well as the anterior
circulation is intact. Note is made of bilateral ventriculostomy
catheters in the frontal lobes terminating within the lateral
ventricles."
1783,"?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-5**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2107-6-24**]"
1784,"Attending Physician: [**Name10 (NameIs) 744**]
Referral date: [**2187-10-8**]
Medical Diagnosis / ICD 9: / 571.2
Reason of referral: Eval/Tx
History of Present Illness / Subjective Complaint: Pt is a 60M with
ESLD/cirrhosis admitted [**10-7**] with hepatic encephalopathy and now s/p
OLT and cadaveric kidney transplant [**2187-10-12**] and extubated [**10-14**]
Past Medical / Surgical History: See Eval
Medications: MethylPREDNISolone, Amlodipine, OxycoDONE
Radiology: [**10-14**] CXR Endotracheal tube has been removed. Retrocardiac
opacification persists. The right hemidiaphragm is not as well seen,
though this may be a technical factor.
Labs:
28.3
10.1
38
8."
1785,"1
[image002.jpg]
Activity Orders: OOB c A
Social / Occupational History: See Eval
Living Environment: See Eval
Prior Functional Status / Activity Level: See Eval
Objective Test
Arousal / Attention / Cognition / Communication: A+O to
person/[**Hospital1 5**]/Current events/Current medical situation/ but reported yr
as [**2187**]. Able to follow all commands.
Aerobic Capacity
HR
BP
RR
O[2] sat
Rest
69
181/85
20
100 2LO2
Activity
72
178/86
28
98 RA
Recovery
68
171/88
24
100 2LO2
Pulmonary Status: Decreased at bases. 1250mL on IS. Weak, nonproductive
cough.
Integumentary / Vascular: R CVL. NGT. Foley. Abdominal incision c JP
drainx3."
1786,"Sensory Integrity: Intact to Lt touch.
Pain / Limiting Symptoms: Pt c/o min incision discomfort c mobility.
Posture: WNL
Range of Motion
Muscle Performance
WNL
hip flexion > 3+/5 limited by incisional pain but o/w grossly [**3-31**].
Motor Function: Able to MAE in isolation. Slight BUE intention tremor.
Functional Status:
Activity
Clarification
I
S
CG
Min
Mod
Max
Gait, Locomotion: Ambulation NT [**1-27**] hypertension.
Rolling:
T
Supine /
Sidelying to Sit:
T
Transfer:
T
Sit to Stand:
2 Reps
T
Balance: S at EOB c I UE support. [**Female First Name (un) **] for dynamic standing balance s
UE support."
1787,"Education / Communication: [**Name6 (MD) **] c RN RE Pt Status
Pt edu RE Role of PT and Importance of OOB
Diagnosis:
1.
Gait, Impaired
2.
Muscle Performace, Impaired
3.
Transfers, Impaired
4.
Ventilation, Impaired
Clinical impression / Prognosis: Pt is a 60M who p/w above impairments
c/w soft tissue surgery. Pt is functioning below baseline and has not
met goals of original eval [**1-27**] OLT/Kidney tx. Pt was limited today by
hypertension and would benefit from improved BP control. Pt has good
potential for home D/C given high baseline and progress thus far since
tx. Pt will require an additional 1-2 weeks of acute PT.
Goals
Time frame: One Week
1.
Amb 150 s AD s LOB I
2.
Sup to Sit to Stand I
3.
5 Stairs c Rail I
4.
RR < 30 c Above
5.
6.
Anticipated Discharge: Home with Home PT
Treatment [**Name (NI) 99**]:
Frequency / Duration: 3-5x/wk for One week
Functional Mobility/Balance Training
Breathing Exercises
T Patient agrees with the above goals and is willing to participate in
the rehabilitation program.
9:10-9:40"
1788,"please try to do prior to 10am for same day
read
CONTRAINDICATIONS for IV CONTRAST:
renal transplant
______________________________________________________________________________
FINAL REPORT
HISTORY: 60-year-old man with aortic stenosis status post liver and kidney
transplant on [**2187-10-11**] with post-op course complicated by bacteremia,
sinus tach and increasing LFTs. Concern for liver transplant rejection.
TECHNIQUE: After discussion of the risks and benefits of the procedure with
the patient, written informed consent was obtained for an ultrasound-guided
liver biopsy. A timeout procedure was performed using three patient
identifiers.
The patient received 20 mcg of IV fentanyl with continuous radiology nursing
staff monitoring of hemodynamic parameters. The right upper quadrant was
prepped and draped in the usual sterile fashion. 2% lidocaine was used for
local anesthesia.
Under ultrasound guidance, a single 18-gauge core biopsy was obtained. The
sample was placed in formalin and sent to pathology for expedited evaluation.
Radiology attending, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1463**], was present and actively participated
throughout the duration of the procedure.
IMPRESSION: Successful ultrasound-guided liver biopsy. A single 18-gauge
core biopsy was sent to pathology for expedited evaluation."
1789,"[**2187-11-1**] 3:32 PM
BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # [**Clip Number (Radiology) 36088**]
Reason: please do US guided biopsy transplant liver with results [**Doctor Last Name **]
Admitting Diagnosis: ALTERED MENTAL STATUS
********************************* CPT Codes ********************************
* BX-NEEDLE LIVER BY RADIOLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
60 year old man aortic stenosis s/p liver and kidney transplant [**10-11**] with
postop course complicated by bacteremia, sinus tach and increasing LFTs.
Concerned that he may be rejecting
REASON FOR THIS EXAMINATION:
please do US guided biopsy transplant liver with results sent to pathology
-process RUSH for same day read."
1790,"SICU
HPI:
60M ESLD [**1-27**] EtOH cirrhosis s/p OLT and kidney transplant [**10-12**]
Chief complaint:
s/p OLT and kidney transplant
PMHx:
EtOH cirrhosis, esophageal varices, portal hypertensive gastropathy,
ascites, CRI (2.5-3.5, ? 2/2 HRS vs IgA nephropathy), h/o Bartonella
sepsis c/b multiorgan failure ('[**82**]), mod AS, HTN, Hchol, 4.5 aortic
aneurysm, depression, s/p L4-5 spinal fusion, s/p L hernia repair, s/p
R knee scope, s/p L knee open meniscus repair
Current medications:
1000 ml D5 1/2NS 2. 1000 mL 1/2NS 3. Chlorhexidine Gluconate 0."
1791,"m.
Tmax: 36.8
C (98.3
T current: 36.8
C (98.3
HR: 71 (66 - 102) bpm
BP: 169/80(112) {132/60(84) - 169/82(112)} mmHg
RR: 15 (9 - 21) insp/min
SPO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 79.4 kg (admission): 73 kg
Height: 69 Inch
CVP: 5 (2 - 9) mmHg
PAP: (34 mmHg) / (16 mmHg)
CO/CI (Fick): (8.3 L/min) / (4.4 L/min/m2)
CO/CI (CCO): (6.8 L/min) / (3.6 L/min/m2)
SvO2: 80%
Mixed Venous O2% sat: 80 - 80
Total In:
6,939 mL
1,492 mL
PO:
Tube feeding:
IV Fluid:
5,578 mL
1,432 mL
Blood products:
1,231 mL
Total out:
5,147 mL
1,155 mL
Urine:
1,326 mL
530 mL
NG:
700 mL
200 mL
Stool:
Drains:
3,121 mL
425 mL
Balance:
1,792 mL
337 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 600 (600 - 600) mL
Vt (Spontaneous): 694 (403 - 704) mL
PS : 10 cmH2O
RR (Set): 14
RR (Spontaneous): 10
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 22
PIP: 16 cmH2O
Plateau: 16 cmH2O
SPO2: 99%
ABG: 7."
1792,"secondary to transplant meds, HIT
pending
Endocrine: RISS
Infectious Disease:
Lines / Tubes / Drains: Foley, NGT
Wounds: Dry dressings
Imaging: CXR today
Fluids: 1/2 NS at 1:1, d5 [**12-27**] at 125
Consults: Transplant
Billing Diagnosis: Post-op complication
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2187-10-12**] 05:07 AM
PA Catheter - [**2187-10-12**] 05:08 AM
16 Gauge - [**2187-10-12**] 05:08 AM
Trauma line - [**2187-10-12**] 05:09 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: ICU
Total time spent: 34 minutes"
1793,"9
12.4
Hct
29.2
30.7
Plt
80
61
Creatinine
2.2
2.1
TCO2
25
24
25
25
Glucose
97
85
119
113
132
118
119
117
119
Other labs: PT / PTT / INR:14.4/48.1/1.2, ALT / AST:171/127, Alk-Phos /
T bili:154/1.4, Amylase / Lipase:108/280, Fibrinogen:183 mg/dL, Lactic
Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:229 IU/L, Ca:8.0 mg/dL, Mg:2.0
mg/dL, PO4:5.7 mg/dL
Assessment and Plan
Assessment and Plan: 60M ESLD [**1-27**] EtOH cirrhosis s/p OLT and kidney
transplant [**10-12**]
Neurologic: Fentanyl prn, pain controlled, consider longer term
Cardiovascular: HD stable, known AS, mild,
Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), Adequate gas on
current settings, [**9-30**], encourage aggressive chest PT/suctioning, SBT
today, consider dose of lasix if volume overload on next CXR
Gastrointestinal / Abdomen: post-op OLT, enzymes trending down, stable
Nutrition: NPO
Renal: Foley, s/p kidney transplant, adequate urine output
Hematology: plts trending down, ?"
1794,"33/45/110/21/-2
Ve: 6.4 L/min
PaO2 / FiO2: 275
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous : )
Abdominal: Soft
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
61 K/uL
11.1 g/dL
119
2.1 mg/dL
21 mEq/L
3.5 mEq/L
55 mg/dL
111 mEq/L
141 mEq/L
30.7 %
12.4 K/uL
[image002.jpg]
[**2187-10-13**] 02:28 PM
[**2187-10-13**] 06:06 PM
[**2187-10-13**] 06:32 PM
[**2187-10-13**] 10:20 PM
[**2187-10-14**] 01:15 AM
[**2187-10-14**] 02:00 AM
[**2187-10-14**] 03:00 AM
[**2187-10-14**] 03:17 AM
[**2187-10-14**] 05:00 AM
[**2187-10-14**] 06:00 AM
WBC
12."
1795,"12% Oral
Rinse 4. Docusate Sodium
5. Fentanyl Citrate 6. Fluconazole 7. Heparin 8. Insulin 9.
MethylPREDNISolone Sodium Succ 10. MethylPREDNISolone Sodium Succ
11. Mycophenolate Mofetil Suspension 12. Nystatin Oral Suspension 13.
Ondansetron 14. Pantoprazole
15. Pamidronate 16. PredniSONE 17. PredniSONE 18. Prochlorperazine 19.
Sulfameth/Trimethoprim Suspension
20. Tacrolimus Suspension 21. ValGANCIclovir Suspension
24 Hour Events:
Post operative day:
POD#2 - S/P liver/Kidney transplant
Allergies:
Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)
itching;
Last dose of Antibiotics:
Ampicillin/Sulbactam (Unasyn) - [**2187-10-13**] 12:10 AM
Infusions:
Insulin - Regular - 4 units/hour
Other ICU medications:
Other medications:
Flowsheet Data as of [**2187-10-14**] 07:33 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**90**] a."
1796,"Demographics
Day of mechanical ventilation: 2
Ideal body weight: 72.6 None
Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg
Airway
Airway Placement Data
Known difficult intubation: No
Tube Type
ETT:
Position: 21 cm at teeth
Route: Oral
Type: Standard
Size: 7.5mm
Lung sounds
RLL Lung Sounds: Diminished
RUL Lung Sounds: Diminished
LUL Lung Sounds: Clear
LLL Lung Sounds: Diminished
Secretions
Sputum color / consistency: Blood Tinged / Thick
Sputum source/amount: Suctioned / Moderate
Ventilation Assessment
Level of breathing assistance: Continuous invasive ventilation
Visual assessment of breathing pattern: Normal quiet breathing
Assessment of breathing comfort: No claim of dyspnea
Plan
Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,
Periodic SBT's for conditioning
Reason for continuing current ventilatory support: Intolerant of
weaning attempts; Comments: Pt became hypercarbic on PS 5, required
increased on PS to 10, will increase vent support as required if
needed."
1797,"HRS vs IgA
nephropathy). No renal disease known prior to these admissions.
3) Hx sepsis from dog bite in '[**82**] c/b multiorgan failure
4) L4-5 spinal fusion '[**78**] at [**Hospital **] Hospital
5) AS of uncertain severity - scheduled for LHC on Fri [**9-14**]
6) HTN - stable off medications
7) Hypercholesterolemia
8) hx aortic aneurysm, stable for last 20 yrs
9) L sided hernia repair
10) Depression
11) R knee arthroscopy and meniscus repair
12) L knee open meniscus repair
Social History:
Pt born in [**State **], lived in [**Male First Name (un) 1056**], then Mass for many
years. Retired school counselor and high school basketball
coach."
1798,"Lives with wife and dog. Drank ~2 drinks/day for appx 40
yrs, last drink [**2187-1-21**] for wife's birthday. Used tob rarely for
8yrs, quit around [**2166**]. Walks [**12-27**] to [**2-27**] mi daily.
Family History:
Father had CABG in 40s, also had 2 heart valve surgeries and 2
CVAs. Mom died at age [**Age over 90 **]. No fhx of liver or kidney disease.
Physical Exam:
VS - Temp 96.2F, BP 117/82, HR 86, R 18, O2-sat 97 % RA
GENERAL - Drowsy but arousable to call, Flap +
LUNGS - Clear B/L
HEART - RRR Systolic murmur
Abd: soft umb hernia non tender non distended
Rectal neg Guiaic neg"
1799,"Brief Hospital Course:
Initially treated for encephalopathy by the medicine team until
[**10-11**] when a liver and kidney donor became available. On
[**2187-10-11**] he underwent Orthotopic deceased-donor liver transplant
(piggyback); portal vein to portal vein anastomosis; common bile
duct to common bile duct anastomosis with no T-tube; celiac
patch (donor) with replaced right hepatic artery to a branch
patch (recipient for Alcoholic cirrhosis; portal hypertension;
ascites; chronic renal failure; aortic stenosis. Surgeon was Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Two JPs were
placed."
1800,"18. 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Hepatorenal syndrome now s/p kidney transplant
Cirrhosis now s/p orthotopic liver transplant
aortic stenosis
Sinus tachycardia
E.coli bacteremia [**2187-10-22**]
UTI, E.coli [**2187-10-22**]
VRE, rectal swab [**2187-10-11**]
Discharge Condition:
Stable/good
Discharge Instructions:
Call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101,
chills, nausea, vomiting, ""racing heart"" or palpitations,
shortness of breath, chest pain, diarrhea or constipation."
1801,"2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILy (Daily).
4. Pantoprazole 40 mg Tablet, Sig: One tab Q12
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every
4-6 hours: Titrate to >5 bowel movements daily.
6. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO three times a
day."
1802,"This was
negative. He then had a TEE to definitively rule out any
vegetation. This was negative.
Around POD 6, the medial JP and the [**Doctor Last Name 406**] (kidney) drainage
increased requiring IV fluid replacements. The 2 JPs around the
liver were removed on POD 8 & 14. Creatinine of this fluid was
1.7. Serum creatinine was 1.1. On POD 11 ([**10-23**]), urine output
increased to 3 liters. IV fluid replacement was given. He
developed dizziness, orthostatic hypotension with tachycardia
and a sense that his heart was racing. He denied sob or chest
pain. This was initially treated with aggressive IV volume
resuscitation."
1803,"Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day)."
1804,"He continued to have sinus tachycardia.
Cardiology was consulted and IV lopressor was started. Sinus
tach improved and lopressor was switched to Toprol 100mg qd.
During this time his only complaint was fatigue that improved as
heart rate was controlled.
On POD 11, an MRCP was done to evaluate elevated alk phos that
had been running in the 300-400 range. There was no evidence of
biliary dilatation. A small amount of ascites was noted. Alk
phos improved some with daily range between 240-280. Alt and AST
somewhat increased. A duplex of the liver was done showing
normal vascular flow, no biliary dilatation or peri-hepatic
collections."
1805,"13. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 5 days.
Disp:*5 gram* Refills:*0*
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous once a day as needed for line flush: after 10ml of
saline via the PICC line .
Disp:*20 syringes* Refills:*0*
15. Picc Line Supplies
pump, tubing, dressing supplies
supply: 1 week
refill: 1
16. Outpatient Lab Work
Blood cultures 3 days after antibiotics stop
fax results to [**Telephone/Fax (1) 697**]
17. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours)."
1806,"Multiple blood products were given over SICU stay to maintain
hemostasis. Platelet count stabilized. Creatinine and LFTS
trended down. Urine output was excellent. Diet was advanced and
tolerated. Glucoses were elevated from the solumedrol. An
insulin drip was initially used then sliding scale insulin was
initiated. [**Last Name (un) **] was later consulted and NPH with sliding scale
was used.
He was transferred out of the SICU to the Med-[**Doctor First Name **] floor on
[**10-15**] where he continued to do well. He was assisted to
ambulate. PT followed him. The foley was removed with incident.
The 2 JPs and the [**Doctor Last Name 406**] drain outputs were in the 20-60cc range."
1807,"Admission Date: [**2187-10-7**] Discharge Date: [**2187-11-2**]
Date of Birth: [**2127-7-22**] Sex: M
Service: SURGERY
Allergies:
Vicodin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Confusion/lethargy
Major Surgical or Invasive Procedure:
[**2187-10-19**]: combined liver/kidney transplant
History of Present Illness:
60 yo M w/ PMH of cirrhosis, encephalopathy p/w lethargy,
vomiting and confusion. Pt. had a paracentesis (9.5L) on
thursday and afterwards had been feeling somewhat tired as
normal for him after a paracentesis. He continued to feel tired
until 0300 this am when he vomited, he went back to bed and then
began having dry heaves around 0600."
1808,"At this time his wife
checked him for asterixis and she noted that he did have a
flapping tremor and she brought him to the ED. She noted that he
had had 4 BMs yesterday. He was admitted from the ED w/o workup.
On the floor he was lethargic but arousable and he was taken for
abdominal u/s w/ IR paracentesis. ON presentation he only
complains of thirst.
Past Medical History:
1) Etoh cirrhosis, diagnosed in '[**82**], transplant candidate (may
need liver-kidney), complicated by:
- variceal bleeding in '[**83**], controlled with medications
- ascites requiring periodic paracenteses
- ? HRS [**8-3**]
- last EGD [**8-3**]: esophageal varices, portal hypertensive
gastropathy
- last colonoscopy [**8-3**]: Two 3mm benign-appearing polyps
2) Recurrent ARF with admissions [**6-3**] and [**8-3**] (?"
1809,"Discharge Medications:
1. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
2. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
3. syringes Sig: One (1) box four times a day: insulin
syringes-lo dose. 25 gauge needle. U 100.
Disp:*1 box* Refills:*2*
4. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
6."
1810,"On [**11-2**], an US guided biopsy was done to evaluate
for rejection given persistent elevation of LFTS. The biopsy was
negative.
On [**11-2**], he was discharged home to complete the Ceftriaxone
course for 5 more day. VNA services were arranged. Blood
cultures were to be done 72 hours after completing the
Ceftriaxone.
Staples were removed from the subcostal incision as well as the
RLQ incision. These incisions were clean, dry and intact. Vital
signs were stable with HRs in the 70-80s. He was ambulatory and
tolerating a carb consistent diet.
Medications on Admission:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
1811,"Call if you are having difficulty taking foods, fluids,
medications
Drink enough fluids to keep the urine light yellow
Labwork every Monday and Thursday to be faxed to transplant
clinic at [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, alk phos,
albumin, T bili, trough prograf level
Monitor incisions for redness, drainage or bleeding. Staples to
be removed at your clinic visit
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2187-11-7**]
10:00
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2187-11-7**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2187-11-14**]
11:00
Dr. [**First Name (STitle) 437**] (Cardiology)-[**11-21**] at 9:20 ([**Last Name (NamePattern1) **], LMOB [**Location (un) 3971**])
Completed by:[**2187-11-2**]"
1812,"Pain was well managed with oxycodone. Solumedrol was tapered,
cellcept was adjusted to 500mg qid for some GI complaints and
prograf was adjusted daily per trough levels.
On POD 7, the NEOB called to report that the donor had had an
E.coli bacteremia. Given this, blood cultures were drawn for
surveillance. These returned + for coag negative staph. IV Vanco
was started and continued for 2 days. Blood, urine and the RLQ
retroperitoneal [**Doctor Last Name 406**] drain fluid cultures were positive for E.
coli. Initially, cipro was started for the urine. Dapto was
started for a surveillance rectal swab that returned postive for
VRE."
1813,"This was only given for two days, then stopped on [**10-23**].
Meropenum was started on [**11-23**] and continued thru [**10-26**]. ID was
consulted and recommended resuming Cipro. This was continued
until ID re-evaluated and felt that he should remain on IV
antibiotics for a 10 day course given h/o aortic valve stenosis,
immunosuppression. Ceftriaxone was started on [**10-29**] and continued
until [**11-2**]. A PICC line was inserted and the plan was for a 10
day course. Given known aortic stenosis and development of sinus
tachycardia, a TTE was done to assess for vegetations."
1814,"There were no complications. He then underwent cadaveric
kidney transplant into the right
iliac fossa with placement of a 6-French double-J stent. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed in the
retroperitoneum. Please see both operative reports for complete
details. Standard immunosuppressive induction therapy was given
(solumedrol and cellcept).
Postop, he was transferred to the SICU for postop management.
Prograf was started on pod 1. He was extubated on [**10-14**] after
bronchoscopy for LLL atelectasis. Platelets trended down.
Heparin was stopped and a HIT was sent which was negative."
1815,"9/23.3/1.3, CK / CK-MB / Troponin
T:1776/30/<0.01, Lactic Acid:2.7 mmol/L, Ca:8.9 mg/dL, Mg:2.0 mg/dL,
PO4:2.9 mg/dL
Assessment and Plan
HYPERGLYCEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), [**Last Name 9**] PROBLEM -
ENTER DESCRIPTION IN COMMENTS
Assessment and Plan: 58M p/w confusion and agraphia, R hemi field cut,
found to have right parietal mass on MRI. Frozen section on biopsy
showed demyelinating disease
Neurologic: keppra, moves L side > R side
Cardiovascular: goal SBP<140
Pulmonary: IS, extubated
Gastrointestinal / Abdomen: NPO
Nutrition: NPO
Renal: adequate UOP
NS @ 100, hyperkalemia resolved
Hematology: Hct stable
Endocrine: hyperglycemic on lantus and insulin gtt
Infectious Disease: Vanc x 3 days, Gent x 3 doses followed by Levo for
2 days
Lines / Tubes / Drains: foley, a-line
Wounds:
Imaging:
Fluids: NS, 100cc/h
Consults: Neuro surgery, Neurology
Billing Diagnosis: CVA
ICU Care
Nutrition:
Glycemic Control: Insulin infusion
Lines:
18 Gauge - [**2176-1-8**] 03:44 PM
Arterial Line - [**2176-1-8**] 04:00 PM
22 Gauge - [**2176-1-9**] 04:18 AM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 35 minutes"
1816,"2 %
9.3 K/uL
[image002.jpg]
[**2176-1-8**] 04:30 PM
[**2176-1-8**] 06:37 PM
[**2176-1-8**] 10:09 PM
[**2176-1-9**] 03:26 AM
[**2176-1-9**] 03:34 AM
[**2176-1-9**] 08:45 AM
[**2176-1-9**] 12:30 PM
[**2176-1-9**] 07:26 PM
[**2176-1-10**] 02:44 AM
[**2176-1-10**] 02:54 AM
WBC
13.2
13.9
9.3
Hct
33.7
34.3
35.2
Plt
[**Telephone/Fax (3) 4154**]
Creatinine
0.8
0.8
Troponin T
<0.01
TCO2
27
26
24
27
24
26
28
Glucose
241
263
115
65
172
Other labs: PT / PTT / INR:14."
1817,"40/44/95.[**Numeric Identifier 253**]/26/1
Ve: 11.8 L/min
PaO2 / FiO2: 240
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: Diminished: )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: Follows simple commands, Moves all extremities
Labs / Radiology
187 K/uL
12.1 g/dL
172 mg/dL
0.8 mg/dL
26 mEq/L
4.3 mEq/L
12 mg/dL
105 mEq/L
139 mEq/L
35."
1818,"m.
Tmax: 36.7
C (98
T current: 35.8
C (96.5
HR: 74 (70 - 98) bpm
BP: 132/58(80) {109/49(68) - 158/76(108)} mmHg
RR: 14 (14 - 30) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
Total In:
3,922 mL
212 mL
PO:
Tube feeding:
IV Fluid:
3,922 mL
212 mL
Blood products:
Total out:
2,661 mL
1,290 mL
Urine:
2,661 mL
1,290 mL
NG:
Stool:
Drains:
Balance:
1,261 mL
-1,078 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 394 (394 - 394) mL
PS : 12 cmH2O
RR (Spontaneous): 30
PEEP: 5 cmH2O
FiO2: 50%
PIP: 18 cmH2O
SPO2: 98%
ABG: 7."
1819,"SICU
HPI:
58M p/w confusion and agraphia, R hemi field cut, found to have right
parietal mass on MRI. Frozen section on biopsy showed demyelinating
disease
Chief complaint:
PMHx:
PMH: DM, dyslipidemia, CAD s/p 4 vessel CABG and stenting [**2164**], OSA
Current medications:
24 Hour Events:
EXTUBATION - At [**2176-1-9**] 09:11 AM
INVASIVE VENTILATION - STOP [**2176-1-9**] 09:11 AM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2176-1-9**] 08:30 AM
Gentamicin - [**2176-1-9**] 02:44 PM
Levofloxacin - [**2176-1-9**] 10:03 PM
Infusions:
Insulin - Regular - 12 units/hour
Other ICU medications:
Lorazepam (Ativan) - [**2176-1-9**] 01:45 PM
Famotidine (Pepcid) - [**2176-1-9**] 05:00 PM
Hydromorphone (Dilaudid) - [**2176-1-9**] 08:00 PM
Haloperidol (Haldol) - [**2176-1-10**] 12:03 AM
Metoprolol - [**2176-1-10**] 12:03 AM
Other medications:
Flowsheet Data as of [**2176-1-10**] 05:14 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**78**] a."
1820,"SICU
HPI:
58M criminal Attorney p/w confusion and agraphia, R hemi field cut,
found to have right parietal mass on MRI. Frozen section on biopsy
showed demyelinating disease not a neoplasm.
Chief complaint:
right parietal mass
PMHx:
DM, dyslipidemia, CAD s/p 4 vessel [**Last Name (un) 4147**] and stenting [**2164**], OSA
Current medications:
Acetaminophen. Bisacodyl. Calcium Gluconate. Chlorhexidine Gluconate
0.12% Oral Rinse. Docusate Sodium. Famotidine. Fluticasone-Salmeterol
Diskus (100/50). Gentamicin. HYDROmorphone (Dilaudid). Insulin.
Levofloxacin. LeVETiracetam. Montelukast Sodium. Nitroprusside Sodium.
Ondansetron. Propofol. Pregabalin. Vancomycin
24 Hour Events:
OR RECEIVED - At [**2176-1-8**] 03:41 PM
crani
INVASIVE VENTILATION - START [**2176-1-8**] 03:41 PM
ARTERIAL LINE - START [**2176-1-8**] 04:00 PM
EKG - At [**2176-1-8**] 06:50 PM
MAGNETIC RESONANCE IMAGING - At [**2176-1-9**] 02:00 AM
s/p open biopsy of right parietal lesion, intubated overnight, moving
L>R side, emergent CT and MRI obtained overnight
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2176-1-8**] 04:49 PM
Gentamicin - [**2176-1-8**] 10:00 PM
Infusions:
Insulin - Regular - 15."
1821,"2 cmH2O/mL
SPO2: 100%
ABG: 7.45/38/102/23/2
Ve: 11.3 L/min
PaO2 / FiO2: 255
Physical Examination
General Appearance: No acute distress, Overweight / Obese
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Bowel sounds present, Obese
Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Responds to: Tactile stimuli), No(t) Moves all
extremities, (RUE: Weakness), (RLE: Weakness), Sedated
Labs / Radiology
205 K/uL
11."
1822,"8 g/dL
263 mg/dL
0.8 mg/dL
23 mEq/L
3.9 mEq/L
15 mg/dL
104 mEq/L
136 mEq/L
33.7 %
13.2 K/uL
[image002.jpg]
[**2176-1-8**] 11:48 AM
[**2176-1-8**] 01:45 PM
[**2176-1-8**] 04:14 PM
[**2176-1-8**] 04:30 PM
[**2176-1-8**] 06:37 PM
[**2176-1-8**] 10:09 PM
[**2176-1-9**] 03:26 AM
[**2176-1-9**] 03:34 AM
WBC
11.6
13.2
Hct
39
44
36.7
33.7
Plt
220
205
Creatinine
1.0
0."
1823,"peaked T-waves, calcium gluconate given, 1st set of cardiac
enzymes normal
Resp: wean to extubate this am
GI: NPO
GU: adequate UOP
FEN: NS @ 100, hyperkalemia resolved
Heme: Hct stable
Endo: hyperglycemic on lantus and insulin gtt, [**Last Name (un) 72**] following
ID: Vanc x 3 days, Gent x 3 doses followed by Levo for 2 days
TLD: ETT, foley, a-line
Wound: C/D/I
Prophylaxis: H2B, boots
Imaging: f/u MRI head
Billing Diagnosis: brain mass
ICU Care
Nutrition:
Glycemic Control: insulin gtt, lantus
Lines:
20 Gauge - [**2176-1-8**] 03:44 PM
18 Gauge - [**2176-1-8**] 03:44 PM
Arterial Line - [**2176-1-8**] 04:00 PM
22 Gauge - [**2176-1-9**] 04:18 AM
Prophylaxis:
DVT: boots
Stress ulcer: famotidine
VAP bundle: ++
Comments:
Communication: Comments:
Code status: Full code
Disposition: SICU vs step down unit
Total time spent: 31 minutes"
1824,"8
Troponin T
<0.01
TCO2
27
25
27
26
24
27
Glucose
90
147
228
241
263
Other labs: PT / PTT / INR:14.4/21.9/1.3, CK / CK-MB / Troponin
T:1776/5/<0.01, Lactic Acid:2.7 mmol/L, Ca:8.6 mg/dL, Mg:1.9 mg/dL,
PO4:2.9 mg/dL
Assessment and Plan
HYPERGLYCEMIA, ALTERED MENTAL STATUS (NOT DELIRIUM), [**Last Name 9**] PROBLEM -
ENTER DESCRIPTION IN COMMENTS
Assessment and Plan: Neuro: propofol gtt, keppra, moves L side > R
side, f/u MRI read
CV: goal SBP<140, not requiring nipride gtt while on propofol, will
likely need prn hydral and lopressor when off propofol, hyperkalemia
resolved, ?"
1825,"5 units/hour
Propofol - 30 mcg/Kg/min
Other ICU medications:
Hydromorphone (Dilaudid) - [**2176-1-8**] 06:33 PM
Famotidine (Pepcid) - [**2176-1-9**] 04:09 AM
Other medications:
Flowsheet Data as of [**2176-1-9**] 05:59 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**78**] a.m.
Tmax: 37
C (98.6
T current: 36.7
C (98
HR: 78 (71 - 87) bpm
BP: 130/60(80) {113/49(69) - 158/70(98)} mmHg
RR: 19 (6 - 27) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
Total In:
2,784 mL
734 mL
PO:
Tube feeding:
IV Fluid:
1,784 mL
734 mL
Blood products:
1,000 mL
Total out:
4,140 mL
740 mL
Urine:
1,640 mL
740 mL
NG:
Stool:
Drains:
Balance:
-1,356 mL
-6 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 650 (650 - 650) mL
RR (Set): 18
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI Deferred: No Spon Resp
PIP: 32 cmH2O
Plateau: 25 cmH2O
Compliance: 34."
1826,"Nat Clin Pract Oncol. [**2171**] [**Month (only) **];2(1):54-8
and
Solitary focal demyelination in the brain as a paraneoplastic
disorder.
[**Last Name (un) 13072**] JH, Bertorini TE, [**Last Name (un) 13073**] FC Jr, [**Name2 (NI) **] TF, [**Doctor Last Name **] H, Becske
T, [**Last Name (un) 13074**] PG, Handorf CR, Horner LH, M??????nkem??????ller KE.
Med Pediatr Oncol. [**2162**] [**Month (only) **];26(2):111-5.
and
Paraneoplastic demyelinating disorder in the brain of a patient
with seminoma.
[**Doctor Last Name 25**] K, [**Last Name (un) 13075**] P, [**Doctor Last Name **] K, [**Doctor Last Name 13076**] C, Kostashuk E."
1827,"ADDENDUM: A stain for LCA is negative (small lymphocytes only).
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 13077**]/jlh
Date: [**2176-1-29**]
Clinical: Retroperitoneal mass.
Gross: The specimen is received in six parts, all labeled with
the patient's name, ""[**Known lastname 8270**], [**Known firstname **]"" and the medical record
number.
Part 1 is additionally labeled ""left peritoneal mass biopsy
frozen section."" It consists of a fragment of soft tissue
measuring 1 x 0.5 x 0.6 cm. The peripheral smear was done on
the specimen. Peripheral smear diagnosis by Dr. [**Last Name (STitle) **] is
""sclerotic tissue with small lymphocytes, likely reactive."
1828,"Name: [**Known lastname **],[**Known firstname 441**] F Unit No: [**Numeric Identifier 13068**]
Admission Date: [**2176-1-4**] Discharge Date: [**2176-1-26**]
Date of Birth: [**2117-6-30**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 542**]
Addendum:
Final pathology of the retroperitoneal mass returned as seminoma
(see path reports below). There are sparse cases of single
demyelinating lesions occurring in pt's with seminomas, thought
to be a paraneoplastic process. See:
Facial numbness in a man with inguinal and retroperitoneal
masses.
[**Last Name (un) 13069**] SR, [**Doctor Last Name 13070**] MV, [**Last Name (un) 13071**] JS."
1829,"5 cm in aggregate. A portion of specimen was frozen. Frozen
section diagnosis by Dr. [**Last Name (STitle) **] is ""positive for poorly
differentiated epithelioid neoplasm."" The specimen was
submitted as follows: Frozen section remnant in F, the remainder
of the specimen is in G.
Part 6 is additionally labeled ""retroperitoneal mass biopsy #6.""
It was received fresh from the Operating Room. It consists of
fleshy and hemorrhagic soft tissue fragment measuring 2 x 1.5 x
1 cm in aggregate. The specimen is partially frozen. Frozen
section diagnosis by Dr. [**Last Name (STitle) **] is ""lesional tissue present.""
The specimen is entirely submitted as follows: H = frozen
section, I-L = remainder of the specimen."
1830,"J Comput Assist Tomogr. [**2164**] [**Month (only) **]-[**Month (only) **];22(1):136-8.
Retroperitoneal Mass Biopsy [**2176-1-23**]:
DIAGNOSIS:
Retroperitoneal mass (parts 1 - 6)
Metastatic malignant neoplasm (see note).
Immunostains and morphology favor a germ cell tumor, Seminoma.
Note: The tumor is composed of large cells with abundant clear
cytoplasm, round nuclei with prominent central nucleoli in
sheets with a background of lymphoid hyperplasia and necrotizing
granulomas. Tumor cells are
Positive for: c-Kit
Negative for: Cytokeratin cocktail, CD30 (immunoblasts
only), S100 (macrophages only), AFP, and PLAP (however, no
internal control).
An LCA will be reported in an addendum."
1831,"Lypmh Node Flow Cytometric Immunophenotyping [**2176-1-24**]:
SPECIMEN SUBMITTED: Immunophenotyping, Lymph Node
Procedure date Tissue received Report Date Diagnosed
by
[**2176-1-24**] [**2176-1-24**] [**2176-1-26**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 13078**]/mrr??????
Previous biopsies: [**Numeric Identifier 13079**] Retroperitoneal Mass BX,
Retroperitoneal Mass Bx,
[**Numeric Identifier 13080**] RETROPERITONEAL MASS. (1 JAR)
[**Numeric Identifier 13081**] left occipital lobe tumor, #2 left occipital lobe
tumor,
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
kappa, lambda, and CD antigens 2, 3, 5, 7, 10, 19, 19, 20, 23,
45."
1832,"RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells comprise 34% of lymphoid-gated events, are polyclonal,
and do not express aberrant antigens.
T cells comprise 59% of lymphoid gated events, express mature
lineage antigens.
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen. Correlation with clinical findings and
morphology (see S09-4354) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.
Discharge Disposition:
Home With Service
Facility:
Community Health and Nursing Services
Discharge Diagnosis:
Retroperitoneal mass: final pathology Seminoma
Left posterior parietal lesion: Final pathology Demyelination
Followup Instructions:
He will follow with his oncologist in [**State 4488**] for treatment of the
seminoma.
[**First Name11 (Name Pattern1) 194**] [**Last Name (NamePattern4) 544**] MD [**MD Number(1) 545**]
Completed by:[**2176-1-30**]"
1833,"9 x 0.4
x 0.2 cm. The specimen is entirely frozen. Frozen section
diagnosis by Dr. [**Last Name (STitle) **] is ""sclerotic tissue with chronic
inflammation, no malignancy identified."" The specimen is
entirely submitted in D.
Part 4 is additionally labeled ""retroperitoneal mass biopsy #4.""
It consists of multiple red tan soft tissue fragments measuring
1 x 1 x 1 cm in aggregate. No frozen section was performed on
that specimen. The specimen is entirely submitted in E.
Part 5 is additionally labeled ""retroperitoneal mass biopsy #5.""
It consists of multiple soft tissue fragments measuring 1 x 1 x
0."
1834,""" The
specimen was entirely submitted in A.
Part 2 is additionally labeled ""retroperitoneal mass, left
frozen section #2."" It consists of red tan multiple soft tissue
fragments measuring 1 x 1 x 0.4 cm in aggregate. The surface of
one of the fragments is smooth and probably has peritoneum.
Frozen section diagnosis by Dr. [**Last Name (STitle) **] is ""poorly differentiated
epithelioid neoplasm plus adjacent reactive/fibrotic tissue.
Insufficient for diagnosis."" Frozen section remnant is
submitted in B, the remainder is submitted in C.
Part 3 is additionally labeled ""retroperitoneal mass biopsy #3.""
It consists of red tan soft tissue fragments measuring 0."
1835,"Admission Date: [**2176-1-4**] Discharge Date: [**2176-1-26**]
Date of Birth: [**2117-6-30**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
MRI under anesthesia
[**1-8**]: Open left parietal craniotomy for biopsy
History of Present Illness:
Mr [**Name13 (STitle) 4027**] is a 58 y/o right handed man with history of DM2
and CAD who presented from OSH with increasing confusion,
forgetfulness, peripheral vision loss and agraphia. The patient
was in his usual state of health until [**2175-12-28**] when he was in a
minor car accident after making a wrong turn on a familiar
street, hitting a post from the R side."
1836,"He has also been placed on
empiric Keppra prophylaxis though no clinical episodes
concerning
for seizure.
Past Medical History:
1. DM2 with poor control and peripheral neuropathy
2. Coronary artery disease s/p CABGx4 and stent deployment circa
[**2164**]
3. Obstructive sleep apnea (uses CPAP at night)
4. Obesity
5. Dyslipidemia
6. Seasonal Allergies
Social History:
The patient is an atorney in [**State 1727**]. He is a college graduate
and received the highest possible score on his LSAT examination.
He is married for 29 years and lives with his wife. [**Name (NI) **] does not
use drugs. He has never had a blood transfusion."
1837,"The first two
abnormalities
signify a widespread encephalopathy. Medications, metabollic
disturbances, and infection are among the most common causes.
The
additional focal slowing indicates subcortical dysfunction in
the left
posterior quadrant, likely related to the reported mass. There
were no
clearly epileptiform features.
retroperitoneal mass needle biopsy:
DIAGNOSIS:
Left retroperitoneal mass, core biopsy:
1. Fibrous tissue with lymphoplasmacytic inflammation; see
hemepath note.
2. Refer to separate cytology report (C09-3221) for
additional information.
Hemepath note (Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]):
H&E sections show small, tight clusters of CD20-positive
B-cells, with a small population of scattered CD3-positive
T-cells."
1838,"Discharge Disposition:
Home With Service
Facility:
Community Health and Nursing Services
Discharge Diagnosis:
left posterior tumefactive demyelinating lesion
retroperitoneal cancer, final pathology pending
Discharge Condition:
stable. Ongoing trouble with attention and memory.
Discharge Instructions:
You were admitted with a large demyelinating lesion in the
posterior part of your left brain, causing some confusion and
visual loss. You were placed on a course of steroids and have
improved over time. You also had a CT of your abdomen and were
found to have a retroperitoneal mass, which was biopsied. The
final results of this biopsy are pending at the time of
discharge, but preliminary resulys sugges this is a type of
cancer."
1839,"Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension
Sig: 50-90 units Subcutaneous TID QAC: Take 90 units before
breakfast, 50 units before lunch, and 50 units before dinner.
Disp:*1 month's supply* Refills:*3*
8. your plavix was held at your admission and you should
continue to hold this until final pathology on the
retroperitoneal mass returns and you follow up with oncology"
1840,"Medications on Admission:
1. Plavix
2. Humalog 160 Units Qam and Qpm
3. Humulin 20 Units Qam and Qpm
4. Metformin 300 mg Qam and 200mg Qpm
5. Lyrica 200 mg [**Hospital1 **]
Discharge Medications:
1. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): Take 750 mg twice daily for 7 days, then 500 mg
twice daily for 7 days, then stop. .
Disp:*70 Tablet(s)* Refills:*0*
3. Bariatric Rolling Walker
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
1841,"7 Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2176-1-4**] 01:45AM BLOOD Glucose-174* UreaN-14 Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-27 AnGap-13
[**2176-1-3**] 11:00PM BLOOD Glucose-105 UreaN-13 Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-26 AnGap-14
[**2176-1-24**] 05:40AM BLOOD ALT-72* AST-54* LD(LDH)-277* AlkPhos-84
TotBili-0.5
[**2176-1-17**] 06:15AM BLOOD ALT-91* AST-43* LD(LDH)-271* CK(CPK)-229*
AlkPhos-88 TotBili-0.5
[**2176-1-10**] 02:08PM BLOOD ALT-62* AST-53* LD(LDH)-217 AlkPhos-96
Amylase-14 TotBili-0."
1842,"8 Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
[**2176-1-12**] 04:13AM BLOOD Glucose-270* UreaN-22* Creat-0.8 Na-138
K-4.1 Cl-104 HCO3-28 AnGap-10
[**2176-1-11**] 03:05AM BLOOD Glucose-111* UreaN-19 Creat-0.7 Na-138
K-4.3 Cl-103 HCO3-29 AnGap-10
[**2176-1-10**] 02:44AM BLOOD Glucose-172* UreaN-12 Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
[**2176-1-9**] 03:26AM BLOOD Glucose-263* UreaN-15 Creat-0.8 Na-136
K-3."
1843,"7 x 0.7 x 0.4 cm in aggregate. 50% of the specimen was frozen
and smeared and the intraoperative diagnosis by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: ""Brain with loss of parenchyma, macrophage,
infiltrate, and gliosis and scattered atypical astroglia"". The
specimen is entirely submitted as follows: A = frozen section
remnant, B = remaining tissue.
Part 2 is additionally labeled ""#2 frozen left occipital tumor"".
It consists of multiple tan-pink soft tissue fragments measuring
1.5 x 0.7 x 0.3 cm in aggregate. 50% of the specimen was frozen
and smeared and the intraoperative diagnosis by Dr."
1844,"He was not injured in
the
fender-bender. The next day, he was forgetful and left his car
door open when at work. On Saturday [**12-30**], he stated to his wife
that he felt ""muttled"", but did not complain of any specific
deficits nor did his wife note any. However, the next day his
daughter reported that he mixed up words when speaking with her.
On Monday ([**1-1**]), he could not remember his address when asked
by
the auto-mechanic. He was able to go to work at court, but was
worried when he could not figure out how to sign his name."
1845,"Although a reactive process is favored, a low-grade
B-cell lymphoma cannot be ruled out.
Clinical: Rest of retroperitoneal mass. 58 year old male found
to have large left retroperitoneal mass with lymphadenopathy.
Gross: The specimen is received in a formalin-filled container
labeled with the patient's name ""[**Last Name (LF) 4027**], [**Known firstname **] F"" and the
medical record number and consists of multiple fragments of core
biopsy and tissue measuring up to 1.0 cm in length. The specimen
is strained through a biopsy bag and submitted entirely in A.
Retroperitoneal mass, needle biopsy touch-prep:
SUSPICIOUS for malignancy."
1846,"4 RBC-4.03* Hgb-11.8* Hct-34.9*
MCV-87 MCH-29.3 MCHC-33.9 RDW-15.7* Plt Ct-152
[**2176-1-22**] 09:40PM BLOOD WBC-11.1* RBC-4.03* Hgb-12.0* Hct-35.3*
MCV-88 MCH-29.8 MCHC-34.1 RDW-15.5 Plt Ct-156
[**2176-1-19**] 06:09AM BLOOD WBC-11.9* RBC-4.14* Hgb-12.1* Hct-35.1*
MCV-85 MCH-29.2 MCHC-34.4 RDW-15.3 Plt Ct-185
[**2176-1-18**] 06:15AM BLOOD WBC-11.4* RBC-4.12* Hgb-12."
1847,"Because
of this disparity, he underwent a laproscopic biopsy of his
retroperitoneal mass. The preliminary results of this suggested
a cancer. The final pathology is still pending, but the
pathologists were able to tell us that it was not a cancer that
required immediate treatment. He received an oncology consult,
and will be followed in the oncology clinic. During the duration
of his admission, he was followed closely by the [**Last Name (un) **] team.
They changed his regimen to Humalog 75/25 90/50/50 TID QAC. His
neurological exam on DC was significant for ongoing deficits in
attention and memory and a right inferior quadrantanopsia."
1848,"Attention: Very inattentive, but temporarily redirectable.
Speech/[**Doctor Last Name **]: He is able to express basic thoughts and give basic
yes/no replies; comprehension intact to simple commands,
repetition intact to ""today is a sunny day"" but impaired to more
abstarct sentence, could not name or read but claimed to not be
able to see what was being shown and was inattentive
Memory: N/A due to inattention
Calculations: N/A due to inattention
L/R confusion: Appears confused, but difficult to assess given
inattentiveness
Praxis: N/A due to inattention
CN:
I: not tested
II,III: Patient inattentive but appears to have a right
homonomous hemianopsia, PERRL 2mm to 1."
1849,"4 Plt Ct-187
[**2176-1-9**] 07:26PM BLOOD WBC-13.9* RBC-4.06* Hgb-11.9* Hct-34.3*
MCV-85 MCH-29.4 MCHC-34.8 RDW-15.5 Plt Ct-184
[**2176-1-9**] 03:26AM BLOOD WBC-13.2* RBC-4.02* Hgb-11.8* Hct-33.7*
MCV-84 MCH-29.4 MCHC-35.1* RDW-15.6* Plt Ct-205
[**2176-1-8**] 04:14PM BLOOD WBC-11.6* RBC-4.31* Hgb-12.7* Hct-36.7*
MCV-85 MCH-29.4 MCHC-34.5 RDW-15.3 Plt Ct-220
[**2176-1-7**] 07:50AM BLOOD WBC-8."
1850,"Large left retroperitoneal soft tissue mass as well as large
retroperitoneal lymphadenopathy. Primary diagnostic
considerations include
paraganglioma, extra-adrenal pheochromocytoma and metastatic
disease.
2: Cholelithiasis.
CT Chest: [**2176-1-5**]:
Airways are patent to the subsegmental levels bilaterally. Lung
volumes are
low bilaterally. Bibasilar dependent atelectasis is visualized.
No focal
pulmonary nodule or mass is visualized. There is no axillary or
mediastinal
lymphadenopathy. Atherosclerotic calcification is visualized of
the coronary
arteries as well as of the aorta. The heart and great vessels
are otherwise
unremarkable. Note is made of a large amount of mediastinal fat.
A large right
pretracheal node measures 13x12 mm (3:14)."
1851,"9 Cl-104 HCO3-23 AnGap-13
[**2176-1-8**] 04:14PM BLOOD Glucose-228* UreaN-18 Creat-1.0 Na-135
K-5.4* Cl-102 HCO3-23 AnGap-15
[**2176-1-7**] 07:50AM BLOOD Glucose-275* UreaN-16 Creat-0.8 Na-136
K-4.4 Cl-101 HCO3-23 AnGap-16
[**2176-1-6**] 07:25AM BLOOD Glucose-192* UreaN-14 Creat-0.8 Na-136
K-4.4 Cl-100 HCO3-26 AnGap-14
[**2176-1-6**] 07:25AM BLOOD Glucose-192* UreaN-14 Creat-0.8 Na-136
K-4.4 Cl-100 HCO3-26 AnGap-14
[**2176-1-5**] 05:48AM BLOOD Glucose-171* UreaN-16 Creat-0."
1852,"7 Na-138
K-3.3 Cl-101 HCO3-27 AnGap-13
[**2176-1-24**] 05:40AM BLOOD Glucose-80 UreaN-12 Creat-0.9 Na-140
K-4.2 Cl-105 HCO3-26 AnGap-13
[**2176-1-23**] 08:40AM BLOOD Glucose-164* UreaN-15 Creat-0.8 Na-138
K-3.7 Cl-105 HCO3-26 AnGap-11
[**2176-1-22**] 09:40PM BLOOD Glucose-259* UreaN-17 Creat-0.9 Na-140
K-4.3 Cl-103 HCO3-26 AnGap-15
[**2176-1-19**] 06:09AM BLOOD Glucose-54* UreaN-19 Creat-0.8 Na-141
K-3."
1853,"Wife [**Name (NI) **] may be reached at [**Telephone/Fax (1) 81578**], Daughter [**Name (NI) **] may
be reached at [**Telephone/Fax (1) 81579**].
Family History:
No family history of demyelinating disease such as MS, no
history of neurologic conditions or autoimmune disorders.
Physical Exam:
T-97.5 BP-131/64 (126-154/57-65) HR-93(74-91)SR RR-20 O2Sat-95%
on Fi40% ventimask
Gen: Lying in bed restrained, NAD
HEENT: Has neurosurgical wound on posterior left aspect of head,
dry oral mucosa.
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: Unable to assess
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Ext: no edema
Skin: No rashes
Neurologic examination:
MS:
General: Awake but drowsy, normal affect, very perseverative
Orientation: Not oriented to person, place, time, or situation."
1854,"You can follow up with both oncology and the [**Hospital **] clinic
who can discuss these results with you.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation."
1855,"[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: ""Destructive white matter process, with gliosis,
macrophages and scattered microglia. Focal neutrophilic
infiltrate"". The specimen is entirely submitted as follows: C =
frozen section remnant, D = all remaining tissue.
Part 3 is submitted for intraoperative consultation additionally
labeled ""left deep occipital tumor #3"". It consists of multiple
tan-pink soft tissue fragments that measure 0.8 x 0.7 x 0.3 cm
in aggregate. 50% of the specimen was used for smear and frozen
section. The frozen section and smear diagnosis by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: ""[**Doctor Last Name **] matter and necrotic white matter."
1856,"0* PTT-23.0 INR(PT)-1.2*
[**2176-1-22**] 10:30AM BLOOD PT-13.7* PTT-22.7 INR(PT)-1.2*
[**2176-1-12**] 04:13AM BLOOD PT-15.2* PTT-20.7* INR(PT)-1.3*
[**2176-1-11**] 03:05AM BLOOD PT-14.5* PTT-20.9* INR(PT)-1.3*
[**2176-1-10**] 02:44AM BLOOD PT-14.9* PTT-23.3 INR(PT)-1.3*
[**2176-1-9**] 03:26AM BLOOD PT-14.4* PTT-21.9* INR(PT)-1.3*
[**2176-1-8**] 04:14PM BLOOD PT-14.3* PTT-24.4 INR(PT)-1."
1857,"2 RBC-4.61 Hgb-13.5* Hct-40.0
MCV-87 MCH-29.3 MCHC-33.7 RDW-15.2 Plt Ct-188
[**2176-1-6**] 07:25AM BLOOD WBC-8.5 RBC-4.39* Hgb-12.7* Hct-37.5*
MCV-86 MCH-29.1 MCHC-33.9 RDW-15.3 Plt Ct-200
[**2176-1-5**] 05:48AM BLOOD WBC-11.6* RBC-4.19* Hgb-12.6* Hct-36.2*
MCV-87 MCH-30.1 MCHC-34.8 RDW-15.3 Plt Ct-194
[**2176-1-4**] 01:45AM BLOOD WBC-10.0 RBC-4.35* Hgb-12."
1858,"He could not remember how to
use
the phone. Because of his clinical deterioration and concern for
high-grade glioma, on [**1-8**], he had a stereotactic brain biopsy
of
the left occipital/parietal mass. He was intubated and sedated
until the morning of [**1-9**]. During the night he was noted to not
be moving his RUE as much as the left, stat head CT was
unchanged. He was extubated and given Haldol 2.5mg for
aggitation
at 9:30am (1.5 hours before exam). He has been on broad-spectrum
empiric Abx (Vanc/gent/Levoflox) given concern for abscess
though
prelim path gram stain was sterile."
1859,"We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
Followup Instructions:
Follow-Up Appointment Instructions
- Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 2 weeks for a wound check.
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 81580**]
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2176-2-8**] 11:00
Dr.[**Name (NI) **] office from oncology will call you Mon or
Tuesday for an appointment. If you do not hear from them by
[**1-31**], call [**Telephone/Fax (1) 81581**] to schedule.
Completed by:[**2176-1-26**]"
1860,"In other white matter
areas there is axon loss.
The findings supportive of an acute and chronic primary
demyelinating disorder (e.g., multiple sclerosis).
Clinical: Specimen submitted: 1. Left occipital lobe tumor #1 2.
Left occipital lobe tumor #2 3. Deep left occipital tumor 4.
Left occipital lobe tumor.
Clinical diagnosis and data: Tumor left brain.
Gross: The specimen is received fresh in four parts, labeled
with the patient's name, ""[**Known lastname **], [**Known firstname **]"" and the medical record
number.
Part 1 is additionally labeled ""left occipital lobe tumor #1"".
It consists of multiple tan-pink soft tissue fragments measuring
0."
1861,"A
smaller subset stains positive for CD4. Only rare scattered
B-lymphocytes are present, marking with CD20. CD68 highlights
the diffuse infiltrates of macrophages within the white matter.
Polyoma virus ([**Male First Name (un) 2326**] and SV40), EBV latent membrane protein (LMP),
and CMV immunostains are negative. . Special stains were
performed on blocks A-D. Luxol fast blue (LFB) shows a near
complete loss of myelin staining in the white matter, with
scattered staining present within macrophages. No hemosiderin
deposition is seen on iron stain arguing against a chronic
vasculitis. Bodian stain reveals areas within the white matter
showing preserved demyelinated axons."
1862,"3
[**2176-1-9**] 03:26AM BLOOD CK(CPK)-1776*
[**2176-1-8**] 04:14PM BLOOD CK(CPK)-196*
[**2176-1-4**] 01:45AM BLOOD ALT-42* AST-38 AlkPhos-101 TotBili-0.4
[**2176-1-10**] 02:08PM BLOOD Lipase-11
[**2176-1-9**] 03:26AM BLOOD CK-MB-30* MB Indx-1.7 cTropnT-<0.01
[**2176-1-8**] 04:14PM BLOOD CK-MB-5 cTropnT-<0.01
[**2176-1-24**] 05:40AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.1 UricAcd-5.2
[**2176-1-22**] 09:40PM BLOOD Calcium-8.4 Phos-2.4*# Mg-2."
1863,"A few clusters of highly atypical cells have large nuclei
and prominent nucleoli. The cytoplasm is stripped and
further classification is not possible
Scrotal US [**2176-1-23**]
IMPRESSION:
1. No testicular mass. Normal epididymis.
2. Diffusely heterogeneous left testis, without enlargement.
This appearance
likely reflects prior injury such as remote trauma or orchitis
Brief Hospital Course:
This 58 yo man was admitted with confusion and right visual
field loss as outlined in the HPI. His brain MRI showed a large
left posterior lesion, suspicious for tumor. Since this may have
been a met, a CT torso was pursued, which showed a large
retroperitoneal mass with enlarged lymph nodes."
1864,"5 Cl-106 HCO3-26 AnGap-13
[**2176-1-18**] 06:15AM BLOOD Glucose-112* UreaN-18 Creat-0.8 Na-140
K-3.9 Cl-107 HCO3-26 AnGap-11
[**2176-1-17**] 06:15AM BLOOD Glucose-155* UreaN-18 Creat-0.8 Na-137
K-4.4 Cl-101 HCO3-27 AnGap-13
[**2176-1-16**] 05:25AM BLOOD Glucose-216* UreaN-18 Creat-0.7 Na-139
K-4.4 Cl-104 HCO3-28 AnGap-11
[**2176-1-14**] 07:20AM BLOOD Glucose-235* UreaN-22* Creat-0.8 Na-137
K-4.2 Cl-102 HCO3-27 AnGap-12
[**2176-1-13**] 07:45AM BLOOD Glucose-262* UreaN-22* Creat-0."
1865,"Specifically, he had difficulty writing letters and was
perseverative. Though he knew what he wanted to write, he was
not
able to do so correctly. This event prompted him to consult his
PCP who discovered [**Name Initial (PRE) **] small right peripheral visual field deficit
which Mr. [**Name (NI) 21862**] wife states was ""about 10% of his vision"".
He
had never had this before. He had no headache. His doctor
requested a head CT which he had on [**1-3**]. The CT scan revealed a
left parietal/occipital mass. The next day, his symptoms
persisted and he was admitted to this hospital."
1866,"5mm,
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-23**] on Left, [**2-22**] on right.
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and ?mild increased tone RLE; no tremor,
asterixis or myoclonus.
Pronator drift N/A due to inattention.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 5 5 5 5 5 5
R 3 3 3 3 3 3 3
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 4- 4- 4- 4- 4- 4-
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0 0 0 2 0 Extensor
R 0 0 0 2 0 Extensor"
1867,"A large right
epicardiac node
measures 13x9 mm
Brain mass pathology:
1. ""Left occipital lobe tumor #1"" (A - B):
Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).
2. ""Left occipital lobe tumor #2"" (C - D):
Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).
3. ""Left deep occipital tumor"" (E - F):
Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).
4. ""Left occipital lobe tumor"" (G):
Leptomeninges and gliotic white matter.
Note: By immunohistochemistry (blocks A-D), the majority of the
lymphocytes are CD-3 and CD-8 positive cytotoxic cells."
1868,"44
calTCO2-25 Base XS-1 Intubat-INTUBATED
[**2176-1-8**] 11:48AM BLOOD Type-ART pO2-199* pCO2-41 pH-7.41
calTCO2-27 Base XS-1 Intubat-INTUBATED Vent-CONTROLLED
ANGIOTENSIN CONVERTING 10 [**8-/2134**] U/L
ENZYME
MRI Brain [**2176-1-4**]:
CONCLUSION: Left parietal lesion with inhomogeneous peripheral
enhancement,
surrounding edema, and strikingly slow diffusion in portions of
the periphery.
Although a malignant neoplasm must be considered, the properties
of the
margin, including the diffusion characteristics, raise the
possibility of an
inflammatory or demyelinating process as discussed above.
CT Abd, pelvis [**2176-1-5**]:
IMPRESSION:
1."
1869,"6 Phos-2.9 Mg-1.9
[**2176-1-8**] 04:14PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
[**2176-1-6**] 07:25AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2
[**2176-1-5**] 05:48AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
[**2176-1-4**] 01:45AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
[**2176-1-10**] 02:08PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2176-1-10**] 02:08PM BLOOD HCG-<5
[**2176-1-23**] 06:57PM BLOOD PSA-0.1
[**2176-1-10**] 02:08PM BLOOD AFP-1."
1870,"2*
[**2176-1-7**] 07:50AM BLOOD PT-15.0* PTT-26.1 INR(PT)-1.3*
[**2176-1-6**] 07:25AM BLOOD PT-14.2* PTT-25.1 INR(PT)-1.2*
[**2176-1-5**] 05:48AM BLOOD PT-14.7* PTT-24.5 INR(PT)-1.3*
[**2176-1-4**] 01:45AM BLOOD PT-15.1* PTT-24.4 INR(PT)-1.3*
[**2176-1-3**] 11:00PM BLOOD PT-14.7* PTT-24.5 INR(PT)-1.3*
[**2176-1-4**] 01:45AM BLOOD ESR-28*
[**2176-1-26**] 06:08AM BLOOD Glucose-81 UreaN-10 Creat-0."
1871,"4* Hct-35.5*
MCV-86 MCH-30.0 MCHC-34.8 RDW-15.4 Plt Ct-180
[**2176-1-16**] 05:25AM BLOOD WBC-10.7 RBC-4.40* Hgb-13.1* Hct-38.0*
MCV-86 MCH-29.6 MCHC-34.4 RDW-15.4 Plt Ct-209
[**2176-1-14**] 07:20AM BLOOD WBC-7.7 RBC-4.35* Hgb-12.7* Hct-37.5*
MCV-86 MCH-29.2 MCHC-33.8 RDW-15.2 Plt Ct-221
[**2176-1-13**] 07:45AM BLOOD WBC-6.1 RBC-4.08* Hgb-12.0* Hct-35.5*
MCV-87 MCH-29."
1872,"Sensation: grimaces and attempts withdrawal from noxious in all
extremities purposefully
Coordination: finger-nose-finger normal on left but R not assess
given hemiparesis.
Gait: N/A
Romberg: N/A
Pertinent Results:
[**2176-1-26**] 06:08AM BLOOD WBC-9.1 RBC-3.72* Hgb-10.7* Hct-32.6*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.4 Plt Ct-121*
[**2176-1-24**] 05:40AM BLOOD WBC-12.9* RBC-3.98* Hgb-11.9* Hct-35.0*
MCV-88 MCH-29.8 MCHC-33.9 RDW-15.7* Plt Ct-186
[**2176-1-23**] 08:40AM BLOOD WBC-9."
1873,"0
[**2176-1-18**] 06:15AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.4
[**2176-1-17**] 06:15AM BLOOD TotProt-6.6 Albumin-3.5 Globuln-3.1
Calcium-8.2* Phos-3.5 Mg-2.4
[**2176-1-12**] 04:13AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.3
[**2176-1-11**] 03:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.3
[**2176-1-10**] 02:08PM BLOOD Albumin-3.6
[**2176-1-10**] 02:44AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
[**2176-1-9**] 03:26AM BLOOD Calcium-8."
1874,"9
[**2176-1-4**] 01:45AM BLOOD CRP-8.9*
[**2176-1-17**] 06:15AM BLOOD PEP-NO SPECIFI
[**2176-1-18**] 06:15AM BLOOD HIV Ab-NEGATIVE
[**2176-1-11**] 07:42AM BLOOD Vanco-12.1
[**2176-1-10**] 02:08PM BLOOD HCV Ab-NEGATIVE
[**2176-1-10**] 02:54AM BLOOD Type-ART pO2-96 pCO2-44 pH-7.40
calTCO2-28 Base XS-1
[**2176-1-9**] 12:30PM BLOOD Type-ART pO2-110* pCO2-44 pH-7.37
calTCO2-26 Base XS-0
[**2176-1-9**] 08:45AM BLOOD Type-ART pO2-155* pCO2-36 pH-7."
1875,"5 MCHC-33.9 RDW-14.9 Plt Ct-205
[**2176-1-12**] 04:13AM BLOOD WBC-7.4 RBC-3.70* Hgb-11.1* Hct-31.3*
MCV-85 MCH-30.1 MCHC-35.6* RDW-15.3 Plt Ct-181
[**2176-1-11**] 03:05AM BLOOD WBC-11.0 RBC-3.98* Hgb-11.6* Hct-33.5*
MCV-84 MCH-29.1 MCHC-34.6 RDW-15.2 Plt Ct-207
[**2176-1-10**] 02:44AM BLOOD WBC-9.3 RBC-4.16* Hgb-12.1* Hct-35.2*
MCV-85 MCH-29.1 MCHC-34.4 RDW-15."
1876,"Smear
contains some calcified and fibrotic material (? abscess wall)"".
The specimen is then entirely submitted as follows: E = frozen
section remnant, F = all remaining tissue.
Part 4 is additionally labeled ""left occipital lobe tumor"". It
consists of multiple tan-pink fragments that measure 0.5 x 0.2 x
0.1 cm in aggregate. The specimen is entirely submitted in
cassette G.
MRI brain [**2176-1-9**]:
1. Allowing for post-biopsy changes, the left parietal lesion
appears similar
to [**2176-1-4**]. Pathology is pending.
2. No evidence of acute intracranial abnormalities.
3. Normal head MRA.
EEG [**2176-1-10**]:
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background, bursts of generalized slowing, and additional focal
delta
slowing in the left posterior quadrant."
1877,"42
calTCO2-24 Base XS-0
[**2176-1-9**] 03:34AM BLOOD Type-ART pO2-102 pCO2-38 pH-7.45
calTCO2-27 Base XS-2
[**2176-1-8**] 10:09PM BLOOD Type-ART pO2-91 pCO2-33* pH-7.46*
calTCO2-24 Base XS-0
[**2176-1-8**] 06:37PM BLOOD Type-ART pO2-240* pCO2-39 pH-7.41
calTCO2-26 Base XS-0
[**2176-1-8**] 04:30PM BLOOD Type-ART pO2-232* pCO2-47* pH-7.35
calTCO2-27 Base XS-0
[**2176-1-8**] 01:45PM BLOOD Type-ART pO2-204* pCO2-36 pH-7."
1878,"Per his wife, in the days leading up to admission, Mr. [**Name13 (STitle) 4027**]
did not have any fever, cough, weight changes, nausea, vomiting,
or diarrhea, or other signs of infection. He did not complain of
numbness, weakness, tingling, or hearing changes. No recent
travel or tick exposure. Most recent immunization was Influenza
vaccine in [**2175-9-20**], which he had received in prior years
without problems. [**Name (NI) **] prior such episodes.
On admission, his R visual field cut was noted to be more
pronounced. Over the next couple of days([**Date range (1) 61317**])), he had
decreased speech production, decreased attention, and decreased
orientation to his surroundings."
1879,"The patient was guiac negative in the ED.
Past Medical History:
- COPD
- CAD
- HTN
- AAA s/p repair
- CRF (recent baseline ~2.7, ?atheroembolic)
- BPH
Social History:
- Quit smoking 30y ago (~50 pack years)
- Lives with his wife who has [**Name (NI) 2481**] dementia; caregiving
has become increasingly stressful.
Family History:
non-contributory
Physical Exam:
General Appearance: Thin, Anxious
.
Eyes / Conjunctiva: PERRL, Pupils dilated
.
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
soft systolic murmur
.
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
.
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bases, Diminished: at bilateral bases)
."
1880,"He will follow up with hematology as an
outpatient. PLTS must be 150 prior to stopping argatroban.
.
# Hyponatremia: The patient was found to be hyponatremic upon
admission. At that point the patient's volume status was unclear
as he had signs of hyper- and hypovolemia. The patient was
intravascularly volume depleted at the level of the kidney: his
FENa was 0.14% (<1), and the urine lytes demonstrated a very
elevated osm, very low Na, high spec [**Last Name (un) **]. The patient was also
thought to be in heart failure given risk factors of CAD and
CKD, bilateral lower leg edema, elevated BNP to >70,000,
crackles on physical exam, and pleural effusions."
1881,".
# Decompensated heart failure: The patient had clinical signs of
heart failure on admission although the patient's last echo in
[**2104**] was normal. Repeat echo on [**8-12**] revealed an EF of 35% and
hypokinesis that had not previously been present. Cardiac
enzymes were negative and pt did not have EKG changes consistent
with ACS. The patient was started on Lasix diuresis with good
urine output, a daily TBB goal of at least -1L, and slow
restoration of his serum sodium. Heart failure meds were held
until pt reaches dry weight. Patient was continued on ASA and
restarted on home atenolol on [**8-12**]."
1882,"LASIX WAS HELD THE 2 DAYS PRIOR TO DISCHARGE DUE TO ORTHOSTASIS
AS ABOVE but he will require lasix when no longer orthostatic
and titrate up to 40mg [**Hospital1 **]. Pt had repear Persantine MIBI to
evaluate patency of the coronary vessels. Result from the
stress test showed Fixed, medium-sized, moderate severity
perfusion defect involving the PDA territory, which is similar
to [**2104**] findings. Also severe changes in systolic function was
seen, which correlates with ECHO findings and presentation of
symptoms. HIS BETA-BLOCKER WAS HELD DUE TO ORTHOSTASIS BUT
SHOULD BE RESTARTED at 12.5mg [**Hospital1 **].
.
# Insomnia/Anxiety: The patient had not been sleeping at home
because, according to his daughter, he was scared of dying in
his sleep since his latest discharge from the hospital."
1883,"The
patient was written for trazodone 25 mg prn. Social Work was
involved in organizing day-care for his progressively demented
wife as pt was unable to continue to be her sole care-giver and
has had significant stress with this in the past few months,
according to his daughters. Sleeping in the hospital helped him
feel much better.
.
# COPD: Moderate-severe emphysema on chest CT. Stable, patient
now on his home O2 requirement of 3L; remote smoking history is
likely cause of his COPD. The patient was put on nebulizer
treatment as needed. On [**8-13**] he started coughing more, probably
due to increased mobilization of secretions with his increasing
strength and fluid shifts."
1884,"Antibiotics were not
intiated. It is possible that the pt never had pneumonia on his
last admission (afebrile, no leukocytosis, no positive cultures)
and that he was actually discharged in heart failure after his
last hospitalization.
.
# CKD: The patient's creatinine appears to be at baseline, at
most slightly elevated from last discharge. Urine lytes suggest
pre-renal state. Likely to improve with treatment of heart
failure. Monitored Cr and urine output with Lasix diuresis.
.
# AAA: Stable per CT scan
.
# BPH: Stable with hematuria likely from traumatic foley
placement.
.
Medications on Admission:
MVI 1 tab [**Hospital1 **]
Simvastatin 20 mg daily
ASA 81 mg daily
Ranitidine 150 mg qHS
Fluticasone 50 mcg nasal spray [**Hospital1 **]
Omega-3 Fatty Acid Cap [**Hospital1 **]
Os-Cal 500+D tabs [**Hospital1 **]
Augmentin 500-125 mg q12 hrs until [**8-9**]
SLNG PRN for chest pain"
1885,"Pt currently guaiac +.
12. Argatroban
See attached sheet on how to dose
13. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: MUST CALL PCP if
you use this.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Congestive heart failure
Heparin induced thrombocytopenia
Discharge Condition:
Pt is currently stable, A&Ox3 and not able to ambulate without
PT help.
HE IS ORTHOSTATIC AND SYMPTOMATIC DO NOT GIVE IVF DUE TO SEVERE
CHF WOULD HAVE PT DRINK
[**Name (NI) **] is no longer fluid overloaded and his low sodium has since
resolved."
1886,"7
[**2110-8-20**] 06:50AM BLOOD ALT-132* AST-45* CK(CPK)-PND AlkPhos-61
TotBili-0.7
[**2110-8-20**] 06:50AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.4 Mg-2.1
[**2110-8-21**] 07:05AM BLOOD ALT-19 AST-33
[**2110-8-16**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES- Optical
density 0.692
.
[**2110-8-22**] 07:35AM BLOOD PT-55.2* PTT-85.7* INR(PT)-6.2*
[**2110-8-22**] 07:35AM BLOOD WBC-5.3 RBC-3.76* Hgb-11.4* Hct-33.7*
MCV-90 MCH-30.2 MCHC-33."
1887,"Patient had symptomatic ORTHOSTATIC
HYPOTENSION WITH SYMPTOMS on the night of [**2110-8-20**] and persisted
up until date of discharge. Lasix were held since the first
episode but will need to be restarted when pt no longer
orthostatic at a dose of 40mg [**Hospital1 **].
.
# Bilateral Feet Discoloration/Edema: The patient's pedal
discoloration was of unclear initial etiology; the main concern
was for atheroemboli given significant aortic calcification on
CT and CKD likely [**3-11**] atheroembolic insults. Due to a concern
for microemboli from the patient's underlying AAA, a abd CT scan
was done in the emergency department and showed stable AAA
without leakage."
1888,"We had to stop the metoprolol
because you are orthostatic but this will be restarted at some
point at rehab. We have made a follow up appointment with a
heart failure doctor for you.
In addition, like most patients that come into the hospital, we
gave you heparin to lower the risk of you getting blood clots.
You reacted to this heparin in a way that you platelets became
very low. This reaction is not common. We stopped the heparin,
and started you on argatroban another medication to help prevent
clots. As your platelet numbers began to rise, we began to
convert you over to warfarin which is an anticlotting medication
you can take by mouth."
1889,"His ekg showed LBBB and 1st degree AVB,
unchanged from the previous admission. Vascular [**Doctor First Name **] was
consulted and recommended a heparin drip, with a rate adjusted
for PTT, and a CT chest to assess for aortic arch thrombus,
which was negative. The Heparin drip was d'ced on [**8-15**] per
vascular surgery when they decided that foot was improved. pt
was placed on sub q heparin. Feet appearance were closely
monitored on the floor by the medicine teams since they had
improved while on heparin, even though the improvement was
attributed to proper treatment of the new onset systolic heart
failure."
1890,"Afternoon electrolytes revealed a modest increase
in Na from 117 to 119. On [**8-13**], pt was given a total of 80 mg IV
Lasix that day with a TBB of -1.9L. His Na that day increased to
125. He was put on standing Lasix 20 mg IV TID on [**8-14**] before
being called out to the floor, at which point his Na had further
increased to 127. Na continued to slowly climb as pt was
diuresed on the floor over the next few days. No symptoms [**3-11**] to
hyponatermia were ever witnessed during admission. On date of
discharge pt [**Name (NI) **] was 135."
1891,"Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomina.
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
6. Argatroban 100 mg/mL Solution Sig: as per algortihm
Intravenous INFUSION (continuous infusion).
7. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily)."
1892,"Discharge Instructions:
Mr. [**Known lastname **] you are being discharged to an extended care facility.
You have had a long complicated hospital course and there have
been some new diagnosis since you came to the hospital. You
came here with a very low sodium level which is now normal, but
we also notice that you had a lot of extra fluid in your body.
We did some tests and they showed that your heart is not working
as well as it used to. You are in heart failure, but are now
doing much better than when you came into the hospital."
1893,"The
patient was infused with 0.142mg/kg/min of Persantine over 4
minutes. No
chest, neck, back or arm discomfort was reported by the patient
throughout the procedure. The EKG is uninterpretable for
ischemia in the
presence of a LBBB. The rhythm was sinus with rare isolated APDs
and
VPDs. Hemodynamic response to infusion was appropriate.
Post-infusion
during the IV injection of 125mg of Aminophylline, the patient
reported
dizziness with a palp blood pressure of 88/-mmHg. Patient was
immediately placed in the Trendelenburg position with a BP of
106/palp
and relief of dizziness.
IMPRESSION: No anginal type symptoms with uninterpretable EKG
changes."
1894,"Admission Date: [**2110-8-11**] Discharge Date: [**2110-8-22**]
Date of Birth: [**2029-1-28**] Sex: M
Service: MEDICINE
Allergies:
Heparin,Porcine
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
leg swelling
Major Surgical or Invasive Procedure:
Persantine MIBI exam
History of Present Illness:
81 y/o M with hx of COPD, CAD, AAA, and BPH presents today after
a recent admission for PNA with new swelling and discoloration
of his bilateral feet. He was found to be newly hyponatremic to
a Na of 117 in the ED and therefore admitted to the MICU.
.
He was discharged last Wednesday (5 days prior to admission), he
was discharged to home after being diagnosed with a pneumonia."
1895,"Nuclear report sent separately.
.
CARDIAC PERFUSION PERSANTINE [**2110-8-19**]:
INTERPRETATION:
The image quality is adequate but limited due to activity
adjacent to the
heart.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a fixed, moderate
reduction in photon counts involving the mid and basal inferior
and inferolateral walls.
Gated images reveal hypokinesis of the mid and basal inferior
and inferolateral walls. There is septal akinesis with normal
thickening, consistent with LBBB.
The remaining segments are mildly hypokinetic.
The calculated left ventricular ejection fraction is 30% with an
EDV of 78 ml.
IMPRESSION:
1. Fixed, medium-sized, moderate severity perfusion defect
involving the PDA territory."
1896,"The mitral valve leaflets are mildly thickened.
Mild to moderate ([**2-8**]+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2104-10-2**], left ventricular function is now
depressed.
.
[**2110-8-17**] CXR read:
Portable chest radiograph is compared to multiple prior
examinations. Since the prior study, there is mild improvement
in the right lower lobe with decreased right pleural effusion
and atelectasis. Left lung is relatively clear.
Cardiomediastinal silhouette is unremarkable. There is no
congestive failure.
.
[**2110-8-12**] echo:
INTERPRETATION: This 81 y/o man with a h/o CAD, CHF, COPD and
renal
failure s/p AAA repair was referred for evaluation of chest
pain."
1897,"7 RDW-15.0 Plt Ct-118*
[**2110-8-22**] 07:35AM BLOOD Glucose-104* UreaN-40* Creat-2.3* Na-135
K-4.0 Cl-96 HCO3-28 AnGap-15
[**2110-8-22**] 07:35AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.1
.
Studies:
[**2110-8-12**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed with inferior/inferolateral akinesis with hypokinesis
elsewhere (LVEF= 35%). 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."
1898,"Started chest PT on [**8-14**]. Despite what
had been initially reported, it was later learned that the
patient was not chronically on home oxygen, but had merely been
on it for the last week after discharge from another hospital
after being treated with a PNA.
.
# H/o diarrhea: The patient's diarrhea was likely secondary to
recent antibiotic therapy. The diarrhea was not concerning for c
diff as the patient did not have a leukocytosis. No diarrhea in
house.
.
# H/o pneumonia: The patient was recently treated during last
admission for pneumonia. The patient was currently stable on his
home O2 (started after the recent discharge) and cxr on
admission was without obvious infiltrate."
1899,"During his admission, he had worsening renal failure and
evaluated with a renal ultrasound that did not show hydro. His
respiratory status returned to baseline. He was discharged home
on augmentin. His Na had already started to drift downward
during the admission and was 129 on discharge. He also had mild
diarrhea during his admission.
.
After going home, he was mostly in bed due to profound weakness.
His family was watching his legs and noted the little bit of
swelling and new blue color. They called his PCP today who
suggested ED evaluation. He otherwise has no complaints. He
has generalized weakness and intermittent periods of shortness
of breath."
1900,"8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-8**] Sprays Nasal
QID (4 times a day) as needed for dryness and bleeding.
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Orthostatic
HE IS ORTHOSTATIC AND SYMPTOMATIC DO NOT GIVE IVF DUE TO SEVERE
CHF WOULD HAVE PT DRINK. Follow orthostatics daily.
11. Labs
Folly daily INRs goal must be [**5-13**] for INR overlap for 5 days
(today [**8-22**] was first day of therapeutic INR) given also on
argatroban. Follow CBC every other day to see that it remains
stable."
1901,"The patient was also found
to be severely hyponatremic.
.
# HIT: Pt's platelets dropped from admission levels of 173,000
([**2110-8-11**]) to 54,000 ([**2110-8-18**]). Suspicion for HIT was high and
Heparin PF4 antibody was sent and was positive with an optical
density of 0.692. Anything greater than 0.4 is considered a
positive result, however, strong positivity occurs when the
optical density is larger than 1. In consideration with the
patient's clinical history a high clinical suspicion for HIT and
the positive test results, Heme felt comfortable with this
diagnosis. Pt stopped all heparin products, was started on
argatroban 0."
1902,"2. Normal left ventricular cavity size. Severe systolic
dysfunction with
hypokinesis of the mid and basal inferior and inferolateral
walls. The
remaining segments are mildly hypokinetic.
Compared with the study of [**2104-10-6**], myocardial perfusion
appears similar.
Left ventricular systolic dysfunction has deteriorated.
.
STRESS TEST:
INTERPRETATION: This 81 y/o man with a h/o CAD, CHF, COPD and
renal
failure s/p AAA repair was referred for evaluation of chest
pain. The
patient was infused with 0.142mg/kg/min of Persantine over 4
minutes. No
chest, neck, back or arm discomfort was reported by the patient
throughout the procedure."
1903,"6 MCHC-32.0 RDW-15.6*
[**2110-8-11**] 04:09PM OSMOLAL-260*
[**2110-8-11**] 04:09PM CALCIUM-10.3 PHOSPHATE-3.9 MAGNESIUM-1.9
[**2110-8-11**] 04:09PM proBNP-GREATER TH
[**2110-8-11**] 04:09PM cTropnT-0.09*
[**2110-8-11**] 04:09PM estGFR-Using this
[**2110-8-11**] 04:09PM GLUCOSE-110* UREA N-36* CREAT-2.5*
SODIUM-117* POTASSIUM-5.4* CHLORIDE-84* TOTAL CO2-22 ANION
GAP-16
[**2110-8-11**] 04:32PM HGB-12.9* calcHCT-39
[**2110-8-11**] 04:32PM LACTATE-1.9 NA+-119* K+-5."
1904,"Per the daughter, he has been not eating, but trying
to drink a lot. He is afraid to sleep because he is scared of
death.
.
In the ED, initial vitals were T 97.8, P 80, BP 147/74, R 24 and
99% on 3L (his home O2 level). He remained stable with some
hypertension to SBPs in the 170s. He had a CXR that showed mild
fluid overlad. He had a CT abd that showed no aortic aneurysm
leak. Vascular was consulted and worried that his foot
discoloration was related to embolic events and heparin was
started with a bolus."
1905,"Abdominal: Soft, Non-tender, Bowel sounds present
.
Extremities: pads of toes and plantar surface of foot is
purplish, but warm, with petechiaie on the dorsum of the feet
.
Musculoskeletal: Muscle wasting
.
Skin: Cool
.
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
On admission:
[**2110-8-11**] 04:09PM PLT COUNT-173
[**2110-8-11**] 04:09PM NEUTS-67.0 LYMPHS-23.1 MONOS-8.1 EOS-1.3
BASOS-0.6
[**2110-8-11**] 04:09PM WBC-5.2 RBC-4.20* HGB-12.0* HCT-37.5* MCV-89
MCH-28."
1906,"The EKG is uninterpretable for
ischemia in the
presence of a LBBB. The rhythm was sinus with rare isolated APDs
and
VPDs. Hemodynamic response to infusion was appropriate.
Post-infusion
during the IV injection of 125mg of Aminophylline, the patient
reported
dizziness with a palp blood pressure of 88/-mmHg. Patient was
immediately placed in the Trendelenburg position with a BP of
106/palp
and relief of dizziness.
IMPRESSION: No anginal type symptoms with uninterpretable EKG
changes.
Nuclear report sent separately.
Brief Hospital Course:
81 y/o M with hx of COPD, CAD, AAA, and BPH presents today after
a recent admission for pneumonia with new swelling and
discoloration of his bilateral feet."
1907,"Yet, the
patient's urine electrolytes suggested hypovolemia, especially
in the setting of recent decreased PO intake, diarrhea, flat
JVP, and dry MM. The patient's cachexia and recent failure to
thrive since his last hospital admission were consistent with
both a hypo or hyper volemic state. The patient was given a
small normal saline bolus overnight observe whether his sodium
improved. As neither his sodium or respiratory status changed,
hyponatremia secondary to heart failure became more probable as
hyponatremia and resp status worsened. The patient was given
20mg of IV lasix in the morning and afternoon of [**8-12**] with good
urine output."
1908,"2
[**2110-8-11**] 04:32PM COMMENTS-GREEN TOP
During hospitalization/On discharge:
[**2110-8-18**] 07:05AM BLOOD WBC-5.3 RBC-3.79* Hgb-11.5* Hct-34.2*
MCV-90 MCH-30.4 MCHC-33.7 RDW-15.9* Plt Ct-54*
[**2110-8-20**] 06:50AM BLOOD WBC-6.4 RBC-4.05* Hgb-12.3* Hct-36.0*
MCV-89 MCH-30.4 MCHC-34.2 RDW-15.4 Plt Ct-80*
[**2110-8-20**] 06:50AM BLOOD Glucose-102* UreaN-46* Creat-2.6* Na-134
K-4.1 Cl-92* HCO3-27 AnGap-19
[**2110-8-14**] 05:30AM BLOOD ALT-768* AST-348* AlkPhos-91 TotBili-0."
1909,"Medications that are new:
Argatroban 0.5 mcg/kg/min IV DRIP INFUSION (until properly
switched to warfarin)
Guaifenesin [**6-16**] mL PO/NG Q6H:PRN
Warfarin 2.5 mg PO/NG DAILY
Nasal Spray for dry nose
Aspirin 325mg Daily
Followup Instructions:
Department: VASCULAR SURGERY
When: FRIDAY [**2110-8-29**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2110-9-8**] at 3:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2110-9-12**] at 11:30 AM
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"
1910,"You will need to take this for a while
and will be advised when to stop by your new outpatient
hematologist doctor.
When we send you to the extended care facility we will continue
you on some of your old medications and also add some new ones.
Here is a list below of all your medications, Old and New:
Meds that will be continued:
MVI 1 tab [**Hospital1 **]
Simvastatin 20mg Daily
Ranitidine 150mg Daily
Omega-3 Fatty Acid cap [**Hospital1 **] (If pt can swallow it)
Os-Cal 500+D tabs [**Hospital1 **]
nitroglycerin 0.3 sl daily prn chest pain you must call your
doctor if you use this"
1911,"Statin was also started. Pt
was found to have large bilateral pulmonary effusions on CXR and
chest CT which correlated with physical exam findings. These
were deemed [**3-11**] to his decomponsated heart failure. Despite what
had been initially reported, it was later learned that the
patient was not chronically on home oxygen, but had merely been
on it for the last week after discharge from another hospital
after being treated with a PNA. As a result, the goal for the
patient's heart failure treatment was to get his respiratory
status to the point where he no longer needed supplemental O2."
1912,"You
were given lasix to help get the extra fluid off your lungs and
you no longer require oxygen. We had to stop the lasix 2 days
ago because you were orthostatic (dropping your blood pressure
when you sat up and stood up). YOu are still orthostatic and we
are encouraging you to drink fluids. We cannot give you IV
fluids due to your heart failure (not pumping blood out of the
heart effectively). You will need to restart lasix at some
point at rehab once you are no longer orthostatic. Also we
started you on a new blood pressure medication which is good for
your heart called metoprolol."
1913,"5 mcg/kg/min IV DRIP on [**2110-8-18**] and then began
being bridge to warfarin with a starting dose of 3mg daily on
[**2110-8-19**]. Last INR before discharge was 6.3 with a goal INR of
[**5-13**] for combined therapy. The pt must be overlapped for a 5 days
bridge with INRS [**5-13**] on argatroban and coumadin (argatroban
elevated your INR which is why the INR goal must be so high
while overlapped). We are decreasing his warfarin dose to 2.5 mg
daily on [**2110-8-22**]. After the 5 day bridge is complete the pt's
INR goal is [**3-12**]."
1914,"PLAN
# Bradycardia: Resolved. PPM placed yesterday. PM interrogated
today.
- SBPs have been > 150, will restart metoprolol at home dose
- Transfer to floor today.
.
# Low Urine output: Resolved. Pt has been negative 200cc. MMM.
- NS bolus, IVF as needed. .
.
# Elevated TSH: T3/T4 normal. Likely sick euthyroid.
.
# Fall: likely that sinus pauses/bradycardia were the etiology, but
unknown as patient has not had then thus far while awake. Echo showed
mild AS, but not likely to be causitive. No focal neuro deficits.
- PT consult
- consider transfer to medicine for further workup once bradycardia
characterized and plan in place
.
# Hypertension; restart metoprolol
.
# Depression: continue fluoxetine
.
# Hyperlipidemia; continue statin
.
# CODE: DNR/DNI"
1915,"8 g/dL
111 mg/dL
0.7 mg/dL
33 mEq/L
3.2 mEq/L
12 mg/dL
105 mEq/L
143 mEq/L
31.4 %
10.6 K/uL
[image002.jpg]
[**2155-12-8**] 09:19 PM
[**2155-12-9**] 05:19 AM
[**2155-12-10**] 05:17 AM
WBC
10.4
10.6
Hct
32.1
31.4
Plt
198
181
Cr
0.9
0.8
0.7
Glucose
151
130
111
Other labs: PT / PTT / INR:13.9/34.6/1.2, Ca++:8.8 mg/dL, Mg++:1.8
mg/dL, PO4:2.6 mg/dL
Assessment and Plan
IMPRESSION: [**Age over 90 **] y/o woman admitted to hospital s/p fall and transfered
to the CCU with bradycardia
."
1916,"7
C (99.8
Tcurrent: 35.8
C (96.4
HR: 74 (40 - 94) bpm
BP: 158/66(86) {118/24(36) - 176/97(161)} mmHg
RR: 22 (14 - 26) insp/min
SpO2: 98%
Heart rhythm: A Paced
Total In:
2,607 mL
60 mL
PO:
60 mL
60 mL
TF:
IVF:
2,547 mL
Blood products:
Total out:
2,890 mL
260 mL
Urine:
990 mL
260 mL
NG:
Stool:
Drains:
Balance:
-283 mL
-200 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///33/
Physical Examination
Gen: NAD lying in bed sleeping
HEENT: laceration note
Resp: CTAB anteriorly
CV: RRR, nl S1/S2, distant heart sounds and and 2/6 systolic murmur
heard @ LUSB radiating to carotids
Abd: + BS, soft, non-tender, non-distended
Ext: 1+ lower ext edema bilaterally, radial and DP 2+ symmetric
Labs / Radiology
181 K/uL
10."
1917,"TITLE:
Chief Complaint:
s/p fall, Bradycardia
24 Hour Events:
Patient had PPM placed yesterday. Patient afebrile, VSS.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cephalexin 500mg po q8hrs
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2155-12-9**] 08:00 AM
Atropine - [**2155-12-9**] 09:30 AM
Other medications:
ASA 81mg
CaCo3 500mg TID
Dopamine 2-5mcg/kg/min (for HR < 40)
Colace 100mg [**Hospital1 **]
Senna prn
Fluoxetine 20mg daily
Vitamin D 400 u [**Hospital1 **]
Simvastatin 10mg qHS
Percocet prn q8hrs
Heparin 5000 u TID
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2155-12-10**] 07:23 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
1918,"Admission Date: [**2155-12-7**] Discharge Date: [**2155-12-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Placement of Permanent Pacemaker
History of Present Illness:
[**Age over 90 **] yo F with PMH of CVA, HTN, TIA and Alzheimer's disease who
presents after a fall at her nursing home. Per the report sent
in, she was walking with an aide who turned away for a min and
heard the patient fall. Unclear what led to her fall. Did not
appear to have any LOC after the event."
1919,"No loss of bowel or
bladder function or seizure activity. She was sent to [**Hospital1 18**] ED.
In our ED, her initial vital signs were T 96.8, HR 56, BP
203/93, RR 20, O2 sat 97% RA. She was given 1L NS. She had a
trauma work up with pelvic xrays, CT of C spine and head. She
was noted to have a hematoma on her occiput and a small
laceration below that which was cleaned and stapled. She was
also given a tetanus shot. She is being admitted for a syncope
work up.
Past Medical History:
-TIAs
-left subcortical ischemic stroke [**2153**] - had R sided hemiparesis
and dysarthria, has since recovered much function and speech, ?"
1920,"ambulates w/ walker now
-dementia
-hypertension
-hyperlipidemia
-migraine headaches
-right intertrochanteric fracture, status post repair
-myofascial pain syndrome
-bilateral knee replacements
-depression
Social History:
Resides in the Alzheimer's unit of an [**Hospital3 **] facility.
No history of EtOH, tobacco or illicit drug use
Family History:
No history of neurologic disease.
Physical Exam:
Vitals: T 96.3, BP 140/80, HR 57, RR 22, O2sat 97% RA.
Gen: NAD lying in bed sleeping
HEENT: laceration note
Resp: CTAB anteriorly
CV: RRR, nl S1/S2, distant heart sounds and and 2/6 systolic
murmur heard @ LLSB
Abd: + BS, soft, non-tender, non-distended
Ext: 1+ lower ext edema bilaterally, radial and DP 2+ symmetric"
1921,"# Bradycardia: Pt was initially admitted to the wards, where
telemetry demonstrated marked sinus pauses with an irregular
rate of approx 20. During these episodes she was witnessed to
be hypotensive and have myoclonic jerking and a blue tinge to
her lips. She was then transferred to the CCU, where she had
similar episodes responsive to atropine, including an epsiode of
severe bradycardia with loss of consciousness, brief respiratory
arrest with stable O2 sat, awoke shaking after atropine.
Etiology was thought to be is sick sinus or sinus exit block as
no unconducted p waves observed during bradycardia. Family
agreed to PPM placement and reversal of DNR/DNI status for
procedure."
1922,"Pacemaker was placed without complications on [**12-9**],
after which pt's code status was reversed back to DNR/DNI and
she had no furthur arrhythmic episodes. Pacemaker was
interigated and chest imaged and pt given 3 day course of
Keflex. She is to follow up with electrophysiology in 1 wk.
# Hypovolemia: Pt appeared dry on presenation and had decreased
urine output which responded well to IVF. The orthostasis may
have contributed to falls.
# Elevated TSH: TFTs were checked and since T3 and T4 were
normal, etiology was thought to be sick euthyroid.
# Fall: Likely etiology was multifactorial - sinus
pauses/bradycardia and orthostasis."
1923,"Mild AS on echo unlikely to
be suffient to be responsible. There were no focal neuro
deficits and pt was evaluated by physical therapy, who
determined that pt would require rehab for strengthening.
# Hypertension: Pt's home metoprolol was initially held, and
restarted after PPM was placed and blood pressures raised.
# Depression: Pt was continued on fluoxetine
# Hyperlipidemia: Statin continued
Medications on Admission:
asa 81 mg daily
Ca w/ Vit D 600 mg [**Hospital1 **]
docusate 100mg [**Hospital1 **]
fluoxetine 20 mg daily
metoprolol 25 mg [**Hospital1 **]
simvastatin 10 mg qhs
vit B-12 100 mg daily
senna prn
Discharge Medications:
1."
1924,"7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): crush meds.
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): crush meds.
9. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): crush meds.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): crush meds.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Sick sinus syndrome requiring pacemaker
Hypertension
Depression
Hyperlipidemia
DNR/DNI
Discharge Condition:
BUN 14
creat 0.7
hct 34.8
wbc 13.1
Discharge Instructions:
You had a fall at your home and injured your head."
1925,"Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) cc PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day."
1926,"0 Leuks-NEG
[**2155-12-7**] 07:10PM URINE RBC-[**4-9**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-[**4-9**]
Urine Culture: No growth
Head CT [**12-7**]:
1. No fracture, hemorrhage, or edema.
2. Chronic small vessel ischemic disease and age-related
parenchymal
involutional change.
3. Right parietal scalp hematoma.
ECHO [**12-8**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg)."
1927,"Right ventricular
chamber size and free wall motion are normal. There is mild
aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2153-7-9**], the
aortic valve gradient has increased.
CXR [**12-10**]: Standard position of the pacemakers with no evidence
of
complications.
Brief Hospital Course:
[**Age over 90 **] y/o woman admitted to hospital s/p fall and transfered to the
CCU with bradycardia"
1928,"Neuro: not oriented. Smiles, pleasant, closes eyes to go to
sleep and has noted myoclonus.
Pertinent Results:
[**2155-12-11**] 05:00AM BLOOD WBC-12.6* RBC-3.51* Hgb-11.3* Hct-32.9*
MCV-94 MCH-32.3* MCHC-34.3 RDW-15.4 Plt Ct-203
[**2155-12-7**] 07:10PM BLOOD Neuts-58.2 Lymphs-37.5 Monos-2.9 Eos-0.9
Baso-0.6
[**2155-12-9**] 05:19AM BLOOD PT-13.9* PTT-34.6 INR(PT)-1.2*
[**2155-12-11**] 05:00AM BLOOD Glucose-111* UreaN-12 Creat-0.6 Na-140
K-3."
1929,"3 Cl-101 HCO3-30 AnGap-12
[**2155-12-8**] 03:45AM BLOOD CK(CPK)-19*
[**2155-12-8**] 03:45AM BLOOD CK-MB-2 cTropnT-<0.01
[**2155-12-9**] 05:19AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.7
[**2155-12-8**] 03:45AM BLOOD VitB12-658 Folate-10.3
[**2155-12-7**] 07:10PM BLOOD TSH-5.1*
[**2155-12-8**] 03:45AM BLOOD T3-88 Free T4-0.98
[**2155-12-7**] 07:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2155-12-7**] 07:10PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8."
1930,"You had a
slow heart rate and needed a pacemaker. You should not lift
anything heavier than 5 pounds for the next 6 weeks. You should
not put your left arm over your head or tuck in your shirt for 6
weeks. Please see the pacemaker handout that was given to you on
discharge with more information. You have been restarted on your
home medicines. You need 1 more day of antibiotics for the pacer
placement.
Followup Instructions:
Cardiology:
Device Clinic follow up on Wednesday [**12-17**] at 3pm. [**Location (un) 3971**] [**Hospital Ward Name 23**]. [**Telephone/Fax (1) 62**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**12-26**] at 10:00am. Phone:
[**Telephone/Fax (1) 62**].
Completed by:[**2156-1-21**]"
1931,"Attending Physician: [**Name10 (NameIs) **]
Referral date: [**2155-12-9**]
Medical Diagnosis / ICD 9: / 780.2
Reason of referral: Eval/Tx
History of Present Illness / Subjective Complaint: Pt is a [**Age over 90 **]F with
Alzheimer's Dementia and HTN s/p fall (no obvious LOC) while walking
with aide at ALF adm [**12-7**] and transferred to CCU with symptomatic
bradycardia to 20s now s/p DDD PM placement [**12-9**].
Past Medical / Surgical History: TIAs, L Subcortical ishcemic CVA [**2153**]
c residual R hemiparesis and dysarthria, hyperlipidemia, R IT hip
fracture s/p ORIF, macular degeneration, B TKR
Medications: Heparin, Metoprolol, Dopamine, Oxycodone
Radiology: [**12-10**] CXR Stardard placement of PM."
1932,"T
Ambulation:
T
Balance: S at EOB. [**Female First Name (un) 939**] for dynamic standing balance requiring frequent
[**Female First Name (un) 939**] for lateral LOBs.
Education / Communication: [**Name6 (MD) 459**] c RN and MD [**First Name (Titles) **] [**Last Name (Titles) **] and D/C planning
Pt [**Name (NI) 460**] RE Role of PT
Diagnosis:
1.
Aerobic Capacity / Endurance, Impaired
2.
Balance, Impaired
3.
Gait, Impaired
4.
Muscle Performace, Impaired
5.
Transfers, Impaired
6.
Ventilation, Impaired
Clinical impression / Prognosis: Pt is a [**Age over 90 **]F who p/w above impairments
c/w cardiovascular pump dysfunction. Pt is functioning well below
baseline limited by tachycardia [**3-8**] not yet getting bblocker and by
decreased endurance [**3-8**] deconditioning."
1933,"Ideally pt would be able to
return to ALF with increased amount of supervision and assistance as pt
would no doubt be more comfortable in a familiar environment given her
dementia. If more A is not available at ALF pt will require STR with
good rehab potential given progress thus far.
Goals
Time frame: One Week
1.
Amb 150 c RW s LOB CTG
2.
Sup to Sit [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 939**]
3.
RR < 26 with Above
4.
5.
6.
Anticipated Discharge: Rehab
Treatment Plan:
Frequency / Duration: 2-3x/wk for about one week
Functional Mobility / Balance Training
T Patient agrees with the above goals and is willing to participate in
the rehabilitation program.
11:45
12:15"
1934,"Labs:
31.4
10.8
181
10.6
[image002.jpg]
Activity Orders: OOB c A.
Social / Occupational History: Lives at ALF [**Name8 (MD) 24**] RN
Living Environment: N/A
Prior Functional Status / Activity Level: Per Chart Pt amb c RW.
Objective Test
Arousal / Attention / Cognition / Communication: Alert. Orientated to
person only. Able to follow all one step commands.
Aerobic Capacity
HR
BP
RR
O[2] sat
RPE
Rest
78
149/88
16
100 3L O2
Activity
132
184/80
28
98 RA
Recovery
75
783/75
20
100 2L O2
Total distance walked: 75
Minutes:
Pulmonary Status: CTA B. +DOE."
1935,"Strong, nonproductive cough.
Integumentary / Vascular: PM incision c gauze dressing C/D/I. Foley.
Sensory Integrity: Intact to Lt touch.
Pain / Limiting Symptoms: Denied pain. Limited by c/o generalized
fatigue and DOE.
Posture: WNL.
Range of Motion
Muscle Performance
WNL
Shd NT but o/w grossly [**5-10**] RUE/LE and 4+/5 LUE/LE
Motor Function: Able to MAE in isolation
Functional Status:
Activity
Clarification
I
S
CG
Min
Mod
Max
Gait, Locomotion: Pt amb 75 pushing w/c with decreased B step length
and increased path deviation.
Rolling:
T
Supine /
Sidelying to Sit:
T
Transfer:
Sit to Stand:"
1936,"- EP consult early for placement. Will need DNR/DNI status temporarily
reversed & consent from HCP (brother).
- Continue atropine for HR at 60, pacer pads placed.
- Dopamine or isoproteronol if needed for chronotrophic support.
- hold metoprolol indefinitely.
.
# Low Urine output: Appears dry. Contraction alkalosis responds to
IVF. Orthostasis may have contributed to falls.
- NS bolus, IVF.
.
# Elevated TSH: T3/T4 normal. Likely sick euthyroid.
.
# Fall: likely that sinus pauses/bradycardia were the etiology, but
unknown as patient has not had then thus far while awake. Echo shoed
mild AS, but not likely to be causitive. No focal neuro deficits.
- PT consult
- consider transfer to medicine for further workup once bradycardia
characterized and plan in place
.
# Hypertension; hold metoprolol
.
# Depression: continue fluoxetine
.
# Hyperlipidemia; continue statin
.
# CODE: DNR/DNI but ok for atropine and transcutaneous pacing.
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2155-12-9**] 06:32 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: DNR / DNI
Disposition:"
1937,"7
C (99.8
Tcurrent: 35.8
C (96.4
HR: 74 (40 - 94) bpm
BP: 158/66(86) {118/24(36) - 176/97(161)} mmHg
RR: 22 (14 - 26) insp/min
SpO2: 98%
Heart rhythm: A Paced
Total In:
2,607 mL
60 mL
PO:
60 mL
60 mL
TF:
IVF:
2,547 mL
Blood products:
Total out:
2,890 mL
260 mL
Urine:
990 mL
260 mL
NG:
Stool:
Drains:
Balance:
-283 mL
-200 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///33/
Physical Examination
Gen: NAD lying in bed sleeping
HEENT: laceration note
Resp: CTAB anteriorly
CV: RRR, nl S1/S2, distant heart sounds and and 2/6 systolic murmur
heard @ LUSB radiating to carotids
Abd: + BS, soft, non-tender, non-distended
Ext: 1+ lower ext edema bilaterally, radial and DP 2+ symmetric
Neuro: not oriented."
1938,"9/34.6/1.2, Ca++:8.8 mg/dL, Mg++:1.8
mg/dL, PO4:2.6 mg/dL
Assessment and Plan
IMPRESSION: [**Age over 90 **] y/o woman admitted to hospital s/p fall and transfered
to the CCU with bradycardia
.
PLAN
# Bradycardia: Transferred from the floor with hypotensive
bradycardia. She has had similar episodes here, worse during periods
around sleep and responsive to atropine. Has had myoclonic jerks
suggestive of cerebral hypoperfusion. Family was initally hesititant
to place a placemaker, but now wishes to have one placed. Most
likely etiology is sick sinus or sinus exit block as no unconducted p
waves observed during bradycardia."
1939,"TITLE:
Chief Complaint:
s/p fall, Bradycardia
24 Hour Events:
Patient had PPM placed yesterday. Patient afebrile, VSS.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cephalexin 500mg po q8hrs
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2155-12-9**] 08:00 AM
Atropine - [**2155-12-9**] 09:30 AM
Other medications:
ASA 81mg
CaCo3 500mg TID
Dopamine 2-5mcg/kg/min (for HR < 40)
Colace 100mg [**Hospital1 **]
Senna prn
Fluoxetine 20mg daily
Vitamin D 400 u [**Hospital1 **]
Simvastatin 10mg qHS
Percocet prn q8hrs
Heparin 5000 u TID
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2155-12-10**] 07:23 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
1940,"Smiles, pleasant, closes eyes to go to sleep and
has noted myoclonus.
Labs / Radiology
181 K/uL
10.8 g/dL
111 mg/dL
0.7 mg/dL
33 mEq/L
3.2 mEq/L
12 mg/dL
105 mEq/L
143 mEq/L
31.4 %
10.6 K/uL
[image002.jpg]
[**2155-12-8**] 09:19 PM
[**2155-12-9**] 05:19 AM
[**2155-12-10**] 05:17 AM
WBC
10.4
10.6
Hct
32.1
31.4
Plt
198
181
Cr
0.9
0.8
0.7
Glucose
151
130
111
Other labs: PT / PTT / INR:13."
1941,"She received ceftriazone 1gm, tylenol for fever and 3L
IVF. CXR ruled out PNA. 2 18 guage IVs were placed. Vitals on
transfer 98.9 86 97/34 20 96% on 2L NC.
.
On arrival to the ICU, she states she has dry mouth, post nasal
drip.
.
Review of systems:
(+) Per HPI
(-) Denies fever, cough, shortness of breath, chest pain,
vomiting, diarrhea, constipation, abdominal pain. Denies rashes
or skin changes.
Past Medical History:
#. Temporal arteritis
#. polymyalgia rheumatica
#. HTN
#. Thyroid nodule
#. hypothyroidism
#. Dyslipidemia
#. Osteoporosis
#. sciatica
#. spinal stenosis
#. IBS
#. diverticulosis
#. h/o gastric ulcer
#. anxiety
#. glaucoma
#. anemia
#. ventral hernia
Social History:
Occupation: former 3rd grade teacher in [**Hospital1 392**]
Drugs: denies
Tobacco: denies
Alcohol:
Other: lives with sister"
1942,"7* Phos-1.9* Mg-1.9
[**2164-7-21**] 03:22PM BLOOD Lactate-2.9*
Labs on Discharge:
[**2164-7-24**] 07:35AM BLOOD WBC-8.4 RBC-3.44* Hgb-10.4* Hct-31.7*
MCV-92 MCH-30.3 MCHC-32.9 RDW-14.7 Plt Ct-226
[**2164-7-24**] 07:35AM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-144
K-4.1 Cl-107 HCO3-28 AnGap-13
[**2164-7-24**] 07:35AM BLOOD Calcium-9.7 Phos-3.0 Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname **] is a 84 yo F on longstanding steroids for
Polymyalgia Rheumatica and temporal arteritis, osteoporosis,
spinal stenosis, anxiety, anemia, HTN, hyperlipidemia who
presents from home with N/V after antibiotic tx for a UTI and
found to be hypotensive."
1943,".
# UTI in context of hypotension: Patient with E coli sensitive
to ceftriaxone on culture. Of note, her hypotension is likely
[**2-14**] adrenal insufficiency in the setting of infxn and
long-standing steroid use rather than sepsis. Initially,
stress-dose steroids were held because patient has h/o
co-morbities with steroids. IVF were also held, as patient with
crackles to mid-lung field on pulmonary exam. Pt was started on
Ceftriaxone 1g daily. Patient was transitioned to PO
cefpodoxime before her discharge home. She tolerated the
medications well.
.
# Hypotension: Likely multifactorial, but given chronic steroid
use, pt probably not able to mount cortisol response to stressor
of infection."
1944,"Pt received boluses of fluids in the ED to which
she was only partially responsive, but did not receive fluids in
the ICU because she was exhibiting crackles on pulm exam. SBP
goal > 95; MAP goal >60. Pt has not received any acute
treatment for hypotension in ICU.
.
# Polymyalgia Rheumatica and Temporal Arteritis: stable; pt
continued on her home dose prednisone
.
# Hypernatremia: pt noted to have Na 146 on ICU day 2;
encouraged PO intake and monitored electrolytes.
.
# Osteoporosis: Known history; cont home fosamax, calcium and
vitamin D
.
# Anxiety: Pt on home benzodiazepines, but held benzos for high
risk of in-house delerium
."
1945,"# Hyperlipidemia: cont home ezetimibe
.
# HTN: held home valsartan given hypotension
Medications on Admission:
ALENDRONATE 70 mg weekly
DIAZEPAM 2.5 -5mg Q 8 prn anxiety (usu takes several/wk)
EZETIMIBE 10 mg daily
HYDROCODONE-ACETAMINOPHEN - 7.5 mg-325 mg 1-2 tabs Q 6 prn pain
(recently taking about [**1-14**]/day)
LATANOPROST 0.005 %Drops - 1 drop in each eye once daily
LEVOTHYROXINE 25 mcg daily
OMEPRAZOLE 20 mg [**Hospital1 **]
PREDNISONE 4mg daily
VALSARTAN 80 mg daily
ACETAMINOPHEN 1000mg PRN pain (pt states she rarely takes)
BIOTIN 3mg daily
CALCIUM CARBONATE-VITAMIN D3 1200 mg-800 unit daily
DOCUSATE SODIUM
CENTRUM SILVER daily"
1946,"14. Biotin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
15. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Urinary Tract Infection
Secondary Diagnosis: Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with low blood pressure and a
wrinary tract infection. Your blood pressure stabilized and you
were placed on an antibiotic for your urinary tract infection.
You were discharged home on oral cefpodoxime. Please take this
medication through [**7-28**].
Please ADD the following medication:
Cefpodoxime 100 mg, take 2 tabs by mouth twice per day for an
additional 3 days
Followup Instructions:
Please follow-up with your primary care provider as listed
below:
Department: [**State **] SQ
When: TUESDAY [**2164-8-7**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking"
1947,"Left
shin with lac- healing well with minimal drainage
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone:
Normal
Pertinent Results:
Labs on Admission:
[**2164-7-21**] 03:00PM BLOOD WBC-22.4*# RBC-3.48* Hgb-10.6* Hct-32.0*
MCV-92 MCH-30.4 MCHC-33.0 RDW-14.6 Plt Ct-225
[**2164-7-21**] 03:00PM BLOOD Glucose-110* UreaN-30* Creat-0.9 Na-139
K-3.8 Cl-102 HCO3-28 AnGap-13
[**2164-7-22**] 02:38AM BLOOD Calcium-7."
1948,"Her u/a came back positive so she was
prescribed cipro. However, the pt has a h/o being allergic to
this so [**7-20**], it was switched to macrobid. On the evening of [**7-20**]
she took her first dose of macrobid. On the am of admission, she
woke up nauseous and had chills. T was 103. She called her PCP
and was referred to the ED.
.
In the ED, she was noted to have a lac on her L ant shin from a
fall at home 2 days ago which was noted to look clean w/o e/o
infxn."
1949,"7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
10. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. Hydrocodone-Acetaminophen 7.5-325 mg Tablet Sig: 1-2 Tablets
PO every six (6) hours as needed for pain.
12. Diazepam 5 mg Tablet Sig: 0.5-1 Tablet PO every eight (8)
hours as needed for anxiety.
13. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet Sig: Two
(2) Tablet PO once a day."
1950,"Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
1951,"Family History:
Non-contributory
Physical Exam:
VS: Tmax: 37 ??????C (98.6 ??????F), HR: 78 (77 - 89) bpm, BP: 108/36, RR:
15 (15 - 31) insp/min, SpO2: 99%
General Appearance: Well nourished, No acute distress
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : [**1-14**] way up bilat, No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, e/o venous stasis."
1952,"Admission Date: [**2164-7-21**] Discharge Date: [**2164-7-24**]
Date of Birth: [**2080-1-17**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Pravachol / Ciprofloxacin / Zoloft / Lipitor
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 84 yo F on longstanding steroids for PMR,
temporal arteritis, osteoporosis, spinal stenosis, anxiety,
anemia, HTN, hyperlipidemia who presents from [**Last Name (un) **] with N/V.
.
Of note, the pt saw her PCP [**7-17**] with a number of complaints incl
a request to be tests for UTI b/c, per her, she ""hadn't been
tested in a while""."
1953,"Admission Date: [**2148-4-5**] Discharge Date: [**2148-4-9**]
Service: MEDICINE
Allergies:
Dicloxacillin / Beta-Blockers (Beta-Adrenergic Blocking Agts) /
Shellfish / Aspirin / Epinephrine / Cefaclor / Neomycin /
clindamycin / Bacitracin / Clavulanic Acid / Latex
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F with history of COPD, CHF sent from [**Hospital 102735**] rehab with
worsening SOB, and hypoxia. Lasix recently decreased because
urinating too much. Per report at [**Hospital 100**] rehab, patient was
found at 1am sleeping on the floor without obvious injury. The
day of admission she was agitated, uncooperative wtih staff, and
delirious."
1954,"02 saturation 76% on RA upto 92% on 4L. She has had
severe anxiety this week and started lorazepam prn 4 days ago.
She received 0.5 mg today at 10:50 AM.
.
In the ED, initial vs were: 99.2 66 153/80 22 96%. She was in
atrial fibrillation. Labs notable for BNP of 7024. ABG pH 7.40
pCO2 57 pO2 137 HCO3 37. CXR was concerning for fluid overload -
cant r/o PNA. Patient was given Albuterol Neb,Ipratropium
Bromide Neb, Levofloxacin 750mg, Furosemide 40mg,
MethylPREDNISolone Sodium Succ 125mg, Vancomycin 1g. She was
started on Bipap in the ED."
1955,"She was given Ativan 2mg IV x2 for
anxiety/agitation, and 4mg IV morphine x2. Prior to transfer, P
70 BP155/65 R O2 sat 96 on bipap 10/4 28% FiO2.
.
The patient notably has a DNR order in her records. Her daughter
who is the HCP was [**Name (NI) 653**] in the [**Name (NI) **]. She lives in [**State 108**],
and confirmed that she is okay to intubate, continues to be DNR.
.
.
On the floor, the patient is sleepy, with BIPAP mask on. While
being moved, she was more awake and agitated.
Past Medical History:
-COPD
-gait disturbance
-Afib
-h/o subdural s/p fall
-restless leg syndrome
-hypothyroidism
-depression/anxiety"
1956,"#dCHF EXACERBATION: Physical exam and CXR consistent with
pulmonary edema. Likely because lasix dose was recently
decreased. Patient's new ativan medication could have
potentially make her hypercarbic, but shouldn't contribute to
hypoxemia. She was afebrile and without leukocytosis. She
received 1 dose of Levofloxacin in the ED. The patient was
admitted to the MICU with respiratory distress and agitation.
She was placed on BiPAP intermittently overnight but continued
to remove the mask. Her SpO2 was at baseline. She continued to
remain agitated but was somewhat redirectable. Swallow consult
placed and lasix 60mg PO daily ordered on day of transfer out of
MICU."
1957,"# Anxiety: Patient had been suffering from this anxiety for
several years. In hospital it was initially controlled with
alprazolam. However, she was evaluated by inpatient psychiatry
who recommended to d/c alprazolam and use 0.25 mg lorazepam TID
(about equivalent to the 0.125 mg alprazolam TID prn she had
beenreceiving at [**Hospital 100**] Rehab before recent increases).
INACTIVE ISSUES:
# Hypothyroidism: Continued synthroid.
# Atrial fibrillation: Rate well controlled. Allergic to beta
blockers. Not anticoagulated, likely because of history of
frequent falls.
#COPD - stable
- albuterol neb
- fluticasone nasal spray
- Fluticasone/salmeterol discus
#Code: DNR,DNI. Confirmed with HCP, patient
#Communication: Patient."
1958,"18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
1)Moderate dCHF exacerbation
2)Anxiety Disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to our facility for exacerbation of your
chronic heart failure as well as anxiety. We have given you
medicine to help with both, your trouble breathing, which
improved, as well as your anxiety.
The following changes were made to your medication regimen:
START Lasix 60mg Daily
START Sarna Lotion - as needed for itching
START Lorazepam [**12-31**] tablet three times a day as needed for
anxiety
STOP Alprazolam
Followup Instructions:
Please call your primary care doctor when you leave the rehab
facility to schedule an appointment.
Completed by:[**2148-4-10**]"
1959,"Social History:
Ambulates with walker with assitance.
Family History:
Non contributory
Physical Exam:
Vitals: BP: 156/64 P: 71 R: 18 O2: 96%
General: Arousable to voice, bipap in place, no acute distress
HEENT: Sclera anicteric. Unable to examine mouth given BIPAP
mask
Neck: supple, unable to assess JVP, no LAD
Lungs: Crackles at R base, no wheezes
CV: Irregularly irregular. No murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
VS - 96.6(96.9)-142/62-68-18-99/2L
General: Anxious, A&Ox2 (oriented to person, writer, president,
but not exact date -stable)."
1960,"The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Pulmonary artery systolic hypertension. Mild aortic
regurgitation.
VIDEO SWALLOW STUDY: Penetration with thin and nectar
consistency. No aspiration. Very slow passage of contrast
through the thoracic esophagus into the stomach with numerous
tertiary waves seen.
Brief Hospital Course:
[**Age over 90 **] yo F with a history of COPD and CHF who presents with hypoxia
and SOB, consistent with pulmonary edema."
1961,"01
[**2148-4-6**] 02:56AM BLOOD CK-MB-3 cTropnT-<0.01
[**2148-4-5**] 05:00PM BLOOD Calcium-8.5 Phos-3.7 Mg-2.3
[**2148-4-6**] 02:56AM BLOOD VitB12-1374* Folate-GREATER TH
[**2148-4-5**] 10:22PM BLOOD Type-ART pO2-65* pCO2-57* pH-7.40
calTCO2-37* Base XS-7
[**2148-4-5**] 05:14PM BLOOD Lactate-0.8 K-5.0
[**2148-4-5**] 05:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2148-4-5**] 05:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6."
1962,"Patient continued to improved and had no shortness of
breath while on the floor. Her ECHO demonstrated The left and
right atria are moderately dilated. There is moderate symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal.
In conclusion, we recommend not decreasing the current lasix
dose in this patient. She will need this dose titrated in the
future to make sure she does not become volume overloaded again."
1963,"11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
[**12-31**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
12. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
14. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
15. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily ().
16. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO once a
day.
17. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily)."
1964,"Her sertraline dose may need to be
adjusted based on how she is doing at the [**Hospital **] rehab in the
next few weeks.
Medications on Admission:
1. Morphine concentrate 5 mg/0.25 mL Oral Oral 1 Solution(s)
Every 4-6 hrs PRN
2. alprazolam 0.25 mg po tid, qhs PRN
3. fluticasone 110 mcg [**Hospital1 **]
4. bisacodyl 10 mg PR daily
5. albuterol sulfate Neb q4-6h PRN
6. Arthritis Pain Relief (acetaminophen) 650 mg po q4-6h PRN
7. Ergocalciferol (vitamin D2) 50,000 unit Tab q month
8. Sodium chloride 0.65 % Nasal Spray qid PRN
9."
1965,"HEENT: Sclera anicteric. signs of cataract surgery, with unequal
but reactive pupils.
Neck: supple, unable to assess JVP, no LAD
Lungs: Crackles at bases bilaterally.
CV: Irregularly irregular. No murmurs, distant.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Skin: multiple areas of ecchymoses, no new lesions noted.
Ext: warm, well perfused, 2+ pulses, no clubbing, minimal edema,
with chronic skin changes. Ecchymosis on R. arm. Ankles -FROM,
with some tenderness of R ankle on movement
Pertinent Results:
Admission Labs:
[**2148-4-5**] 05:00PM BLOOD WBC-5.2 RBC-2.84* Hgb-10."
1966,"25 mg po daily
Discharge Medications:
1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: One
(1) PO every four (4) hours as needed for pain.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for shortness of breath.
5. Arthritis Pain Relief (acetam) 650 mg Tablet Sig: One (1)
Tablet PO every 4-6 hours as needed for pain."
1967,"6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
7. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-31**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
8. phenylephrine HCl 0.5 % Spray, Non-Aerosol Sig: One (1) Spray
Nasal Q4H (every 4 hours) as needed for dry nose.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for upset stomach."
1968,"0* Hct-30.0*
MCV-106* MCH-35.1* MCHC-33.2 RDW-19.2* Plt Ct-289
[**2148-4-5**] 05:00PM BLOOD Neuts-76.9* Bands-0 Lymphs-15.5*
Monos-4.5 Eos-1.6 Baso-1.4
[**2148-4-5**] 05:00PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL
[**2148-4-5**] 05:00PM BLOOD PT-12.9 PTT-23.7 INR(PT)-1.1
[**2148-4-5**] 05:00PM BLOOD Glucose-107* UreaN-29* Creat-0.9 Na-137
K-5.0 Cl-98 HCO3-32 AnGap-12
[**2148-4-6**] 02:56AM BLOOD CK(CPK)-39
[**2148-4-5**] 05:00PM BLOOD proBNP-7024*
[**2148-4-5**] 05:00PM BLOOD cTropnT-<0."
1969,"Pt's daughter in [**Name (NI) 108**]: [**Name (NI) 102736**]
[**Name (NI) **] HCP - [**Telephone/Fax (1) 102737**]
TRANSITIONAL ISSUES:
#Hypothyroidism - per psych, patient will need outpatient workup
of her hypothyroidism. PCP may need to reevaluate the need for
thyroid supplementation in this patient. As per psych: The
patient's daughter reports that she had equivocal TFTs in
thepast and against the daughter's better judgment, her doctors
decided to [**Name5 (PTitle) **] thyroxine. If in fact the thyroxine is not
necessary, tapering the thyroxine may contribute to a reduction
in her experienced anxiety.
#Anxiety - patient is being discharged to rehab on lorazepam, as
per psych recommendation."
1970,"0 Leuks-NEG
[**2148-4-5**] 05:45PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
TransE-<1
[**2148-4-5**] 05:45PM URINE CastHy-3*
.
CXR: Limited study with mild pulmonary vascular congestion.
Limited
evaluation of the lung bases.
ECHO: The left and right atria are moderately dilated. There is
moderate symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal."
1971,"Phenylephrine 0.25 % Nasal Spray qid PRN
10. Polyethylene glycol 3350 17 gram/dose daily PRN
11. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb Chewable Tab q4-6h PRN
12. Lorazepam 0.5 mg po q6h PRN
13. Fluticasone 50 mcg Nasal Spray [**Hospital1 **] PRN
14. Levothyroxine 112 mcg po daily
15. Albuterol sulfate Inh Neb [**Hospital1 **] PRN
16. Ipratropium inh [**Hospital1 **] PRN
17. Guiatuss 100 mg/5 mL Oral Liquid q4-6 hrs PRN
18. Sertraline 125 mg po daily
19. Furosemide 40 mg po daily
20. Mirapex 1 mg po daily
21. Pramipexole 0."
1972,"Admission Date: [**2139-7-7**] Discharge Date: [**2139-7-16**]
Date of Birth: [**2058-11-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22864**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
PICC line placed on [**2139-7-13**]
History of Present Illness:
80 year old female with a history of multiple sclerosis,
alzheimer's disease, hypertension who presents from a nursing
home with one day of back pain. Per staff at her nursing home
she was in her usual state of health until the day prior to
presentation when she began to complain of back pain."
1973,"Past Medical History:
Multiple sclerosis
Coronary Artery Disease
Hypertension
Hyperlipidemia
Osteoporosis
Hypothyroidism
Depression
Chronic sinusitis and allergic rhinitis.
Endometriosis, status post laparoscopy.
Dysfunctional uterine bleeding
Social History:
Currently coming from nursing home. No current smoking, alcohol
or illict drug use. Very remote smoking history (less than 3
pack years). Used to work in a cardiology office.
Family History:
Coronary artery disease in brother. Possible MS in a deceased
sister.
Physical Exam:
Vitals: T: 99.8 BP: 109/68 P: 89 R: 16 O2: 95% on RA
General: Alert, oriented to person and hospital, not [**Hospital1 18**], date
or year, speech slurred (noted in previous neurologic exams)
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender in epigastric region and right upper
quadrant, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: foley draining [**Location (un) 2452**] urine (received pyridium in ER)
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, excoriations throughout
Back: Pain in paraspinal region bilaterally, no flank pain
Neurologic: CN II-XII tested and intact, strength 5/5
throughout, sensation intact across all dermatomes, reflexes 2+
and symmetric, unable to assess gait"
1974,"There is no gallbladder wall thickening and no
pericholecystic fluid is seen. The visualized portion of the
pancreas is unremarkable, however, the pancreas is partially
obscured by overlying bowel. The spleen is unremarkable and
measures 9.3 cm. Both right and left kidneys show no
hydronephrosis. The right kidney measures 9.0 cm and the left
kidney measures 8.8 cm. No AAA is identified on limited views of
the aorta.
IMPRESSION: 1) Cholelithiasis with no sign of cholecystitis.
Brief Hospital Course:
This is a 80 yo female with history of MS, alzheimers,
hypertension who presents from a nursing home with one day of
back pain, fever and confusion who was found to have MSSA
bacterimia and developed an ileus and transaminitis."
1975,".
#BACTERIMIA/BACK PAIN: Given patients history of acute onset,
change in mental status, fever and elevated WBCs this was
concerning for sepsis/infection paraspinal abcess,
osteomyelitis. Given history of osteoporosis, compression
fracture was also in the differential but preliminarily no
evidence on CT chest. MRI T&L done on [**2139-7-9**] which showed no
acute processes. She was given broad spectrum antibiotics
including: ciprofloxacin and ceftaxine were given x1, Vanco IV
x 2 days until her blood culture results were available. She was
foud to have MSSA so she was started on Nafcillin 2 gm IV Q4
hrs, from [**7-10**]->[**7-13**]."
1976,"+ BS x
4 quads and she had two BMs. We advanced her diet. She has been
tolerating her diet well with no N/v and no complain of
abdominal pain.
Her C-diff culture was negative and her Flagyl was D/c on
[**2139-7-16**].
#TRANSMIANITIS: As noted above she had sl. increase in AST, ALT
and Alk phos with nausea and vomiting for 2 days and RUQ
tenderness. This was thought to be related to the Nafcillin.
Once Nafcillin was D/c'd and labs started to trend down. She was
also found to have increase in Lipase of 79 and amylase of 113
on [**7-16**] ."
1977,"This was believed to be caused by mild pancreatitis
also related to prior treatment administration of Nafcillin. She
will have continue monitoring of LFTs, including lipase and
amylase weekly. She was doing well at discharge, tolerating her
regular diet with no complains of N/V or abdominal pain.
.
#UTI: Urine culture Positive for E.Coli > 100,000 colonies,
rresistant to cipro and ampicillin. Sensitive to the
cefalosporins, zozyn, tobramycin, Bactrim, and Nitrofurantoin.
Received 3 days of Bactrim. D/c on [**7-11**]. Repeat UA on [**7-11**].
Urine culture on [**7-11**] shows no growth.
.
#Tachycardia: Patient has been sinus tachycardic for most of her
admission."
1978,"EKG remained unchanged, she was placed on tele for
the first few day of admission where she remained on sinus tachy
in rates ranging from 90s to low 100s, asymptomatic. This could
be due to mild hyperthyroidism, TSH low 0.08 and on
levothryroxine. Patient also given extra fluid bolus which she
responded well, so could also be due to dehydration. Patient
stable at time of discharge. Follow TSH and T4 as outpaint
encourage PO fluids.
.
# 2nd degree right buttock ulcer: Patient with small 2x1 cm in
diameter excoriation on right buttock. The wound care nurse
assessed and treated the wound."
1979,"20. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
21. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
22. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
month.
23. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
Q Day PRN as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care
Discharge Diagnosis:
Primary:
Bacteremia
Urinary tract infection
ileus
Secondary:
Alzheimers
dementia
Multiple sclerosis
HTN
depression
Discharge Condition:
Stable, confusion and pain improved."
1980,"4
[**2139-7-7**] 04:15PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.026
[**2139-7-7**] 04:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2139-7-7**] 04:15PM URINE RBC-3* WBC-21-50* Bacteri-MANY Yeast-NONE
Epi-4
.
Micro
[**2139-7-7**] Aerobic Bottle Gram Stain (Final [**2139-7-8**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2139-7-8**]):
GRAM POSITIVE COCCI IN CLUSTERS.
LAST POSITIVE BLOOD CULTURE ON [**7-9**]:
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 101883**],
[**2139-7-7**]."
1981,"You had a xray of your abdomen which showed
that you had a blockage in your intestine. You didn't eat for
one day and we changed some of your medications which helped you
started to feel better.
We have made the following medication changes:
-Started on Cefazolin 2 gm IV every 8 hours
You should have blood draws every week and you should follow the
appointments as noted below.
If you develop any chest pain, shortness of breath, fever
(temperature greater than 101.3 F), chills, palpitations,
confusion or for increase pain in your abdomen or in your back,
or for any other concerns you should call your doctor or come
the emergency room.
Followup Instructions:
PROVIDER: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 1420**], infectious diseases doctor,
on [**2139-8-6**] at 9:OO AM. Location: [**Hospital Unit Name **] at [**Doctor First Name **], across from [**Hospital1 **] Emergency room. Phone:
[**Telephone/Fax (1) 457**]
BLOOD DRAW: Please have CBC, Chem 7 (Na, K, Cl, HCO2, BUN,
Creat, gluc), LFTs (ALT,AST,T.bili, Alk phos), drawn weekly
while on antibiotics and have results faxed to Dr.
[**Name (NI) 1420**] at [**Telephone/Fax (1) 1419**] (Phone # [**Telephone/Fax (1) 457**])."
1982,"She had increased liquid BMs
for the prior 2 days which were attributed to motility agents
she had received. Given that she was in numerous antibiotics,
stool was sent for C-Diff and place her on prophylactic Flagyl
500mg PO. We also did a KUB which showed an ileus. This was most
likely related to an functional ileus, since she was on
narcotics, laying in bed with decreased mobility, and no BM for
a 4-5 days prior to receiving motility agents. She was made NPO
for 1 day. On physical exam her abdomen on the following day was
soft, continued to be mildly distended, but less tender."
1983,"5 mg Q6H:PRN
Prochlorperazine 10 mg Q6H:PRN
Tylenol 650 mg PRN
Milk of Magnesia 400 mg daily:PRN
Bisacodyl 10 mg PR daily:PRN
Fleets enema PRN
Senna PRN
Calcium 500 mg TId
Detrol 4 mg QHS
Aricept 10 mg QHS
Levothyroxine 125 mcg daily
Colace
Aspirin 325 mg daily
Vitamin D 50,000 q month
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
1984,"She was
unable to clarify further. Her temperature was 100.4 with blood
pressure 162/82. She received vicodin and tylenol without
improvement. At baseline she is alert, oriented but does not
ambulate. She is able to eat by herself but is incontinent of
urine and stools. She was transferred to [**Hospital3 **] for further
management.
.
In the ED, initial vs were: T: 98.0 P: 90 BP: 104/69 R: 16 O2
sat: 92% on RA. She became tachycardic to the 140s (sinus
tachycardia) with stable blood pressures and spiked a fever to
101.5. Her antibiotics were broadened to vancomycin and cefepime
and she had a CT of the chest with contrast which was not timed
appropriately and did not show a large pulmonary embolism but
could not rule out a small pulmonary embolism."
1985,"Nafcillin was stopped due to increased in
LFTs, RUQ abdominal pain, nausea and vomiting. She was started
on Cefazolin 2 gm IV Q 8hrs. Patient's condition had overall
improved, her confusion resolved on the second day of admission
although she has Alzheimers at baseline. She states to always
have a baseline backpain, but it was much improved from
admission. Pt was also found to have a UTI + E.Coli which she
was treated for a total of 3 days, urine culture was repeated on
[**7-11**] which was negative.
Patient also has been followed by infectious diseases who gave
antibiotic recommendations."
1986,"She had a PICC line placed on
[**2139-7-13**] which she had removed after the first day, she stated
that if was ictching and she pulled it out. She had another PICC
replaced on her Right AC which was working well prior to
discharge.
.
# Nausea and vomiting: pt complained of nausea and vomited a
small amount of greenish fluid on [**2138-7-12**] and [**7-13**]. she also had
tenderness on her right upper quad. Abdominal US showed
cholelithiasis without cholecystitis. Since Naficillin can cause
some liver toxicity, the medication was discontinued.
Transaminitis started to trend down. However, on [**2139-7-14**]
patient's abdomen looked distended, tympanic, and she continued
to complaint of RUQ abdominal pain."
1987,"4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q 6HRS: PRN as
needed for anxiety.
8. Donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain: ON FOR 12 HRS AND OFF FOR 12 HRS.
10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
1988,"11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain: PLEASE DO NOT EXCEED 2GM PER
DAY .
13. Cefazolin in Normal Saline 2 gram/100 mL Solution Sig: Two
(2) gram Intravenous every eight (8) hours for 22 days: MSSA
bacterimia. PLEASE STOP ON [**2139-7-30**].
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous once a day as needed for line flush: PICC, heparin
dependent: Flush with 10mL Normal Saline followed by 2 mL of
Heparin daily and PRN per lumen."
1989,"URINE CULTURE ON [**2139-7-11**]: NO GROWTH.
.
[**2139-7-7**] ECG: Probable sinus tachycardia versus regular SVT at
148, borderline left axis, borderline prolonged QTc at 470, no
St segment elevation or depression, compared with prior dated
[**2138-2-25**] the rate is faster.
.
[**2139-7-7**] CXR: No evidence of pneumonia.
.
[**2139-7-7**] CTA chest: Equivocal subsegmental pulmonary embolism in
a right upper lobe branch (3:38, 402b:54) may reflect volume
averaging artifact. no large PE. bibasilar atelectesis. no acute
aortic pathology.
ABD XRAY ON [**2139-7-14**]: Mild distension of the stomach is once
again noted in this study."
1990,"Anaerobic Bottle Gram Stain:
GRAM POSITIVE COCCI IN CLUSTERS
MRSA SCREEN: No MRSA isolated
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
[**2139-7-8**] Urine culture: ESCHERICHIA COLI. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S"
1991,"The wound has overall improved,
now there is only very small wound healing well less than .5cm
in diameter at the time of discharge with dressing over it.
.
#Coronary Artery Disease: No changes on EKG.
- continue aspirin 81 mg daily
.
At discharge: Patient is alert and oriented times place and
time. She respond appropriately to questions, and conversing.
Very pleasant. She moves in bed with minimal assist. She is
incontinent of urine and stool which is her baseline. She is
stable and medically clear to go back to her extended care
facility.
Medications on Admission:
Cymbalta 30 mg daily
Folic Acid 1 mg daily
Loratadine 10 mg daily
Multivitamin
Thiamine 100mg daily
Simvastatin 40 mg dialy
Vicodin 5-500 [**Hospital1 **] and Q4H:PRN
Namenda 10 mg [**Hospital1 **]
Lorazepam 0."
1992,"15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by 2
mL Heparin daily and PRN per lumen.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation: Please hold for loose stool.
17. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day:
PLEASE HOLD FOR LOOSE BM.
18. Compazine 10 mg Tablet Sig: One (1) Tablet PO Q 6HRS: PRN.
19. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day."
1993,"Afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] for severe back pain and confusion.
When you came into the emergency room your temperature was 101.5
F and your heart rate was fast. We found that you have an
urinary tract infection and an infection in your blood. We have
been giving you antibiotics and your symptoms of back pain and
confusion have improved.
You had Infectious Diseases consult and you will need to be in
IV antibiotics for a total of 4 to 6 weeks. You also had a PICC
line placed for the IV antibiotics.
You also developed nausea, vomiting, and pain in the right side
of your abdomen."
1994,"Pertinent Results:
[**2139-7-7**] 01:35PM BLOOD WBC-12.2*# RBC-4.03* Hgb-11.9* Hct-37.1
MCV-92 MCH-29.6 MCHC-32.2 RDW-13.8 Plt Ct-338
[**2139-7-7**] 01:35PM BLOOD Neuts-80.9* Lymphs-12.4* Monos-5.4
Eos-1.0 Baso-0.3
[**2139-7-7**] 01:35PM BLOOD Glucose-118* UreaN-22* Creat-1.0 Na-140
K-3.6 Cl-101 HCO3-29 AnGap-14
[**2139-7-8**] 04:08AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.8
[**2139-7-7**] 01:35PM BLOOD ALT-13 AST-15 AlkPhos-90 TotBili-0."
1995,"Dilated loops of small bowel are
noted. Multiple air- fluid levels are noted on left lateral
decubitus. Colon is noted to be filled with air throughout the
colon. Overall findings are consistent with ileus.
IMPRESSION: Dilated loops of small bowel with air noted
throughout colon
consistent with ileus. Gastric distension is once again noted in
this study.
ABD US ON [**2139-7-13**]: There is no focal liver lesion identified.
There is no biliary dilatation and the common duct measures .6
cm. The portal vein is patent with hepatopetal flow. Multiple
shadowing gallstones are seen in the gallbladder which is not
overly distended."
1996,"She also received
2 mg morphine, tylenol, ciprofloxacin 500 mg x 1, morphine 2 mg
IV x 1 and haldol 2.5 mg IV x 1. She received 2 liters of IV
with improvement in her heart rate to the high 100s. She was
admitted to the ICU for further management.
.
On the floor, she is unable to clarify further. She says that
she has been having back pain for 2-3 days. The pain is in her
bilateral back. It is worse with movement. It was not associated
with any trauma that she recalls. She denies fevers, chills,
lightheadedness, dizziness, chest pain, difficulty breathing,
nausea, vomiting, abdominal pain, diarrhea, constipation,
dysuria, hematuria, leg pain or swelling."
1997,"Assessment and Plan
80 year old female with a history of multiple sclerosis, alzheimer's
disease, hypertension who presents from a nursing home with one day of
back pain, fever and confusion.
Back pain: in the context of fever and positive blood cultures, we need
to exclude a paraspinal infection. Also consider compression frx
-MRI t/l spine
- Vicodin 5-500 [**Hospital1 **] and Q4H:PRN for pain
-f/u cultures
Will request Dr [**Last Name (STitle) 7737**] to see ( know to him for MS) while she is in
house
Possible UTI:
-f/u urine cx
-covered by vanco + CTX for now
Tachycardia:
-w/ some R-sided prominence on CXR and loud S2 w/ bounding JVP will
check echo today
remainder of plan as per housestaff note
ICU Care
Nutrition:
Comments: po diet
Glycemic Control: Blood sugar well controlled
Lines:
20 Gauge - [**2139-7-8**] 02:01 AM
18 Gauge - [**2139-7-8**] 02:03 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: Not indicated
VAP: HOB elevation
Comments:
Communication: Comments:
Code status: DNR / DNI
Disposition :Transfer to floor
Total time spent: 35 minutes"
1998,"7
C (99.8
Tcurrent: 37
C (98.6
HR: 81 (78 - 93) bpm
BP: 130/58(77) {96/49(61) - 130/73(83)} mmHg
RR: 18 (13 - 18) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Total In:
3,410 mL
PO:
160 mL
TF:
IVF:
250 mL
Blood products:
Total out:
0 mL
265 mL
Urine:
265 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,145 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 96%
ABG: ///27/
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Loud), prominent JV pulsation
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Musculoskeletal: c/o severe back pain with limited exam
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
11."
1999,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
80 year old female with a history of multiple sclerosis, alzheimer's
disease, hypertension who presents from a nursing home with one day of
back pain, fever and confusion.
24 Hour Events: 2/2 blood cultures positive for GPC
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefipime - [**2139-7-8**] 12:00 AM
Vancomycin - [**2139-7-8**] 01:00 AM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2139-7-8**] 06:00 AM
Other medications:
vancomycin IV, CTX IV, ASA 325, Synthroid, Aricept, CaHCO3, Colace,
Namenda, Simvastatin, Thiamine, MVI, Folate, Cymbalta
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2139-7-8**] 09:37 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2000,"3 g/dL
309 K/uL
120 mg/dL
0.7 mg/dL
27 mEq/L
3.6 mEq/L
14 mg/dL
105 mEq/L
140 mEq/L
34.8 %
10.9 K/uL
[image002.jpg]
[**2139-7-8**] 04:08 AM
WBC
10.9
Hct
34.8
Plt
309
Cr
0.7
Glucose
120
Other labs: Differential-Neuts:80.9%, Lactic Acid:1.5 mmol/L, Ca++:8.0
mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL
Imaging: Imaging: CTA (wetread): equivocal subsegmental pulmonary
embolism in a right upper lobe branch (3:38, 402b:54) may reflect
volume averaging artifact."
2001,"no large PE. bibasilar atlectesis. no acute
aortic pathology.
CXR Portable: Cardiac size is top limits of normal. The aorta is
tortuous with aortic knob calcifications redemonstrated. Aside from
minimal subsegmental atelectasis in the left lower lobe, the lungs are
clear without focal consolidation. No pleural effusion or pneumothorax
is seen. The pulmonary vascularity is normal. The osseous structures
are unremarkable.
Microbiology: Microbiology: UA trace positive, culture pending, [**12-26**]
blood cx + for GPCs in clusters
ECG: ECG: probable sinus tachycardia versus regular SVT at 148,
borderline left axis, borderline prolonged QTc at 470, no St segment
elevation or depression, compared with prior dated [**2138-2-25**] the rate is
faster."
2002,"- continue aspirin 325 mg daily
Hyperlipidemia
- Simvastatin 40 mg dialy
Osteoporosis:
- continue calcium and vitamin D
Hypothyroidism
- Continue levothyroxine 125 mcg daily
Depression:
- Cymbalta 30 mg daily
Dementia:
- Namenda 10 mg [**Hospital1 **]
- Aricept 10 mg QHS
FEN: No IVF, replete electrolytes, regular diet
Prophylaxis: Subutaneous heparin
Access: peripherals
Code: DNR/DNI (discussed with nursing home)
Communication: Patient, [**Name (NI) 313**] [**Last Name (NamePattern1) 7714**] [**Telephone/Fax (1) 7715**] (temporary legal
guardian)
Disposition: pending clinical improvement
ICU Care
Nutrition:
Glycemic Control: Blood sugar well controlled
Lines:
20 Gauge - [**2139-7-8**] 02:01 AM
18 Gauge - [**2139-7-8**] 02:03 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)
Stress ulcer: Not indicated
VAP:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: DNR / DNI
Disposition: ICU"
2003,"[**Month (only) 8**] be related to
urinary tract infection. Blood and urine cultures pending. Only
localizing symptom is back pain, epigastric pain on exam.
- LFTs, lipase pending
- trend fever curve
- ciprofloxacin for postiive UA
- consider additional abdominal or spine imaging if clinical course
worsens
Tachycardia: Unable to identify clear p waves but regular rhythm. Now
resolved with IVF. Associated with fevers.
- IVF for tachycardia
Positive Urinalysis: Trace positive, culture pending. Given back
pain, possible altered mental status will treat pending culture data.
- ciprofloxacin day [**12-31**]
- follow urine culture
Coronary Artery Disease: Details unclear. [**Name2 (NI) **] ischemic changes on EKG."
2004,"Chief Complaint: Back Pain
HPI:
This is an 80 year old female with a history of multiple sclerosis,
alzheimer's disease, hypertension who presents from a nursing home with
one day of back pain. Per staff at her nursing home she was in her
usual state of health until the day prior to presentation when she
began to complain of back pain. She was unable to clarify further.
Her temperature was 100.4 with blood pressure 162/82. She received
vicodin and tylenol without improvement. At baseline she is alert,
oriented but does not ambulate. She is able to eat by herself but is
incontinent of urine and stools."
2005,"She was transferred to [**Hospital3 389**]
for further management.
In the ED, initial vs were: T: 98.0 P: 90 BP: 104/69 R: 16 O2 sat: 92%
on RA. She became tachycardic to the 140s (sinus tachycardia) with
stable blood pressures and spiked a fever to 101.5. Her antibiotics
were broadened to vancomycin and cefepime and she had a CT of the chest
with contrast which was not timed appropriately and did not show a
large pulmonary embolism but could not rule out a small pulmonary
embolism. She also received 2 mg morphine, tylenol, ciprofloxacin 500
mg x 1, morphine 2 mg IV x 1 and haldol 2."
2006,"5 mg Q6H:PRN
Prochlorperazine 10 mg Q6H:PRN
Tylenol 650 mg PRN
Milk of Magnesia 400 mg daily:PRN
Bisacodyl 10 mg PR daily:PRN
Fleets enema PRN
Senna PRN
Calcium 500 mg TId
Detrol 4 mg QHS
Aricept 10 mg QHS
Levothyroxine 125 mcg daily
Colace
Aspirin 325 mg daily
Vitamin D 50,000 q month
Past medical history:
Family history:
Social History:
Multiple sclerosis
Coronary Artery Disease
Hypertension
Hyperlipidemia
Osteoporosis
Hypothyroidism
Depression
Chronic sinusitis and allergic rhinitis.
Endometriosis, status post laparoscopy.
Dysfunctional uterine bleeding
Coronary artery disease in brother. Possible MS in a deceased sister.
Occupation: Retired, used to work in medical office."
2007,"No pleural
effusion or pneumothorax is seen. The pulmonary vascularity is normal.
The osseous structures are unremarkable.
Microbiology: UA trace positive, culture pending
Blood cultures pending
ECG: probable sinus tachycardia versus regular SVT at 148, borderline
left axis, borderline prolonged QTc at 470, no St segment elevation or
depression, compared with prior dated [**2138-2-25**] the rate is faster.
Assessment and Plan
Assessment and Plan: 80 year old female with a history of multiple
sclerosis, alzheimer's disease, hypertension who presents from a
nursing home with one day of back pain, fever and confusion.
.
Back Pain: Etiology unclear. Exam notable for bilateral paraspinal
tenderness with normal strength and sensation on exam."
2008,"5 mg IV x 1. She received 2
liters of IV with improvement in her heart rate to the high 100s. She
was admitted to the ICU for further management.
On the floor, she is unable to clarify further. She says that she has
been having back pain for 2-3 days. The pain is in her bilateral
back. It is worse with movement. It was not associated with any
trauma that she recalls. She denies fevers, chills, lightheadedness,
dizziness, chest pain, difficulty breathing, nausea, vomiting,
abdominal pain, diarrhea, constipation, dysuria, hematuria, leg pain or
swelling.
Patient admitted from: [**Hospital1 5**] ER
History obtained from [**Hospital 19**] Medical records
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefipime - [**2139-7-8**] 12:00 AM
Vancomycin - [**2139-7-8**] 01:00 AM
Infusions:
Other ICU medications:
Other medications:
Home Medications:
Cymbalta 30 mg daily
Folic Acid 1 mg daily
Loratadine 10 mg daily
Multivitamin
Thiamine 100mg daily
Simvastatin 40 mg dialy
Vicodin 5-500 [**Hospital1 **] and Q4H:PRN
Namenda 10 mg [**Hospital1 **]
Lorazepam 0."
2009,"7
C (99.8
Tcurrent: 37.7
C (99.8
HR: 89 (89 - 93) bpm
BP: 109/58(70) {109/58(70) - 114/73(83)} mmHg
RR: 16 (14 - 17) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Total In:
3,250 mL
PO:
TF:
IVF:
250 mL
Blood products:
Total out:
0 mL
50 mL
Urine:
50 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,200 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 95%
Physical Examination
Vitals: T: 99.8 BP: 109/68 P: 89 R: 16 O2: 95% on RA
General: Alert, oriented to person and hospital, not [**Hospital1 5**], date or
year, speech slurred (noted in previous neurologic exams)
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, tender in epigastric region and right upper quadrant,
non-distended, bowel sounds present, no rebound tenderness or guarding,
no organomegaly
GU: foley draining [**Location (un) 257**] urine (received pyridium in ER)
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema,
excoriations throughout
Back: Pain in paraspinal region bilaterally, no flank pain
Neurologic: CN II-XII tested and intact, strength 5/5 throughout,
sensation intact across all dermatomes, reflexes 2+ and symmetric,
unable to assess gait
Labs / Radiology
338
118
1."
2010,"0
22
29
101
3.6
140
37.1
12.2
[image002.jpg]
Other labs: Differential-Neuts:80.9, Lymph:12.4, Mono:5.4, Eos:1.0,
Lactic Acid:1.5 mmol/L
Imaging: CTA (wetread): equivocal subsegmental pulmonary embolism in a
right upper lobe branch (3:38, 402b:54) may reflect volume averaging
artifact. no large PE. bibasilar atlectesis. no acute aortic pathology.
CXR Portable: Cardiac size is top limits of normal. The aorta is
tortuous with aortic knob calcifications
redemonstrated. Aside from minimal subsegmental atelectasis in the left
lower lobe, the lungs are clear without focal consolidation."
2011,"Spiked a
temperature in the emergency room with associated tachycardia.
Although urinarlysis is positive, bilateral nature makes pyelonephritis
unlikely. Most concerning etiology of back pain would be epidural
abscess but lack of findings on neurologic exam and significant
paraspinal muscle tenderness makes this less likely. Most likely
etiology would be musculoskeletal back pain but this is a diagnosis of
exclusion. Given history of osteoporosis, compression fracture is
possible but preliminarily no evidence on CT chest.
- Vicodin 5-500 [**Hospital1 **] and Q4H:PRN for pain
- LFTs, lipase
- blood and urine cultures pending
- ciprofloxacin for positive urinalysis
- consider lumbar/thoracic spine films in AM to assess for compression
fracture
- if persistent fevers or change in neurologic exam will need to
consider MRI to assess for epidural abscess
Low Grade Fevers: As above, unclear etiology."
2012,"Drugs: None
Tobacco: Remote, < 5 pack years
Alcohol: Remote
Other: Lives in nursing home
Review of systems:
Constitutional: Fever
Ear, Nose, Throat: No(t) OG / NG tube
Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,
Tachycardia, No(t) Orthopnea
Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze
Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, No(t)
Diarrhea, No(t) Constipation
Genitourinary: No(t) Dysuria, Foley
Integumentary (skin): No(t) Jaundice, No(t) Rash
Endocrine: No(t) Hyperglycemia, History of thyroid disease
Heme / Lymph: No(t) Anemia
Neurologic: No(t) Headache
Allergy / Immunology: No(t) Immunocompromised
Pain: [**2-25**] Mild
Pain location: Diffuse back pain
Flowsheet Data as of [**2139-7-8**] 03:32 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37."
2013,"Admission Date: [**2120-1-25**] Discharge Date: [**2120-2-1**]
Date of Birth: [**2053-1-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypoxic respiratory distress
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
67yoM w/ h/o squamous cell esophageal cancer s/p XRT with a
gastric pull-up in [**2104**] w/ subsequent tracheo-esophageal fistula
and eventual tracheostomy/ PEG tube placement who presents from
rehab with respiratory distress. Apparently pt vomiting earlier
in the day, then noted to desaturate down to 70s off vent and
became apneic (up until this point pt had been doing well off
the vent per report)."
2014,"6 HR88 BP106/76 PO288% (though
noted to be difficult to get an accurate sat). CXR showed right
upper lobe opacity concerning for PNA, pulmonary vascular
congestion and small b/l pleural effusions. EKG was reportedly
unremarkable. ABG was 7.41/38/184/25 on pressure support
ventilation. Remarkable labs include lactate 2.7, WBC 13.7 with
94% PMN no bands, Na 147. Patient was given levaquin in the ED
(ordered also for CTX and levaquin, but not yet received).
Patient was noted to gradually drop systolic pressure to 70's.
Felt to be mentating well in the ED, though orientation was not
assessed."
2015,"Does not
recall vomiting.
Past Medical History:
-Hypertension
-Hypothyroidism
-Prostate cancer s/p XRT
-h/o esophageal CA s/p XRT with 3-hole esohagectomy in [**2104**] at
[**Hospital1 112**]. Recently hospitalized at [**Hospital1 18**] for PNA and found to have
stricture near cricopharyngeus, with evidence of TEF. EGD showed
no cancer recurrence. J-tube placed [**4-/2119**]
-Small bowel obstruction
-Cognitive deficit NOS vs limited safety awareness
-Orthostatic hypotension - hospitalization [**1-/2119**] after fall
-DVT of the L subclavian and L axillary vein
-R hip fracture s/p ORIF by Dr. [**Last Name (STitle) **] @ [**Hospital1 112**]
-RLL PNA [**1-11**], treated with levofloxacin
-multiple stab wounds to the abdomen in the [**2079**]
-right sided PTX after bronchoscopy s/p CT placement
-Tonsillectomy and adenoidectomy
-R wrist and hand surgery
-large bowel obstruction in [**2119**] s/p exploratory laparotomy with
reduction of a paraesophageal hernia and was left with an open
abdomen due to edema and bowel distention s/p closure on [**2119-10-17**]"
2016,"Social History:
Originally from [**State 9512**]. He has three daughters. One daughter
lives in [**State 4260**], another is in [**Name (NI) 86**], [**First Name3 (LF) 2184**] who is very involved.
Reports he recently stopped smoking. Although he has a history
of binge drinking, he reports he hasn't drank since [**Month (only) 1096**] of
[**2118**]. Retired construction worker and plumber.
Family History:
Mother died of a blood clot. Doesn't know what his father died
of. Sister died of obesity and ""fat around her heart""
Physical Exam:
On admission to the MICU:
Vitals: T 101 HR 77 BP 72/45 18 97% on RA
-low tidal volumes, elevated airway pressures, BP's in 70's
systolic, and saturations in 70's to 80's
General: Alert, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: trached
Lungs: Upper airway sounds heard throughout
CV: Tachycardic rate, regular
Abdomen: scaphoid, soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, PEG in place, well healing
abdominal wound with pink granulation tissue
GU: no foley
Ext: warm, well perfused
."
2017,"Brief Hospital Course:
67yoM h/o squamous cell esophageal cancer s/p XRT with a gastric
pull-up in [**2104**] w/ subsequent tracheo-esophageal fistula and
eventual tracheostomy/ PEG tube placement who presents from
rehab with respiratory distress.
.
# Shock: Pt with BP in 70s/40s on arrival to the MICU and
febrile to 101. Lactate 2.7 -> 3.2 -> 1.8 in first 24 hours with
~7-8L of fluid. Was initially on levophed but this was weaned by
hospital day #2. Antibiotics were started on arrival to the ICU
- were eventually broadened to meropenem/linezolid as patient
had persistent hypotension."
2018,"Antibiotics were
administered as above out of concern for RUL pneumonia. The
patient's trach was changed on HD #2 because of problems with
ongoing cuffleaks. The original trach was found to have a
defective balloon. The patient's tidal volumes improved with new
trach. The patient remained stable from a respiratory standpoint
for the rest of his MICU stay and tolerated trach mask; he was
satting in the high 90s on 50% trach mask prior to discharge.
.
# TE fistula: Pt is s/p fibrin injection [**2120-1-22**]. Patient with
known TEF s/p recent injection. On HD #5, IP performed a
bronchoscopy, which showed a partially closed TE fistula."
2019,"care was also consulted. Patient complained of abdominal
pain and received prn IV morphine. Abd exam was benign.
Thoracics recommended a barium swallow through the j tube with
small bowel follow through showed no abnormalities. Given this,
tube feeds were re-started on [**1-31**]. Thoracics will not attempt
to replace the j-tube given his complicated anatomy.
.
# Anemia: The patient had a Hct of 20.5 on ICU day #2. Stool was
guaiac negative. He was transfused 2U PRBC with appropriate
response. Iron studies showed elevated ferritin (likely as acute
phase reactant). His Hct stayed stable ~27 to 28 for the
remainder of his hospitalization."
2020,".
# Hypernatremia - Na in the 145-150 range; stable over recent
admissions. TF and free water flushes were utilized. Na was
trended daily and improved to the normal range for the remainder
of his admission.
.
# Prophylaxis was with subcutaneous heparin. Communication was
with the patient and Daughter [**First Name8 (NamePattern2) 2184**] [**Known lastname 93756**] [**Telephone/Fax (1) 93877**]. He
remained full code during this admission.
Medications on Admission:
1. kayexelate MWF
2. citalopram 20 mg Tablet daily
3. Prilosec 20mg daily
4. ergocalciferol (vitamin D2) 8,000 unit/mL Drops [**Telephone/Fax (1) **]: 5000
units weekly
5. combivent/albuterol nebs
6."
2021,"5. acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO every [**5-9**]
hours.
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
7. oxycodone 20 mg/mL Concentrate [**Last Name (STitle) **]: 2.5-5 mg PO every [**7-11**]
hours as needed for pain.
8. acetaminophen 325 mg/10.15 mL Suspension [**Month/Day (3) **]: 325-650 mg PO
every 4-6 hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Sepsis
Pneumonia
TE fistula
Anemia
."
2022,"Secondary:
Hypertension
s/p esophageal radiation and gastric pull-up surgery
Discharge Condition:
Mental Status: Clear and coherent --> pt did not use speaking
valve but would communicate by writing and mouthing words
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Dear Mr. [**Known lastname 93756**],
You were admitted for respiratory distress and with low blood
pressure. We treated you with IV fluids, blood
pressure-supporting medications, and antibiotics and you
improved. You were initially on a breathing machine to help
support your lungs. We believe the source of the low blood
pressure was an infection in your lungs."
2023,"You were able to
breathe well with the trach mask in place prior to your
discharge. The pulmonary doctors also looked to see if the
abnormal connection between your trachea and esophagus was
healed - they found that it was partially healed. Finally, we
had the thoracic surgeons evaluate your J-tube. A study was
performed, which showed that the J-tube was working normally and
that you had normal bowel function. You did have leakage around
the J-tube but the surgeons thought it would be too dangerous to
attempt to fix.
.
We made the following changes to your medications:
We STOPPED Kayexelate because your potassium levels were normal
We STARTED oxycodone 2."
2024,"9 Cl-102 HCO3-30 AnGap-10
[**2120-2-1**] 03:33AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.4*
[**2120-1-26**] 02:27AM BLOOD calTIBC-183* Ferritn-687* TRF-141*
.
SB follow-through:
IMPRESSION:
Within the limits of a small bowel follow-through, there are no
fistulae or
strictures identified. Transit time through the small intestine
is within
expected (normal) range.
.
CXR:
IMPRESSION:
1. Increased right lower lobe density, which may either
represent fissural
fluid or consolidation.
2. Stable bilateral loculated pleural effusions.
3. Stable left lower lobe atelectasis.
4. Mild worsening pulmonary edema.
5. Contrast opacification of the large bowel with further small
bowel
opacification, if an enteroenteric fistula is suspect, further
evaluation with
fluroscopy or an abdominal radiograph is suggested to localize
the small bowel
loop and assess a potential fistulous communication with large
bowel."
2025,"The
patient had 2 episodes of bilious contents being suctioned from
his trach. Thoracic surgery was consulted and attempted to place
an NG tube endoscopically; the attempt was not successful given
his complicated anatomy and will not attempt again. IP has no
plans to attempt another injection for pts TE fistula.
.
# J tube leakage: The patient has had a chronic problem with his
jtube leaking and has had it changed 3 times in the recent past.
The patient had continued profuse leakage while in the MICU. His
tube feeds were stopped and PPN was started. Surgery was
consulted who recommended a KUB with gastrografin, which was
normal."
2026,"No UOP as per ED resident. Received 2L IVF. On the way
to the ICU, levophed gtt was started for hypotension.
.
On arrival to ICU, patient noted to have low tidal volumes,
elevated airway pressures, BP's in 70's systolic, and
saturations in 70's to 80's. With anesthesia and RT at bedside,
trach was repositioned (likely had been auto-PEEPing). Bronch
performed which showed trach well-seated in trachea. Currently
pt states breathing more comfortable, c/o pain at site of
abdominal wound. Denies CP, states intermittent diarrhea. States
he doesn't remember what brought him to the hospital."
2027,"He has been placed back on the vent since
the desaturations and is noted to be tachypnic.
.
Initially presented on [**2119-4-13**] with complaints of difficulty
swallowing and productive cough and who was found to have a
right base pneumonia. A failed swallow evaluation prompted a CT
neck that revealed a tracheoesophageal fistula just below the
level of the thoracic inlet, confirmed via barium swallow, then
at bronchoscopy. TE fistula determined to be benign by
pathological exam of biopsies. After J-tube placement for
nutrition support, the TE fistula was repaired and esophageal
stricture resected on [**2119-8-3**]."
2028,"7* RBC-3.30* Hgb-9.2* Hct-29.1*
MCV-88 MCH-28.0 MCHC-31.7 RDW-17.7* Plt Ct-422
[**2120-1-25**] 03:05AM BLOOD Neuts-94.0* Lymphs-3.9* Monos-1.6*
Eos-0.3 Baso-0.2
[**2120-1-25**] 03:05AM BLOOD PT-14.4* PTT-33.6 INR(PT)-1.3*
[**2120-1-25**] 03:05AM BLOOD Glucose-125* UreaN-31* Creat-1.3* Na-147*
K-5.9* Cl-112* HCO3-25 AnGap-16
[**2120-1-26**] 02:27AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.4* Iron-14*
[**2120-1-25**] 03:05AM BLOOD TSH-27*
[**2120-1-25**] 03:05AM BLOOD Free T4-0."
2029,"levothyroxine 125 mcg Tablet *** TSH [**2120-1-16**] 16***** [**Month (only) 116**]
need adjustment per last DC summary.
7. Tylenol 325 mg Tablet [**Month (only) **]: 1-2 Tablets PO every 4-6 hrs PRN
pain
Discharge Medications:
1. citalopram 20 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily).
2. ergocalciferol (vitamin D2) 8,000 unit/mL Drops [**Month (only) **]: 5000
(5000) Units PO once a week.
3. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Month (only) **]: [**2-4**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
4. levothyroxine 125 mcg Capsule [**Month/Day (2) **]: One (1) Capsule PO once a
day."
2030,"On discharge,
O2 sats 97% on 50% trach mask; equal breath sounds bilaterally
J tube site with mild erythema around site
abd wound with granulation tissue, appears to be healthy and
healing
Pertinent Results:
Admission Labs:
.
Images:
CXR [**1-25**]:
1. Increased right upper lobe opacity concerning for PNA.
2. Pulmonary vascular congestion with mild interstitial edema.
3. Small bilateral pleural effusions.
.
EKG: Rate 138, LAD appears to be sinus but unclear if
consistent P waves given poor baseline. Again difficult to
assess but ? rate related ST depressions in V4-V6 in lateral
leads.
.
[**2120-1-25**] 03:05AM BLOOD WBC-13."
2031,"CXR showed new RUL infiltrate
concerning for pneumonia. U/A looked infected. Sputum culture
grew morganella morganii, sensitive to meropenem - identical
culture to earlier admission. Patient's lactate normalized and
he was weaned off pressors. He was continued on meropenem for
g-negative rods in sputum and finished his course on [**2-1**].
.
# Hypoxemic respiratory distress: Given timing of hypoxic
respiratory distress, likely had aspiration event most
immediately. On arrival to the floor, patient was seen by
anesthesia and a bronchoscopy was performed out of concern for
trach displacement. The trach was visualized in the correct
location. The patient was initially ventilated on A-C, but this
was weaned and on ICU day #2 was on PSV."
2032,"This was c/b left vocal cord
paralysis after the operation (had to remove left recurrent
laryngeal nerve), and required tracheostomy from respiratory
failure after anastomotic incompetence on [**2119-8-18**]. Since
discharge after an admission [**2119-10-3**] - [**2119-11-8**] for large bowel
obstruction, he has been weaned from the ventilator to trach
collar with humidified air. She continued to have a TEF and
underwent a rigid bronchoscopy with fibrin injection into the
fistula on [**2120-1-22**]. Apparently the fibrin clotted the fistula
and he was admitted overnight for monitoring, though no other
complications per OMR.
.
In the ED, initial vs were: T98."
2033,"5-5 mg (liquid) every 6-8 hours as needed
for abdominal pain
We STOPPED Prilosec
We STARTED Lansoprazole (rapid dissolve tablet) 30 mg once per
day
.
You should continue to see the medical doctor at your rehab
facility. Your follow-up appointments are listed below.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2120-2-20**] at 9:45 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2120-2-20**] at 10:30 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage"
2034,"98
[**2120-1-25**] 03:51AM BLOOD Type-ART pO2-184* pCO2-38 pH-7.41
calTCO2-25 Base XS-0
[**2120-1-25**] 03:10AM BLOOD Lactate-2.7* K-4.3
[**2120-1-25**] 12:20PM BLOOD Lactate-3.2*
[**2120-1-25**] 03:08PM BLOOD Lactate-1.8
.
Discharge labs:
[**2120-2-1**] 03:33AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.0* Hct-30.8*
MCV-87 MCH-28.3 MCHC-32.6 RDW-17.2* Plt Ct-222
[**2120-2-1**] 03:33AM BLOOD Glucose-91 UreaN-11 Creat-0.5 Na-138
K-3."
2035,"Admission Date: [**2135-6-28**] Discharge Date: [**2135-7-1**]
Date of Birth: [**2089-8-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
minimally invasive coronary artery bypass graft [**6-28**]
History of Present Illness:
45 year old white male with LAD disease.
Past Medical History:
This patient has known LAD disease and has opted for minimally
invasive bypass grafting.
hyperlipidemia
hypertension
Social History:
nonsmoker
Family History:
non contributory.
Physical Exam:
Admission:
On physical examination, his heart rate is 60."
2036,"Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease
s/p minimally invasive coronary artery bypass graft
hypertension
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks ([**Telephone/Fax (1) 4775**])
please call for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2135-7-1**]"
2037,"0 Na-140
K-3.8 Cl-107 HCO3-27 AnGap-10
Brief Hospital Course:
Following admission he underwent minimally invasive LAD grafting
with endoscopic LIMA takedown. He tolerated the procedure well
and was extubated in the Operating Room.
His ICU course was uneventful and he was given Toradol for
analgesia. Plavix was given due to the off-pump nature of the
operation. His CT was removed on POD 1 and he was transferred
to the floor. The physical therapy service was consulted for
assistance with post-operative strength and mobilitiy. Beta
blocker was started and the patient was gently diuresed toward
his preoperative weight."
2038,"Disp:*60 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for off pump.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours). Tablet(s)
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust."
2039,"Post-operative course was uneventful
and the patient was discharged home with VNA on POD 3.
Medications on Admission:
crestor 40mg/D
lopressor 50mg [**Hospital1 **]
ASA 325 mg/D
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain."
2040,"Neurologically, he
is grossly intact and 2+ bilateral femoral, DP, PT, and radial
Pertinent Results:
[**2135-6-29**] 12:19AM BLOOD WBC-11.9* RBC-3.99* Hgb-12.0* Hct-35.9*
MCV-90 MCH-30.1 MCHC-33.4 RDW-12.6 Plt Ct-178
[**2135-6-29**] 12:19AM BLOOD Glucose-162* UreaN-22* Creat-1.0 Na-138
K-4.0 Cl-106 HCO3-23 AnGap-13
[**2135-6-30**] 05:44AM BLOOD WBC-9.6 RBC-3.70* Hgb-11.5* Hct-32.9*
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.0 Plt Ct-174
[**2135-6-30**] 05:44AM BLOOD Glucose-130* UreaN-16 Creat-1."
2041,"Respiratory rate
was 14. Blood pressure taken in the right arm is 122/80. He is
5' 11"" inches tall. Weighing 165 lbs. He is well developed,
well nourished, and in no apparent distress. Skin is
unremarkable, clean, dry, and intact. His EOMs are intact.
Pupils are equally, round, and reactive to light. His
oropharynx is benign. Neck is supple with full range of motion.
No JVD or carotid bruits are appreciated. Lungs are clear
bilaterally. Heart is regular in rate and rhythm without
murmur. Abdomen is soft, nontender, nondistended with positive
bowel sounds. Extremities are warm and well perfused without
any peripheral edema or varicosities noted."
2042,"CVICU
HPI:
HD2
[**6-29**] POD 1
45M s/p OP CABGx1(LIMA-LAD)[**6-28**]
EF:60% Cr: 1.1 Wt:77kg HgA1c:
PMH:hyperlipidemia,CAD
[**Last Name (un) **]:ASA 325mg/D,Pravastatin 80mg/D,Lopressor 50mg [**Hospital1 **]
[**6-29**]-BB and transfer
Current medications:
4. Acetaminophen 5. Aspirin EC 6. Calcium Gluconate 7. CefazoLIN 8.
Clopidogrel
Dextrose 50% Docusate Sodium . Insulin . Ketorolac . Magnesium Sulfate
. Metoclopramide Milk of Magnesia . Morphine Sulfate .
Oxycodone-Acetaminophen . Potassium Chloride . Ranitidine Rosuvastatin
Calcium .
24 Hour Events:
MULTI LUMEN - START [**2135-6-28**] 02:00 PM
ARTERIAL LINE - START [**2135-6-28**] 02:00 PM
OR RECEIVED - At [**2135-6-28**] 02:00 PM
EKG - At [**2135-6-28**] 02:21 PM
MULTI LUMEN - STOP [**2135-6-29**] 06:20 AM
ARTERIAL LINE - STOP [**2135-6-29**] 06:27 AM
Post operative day:
POD#1 - CABG x1 LIMA to LAD, off pump,
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Morphine Sulfate - [**2135-6-28**] 05:00 PM
Other medications:
Flowsheet Data as of [**2135-6-29**] 09:22 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**37**] a."
2043,"36/47/162/23/-1
PaO2 / FiO2: 162
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : ), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
178 K/uL
12.0 g/dL
122
1.0 mg/dL
23 mEq/L
4."
2044,"0 mEq/L
22 mg/dL
106 mEq/L
138 mEq/L
35.9 %
11.9 K/uL
[image002.jpg]
[**2135-6-28**] 01:01 PM
[**2135-6-28**] 02:13 PM
[**2135-6-28**] 02:21 PM
[**2135-6-28**] 04:27 PM
[**2135-6-28**] 05:30 PM
[**2135-6-28**] 06:30 PM
[**2135-6-28**] 10:00 PM
[**2135-6-29**] 12:19 AM
[**2135-6-29**] 02:00 AM
WBC
18.6
11.9
Hct
39
35.8
35.9
Plt
227
178
Creatinine
1.1
1.0
TCO2
26
28
26
Glucose
131
138
114
128
121
131
162
122
Other labs: PT / PTT / INR:14."
2045,"2/27.6/1.2, Lactic Acid:1.5 mmol/L
Imaging: CXR- clear drains out.
Assessment and Plan
CORONARY ARTERY BYPASS GRAFT (CABG)
Assessment and Plan: Stable, ready for floor.
Neurologic: Neuro checks Q: 4 hr, Pain controlled
Cardiovascular: Aspirin, Beta-blocker, Statins
Pulmonary: IS
Gastrointestinal / Abdomen:
Nutrition: Advance diet as tolerated
Renal: Foley, Adequate UO
Hematology:
Endocrine:
Infectious Disease:
Lines / Tubes / Drains: Foley, Chest tube - pleural
Wounds: Dry dressings
Imaging: CXR today
Fluids:
Consults: P.T.
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2135-6-29**] 06:34 AM
Prophylaxis:
DVT:
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status:
Disposition: Transfer to floor"
2046,"m.
Tmax: 37.2
C (98.9
T current: 37.2
C (98.9
HR: 72 (63 - 82) bpm
BP: 119/61(76) {116/61(74) - 123/64(79)} mmHg
RR: 17 (9 - 24) insp/min
SPO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Height: 71 Inch
CVP: 3 (0 - 9) mmHg
Total In:
4,156 mL
743 mL
PO:
600 mL
Tube feeding:
IV Fluid:
3,556 mL
743 mL
Blood products:
Total out:
955 mL
540 mL
Urine:
600 mL
530 mL
NG:
Stool:
Drains:
Balance:
3,201 mL
203 mL
Respiratory support
O2 Delivery Device: None
SPO2: 95%
ABG: 7."
2047,"Admission Date: [**2120-1-10**] Discharge Date: [**2120-1-13**]
Date of Birth: [**2100-8-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Macrodantin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
elective Chiari Malformation
Major Surgical or Invasive Procedure:
craniectomy
History of Present Illness:
The patient came into the hospital for an elective craniectomy
for a Chiari malformation.
Past Medical History:
headaches
Social History:
lives with parents
Family History:
non-contributory
Physical Exam:
Oriented x 3. The patient is full strength in all 4 extremites.
Her sensation in her face and extremities is intact. She does
have some numbness around the back portion of her head."
2048,"There is no evidence of hemorrhage or shift of
normally
midline structures.
Brief Hospital Course:
The patient went to the OR for an elective craniectomy and the
procedure went well with no complications. She was transferred
to the ICU overnight. The patient had a significant amount of
nausea and vomiting for many hours. She also had a significant
amount of pain the first night. After changing her antiemetic
regimen and increasing her pain medication she improved. By the
afternoon of post-op day#1 she was able to be transferred to the
floor. The patient continued to improve and started taking in
liquids on post-op day#2."
2049,"Disp:*90 Tablet(s)* Refills:*0*
5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as
needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Chiari Malformation
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? You must wear your hard collar until you come back to the
office for follow up. You may remove it briefly for showering.
No baths until your sutures are removed.
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending."
2050,"CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office in [**8-10**] days(from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 3 months.
?????? You will need a CT scan of the brain without contrast.
Completed by:[**2120-1-16**]"
2051,"She was voiding on her own and walked
with PT. The patient was safe to be discharged and went home
with her parents on post-op day#3.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for Pain: No driving while on narcotics.
Disp:*60 Tablet(s)* Refills:*0*
4. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day)."
2052,"?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to."
2053,"Pertinent Results:
CT Head [**2120-1-10**]:
FINDINGS: Resection changes at the posterior atlas and inferior
occipital bone at the level of the foramen magnum are noted
without evidence of hemorrhage. There is a large amount of
pneumocephalus which layers along the frontal and temporal lobes
as well as the near the site of occipital resection and brain
stem. There is no evidence of hydrocephalus or shift of normally
midline structures. There is no evidence of infarction. The
cerebellar tonsils are again noted to lie below the level of
the foramen magnum.
IMPRESSION: Post-craniectomy changes include a large amount of
pneumocephalus."
2054,"No
dysmetria. Correct diadokokinesia.
Labs / Radiology
[image002.jpg]
Assessment and Plan
19 yo F with Hx of [**Doctor Last Name 4210**] Chiari I malformation and thoracic
syringomelia, currently s/p elective decompressive suboccipital
craniotomy.
Assessment And Plan:
Neurologic: Alert. Oriented. Refering headache. Will continue w/
dilaudid PCA, robaxan. CT tonight. Monitor SBP, goal < 160.
Cardiovascular: Hemodynamically stable. Not on pressors. Hydralazine
prn to keep SBP<160.
Pulmonary: Sat 100% with 4L NC. Will monitor.
Gastrointestinal: NPO for now, will start diet after CT scan results.
Renal: Will check chemistry and lytes.
Hematology: Stable with HCT 42 / Hgb 14.1 on OR ABG, EBL during case
only 150 cc and pt hemodynamically stable
will check repeat CBC in
AM.
Infectious Disease: Will continue with Vanc and Gent for prophylaxis.
Endocrine: no issues
Fluids: NS w/ K supps @ 85 cc/hr
Electrolytes: check chemistries, replete lytes prn
Nutrition: Currently NPO. Will advance diet as tolerated.
General:
ICU Care
Nutrition:
Glycemic Control:
Lines: Foley, 2 PIVs
Arterial Line - [**2120-1-10**] 04:00 PM
18 Gauge - [**2120-1-10**] 04:00 PM
Prophylaxis:
DVT: Heparin SQ, boots
Stress ulcer: PPI for now, d/c when taking po
VAP:
Comments:
Communication: Comments:
Code status: full
Disposition: ICU
Total time spent: 32 minutes"
2055,"7
C (98.1
Tcurrent: 36.7
C (98.1
HR: 80 (80 - 92) bpm
BP: 112/67(86) {112/67(86) - 118/71(92)} mmHg
RR: 8 (7 - 8) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Total In:
994 mL
PO:
TF:
IVF:
94 mL
Blood products:
900 mL
Total out:
0 mL
1,420 mL
Urine:
120 mL
NG:
Stool:
Drains:
Balance:
0 mL
-426 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 99%
ABG: ////
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL, Non icteric
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): time, space and person, Movement: Purposeful,
No(t) Sedated, No(t) Paralyzed, Tone: Normal, Strengh [**5-6**]."
2056,"Chief Complaint: Recurrent episodes of headaches,cranial nerve
dysfunction, and dysesthesias
HPI:
[**Known firstname 549**] 19 yo F with Hx of [**Doctor Last Name 4210**] Chiari I malformation s/p elective
decompressive posterior craniectomy. Pt initially evaluated for
development of a patch of pain (hyperpathia) and numbness in
approximately the left T5 or T6 dermatome region posteriorly, 1 mo ago.
Further involvement of V2 and V3 trigeminal branches was present,
mainly in the onset of bifrontal and throbbing longstanding headaches.
MRI finally confirmed AC 1 malformation, tonsils 8 mm below F magnum
and syringomyelia with syrinx cavities at T5, T7 and T8-T11 levels."
2057,"Based on recurrent episodes of headaches,cranial nerve dysfunction, and
dysesthesias, pt underwent elective repair.
Post operative day:
POD#0 - Decompressive suboccipital craniectomy for A.Chiari
malformation Type I
Allergies:
Macrodantin (Oral) (Nitrofurantoin Macrocrystal)
Rash;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Past medical history:
Family / Social history:
s/p tonsillectomy, bilateral reimplanted ureters forurinary reflux, hxo
tick bites with negative lyme serology ([**2119-10-11**] at [**Hospital1 19**]).
Social: College student. Originally from CT.
Flowsheet Data as of [**2120-1-10**] 05:20 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
2058,"Admission Date: [**2137-5-6**] Discharge Date: [**2137-5-13**]
Date of Birth: [**2052-1-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Aortic valve replacement (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve) [**2137-5-7**]
History of Present Illness:
85 year old female with known history of heart murmur. She was
recently referred to Dr. [**Last Name (STitle) **] for cardiac evaluation. An
echocardiogram in [**Month (only) 958**] revealed left ventricular hypertrophy
and
severe aortic stenosis. She is symptomatic with dyspnea on
exertion and 3 pillow orthopnea however her symptoms vary in the
sense that she often has days where she is very active without
limitation or symptoms."
2059,"Given the severity of her disease, she
has been referred for surgical management. Cardiac cath was
performed prior to admission. Coronary arteries are
without significant disease.
Past Medical History:
Aortic stenosis
Hyperlipidemia
Hypertension
Right renal cyst
Asthma
Past Surgical History:
s/p Laparoscopic cholecystectomy [**39**] yrs ago
Social History:
Lives with: Lives with son.
Contact: Phone #
Occupation: Retired
Cigarettes: Smoked no [] yes [X] last cigarette - 60 yrs ago
Other Tobacco use: Denies
ETOH: < 1 drink/week [] [**1-8**] drinks/week [X] >8 drinks/week []
Illicit drug use: Denies
Family History:
One sister with CVA in her 70s
Physical Exam:
Pulse: 84 Resp: 16 O2 sat: 98%
B/P Right: 120/70 Left:
Height: 5'3."
2060,"12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
13. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO bid prn () as needed for secretions.
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day: &
reevaluate weight & edema.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Aortic Stenosis
Hyperlipidemia
Hypertension
Right renal cyst
Asthma
Past Surgical History:
s/p Laparoscopic cholecystectomy [**39**] yrs ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage"
2061,"Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] 07/11/12/12 at 1:30pm
Cardiologist: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**2137-5-24**] 2:45p
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) 1877**],[**First Name3 (LF) 539**] E. [**Telephone/Fax (1) 4475**] in [**3-7**] 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**
Completed by:[**2137-5-13**]"
2062,"Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
2. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily)."
2063,"5"" Weight: 169 lbs
General: Well-developed elderly female appears less than stated
age
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 [X] grade 3/6 systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema [] _trace__
Varicosities: Large varicosities on both legs
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: cath site Left: 2+
Carotid Bruit - Right/Left: transmitted murmur"
2064,"Pertinent Results:
[**2137-5-7**] Intra-op TEE:
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No spontaneous echo contrast is seen
in the body of the right atrium. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50-55%). The right ventricular cavity is mildly dilated
with normal free wall contractility. There are simple atheroma
in the ascending aorta. There are complex (>4mm) atheroma in the
descending thoracic aorta."
2065,"There is severe aortic valve stenosis
(valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is
moderate thickening of the mitral valve chordae. There is no
pericardial effusion.
POST CPB:
1.Preserved [**Hospital1 **]-ventricular systolic function
2. A bioprosthetic valve is identified in aortic position. Well
seated and good leaflet excursion. Np AI. Peak transvslvular
gradient of 45 mm Hg, with carfiac output = 6.5 liters/min.
3. MR is now mild.
4. No other change
[**2137-5-13**] 04:53AM BLOOD WBC-8.4 RBC-3.06* Hgb-9."
2066,"6 Na-140
K-3.4 Cl-102 HCO3-25 AnGap-16
Brief Hospital Course:
The patient was brought to the Operating Room on [**2137-5-7**] where
she underwent an Aortic Valve Replacement (#21 mm Biocor apical
tissue valve)with Dr. [**Last Name (STitle) **]. 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, Statin, aspirin, and
diuresis was initiated and the patient was gently diuresed
toward her preoperative weight."
2067,"6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day)."
2068,"8* Hct-29.3*
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.5 Plt Ct-219
[**2137-5-6**] 01:00PM BLOOD WBC-6.5 RBC-4.13* Hgb-13.5 Hct-39.2
MCV-95 MCH-32.7* MCHC-34.5 RDW-12.8 Plt Ct-192
[**2137-5-7**] 12:30PM BLOOD PT-12.9* PTT-29.6 INR(PT)-1.2*
[**2137-5-6**] 01:00PM BLOOD PT-11.9 INR(PT)-1.1
[**2137-5-13**] 04:53AM BLOOD Glucose-96 UreaN-19 Creat-0.6 Na-141
K-4.4 Cl-99 HCO3-33* AnGap-13
[**2137-5-6**] 01:00PM BLOOD Glucose-102* UreaN-14 Creat-0."
2069,"POD#3 Mrs.[**Known lastname 110087**] 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 #6 she was ambulating freely, the wound was healing and
pain was controlled with oral analgesia. The patient was
discharged to [**Doctor First Name 37**] House Rehab & Nursing Center in
[**Location (un) 38**] in good condition. All follow up appointments were
advised.
Medications on Admission:
amlodipine 10mg daily, advair diskus 100/50 one puff [**Hospital1 **],
simvastatin 20mg daily, asa 81mg daily"
2070,"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**]."
2071,"Admission Date: [**2157-12-1**] Discharge Date: [**2157-12-4**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nsaids
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is a 86 year-old female with a history of mild CHF,
diverticulitis who was transfered from OSH with
cholangitis/choledocolithiasis for ERCP. The patient reports
that she has been having watery diarrhea, gas and mild abd pain
for several weeks - stopped taking lasix [**1-2**] diarrhea. She
recently saw her PCP who had placed her on two antibiotics. Her
diarrhea began to resolve."
2072,"In the ED, the patient was febrile to 103. RUQ U/S confirmed
choledocolithiasis. GI contact[**Name (NI) **] - ERCP when IR less than 1.5.
She was given tylenol and one liter IVF. On exam in the ED, she
was well appearing, mildly diffusely tender in her abd,
initially tachycardic to 155. She also had one large watery foul
smelling stool. Vitals: temp 100.1 Hr 95, Bp 110/50 19 97% 2L.
Past Medical History:
Diverticulitis- s/p colectomy and reanastamosis may years ago
? Mild CHF
Hypothyroidism
Hernia
Social History:
widowed, lives with her daughter, [**Name (NI) 15310**] in [**Name (NI) 5669**], no
tob/Etoh/drugs"
2073,"Impression: Stones in the bile duct, otherwise normal biliary
tree. No pus was seen. A biliary sphincterotomy was performed.
Stones were extracted using a balloon. (sphincterotomy, stone
extraction)
Recommendations: Absence of pus and normal LFTs do not eliminate
cholangitis as the cause of patients high fevers, but make it
less likely. Consider evaluation for colits given diarrhea and
thickening in the sigmoid colon on CT scan.
[**2157-12-3**] CT abd/pelvis with contrast:
STUDY: CT of the abdomen and pelvis.
HISTORY: 86-year-old female with recurrent diarrhea, fevers and
question of
colon mass seen at outside hospital.
COMPARISONS: None."
2074,"1. Leukocytosis, fever, Diverticulitis: with LLQ pain and
copious/watery diarrhea most concerning for
colitis/diverticulitis. OSH CT consistent with colitis, but
also demonstrates choledocholithiasis. Underwent ERCP (see
below) and large stone removed, but no pus. LFTs wnl, not
consistent with biliary obstruction. Initially treated with
levofloxacin and flagyl for presumed LLQ source. CT abd/pelvis
with contrast performed at [**Hospital1 18**] revealed a long segment of
lower sigmoid colonic wall irregularity and possible associated
contained foci of extraluminal air and a few sigmoid colonic
diverticula are noted. The differential diagnosis includes long
segment diverticulitis with contained perforation, but given the
irregular appearance of the wall of the lower sigmoid colon in
particular, carcinoma must also be considered and direct
visualization via endoscopy is advised."
2075,"The surgical service was consulted regarding the CT findings and
the patient's recurrent diverticulitis and the plan was made for
outpatient surgical evaluation. The patient was discharged on a
prolonged course of cipro/flagyl to continue for another 14 days
after discharge (for a total of almost 21 days) given the CT
findings of diverticulitis with contained perforation.
-Patient to f/u closely with surgery and PCP as outpatient.
-Patient needs outaptient colonoscopy when diverticulitis flare
has resolved.
2. Choledocholithiasis: ERCP on [**2157-12-1**]--sphincterotomy performed
and 3 stones removed. With abscence of pus or LFT
abnormalities, ascending cholangitis thought to be less likely
source of high fever and leukocytosis."
2076,"General surgery consult
for consideration of cholecystectomy was placed. Given the
patient's ventral hernia and prior abdominal surgery, the plan
was for an outpatient elective open cholecystectomy.
-Outpatient open cholecystectomy.
3. Diarrhea: large volume and watery for weeks prior to
admission. Had improvement with an initial course of
antibiotics. Stool studies pending. CT also demonstrates
fecal-loaded colon--but given ongoing diarrhea, bowel regimen
not started. Treated with levofloxacin and flagyl.
4. Elevated INR: 1.8 on admission, 1.6 day after admission.
Patient not on anticoagulation. Likely related to protein loss
with the diarrhea. Also has low albumin."
2077,"FFP given prior to
ERCP.
5. Code Status: Full code.
Medications on Admission:
Digoxin 0.25mg every other day
Digoxin 0.125mg every other day
protonix
lasix - stopped recently for diarrhea
Alendronate
recently started on Levofloxacin and Flagyl on [**2157-11-30**]
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
2078,"5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days.
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home
Discharge Diagnosis:
Choledicholithiasis
Diverticulitis, Acute
Diarrhea
Supratherapeutic INR
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to the ED if you are having high fevers, vomiting, severe
abdominal pain, unable to tolerate food, rigors, confusion, low
blood pressure.
Followup Instructions:
Please call the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to arrange an
appointment to discuss open cholecystectomy. She can be reached
at [**Telephone/Fax (1) 8792**].
Patient's daughter to arrange f/u with patient's PCP:
[**Name10 (NameIs) **],[**First Name3 (LF) 251**] D [**Telephone/Fax (1) 79695**] for appointment in 2 weeks.
The patient needs a colonoscopy in [**5-8**] weeks."
2079,"TECHNIQUE: Following the administration of intravenous contrast,
MDCT axial
images were acquired from the lung bases to the pubic symphysis.
Coronal and
sagittal reformatted images were then obtained.
CT OF THE ABDOMEN WITH IV CONTRAST: Tiny bilateral pleural
effusions with
associated atelectasis are present at the lung bases. Left-sided
pneumobilia
which may relate to the patient's recent ERCP two days prior is
evident.
Minimal intrahepatic biliary dilatation is present. The liver is
otherwise
unremarkable without focal lesion. Layering gallstones are
evident. However,
the gallbladder is not distended and no wall edema or
pericholecystic fluid is
seen. The pancreatic duct is prominent at the level of the
pancreatic head
measuring 4 mm in diameter (2:26)."
2080,"Brief Hospital Course:
MICU COURSE:
86year-old female with a history of mild CHF, diverticulitis who
was transfered from OSH with cholangitis/choledocolithiasis for
ERCP. At the OSH she was febrile to 105 and CT scan there
showed biliary dilation. She was started on cipro/flagyl on
admission to [**Hospital1 18**]. Here, her RUQ ultrasound also showed biliary
dilation. She underwent ERCP on [**2157-12-1**] which showed several
large steons which were removed by no frank pus or other
evidence of cholangitis. Of note, she also reported having 4
weeks of intermittent watery diarrhea which is improving. She is
currently free of abdominal pain at rest, has minimal pain with
palpation."
2081,"7
Ultrasound: The liver shows normal echogenicity. No focal
hepatic
lesion is identified. The intra- and extra-hepatic bile ducts
are dilated.
The common duct at the head of the pancreas measures 1 cm.
Multiple shadowing echogenic foci are identified within the
common bile duct consistent with stones. The gallbladder
contains multiple stones. There is no evidence of cholecystitis.
The visualized pancreas is normal. The right kidney measures
10.4 cm and shows mild dilatation of the collecting system and
ureter
ERCP:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla"
2082,"Several foci of probable extraluminal air are
noted along the
antimesenteric border (2:58). These may represent outpouchings
of the wall
and diverticula or contained perforation. A long segment of
sigmoid colonic
wall irregularity, extending to the rectosigmoid junction, spans
a distance of
approximately 7 mm and mild surrounding inflammatory change is
also evident.
The bladder is unremarkable, although it contains a moderate
amount of air. No
Foley catheter is seen. Intrapelvic loops of small bowel are
unremarkable. No
adnexal masses. No pathologically enlarged inguinal or pelvic
lymph nodes are
present.
OSSEOUS STRUCTURES: Degenerative change at the L2-3 level with
associated
endplate sclerosis."
2083,"No pus was noted.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
3 stones were extracted successfully using a balloon. Occlusion
cholangiogram did not show any filling defects.
Impression: Stones in the bile duct, otherwise normal biliary
tree. No pus was seen.
A biliary sphincterotomy was performed.
Stones were extracted using a balloon.
(sphincterotomy, stone extraction)
Recommendations: Return to ICU.
Absence of pus and normal LFTs do not eliminate cholangitis as
the cause of patients high fevers, but make it less likely.
Consider evaluation for colits given diarrhea and thickening in
the sigmoid colon on CT scan."
2084,"Family History:
NC
Physical Exam:
On admission:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, 3/6 systolic ejection murmur, normal S1 S2, radial
pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mildly tender in RLQ w/o guarding or rebound, ND,
+BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities."
2085,"Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree: Three stones ranging in size from 3mm to 6mm that
were causing partial obstruction were seen at the lower third of
the common bile duct and middle third of the common bile duct.
Otherwise the bile duct was normal. No pus was noted.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire. 3
stones were extracted successfully using a balloon. Occlusion
cholangiogram did not show any filling defects."
2086,"0
LEUK-NEG
[**2157-12-1**] 02:30AM URINE RBC-[**10-20**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0
[**2157-12-1**] 02:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2157-12-1**] 02:38AM DIGOXIN-1.0
[**2157-12-1**] 02:38AM ALBUMIN-3.1*
[**2157-12-1**] 02:38AM ALT(SGPT)-13 AST(SGOT)-42* ALK PHOS-67 TOT
BILI-0.4
[**2157-12-1**] 02:38AM GLUCOSE-133* UREA N-11 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
[**2157-12-1**] 02:59AM LACTATE-1."
2087,"However, she then underwent a abd CT
scan with barium on [**2157-11-21**] and then began having diarrhea
since then. She saw her PCP again on [**2157-11-29**] and was doing
well. On her return home, she began to feel very weak. Her
daughter, a nurse, noted that she was unstable, confused and had
her BIBA to an OSH ED. There she had a repeat CT scan and RUQ
showing common bile duct stones. In addition, she had a fever to
105, abdominal pain and vomiting x 2 and was given Unasyn and
Levofloxacin. She was then transfered to [**Hospital1 18**] ED for ERCP."
2088,"[**2157-12-1**] ERCP:
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree: Three stones ranging in size from 3mm to 6mm that
were causing partial obstruction were seen at the lower third of
the common bile duct and middle third of the common bile duct.
Otherwise the bile duct was normal."
2089,"SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2157-12-1**] 02:38AM WBC-16.6* RBC-3.93* HGB-11.4* HCT-33.3*
MCV-85 MCH-29.1 MCHC-34.3 RDW-12.7
[**2157-12-1**] 02:38AM NEUTS-92.3* LYMPHS-3.2* MONOS-4.1 EOS-0.3
BASOS-0.2
[**2157-12-1**] 02:38AM PLT COUNT-457*
[**2157-12-1**] 02:38AM PT-18.1* PTT-28.2 INR(PT)-1.7*
[**2157-12-1**] 02:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5."
2090,"The pancreatic duct at the
level of the
body and tail is normal in caliber. Mild stranding at the level
of the amuplla
is compatibel with recent ERCP. The spleen and adrenal glands
are
unremarkable. Several low- attenuation foci within the left
kidney are too
small to characterize but likely represent simple cysts. The
stomach and small
bowel are unremarkable. There is no free air within the abdomen.
The abdominal
portion of the colon is unremarkable.
CT OF THE PELVIS WITH IV CONTRAST: A few diverticula of the
sigmoid colon are
present. The wall of the sigmoid colon along the majority of its
entire
course is irregular and oral contrast material does not pass
distal to the
lower aspect."
2091,"No suspicious lytic or blastic lesions.
IMPRESSION:
1. Long segment of lower sigmoid colonic wall irregularity and
possible
associated contained foci of extraluminal air. A few sigmoid
colonic
diverticula are noted. The differential diagnosis includes long
segment
diverticulitis with contained perforation, but given the
irregular appearance of the wall of the lower sigmoid colon in
particular, carcinoma must also be considered and direct
visualization via endoscopy is advised.
2. Pneumobilia likely related to recent ERCP. Minimal
intrahepatic biliary
dilatation.
3. Mild pancreatic ductal dilatation at the level of the
pancreatic head may be related to recent ERCP procedure.
4. Cholelithiasis without evidence of acute cholecystitis."
2092,"In ED here--patient with minimal hypoxia (3 lpm at 94%) and no BRBPR
seen, no clinical signs of dissection. Zofran given and patient to ICU
for further care following wean of levophed to off.
Patient does note some increase in exertional dyspnea over the past
days
Patient admitted from: Transfer from other hospital
History obtained from [**Hospital 19**] Medical records
Allergies:
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
HTN
DM
HCV
COPD
Liver Nodule
Esophageal Varices--noted by patient
Depression
Non-contributory for hypotension and renal failure
Occupation:
Drugs: Cocaine and IVDA in past
Tobacco: 2 ppd
Alcohol: 70 proof brandy-last drink [**1-26**]
Other:
Review of systems:
Constitutional: Fatigue
Cardiovascular: No(t) Chest pain, Tachycardia
Respiratory: Dyspnea
Gastrointestinal: No(t) Abdominal pain
Genitourinary: Foley
Heme / Lymph: No(t) Anemia
Psychiatric / Sleep: No(t) Agitated
Flowsheet Data as of [**2154-1-28**] 02:23 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**55**] AM
Tmax: 36."
2093,"2)Hypoxemia-This would appear to be A-a gradient hypoxia
-It is difficult to reconcile PCO2 of 36 with hypoxia driven by COPD
but this in the setting of pH=7.11 represents a marked acidemia and
co-existing respiratory acidosis
-Continue to wean O2 to goal of 90-92
-Will attempt to obtain past medical records
-Will consider further evaluation with alternative source such as PE or
extra-pulmonary shunt if fails to resolve.
3)Acidemia-
-Has non-gap contribution which is small and may be related to diarrhea
-The AG contribution may well be lactic acidosis in the setting of
shock and combined with renal failure may well explain the findings
4)Renal Failure-LIkely pre-renal acute failure
-WIll provide replacement of volume
-Will check FeNA
-Will renally dose medications
-Will check urine sediment
5)EtOH Abuse-
-Ativan CIWA
-Thimaine/Folate/MVI
-Follow exam
ICU Care
Nutrition: PO intake
Glycemic Control:
Lines / Intubation:
Multi Lumen - [**2154-1-28**] 01:32 PM
20 Gauge - [**2154-1-28**] 01:43 PM
Comments:
Prophylaxis:
DVT: boots
OOB and ambulation
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent: 35 minutes"
2094,"Chief Complaint: Hypotension
Acute Renal Failure
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
Patient with onset Saturday night following ingestion of clams of
nausea/vomiting but then with trace blood noted in both emesis and
stool. Patient overnight last night had muscle cramps and weakness and
was to [**Hospital3 902**] for care.
There--had WBC=20 and HCT=61 and Cr=5 all consistent with severe
hypovolemia
7.11/36/143
Patient given Zosyn, levophed given through CVL and transfered to [**Hospital1 5**]
for further care."
2095,"The presentation is quite consistent
with severe hypovolemia and dehydration with increase in HCT and likely
pre-renal source of renal failure. What is difficult to reconcile is
the compaint of progressive dyspnea on exertion and current oxygen
requirement at 3 lpm.
1)Shock--Hypovolemic--Clearly most likely source at this time based
upon clinical exam. Obstructive shock can be entertained but certainly
less likely and no clear evidence of source of vasodilatory shock.
-WIll provide IVF to target euvolemia
-Follow Urine output
-Will look to normalize HCT at this time
-Will look to normalize HR as well
-Will evaluate for infectious insult with stool O+P and will move to
symptomatic control at this time
-Cardiac enzymes and ECG reassuring for no evidence of acute myocardial
infarction."
2096,"6
C (97.9
Tcurrent: 36.6
C (97.9
HR: 106 (102 - 106) bpm
BP: 113/63(75) {113/63(75) - 113/63(75)} mmHg
RR: 20 (20 - 23) insp/min
SpO2: 94%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
506 mL
PO:
TF:
IVF:
506 mL
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
506 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 94%
ABG: ////
Physical Examination
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),
(Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
[**Telephone/Fax (2) 11980**]3
104
3."
2097,"5
137
22.4
[image002.jpg]
Other labs: PT / PTT / INR://1.6, CK / CKMB / Troponin-T://0.11, ALT /
AST:89/267, Amylase / Lipase:/wnl, Differential-Neuts:86, Band:0,
Lymph:6, Lactic Acid:2.7
Fluid analysis / Other labs: Tox-
Imaging: CT--At [**Hospital1 **]--Ileus and fatty liver identified.
CT--ABD--ileus, no AAA
CXR-
ECG: NSR, normal axis, modest increase in P-wave voltage, nl intervals,
no ST-T changes
Assessment and Plan
53 yo male with initial presentation with acute renal failure and
significant hypotension in the setting of recent signficant GI illness
with significant nausea/vomiting."
2098,"- Renally dose meds
- Avoid nephrotoxins
- Monitor UOP, trend CK
- F/U renal recs
# AG Metabolic Acidosis: Initially with a mixed AG/non-AG metabolic
acidosis from diarrhea and uremia, now stool output significantly
decreased, ~600cc over past 24 hours. Serum AG 13 this AM, urine AG 8
on [**1-30**] AM. HCO3 20 on AM labs after bicarbonate gtt
- [**Hospital1 **] lytes
- Continue bicarb gtt, titrate to even I/O
- Renal recs
# COPD: Patient with mild hypoxia & baseline low O2 sats from COPD.
Required low flow O2 by NC initially, but currently sat
ing well on RA.
CXR without pulmonary edema or e/o infectious process."
2099,"- Albuterol nebs q2H:PRN
- Ipratropium nebs q6H
- Repeat CXR in AM
# GIB: Hct stable at 37.9 today. From the OSH there is a report of
BRBPR but from here only trace guaiac positive stools. Had single
episode of coffee ground emesis on admission. HCT initially dropped on
admissionin setting of hemoconcentration and aggressive hydration, but
no significant changes since [**1-29**].
- Active T+C
- Continue home PPI
- Trend Hct
# Transaminitis: LFT
s now trending down. Patient already with HCV but
per him has been treated and is in remission. Also started drinking
again recently and may have ETOH-hepatitis."
2100,"2
C (99
Tcurrent: 36.6
C (97.9
HR: 91 (87 - 113) bpm
BP: 155/95(108) {119/60(74) - 155/95(108)} mmHg
RR: 18 (15 - 26) insp/min
SpO2: 92%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 117.9 kg (admission): 103.9 kg
Height: 72 Inch
Total In:
3,040 mL
808 mL
PO:
300 mL
TF:
IVF:
2,740 mL
808 mL
Blood products:
Total out:
3,695 mL
670 mL
Urine:
2,095 mL
670 mL
NG:
Stool:
600 mL
Drains:
Balance:
-655 mL
138 mL
Respiratory support
O2 Delivery Device: None
SpO2: 92%
ABG: 7."
2101,"# Hypovolemic Shock/Gastroenteritis: Blood pressure stable, has not
needed pressors since admission. Initially, hypovolemic shock from
diarrhea, vomiting, and poor PO intake. Now with significantly
decreased stool output, no further emesis, tolerating a BRAT diet.
Given shellfish ingestion, Vibrio is most likely cause, but cultures
pending. Negative C.diff x 2.
- IVF
s with net I/O even goal
- Follow up culture data
# Acute Renal Failure: Unknown baseline. Initially thought to be [**12-18**]
hypovolemia (prerenal), now with ATN and rising Cr, but with good urine
output & down trending CK (394). Negative renal ultrasound. Urine AG 8
on [**1-30**] AM, improved from prior."
2102,"3 mEq/L
71 mg/dL
103 mEq/L
136 mEq/L
37.9 %
6.3 K/uL
[image002.jpg]
[**2154-1-28**] 11:05 PM
[**2154-1-29**] 02:53 AM
[**2154-1-29**] 07:44 AM
[**2154-1-29**] 02:59 PM
[**2154-1-29**] 07:28 PM
[**2154-1-30**] 04:11 AM
[**2154-1-30**] 09:32 AM
[**2154-1-30**] 02:42 PM
[**2154-1-30**] 02:43 PM
[**2154-1-31**] 04:27 AM
WBC
14.1
9.7
9.4
7.5
6.3
Hct
43.5
41.9
38.8
39.4
36."
2103,"37/28/77.[**Numeric Identifier 253**]/20/-7
Physical Examination
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Diffuse expiratory wheezes throughout all lung fields, no
crackles
CV: Regular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, diffusely distended, hyperactive BS, no
rebound tenderness or guarding
GU: foley draining significant pale yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema,
pneumboots in place
Labs / Radiology
104 K/uL
12.6 g/dL
105 mg/dL
8.9 mg/dL
20 mEq/L
3."
2104,"8
38.4
37.9
Plt
113
104
119
100
104
Cr
4.7
6.0
6.6
7.5
8.2
8.9
TropT
0.15
TCO2
13
17
Glucose
151
115
117
131
116
105
Other labs: PT / PTT / INR:14.3/36.7/1.2, CK / CKMB /
Troponin-T:394/98/0.15, ALT / AST:71/86, Alk Phos / T Bili:72/1.3,
Differential-Neuts:88.0 %, Band:0.0 %, Lymph:8.0 %, Mono:4.0 %, Eos:0.0
%, Fibrinogen:301 mg/dL, Lactic Acid:1.2 mmol/L, LDH:307 IU/L, Ca++:7.1
mg/dL, Mg++:1."
2105,"8 mg/dL, PO4:4.2 mg/dL
Fluid analysis / Other labs: Urine anion gap: 8
Imaging: [**1-30**] Renal Ultrasound: Both kidneys are normal in appearance
without evidence of hydronephrosis, nephrolithiasis, or discrete
masses. The bladder is collapsed about a Foley catheter and
suboptimally assessed.
[**1-30**] CXR: The lungs are well expanded and clear. The cardiomediastinal
silhouette, hilar contours, and pleural surfaces are normal. No pleural
effusions or pulmonary edema is present.
IMPRESSION:
No pulmonary edema.
Microbiology: [**1-29**]
Stool cx: pending
Campylobacter cx: pending
Vibrio cx: pending
Urine cx: negative
[**1-30**]
O&P: pending
Assessment and Plan
53yo M with h/o HCV and DM2 admitted with diarrhea and hypovolemic
shock requiring pressor support, now improving clinically with
worsening ARF."
2106,"- Trend LFTs
- SW consult
# ETOH: Last drink, [**1-26**]. Drinking a significant amount of brandy daily
and with history of shakes in last day from not drinking. No h/o
withdrawal seizures.
- CIWA discontinued today as patient has not triggered
- MVI, Thiamine, Folate
- SW consult
- Seizure precautions
# DM2: Diet controlled at baseline.
- ISS
- Diabetic diet
# h/o HTN: Currently mildly hypertensive
- Holding Lisinopril in context of renal failure
- Can trial Metoprolol Tartrate 25mg x 1 if bp
s remain elevated
ICU Care
Nutrition: BRAT diet
Glycemic Control: Insulin sliding scale
Lines:
PICC Line - [**2154-1-29**] 12:41 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Patient
Code status: Full code
Disposition: pending clinical improvement"
2107,"Chief Complaint: diarrhea
24 Hour Events:
- Tolerating brat diet
- Renal ultrasound was unremarkable
- C.diff negative x 2
- PM electrolytes showed bicarb is up to 16, Cr continues to rise to
8.2 with stable BUN
- Renal recs: Change fluids to 1/2 NS with 75 mEq of Na bicarb titrate
to I/O even
- Urine anion gap from [**1-30**] AM = 8
- Early this AM, patient with wheezing on exam, HCO3 up to 20, so rate
decreased to 20cc/hr
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Furosemide (Lasix) - [**2154-1-30**] 08:44 AM
Pantoprazole (Protonix) - [**2154-1-30**] 08:00 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2154-1-31**] 07:48 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**55**] AM
Tmax: 37."
2108,"Will move to CPAP if not tolerated. Atrovent
and Albuterol to continue as standing Rx with q 2-4 hours.
Thrombocytopenia--Significant PLT drop at 2 days into hospitalization
in the setting of sq heparin. Will need to get an evaluation for
schistocytes as above. If this is related to sq heparin it is early
and would expect type I which should resolve acutely with
discontinuation--will hold heparin for now and follow return of counts.
Diarrhea--Patient has no return of positive culture results to date and
has continued high volume GI output at 4 liters today. Is consistent
with acute infectious source and will need to work to slow response
when we have confirmed source. Patient will remain NPO for Rx at this
time. Will Rx with oral rehydration therapy if possible as limited by
emesis. Norovirus is certainly possible as well and are limited by
coffee ground emesis
Issues and concerns discussed on evening rounds with nursing and with
patient in detail.
Total time spent: 45 minutes"
2109,"Clinician: Attending
Patient with worsening renal function--peristent oliguria and with
rising creatinine and in the setting of patient being volume replete
all concerning for intrinsic renal failure and with altered mental
status, falling platelets, low grade fever and uremia all concerning
for possible TTP-HUS. We have raised a concern here and both renal and
heme consult services are to evaluate for possible TTP-HUS. Will
continue with renal support with minimization of nephrotoxic
medications, will avoid fluid as possible, will add on urine K+ and Cl-
and Na+.
Respiratory Distress--Patient with diffuse wheezes on exam, limited
crackles seen, has increased RR and on CXR--has modest incresase in
interstitial edema noted and with significant volume challenge has
likely acquired some significant pulmonary edema and will need negative
fluid balance--will trial Lasix 40mg IV to look for response initially
and hope to see response."
2110,"-Urine lytes
FeNA was 1.7%
-No evidence of muddy brown casts seen
-Will pursue renal consult if not resolving by today.
4)Acidosis
He has had in large part resolution with lactic acidosis
improving source. The non-gap acidosis is likely in part attributable
to diarrhea. He has an HCO3- deficit of 5 mEq/l and will replace with
100meq Hco3 this morning and look to recheck and continue replacement
across the day.
-3 amps HCO3 in D5 this morning
-Recheck in [**2-19**] hours
-Replace as needed for non-gap acidosis today
5)Rhabdomyolysis-Very mild elevation in CK in the setting of renal
failure
-Will continue to support with IVF
-Follow CK
6)COPD-
-Will need MDI
atrovent at a minimum
7)GI Bleed
-No change in HCT with likely [**Doctor First Name **] [**Doctor Last Name **] tear and peri-rectal insult
leading to bleeding
-GI for endoscopy if more brisk
-Will continue to follow HCT
ICU Care
Nutrition: NPO
Glycemic Control:
Lines:
Multi Lumen - [**2154-1-28**] 01:32 PM
will be removed
20 Gauge - [**2154-1-28**] 01:43 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 45 minutes"
2111,"6/33.9/1.4, CK / CKMB /
Troponin-T:1585/98/0.15, ALT / AST:87/188, Alk Phos / T Bili:74/0.8,
Lactic Acid:1.3 mmol/L, Ca++:6.9 mg/dL, Mg++:1.7 mg/dL, PO4:5.5 mg/dL
Fluid analysis / Other labs: 7.26/28/78
AG-17
delta gap-4
Consistent with significant non-gap acidosis as well.
Microbiology: C. Diff negative
O+P pending
Assessment and Plan
53 yo male admitted with hypovolemic shock in the setting of recent
shellfish ingestion and with antecedent illness of wather diarrhea. He
has had reasonable response to initial volume support but now maintains
persistent and significant metabolic acidosis with both gap and non-gap
components."
2112,"26/28/77.[**Numeric Identifier 253**]/12/-12
Physical Examination
General Appearance: Overweight / Obese
Cardiovascular: (S1: Normal), (S2: Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),
(Breath Sounds: Clear : , Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower extremity
edema: Trace
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
14.0 g/dL
113 K/uL
151 mg/dL
4."
2113,"7 mg/dL
12 mEq/L
3.2 mEq/L
53 mg/dL
107 mEq/L
136 mEq/L
41.9 %
14.1 K/uL
[image002.jpg]
[**2154-1-28**] 02:05 PM
[**2154-1-28**] 05:08 PM
[**2154-1-28**] 05:40 PM
[**2154-1-28**] 09:52 PM
[**2154-1-28**] 11:05 PM
[**2154-1-29**] 02:53 AM
[**2154-1-29**] 07:44 AM
WBC
14.1
Hct
47.6
46.3
43.5
41.9
Plt
113
Cr
4.7
4.7
TropT
0.13
0.15
TCO2
11
12
13
Glucose
119
151
Other labs: PT / PTT / INR:15."
2114,"Chief Complaint: Shock
Diarrhea
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
MULTI LUMEN - START [**2154-1-28**] 01:32 PM
EKG - At [**2154-1-28**] 03:30 PM
-Patient with increased urine output in the setting of IVF replacement
-Patient did have dark emesis noted overnight
-Patient with increase in CK to 1585
-Oozing at rectum with loss of rectal tube
History obtained from [**Hospital 19**] Medical records
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Omeprazole (Prilosec) - [**2154-1-28**] 04:30 PM
Heparin Sodium (Prophylaxis) - [**2154-1-28**] 06:00 PM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Gastrointestinal: Emesis
Flowsheet Data as of [**2154-1-29**] 08:36 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**55**] AM
Tmax: 36."
2115,"1)Shock
Hypovolemic. He has had modest improvement in HCT and overall
urine output but still remains with some peristent hypovolemia with
continued positive fluid balance.
-Will continue to bolus PRN
-We have improved blood pressure stability
-Will move to PICC today
2)DIARRHEA-Patient with large volume watery diarrhea concerning for
infectious source. We have a broad differential with vibrio, hep A,
cholera all possible to be contributing. Salmonella/Shigella/E. coli
must all be considered.
-Follow up stool cultures and results
-Based on large volume watery diarrhea will continue to control
symptoms as vibrio/viral would appear most likely
-If culture results seen or colonic source suspected will add empiric
antibiotics
3)RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)-Likely pre-renal
souce with ATN likely present as well."
2116,"7
C (98
Tcurrent: 36.6
C (97.9
HR: 99 (97 - 112) bpm
BP: 133/64(79) {101/37(58) - 136/73(86)} mmHg
RR: 20 (17 - 28) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Height: 72 Inch
Total In:
12,812 mL
3,577 mL
PO:
820 mL
TF:
IVF:
8,992 mL
3,577 mL
Blood products:
Total out:
2,869 mL
2,490 mL
Urine:
249 mL
165 mL
NG:
120 mL
50 mL
Stool:
950 mL
Drains:
Balance:
9,943 mL
1,087 mL
Respiratory support
O2 Delivery Device: None
SpO2: 94%
ABG: 7."
2117,"- trend LFTs
- Viral studies
- RUQ U/S r/o portal venous thrombosis if other studies unrevealing
.
# Renal Failure: Unknown baseline. Likely [**12-18**] hypovolemia.
- Liberal IVF
- Renally dose meds
- Avoid nephrotoxins
- Check urine lytes
- Monitor UOP
- find baseline creatinine from OSH records
.
# ETOH: Drinking a significant amount of brandy daily and with history
of shakes in last day from not drinking. Never withdrawl seizures
before.
- banana bag
- MVI
- Thiamine
- Folate
- Ativan CIWA given
- SW consult when healthy
- Seizure precautions
.
# DM2: Diet controlled at baseline.
- ISS
- Diabetic diet
.
# h/o HTN: Now hypotensive
- hold lisinopril for now
.
FEN: IVF, replete electrolytes, BRAT diet with liberal oral fluid
intake for ORT
.
Prophylaxis: Boots given concern for GIB
.
Access: peripherals, RIJ (needs replacement)
.
Code: presumed full
.
Communication: Patient/OSH records
.
Disposition: pending clinical improvement
ICU Care
Nutrition: NPO
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2154-1-28**] 01:32 PM (R subclavian placed at OSH)
2 x 20 Gauge PIVs - [**2154-1-28**] 01:43 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Patient
Code status: Full code
Disposition: ICU"
2118,"- Repeat ABG pending
- [**Hospital1 **] lytes
.
# Hypoxia: Likely patient has baseline low O2 sats from COPD and likely
chronic COPD given elevated HCT, however, PE also on differential if
does not resolve over next few hours.
- Nebs standing and PRN
- repeat CXR in am
- weaning O2 as pt tolerates
- Repeat ABG
.
# Gastroenteritis: Likely infectious given leukocytosis although other
possibilities include mesenteric ischemia given report of GIB. Ischemic
colitis unlikely given no inflammation seen on CT Abd. infectious
etiologies include Hep A, vibrio, less likely giardia. Also at risk for
Cdiff given PPI use but cdiff negative x 1.
- f/u Stool O+P, hepatits and viral serologies
- NPO
- Hepatitis serologies
."
2119,"20/30/84.[**Numeric Identifier 117**]/12/-14
Physical Examination
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Diffuse expiratory wheezes, no crackles.
CV: Tachycardic regular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, NABS, no rebound tenderness or
guarding
GU: foley draining small amounts of brownish urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Labs / Radiology
113 K/uL
14.0 g/dL
151 mg/dL
4.7 mg/dL
12 mEq/L
3.2 mEq/L
53 mg/dL
107 mEq/L
136 mEq/L
41."
2120,"# GIB: Unclear whether patient really has a GIB. From the OSH there is
a report of BRBPR but from here only trace guaiac positive stools.
- Active T+C
- check PM hct
- continue home PPI
- GI consult if hcts drop given history of esophageal varices and
higher risk of GIB given cirrhosis
- Need to get records from [**Hospital3 5496**].
.
# Transaminitis: [**Month (only) 8**] be [**12-18**] shock or component of viral hepatitis.
Patient already with HCV but per him has been treated and is in
remission. Also started drinking again recently and may have
ETOH-hepatitis although this is usually more cholestatic."
2121,"8,
Lactic Acid:0.8 mmol/L, Ca++:6.9 mg/dL, Mg++:1.7 mg/dL, PO4:5.5 mg/dL
Imaging: CT Abd/Pel [**1-28**] prelim read:
Ileus. Nl appendix. No AAA, hematoma/fluid, or free air. Heterogeneous
nodular liver- h/o cirrhosis? Large hiatal hernia.
Microbiology: OVA + PARASITES (Pending)
CLOSTRIDIUM DIFFICILE negative
Blood cltx pending
Urine cltx pending
CMV pending
EBV pending
Assessment and Plan
53yo M with h/o HCV and DM2 admitted with hypovolemic shock requiring
and diarrhea.
.
# Shock: hypovolemic shock from diarrhea, vomiting, and poor PO intake.
If infectious/sepsis likely have GI source given GI symptoms."
2122,"Does have
hypoxia and PE considered but pt has a h/o COPD and may have long term
hypoxia from this.
- Aggressive IVF resuscitation with bicarb administration.
- Follow up culture data. Negative cdiff.
- If has further hypotension requiring pressors will need to replace
central line but for now pressors have been weaned off and if continue
to be off pressors will not need another line.
- A-line if needs pressors again.
.
# AG and non-AG Metabolic Acidosis: With AG of 20 and change of bicarb
of 11 on admission suggesting a mixed AG/non-AG metabolic acidosis.
Likely the non-gap acidosis from diarrhea and gap acidosis from lactate
(hypovolemic shock) and uremia."
2123,"7
C (98
Tcurrent: 36.7
C (98
HR: 97 (97 - 112) bpm
BP: 123/65(75) {101/37(58) - 136/73(86)} mmHg
RR: 20 (17 - 28) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Height: 72 Inch
Total In:
12,812 mL
2,987 mL
PO:
820 mL
TF:
IVF:
8,992 mL
2,987 mL
Blood products:
Total out:
2,869 mL
1,155 mL
Urine:
249 mL
130 mL
NG:
120 mL
50 mL
Stool:
950 mL
Drains:
Balance:
9,943 mL
1,832 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 96%
ABG: 7."
2124,"9 %
14.1 K/uL
[image002.jpg]
[**2154-1-28**] 02:05 PM
[**2154-1-28**] 05:08 PM
[**2154-1-28**] 05:40 PM
[**2154-1-28**] 09:52 PM
[**2154-1-28**] 11:05 PM
[**2154-1-29**] 02:53 AM
WBC
14.1
Hct
47.6
46.3
43.5
41.9
Plt
113
Cr
4.7
4.7
TropT
0.13
0.15
TCO2
11
12
Glucose
119
151
Other labs: PT / PTT / INR:15.6/33.9/1.4, CK / CKMB /
Troponin-T:1585/98/0.15, ALT / AST:87/188, Alk Phos / T Bili:74/0."
2125,"Chief Complaint:
24 Hour Events:
-CK trending up from 376 --> 1234 -->1585. ?rhabdomyolysis?. Urine
myoglobin pending.
-Lactate trended down with IVFs, now on LR at 500cc/hr. Trying to
increase UOP since very low since admission.
-Given 8L NS and 3L LR. Started on bicarb drip for metabolic acidosis
and bicarb of 11.
-Had several episodes of coffee ground? brown emesis starting at 7 PM.
serial HCTs ordered, type and screen active. Pt HD stable. Started on
zofran and compazine prn and IV PPI.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Omeprazole (Prilosec) - [**2154-1-28**] 04:30 PM
Heparin Sodium (Prophylaxis) - [**2154-1-28**] 06:00 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2154-1-29**] 07:27 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**55**] AM
Tmax: 36."
2126,"Admission Date: [**2154-1-28**] Discharge Date: [**2154-2-7**]
Date of Birth: [**2100-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
weakness/diarrhea
Major Surgical or Invasive Procedure:
colonoscopy with biopsy
History of Present Illness:
53yo M with PMHx HCV, DM2 (diet controlled) likely from ETOH
admitted to [**Hospital Unit Name 153**] with GIB. Patient started drinking a few months
ago again. He was feeling fine on Saturday, ate some steamers,
and then went home. Since sat reports haveing had profuse watery
diarrhea (3 enroute to transfer here from [**Hospital1 46**]), N/V."
2127,"Social History:
Living with his brother. Drinking quart of brandy (70 proof)
daily. Shakes if stops. Last drink Saturday/Sunday. Smokes 2ppd
for many years. Prior history of cocaine use to the point that
no longer has nasal septum. IVDU in past.
Family History:
Mom with PPM in 80s.
Physical Exam:
T: 97.9 BP:113/70 P: 104 R: 21 O2: 94% 6LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, severely dry MM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic regular, 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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
2128,"9* Na-137
K-3.5 Cl-104 HCO3-13* AnGap-24*
[**2154-1-28**] 10:43AM BLOOD ALT-89* AST-267* CK(CPK)-376* AlkPhos-117
TotBili-2.1*
[**2154-1-28**] 10:43AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
CT A/P:
1. Fluid-filled small bowel, suggestive of gastroenteritis.
2. Probable cirrhosis. Correlate clinically.
3. Bladder contents may reflect hyperconcentrated urine or
hematuria.
Brief Hospital Course:
53yo M with h/o HCV and DM2 admitted with hypovolemic
hypotension and diarrhea.
.
# Shock/Gastroenteritis: This was likely hypovolemic shock from
diarrhea, vomiting, and poor PO intake."
2129,".
# GIB: Per report, patient had episode of coffee ground emesis
on presentation. Serial hematocrits initially decreased, but
this was likely due to dilution as he was severely hypovolemic
on arrival. His hematocrit then stablized at 38
.
# Transaminitis: [**Month (only) 116**] be [**12-18**] shock or component of viral
hepatitis. Patient already with HCV but per him has been treated
and is in remission. Also started drinking again recently and
may have ETOH-hepatitis although this is usually more
cholestatic.
His LFTs improved during his hospitalization.
.
# ETOH: Drinking a significant amount of brandy daily and with
history of shakes in last day from not drinking."
2130,"He was intially
treated with IV thiamine and folate, and then supplemented with
a multivitmain, thiamine and folate daily. Social work was
consulted. No significant etoh w/d seen.
.
# DM2: Patient was covered with an insulin sliding scale with
excellent glycemic control.
.
# h/o HTN: Lisinopril was held in the setting of ARF. Was not
restarted on discharge.
.
# Code Status: FULL CODE
Medications on Admission:
Seroquel 100mg daily at night
Lisinopril 10mg daily
Zoloft 50mg daily
Omeprazole 20mg [**Hospital1 **]
Discharge Medications:
1. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning))."
2131,"3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. Loperamide 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for loose stools.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: 009.1 GASTROENTERITIS
Secondary Diagnosis: 584.9 ACUTE RENAL FAILURE
Secondary Diagnosis: 584.5 ACUTE TUBULAR NECROSIS
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
Secondary Diagnosis: 250.00 DIABETES TYPE II, CONTROLLED, W/O
COMPLICATIONS
Secondary Diagnosis: 578.9 BLEEDING, GASTROINTESTINAL NOS
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent"
2132,".
Received Vancomycin here (Zosyn in OSH) and 3LNS. Also started
on norepinephrine. Concern for dissection in call-out but good
peripheral pulses and no clinical evidence of dissection.
VS 99 129/58 20 90%onNRB breathing comfortably. on 0.1
mcg/kg/min.
.
On the floor, patient complained of dry mouth, thirst, body
aches, no abdominal pain unless really push on the abdomen. Also
complained of watery diarrhea (at least 5 BMs in the last few
hours). Endorsed shortness of breath associated with exertion
worse than his usual SOB. No cough, orthopnea, PND.
Past Medical History:
HCV ""cleared"" per his hepatologist
COPD not on medications
HTN
DM2
Liver nodule that per radiologist is not malignant
Esophageal varices"
2133,"We have also stopped your
lisinopril, which you should not restart until after speaking
with the kidney doctors at your follow up. If you blood
pressures run high, your primary doctor may add a different
blood pressure medication that does not involve the kidneys.
Followup Instructions:
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Address: [**State **], [**Apartment Address(1) 86743**], [**Location (un) **],[**Numeric Identifier 994**]
Phone: [**Telephone/Fax (1) 31923**]
Appointment: [**2154-2-14**] 12:45pm
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2154-3-7**] at 1 PM
With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2154-2-26**] at 3:30 PM
With: [**Name6 (MD) 81**] [**Name8 (MD) **], 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"
2134,"Pertinent Results:
Labs from OSH:
WBC 20, ABG: pH 7.11/36/143 HCO3 10. Hct 61, ammonia 250
Admission Labs:
[**2154-1-28**] 10:43AM BLOOD WBC-22.4* RBC-5.34 Hgb-17.2 Hct-54.1*
MCV-101* MCH-32.2* MCHC-31.8 RDW-15.5 Plt Ct-215
[**2154-1-28**] 10:43AM BLOOD Neuts-86* Bands-0 Lymphs-6* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2154-1-28**] 10:43AM BLOOD PT-17.4* PTT-37.9* INR(PT)-1.6*
[**2154-1-28**] 10:43AM BLOOD Glucose-166* UreaN-42* Creat-4."
2135,"7 from [**8-24**]. He was
initially anuric, and his serum creatinine rapidly increased to
a peak of 10. Renal was consulted, and a renal u/s showed no
obstruction. Urine electrolytes were consistent with pre-renal
etiology. Urine sediment showed muddy brown casts c/w ATN. On
[**2154-1-30**], his urine output increased, with a concomitant decrease
in stool output. Over the following days his serum creatinine
decreased to 4.4, but did not return to normal. The renal team
feels he should regain most of his renal function and should be
followed in nephrology clinic. Urine output good."
2136,"Reportedly
showed ileus and fatty liver. He received zosyn, 2.5L NS, 8mg
zofran, and was started on levophed. He also had a right-sided
central line placed. In the meantime he was noted to have BRBPR.
For unclear reasons the OSH was also concerned for dissection.
He was then transferred to our ED for concern for
GIB/dissection. In our ED initial vs were: T97.3 P104 BP92/59
R20 O2 sat94%on 3L.Exam revealed only BMs with trace guaiac
positive stool. No clinical signs of dissection with good
peripheral pulses and non-con CT without evidence of AAA."
2137,"Discharge Instructions:
As we discussed, you were admitted with a dirrhea that was
likely infectious and resolved spontaneously, but caused to have
very low blood pressures and injury to your kidneys. If you have
any worsening in your symptoms, please call your doctor or
return to the ER for evaluation. We have scheduled follow up
with gastroenterology and renal clinics for you. Please keep
these appointments. We also would like you to follow up with
your primary care physician within [**Name Initial (PRE) **] week.
Medication changes:
We have added immodium to take as needed for loose stools. You
should not need these long term and if you being to need more
doses, please call your doctor."
2138,"CT confirmed small
bowel inflammation. He was initially supported with aggressive
IVF and norepinephrine was stopped. C. Diff toxin was negative
x 6. Stool cultures demonstrated no pathogens. His stool output
was initally copious, over 6L on hospital day one, but
decreased. HIV neg. He received IVF boluses with lactated
ringers, and maintenace fluid with NaHCO3. A colonoscopy with
biopsies was done and appeared grossly normal with path PENDING
at discharge. Without intervention, his stool output slowed.
Immodium was started to improve loose stools even more. f/u with
GI planned, but etiology presumed to be infectious.
.
# Acute Renal Failure: Baseline Cr was 0."
2139,"He tried
to keep up with oral fluids but then started feeling weak all
over with muscle cramps and so decided to come to ED.
He initially presented to [**Hospital3 3583**] today with complaint
of possible reaction to seroquel and weakness. He also
complained of body aches, N/V, diarrhea, and back pain. Rectal
exam at OSH showed BRB in rectum. labs there were consistent
with possible septic shock with WBC 20, ABG: pH 7.11/36/143 HCO3
10. Hct 61, ammonia 250. Also had ARF with creatinine 5.0 and
only 5cc UOP at [**Hospital1 46**]. He then complained of [**6-25**] chest pain
and had a non-con CT scan to rule out dissection."
2140,"Admission Date: [**2174-1-26**] Discharge Date: [**2174-2-1**]
Date of Birth: [**2100-4-4**] Sex: M
Service: SURGERY
Allergies:
Cipro
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2174-1-26**]: Open abdominal aortic aneurysm repair
History of Present Illness:
73yom with enlarging AAA presents for elective open AAA repair.
Past Medical History:
Hypercholesterolemia, multiple skin cancers, (basal/squamous),
depression.
PAST SURGICAL HISTORY: Left knee meniscus repair many years ago.
cystoscopy with kidney stone removal, multiple Mohs micrographic
surgery for skin cancers.
Social History:
The patient lives alone. He cares for his wife who has multiple
sclerosis."
2141,"She does live independently, however. He has
several children who live locally and in other countries.
He continues to smoke a pack of cigarettes daily.
He uses alcohol occasionally.
Family History:
CAD/MI
no known aneurysmal disease
Physical Exam:
tm 99.1 t 98.1 hr 82 bp 137/88 rr 18 02 96% ra
Gen: WDWN male in NAD. Alert and Oriented x 3
Card: RRR
Lungs: CTA bilat
Abd: Soft, incision c/d/i, non tender
Extremities: Warm, well perfused, slightly edematous
Pulses: Dp/Pt palpable bilat
Pertinent Results:
[**2174-2-1**] 09:05AM BLOOD WBC-8.0 RBC-3."
2142,"On
POD 2 he was out of bed to chair and began sips. He was
transferred to the vicu. He became confused and agitated and was
started on a CIWA scale. Overnight he was a bit more confused
and had a hct of 21.9. He was transfused 2 units prbcs for acute
blood loss anemia in the post op setting. Over the next few days
his confusion and agitation completely resolved. He was diuresed
for volume overload and responded appropriately. He was
transfused an additional 2 units prbc with appropriate bump in
h/h. He continued to do well, voiding when his foley was
removed, tolerating a regular diet and ambulating independently."
2143,"Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Abdominal Aortic Aneurysym
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-10**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!"
2144,"5 cTropnT-<0.01
[**2174-1-27**] 06:45AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES NEGATIVE
COMMENT: NEGATIVE PF4 HEPARIN ANTIBODY BY [**Doctor First Name **]
Complete report on file in the laboratory.
[**2174-1-26**] 5:11 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2174-1-29**]**
MRSA SCREEN (Final [**2174-1-29**]): No MRSA isolated.
Brief Hospital Course:
Mr. [**Known lastname 4894**] was admitted and taken for open AAA repair on [**1-26**].
He was transferred to the cvicu postoperatively and was neo gtt.
He remained intubated overnight and on POD 1 extubated. His neo
gtt was weaned off and he remained hemodynamically stable."
2145,"44*# Hgb-11.6*# Hct-31.6*
MCV-92 MCH-33.7* MCHC-36.6* RDW-15.4 Plt Ct-203#
[**2174-2-1**] 09:05AM BLOOD Glucose-107* UreaN-21* Creat-0.8 Na-142
K-4.4 Cl-104 HCO3-34* AnGap-8
[**2174-2-1**] 09:05AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.2
[**2174-1-26**] 05:10PM BLOOD CK-MB-6 cTropnT-<0.01
[**2174-1-27**] 02:15AM BLOOD CK-MB-20* MB Indx-0.8 cTropnT-<0.01
[**2174-1-27**] 09:48AM BLOOD CK-MB-13* MB Indx-0."
2146,"His wound was a bit oozy and was kept covered with a dsd. He is
discharged on 5 days of lasix. He will be set up with a VNA for
wound check and lab draws on friday.
Medications on Admission:
simvastatin - unknown dose
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
resume home dose.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4."
2147,"Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
5. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 5 days.
Disp:*5 Tablet Extended Release(s)* Refills:*0*
6. Outpatient Lab Work
CHEM 7 to be drawn friday [**2-4**]
results to:
Name: [**Last Name (LF) **],[**First Name3 (LF) 198**] P.
Location: [**Location (un) **] FAMILY PRACTICE
Address: [**Street Address(2) 19979**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 19980**]
Fax: [**Telephone/Fax (1) 19981**]
7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain."
2148,"????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?"
2149,"????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2174-2-17**] 10:15
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD Phone:[**Telephone/Fax (1) 3965**]
Date/Time:[**2174-5-2**] 9:30
Completed by:[**2174-2-1**]"
2150,"2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-4**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?"
2151,"Admission Date: [**2153-4-30**] Discharge Date: [**2153-5-6**]
Date of Birth: [**2081-10-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional dyspnea
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x2 with
left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft to the ramus
intermedius
History of Present Illness:
Patient presented with increasing
dyspnea, given multiple cardiac risk factors had ETT which was
positive
Past Medical History:
Coronary artery disease, Hypertension,
Diabetes mellitus type 2, hyperlipidemia, Gout
End stage renal disease on hemodialysis x2 years(M-W-F)Dr
[**Last Name (STitle) 11427**] is nephrologist."
2152,"**Awaiting renal transplant**
Social History:
Lives with: wife
Occupation: retired from [**Company **]
Tobacco: cigar 1/wk
ETOH: none
Drugs: none
Family History:
Both parents w/MI Mother died @66, father died
@72. Sister colon CA, Sister-leukemia, Brother prostate CA,
[**Name (NI) 50273**]
Physical Exam:
Pulse: 72 Resp: 20 O2 sat:
B/P Right: 122/66 Left: deferred AV fistula
Height: 5'8"" Weight: 125.2 Kg 258 lbs
General: NAD-obese
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
Abdomen: Soft[x] non-distended[x] non-tender[x]
bowel sounds + [x]
Extremities: Warm [x], well-perfused [] Edema: none
Varicosities: None [] mild
Neuro: Grossly intact, non focal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Left AV fistula with thrill"
2153,"Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. He
was maintained on his regular M/W/F hemodialysis schedule. 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. He
did have several episodes of rate controlled atrial
fibrillation. His beta-blocker was titrated and amiodarone was
initiated. Anti-coagulation was initiated with coumadin. By
the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics."
2154,"Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Dose
to change daily for goal INR [**1-10**] for atrial fibrillation. First
INR [**2153-5-8**] with results to cardiac surgery [**Telephone/Fax (1) 170**].
Disp:*30 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Serial PT/INR
dx: atrial fibrillation
goal INR [**1-10**]
Results to Cardiac Surgery [**Telephone/Fax (1) 170**]
1st draw Tues. [**2153-5-8**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease, Hypertension,
Diabetes mellitus type 2, hyperlipidemia, Gout
End stage renal disease on hemodialysis x2 years(M-W-F)Dr
[**Last Name (STitle) 11427**] is nephrologist."
2155,"**Awaiting renal transplant**
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
2156,"Answering service will contact on call
person during off hours
Followup Instructions:
Dr. [**Last Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6254**] in 3 weeks [**Telephone/Fax (1) 6256**]
Dr. [**First Name8 (NamePattern2) 12334**] [**Last Name (NamePattern1) 50274**] in 2 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**
**First INR draw [**2153-5-8**], results to cardiac surgery
[**Telephone/Fax (1) 170**]**
Completed by:[**2153-5-6**]"
2157,"5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for acute gout flair.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day.
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Hydrocortisone 5 mg Tablet Sig: 2."
2158,"7 Phos-6.4*# Mg-2.6
[**2153-5-4**] 05:22AM BLOOD Calcium-9.7 Phos-9.3*# Mg-2.5
Brief Hospital Course:
The patient was brought to the operating room on [**2153-5-3**] where
the patient underwent coronary artery bypass x 4. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Vancomycin was used for surgical
antibiotic prophylaxis. POD 1 found the patient extubated,
alert and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support."
2159,"Carotid Bruit Right: no Left: yes
Pertinent Results:
[**2153-5-4**] 05:22AM BLOOD WBC-10.7 RBC-3.49* Hgb-11.2* Hct-34.6*
MCV-99* MCH-32.1* MCHC-32.3 RDW-15.0 Plt Ct-274
[**2153-5-1**] 06:45PM BLOOD PT-13.3 PTT-28.3 INR(PT)-1.1
[**2153-5-5**] 09:20AM BLOOD Glucose-217* UreaN-47* Creat-7.0*# Na-136
K-5.0 Cl-94* HCO3-29 AnGap-18
[**2153-5-4**] 05:22AM BLOOD Glucose-136* UreaN-59* Creat-8.7*# Na-133
K-5.6* Cl-92* HCO3-26 AnGap-21*
[**2153-5-5**] 09:20AM BLOOD Calcium-9."
2160,"The patient was discharged to home in good
condition with appropriate follow up instructions.
Medications on Admission:
Metoprolol 25"", Lisinopril 40', Amlopidine
10', ASA 81', Clonidine 0.2 @HS/prn, Pravastatin 40',
Allopurinol
100', Colchicine 0.6', Actos 45', Nephrocaps 1', Phoslo 667''',
Hydrocortisone 12.5'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
2161,"5 Tablets PO DAILY
(Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily.
Disp:*120 Tablet(s)* Refills:*2*
15."
2162,"CVICU
HPI:
HD11 POD 4-redo sternotomy/MVR(29 StJude Epic Porcine)
Ejection Fraction:75(preop)
Hemoglobin A1c:7.0
Pre-Op Weight:156.53 lbs 71 kgs
Baseline Creatinine:1.3
PMH: hypertension, pulmonary hypertension, mitral stenosis, chronic
diastolic heart failure, s/p mitral valve replacement
(bioprosthetic)[**2097**], post-op atrial fibrillation, s/p radiofrequency
ablation, sick sinus syndrome, s/p pacemaker [**2097**], hypothyroidism,
multiple myeloma, chronic renal insufficiency, paralyzed right
hemidiaphragm, raynaud's disease, gastroesophageal reflux disease
PSH: mitral valve replacement [**2097**], permanent pacemaker [**2097**] ([**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 12752**] Model #5376), right total knee replacement, left lower
extremity vein ligation
[**Last Name (un) **]: levoxyl 25', ambien 5/prn, norvasc 2."
2163,"Still
significant fluid overload. Will d/c nesiritide and continue lasix.
Will add diamox for alkalosis
Hematology: Serial Hct
Endocrine: RISS
Infectious Disease: Check cultures, No evidence of infection
Lines / Tubes / Drains: Foley
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: CT surgery
Billing Diagnosis: Post-op hypotension, Post-op complication, Acute
renal failure
ICU Care
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2104-12-16**] 04:00 PM
CCO PAC - [**2104-12-16**] 04:00 PM
Cordis/Introducer - [**2104-12-16**] 04:00 PM
Indwelling Port (PortaCath) - [**2104-12-18**] 10:47 AM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status:
Disposition: ICU
Total time spent: 32 minutes
Patient is critically ill"
2164,"jpg]
[**2104-12-18**] 12:59 AM
[**2104-12-18**] 03:00 AM
[**2104-12-18**] 03:26 AM
[**2104-12-18**] 12:37 PM
[**2104-12-18**] 12:43 PM
[**2104-12-18**] 05:26 PM
[**2104-12-19**] 02:16 AM
[**2104-12-19**] 11:13 AM
[**2104-12-19**] 11:23 AM
[**2104-12-20**] 01:08 AM
WBC
18.7
12.8
12.7
11.3
Hct
29
30.7
27.4
23
26.0
27.0
Plt
[**Telephone/Fax (3) 12798**]32
Creatinine
2.1
2.4
2.4
1.8
TCO2
25
27
27
Glucose
151
147
147
124
113
110
118
Other labs: PT / PTT / INR:13."
2165,"m.
HR: 86 (74 - 91) bpm
BP: 121/53(72) {102/41(57) - 145/60(86)} mmHg
RR: 19 (13 - 29) insp/min
SPO2: 100%
Heart rhythm: V Paced
Wgt (current): 76 kg (admission): 71 kg
Height: 65 Inch
CVP: 3 (3 - 22) mmHg
PAP: (65 mmHg) / (24 mmHg)
CO/CI (Fick): (4.6 L/min) / (2.6 L/min/m2)
CO/CI (CCO): (4.9 L/min) / (3.5 L/min/m2)
SvO2: 60%
Mixed Venous O2% sat: 65 - 65
Total In:
1,741 mL
79 mL
PO:
640 mL
Tube feeding:
IV Fluid:
1,101 mL
79 mL
Blood products:
Total out:
4,855 mL
1,025 mL
Urine:
4,855 mL
1,025 mL
NG:
Stool:
Drains:
Balance:
-3,114 mL
-946 mL
Respiratory support
O2 Delivery Device: None
SPO2: 100%
ABG: 7."
2166,"Calcium Gluconate 9.
Docusate Sodium 10. Furosemide 13. Insulin 14. Levothyroxine Sodium 15.
Magnesium Sulfate 16. Metoclopramide 18. Milrinone 19. Morphine Sulfate
20. Nesiritide 21. Oxycodone-Acetaminophen 22. Pneumococcal Vac
Polyvalent 24. Ranitidine
24 Hour Events:
TEMPORARY PACEMAKER WIRES DISCONTINUED - At [**2104-12-19**] 10:15 AM
Post operative day:
POD#4 - Redo mitral valve.
Allergies:
Keflex (Oral) (Cephalexin Monohydrate)
Hives;
Penicillins
Hives;
Last dose of Antibiotics:
Vancomycin - [**2104-12-17**] 10:00 PM
Infusions:
Milrinone - 0.12 mcg/Kg/min
Nesiritide - 0.01 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2104-12-19**] 10:05 AM
Other medications:
Flowsheet Data as of [**2104-12-20**] 07:46 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**06**] a."
2167,"5',
on admission:lorazepam 0.5 q6/prn, amiodarone 200', asa 81', bisacodyl
10', mylanta 30 q4/prn, ambien 5/prn, enoxaparin 40 hs,
Events:
[**2104-12-19**] lasix gtt d/c'd, weaning milrinone. much improved fluid
status, cre stable 2.4
[**2104-12-18**] Lasix to 15, Natricor started. Renal on board.Echo for RV fxn,
d/c CT.
[**2104-12-17**] Extubated, epi, vasopressin weaned off, milrinone kept on -
swan left in
[**2104-12-16**] OR-
Assessment:76yoW s/p redo sternotomy/MVR(29 StJude Epic Porcine)[**12-16**]
Current medications:
1. Acetaminophen 5. Amiodarone 6. Aspirin EC 7."
2168,"48///31/
Physical Examination
General Appearance: No acute distress
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: bases)
Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
132 K/uL
9.1 g/dL
118 mg/dL
1.8 mg/dL
31 mEq/L
4.1 mEq/L
48 mg/dL
99 mEq/L
137 mEq/L
27.0 %
11.3 K/uL
[image002."
2169,"6/47.0/1.2, ALT / AST:21/36, Alk-Phos / T
bili:57/1.1, Amylase / Lipase:91/12, Lactic Acid:1.4 mmol/L,
Albumin:3.1 g/dL, LDH:406 IU/L, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:6.1
mg/dL
Assessment and Plan
VALVE REPLACEMENT, MITRAL BIOPROSTHETIC (MVR), MITRAL REGURGITATION
(MITRAL INSUFFICIENCY)
Assessment and Plan: Resolving [**Last Name (un) **]. Still on milrinone and nesiritide.
Neurologic: Neuro checks Q: 4 hr, Pain controlled
Cardiovascular: Aspirin, Start statin. Wean milrinone
Pulmonary: IS, OOB and CPT
Gastrointestinal / Abdomen:
Nutrition: Regular diet
Renal: Foley, Adequate UO, 3 liters negative yesterday."
2170,"She is transferred for
cardiac surgery evaluation.
Past Medical History:
Mitral Stenosis
Hypertension
Pulmonary hypertension
Chronic diastolic heart failure
s/p mitral valve replacement (bioprosthetic) [**2097**] with post-op
atrial fibrillation s/p radiofrequency ablation
Sick sinus syndrome s/p pacemaker [**2097**]
Hypothyroidism
Multiple myeloma
Chronic renal insufficiency
Paralyzed right hemidiaphragm
Raynaud's disease
Gastroesophageal reflux disease
Right total knee replacement
Left lower extremity vein ligation
Social History:
Last Dental Exam: [**2104-9-28**], Dr. [**Last Name (STitle) 83783**], [**Location (un) 12017**], NH
Lives with: husband
Occupation: -
[**Name2 (NI) 1139**]: denies
ETOH: denies
Family History:
mom 42 colon ca
dad 56 HOCM"
2171,"7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 83785**] Pines
Discharge Diagnosis:
Mitral valve stenosis s/p Redo-Sternotomy, Mitral valve
replacement
Past medical history:
Hypertension
Pulmonary hypertension
Chronic diastolic heart failure
s/p mitral valve replacement (bioprosthetic) [**2097**] with post-op
atrial fibrillation s/p radiofrequency ablation
Sick sinus syndrome s/p pacemaker [**2097**]
Hypothyroidism
Multiple myeloma
Chronic renal insufficiency
Paralyzed right hemidiaphragm
Raynaud's disease
Gastroesophageal reflux disease"
2172,"7
liters/minute. The tricuspid regurgitation is significantly
improved and is now mild. The aortic valve is unchanged. The
thoracic aorta appears intact.
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 83784**]
Final Report
PA AND LATERAL CHEST RADIOGRAPHS: Comparison is made to multiple
prior
radiographs, most recently [**12-15**] and [**2104-12-18**]. Lung
volumes
remain low without evidence of pneumothorax and with unchanged
positioning to left-sided pacemaker and right Port-A-Cath. Left
pleural effusion has
increased in the interval with expected probable adjacent
compression
atelectasis. Mild right basilar atelectasis is improved with
stable
eventration of the hemidiaphragms."
2173,"Vasopressin was added and Levophed was weaned to off on the
operative day. On the morning of POD1 sedation was weaned and
she was extubated. She was continued on milronone until post
operative day 4 due to right ventricular dysfunction. She did
have acute tubular nephrosis with a peak creatinine of 2.4. The
renal team was consulted. The patient was started on Natrecor
and Lasix drips with increased diuresis. The drips were
discontinued on post operative day 4 and she continued to
diurese with Lasix daily. Her renal function continued to
improve with creatinine returning to baseline prior to
discharge."
2174,"The right ventricular cavity
is dilated with mild hypokinesis of the basilar portion but
severe mid and apical free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. There are simple atheroma in the
aortic arch. There are focal calcifications in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. The non-coronary cusp is immobilized.
There is mild to moderate aortic valve stenosis (valve area 1.3
cm2). Trace aortic regurgitation is seen."
2175,"Chest tubes and pacing wires were removed per cardiac
surgery protocol. Physical therapy worked with her to improve
strength and endurance. She was transferred to the floor on
post operative day 6 (held in the unit one extra day due to bed
availability). The patient continued to progress slowly with
physical therapy and was found ready for transfer to rehab on
POD 8.
Medications on Admission:
At home: Levoxyl 25mcg', Ambien 5 prn, Norvasc 2.5'
On admission: Lorazepam 0.5 q6h prn, Amiodarone 200', Aspirin
81', Bisacodyl 10', Mylanta 30 q4h prn, Ambien 5 prn, Enoxaparin
40 hs, Acetylcysteine 600mg 2 doses, Lasix 40 x1"
2176,"Admission Date: [**2104-12-10**] Discharge Date: [**2104-12-24**]
Date of Birth: [**2028-4-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2104-12-16**] Redo-Sternotomy, Mitral Valve Replacement
History of Present Illness:
76F who underwent MVR in [**2097**] has developed progressive fatigue
and dyspnea since [**2104-7-29**]. She also developed lower
extremity edema. She was found to have severe MS [**First Name (Titles) **] [**Last Name (Titles) 113**] as
well as 3+MR and pulmonary htn with PA pressures in the 50s.
She underwent cardiac catheterization and coronary angiography
in preparation for cardiac surgery."
2177,"2m/s). The
right atrium is dilated. No atrial septal defect is seen by 2D
or color Doppler. The coronary sinus is dilated (diameter
>15mm). Injection of agitated saline into the left upper
extremity appeared in the right atrium through the superior vena
cava, ruling out a persistent left SVC. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely not as
good given the severity of valvular regurgitation.] Left
ventricular dysnchrony is present."
2178,"There
is a large left pleural effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results in the operating room at the time of the
study.
POST BYPASS The patient is being AV placed. The patient is
receiving milrinone, epinephrine, and norepinephrine by
infusion. The right ventricle displays improved systolic
function with mild free wall hypokinesis. The left ventricle is
hyperdynamic with an ejection fraction near 75 to 80%. There is
a bioprosthesis in the mitral position. It appears well seated
with normal leaflet function. There is trace valvular mitral
regurgitation. No perivalvular regurgitation is seen. The
maximum gradient through the mitral valve is 12 mmHg with a mean
gradient of 5 mmHg at a cardiac output of about 5."
2179,"4 Cl-97 HCO3-34* AnGap-11
[**2104-12-11**] Carotid U/S: No significant carotid artery stenosis
identified(less than 40% on the right, none on the left).
[**2104-12-16**] [**Month/Day/Year **]: PRE BYPASS The left atrium is markedly dilated.
The left atrium is elongated. Mild spontaneous [**Month/Day/Year 113**] contrast is
seen in the body of the left atrium. No mass/thrombus is seen in
the left atrium or left atrial appendage. Mild spontaneous [**Month/Day/Year 113**]
contrast is present in the left atrial appendage. The left
atrial appendage emptying velocity is depressed (<0."
2180,"Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 83786**] pain managed with percocet prn
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**1-22**] at 1:00 PM
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) 83787**] in [**11-29**] weeks [**Telephone/Fax (1) 10026**]
Cardiologist Dr. [**Last Name (STitle) 83788**] in [**11-29**] weeks
Completed by:[**2104-12-24**]"
2181,"7
[**2104-12-10**] 07:45PM GLUCOSE-212* UREA N-36* CREAT-1.4* SODIUM-138
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
[**2104-12-22**] 05:49AM BLOOD WBC-9.1 RBC-3.33* Hgb-9.6* Hct-30.2*
MCV-90 MCH-28.6 MCHC-31.7 RDW-16.1* Plt Ct-258
[**2104-12-22**] 05:49AM BLOOD Plt Ct-258
[**2104-12-18**] 03:00AM BLOOD PT-13.6* PTT-47.0* INR(PT)-1.2*
[**2104-12-22**] 05:49AM BLOOD Glucose-94 UreaN-29* Creat-1.0 Na-138
K-4."
2182,"Carotid Bruit Right: Left: no carotid bruits
Pertinent Results:
[**2104-12-10**] 07:45PM PT-13.7* PTT-58.1* INR(PT)-1.2*
[**2104-12-10**] 07:45PM PLT COUNT-467*
[**2104-12-10**] 07:45PM WBC-8.9 RBC-4.00* HGB-10.9* HCT-35.6* MCV-89
MCH-27.2 MCHC-30.6* RDW-14.3
[**2104-12-10**] 07:45PM %HbA1c-7.0*
[**2104-12-10**] 07:45PM ALBUMIN-3.7 CALCIUM-8.8 PHOSPHATE-3.4
MAGNESIUM-1.9
[**2104-12-10**] 07:45PM ALT(SGPT)-47* AST(SGOT)-44* LD(LDH)-306* ALK
PHOS-77 TOT BILI-0."
2183,"The prosthetic mitral
valve leaflets are thickened. Motion of the prosthetic mitral
valve leaflets is abnormal. The leaflets appear to be fused at
their bases. The gradients are higher than expected for this
type of prosthesis. There is severe valvular mitral stenosis
(area <1.0cm2). Moderate (2+) mitral regurgitation is seen. The
valve ring appears somewhat more mobile than expected but there
is no perivalvualr leak and no evidence of dehiscence. The
tricuspid valve leaflets are mildly thickened. The tricuspid
regurgitation is at least mild to moderate. At times it may be
slightly worse and emanates from the center of the valve."
2184,"Cardiac silhouette remains
enlarged with no other change to mediastinal and hilar contours.
The epicardial pacing leads as well as right central venous line
have been removed in the interval.
Degenerative changes involving the right humeral head are again
noted.
IMPRESSION:
Marked interval increase in size to moderate left pleural
effusion and small right pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
76F who underwent mitral valve replacement in [**2097**] who had
developed progressive fatigue and dyspnea since [**2104-7-29**]."
2185,"She also developed lower extremity edema. She was found to have
severe MS [**First Name (Titles) **] [**Last Name (Titles) 113**] as well as 3+MR and pulmonary hypertension
with PA pressures in the 50s. She underwent cardiac
catheterization at outside hospital, which showed no coronary
artery disease. She was transferred to [**Hospital1 18**] and on [**2104-12-16**]
underwent a redo sternotomy and redo mitral valve replacement
with a 29-mm St. [**Hospital 923**] Medical Biocor tissue valve. Her bypass
time was 108 minutes with a crossclamp time of 66 minutes. See
operative note for full details. She tolerated the operation
but required inotropic and pressor support post operatively, she
was transferred from the operating room to the cardiac surgery
ICU in stable condition on epinephrine, Milrinone and Levophed."
2186,"Physical Exam:
Pulse: 98 Resp: 20 O2 sat: 98%2L
B/P Right: 122/82 Left:
Height: 5'5"" Weight: 157lb
General:
Skin: Dry [x] intact [x]
well healed median sternotomy incision
right upper chest- port-a-cath
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] crackles at bases
Heart: RRR [x] Irregular [] Murmur soft systolic and diastolic
murmurs
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 2+ Varicosities:
small varicosities b/l LEs None []
Neuro: Grossly intact X
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: Left: not palpable [**12-30**] edema
Radial Right: 2+ Left: 2+"
2187,"Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain."
2188,"Start 40mg lasix IV
BID. wean nesiritide.
Hematology: Stable anemia
Endocrine: RISS, Blood glucose well controlled
Infectious Disease: No signs of infection
Lines / Tubes / Drains: Foley, Pacing wires, Discontinue pericardial
pacing wires
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: CT surgery, Nephrology
Billing Diagnosis: Post-op hypotension, Acute renal failure
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2104-12-16**] 04:00 PM
CCO PAC - [**2104-12-16**] 04:00 PM
Cordis/Introducer - [**2104-12-16**] 04:00 PM
Indwelling Port (PortaCath) - [**2104-12-18**] 10:47 AM
Prophylaxis:
DVT:
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: ICU consent signed Comments:
Code status:
Disposition: ICU
Total time spent: 33 minutes"
2189,"4 %
12.8 K/uL
[image002.jpg]
[**2104-12-17**] 10:15 PM
[**2104-12-17**] 11:42 PM
[**2104-12-18**] 12:54 AM
[**2104-12-18**] 12:59 AM
[**2104-12-18**] 03:00 AM
[**2104-12-18**] 03:26 AM
[**2104-12-18**] 12:37 PM
[**2104-12-18**] 12:43 PM
[**2104-12-18**] 05:26 PM
[**2104-12-19**] 02:16 AM
WBC
18.7
12.8
Hct
32
29
30.7
27.4
Plt
208
150
Creatinine
2.1
2.4
2.4
TCO2
29
27
27
25
27
27
Glucose
120
151
147
147
124
113
Other labs: PT / PTT / INR:13."
2190,"Furosemide 15. Insulin 16. Levothyroxine 17. Magnesium Sulfate 18.
Metoclopramide 20. Milrinone 21. Morphine Sulfate 22. Nesiritide 24.
Oxycodone-Acetaminophen 27. Ranitidine
24 Hour Events:
INDWELLING PORT (PORTACATH) - START [**2104-12-18**] 10:47 AM
CHEST TUBE REMOVED - At [**2104-12-18**] 11:30 AM
TRANSTHORACIC ECHO - At [**2104-12-18**] 01:50 PM
Post operative day:
POD#3 - Redo mitral valve.
Allergies:
Keflex (Oral) (Cephalexin Monohydrate)
Hives;
Penicillins
Hives;
Last dose of Antibiotics:
Vancomycin - [**2104-12-17**] 10:00 PM
Infusions:
Nesiritide - 0.01 mcg/Kg/min
Milrinone - 0.25 mcg/Kg/min
Other ICU medications:
Other medications:
Flowsheet Data as of [**2104-12-19**] 08:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**06**] a."
2191,"40/42/89.[**Numeric Identifier 126**]/27/0
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), V-paced
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
bilateral), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: 2+), (Pulse - Dorsalis pedis: Present)
Right Extremities: (Edema: 2+), (Pulse - Dorsalis pedis: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
150 K/uL
8.8 g/dL
113 mg/dL
2.4 mg/dL
27 mEq/L
3.4 mEq/L
55 mg/dL
97 mEq/L
133 mEq/L
27."
2192,"m.
HR: 74 (73 - 84) bpm
BP: 123/54(72) {104/45(62) - 140/61(84)} mmHg
RR: 21 (9 - 25) insp/min
SPO2: 100%
Heart rhythm: V Paced
Wgt (current): 77.5 kg (admission): 71 kg
Height: 65 Inch
CVP: 18 (7 - 22) mmHg
PAP: (61 mmHg) / (23 mmHg)
CO/CI (Fick): (6.5 L/min) / (3.7 L/min/m2)
CO/CI (CCO): (5.9 L/min) / (2.9 L/min/m2)
SvO2: 71%
Total In:
1,732 mL
548 mL
PO:
950 mL
240 mL
Tube feeding:
IV Fluid:
782 mL
308 mL
Blood products:
Total out:
1,449 mL
2,140 mL
Urine:
1,189 mL
2,140 mL
NG:
Stool:
Drains:
Balance:
283 mL
-1,592 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 100%
ABG: 7."
2193,"CVICU
HPI:
resolving ARF and hypotension s/p redo MVR
Chief complaint:
PMHx:
hypertension, pulmonary hypertension, mitral stenosis, chronic
diastolic heart failure, s/p mitral valve replacement
(bioprosthetic)[**2097**], post-op atrial fibrillation, s/p radiofrequency
ablation, sick sinus syndrome, s/p pacemaker [**2097**], hypothyroidism,
multiple myeloma, chronic renal insufficiency, paralyzed right
hemidiaphragm, raynaud's disease, gastroesophageal reflux disease
PSH: mitral valve replacement [**2097**], permanent pacemaker [**2097**] ([**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 12752**] Model #5376), right total knee replacement, left lower
extremity vein ligation
Current medications:
Acetaminophen 5. Amiodarone 6. Aspirin EC 9. Docusate Sodium 10."
2194,"6/47.0/1.2, ALT / AST:21/36, Alk-Phos / T
bili:57/1.1, Amylase / Lipase:91/12, Lactic Acid:1.4 mmol/L,
Albumin:3.1 g/dL, LDH:406 IU/L, Ca:8.2 mg/dL, Mg:2.3 mg/dL, PO4:6.1
mg/dL
Assessment and Plan
VALVE REPLACEMENT, MITRAL BIOPROSTHETIC (MVR), MITRAL REGURGITATION
(MITRAL INSUFFICIENCY)
Assessment and Plan: 76yoW POD#3 s/p redo sternotomy/MVR
Neurologic: Pain controlled, Percocet prn
Cardiovascular: Aspirin, Discontinue epicardial wires, Wean milrinone.
V-paced via permanent pacer
Pulmonary: IS, OOB/IS, wean supplemental oxygen
Gastrointestinal / Abdomen: Bowel regimen
Nutrition: Full liquids, advance diet as tolerates
Renal: Foley, Adequate UO, discontinue lasix drip."
2195,"Non focal neuro exam at OSH. Transferred to [**Hospital1 18**] for
neurosurgical evaluation. In our emergency [**Hospital1 **] her pain was
resolving, but she had received pain medications. She had no
focal symptoms.
Past Medical History:
Lyme disease
chronic left facial nerve palsy
hypothyroidism
pheochromocytoma: s/p right adrenelectomy
mastocytosis
Social History:
Social Hx:
smokes
married with grown children
Physical Exam:
PHYSICAL EXAM:
96.6 70 145/84 16 99% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:bilaterally reactive to light
EOMs: Intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused."
2196,"Disp:*6 Tablet(s)* Refills:*0*
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
4. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days.
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily."
2197,"????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please make an appointment to see Dr. [**First Name (STitle) **] in 4 weeks with a
noncontrast head CT
Completed by:[**2146-3-26**]"
2198,"[**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 [**6-16**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Brief Hospital Course:
Ms. [**Known lastname 67042**] was evaluated in the ED and admitted to the
neurosurgery service for further workup.
Her initial CTA was negative for an underlying vascular lesion
as the source of the SAH."
2199,"????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?"
2200,"Admission Date: [**2146-3-22**] Discharge Date: [**2146-3-26**]
Date of Birth: [**2094-7-28**] Sex: F
Service: NEUROSURGERY
Allergies:
Tegretol / Gluten
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
51F with worst headache of life at 1 pm today after smoking a
cigarrete and having lunch. HA was global, involved back of
neck,
and was worse with flexing neck. She had nausea and vomited
multiple times. No change in vision/balance/motor strength.
Outside ED- CT head showed SAH layering in interpenduncular
fossa
and basilar cisterns with some extension into the propontine
space. Non focal neuro exam at OSH."
2201,"Transferred to [**Hospital1 18**] for
neurosurgical evaluation. In our emergency [**Hospital1 **] her pain was
resolving, but she had received pain medications. She had no
focal symptoms.
Major Surgical or Invasive Procedure:
Cerebral Angiogram [**3-23**]
History of Present Illness:
51F with worst headache of life at 1 pm today after smoking a
cigarrete and having lunch. HA was global, involved back of
neck,
and was worse with flexing neck. She had nausea and vomited
multiple times. No change in vision/balance/motor strength.
Outside ED- CT head showed SAH layering in interpenduncular
fossa
and basilar cisterns with some extension into the propontine
space."
2202,"?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
?????? You may restart your premrin on discharge
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?"
2203,"No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-14**] objects at 5 minutes.
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, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Mild left sided facial droop. Otherwise facial strength
and sensation intact.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical."
2204,"On the morning after her admission
she underwent a formal angiogram that revealed that there was no
underlying anomoly.
Patient was taken to angio on [**3-23**] where no aneurysm or vascular
anomolies were found. Post operatively patient was
neurologically stable. On [**3-24**], she was transferred to the
stepdown unit.
She continued to do well on the floor and was seen by physical
therapy team. She was cleared for discharge home. She will be
DC'd home in stable condition on [**2146-3-26**].
Medications on Admission:
levoxil, spirvia, pempril, multi-vit, trazadone
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
2205,"LEFT VERTEBRAL ARTERY ANGIOGRAM:
Selective injection of the left vertebral artery demonstrated brisk filling.
(Over)
[**2146-3-23**] 2:22 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 5089**]
Reason: 51 year old woman with SAH, WHOL yesterday,r/o vascular anom
Admitting Diagnosis: SUBARACHNOID HEMORRHAGE
Contrast: OPTIRAY Amt: 207
______________________________________________________________________________
FINAL REPORT
(Cont)
The vertebral and basilar arteries and branches are patent. The capillary and
venous phases were unremarkable. No dural AV fistula
RIGHT COMMON CAROTID ARTERY ANGIOGRAM:
Selective injection of the right common carotid artery demonstrates brisk
filling of the external and the internal carotid arteries. There is minimal
narrowing at the origin of the right internal carotid artery which is not flow
limiting."
2206,"RIGHT INTERNAL CAROTID ARTERY:
The right internal carotid artery demonstrates non-flow-limiting minimal
stenosis at its origin. No abnormality otherwise seen in the course of the
right internal carotid artery. The ACA and MCA branches are patent. No
aneurysm, AVM or fistula was noted.
LEFT COMMON CAROTID ARTERY:
Selective injection of the left common carotid artery demonstrates brisk
filling of the external and internal carotid arteries and ACA and MCA
branches. No aneurysm, AVM or fistula was noted.
RIGHT VERTEBRAL ARTERY:
Selective injection of the right vertebral artery demonstrates brisk filling.
The vertebral and basilar arteries and branches are patent."
2207,"The capillary and
venous phases were unremarkable. No dural AV fistula.
RIGHT COMMON FEMORAL ARTERY ANGIOGRAM:
The right common femoral artery angiogram did not demonstrate any significant
flow limiting stenosis within the vessels.
Puncture site was closed with an Angio-Seal closure device. The patient
tolerated the procedure well. There were no immediate complications. The
patient was sent to ICU with post-procedure orders.
IMPRESSION:
Cerebral angiogram without evidence of a significant flow limiting stenosis,
aneurysm, or an AVM. No immediate post-procedure complications.
(Over)
[**2146-3-23**] 2:22 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 5089**]
Reason: 51 year old woman with SAH, WHOL yesterday,r/o vascular anom
Admitting Diagnosis: SUBARACHNOID HEMORRHAGE
Contrast: OPTIRAY Amt: 207
______________________________________________________________________________
FINAL REPORT
(Cont)"
2208,"The patient was
brought to the neuro-interventional suite and placed in supine position on the
angiography table. A preprocedure huddle and timeout was performed as per
[**Hospital1 51**] protocol. The patient was draped and prepped in the usual sterile
fashion. Using a micropuncture set, intra-arterial access was obtained into
the right femoral artery. The above-mentioned vessels were selected, and
angiogram were performed in the AP, lateral, and oblique projections with
three-dimensional rotation acquisitions where appropriate.
There were no immediate complications of the procedure. The patient was sent
back to the ICU with post-procedure orders.
FINDINGS:"
2209,"PROCEDURE: Cerebral angiogram.
PHYSICIANS: Dr. [**First Name (STitle) 2359**] [**Name (STitle) 2360**] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
SEDATION: Moderate sedation was provided by administering three divided doses
of fentanyl (100 mcg) and single dose of Versed (1 mg), throughout the total
intraservice time of 40 minutes during which patient's hemodynamic parameters
were continuously monitored.
VESSELS SELECTED: Left vertebral artery, right internal carotid artery, right
common carotid artery, left common carotid artery, right vertebral artery and
right common femoral artery.
TECHNIQUE: Informed consent was obtained from the patient after explaining
the risks, indications and alternative to the procedure."
2210,"[**2146-3-23**] 2:22 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 5089**]
Reason: 51 year old woman with SAH, WHOL yesterday,r/o vascular anom
Admitting Diagnosis: SUBARACHNOID HEMORRHAGE
Contrast: OPTIRAY Amt: 207
********************************* CPT Codes ********************************
* [**Numeric Identifier 285**] SEL CATH 3RD ORDER [**Last Name (un) 286**] [**Numeric Identifier 287**] SEL CATH 2ND ORDER *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 820**] ADD'L 2ND/3RD ORDER *
* [**Numeric Identifier 288**] CAROTID/CEREBRAL BILAT [**Numeric Identifier 821**] CAROTID/CERVICAL BILAT *
* [**Numeric Identifier 289**] VERT/CAROTID A-GRAM [**Numeric Identifier 44**] MOD SEDATION, FIRST 30 MIN. *
* [**Numeric Identifier 45**] MOD SEDATION, EACH ADDL 15 MIN *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
51 year old woman with SAH, WHOL yesterday,r/o vascular anomoly
REASON FOR THIS EXAMINATION:
51 year old woman with SAH, WHOL yesterday,r/o vascular anomoly
______________________________________________________________________________
FINAL REPORT
HISTORY: Patient with subarachnoid hemorrhage, to rule out intracranial
vascular anomaly."
2211,"Admission Date: [**2119-5-12**] Discharge Date: [**2119-5-28**]
Date of Birth: [**2042-2-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Indocin / Naftifine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
right carotid stenosis
Major Surgical or Invasive Procedure:
[**2119-5-23**] Off pump CABG x3(LIMA-LAD, SVG-OM-d1 at y graft)
[**2119-5-12**] - Right carotid endarterectomy and bovine patch
angioplasty
[**2119-5-18**] - Cardiac Cath
History of Present Illness:
The patient is a 77 year-old gentleman who has been followed at
[**Hospital1 **] in [**Location (un) **] for a number of years for right
carotid stenosis."
2212,"This has been in the moderate range and
recently progressed to the 80% or greater range and is
undergoing right carotid endarterectomy this admission.
Post-operatively he experienced chest pain and underwent a
cardiac catheterization which revealed multi-vessel coronary
artery disease. Therefore he was referred for a coronary artery
bypass.
Past Medical History:
atrial fibrillation (since [**10/2118**], cardioverted [**2118-11-29**]), CAD,
s/p MI, hypertension, hypercholesterolemia, s/p A.fib
cardioversion [**10/2118**]
Social History:
Lives with his wife, in [**Name (NI) 730**]. He is retired from American
Airlines. He volunteers at the [**Location (un) 511**] Aquarium once per
week."
2213,"He stopped using tobacco in [**2102**] and drinks one glass of
wine every evening with no recreational substance use.
Family History:
His mother died of an myocardial infarction at age 72. His
father died at age 74 from prostate cancer. One brother had a
coronary srtery bypass grafting.
Physical Exam:
VITALS: Afebrile, vitals signs stable.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
Right carotid incision clean, dry and intact with sutures in
place.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2. No evidence of carotid bruits.
RESP: Clear to auscultation bilaterally without adventitious
sounds."
2214,"Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Post Grafting: Patient is on Epi 0.02. Improved apical function,
LVEF 55%. MR is now trace. Aortic contours intact. Remaining
exam is unchanged. All findings discussed with surgeons at the
time of the exam.
:
Electronically signed by [**Known firstname **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2119-5-23**] 19:51
Brief Hospital Course:
NEURO/PAIN: The patient was maintained on IV pain medication in
the immediate post-operative period and transitioned to oral
medication with adequate pain control on POD#0. The patient
remained neurologically intact and without change from baseline
during their stay."
2215,"All follow-up appointments were advised.
Medications on Admission:
Allopurinol 300 mg', Fluocinonide 0.05% cream, Ketoconazole 2%
cream PRN, Metoprolol 100 mg'', Nifedipine 30 mg ER',
Nitroglycerin 0.4 mg SL PRN, Simvastatin 80 mg', Warfarin 5 mg',
Aspirin 81 mg', MVI, Naproxen 220 mg' PRN
Discharge Medications:
1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain."
2216,"16. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. insulin regular human 100 unit/mL Solution Sig: see sliding
scale Injection ASDIR (AS DIRECTED).
18. ketoconazole 2 % Cream Sig: One (1) appl Topical twice a
day: to both feet.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
Coronary Artery Disease
Right Carotid Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. 1+LE
edema
Discharge Instructions:
What to expect when you go home:
1."
2217,"9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast in the body of the LA. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size."
2218,"No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: The right lower extremity is warm well-perfused and is
without erythema, drainage or edema. The left lower extremity is
warm well-perfused and is without erythema, drainage or edema.
PULSE EXAM: Fem [**Doctor Last Name **] DP PT
[**Name (NI) 2325**] P P P P
Right P P P P
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 88036**] (Complete)
Done [**2119-5-23**] at 4:58:20 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2042-2-16**]
Age (years): 77 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease."
2219,"Coronary artery disease. Left
ventricular function. Mitral valve disease. Off pump CABG
ICD-9 Codes: 424.1, 424.0, 424.2
Test Information
Date/Time: [**2119-5-23**] at 16:58 Interpret MD: [**Known firstname **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW4-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0."
2220,"The
patient's intake and output was closely monitored for > 30 mL
per hour output. The patient's creatinine was stable.
HEME: The patient's post-op hematocrit was stable and trended
closely. The patient remained hemodynamically stable and did not
require transfusion. The patient's coagulation profile remained
normal. The patient had no evidence of bleeding from his
incision. After his bypass coumadin for atrial fibrillation was
restarted.
ID: The patient showed no signs of infection and remained
afebrile in the post-op period. Their white count was stable
post-operatively and their incision was closely monitored for
any evidence of infection or erythema."
2221,"TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre grafting: The left atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the left
atrium. No spontaneous echo contrast or thrombus is seen in the
body of the left atrium or left atrial appendage."
2222,"5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: for
goal INR of [**2-16**] for atrial fibrillation.
6. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain for 40 doses.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: titrate according to weight, creatinine, and exam."
2223,"Answering service will contact on call
person during off hours**
Followup Instructions:
Please call Dr.[**Name (NI) 5695**] office to schedule a follow-up
appointment in 2-week for suture removal. [**Telephone/Fax (1) 3121**]
Cardiac Surgeon: Dr.[**First Name (STitle) **] [**Telephone/Fax (1) 170**], on [**2119-6-19**] at 2p
Cardiologist: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2119-6-28**] at 2:30p
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 88037**] in [**4-18**] weeks
Labs: PT/INR for Coumadin ?????? atrial fibrillation
Goal INR [**2-16**]
First draw Monday, [**5-29**]
**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:[**2119-5-28**]"
2224,"What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?"
2225,"Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples or sutures
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?"
2226,"The patient received only
standard peri-operative antibiotics, and did not require further
antibiotics post-op.
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.
PROPHYLAXIS: The patient also had sequential compression boot
devices in place during immobilization to promote circulation.
GI prophylaxis was sustained with Protonix/Famotidine when
necessary. The patient was encouraged to utilize incentive
spirometry, ambulate early and was discharged in stable
condition to [**Hospital 1886**] rehab in [**Last Name (un) **] on post-operative day five
from his bypass."
2227,"????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication"
2228,"Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
2229,"No spontaneous
echo contrast in the body of the RA. A catheter or pacing wire
is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Low normal LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV
systolic function.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Normal descending aorta diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR."
2230,"????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions"
2231,"10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours.
14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days."
2232,"No spontaneous
echo contrast is seen in the body of the right atrium. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. There are simple atheroma in the
ascending aorta. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened.. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened."
2233,"The patient remained alert and oriented to
person, location and place. Sequential neurologic exams were
repeated Q4 hours and were stable post-op.
CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. He
extubated and was weaned from pressors. He was transferred to
the surgical step down floor by the following day. Chest tubes
and epicardial wires were removed. The patient's
cardioprotective dose of Aspirin was continued post-op.
Coumadin was started for his history of strial fibrillation.
RESPIRATORY: The patient was extubated in the immediate post-op
period successfully. The patient had no episodes of desaturation
or pulmonary concerns."
2234,"The patient denied cough or respiratory
symptoms. Pulse oximetry was monitored closely and the patient
maintained adequate oxygenation.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#0. The
patient experienced no nausea or vomiting. The patient was
transitioned to a regular/cardiac healthy diet on POD#1 and IV
fluids were discontinued once adequate PO intake was
established.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed intra-operatively and removed on POD#1, at which time the
patient was able to successfully void without issue."
2235,"Admission Date: [**2170-1-18**] Discharge Date: [**2170-2-4**]
Date of Birth: [**2090-11-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 69390**]
Chief Complaint:
Atrial Flutter
Major Surgical or Invasive Procedure:
electrical cardioversion
History of Present Illness:
Mr. [**Known lastname 34366**] is a 79 y.o. Male w/ h.o. RA, mild AS, HTN, HL p/w
chest palpitations found to be in A. flutter.
.
Pt is a poor historian. He states that 2 days ago he noted a
fluttering sensation in his chest, he denied any chest pain but
stated it felt like he had an itch in his chest."
2236,"He also noted
some new onset DOE specifically when climbing up stairs. He
states he has had these symptoms before, several years ago, but
cannot remember what it was thought to be. He decided to make an
appointment to see his [**Hospital1 **] primary care provider on the day
of admission. Per ED call-in he was noted to be on EKG in SVT
with a rate of 180, saturating 94% on 2L. He was then
transferred by ambulance to the ED.
.
In the ED initial VS were noted to be T 98.1, HR 139, BP 108/81,
RR 17, Sat 97% on 4L."
2237,"He denies SOB.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes-, Dyslipidemia+, Hypertension+
2. CARDIAC HISTORY:
?Mild AS
3. OTHER PAST MEDICAL HISTORY:
RA
Social History:
-Tobacco history: Never
-ETOH: 3 drinks per day/ 1 bottle per week
-Illicit drugs: None
Family History:
non contributory
Physical Exam:
ADMISSION PHYSICAL:
GENERAL: Caucasian Male sitting up in bed in NARD
HEENT: Sclera anicteric. EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
CARDIAC: Distant S1, S2, tachycardic to 140s, unable to clearly
auscultate murmur.
LUNGS: Distant but clear to auscultation.
ABDOMEN: Soft, obese, NT, ND.
EXTREMITIES: No edema noted
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
."
2238,"He is being
discharged to a rehab facility for continued strength building.
.
ACTIVE ISSUES:
# ATRIAL FIB/FLUTTER: The patient presented in atrial flutter
with a variant block from 2-4:1 of unclear onset or duration.
Thyroid function was normal. He received diltiazem in the
emergency department with initial rate control, but subsequently
became hypotensive. He was started on metoprolol for rate
control, anticoagulated with a heparin gtt and transferred to
the cardiac ICU. TEE/ablation was attempted; however, only
cardioversion was performed because the patient's O2 saturations
acutely dropped during the TEE, likely secondary to pulmonary
edema. The patient remained in sinus rhythm for less than 2
hours before flipping back into atrial flutter."
2239,"On discharge he was asymptomatic and
hemodynamically stable.
.
# ANTICOAGULATION: Patient was started on heparin gtt with
transition to Coumadin. He will need to have his INR monitored
for Coumadin dosing in the future (goal [**1-11**]).
.
# ACUTE SYSTOLIC CONGESTIVE HEART FAILURE: Etiology of
cardiomyopathy is likely multifactorial in the setting of
suspected multi-vessel coronary artery disease, tachyarrhythmia
of unclear duration, and possible alcohol-related
cardiomyopathy. Echo on HD 2 revealed an EF of 20% consistent
with multivessel disease, severe global left ventricular
hypokinesis, moderate global right ventrical free wall
hypokinesis, moderate AS and MR. [**First Name (Titles) 616**] [**Last Name (Titles) **] loading on
HD3, the patient became acutely hypotensive with systolic blood
pressures in the 70s requiring temporary discontinuation of
[**Last Name (Titles) **] and fluid boluses to maintain adequate mean arterial
pressures."
2240,"He was also started on
Epleronone 25 daily and Digoxin as above. He may benefit from a
cardiac catheterization to evaluate his coronaries in the
future.
.
# HYPOTENSION: Lactate, Creatinine, and Liver Function Tests
were elevated concerning for the development of cardiogenic
shock during his hypotensive episode. These improved as the
patient was diuresed and his heart rate controlled. Currently
the patient has intermittent relative, asymptomatic hypotension
during the night-time hours to the 80s/50s.
.
# TRANSAMINITIS: Likely secondary to hypoperfusion. A right
upper quadrant ultrasound was obtained and revealed no liver
pathology. Review of prior notes revealed normal liver function
tests in [**Month (only) 404**] making underlying alchohol-related pathology
unlikely."
2241,"His statin and rheumatoid arthritis medications were
initially held. As he clinically improved, his transaminases
improved. Simvastatin was re-started prior to discharge.
Sulfasalazine and hydroxychloroquine were restarted at
discharge. He should have repeat LFTs checked the week of
discharge to assess for stabilization.
.
# ACUTE KIDNEY INJURY: Likely secondary to hypoperfusion from
low cardiac output and poor forward flow. His creatinine
improved with diuresis and was at baseline 0.9 at time of
discharge. He should have repeat BUN/Creatinine checked the week
after discharge.
.
# CORONARY ARTERY DISEASE: The patient has cardiac risk factors
of hypertension and hyperlipidemia. Echo was consistent with
multivessel coronary artery disease."
2242,"On admission his cardiac
enzymes were notable for a mild elevation in troponin of 0.05
likely secondary to mild demand ischemia in the setting of
tachycardia. Enzymes were trended and remained flat. He remained
chest pain free throughtout the admission. He was started on ASA
81 daily and Simvastatin 20 daily prior to discharge
(Simvastatin was decreased from 40 to 20 daily given also on
[**Month (only) **]).
.
# ALCOHOL WITHDRAWAL: The patient intially endorsed only 1 drink
per day. 72 hours into admission he became restless,
diaphoretic, anxious, and endorsed a more substantial drinking
history (of unclear amount- very inconsistent historian)."
2243,"The
patient's family was unaware of the extent of his history.
Social work was consulted. The patient was started on a CIWA
scale with ativan with improvement in his behavioral symptoms of
withdrawal. The patient was continued on a multivitamin and
folic acid and started on thiamine supplement.
.
# URINARY TRACT INFECTION: Prior to discharge, the patient
complained of bladder spasms and dysuria. A urinalysis was
significant for pyuria and a culture was consistent with coag
negative staph aureus. The patient was treated with pyridium,
and a 10 day course of ciprofloxacin 500 [**Hospital1 **] (to be finished on
[**2170-2-10**])."
2244,"An ECG was checked on day of discharge, and QTc was
447.
.
# URINARY RETENTION: Patient failed initial voiding trial and
was started on tamsulosin. He was voiding well on the day of
discharge without further retention.
.
INACTIVE ISSUES:
# HYPERTENSION: Outpatient blood pressure medications were held
(lisinopril and hydrochlorothiazide) in setting of hypotension
and need for aggressive diuresis. His heart failure and atrial
fibrillation rate control regimens were optimized with
subsequent well-control of blood pressures.
.
# HYPERLIPIDEMIA: He was initally continued on Simavastatin,
which was subsequently discontinued in the setting of likely
shock liver, and restarted prior to discharge at lower dose as
above (40 to 20 given also on [**Date Range **] now)."
2245,".
# RHEUMATOID ARTHITIS: Joint examination on admission
demonstrated no acute rheumatoid flare. Sulfasalazine 1 g [**Hospital1 **]
and Hydroxychloroquine 400 daily were held in setting of hepatic
and renal dysfunction. These were restarted at discharge.
.
TRANSITIONAL ISSUES:
Medical Management: Start Metoprolol succinate 150 daily, Start
[**Hospital1 **] 400 daily, Start Lasix PO 80 BID, Start Digoxin 0.125
daily, Start Eplerenone 25 daily, Continue Lisinopril 5 daily,
Start Coumadin 5 daily, STOP HCTZ, Complete course of
Ciprofloxacin for UTI, Start Tamsulosin
Follow Up: Cardiology, Primary Care
To Do: Check Chem 10 and LFTs in 3-4days, monitor INR frequently
Code Status: Full Code"
2246,"[**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Start Ciprofloxacin to treat a urinary tract infection
2. Start Tamulosin to help your bladder empty fully
3. Start Famotidine to protect your stomach
4. Start Digoxin to help your heart pump better and slower
5. Start [**Last Name (STitle) **] to slow your heart rate and help your rhythm
convert to a normal sinus rhythm
6. Start potassium while you are on the lasix
7. Start Lasix to help keep the fluid in your lungs and abdomen
from re accumulating
8."
2247,"Your heart is
weaker than before and you have been started on some new
medicines to help your heart pump better. Your kidneys were also
affected but your kidney function is normal now. You developed a
urinary tract infection and required an antibiotic to treat
this. A foley catheter was also reinserted because you had
urinary retention. You will need to keep the foley catheter in
for another 4 days, then the staff will remove it. You will need
to have a cardiac catheterization at some point to evaluate your
coronary arteries for blockages
.
Weigh yourself every morning, call Dr."
2248,"Possible multifocal atrial tachycardia. Leftward axis.
Right bundle-branch block. Since the previous tracing of [**2170-1-21**]
the rate is slower and the rhythm is more irregular. ST-T wave
abnormalities are less prominent.
.
ECHO [**2170-1-19**]
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. Overall left ventricular systolic
function is severely depressed (LVEF= 15-20 %). There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened."
2249,"Aortic stenosis is likely
present (not quantified). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
.
IMPRESSION: No spontaneous echo contrast or thrombus in the
atria/ atrial appendages. Severely depressed global left
ventricular systolic function. Aortic stenosis (not quantified
on current study). Moderate mitral regurgitation.
.
ECHO [**2170-1-22**]
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is 10-15mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated."
2250,"Disp:*30 Tablet(s)* Refills:*3*
17. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*3*
18. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
19. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
20. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: take
in addition to 50 mg tablet to make a total of 150 daily.
21. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: please
take in addition to 100 mg tablet to make a total of 150 mg
daily."
2251,"Start Metoprolol succinate to help slow your heart rate
9. Start Warfarin to prevent blood clots and strokes from the
atrial fibrillation. You will need to have your blood monitored
closely while on the medicine, the goal warfarin level is
2.0-3.0
10. Start Eplerenone to help your heart failure
11. Start Thiamine 100mg daily
12. Start Aspirin 81mg daily
13. Decrease dose of Simvastatin from 40mg daily to 20mg daily.
14. Stop Hydrochlorothiazide
Followup Instructions:
Please make an appt to see Dr.[**Last Name (STitle) **] when you get out of
rehabilitation.
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Street Address(2) 34126**] [**Location 1268**], [**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 38275**]
Appointment: Thursday [**2170-2-15**] 2:50pm
[**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 69391**]
Completed by:[**2170-2-4**]"
2252,"He was started
on [**Known lastname **] and electrical cardioversion was attempted one
additional time, and was unsuccessful. Echo demonstrated EF of
20% with severe LV hypokinesis, an elongated left atrium, and
dilated right atrium. Given his large atrial size, the goals
were changed from rhythm to rate control. Initially we were
unable to control his rate without subsequent drop in his blood
pressure. His heart rate remained persistently in the 120s
(atrial fibrillation with rapid ventricular response), until
started on Digoxin. He is currently on [**Known lastname **] 400 daily,
Metoprolol succinate 150 daily, and Digoxin 0.125 daily with
good rate control."
2253,"DISCHARGE PHYSICAL:
vs: afebrile, VSS
GENERAL: Caucasian Male sitting up in bed in NARD
HEENT: Sclera anicteric. EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
CARDIAC: Distant S1, S2, tachycardic to 140s, unable to clearly
auscultate murmur.
LUNGS: Distant but clear to auscultation.
ABDOMEN: Soft, obese, NT, ND.
EXTREMITIES: No edema noted
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
.
ECG [**2170-1-18**]: Wide complex tachycardia suggestive of
supraventricular tachycardia with aberrancy in a right
bundle-branch block pattern. No previous tracing available for
comparison.
.
ECG [**2170-1-18**]: Atrial tachycardia is suggested with right
bundle-branch block."
2254,"05. A CXR showed cardiomegaly and a right
pleural effusion,he was thus given empirical Levofloxacin 750mg
IV x 1. In the ED he continued to intermittently increase his HR
back in the 130s, he was Metoprolol 25mg PO x 1, and 5mg IV
Metoprolol. Atrius cardiologist was consulted, given his low
pressures ED felt he should be admitted to the CCU. He was
guaiac negative in the ED.
.
On the floor pt continues to be in the 130s, SBP 110s but
asymptomatic. He denies any chest pain, fevers, chills, nausea,
vomiting, cough, abdominal pain. He does admit to feeling some
sensation of fluttering in his chest but it does not bother him
currently."
2255,"Medications on Admission:
Folic Acid 1 mg daily
Simvastatin 40 mg qHS
Lisinopril 5 mg daily
Sulfasalazine 1gm [**Hospital1 **]
Hydroxychloroquine 400 mg daily
Hydrochlorothiazide 25 mg daily
MVI daily
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days: last day [**2-10**].
Disp:*16 Tablet(s)* Refills:*0*
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime) for 7 days: Please
remove Foley catheter on [**2170-2-8**] and continue Tamulosin for [**1-11**]
more days after this."
2256,"Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Acute systolic congestive heart failure
Acute kidney injury
Urinary Tract infection
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:
Dear Mr. [**Known lastname 34366**],
It was a pleasure taking care of you during this admission.
You had a rapid irregular heartbeat called atrial fibrillation
that caused fluid to back up into your lungs. You required
medicine to keep your blood pressure up and needed some sedation
because of confusion and agitation in the CCU."
2257,"There is severe global left
ventricular hypokinesis (LVEF = 25 %). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
are moderately thickened. Significant aortic stenosis is present
(not quantified). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**1-20**]/201, the
LV systolic funciton is slightly more vigorous."
2258,"Left anterior fascicular block.
.
ECG [**2170-1-19**]: Atrial flutter with right bundle-branch block.
Left anterior fascicular block pattern.
.
ECG [**2170-1-20**]: Supraventricular tachy-arrhythmia which could be
sinus or ectopic atrial, etc. Compared to the previous tracing
of [**2170-1-19**] isolated atrial ectopy is not seen.
.
ECG [**2170-1-21**]: Baseline artifact precludes definite assessment
of rhythm which could be atrial tachy-arrhythmia with 2:1 or 1:1
conduction. Sinus tachycardia is less likely. Compared to the
previous tracing of [**2170-1-20**] supraventricular tachy-arrhythmia is
again noted.
.
ECG [**2170-1-22**]: Sinus rhythm with frequent atrial premature
beats."
2259,"3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin, stress formula Tablet Sig: One (1) Tablet
PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. [**Month/Day (3) **] 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day.
10. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO twice a
day."
2260,"His chest xray revealed significant pulmonary edema,
his JVP was elevated, and he required 6L of O2 via nasal cannula
to maintain adequate oxygen saturations. Once stable, he was
diuresed with a lasix gtt, supported by low dose dopamine (for
increased renal perfusion). His cardiac output improved and his
labwork reflected this with a decrease in creatinine. Once
adequately diuresed he was switched to IV lasix boluses, then an
outpatient regimen of PO Lasix 80 [**Hospital1 **]. He was started on low
dose Captopril that was converted to Lisinopril 5 at discharge
and his Metoprolol was uptitrated to 50 TID, and switched to
succinate 150mg daily on discharge."
2261,".
HEPATIC ULTRASOUND WITH DOPPLER [**2170-1-22**]
IMPRESSION:
1. The hepatic architecture is unremarkable and there are no
liver lesions
identified.
2. Patent hepatic vasculature.
Brief Hospital Course:
HOSPITAL COURSE:
Mr. [**Known lastname 34366**] is a 79 year-old gentleman with aortic stenosis,
hypertension, hyperlipidemia, and rheumatoid arthritis who
presented with atrial fib/flutter and acute systolic heart
failure. Electrical cardioversion was attempted twice and
ultimately failed. He was started on [**Known lastname **], Digoxin,
Metoprolol and diuresed with a Lasix gtt. His hospital course
was complicated by hypotension, acute kidney injury, and
transaminitis, which have resolved. He was diagnosed with a
catheter-associated UTI prior to discharge."
2262,"11. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO once
a day.
12. Outpatient Lab Work
Please check Chem 10 (Na, Cl, K, HCO2, BUN, Cr, Glucose, Ca, Mg,
Phos) and LFTs (AST, ALT, Alk Phos, T bili) on [**2170-2-7**]) and
13. Outpatient Lab Work
Please check PT/INR on [**2-5**] and as needed for appropriate
Coumadin dosing
14. eplerenone 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
15. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
16. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day)."
2263,"He was triggered on arrival for his
tachycardia. An EKG showed a rate of 140s which was thought to
be SVT vs A. flutter. He was given 20mg IV Diltiazem which
decreased his rate from 140s to 80s-90s where an A. flutter
rhythm was seen. His BP also decreased to the high 70s/low 80s.
Per the [**Name (NI) **] pt was asymptomatic, he was given IV fluid with his
pressure increasing back to 100. His initial labs were notable
for proBNP 7509, Hgb/Hct 13.2/38.6, Lactate 1.8, CK/CKMB/CKMBI
321/14/4.4, Troponin 0."
2264,"- Wean O2 as tolerated.
.
# Congestive heart failure, systolic dysfunction, acute on chronic:
Elevated BNP and pulmonary edema on CXR.
- Continue beta blocker, hold ACEI for now with hypotension.
- hold PO lasix, will attempt to diurese once hemodynamic issues
resolve.
.
# Leukocytosis.
Patient has no normal recorded WBC count in recent history. Infection
vs. hematopatholgy.
- Cover with vancomycin for now.
- Consider outpatient hematology workup for ?myelodysplasia.
# PVD with recent revascularization.
- Vascular following.
- Will continue vanco with concern of ?cellulitis surrounding proximal
ulcer.
# Sacral decubitus.
- Wound care consult; may need plastics intervention as well.
# CAD
- ASA, statin, BB
# CKD. Consistent with recent baseline. Will follow.
ICU Care
Nutrition: Regular; Low sodium / Heart healthy Consistency: Pureed
(dysphagia); Thin liquids Supplement: Ensure breakfast, lunch, dinner
Glycemic Control:
Lines:
20 Gauge - [**2117-3-6**] 06:01 PM
22 Gauge - [**2117-3-6**] 07:39 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:"
2265,"cellulitis until 48 hours negative culture data;
no evidence for gram negative infections currently
- Cardiac enzymes
trop 0.09-0.10 stable
- Hold ACEI and alpha block, continue low dose beta block given
arrhythmia.
- Attempt diuresis later today if BP stabilizes.
# Ventricular tachycardia:
Wide complex tachycardia but ECG appearance is Vtach. Discussed with
cards at arrival to MICU. Reason for recurrence of VT unclear - new
ischemia, stretch from volume overload, and further disruption of pacer
leads leading to more irritation of ventricle. Patient with episode of
asymptomatic ventricular tachycardia on night of admission that
spontaneously aborted. Patient also received amiodarone 150 mg IV at
time of ventricular tachycardic episode."
2266,"No repeat episodes of v tach
since admission.
- Replete mag and potassium aggressively.
- Appreciate cardiology input- per cards, additional 150 mg IV
amiodarone as well as maintenance oral amiodarone dose increase to 400
mg twice daily
- Needs eventual pacer/ICD lead replacement if appropriate candidate.
- Will recheck TTE to eval for any change in the pacer/ICD leads or
significant change in function to explain recurrent VT.
# Hypoxia:
On NRB in ED but easily transitioned to NC in ICU. Likely volume
overload related. Also with history of COPD though not particularly
wheezy on exam. Sating 99-100% RA
- Diuresis when able."
2267,"9 %
17.8 K/uL
[image002.jpg]
[**2117-3-6**] 03:42 PM
[**2117-3-6**] 07:37 PM
[**2117-3-7**] 03:32 AM
[**2117-3-8**] 04:04 AM
WBC
19.1
17.8
Hct
31.3
30.9
Plt
347
379
Cr
1.3
1.2
TropT
0.09
0.10
TCO2
27
Glucose
89
113
Other labs: PT / PTT / INR:15.2/35.9/1.3, CK / CKMB /
Troponin-T:75/3/0.10, Differential-Neuts:73.0 %, Band:2.0 %, Lymph:3.0
%, Mono:18.0 %, Eos:1.0 %, Lactic Acid:0.8 mmol/L, Ca++:7."
2268,"9 mg/dL,
Mg++:2.1 mg/dL, PO4:3.0 mg/dL
Assessment and Plan
A/P: 84M with history of PVD s/p recent axillobifemoral grafting with
course c/b wide complex tachycardia; now admit to MICU after getting
multiple nodal agents for ?SVT at rehab; however, rhythm appears to be
ventricular tachycardia.
# Hypotension:
Possible causes include sepsis / vasodilatory (given leukocytosis and
questionable appearance of gangrenous ulcers), cardiogenic (ACS or poor
forward flow from CHF; less likely pericardial effusion), most likely
med related (multiple nodal/negative inotropic agents for tachycardia).
Lactate not elevated.
- Hypotension responded to 250 cc fluid bolus x 1 overnight
- Continue to monitor in ICU with possible call-out to cardiology
service later today if blood pressures stabilize
- Continue vanco for ?"
2269,"Chief Complaint:
24 Hour Events:
- Had low SBP in the 70's, mostly when sleeping. Responsive to 250cc
fluid bolus.
- No episodes of vtach.
Allergies:
Penicillins
Unknown;
Last dose of Antibiotics:
Vancomycin - [**2117-3-7**] 11:56 AM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2117-3-7**] 10:15 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2117-3-8**] 06:54 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.1
C (98.7
Tcurrent: 36."
2270,"7
C (98.1
HR: 82 (75 - 88) bpm
BP: 82/56(62) {75/53(59) - 102/79(84)} mmHg
RR: 28 (19 - 29) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
1,842 mL
69 mL
PO:
820 mL
TF:
IVF:
1,022 mL
69 mL
Blood products:
Total out:
731 mL
330 mL
Urine:
731 mL
330 mL
NG:
Stool:
Drains:
Balance:
1,111 mL
-261 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ///24/
Physical Examination
GEN: Alert elderly male, no respiratory distress.
HEENT: PERRL, EOMI, oral mucosa dry with thick secretions
NECK: Prominent carotid pulsations, JVD appears to be at ~ 8 cm, no
adenopathy."
2271,"Bilat carotid bruits.
PULM: Diminished throughout with further decrease at bases, rare wheeze
and basilar crackles.
CARD: diminished heart sounds, no murmurs appreciated.
ABD: + BS, soft, NT, mildly distended and tympanitic throughout.
Extrem/Skin: Warm. 2+ pitting edema of dependent extremities, multiple
dry gangrene lesions with dark eschar. Most concerning is left lateral
lower extremity, which has area of erythema surrounding; however, no
exudates
NEURO: Oriented to hospital, year and month, but not to specific date
Labs / Radiology
379 K/uL
10.3 g/dL
113 mg/dL
1.2 mg/dL
24 mEq/L
3.7 mEq/L
16 mg/dL
106 mEq/L
137 mEq/L
30."
2272,"NECK: Prominent carotid pulsations, JVD appears to be at ~ 8 cm, no
adenopathy. Bilat carotid bruits.
PULM: Diminished throughout with further decrease at bases, rare wheeze
and basilar crackles.
CARD: very diminished heart sounds, no murmurs appreciated.
ABD: + BS, soft, NT, mildly distended but tympanic throughout.
Extrem/Skin: Warm. 2+ pitting edema of bilat UEs, LEs, and sacrum.
LLE severely affected by vascular ulcerations/eschars (particularly L
lateral leg with minimal surrounding erythema except most proximal
portion of ulceration with increased erythema concerning for
?cellulitis. No drainage. Bilat heel ulcers (likely pressure
ulcers). R axillary and bilateral groin incisions C/D/I with intact
staples."
2273,"4
C (99.3
Tcurrent: 36.2
C (97.2
HR: 81 (70 - 131) bpm
BP: 88/61(67) {76/51(57) - 98/68(71)} mmHg
RR: 19 (16 - 30) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Total In:
1,725 mL
300 mL
PO:
25 mL
TF:
IVF:
700 mL
300 mL
Blood products:
Total out:
800 mL
256 mL
Urine:
800 mL
256 mL
Balance:
925 mL
44 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 97%
ABG: 7.48/35/156/26/3
Physical Examination
GEN: Alert elderly male, no respiratory distress.
HEENT: PERRL, EOMI, MMM."
2274,"Chief Complaint: Hypotension, tachycardia
24 Hour Events:
- Cardiology consult stopped by and felt that tachycardia at rehab was
a different presentation of ventricular tachycardia as the axis of the
tachycardia was different from at last admission
- Had multiple episodes of ventricular tachycardia around 0300 this
morning. Patient was complaining of dyspnea, but mentating during
episodes. spontaneously aborted. Received 150 mg of amiodarone then had
no further VT overnight
Allergies:
Penicillins
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2117-3-7**] 07:43 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2275,"Dopplerable DP/PT.
BACK: ~5x5cm sacral decub with central eschar.
NEURO: Oriented to ---------
Labs / Radiology
347 K/uL
10.4 g/dL
89 mg/dL
1.3 mg/dL
26 mEq/L
3.6 mEq/L
18 mg/dL
106 mEq/L
139 mEq/L
31.3 %
19.1 K/uL
[image002.jpg]
[**2117-3-6**] 03:42 PM
[**2117-3-6**] 07:37 PM
[**2117-3-7**] 03:32 AM
WBC
19.1
Hct
31.3
Plt
347
Cr
1.3
TropT
0.09
TCO2
27
Glucose
89
Other labs: PT / PTT / INR:15.7/31.1/1.4, CK / CKMB /
Troponin-T:80//0.09, Differential-Neuts:66.0 %, Band:7.0 %, Lymph:2.0
%, Mono:11.0 %, Eos:2.0 %, Lactic Acid:0.8 mmol/L, Ca++:8.0 mg/dL,
Mg++:2.2 mg/dL, PO4:3.4 mg/dL
Assessment and Plan
PERIPHERAL VASCULAR DISEASE (PVD) WITH CRITICAL LIMB ISCHEMIA
DECUBITUS ULCER (PRESENT AT ADMISSION)
.H/O SUPRAVENTRICULAR TACHYCARDIA (SVT)
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2117-3-6**] 06:01 PM
22 Gauge - [**2117-3-6**] 07:39 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
2276,"0
%, Mono:11.0 %, Eos:2.0 %, Lactic Acid:0.8 mmol/L, Ca++:8.0 mg/dL,
Mg++:2.2 mg/dL, PO4:3.4 mg/dL
Assessment and Plan
Hypotension
-sepsis vs. cardiogenic vs. med related vs. baseline (lactate nl)
-IVF boluses carefully given h/o CHF Hasn't required pressors
-empiric coverage with abx. Broaden if worsening of hemodyn status
-elevated wbc/bandemia has been present since prior admission
Heart failure
- Cycle enzymes.
- Hold ACEI, lyte
- cont b- block given arrhythmia.
Ventricular tachycardia
-hemodyn stable (relative to current pressures) during event
-cards consulted following
-amio
- Replete lytes
-not seeing clear overdrive/AICD activity - lead fracture per report."
2277,"4
C (99.3
Tcurrent: 36.5
C (97.7
HR: 83 (70 - 131) bpm
BP: 95/64(72) {76/51(57) - 98/68(72)} mmHg
RR: 22 (16 - 30) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
1,726 mL
1,182 mL
PO:
25 mL
240 mL
TF:
IVF:
701 mL
942 mL
Blood products:
Total out:
800 mL
301 mL
Urine:
800 mL
301 mL
NG:
Stool:
Drains:
Balance:
926 mL
881 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: 7.48/35/156/26/3
Physical Examination
General Appearance: No(t) Well nourished, No acute distress, Thin
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: 2+, Left: 2+
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
10."
2278,"d/w cards
Hypoxia
-improved since admission - currently on NC
-wean supp O2 as tol
Leukocytosis
-at baseline from prior admission. no normal wbc since [**12/2116**]
-infection possible but no clear source, nontoxic
-pan cx, empiric abx for now. if cx negative would dc abx
-? myelodysplasia
PVD with recent revascularization.
- Vascular following.
- Cont vanco given concern of ?cellulitis surrounding proximal ulcer.
Sacral decubitus.
- Wound care consult\
.
CKD
-at baseline
Remainder of plan per resident note.
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2117-3-6**] 06:01 PM
22 Gauge - [**2117-3-6**] 07:39 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition :
Total time spent: 40 minutes
Patient is critically ill"
2279,"4 g/dL
347 K/uL
89 mg/dL
1.3 mg/dL
26 mEq/L
3.6 mEq/L
18 mg/dL
106 mEq/L
139 mEq/L
31.3 %
19.1 K/uL
[image002.jpg]
[**2117-3-6**] 03:42 PM
[**2117-3-6**] 07:37 PM
[**2117-3-7**] 03:32 AM
WBC
19.1
Hct
31.3
Plt
347
Cr
1.3
TropT
0.09
TCO2
27
Glucose
89
Other labs: PT / PTT / INR:15.7/31.1/1.4, CK / CKMB /
Troponin-T:80//0.09, Differential-Neuts:66.0 %, Band:7.0 %, Lymph:2."
2280,"TITLE:
Chief Complaint: Ventricular tachycardia , leukocytosis & hypotension
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
- 3am several minutes run PVCs, ~20 beat run VT
- mentating throughout
- amio pushed
History obtained from [**Hospital 15**] Medical records
Allergies:
Penicillins
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2117-3-7**] 10:04 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2281,"Admission Date: [**2117-3-6**] Discharge Date: [**2117-3-12**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 14820**]
Chief Complaint:
Tachycardia at rehabilitation facility, hypotension.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is an 84 year old male with PVD and recent admission for
right axillobifemoral artery bypass grafting c/b wide complex
tachycardia, systolic CHF, COPD, nonfunctional ICD; admit with
hypotension following treatment for ""SVT"" and concern of sepsis.
Patient was recently admitted [**2117-2-12**] - [**2117-3-5**] for gangrenous
lower extremities; workup included angiography with eventual
revascularization (axillobifemoral grafting). Course complicated
by wide complex tachycardia (SVT with aberrancy vs."
2282,"In the [**Hospital1 18**] ED, vitals T 97.9, HR 80, 91/55, R18, 94% 3L. SBP
range 81-92. Started NRB for sats in high 80s on 5L. Labs
notable for WBCs 22K with abnormal diff (though has this at
baseline), BNP 33K, troponin 0.09, lactate 2-> 0.8, ABG
7.48/35/156 on NRB. UA negative. CXR with pulm edema and
worsened effusions, otherwise unremarkable. Guaiac negative. Got
vanc/?levoflox (per verbal report only) for concern for sepsis.
1 L NS given. Vascular consulted, felt surgical wounds healing
well without evidence of infection.
Past Medical History:
- chronic systolic heart failure with EF 20%; s/p ICD placement
but currently nonfunctional [**12-21**] wire fracture
- CAD with history of large anterior MI in past
- History of Vtach and Vfib in past, managed by ICD
- Left hip fx s/p repair
- PVD, s/p recent axillobifemoral bypass
- carotid stenosis s/p bilat CEAs
- COPD
- macular degeneration
- GERD
- PUD s/p surgical repair in past
- anemia"
2283,"No LAD
on exam.
.
# PVD with recent revascularization:
Vascular surgery followed patient. No acute events. Qday
dressing changes on left leg (cover with dry guaze, then wrap
with kerlix)
.
# Sacral decubitus:
Wound care was consulted and directed care. Pt was turned every
2-3 hours.
.
Medications on Admission:
Aspirin 81 mg DAILY
Digoxin 125 mcg MONDAY, WEDNESDAY, FRIDAY
Ferrous Sulfate 325 mg DAILY
Camphor-Menthol TID as needed.
Simvastatin 20 mg DAILY
Omeprazole 20 mg DAILY
Lisinopril 2.5 mg DAILY
Tamsulosin 0.4 mg HS
Amiodarone 200 mg DAILY
Metoprolol 12.5 mg [**Hospital1 **]
Thiamine HCl 100 mg DAILY
Multivitamin DAILY
Ipratropium neb Q6H
Albuterol Sulfate Nebulization Q6H and Q2H as needed for
wheezing."
2284,"13. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: through [**3-18**], then 200mg [**Hospital1 **] for two
weeks, then 200 mg Qday indefinitely.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Wide complex tachycardia
Chronic systolic heart failure
Acute on chronic renal failure
PVD w/ cellulitis/dry gangrene LLE
Decubiti (scaral area, both buttocks and both hip areas)"
2285,"He was given solumedrol 125 mg IV with improvement.
Steroids and nebulizers were discontinued and goal even to
negative fluid balance was maintained with PRN IV Lasix. Lasix
was held since [**3-10**] due to mild elevation of creatinine. Pt
maintained O2 sats in mid-upper 90s on RA-2L via NC.
.
# Congestive heart failure, systolic dysfunction, acute on
chronic:
The patient had elevated BNP and pulmonary edema on chest x-ray.
His beta-blocker dose was increased over the night of admission
and continued as pressures tolerated. His ACEI was held for
hypotension. His I/Os were also targeted for a net diuresis with
PRN Lasix."
2286,".
Please call your doctor if you experience any symptoms
concerning to you. They will be able to triage and will tell you
whether you need an evaluation in the emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2117-4-27**] 8:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2117-4-27**] 9:00
Vascular surgery: Dr. [**Last Name (STitle) 38759**] Wednesday, [**3-17**] at 10:15 am.
([**Telephone/Fax (1) 4852**] (Please call to confirm appointment. You will
also get staples removed then)
Completed by:[**2117-3-12**]"
2287,"He had another
episode of VT on the morning of [**3-10**] which converted with
another bolus of amiodarone 150 mg IV. He did not have any
further episodes of VT since then.
He was continued on oral amiodarone 400 mg twice daily, his
electrolytes (magnesium and potassium) were repleted
aggressively.
According to Cardiology, he is not a candidate for lead
replacement, and should be medically managed. This is also in
line with the patient and his family's wishes to avoid
aggressive care. (The patient is DNR/DNI, and moving towards
comfort care, although not at officially comfort care only)."
2288,"6
[**2117-3-6**] 11:55AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 38760**]*
[**2117-3-5**] 06:40AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.3
[**2117-3-6**] 11:55AM BLOOD Digoxin-1.2
.
CXR [**3-6**]
AP UPRIGHT CHEST: A left pacer/AICD with leads overlying the
right atrium and ventricle is stable. Mild cardiomegaly
persists. Moderate left and small right pleural effusions are
noted. There is diffuse hazy bilateral reticular opacity with
[**Last Name (un) 16765**] A and B lines. There is no focal consolidation or
pneumothorax.
IMPRESSION: Moderate CHF.
.
CXR [**3-9**]
In comparison with the study of [**3-7**], there is increasing
prominence of the cardiac silhouette with evidence of pulmonary
edema and bilateral pleural effusions."
2289,"Again, lasix was held since [**3-10**] and remained net
even since then. Pt remained stable from respiratory
perspective. Consider restarting lasix (was on 20 mg PO Qday) in
[**12-22**] weeks.
.
# Lung Nodules/Spiculated Mass: on CT [**2117-3-2**] from prior
admission. At that time it was felt to be infectious process but
it needs to be followed for resolution.
- Repeat CT in 3 months vs pulmonary consult as outpatient
.
# Leukocytosis:
Vancomycin was discontinued on [**3-9**]. The patient has no normal
recorded WBC count in recent history. Thoughts are Infection vs.
hematopatholgy, and it is felt the patient should consider
outpatient hematology workup for possible myelodysplasia."
2290,"Discharge Condition:
Stable.
Discharge Instructions:
You were brought to the hospital for evaluation of a fast heart
rhythm that was noticed at the rehab. We were able to control it
with medications. You expressed the wish to shift the overall
goal of care away from aggressive measures. Our
electrophysiologists (cardiologists that specialize in heart
rhythm) agreed with the plan, and again recommended against
fixing the fractured defibrillator leads.
.
Changes were made to your medication regimen. Most notably, you
will take amiodarone 400 mg twice a day for one more week
(through [**3-18**], then 200 mg twice a day for two weeks ([**3-19**] through [**4-1**]), then 200 mg once a day indefinitely."
2291,"Vtach)
following central line change requiring amio drip, eventually
discharged on PO amiodarone.
Patient noted at rehab to have ""SVT"" with HR 140s at 7:30 AM.
ECG performed and thought to be SVT by rehab (review actually
concerning for VT). Given 10 mg IV lopressor and 25 mg IV
diltiazem total. SBP 83 with HR 138 at rehab. Maintained SBPs in
80s-90s with HRs in 120s-130s throughout [**Hospital1 **] course; per
page one at least 90 minutes in this rhythm. Does note mild
dyspnea during this time, but otherwise reports being
asymptomatic (though poor historian). Denies CP, palps, cough,
abdominal pain, diarrhea, fever, bleeding, HA, dizziness,
lightheadedness, lower extremity pain, change in baseline edema
(denies edema)."
2292,"The reason for recurrence of VT is unclear:
new ischemia, stretch from volume overload, or possibly further
disruption of pacer leads leading to more irritation of
ventricle. The patient did have an episode of asymptomatic
ventricular tachycardia on night of admission that spontaneously
aborted. He also received amiodarone 150 mg IV at time of that
ventricular tachycardic episode. He had a repeat episode of VT
on [**3-9**] in the morning. He was given amiodarone 150 mg IV x 1,
Lidocaine 75 mg IV x 2. EP converted to sinus rhythm via
patient??????s AICD. He was started on Mexiletine 150 mg [**Hospital1 **] with
plans to titrate this medication per Cardiology."
2293,"Social History:
Previously lived with son, widower of 2 years, now in rehab.
Smoked [**11-20**] ppd up through recent hospital admission. Non-alcohol
beer in the day and whiskey x 3 at night prior to rehab stay.
Family History:
No family history of early CAD or early sudden cardiac death.
Physical Exam:
On admission:
General: Alert elderly male, no respiratory distress.
HEENT: PERRL, EOMI, MMM.
Neck: Prominent carotid pulsations, JVD appears to be only ~3
ASA, no adenopathy. Bilat carotid bruits.
Heart: very diminished heart sounds, no murmurs appreciated.
Lungs: Diminished throughout with further decrease at bases,
rare wheeze and basilar crackles."
2294,"TTE
on [**3-9**] showed slightly increased EF (25-30%), slightly
decreased left ventricular cavity size and slightly worse mitral
regurg. Amiodarone dosing should be adjusted as follows:
Amiodarone 400 mg twice a day for one more week (through [**3-18**]), then 200 mg twice a day for two weeks ([**3-19**] through
[**4-1**]), then 200 mg once a day indefinitely.
.
# Hypotension:
Possible causes include sepsis / vasodilatory (given
leukocytosis and questionable appearance of gangrenous ulcers),
cardiogenic (ACS or poor forward flow from CHF; less likely
pericardial effusion), most likely med related (multiple
nodal/negative inotropic agents for tachycardia). Lactate was
not elevated."
2295,"Pertinent Results:
Labs on admission:
[**2117-3-5**] 06:40AM BLOOD WBC-18.0* RBC-3.34* Hgb-10.6* Hct-31.6*
MCV-95 MCH-31.6 MCHC-33.4 RDW-18.8* Plt Ct-287
[**2117-3-5**] 06:40AM BLOOD Neuts-60 Bands-3 Lymphs-8* Monos-15*
Eos-6* Baso-0 Atyps-0 Metas-1* Myelos-5* Promyel-2*
[**2117-3-6**] 11:55AM BLOOD PT-14.7* PTT-28.9 INR(PT)-1.3*
[**2117-3-5**] 06:40AM BLOOD Glucose-87 UreaN-24* Creat-1.4* Na-139
K-3.9 Cl-105 HCO3-26 AnGap-12
[**2117-3-6**] 11:55AM BLOOD ALT-14 AST-34 LD(LDH)-553* CK(CPK)-98
AlkPhos-86 TotBili-0."
2296,"The change in heart size
raises the possibility of underlying pericardial effusion.
Pacemaker leads remain in place. Retrocardiac opacification most
likely is consistent with atelectasis, though supervening
pneumonia cannot be
unequivocally excluded.
Brief Hospital Course:
This is an 84 year old male with history of PVD status-post
recent axillobifemoral grafting with course complicated by wide
complex tachycardia; now admitted to MICU after getting multiple
nodal agents for VT at rehab.
# Ventricular tachycardia:
The patient has had previous Ventricular Tachycardia (VT). On
this admission, he presented with a wide complex VT which is
different from his previous VT. Cardiology followed the patient
at arrival to MICU."
2297,"Oxycodone-Acetaminophen 5-325 mg [**11-20**] Q4H as needed
Lasix 20 mg once a day.
Collagenase 250 unit/g Ointment DAILY
Miconazole Nitrate 2 % TID as needed.
Heparin SC 5000 units [**Hospital1 **]
colace 100 mg [**Hospital1 **] prn
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day) as needed for constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily)."
2298,"Vancomycin was discontinued after 48 hours with
continued negative culture data; he remained afebrile. His ACEI
and alpha blockers were held; he was continued on low dose beta
block given arrhythmia as BPs tolerate. Pt remained 110s-130s
systolic since transfer out of MICU on [**3-10**].
.
# Hypoxia:
He was on a non-rebreather (NRB) in the ED but easily
transitioned to nasal cannula (NC) in ICU. This was likely
volume overload related. He also has a history of COPD. He was
satting 99-100% on RA, although he did have increased wheezing
and dyspnea over the night of admission without relief with
nebs."
2299,"5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical
DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4-Q6 ().
12. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours)."
2300,"Abdomen: + BS, soft, NT, mildly distended but tympanic
throughout.
Extrem/Skin: Warm. 2+ pitting edema of bilat UEs, LEs, and
sacrum. LLE severely affected by vascular ulcerations/eschars
(particularly L lateral leg with minimal surrounding erythema
except most proximal portion of ulceration with increased
erythema concerning for ?cellulitis. No drainage. Bilat heel
ulcers (likely pressure ulcers). R axillary and bilateral groin
incisions C/D/I with intact staples. Dopplerable DP/PT.
Back: ~5x5cm sacral decub with central eschar.
Neuro: II-XII intact. Strength 5/5 bilateral UE and RLE; LLE
with weak (3 to 4-/5) dorsiflexion. Oriented to place and [**Month (only) 547**]
[**2115**]."
2301,"Preoperative evaluation for resection of
mass revealed borderline PFT's. He [**Known lastname 1834**] VQ scan on [**2136-7-19**]
with evidence of sufficient residual lung volume to tolerate LLL
resection. Patient [**Month/Day/Year 1834**] preop cardiac evaluation today with
MIBI and was found to have new onset atrial fibrillation with
RVR 120's. Cardiologists
recommended no additional work up since patient was without
angina or other symptoms of ischemia. Echo revealed normal
systolic function with mild MR.
Past Medical History:
- Cardiac stenting 12 years ago without recent stress test
- 2 lumbar disk surgeries
- Cholecystectomy [**45**] years ago
- Neuropathy
- Right thyroid nodule"
2302,"Social History:
Cigarettes: quit 15 yrs ago, 20 pk yr hx
ETOH: 1 glass wine/night
Family History:
Sister had cervical CA in 80s, otherwise no family cancer hx.
Both mother and father died in 70's from DM complications:
amputations and DM.
Physical Exam:
Vital signs: T- HR- BP- RR- O2 Sat-
General: Well appearing, breathing comfortably
HEENT: Moist mucous membranes, no nasal flaring
CV: Irregular, Nl S1, S2
Resp: Right lung with breath sounds throughout, left lung -no
breath sounds at midchest downward, occasional wheezes
Abdomen: Soft, nontender, nondistended
Ext: Mild pedal edema (at baseline), no cyanosis, or sking
breakdown
Neuro: No gross abnormalities
Psych: A&Ox3, appropriate"
2303,"He was extubated
without difficulty in the OR and was admitted to the ICU for
management of atrial fibrillation with sick sinus syndrome. The
rest of Mr. [**Known lastname 20693**] hospital course is described below by
system:
1. Respiratory:
Postoperatively, Mr. [**Known lastname 20692**] was kept on 4L of oxygen by nasal
cannula with O2 sats >95% and was breathing comfortably with
pain control by bupivicaine epidural and dilaudid PCA. Chest
tube had minimal serosanginous ouput with no leak detected. On
POD#2, patient had an episode of desaturation to high 80s on
100% O2. CXR showed complete collapse of left lung."
2304,"4. Heme/Onc:
Pathology reports are pending on Mr. [**Known lastname 20693**] resected lung
mass. EBL from surgery was 1 liter and patient's hct post-op
trended down to 25.2 from preop of 30. He was transfused 2U
PRBCs with appropriate increase in HCT and Hct on day of
discharge was 32.8.
5. ID: No issues.
6. Renal: No issues, Cr less than 1 throughout stay, 0.7 on
discharge.
7. GI/FEN: No issues, tolerated regular diet with normal bowel
functions.
Medications on Admission:
Hydrocodone 5 mg + acetaminophen 500 mg prn
Discharge Medications:
1. Nebulizers Kit Sig: One (1) Miscellaneous every [**3-13**]
hours."
2305,"Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left lower lobe lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you develop fevers
greater than 101.5, chills, nightsweats, shortness of breath,
unmanageable pulmonary secretions, uncontrolled pain or if left
chest incision develops redness, drainage or opens.
Walk 10-15 minutes 3-5 times a day."
2306,"2. Cardiac:
Mr. [**Known lastname 20693**] newly diagnosed afib was present throughout his
postoperative period. He was started on IV lopressor and
transitioned to po lopressor with dose titrated to keep rate
less than 120. He did not experience any ischemic symptoms
throughout this period. He was started on coumadin on POD#6, as
per his cardiologist, with plans to follow up with his PCP for
coumadin dosing.
3. Endocrine:
Mr. [**Known lastname 20693**] blood glucose was 150-200 in the PACU after
surgery. He was kept on a sliding scale during his hospital
stay. He will follow up with his PCP regarding diabetes work up."
2307,"Disp:*1 * Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain. Disp:*20 Tablet(s)* Refills:*1*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
Disp:*1 * Refills:*2*
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).Disp:*1 * Refills:*2*
7."
2308,"Pertinent Results:
[**2136-8-8**]
CBC: WBC-11.4 Hgb-10.7 Hct-32.8 Plt Ct-347
Chemistry: Na-137 K-4.1 Cl-102 HCO3-26 UreaN-16 Creat-0.7
Glucose-105
CXR [**2136-8-9**]:
Status post left lower lobectomy with according pleural and
chest wall changes, as well as overall volume loss of the left
hemithorax. There is
no visualization of an apical pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname 20692**] [**Last Name (Titles) 1834**] a left lower lobectomy with en bloc 4 rib
resection, chest wall reconstruction with a 2-mm [**Doctor Last Name 4726**]-Tex mesh,
mediastinal lymph node dissection, and intercostal muscle flap
buttress on [**2136-8-3**] without complications."
2309,"Bronchoscopy
was performed with removal of copious clear mucus plugs from
left mainstem and LUL bronchi. Patient was placed on BIPAP
overnight for improved ventilation. AM CXR on POD#3 showed
re-expansion of lung and patient was started on nebulizer
treatments, with improvement in dyspnea, cough production, and
oxygen saturation. Chest tube was removed on POD#4 without
evidence of pneumothorax on post-pull CXR. Oxygen was gradually
weaned to 2L and patient was transferred to the floor on POD#5.
With chest PT and continued nebs, oxygen was weaned completely
by POD#5 during rest and exertion. Patient was discharged home
on POD#6 with O2 sats >98% on room air and arrangements for VNA
and nebulizer treatments at home."
2310,"Start slow and increase.
Do not drive while on narcotics for pain. Take stool softeners
while on narcotics to prevent constipation.
Use nebulizer treatments every 6 hours (albuterol and
ipratropium) until you can cough easily without them. Do daily
breathing exercises (deep breath in, hold for 3 sec, breath out)
to keep your lungs expanded.
Followup Instructions:
Followup appointments:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2136-8-21**] 1:00 [**Hospital Ward Name 23**] 9 [**Hospital Ward Name **]. Get a chest xray
30 minutes before this appointment on the [**Location (un) **] radiology
department of the [**Hospital Ward Name **].
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2136-8-21**]
11:45 [**Hospital Ward Name 23**] 9 [**Hospital Ward Name **]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2136-8-23**] 8:30
Completed by:[**2136-8-14**]"
2311,"Admission Date: [**2136-8-3**] Discharge Date: [**2136-8-9**]
Date of Birth: [**2064-2-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin Preparations
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left lower lobe mass
Major Surgical or Invasive Procedure:
[**2136-8-3**] Left thoracotomy and left lower lobectomy with en bloc
chest wall resection and reconstruction with a 2-mm [**Doctor Last Name 4726**]-Tex
mesh, mediastinal lymph node dissection, intercostal muscle flap
buttress.
History of Present Illness:
Mr. [**Known lastname 20692**] is a 72 year old male with a 10 cm LLL NSCLC
confirmed by EBUS with negative work up for nodal and distant
metastatic disease."
2312,"# AML and Cecal Mass: Followed by Heme/Onc during admission. Initial
concern for recurrence given leukocytosis - peripheral smear showed No
blast, consistent with known MDS.
- Follow-up with Onc
.
# DM 2: FS in mid 100's, well controlled
- ISS and accuchecks.
-----------------------------------------------------------------------
--------------------------------------------------------------
Problems
Complicated bowel anatomy (see operations above)
Low bicarbonate
This was previously dominantly a respiratory alkalosis, but
HCO3 has continued to fall.
Check ABG, ULytes, ostomy lytes and then evaluate further
TPN is low-chloride already
Liver disease
Appears mostly cholestatic. However, holding TPN is a major
issue in this patient.
Appreciate hepatology
s input
Ferritin > Assay
Ask lab to dilute
Discuss with hepatology: does she have hemochromatosis?
Could this help explain her pancreatitis?
Acute renal failure
Continues to improve
AML and cecal mass
heme-onc following
Discussed with patient, son, and with surgical team.
Other issues as per ICU team note
ICU Care
Nutrition:
TPN w/ Lipids - [**2177-10-11**] 06:16 PM 58 mL/hour
Glycemic Control:
Lines:
PICC Line - [**2177-9-26**] 10:20 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
2313,"EBV and CMV IgG positive. EBV IgM negative.
Hepatitis Panel unrevealing for active disease. [**Month (only) 8**] also be stone
although imaging has shown no ductal dilation.
- Ferritin too high to measure -> will call lab to dilute sample to
remeasure and have a number
- ? hemachromatosis or Still
s disease
- Avoid hepatotoxic medications
- Liver following
- Cont to trend LFTs, lipase and amylase
.
# Decreased bicarb.: Down now from 18 to 15. Previously had a
respiratory alkalosis for unclear reasons. Now may be compensatory
acidosis or primary acidosis. Will need more info
- ABG today
- Urine lytes
- ostomy output lytes
# Fluid Balance: -1L yesterday, lasix gtt remains off."
2314,"9
25.5
22.7
Hct
31.0
34.5
30.5
32.9
33.2
33.1
Plt
69
72
65
67
70
Cr
2.0
1.8
1.8
1.6
1.6
1.6
1.7
1.5
TCO2
19
18
Glucose
160
130
131
110
100
121
105
95
Other labs: PT / PTT / INR:17.0/29.9/1.5, CK / CKMB /
Troponin-T:50/5/0.04, ALT / AST:151/120, Alk Phos / T Bili:191/7.0,
Amylase / Lipase:482/927, Differential-Neuts:71.0 %, Band:4.0 %,
Lymph:2.0 %, Mono:9.0 %, Eos:0."
2315,"0 %, D-dimer:5744 ng/mL, Fibrinogen:412
mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.8 g/dL, LDH:734 IU/L, Ca++:7.9
mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL
Assessment and Plan
75yoF with AML s/p chemo and R hemicolectomy for cecal mass c/b
anastomotic leak and intra-abdominal hematoma here with resolving
sepsis now POD #13 from wound closure and wash out.
# Increased LFTs: TB slightly down to 7.1, peak was 8.1 on [**10-5**].
Fractionation showed elevated Direct bili. Transaminases stable. Liver
consulted yesterday think it is unlikely shock liver but could have
been an effect of caspo with contribution to elevated T bili from
resolving hematomas."
2316,"9 g/dL
95 mg/dL
1.5 mg/dL
15 mEq/L
4.3 mEq/L
47 mg/dL
117 mEq/L
143 mEq/L
33.1 %
22.7 K/uL
[image002.jpg]
[**2177-10-7**] 05:33 PM
[**2177-10-8**] 05:23 AM
[**2177-10-8**] 04:39 PM
[**2177-10-9**] 05:25 AM
[**2177-10-9**] 08:55 AM
[**2177-10-9**] 03:57 PM
[**2177-10-9**] 04:55 PM
[**2177-10-10**] 07:54 AM
[**2177-10-10**] 03:34 PM
[**2177-10-11**] 03:39 AM
WBC
21.6
25.6
25."
2317,"- I=O today
- Repleting electrolytes PRN
- PM lytes
# Sepsis: Afebrile. Remains off pressors. WBC stable at 22 today.
Cultures NGTD.
- Following WBC count, fever curve
- Off antibiotics since [**2177-10-3**]
- JP drains out. Ostomy draining well..
.
# Intra-abdominal Hematoma. Hct stable.
- Stable, no current intervention.
# Acute Hypoxemic Respiratory Failure: Pt remains extubated good O2 Sat
on RA.
- Continue to monitor
# Thrombocytopenia: Stable for last several days. No signs of further
worsening of hematoma.
- continue to monitor
# Coagulopathy: Stable at 1.5 yesterday
- Trending INR
# Acute renal failure: Good UOP yestedary. Creatinine yest stable at
1.6
- Monitor UOP- will try to keep I=O today
- Renally dose meds, avoid nephrotoxins
."
2318,"Chief Complaint:
24 Hour Events:
- LFTs and pancreatic enzymes stable
- Liver recommended MRCP, although feel that TPN could be playing a
role
- Surgery would like to hold off on MRCP until patient more stable
- Psychiatry feels patient is mildly delerious although compensated by
family -> no psychoactive medications at this time
- Ferritin elevated to 3303 - ? of hemochromatosis (Ask liver tomorrow)
- Bicarb down to 15 and VBG with pH of 7.31/38/38/20
- Urine and Ostomy lytes indicate ? bicarb wasting out of ostomy.
Allergies:
Lisinopril
Hives;
Aspirin
dyspepsia;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2177-10-11**] 08:00 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2177-10-12**] 05:50 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2319,"7
C (99.9
Tcurrent: 37.7
C (99.9
HR: 98 (77 - 106) bpm
BP: 127/57(75) {109/49(66) - 145/62(80)} mmHg
RR: 24 (12 - 38) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 87.2 kg (admission): 81.2 kg
Height: 61 Inch
Total In:
2,280 mL
896 mL
PO:
TF:
IVF:
881 mL
558 mL
Blood products:
Total out:
2,775 mL
500 mL
Urine:
2,175 mL
500 mL
NG:
Stool:
Drains:
Balance:
-495 mL
396 mL
Respiratory support
O2 Delivery Device: None
SpO2: 100%
ABG: ////
Physical Examination
Gen: NAD, NG tube in place
CV: RRR no M/R/G
Pulm: CTAB
Abd: Ostomies with drainage, Mid-line incision without drainage,
non-tender
Extr: No edema, pulses faint but present
Labs / Radiology
70 K/uL
10."
2320,"# Coagulopathy: Received 1u FFP and 10 mg po vitamin K tonight prior to
transfer to ICU for INR of 1.7.
- Given likely bleeding, give 2mg IV vitamin K.
- Trend coags
.
# Acute renal failure: Patient developed ARF post-op likely secondary
to ATN from intra-operative hypotension. Renal function had trended
down to 2.7 yesterday but has since increased to 3.2 today.
- Trend creatinine
- Monitor UOP
- Renally dose meds, avoid nephrotoxins.
- Follow-up with Renal
.
# Cecal mass: Pathology consistent with low grade B cell lymphoma. Per
oncology notes, patient refused bone marrow biopsy today. Tentative
plan to reattempt biopsy on Monday.
- Follow-up with onc recs if any
- Per onc, send Bcr-Abl
.
# AML: Treated [**2171**], followed by Heme/Onc during admission. Initial
concern for recurrence given leukocytosis - peripheral smear showed No
blast, consistent with known MDS.
- Follow-up with Onc
.
# DM 2: ISS and accuchecks.
.
# FEN: NPO, TPN. Replete as necessary.
.
# Access: PICC
.
# PPx: SCDs and PPI
.
# Code: Full, confirmed with husband
.
# Comm: [**Name (NI) **] [**Name (NI) 1904**] ([**Telephone/Fax (1) 1907**]
.
# Dispo: ICU level of care
ICU Care
Nutrition:
Glycemic Control:
Lines:
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
2321,"She was also
noted to have sudden anemia with a hct of 17.9 from 28.8 requiring 2u
PRBC, as well as a coagulopathy with an INR of 1.7 requiring 1u FFP.
In addition, she has had decreased UOP. She was afebrile but with a
more distended abdomen. Of note, the patient has also been noted to
have increasing ostomy output. On transfer to the [**Hospital Unit Name 4**], VS were 96.7
109 113/57 30 99%RA.
Patient admitted from: [**Hospital1 5**] [**Hospital1 **]
History obtained from Patient, Family / [**Hospital 216**] Medical records
Allergies:
Lisinopril
Hives;
Aspirin
dyspepsia;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
AML - s/p one cycle induction with 7+3; [**2173**]."
2322,"Subsequently, CT scan [**9-11**] of her abdomen was unrevealing, but pt had
persistent leukocytosis despite broad spectrum abx, repeat CT abdomen
was performed and showed free fluid under the diaphragm and at the
anastomotic site. At that time ([**Date range (1) 1905**]) she underwent IR guided
drain placement of the fluid collections and vancomycin was added to
her regimen. Despite the above procedures, she continued to have a
rising WBC count and it was decided to take her to the OR for more
complete washout and ileostomy to divert fecal stream. Intraoperatively
she was found to have significant leakage at prior anastomosis site as
well as 300cc EBL and approx 1."
2323,"2). She received 2u PRBC today with
hematocrit increase to 19.4, suggesting continued bleeding or
hemolysis. Given degree of leukocytosis, likely combination of
pre-existing MDS with superimposed infectious process and less likely
leukemoid reaction. Patient has had C.diff negative x1 recently.
Given degree of leukocytosis, concerning for intra-abdominal
abscess/infection versus C.diff colitis with increasing ostomy output.
- Continue IV vanco, flagyl, pip/tazo
- Add PO vanco for empiric C. diff coverage
- Daily vanco AM levels, dose as needed with goal 15-20.
- Pan-culture, C.diff toxin [**Doctor First Name 1021**] x2
- Repeat CXR
- Discussed with surgical resident, and plan for CT torso tomorrow."
2324,"jpg]
Other labs: Lactic Acid:1.8 mmol/L
Assessment and Plan
Mrs. [**Known lastname 1904**] is a 75 year old female with a PMH significant for AML s/p
chemo and right-sided hemicolectomy for cecal mass found to be a low
grade B cell lymphoma complicated by anastomotic leak and
intra-abdominal abscesses s/p IR guided drain placement and washout
with surgical drain placement now readmitted to the [**Hospital Ward Name 29**] ICU for
hypotension, anemia, coagulopathy, and worsening leukocytosis.
.
# Hypotension: Likely secondary to sepsis/SIRS (tachycardia,
leukocytosis) and intravascular volume depletion secondary to bleeding
and hypoalbuminemia (albumin 2."
2325,"Independent with normal
mental status
Review of systems:
Constitutional: Fatigue, No(t) Fever
Ear, Nose, Throat: Dry mouth
Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema,
Tachycardia
Nutritional Support: NPO, No(t) Tube feeds, Parenteral nutrition
Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze
Gastrointestinal: Abdominal pain, Nausea, No(t) Emesis, No(t) Diarrhea,
No(t) Constipation
Genitourinary: Foley
Heme / Lymph: Anemia, Coagulopathy
Flowsheet Data as of [**2177-9-27**] 12:25 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 35.9
C (96.7
Tcurrent: 35.9
C (96."
2326,"- Trend fever curve, WBC, monitor UOP.
- Check lactate and fibrinogen.
- Transfuse additional 2u PRBC
- If continues to be hypotensive, bolus as necessary. Patient may
require additional CVL access as she only has a PICC.
.
# Anemia: Hematocrit today of 17.9 from 28.8 yesterday. Given recent
history of abdominal surgery and bloody ostomy output, likely is due to
blood loss as opposed hemolysis. Repeat hct after 2units PRBC 19.4.
- Check hemolysis labs
- Transfuse additional 2u PRBC
- Cross-match additional 2u PRBC
- Recheck hct with AML
.
# Post-op/anastomotic leak: As above. Currently hemodynamically
stable.
- Morphine and darvocet prn.
- Follow-up with surgery
."
2327,"5L of ascites. In addition to the loop
ostomy, a large drain was placed at this site. During the procedure,
she received 2u pRBCs, 4u FFP, and 1600cc crystaloid.
.
Her surgical procedure was complicated by acute renal failure likely
secondary to hypotension and inadequate renal perfusion with an initial
increase in creatinine to 2.3 from a baseline of 0.9-1. During her
[**Hospital Unit Name 4**] admission, she was extubated successfully and transferred to the
surgical service. Initial path results of the cecal mass were
consistent with low grade B cell lymphoma.
.
Since transfer the floor, the patient was initially stable but has over
the past day developed a worsening leukocytosis to 62k from 38k, as
well as hypotension with SBP in the 90s with HR 110."
2328,"Chief Complaint: Hypotension, anemia s/p rectocolectomy
HPI:
Ms. [**Known lastname 1904**] is a 75 year old female with a PMH significant for AML s/p
chemotherapy 3 years ago, recent right hemicolectomy for a cecal mass
on [**9-5**] complicated by anastomotic leak now s/p diverty loop ostomy on
[**9-19**]. Per the last [**Hospital Unit Name 4**] admission note:
.
She initially represented to the surgical service on [**9-9**] with
fever/chills and shortness of breath and empirically covered with
zosyn/flagyl. A large R pleural effusion was discovered and she
underwent thoracentesis [**9-12**] which to date has shown no growth on cx."
2329,"Evidence of MDS since
[**2-5**]. Recent finding of R cecal mass on colonoscopy
.
Type 2 diabetes with no known nephropathy, neuropathy, or
retinopathy; hypercholesterolemia; hypertension
.
Past Surgical History:
s/p R Hemicolectomy [**9-5**], status post tubal ligation; status post
benign breast biopsy; and cataract.
Cardiac disease, otherwise non-contributory. No heme malignancies or
cancers.
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Married, lives at home with her husband. She has 9 children. 1
son lives on her floor in the same building. She never was a
smoker and does not drink alcohol. She and her husband are both
retired. She formerly worked as a hairdresser."
2330,"7
Heart rhythm: ST (Sinus Tachycardia)
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
0 mL
Respiratory
O2 Delivery Device: None
Physical Examination
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,
No(t) S4, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: Right base)
Abdominal: Soft, Tender: throughout
Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
[image002."
2331,"Acute respiratory failure
remains vent dependent, will check SBT
today, will likely need therapeutic thoracentesis, possible extubation
next 1-2 days.
CVS - echo pending
Acute renal failure - felt to be contrast-induced, renal service
consulted, urine output improving, will diurese and aim for negative
fluid balance
ID - redose vanco by level, keep 15-20, continue Zosyn.
FEN- on TPN
ICU Care
Nutrition:
TPN w/ Lipids - [**2177-9-20**] 10:46 PM 62 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2177-9-19**] 09:58 PM
PICC Line - [**2177-9-19**] 10:37 PM
18 Gauge - [**2177-9-19**] 10:39 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP: HOB elevation
Comments:
Communication: Comments:
Code status: Full code
Disposition :
Total time spent: 37 minutes
Patient is critically ill"
2332,"Postop presented with fever, SOB, leukocytosis. CT
abd showed air around anastomosis and a right pleural effusion.
Thoracentesis c/w exudate, cultures negative. Wbc progressively
increased. Yesterday had diverting loop enterostomy with drain inserted
at site of anastomosis. Operative course with low u/o. Postop
hypotension, administered LR and transfused 2 u prbc, ffp. Transferred
intubated, on vanco/zosyn/fluconazole. Currently responding to IV
crystaloid with improved u/o.
Complicated case with hx of AML, MDS, now cecal mass resected (path
pending) with post-op course complicated by hypotension, likely
hypovolemic, acute renal failure, exudative pleural effusion (LDH 1154,
no organisms, cytology neg), and acute resp failure."
2333,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
75 yr old woman with hx of AML tx with chemo [**2173**], right cecal mass
resected [**2177-9-5**]. Postop presented with fever, SOB, leukocytosis. CT
abd showed air around anastomosis and a right pleural effusion.
Thoracentesis c/w exudate, cultures negative. Wbc progressively
increased. [**9-19**] had diverting loop enterostomy with surgical drain
inserted at site of anastomosis. Operative course with low u/o."
2334,"Postop
hypotension, administered LR and transfused 2 u prbc, ffp. Transferred
intubated, on vanco/zosyn/fluconazole. Currently responding to IV
crystaloid with improved u/o. Path on cecal mass is lymphoid tissue
without evidence of malignancy.
24 Hour Events:
Transfused 1 unit of PRBC for Hct 23
Allergies:
Lisinopril
Hives;
Aspirin
dyspepsia;
Last dose of Antibiotics:
Fluconazole - [**2177-9-20**] 08:30 AM
Vancomycin - [**2177-9-20**] 02:35 PM
Piperacillin/Tazobactam (Zosyn) - [**2177-9-21**] 08:07 AM
Infusions:
Propofol - 20 mcg/Kg/min
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2177-9-21**] 08:07 AM
Hydromorphone (Dilaudid) - [**2177-9-21**] 08:07 AM
Other medications:
ISS, PPI, last dose of vanco 4pm [**9-20**], atrovent q6,
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Cardiovascular: No(t) Chest pain
Gastrointestinal: No(t) Abdominal pain
Flowsheet Data as of [**2177-9-21**] 09:44 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2335,"37/43/111/23/0
Ve: 7.8 L/min
PaO2 / FiO2: 277
Physical Examination
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished: at
bases)
Abdominal: Soft, BS scant
Extremities: Right: 1+, Left: 1+
Skin: Not assessed
Neurologic: Follows simple commands, Responds to: Not assessed,
Movement: Not assessed, Tone: Not assessed
Labs / Radiology
10.1 g/dL
110 K/uL
152 mg/dL
2."
2336,"7
Plt
99
97
93
110
Cr
2.3
2.4
2.5
2.7
TCO2
25
25
25
26
Glucose
151
189
159
152
Other labs: PT / PTT / INR:15.7/59.8/1.4, ALT / AST:16/23, Alk Phos / T
Bili:56/0.6, Amylase / Lipase:104/45, Lactic Acid:1.2 mmol/L,
Albumin:2.2 g/dL, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL
Fluid analysis / Other labs: vanco 29.4
Imaging: CXR ETT ~3cm above carina, persistent large right sided
effusion
Assessment and Plan
75 yr old woman with hx of AML tx with chemo [**2173**], right cecal mass
resected [**2177-9-5**]."
2337,"7 mg/dL
23 mEq/L
3.7 mEq/L
38 mg/dL
112 mEq/L
143 mEq/L
27.7 %
41.7 K/uL
[image002.jpg]
[**2177-9-19**] 10:53 PM
[**2177-9-20**] 01:04 AM
[**2177-9-20**] 04:22 AM
[**2177-9-20**] 04:56 AM
[**2177-9-20**] 08:45 AM
[**2177-9-20**] 04:50 PM
[**2177-9-20**] 05:53 PM
[**2177-9-21**] 04:50 AM
[**2177-9-21**] 08:29 AM
WBC
42.2
44.6
40.7
41.7
Hct
26.0
27.0
24.4
23.0
27."
2338,"7
C (99.8
Tcurrent: 37.7
C (99.8
HR: 93 (86 - 103) bpm
BP: 122/42(66) {78/40(63) - 143/73(86)} mmHg
RR: 21 (15 - 28) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 96.3 kg (admission): 81.3 kg
Total In:
5,250 mL
891 mL
PO:
TF:
IVF:
2,619 mL
311 mL
Blood products:
1,154 mL
Total out:
1,070 mL
710 mL
Urine:
905 mL
710 mL
NG:
75 mL
Stool:
Drains:
70 mL
Balance:
4,180 mL
181 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 433 (347 - 433) mL
PS : 10 cmH2O
RR (Spontaneous): 19
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 61
PIP: 16 cmH2O
SpO2: 100%
ABG: 7."
2339,"History of Present Illness:
75F POD4 s/p Right colectomy for cecal mass was discharged home
[**2177-9-8**] and returns [**2177-9-9**] with fever/chills and shortness
of breath. Patient reports doing after discharge yesterday
however awoke this morning with fever. She otherwise has no
complaints and denies nausea, vomiting, diarrhea, denies having
any bowel movements or passage of blood, dizziness or
lightheadedness.
Past Medical History:
Type 2 diabetes with no known nephropathy, neuropathy, or
retinopathy; hypercholesterolemia; hypertension status post
tubal ligation; status post benign breast biopsy; and cataract.
Social History:
Married, lives at home with her husband."
2340,"These
free water boluses can be continued as needed. Imodium may also
be added to her medication regimen to help control her ostomy
output.
Heme: She has had recurrent issues of leukocytosis, anemia, and
thrombocytopenia. Her initial leukocytosis was attributed to
sepsis, which resolved with antibiotics and drainage of abscess
collections. Her recurrent bouts of leukocytosis were thought
to be consistent with a leukemoid reaction. Her WBC is trending
downward and is now at a low of 18K. She has ongoing problems
with anemia secondary to her myelodysplastic syndrome. She
received transfusions of packed RBCs when necessary.
ID: After the initial operation she had a persistent
leukocytosis so she was started on empiric Zosyn and Flagyl."
2341,"Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Anastamotic leak
Abdominal fluid collections managed with CT drainage
Renal insufficiency related to IV contrast
Hypervolemia managed with IV Lasix
Hypovolemia managed with IV fluid
Anasarca
Acute Blood loss anemia
.
Secondary:
AML, DM 2, Hyperlipidemia, HTN
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications."
2342,"7
[**2177-9-15**] 03:20PM BLOOD ALT-24 AST-33 LD(LDH)-392* AlkPhos-115
Amylase-245* TotBili-0.3 DirBili-0.2 IndBili-0.1
[**2177-9-9**] 07:30PM BLOOD LD(LDH)-317* DirBili-0.7*
[**2177-9-16**] 06:55AM BLOOD Lipase-282*
[**2177-9-15**] 03:20PM BLOOD Lipase-493*
[**2177-9-15**] 06:55AM BLOOD Lipase-363*
[**2177-9-17**] 07:55AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.8
[**2177-9-16**] 06:55AM BLOOD Albumin-2.6* Calcium-7.8* Phos-2.3*
Mg-1.9 Iron-97
[**2177-9-13**] 08:25AM BLOOD Albumin-2."
2343,"Vancomycin was added on [**9-15**] when a peri-anastomotic collection
was found. With her impressive leukocytosis, multiple stool
samples were sent for C.diff, which all were negative.
Fluconazole was added on [**9-18**]. A 10 day course of Vancomycin
was complete for coag negative staph isolated from a blood
culture. A 9 day course of Meropenem was completed for
Enterobacter that was grown from the pigtail catheter.
Medications on Admission:
Vicodin and colace. No other routine medications
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed for wheezing."
2344,"Her TPN was able to be weaned off. She is currently
tolerating tube feeds cycled overnight. Her staples were
removed and her incision is healing nicely. The penrose drain
was backed out 4cm and restitched to the ostomy appliance, this
will remain to ostomy bag drainage.
Genitourinary: On [**9-18**] her serum creatinine rose to 1.5 and she
was bolused with IVF for low urine output. After her 2nd
operation, her creatinine continued to rise. A renal consult
was obtained and they felt that her acute renal failure was due
to ATN. On [**9-26**] she became increasinly oliguric and was
transferred back to the ICU."
2345,"CT guided drainage of this
collection was performed. A repeat CT scan was obtained on
[**9-16**] and showed two smaller intra-abdominal fluid collections
that were percutaneously drained. A repeat CT scan on [**9-18**]
showed a new LLQ fluid collection which was percutaneously
drained with a pigtail catheter and the current RUQ drain was
exchanged. Her clinical condition failed to improve so on [**9-19**]
she returned to the operating room for an exploratory
laparotomy, diverting ileostomy and penrose placement around the
anastamotic site. The diverting ileostomy began to function on
[**9-23**]. On [**9-26**] she became increasingly oliguric."
2346,"Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers
71-140 mg/dL 0 Units 0 Units 0 Units 0 Units
141-160 mg/dL 2 Units 2 Units 2 Units 2 Units
161-180 mg/dL 5 Units 5 Units 5 Units 5 Units
181-200 mg/dL 8 Units 8 Units 8 Units 8 Units
201-220 mg/dL 11 Units 11 Units 11 Units 11 Units
221-240 mg/dL 14 Units 14 Units 14 Units 14 Units
241-260 mg/dL 17 Units 17 Units 17 Units 17 Units
261-280 mg/dL 20 Units 20 Units 20 Units 20 Units
281-300 mg/dL 23 Units 23 Units 23 Units 23 Units
301-320 mg/dL 26 Units 26 Units 26 Units 26 Units"
2347,"At Discharge:
Vitals: 98.8, 79, 111/61, 18, 98% on room air
GEN: NAD, A/Ox3
CV: RRR, no m.r.g
RESP: lungs clear
ABD: soft, nontender, nondistended, ostomy functioning, penrose
drain stitched in place, incision healing well
Extrem: no c/c/e
Pertinent Results:
[**2177-9-17**] 07:55AM BLOOD WBC-23.2* RBC-3.33*# Hgb-10.1*#
Hct-30.0*# MCV-90 MCH-30.3 MCHC-33.6 RDW-15.2 Plt Ct-119*
[**2177-9-16**] 07:40PM BLOOD Hct-21.3*
[**2177-9-16**] 06:55AM BLOOD WBC-25.1* RBC-2.34* Hgb-7."
2348,"0 MCHC-32.1 RDW-14.4 Plt Ct-104*
[**2177-9-13**] 08:25AM BLOOD WBC-33.8* RBC-3.33* Hgb-10.0* Hct-30.7*
MCV-92 MCH-30.2 MCHC-32.7 RDW-14.4 Plt Ct-114*
[**2177-9-9**] 09:10PM BLOOD WBC-47.6* RBC-3.53* Hgb-10.5* Hct-33.0*
MCV-94 MCH-29.8 MCHC-31.9 RDW-15.0 Plt Ct-117*
[**2177-9-9**] 09:00AM BLOOD WBC-20.0* RBC-2.39* Hgb-7.6* Hct-22.8*
MCV-95 MCH-31.9 MCHC-33.5 RDW-13."
2349,"She has 9 children. 1
son lives on her floor in the same building. She never was a
smoker and does not drink alcohol. She and her husband are both
retired. She formerly worked as a hairdresser.
Family History:
Cardiac disease, otherwise non-contributory. No heme
malignancies or cancers.
Physical Exam:
On day of admission:
VS: T 103.2 P 120 BP 108/55 RR 32 O2 99% 2L
PE: Gen - alert and oriented times 3, no acute distress
CV - Tachycardia, regular rhythm
Pulm - clear to ascultation bilaterally
Abd - Soft, mild right flank tenderness to palpation,
nondistended, no rebound/guarding, incision
clean/dry/intact
Ext - no edema
."
2350,"2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed: Symptoms of oral thrush.
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
5. Loperamide 2 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for increased ostomy output: For ostomy output
>1500cc/24hrs .
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)."
2351,"Pulmonary: A right thoracentesis was performed on [**2177-9-12**].
Post-operatively she required ventilatory support. After her
third operation she was volume overloaded and remained on the
ventilator while she was aggressively diuresed. When she was
back to her dry weight she tolerated extubation and has remained
stable from a respiratory standpoint since. Due to her
persistent tachycardia a CTA of her chest was obtained, which
revealed no pulmonary embolus.
Gastrointestinal: She underwent a right colectomy with a
hand-sewn ileotransverse colostomy on [**2177-9-5**]. Her clinical
status improved initially but then slowly began to deteriorate.
This decline along with a substantial leukocytosis prompted a CT
scan on [**9-15**] which revealed a large abdominal fluid collection
surrounding the anastomotic site."
2352,"[**2177-9-27**] Evacuation of pelvic hematoma
4. [**2177-9-29**] Abdominal closure
.
Neuro: She required prn narcotics for pain. On [**9-24**] her pain
medications were discontinued due to increased lethargy. Her
pain improved and was well controlled on tylenol. She did
appear depressed at times but as her strenght improved so did
her affect and willingness to ambulate and participate in her
care.
Cardiovascular: She required vasopressor support
post-operatively. This was able to be weaned to off after a
couple of days. She did remain tachycardic in the low 100s
during her entire hospital stay. She was started on a beta
blocker and her heart rate improved."
2353,"* 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.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you."
2354,"A CT scan
showed a large hematoma compressing both ureters and causing
hydronephrosis. She was taken back to the operating room for a
hematoma evacuation. She returned to the operating [**Apartment Address(1) **] days
later for abdominal packing removal and abdominal closure with
mesh. She required TPN support for nutrition. She developed
pancreatitis and an elevated bilirubin. The elevated bilirubin
was attributed to TPN and cholestasis, and has been trending
down to near normal. Due to her pancreatitis, a Dobhoff tube
was placed and tube feeds started. Her lipase remain elevated
for a number of days and has since trended back down towards
normal."
2355,"8* Calcium-7.7* Phos-2.6*
Mg-2.2
[**2177-9-16**] 06:55AM BLOOD calTIBC-156* Ferritn-1170* TRF-120*
[**2177-9-15**] 03:20PM BLOOD Hapto-232*
[**2177-9-9**] 07:30PM BLOOD Hapto-162
[**2177-9-16**] 06:55AM BLOOD Triglyc-99
Brief Hospital Course:
The patient was admitted on [**2177-9-5**] to the surgical service.
Due to her prolonged hospital course, her summary will be done
by systems.
.
Operations:
1. [**2177-9-5**] Exploratory laparotomy, right colectomy, hand-sewn 2
layer side to side ileotranverse colostomy.
2. [**2177-9-19**] Exploratory laparotomy, LOA, drainage and washout of
abdomen, diverting loop ileostomy
3."
2356,"8 Plt Ct-91*
[**2177-9-17**] 07:55AM BLOOD PT-17.2* PTT-46.5* INR(PT)-1.6*
[**2177-9-15**] 03:20PM BLOOD Fibrino-611*
[**2177-9-9**] 07:30PM BLOOD Fibrino-486*# D-Dimer-3758*
[**2177-9-17**] 07:55AM BLOOD Glucose-92 UreaN-11 Creat-0.9 Na-143
K-3.3 Cl-106 HCO3-29 AnGap-11
[**2177-9-16**] 06:55AM BLOOD Glucose-95 UreaN-12 Creat-0.8 Na-145
K-3.8 Cl-111* HCO3-28 AnGap-10
[**2177-9-16**] 06:55AM BLOOD ALT-21 AST-32 LD(LDH)-341* AlkPhos-115
Amylase-187* TotBili-0."
2357,"0* Hct-21.7*
MCV-93 MCH-30.1 MCHC-32.5 RDW-14.5 Plt Ct-113*
[**2177-9-15**] 03:20PM BLOOD WBC-39.8* RBC-2.58* Hgb-7.8* Hct-24.1*
MCV-93 MCH-30.1 MCHC-32.2 RDW-14.5 Plt Ct-112*
[**2177-9-15**] 06:55AM BLOOD WBC-36.9* RBC-2.62* Hgb-7.8* Hct-24.7*
MCV-94 MCH-29.9 MCHC-31.7 RDW-14.4 Plt Ct-101*
[**2177-9-14**] 06:30AM BLOOD WBC-41.9* RBC-3.08* Hgb-9.2* Hct-28.8*
MCV-93 MCH-30."
2358,"7. Acetaminophen 160 mg/5 mL Solution Sig: 20mL PO Q6H (every 6
hours) as needed for Pain/HA: Do not exceed 4000mg in 24hrs .
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100, HR<60.
9. Lantus 100 unit/mL Solution Sig: 4 Units Subcutaneous at
bedtime.
10. Insulin Regular Human 100 unit/mL Solution Sig: Per Sliding
Scale Injection Before meals and at bedtime, or every 6 hours.
11. Regular Insulin Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL 4 oz."
2359,".
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Right upper quadrant ostomy appliance:
-Penrose inserted into hepatic flexure. The drain is sutured to
the stoma wafer to prevent from falling out.
-The penrose drain site will be re-assessed per Dr. [**Last Name (STitle) 1924**] at
the follow-up appointment on [**2177-11-11**].
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 500mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 1924**] [**Telephone/Fax (1) 7508**] on Tuesday
[**2177-11-11**]. Please call to confirm appointment time.
2. Follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6**] [**Name (STitle) **] [**Telephone/Fax (1) 7976**] as needed."
2360,"Admission Date: [**2177-9-9**] Discharge Date: [**2177-10-28**]
Date of Birth: [**2101-12-30**] Sex: F
Service: SURGERY
Allergies:
Lisinopril / Aspirin
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Fever, shortness of breath
Major Surgical or Invasive Procedure:
Operations
1. [**2177-9-5**] Exploratory laparotomy, right colectomy, hand-sewn 2
layer side to side ileotranverse colostomy.
2. [**2177-9-19**] Exploratory laparotomy, LOA, drainage and washout of
abdomen, diverting loop ileostomy
3. [**2177-9-27**] Evacuation of pelvic hematoma
4. [**2177-9-29**] Abdominal closure
Procedures:
[**2177-9-10**] and [**2177-9-12**] - thoracic ultrasound and thoracentesis -
Right chest
[**2177-9-15**] CT guided drainage of abdominal fluid collection
[**2177-9-16**] - CT guided drainage right abdominal fluid collection
[**2177-9-16**] - CT guided aspiration of left lower quadrant fluid
collection"
2361,"A repeat CT scan showed a large
pelvic hematoma which was compressing the ureters and causing
hydronephrosis. This hematoma was evacuated and her renal
function has returned to [**Location 213**]. While she was in acute renal
failure, her medications were renally dosed.
FEN: She was advanced to a regular diet post-operatively. When
she was found to have an anastomotic leak she was made NPO, a
PICC line was placed, and TPN was started on [**9-17**]. She became
hypernatremic on [**9-24**] which was treated with D5W to replace her
free water deficit. Due to increased ostomy output at times,
she has required free water boluses per her Dobhoff tube."
2362,"- Acute respiratory failure
remains vent dependent, will check SBT
today, will likely need repeat thoracentesis, possible extubation next
24 hrs.
- CVS - echo pending
Acute renal failure - felt to be contrast-induced, renal service
consulted, u/o improving, will diurese gently and aim for negative
fluid balance.
- ID
etiology of lymphoid mass unclear but suggests systemic
infection. Will ask ID to get involved. Continue vanco (dose by level,
keep 15-20) and Zosyn.
- FEN- on TPN
ICU Care
TPN w/ Lipids - [**2177-9-20**] 10:46 PM 62 mL/hour
Glycemic Control: Regular insulin sliding scale
Arterial Line - [**2177-9-19**] 09:58 PM, PICC Line - [**2177-9-19**] 10:37 PM,
18 Gauge - [**2177-9-19**] 10:39 PM
Prophylaxis: DVT: SCH, Stress ulcer: PPI, VAP: HOB elevation
Communication: Husband updated personally
Code status: Full code, Disposition : ICU
Total time spent: 37 minutes, patient is critically ill"
2363,"37/43/111/23/0
Ve: 7.8 L/min
PaO2 / FiO2: 277
Physical Examination
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL, Head, Ears, Nose, Throat: Normocephalic,
Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Normal), Respiratory / Chest:
(Breath Sounds: No(t) Wheezes : , Diminished: at bases)
Abdominal: Soft, BS scant, Extremities: Right: 1+, Left: 1+
Skin: warm, Neurologic: Follows simple commands, Responds to verbal
commands
Labs / Radiology
10.1 g/dL
110 K/uL
152 mg/dL
2.7 mg/dL
23 mEq/L
3.7 mEq/L
38 mg/dL
112 mEq/L
143 mEq/L
27.7 %
41.7 K/uL
[image002."
2364,"jpg]
[**2177-9-19**] 10:53 PM
[**2177-9-20**] 01:04 AM
[**2177-9-20**] 04:22 AM
[**2177-9-20**] 04:56 AM
[**2177-9-20**] 08:45 AM
[**2177-9-20**] 04:50 PM
[**2177-9-20**] 05:53 PM
[**2177-9-21**] 04:50 AM
[**2177-9-21**] 08:29 AM
WBC
42.2
44.6
40.7
41.7
Hct
26.0
27.0
24.4
23.0
27.7
Plt
99
97
93
110
Cr
2.3
2.4
2.5
2.7
TCO2
25
25
25
26
Glucose
151
189
159
152
Other labs: PT / PTT / INR:15."
2365,"Postop hypotension, administered LR and transfused 2 u prbc,
ffp. Transferred intubated, on vanco/zosyn/fluconazole. Currently
responding to IV crystaloid with improved u/o. Path on cecal mass is
lymphoid tissue without evidence of malignancy.
24 Hour Events:
Transfused 1 unit of PRBC for Hct 23
Allergies:
Lisinopril
Hives;
Aspirin
dyspepsia;
Last dose of Antibiotics:
Fluconazole - [**2177-9-20**] 08:30 AM
Vancomycin - [**2177-9-20**] 02:35 PM
Piperacillin/Tazobactam (Zosyn) - [**2177-9-21**] 08:07 AM
Infusions:
Propofol - 20 mcg/Kg/min
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2177-9-21**] 08:07 AM
Hydromorphone (Dilaudid) - [**2177-9-21**] 08:07 AM
Other medications:
ISS, PPI, last dose of vanco 4pm [**9-20**], atrovent q6,
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Cardiovascular: No(t) Chest pain
Gastrointestinal: No(t) Abdominal pain
Flowsheet Data as of [**2177-9-21**] 09:44 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2366,"CT
abd showed air around anastomosis and a right pleural effusion.
Thoracentesis c/w exudate, cultures negative. Wbc progressively
increased. Yesterday had diverting loop enterostomy with drain inserted
at site of anastomosis. Operative course with low u/o. Postop
hypotension, administered LR and transfused 2 u prbc, ffp. Transferred
intubated, on vanco/zosyn/fluconazole. Currently responding to IV
crystaloid with improved u/o.
Complicated case with hx of AML, MDS, now cecal mass resected (lymphoid
tissue, no malignancy per prelim report) with post-op course
complicated by hypotension, likely hypovolemic, acute renal failure,
exudative pleural effusion (LDH 1154, no organisms, cytology neg), and
acute resp failure."
2367,"7/59.8/1.4, ALT / AST:16/23, Alk Phos / T
Bili:56/0.6, Amylase / Lipase:104/45, Lactic Acid:1.2 mmol/L,
Albumin:2.2 g/dL, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL, Fluid
analysis / Other labs: vanco 29.4
Imaging: CXR ETT ~3cm above carina, persistent large right sided
effusion. CT chest reviewed personally. Elevated rt hemidiaph and
moderate right pleural effusion
Assessment and Plan
75 yr old woman with hx of AML tx with chemo [**2173**], right cecal mass
resected [**2177-9-5**]. Postop presented with fever, SOB, leukocytosis."
2368,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
75 yr old woman with hx of AML tx with chemo [**2173**], right cecal mass
resected [**2177-9-5**]. Postop presented with fever, SOB, leukocytosis. CT
abd showed air around anastomosis and a right pleural effusion.
Thoracentesis c/w exudate, cultures and cytology negative. Wbc
progressively increased. [**9-19**] had diverting loop enterostomy with
surgical drain inserted at site of anastomosis. Operative course with
low u/o."
2369,"7
C (99.8
Tcurrent: 37.7
C (99.8
HR: 93 (86 - 103) bpm
BP: 122/42(66) {78/40(63) - 143/73(86)} mmHg
RR: 21 (15 - 28) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 96.3 kg (admission): 81.3 kg
Total In:
5,250 mL
891 mL
PO:
TF:
IVF:
2,619 mL
311 mL
Blood products:
1,154 mL
Total out:
1,070 mL
710 mL
Urine:
905 mL
710 mL
NG:
75 mL
Stool:
Drains:
70 mL
Balance:
4,180 mL
181 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 433 (347 - 433) mL
PS : 10 cmH2O
RR (Spontaneous): 19
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 61
PIP: 16 cmH2O
SpO2: 100%
ABG: 7."
2370,"Chief Complaint: respiratory failure, post-op for anastomotic leak
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
75 yo women right cecal mass removed on [**9-5**] with colectomy and
anastomasis. Readmitted on [**9-9**] with fever, chills, SOB. Covered with
Zosyn and Flagyl. CT abdomen with some free air and fluid around
anastomosis. Had moderate right effusion tapped, negative cultures.
protein 4.0, LDH 1154, so was exudative. Repeat CT scan - with
multiple abscesses which were enlarged - IR drainage of abscesses with
two drains."
2371,"Vanco added. Negative cultures. Continued with fevers and
increased WBC. Went to OR today with washout and ileostomy. Large
penrose drain placed at site of anastomosis. Also had acute renal
failure during course Cr. of 0.9 to 2.3. 1.5L of ascites removed
during procedure with poor urine output. Got 2U PRBC, 4U FFP, and 1.6L
of crystalloid. Tranferred to MICU intubated on propofol, no
pressors.
Allergies:
Lisinopril
Hives;
Aspirin
dyspepsia;
Last dose of Antibiotics:
Vanco, Zosyn, flagyl
Infusions:
Propofol - 49.2 mcg/Kg/min
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
AML 7+3 induction chemo in [**2173**] with evidence of MDS since."
2372,"8
C (96.4
Tcurrent: 35.8
C (96.4
HR: 78 (75 - 78) bpm
BP: 111/57(74) {111/57(74) - 123/59(80)} mmHg
RR: 14 (14 - 15) insp/min
Heart rhythm: SR (Sinus Rhythm)
Total In:
4,694 mL
PO:
TF:
IVF:
471 mL
Blood products:
Total out:
0 mL
342 mL
Urine:
240 mL
NG:
50 mL
Stool:
Drains:
52 mL
Balance:
0 mL
4,352 mL
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 12
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
PIP: 33 cmH2O
Plateau: 25 cmH2O
ABG: 7."
2373,"1
2.3
30
23
111
3.9
144
38.9
[image002.jpg]
[**2177-9-19**] 10:53 PM
TC02
25
Assessment and Plan
Drainage of intraabdominal infection: Slightly improved WBC, continue
broad spectrum antibiotics, follow up cultures.
Acute renal failure: Contrast nephropathy, low urine output, may also
be intravascularly depleted. Consider PRBCs if low Hct. recheck labs.
Pleural effusions: Exudative effusion, infection versus malignancy.
Should be retapped at some point and send cell count for flow cytometer
for cellular markers to r/o lymphoma.
Respiratory failure: Wake in AM and extubate. Pain control when
waking in AM.
F/E/N: NGT, on TPN, NPO
ICU Care
Nutrition:
Glycemic Control:
Lines / Intubation:
Arterial Line - [**2177-9-19**] 09:58 PM
PICC Line - [**2177-9-19**] 10:37 PM
18 Gauge - [**2177-9-19**] 10:39 PM
Comments:
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 45 minutes
Patient is critically ill"
2374,"right cecal mass, colonscopic biospy with polyclonal lymphoid
infiltrates
hypercholesterol
HTN
DM II
tubal ligation
benign best bx
cataract surgery
MED:
colace
percocet
cardiac disease
Occupation: hair dresser, retired
Drugs: none
Tobacco: none
Alcohol: none
Other:
Review of systems:
Constitutional: Fever
Ear, Nose, Throat: OG / NG tube
Cardiovascular: No(t) Edema
Respiratory: ventilatory support
Gastrointestinal: Abdominal pain
Genitourinary: oliguria
Musculoskeletal: No(t) Myalgias
Integumentary (skin): No(t) Rash
Heme / Lymph: Anemia
Neurologic: No(t) Seizure
Psychiatric / Sleep: No(t) Delirious
Allergy / Immunology: No(t) Immunocompromised
Signs or concerns for abuse : No
Pain: No pain / appears comfortable
Flowsheet Data as of [**2177-9-20**] 12:29 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 35."
2375,"46/34/91//0
Ve: 7.1 L/min
PaO2 / FiO2: 228
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Breath Sounds: Diminished: right)
Abdominal: No(t) Bowel sounds present, Distended, left ostomy, right
drains
Extremities: Right: 2+, Left: 2+
Musculoskeletal: No(t) Muscle wasting, Unable to stand
Skin: Warm, No(t) Rash:
Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds
to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed
Labs / Radiology
93
27."
2376,"8/33.3/1.7, CK / CKMB /
Troponin-T:50/5/0.04, ALT / AST:135/134, Alk Phos / T Bili:241/7.2,
Amylase / Lipase:250/550, Differential-Neuts:63.0 %, Band:5.0 %,
Lymph:2.0 %, Mono:19.0 %, Eos:0.0 %, D-dimer:5744 ng/mL, Fibrinogen:412
mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.4 g/dL, LDH:791 IU/L, Ca++:7.5
mg/dL, Mg++:2.2 mg/dL, PO4:2.3 mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE ON CHROIC (NOT ARDS/[**Doctor Last Name 76**]): Mainly limited
by volume overload."
2377,"1
C (100.5
Tcurrent: 37.2
C (99
HR: 99 (87 - 123) bpm
BP: 158/71(105) {145/61(93) - 189/92(134)} mmHg
RR: 31 (11 - 32) insp/min
SpO2: 99%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 87.4 kg (admission): 81.2 kg
Height: 61 Inch
CVP: 4 (4 - 16)mmHg
Total In:
4,287 mL
881 mL
PO:
TF:
IVF:
2,806 mL
257 mL
Blood products:
Total out:
4,336 mL
3,440 mL
Urine:
3,745 mL
3,230 mL
NG:
250 mL
75 mL
Stool:
Drains:
31 mL
35 mL
Balance:
-49 mL
-2,559 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 365 (324 - 390) mL
PS : 5 cmH2O
RR (Spontaneous): 30
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 97
PIP: 11 cmH2O
SpO2: 99%
ABG: 7."
2378,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
Back on lasix drip overnight at 3 mg/hour
Getting free water replacement for hypernatremia
Last received fentanyl at MN
Patient unable to provide history: intubated
Allergies:
Lisinopril
Hives;
Aspirin
dyspepsia;
Last dose of Antibiotics:
Infusions:
Furosemide (Lasix) - 3 mg/hour
Other ICU medications:
Morphine Sulfate - [**2177-10-5**] 04:41 PM
Fentanyl - [**2177-10-6**] 12:22 AM
Pantoprazole (Protonix) - [**2177-10-6**] 12:23 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: Fatigue
Genitourinary: Foley
Pain: No pain / appears comfortable
Flowsheet Data as of [**2177-10-6**] 10:58 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 38."
2379,"3 %
24.5 K/uL
[image002.jpg]
[**2177-10-4**] 05:43 AM
[**2177-10-4**] 11:11 AM
[**2177-10-4**] 05:00 PM
[**2177-10-5**] 04:03 AM
[**2177-10-5**] 09:12 AM
[**2177-10-5**] 12:54 PM
[**2177-10-5**] 06:08 PM
[**2177-10-6**] 12:12 AM
[**2177-10-6**] 04:26 AM
[**2177-10-6**] 05:26 AM
WBC
25.0
24.5
Hct
33.3
33.3
Plt
80
68
Cr
3.2
2.7
2.4
2.4
2.0
2.1
TCO2
29
27
25
26
Glucose
99
126
162
132
131
120
Other labs: PT / PTT / INR:18."
2380,"39/41/121/23/0
Ve: 9.5 L/min
PaO2 / FiO2: 303
Physical Examination
Lymphatic: Cervical WNL, Supraclavicular WNL
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: Crackles : dependent)
Abdominal: Soft, Non-tender
Extremities: Right: 2+, Left: 2+
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
11.5 g/dL
68 K/uL
120 mg/dL
2.1 mg/dL
23 mEq/L
4.2 mEq/L
59 mg/dL
113 mEq/L
145 mEq/L
33."
2381,"She has been aggressively diuresed over the past
several days. Anasarca much improved. Minimal secretions except for
orally per nursing. Holding sedation in anticipation of extubation
later today. Will discuss with surgery.
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr continues to
improve, down to 2.0. Repleting K with aggressive diuresis.
ALTERATION IN NUTRITION: Continues on TPN.
ELECTROLYTE & FLUID DISORDER, OTHER: As above. Hypernatremia
resolving with free water replacement. Checking [**Hospital1 **] electrolytes.
ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS): More ostomy output
today. Abdomen soft. Hct stabe.
ICU Care
Nutrition:
TPN w/ Lipids - [**2177-10-5**] 06:17 PM 58 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2177-9-26**] 10:20 PM
Multi Lumen - [**2177-9-27**] 10:00 PM
Arterial Line - [**2177-9-30**] 07:30 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Need for restraints reviewed
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition :ICU
Total time spent: 55 minutes
Patient is critically ill"
2382,"7. No new culture data.
Problems:
1) Chronic respiratory failure secondary to volume overload. Has
had secretions, mostly described as frothy albeit today more thick,
tan. Bronchoscopy showed minimal frothy secretions throughout, BAL
clear sent for gram stain, C+S as per surgery. Continues broad spectum
abx/antifungal therapy. Need to readdress with ID service as to
endpoint. Try to diurese with blood transfusions today if blood
pressure will tolerate. Needs a-line replaced as this came out
overnight.
2) Anemia: No clear evidence of blood loss in abdomen given
drains not producing much output. Will give FFP to maintain INR <1."
2383,"Cultures NGTD. C. diff negative x2.
Afebrile since procedure.
- Following WBC count, fever curve
- Continue Vanc/[**Last Name (un) 350**]/Caspofungin/ Flagyl
- Transfuse U prior to OR
# Post-op: Pt taken back to OR for wound closure, washout and re-pack
overnight. Tolerated procedure well. Anterior drains with good output.
Posterior drains with minimal inferiorly, no drainage superiorly.
- Follow-up surgery recs
# Anemia: Given 2U pRBCs [**2177-9-28**], 1 ([**9-29**]), Hct 21 this AM, will
transfuse 2 more pRBCs.
- Serial hct, transfuse for hct <25
.
# Thrombocytopenia: AM level pending. Will likely need further
transfusions of platlets [**1-4**] to both consumption in abdominal hematoma
and dilutional secondary to blood transfusions."
2384,"5.
Plts up to 100K. Follow serial CBC, if trending down will obtain
repeat CT of the abdomen.
3) Hypotension secondary to hypovolemia vs. sepsis: Managing
with IVF challenge, transfuse pRBCs as above given hct drop, continues
broad spectum abx.
4) Acute renal failure secondary to hematoma/obstruction and
component of ATN related to episodes of hypotension. Cr stable from
yesterday. Trying to aggressively avoid further hypotensive insults as
above. Dose meds accordingly.
Else assessment and plan as per Dr.[**Last Name (STitle) 1538**]
s note above. Total time
spent 60 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 2140**] [**Last Name (NamePattern1) 2141**], MD
on:[**2177-9-30**] 14:17 ------"
2385,"8 cmH2O/mL
SpO2: 98%
ABG: 7.33/53/116/24/1
Ve: 8 L/min
PaO2 / FiO2: 232
Physical Examination
Gen
intubated, sedated
HEENT- PERRL
CV
RRR no M/R/G
Pulm
Equal breath sounds bilaterally, no W/R/R
Abd
Ostomy and loop ileostomy intact. Midline incision CDI.
Suprapubic drains intact with serosanginous. Penrose drain in RUQ.
Posterior superior drain (pig-tail) without drainage, posterior
inferior drain minimal drainage.
Extr
3+ edema to knee bilaterally, WWP
Labs / Radiology
100 K/uL
7.7 g/dL
110 mg/dL
4.6 mg/dL
24 mEq/L
3.7 mEq/L
83 mg/dL
107 mEq/L
142 mEq/L
21."
2386,"- Follow-up with onc recs
# AML: Treated [**2171**], followed by Heme/Onc during admission. Initial
concern for recurrence given leukocytosis - peripheral smear showed No
blast, consistent with known MDS.
- Follow-up with Onc
# DM 2: FS 140-150s overnight.
- ISS and accuchecks.
# FEN: NPO, TPN. Replete as necessary.
# Access: PICC + CVL + PIV . Arterial line lost overnight. Will need
replacement today.
# PPx: SCDs and PPI
# Code: Full, confirmed with husband
# Comm: [**Name (NI) **] [**Name (NI) 1904**] ([**Telephone/Fax (1) 1907**]
.
# Dispo: ICU level of care
ICU Care
Nutrition:
TPN w/ Lipids - [**2177-9-29**] 07:03 PM 59 mL/hour
Glycemic Control:
Lines:
PICC Line - [**2177-9-26**] 10:20 PM
Multi Lumen - [**2177-9-27**] 10:00 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:
------ Protected Section ------
I saw and examined the patient with the medical resident, reviewed 24
hour events and was present for key portions of the services provided."
2387,"Assessment and Plan (made prior to rounding, please refer to addendum
for changes)
75yoF with AML s/p chemo and R hemicolectomy for cecal mass (low grade
B cell lymphoma) c/b anastomotic leak and intra-abdominal abscesses s/p
IR guided drain placement and washout with surgical drain now
readmitted to the [**Hospital Unit Name 4**] for sepsis (hypotension, anemia, coagulopathy,
and worsening leukocytosis), now POD#1 from would closure and wash out.
# Sepsis: Was on and off Levophed overnight. Currently off pressors
following closure of her ventral wound. WBC 72.8 down from 79.4
yesterday AM. Tachy in low 100s."
2388,"Chief Complaint:
24 Hour Events:
- Went to OR - removed packing and closed wound
- Post-op CBC with rise in Hct to 27.7 after 2 U PRBC
- Platelets to 100 after 1 U plts
- Vanc redosed for level of 12
- Weaned from Propofol -> Fent/Midaz
Allergies:
Lisinopril
Hives;
Aspirin
dyspepsia;
Last dose of Antibiotics:
Piperacillin - [**2177-9-27**] 08:00 AM
Piperacillin/Tazobactam (Zosyn) - [**2177-9-28**] 08:13 AM
Meropenem - [**2177-9-29**] 07:45 AM
Vancomycin - [**2177-9-29**] 11:00 PM
Metronidazole - [**2177-9-30**] 12:00 AM
Caspofungin - [**2177-9-30**] 01:01 AM
Infusions:
Midazolam (Versed) - 2 mg/hour
Fentanyl - 125 mcg/hour
Other ICU medications:
Morphine Sulfate - [**2177-9-29**] 10:54 AM
Midazolam (Versed) - [**2177-9-29**] 07:25 PM
Fentanyl - [**2177-9-29**] 08:47 PM
Pantoprazole (Protonix) - [**2177-9-30**] 12:00 AM
Other medications:
Changes to medical and family history: No changes
Review of systems is unchanged from admission except as noted below
Review of systems: Unable to attain
Flowsheet Data as of [**2177-9-30**] 06:06 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2389,"3
C (99.2
Tcurrent: 36.1
C (96.9
HR: 103 (95 - 103) bpm
BP: 116/59(73) {98/32(48) - 141/59(76)} mmHg
RR: 21 (14 - 21) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 96.9 kg (admission): 81.2 kg
Height: 61 Inch
CVP: 8 (7 - 17)mmHg
Total In:
5,531 mL
815 mL
PO:
TF:
IVF:
2,628 mL
455 mL
Blood products:
1,542 mL
Total out:
4,338 mL
1,120 mL
Urine:
3,105 mL
740 mL
NG:
200 mL
Stool:
Drains:
433 mL
120 mL
Balance:
1,193 mL
-305 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 366 (366 - 366) mL
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
RSBI: 46
PIP: 27 cmH2O
Plateau: 26 cmH2O
Compliance: 23."
2390,"- Serial Platlets checks and transfusion
# Coagulopathy: INR may be [**1-4**] thrombocytopenia. Given recent surgery,
will aim for lower INR. Given vitamin K [**2177-9-28**]. Likely due to
combination of malnutrition/malabsorption and sepsis.
- Trend INR
- 2 units of FFP this AM for INR of 1.7.
# Acute renal failure: Good UOP overnight. Differential etiologies were
ATN from hypotension + obstruction secondary to hematoma. Creatinine
stable today at 4.6 from 4.5.
- Hold off on giving furosemide today
autodiuresing very well.
- Monitor UOP
- Renally dose meds, avoid nephrotoxins
- Check renal recs
.
# Cecal mass: Pathology consistent with low grade B cell lymphoma."
2391,"Patient continues to be critically ill, ventilated for respiratory
failure. To OR yesterday where abdomen was unpacked and wound closed.
A-line came out overnight. Overnight hct dropped to 21 without evidence
of increased output from surgical drains. Weaned off pressors at 5 am
albeit given hemodynamic lability needed to go back on at 0945 just
prior to our rounding. Low grade fevers overnight. Lungs with
scattered crackles albeit mostly dependent. Tachy, regular. Abdomen
distended, midline wound dressing clean and dry. Anasarca increased.
Unresponsive even to noxious stimuli, have decreased fentanyl and
versed as suspect she is oversedated. Labs notable for WBC 72, plts
100K, INR 1."
2392,"0 %
72.8 K/uL
[image002.jpg]
[**2177-9-28**] 03:52 PM
[**2177-9-28**] 04:00 PM
[**2177-9-29**] 04:56 AM
[**2177-9-29**] 05:26 AM
[**2177-9-29**] 12:58 PM
[**2177-9-29**] 03:45 PM
[**2177-9-29**] 05:59 PM
[**2177-9-30**] 12:27 AM
[**2177-9-30**] 02:06 AM
[**2177-9-30**] 03:33 AM
WBC
87.7
79.4
67.1
72.8
Hct
23.8
23.2
28
27.6
21.0
Plt
78
66
100
Cr
5.0
5.0
5.0
4.5
4."
2393,"Chief Complaint: Hypotension
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
75 yo female with AML s/p chemo, right hemicholectomy [**2177-9-5**] for B cel
lymphoma with anasatomic leak s/p ostomy [**9-19**].
24 Hour Events:
*Urine did not respond to Lasix or fluid resusc.
*continued hyperkalemia-- treated with bicarb
*CT torso: increase in intraperitoneal hematoma with bilateral
hydronephrosis, pleural effusions decreased
*Worsening hypotension requiring levophed and developement of acidosis
*Went to OR: hematoma evacuated and wounds left open."
2394,"8 mg/dL
22 mEq/L
5.8 mEq/L
87 mg/dL
106 mEq/L
143
26.7 %
83.4 K/uL
[image002.jpg]
[**2177-9-26**] 11:20 PM
[**2177-9-27**] 06:38 AM
[**2177-9-27**] 02:24 PM
[**2177-9-27**] 05:46 PM
[**2177-9-27**] 09:47 PM
[**2177-9-28**] 01:29 AM
[**2177-9-28**] 05:14 AM
[**2177-9-28**] 05:38 AM
WBC
52.0
68.8
83.4
Hct
19.4
27.6
26.3
23.8
31
26.7
Plt
116
95
88
Cr
3.9
4."
2395,"4
C (97.5
Tcurrent: 35.7
C (96.2
HR: 103 (97 - 127) bpm
BP: 104/55(70) {91/49(64) - 136/65(90)} mmHg
RR: 18 (13 - 43) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Bladder pressure: 26 (26 - 26) mmHg
Total In:
7,129 mL
1,420 mL
PO:
TF:
IVF:
3,621 mL
1,370 mL
Blood products:
2,357 mL
Total out:
195 mL
1,460 mL
Urine:
85 mL
1,190 mL
NG:
Stool:
Drains:
60 mL
270 mL
Balance:
6,934 mL
-40 mL
Respiratory support
O2 Delivery Device: None
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 550) mL
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
RSBI Deferred: No Spon Resp
PIP: 31 cmH2O
Plateau: 22 cmH2O
SpO2: 100%
ABG: 7."
2396,"Received blood,
platelets and ffp
History obtained from [**Hospital 19**] Medical records, ICU housestaff
Allergies:
Lisinopril
Hives;
Aspirin
dyspepsia;
Last dose of Antibiotics:
Vancomycin - [**2177-9-27**] 02:00 AM
Piperacillin - [**2177-9-27**] 08:00 AM
Caspofungin - [**2177-9-28**] 12:30 AM
Metronidazole - [**2177-9-28**] 01:07 AM
Piperacillin/Tazobactam (Zosyn) - [**2177-9-28**] 08:13 AM
Infusions:
Norepinephrine - 0.1 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2177-9-27**] 02:48 PM
Morphine Sulfate - [**2177-9-27**] 04:17 PM
Sodium Bicarbonate 8.4% (Amp) - [**2177-9-27**] 11:30 PM
Pantoprazole (Protonix) - [**2177-9-28**] 01:00 AM
Dextrose 50% - [**2177-9-28**] 06:20 AM
Insulin - Regular - [**2177-9-28**] 06:20 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2177-9-28**] 09:49 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
2397,"4
4.9
4.8
TCO2
20
23
25
Glucose
129
124
79
85
111
Other labs: PT / PTT / INR:21.0/49.2/2.0, Alk Phos / T Bili:/1.0,
D-dimer:5744 ng/mL, Fibrinogen:502 mg/dL, Lactic Acid:2.3 mmol/L,
Albumin:2.6 g/dL, LDH:516 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:7.9
mg/dL
Imaging: CXR: continued R effusion, patchy infiltrates, ETT low and
heading
Assessment and [**Last Name 99**]
Problem [**Name (NI) 670**]:
Cecal B cell lymphoma s/p hemi-colectomy, colostomy for anastomotic
leak, now s/p peritoneal hematoma evacuation
*Acute Respiratory failure
*Acute renal failure from post-obstructive uropathy +/- pre-renal/AtN
*Open abdominal wound
*Hyperkalemia in the setting of ARF
*Shock from acute blood loss anemia
Shock:
*Pressor requirements decreased since OR/hematoma evacuation yesterday
*Remains on levophed, adjust for MAP>60
*Per ID change to Merepenem
*Hct unchanged
Acute renal failure:
*Remains on bicarb drip and will continue to check K
*Urine output is beginniing to increase so hopefully renal function and
hyperkalemia will begin to improve s/p hematoma evacuation
Coagulopathy
*INR still high - administer further vitamin K
Acute respiratory failure:
*Intubated prior to surgery with no plans to wean today as she requires
heavy sedation/pain control due to open abdominal wound
*Oxygenation adequate, will move ETT
*Peritoneal hematoma: back to OR tomorrow to close wound
Other plans per housetaff note
ICU Care
Nutrition:
Comments: TPN
Glycemic Control:
Lines:
PICC Line - [**2177-9-26**] 10:20 PM
22 Gauge - [**2177-9-27**] 01:51 AM
Multi Lumen - [**2177-9-27**] 10:00 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 45 minutes
Patient is critically ill"
2398,"36/42/66/22/-1
Ve: 8.6 L/min
PaO2 / FiO2: 132
Physical Examination
General Appearance: Well nourished
Head, Ears, Nose, Throat: Endotracheal tube, OG tube
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,
No(t) S4
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: slightly coarse, BS at base
Extremities: Right: 1+, Left: 1+
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,
Tone: Not assessed
Labs / Radiology
9.6 g/dL
88 K/uL
111 mg/dL
4."
2399,"0 mg/dL
[**2177-10-8**] 05:23 AM
Phosphorus
2.5 mg/dL
[**2177-10-8**] 05:23 AM
Ionized Calcium
0.98 mmol/L
[**2177-9-29**] 03:45 PM
Magnesium
2.2 mg/dL
[**2177-10-8**] 05:23 AM
Current diet order / nutrition support: TPN: 1.4L (260g dextrose/80g
AA/28g lipids) - provides 1484kcal and 80g protein
TF: Impact with Fiber at 10ml/hr (goal = 80ml/hr which provides
1920kcal and 107g protein)
GI: Abdomen soft/distended with positive bowel sounds
Assessment of Nutritional Status
Specifics:
75yoF with AML s/p chemo and R hemicolectomy for cecal mass c/b
anastomotic leak and intra-abdominal hematoma here with resolving
sepsis now POD #10 from wound closure and wash out."
2400,"Subjective
Patient extubated, failed swallow evaluation
Objective
Pertinent medications: RISS, others noted
Labs:
Value
Date
Glucose
130 mg/dL
[**2177-10-8**] 05:23 AM
Glucose Finger Stick
148
[**2177-10-8**] 06:00 AM
BUN
51 mg/dL
[**2177-10-8**] 05:23 AM
Creatinine
1.8 mg/dL
[**2177-10-8**] 05:23 AM
Sodium
147 mEq/L
[**2177-10-8**] 05:23 AM
Potassium
3.5 mEq/L
[**2177-10-8**] 05:23 AM
Chloride
116 mEq/L
[**2177-10-8**] 05:23 AM
TCO2
23 mEq/L
[**2177-10-8**] 05:23 AM
Albumin
2.4 g/dL
[**2177-10-7**] 04:15 AM
Calcium non-ionized
8."
2401,"Patient s/p SLP
evaluation and was unable to pass. So, consult received for tube
feeding recommendations and patient started on Impact with Fiber at
10ml/hr. Patient currently tolerating, noted ostomy output. Current
tube feeding order is overfeeding so would decrease goal to 65ml/hr x
24 hours to provide 1560kcal and 87g protein. Would continue with TPN
until tube feeding rate at 50ml/hr and tolerated well.
Medical Nutrition Therapy Plan - Recommend the Following
1. Decrease goal of Impact with Fiber to 65ml/hr x 24 hours.
Continue to advance by 10ml q6H to goal rate
2. TPN: 1.4L (260g dextrose/80g AA/28g lipids) with 10NaCl,
10KCl, 15KAc, 35KPO4, 8MgSulf, 10Ca
3. Will follow tomorrow and possible decrease TPN if tube
feedings are well tolerated
09:38 AM"
2402,"Admission Date: [**2103-9-18**] Discharge Date: [**2103-9-21**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
SDH
Major Surgical or Invasive Procedure:
.
History of Present Illness:
This is an 89 year man with with a history of a subdural
hematoma who underwent a craniotomy with evacuation of bilateral
SDH with drains on [**2103-9-17**] at [**Hospital **] Hospital.
Originally Mr. [**Known lastname 46825**] [**Last Name (Titles) 50921**] and fell on [**2103-7-23**] while
gardening. This seemed to be related to his chronic right foot
drop. There was no LOC."
2403,"Head CT showed increase in R subdural collection no change
in the left. Abdominal CT showed 18mm infrarenal abdominal
aortic dissection. He had SBPs in 200s, became bradycardic to
50s despite IV hydralazine. He was then transfered to the [**Hospital1 18**].
Past Medical History:
Hypertension (usually runs 140/80 per pt and family)
EF of 50% ([**2103**])
Left BBB
Nephrolithiasis
Osteoarthritis
BPH Chronic LBP
PSH:
B/l carotid endarterectomy (Dr. [**Last Name (STitle) 8521**], [**First Name3 (LF) **])
cataract surgery
utereral stone removal/cystoscopy
Social History:
lives alone and is independent, mobile, Tobacco: 50+ pack year
hx (quit 20 years ago), EtOH: family endorses at least
6oz/scotch/day, no known illicits"
2404,"CT head [**2103-9-19**]
1. Marked reduction in size of a right subdural hematoma, with a
drain in
place, and some residual blood products, layering dependently.
2. Bifrontal pneumocephalus, increased on the left, following
removal of this drain.
3. No new focus of hemorrhage.
4. Partial sinus opacification, particular of the sphenoid air
cells, which may relate to intubation and supine positioning.
Brief Hospital Course:
Mr. [**Known lastname 46825**] was admitted to [**Hospital1 18**] TSICU. On arrival,
intubated, he was sedated with bradycardia to the 30s requiring
x1 atropine with good response. A right axillary arterial line
placed. Neurosurgery evaluated the patient and removed the L JP
drain."
2405,"sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day.
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Bilateral SDH
Brain Compression
AAA
Bradycardia
Hypertension
COPD
Back pain
PVC
Ventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent."
2406,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication."
2407,"Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever: max 4g/24 hrs.
4. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold sbp<100.
Disp:*60 Tablet(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
7."
2408,"Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
CXR [**2103-9-18**]
1. Progression of left perihilar and lower hemithorax opacities
may represent aspiration or consolidation.
2. Esophageal catheter with side port in the distal esophagus
and would need to be advanced 7 cm to ensure most proximal side
port within the stomach."
2409,"ECHO [**2103-9-18**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is at
least 15 mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is probably mild global left ventricular hypokinesis (LVEF = 50
%) (the degree of bradycardia and conduction delay associated LV
dysynchrony make an accurate estimate of LVEF more difficult).
No masses or thrombi are seen in the left ventricle. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect."
2410,"..He had expiratory whezzing
and nebulizer treatment was started. SQH was started for DVT
prophylaxis. Foley cathter was discontinued. PT was consulted.
They recommended rehab. Now DOD he is set for d/c to rehab and
will f/u accordingly.
Medications on Admission:
Lisinopril 20mg qd
sertraline 50mg qd
atenolol 25 mg qd
doxazosin 4 mg qd
diclofenac 25 mg qd
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day)."
2411,"5* LYMPHS-3.9* MONOS-3.1 EOS-0.4
BASOS-0.1
[**2103-9-18**] 01:29PM WBC-14.8* RBC-4.17* HGB-14.1 HCT-38.7* MCV-93
MCH-33.9* MCHC-36.5* RDW-13.9
[**2103-9-18**] 01:29PM CALCIUM-8.4 PHOSPHATE-2.9 MAGNESIUM-1.7
[**2103-9-18**] 01:29PM CK-MB-3 cTropnT-<0.01
[**2103-9-18**] 01:29PM CK(CPK)-21*
[**2103-9-18**] 01:29PM estGFR-Using this
[**2103-9-18**] 01:29PM GLUCOSE-175* UREA N-18 CREAT-0.4* SODIUM-140
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13"
2412,"?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to."
2413,"The right drain was less functional and was milked with
improved output.
A chest X-rays showed progression of left perihilar and lower
hemithorax opacities may represent aspiration or consolidation.
An ECHO was done showed
EF 50% (the degree of bradycardia and conduction delay
associated LV dysynchrony make an accurate estimate of LVEF more
difficult).
He was on a nitro drip at 1mcg/kg/min with SBP goal < 140. EPS
was consulted.
They agreed with the plan for Hydralazine PRN for BP control
and approved restarting home dose of lisinopril and amlodipine
when tolerating po's. He was extubated overnight."
2414,"He immediately ambulated. His family
noticed an altered mental status; however, he did not seek
medical attention until [**2103-8-2**] when he was found to have
bilateral SDH's on CT and MR [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]. He went on vacation for
a week, had increased headaches and returned to OSH for CT/MR of
the head which revealed no significant SDH change, but
evacuation was required and performed on [**9-17**] with placement of
bilateral subdural drains.
Per the outside records, he had postop abdominal pain relieved
in decubitus position. He became confused, diaphoretic,
hypertensive was intubated and sedated in the early am of POD
#1."
2415,"Vascular surgery consulted and they felt that this abdominal
pain at OSH was likely not due to his 18mm dissection. There are
no plan for intervention at this point.
He was trasnfered to the Neurosurgery service under the care of
Dr. [**Last Name (STitle) 739**]. He was getting Dilantin 100mg TID with 1000mg
initial load. CT head on [**9-19**] showed improvement in right SDH
but the drain was left in place for further evacuation in the am
and this was removed in the pm. Orders for trasnfer to SDU were
written.
CT head in the am of [**2103-9-20**] showed."
2416,"Family History:
NC
Physical Exam:
On Admission:
The patient was intubated.
T:97 BP:140/52 HR: 66 R 7 O2Sats: 97%
Gen: intubated
HEENT: atraumatic, normocephalic
Pupils: 2-1.5mm bilaterally
Neuro:
Patient is intubated
EO to noxious stimuli
follows simple commands on R UE (shows thumbs up)
wiggles toes bilaterally
w/d LUE to noxious
Bilateral subdural drains in place
L drain 100cc since admission
R drain minimal out put since admission
Pertinent Results:
[**2103-9-18**] 01:29PM PT-13.1 PTT-26.5 INR(PT)-1.1
[**2103-9-18**] 01:29PM PLT COUNT-151
[**2103-9-18**] 01:29PM NEUTS-92."
2417,"CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to see your Neurosurgeon at [**Location (un) **] on [**9-26**] for
removal of your staples. You may also have these removed at
rehab
??????Please call your Neurosurgeon at [**Location (un) **] for a one month follow
up appointment.
- Please follow up with your PCP as soon as possible
regarding you Abdominal Aortic Aneurysm
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2103-9-21**]"
2418,"Admission Date: [**2139-11-27**] Discharge Date: [**2139-11-29**]
Service: MEDICINE
Allergies:
Iodine / Codeine / Rose Hips / Zocor / Flecainide / Diamox
Sequels
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Weakness and Melena
Major Surgical or Invasive Procedure:
Eesophagogastroduodenoscopy
History of Present Illness:
Ms. [**Known lastname **] is an 89 year-old woman with a history of atrial
fibrillation on coumadin who presents with a GI bleed. She was
in her usual state of excellent health until yesterday morning
when she woke up feeling weak and unable to do her usual ADLs.
She also noted two black stools, which had never happened to her
before."
2419,"She had no abdominal pain, nausea, vomitting.
.
In the ED, initial VS: T 99, 79, 143/54, 20, 97% RA
Labs were notable for INR 3.2 and Hct 19.7, down from 35 10 days
ago. She received vitamin K 5 mg IV and pantoprazole 80 mg
followed by 8 mg/h drip. 2 PIV were placed. GI was contact[**Name (NI) **] and
would like to scope in the morning.
VS prior to transfer: 89, 136/54, 20, 98%
Past Medical History:
-paroxysmal atrial fibrillation
-s/p PPM for pauses
-mitral and tricuspid regurgitation
-mild AS and AR
-hyperlipidemia
-chronic kidney disease
-cholelithiasis (asymptomatic
-osteoporosis
-DJD
-hearing loss
-glaucoma"
2420,"Social History:
She quit smoking 25 years ago. She drinks wine very
occasionally. she lives alone and is independent in her ADLs.
She plans to travel to [**State 108**] for the winter in 3 days as per
her usual routine.
Family History:
Non-Contributory
Physical Exam:
VS: 96.3, 103/85, 500 cc u/o
GEN: pleasant, A&Ox 3, pale
HEENT: MMM, no scleral icterus
RESP: bilateral apical expiratory wheeze
CV: regular, 3/6 systolic murmur
ABD: No echymoses, + BS, no hepatosplenomegaly, non tender to
palpation. No rebound or gaurding
EXT: trace bilateral pitting edema
RECTAL: Skin tag, small amount of black stool in vault"
2421,"Brief Hospital Course:
Ms. [**Known lastname **] is a 89 year-old woman with atrial fibrillation on
warfarin who was admitted for an upper gastrointestinal bleed
with an INR of 3.2.
# GI bleed: She was admitted with a hematocrit of 20.4 and an
INR of 3.2. She received 5 mg IV vitamin K in the ED and her INR
fell to 1.4 over the ensuing 12 hours. She also received 2
units of pRBC with an appropriate rise in Hct to 26. After this
she felt subjectively much improved. Her coumadin was held
durring her admission. An upper endoscopy revealed gastritis,
small non-bleeding antral ulcer and 1."
2422,"5 cm raised gastric
lesion. The gastroenterology service advised twice daily PPI and
a follow-up EGD in 6 weeks. H. pylori IgG was also collected and
was pending at the time of discahrge. She was to follow up with
her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in [**State 108**] early the following week.
.
# Atrial fibrillation: She had paroxysmal atrial fibrillation
and had been anticoagulated with coumadin. She did not require
rate control agents, and her rate remained stable in the
70s-80s. Anticoagulation was held durring her admission. Upon
discharge, it was decided that given her risk of stroke
anticoagulation should not be discontinued altogether."
2423,"Thus, her
aspirin was stopped and she was restarted
on her anticoagulation at 5 mg on the day of discharge and 2.5
mg daily thereafter with close PCP [**Name9 (PRE) 702**] advised. She was to
get her INR checked 2-3 days following discharge with her PCP in
[**Name9 (PRE) 108**].
.
# Acute Renal Failure: Her acute elevation in serum creatinine
was likely due to relative renal hypoperfusion in the setting of
acute blood loss anemia. Her renal function improved following
blood transfusion to its prior baseline of 1.2-1.4.
.
# Hypothyroidism: Her home dose of levothyroxine 100 mcg daily
was continued."
2424,"Medications on Admission:
atorvastatin 20 mg daily
brimonidine .1% gtt one drop OD TID
levothyroxine 100 mcg daily
valsartan 80 mg [**Hospital1 **]
warfarin 2.5 mg MF, 2 mg all other days
ascorbic acid 500 mg daily
ASA 81 mg daily
calcium carbonate-vitamin D3 1250 - 200 mg daily
MVI
omega 3
vitamin E
Social History
Discharge Medications:
1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. valsartan 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4."
2425,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for black tarry stools, a sign
of upper GI bleeding. You were evaluated and treated by the
medicine service and found to be anemic. You INR was elevated at
3.2, so your coumdin was held. You also received IV vitamin K.
You were transfused 2 units of packed red blood cells for your
anemia and your blood levels remained stable througout the
remainder of your admission. You also underwent an endoscopy,
which show gastritis, a small ulcer and a 1."
2426,"No active bleeding. Bile
noted in duodenum, no blood.
Erythema and petechiae in the fundus compatible with gastritis.
Otherwise normal EGD to second part of the duodenum.
Recommendations: Small non-bleeding ulceration and gastritis
noted in stomach. 1.5 cm raised gastric lesion of unknown
significance potentially from previous ulcer with raised edges
or potential submucosal lesion such as GIST.
Recommend IV BID PPI, test and treat for H-pylori, call out from
ICU. Can resume anticoagulation as needed at discharge. Advance
diet. Recommend repeat endoscopy in 6 weeks to assess
improvement in ulceration and address raised lesion if still
present and or need for EUS."
2427,"Pertinent Results:
[**2139-11-27**] 03:30PM BLOOD WBC-11.5* RBC-2.37*# Hgb-6.9*# Hct-20.4*#
MCV-86 MCH-29.2 MCHC-34.0 RDW-17.9* Plt Ct-248
[**2139-11-27**] 11:07PM BLOOD Hct-26.5*#
[**2139-11-28**] 03:14AM BLOOD WBC-9.3 RBC-3.01*# Hgb-9.1*# Hct-26.1*
MCV-87 MCH-30.2 MCHC-34.9 RDW-16.7* Plt Ct-210
[**2139-11-28**] 01:44PM BLOOD Hct-26.7*
[**2139-11-28**] 09:00PM BLOOD Hct-27.1*
[**2139-11-29**] 07:25AM BLOOD WBC-9."
2428,"5mg daily until Tuesday when you should present to
Dr. [**Last Name (STitle) **] for an INR check and adjust the of coumdin dose
accordingly.
3. Your Valsartan has been DECREASED to 40mg [**Hospital1 **], please discuss
this change with your PCP.
4. Your Aspirin has been STOPPED, please discuss this change
with your PCP.
No other changes have been made to your medications.
Please take your medications as prescribed and keep your
outpatient appointments.
Followup Instructions:
You shold follow up with you physcian in [**State 108**] for this bleed
and your atrial fibrillation management. Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 100546**]
You will be contact[**Name (NI) **] about the results of the H. Pylori test to
your cellular phone number: [**Telephone/Fax (1) 100547**]."
2429,"9 RBC-3.14* Hgb-9.4* Hct-27.6*
MCV-88 MCH-29.8 MCHC-33.9 RDW-16.8* Plt Ct-214
[**2139-11-27**] 03:30PM BLOOD Glucose-106* UreaN-57* Creat-2.0* Na-140
K-4.2 Cl-106 HCO3-24 AnGap-14
[**2139-11-29**] 07:25AM BLOOD Glucose-98 UreaN-28* Creat-1.4* Na-145
K-3.8 Cl-111* HCO3-25 AnGap-13
[**2139-11-27**] 03:30PM BLOOD cTropnT-<0.01
[**11-28**] EGD report
Ulcer in the antrum 1.5 cm raised lesion with central erosion
noted in the antral-body junction."
2430,"5cm lesion in your
stomach that will require a follow-up endoscopy in 6 weeks. You
also received a blood test for H. pylori, a bacteria that causes
ulcers; this test is still pending. If this test is positive you
will need appropriate treatment for this infection from your
PCP. [**Name10 (NameIs) **] will be contact[**Name (NI) **] via your cell phone to inform you of
the result of this test.
The following changes were made to your medication:
1. You have been STARTED on Pantoprazole 40mg twice daily for 6
weeks.
2. You have been Re-STARTED on Coumadin, you should take 5mg
today and 2."
2431,"atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Calcium+D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
6. Omega-3 Fish Oil Oral
7. Multiple Vitamins Oral
8. vitamin E Oral
9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take two tablets today [**2139-11-29**] and one table daily
thereafter. Please see your PCP to check to INR and adjust your
dose on Tuesday [**2139-12-1**].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Gastrointestinal Bleed"
2432,"[**2194-8-20**] 11:48 AM
BILIARY CATH CHECK Clip # [**Clip Number (Radiology) 2905**]
Reason: Please evaluate anatomy via drain study of PTBD.
Admitting Diagnosis: CHRONIC DISTAL COMMON BILE DUCT/SDA
Contrast: OPTIRAY Amt: 20
********************************* CPT Codes ********************************
* [**Numeric Identifier 162**] TUBE CHOLANGIOGRAM -58 SERVIC BY SAME MD DURING POST OP *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
43 year old woman s/p open chole and choledocoduodenostomy, with prior PTBD in
place which has been capped for past 2 days. Please evaluate anatomy with drain
study.
REASON FOR THIS EXAMINATION:
Please evaluate anatomy via drain study of PTBD.
______________________________________________________________________________
FINAL REPORT
INDICATION: 43-year-old female with prior episode of pancreatitis obstructing
the common bile duct, now status post surgical choledochoduodenostomy, with
PTBD from right lobe left in place."
2433,"Please evaluate anatomy and to
discontinue tube if possible.
PHYSICIAN: [**Last Name (NamePattern4) **], M.D., attending, was present and supervising. [**First Name8 (NamePattern2) 60**]
[**Last Name (NamePattern1) 61**], M.D., fellow, was performing the procedure.
FLUOROSCOPY TIME: 1.4 minutes.
MEDICATIONS: Moderate sedation was provided by administering divided doses of
Versed totaling 2 mg throughout the total intraservice time of 40 minutes,
during which the patient's hemodynamic parameters were continuously monitored.
Patient remained in control with her PCA device.
PROCEDURES: Gravity cholangiogram via indwelling right lobe biliary drain.
Removal of drain.
PROCEDURE DETAILS: Informed consent was obtained from the patient."
2434,"Patient left the
department in stable condition without any immediate complication.
FINDINGS: Patent choledochoduodenostomy tract with free flow from the upper
common bile duct into the duodenum. The ampulla appears to be fully
obstructed. There was no appreciable flow along this anatomic pathway, though
this is likely just higher resistance than the bypass. No intrahepatic
(Over)
[**2194-8-20**] 11:48 AM
BILIARY CATH CHECK Clip # [**Clip Number (Radiology) 2905**]
Reason: Please evaluate anatomy via drain study of PTBD.
Admitting Diagnosis: CHRONIC DISTAL COMMON BILE DUCT/SDA
Contrast: OPTIRAY Amt: 20
______________________________________________________________________________
FINAL REPORT
(Cont)
strictures identified. Left-sided ducts were not filled during this
examination.
CONCLUSION: Uncomplicated tube gravity cholangiogram as above. Uncomplicated
removal of indwelling biliary drain. Patient may continue to have some
leaking into the bandage. Please change the dressing p.r.n. with a
pressure-type dressing. The tract should close completely in several days."
2435,"She was
positioned supine on the angiography table. The area was prepped and draped
in sterile fashion. Appropriate timeout was performed. Fluoroscopy was used
intermittently.
With gravity, contrast was dripped into the indwelling drain. This showed
adequate flow through the choledochoduodenostomy into the duodenum. There was
no appreciable flow through the ampulla. The drain was then pulled back
slightly and more contrast was administered. No intrahepatic strictures were
evident. There was free flow of contrast into the bowel. The drain was then
removed. Pressure was held for about 15 minutes until there was no longer
leaking along the tract. A pressure dressing was applied."
2436,"Admission Date: [**2194-8-14**] Discharge Date: [**2194-8-25**]
Date of Birth: [**2150-10-24**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
1. Biliary obstruction.
2. Biliary stricture secondary to chronic pancreatitis.
3. Status post fulminant necrotizing pancreatitis.
4. Status post intraabdominal sepsis.
Major Surgical or Invasive Procedure:
1. Extensive lysis of adhesions.
2. Open cholecystectomy with common bile duct exploration.
3. Partial wedge hepatectomy.
4. Choledochoduodenostomy biliary bypass.
History of Present Illness:
43F with history of severe hemorrhagic pancreatitis ([**8-15**])
complicated by pancreatic necrosis & retroperitoneal abcess
formation & ampullary stricture s/p necrosectomy and abcess
drainage [**10/2192**] with PTBD drain placement."
2437,"She has had multiple
exchanges of this drain, the last on [**2194-8-7**]. She presented
for the following scheduled operation:
1. Extensive lysis of adhesions.
2. Open cholecystectomy with common bile duct exploration.
3. Partial wedge hepatectomy.
4. Choledochoduodenostomy biliary bypass.
Past Medical History:
PMH: necrotizing pancreatitis [**8-/2192**], HCV, HTN, depression,
chronic back pain, asthma
PSH: pancreatic necrosectomy, left and right peritoneal abscess
wide drainage ([**2192-10-23**]); bilateral RP abscess washout and
J-tube
placement ([**2192-10-25**]); tracheostomy ([**2192-11-1**]); PTC with
placement of 8-Fr internal/external biliary drain ([**2192-12-24**])
for ampullary stenosis with multiple subsequent dilations and
exchanges of PTC drain, most recently [**2192-4-14**] where a 12 Fr
int/ext drain was placed"
2438,"For a short period (approximately 1 hour) after placing
the epidural, the patient required a small dose of pressor
support to maintain her blood pressures. Thereafter, she no
longer required this, and tolerated the epidural well. Her
drains were maintained. She remained NPO, with all her drains
and tubes still in place.
On POD#2, the patient was transfused 2 units of PRBC. Her
epidural and drains/tubes were maintained. She was out of bed to
chair.
On POD#3, she was well enough to be transferred out of the ICU,
and onto the general surgical floor. She remained NPO, with JP,
PTBD, NGT and foley in place, as well as the epidural continued
for pain control."
2439,"Extensive lysis of adhesions.
2. Open cholecystectomy with common bile duct exploration.
3. Partial wedge hepatectomy.
4. Choledochoduodenostomy biliary bypass.
This procedure went well without complication (reader referred
to the Operative Note for details). After her operation, the
patient was admitted to the ICU NPO, on IV fluids, on a 1-day
course of antibiotics, with a foley catheter, JP drain, PTBD,
and NGT in place. She remained intubated, on a ventillator, and
was hemodynamically stable.
On POD#1, the patient was successfully extubated, and placed on
a ketamine drip for pain control. Later that day, the ketamine
drip was discontinued, and an epidural was placed for pain
control."
2440,"Medications on Admission:
methadone 20''', oxycodone 30''', losartan 50', ibuprofen 600'
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 capsule(s) by mouth twice per day Disp #*60
Capsule Refills:*0
2. Methadone 20 mg PO TID
3. Losartan Potassium 50 mg PO DAILY
Hold for SBP<110 and HR<60
4. Senna 1 TAB PO BID
RX *senna 8.6 mg 1 tablet by mouth twice per day Disp #*30
Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once per day Disp
#*60 Tablet Refills:*0
6."
2441,"Social History:
SH: 2 children. Lives in [**Location 3610**]. Does not currently smoke
and
quit drinking alcohol since her episode of severe pancreatitis
in
[**2192**].
Family History:
FH: liver disease and bone cancer, no known pancreatic issues
Physical Exam:
Upon Discharge:
All vitals stable and within normal limits, afebrile
Gen - AAOx3, in no apparent distress
CV - RRR +S1/S2 no murmurs/rubs/gallops
Resp - CTAB no wheezes/crackles/rhonchi
Abd - soft, mildly tender to palpation appropriately near
incision, non-distended, +BS, no rebound/rigidity/guarding, no
palpable masses
Inc - clean/dry/intact, with no erythema/induration/drainage
Ext - no edema/clubbing/cyanosis"
2442,"Pertinent Results:
OPERATIVE PATHOLOGY ([**8-14**]):
Gallbladder, open cholecystectomy:
- Chronic cholecystitis.
- Cystic lymph node with reactive, florid follicular
hyperplasia and sinus histiocytosis.
DRAIN STUDY AND REMOVAL OF DRAIN ([**8-20**]):
- Patent choledochoduodenostomy tract with free flow from the
upper common bile duct into the duodenum. The ampulla appears
to be fully obstructed. There was no appreciable flow along
this anatomic pathway, though this is likely just higher
resistance than the bypass. No intrahepatic strictures
identified. Left-sided ducts were not filled during this
examination.
- Uncomplicated removal of indwelling biliary drain. Patient
may continue to have some leaking into the bandage."
2443,"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 [**5-15**] lbs until you follow-up with your
[**Month/Year (2) 5059**], who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your [**Month/Year (2) 5059**] and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site."
2444,"Additionally, her JP drain was
discontinued. Due to some concern for nausea, she was made NPO.
However, upon feeling much better in the evening, she was put
back on clear liquids, and then a regular diet. She tolerated
this very well.
On POD#7, due to a marked improvement in the appearance of her
incision, her IV cefazolin was discontinued. Her epidural was
removed, and she was transitioned to oral pain medications,
which she tolerated well. She was seen by Physical Therapy, and
ambulated mutiple times per day.
She continued to progress well. On POD#9, she was noted to spike
a fever to 102."
2445,"0 MCHC-32.7 RDW-13.2 Plt Ct-177
[**2194-8-25**] 07:10AM BLOOD Plt Ct-177
[**2194-8-23**] 01:28AM BLOOD Glucose-123* UreaN-5* Creat-0.7 Na-131*
K-4.1 Cl-101 HCO3-26 AnGap-8
[**2194-8-19**] 05:10AM BLOOD ALT-34 AST-38 AlkPhos-344* TotBili-0.7
DirBili-0.3 IndBili-0.4
[**2194-8-23**] 01:28AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.6
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2194-8-14**], the patient underwent
the following procedure:
1."
2446,"*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.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Please call your doctor or nurse practitioner if you experience
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."
2447,"On POD#5, her NGT was clamped, and epidural and all other drains
were maintained. On this day, due to some concern about erythema
around her incision, she was stared on IV cefazolin. Her
epidural was removed, and she was transitioned to a PCA for pain
control, which she tolerated well. Her foley was removed and she
urinated independently. Later in the day, her NGT was removed,
and she was permitted to have clear liquids, which she tolerated
very well.
On POD#6, her PTBD had a drain study performed on it, and upon
satisfactory results (reader referred to ""Pertinent Results"")
the drain was removed."
2448,"*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 is 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.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 2835**]
Date/Time:[**2194-9-1**] 11:00
Location: [**Hospital Ward Name **] BUILDING, [**Location (un) **]
Completed by:[**2194-8-25**]"
2449,"OxycoDONE (Immediate Release) 30 mg PO Q8H
RX *oxycodone 30 mg 1 tablet(s) by mouth every 8 hours Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
1. Biliary obstruction.
2. Biliary stricture secondary to chronic pancreatitis.
3. Status post fulminant necrotizing pancreatitis.
4. Status post intraabdominal sepsis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for an open
cholecystectomy and choledocoduodenostomy . You have done well
in the post operative period and are now safe to return home to
complete your recovery with the following instructions:"
2450,"4, upon which a fever workup was initiated, and
all results were negative for any infectious process. A second
fever on POD#10 prompted ultrasounds of the LEs and RUQ, both of
which were unconcerning as well. Thereafter, the patient had no
more fevers. She continued to feel well, with good pain control,
ambulating multiple times per day, and tolerating regular diet.
Her staples were removed on POD#10 and steri strips were placed.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization. Electrolytes were routinely
followed, and repleted when necessary."
2451,"Please
change the dressing p.r.n. with a pressure-type dressing. The
tract should close completely in several days.
RUQ ULTRASOUND ([**8-24**]):
1. Diffuse pneumobilia, unchanged from prior. No significant
biliary ductal dilatation.
2. No definite fluid collection within the region of the porta
hepatis.
Examination is limited due to overlying bowel gas. If high
clinical
suspicion, consider CT for further assessment.
3. Unchanged splenomegaly.
4. Mild abdominal ascites.
BILATERAL LE ULTRASOUND ([**8-24**]): No lower extremity DVT
DISCHARGE LABS:
[**2194-8-25**] 07:10AM BLOOD WBC-4.9 RBC-3.12* Hgb-9.4* Hct-28.7*
MCV-92 MCH-30."
2452,"The patient's white blood
count and fever curves were closely watched for signs of
infection. Wound care was performed regularly and thoroughly.
The patient's blood sugar was monitored throughout his stay;
insulin dosing was adjusted accordingly. The patient received
subcutaneous heparin and venodyne boots were used during this
stay; was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan."
2453,"Admission Date: [**2122-6-13**] Discharge Date: [**2122-6-23**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
ruptured AAA
Major Surgical or Invasive Procedure:
[**2122-6-13**]:
Endovascular stent graft exclusion of ruptured abdominal aortic
aneurysm with a [**Doctor Last Name 4726**] 31 x 14-1/2 x 130 main body endo prosthesis
and right [**Doctor Last Name 4726**] 20 x 9.5 iliac limb and [**Doctor Last Name 4726**] 14-1/2 x 7 left
iliac extension limb
[**2122-6-22**]:
[**Company 1543**] Permanent Pacemaker generator exchange [**2122-6-22**]"
2454,"History of Present Illness:
The patient is a [**Age over 90 **] year old woman with a history of CAD s/p
pacemaker placement, atrial fibrillation, and known AAA who
presented to an OSH today with abdominal and back pain, and was
scanned demonstrating an 8.4 X 7.5 cm AAA with evidence of leak.
She was therefore transferred to [**Hospital1 18**]
urgently for vascular surgery evaluation.
Past Medical History:
PMH:
HTN
hypothyroidism
s/p pacemaker
Atrial fibrillation
CHF
h/o MRSA cellulitis in legs
history of falls
PSH:
s/p cholecystectomy
s/p L CEA
Social History:
lives alone with daughter nearby"
2455,"Neuro: no active issues, patient is alert and interactive
Cardiopulmonary: Post-operatively she was closely monitored in
the CVICU. Initally her PPM was pacing her appropriately,
however, overnight she had an episode of asystole, lasting less
than 30 seconds. Compression were started, and the pt almost
immediately began pacing appropriately again. These episodes
recurred a few more times the evening of POD 0 and
electrophysiology was urgently consulted. The EP fellow
interrogated the device and found the RV lead to be dislodged.
He adjusted the settings, and the pacer functioned properly. He
recommended repleting electrolytes and discontinuing digoxin as
well."
2456,"On the
morning of [**6-16**] the patient began to c/o SOB, required increased
O2 and was hypoxemic on her ABG. There was concern for CHF
exacerbation as well as PE. She urgently underwent CTA which
ruled out pulmonary embolism. The CT did reveal pulmonary edema
and bilateral pleural effusions. Interventional pulmonology was
consulted and felt these effusions were not large enough to
drain. There was some concern the pt may have developed
pneumonia as well given her previous emesis and immobility. The
patient was put on broad spectrum antibiotic coverage and put on
a fluid restriction and aggressively diuresed with lasix over
the next several days with close monitoring and repletion of her
electrolytes."
2457,"On preliminary
examination she passed her swallow evaluation and she was
started on a ground puree diet which was later advanced to
regular diet with thin liquids which she tolerated well.
GU: patient was found to have a UTI on Urinalysis and she was
started on antibiotics. The culture grew moderate amt of
pseudomonas and she was started on cirpo. Her foley was
exchanged. It was not removed as she was being aggressively
diuresed and her I/O's required close monitoring. A second UA/Cx
was sent on [**6-22**] and was negative with no bacterial growth. At
the time of discharge her foley was removed and she was voiding
without difficulty."
2458,"Medications on Admission:
potassium 20 meq daily
lasix 40 mg po qd
digoxin .125 mg daily
cardizem ER 240 mg po qd
ASA 81 mg po qd
miralax
clonidine 0.1 mg po bid
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): until pt fully
ambulatory and low risk for dvt.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
4. Albuterol Sulfate 2.5 mg /3 mL (0."
2459,"10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: when
on lasix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]
Discharge Diagnosis:
8.4 X 7.5cm ruptured AAA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)."
2460,"Family History:
NC
Physical Exam:
On Admission:
PE:
HR 61 BP 170/75 94% RA
NAD, awake/alert, responsive; poor historian
RRR
lungs clear
abdomen soft, moderately distended, pulsatile mass with deep
palpation
bilateral lower extremities warm, no ulceration
Pulses:
R femoral palpable, R DP palpable
L femoral palpable, L DP palpable
\
On Discharge:
VSS Afebrile
WDWN in NAD
Lungs - cta bilat
Card - RRR, paced at 60, strong PMI felt in the distal,external
thoracic cavity, due to pts habitus can feel PMI in the extreme
LUQ of the abd
Abd- soft +bs, no m/t/o
Ext- warm and dry, Fem/DP/PT pulses all palpable bilat"
2461,"????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?"
2462,"????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Keep your f/u appointment to be seen for post procedure check
and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2122-6-30**]
1:00
(pacemaker follow up and wound check)
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-7-16**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2122-7-16**] 12:00
(vascular surgery f/u, imaging of aorta and see surgeon)
Completed by:[**2122-6-23**]"
2463,"2. Bilateral introduction of catheter into aorta.
3. Abdominal aortogram and selective iliac arteriogram.
4. Endovascular stent graft exclusion of ruptured abdominal
aortic aneurysm with a [**Doctor Last Name 4726**] 31 x 14-1/2 x 130 main body
endo prosthesis and right [**Doctor Last Name 4726**] 20 x 9.5 iliac limb and
[**Doctor Last Name 4726**] 14-1/2 x 7 left iliac extension limb.
5. Perclose closure of bilateral common femoral
arteriotomies.
6. Left common femoral endarterectomy with vein patch
angioplasty.
The patient tolerated the procedure well. Of note, she was not
intubated for the procedure given her age and co-morbidities."
2464,"0 Leuks-SM
[**2122-6-22**] 05:46AM URINE Blood-MOD Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2122-6-16**] 12:17AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2122-6-22**] 05:46AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016
Brief Hospital Course:
Patient was admitted from an OSH with leaking AAA seen on OSH
imaging. She was emergently taken to the angio suite and her
images were uploaded and reviewed. She underwent:
1. Ultrasound-guided puncture of bilateral common femoral
arteries."
2465,"Pertinent Results:
[**2122-6-13**] 11:31 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2122-6-16**]**
MRSA SCREEN (Final [**2122-6-16**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2122-6-16**] 12:17 am BLOOD CULTURE Source: Line-arterial.
**FINAL REPORT [**2122-6-22**]**
Blood Culture, Routine (Final [**2122-6-22**]): NO GROWTH.
[**2122-6-16**] 12:17 am BLOOD CULTURE 2ND.
**FINAL REPORT [**2122-6-22**]**
Blood Culture, Routine (Final [**2122-6-22**]): NO GROWTH.
[**2122-6-16**] 12:17 am URINE Source: Catheter.
**FINAL REPORT [**2122-6-18**]**
URINE CULTURE (Final [**2122-6-18**]):
PSEUDOMONAS AERUGINOSA."
2466,"8 RBC-3.09* Hgb-10.6* Hct-31.9*
MCV-103* MCH-34.3* MCHC-33.2 RDW-18.6* Plt Ct-249
[**2122-6-23**] 03:56AM BLOOD Glucose-81 UreaN-31* Creat-1.3* Na-137
K-3.2* Cl-95* HCO3-33* AnGap-12
[**2122-6-23**] 03:56AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
[**2122-6-16**] 12:17AM URINE RBC-[**3-13**]* WBC-21-50* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2122-6-22**] 05:46AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-FEW
Epi-0-2
[**2122-6-16**] 12:17AM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5."
2467,"10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2122-6-14**]
1:12 PM
IMPRESSION:
Extremely limited examination due to lack of intravenous
contrast.
1. Cardiomegaly. Small bibasal effusions and pulmonary
ground-glass
opacities. The lung findings may represent infection, fluid
overload or ARDS.
2. AAA with an aortofemoral bypass graft in situ. The
appearances are
suggestive of an endoleak as described above."
2468,"The diureses significantly improved her symptoms
and her O2 requirements were subsequently minimal. On [**6-22**] she
was thought to be quite stable from a medical and surgical
standpoint and EP took her to the procedure lab where they
exchanged her PPM for a new device. She tolerated the procedure
well and her.
GI/Nutrition: The patient vomitted twice on POD 0 during chest
compressions, after which an NG tube placed. The tube was
removed a few days later when her bowel function returned.
Speech and swallow was consulted to evaluate for aspiration risk
prior to advancing the patients diet."
2469,"3. Unchanged ascending aorta and aortic arch dilatation with
focal aortic
arch aneurysm.
4. Unchanged cardiomegaly without significant pulmonary edema.
5. A central line ends in the distal left brachiocephalic vein.
UNILAT UP EXT VEINS US RIGHT Study Date of [**2122-6-18**] 1:36 PM
Reason: r/o dvt in rue
Occlusive thrombus involving the right cephalic vein. No DVT in
the right upper extremity.
[**2122-6-19**] 4:13 PM
UNILAT LOWER EXT VEINS RIGHT
Reason: CALF PAIN, PLEASE EVAL FOR DVT
IMPRESSION: No evidence of DVT in right lower extremity.
[**2122-6-23**] 03:56AM BLOOD WBC-8."
2470,"Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
except for the following changes: we have stopped your digoxin
and diltiazem and you are now on sotalol. You should take
aspirin [**Street Address(2) 42488**] of your previous 81mg.
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go to rehab:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-11**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?"
2471,"These interventions resolved her arrythmias. On [**6-16**]
the patient went into atrial fibrillation with rapid ventricular
response and required IV lopressor and then a diltiazem drip for
rate control. EP and cardiology were asked to advise on
treatment. Soltalol 80mg [**Hospital1 **] and diltiazem 30mg qid were
started and the diltiazem gtt weaned off. The pt returned to a
paced sinus rhythm within 24hrs of the atrial fibrillation and
had no further episodes throughout her stay. Anticoagulation
was initally recommended, however given the pts age and
comorbidities it was decided that heparin/coumadin benefit would
not outway the risk, and thus asprin 325mg was initiated."
2472,"3. Extensive atherosclerosis in the vasculature of the abdomen
and pelvis
including the coronary arteries.
4. Striated appearance of both kidneys, most marked on the
right. The
appearances may represent acute tubular necrosis from prior
contrast
administration.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2122-6-16**] 10:34 AM
Reason: PE PROTOCOL. Please eval for PE.
IMPRESSION:
1. Unchanged multifocal bilateral ground-glass opacities
consistent with
multifocal pneumonia.
2. Compared to [**2122-6-14**] increase of now large bilateral
simple pleural
effusion and partial atelectasis of the superior segments of the
lower lobes
bilaterally."
2473,"083 %) Solution for
Nebulization Sig: One (1) neb INH Inhalation Q6H (every 6 hours)
as needed for wheezing.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb inh
Inhalation Q6H (every 6 hours) as needed for SOB."
2474,"ID: Post-operatively patient received 3 days of kefzol for
perioperative coverage. Given her UTI, she was started on
ciprofloxacin on [**2122-6-16**], but this was switched to ceftriaxone
and doxyclycline given concern for PNA after episodes of
vomitting and consolidation seen on CXR and CT.
Heme: patient received SQH throughout her stay for dvt
prophylaxis. There was concern for a DVT in her RUE and RLE
during her stay, however both were ruled out. She did work with
physical therapy but given her deconditioned state only
ambulated minimally. She is discharged on SQH to continue at
rehabilitation facility until she is ambulating at her baseline
state."
2475,"????? Do not shower x 1 week, you may have sponge baths. After 1
week you may shoewer, but no soaking tubs
?????? Your right chest/shoulder dressing covering the incision from
the pacemaker exchange should stay on for three days, it may be
removed on thursday [**6-25**]. The groin and leg incisions may be
left uncovered, unless you have small amounts of drainage from
the wound, then place a dry dressing or band aid over the area
that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?"
2476,"Admission Date: [**2151-11-9**] Discharge Date: [**2151-11-13**]
Date of Birth: [**2069-3-22**] Sex: M
Service: SURGERY
Allergies:
Moexipril
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
splenic artery pseudoaneurysms
Major Surgical or Invasive Procedure:
splenectomy [**2151-11-11**]
History of Present Illness:
82M who sustained left-sided rib fractures, left hemorrhagic
pleural effusion and a splenic laceration with surrounding
hematoma one month ago after falling from a chair. Follow-up
outpatient ultrasound approximately one month after the injury
ultrasound which detected three splenic artery aneurysms. Thus
he
was taken to the interventional suite with angiography today.
The
procedure was uneventful but they were unable to embolize either
of the three aneurysms due to aberrant anatomy."
2477,"During the
procedure, pt HR dropped to 30s with advancement of guidewire
and with breath holding. There was concern for rupture of
pseudoaneurysm (per ACS). Pt went to PACU and became bradycardic
to 30s when sheath was removed. SBP dropped to 70s. 1 amp
Atropine was given and 1.5L of fluid was given. He has been HD
stable.
Patient was former athlete and used to run track. He walks at a
fast pace on his treadmil 30 min every day. He denies having CP
(had CP with previous MI), diaphoresis with any activity or
during bradycardic events.
Past Medical History:
CAD s/p quadruple CABG in [**2137**]
HTN
HLD
Anemia of chronic disease
Chronic kidney disease stage II
Osteoarthritis, right knee
R neck shingles, treated with acyclovir [**2151-4-25**]
Left inguinal hernia repair [**2150-9-25**]
Cataracts bilaterally s/p extraction at [**Hospital1 2177**] [**2149**]"
2478,"Social History:
Quit smoking in [**2109**], previously smoked half ppd for 20 years.
Minimal EtOH socially. No illicit drugs. Retired [**Company 2318**]
consultant, now working in [**Location (un) 86**] Public Schools 9th grade.
Family History:
No history of syncope, cardiovascular disease, stroke, seizures.
Mother had HTN, died in 80s from GI blood loss,
?diverticulosis. Father died in 50s from cancer. Had 4
sisters, they died from childbirth, COPD, cancer.
Physical Exam:
Vitals: 97 105 126/82 22 97 3L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist. No scalp
lacerations or hematomas. PERRL, EOMI.
Cspine: no TTP, full AROM without pain
CV: sinus bradycardia."
2479,"Disp:*50 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*1*
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 2 weeks.
Disp:*40 Tablet(s)* Refills:*0*
7."
2480,"losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
splenic artery pseudoaneurysms
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after failed embolization of
multiple splenic artery aneuryms. You had your spleen removed
this admission and have done well since the operation."
2481,"Well healed sternotomy incision
PULM: Clear to auscultation b/l, No W/R/R.
ABD: Soft, non-tender, nondistended, no guarding. No masses
palpated, incision CDI, JP drains x 2 SS output
Groin: no hematoma at previous
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
Laboratory:
2.8 >------< 162
30.6
Cr: 1.2
[**2151-11-9**] WBC-4.5 Hct-35.4 Plt Ct-170
[**2151-11-9**] WBC-2.8* Hct-30.6* Plt Ct-162
[**2151-11-10**] WBC-5.6# Hct-28.5* Plt Ct-162
[**2151-11-10**] WBC-5.0 Hct-29."
2482,"Once stabalized it was decided that he have a splenectomy given
the high risk of a rebleed. He did so on HD 3 and tolerated the
procedure well. Post splenectomy he has tolerated a regular
diet, is ambulating, and his pain is controlled with PO pain
medications. He will be discharged to home today and follow up
in clinic in [**7-4**] day's time. He will receive post plenectomy
vaccines prior to discharge.
Medications on Admission:
amlodipine 10mg', atenolol 25mg', HCTZ 25mg',
losartan 100mg', lovastatin 40mg', sildenafil 25mg', ASA 81mg'
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours)."
2483,"You are
now ready to be discharged home. Please return to the hospital
if you develop chest pain, shortness of breath, abdominal pain,
or if you increased or bloody output from the drains. The drains
will stay in until your follow up appointment at which time they
will be removed. Please follow up as instructed below.
Followup Instructions:
Please follow up in [**Hospital 2536**] clinic in [**7-4**] days. Please call for a
follow up appointment. The number to call is [**Telephone/Fax (1) 11173**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2151-11-13**]"
2484,"2* Plt Ct-161
[**2151-11-10**] WBC-5.0 Hct-29.2* Plt Ct-161
[**2151-11-12**] WBC-11.7 Hct-28.6* Plt Ct-122*
[**2151-11-13**] WBC-13.7* Hct-27.2* Plt Ct-156
Brief Hospital Course:
Mr. [**Known lastname 11172**] was admitted to the TSICU from the angiography suite.
He remained hemodynamically stable overnight. Serial hematocrits
were checked and remained stable. Cardiology consult obtained.
Their suspicion was that he was hypovolemic in the setting of
beta blockade, contributing to bradycardia and intermittent
hypotension. He tolerated a regular diet and was transferred to
the floor."
2485,"Admission Date: [**2111-4-6**] Discharge Date: [**2111-4-9**]
Date of Birth: [**2062-11-2**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Melena, Alcohol Withdrawal
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
48 yo with hx ETOH abuse complicated by cirrhosis and ascites
s/p TIPS in [**5-19**] presenting with GIB. Pt was in his usual state
of health until 2.5 weeks ago, he began to note diffuse
abdominal pain. This was accompanied by increasing
constipation, self-medicated with increasing doses of lactulose
to 30 cc every 3-4 hours."
2486,"- Mild COPD
- Depression
- EtOH abuse: Drinks [**12-13**] gallon vodka x >25 years, started
drinking at age 14.
- [**2110-9-24**] Incarcerated right inguinal hernia repair with
mesh.
Social History:
Lives alone with a cat, drinks daily 1 pint to [**12-13**] quart of
""cheap vodka"" daily, smokes [**12-13**] ppd, occ MJ, denies IV drug use.
Has history of withdrawl seizures.
Family History:
father died from complications of diabetes, has 2 sisters and
brother with limited to no contact.
Physical Exam:
VSS: 112/70 HR 90 95% RA RR 13 T 96.2
Gen: NAD, tremulous
HEENT: Scleral icterus, sublingual icterus
Chest: Coarse breath sounds throughout
CV: RRR, S1/S2, no m/r/g
Abd: +Distended, firm, mild tenderness diffusely, no rebound or
guarding."
2487,"Known cirrhosis s/p TIPS,
ultrasound on admission showed patent TIPS but with decreased
velocity. He was transfused two units of PRBC's on admission,
started on both octreotide and PPI drips. In addition to
cirrhosis, the patient also had active alcohol use and high dose
NSAID use. He was seen by the liver service and underwent an
urgent upper endoscopy that showed duodenal ulcers with no
active bleeding, grade I esophageal varices with no stigmata of
recent bleeding, and one ulcer with clot indicating likely
source of recent GIB. Pt received 3 units PRBC in MICU total,
hct stable and increased appropriately with transfusion
post-EGD."
2488,".
# Alcohol abuse - Tremulous, last drink the afternoon prior to
admission. He was initially managed on a Q1h CIWA scale, but
was quickly able to be tapered to a Q4h CIWA scale, he was
initially given a banana bag, then maintained on folic acid, MVI
and thiamine daily. He was stable at the time of discharge
without need for Valium.
.
# Acute renal failure - Likely pre-renal in setting of GIB and
poor PO intake, FeUrea was 4.8%, consistent with a prerenal
etiology and his creatinine improved with blood transfusions and
IV fluids.
Medications on Admission:
Current Medications: As noted above, he has discontinued his
medications as of several weeks ago."
2489,"11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every four (4) hours as needed for
wheezing.
12. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Endocet 5-325 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleed
Duodenal ulcer
Secondary Diagnosis:
Alcoholic Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent."
2490,"Due to increasing pain and
constipation, his PO intake has been minimal and he has
discontinued all of his PO medications. Abdominal pain was
accompanied by nausea, and vomitting of muddy material. Also
during this same time course, he has noted black stools. At
approximately 2 AM, he began to have frankly bloody stools with
clots and thus came into the hospital. His last ETOH
consumption was at approximately 7 PM yesterday. Of note, he
has been taking ibuprofen 1200 mg [**Hospital1 **] for the last few weeks
after running out of his percocet. He has been on percocet for
chronic knee pain."
2491,"5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO three times a
day."
2492,"0* DirBili-4.6* IndBili-2.4
[**2111-4-7**] 11:36AM BLOOD ALT-84* AST-339* AlkPhos-451*
TotBili-6.8*
.
Hematocrit Trend:
[**2111-4-6**] 06:48AM Hct-25.0
[**2111-4-6**] 12:46PM Hct-26.5
[**2111-4-6**] 05:39PM Hct-24.3*
[**2111-4-6**] 11:57PM Hct-27.5*
[**2111-4-7**] 04:39AM Hct-26.4
[**2111-4-7**] 11:38AM Hct-26.6*
Brief Hospital Course:
48 yo with hx ETOH abuse complicated by cirrhosis and ascites
s/p TIPS in [**5-19**] presenting with melena and hematochezia.
.
# UGIB - No prior history of UGIB."
2493,"4* Na-134
K-3.0* Cl-92* HCO3-30 AnGap-15
[**2111-4-6**] 06:48AM BLOOD ALT-105* AST-487* AlkPhos-586*
TotBili-5.6* DirBili-4.0* IndBili-1.6
[**2111-4-6**] 06:48AM BLOOD Albumin-3.2* Calcium-8.1* Phos-1.9*
Mg-2.0
.
LFT Trend:
[**2111-4-6**] 06:48AM BLOOD ALT-105* AST-487* AlkPhos-586*
TotBili-5.6* DirBili-4.0* IndBili-1.6
[**2111-4-6**] 05:39PM BLOOD ALT-92* AST-411* LD(LDH)-314*
AlkPhos-496* TotBili-6.3*
[**2111-4-7**] 04:39AM BLOOD ALT-84* AST-349* LD(LDH)-273*
AlkPhos-453* TotBili-7."
2494,"Melena thought to be [**1-13**] resolving UGIB from ulcers
rather than new lower GIB. He was transitioned to po PPI with a
stable hct, continued on Ceftriaxone which was transitioned to
Cipro, and discharged with outpatient followup.
.
# Cirrhosis - Cirrhosis felt to be secondary to ETOH abuse.
Currently with acute elevation of liver enzymes, with AST/ALT
ratio > 2 and elevated bilirubin. Acute decompensation maybe
related to TIPS stenosis, ETOH hepatitis, infection. Also with
mild synthetic dysfunction. RUQ US for TIPS patency showed
slowed velocity, and patient will need IR TIPS venogram once
stable as an outpatient. US showed insufficient ascites for
paracentesis, unlikely to be SBP."
2495,"+Reducible umbilical hernia.
Ext: No edema, no asterixis
Neuro: AOx3, CNS [**2-20**] grossly intact
Pertinent Results:
Admission Labs:
[**2111-4-6**] 06:48AM BLOOD WBC-11.0# RBC-2.61*# Hgb-8.6*# Hct-25.0*#
MCV-96# MCH-33.1* MCHC-34.7 RDW-16.8* Plt Ct-130*
[**2111-4-6**] 06:48AM BLOOD Neuts-72.7* Lymphs-19.5 Monos-5.5 Eos-1.9
Baso-0.4
[**2111-4-6**] 06:48AM BLOOD PT-16.0* PTT-33.3 INR(PT)-1.4*
[**2111-4-6**] 06:48AM BLOOD Glucose-112* UreaN-51* Creat-1."
2496,"This is his last
medication list from [**9-19**].
Cholestyramine-Sucorse 4 gm [**Hospital1 **]
Thiamine 100
Furosemide 40 [**Hospital1 **]
Omeprazole 20
MVI
Lactulose 30
Simethicone 80
Folic acid 1 mg
Spirnolactone 200 daily
Quetiapine 25 TID
Fluticasone-salmeterol 250/50 [**Hospital1 **]
Albuterolo 1 puff q6H
Calcium/vit D
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) PO twice a
day."
2497,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for abdominal pain and bloody
bowel movements. You underwent an upper endoscopy which showed
ulcers in your small intestine. You were treated with
medications for the ulcer with resolution of your bloody bowel
movements.
The following medication changes were made:
- Omeprazole was increased in dose to 40mg and changed to twice
daily
- Sucralfate was added
- Spironolactone 100mg daily was added
- Lasix 40mg daily was added
Followup Instructions:
You have the following appointments scheduled:
Dr. [**Last Name (STitle) **] on Tuesday [**4-14**] at 9am
Liver Center
([**Telephone/Fax (1) 1582**]
You should also follow up with your primary care physician
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] T.
[**Telephone/Fax (1) 22331**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]"
2498,"5 IV, pIV 18
and 16g. Labs pending at time of transfer, typed and crossed
for 4 units. Per GI, plan to scope ASAP in MICU. US performed
with read pending at time of transfer.
.
On the floor, he reports continued abdominal discomfort,
requesting diluadid (noting that he usually takes 6 mg IV prn
when in the hospital). Also feeling anxious and tremulous.
Last bloody BM in the ER about 1 hour ago.
Past Medical History:
- Cirrhosis [**1-13**] to ETOH: Diagnosed a few years ago,
radiographically, no history of biopsy. TIPS in [**5-19**], recurrent
ascites requiring frequent paracentesis."
2499,"Per pt, last EGD a few years ago at [**Hospital1 2025**] that
was unremarkable per his knowledge.
.
Review of systems is positive for increasing abdominal girth in
the last 4 days. His last paracentesis was one month ago with
1.5 L removed. Denies fevers, chills, cough, chest pain,
shortness of breath.
.
EDVS 99/50, SBP subsequently dropped to 80s, HR 110s, temp 98.1,
100% RA, RR 16. He passed multiple frankly bloody stools, NG
lavage with coffee ground emesis, not clearing with 500cc NS.
Given 5 L IVF with recovery of SBP to 110s. Given protonix 80
IV, started on protonix gtt, octreotide, dilaudid 0."
2500,"Admission Date: [**2107-9-24**] Discharge Date: [**2107-9-29**]
Date of Birth: [**2041-4-11**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 665**] is a 66 yo M with DM2, PVD, s/p surgical debridement
of right thigh MRSA abscess sent to ED for evaluation when he
was found to have elevated potassium at his PCP's office. He
reports that he presented to his PCP's for a scheduled follow up
visit but otherwise was without specific complaints."
2501,"He was discharged
on bactrim and augmentin with a wound vac in place.
In the ED, initial vs were: T 98 P 58 BP 118/46 R 18 O2 sat 100%
RA. Potassium was checked in the ED and was noted to be 7.8.
Patient was given calcium gluconate 1g IV x1, insulin 10 units
x1, D50 x 1 amp, bicarb x1amp and kayexalate 30g po. He had an
EKG which showed PR prolongation compared with baseline but no
other changes. Following this therapy he became
asymptomatically hypoglycemic with decrease in blood sugar to 56
from 114 on arrival and he was given a second amp of D50."
2502,"Repeat glucose three hours later was persistently low at 40 and
he was given a third amp of d50. He reports being asymptomatic
with all of these levels.
On the floor, he reports feeling at his baseline. His FSBG was
100 on arrival.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denied cough, he does
endorse occasional dyspnea on exertion. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
Past Medical History:
DM2 - last A1C 5.9 [**1-/2106**]
HTN
severe DJD
hyperlipidemia
PVD
testicular CA
Anemia - unknown cause (bl HCT ~30)
chronic renal insufficiency (bl creatinine ~1."
2503,"5)
.
Surgical History:
s/p right common iliac artery to SFA bypass
s/p gastric bypass [**2101**]
right groin dissection and XRT
right cataract surgery
appendectomy tonsillectomy
multiple foot surgeries
Social History:
lives with wife, works as CEO of company and does a lot of
travelling for work, remote smoking history of 1 PPD x12 years
quit in [**2071**], denies ETOH or drug use.
Family History:
both parents died from aplastic anemia
Physical Exam:
Vitals: T: 98.1 BP: 177/48 P:76 R:19 O2: 100% RA
General: Alert, oriented, no acute distress
Skin: warm, scattered bruises over extremities
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, well healed surgical
scars, bowel sounds present, no rebound tenderness or guarding,
no organomegaly
Ext: 2+ pitting edema of LE's bilaterally, atrophy of right
lower leg muscles, clean bandage in placeover toes of letf foot."
2504,"9. Humalog sliding scale was continued,
and NPH [**Hospital1 **] was held per patient's request.
#Hypertension - Clonidine 0.3mg qam and 0.2mg qpm was continued
while metoprolol and benicar were held in the setting of
hyperkalemia. His blood pressures remained well-controlled.
#PVD - Arterial insufficiency ulcers were seen on lower
extremities bilaterally. Aspirin was continue during his stay in
the hospital.
Medications on Admission:
Reconciled on [**2107-9-26**] [**Doctor Last Name **]
Lotrel (Amlodipine/benazepril) 5/20 QD
Benicar (olmesartan/hctz) 40/25 one tab [**Hospital1 **]
Bactrim DS 160-800 mg One (1) Tablet PO BID x 4 weeks."
2505,"4mg take 1 tablet (0.4MG) by ORAL route
every day
Chromium Picolinate Calcium Phosphate/[**First Name9 (NamePattern2) 27373**] [**Last Name (un) 27374**]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
4. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day)."
2506,"Pertinent Results:
[**2107-9-23**] 02:45PM BLOOD WBC-6.1 RBC-3.07* Hgb-9.3* Hct-30.1*
MCV-98 MCH-30.2 MCHC-30.8* RDW-14.8 Plt Ct-404#
[**2107-9-23**] 02:45PM BLOOD Neuts-45.0* Lymphs-40.5 Monos-8.4
Eos-5.4* Baso-0.7
[**2107-9-23**] 11:00PM BLOOD PT-12.8 PTT-30.1 INR(PT)-1.1
[**2107-9-23**] 02:45PM BLOOD UreaN-14 Creat-1.6* Na-132* K-7.8* Cl-107
HCO3-21* AnGap-12
[**2107-9-23**] 11:00PM BLOOD ALT-18 AST-28 LD(LDH)-157 CK(CPK)-27*
AlkPhos-136* TotBili-0."
2507,"6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: As directed
Injection ASDIR (AS DIRECTED).
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperkalemia
Discharge Condition:
Improved
Discharge Instructions:
Please return to the hospital if you develop fevers, chills,
nausea, vomiting, chest pain or shortness of breath. It is very
important that you have your blood drawn tomorrow to make sure
your potassium and creatinine are stable."
2508,"2
[**2107-9-23**] 11:00PM BLOOD Albumin-2.7* Calcium-8.5 Phos-3.8 Mg-1.9
[**2107-9-23**] 02:45PM BLOOD VitB12-1824*
[**2107-9-23**] 02:45PM BLOOD Triglyc-76 HDL-51 CHOL/HD-2.9 LDLcalc-80
[**2107-9-24**] 07:43AM BLOOD TSH-9.0*
[**2107-9-24**] 07:43AM BLOOD Free T4-1.0
[**2107-9-24**] 02:09AM BLOOD Cortsol-6.5
[**2107-9-24**] 07:43AM BLOOD Cortsol-15.5
[**2107-9-29**] 06:55AM BLOOD WBC-5.9 RBC-3.06* Hgb-9.4* Hct-29.5*
MCV-96 MCH-30."
2509,"Dr.[**Last Name (STitle) 5263**] will
follow-up those results and help adjust your medications. You
also need to follow-up in the [**Hospital 1944**] clinic to have your
blood pressure checked since two of your blood pressure
medicines have been stopped.
Followup Instructions:
Dr. [**Last Name (STitle) **], [**Location (un) **], Central Suite, [**Hospital **] Clinic:
Monday [**10-3**] 8:30 [**Telephone/Fax (1) 250**]
[**Name6 (MD) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2107-10-19**]
11:00
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2107-10-27**]
12:40
[**First Name4 (NamePattern1) 1877**] [**Last Name (NamePattern1) **],MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 721**] Date/Time:[**2107-10-28**]
9:00"
2510,"All were discontinued. IV lasix was started to enhance
K secretion and remove volume. On discussion with ID, patient's
bactrim was replaced with linezolid. Pt's K currently corrected
to 4.8, and he is being discharged on Lasix 10mg PO Daily.
#MRSA abscess s/p surgical debridement with wound vac in place -
Patient was evaluated by vascular surgery team in the ED, no
acute issues. As bactrim may have played a role in patient's
hyperkalemia, it was replaced with linezolid after discussing
with ID. given the risk for serotonin syndrome, his Tramadol was
discontinued.
#DM2 - Diabetes was very well controlled per history with last
A1c in our system of 5."
2511,"He does
endorse weight gain of 21 pounds since his hospital discharge on
[**9-11**]. Due to this he took some of his wifes water pills, the
name he cant remember for three doses total. Otherwise he
reports recent decrease in his total daily naproxen dose and
slight increase in his tramadol dose. He has recently been
taking Bactrim and Augmentin following surgical debridement
Recent admission [**Date range (1) 27372**] to vascular surgery service for right
groin mass c/w abscess on CTA without any evidence of
communication with prior right CIA to SFA graft. He had
ultrasound guided drainage which showed purulent material so he
was taken to the OR for surgical debridement."
2512,"9 MCHC-32.1 RDW-14.0 Plt Ct-281
[**2107-9-29**] 01:10PM BLOOD UreaN-17 Creat-1.6* Na-134 K-4.8 Cl-97
HCO3-32 AnGap-10
[**2107-9-29**] 06:55AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.6
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
#Hyperkalemia - Patient presented with severe hyperkalemia K of
7.8 with EKG changes of prolonged PR interval, it was 3.8 less
than a month ago. Unclear etiology, but differential diagnoses
include adrenal insufficiency given hyponatremia, hyperkalemia,
and peripheral eosinophilia. However, he does not have
hypotension."
2513,"Morning cortisol was within normal limits. Other
consideration would be hyperkalemia associated with metabolic
acidosis, although ph normal on ABG. Another consideration was
renal tubular acidosis given elevated potassium and low serum
bicarbonate on admission. No evidence of tissue breakdown or
hemolysis with normal CK. Hypoaldosteronism was also a possible
cause, however he was not volume depleted on examination.
Transtubular potassium gradient was 2.5, suggesting that
patient's hyperkalemia was likely secondary to
hypoaldosteronism. Renal was consulted who suggested that
hyperkalemia was likely due to renal K secretion inhibition by
multiple medications (benzapril, [**Last Name (un) **], triamtereme, nsaids,
bactrim)."
2514,"Augmentin 875-125 mg one po tid (stopped [**9-22**])
Metoprolol Tartrate 50 [**Hospital1 **]
Clonidine 0.3mg AM and 0.2mg PM
Pantoprazole 40 mg [**Hospital1 **]
Januvia (Sitagliptin) 100mg QD
Aspirin-Coated 325 mg PO QD
NPH 2 units [**Hospital1 **]
Humulin R 10 units AM, 8 NOON, 9 PM
Zetia 10mg [**Hospital1 **]
Naproxen 220mg [**Hospital1 **]
Tramadol 50mg qam and 100mg qpm
Aspirin 325 mg PO DAILY
Protonix Pantoprazole Sodium 40mg in the morning
Ferrous Sulfate Ferrous Sulfate 325(65)mg 1 time per day
Multivitamin Multivitamins 1 per day
Vitamin C Ascorbic Acid 1000mg 1 per day
Vitamin B-6 Pyridoxine Hcl 100mg twice a day
Viactiv Ca Carbonate/vitamin D3/vit K 500-500-40 twice a day
Vitamin B12 Cyanocobalamin 100mcg 1 time per day
Vitamin E Vitamin E Acetate
Super B Complex Vitamin B Complex 1 per day
Glucagon Emergency Kit Glucagon 1mg as directed
Folic Acid Folic Acid 0."
2515,"Admission Date: [**2173-9-21**] Discharge Date: [**2173-9-25**]
Date of Birth: [**2105-9-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic with positive nuclear perfusion study
Major Surgical or Invasive Procedure:
[**2173-9-21**]
Coronary Artery Bypass Graft Surgery x 2 Left internal mammory
artery
-> Left anterior descending and Reverse Saphenous vein graft ->
Obtuse marginal
History of Present Illness:
67 year old man with a history of coronary artery disease. Was
found to have 50% left main in [**2169**] and decided on medical
management. He currently is asymptomatic but recently underwent
an nuclear perfusion study which
demonstrated anteroapical ischemia with an ejection fraction of
57%."
2516,"Therefore he was brought for a cardiac cath which now
showed 60-70% left main distal stenosis. He presents for
evaluation for surgical revascularization.
Cardiac Catheterization: Date: [**2173-8-12**] Place: [**Hospital3 **]
60-70% distal left main, LAD with minor luminal irregularities,
LCx dominant vessel with minor luminal irregularities, RCA small
and normal, EF 76%
Past Medical History:
CVA [**2162**] -- no residual losses
S/P RCEA
COPD
HTN
Obesity
Hyperlipidemia
Social History:
Pt quit smoking 12 y/a smoked 1 day for many, many years.
Occassional ETOH, approx 2 beers every 2 weeks.
Pt works in sales and marketing.
Family History:
There is no family history of premature coronary artery disease
or sudden death."
2517,"POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Beta blocker was initiated and titrated up and the patient was
gently diuresed toward the preoperative weight. CPAP for known
obstructive sleep apnea was initiated with his home settings.
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 #4 he was ambulating freely, the wound was
healing and pain was controlled with oral analgesics."
2518,"Mr.[**Known lastname 1250**]
was discharged to [**Doctor First Name 391**] [**Hospital **] Rehab in good condition with
follow up instructions advised.
Medications on Admission:
Plavix 75mg daily ( stopped in mid-[**Month (only) 205**] by pt for financial
reasons)
Lisinopril 10mg daily
Aspirin 325 mg daily
metoprolol 100mg [**Hospital1 **]
Crestor 20mg daily
Albuterol prn
Flovent 110 mcg 2 puffs [**Hospital1 **]
Niaspan 500 mg [**Hospital1 **]
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)."
2519,"15. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon."
2520,"3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. albuterol sulfate 2.5 mg /3 mL (0."
2521,"9.There is an anterior space which most likely represents a
prominent fat pad.
POSTBYPASS:
The patient is mainained on low dose phenylephrine infusion &
V-paced.
Biventricular function is maintained. There are no new wall
motion abnormalities.
The aorta remains intact.
Valve structure & function remain unchanged
[**2173-9-25**] 06:28AM BLOOD WBC-9.4 RBC-3.28* Hgb-11.1* Hct-31.5*
MCV-96 MCH-33.8* MCHC-35.3* RDW-13.0 Plt Ct-226
[**2173-9-21**] 01:18PM BLOOD WBC-10.2# RBC-3.30*# Hgb-11.3*#
Hct-31.6*# MCV-96 MCH-34."
2522,"Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
Conclusions
PREBYPASS:
1.No spontaneous echo contrast or thrombus is seen in the body
of the right atrium or the right atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler."
2523,"Carotid Bruit Right:none Left:none
Pertinent Results:
[**2173-9-21**]
LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast or
thrombus in the body of the RA or RAA. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Mild symmetric LVH. Normal
LV cavity size. Doppler parameters are most consistent with
Grade I (mild) LV diastolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic arch."
2524,"4* MCHC-36.0* RDW-12.9 Plt Ct-129*
[**2173-9-25**] 06:28AM BLOOD UreaN-23* Creat-1.2 Na-135 K-3.9 Cl-93*
[**2173-9-21**] 03:17PM BLOOD UreaN-18 Creat-1.1 Na-140 K-4.3 Cl-109*
HCO3-24 AnGap-11
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2173-9-21**] where the patient underwent Coronary
Artery Bypass Graft Surgery x 2. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring."
2525,"3. There is mild symmetric left ventricular hypertrophy with
normal cavity size and global systolic function (LVEF>55%). The
left ventricular cavity size is normal.
4. Doppler parameters are most consistent with Grade I (mild)
left ventricular diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6.There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
7.There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen."
2526,"Look at
your incisions daily for redness or drainage
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
Surgeon: Dr [**Last Name (STitle) **] on [**10-27**] at 1:00pm
Cardiologist - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9751**] on [**10-20**] at 2:30pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 65217**] in [**4-20**] weeks [**Telephone/Fax (1) 73576**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2173-9-25**]"
2527,"Physical Exam:
Pulse:89 O2 sat: 97%
B/P Right: 128/78 Left: 127/70
Height: 72"" Weight:325#
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally except for faint BS at bases
Heart: RRR [x] Irregular [] Murmur [] grade __none____
Abdomen: Soft [xx] non-distended [x] non-tender [x] bowel
sounds
+ [x]; very obese, no HSM
Extremities: Warm [x], well-perfused [x] Edema [x] __trace___
Varicosities: None [x]
Neuro: Grossly intact [x];MAE [**5-20**] strengths; nonfocal exam
Pulses:
Femoral Right:2+ Left:1+
DP Right: NP Left:NP
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+"
2528,"083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
14. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day)."
2529,"Admission Date: [**2119-10-3**] Discharge Date: [**2119-11-8**]
Date of Birth: [**2053-1-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Hypotension and Hypoxia
Major Surgical or Invasive Procedure:
[**10-7**] - Endoscopic placement of NG tube
[**10-13**] - Repair of hiatal hernia, LOA
[**10-15**] - Abdominal washout
[**10-17**] - Placement of [**State 19827**] patch for open abdomen
[**11-1**] - EGD w balloon dilation of the proximal duodenum
- Conversion of [**State 19827**] Patch to wound vac
History of Present Illness:
Mr. [**Known lastname 93756**] is a 66 yo Male well-known to the Thoracic service
now presenting from rehab facility with hypotension, hypoxia,
and thick respiratory secretions."
2530,"J-tube placed [**4-/2119**]
-Small bowel obstruction
-Cognitive deficit NOS vs limited safety awareness
-Orthostatic hypotension - hospitalization [**1-/2119**] after fall
-DVT of the L subclavian and L axillary vein
-R hip fracture s/p ORIF by Dr. [**Last Name (STitle) **] @ [**Hospital1 112**]
-RLL PNA [**1-11**], treated with levofloxacin
-multiple stab wounds to the abdomen in the [**2079**]
-right sided PTX after bronchoscopy s/p CT placement
-Tonsillectomy and adenoidectomy
-R wrist and hand surgery
Social History:
Originally from [**State 9512**]. He has three daughters. One daughter
lives in [**State 4260**], another is in [**Name (NI) 86**], [**First Name3 (LF) 2184**] who is very involved."
2531,"Reports he recently stopped smoking. Although he has a history
of binge drinking, he reports he hasn't drank since [**Month (only) 1096**] of
[**2118**]. Retired construction worker and plumber
Family History:
Mother died of a blood clot. Doesn't know what his father died
of. Sister died of obesity and ""fat around her heart""
Physical Exam:
VS: T: 97.5 HR: 80-90's Sr BP: 110-130 RR 15-19 Sats: 100%
40% TC
Overnight CPAP 40% 7/5
General: sitting up in no apparent distress
HEENT: mucus membranes moist
Neck: Trach in place
Cardiac: RRR
Resp: clear breath sounds, strong/productive cough
GI: J-tube in place
Wound: Vac dressing in place, changed [**2119-11-7**] site with good
granulated tissue."
2532,"While in the ED he was given a fluid challenge
with a good response He was re-started back on his previous
antibiotics meropenum for multidrug resistant Klebsiella
bacteremia and Proteus bacteremia, and Linezolid for VRE UTI. He
was pancultured. RUQ ultrasound showed a dilated gallbladder.
CT Torso showed small bowel which has herniated through the
diaphgragmatic hiatus adjacent to the gastric pull-up. A
portion of pancreas also appears to be above the diaphragm. On
[**2119-10-7**] he had Flexible upper endoscopy with endoscopic
placement of nasogastric tube (which he pulled out and was later
replaced). A fistula could not be visualized but we could
clearly see the Jagwire as it entered the stomach about a
centimeter below the esophagogastric anastomosis, therefore
identifying the fistula location."
2533,"During the same operation on [**11-1**],
the patient's midline abdominal wound was assessed. It was
concluded that the [**State 19827**] Patch was no longer able to preserve
the patient's abdominal domain, and it was exchanged for a wound
vac. The wound vac was changed every 3 days following it's
initial placement with no issues.
Nutrition: Tube feeds were intially stopped due to bilious NG
output. Restarted and goal was reached by [**10-23**]. Held and
restarted on [**11-1**] for his operation and advanced to goal
without issues.
Heme: Pt received a total of 6U PRBC and 6 vials of albumin over
the course of his hospital stay for both low hematocrit and low
intravascular volume."
2534,"9. Insulin sliding scale
Q6H Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units
120-159 mg/dL 2 Units
160-199 mg/dL 4 Units
200-239 mg/dL 6 Units
240-279 mg/dL 8 Units
280-319 mg/dL 10 Units
> 320 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
-Recurrent Tracheal esophageal fistula
-Hypertension
-Hypothyroidism
-Prostate cancer s/p XRT
-h/o esophageal CA s/p XRT with 3-hole esohagectomy in [**2104**] at
[**Hospital1 112**]."
2535,"Recently hospitalized at [**Hospital1 18**] for PNA and found to have
stricture near cricopharyngeus, with evidence of TEF. EGD showed
no cancer recurrence. J-tube placed [**4-/2119**]
-Small bowel obstruction
-Cognitive deficit NOS vs limited safety awareness
-Orthostatic hypotension - hospitalization [**1-/2119**] after fall
-DVT of the L subclavian and L axillary vein
-R hip fracture s/p ORIF by Dr. [**Last Name (STitle) **] @ [**Hospital1 112**]
-RLL PNA [**1-11**], treated with levofloxacin
-multiple stab wounds to the abdomen in the [**2079**]
-right sided PTX after bronchoscopy s/p CT placement
-Tonsillectomy and adenoidectomy
-R wrist and hand surgery
PSH:
-transhiatal esophagectomy [**2104**]
-Repair tracheoesophageal fistula tracheal
resection/reconstruction [**8-12**]
-PTC drain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] with any questions
STRICT: Keep the head of the bed elevated at all times 30-45
degress to prevent aspiration of secretions
Followup Instructions:
Call for follow-up with Dr. [**Last Name (STitle) **] in 2 weeks [**Telephone/Fax (1) 2348**]
Completed by:[**2119-11-14**]"
2536,"After hernia repair and [**State **]
patch placement, the patient continued to have copious bilious
drainage from the NGT placed in the gastric conduit and
intolerance of NGT clamping. A SBFT study was obtained on [**10-27**]
which showed no contrast movement through the pylorus. The
patient was taken to the operating room on [**11-1**] for an EGD,
which showed that the likely source of the patient's obstructive
symptoms was a ""hairpin turn"" like kink in his proximal
duodenum, just after the pylorus. This area was dilated with a
balloon. His NGT output decreased over the next 3 days, and his
NGT was eventually removed."
2537,"PICC: right PICC placed [**2119-9-22**]: terminates
Medications on Admission:
Acetylcysteine 20%
Albuterol Inhaler
Albuterol Sulfate (Extended Release)
Lansoprazole 30 mg Daily
Heparin HSQ
Ipratropium Bromide MDI
Levothyroxine Sodium 75 mcg
Metoprolol Tartrate
Nystatin Oral Suspension
Oxycodone-Acetaminophen 5/325 q4-6 PRN pain
Metoclopramide 5mg Q6H
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection [**Hospital1 **] (2 times a day).
2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): via
J-tube.
3. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours)."
2538,"7 Na-147* K-4.5 Cl-112*
HCO3-30
[**2119-11-6**] 01:45AM BLOOD Glucose-93 UreaN-16 Creat-0.6 Na-148*
K-4.7 Cl-114* HCO3-29 AnGap-10
[**2119-11-5**] Glucose-100 UreaN-15 Creat-0.7 Na-146* K-4.4 Cl-113*
HCO3-28 AnGap-9
[**2119-11-6**] ALT-36 AST-52* LD(LDH)-177 AlkPhos-153* TotBili-0.2
[**2119-11-8**] Calcium-8.9 Phos-2.2* Mg-2.0
[**2119-11-1**] calTIBC-111* Ferritn-921* TRF-85*
[**2119-10-30**] calTIBC-173* TRF-133*
[**2119-10-11**] calTIBC-203* TRF-156*
[**2119-10-4**] calTIBC-246* Ferritn-983* TRF-189*
[**2119-11-8**] WBC-8."
2539,"He was noted to have
increasing secretions and a thickening of the secretions.
Patient is also complaing of chest pain, which appears to be
chronic, and abdominal pain which is apparently a new complaint.
Patient reports some nausea today, but no vomiting. Reports
fevers and chills over the past two days.
Past Medical History:
-Hypertension
-Hypothyroidism
-Prostate cancer s/p XRT
-h/o esophageal CA s/p XRT with 3-hole esohagectomy in [**2104**] at
[**Hospital1 112**]. Recently hospitalized at [**Hospital1 18**] for PNA and found to have
stricture near cricopharyngeus, with evidence of TEF. EGD showed
no cancer recurrence."
2540,"ID: Was consulted and recommended continue previous
antibiotics. Repeat BAL. Cultures only growing Proteus and
Klebs. Urine culture was negative therefore Linezolid was
stopped on [**2119-10-8**]. Pt's white count and fever curve improved
over the next week and a half, and his antibiotic regimen was
then stopped on [**10-17**]. On [**10-27**], the patient was thought to
have aspirated some of his bilious NGT secretions, and a WBC to
14 was noted. Proteus and Klebsiella were again found in the
sputum and GU tract cultures, and the patient was given a 10d
course of meropenem which ended on [**11-7**]."
2541,"4. oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q6H (every 6
hours) as needed for pain.
5. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig: One
(1) dose Intravenous Q12H (every 12 hours).
6. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: flush with
10 cc of normal saline followed by heparin.
7. levothyroxine 200 mcg Recon Soln Sig: 37.5 mcg Injection
DAILY (Daily).
8. hydromorphone (PF) 1 mg/mL Syringe Sig: One (1) Injection
Q2H (every 2 hours) as needed for pain."
2542,"The patient has been
afebrile since with a normal WBC count.
Respiratory: Pt intially placed on mechanical ventilation on
admission for low 02 saturations. Weaned to CPAP 8/5 with
oxygen saturations of 98%, eventually progressed to tolerating
only Trach piece by [**10-24**]. On [**10-27**], pt desaturated in the
setting of presumed aspiration. Bronchoscopy yielded only
minimal thin secretions, pt required CMV for adequate
oxygenation. Weaned again to trach piece by [**11-1**], but then a
trip to the operating room for EGD/wound vac placement resulted
in the patient being placed on CMV and CPAP for 2-3 days."
2543,"0 RBC-3.31* Hgb-9.3* Hct-29.2* MCV-88 MCH-28.1
MCHC-31.9 RDW-16.0* Plt Ct-195
Cultures:
multidrug resistant klebsiella and proteus sensitive to
meropenum
CXR:
[**2119-11-7**]: FINDINGS: In comparison with the study of [**11-5**], the
nasogastric tube has been
removed. There is little overall change in the appearance of the
heart and
lungs and monitoring and support devices. Bilateral pleural
effusions with
bibasilar atelectasis are again seen. Some indistinctness of
pulmonary
vessels again is consistent with some elevation in pulmonary
venous pressure.
Brief Hospital Course:
Mr. [**Known lastname 93756**] was admitted from the ED on [**2119-10-3**] with hypotension
and tachycardia."
2544,"IV: Right PICC site clean no erythema
Neuro: awake alert, oriented. Makes his needs known
Pertinent Results:
[**2119-11-8**] WBC-8.0 RBC-3.31* Hgb-9.3* Hct-29.2* MCV-88 MCH-28.1
MCHC-31.9 RDW-16.0* Plt Ct-195
[**2119-11-7**] WBC-6.0 RBC-3.07* Hgb-8.8* Hct-27.0* MCV-88 MCH-28.6
MCHC-32.5 RDW-16.0* Plt Ct-200
[**2119-11-8**] Glucose-97 UreaN-16 Creat-0.7 Na-151* K-4.6 Cl-112*
HCO3-34*
[**2119-11-7**] Glucose-107* UreaN-16 Creat-0."
2545,"Mr [**Known firstname 93876**] previously had a
3-hole esophagectomy in [**2104**] for Esophageal CA and on [**2119-8-2**]
underwent repair of tracheoesophageal fistula at [**Hospital1 18**]. He was
readmitted on [**2119-9-13**] for GNR positive blood cxs, renal failure,
and leaking from J-tube. He had multidrug resistant klebsiella
and proteus bacteremia and was placed on Meropenem. Urine
cultures grew VRE and he was placed on Linezolid. The
antibiotics were continued until [**2119-9-30**].
This evening the patient presented from his facility with
hypotension (SBP in 70's), tachycardia (110-130), and increasing
respiratory rate and oxygen requirment."
2546,"By
[**11-8**], the patient had been able to tolerate trach piece
ventilation for multiple hours a day, mainly needing minimal
CPAP assistance at night.
GI: on [**10-13**], the patient was taken to the operating room for
hiatal hernia repair for ? colonic obstruction in the setting of
large amounts of NGT output. An abdominal CT scan showed
herniation of the transverse colon and part of the pancreas into
the thoracic cavity. The abdomen was left open after this
operation due to concerns that his large amount of ascites and
increased abdominal pressure would not allow for adequate
closure. On [**10-17**], a [**State 19827**] patch was placed to facilitate
stepwise abdominal closure."
2547,"CTA demonstrating likely
anterior communicating artery aneurysm. Endovascular angiography with
possible intervention.
OPERATORS: Dr. [**First Name8 (NamePattern2) 2269**] [**Name (STitle) **] (attending physician), Dr. [**First Name8 (NamePattern2) 11758**] [**Name (STitle) 4652**] (fellow),
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20261**] and Dr. [**First Name4 (NamePattern1) 4220**] [**Last Name (NamePattern1) 1813**] (resident).
PROCEDURE PERFORMED:
1. Left common and internal carotid angiography.
2. Coiling of left anterior communicating artery aneurysm.
RADIATION: Fluoro time 39.9 minutes; source A: 1492 mGy; source B: 455 mGy.
ANESTHESIA: Procedure performed under general anesthesia. Please see
separate anesthesia report for details.
PROCEDURE AND FINDINGS: Written informed consent was obtained from the
patient prior to the procedure, explaining the risks, benefits and
alternatives."
2548,"Extensive atherosclerotic disease was again noted with
moderate stenosis of the left internal carotid artery. The findings were
discussed by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) **] at this time and, given the difficulty
with access, the decision was made to proceed immediately with aneurysm
coiling without additional diagnostic angiography.
A 6 Fr straight Neuron catheter was placed over an exchange length Glidewire
and a SL-10 microcatheter with Synchro 2, 0.014 wire was used to access the
anterior communicating artery aneurysm. After positioning the tip of the
microcatheter within the aneurysm, a Target 360 Ultra 5 mm x 10 cm detachable
coil was placed and deployed into the aneurysm sac."
2549,"[**2197-8-8**] 1:09 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 75030**]
Reason: eval for endovascular intervention for active extravasation
Contrast: OPTIRAY Amt: 290
********************************* CPT Codes ********************************
* [**Numeric Identifier 526**] EMBO TRANSCRANIAL [**Numeric Identifier 527**] SEL CATH 2ND ORDER *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 2388**] CAROTID/CEREBRAL UNILAT *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 242**] CAROTID/CERVICAL UNILAT *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 531**] TRANSCATH EMBO THERAPY *
* [**Numeric Identifier 3637**] F/U TRANS CATH THERAPY *
****************************************************************************
______________________________________________________________________________
[**Hospital 3**] MEDICAL CONDITION:
72 year old woman with subarachnoid hemorrhage
REASON FOR THIS EXAMINATION:
eval for endovascular intervention for active extravasation
______________________________________________________________________________
FINAL REPORT
INDICATION: Extensive Subarachnoid hemorrhage."
2550,"Initial
attempts to cannulate the great vessels of the aortic arch were unsuccessful.
A 5 French [**Doctor Last Name **] 2 catheter was then formed across the aortic bifurcation in the
pelvis and advanced to the aortic arch. In combination with Glidewire, the
[**Doctor Last Name **] 2 catheter was advanced to the left common carotid artery. Angiography
was performed from this position demonstrating a 6 x 5 mm wide-neck aneurysm
with irregular walls consistent with rupture arising from the anterior
(Over)
[**2197-8-8**] 1:09 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 75030**]
Reason: eval for endovascular intervention for active extravasation
Contrast: OPTIRAY Amt: 290
______________________________________________________________________________
FINAL REPORT
(Cont)
communicating artery."
2551,"No additional
coils could be placed. Post-coiling angiography demonstrated appropriate
placement of the coil within the aneurysm sac. A smaller aneurysm measuring
approximately 2 x 1 mm at the bifurcation of the left carotid/origin of left
MCA and ACA (15A:14) may also be present. The catheters were withdrawn and
the 25-cm Terumo sheath was replaced with a 6 French 10-cm Terumo sheath which
was secured to the groin with a single 0 silk suture. Sterile dressing was
applied.
IMPRESSION:
1. Large, approximately 6 x 5 mm wide-neck anterior communicating artery
aneurysm with irregular walls, consistent with rupture."
2552,"After placement of the first coil, the microcatheter tip came back into the
parent artery due to tortuosity. Subsequently, the microcatheter could not be
readily advanced into the aneurysm. Attmepts to reposition the tip of the
catheter into the anuerysm was unsuccessful. At this time, the patient's blood
pressure transiently increased raising a suspicion of possible leak of the
aneursym. However follow up angiogram demonstrates no active extravasation of
the contrast noted. This case was again discussed with Dr. [**Last Name (STitle) **]. Given the
transient blood pressure increase and extensive tortuosity of the vessels
limiting catheter manipulation, the decision was made to terminate the
procedure and send the patient to obtain a CT scan of the head."
2553,"The patient was brought to the angiography suite under general
anesthesia and placed supine on the angiography table. A timeout was
performed per [**Hospital1 351**] protocol. The patient then underwent an external
ventricular drain procedure performed by the neurosurgery team and reported
separately. Following this, both groins were prepped and draped in the usual
sterile fashion. Access was gained to the right femoral artery with a
19-gauge single-wall needle. A 0.035 [**Last Name (un) 180**] wire was advanced to the
thoracic aorta and a 6 French Terumo sheath placed.
Extensive atherosclerotic disease was noted throughout the common femoral
arteries, aorta and origins of the major intracranial vessels."
2554,"Due to extensive
atherosclerotic disease, limiting catheter access to the great vessels,
angiography was performed from the left common and internal carotid only.
2. Coiling of anterior communicating artery aneurysm with single Target 360 5
mm x 10 cm coil. Given the extreme difficulty in cathterizing the aneurysm
with the microcatheter, due to severe tortuosity of vessels and
atherosclerotic disease, 'surgical clipping' of the residual aneurysm
recommended.
3. 6 French 10 cm Terumo sheath left in place in right groin. The patient
was sent directly to CT from the angiography suite.
Findings discussed by Dr. [**Last Name (STitle) **] with Dr. [**Last Name (STitle) **] during and subsequently at the
(Over)
[**2197-8-8**] 1:09 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 75030**]
Reason: eval for endovascular intervention for active extravasation
Contrast: OPTIRAY Amt: 290
______________________________________________________________________________
FINAL REPORT
(Cont)
conclusion of the case at 5.20 pm on [**2197-8-8**]."
2555,"She continued to have
headaches but did not seek care. This am, she had emesis on
awakening and neck pain. She went to [**Hospital1 18**] [**Location (un) 620**] and CT showed
diffuse SAH. She was loaded with Dilantin, started on Nimodine
and was transfered to [**Hospital1 18**].
Past Medical History:
Emphysema/chronic bronchitis, hyperlipidemia, history of
anterior wall MI, chest pain with recent echocardiagram and
nuclear stress test showing no evidence of ischemia or valvular
disease
Social History:
TOB [**11-28**] ppd x 40 yrs
Denies ETOH
Lives alone with her cat.
USed to work in a medical office
Family History:
First cousin with breast cancer in her 70's
Sister with [**Name2 (NI) 499**] cancer at age 65"
2556,"The patient was out of bed to the chair. The
patient was febrile to 101.4. Cerebral Spinal Fluid, Urine and
sputum were cultured. Restarted ASA 81mg per neurosurgery. The
External Ventricular Drain was electively discontinued in the
evening. Intravenous medications were transitioned to pill form.
The arterial line was discontinued. A Chest radiolgraph was
consistent with increased pleural effusions. The patient
tolerated CPAP ventilation peep of 5/and pressure support of 5
overnight. On Exam, the patient was Reponsive and moving all
extremities.
On [**8-19**], A PICC ordered for continued antibiotic thereapy. A CTA
Head was ordered. There was no evidence of new hemorhage."
2557,"18. Tiotropium Bromide 1 CAP IH DAILY
19. Nimodipine 60 mg PO Q4H
RX *nimodipine 30 mg 1 capsule(s) by mouth every 2 hours Disp
#*24 Capsule Refills:*0
20. Aspirin 81 mg PO DAILY
21. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
22. Labetalol 10 mg IV Q6H:PRN > 200
23. Vancomycin 1000 mg IV Q 12H Duration: 5 Days
24. CefePIME 1 g IV Q12H Duration: 5 Days
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
SAH
Aneurysm
Syncope
Hydrocephalus
Fevers
Pneumonia
Respiratory failure
Discharge Condition:
stable neurological exam:
patient opens eyes spontaneously, mouths words- has trach in
place."
2558,"motor exam: left upper and lower extremity slightly weaker than
right upper and lower extremity: left upper ext [**3-2**] , IP [**1-30**]
rest of leg 4-/5
right upper 5-/5 IP 4+/5
pupils [**3-31**] bilaterally
face symetric
toungue midline
angio site at right groin clean/dry/intact there is no
eccymosis or hematoma, pedal pulses are present bilaterally
Discharge Instructions:
Angiogram with Embolization
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Medications:
?????? Take Aspirin 81mg (enteric coated) once daily.
nimodipine 30 mg po every 2 hours for a total of 21 days
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?"
2559,"?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please CALL MS. [**First Name8 (NamePattern2) 14882**] [**Last Name (Titles) **] ([**Telephone/Fax (1) 88**] to schedule an
appointment with Dr.[**First Name (STitle) **], to be seen in 4 weeks FROM TODAY
WITH A MRI/MRA PER DR [**First Name (STitle) **] PROTOCOL.
??????You will need a MRI/MRA of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2197-8-21**]"
2560,"3. Status post removal of external ventricular drainage
catheter with stable layering intraventricular blood and a small
amount of air, and no finding to suggest developing
hydrocephalus.
EEG [**2109-8-20**]
pending final reads prelim: NO seizures
CHEST (PORTABLE AP) Study Date of [**2197-8-20**] 3:45 AM
REASON FOR EXAMINATION: Tracheostomy in a patient with
subarachnoid
hemorrhage with copious secretions.
Portable AP radiograph of the chest was reviewed in comparison
to [**8-18**], [**2196**].
Tracheostomy is in place. The tip is approaching 4.3 cm above
the carina. Left subclavian line tip is at the mid SVC. Heart
size and mediastinum are unchanged."
2561,"Physical Exam:
On Admission:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 4 GCS 15 E:4V:5 Motor:6
O: T: 97.6 60 101/52 18 96% 2L
Constitutional: She is uncomfortable because of the pain.
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact no papilledema
Neck is nontender, no thyromegaly
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds, no murmurs
Abdominal: Soft, Nontender
Extr: No cyanosis, clubbing or edema, no deformities
Neuro: Speech fluent, awake alert oriented, appropriate. A/O X
3
but now slight disoriented to hospital, CN 3-12 intact, normal
sensory, normal motor, normal cerebellar function, downgoing
toes, DTRs normal, recall 1 out of 3
Handedness Left"
2562,"7* Hct-22.5*
MCV-99* MCH-34.1* MCHC-34.3 RDW-13.9 Plt Ct-312
[**2197-8-17**] 01:54AM BLOOD WBC-8.8 RBC-2.37* Hgb-7.9* Hct-23.9*
MCV-101* MCH-33.5* MCHC-33.2 RDW-12.9 Plt Ct-243
[**2197-8-16**] 01:58AM BLOOD WBC-8.1 RBC-2.46* Hgb-8.2* Hct-24.0*
MCV-98 MCH-33.5* MCHC-34.2 RDW-12.8 Plt Ct-204
[**2197-8-21**] 03:26AM BLOOD Plt Ct-407
[**2197-8-21**] 03:26AM BLOOD PT-12.8* PTT-26."
2563,"There is multifocal slowing
over bilateral frontal region, as well as right central temporal
region. This could be multifocal structural lesions. There are
also some non-periodic bilateral frontal central sharp waves.
They do not appear to evolve into electrographic seizures but
could be potentially epileptogenic. There are no electrographic
seizures recorded.
INTERPRETED BY:
CTA HEAD W&W/O C & RECONS Study Date of [**2197-8-19**] 2:57 PM
IMPRESSION:
1. No finding to suggest the development of cerebral vasospasm
and no
evidence of developing vascular territorial infarction, (though
no dedicated perfusion sequence was performed).
2. Status post coiling of large ACom aneurysm with adjacent
small right
frontal parenchymal hematoma, unchanged over the series of
recent studies; the overall extent of subarachnoid blood is also
unchanged."
2564,"Codeine Sulfate 15-30 mg PO Q4H:PRN pain
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. Docusate Sodium 100 mg PO BID
9. Famotidine 20 mg PO BID
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Heparin 5000 UNIT SC BID
13. LeVETiracetam 500 mg PO BID
14. Lisinopril 5 mg PO DAILY
Hold for SBP <130.
15. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN rash
16. Senna 1 TAB PO HS
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN."
2565,"?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?"
2566,"The etiology of
these findings is uncertain, but they are concerning for
multifocal infection in the appropriate clinical setting.
Outside of the chest, note is made of dense calcifications in
the expected location of the right carotid artery.
BILAT LOWER EXT VEINS Study Date of [**2197-8-15**] 9:28 AM
IMPRESSION: No evidence of deep vein thrombosis in either leg.
CTA HEAD W&W/O C & RECONS Study Date of [**2197-8-16**] 12:44 PM
IMPRESSION:
1. Interval improvement or stability of diffuse foci of
hemorrhage, as
described above. No new hemorrhage or evidence of acute
territorial
infarction."
2567,"6 Cl-105 HCO3-27 AnGap-12
[**2197-8-18**] 02:27AM BLOOD Glucose-122* UreaN-12 Creat-0.4 Na-137
K-3.4 Cl-105 HCO3-23 AnGap-12
[**2197-8-17**] 01:54AM BLOOD Glucose-93 UreaN-18 Creat-0.4 Na-139
K-3.9 Cl-107 HCO3-28 AnGap-8
[**2197-8-17**] 01:54AM BLOOD ALT-25 AST-34 LD(LDH)-236 AlkPhos-55
TotBili-0.2
[**2197-8-15**] 01:51AM BLOOD CK-MB-2 cTropnT-0.29*
[**2197-8-14**] 06:15PM BLOOD CK-MB-2 cTropnT-0.32*
[**2197-8-14**] 09:37AM BLOOD CK-MB-2 cTropnT-0."
2568,"On the day of discharge [**2197-8-21**]:
stable neurological exam:
patient opens eyes spontaneously, mouths words- has trach in
place.
motor exam: left upper and lower extremity slightly weaker than
right upper and lower extremity: left upper ext [**3-2**] , IP [**1-30**]
rest of leg 4-/5
right upper 5-/5 IP 4+/5
pupils [**3-31**] bilaterally
face symetric
toungue midline
angio site at right groin clean/dry/intact there is no eccymosis
or hematoma, pedal pulses are present bilaterally
Pertinent Results:
[**2197-8-8**] 12:35PM PT-11.7 PTT-27.7 INR(PT)-1.1
[**2197-8-8**] 12:35PM PLT COUNT-232"
2569,"Panels include automated seizure detection, rhythmic
run detection
and display, color spectral density array, absolute and relative
asymmetry
indices, asymmetry spectrogram, amplitude integrated EEG, burst
suppression
ratio, envelope trend, and alpha delta ratios.
PUSHBUTTON ACTIVATIONS: There are no pushbutton activations.
SLEEP: The patient progresses from wakefulness to stage II which
is
characterized by partially formed sleep spindles, then
progressed to slow wave
sleep.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate of
60-70 bpm with occasional PVCs.
IMPRESSION: This is an [**Month (only) **] continuous ICU monitoring study.
The
background activity seems somewhat disorganized although it
still maintains as alpha rhythm."
2570,"Clinically the patient was improving and was moving right arm in
the evening. The External Ventricular Drain was clamped with no
increase in Intercranial Pressure overnight. Plan to repeat CTA
of the Head in AM to eval for hydrocephalus.
On [**8-17**]: The Transcranial Dopplers in am were 30-40, repeat Head
CT in the morning to rule out hydrocephalus. The patient
underwent Tracheostomy and PEG today. sedation and the
ventilator was weaned as tolerated. Transcranial Dopplers were
in 30s. CT scan of the Head showed stable ventricles with
External Ventricular drain clamped over 24 hours.
On [**8-18**], The patient had been on the Tracheostomy collar from 8
am to 8 pm."
2571,"2. No findings suggestive of acute territorial infarction.
3. No change in the shape and size of the lateral ventricles to
suggest
obstructive hydrocephalus, and overall unchanged position of the
ventricular drain.
[**8-9**] CXR:
ET tube is in standard placement, nasogastric tube ends in the
upper stomach. Previous large opacity in the right upper lung
zone is much smaller and less radiodense. The rapid
disappearance suggests this was focal pulmonary hemorrhage, less
likely pneumonia given substantial involution in only 24 hours.
Left lung is grossly clear. Heart size is normal.
[**8-9**] Angio: IMPRESSION: [**Known firstname 14880**] [**Known lastname 14879**] underwent cerebral
angiography demonstrating persistent large, approximately 6 x 5
mm wide neck anterior communicating artery aneurysm."
2572,"2. Patent intracranial anterior and posterior circulation,
without change in caliber, contour, or overall branching pattern
to suggest vasospasm. No evidence of other vascular
abnormality.
3. No interval change in the size of the ventricles to suggest
hydrocephalus.
CT HEAD W/O CONTRAST Study Date of [**2197-8-17**] 10:23 AM
IMPRESSION:
1. Stable ventricular size.
2. Evolving intraventricular, subarachnoid, and
intraparenchymal hemorrhages
as previously described.
CHEST (PORTABLE AP) Study Date of [**2197-8-18**] 8:05 AM
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Subarachnoid hemorrhage originating from the
anterior
communicating arteries status post angiogram. Comparison is made
with prior study performed four hours earlier."
2573,"CT head [**2197-8-8**]: Interval increase in the degree of intracranial
subarachnoid and intraventricular blood, as well as new,
hyperdense material immediately adjacent to a coiled anterior
communicating artery aneurysm. This latter raises concern for a
small amount of extravascular leakage of intravenous contrast.
CXR [**2197-8-8**]: Adequate position of the ET tube on the third
image of the
series. NG tube positioned appropriately. Rounded opacity in
the right upper lung which is concerning for mass lesion versus
infection/aspiration. Followup to resolution is advised
CT Head [**8-9**]: IMPRESSION:
1. Unchanged distribution of the diffuse subarachnoid
hemorrhage, with
interval resorption/redistribution of the intraventricular
hemorrhage, and no new hemorrhage."
2574,"We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin,Advil, or Ibuprofen
etc.
?????? dO NOT BEGIN medication such as Coumadin (Warfarin)WITHOUT
FIRST DICUSSING THIS WITH dR [**First Name (STitle) **].
?????? You have been discharged on Keppra (Levetiracetam)500 MG [**Hospital1 **],
you will not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities."
2575,"32*
[**2197-8-9**] 02:39AM BLOOD CK-MB-4 cTropnT-0.04*
CHEST (PORTABLE AP) Study Date of [**2197-8-10**] 5:29 PM
AP radiograph of the chest was reviewed in comparison to
[**2197-8-9**].
Heart size and mediastinum are stable in appearance. The NG
tube tip is in the stomach. Widespread parenchymal opacities
are noted in the lung bases that are in some areas improved and
some progressed since the prior study and there is interval
resolution of right mid lung opacity. Overall, dynamic in
appearance are concerning for aspiration. No pneumothorax or
pleural effusion seen."
2576,"Continued on vancomycin/cefepime
for presumed Pneumonia.
On [**8-21**], the patient was in stable on neurological exam. She
was lfted out of bed to the chair. The patient's CXR was
consistent with New right upper lung opacity concerning for
pneumonia and was continued on vancomycin and cefepime for her
pneumonia. The EEG was negative for seizure and the EEG was
discontinued. The patient hematocrit was stable at 22.8 and a
hemoglobin of 7.6. This was discussed with the intensive care
team and given stable chronic nature of hematocrit the patient
was not transfused. The patient will be transferred to a
rehabilitation center today with plan for follow up with Dr
[**First Name (STitle) **] in 4 weeks with a MRI/MRA of the Brain."
2577,"A EEG
ordered as the patient was suspected seizures x2 while febrile.
The patient was administered IV Ativan and Tylenol.
On [**8-20**], The patient continued 24hr EEG which was negative for
seizures. The patient had a low-grade temp in AM and procedded
to spike to 101.3 around 2pm. The Nurse [**First Name (Titles) 8706**] [**Last Name (Titles) **] patient
behavior which included slight downward gaze and increased
pupillary size on R>L (baseline anisocoria). The patent remained
alert and oriented without motor deficits. The epilepsy
attending was constacted ( Dr [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] )and there was no
seizure activity noted on EEG."
2578,"A
previously placed coil was found unchanged and in appropriate
position. The anterior communicating artery aneurysm was
successfully coiled with an additional five Target 360
detachable coils.
[**8-11**] ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is moderately depressed (LVEF = 35 %) secondary to
extensive apical hypokinesis with focal akinesis, severe
hypokinesis of the anterior free wall, and hypokinesis of the
inferior free wall. The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal. Overall right
ventricular function appears preserved. However, there is focal
dyskinesis of the apical free wall."
2579,"There is also slightly more slowing over the right
central
temporal region. There are also some bilateral frontal central
sharp waves
and slow sharp waves recorded. They do not appear to be periodic
or evolving
into electrographic seizures.
SPIKE DETECTION PROGRAMS: There are numerous automated spike
detections
predominantly for bilateral frontal central sharp waves and slow
sharp.
SEIZURE DETECTION PROGRAMS: There are many automated seizure
detections
predominantly for bursts of left frontal slowing with embedded
sharp waves.
The rest of the seizure detection captures muscle and electrode
artifact.
There were no electrographic seizures.
QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic
Marker
software."
2580,"????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go TO REHAB, you may walk and go up and down stairs
WITH PHYSICAL THERAPY.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)."
2581,"On [**8-11**] she was neurologically stable but
continued to have some respiratory distress. Her IVF's were
continued due to concern for vasospasm. Late morning she
required re-intubation due to respiratory distress. Her IVF were
then decreased to 50ml/hr.
On [**8-12**] she continued to be febrile and requiring the cooling
blanket. Her exam was stable. Her EVD continued to be open at
15.
On [**8-13**] she had a CTA head which showed no vasospasm.
On [**8-14**], her EVD was raised to 20. She remained febrile and CSF
was sent. The gram stain showed no microorganisms."
2582,"Mild
cardiomegaly, tortuous aorta, mild vascular congestion,
bibasilaratelectasis larger on the right are stable. If any.
there are small bilateral pleural effusions. Left subclavian
catheter tip is in the mid SVC. Tracheostomy is in the standard
position. There is no pneumothorax
CHEST (PORTABLE AP) Study Date of [**2197-8-18**] 8:05 AM
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Subarachnoid hemorrhage originating from the
anterior
communicating arteries status post angiogram.
Comparison is made with prior study performed four hours
earlier.
Mild cardiomegaly, tortuous aorta, mild vascular congestion,
bibasilar
atelectasis larger on the right are stable. If any."
2583,"Admission Date: [**2197-8-8**] Discharge Date: [**2197-8-21**]
Date of Birth: [**2124-10-27**] Sex: F
Service: NEUROSURGERY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
* Right EVD placement [**2197-8-8**]
* Cerebral Angiogram and partial coil embolization of Acomm
Aneurysm Dr. [**Last Name (STitle) **] [**2197-8-8**]
* Cerebral Angiogram and completion of coil embolization of
Acomm Aneurysm Dr. [**First Name (STitle) **] [**2197-8-9**]
History of Present Illness:
Ms. [**Known lastname 14879**] reports a terrible frontal headache on 0900 [**2197-8-7**]
and then she had a syncopeal fall."
2584,"The aortic valve is not well
seen. There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: extensive, segmental wall motion abnormalities of
the left ventricle are present
CHEST (PORTABLE AP) Study Date of [**2197-8-13**] 4:53 AM
Final Report
CHEST ON [**8-13**]
HISTORY: Subarachnoid hemorrhage.
FINDINGS: ET tube and left subclavian line are unchanged. The
Dobbhoff tube tip is off the film, at least in the stomach."
2585,"Medications on Admission:
lisinopril 5 mg Tab, 81 mg, Aspirin Child Chewable Tab, Lipitor
80 mg Tab, Lexapro 20mg Tab, diazepam Oral, Advair Diskus 500
mcg-50 mcg/dose for Inhalation, Spiriva with HandiHaler 18 mcg
inhalation Caps, Combivent Inhl, albuterol sulfate 2.5 mg/0.5
mL Neb Solution, ASA 81mg chewable tablet
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN headache/pain
2. Acetylcysteine 20% 3-5 mL NEB Q6H:PRN scheduled Q6, plus prn
instilled
3. Albuterol-Ipratropium [**11-28**] PUFF IH Q6H
4. Atorvastatin 80 mg PO DAILY
once extubated
5. Bisacodyl 10 mg PO/PR DAILY
6."
2586,"[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 14881**]TTE
(Complete) Done [**2197-8-11**] at 12:07:50 PM FINAL
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is moderately depressed (LVEF = 35 %) secondary to
extensive apical hypokinesis with focal akinesis, severe
hypokinesis of the anterior free wall, and hypokinesis of the
inferior free wall. The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal. Overall right
ventricular function appears preserved. However, there is focal
dyskinesis of the apical free wall."
2587,"????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergenc
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation."
2588,"Admission Date: [**2156-8-28**] Discharge Date: [**2156-9-16**]
Date of Birth: [**2133-2-14**] Sex: F
Service: NEUROLOGY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 28082**] is a previously healthy 23-year old woman who was hit
by a drunk driver in [**State 531**] and sustained massive traumatic
brain injuries in [**2155-12-29**], s/p craniectomy, cranioplasty,
and VP shunt, who currently presents from [**Hospital3 **] with
fever. Per her parents, on [**2156-8-22**] she had a low grade
temperature of 100."
2589,"Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, large
ecchymoses on lower quadrants b/l, PEG tube site looks clean,
dry, and intact, w/o erythema
GU: Foley
Ext: warm, well perfused, 2+ DP pulses b/l, mottled pattern
resembling livedo reticularis on both lower extremities.
Skin: no rashes or ulcers
Neuro: in a vegetative state, nonresponsive, nonverbal. R pupil
with sluggish response to light; unable to assess L pupil as not
visible due to opacity over left [**Doctor First Name 2281**] and pupil."
2590,"Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary
- Seizures
Seconadry
- TBI ([**2155-12-29**])
Discharge Condition:
Discharge condition: stable and at baseline
Mental status: In a vegetative state at baseline, nonverbal, not
oriented, does not follow commands--all at baseline.
Ambulatory status: nonambulatory (baseline)
Discharge Instructions:
You were admitted to the [**Hospital1 69**] on
[**2149-8-28**] because at your rehabilatation facility, [**Hospital1 **], you
had a temperature up to 101. We performed multiple tests to
determine the cause of your fever, but your work up was
negative. You were found to have seizures. You were intubated
for a short period of time while your seizures were better
controlled. We started you on two medications for this (Keppra
and Dilantin). You were placed on antibiotics without a definite
source of infection, later discontinued. Dilantin was stopped
and replaced by valproic acid. You were discharged seziure-free
on oral keppra and valproate.
Followup Instructions:
You will be returning to [**Hospital3 **] and should follow up
with your physicians there.
1. You should follow up with your primary care physician at
[**Name9 (PRE) **].
2. You should follow up with an ophthalmologist in [**1-1**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]"
2591,"These episodes last
about 30 seconds and don't appear to be in repsonse to anything.
For the past two weeks she has also had mottling on the lower
extremities, but this may be connected to their utilization of
the tilt table at rehab. At rehab on [**2156-8-28**], she had a
temperature of 101, and she may hvae had abdominal tenderness
per physician's exam (she grimaced with abdominal exam). She was
sent to the [**Hospital1 18**] ED and spiked to 102 while in triage at the
BED.
.
On arrival to the ED her initial VS were T99."
2592,"63 mg/3 mL Inhalation q2hrs wheezing
MED Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
MED Atomoxetine *NF* 80 mg OGT daily
MED Amantadine 200 mg PO/NG DAILY
please schedule for 0800, 1400
MED Multivitamins 1 TAB NG DAILY
MED Omeprazole 20 mg PO DAILY
please give through OGT
MED Ondansetron 4 mg IV Q8H:PRN nausea
IV 500 mL NS Bolus 500 ml Over 30 mins
Discharge Medications:
1. Keppra 100 mg/mL Solution [**Hospital1 **]: [**2145**] mg PO twice a day: Stop
feeds one hour prior and for two hours after instilling. Give
with valproate.
2. valproic acid (as sodium salt) 250 mg/5 mL Syrup [**Year (4 digits) **]: 750 mg
PO Q12H (every 12 hours): Liquid."
2593,"Persistent stable
ventriculomegaly and hydrocephalus.
2. No interval change in position of the VP shunt.
3. No definite rim-enhancing fluid collection. Post-contrast
images degraded by motion
.
[**2156-8-29**] CXR: Prelim read: no pleural effusion, evidence of
pneumonia, no retrocardiac effusion, no pulmonary edema, no lung
nodules or masses, minimal retrocardiac effusion, normal cardiac
silhoutte. VP shunt visible.
.
[**2156-8-29**] CT Abdomen/Pelvis with and w/o contrast:
Normal intraperitoneal course of VP shunt with no kinking or
fracture
identified. Normal appearing adjacent fluid.
Trace of free fluid noted in both adnexae. The uterus and both
adnexa are normal with simple follicular cyst identified in
relation to both ovaries."
2594,"3. miconazole nitrate 2 % Powder [**Year (4 digits) **]: One (1) Appl Topical TID
(3 times a day).
4. docusate sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: 100 mg PO TID (3
times a day).
5. lorazepam 2 mg/mL Syringe [**Year (4 digits) **]: 1-3 mg Injection PRN (as
needed) as needed for seizure>5 min or >3 /hr.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Year (4 digits) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for Wheeze.
7. enoxaparin 40 mg/0.4 mL Syringe [**Year (4 digits) **]: One (1) Subcutaneous
DAILY (Daily)."
2595,"No adenopathy. The rectum and sigmoid
colon are unremarkable.
Urinary catheter noted within the bladder.
Brief Hospital Course:
[**Known lastname 28082**] was admitted to the medicine service for fever of unknown
source. She is in a persistent vegetative state at baseline. A
full workup for fever remained negative. She was found on
[**2156-8-31**] to have a generalized seizure. Her oxygen saturation was
in the 80's at that moment and she was intubated and transferred
to the ICU. In the ICU she was placed on two AED's (dilantin and
Keppra). Her Shunt was tapped and adjusted per neurosurgery."
2596,"19. propranolol 10 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3
times a day).
20. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1)
PO DAILY (Daily) as needed for constipation.
21. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Last Name (STitle) **]: One
(1) Tablet, Chewable PO TID (3 times a day).
22. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
23. senna 8.6 mg Capsule [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care"
2597,".
Review of systems:
(+) Per HPI
(-) Unable to assess. Parents confirm no diarrhea and no other
mental status changes. Other than HPI, she is at baseline.
Past Medical History:
1. L craniectomy and cranioplasty
2. Ventriculoperitoneal shunt
3. Traumatic Brain Injury
4. G-tube placement [**2156-1-29**]
5. Exposure keratopathy and keratitis of the L eye
6. s/p L tarsorrhaphy
7. Traumatic optic neuropathy of the left eye
8. Facial fractures, including Lefort III, b/l s/p open
reduction, internal fixation on [**2156-1-30**], type 2 nasal orbital
ethmoidal fractures.
9. L clavicle fracture s/p ORIF [**2156-2-4**]
10."
2598,"Tube feeds were increased with
two three hour pauses daily to give these medications (hold one
hour before and two hours after). She had no further seizures on
the floor. Occulopalatal myoclonus continued.
Medications on Admission:
MED 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.
MED Acetaminophen 1000 mg NG Q6H:PRN fever
Do not exceed 4gm per day.
MED Adderall *NF* (Amphetamine-Dextroamphetamine) 10 mg OGT [**Hospital1 **]
please schedule for 0700, 1200
MED Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
MED Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **]
MED Dantrolene Sodium 75 mg PO TID
please give through G tube
MED Bisacodyl 10 mg PR QOD
MED Propranolol 30 mg PO/NG TID
MED Artificial Tear Ointment 1 Appl BOTH EYES HS
MED Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation
MED Calcium Carbonate 500 mg PO/NG TID
MED Vitamin D 800 UNIT PO/NG DAILY
MED Levalbuterol Neb *NF* 0."
2599,"4, HR 122, BP
122/71, RR 18, Sat 98%. On exam she was noted to have a
nontender abdomen, a maculopapular rash on her face (which her
parents said has been going on for weeks) and very cloudy urine.
Neurosurgery was consulted. Preliminary read of the CT scan of
her head (which was done with and without contrast at the
request of neurosurgery) did not show any clear focus of
infection in her head and was overall not significantly changed
from prior. Labs were notably primarily for a WBC of 11.9
(79%N), an LDH of 273 (no prior for comparison)."
2600,"Her UA was
relatively unremarkable and a CXR appeared to have no evidence
of a PNA although it was somewhat nondiagnostic.
.
Neurosurgery felt that she should be admitted to medicine for
workup of fever. They feel it is very unlikely that the cause of
her fever is her IC shunt given that she has had it for the
better part of a year, however if her workup remains negative
they could consider tapping it.
.
On the floor, she was tachycardic to 111, with a Tmax of 99.3
and BP of 133/69. She was nonverbal and therefore unable to give
history."
2601,"Roving eye
movements horizontally. L arm flexed, with decortical
spontaneous movements of all extremities. Unable to elicit
reflexes in upper extremities, but right patellar reflex 2+, and
2-3 beats of clonus in Right foot.
Pertinent Results:
[**2156-8-28**] 04:05PM WBC-11.9* RBC-3.90* HGB-12.7 HCT-36.2 MCV-93
MCH-32.7* MCHC-35.2* RDW-14.3
[**2156-8-28**] 04:05PM NEUTS-78.9* LYMPHS-11.8* MONOS-7.1 EOS-1.4
BASOS-0.8
[**2156-8-28**] 04:05PM GLUCOSE-114* LACTATE-1.2 NA+-138 K+-4.0
CL--101 TCO2-28
[**2156-8-28**] 04:05PM ALT(SGPT)-22 AST(SGOT)-21 LD(LDH)-273* ALK
PHOS-80 TOT BILI-0."
2602,"8. nystatin 100,000 unit/mL Suspension [**Year (4 digits) **]: Five (5) ML PO QID
(4 times a day) as needed for oral thrush.
9. amantadine 50 mg/5 mL Syrup [**Year (4 digits) **]: 100 mg PO BID (2 times a
day).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Year (4 digits) **]:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
11. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Year (4 digits) **]: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
12. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Year (4 digits) **]: One
(1) Appl Ophthalmic QID (4 times a day)."
2603,"She is a graudate
of [**University/College 85112**] and was working as an aide for Mayor [**Last Name (un) 41364**]
prior to her accident. She is currently a resident at [**Hospital1 **]. She has a very supportive family and her parents are
quite involved in her care.
Family History:
non-contributory
Physical Exam:
Vitals: T: 99.3 BP: 133/69 P: 111 R: 20 O2: 98% on RA
General: In a vegetative state. Does not respond to voice,
sometimes withdraws from painful stimuli.
HEENT: Sclera anicteric, dried blood in oropharynx on tongue and
hard palate, along with a small amount of mcuous on tongue."
2604,"Fracture of left coracoid process and inferior sternum
11. L medial malleolus fracture and left tibial plateau
fracture, s/p ORIF
12. Minimally displaced comminuted fracture of the L inferior
pubic rami and minimally displaced fracture of the superior
pubic ramus.
13. R transverse process fracture of L5
14. Vertical midling sacral fracture
15. Myositis ossificans of the R proximal quadriceps
16. B/L pulmonary contusions.
17. IVC filter placement [**2156-1-22**].
18. Hepatic laceration
19. Autonomic dysfunction
20. S/P L keratograft at Mass Eye & Ear in [**2-4**].
Social History:
Ms. [**Known lastname 28082**] was a previously healthy, fully functioning woman
prior to being hit by a drunk driver in [**Location (un) 7349**]."
2605,"5
[**2156-8-28**] 04:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**1-30**]
[**2156-8-28**] 04:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2156-8-28**] 04:40PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
Imaging:
[**2156-8-28**] CXR:Nearly nondiagnostic study with no gross opacity
noted. If clinically feasible, consider repeat study. IVC
filter present. VP shunt visible.
.
[**2156-8-29**] CT head with and w/o contrast:
1. No significant interval change."
2606,"One
of two bottles from the CSF grew out coagulase negative staph.
We believe this is a contaminate given the benign nature of the
CSF profile. Still she was started on empiric antibiotics which
were Vancomycin and Ceftazidime. This was written for a 7 day
course and completed. She was subsequently afebrile. She was
extubated on [**2156-9-2**] and observed in the ICU overnight. There
were no acute events. She was transferred to the floor for
further care.
On the floor her antiepileptic drugs were adjusted to ensure
control with oral agents. Dilantin was stopped and valproate
started. Keppra was continued."
2607,"0. On [**2156-8-25**] she had two episodes of
nonbloody emesis, and she started to have a dry, nonproductive
cough. Ms. [**Known lastname 85111**] parents also noted that the she had
diaphoresis and increased movements. On [**2156-8-26**] they noticed
that her left eye, which has a keratograft and tarsorrhaphy,
became red and injected, with a small amount of purulent yellow
drainage. Per her parents, she has had eye infections multiple
times but they have resolved with drops. During the last week,
her rehab reports that she has been arching her back with head
turning to the left, has had increasing tone in LUE and lower
extremities, with flexion of the right arm."
2608,"13. ciprofloxacin 0.3 % Drops [**Year (4 digits) **]: 1-2 Drops Ophthalmic Q4H
(every 4 hours): Continue until ophthalmology f/u.
14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
16. therapeutic multivitamin Liquid [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
17. dantrolene 25 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO TID (3
times a day).
18. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
QOD () as needed for constipation."
2609,"Admission Date: [**2197-3-20**] Discharge Date: [**2197-5-18**]
Date of Birth: [**2123-11-27**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Right cerebellar hemorrhage
Major Surgical or Invasive Procedure:
[**2197-3-21**] Suboccipital crani for evacuation of the Right
cerebellar hemorrhage
[**2197-3-21**] Right frontal EVD placement
History of Present Illness:
This is a 73 year old man with hypertension and vascular disease
transferred from [**Hospital3 417**] Hospital with reported
cerebellar hemorrhage. He reportedly was brought to the OSH
after developing nausea, vomiting, and diaphoresis at his
apartment complex."
2610,"Past Medical History:
1. Hypertension
2. Renal artery stenosis
3. AAA endovascular repair c/b R ext iliac pseudoaneurysm, also
s/p repair [**2195**]
4. Peripheral vascular disease
5. Nephrolithiasis
6. Hyperlipidemia
7. COPD
Social History:
Lives alone, ex wife lives in U.S. but the rest of extended
family resides in [**Country 1684**]. He is primarily arabic speaking, but
understands some English. no tobacco.
Family History:
non-contributory
Physical Exam:
On admission:
Mental Status: Sedated / non-responsive. Does not blink or
track.
Later, as paralytic lifted, he grimaced inconsistently to
noxious
stimulation and spontaneously moved his Right shoulder and both
legs."
2611,"megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
DAILY (Daily).
Disp:*1 bottle* Refills:*2*
10. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
inhalation Inhalation once a day.
11. Atrovent HFA 17 mcg/actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation Inhalation q6hr as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Right cerebellar hemorrhage
Intraventricular hemorrhage
Hydrocephalus
Cerebral edema
Confusion
C-Diff
VAP
Respiratory failure requiring intubation
Hypotension
Urinary retention
Nausea
Vomiting
Orthostasis
Malnutrition
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable."
2612,"Stool O+P were
sent, although discomfort is likely just due to history of +
cdiff. Laboratory values were stable.
Throughout his hospital course, he coninued to have episodes of
nausea with occasional vomiting. This responded well to Zofran
and fluid resuscitation. On [**4-19**], he remained stable.
His PO intake remained poor and the psychiatry team was
consulted as it was felt his poor po intake could be a result of
depression. The psychiatry team recommended starting remeron to
help with sleep/wake cycle.
On [**4-25**] a foley catheter d/c trial was once again initiated but
the pt failed to void so it was replaced."
2613,"Prior to this procedure a R frontal EVD
was placed without difficulty. He did recieve 2 units of
platelets for his use of Plavix. Post operatively he remained
intubated and was taken to the ICU for further care including
SBP control and q1 neurochecks. His EVD was kept at 15cm above
the tragus. On post op exam he was not following commands but
moved everything to noxious. His pupils were equal and reactive.
A head CT on the morning of [**3-21**] showed good evacuation of ICH
and decreased hydrocephalus.
On [**3-22**] he was extubated without difficulty. He was noted to be
awake and alert to self, following commands and moving all
extremities with full strength."
2614,"doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9."
2615,"8,
and we again attempted to remove his foley.
His sutures were removed on [**4-4**].....He had screening LENIs on
[**4-4**] that were again negative for DVT. He remained stable [**4-4**]-
[**4-11**]. Disposition planning continues.
A stool sample was sent on [**4-11**] which was negative for Cdiff. On
[**4-12**] he remained stable and his creatinine was done to 1.7 from
2.0
[**4-13**] He was seen by OT and c/o dizziness - he vomited x 1 with ?
of some small blood tinged mucus. This was discarded and not
seen by staff. He did vomit again while OOB to chair without
any blood."
2616,"-Motor: Initially, flaccid x all extremities and axially. Later,
spontaneous minimal movements of RUE and bilatearl LEs.
At discharge:
awake, alert to self, hospital, month. following all commands.
MAE with full strengths. incision well healed.
Pertinent Results:
Head CT [**2197-3-20**]:
FINDINGS: Centered within the right cerebellum, there is a 5.4 x
3 cm
hyperdense hemorrhage with surrounding edema (previously 2.8 x 3
cm); this
hemorrhage crosses the cerebellar vermis into the left
cerebellar hemisphere. Hyperdense blood is seen within the
fourth ventricle extending up into the third ventricle. The
lateral ventricles and third ventricle are dilated measuring up
to 4."
2617,"Labs and CT were ordered after reviewing OMR.
His CT was stable with no changes. quetiapine dosing was
decreased by half.
On [**5-8**] he continued to have nausea and poor PO intact.
Nutrition was consulted and stool was sent for c-diff. nystatin
and second alpha blocker were discontinued.
On [**4-16**] the patient was orthostatic when he got up with PT. He
was given an IVF bolus and standing IVF due to his continued
poor PO intake. He was started on calorie counts.
On [**4-17**] he was neurologically stable. He continued to have
abdominal discomfort despite c-diff negative x3."
2618,"Unchanged biparietal and
bitemporal
subarachnoid blood. Unchanged minor parenchymal hemorrhage along
the prior
ventriculostomy catheter tract. Unchanged ventricle size. No
evidence of
vascular territorial infarction
LENIS [**2197-3-28**] IMPRESSION: No evidence of deep venous thrombosis
in the lower extremities.
CHest Xray [**3-31**]: PA and lateral radiograph demonstrates
unremarkable mediastinal, hilar and cardiac contours. Lungs are
clear. Previously noted pulmonary edema has resolved. Small
bilateral pleural effusions noted. Left subclavian line tip is
terminating in the mid-to-distal superior vena cava. No
pneumothorax.
Lower Extremity Doppler Ultrasound [**2197-4-4**]:
No evidence of deep vein thrombosis in either right or left
lower extremity."
2619,"The urology team was
consulted since this was the 4th time he failed. They
recommended keeping the foley in place for an additional 6 days
then following up in the urology clinic.
The patient continued to remain stable awaiting his family's
arrival from [**Country 1684**].
On [**4-28**] the patient's ex-wife arrived and worked with PT/OT.
Teaching was initiated on how to care for the patient upon
leaving the hospital. He remained stable on [**5-5**]. He continued
to await disposition to an extended care facility. He had
another repeat LENIs on [**5-13**] which showed no evidence of DVT."
2620,"4 cm. Hyperdense blood is seen layering within the
occipital horns bilaterally. There is no significant shift of
normally midline structures. The basal cisterns inferiorly are
obliterated. The posterior fossa is expanded with mass effect on
the brainstem. The cerebellar tonsils are at the level of the
foramen magnum. No acute fracture is seen. The visualized
portions of the paranasal sinuses and mastoid air cells are well
aerated. Retained secretions are noted in the nasopharynx.
IMPRESSION: Large parenchymal hemorrhage centered in the right
cerebellar
hemisphere with intraventricular extension, mass effect, and
hydrocephalus as above, increased since 2 hours prior.
[**3-21**] Head CT
1."
2621,"Interval occipital craniectomy with increased but residual
hyperdense
blood in the cerebellum and ventricles; evaluation of mass
effect is
suboptimal on this study due to portable technique.
2. Interval placement of a right frontal approach ventricular
catheter with
persistent hydrocephalus.
[**3-24**] CT head
IMPRESSION:
1. Interval significant decrease of the hydrocephalus with
normal size of the lateral ventricles and with the EVD in place.
2. Increase of subarachnoid hemorrhage in the both temporal and
occipital
lobes, likely due to redistribution of the intraventricular
hemorrhage.
3. Compared to the most recent prior study from [**2197-3-21**],
unchanged
amount of hemorrhage in the fourth ventricle and the cerebellar
hemispheres."
2622,"A
CT head was obtained on [**5-14**] which showed expected evolution of
intracranial hemorrhages. No acute infarct or hemorrhage. No
evidence of hydrocephalus.
On [**5-16**] the patient failed another voiding trial and the foley
catheter was replaced. On [**5-17**] Urology was re-consulted for
persistent failure to void. They continued to recommend a
urodynamic study as an outpatient. They also recommended
intermittent catheterization, which is preferred over indwelling
foley catheter but this was not possible due to patient's lack
of participation.
On [**5-18**] the patient and his ex-wife worked with PT and OT with
the help of an interpreter and he was cleared for discharge."
2623,"Emergent reintubation at
1230pm for poor ventilatory status. A triple lumen placed. and a
Bronchcoscopy was performed at the bedside and a BAL was sent.
On [**3-25**], The patient's exam improved and he was able to follow
some simple commands. The External Ventricular Drain was
discontinued as there was no drainage of CSF from the EVD and
the patient's 4th ventircle was noted to be patent on head CT.
There staples were placed for closure.
On [**3-26**], The patient neurological exam was improved and he was
able to follow commands in all four extremities with full
strength."
2624,"On [**3-24**], The patient experienced respiratory issues overnight
into am. Bipap ventilation was started at 930 am. Teh patient
was given lasix. A CXR was consistent with worseing
consolidation and empiric antibiotic therapy was initiated for
for Ventilatory Aquired Pneumonia. The WBC level was 17.2 from
14.8 on [**3-23**]. The External Ventricular Drain exhibited poor
output of 4cc from 7-9am. The EVD was distally/proximally
flushed and the extrenal ventricular drain decreased to 10 and
left open. ICPs were correlating with patient's activity and
were [**4-30**]. A NCHCT was performed which was consistent with good
placement EVD and no hydrocephalas."
2625,"CT head [**2197-3-25**]
Overall stable examination without significant hydrocephalus in
the setting of external ventricular drain. Parenchymal
hemorrhage centered in the right cerebellum with extension into
the fourth ventricle and
biparietal/bitemporal subarachnoid hemorrhage, similar to 20
hours prior.
CT head [**2197-3-26**]
1. Interval removal of the right transfrontal ventriculostomy
catheter with hyperdensity along catheter tract, representing
minor parenchymal hemorrhage with trace intraventricular
extension.
2. Otherwise, the appearance is largely unchanged with
biparietal and
bitemporal subarachnoid blood, likely redistributional, related
to the right cerebellar hemispheric hemorrhage with fourth
ventricular extension, status post occipital craniectomy.
CT head [**2197-3-27**]
Unchanged right cerebellar hemorrhage with intraventricular
extension into the fourth ventricle."
2626,"He had some hypotension on [**4-1**] that
responded to fluid bolus. He was stable on [**4-2**].
On [**4-3**] his abdomen was found to be distended and post void
bladder scan revealed 1000cc remaining in the bladder so a foley
was replaced and the patient was started on Flomasx. His
creatinine bumped on [**4-4**] to 2.1 (baseline elevated > 1.3)
likely due to mild dehydration as his oral intake was poor. He
was given a fluid bolus and placed on low IV maintenence fluids.
His labs were trended. On [**4-6**] his creatinine decreased to 1."
2627,"PT and
SW were consulted.
On [**3-28**], patient was transferred to the Step Down Unit. His EVD
staples were removed. His catheter was removed, but unfortnately
patient was unable to void on his own requiring him to undergo a
straight catheterization.
On [**3-29**] his dressing remained clean and dry without evidence of
leak and the patient continued to improved neurologically. He
worked with PT and was found to be orthostatic. On [**3-30**] he
continued to improve and worked with PT and began being screened
for rehab.
Attempts were made to contact the family in [**Name (NI) 1684**] but three
numbners were disconnected."
2628,"-Cranial Nerves: Pupils are equally small (1.5-2mm), round, and
non-reactive to light (?""pontine"" pupils). No good view for
fundoscopy (small pupils). No doll's eye response initially.
Eyes
mid-position with no movement. Initially, no corneal response or
response to nasal tickle. Later, bilateral weak eyelash-blink
responses and legs moved to bilateral nasal tickle. Face was
symmetrically lax; when he later furrowed his brow to noxious
stimulation, it elevated symmetrically. Initially, no gag or
cough; later strong cough (tracheal suction) and weak gag
(gentle
ETT-wiggle). Initially, not over-breathing the vent and not
initiating full breaths on CPAP."
2629,"He arrived complaining of a [**10-25**] headache;
the nursing notes says he was awake and speaking and denied
CP/SOB on arrival. He was markedly hypertensive on arrival -- BP
was recorded initially as 232/132
(VS otherwise unremarkable). CBC and coags were normal (INR 0.9
and no known h/o A/C); BMP was pending. ECG remarkable for
obvious LVH (voltage criteria) and ?RBBB (RSR' in III), with
NSR. He was given Zofran and labetalol, and when his systolics
remained elevated in the 200s, he was started on a nitroprusside
drip. He was taken for NCHCT, which showed a 3cm Right
cerebellar hemorrhage."
2630,"At some point during this initial
evaluation, he became acutely non-responsive, so he was
intubated (induced with etomodate and succinylcholine, also
fentanyl) and Med-Flighted here to [**Hospital1 18**]. He was continued on
the Nipride gtt en route, and paralyzed for transport using
rocuronium and propofol gtt.
He arrived here around 21:30 with BP 267/131, down to 168/96
with increased nitroprusside gtt rate. He was flaccid
(paralyzed). The ED resident informed me that someone had
commented on ""asymmetric pupils"" at some point, but the
[**Location (un) **] personell said that his pupils were 2mm and equal the
entire trip (they were this size of smaller, non-reactive, on my
arrival to the ED a few minutes after his arrival)."
2631,"He
is afebrile, VSS, and neurologically stable. Patient's pain is
well-controlled and the patient is tolerating a good oral diet.
Pt's incision is clean, dry and inctact without evidence of
infection. Patient is ambulating safely over short distances
and has been given a wheelchair for longer distances.
Medications on Admission:
1. Plavix
2. simvastatin
3. amlodipine
4. labetatlol
5. lisinopril
6. Cardura (doxazosin)
7. Percocet
8. Ambien
9. Atrovent
10. Advair
11. Miralax
12. colace
13. vitamin C
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2."
2632,"Eyes were open sponanteously, pupils were equal and
reactive. The patient was electively extubated after diuresis
with lasix. He tolerated extubation well. The steroids were
discontinued as the patient has pneumonia and Cdiff
concurrently.
He was agitated on [**3-27**] and seroquel was increased. In the
evening he did well on Q2 hr neuro checks. He was less agitated.
Staining was noted on his pillowcase and there was a concern for
CSF leak. A clean dressing was applied and scant staining only
was noted. He had no sign of hydrocephalus on [**3-28**]. He was more
oritented and appropriate. Orders to the SDU were done."
2633,"Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? You may shower
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a Head CT w/o
contrast. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Completed by:[**2197-5-18**]"
2634,"LENIS [**4-12**]:
No evidence of deep vein thrombosis in either leg.
NCHCT: [**4-13**]: IMPRESSION:
1. Increased prominence of the extra-axial CSF spaces,
particularly evident in the right posterior fossa and right
frontal region. This may be related to volume loss from surgery,
but the patient should be followed for intracranial hypotension
with clinical correlation. Indentation on the right cerebellar
hemisphere from the right posterior fossa extra-axial fluid
collection.
2. Expected evolution of intracranial hemorrhage with decreased
density of
right cerebellar hemispheric hemorrhage, and near complete
resolution of
subarachnoid and ventriculostomy catheter tract hemorrhage.
Brief Hospital Course:
Pt was taken to the OR emergently for suboccipital craniectomy
and evacuation of ICH."
2635,"Admission Date: [**2103-11-23**] Discharge Date: [**2103-11-30**]
Date of Birth: [**2023-9-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
dyspnea at rest
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 year old female with COPD on home 2L, HTN, recurrent anemia,
diastolic CHF who presents with progressive dyspnea. She was
discharged from [**Hospital1 112**] 7 days PTA for COPD and CHF, where she was
treated with blood transfusions, steroids and diuresis. Since
discharge her dyspnea has progressively worsened. She states
that it is exacerbated by activity and laying flat."
2636,"She
was placed on a BIPAP. On arrival to the MICU, patient was
satting 96% 40% BIPAP.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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:
Diastolic CHF
COPD, severe
COLONIC ADENOMA
CANCER - BREAST, INTRADUCTAL
Anemia
CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min
Tobacco dependence
INTESTINAL VASC INSUFFIC
HISTORY CAROTID ENDARTERECTOMY
DIVERTICULOSIS
HYPERCHOLESTEROLEMIA
CORONARY ARTERY DISEASE S/P CORONARY ARTERY BYPASS [**Doctor First Name 147**]
HYPERTENSION - ESSENTIAL"
2637,"Social History:
- Tobacco: 1 pack/day for 50 years, currently does not smoke
- Alcohol: denies
- Illicits: denies
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals:afebrile, 115/80, P-77, 95% face mask 40%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, poor air movement, no
wheezes, bibasilar insp. rales, ronchi.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Rectal: brown, Guiac neg stool
GU:foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
."
2638,"The right ventricular cavity is mildly dilated with
normal free wall contractility. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate to severe ([**12-21**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
80 year old female with COPD, HTN, recurrent anemia, diastolic
CHF who was admitted for dyspnea and anemia."
2639,".
#Dyspnea- The patient was admitted to the MICU with hypoxia to
the 70%s on room air. She briefly required non-invasive
ventilation. She was covered for a possible COPD exacerbation
with nebs, prednisone and azithromycin (antibiotic course
completed). She also was started on a lasix and nitro drip for
acute on chronic diastolic CHF (EF 60%). Chest X-ray revealed
bilateral pulmonary opacities with pulmonary edema. The patient
diuresed well and dyspnea improved, making acute on chronic
diastolic CHF the chief diagnosis. The patient underwent a
transthoracic echo that showed moderate to severe MR worsened
since [**9-/2103**], which may be contributing to CHF exacerbation."
2640,"Etiology of
anemia likely multifactorial, secondary to CKD, repeated
phlebotomy. Stools remained guaiac negative throughout
admission.
.
#Acute on chronic kidney injury - Baseline creatinine is 1.5-2.0
over the past few months. With diuresis, creatinine increased
to 2.4-2.6 daily. The patient should follow up regarding her
creatinine within a week of discharge.
.
#Chronic Angina/CAD- Chronic angina has been controlled on
ranolazine and isosorbide mononitrate. Stress test in [**10/2103**]
revealed reversible inferior defect on nuclear imaging. Patient
remained chest pain free throughout admission. The patient was
continued on atorvastatin, ASA, hydralazine and imdur. Ranexa
was discontinued due to acute kidney injury."
2641,"The patient should
follow up with her cardiologist about reinitiation of ranexa
with improvement in renal function to baseline.
.
# Code:DNR/DNI
====================================================
TRANSITIONAL ISSUES:
#The patient should follow up regarding her BUN/creatinine [**12-4**].
Results to be reported to Dr. [**Last Name (STitle) **].
#The patient should follow up with her cardiologist about
reinitiation of ranexa with improvement in renal function to
baseline.
Medications on Admission:
Prednisone 10 mg Oral Tablet Take 1 tablet in morning or as
directed
Atorvastatin 80 mg Oral Tablet Take one-half tablet (40mg) daily
Folic Acid 1 mg Oral Tablet Take 1 tablet daily
Omeprazole 20 mg Oral Capsule, Delayed Release(E."
2642,"Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 80426**]
Fax: [**Telephone/Fax (1) 6808**]
18. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary diagnosis: Acute on chronic systolic CHF
Secondary diagnosis: COPD exacerbation, acute on chronic kidney
disease, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the intensive care unit with shortness of
breath and found to have an acute worsening of your heart
failure and a possible exacerbation of your COPD."
2643,"Symptoms
accompanied by cough with clear sputum for 1 day, palpitations,
and chest pressure associated with some gas. No radiation to
extremities or jaw, diaphoresis. Patient states that chest
pressure was present for many hours on admission, consistent
with her baseline chest discomfort she has experienced for
years. Of note, the patient is on 2L home O2 at baseline, with
home O2 sat ranging from 92-95%.
.
In the ED, initial VS were: 98.1, Pulse: 73, RR: 30, BP: 137/46.
CXR revealed pulmonary edema. Foley was placed and the patient
was given 40mg IV lasix, IV solumedrol, and levofloxacin."
2644,"12. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
inh Inhalation twice a day: rinse thoroughly afterward.
13. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
take in AM 30 min prior to eating. Do not lie down for at least
30 min .
16. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient Lab Work
Please check BUN/creatinine [**12-4**]. Report results to:
[**Last Name (LF) **],[**First Name3 (LF) 488**] M."
2645,"do not lie down for at least
30 minutes
Discharge Medications:
1. prednisone 10 mg Tablet Sig: as directed Tablet PO daily ():
take 4 tablets x 1 day, then take 3 tablets x 2 days, then take
2 tablets x 2 days, then take 1 tablet daily (ongoing).
Tablet(s)
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): take 30 min
prior to first meal."
2646,"C.) Take 1
capsule 30 minutes before first meal of day
Ranolazine 500 mg Oral Tablet Extended Release 12 hr one [**Hospital1 **]
Ferrous Sulfate 325 mg (65 mg iron) Oral Tablet one qd
Docusate Sodium (STOOL SOFTENER) 100 mg Oral Capsule one [**Hospital1 **]
Furosemide 40 mg Oral Tablet Take 1 tablet daily
Tiotropium Bromide (SPIRIVA WITH HANDIHALER) 18 mcg Inhalation
Capsule, w/Inhalation Device One capsule (2 puffs) inhaled daily
Prednisone 20 mg Oral Tablet 2 tablets daily for 3 days, then 1
tablet daily for 3 days, then [**11-19**] tab daily for 3 days.
Isosorbide Mononitrate (IMDUR) 60 mg Oral Tablet Extended
Release 24 hr 3 tablets = 180 mg once daily
Metoprolol Tartrate 100 mg Oral Tablet Take 1 tablet twice daily"
2647,"5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
Two (2) puffs Inhalation once a day.
9. Imdur 60 mg Tablet Extended Release 24 hr Sig: Three (3)
Tablet Extended Release 24 hr PO once a day.
10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing."
2648,"Slight blunting of the left costophrenic angle
may be due to trace pleural effusion. The patient is status post
median sternotomy. The cardiac silhouette is top normal. The
aorta is calcified.
.
IMPRESSION: Diffuse bilateral, right much greater than left
alveolar opacities could relate to asymmetric edema and/or
infection. Correlate clinically and consider repeat after
diuresis. Comparison with prior radiographs would be helpful.
.
ECHO [**2103-11-26**]: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect."
2649,"Cardiac enzymes were negative X3 for ischemic cause of heart
failure exacerbation. Prior to transfer to the floor, lasix and
nitro drips were discontinued. The patient was started on
torsemide (in place of home lasix) and imdur. She continued to
diurese well. Her oxygenation improved. At time of discharge,
the patient was saturating well on 3L O2. She was discharged on
torsemide for diuresis and a prednisone taper.
.
#Anemia- Patient has a history of significant anemia, with acute
decrease in HCT on admission from 30 to 21. Stools guaiac
negative. Patient was transfused 1 unit PRBCs. Hematocrit
stabilized at 25 for the remainder of admission."
2650,"Hydralazine 25 mg Oral Tablet one pill 3 x per day
Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation HFA
Aerosol Inhaler INHALE 2 PUFFS EVERY FOUR TO SIX HOURS AS NEEDED
Fluticasone-Salmeterol (ADVAIR DISKUS) 500-50 mcg/dose
Inhalation Disk with Device use 1 inhalation TWICE DAILY and
rinse thoroughly afterward
Amlodipine 10 mg Oral Tablet Take 1 tablet daily
Montelukast (SINGULAIR) 10 mg Oral Tablet take one tablet once
daily
Aspirin 325 mg Oral Tablet, Delayed Release (E.C.) 1 tablet
daily
Alendronate 70 mg Oral Tablet TAKE 1 TABLET one day a week in
the morning 30 minutes before food."
2651,"DEPARTMENT: INTERNAL MEDICINE
WITH: [**Last Name (LF) **],[**First Name3 (LF) 488**] M.
When: [**2103-12-25**] 1:00PM
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 80426**]
.
Department: VASCULAR SURGERY
When: TUESDAY [**2104-1-15**] at 10:00 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: VASCULAR SURGERY
When: TUESDAY [**2104-1-15**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]/ CARDIOLOGY
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
*Dr. [**Last Name (STitle) 80427**] office staff will contact you to schedule a
follow up appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]"
2652,"Discharge Physical Exam:
VS: 98.0 143-166/70-84 79-92 20 98%3L
General: Pleasant woman; Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 8 mm H2O, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Poor air movement bilaterally, scattered expiratory
wheezing.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU:foley in place draining light colored urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2103-11-23**] 04:00PM BLOOD WBC-16."
2653,"In the ICU,
you received medications IV to help remove the excess fluid from
your body. You were also treated for worsening COPD with
antibiotics and steroids. You will complete a steroid taper as
an outpatient. You will also be discharged on torsemide to
continue to remove the excess fluid form your body.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
MEDICATIONS CHANGED THIS ADMISSION:
STOP lasix
STOP ranexa. Please discuss reinitiation of this medication
with your cardiologist
START torsemide 80 mg by mouth daily
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] NP
Location: [**Hospital1 641**]/CARDIOLOGY
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
When: [**Last Name (LF) 2974**], [**12-7**], 9:10 AM
."
2654,"6* RBC-2.54* Hgb-7.3* Hct-21.7*
MCV-86 MCH-28.9 MCHC-33.7 RDW-15.0 Plt Ct-240
[**2103-11-23**] 04:00PM BLOOD PT-13.3* PTT-25.4 INR(PT)-1.2*
[**2103-11-23**] 04:00PM BLOOD Glucose-163* UreaN-47* Creat-2.2* Na-137
K-3.4 Cl-99 HCO3-25 AnGap-16
[**2103-11-23**] 11:38PM BLOOD Mg-2.1 Iron-75
[**2103-11-24**] 03:28PM BLOOD Type-[**Last Name (un) **] pO2-83* pCO2-72* pH-6.96*
calTCO2-18* Base XS--17
.
Discharge Labs:
[**2103-11-30**] 06:30AM BLOOD WBC-13."
2655,"0* RBC-3.30* Hgb-9.8* Hct-28.0*
MCV-85 MCH-29.9 MCHC-35.2* RDW-15.0 Plt Ct-212
[**2103-11-30**] 06:30AM BLOOD PT-11.9 PTT-26.9 INR(PT)-1.1
[**2103-11-30**] 06:30AM BLOOD Glucose-112* UreaN-121* Creat-2.6* Na-139
K-4.0 Cl-90* HCO3-36* AnGap-17
[**2103-11-30**] 06:30AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.9
.
CXR [**2103-11-23**]:
FINDINGS: Single AP upright portable view of the chest was
obtained. Diffuse alveolar opacities throughout the lungs,
right greater than left, which could represent asymmetric edema
and/or infection."
2656,"SICU
HPI:
HPI:59 year old male with posterior brainstem hemorrhage, blood in 4th
ventricle and developing hydrocephalus
[**9-1**]-failed speech and swallow for second time
[**9-3**]-s/p PEG, has esophageal candidiasis
[**9-4**]-contrast KUB showed no evid of extrav, cont abd pain
[**9-5**]-no events
[**9-6**]- consented for PEG, NPO after midnight for PEG. Tube feeds
restarted until midnight
[**9-7**]-slight abdominal pain overnight, responded to pain
PMH:HTN, prostate ca
[**9-8**]- wean to PS, perc trach'ed, sedated after trach, trach collar
tolerated o/n
Chief complaint:
Brainstem stroke
PMHx:
prostate ca
Current medications:
1."
2657,"2. 3. Acetaminophen 4. Bisacodyl 5. Chlorhexidine Gluconate 0.12%
Oral Rinse 6. Docusate Sodium (Liquid)
7. Fentanyl Citrate 8. Fluconazole 9. Heparin 10. HydrALAzine 11.
Insulin 12. Labetalol 13. Lactulose
14. Metoprolol Tartrate 15. Nystatin Oral Suspension 16. Potassium
Chloride 17. Senna 18. Sodium Chloride 0.9% Flush
19. Sodium Chloride 0.9% Flush
24 Hour Events:
OPEN TRACHEOSTOMY - At [**2122-9-8**] 12:28 PM
Post operative day:
POD#6 - returned s/p PEG. Reversed but taking small tidal volumes so
arrived intubated with plan to extubate when awake
Allergies:
Iodine
Unknown;
Last dose of Antibiotics:
Fluconazole - [**2122-9-8**] 06:40 PM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2122-9-9**] 08:00 AM
Hydralazine - [**2122-9-9**] 10:12 AM
Metoprolol - [**2122-9-9**] 10:12 AM
Other medications:
Flowsheet Data as of [**2122-9-9**] 11:35 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**25**] a."
2658,"2
4.7
4.7
5.7
10.6
8.8
7.1
6.9
6.1
Hct
36.2
35.8
35.3
31.1
34.9
34.1
33.7
33.1
27.7
Plt
[**Telephone/Fax (3) **]96
230
258
280
299
260
Creatinine
1.0
1.0
0.8
0.7
0.9
0.8
0.8
0.8
0.7
TCO2
35
Glucose
124
113
98
101
119
105
101
131
123
Other labs: ALT / AST:61/, Alk-Phos / T bili:30/0.8, Amylase /
Lipase:41/28, Lactic Acid:0.6 mmol/L, Albumin:3."
2659,"m.
Tmax: 37.4
C (99.3
T current: 37.4
C (99.3
HR: 90 (80 - 110) bpm
BP: 125/73(84) {112/59(74) - 142/90(99)} mmHg
RR: 12 (9 - 37) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 83.3 kg (admission): 89.8 kg
Height: 67 Inch
Total In:
2,610 mL
863 mL
PO:
Tube feeding:
1,174 mL
748 mL
IV Fluid:
1,286 mL
115 mL
Blood products:
Total out:
947 mL
398 mL
Urine:
947 mL
398 mL
NG:
Stool:
Drains:
Balance:
1,663 mL
465 mL
Respiratory support
O2 Delivery Device: Trach mask
Ventilator mode: CPAP/PSV
Vt (Set): 550 (550 - 550) mL
Vt (Spontaneous): 356 (356 - 558) mL
PS : 5 cmH2O
RR (Set): 14
RR (Spontaneous): 18
PEEP: 5 cmH2O
FiO2: 40%
PIP: 18 cmH2O
SPO2: 100%
ABG: ///31/
Ve: 5."
2660,"6 L/min
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-tender
Left Extremities: (Pulse - Dorsalis pedis: Present)
Right Extremities: (Pulse - Dorsalis pedis: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Neurologic exam stable
Labs / Radiology
260 K/uL
9.7 g/dL
123 mg/dL
0.7 mg/dL
31 mEq/L
3.3 mEq/L
21 mg/dL
105 mEq/L
141 mEq/L
27.7 %
6.1 K/uL
[image002.jpg]
[**2122-8-31**] 10:28 AM
[**2122-9-1**] 03:00 AM
[**2122-9-2**] 03:03 AM
[**2122-9-3**] 03:29 AM
[**2122-9-4**] 02:49 AM
[**2122-9-5**] 02:25 AM
[**2122-9-6**] 03:17 AM
[**2122-9-7**] 03:12 AM
[**2122-9-8**] 03:25 AM
[**2122-9-9**] 03:00 AM
WBC
4."
2661,"4 g/dL, LDH:161 IU/L,
Ca:8.6 mg/dL, Mg:2.2 mg/dL, PO4:2.9 mg/dL
Assessment and Plan
CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC
Assessment and Plan: 59 year old male with CVA
Neurologic: Neurologically stable
Cardiovascular: metoprolol, hydralazine
Pulmonary: Trach, s/p trach for airway protection from secretions,
doing well post op
Gastrointestinal / Abdomen: PEG
Nutrition: Tube feeding, @ goal
Renal: Foley
Hematology: Serial Hct, stable
Endocrine: RISS
Infectious Disease: On fuconazole for [**First Name4 (NamePattern1) 474**]
[**Last Name (NamePattern1) 604**] / Tubes / Drains: Foley, G-tube, Trach
Wounds: Dry dressings
Imaging:
Fluids:
Consults: Neurology
Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural), CVA,
(Respiratory distress: Failure)
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2122-9-8**] 02:00 PM 65 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2122-9-6**] 08:00 AM
18 Gauge - [**2122-9-6**] 08:00 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition: Transfer to floor
Total time spent: 20 minutes"
2662,"Admission Date: [**2122-8-24**] Discharge Date: [**2122-9-10**]
Date of Birth: [**2064-8-3**] Sex: M
Service: NEUROLOGY
Allergies:
Iodine
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Acute onset dizziness and bilateral leg weakness after sexual
intercourse, transferred for pontine hemorrhage
Major Surgical or Invasive Procedure:
Intubation/Extubation
PEG placement
Tracheostomy
History of Present Illness:
The patient is a 58 year old man with a history of uncontrolled
hypertension, HCV, and prostate cancer s/p resection in [**2114**] who
presents with a 2 week history of throbbing headaches and then 1
day PTA developed acute onset dizziness and bilateral leg
weakness after sexual intercourse and Viagra use, who was
transferred from an OSH with pontine hemorrhage and extension
into the fourth ventricle with resultant hydrocephalus."
2663,"He was
given Labetalol 10 mg IV x1, 20 mg IV x1, then started on
Labetalol gtt. Neurosurgery was consulted and indicated that
there is no neurosurgical indication at this time. He was
transferred to Neurology/SICU.
Past Medical History:
-Hypertension
-Chronic hepatitis C genotype 1, stage 0-I fibrosis
-? heart murmur vs. ""hole in heart"" per wife, takes [**Name (NI) **] [**Name (NI) 5**]
prior to dental procedures
-Prostate cancer s/p radical prostatectomy in [**3-31**]
-Laparoscopic pelvic lymphocele decortication [**5-31**]
Social History:
He lives at home with his wife and brother. [**Name (NI) **] formerly was an
underground cable splicer for an electric company, but now works
in electrical system design."
2664,"He quit smoking in [**1-6**], but prior
to that was smoking 1 pack every 3 days for the past 43 years.
He has not had a problem with alcohol abuse. He did use heroin
40 years ago, which his wife reports was how he aquired HCV. He
has had no recent cocaine or heroin use.
Family History:
His mother had hypertension, strokes, and a heart valve
replacement. His brother had sleep apnea.
Physical Exam:
Vitals: T:97.6 P:78 R:13 BP146/88: SaO2:100% RA
General: Intubated. Not sedated, but unresponsive as below.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated."
2665,"CXR ([**8-24**]): IMPRESSION:
Properly positioned lines and tubes with a minimal left basilar
atelectasis.
Prominent left upper mediastinal border of unclear etiology, but
probably related to thyroid enlargement or vascular ectasia.
CTA Head/Neck ([**8-26**]): IMPRESSION:
1. Stable appearance of pontine hemorrhage extending into the
fourth ventricle. No vascular abnormality or abnormal
enhancement is identified in the region of hemorrhage.
2. Stable appearance of hydrocephalus.
3. The carotid and vertebral arteries and their major branches
are patent without evidence of stenosis.
Brief Hospital Course:
1. Pontine Hemorrhage: The patient is a 58 year old man with a
history of uncontrolled hypertension, HCV, and prostate cancer
s/p resection in [**2114**] who presented with a 2 week history of
throbbing headaches and then 1 day prior to admission developed
acute onset dizziness and bilateral leg weakness after sexual
intercourse and Viagra use, who was transferred from an OSH with
pontine hemorrhage and extension into the fourth ventricle with
resultant hydrocephalus."
2666,"At that time he was having
increased secretions from his ET tube. A sputum culture grew
moderate Moraxella catarrhalis and sparse oropharyngeal flora.
He received 5 days of Unasyn.
5. Esophageal candidiasis: During PEG placement, gastroscope
showed considerable whitened mucosa and exudate in the
esophagus. He was started on Fluconazole to complete a [**10-13**] day
course.
6. FEN: Speech and swallow evaluated the patient after
extubation, and recommended that he remain NPO. An NG tube was
placed initially, and a PEG tube was placed [**2122-9-3**]. He had pain
at the PEG tube site after insertion, and KUB showed marked
gaseous distension of splenic flexure and stomach."
2667,"6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY:
Pontine hemorrhage
Sinusitis
Esophageal candidiasis
SECONDARY:
Hypertension
Discharge Condition:
Mr [**Last Name (Titles) **] exam was significant at discharge for:
Alert, oriented to time and person. Non-fluent aphasia, with
preserved comprehension. Follows commands.
CN: pinpoint pupils 1.5 mm to 1."
2668,"She is unclear what his blood pressure
normally runs, but his most recent PCP appointment in [**2122-4-22**]
his bp was 158/100.
At [**Hospital3 934**] Hospital, vitals on admission were temp 95.8,
bp 203/98, HR 88, RR 16, SaO2 100% on NRB. He was reported to
""move UE bilaterally proximally"" and ""nod head to answer some
questions"", but ""no spontaneous movement of LE."" He was given
Narcan 1 mg IV x1. He had SOB and was intubated with Etomidate
20 mL IV x1, Succinylcholine, and Versed 2.5 mg x4. He was also
given Vecuronium 10 mg IV x1."
2669,"0 mm R eye, 1.0 mm to trace LEFT
eye both to direct and consensual stimuli. bl VI cranial nerve
paresis, b/l face weakness, no palate elevation. RIGHT sided
weakness: Delt 3, tric 3, bicepd 3-, WE 3-, WF 3-, FE anf FF 3.
LEFT sided weakness 5/5 for all muscle groups. Inferior
extremity RIGHT weakness: [**2-3**] toe flexion and extension,
hamstring [**3-4**], quad 3-,IP 3/ 5. Left leg: [**5-4**] all groups.
Decreased pinprick sensation in left hemibody.
Followup Instructions:
You will need to follow up with Dr. [**First Name (STitle) **] in Neurology 10/ 06/
08 at 2:30 pm in the stroke clinic ([**Hospital Ward Name 23**] [**Location (un) 442**])."
2670,"This
history is obtained from the patient's wife and the medical
record. Over the past 2 weeks, he has complained of headaches
that are not constant and relieved by Excedrin. They have not
been associated with weakness, numbness, or visual changes. 2
days PTA, he was at a wedding and had a throbbing headache
around 6:30-7:00 pm, but this was relieved by Excedrin. On the
day of admission, he took a Viagra and had sexual intercourse
with his wife. This was not the first time he had used Viagra.
After having sex, they were lying down in bed and talking, and
he had no deficits."
2671,"Physical examination on
admission showed no response to verbal stimuli, pinpoint pupils
that are not reactive to light, fixed eyes on OCRs, does not
blink to threat. He withdrew his bilateral UE and LE to nailbed
pressure, but was weaker on the right than left. His reflexes
were 3+ and symmetric in biceps, brachioradialis, triceps, and
knees with nonfatiguable clonus in the bilateral ankles and
upgoing toes bilaterally. The most likely cause of his pontine
hemorrhage was uncontrolled hypertension. His neurological exam
continued to improve, and subsequent head CTs showed stable
appearance of the hemorrhage. CTA head showed no vascular
abnormality or abnormal enhancement in the region of hemorrhage,
the carotid and vertebral arteries and their major branches are
patent without evidence of stenosis."
2672,"Then he sat up on the side of the bed (at
approximately 11:30 pm), and suddenly felt dizzy, SOB, and had
the feeling that he could not move his legs. He told his wife to
call 911. His wife had to dress him because he was unable to use
his legs. His wife reported that he had slurred speech like his
""voice was thick"", and she wondered if he was having trouble
swallowing. He did not have a headache associated with this
episode. On the scene, EMS noted pinpoint pupils and gave Narcan
4 mg total without change.
His wife reports that he misses his anti-hypertensives more
often than he takes them."
2673,"A
gastrograffen study showed no leaking around the PEG. His pain
improved with Fentanyl prn, and he was tolerating tube feeds at
the time of discharge.
7. Full Code: Social work and Palliative care were consulted
during this admission, and family meetings were held on [**2122-8-28**]
and [**2122-9-2**]. His living will states he wishes no resuscitation,
artificial feeding, or hydration IF in a persistent vegatative
state or has a terminal illness. Currently neither of these are
true, so he remained full code. The family and patient agreed to
PEG and tracheostomy placement. PT was consulted during the
admission."
2674,"Left leg: [**5-4**] all groups.
Decreased pinprick sensation in left hemibody. The patient
should follow up with Dr. [**First Name (STitle) **] in Neurology as an outpatient.
2. Hypertension: He was intially on a Labetalol gtt to keep his
MAP <130 and SBP 120-150. His blood pressure medications on
discharge were [ ].
3. Respiratory: The patient was intubated at the OSH after
complaining of shortness of breath. He was extubated at [**Hospital1 18**] on
[**2122-8-28**]. He continued to have increased secretions requiring
frequent suctioning, so a tracheostomy was placed on [**2122-9-8**].
4. Sinusitis: Head CT on [**2122-8-24**] showed new air-fluid level seen
within the left maxillary sinus."
2675,"MRI head showed a pontine
hemorrhage. Neurological examination on discharge showed Mr
[**Name13 (STitle) **] exam was significant at discharge for:
Alert, oriented to time and person. Non-fluent aphasia, with
preserved comprehension. Follows commands.
CN: pinpoint pupils 1.5 mm to 1.0 mm R eye, 1.0 mm to trace LEFT
eye both to direct and consensual stimuli. bl VI cranial nerve
paresis, b/l face weakness, no palate elevation. RIGHT sided
weakness: Delt 3, tric 3, biceps 3-, WE 3-, WF 3-, FE anf FF 3.
LEFT sided weakness 5/5 for all muscle groups. Inferior
extremity RIGHT weakness: [**2-3**] toe flexion and extension,
hamstring [**3-4**], quad 3-,IP 3/ 5."
2676,"The
remaining cerebral matter is normal with appropriate maintenance
of the [**Doctor Last Name 352**]-white differentiation and no evidence of acute large
vascular territorial infarct. The globes are intact. Mild soft
tissue asymmetry is noted along the left cerebral hemisphere
likely related to patient positioning. Aerosolized secretions
are noted within the oral and nasopharynx in this intubated
patient. The paranasal sinuses and mastoid air cells are
otherwise unremarkable.
IMPRESSION: Moderate-sized pontine hemorrhage with extension
into the fourth ventricle resulting in mild hydrocephalus
involving the lateral ventricles and third ventricle which
appears progressed from outside imaging.
ECG ([**8-24**]): Sinus rhythm at a rate of 78, Prominent precordial
low QRS voltage - is nondiagnostic and is probably normal ECG"
2677,"No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RR, 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: Unresponsive to name or noxious. Doesn't follow
any commands. Eyes closed at all times.
-Cranial Nerves: Pupils midline, pinpoint, symmetrical and
unreactive. No corneal reflexes. No OCRs. Minimal but
definite response to nasal stimulus. Inconsistent response to
tug on the ETT. No obvious facial droop.
-Motor: No movement of any limbs to noxious stimuli."
2678,"He was given Labetolol 10 mg IV
x1, and Ativan 2 mg IV x2. Labs showed CKMB 2.0, Trop I 0.01, PT
13.9, INR 1.1, PTT 27.9, WBC 7.2, Hct 38.8, plt 197. CT Head
showed pontine hemorrhage with extension into the fourth
ventricle, nonspecific bilateral frontal and parietal lobe white
matter disease, which may represent chronic small vessel
ischemia. He was transferred to [**Hospital1 18**] At the [**Hospital1 18**] ED, he had a
CT head which showed moderate-sized pontine hemorrhage with
extension into the fourth ventricle resulting in mild
hydrocephalus involving the lateral ventricles and third
ventricle which appears progressed from outside imaging."
2679,"-Sensory: As above.
- Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Toes
C5 C7 C6 L4 S1 CST
Ltr tr tr tr 2 down
Rtr tr tr tr 2 down
Pertinent Results:
IMAGING:
CT Head ([**8-24**]): FINDINGS: There is a large brainstem hemorrhage
measuring approximately 16.5 x 22.5 mm centered within the left
dorsolateral aspect of the pons with extension into the fourth
ventricle, resulting in now worsening mild hydrocephalus with
dilatation of the occipital and temporal horns when compared to
outside imaging. The left occipital [**Doctor Last Name 534**] measures up to 14 mm.
Mild surrounding hyperattenuating changes noted around the
hemorrhage likely related to underlying brainstem edema."
2680,"On the day prior to admission after
Viagra use and sexual intercourse, he developed acute onset
dizziness, weakness in bilateral legs, and SOB. He was
transferred to an OSH where he was found to have a blood
pressure of 203/98 and pinpoint pupils, and was intubated given
his SOB. Head CT there showed pontine hemorrhage with extension
into the fourth ventricle. He was transferred to [**Hospital1 18**] where
neurosurgery determined there was no acute indication for
neurosurgery. Head CT showed pontine hemorrhage with extension
into the fourth ventricle resulting in mild hydrocephalus of the
lateral ventricles and third ventricles."
2681,"Medications on Admission:
Triamterene/HCTZ 37.5-25 mg daily
Lisinopril 10 mg daily
Viagra 100 mg prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day)."
2682,"8 mg/dL, Mg:2.2 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC
Assessment and Plan: 59 year male with brainstem stroke
Neurologic: stable
Cardiovascular: cont labetaol, hydralazine
Pulmonary: Trach today for secretion control
Gastrointestinal / Abdomen: Start bowel regiment
Nutrition: Tube feeding
Renal: Foley, Adequate UO
Hematology: Serial Hct
Endocrine: RISS
Infectious Disease: stable, afebvrile. on fluconazole
Lines / Tubes / Drains: Foley, G-tube
Wounds:
Imaging:
Fluids: KVO
Consults: Neurology
Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural), CVA
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2122-9-6**] 08:00 AM
18 Gauge - [**2122-9-6**] 08:00 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent: 28 minutes"
2683,"SICU
HPI:
HPI:59 year old male with posterior brainstem hemorrhage, blood in 4th
ventricle and developing hydrocephalus
[**9-1**]-failed speech and swallow for second time
[**9-3**]-s/p PEG, has esophageal candidiasis
[**9-4**]-contrast KUB showed no evid of extrav, cont abd pain
[**9-5**]-no events
[**9-6**]- consented for PEG, NPO after midnight for PEG. Tube feeds
restarted until midnight
[**9-7**]-slight abdominal pain overnight, responded to pain
Chief complaint:
Brainstem stroke
PMHx:
HTN, prostate ca
Current medications:
1. 2. Acetaminophen 3. Bisacodyl 4. Docusate Sodium (Liquid) 5.
Famotidine 6. Fentanyl Citrate
7."
2684,"3 g/dL
131 mg/dL
0.8 mg/dL
30 mEq/L
3.4 mEq/L
22 mg/dL
103 mEq/L
140 mEq/L
33.1 %
6.9 K/uL
[image002.jpg]
[**2122-8-31**] 03:17 AM
[**2122-8-31**] 10:28 AM
[**2122-9-1**] 03:00 AM
[**2122-9-2**] 03:03 AM
[**2122-9-3**] 03:29 AM
[**2122-9-4**] 02:49 AM
[**2122-9-5**] 02:25 AM
[**2122-9-6**] 03:17 AM
[**2122-9-7**] 03:12 AM
[**2122-9-8**] 03:25 AM
WBC
5.7
4.2
4."
2685,"7
4.7
5.7
10.6
8.8
7.1
6.9
Hct
37.7
36.2
35.8
35.3
31.1
34.9
34.1
33.7
33.1
Plt
[**Telephone/Fax (3) 500**]
258
280
299
Creatinine
1.0
1.0
1.0
0.8
0.7
0.9
0.8
0.8
0.8
TCO2
35
Glucose
138
124
113
98
101
119
105
101
131
Other labs: ALT / AST:61/, Alk-Phos / T bili:30/0.8, Amylase /
Lipase:41/28, Lactic Acid:0.6 mmol/L, Albumin:3.4 g/dL, LDH:161 IU/L,
Ca:8."
2686,"Fluconazole 8. Heparin 9. HydrALAzine 10. Insulin 11. Labetalol 12.
Metoprolol Tartrate 13. Metoprolol Tartrate
14. Nystatin Oral Suspension 15. Senna 16. Sodium Chloride 0.9% Flush
24 Hour Events:
[**9-7**]-slight abdominal pain overnight, responded to pain
Post operative day:
POD#5 - returned s/p PEG. Reversed but taking small tidal volumes so
arrived intubated with plan to extubate when awake
Allergies:
Iodine
Unknown;
Last dose of Antibiotics:
Fluconazole - [**2122-9-7**] 06:00 PM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2122-9-7**] 04:00 PM
Metoprolol - [**2122-9-7**] 04:00 PM
Hydralazine - [**2122-9-7**] 04:00 PM
Fentanyl - [**2122-9-7**] 11:50 PM
Other medications:
Flowsheet Data as of [**2122-9-8**] 10:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**25**] a."
2687,"m.
Tmax: 37.3
C (99.2
T current: 37.3
C (99.2
HR: 92 (82 - 116) bpm
BP: 129/74(86) {105/61(72) - 162/95(107)} mmHg
RR: 13 (12 - 21) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 82.6 kg (admission): 89.8 kg
Height: 67 Inch
Total In:
2,284 mL
564 mL
PO:
Tube feeding:
609 mL
524 mL
IV Fluid:
1,675 mL
40 mL
Blood products:
Total out:
1,545 mL
358 mL
Urine:
1,245 mL
358 mL
NG:
300 mL
Stool:
Drains:
Balance:
739 mL
206 mL
Respiratory support
O2 Delivery Device: Aerosol-cool
SPO2: 98%
ABG: ///30/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-tender
Left Extremities: (Pulse - Dorsalis pedis: Present)
Right Extremities: (Pulse - Dorsalis pedis: Present)
Neurologic: (Awake / Alert / Oriented: x 3), unchanged exam
Labs / Radiology
299 K/uL
11."
2688,"Lorazepam 14. Montelukast
Sodium 15. Omeprazole 16. Potassium Chloride
17. Simvastatin 18. Sodium Chloride 0.9% Flush 19. Theophylline SR
24 Hour Events:
lumbar puncture performed
IVIG started
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Lorazepam (Ativan) - [**2192-2-25**] 05:10 PM
Omeprazole (Prilosec) - [**2192-2-25**] 08:19 PM
Heparin Sodium (Prophylaxis) - [**2192-2-26**] 01:11 AM
Other medications:
Flowsheet Data as of [**2192-2-26**] 04:13 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**95**] a.m.
Tmax: 38.2
C (100.8
T current: 37.7
C (99."
2689,"4, CK / CK-MB / Troponin
T:63//<0.01, ALT / AST:33/27, Alk-Phos / T bili:82/1.7, Amylase /
Lipase:35/22, Differential-Neuts:84.0 %, Lymph:9.6 %, Mono:6.1 %,
Eos:0.2 %, Albumin:3.8 g/dL, LDH:252 IU/L, Ca:8.6 mg/dL, Mg:2.2 mg/dL,
PO4:2.7 mg/dL
Assessment and Plan
HYPERTENSION, BENIGN, WHEEZING, [**Last Name **] PROBLEM - ENTER DESCRIPTION IN
COMMENTS, ASTHMA
Assessment and Plan: 56yM with likely GBS being treated with IVIG
Neurologic: likely GBS, cont IVIG therapy. LP done
Cardiovascular: Simvastatin
Pulmonary: Vital capacity NIF Q4 hours, albuterol nebs prn, home
theophylline, Montelukast, follow ABGs
Gastrointestinal / Abdomen: NPO
Nutrition: NPO
Renal: NS c 40KCL @ 80cc/hr
Hematology: Hct stable
Endocrine: RISS
Infectious Disease: no antibiotics. Follow up cultures and CSF
analysis
Lines / Tubes / Drains:
Wounds:
Imaging:
Fluids: NS
Consults: Neurology
Billing Diagnosis: Other: proximal muscle weakness
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2192-2-24**] 08:46 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition:
Total time spent:"
2690,"SICU
HPI:
Mr [**Known lastname 3780**] is a 56 years old left handed man with significant past
medical history for asthma, hyperlipidemia presenting with acute
progressive weakness. Patient stated that he was in his USOH until the
morning of [**2192-2-23**] when he felt mild pain involving his left shoulder
mostly biceps area, followed by weakness in the upper extremities
proximally and bilaterally. Through the day he developed pain and
weakness in both thighs. The weakness progressed to the point that in
the evening he was not able to get up from a chair. In the morning of
[**2192-2-24**] he needed assistance to get out of his bed and to dress
himself."
2691,"9 g/dL
116 mg/dL
1.1 mg/dL
26 mEq/L
3.6 mEq/L
18 mg/dL
98 mEq/L
135 mEq/L
39.3 %
7.3 K/uL
[image002.jpg]
[**2192-2-24**] 09:51 PM
[**2192-2-25**] 04:04 AM
[**2192-2-25**] 04:30 AM
[**2192-2-26**] 02:25 AM
WBC
16.4
9.6
7.3
Hct
45.8
43.6
39.3
Plt
[**Telephone/Fax (3) 3794**]
Creatinine
1.3
1.1
Troponin T
<0.01
TCO2
28
Glucose
99
116
Other labs: PT / PTT / INR:15.5/32.9/1."
2692,"He went to see his PCP and around 8:30 in the morning he was
not able to walk. He was transfered to the OSH and no difficulties to
breath was noted, however upon arrival in the [**Hospital1 1**] ICU patient was
presenting mild effort to breath.
Chief complaint:
weakness
PMHx:
1. Asthma
2. Hyperlipidemia
Current medications:
1. 2. 40 mEq Potassium Chloride / 1000 mL NS 3. Acetaminophen 4.
Albuterol 0.083% Neb Soln 5. Allopurinol
6. Albuterol Inhaler 7. DiphenhydrAMINE 8. Fluticasone-Salmeterol
Diskus (100/50) 9. Heparin 10. Immune Globulin Intravenous (Human)
11. Influenza Virus Vaccine 12. Insulin 13."
2693,"8
HR: 110 (97 - 140) bpm
BP: 144/82(95) {126/74(90) - 161/99(112)} mmHg
RR: 23 (16 - 24) insp/min
SPO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Height: 68 Inch
Total In:
5,549 mL
736 mL
PO:
520 mL
400 mL
Tube feeding:
IV Fluid:
2,409 mL
160 mL
Blood products:
300 mL
176 mL
Total out:
3,325 mL
900 mL
Urine:
3,325 mL
900 mL
NG:
Stool:
Drains:
Balance:
2,224 mL
-164 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 97%
ABG: ///26/
NIF: -80 cmH2O
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities, proximal muslce weakness of upper and lower
extremities
Labs / Radiology
249 K/uL
13."
2694,"Admission Date: [**2192-2-24**] Discharge Date: [**2192-3-1**]
Date of Birth: [**2135-3-4**] Sex: M
Service: [**Year (4 digits) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
progressive weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 years old left handed man with significant past medical
history for asthma, hyperlipidemia presenting with acute
progressive weakness. Patient stated that he was in his USOH
until the morning of [**2192-2-23**] when he felt mild pain involving
his left shoulder mostly biceps area, followed by weakness in
the
upper extremities proximally and bilaterally."
2695,"Disp:*20 Tablet(s)* Refills:*0*
9. Outpatient Physical Therapy
Discharge Disposition:
Home with Service
Discharge Diagnosis:
[**First Name9 (NamePattern2) 7816**] [**Location (un) **] Syndrome
Discharge Condition:
stable. Remarkable improvement. patient left the hospital able
to walk.
Discharge Instructions:
You were admitted to this hospital because you had a rapidly
progressive weakness. You came to the neuro ICU concerning for
risk of respiratory failure. You were stable in the ICU and no
special intervention was necesssary.
Your clinical presentation, spinal fluid results and EMG point
to [**First Name9 (NamePattern2) 7816**] [**Location (un) **] Syndrome. You started to reveived IVIG in the
same night of your admission, and continue for 5 days total."
2696,"He also received prescription with 10 days taper of
prednisone.
Medications on Admission:
1. Advair 250/50 one inh [**Hospital1 **]
2. Theophylline 400mg TID
3. Prilosec 20mg po daily
4. Allopurinol 300mg po daily
5. Zocor 40mg po daily
6. Singulair 10mg po daily
7. por-air two inh qid prn
Discharge Medications:
1. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: Two
(2) Tablet Sustained Release 12 hr PO TID (3 times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
2697,"01
[**2192-2-24**] 09:51PM ALBUMIN-3.8 CALCIUM-8.9 PHOSPHATE-3.1
MAGNESIUM-2.2 URIC ACID-5.5
[**2192-2-24**] 09:51PM TSH-1.9
[**2192-2-24**] 09:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2192-2-24**] 09:51PM WBC-16.4* RBC-5.24 HGB-16.9 HCT-45.8 MCV-88
MCH-32.3* MCHC-36.9* RDW-14.2
[**2192-2-24**] 09:51PM NEUTS-84.0* LYMPHS-9.6* MONOS-6.1 EOS-0.2
BASOS-0.1
[**2192-2-24**] 09:51PM PLT COUNT-312
[**2192-2-24**] 09:51PM PT-15."
2698,"This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2192-2-28**]): NO GROWTH.
[**2192-2-24**] 11:22PM HIV Ab-NEGATIVE
[**2192-2-24**] 09:51PM GLUCOSE-99 UREA N-17 CREAT-1.3* SODIUM-133
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
[**2192-2-24**] 09:51PM estGFR-Using this
[**2192-2-24**] 09:51PM ALT(SGPT)-33 AST(SGOT)-27 LD(LDH)-252*
CK(CPK)-63 ALK PHOS-82 AMYLASE-35 TOT BILI-1.7*
[**2192-2-24**] 09:51PM LIPASE-22
[**2192-2-24**] 09:51PM CK-MB-NotDone cTropnT-<0."
2699,"Through the day he
developed pain and weakness in both thighs. The weakness
progressed to the point that in the evening he was not able to
get up from a chair. In the morning of [**2192-2-24**] he neede
assistance to get out of his bed and to dress himself. He went
to
see his PCP and around 8:30 in the morning he was not able to
walk. He was transfered to the OSH and no difficulties to breath
was noted, however upon arrival in the [**Hospital1 18**] ICU patient was
presenting mild effort to breath.
Patient denied double vision, difficult to swallow, sensory
changes, changes in bladder or [**Last Name (un) 12376**] movements."
2700,"Motor: normal bulk and tone; no tremor, rigidity, or
bradykinesia. No pronator drift.
Strength: Right upper limb: b/l infraspinatus weakness. Neck
flexion more than neck extension weakness
Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Grip:C8/ T1
Left 4 4 4 5- 5- 5-
Right 4 4 4 5- 5- 5-
IP:L2 Quad:L3 Hamst:L4-S1 Dorsiflex:L4 [**Last Name (un) 938**]:L5 Pl.flex:S1-S2
Left 2 2 2 3 4- 4-
Right 2 2 2 3 4- 4-
Deep tendon Reflexes: No clonus
Reflex: 1+ bilaterally in biceps, triceps, brachioradialis,
0 patella, 0 ankle."
2701,"You
had a remarkable recovery from your symptoms. However you are
having persistent pain in diferent ares of your body, and this
is common in [**First Name9 (NamePattern2) 7816**] [**Location (un) **]. To control the pain you will need
to take Neurontin and the dose will be adjusted as needed.
You will need to continue receiving physical therapy as
outpatient.
You received steroids for asthma and will have prescription for
taper off prednisone: 15mg (1tablet+[**1-27**])for 5 days, then 10mg
(1tablet) for 5days,then 5mg ([**1-27**] tablet) for 5 days and then
zero
Dr [**Last Name (STitle) 67626**] was contact[**Name (NI) **] and he is aware of your condition.
Please contact your PCP or return to the emergency Department if
you have weakness, dificulties to walk, numbness, dificulties to
swallow or to breath, or other concerning symptoms.
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2192-4-17**] 4:00
Provider: [**Name10 (NameIs) **] UNIT CC8 (SB) [**Telephone/Fax (1) 44**] Follow-up
appointment should be in 2 months
Provider: [**Name10 (NameIs) **] [**First Name4 (NamePattern1) 16284**] [**Last Name (NamePattern1) 67626**] [**Numeric Identifier 81149**] [**2192-3-5**] at 03:00PM"
2702,"Babinski was down doing bilaterally.
Coord: rapid alternating and point-to-point (FNF, HTS, TTF)
movements intact
[**Last Name (un) **]: Intcat pinprick, vibration, temperature, light touch and
joint position intact.
Gait: not possible to test.
Pertinent Results:
EKG [**2192-2-24**]
Sinus tachycardia. Atrial ectopy. No previous tracing available
for comparison.
CHEST XR [**2-24**]
FINDINGS: The lung volumes are normal. There is no evidence of
pleural
effusion or pneumothorax. The size of the cardiac silhouette is
at the upper range of normal, there are no signs indicative of
overhydration. Moderate tortuosity of the thoracic aorta. The
hilar and mediastinal contours are unremarkable."
2703,"CVS: regular rhythm
ABD: soft, NT, ND, +BS
EXT: no c/c/e, distal pulses strong, no rash
Neurological exam:
MS: Alert. Oriented to person, place, date and situation.
Attention: was adequade. Speech: fluent w/o paraphasic errors;
repetition and naming. L/R confusion: No L/R confusion.
CN: I: not tested
II,III: pupils 5 to 3 mm direct and consensual responses. Intact
visual field to confrontation test
III,IV,VI: EOMI w/o nystagmus, no ptosis, no fatigability
V: sensation intact to LT/PP
VII: face symmetric weakness bilaterally in the cheeks
VII: hears finger rub bilaterally
IX,X: voice normal, palate elevates symmetrically
[**Doctor First Name 81**]: SCM/trapezii 5-/5
XII: tongue protrudes midline, no atrophy or fasciculation"
2704,"There is no
abnormal parenchymal density, notably no indication for the
presence of atelectasis or pneumon
EMG [**2192-2-27**]
IMPRESSION:
Abnormal study. There is electrophysiologic evidence for
moderate median
neuropathies at both wrists and for a mild, chronic L5
radiculopathy on the left. The impersistent upper extremity F
waves would be consistent with early Guillian-[**Location (un) **] syndrome;
however, there was no other evidence for this entity. This may
be due to the fact that the study was performed only 4 days into
the course; if concern remains for a demyelinating
polyneuropathy (as in Guillian-[**Location (un) **] Syndrome), this test could
be repeated in [**1-27**] weeks as it may be normal in very early
cases."
2705,"Admission Date: [**2183-10-27**] Discharge Date: [**2183-10-30**]
Date of Birth: [**2105-1-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lipitor
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
CC:[**CC Contact Info 19166**]
Major Surgical or Invasive Procedure:
Right pleurex catheter placement.
History of Present Illness:
78-year-old man with h/o recent relapse of pre-B cell ALL with
chemotherapy currently on hold for newly diagnosed metastatic
epitheloid rhabdomyosarcoma with diffuse mets including
extensive pulmonary involvement and bilateral malignant
effusions; s/p palliative XRT to para-aortic and psoas masses.
Pt was recently admitted [**10-20**] for palliative cycle #1 of
vincristine and cyclophosphamide for the sarcoma."
2706,"Otherwise, denies fevers, h/a's, blurry vision,
CP/palpitations, diarrhea. Endorses abd pain x3 mos, decreased
appetite, and inability to take good PO's.
Past Medical History:
ONCOLOGIC HISTORY:
# Metastatic epitheloid rhabdomyosarcoma: Diagnosed [**8-/2183**], s/p
XRT to retroperitoneal mass and psoas muscle. PET-CT on
[**2183-8-30**], which showed FDG avidity in the periaortic mass as
well as lesions in the left psoas muscle, a left peritoneal
implant, a 4-mm left upper lobe pulmonary nodule, and osseous
lesions in the left iliac bone, right and left proximal femurs,
and S1 vertebra. MRI of the L-spine on [**2183-8-25**] also showed a
lesion in L3."
2707,"Biopsy of the psoas muscle nodule [**2183-9-2**] was
consistent with epithelioid rhabdomyosarcoma
[**9-/2183**]: admitted for palliative chemoTx and found to have
malignant bilateral pleural effusions
# ALL:
- diagnosed with Ph-negative pre-B-cell ALL in [**2178**].
- treated on the [**Doctor Last Name **] protocol and completed maintenance
therapy in 10/[**2180**]. Had also received intrathecal Methotrexate.
Chemo course was complicated by bladder obstruction related to
MTX and two hospitalizations for PNA.
- in [**9-/2182**], had evidence of relapse and was admitted for
reinduction. Treated again per the [**Doctor Last Name **] protocol with
treatment being held during the prolonged maintenence phase when"
2708,"he was discovered to have an abdominal mass consistent with a
metastatic soft tissue sarcoma.
- his leukemia therapy has been held and he is currently under
the care of Dr. [**Last Name (STitle) 1852**] for sarcoma.
OTHER MEDICAL HISTORY:
CAD s/p cath in [**2170**], preserved EF 55% with low normal systolic
function
Hyperlipidemia
Squamous cell skin cancer s/p multiple excisions
Hyperplastic colon polyp, [**2176**]
Social History:
Never smoked. Used to drink 0-2 drinks per night but none
currently. No drug use. Retired, used to sell bonds. Married,
has five adult children and 16 grandchildren. Lives with his
wife."
2709,"7
[**2183-10-27**] 01:15PM BLOOD Lipase-14
[**2183-10-27**] 01:15PM BLOOD cTropnT-<0.01
[**2183-10-27**] 01:15PM BLOOD Albumin-2.8* Calcium-8.6 Phos-4.2 Mg-2.2
[**2183-10-28**] 03:24AM BLOOD Cortsol-26.6*
[**2183-10-27**] 01:22PM BLOOD Lactate-5.6*
Brief Hospital Course:
In summary this is a 78-year-old man with h/o pre-B cell ALL
with (chemo on hold), newly diagnosed widely metastatic
epitheloid rhabdomyosarcoma with mets to liver, pulmonary,
adrenal, psoas, and peritoneal mets with bilateral pleural
effusions who presents with hypoxia and hypotension."
2710,"1. Hypotension/tachycardia: Felt to be secondary to volume
depletion and hemodynamic compromise from his disease
progression. He remained tachycardic even after fluid boluses.
As he was never febrile, he was not treated with antibiotics.
Blood cultures were drawn and these were negative. Chest x-ray
showed extensive involvement of tumor and bilateral pleural
effusions, but no clear infiltrate to suggest pneumonia. A
cortisol level was 26.6.
2. Hypoxia: He was discharged last admission with ongoing need
for nasal cannula, with 5L prescribed, but not clear if he was
using it. He has an impressive CXR with extensive pulmonary
metastatic disease with ""innumerable"" pulmonary nodules, and
recently had 1."
2711,"2L drained from each side. DDx included worsening
of metastatic disease vs re-accumulation of pleural effusions
which appeared possible by CXR vs PNA vs PE given pt not
currently on anticoagulation. CTA was not pursued because
patient would not have been a candidate for anticoagulation due
to sanguinous pleural effusions. Patient underwent Pleurex
catheter placement on the first hospital day and 1500 cc's was
drained; 4 hours later an additional 500 cc's was drained.
Unfortunately even after this fluid was removed he remained
hypoxic to the mid to high 80s on non-rebreather. A family
meeting was held and it was decided not to escalate care."
2712,"Patient's code status was changed to DNR/DNI. The Pleurex
catheter was left in place. His air hunger was treated with
morphine and ativan which his blood pressure tolerated, as well
as continued drainage of his pleural effusion via his pleurex
catheter. He expired in no distress with his family at his
bedside on his 5th hospital day.
3. Splenic and portal vein thrombosis: Anticoagulation with
Lovenox was deferred due to thrombocytopenia.
4. Widely metastatic epitheloid rhabdomyosarcoma: S/p 1st cycle
([**10-20**] = day 1) of vincristine and cyclophosphamide. The patient
was treated with supportive measures. As above, goals of care
were addressed during this admission and the plan was not to
escalate care."
2713,"5. Pancytopenia: Felt due to chemotherapy, given counts have
dropped since pt started chemo on [**10-20**]. Counts were followed as
an inpatient.
Medications on Admission:
ACYCLOVIR - 400 mg [**Hospital1 **]
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily
OXYCONTIN - 10 mg / 20 mg every am / pm
OXYCODONE - 5 mg Tablet - [**11-23**] Tablet(s) by mouth every four (4)
hours as needed for pain
Medications - OTC
DOCUSATE SODIUM - (Prescribed by Other Provider; OTC) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day as needed for
constipation
SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 8.6 mg
Tablet(s) by mouth one tab twice daily when taking oxycodone
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic sarcoma
hypotension
hypoxemia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired"
2714,"9* RBC-3.34* Hgb-11.0* Hct-30.9*
MCV-93 MCH-33.0* MCHC-35.7* RDW-14.1 Plt Ct-48*
[**2183-10-27**] 05:57PM BLOOD Neuts-43* Bands-0 Lymphs-33 Monos-13*
Eos-9* Baso-1 Atyps-1* Metas-0 Myelos-0
[**2183-10-27**] 05:57PM BLOOD PT-14.0* PTT-27.4 INR(PT)-1.2*
[**2183-10-27**] 01:15PM BLOOD Glucose-124* UreaN-29* Creat-0.8 Na-134
K-4.9 Cl-99 HCO3-23 AnGap-17
[**2183-10-27**] 01:15PM BLOOD ALT-15 AST-29 AlkPhos-69 TotBili-0."
2715,"ChemoTx was
tolerated well but pt had increased dyspnea that admission with
restaging CT showing marked progression of his sarcoma with
liver, pulmonary, adrenal, psoas, and peritoneal mets with
bilateral pleural effusions. He was diuresed and had IP drainage
with 1.2L removed from each side, both positive for malignant
cells. He had subjective improvement in SOB but continued need
for NC, unclear amt. Also that admission, CT showed splenic and
portal vein thrombosis and he was started on Lovenox but was
actually held at the time of discharge due to thrombocytopenia.
He was discharged to rehab last Friday and reports not feeling
much better over the weekend."
2716,"Wife and 2 sons at bedside.
Mouth is extremely dry appearing but no thrush noted
No JVD noted
Lungs fairly CTAB without gross w/c/r/r, but with only fair to
poor air movement
RRR with no m/g appreciated, bilateral radial pulses not well
palpated.
Diffuse TTP of abdomen periumbilical, but is soft, ND, BS+
No BLE edema noted, BUE's with eccymoses, and PIV in L arm
CN 2-12 grossly intact, no focal deficits noted, mental status
is conversant and grossly without deficit
Pertinent Results:
Labs at Admission:
[**2183-10-27**] 05:57PM BLOOD WBC-0."
2717,"Family History:
Brother had CAD and lung disease. Another brother who is
healthy. The patient's mother died at [**Age over 90 **] years. The patient's
father died at 60 years of complications of alcohol abuse. He
has five children and 16 grandchildren without health concerns.
A maternal uncle died of an MI at 54 years.
Physical Exam:
96 p105 92% on NRB 100/66 (67) sbp 91-106 rr 24-27
Thin man laying in bed, doesn't appear uncomfortable, but only
able to speak half a sentence at a time, with NRB on. Is lucid
and pleasant, relates history well."
2718,"He then had a clinic appt with Dr.
[**Last Name (STitle) 1852**] today and noted to have low bp's to 80/40's and hypoxic
to 80% on [**Last Name (LF) **], [**First Name3 (LF) **] sent to the ED. Initial vitals in the ED were:
98.2 105 87/42 28 94% on 12L NRB. He received 2L of NS
and was given Vancomycin and Cefepime.
Vitals before transfer: hr 97, Blood pressure 111/59, satting
93% with face mask. RR in the 30s.
ROS on arrival with decreased energy, orthostatic changes in his
blood pressures, and ""decreased oxygen levels"" since XRT which
ended 2 wks ago."
2719,"Admission Date: [**2133-3-3**] Discharge Date: [**2133-3-12**]
Date of Birth: [**2089-4-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted for weight reduction surgery.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Bypass
History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight of 290.1 lbs as
of [**2132-10-15**] (her initial screen weight on [**2132-10-6**] was 286.9
lbs),
height of 64.5 inches and BMI of 49. Her previous weight loss
efforts have included 2 months of the [**Doctor Last Name 1729**] diet in [**2127**] and
[**2129**] losing 20 lbs, 4 months of prescription weight loss
medication Phentermine in [**2122**]-[**2123**] losing 47 lbs that she
regained after stopping medication in one year and 3 months of
Pondimin (Fenfluramine) in [**2112**] losing 20 lbs."
2720,"Past Medical History:
dyslipidemia, urinary stressincontinence, migraine headaches,
GERD, gallbladder disease and b/l knee and low back pain
Social History:
She denied tobacco and recreational drug usage, has one bottle
of wine cooler twice a month and drinks 5-7 cups of coffee a
day. She works as a manager for
[**Company 33655**] insurance company. She is married living with her
husband age 43 and they have 3 children ages 12, 17 and 20 years
old.
Family History:
Her family history is
noted for both parents living father age 74 with obesity; mother
in her 70s with cancer; aunt living in her 70s with diabetes and
grandmother deceased with diabetes."
2721,"Brief Hospital Course:
Patient admitted and underwent a laparoscopic gastric bypass on
[**2133-3-3**]. Postoperatively patient developed tachycardia and
intermittent drops in oxygen saturation. On postoperative day
one she underwent an upper gi study that confirmed no leak or
obstruction. A chest x-ray showed lung volumes relatively low,
a heart that is moderately enlarged, but no signs of
overhydration was seen and
Moderate retrocardiac atelectasis, but no evidence of pneumonia,
no pneumothorax. Patient was then given CT scan of chest. This
confirmed a Massive PE, including a saddle embolus, occluding
right main pulmonary artery and multiple lobar, segmental and
subsegmental right sided emboli."
2722,"Discharge Diagnosis:
Primary Diagnosis: Obesity
Discharge Condition:
Stable
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum."
2723,"Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern."
2724,"Medications on Admission:
Midol PRN cramps; Tylenol ES, Aleve and Advil for knee and back
pain PRN; daily MV with minerals and Vitamin D 1000 U QD
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
Disp:*500 ml* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*500 ml* Refills:*0*
3. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day.
Disp:*600 ml* Refills:*0*
Discharge Disposition:
Home"
2725,"Patient was immediately started
on a heparin gtt and transfered to the intensive care unit for
close monitoring.
On postoperative day 3 patient had an ultrasound of her lower
extremities to rule out clot. This exam showed Compressible but
echogenic left greater saphenous and common femoral veins with
possible slight decrease of variability in the common femoral
veins (compared with the right) is compatible with a more
proximal
partially-occlusive thrombus.
Vascular service consulted. Recommends that INR be maintained
between 2.5 - 3. Coumadin to be continued for 6 months.
On Postoperative day 7 her heparin gtt was discontinued as her
INR was 3."
2726,"5.
On postoperative day 9 her INR was 3.6.
We will discharge her home on coumadin 2.5mg daily with follow
up management by her primary care provider. [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 60008**]. I have spoken with Dr. [**Last Name (STitle) **] regarding [**Hospital 228**]
hospital course and follow up needs. Dr. [**Last Name (STitle) **] has agreed to
see [**Known firstname **] on Friday [**3-13**] and manage her coumadin regimen.
[**Known firstname **] has been given information regarding coumadin and it's
side effects. She will follow up with Dr. [**Last Name (STitle) **] in 2 weeks."
2727,"6 Na-136
K-3.5 Cl-101 HCO3-25 AnGap-14
[**2133-3-5**] 01:42AM BLOOD Type-ART pO2-45* pCO2-34* pH-7.47*
calTCO2-25 Base XS-1 Intubat-NOT INTUBA Comment-COLLECTION
[**2133-3-5**] 01:42AM BLOOD freeCa-1.10*
[**2133-3-5**] CTA of Chest
Massive PE, including a saddle embolus, occluding right main
pulmonary artery
and multiple lobar, segmental and subsegmental right sided
emboli. Evidence
of right ventricular strain; right main pulmonary artery is
progressively
dilated on delayed scan.
[**2133-3-6**] Lower extremity Ultrasound
Compressible but echogenic left greater saphenous and common
femoral veins
with possible slight decrease of variability in the common
femoral veins
(compared with the right) is compatible with a more proximal
partially-occlusive thrombus."
2728,"5. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**9-17**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2133-3-18**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2133-3-18**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2133-4-24**] 9:00
Completed by:[**2133-3-12**]"
2729,"The
abdomen was obese but soft and non-tender, non-distended with
normal bowel sounds, no masses, healed trocar scars, no hernias.
There was no spinal tenderness or flank pain. Lower extremities
were without edema, venous insufficiency or clubbing. There was
no joint swelling or joint inflammation. There were no focal
neurological deficits.
Pertinent Results:
[**2133-3-5**] 10:21PM BLOOD PTT-38.4*
[**2133-3-6**] 04:10AM BLOOD WBC-13.8*# RBC-3.83* Hgb-11.8* Hct-32.8*
MCV-86 MCH-30.7 MCHC-35.8* RDW-13.9 Plt Ct-224
[**2133-3-6**] 04:10AM BLOOD Glucose-108* UreaN-7 Creat-0."
2730,"Physical Exam:
Her blood pressure was 134/90, pulse 98 and O2 saturation 98%
room air. On physical examination [**Known firstname **] was casually dressed,
slightly anxious but in no distress. Skin was warm, moist, no
rashes. Sclerae were anicteric, conjunctiva clear, pupils were
equal round and reactive to light, fundi were normal, mucous
membranes were moist, tongue pink and the oropharynx was without
exudates or hyperemia. Trachea was in the midline and the neck
was supple without adenopathy, thyromegaly or carotid bruits.
Chest was symmetric and the lungs were clear to auscultation
bilaterally with good air movement. Cardiac exam was regular
rate
and rhythm, normal S1 and S2, no murmurs, rubs or gallops."
2731,"2 mg/dL,
PO4:2.9 mg/dL
Assessment and Plan
.H/O OBSTRUCTIVE SLEEP APNEA (OSA), PULMONARY EMBOLISM (PE), ACUTE
Assessment and Plan: 43 yo F with PE 3 days s/p gastric bypass
Neurologic: Dilaudid PCA for pain - controlled;
Cardiovascular: stable, no issues.
Pulmonary: nasal canula O2 weened. Uses CPAP and O2 while sleeping.
Titrate hep gtt for PTT 60-80. Vasc surgery says no indication for
embolectomy or IVC filter now.
Gastrointestinal / Abdomen: Stage 3 diet
Nutrition: Stage 3 diet
Renal: Good urine output. Cr stable
Hematology: Continue heparin drip goal PTT 60-80. Heme c/s with
heparin nomogram in OMR for heparin gtt adjustments. Coumadin held
until PTT therapeutic x24hrs.
Endocrine: RISS, RISS, glucose controlled
Infectious Disease: No sign of infection
Lines / Tubes / Drains: piv, JP
Wounds:
Imaging:
Fluids: KVO
Consults: Platinum surgery, Vascular, Heme
Billing Diagnosis: Other: PE
ICU Care
Nutrition:
Glycemic Control:
Lines:
22 Gauge - [**2133-3-7**] 08:04 PM
Prophylaxis:
DVT: (Systemic anticoagulation: Heparin drip)
Stress ulcer:
VAP bundle:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: Transfer to floor
Total time spent: 21 minutes"
2732,"Heme made nomogram
for heparin managagement. diet advanced to stage3
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Heparin Sodium - 3,000 units/hour
Other ICU medications:
Heparin Sodium - [**2133-3-7**] 10:00 AM
Famotidine (Pepcid) - [**2133-3-7**] 08:07 PM
Other medications:
Flowsheet Data as of [**2133-3-8**] 04:09 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**35**] a.m.
Tmax: 37.1
C (98.7
T current: 36.7
C (98.1
HR: 99 (97 - 122) bpm
BP: 121/68(81) {90/44(62) - 136/103(108)} mmHg
RR: 14 (12 - 26) insp/min
SPO2: 91%
Heart rhythm: SR (Sinus Rhythm)
Total In:
1,835 mL
359 mL
PO:
550 mL
200 mL
Tube feeding:
IV Fluid:
1,285 mL
159 mL
Blood products:
Total out:
1,650 mL
950 mL
Urine:
1,550 mL
950 mL
NG:
Stool:
Drains:
100 mL
Balance:
185 mL
-591 mL
Respiratory support
O2 Delivery Device: None
SPO2: 91%
ABG: ///25/
Physical Examination
General Appearance: No acute distress
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
311 K/uL
10."
2733,"TSICU
HPI:
Pt 2 days s/p gastric bypass with large saddle PE. Pt had increasing
shortness of breath yesterday and increased work of breathing since
yesterday evening. She also reports fatigue and mild cough - no
hemoptysis. Pt denies chest pain, palpitations, leg swelling, or
history of clots.
Chief complaint:
PE s/p gastric bypass
PMHx:
PMH: dyslipidemia, urinary stress incontinence, migraine headaches,
GERD, gallbladder disease and b/l knee and low back pain
PSH: Lap chole
Current medications:
24 Hour Events:
ULTRASOUND - At [**2133-3-6**] 09:00 AM
Bilateral Lower Extrems, ?embolism?
Post operative day:
[**3-8**] POD 5
24hr events: [**3-7**]: no surgical intervention by vasc."
2734,"0 g/dL
109 mg/dL
0.5 mg/dL
25 mEq/L
3.4 mEq/L
10 mg/dL
101 mEq/L
139 mEq/L
29.5 %
10.3 K/uL
[image002.jpg]
[**2133-3-6**] 04:10 AM
[**2133-3-7**] 05:25 AM
[**2133-3-8**] 12:19 AM
WBC
13.8
11.5
10.3
Hct
32.8
30.2
29.5
Plt
[**Telephone/Fax (3) 6775**]
Creatinine
0.6
0.5
0.5
Glucose
108
119
109
Other labs: PT / PTT / INR:16.3/69.7/1.5, Ca:8.1 mg/dL, Mg:2."
2735,"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:
ADD
PANCREATITIS, CHRONIC
ABDOMINAL PAIN, GENERALIZED
NAUSEA
INTESTINAL MALABSORPTION, POSTSURGICAL
OSTEOPOROSIS
TOBACCO USE
PSHx:
CCY with lateral pancreaticojejunostomy and
Roux-en-Y(complicated by bile duct leak, partial CBD stricture
acute pancreatitis, and hernia) [**2168**]
re-op for biliary drain and transhepatic biliary stent
incisional hernia repair (complicated by stent abscess) [**2168**].
Social History:
Patient moved from VT to [**Location (un) 86**] with his husband last year seek
out better medical care."
2736,"2 Phos-2.6* Mg-2.0
[**2176-12-17**] 04:55AM BLOOD %HbA1c-11.1* eAG-272*
[**2176-12-16**] 08:30PM BLOOD Triglyc-83 HDL-38 CHOL/HD-2.3 LDLcalc-33
Brief Hospital Course:
50M with chronic panceatitis and multiple pancreatic surgeries
including pancreaticojejunostomy c/b biliary leak and stricture
admitted with abdominal pain and DKA
#Diabetes complicated by diabetic ketoacidosis:
A1c of 11.1 suggests that patient has been hyperglycemic for
some time. The exact cause is unclear, but it is likely a
reflection of pancreatic destruction from pancreatitis as his
blood sugars were very sensitive to insulin during
hospitalization."
2737,"Extensive time
was spent teaching the patient how to accurately and
appropriately check his finger sticks and administer his insulin
and when to call doctors and of the warning signs of hyper and
hypoglycemia. Patient was discharged with plan to be in close
communication with his PCP and [**Name9 (PRE) **] re: insulin titration.
#Acute on chronic pancreatitis:
Patient's abdominal pain was felt to represent acute on chronic
pancreatitis. Pain improved over hospitalization and patient was
discharged on home pain regimen tolerating a diet. He was
continued on Creon.
# Occluded/Stenotic common iliac artery: Seen incidentally on CT
scan on admission."
2738,"There is no free fluid and no inguinal lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or
malignancy is seen.
IMPRESSION:
1. Pancreatic calcifications consistent with known chronic
pancreatitis. No evidence of pseudocyst or acute pancreatitis.
2. Diffuse small bowel wall thickening is nonspecific and may be
related to hypoperfusion, infection, or inflammation. No bowel
obstruction, free
intra-abdominal fluid or free air.
3. Occlusion of the right common iliac artery as described
above.
Studies:
LE Arterial Duplex:FINDINGS: The ABI on the right is 0.71 and on
the left is 0.69. Doppler
demonstrates monophasic waveforms diffusely and bilaterally."
2739,"Admission Date: [**2176-12-16**] Discharge Date: [**2176-12-19**]
Date of Birth: [**2126-2-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Ciprofloxacin
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50M with h/o recurrent pancreatitis and multiple pancreatic
surgeries here with abdominal pain radiating to back, consistent
with previous pancreatitis flares. Pain has been going on for 3
weeks, getting worse. Per patient, he has not eaten or stooled
for 3 weeks. He tried small sips yesterday. Report that he is
passing gas but had significant weight loss, weak, and unable to
ambulation."
2740,"The
volume
recordings demonstrate waveform widening and low amplitude
bilaterally,
symmetrically.
IMPRESSION: Findings consistent with CT of [**2176-12-16**].
Discharge/Notable Labs:
[**2176-12-19**] 08:00AM BLOOD WBC-6.3 RBC-3.81* Hgb-11.7* Hct-32.8*
MCV-86 MCH-30.8 MCHC-35.8* RDW-13.4 Plt Ct-282
[**2176-12-19**] 08:00AM BLOOD Glucose-248* UreaN-2* Creat-0.5 Na-132*
K-3.6 Cl-99 HCO3-27 AnGap-10
[**2176-12-16**] 08:30PM BLOOD ALT-19 AST-13 LD(LDH)-130 AlkPhos-135*
Amylase-62 TotBili-0.3
[**2176-12-17**] 12:34PM BLOOD Calcium-9."
2741,"Please be in close communication with your PCP and the [**Name9 (PRE) **]
center regarding your sugars so that your insulin dosing may be
adjusted as needed.
Please call your 911 if your blood sugars are continually
elevated above 500 or if you have low blood sugars with symptoms
that do not improve with sugar containing compounds such as
juice, soda, chocolate, or sweets.
Followup Instructions:
1) Please make an appointment to see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within
the next week
2) Please follow up the Vascular Surgery service as noted below:
Department: VASCULAR SURGERY
When: FRIDAY [**2177-1-3**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage"
2742,"Main portal vein, splenic vein and SMV are
patent.
The proximal aorta is of normal caliber with a significant
amount of
atherosclerotic calcifications. There is luminal narrowing of
the distal aorta with eccentric intraluminal thrombus. There is
minimal to no flow in the right common iliac artery. The right
common iliac artery at the bifurcation of the internal and
external iliac arteries is patent. The right external iliac
artery is attenuated. The left common iliac and external iliac
arteries are patent. The bilateral internal iliac arteries are
not well assessed due to extensive atherosclerotic
calcifications.
CT PELVIS: The rectum, sigmoid colon, bladder and prostate are
normal."
2743,"Discharge Exam:
GENERAL: [x] NAD [] Uncomfortable. Cachectic.
Eyes: [x] anicteric [] PERRL
ENT: [x] MMM [] Oropharynx clear [] Hard of hearing
NECK: [] No LAD [] JVP:
CVS: [x] RRR [x] nl s1 s2 [] no MRG [x] no edema
LUNGS: [x] No rales [x] No wheeze [x] comfortable
ABDOMEN: [x] Soft []nontender [x]bowel sounds present []No
hepatosplenomegaly. mild ttp epigastrum without guarding or
rebound. midline abd scar.
SKIN: [x]No rashes [x]warm []dry [] decubitus ulcers:
LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD
NEURO: [x] Oriented x3 [x] Fluent speech
Psych: [x] Alert [x] Calm [x] Mood/Affect: appropriate
.
Pertinent Results:
Admission Labs:
[**2176-12-16**] 02:00PM BLOOD WBC-14."
2744,"One Touch Test Strip Sig: as directed Miscellaneous as
directed.
Disp:*120 strips* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Acute on chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with high blood sugars and diabetic
ketoacidosis. You were treated in the Intensive Care Unit with
IV insulin and then given insulin on the medical floor. You were
also found to have a flare of your pancreatitis which improved
over the course of your hospitalization and you were able to
tolerate a regular diet prior to discharge."
2745,"He ran out of pain meds this week. Denies HA,
fevers/chills, N/V, chest pain, sob, cough.
.
In the ED inital vitals were, 99.4 106 122/94 20 100%. His labs
were notable for WBC of 14.3, ALT: 21 AP: 189 Tbili: 0.7 Alb:
4.2 AST: 18 Lip: 51 Ca: 8.9 Mg: 2.9 P: 5.9, Na: 121, Cl: 78, K
5.3, HCO3 18 BUN 27, Cr. 1.2, Gluc 707. He recieved dilaudid
x2, zofran, Insulin gtt with NS 2L. FSBS trended down to 335
then 301. He did not get an EKG."
2746,"Patient did endorse claudication. He was seen
by the Vascular Surgery service and will follow up in Vascular
Surgery outpatient clinic.
#Dispostion: Patient was discharged home to follow up with his
PCP, [**Name10 (NameIs) **], and Vascular Surgery
Medications on Admission:
OXYCONTIN 15 MG XR 1 tab po twice daily
OXYCODONE HCL TABS 15 MG po q3-4 hr prn
CREON [**Numeric Identifier 17514**] UNIT CPEP (PANCRELIPASE (LIP-PROT-AMYL)) [**1-26**] with
each main meal and [**11-25**] with snacks
Discharge Medications:
1. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Four (4)
units Subcutaneous once a day: Please take in the morning."
2747,"The patient is status
post cholecystectomy. The spleen and right adrenal gland are
normal. Mild thickening of the medial limb of the left adrenal
gland is similar to [**2175-1-30**]. The kidneys enhance symmetrically
and excrete contrast promptly without hydronephrosis.
Lack of intra-abdominal fat makes evaluation of the bowel
suboptimal. There is marked small bowel wall thickening to 9 mm
(2:42), which is nonspecific. There is no small bowel
obstruction. The large bowel are normal in course and caliber
without obstruction. There is no free fluid and no free air. No
pathologically enlarged mesenteric or retroperitoneal lymph
nodes are identified, although evaluation is limited by lack of
intra-abdominal fat."
2748,"2 Calcium-8.9 Phos-5.9*#
Mg-2.9*
[**2176-12-16**] 08:30PM BLOOD Triglyc-83 HDL-38 CHOL/HD-2.3 LDLcalc-33
[**2176-12-16**] 05:24PM BLOOD Type-ART pO2-68* pCO2-36 pH-7.37
calTCO2-22 Base XS--3
[**2176-12-16**] 06:05PM BLOOD Glucose-287* K-4.4
IMAGING:
[**12-16**] CXR:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Unchanged bilateral basal pleural scarring, more evident
on the right than on the left side of the thorax. No acute
pulmonary or cardiac changes, no pleural effusions."
2749,"Used to work in manufacturing, unable
to work recently. No EtOH since pancreatitis diagnosis in [**2167**];
prior to that was drinking [**2-28**] drinks/day for a few years and
had been drinking less heavily before that time. Smokes 1.5
packs cigarettes/day. No history IVDU, remote history of
marijuana.
Family History:
Paternal grandmother and uncle with diabetes, maternal family
history unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: bowel sounds absent, notable tenderness with guarding
on light touch, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
2750,"CT abd showed pancreatic
calcifications consistent with history of chronic pancreatitis,
no adjacent stranding or pseudocyst. Diffuse small bowel wall
thickening is nonspecific and may be related to infection or
inflammation. No free fluid. He was transferred to ICU for
further management. vitals prior to transfer: Vital Signs:
Pulse: 96, RR: 16, BP: 119/80, O2Sat: 100, O2Flow: rm air, Pain:
8.
.
On arrival to the ICU, he appears to be in good spirit.
.
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."
2751,"He was initially admitted to the ICU where he
was treated with an insulin gtt and then transitioned to
subcutaneous insulin. He was seen by [**Last Name (un) **] Diabetes team and he
was discharged on Lantus 4units QAM. Given the patients erratic
food intake including during flares of his pancreatitis,
combined with his history of poor medical followup, there was
concern that insulin may be associated with increased risk of
hypoglycemia in the patient. However, he had finger sticks of
300-400 consistently during hospitalization after he resumed a
regular diet so the decision was made to discharge the patient
on a regimen of low dose Lantus insulin alone."
2752,"You were seen by the [**Last Name (un) **] Diabetes service and were taught how
to give yourself insulin injections and check your blood sugars
using finger sticks.
You should take your Lantus insulin in the morning and check
your blood sugars before meals and before bedtime. Please lower
your insulin dose if you are not eating or if your blood sugars
are low. You should also keep juice, or non-diet soda,
chocolates or sweets with you to take in case your finger stick
readings are less than 70 or if you feel tremulous, start
sweating, notice vision changes, or feel as if you are going to
pass out."
2753,"Please call your doctor to adjust the dose if you have morning
finger stick sugars >200 or have readings <70 during the day.
Disp:*1 Pen* Refills:*2*
2. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*28 Tablet Extended Release 12 hr(s)* Refills:*0*
3. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. One Touch UltraSoft Lancets Misc Sig: as directed
Miscellaneous with meals and at bedtime.
Disp:*120 lancets* Refills:*2*
5."
2754,"3* RBC-5.61 Hgb-17.0 Hct-48.7
MCV-87 MCH-30.3 MCHC-34.9 RDW-13.0 Plt Ct-415
[**2176-12-16**] 02:00PM BLOOD Neuts-87.4* Lymphs-9.4* Monos-2.7 Eos-0
Baso-0.4
[**2176-12-16**] 02:27PM BLOOD PT-9.3* PTT-22.5* INR(PT)-0.9
[**2176-12-16**] 02:00PM BLOOD Glucose-707* UreaN-27* Creat-1.2 Na-121*
K-5.3* Cl-78* HCO3-18* AnGap-30*
[**2176-12-16**] 02:00PM BLOOD ALT-21 AST-18 AlkPhos-189* TotBili-0.7
[**2176-12-16**] 02:00PM BLOOD Lipase-51
[**2176-12-16**] 02:00PM BLOOD Albumin-4."
2755,"No
pneumothorax. No focal parenchymal opacities indicative of
pneumonia.
[**12-16**] CT abdomen/pelvis:
CT ABDOMEN: The visualized lung bases are clear. There is no
pleural or
pericardial effusion. Pleural thickening or atelectasis is seen
in the right lower lobe (2:7).
Patient is status post Puestow procedure with suture lines in
the jejunum, not well assessed on this study. Pancreatic
calcifications are consistent with known chronic pancreatitis.
There is no evidence of pseudocyst or acute pancreatitis. The
liver is normal without focal liver lesion identified.
Pneumobilia throughout the mildly dilated intrahepatic biliary
tree is re-demonstrated as seen on MRI."
2756,"Admission Date: [**2145-2-6**] Discharge Date: [**2145-2-11**]
Date of Birth: [**2059-7-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Black stools
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
This is an 85 year old male with h/o CAD, CVA, HTN, COPD, with
black/maroon stools x 6-7 days. He has had 2 black BMs today
with increased fatigue and some lightheadedness when moving from
a sitting to standing position. He first noticed these dark
bowel movements a few months ago, but they were intermittent and
would resolve on their own."
2757,"When he arrived at
[**Location (un) 620**], his INR was measured at 5.6, for which he was given Vit
K 10mg PO x 1 and 2 units FFP. Hct reportedly measured at 31.
Patient has been taking his [**Location (un) **], coumadin, and plavix at home
and still has his biliary drain in place from the placement in
[**Month (only) 404**]. He has gotten a few colonoscopies at [**Location (un) 620**] in the
past 10 years, but does not remember the results.
.
Of note, during a hospitalization back in [**2144-3-26**], endoscopic
CABG was performed d/t worsening exertional chest pain."
2758,"He is feeling well with
some mild epigastric tenderness.
Past Medical History:
- CAD s/p right coronary artery stent x2 ([**10-3**], [**3-4**]) and s/p
elective CABG on [**2144-4-21**] (LIMA-> LAD), c/b re-exploration
required for bleeding
- h/o stroke
- h/o acute cholecystitis s/p perc chole placement on [**2144-5-12**]
- Hypertension
- Hyperlipidemia
- Chronic obstructive pulmonary disease
- Asbestos exposure
- Chronic back pain
- Insomnia and obstructive sleep apnea (untreated)
Social History:
He lives with his wife. Defers all medical decisions to son who
is a chiropractor.
He is a retired postal worker.
Tobacco: 3 PPD x 30 years, quit 45 years ago
ETOH: None"
2759,"Normal mucosa in the duodenum. Otherwise normal EGD to third
part of the duodenum
Brief Hospital Course:
ICU course
85M with hx of CAD, CVA, PTC x2 for recurrent cholecystitis and
ERCP for suspected cholangitis, now presenting with GI bleed.
.
# GI bleed/acute blood loss anemia: Patient has had maroon/dark
stools and symptoms of orthostasis in setting of acute hemtocrit
drop. NG lavage was mildly positive + [**Last Name (LF) **], [**First Name3 (LF) **] likely a upper
GI source. Pt at risk due to [**First Name3 (LF) **], plavix and coumadin. INR was
supratheraputic at [**Location (un) 620**] and reversed with FFP and Vitamin K."
2760,"The patient received two units of packed red blood cells, and
his hematocrit responded appropriately. Over the course of the
next day, his hematocrit remained stable.
The patient was started on a PPI drip, but then changed to PPI
iv BID. The patient's triple anticoagulation of aspirin,
Coumadin, and Plavix was held, but metoprolol was
restarted once blood pressures were likely to remain stable. Pt
then underwent EGD on [**2145-2-10**] which revealed hiatal hernia,
antral gastritis, and ischemic damage to esophageal mucosa with
sloughing. GI thought that the latter represented a healing
process. He was then transitioned to po PPI and did fine
throughout his hospital stay without any further evidence of
bleeding."
2761,".
# Acute renal failure: Acute rise to 1.4 from a baseline of 0.9
to 1.0. With concomitant increase in BUN, likely
pre-renal/hypovolemia due to GI bleed. Given 2 units pRBCs. By
transfer from ICU, creatinine was 1.1, so no further work-up
pursued.
.
# Percutaneous biliary drain: placed [**2144-12-31**] with good drainage,
and patient is without pain. The patient had previously
considered a poor surgical candidate due to multiple
comorbidities. Liver function tests were within normal limits.
.
# History of CAD: No signs or symptoms of ACS upon this
admission. No evidence of demand ischemia, no EKG changes and
no chest discomfort."
2762,"Negative CE. Some mild epigastric pain,
but patient not troubled by it. Aspirin and Plavix were held
during the admission. We contact[**Name (NI) **] Dr. [**Last Name (STitle) 11302**], her PCP, [**Name10 (NameIs) 1023**]
agreed that we could stop his plavix (initial plan was to
continue until 3/[**2144**]). He was therefore discharged only on
aspirin with follow up with Dr. [**Last Name (STitle) 11302**].
.
# CVA hx: On lifelong coumadin [**1-27**] likely cardioembolic etiology
of CVA in past. Residual right-sided ""pins/needles"" sensation
and mild weakness with decreased functional ability. Held
coumadin for EGD, and reversed with FFP and vit K."
2763,"Neurology was
contact[**Name (NI) **] regarding need for lifelong coumadin, given that his
cardioembolic CVA was in the setting of off-pump CABG. It was
decided that he would not need coumadin, given the risk-benefit
profile, and he was thus discharged without coumadin. He will
follow-up with stroke neurologist Dr. [**Last Name (STitle) **] for further
management.
.
# COPD: Stable, no home O2 at baseline. Mild bibasilar rales,
without coughing or URI sx. No evidence of an acute
exacerbation on this admission. CXR if worsening oxygenation or
increased respiratory symptoms. He was continued on home [**Last Name (STitle) **]
and spiriva, with albuterol nebs PRN."
2764,"Pt noted, however, that he
has stopped taking [**Last Name (LF) **], [**First Name3 (LF) **] this medication was discontinued.
.
# Recurrent cholecystitis: Prior to hospitalization, there have
the discussions about elective cholecystectomy given pt
anticoagulation. We contact[**Name (NI) **] surgery during this admission for
possible cholecystectomy given that pt is off of
anticoagulation. Given signs of ischemic injury (though
resolving) in esophagus, surgery chose to defer surgery for now.
He will have outpt follow up with Dr. [**First Name (STitle) 2819**].
Medications on Admission:
-fluticasone-salmeterol 250-50 mcg/dose [**Hospital1 **]
-tiotropium bromide 18 mcg Capsule, DAILY
-albuterol sulfate 2.5 mg /3 mL (0."
2765,"C.) PO Q24H (every 24 hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. aspirin 81 mg po daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area [**Location (un) 269**]
Discharge Diagnosis:
Primary: Gastritis
.
Secondary:
chronic obstructive pulmonary disease
history of stroke
coronary artery disease
hypertension
Hyperlipidemia
Discharge Condition:
Mental status - alert and appropriate
Ambulatory status - ambulatory
Overall - good
Discharge Instructions:
You have been admitted with a bleed from your stomach worsened
by the fact that you are on multiple blood thinning agents. We
have evaluated your stomach and found the source, which does not
appear to be serious."
2766,"They start to increased in
frequency of the past 6-7 days, but did not result in any
increased stool output and he describes them currently as
intermittent. He denies any recent use of NSAIDs and has been
taking his Coumadin normally, without changing any doses. He
denies any hematemesis, BRBPR, chest tightness/discomfort during
these episodes. He does acknowledge coughing up pink-tinged
sputum from time to time, but this has not worsened recently.
Over the past year, since his CVA, he has complained of chronic
pins/needles over his right side, which seem to have worsened
slightly during the last week or so."
2767,"[**2145-2-7**] 04:30AM BLOOD ALT-16 AST-19 LD(LDH)-151 AlkPhos-62
TotBili-0.6
[**2145-2-6**] 10:00PM BLOOD CK(CPK)-36*
[**2145-2-6**] 05:58AM BLOOD ALT-17 AST-19 LD(LDH)-149 AlkPhos-62
TotBili-1.2
[**2145-2-6**] 12:23AM BLOOD ALT-18 AST-23 LD(LDH)-143 CK(CPK)-39*
AlkPhos-69 TotBili-0.3
.
[**2145-2-6**] 12:23AM BLOOD Neuts-64.5 Lymphs-23.0 Monos-7.5 Eos-4.8*
Baso-0.3
.
[**2145-2-7**] 04:30AM BLOOD PT-19.4* PTT-27.8 INR(PT)-1."
2768,"Cn II-XII intact. 4/5 strength of right arm and
leg, [**4-29**] on left. Mild sensory deficits to light touch on right
side. Hyporeflexic DTR's - patellar and biceps
Pertinent Results:
[**2145-2-7**] 04:30AM BLOOD Hct-31.5*
[**2145-2-6**] 10:00PM BLOOD Hct-30.9*
[**2145-2-6**] 01:20PM BLOOD Hct-29.6*
[**2145-2-6**] 05:58AM BLOOD Hct-29.5*
[**2145-2-6**] 12:23AM BLOOD WBC-6.2 RBC-2.41* Hgb-8.0* Hct-23.8*
MCV-99* MCH-33.1* MCHC-33.4 RDW-14.1 Plt Ct-388
."
2769,"Family History:
Non-contributory.
Physical Exam:
Admission exam
VS: T 97.5, BP 133/63, HR 70, RR 16, O2 98% on 2L NC
GEN: pleasant, comfortable, NAD, AAOx3
HEENT: PERRL, EOMI, anicteric, MMM, OP without lesions or
bleeding, no supraclavicular or cervical lymphadenopathy, no
JVD, no carotid bruits, no thyromegaly or thyroid nodules
RESP: bibasilar rales, R>L, with otherwise good air exchange B/L
CV: RR, soft S1 and S2, no m/r/g appreciated
ABD: NABS, soft, ND, mild tenderness in to right of umbilicus,
no tenderness over PTC drain, with dressings C/D/I and draining
well, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3."
2770,"083 %) neb q6h prn
-Plavix 75 mg once a day
-metoprolol tartrate 25 mg Tablet PO BID
-Colace 100mg [**Hospital1 **]
-MV qday
-Zocor 20mg HS
-Coumadin 4mg qday
-[**Hospital1 **] 81ng
-Tylenol prn
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily). Cap(s)
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
3. simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO [**Hospital1 **] (once a
day (at bedtime)).
4. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day)."
2771,"Hct dropped form 31 at OSH
to 23. Pt had a NG lavage with minimal coffee grounds. Protonix
gtt was started. RBCs x 2 units ordered. Noted to have ARF with
Cr 1.4 from baseline on 0.9 to 1.0. PIV 16 and 18 g. GI made
aware and plan to see patient in AM for likely EGD. At transfer,
VS were 97.5 65 121/64 24 95% on 4L.
.
In the ICU, he is comfortable, breathing well on 2-4L NC. He is
not usually on O2 at home. He has not had any bowel movements
since coming to the hospital yesterday."
2772,"left thalamus, left cerebellar hemisphere and right superior
cerebellum with resulting right-sided deficits. The etiology
was thought to be cardioembolic and he was started on lifelong
anticoagulation with coumadin.
.
He was most recently admitted on [**2144-12-30**] with right upper
quadrant pain, with management of acute cholecystitis once again
with placement of a percutaneous cholecystostomy tube, resulting
in removal of purulent bile. He was treated with augmentin for
2 weeks. This was immediately proceeded by an ERCP in [**2144-6-25**]
with stent placement for suspected cholangitis.
.
In the ER, VS 99.8 81 111/72 16 100%."
2773,"You should however take your new
medication, which reduces the acid in your stomach.
.
You were considered for possible removal of your gallbladder
during this admission, but the surgeons felt that you should
best weight until your stomach issues have completely resolved.
You are scheduled with follow-up appointments with your PCP, [**Last Name (NamePattern4) **].
[**First Name (STitle) 2819**], and the gastroenterologist who saw you during this
admission, Dr. [**First Name (STitle) 679**].
.
Medication changes:
1. Stop plavix
2. Stop coumadin
3. Stool softeners for constipation as needed
4. Proton pump inhibitor for your stomach inflammation
Followup Instructions:
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appt: [**2-18**] at 12noon
Name: [**Last Name (un) **],PERMINDER
Address: [**Apartment Address(1) 45001**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 29110**]
Appt: [**2-19**] at 11:15am
Department: SURGICAL SPECIALTIES
When: MONDAY [**2145-3-8**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD [**Telephone/Fax (1) 2998**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
[**2145-3-1**] 03:30p [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] C.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)"
2774,"5. zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
[**Hospital1 **]:*qs Tablet(s)* Refills:*0*
7. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*2*
8. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
[**Hospital1 **]:*qs Suppository(s)* Refills:*0*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E."
2775,"8*
.
[**2145-2-7**] 04:30AM BLOOD Glucose-73 UreaN-25* Creat-1.1 Na-140
K-4.0 Cl-110* HCO3-19* AnGap-15
[**2145-2-7**] 04:30AM BLOOD Glucose-73 UreaN-25* Creat-1.1 Na-140
K-4.0 Cl-110* HCO3-19* AnGap-15
.
[**2145-2-7**] 04:30AM BLOOD ALT-16 AST-19 LD(LDH)-151 AlkPhos-62
TotBili-0.6
[**2145-2-6**] 10:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-2-6**] 10:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-2-6**] 12:23AM BLOOD CK-MB-3 cTropnT-<0."
2776,"His
hospital course was c/b the need to return to the OR for
re-exploration of his chest for bleeding after increased chest
tube output was noted with a L sided pleural effusion and
increased O2 requirement. 1 week after discharge, the patient
re-presented in [**2144-4-25**] with his 1st bout of acute
cholecystitis. Since he was deemed a poor surgical candidate,
PTC was placed and he completed a 10-day course of Cipro/Flagyl.
However, this hospitalization was c/b an acute stroke wit head
CT and MRI showing acute infarctions in the left occipital lobe,"
2777,"01
[**2145-2-7**] 04:30AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1
EKG ([**2145-2-6**]): Baseline artifact. Sinus rhythm. Low amplitude P
waves with slight P-R interval prolongation of about 220
milliseconds. Borderline low
limb lead voltage. Slow R wave progression in leads V1-V2 which
is
non-diagnostic. Cannot exclude underlying anteroseptal
myocardial infarction. Compared to the previous tracing of
[**2144-12-30**] no diagnostic change.
EGD ([**2145-2-10**]): Large hiatal hernia. Sloughing in the whole
esophagus compatible with ischemic injury to esophagus. Erythema
and granularity in the antrum compatible with antral gastritis."
2778,"Admission Date: [**2152-4-19**] Discharge Date: [**2152-4-23**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 78 yo male with history of CAD s/p CABG, CHF,
? COPD presents from home with acute shortness of breath. He
reports drinking ETOH tonight, but denies aspiration. The
patient was found by EMS to not be able to talk in complete
sentences. His BPs were 220s/140s. He received nitro spray x 4
enroute with BiPAP with mild improvement."
2779,".
In the ED, initial VS were 138 139/126 28 97% on CPAP. Initially
he was thought to have CHF exacerbation, so was treated with
morphine, nitro drip. He then was found to have a rectal temp of
103.6 and CXR returned with large RLL infiltrate. Nitro drip was
stopped and he was given 1300mg PR tylenol. He was then treated
for suspected aspiration PNA with vanc/levofloxacin/flagyl. ETOH
negative despite report of ETOH use tonight. He was maintained
on CPAP 10/5 now with FiO2 100%, satting 100%. After report was
given, attempt to titrate off non-invasive mechanical
ventilation was attempted given concern for autopeep with BPs in
the 80s."
2780,"He was placed on NRB with adequate saturation, however
felt more dyspnea, thus non-invasive was restarted. He was given
a total of 2L NS for fluid resuscitation. 2 PIVs were placed.
.
Upon arrival to the ICU, the patient reports improvement in
symptoms. Does not remember the events of the night.
Past Medical History:
CABG
CHF
COPD
two recent PNA infections
Social History:
- Home: Wife lives in a NH in [**Last Name (un) **]. Has two sons one in FL,
one in [**Location (un) **] is [**Name (NI) 86**] PD.
- Tobacco: denies
- Alcohol: +etoh
- Illicits: denies
Family History:
NC
Physical Exam:
ADMISSION EXAM
General: Alert, mildly confused, slow to answer questions in no
respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Rhonchi BL worse on R than l, expiratory wheezes worse on
left than right
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
."
2781,".
VIDEO OROPHARYNGEAL SWALLOW:
1. Gross aspiration seen with thin barium and penetration seen
with
nectar-thickened barium.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Mr. [**Known lastname **] is an 87y/o gentleman with history of CAD s/p CABG,
CHF who was admitted to the MICU for hypoxic respiratory failure
that was likely secondary to CAP with possible aspiration event.
His respiratory status was stable, he was treated with
antibiotics, and he was discharged home.
.
ACTIVE ISSUES:
==============
# Hypoxic respiratory failure: resolved.
Etiology was likely multifactorial due to aspiration vs
community acquired PNA with component of flash pulmonary edema.
Patient does have a history of recurrent aspiration pneumonias
which were thought to be due to his esophageal stenosis, GERD,
and nocturnal reflux."
2782,"Aspiration was seen on video swallow.
In the ED, he was treated with morphine and nitro drip for a CHF
exacerbation and then found to have temp of 103.6 rectally.
Nitro drip was stopped and he was treated with vanco,
levofloxacin, and flagyl for aspiration PNA. He was maintained
on CPAP and transferred to the MCIU on a non-rebreather with O2
sats 93%. In the MICU, he was changed to azithromycin and
ceftriaxone and improved overnight to breathing comfortably on
room air. His legionella was negative and sputum sample was
contaminated. Because the patient woke up in the early morning
with acute dyspnea and had elevated BP on admission, flash
pulmonary edema was a concern as well and TTE was done which
showed mild MR, mild AS, mild focal LV systolic [**Last Name (LF) 20559**], [**First Name3 (LF) **]
50-55% with an eccentric, posteriorly directed jet of mild to
moderate MR."
2783,"This likely explains the unilateral pleural
effusion. For his pneumonia likely due to aspiration, patient
was changed from IV antibiotics to PO augmentin. He was
discharged home with plans to complete a course of PO Augmentin.
Was counseled about modified diet to prevent aspiration events.
He will follow up with his PCP.
.
# Hypotension: Resolved.
Was hypertensive per EMS which was treated with morphine, nitro
given in the setting of SIRS/sepsis. Fluid resuscitated with 2L
IVF in the ED. Patient likely flashed in setting of hypertension
during REM sleep prior to admission. He remained normotensive in
the MICU and his carvedilol and lisinopril were restarted at
home doses."
2784,"He does take plavix though it is unclear for what
reason. He has not taken coumadin so his AVR is likely to be
bioprosthetic. He was continued on aspirin and plavix and was
discharged with instructions to follow up with his PCP.
.
# COPD: stable.
Patient has remote smoking history and currently takes advair
diskuk and porair at home. He was given nebulizers throughout
hospitalization though no evidence of COPD exacerbation.
.
# Hyperlipidemia: stable.
He was continued on home statin.
.
# GERD: stable.
Reflux likely contributes to his aspiration. He was continued
on home omeprazole.
.
TRANSITION OF CARE:
===================
# Labs pending at discharge: none."
2785,"Disp:*1 inhaler* Refills:*0*
8. Robaxin 500 mg Tablet Sig: One (1) Tablet PO four times a
day.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
11. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days: To be taken through
[**4-27**].
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted with difficulty breathing and were found to
have a pneumonia which we are treating with antibiotics.
.
We made the following changes to your medications:
- STARTED Augmentin 850mg twice daily to be taken through
[**2152-4-27**]
Followup Instructions:
Please call your primary care doctor BROWN,[**Doctor First Name **]
[**Telephone/Fax (1) 37165**] to schedule a follow up appointment within the next
1-2 weeks."
2786,"01
[**2152-4-19**] 09:22AM BLOOD CK-MB-3 cTropnT-0.03*
[**2152-4-19**] 05:45PM BLOOD CK-MB-4 cTropnT-0.01
[**2152-4-19**] 05:11AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.8
[**2152-4-19**] 05:11AM BLOOD Ethanol-NEG
[**2152-4-19**] 05:56PM BLOOD Lactate-1.8
.
Discharge labs:
===============
[**2152-4-23**] 06:40AM BLOOD WBC-4.4 RBC-4.12* Hgb-12.9* Hct-37.6*
MCV-91 MCH-31.3 MCHC-34.3 RDW-14.0 Plt Ct-195
[**2152-4-23**] 06:40AM BLOOD Glucose-98 UreaN-17 Creat-0."
2787,"#). There is mild aortic valve stenosis (valve area
1.2-1.9cm2). There is no mitral valve prolapse. An eccentric,
posteriorly directed jet of Mild to moderate ([**12-12**]+) mitral
regurgitation is seen without clear evidence of mitral valve
prolapse or significant anterior mitral leaflet tethering. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild focal LV systolic dysfunction c/w CAD. Mild aortic
stenosis. Mild-moderate mitral regurgitation.
.
CXR:
1. Opacification at the right base concerning for aspiration
pneumonia.
2. Diffuse haziness in the right lung likely due to asymmetric
edema, particularly as the patient was found lying on his right
side for a prolonged period of time."
2788,"2. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) 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. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
7. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing."
2789,"His BP was reasonably controlled on the medical
floor as well. His hypertension regimen was not adjusted; he
will f/u with his PCP after discharge.
.
# CHF: EF 50-55% on TTE this admission. As above, patient likely
had flash pulmonary edema in setting of hypertension prior to
admission, in addition to pneumonia. He had a unilateral pleural
effusion, but did not appear to be fluid overloaded on exam. He
was not diuresed and restarted on his home carvedilol and
lisinopril.
.
INACTIVE ISSUES
.
# CAD s/p 2 CABGs and AVR in [**1-19**]: stable.
There did not appear to be a cardiac etiology to patient's
respiratory distress and he was ruled out for MI with serial
enzymes."
2790,"8*
Eos-1.3 Baso-0.8
[**2152-4-19**] 05:11AM BLOOD PT-11.0 PTT-21.3* INR(PT)-0.9
[**2152-4-19**] 05:11AM BLOOD Fibrino-436*
[**2152-4-19**] 05:11AM BLOOD Glucose-147* UreaN-17 Creat-0.9 Na-135
K-5.6* Cl-97 HCO3-29 AnGap-15
[**2152-4-19**] 05:11AM BLOOD ALT-15 AST-36 LD(LDH)-457* CK(CPK)-86
AlkPhos-76 TotBili-0.8
[**2152-4-19**] 05:11AM BLOOD Lipase-34
[**2152-4-19**] 05:11AM BLOOD CK-MB-3 proBNP-822
[**2152-4-19**] 05:11AM BLOOD cTropnT-<0."
2791,"# Follow-up: Patient was instructed to follow up with his PCP.
# Communication: Patient and son/HCP [**Name (NI) **]
# Emergency Contact: [**Name (NI) **] [**Name (NI) **] (son) [**Telephone/Fax (1) 89317**]
# Code: Full Code
Medications on Admission:
Carvedilol 3.125mg [**Hospital1 **]
Lisinopril 2.5mg daily
Plavix 75mg daily
Simvastatin 20mg qhs
Omperazole 20mg daily
Advair 500-50mcg/dose 1 puff [**Hospital1 **]
proair HFA 108 mcg/act 2 puffs every 4hrs prn
Robaxin 500mg 1 tab QID
Neurontin 300mg TID
Percoset 5-325mg 1 tab q6hr prn
Discharge Medications:
1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day)."
2792,"9 Na-137
K-4.0 Cl-99 HCO3-31 AnGap-11
[**2152-4-23**] 06:40AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.9
.
Imaging:
========
TTE: The left atrium is moderately dilated. The left atrium is
elongated. The estimated right atrial pressure is 0-5 mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal-mid infero-lateral
walls. Overall left ventricular systolic function is low normal
(LVEF 50-55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened (?"
2793,"DISCHARGE EXAM
Vitals: 99.3 168/97 78 20 94%2L
General: NAD
HEENT: NC/AT, EOMI, no pallor or icterus, MMM
Neck: no JVD
CV: regular, nml S1/S2,
Pulm: quiet bibasilar crackles, R>L, no wheezing
Abdom: obese, soft, NT, NABS
Extrem: WWP, 1+ pedal pulses, no edema
Pertinent Results:
Admission labs:
===============
[**2152-4-19**] 05:11AM BLOOD WBC-9.1 RBC-5.09 Hgb-15.8 Hct-47.1 MCV-93
MCH-31.0 MCHC-33.6 RDW-14.1 Plt Ct-189
[**2152-4-19**] 05:11AM BLOOD Neuts-90.8* Lymphs-5.4* Monos-1."
2794,"8 g/dL, LDH:321 IU/L, Ca++:8.6 mg/dL,
Mg++:1.7 mg/dL, PO4:3.3 mg/dL
Assessment and Plan
ACIDOSIS, METABOLIC
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 2**])
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)
IMPAIRED SKIN INTEGRITY
DELIRIUM / CONFUSION
.H/O DIABETES MELLITUS (DM), TYPE I
.H/O SEIZURE, WITHOUT STATUS EPILEPTICUS
SEPSIS WITHOUT ORGAN DYSFUNCTION
HYPOGLYCEMIA
HYPOTENSION (NOT SHOCK)
HYPOTHERMIA
HYPOXEMIA
URINARY TRACT INFECTION (UTI)
ICU Care
Nutrition:
Nutren Renal (Full) - [**2120-10-17**] 05:00 PM 20 mL/hour
Lines:
18 Gauge - [**2120-10-15**] 01:31 AM
20 Gauge - [**2120-10-15**] 01:32 AM
Arterial Line - [**2120-10-15**] 04:00 AM
Multi Lumen - [**2120-10-15**] 08:14 AM"
2795,"6
16.4
13.4
Hct
25.0
24.6
23.6
Plt
97
89
81
Cr
1.7
1.6
1.9
1.9
TCO2
17
17
23
23
24
Glucose
154
87
123
163
101
89
87
88
107
93
Other labs: PT / PTT / INR:15.7/45.3/1.4, CK / CKMB /
Troponin-T:35/5/0.05, ALT / AST:14/21, Alk Phos / T Bili:108/0.2,
Amylase / Lipase:38/7, Differential-Neuts:49.0 %, Band:26.0 %,
Lymph:13.0 %, Mono:0.0 %, Eos:3.0 %, Fibrinogen:341 mg/dL, Lactic
Acid:1.8 mmol/L, Albumin:1."
2796,"Chief Complaint:
24 Hour Events:
- Held sedation, with small boluses PRN
- Attempted to diurese, with encouraging results and attempted a second
time (20 IV lasix each time).
- Bronchoscopy, for which TF were held
- Discontinued flagyl
- FDP pending.
- Legionella ag sent
- Renal ultrasound: nl kidneys,
- Follow up podiatry's recs: adaptic on dorsum and betadine in between
toes.
- Fluids: -.18
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefipime - [**2120-10-15**] 06:00 AM
Metronidazole - [**2120-10-17**] 04:45 AM
Vancomycin - [**2120-10-17**] 08:00 AM
Levofloxacin - [**2120-10-17**] 12:00 PM
Piperacillin/Tazobactam (Zosyn) - [**2120-10-17**] 08:03 PM
Infusions:
Other ICU medications:
Ranitidine (Prophylaxis) - [**2120-10-17**] 08:03 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2120-10-18**] 05:00 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 38."
2797,"38/39/68/24/-1
Ve: 8.5 L/min
PaO2 / FiO2: 136
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
81 K/uL
7.8 g/dL
93 mg/dL
1.9 mg/dL
24 mEq/L
3.4 mEq/L
27 mg/dL
116 mEq/L
147 mEq/L
23.6 %
13.4 K/uL
[image002.jpg]
[**2120-10-16**] 03:04 AM
[**2120-10-16**] 07:49 AM
[**2120-10-16**] 08:00 AM
[**2120-10-16**] 11:30 AM
[**2120-10-17**] 01:34 AM
[**2120-10-17**] 01:51 AM
[**2120-10-17**] 09:16 AM
[**2120-10-17**] 11:34 AM
[**2120-10-17**] 06:35 PM
[**2120-10-18**] 01:57 AM
WBC
11."
2798,"2
C (100.7
Tcurrent: 37.1
C (98.8
HR: 87 (87 - 126) bpm
BP: 162/63(97) {117/52(74) - 173/74(112)} mmHg
RR: 20 (11 - 28) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 46 kg (admission): 39.6 kg
Height: 60 Inch
CVP: 7 (6 - 12)mmHg
Total In:
2,090 mL
240 mL
PO:
TF:
458 mL
100 mL
IVF:
1,572 mL
50 mL
Blood products:
Total out:
2,270 mL
650 mL
Urine:
1,820 mL
650 mL
NG:
Stool:
50 mL
Drains:
Balance:
-180 mL
-411 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 486 (485 - 585) mL
PS : 10 cmH2O
RR (Spontaneous): 17
PEEP: 12 cmH2O
FiO2: 50%
RSBI Deferred: PEEP > 10
PIP: 22 cmH2O
SpO2: 100%
ABG: 7."
2799,"Chief Complaint: hypothermia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
69 yr old woman with CHF, PVD s.p BKA, CAD, CKD, who was picked up by
dtr at daycare today and noted to be somnelent, fingerstick was 25 and
pt given amp d50 and taken to OSh- desating and given Zosyn, tc to [**Hospital1 **]
ER.
temp 93 rectal HR 60 BP 160/60 rr 20 98% on NRB blood and urine cx sent
lactate 1."
2800,"32/35/67
Physical Examination
Labs / Radiology
122
30.5
266
1.8
23
19
118
5.6
144
3.4
[image002.jpg]
Other labs: PT / PTT / INR://11.6/31/1.0, CK / CKMB /
Troponin-T://51/-/ 0.03, Differential-Neuts:69, Lymph:27, Mono:4,
Lactic Acid:1.5, Ca++:8.6, Mg++:3.5, PO4:2.0
Fluid analysis / Other labs: BNP 1843
UA > 50 WBC mod leuk nitrite neg
Microbiology: Blood Cx and Urine Cx pending
Assessment and Plan
ICU Care
Nutrition:
Glycemic Control:
Lines / Intubation:
18 Gauge - [**2120-10-15**] 01:31 AM
20 Gauge - [**2120-10-15**] 01:32 AM
Comments:
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:
Total time spent:"
2801,"Seizure disorder
Occupation: retired
Drugs:
Tobacco:
Alcohol:
Other: lives with dtr
Review of systems:
Constitutional: Fatigue
Eyes: No(t) Blurry vision
Ear, Nose, Throat: No(t) Dry mouth
Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea
Endocrine: Hyperglycemia
Heme / Lymph: Anemia
Neurologic: Seizure
Psychiatric / Sleep: Agitated
Flowsheet Data as of [**2120-10-15**] 02:14 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 33.6
C (92.4
Tcurrent: 33.6
C (92.4
HR: 67 (67 - 67) bpm
BP: 83/35(47) {83/35(47) - 83/35(47)} mmHg
RR: 30 (20 - 30) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Total In:
4 mL
PO:
TF:
IVF:
4 mL
Blood products:
Total out:
0 mL
280 mL
Urine:
280 mL
NG:
Stool:
Drains:
Balance:
0 mL
-276 mL
Respiratory
O2 Delivery Device: Non-rebreather
SpO2: 94%
ABG: ////7."
2802,"5 CXR pulm edema and Cr 1.8
ROS: seizure of few days ago
Patient admitted from: [**Hospital1 1**] ER
History obtained from Family / [**Hospital 380**] Medical records
Patient unable to provide history: dementia
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Heparin Sodium - 650 units/hour
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
CHF EF 20%:
DM II x 15 years - complicated by peripheral neuropathy;
retinopathy
CAD - h/o distant MI per family report, no PCI or CABG
Pancreatitis
- s/p pancreatic duct stent
CKD (baseline 1.1-1.3 per report)
Anemia - Mixed iron deficient and anemia of chronic disease
Thrombocytopenia
osteopenia
History of stroke
Dementia
?"
2803,"Admission Date: [**2120-10-14**] Discharge Date: [**2120-10-28**]
Date of Birth: [**2057-12-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Hypoglycemia, hypoxemia, hypothermia
Major Surgical or Invasive Procedure:
endotracheal intubation
Arterial line placement
Central venous line placement
Peripherally-inserted venous catheter
History of Present Illness:
Ms. [**Known lastname 32496**] is a 62 yo wheelchair bound F with IDDM c/b
peripheral neuropathy with CHF 20%, s/p right BKA, daughter
nurse, picked her up at adult day care, noticed somnolence,
checked glu - 25."
2804,"Went to local ER. Gave amp D50 and gave her
zosyn, but there is no documented temperature. She was noted to
desat to the 70s on RA, but she was asymptomatic. She was put
on nonrebreather. She was also noted to be bradycardic in 40s.
She was tx here for further management. Upon arrival, she was
again without complaints. She was noted to desat to 82 without
NRB.
Vitals in the ED: HR 60s. T 92-93 rectal. HR 60, BP 160/63, RR
19, 98%NRB. No other antibiotics. 1 blood and urine here. 2
bloods at outside ed."
2805,"Moderate pulmonary hypertension. Small
pericardial effusion.
- MIBI [**2117**] with normal perfusion
#. DM II x 15 years - complicated by peripheral neuropathy;
retinopathy
#. HTN
#. CAD - h/o distant MI per family report, no PCI or CABG
#. History of Pancreatitis
- s/p pancreatic duct stent
#. CKD (baseline 1.1-1.3 per report, but was 0.7-0.9 in [**4-17**])
#. Anemia - Mixed iron deficient and anemia of chronic disease
#. Thrombocytopenia
#. h/o thickened endometrium per US
#. osteopenia
#. History of stroke
#. Dementia
#. ? Seizure disorder
Social History:
The patient was previously living in [**Location (un) **] with her other
daughter. She recently returned to [**Location 86**] to live with her
daughter [**Name (NI) 70555**] who is employed at [**Hospital1 18**] as a coworker
[**Name (NI) 1139**]: Quit 1 year ago, previously [**12-13**] PPD x 50 years
ETOH: Rare
Illicits: None"
2806,"Family History:
Mother with DM, breast cancer, MI in her 70's. Brother has DM.
Sister with heart disease.
Physical Exam:
vitals: 92 axillary, HR 67 83/35-->121/84 RR20 O2 83-94% NRB
heent: ncat, mmm, eomi
neck: no lad
pulm: ctab, no w/r/r
cv: hrrr, no m/r/g
abd: s/nd, mild diffuse ttp, hypoactive bs
extr: s/p right BKA, multiple ulcers on left foot without
erythema. exudate between 3rd and 4th toes where there is an
ulcer.
neuro: ao x 1 (self)
Pertinent Results:
[**2120-10-14**] 11:06PM PO2-67* PCO2-35 PH-7."
2807,"If there
remains a high clinical concern for an occult infection, can
consider correlation with a dedicated tagged white cell scan.
2. Ground glass and interstitial opacities within visualized
lung bases in
conjunction with small bilateral pleural effusions, small
pericardial
effusion, and probable compression atelectasis. These all likely
relate to
fluid overload/CHF with no discrete pneumonia noted.
3. Diffuse anasarca.
4. Unchanged pancreatic parenchymal calcifications again
suggestive of prior episodes of pancreatitis.
Brief Hospital Course:
62 yo female with DM, HTN, CAD, dementia, who presented with
hypothermia, hypoxia, and hypotension.
# Sepsis: The patient's clinical picture was consistent with
sepsis, initially concerning for urosepsis based on her UA in
the ED."
2808,"# Respiratory Failure: While in the ICU, she developed
progressive respiratory distress requiring endotracheal
intubation, the etiology of which proved unclear. Serial CXRs
appeared most consistent with ARDS, but lung compliance proved
good on the ventilator. Fluid overload was also postulated. She
was diuresed with Lasix, and successfully extubated on [**2120-10-23**].
Her length of stay fluid balance was still +4 L at the time of
discharge but she was autodiuresing well so no diuretics were
initiated.
# Acute Renal Failure: Creatinine was elevated to 1.8 on
admission and peaked at 2.1 but returned to a baseline of 1."
2809,"2.
The patient likely had ARF [**1-13**] hypoperfusion.
# Question of DIC: Concering because of thrombocytopenia and
coagulopathy. However, Heme was consulted and did not think her
presentation was consistent with DIC. She also ruled out for
HIT. Her platelet count was stable at the time of discharge.
# Chronic diastolic heart failure: Pt. was found to have a
normal EF on ECHO (>55%) and severe diastolic dysfunction. She
was restarted on an ACEi as described above, a beta blocker, and
aspirin.
# History of seizure: Patient has a history of a recent seizure
of unclear etiology. It may be related to a past stroke,
however."
2810,"She was managed with keppra.
# DM: Patient was managed on an ISS while inpatient. At the
time of discharge, her daughter reported episodes of
hypoglycemia as an outpatient and requested a script for
glucagon pens, which were given.
# Foot ulcers/bullae: Podiatry evaluated the patient's foot
ulcers and made recommendations for wound care. Her ulcers grew
pan-resistant bacteria (including VRE) but they felt that the
ulcers were not the cause of her septic presentation, and that
they were instead colonized. She additionally improved
clinically in the abscence of directed antimicrobial therapy
against VRE. She was discharged with wound care recommendations
for at-home wound care."
2811,"Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Sepsis
2. Acute respiratory failure
3. Acute renal failure, resolved
4. Low-grade DIC
Secondary diagnoses:
1. Chronic diastolic heart failure, compensated
2. Hypertension
3. Diabetes mellitus type 2, controlled with complications
4. Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted because you had a serious infection in your
blood stream. We treated you with antibiotics to help clear the
infection. We also had to assist your breathing with a
breathing tube. Your condition improved gradually and we
discharged you home with physical therapy services."
2812,"8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Disp:*120 Tablet(s)* Refills:*2*
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Lantus 100 unit/mL Cartridge Sig: Seven (7) U Subcutaneous
QAM.
13. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED
Subcutaneous ASDIR (AS DIRECTED).
14. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for DIARRHEA."
2813,"lactate 1.5. Cr 1.4 there, 1.8 here. No
CTA done, but she was placed on heparin out of concern for PE.
She was put on a warming blanket.
In the ICU, she endorsed cough x 2 days, atypical chest pain.
She denies abd pain, dysuria or increased frequency, diarrhea,
n/v. She subsequently developed hypotension with SBP 70s to
80s. Given her evolving sepsis picture, pulmonary edema,
possible benefit of better monitoring, and possible need for
pressors, an arterial line was placed and she was intubated.
Past Medical History:
#. Chronic Systolic CHF EF 20%:
- h/o hospitalizations for CHF exacerbation
- Echo [**10-17**]: Moderate symmetric LVH with severe global left
ventricular dysfunction (EF 20-25%) Moderate tricuspid
regurgitation."
2814,"32* TOTAL CO2-19* BASE
XS--7
[**2120-10-14**] 11:06PM LACTATE-1.5
[**2120-10-14**] 10:55PM GLUCOSE-266* UREA N-23* CREAT-1.8* SODIUM-144
POTASSIUM-5.6* CHLORIDE-118* TOTAL CO2-19* ANION GAP-13
[**2120-10-14**] 10:55PM CK(CPK)-51
[**2120-10-14**] 10:55PM cTropnT-0.03*
[**2120-10-14**] 10:55PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2120-10-14**] 10:55PM TSH-11*
[**2120-10-14**] 10:55PM TSH-11*
[**2120-10-14**] 10:55PM T4-8.7
[**2120-10-14**] 10:55PM PLT SMR-NORMAL PLT COUNT-122* LPLT-3+
[**2120-10-14**] 10:55PM PLT SMR-NORMAL PLT COUNT-122* LPLT-3+
[**2120-10-14**] 10:55PM PT-11."
2815,"# CAD/hx of stroke: Patient was discharged on ASA and a beta
blocker.
Medications on Admission:
Per D/C summary [**10-8**]:
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Levetiracetam 500mg PO bid
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day)."
2816,"6 PTT-31.3 INR(PT)-1.0
CXR [**10-23**]:
FINDINGS: In comparison with the study of [**10-22**], there is
persistence of
diffuse bilateral pulmonary opacifications. Again, this is
consistent with
ARDS, though vascular congestion or diffuse pneumonia can
certainly not be
excluded radiographically. Various monitoring and support
devices remain in place. The left hemidiaphragm is not sharply
seen on the current study. This could reflect some pleural
fluid, atelectatic change, or even focal
consolidation at the left base.
ABD/PELVIS CT [**10-18**]:
1. Significantly limited CT examination without intravenous
contrast with no source of infection identified."
2817,"Early goal-directed therapy was initiated, with prompt
transfer to the ICU. However, no bacteria grew from the urine,
and nothing was grown from blood and sputum cultures. She was
covered broadly with vancomycin, zosyn, and levofloxacin and she
improved clinically. She was ruled out for respiratory viruses.
Podiatry was consulted and did not feel that her left foot was
infected, only colonized. Bronchoscopy was also not revealing.
CT abd & pelvis were also unremarkable for source. Given no
clear source and clinical improvement she was given a 10-day
course of empiric antibiotics with the last doses on [**10-25**]."
2818,"8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Silvadene 1 % Cream Sig: One (1) Topical once a day: Apply
to the blister once dry and stops draining.
Disp:*1 * Refills:*2*
13. Glargine 7 Units qAM
Insulin SC Sliding Scale
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
2."
2819,"She
remained afebrile during the latter portion of her hospital
course.
# Hypotension/Hypertension: The patient was hypotensive on
admission requiring agressive fluid resuscitation (11L in the
first 24 hours) and pressors. She became hypertensive after the
second or third day of her ICU stay and was gradually started
back on some of her home medications, metoprolol and amlodipine.
Hydralazine was started due to hypertension and wanting to hold
enalapril and HCTZ given her acute renal failure. As kidney
function improved enalapril was started and gradually titrated
upward, while Hydralazine was discontinued. Her
anti-hypertensive regimen will need further adjustment as an
outpatient."
2820,"Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Please call your doctor or return to the hospital if you
experience fevers, chills, sweats, chest pain, shortness of
breath or anything else of concern.
Followup Instructions:
Please schedule an appointment with your primary care doctor
within the next one to two weeks:
PCP: [**Name10 (NameIs) 70557**],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **] [**0-0-**]
We scheduled you for an appointment with a nurse practicioner at
[**Hospital1 18**] next week. To keep this appointment, you will need to
call the office (the number is below). If you would rather see
Dr. [**Last Name (STitle) **], please call his office to schedule an appointment
there.
Scheduled Appointments :
[**Hospital1 18**]--Provider [**Name9 (PRE) 10160**] [**Name9 (PRE) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2120-11-4**] 2:00
Please schedule an appointment with the podiatry clinic within
the next week:
Podiatry
[**Hospital1 18**], [**Location 70558**]
Office Phone: ([**Telephone/Fax (1) 4335**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2120-10-29**]"
2821,"Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed."
2822,"Clinician: Attending
MICU overnight
Remains hypotensive, requiring vasopressor to maintain MAP > 60 mmHg.
CVP ~ 8 cmH2O, lactic acid rising, and urine output now improving over
past several hours. Likely sepsis, now with evidence for septic shock
and component of hypovolemia. Continue to provide iv expansion (iv
crystalloid, PRBC transfusion to >28), monitor urine output, lactic
acid. Adjust ventilator settings to higher RR, aiming for pH >7.30.
Total time spent: 35 minutes
Patient is critically ill."
2823,"0 mg/dL, PO4:2.6 mg/dL
Imaging: CXR-[**2120-10-21**]
-Modest bilateral non-hypdrostatic pulmonary edema
-CVL/ETT/NGT all in good position
Microbiology: Wound Culture-VRE
C. Diff-negative
Assessment and Plan
62 yo female admitted with sepsis related to urinary tract infection
and now in ICU with persistent ventilatory failure with re-intubation
with hypoxemic respiratory failure.
1)Respiratory Failure
-Versed
-Continue with A/C support with lung protective stragegy
-Patient with non-hydrostatic edema contributing and will continue to
move to diuresis as possible.
-Move to negative fluid balance as tolerated but patient with some
intra-vascular depletion with CVP=2 and 1000cc negative yesterday
2)Pneumonia-Possible aspiration but pattern is not classic for
bacterial pneumonia
-Vanco/Zosyn/Levofloxacin
-Aspiration is a concern as possible source so will have to continue
with reasonable broad spectrum antibiotic support
-Encouraging decrease in WBC count
3)Foot Ulcer-
-Wound care to continue
-Will need podiatry eval for any worsening
-Antibiotic treatment to be driven by concern for systemic insult from
foot
Hypertension-
-Decrease beta-blockers with decrease in HR
-Will need to continue with anit-hypertensives
Thrombocytopenia-
-In part likely related to Sepsis and no evidence of DIC
-Heparin held and some improvement in PLT count prior to restart
HYPERTENSION, BENIGN
DIARRHEA
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 2**])
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)
IMPAIRED SKIN INTEGRITY
DELIRIUM / CONFUSION
.H/O DIABETES MELLITUS (DM), TYPE I
SEPSIS WITHOUT ORGAN DYSFUNCTION
HYPOGLYCEMIA
HYPOTHERMIA
HYPOXEMIA
URINARY TRACT INFECTION (UTI)
ICU Care
Nutrition:
Nutren Renal (Full) - [**2120-10-21**] 02:59 AM 20 mL/hour
Glycemic Control:
Lines:
Arterial Line - [**2120-10-15**] 04:00 AM
Multi Lumen - [**2120-10-15**] 08:14 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer:
VAP:
Comments:
Communication: Comments: Daughter updated in full in regards to
current clinical course and future goals for treatment.
Code status: Full code
Disposition :ICU
Total time spent: 45 minutes
Patient is critically ill"
2824,"9
1.8
1.6
1.5
1.6
TropT
0.02
TCO2
26
28
27
24
24
Glucose
55
124
121
57
55
135
114
Other labs: PT / PTT / INR:13.5/37.9/1.2, CK / CKMB /
Troponin-T:11/5/0.02, ALT / AST:14/21, Alk Phos / T Bili:108/0.2,
Amylase / Lipase:38/7, Differential-Neuts:63.0 %, Band:26.0 %,
Lymph:29.2 %, Mono:4.8 %, Eos:2.5 %, Fibrinogen:627 mg/dL, Lactic
Acid:1.8 mmol/L, Albumin:1.8 g/dL, LDH:396 IU/L, Ca++:8.1 mg/dL,
Mg++:2."
2825,"3 mEq/L
31 mg/dL
116 mEq/L
144 mEq/L
25.6 %
4.5 K/uL
[image002.jpg]
[**2120-10-18**] 08:35 PM
[**2120-10-19**] 03:31 AM
[**2120-10-20**] 02:55 AM
[**2120-10-20**] 03:15 AM
[**2120-10-20**] 02:52 PM
[**2120-10-20**] 07:25 PM
[**2120-10-20**] 07:40 PM
[**2120-10-20**] 09:57 PM
[**2120-10-21**] 03:06 AM
[**2120-10-21**] 03:18 AM
WBC
9.1
9.0
5.6
4.5
Hct
22.6
25.9
26.3
25.6
Plt
76
85
74
64
Cr
1."
2826,"34/43/105/24/-2
Ve: 9.2 L/min
PaO2 / FiO2: 263
Physical Examination
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),
(Breath Sounds: Diminished: )
Abdominal: Soft, Non-tender
Musculoskeletal: Unable to stand
Skin: Not assessed
Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
8.4 g/dL
64 K/uL
114 mg/dL
1.6 mg/dL
24 mEq/L
4."
2827,"Chief Complaint: Sepsis
Respiratory Failure
ARDS
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
UNPLANNED EXTUBATION (PATIENT-INITIATED) - At [**2120-10-20**] 02:20 PM
INVASIVE VENTILATION - STOP [**2120-10-20**] 02:25 PM
INVASIVE VENTILATION - START [**2120-10-20**] 05:56 PM
EKG - At [**2120-10-20**] 08:04 PM
STOOL CULTURE - At [**2120-10-21**] 06:00 AM
c-diff #3of3
History obtained from [**Hospital 31**] Medical records
Patient unable to provide history: Sedated
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Levofloxacin - [**2120-10-19**] 04:18 AM
Vancomycin - [**2120-10-19**] 08:07 AM
Piperacillin/Tazobactam (Zosyn) - [**2120-10-21**] 04:00 AM
Infusions:
Midazolam (Versed) - 0."
2828,"1
Tcurrent: 36.9
C (98.5
HR: 67 (55 - 84) bpm
BP: 157/51(82) {114/43(64) - 177/84(113)} mmHg
RR: 19 (12 - 20) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 46 kg (admission): 39.6 kg
Height: 60 Inch
CVP: 2 (2 - 13)mmHg
Total In:
1,808 mL
1,101 mL
PO:
TF:
415 mL
208 mL
IVF:
629 mL
233 mL
Blood products:
Total out:
2,910 mL
703 mL
Urine:
1,910 mL
248 mL
NG:
55 mL
Stool:
1,000 mL
400 mL
Drains:
Balance:
-1,102 mL
398 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 300 (300 - 410) mL
Vt (Spontaneous): 647 (491 - 647) mL
PS : 5 cmH2O
RR (Set): 22
RR (Spontaneous): 0
PEEP: 8 cmH2O
FiO2: 40%
RSBI: 34
PIP: 22 cmH2O
Plateau: 21 cmH2O
SpO2: 100%
ABG: 7."
2829,"5 mg/hour
Fentanyl - 12.5 mcg/hour
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2120-10-20**] 04:00 PM
Dextrose 50% - [**2120-10-20**] 11:00 PM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: No(t) Fever, HYpothermia
Respiratory: Tachypnea
Endocrine: Hypoglycemia
Flowsheet Data as of [**2120-10-21**] 10:32 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.3
C (99."
2830,"Clinician: Resident
In brief, patient's course notable for significant decompensation in
the last 24 hours, including need for mechanical ventilation, profound
acidosis, need for multiple pressors, anuric renal failure/multiorgan
dysfunction, and documentation of GNR peritonitis. Surgery consulted
but ultimately not thought to be appropriate surgical candidate given
high likelihood of intraop mortality. Family notified by phone
throughout the day re: patient's grave prognosis. Family arrived
around 730 pm on [**5-5**] and family meeting occurred. Again related poor
prognosis and decision was made for withdrawal of care. Organ bank
notified and declined case. Pressors and ventilatory support withdrawn
and patient died at 815pm. Absent corneal and pupillary reflexes, no
pulses or heart sounds, no spontaneous respiratory efforts. Family
interested in autopsy and was consented for this."
2831,".
# Sepsis - Hx SBP with admit to [**Hospital 869**] Hosp on [**2200-4-11**] with SBP
complicated by e.coli sepsis from possible gallbladder source, s/p 2
week tx with zosyn/augmentin. Now admitted to OSH [**4-30**] with abd pain,
dx paracentesis from OSH negative but here at [**Hospital1 **] with elevated WBC,
temp to 102, tachycardic to 110's.
- Vanco, zosyn
- Paracentesis
- lactate
- DIC
- Blood products for rescusitation
- a-line if HD unstable
.
# GI bleed - Transfer to MICU with bloody BM's. Per OSH records, pt
with recent nml colonoscopy. EGD from OSH with report of portal
gastropathy and esophageal candidiasis."
2832,"- nutrition consult.
- consider vitamin K repletion.
.
# ARF - per OMR, creatinine 0.9 on [**2200-3-24**], up to 2.1 during [**4-11**] OSH
admission for SBP and then d/c with Cr 1.6, felt [**3-3**] pre-renal from
cirrhosis. Up to 2.5 upon admission to OSH [**4-30**], and 3.3 on admit at
[**Hospital1 5**]. Most concerning for HRS, though ddx also includes pre-renal, AIN
(recent course of augmentin and zosyn for SBP and E. Coli bacteremia).
U/S abd to eval kidneys without hydro/stones/masses. Ulytes neg, eos
neg.
- cont albumin boluses
- consider octreotide/midodrine based on labs above."
2833,".
# AMS - Patient on admit to [**Hospital1 5**] with MS aaox3, acute change in mental
in association with GI bleed and fever. On MICU transfer, pt
encephalopathic with +asterixis, likely contribution from hepatic
dysfunction and uremia.
- continue lactulose as above.
- if fails to improve, consider renal consult.
.
# Hyponatremia - Resolved from admit. Likely [**3-3**] liver disease.
- hold diuretics, free water restrict, and trend.
.
# Acidosis - Gap 11 on admit, likely [**3-3**] ARF, though could have
contribution from alcoholic or starvation ketosis. On transfer to
MICU, gap 23, likely related to lactic acidosis
- check ABG, lactate.
- trend HCO3.
.
# Anemia - macrocytic, HCT 38."
2834,"After 500
cc bolus, BP increased to 119/68. During this time, pt also had 2
large bloody bowel movements. He was assessed and transferred to the
MICU for GI bleed in setting of decompensating liver failure, possible
SBP
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2200-5-4**] 10:17 PM
Vancomycin - [**2200-5-4**] 11:00 PM
Infusions:
Dopamine - 10 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2200-5-4**] 11:30 PM
Other medications:
Past medical history:
Family history:
Social History:
- EtOH cirrhosis - per pt dx in [**3-10**] in the setting of tylenol
toxicity, first noted ascites [**1-6**], quit drinking [**3-10**], h/o portal
HTN, ascites, reportedly refractory to diuretics."
2835,"9
C (100.2
Tcurrent: 37.9
C (100.2
HR: 114 (90 - 118) bpm
BP: 111/62(79) {85/38(53) - 111/62(79)} mmHg
RR: 19 (19 - 30) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Bladder pressure: 23 (23 - 23) mmHg
Total In:
1,071 mL
965 mL
PO:
TF:
IVF:
317 mL
578 mL
Blood products:
754 mL
388 mL
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
1,071 mL
966 mL
Respiratory
O2 Delivery Device: Venti mask
SpO2: 98%
ABG: 7.27/22/107/9/-14
Physical Examination
General Appearance: Anxious
Eyes / Conjunctiva: PERRL, +scleral icterus
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: bilateral bases)
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: 2+, Left: 2+, No(t) Clubbing
Skin: Not assessed, Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): AAOx1-2, Movement: Not assessed, Tone: Not
assessed
Labs / Radiology
112 K/uL
9."
2836,"3.
He was then readmitted on [**4-30**] to [**Hospital 869**] hospital again with a c/o abd
pain. Work-up was significant for a tbili of 31, WBC of 14, Cr 3. A
diagnostic paracentesis was performed and was negative for SBP (WBC 60,
RBC 790 PMN 23 GLC 168 [**Doctor First Name **] 22 ALB <1). The decision was made to
transfer the patient to [**Hospital1 5**] for eval of liver failure for possible
transplantation eval. Of note per records, his bilirubin level was
twice that seen on his previous admission.
.
Upon arrival to [**Hospital1 5**] VS: 97.9 95/50 88 16 100%RA."
2837,"2 in [**3-10**], down to 30 on [**4-30**]. LDH not
elevated arguing against hemolysis, as does low indirect bilirubin. pt
denies blood in stools or hemetemesis.
- guaic stools.
- maintain t&c.
- check iron studies to evaluate for ACD and pt's h/o
?hemochromotosis.
.
#DM2:
- HISS
.
FEN: NPO for now with encephalopathy
Prophylaxis: Pneumoboots, PPI, Lactulose
ACCESS: PIVs, a-line
CODE: FULL.
.
# COMM: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5579**] (h) [**Telephone/Fax (1) 5580**], (c) [**Telephone/Fax (1) 5581**], (w)
[**Telephone/Fax (1) 5582**].
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2200-5-4**] 10:01 PM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU"
2838,"Chief Complaint: BRBPR/Melena
HPI:
Patient is a 48 yo M with a hx of alcoholic cirrhosis who presented to
[**Hospital 869**] hospital on [**4-30**] with a c/o abd pain. Per OSH records, he
originally was dx with liver failure in [**3-10**] after presenting with
acute hepatitis in the setting of recent heavy tylenol use in
conjunction with chronic EtOH use. Since that time, he was admitted in
[**2200-4-11**] for SBP during which time his hospital course was complicated
by E.coli sepsis from presumed gallbladder source due to a
non-visualized gallbladder on HIDA scan as well as persistently rising
tbili."
2839,"1. Limited assessment of the portal vein. Probable patency of the
extrahepatic portion of the main portal vein. Likely slow flow within
the intrahepatic portal veins. However, partial occlusion cannot be
completely excluded and this could be further assessed by non-contrast
MRI of the liver (given the patient's renal insufficiency).
2. Mildly distended gallbladder in the setting of large volume
abdominal ascites. Correlation with clinical suspicion for acute
cholecystitis is recommended. A HIDA scan could be performed if
clinically indicated.
3. Splenomegaly.
4. No hydronephrosis.
5. Large volume ascites.
Assessment and Plan
48M with etoh cirrhosis, transferred from OSH with rising Tbili and
creatinine."
2840,"On the floor, an
abdominal US showed probable patency of the extrahepatic portion of the
main portal vein. Likely slow flow within the intrahepatic portal veins
as well as a mildly distended gallbladder in the setting of large
volume abdominal ascites. For his renal failure, lasix/spirinolactone
was being held and pt was receiving albumin challenge to assess for
HRS.
.
At 4PM on [**5-4**], pt had an episode of shaking chills. VS at the time
were: 97.9, 110/68, 89, 18, 100RA. Pt subsequently spiked a temp to
102.1, became tachycardic to 130, and hypotensive to 91/53."
2841,"1 g/dL
109 mg/dL
3.2 mg/dL
48 mg/dL
9 mEq/L
101 mEq/L
3.0 mEq/L
133 mEq/L
25.8 %
7.0 K/uL
[image002.jpg]
[**2197-1-30**]
2:33 A4/5/[**2200**] 09:50 PM
[**2197-2-3**]
10:20 P4/6/[**2200**] 01:23 AM
[**2197-2-4**]
1:20 P
[**2197-2-5**]
11:50 P
[**2197-2-6**]
1:20 A
[**2197-2-7**]
7:20 P
1//11/006
1:23 P
[**2197-3-2**]
1:20 P
[**2197-3-2**]
11:20 P
[**2197-3-2**]
4:20 P
WBC
7."
2842,"0
Hct
25.8
Plt
112
Cr
3.2
TC02
11
Glucose
21
109
Other labs: PT / PTT / INR:30.3/79.0/3.1, ALT / AST:57/119, Alk Phos /
T Bili:142/32.8, Differential-Neuts:76.0 %, Band:15.0 %, Lymph:3.0 %,
Mono:4.0 %, Eos:1.0 %, D-dimer:[**Numeric Identifier 1804**] ng/mL, Fibrinogen:106 mg/dL,
Lactic Acid:8.7 mmol/L, Albumin:3.1 g/dL, LDH:166 IU/L, Ca++:9.1 mg/dL,
Mg++:2.4 mg/dL, PO4:4.4 mg/dL
Imaging: U/S abd [**5-3**]:
IMPRESSION: Technically limited ultrasound."
2843,"Eventually during that admission an ERCP was performed on
[**2200-3-31**] with biliary stent placement with good biliary flow
post-procedures, but this did not resolve the patients rising
bilirubin. An AFP was negative. He was discharged on [**4-19**] from the
OSH with a 2 week course of augmentin after having been treated inpt
with zosyn. Additionally, the patients creatinine was found to be 2.1
on admission and he was eventually discharged with a cr of 1.6, where
records indicate that he had had a cr of 0.9 in [**3-10**] and then by mid
[**Month (only) 1530**] had a cr of 2."
2844,"TBil rising since
[**3-10**], HIDA showed non-visualization of gallbladder, prompting ERCP
[**2200-4-18**] with biliary stent placed. Pre-transplant outpt colonoscopy
[**4-7**].
- h/o SBP in [**4-7**] c/b e. coli sepsis, concerning for gallbladder
source.
- DM2
- CRI - baseline cre 0.9 in [**3-10**], up to 2.1 in [**4-7**], lasix/aldactone
discontinued, and creatinine down to 1.6.
- h/o cardiac arrhythmia in [**2185**] felt [**3-3**] EtOH
Father with [**Name2 (NI) 259**] cancer, diagnosed in 30s. Mother with diabetes.
Occupation: Worked at Golf club until [**12-7**]
Drugs: Denies IVDU
Tobacco: Smoked 1-2ppd x 30y quit [**3-10**]
Alcohol: Describes 5-6 beers/day x 20 yrs, quit in [**3-10**]
Other:
Review of systems:
Constitutional: Fever
Ear, Nose, Throat: Dry mouth
Gastrointestinal: Abdominal pain
Integumentary (skin): Jaundice, Rash
Heme / Lymph: Coagulopathy
Flowsheet Data as of [**2200-5-5**] 03:02 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37."
2845,"Now, pt admitted to OSH [**4-30**] with abd
pain, found to have worsening tbili/cr and transferred from OSH for
transplant workup. At present he denies abdominal discomfort. His tbili
is marginally elevated compared to his baseline of 28 earlier this
month. More concerning is his progressively rising creatinine.
Abdominal U/S on [**5-3**] showed no intra/extra bil dil, probable portal
venous flow.
- consider CT abd/pelvis r/o infection
- plan possible MRI to eval portal vein.
- continue lactulose QID given mild confusion, titrate up prn.
- hold off on lasix/spirinolactone given ARF and hyponatremia.
- given worsening status with elevated WBC and new fever, will perform
dx paracentesis
- GI consult to perform EGD/flex sig
- obtain OSH colonoscopy results."
2846,"Source of bloody stool likely
from upper source. HCT 26->26 from AM to PM.
- Liver consult called, will plan to perform EGD and flex sig
- 1u PRBC, 2u FFP to start in MICU
- serial HCT
.
# ESLD - Hx of EtOH cirrhosis dx during admit in [**3-10**] for acute
hepatitis in setting of heavy tylenol use for URI on background of
history of heavy EtOH use. EGD at that time showed portal gastropathy
and esophageal candidiasis. Liver disease so far complicated by SBP,
worsening renal failure. Pt has been evaluated at [**Hospital1 5**] by Dr. [**Last Name (STitle) 356**]
[**4-7**] for possible transplant, complicated by lack of insurance, history
of alcohol use as recent as [**3-10**]."
2847,"Transferred for transplant eval. Abd ultrasound - large ascites,
difficult to visualize but likely patent portal vein.
This evening, spiked temp 102, had bloody stools, tachy at 130, and
became progressively encephalopathic. Given vanc/zosyn, 1 unit of
PRBCs, and 2 units of FFP, and IVF.
Had upper and lower endoscopies by Dr [**Last Name (STitle) 356**]
felt to be a LGI source,
likely diverticular. Bladder pressure transduced
23. Urgent
paracentesis done with removal of 3 L ascites.
Patient admitted from: [**Hospital1 5**] [**Hospital1 **]
History obtained from Medical records
Patient unable to provide history: Encephalopathy
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2200-5-4**] 10:17 PM
Infusions:
Other ICU medications:
Other medications:
MEDS @ TRANSFER: ciprofloxacin 250 mg po qdaily, lactulose 15ml TID
(gotten 2 doses on [**5-2**]), mylanta prn, potassium 80 meq on [**4-30**]
Past medical history:
Family history:
Social History:
1- EtOH cirrhosis exacerbated by tylenol toxicity, first noted ascites
[**1-6**], quit drinking [**3-10**], h/o portal HTN, ascites, reportedly
refractory to diuretics."
2848,"8 %
9.1 g/dL
23 - tx with D50
3.2
46
9
3.0
133
7.0 K/uL
[image002.jpg]
[**2200-5-4**] 09:50 PM
WBC
7.0
Hct
25.8
Plt
112
Other labs: PT / PTT / INR:33.4/104.4/3.5, Differential-Neuts:76.0 %,
Band:15.0 %, Lymph:3.0 %, Mono:4.0 %, Eos:1.0 %, D-dimer:[**Numeric Identifier 1804**] ng/mL,
Fibrinogen:121 mg/dL
Fluid analysis / Other labs: OSH [**2200-4-30**]
WBC 13.8 HCT 30.0 PLT 142.
Na 127 K 2.4 CL 97 HCO3 18 BUN 31 Creat 2."
2849,"46
ALB 1.8 TBIL 31.5 AP 139 AST 83 ALT 142 DBIL 14.9 INR 2.2
Assessment and Plan
IMPRESSION
48M with Etoh cirrhosis, transferred from OSH with rising Tbili and
creatinine. Had progressive decline this evening with fever 102,
tachycardia, fluid-responsive hypotension, altered mental status and
bloody stools. It appears to be a diverticular bleed but clearly at
risk of other sources with his coagulopathy. Upper endoscopy reportedly
did not show evidence of variceal bleeding. Tense, distended abdomen
with elevated bladder pressure consistent with abdominal compartment
syndrome. Urgent 3 liter paracentesis performed both for diagnostic
(rule out evidence of perf, SBP, etc."
2850,"Chief Complaint: Fever, bloody stools, tachycardia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
48M with hx of recently diagnosed EtOH cirrhosis exacerbated by tylenol
toxicity in 1/[**2200**]. Was admitted in [**Month (only) **] with SBP and e coli sepsis.
Had ERCP at [**Hospital 869**] Hospital - question of gallbladder source due to
progressively rising bilirubin. On [**4-30**] presented to OSH with
epigastric discomfort, increasing creatinine, and rising bilirubin.
Diagnostic para essentially negative - wbc 60, rbc 790, alb < 1."
2851,"Worked at Golf club until
[**12-7**]. Smoked 1-2ppd x 30y quit [**3-10**]. Denies IVDU. 5-6 beers/day x 20
yrs, quit in [**3-10**]
Review of systems:
Flowsheet Data as of [**2200-5-4**] 11:46 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36.6
C (97.9
Tcurrent: 36.6
C (97.9
HR: 115 (115 - 117) bpm
BP: 103/49(62) {103/49(62) - 103/49(62)} mmHg
RR: 27 (27 - 29) insp/min
SpO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
469 mL
PO:
TF:
IVF:
110 mL
Blood products:
358 mL
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
469 mL
Respiratory
SpO2: 97%
ABG: ////
Physical Examination
General Appearance: Well nourished
Eyes / Conjunctiva: sclera icteric
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), at LLSB
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)
Wheezes : , Diminished: at bases)
Abdominal: Non-tender, Distended, tense, no guarding, no rebound
Extremities: Right: 2+, Left: 2+, No(t) Clubbing
Skin: Not assessed, Jaundice
Neurologic: No(t) Follows simple commands, Responds to: Not assessed,
Oriented (to): person +/- place, Movement: Not assessed, Tone: Not
assessed, asterixis, moving extremities
Labs / Radiology
112 K/uL
25."
2852,"TBil rising since [**3-10**], HIDA showed
non-visualization of gallbladder, prompting ERCP [**2200-4-18**] with biliary
stent placed. Pre-transplant outpt colonoscopy [**4-7**].
- h/o SBP in [**4-7**] c/b e. coli sepsis, concerning for gallbladder
source.
2- DM2
3- Renal Insufficiency - b/l creat 0.9 in [**3-10**], up to 2.1 in [**4-7**],
lasix/aldactone d/c'd, and creat down to 1.6.
4- h/o cardiac arrhythmia in [**2185**] felt [**3-3**] EtOH
Father with [**Name2 (NI) 259**] cancer, diagnosed in 30s. Mother with diabetes.
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Lives in [**Location 5573**], RI with girlfriend."
2853,") and therapeutic purposes. If
gram stain is polymicrobial then would do urgent CT to rule out
perforation. Upright CXR shows no air under diaphragm.
He received Vanc/Zosyn, IVF, FFP and albumin earlier today. He may now
be developing volume overload and renal function appears to be
worsening. He will likely require central access if urine output does
not increase. Progressive metabolic acidosis is concerning
likely
intraabdominal process with lactate 2.0, ARF and diarrhea.
Will watch Hct closely due to GI bleed. Coagulopathy being managed
with vit K and FFP. Also watch for progressive respiratory failure.
Lytes to be followed.
ICU Care
Nutrition: keep NPO
Glycemic Control: Regular insulin sliding scale
Lines / Intubation:
20 Gauge - [**2200-5-4**] 10:01 PM
Comments:
Prophylaxis:
DVT: Boots(Systemic anticoagulation: None)
Stress ulcer: Not indicated
VAP: HOB elevation
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 80 minutes
Patient is critically ill"
2854,"1/87.8/3.6, ALT / AST:75/229, Alk Phos /
T Bili:97/31.6, Differential-Neuts:76.0 %, Band:15.0 %, Lymph:3.0 %,
Mono:4.0 %, Eos:1.0 %, D-dimer:[**Numeric Identifier 1804**] ng/mL, Fibrinogen:82 mg/dL, Lactic
Acid:8.6 mmol/L, Albumin:3.5 g/dL, LDH:237 IU/L, Ca++:8.7 mg/dL,
Mg++:2.6 mg/dL, PO4:4.3 mg/dL
Assessment and Plan
CIRRHOSIS OF LIVER, ALCOHOLIC
ASCITES
ALTERED MENTAL STATUS (NOT DELIRIUM)
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)
GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)
DIABETES MELLITUS (DM), TYPE II
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2200-5-4**] 10:01 PM
Arterial Line - [**2200-5-5**] 12:35 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
2855,"5 g/dL
44 mg/dL
3.5 mg/dL
9 mEq/L
3.2 mEq/L
48 mg/dL
101 mEq/L
131 mEq/L
24.5 %
27.1 K/uL
[image002.jpg]
[**2200-5-4**] 09:50 PM
[**2200-5-5**] 01:23 AM
[**2200-5-5**] 02:01 AM
[**2200-5-5**] 04:52 AM
[**2200-5-5**] 05:00 AM
WBC
7.0
22.7
27.1
Hct
25.8
25.0
24.5
Plt
112
71
77
Cr
3.2
3.8
3.5
TCO2
11
9
Glucose
21
109
65
44
Other labs: PT / PTT / INR:34."
2856,"Chief Complaint:
24 Hour Events:
ENDOSCOPY - At [**2200-5-4**] 10:30 PM
COLONOSCOPY - At [**2200-5-4**] 10:30 PM
PARACENTESIS - At [**2200-5-5**] 12:18 AM
ARTERIAL LINE - START [**2200-5-5**] 12:35 AM
- admitted to MICU as transfer from ET for GI bleed in setting of liver
failure with fever
- dx paracentesis performed with 3L ascites taken off, no e/o SBP
- GI performed EGD/sigmoidoscopy. EGD without bleeding, grade 1
varices at GE jnct, no active bleeding. Sigmoidoscopy with multiple
diverticula in sigmoid with clotted blood in few diverticula without
active bleeding, grade 1 internal hemorrhoids, recs albumin, ppi [**Hospital1 **]."
2857,"- persistent hypotension despite 1500cc NS and 100gm albumin.
- a line placed
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2200-5-4**] 11:00 PM
Piperacillin/Tazobactam (Zosyn) - [**2200-5-5**] 05:04 AM
Infusions:
Dopamine - 2 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2200-5-4**] 11:30 PM
Morphine Sulfate - [**2200-5-5**] 05:55 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2200-5-5**] 06:41 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2858,"9
C (100.2
Tcurrent: 36.3
C (97.4
HR: 90 (90 - 118) bpm
BP: 97/62(72) {85/38(53) - 112/64(80)} mmHg
RR: 20 (18 - 30) insp/min
SpO2: 96%
Heart rhythm: ST (Sinus Tachycardia)
Bladder pressure: 18 (18 - 23) mmHg
Total In:
1,071 mL
2,280 mL
PO:
TF:
IVF:
317 mL
1,732 mL
Blood products:
754 mL
488 mL
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
1,071 mL
2,280 mL
Respiratory support
O2 Delivery Device: Venti mask
SpO2: 96%
ABG: 7.25/20/87.[**Numeric Identifier 7**]/9/-16
Labs / Radiology
77 K/uL
7."
2859,"Admission Date: [**2200-5-2**] Discharge Date: [**2200-5-5**]
Date of Birth: [**2151-6-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Paracentesis x 2
History of Present Illness:
48M EtOH cirrhosis who developed epigastric discomfort after
eating pizza was [**4-29**] prompting presentation to OSH ED, where he
states his symptoms resolved after receiving mylanta. Lab work
revealed TBIL of 31.5 which was apparently twice the level from
2 weeks earlier after he was admitted with SBP, prompting
admission."
2860,"Pre-transplant
outpt colonoscopy [**4-7**].
- h/o SBP in [**4-7**] c/b e. coli sepsis, concerning for gallbladder
source.
- DM2
- CRI - baseline cre 0.9 in [**3-10**], up to 2.1 in [**4-7**],
lasix/aldactone discontinued, and creatinine down to 1.6.
- h/o cardiac arrhythmia in [**2185**] felt [**3-3**] EtOH
Social History:
Lives in [**Location 16221**], RI with girlfriend. Worked at Golf club until
[**12-7**]. Smoked 1-2ppd x 30y quit [**3-10**]. Denies IVDU. Describes [**6-4**]
beers/day x 20 yrs, quit in [**3-10**].
Family History:
Father with [**Name2 (NI) 499**] cancer, diagnosed in 30s."
2861,"Pt was started on
fluids, vanc/zosyn and transferred to the MICU for sepsis,
likely complicated by DIC. In the MICU, paracentesis revealed
SBP, blood cultures grew GNRs. Pt was started on pressors,
cipro/metronidazole were added, however, the pt became
successively more acidotic. Family discussion took place, pt was
switched to CMO and died soon afterward.
Medications on Admission:
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: [**5-5**] @ 0742
Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
Pantoprazole 40 mg IV Q12H
Piperacillin-Tazobactam Na 2.25 g IV Q6H
Albumin 25% (12.5g / 50mL) 50 g IV BID
Ciprofloxacin 400 mg IV Q24H
Vancomycin 1000 mg IV Q 24H Day 1: 4/5/9
SSI
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Bacterial Peritonitis
Secondary:
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
expired
Completed by:[**2200-5-7**]"
2862,"3*# Na-125*
K-3.4 Cl-98 HCO3-16* AnGap-14
[**2200-5-3**] 05:45AM BLOOD Glucose-110* UreaN-44* Creat-2.8* Na-127*
K-3.8 Cl-97 HCO3-17* AnGap-17
[**2200-5-4**] 05:35AM BLOOD Glucose-86 UreaN-46* Creat-2.8* Na-128*
K-3.2* Cl-98 HCO3-17* AnGap-16
[**2200-5-4**] 09:50PM BLOOD Glucose-21* UreaN-48* Creat-3.2* Na-133
K-3.0* Cl-101 HCO3-9* AnGap-26*
[**2200-5-5**] 04:52AM BLOOD Glucose-44* UreaN-48* Creat-3.5* Na-131*
K-3."
2863,"2* RBC-2.63* Hgb-9.9* Hct-27.3*
MCV-104* MCH-37.7* MCHC-36.3* RDW-15.2 Plt Ct-152
[**2200-5-3**] 05:45AM BLOOD WBC-13.1* RBC-2.62* Hgb-9.8* Hct-27.0*
MCV-103* MCH-37.5* MCHC-36.4* RDW-15.7* Plt Ct-144*
[**2200-5-4**] 05:35AM BLOOD WBC-14.1* RBC-2.55* Hgb-9.4* Hct-26.4*
MCV-103* MCH-36.8* MCHC-35.6* RDW-15.7* Plt Ct-147*
[**2200-5-4**] 07:56PM BLOOD WBC-2.2*# RBC-2.53* Hgb-9."
2864,"9 to 2.3 in mid-[**Month (only) **], up to 2.5
upon admission to OSH, felt likely 2/2 HRS per notes, but not
documented by labs.
.
Upon arrival to [**Hospital1 18**] VS=97.9 95/50 88 16 100%RA. At present, he
denies cp, sob, n/v, abdominal pain, dysuria, diarrhea,
constipation.
Past Medical History:
EtOH cirrhosis - per pt dx in [**3-10**] in the setting of tylenol
toxicity, first noted ascites [**1-6**], quit drinking [**3-10**], h/o
portal HTN, ascites, reportedly refractory to diuretics. TBil
rising since [**3-10**], HIDA showed non-visualization of gallbladder,
prompting ERCP [**2200-4-18**] with biliary stent placed."
2865,"2* Cl-101 HCO3-9* AnGap-24*
[**2200-5-5**] 08:32AM BLOOD Glucose-47* UreaN-48* Creat-3.6* Na-134
K-3.4 Cl-98 HCO3-8* AnGap-31*
[**2200-5-5**] 02:47PM BLOOD Glucose-100 UreaN-48* Creat-4.2* Na-134
K-3.8 Cl-96 HCO3-10* AnGap-32*
[**2200-5-2**] 09:16PM BLOOD ALT-74* AST-132* LD(LDH)-169 AlkPhos-156*
TotBili-30.6* DirBili-19.6* IndBili-11.0
[**2200-5-3**] 05:45AM BLOOD ALT-72* AST-126* AlkPhos-154*
TotBili-29.0*
[**2200-5-4**] 05:35AM BLOOD ALT-63* AST-115* AlkPhos-136*
TotBili-34."
2866,"RADIOLOGY:
Abd U/S [**5-3**]:
IMPRESSION: Technically limited ultrasound.
1. Limited assessment of the portal vein. Probable patency of
the
extrahepatic portion of the main portal vein. Likely slow flow
within the
intrahepatic portal veins. However, partial occlusion cannot be
completely
excluded and this could be further assessed by non-contrast MRI
of the liver (given the patient's renal insufficiency).
2. Mildly distended gallbladder in the setting of large volume
abdominal
ascites. Correlation with clinical suspicion for acute
cholecystitis is
recommended. A HIDA scan could be performed if clinically
indicated.
3. Splenomegaly.
4. No hydronephrosis.
5. Large volume ascites."
2867,"Mother with
diabetes.
Physical Exam:
On admission:
VS: 97.9 95/50 88 16 100%
GEN: sleepy. jaundiced.
HEENT: PERRLA, EOMI, OP clear, MM dry, no LAD.
CV: regular, nl s1, s2, no m/r/g.
PULM: CTA B, no r/r/w.
ABD: distended, +BS, no appreciable HSM.
EXT: warm, 2+ dp/radial pulses BL. 2+ edema B LE.
NEURO: alert & oriented x 3, CN II-XII grossly intact. [**6-3**]
strength symmetric @ triceps, biceps, delts, hip flexion,
dorsoflexion, plantarflexion. sensation grossly intact. no
asterixis.
SKIN: jaundiced, spider telangiectasias.
Pertinent Results:
HEME:
.
[**2200-5-2**] 09:16PM BLOOD WBC-12."
2868,"7*
[**2200-5-4**] 09:50PM BLOOD ALT-57* AST-119* LD(LDH)-166 AlkPhos-142*
TotBili-32.8*
[**2200-5-5**] 04:52AM BLOOD ALT-75* AST-229* LD(LDH)-237 AlkPhos-97
TotBili-31.6*
[**2200-5-4**] 09:50PM BLOOD D-Dimer->[**Numeric Identifier 3652**]
.
MICROBIOLOGY:
.
[**2200-5-3**] 09:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-4* pH-6.5 Leuks-TR
[**2200-5-5**] 12:24AM ASCITES WBC-116* RBC-3600* Polys-47* Lymphs-14*
Monos-11* Mesothe-12* Macroph-16*
[**2200-5-5**] 02:10PM ASCITES WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier 41131**]* Polys-92*
Lymphs-3* Monos-0 Macroph-5*
4/6/9 - Bl Cx - GNR
."
2869,".
Pt seen by GI service, and diagnostic paracentesis was negative
for SBP (WBC 60, RBC 790 PMN 23 GLC 168 [**Doctor First Name 674**] 22 ALB <1). His
rising TBIL had been previously worked up without clear cause,
and pt underwent ERCP [**4-7**] with stent placement without benefit.
Consideration was given for cholecystostomy tube placement,
however [**Hospital 7188**] Hospital does not perform this procedure. Per
report, pt requested transfer to [**Hospital1 18**] as he was recently
evaluated by Dr. [**Last Name (STitle) 497**].
.
Of note, pt has had progressive decline in his renal function
since [**3-10**] from baseline of 0."
2870,"The decision was made to transfer the
patient to [**Hospital1 18**] for eval of liver failure for possible
transplantation eval. On the floor, an abdominal US showed
probable patency of the extrahepatic portion of the main portal
vein. Likely slow flow within the intrahepatic portal veins as
well as a mildly distended gallbladder in the setting of large
volume abdominal ascites. For his renal failure,
lasix/spiranolactone was being held and pt was receiving albumin
challenge to assess for HRS. On [**5-4**], pt had an episode of
shaking chills, which was followed by fever to 102.1,
tachycardia, hypotension, and large bloody BM."
2871,".
CT A/P [**5-5**]:
IMPRESSION: Fecalized ileal small bowel with mild proximal
dilation
may represents partial small bowel obstruction. There is no
pneumatosis or
wall thickening, however the indistinct wall of the fecalized
bowel loops is concerning for ischemia, although not specific.
There is no evidence of
perforation or abscess.
.
Brief Hospital Course:
In short, Mr [**Known lastname 33681**] is a 48M w alcoholic cirrhosis who
originally p/w abdominal pain to an OSH on [**4-30**], was found to
have tbili of 31, WBC of 14, Cr 3. A diagnostic paracentesis was
performed and was negative for SBP (WBC 60, RBC 790 PMN 23 GLC
168 [**Doctor First Name 674**] 22 ALB <1)."
2872,"5* MCV-UNABLE TO MCH-UNABLE TO MCHC-33.7 RDW-UNABLE TO
Plt Ct-77*
[**2200-5-5**] 02:47PM BLOOD WBC-52.6*# RBC-UNABLE TO Hgb-UNABLE TO
Hct-26* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE
TO Plt Ct-68*
[**2200-5-5**] 04:16PM BLOOD Hct-25*
.
[**2200-5-2**] 09:16PM BLOOD PT-23.7* PTT-52.9* INR(PT)-2.3*
[**2200-5-3**] 05:45AM BLOOD PT-24.8* PTT-55.2* INR(PT)-2.4*
[**2200-5-4**] 05:35AM BLOOD PT-25.9* PTT-110.2* INR(PT)-2."
2873,"6*
[**2200-5-4**] 01:50PM BLOOD PT-25.8* PTT-76.8* INR(PT)-2.5*
[**2200-5-4**] 09:50PM BLOOD PT-33.4* PTT-104.4* INR(PT)-3.5*
[**2200-5-5**] 02:01AM BLOOD PT-30.3* PTT-79.0* INR(PT)-3.1*
[**2200-5-5**] 02:01AM BLOOD Plt Ct-71*
[**2200-5-4**] 09:50PM BLOOD FDP-80-160*
[**2200-5-5**] 02:01AM BLOOD Fibrino-106*
[**2200-5-5**] 02:01AM BLOOD FDP-80-160*
[**2200-5-5**] 04:52AM BLOOD FDP-320-640*
.
CHEMISTRY:
[**2200-5-2**] 09:16PM BLOOD Glucose-89 UreaN-43* Creat-3."
2874,"4* Hct-26.4*
MCV-104* MCH-37.0* MCHC-35.5* RDW-15.8* Plt Ct-131*
[**2200-5-4**] 09:50PM BLOOD WBC-7.0# RBC-2.46* Hgb-9.1* Hct-25.8*
MCV-105* MCH-37.1* MCHC-35.4* RDW-15.7* Plt Ct-112*
[**2200-5-5**] 02:01AM BLOOD WBC-22.7*# RBC-UNABLE TO Hgb-7.3*
Hct-25.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-34.0 RDW-UNABLE TO
Plt Ct-71*
[**2200-5-5**] 04:52AM BLOOD WBC-27.1* RBC-UNABLE TO Hgb-7.5*
Hct-24."
2875,"EGD/flex sig without active
bleeding, e/o possible diverticular bleeding.
- GI performed EGD/sigmoidoscopy. EGD without bleeding, grade 1
varices at GE jnct, no active bleeding. Sigmoidoscopy with multiple
diverticula in sigmoid with clotted blood in few diverticula without
active bleeding, grade 1 internal hemorrhoids, recs albumin, ppi [**Hospital1 **]
- serial HCT
.
# ESLD - Hx of EtOH cirrhosis dx during admit in [**3-10**] for acute
hepatitis in setting of heavy tylenol use for URI on background of
history of heavy EtOH use. EGD at that time showed portal gastropathy
and esophageal candidiasis. Liver disease so far complicated by SBP,
worsening renal failure."
2876,"Chief Complaint:
24 Hour Events:
ENDOSCOPY - At [**2200-5-4**] 10:30 PM
COLONOSCOPY - At [**2200-5-4**] 10:30 PM
PARACENTESIS - At [**2200-5-5**] 12:18 AM
ARTERIAL LINE - START [**2200-5-5**] 12:35 AM
- admitted to MICU as transfer from ET for GI bleed in setting of liver
failure with fever
- dx paracentesis performed with 3L ascites taken off, no e/o SBP
- GI performed EGD/sigmoidoscopy. EGD without bleeding, grade 1
varices at GE jnct, no active bleeding. Sigmoidoscopy with multiple
diverticula in sigmoid with clotted blood in few diverticula without
active bleeding, grade 1 internal hemorrhoids, recs albumin, ppi [**Hospital1 **]."
2877,"5 g/dL
44 mg/dL
3.5 mg/dL
9 mEq/L
3.2 mEq/L
48 mg/dL
101 mEq/L
131 mEq/L
24.5 %
27.1 K/uL
[image002.jpg]
[**2200-5-4**] 09:50 PM
[**2200-5-5**] 01:23 AM
[**2200-5-5**] 02:01 AM
[**2200-5-5**] 04:52 AM
[**2200-5-5**] 05:00 AM
WBC
7.0
22.7
27.1
Hct
25.8
25.0
24.5
Plt
112
71
77
Cr
3.2
3.8
3.5
TCO2
11
9
Glucose
21
109
65
44
Other labs: PT / PTT / INR:34."
2878,"On transfer to
MICU, gap 23, likely related to lactic acidosis
- check ABG, lactate.
- trend HCO3.
.
# Anemia - macrocytic, HCT 38.2 in [**3-10**], down to 30 on [**4-30**]. LDH not
elevated arguing against hemolysis, as does low indirect bilirubin. pt
denies blood in stools or hemetemesis.
- guaic stools.
- maintain t&c.
- check iron studies to evaluate for ACD and pt's h/o
?hemochromotosis.
.
#DM2:
- HISS
.
FEN: NPO for now with encephalopathy
Prophylaxis: Pneumoboots, PPI, Lactulose
ACCESS: PIVs, a-line
CODE: FULL.
.
# COMM: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5579**] (h) [**Telephone/Fax (1) 5580**], (c) [**Telephone/Fax (1) 5581**], (w)
[**Telephone/Fax (1) 5582**].
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2200-5-4**] 10:01 PM
Arterial Line - [**2200-5-5**] 12:35 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
2879,"- persistent hypotension despite 1500cc NS and 100gm albumin.
- started on dopamine
- a line placed
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2200-5-4**] 11:00 PM
Piperacillin/Tazobactam (Zosyn) - [**2200-5-5**] 05:04 AM
Infusions:
Dopamine - 2 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2200-5-4**] 11:30 PM
Morphine Sulfate - [**2200-5-5**] 05:55 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2200-5-5**] 06:41 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2880,"9
C (100.2
Tcurrent: 36.3
C (97.4
HR: 90 (90 - 118) bpm
BP: 97/62(72) {85/38(53) - 112/64(80)} mmHg
RR: 20 (18 - 30) insp/min
SpO2: 96%
Heart rhythm: ST (Sinus Tachycardia)
Bladder pressure: 18 (18 - 23) mmHg
Total In:
1,071 mL
2,280 mL
PO:
TF:
IVF:
317 mL
1,732 mL
Blood products:
754 mL
488 mL
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
1,071 mL
2,280 mL
Respiratory support
O2 Delivery Device: Venti mask
SpO2: 96%
ABG: 7.25/20/87.[**Numeric Identifier 7**]/9/-16
Physical Examination
General Appearance: Anxious
Eyes / Conjunctiva: PERRL, +scleral icterus
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: bilateral bases)
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: 2+, Left: 2+, No(t) Clubbing
Skin: Not assessed, Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): AAOx1-2, Movement: Not assessed, Tone: Not
assessed
Labs / Radiology
77 K/uL
7."
2881,"- continue lactulose QID given mild confusion, titrate up prn.
- hold off on lasix/spirinolactone given ARF and hyponatremia.
- obtain OSH colonoscopy results.
- nutrition consult.
- consider vitamin K repletion.
.
# ARF - per OMR, creatinine 0.9 on [**2200-3-24**], up to 2.1 during [**4-11**] OSH
admission for SBP and then d/c with Cr 1.6, felt [**3-3**] pre-renal from
cirrhosis. Up to 2.5 upon admission to OSH [**4-30**], and 3.3 on admit at
[**Hospital1 5**]. Most concerning for HRS, though ddx also includes pre-renal, AIN
(recent course of augmentin and zosyn for SBP and E."
2882,"Pt has been evaluated at [**Hospital1 5**] by Dr. [**Last Name (STitle) 356**]
[**4-7**] for possible transplant, complicated by lack of insurance, history
of alcohol use as recent as [**3-10**]. Now, pt admitted to OSH [**4-30**] with abd
pain, found to have worsening tbili/cr and transferred from OSH for
transplant workup. At present he denies abdominal discomfort. His tbili
is marginally elevated compared to his baseline of 28 earlier this
month. More concerning is his progressively rising creatinine.
Abdominal U/S on [**5-3**] showed no intra/extra bil dil, probable portal
venous flow.
- f/u CT abd/pelvis
- plan possible MRI to eval portal vein."
2883,"1/87.8/3.6, ALT / AST:75/229, Alk Phos /
T Bili:97/31.6, Differential-Neuts:76.0 %, Band:15.0 %, Lymph:3.0 %,
Mono:4.0 %, Eos:1.0 %, D-dimer:[**Numeric Identifier 1804**] ng/mL, Fibrinogen:82 mg/dL, Lactic
Acid:8.6 mmol/L, Albumin:3.5 g/dL, LDH:237 IU/L, Ca++:8.7 mg/dL,
Mg++:2.6 mg/dL, PO4:4.3 mg/dL
Assessment and Plan
48M with etoh cirrhosis, transferred from OSH with rising Tbili and
creatinine. Transferred to MICU with fever, GI bleed.
.
# Sepsis - Hx SBP with admit to [**Hospital 869**] Hosp on [**2200-4-11**] with SBP
complicated by e."
2884,"Coli bacteremia).
U/S abd to eval kidneys without hydro/stones/masses. Ulytes neg, eos
neg.
- cont albumin boluses
- consider octreotide/midodrine based on labs above.
.
# AMS - Patient on admit to [**Hospital1 5**] with MS aaox3, acute change in mental
in association with GI bleed and fever. On MICU transfer, pt
encephalopathic with +asterixis, likely contribution from hepatic
dysfunction and uremia.
- continue lactulose as above.
- if fails to improve, consider renal consult.
.
# Hyponatremia - Resolved from admit. Likely [**3-3**] liver disease.
- hold diuretics, free water restrict, and trend.
.
# Acidosis - Gap 11 on admit, likely [**3-3**] ARF, though could have
contribution from alcoholic or starvation ketosis."
2885,"coli sepsis from possible gallbladder source, s/p 2
week tx with zosyn/augmentin. Now admitted to OSH [**4-30**] with abd pain,
dx paracentesis from OSH negative but here at [**Hospital **] transferred to MICU
with elevated WBC, temp to 102, tachycardic to 110's. Dx/therapeutic
3L paracentesis in MICU without SBP, continued hypotension, dopamine
started. Decreasing fibrinogen, elevated coags, possible DIC.
- Cont Vanco, zosyn
- s/p 3L paracentesis
- cont follow lactate
- Blood products for rescusitation
.
# GI bleed - Transfer to MICU with bloody BM's. Per OSH records, pt
with recent nml colonoscopy. EGD from OSH with report of portal
gastropathy and esophageal candidiasis."
2886,"Chief Complaint:
24 Hour Events:
ENDOSCOPY - At [**2200-5-4**] 10:30 PM
COLONOSCOPY - At [**2200-5-4**] 10:30 PM
PARACENTESIS - At [**2200-5-5**] 12:18 AM
ARTERIAL LINE - START [**2200-5-5**] 12:35 AM
- admitted to MICU as transfer from ET for GI bleed in setting of liver
failure with fever
- dx paracentesis performed with 3L ascites taken off, no e/o SBP
- GI performed EGD/sigmoidoscopy. EGD without bleeding, grade 1
varices at GE jnct, no active bleeding. Sigmoidoscopy with multiple
diverticula in sigmoid with clotted blood in few diverticula without
active bleeding, grade 1 internal hemorrhoids, recs albumin, ppi [**Hospital1 **]."
2887,"- consider vitamin K repletion.
.
# ARF - per OMR, creatinine 0.9 on [**2200-3-24**], up to 2.1 during [**4-11**] OSH
admission for SBP and then d/c with Cr 1.6, felt [**3-3**] pre-renal from
cirrhosis. Up to 2.5 upon admission to OSH [**4-30**], and 3.3 on admit at
[**Hospital1 5**]. Most concerning for HRS, though ddx also includes pre-renal, AIN
(recent course of augmentin and zosyn for SBP and E. Coli bacteremia).
U/S abd to eval kidneys without hydro/stones/masses. Ulytes neg, eos
neg.
- cont albumin boluses
- consider octreotide/midodrine based on labs above."
2888,"- persistent hypotension despite 1500cc NS and 100gm albumin.
- started on dopamine
- a line placed
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2200-5-4**] 11:00 PM
Piperacillin/Tazobactam (Zosyn) - [**2200-5-5**] 05:04 AM
Infusions:
Dopamine - 2 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2200-5-4**] 11:30 PM
Morphine Sulfate - [**2200-5-5**] 05:55 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2200-5-5**] 06:41 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2889,"coli sepsis from possible gallbladder source, s/p 2
week tx with zosyn/augmentin. Now admitted to OSH [**4-30**] with abd pain,
dx paracentesis from OSH negative but here at [**Hospital1 **] with elevated WBC,
temp to 102, tachycardic to 110's.
- Vanco, zosyn
- Paracentesis
- lactate
- DIC
- Blood products for rescusitation
- a-line if HD unstable
.
# GI bleed - Transfer to MICU with bloody BM's. Per OSH records, pt
with recent nml colonoscopy. EGD from OSH with report of portal
gastropathy and esophageal candidiasis. Source of bloody stool likely
from upper source. HCT 26->26 from AM to PM.
- Liver consult called, will plan to perform EGD and flex sig
- 1u PRBC, 2u FFP to start in MICU
- serial HCT
."
2890,"2 in [**3-10**], down to 30 on [**4-30**]. LDH not
elevated arguing against hemolysis, as does low indirect bilirubin. pt
denies blood in stools or hemetemesis.
- guaic stools.
- maintain t&c.
- check iron studies to evaluate for ACD and pt's h/o
?hemochromotosis.
.
#DM2:
- HISS
.
FEN: NPO for now with encephalopathy
Prophylaxis: Pneumoboots, PPI, Lactulose
ACCESS: PIVs, a-line
CODE: FULL.
.
# COMM: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5579**] (h) [**Telephone/Fax (1) 5580**], (c) [**Telephone/Fax (1) 5581**], (w)
[**Telephone/Fax (1) 5582**].
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2200-5-4**] 10:01 PM
Arterial Line - [**2200-5-5**] 12:35 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
2891,"At present he denies abdominal discomfort. His tbili
is marginally elevated compared to his baseline of 28 earlier this
month. More concerning is his progressively rising creatinine.
Abdominal U/S on [**5-3**] showed no intra/extra bil dil, probable portal
venous flow.
- consider CT abd/pelvis r/o infection
- plan possible MRI to eval portal vein.
- continue lactulose QID given mild confusion, titrate up prn.
- hold off on lasix/spirinolactone given ARF and hyponatremia.
- given worsening status with elevated WBC and new fever, will perform
dx paracentesis
- GI consult to perform EGD/flex sig
- obtain OSH colonoscopy results.
- nutrition consult."
2892,".
# AMS - Patient on admit to [**Hospital1 5**] with MS aaox3, acute change in mental
in association with GI bleed and fever. On MICU transfer, pt
encephalopathic with +asterixis, likely contribution from hepatic
dysfunction and uremia.
- continue lactulose as above.
- if fails to improve, consider renal consult.
.
# Hyponatremia - Resolved from admit. Likely [**3-3**] liver disease.
- hold diuretics, free water restrict, and trend.
.
# Acidosis - Gap 11 on admit, likely [**3-3**] ARF, though could have
contribution from alcoholic or starvation ketosis. On transfer to
MICU, gap 23, likely related to lactic acidosis
- check ABG, lactate.
- trend HCO3.
.
# Anemia - macrocytic, HCT 38."
2893,"5 g/dL
44 mg/dL
3.5 mg/dL
9 mEq/L
3.2 mEq/L
48 mg/dL
101 mEq/L
131 mEq/L
24.5 %
27.1 K/uL
[image002.jpg]
[**2200-5-4**] 09:50 PM
[**2200-5-5**] 01:23 AM
[**2200-5-5**] 02:01 AM
[**2200-5-5**] 04:52 AM
[**2200-5-5**] 05:00 AM
WBC
7.0
22.7
27.1
Hct
25.8
25.0
24.5
Plt
112
71
77
Cr
3.2
3.8
3.5
TCO2
11
9
Glucose
21
109
65
44
Other labs: PT / PTT / INR:34."
2894,"1/87.8/3.6, ALT / AST:75/229, Alk Phos /
T Bili:97/31.6, Differential-Neuts:76.0 %, Band:15.0 %, Lymph:3.0 %,
Mono:4.0 %, Eos:1.0 %, D-dimer:[**Numeric Identifier 1804**] ng/mL, Fibrinogen:82 mg/dL, Lactic
Acid:8.6 mmol/L, Albumin:3.5 g/dL, LDH:237 IU/L, Ca++:8.7 mg/dL,
Mg++:2.6 mg/dL, PO4:4.3 mg/dL
Assessment and Plan
48M with etoh cirrhosis, transferred from OSH with rising Tbili and
creatinine. Transferred to MICU with fever, GI bleed.
.
# Sepsis - Hx SBP with admit to [**Hospital 869**] Hosp on [**2200-4-11**] with SBP
complicated by e."
2895,"# ESLD - Hx of EtOH cirrhosis dx during admit in [**3-10**] for acute
hepatitis in setting of heavy tylenol use for URI on background of
history of heavy EtOH use. EGD at that time showed portal gastropathy
and esophageal candidiasis. Liver disease so far complicated by SBP,
worsening renal failure. Pt has been evaluated at [**Hospital1 5**] by Dr. [**Last Name (STitle) 356**]
[**4-7**] for possible transplant, complicated by lack of insurance, history
of alcohol use as recent as [**3-10**]. Now, pt admitted to OSH [**4-30**] with abd
pain, found to have worsening tbili/cr and transferred from OSH for
transplant workup."
2896,"9
C (100.2
Tcurrent: 36.3
C (97.4
HR: 90 (90 - 118) bpm
BP: 97/62(72) {85/38(53) - 112/64(80)} mmHg
RR: 20 (18 - 30) insp/min
SpO2: 96%
Heart rhythm: ST (Sinus Tachycardia)
Bladder pressure: 18 (18 - 23) mmHg
Total In:
1,071 mL
2,280 mL
PO:
TF:
IVF:
317 mL
1,732 mL
Blood products:
754 mL
488 mL
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
1,071 mL
2,280 mL
Respiratory support
O2 Delivery Device: Venti mask
SpO2: 96%
ABG: 7.25/20/87.[**Numeric Identifier 7**]/9/-16
Physical Examination
General Appearance: Anxious
Eyes / Conjunctiva: PERRL, +scleral icterus
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: bilateral bases)
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: 2+, Left: 2+, No(t) Clubbing
Skin: Not assessed, Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): AAOx1-2, Movement: Not assessed, Tone: Not
assessed
Labs / Radiology
77 K/uL
7."
2897,"2 in [**3-10**], down to 30 on [**4-30**]. LDH not
elevated arguing against hemolysis, as does low indirect bilirubin. pt
denies blood in stools or hemetemesis.
- guaic stools.
- maintain t&c.
- check iron studies to evaluate for ACD and pt's h/o
?hemochromotosis.
.
#DM2:
- HISS
.
FEN: NPO for now with encephalopathy
Prophylaxis: Pneumoboots, PPI, Lactulose
ACCESS: PIVs, a-line
CODE: FULL.
.
# COMM: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5579**] (h) [**Telephone/Fax (1) 5580**], (c) [**Telephone/Fax (1) 5581**], (w)
[**Telephone/Fax (1) 5582**].
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2200-5-4**] 10:01 PM
Arterial Line - [**2200-5-5**] 12:35 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
2898,"9
C (100.2
Tcurrent: 36.3
C (97.4
HR: 90 (90 - 118) bpm
BP: 97/62(72) {85/38(53) - 112/64(80)} mmHg
RR: 20 (18 - 30) insp/min
SpO2: 96%
Heart rhythm: ST (Sinus Tachycardia)
Bladder pressure: 18 (18 - 23) mmHg
Total In:
1,071 mL
2,280 mL
PO:
TF:
IVF:
317 mL
1,732 mL
Blood products:
754 mL
488 mL
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
1,071 mL
2,280 mL
Respiratory support
O2 Delivery Device: Venti mask
SpO2: 96%
ABG: 7.25/20/87.[**Numeric Identifier 7**]/9/-16
Labs / Radiology
77 K/uL
7."
2899,"coli sepsis from possible gallbladder source, s/p 2
week tx with zosyn/augmentin. Now admitted to OSH [**4-30**] with abd pain,
dx paracentesis from OSH negative but here at [**Hospital1 **] with elevated WBC,
temp to 102, tachycardic to 110's.
- Vanco, zosyn
- Paracentesis
- lactate
- DIC
- Blood products for rescusitation
- a-line if HD unstable
.
# GI bleed - Transfer to MICU with bloody BM's. Per OSH records, pt
with recent nml colonoscopy. EGD from OSH with report of portal
gastropathy and esophageal candidiasis. Source of bloody stool likely
from upper source. HCT 26->26 from AM to PM.
- Liver consult called, will plan to perform EGD and flex sig
- 1u PRBC, 2u FFP to start in MICU
- serial HCT
."
2900,"- persistent hypotension despite 1500cc NS and 100gm albumin.
- a line placed
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2200-5-4**] 11:00 PM
Piperacillin/Tazobactam (Zosyn) - [**2200-5-5**] 05:04 AM
Infusions:
Dopamine - 2 mcg/Kg/min
Other ICU medications:
Furosemide (Lasix) - [**2200-5-4**] 11:30 PM
Morphine Sulfate - [**2200-5-5**] 05:55 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2200-5-5**] 06:41 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
2901,"5 g/dL
44 mg/dL
3.5 mg/dL
9 mEq/L
3.2 mEq/L
48 mg/dL
101 mEq/L
131 mEq/L
24.5 %
27.1 K/uL
[image002.jpg]
[**2200-5-4**] 09:50 PM
[**2200-5-5**] 01:23 AM
[**2200-5-5**] 02:01 AM
[**2200-5-5**] 04:52 AM
[**2200-5-5**] 05:00 AM
WBC
7.0
22.7
27.1
Hct
25.8
25.0
24.5
Plt
112
71
77
Cr
3.2
3.8
3.5
TCO2
11
9
Glucose
21
109
65
44
Other labs: PT / PTT / INR:34."
2902,".
# AMS - Patient on admit to [**Hospital1 5**] with MS aaox3, acute change in mental
in association with GI bleed and fever. On MICU transfer, pt
encephalopathic with +asterixis, likely contribution from hepatic
dysfunction and uremia.
- continue lactulose as above.
- if fails to improve, consider renal consult.
.
# Hyponatremia - Resolved from admit. Likely [**3-3**] liver disease.
- hold diuretics, free water restrict, and trend.
.
# Acidosis - Gap 11 on admit, likely [**3-3**] ARF, though could have
contribution from alcoholic or starvation ketosis. On transfer to
MICU, gap 23, likely related to lactic acidosis
- check ABG, lactate.
- trend HCO3.
.
# Anemia - macrocytic, HCT 38."
2903,"At present he denies abdominal discomfort. His tbili
is marginally elevated compared to his baseline of 28 earlier this
month. More concerning is his progressively rising creatinine.
Abdominal U/S on [**5-3**] showed no intra/extra bil dil, probable portal
venous flow.
- consider CT abd/pelvis r/o infection
- plan possible MRI to eval portal vein.
- continue lactulose QID given mild confusion, titrate up prn.
- hold off on lasix/spirinolactone given ARF and hyponatremia.
- given worsening status with elevated WBC and new fever, will perform
dx paracentesis
- GI consult to perform EGD/flex sig
- obtain OSH colonoscopy results.
- nutrition consult."
2904,"1/87.8/3.6, ALT / AST:75/229, Alk Phos /
T Bili:97/31.6, Differential-Neuts:76.0 %, Band:15.0 %, Lymph:3.0 %,
Mono:4.0 %, Eos:1.0 %, D-dimer:[**Numeric Identifier 1804**] ng/mL, Fibrinogen:82 mg/dL, Lactic
Acid:8.6 mmol/L, Albumin:3.5 g/dL, LDH:237 IU/L, Ca++:8.7 mg/dL,
Mg++:2.6 mg/dL, PO4:4.3 mg/dL
Assessment and Plan
48M with etoh cirrhosis, transferred from OSH with rising Tbili and
creatinine.
.
# Sepsis - Hx SBP with admit to [**Hospital 869**] Hosp on [**2200-4-11**] with SBP
complicated by e."
2905,"- consider vitamin K repletion.
.
# ARF - per OMR, creatinine 0.9 on [**2200-3-24**], up to 2.1 during [**4-11**] OSH
admission for SBP and then d/c with Cr 1.6, felt [**3-3**] pre-renal from
cirrhosis. Up to 2.5 upon admission to OSH [**4-30**], and 3.3 on admit at
[**Hospital1 5**]. Most concerning for HRS, though ddx also includes pre-renal, AIN
(recent course of augmentin and zosyn for SBP and E. Coli bacteremia).
U/S abd to eval kidneys without hydro/stones/masses. Ulytes neg, eos
neg.
- cont albumin boluses
- consider octreotide/midodrine based on labs above."
2906,"# ESLD - Hx of EtOH cirrhosis dx during admit in [**3-10**] for acute
hepatitis in setting of heavy tylenol use for URI on background of
history of heavy EtOH use. EGD at that time showed portal gastropathy
and esophageal candidiasis. Liver disease so far complicated by SBP,
worsening renal failure. Pt has been evaluated at [**Hospital1 5**] by Dr. [**Last Name (STitle) 356**]
[**4-7**] for possible transplant, complicated by lack of insurance, history
of alcohol use as recent as [**3-10**]. Now, pt admitted to OSH [**4-30**] with abd
pain, found to have worsening tbili/cr and transferred from OSH for
transplant workup."
2907,"Chief Complaint:
24 Hour Events:
ENDOSCOPY - At [**2200-5-4**] 10:30 PM
COLONOSCOPY - At [**2200-5-4**] 10:30 PM
PARACENTESIS - At [**2200-5-5**] 12:18 AM
ARTERIAL LINE - START [**2200-5-5**] 12:35 AM
- admitted to MICU as transfer from ET for GI bleed in setting of liver
failure with fever
- dx paracentesis performed with 3L ascites taken off, no e/o SBP
- GI performed EGD/sigmoidoscopy. EGD without bleeding, grade 1
varices at GE jnct, no active bleeding. Sigmoidoscopy with multiple
diverticula in sigmoid with clotted blood in few diverticula without
active bleeding, grade 1 internal hemorrhoids, recs albumin, ppi [**Hospital1 **]."
2908,"Admission Date: [**2119-1-3**] Discharge Date: [**2119-1-10**]
Date of Birth: [**2057-10-15**] Sex: F
Service: SURGERY
Allergies:
Codeine / NSAIDS
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61 Year old female, driving on highway, missed exit and backed
up, struck by oncoming truck. + airbag deployment, +LOC. At OSH
found to have small frontal contusion, and multiple rib
fractures and small PTX. Awake and alert on arrival to [**Hospital1 18**].
Multiple facial fractures.
Past Medical History:
PMH: diabetes, bleeding ulcer, HTN, opioid abuse
PSH: total hysterectomy, back surgery"
2909,"Social History:
single, lives at home, smoker, no EtOH
Family History:
Noncontributory
Physical Exam:
On arrival to [**Hospital1 18**]:
Constitutional: Uncomfortable
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Oropharynx within normal limits
chin laceration
Chest: Clear to auscultation, tender to palpation -right
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema
Neuro: Speech fluent, GCS 15, moves all extremities
On discharge:
Vitals 98.5 81 122/73 18 93% RA
Constitutional: A&O, NAD
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Oropharynx within normal limits
chin laceration sutures removed, well approximated, no drainage
Chest: Clear to auscultation, tender to palpation -right
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema
Neuro: Speech fluent, GCS 15, moves all extremities"
2910,"01
[**2119-1-3**] 01:20PM UREA N-25* CREAT-1.2*
[**2119-1-3**] 01:31PM GLUCOSE-140* LACTATE-2.4* NA+-139 K+-4.0
CL--99 TCO2-27
Brief Hospital Course:
61 F s/p MVC admitted to the ACS service for treatment of the
following injuries:
- small R SAH
- R frontal lobe contusion
- R zygomatic arch fracture
- fracture of lateral and frontal wall of R maxillary sinus
- minimally displaced fx of the right and left orbital roofs
- 3cm anterior neck laceration
- Rib fracures right 1,2,[**5-20**]; left 2nd rib
- small left apical pneumothorax
The patient has a history of narcotic abuse and was on suboxone
at the time of admission."
2911,"acute pain consult - unable to place
epidural. dilaudid PCA. ophtho exam.
[**1-4**]: Resumed regular diet, home meds. Added PO oxycodone to
pain regimen. Decreased frequency of neurochecks to Q4h.
She was transferred to the surgical floor on [**1-5**]. She remained
alert and oriented and neuro checks were performed q8h, with no
changes in neuro status. Her pain was frequently assessed and
she remained on the Dilaudid PCA initially and was transitioned
to an oral narcotic pain regimen subsequently, with which she
reported adequate pain relief. Her vitals signs were routinely
monitored and she remained hemodynamically stable. She was
placed on telemetry with continuous O2 monitoring given her rib
fractures."
2912,"[**1-7**] SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT
Bone fragments projecting superior to the narrowed
acromioclavicular joint
could be acute avulsions. There also appear to be areas of
erosion on the
distal clavicle suggesting a chronic degenerative component. The
head of the humerus is smooth, and there is no dislocation.
Glenoid is intact.
[**2119-1-9**] CHEST (PA & LAT)
1. No new focal consolidation.
2. Increased small right pleural effusion and new, loculated,
right pleural or extrapleural fluid, could be due to interval
bleeding of displaced rib fractures.
3. Pulmonary edema has resolved.
4. Decrease in subcutaneous emphysema.
[**2119-1-3**] 01:20PM WBC-13."
2913,"4* RBC-3.45* HGB-11.5* HCT-34.4*
MCV-100* MCH-33.4* MCHC-33.4 RDW-13.7
[**2119-1-3**] 01:20PM PLT COUNT-228
[**2119-1-3**] 01:20PM PT-11.6 PTT-21.0* INR(PT)-1.0
[**2119-1-3**] 01:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.039*
[**2119-1-3**] 01:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2119-1-3**] 01:20PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2119-1-3**] 01:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2119-1-3**] 01:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2119-1-3**] 01:20PM LIPASE-20
[**2119-1-3**] 01:20PM cTropnT-<0."
2914,"6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily)."
2915,"You should take your pain medicine as as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths.
If the pain medication is too sedation, take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the samll
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing."
2916,"Please follow up as instructed below with the Acute Care
Service, orthopedics and plastic surgery.
You were also seen by the opthomology doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **] were in
the hospital who recommended that you have annual eye exams
given your history of diabetes mellitus and high blood pressure.
Followup Instructions:
Department: DIV. OF PLASTIC SURGERY
When: FRIDAY [**2119-1-20**] at 9:15 AM
With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD and Dr [**Last Name (STitle) 65728**]
Phone[**Telephone/Fax (1) 6331**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage"
2917,"She was admitted to the ICU for neuro
checks which were intact throughout her time in the ICU. She was
seen by neurosurgery who recommended a a follow head CT. This CT
was not obtained as the patient able to participate in neuro
checks. Plastic surgery saw the patient and determined that her
facial fractures were nonoperative and she will follow up with
them in clinic and sinus precautions while she was hospitalized.
Her pain was difficult to manage because of the suboxone but
became manageable after the medication cleared her system.
Events in the TICU were the following:
[**1-3**]: admitted to TSICU."
2918,"Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Thefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal anti-inflammatory drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves."
2919,"13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q8H (every 8 hours).
Disp:*65 Tablet Extended Release(s)* Refills:*0*
16. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
s/p MVC
Injuries:
SAH in the right sylvian fissure
Right frontal lobe contusion
Rib fractures- Right: 1,2,[**5-20**]."
2920,"Her blood sugars were monitored routinely and managed with her
home metformin and a sliding scale of regular insulin as needed.
They remained controlled in the 100's at the time of discharge
so she was not continued on the sliding scale insulin.
Plastic surgery was consulted initially for her facial
fractures. It was determined that her facial fractures did not
require operative intervention at that time. Plastics
recommended follow up as an outpatient, for which the patient
was scheduled at discharge.
Orthopedics was consulted for new complaints of right shoulder
pain. Xrays were obtained (see pertinent results for details."
2921,"Department: ORTHOPEDICS
When: THURSDAY [**2119-1-26**] at 11:20 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
Department: ORTHOPEDICS
When: THURSDAY [**2119-1-26**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2119-1-31**] at 1 PM
With: ACUTE CARE CLINIC with Dr [**Last Name (STitle) 853**]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2119-1-10**]"
2922,"The patient was scheduled for follow up at discharge in the [**Hospital 2536**]
clinic on [**2119-1-31**].
Medications on Admission:
lisinopril, atenolol, lasix, suboxone, simvastatin, Asa,
prilosec, prozac, amitryptiline
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
5. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime)."
2923,")
She was noted to have weakness in her right shoulder which may
be secodary to pain vs. from a rotator cuff injury. However it
was decided that there was no acute injury and the patient was
scheduled for orthopedic follow up as an outpatient. The patient
was given a sling for comfort.
Opthlomology was consulted when the patient was in the ICU for
her eye fracture who deferred to the plastic surgery team for
acute management and recommended routine annual exams for
DM/HTN.
Neurosurgery was consulted initially for cerebral ecchymosis and
SAH. The patient remained neurologically stable the neurosurgery
signed off."
2924,"She was tolerating a regular diet and started on a bowel regimen
given her use of narcotics. A foley catheter was placed on
admission and removed on [**1-5**], at which time she voided without
difficulty.
She was evaluated by physical therapy and occupational therapy
who initially recommended discharge to an extended care facility
for further rehabilitation when medically stable. However, as
she progressed toward discharge her mobility greatly improved
and she become much more independent and was able to dress
herself independently. She was out of bed ambulating with
supervision at the time of discharge, and was discharged to home
with VNA services in place."
2925,"Left: 2nd rib
Fracture of right zygomatic arch
Fracture of lateral & frontal wall of the right maxillary sinus
Minimally displaced fracture of bilateral orbital roofs
3cm anterior neck laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a motor vehicle
accident. You sustained multiple injuries including a small head
bleed and bruising, multiple facial fractures, multiple rib
fractures, and a laceration on your neck.
You are being discharged with the following instructions:
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain."
2926,"It was noted that her O2 saturation was decreasing to
the high 80's on RA. The patient denied SOB and incentive
spirometry and pulmonary toileting were encouraged. However,
difficulty remained weaning supplemental oxygen and a chest xray
was obtained on [**1-9**] which showed a very small right pleural
effusion (old) and new, small loculated, right pleural or
extrapleural fluid. However the xray showed resolution of prior
pulmonary edema when compared to prior xrays, no new focal
consolidation, and no evidence of prior pneumothorax seen
initially on CT scan at admission. The patient continued to deny
any shortness of breath, and O2 her sats at discharge remained
between 89-93% on RA (patient with significant smoking history)."
2927,"Left apical pneumothorax and atelectasis at the lung apices.
4. Large amount of subcutaneous emphysema tracking to the
fascial planes of the neck. No evidence of airway injury.
CT sinus:
1. Minimally displaced fractures of the right zygomatic arch,
and lateral and anterior walls of the right maxillary sinus with
hemorrhagic fluid within the sinus cavity.
2. Minimally displaced fractures of the bilateral orbital roof
with a small amount of associated subcutaneous emphysema.
3. Mucosal thickening in the ethmoidal sinus as well as minimal
mucosal
thickening in the left maxillary and left sphenoid sinus.
4. Cervical subcutaneous emphysema, better assessed on
concurrent C-spine
study."
2928,"Pertinent Results:
CT head/ Sinus:
1. Small subarachnoid hemorrhage in the sulci of the right
temporo-parietal
lobe.
2. Hyperdense focus in the right frontal lobe, likely contusion.
Possible
contusion in the left frontal lobe.
3. Fracture of the right zygomatic arch and lateral wall of the
right
maxillary sinus with hemorrhagic fluid within the right
maxillary sinus.
Facial bone fractures are better seen on subsequent CT sinus.
4. Subcutaneous emphysema as outlined above.
CT Neck:
1. No acute fracture or traumatic malalignment of the cervical
spine.
2. Displaced fractures of the second and third ribs on the
right.
3."
2929,"Name: [**Known lastname 1395**],[**Known firstname 9312**] Unit No: [**Numeric Identifier 14493**]
Admission Date: [**2185-1-5**] Discharge Date: [**2185-1-13**]
Date of Birth: [**2110-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 265**]
Addendum:
on [**1-11**] the patient had a CXR that showed: Continued enlargement
of
the cardiac silhouette with bilateral pleural effusions, more
prominent on the right, and underlying compressive atelectasis.
There is persistent mild engorgement of the pulmonary vessels.
These changes are consistant with post-operative volume
overload.
She was also noted to have several episodes of post-op atrial
fibrillation which could cause some degree of congestive heart
failure- and pulmonary engorgement
Pertinent Results:
on [**1-11**] the patient had a CXR that showed: Continued enlargement
of
the cardiac silhouette with bilateral pleural effusions, more
prominent on the right, and underlying compressive atelectasis.
There is persistent mild engorgement of the pulmonary vessels.
These changes are consistant with post-operative volume
overload.
She was also noted to have several episodes of post-op atrial
fibrillation which could cause some degree of congestive heart
failure- and pulmonary engorgement
Discharge Disposition:
Extended Care
Facility:
[**Hospital 14494**] nursing and rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2185-3-4**]"
2930,"Admission Date: [**2185-1-5**] Discharge Date: [**2185-1-13**]
Date of Birth: [**2110-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2185-1-6**] Four Vessel Coronary artery bypass grafting utilizing
left internal mammary artery to left anterior descending with
saphenous vein grafts to first obtuse marginal, second obtuse
marginal and PDA.
History of Present Illness:
This is a 74 year old female who presented to [**Hospital3 **]
with exertional chest pain with radiation to both arms since
summer. Patient denied rest pain and stated that her chest pain
was relieved by rest."
2931,"She underwent cardiac catheterization
which revealed severe three vessel coronary artery disease
including a 95% left main lesion with normal left ventricular
function. She was urgently transferred to the [**Hospital1 18**] for surgical
revascularization.
Past Medical History:
Carotid artery disease
Hypertension
History of abnormal mammogram
Hyperlipidemia
Stress incontinence
Peripheral vascular disease
Hypothyroidism
Asthamtic bronchitis
s/p cholecystectomy
s/p hysterectomy-tubal pregnancy
s/p aorto-bifem [**1-/2183**]
Social History:
Widowed, lives alone.
Occupation: Retired from Lucent
Cigarettes: Smoked no [] yes [x] last cigarette [**2162**]
ETOH: denies
Illicit drug use: denies
Family History:
Denies premature coronary artery disease
Physical Exam:
Admission Exam:
T 98."
2932,"On
the stepdown floor she was noted to have bursts of Atrial
Fibrillation and was started on amiodarone and coumadin for
anticoagulation, following which she converted to sinus rhythm.
The remainder of her hospital course was largely uneventful. She
worked with nursing and physical therapy, however progress was
slow and she was cleared for discharge to Nevins Nursing and
Rehab in [**Location (un) 7661**] on POD #7. Target INR 2.0-2.5 for A Fib. First
blood draw tomorrow [**1-14**]. All f/u appts advised.
She is to follow up with Dr [**First Name (STitle) **] in 1 month."
2933,"Medications on Admission:
Ditropan XL 5 daily
ASA 81 daily
Cartia XL 240 daily
Fosamax 35 qwk
Levothyroxine 50 mcg daily
Losartan 50 daily
Pravachol 80 daily
NTG 0.4 sl/prn
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
2. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months."
2934,"15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
every other day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] nursing and rehab
Discharge Diagnosis:
Coronary artery disease, s/p CABG
Postop Atrial Fibrillation
Peripheral Vascular Disease, prior aorto-bifem in [**2183-1-27**]
Carotid Disease
Hypertension
Dyslipidemia
Hypothyroidism
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol and Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 2+ bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon."
2935,"2. Endoscopic harvesting of the long saphenous vein.
Cardiopulmonary bypass time was 89 minutes with a crossclamp
time of 80 minutes. She tolerated the operation well and
following the operation, she was brought to the CVICU for
invasive monitoring. In the immediate post-op period she
remained hemodynamically stable, woke neurologically intact and
extubated later that day. She continued to be hemodynamically
stable throughout POD1 and transferred to the floor on POD2 for
further recovery and post operative care. Chest tubes and pacing
wires removed per cardiac surgery protocol. the patient started
on Bblockers and was gently diuresed toward her preop weight."
2936,"5* Na-134 K-4.5 Cl-104
[**2185-1-9**] 06:20AM BLOOD Glucose-93 UreaN-19 Creat-1.3* Na-136
K-3.9 Cl-100 HCO3-28 AnGap-12
[**2185-1-8**] 02:01AM BLOOD Glucose-114* UreaN-17 Creat-1.3* Na-136
K-4.1 Cl-103 HCO3-27 AnGap-10
[**2185-1-7**] 12:31AM BLOOD Glucose-93 UreaN-18 Creat-1.4* Na-139
K-4.3 Cl-108 HCO3-28 AnGap-7*
.
[**2185-1-11**] Chest x-ray PA and Lat:
In comparison with the study of [**1-8**], allowing for the PA versus
AP projection, there is probably little overall change."
2937,"Look at
your incisions daily for redness or drainage
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 one month or while taking narcotics., Driving
will be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**"
2938,"Continued enlargement of the cardiac silhouette with bilateral
pleural effusions, more prominent on the right, and underlying
compressive atelectasis. There is persistent mild engorgement of
the pulmonary vessels.
.
[**2185-1-6**] Intraop TEE:
PRE-CPB:
The left atrium is moderately dilated. No thrombus is seen in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Hypokinesis is noted in
the mid inferior and inferoseptal walls. Right ventricular
chamber size and free wall motion are normal."
2939,"6* Hct-31.5*
MCV-87 MCH-29.2 MCHC-33.7 RDW-14.1 Plt Ct-143*
[**2185-1-12**] 11:10AM BLOOD PT-PND PTT-PND INR(PT)-PND
[**2185-1-11**] 05:15AM BLOOD PT-16.7* INR(PT)-1.6*
[**2185-1-10**] 05:10AM BLOOD PT-13.2* INR(PT)-1.2*
[**2185-1-7**] 12:31AM BLOOD PT-12.6* PTT-28.4 INR(PT)-1.2*
[**2185-1-12**] 04:55AM BLOOD Glucose-84 UreaN-28* Creat-1.4* Na-138
K-4.3 Cl-102 HCO3-24 AnGap-16
[**2185-1-10**] 05:10AM BLOOD UreaN-33* Creat-1."
2940,"1 Pulse: 68 bpm Resp: O2 sat:
B/P Right: 140/70 Left:
Height: 61 inches Weight: 153 lbs
General: well nourished/ NAD
Skin: Dry [x] intact [x] Well healed aorta bifem incision
HEENT: PERRLA [x] EOMI [x] MMM, normal oropharynx
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] No M/R/G
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], NO CCE
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: dopplerable Left: dopplerable
PT [**Name (NI) 167**]:dopplerable Left: dopplerable
Radial Right: 2+ Left: 2+
Carotid Bruit Right: 1+ w/bruit Left: 1+"
2941,"There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**11-29**]+) mitral regurgitation is seen.
Dr.[**Last Name (STitle) **] was notified in person of the results at time
of study.
POST-CPB:
The patient is on a phenylephrine infusion. The mid inferior and
inferoseptal segments appear severely hypokinetic bordering on
akinetic, which is worse than pre-bypass. Other wall segments
are contracting well."
2942,"5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold hr<50 and/or sbp<100 .
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-4**]
hours as needed for pain.
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day."
2943,"Discharge:
98.6 57 126/68 18 96%-RA
Gen NAD
Neuro A&O x3
CV RRR, no murmur. Sternum stable, incision CDI
Pulm CTA-bilat
Abdm soft, NT/ND/+BS
Ext warm, well perfused 2+ pedal edema bilat
Pertinent Results:
Admit Labs:
[**2185-1-5**] 07:58PM BLOOD WBC-7.0 RBC-4.18* Hgb-12.6 Hct-35.7*
MCV-85 MCH-30.2 MCHC-35.4* RDW-13.2 Plt Ct-298
[**2185-1-5**] 07:58PM BLOOD PT-10.6 PTT-150* INR(PT)-1.0
[**2185-1-5**] 07:58PM BLOOD Glucose-102* UreaN-8 Creat-1."
2944,"7* Na-134
K-4.2 Cl-100 HCO3-26 AnGap-12
[**2185-1-5**] 07:58PM BLOOD ALT-15 AST-6 CK(CPK)-102 AlkPhos-54
Amylase-19 TotBili-0.4
[**2185-1-5**] 07:58PM BLOOD CK-MB-2.7 cTropnT-0.01
.
Discharge Labs:
[**2185-1-12**] 04:55AM BLOOD Hct-34.1*
[**2185-1-11**] 05:15AM BLOOD WBC-5.8 RBC-3.63* Hgb-10.9* Hct-32.2*
MCV-89 MCH-30.1 MCHC-33.9 RDW-14.3 Plt Ct-231#
[**2185-1-9**] 06:20AM BLOOD WBC-8.2 RBC-3.64* Hgb-10."
2945,"Overall estimated systolic EF=50%. The
right ventricular systolic function is preserved.
Valve function remains unchanged. There is no evidence of
dissection.
Brief Hospital Course:
Mrs. [**Known lastname 19122**] was admitted and underwent routine preoperative
evaluation. She remained pain free on medical therapy and was
cleared for surgery. On [**1-6**], Dr. [**First Name (STitle) **] performed
coronary artery bypass grafting surgery. For surgical details,
please see operative note. In summary she had:
1. Urgent coronary artery bypass graft x4 left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to obtuse marginal 1 and 2
posterior descending artery."
2946,"Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**2185-2-8**] at 1:00p
Cardiologist: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2185-2-2**] at 2:45p
Wound check @ [**Hospital Unit Name **], [**Hospital Unit Name **] on [**2185-1-20**] at 10:00a
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],MIROSLAWA [**Telephone/Fax (1) 34574**] in [**3-3**] 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**
.
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR: 2.0 to 2.5
First draw: [**2185-1-14**]
Please arrange followup with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 63252**] prior to discharge
from rehab. Office # [**Telephone/Fax (1) 34574**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2185-1-13**]"
2947,"11. warfarin 1 mg Tablet Sig: daily dosing per rehab provider;
target INR 2.0-2.5 for A Fib Tablets PO DAILY (Daily): dose
today [**1-13**] only is 0.5 mg; all further dosing per rehab
provider.
12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 2 weeks:
while on lasix; hold for K+ > 4.5.
13. Ditropan XL 5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
14. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day."
2948,"Admission Date: [**2189-7-20**] Discharge Date: [**2189-7-27**]
Date of Birth: [**2150-11-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Cocaine Overdose
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is a 38 year-old male with no PMH presents with cocaine
overdose. The patient was confronted by the [**Last Name (un) **]/police during a
drug deal and proceeded to ingest 14-16 grams of powder cocaine.
There is a question as to whether he ingested multiple small
bags or one large bag."
2949,"Pt tachycardic and BP elevated at OSH, but
controlled in the ED with valium IV. Tox screen neg at OSH
other then cocaine and BZD. In the [**Name (NI) 153**], pt was extubated on
[**2189-7-20**] and remained stable on oxygen by NC. Additionally a
toxicology cosult was called and recommended KUB to rule out any
retained packages in the bowel which is negative. His vitals
signs: HR, BP, all remained stable after transfer to the floor.
No additional benzodiazepine was required.
# Rhabdomyolysis: Pt was started on IVF for elevated CK to 3226.
Pt was monitored for signs of hyperthermia and tachycardia."
2950,"On
the floor, CK steadily trended down and was 287 day before
transfer. UA did not show myoglobinuria. His renal function
remained stable.
#. Depression: On further questioning, the pt reported that the
cocaine ingestion was a suicide attempt. He stated that he was
having more financial difficulty over the past few months and
thought that if he attempted suicide, his family would be able
to receive his life insurance. A 1:1 sitter was ordered and
psychiatry consult was called. He was placed on a Section 12 and
is currently awaiting an inpatient psychiatry bed for further
evaluation. He denied any futher suicidal ideations while in
the hospital."
2951,"#. Fever: Pt developed fever to 101 with leukocytosis on [**2189-7-20**].
BCx were sent with no growth to date and CXR was concerning for
aspiration pneumonia, but final read demonstrated no infiltrate.
His fever defervesced while blood and urine culture remained
negative. WBC also trended down and normalized. Unasyn was dc'd
on [**2189-7-23**]. Pt was felt to have aspiration pneumonitis and
therefore was not continued on antibiotics. He remained afebrile
without cough or shortness of breath.
#. NSTEMI: Likely demand ischemia in the setting of cocaine
overdose causing vasospasm and not acute thrombosis. No prior
history of CAD or risk factors per family."
2952,"Heparin gtt was held
given risk for intracranial bleed. Pt was started on ASA 325mg
and lipitor 80mg. Beta blocker was contraindicated. Cardiac
enzymes trended downwards. EKG normalized. ECHO showed no LV/RV
or valvular function. Lipid panel was wnl and statin was
stopped. Pt switched to ASA 81 mg given no cardiovascular risk
factors.
#. Transaminitis: Pt with elevated transaminitis with no prior
for comparison. Likely related to crack cocaine ingestion.
Non-obstructive picture. Tylenol neg at OSH. Possible ischemia
related in the setting of cocaine over dose. LFTs began to trend
downward while on the floor and normalized on [**7-23**]."
2953,"Hepatitis
serologies were negative.
# Comm: [**Name (NI) 82820**] (wife) [**Telephone/Fax (1) 82821**]; [**Doctor First Name **]- [**Telephone/Fax (1) 82822**]
# Dispo - to psych inpatient unit for further management of
depression
Medications on Admission:
Tramadol
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Cocaine overdose
NSTEMI
Hyperthermia
Aspiration pneumonitis
Depression
Discharge Condition:
Afebrile, vital signs stable, medically cleared for discharge.
Discharge Instructions:
You were admitted to the hospital after ingesting a large amount
of cocaine. You were admitted to the intensive care unit for
close monitoring. The large cocaine caused muscle pain and
fevers, and also caused a small amount of damage to your heart
muscle. You recovered quickly with treatment. We checked an
echocardiogram and it showed no evidence of significant damage.
You were evaluated by the psychiatrists, who feel that you'd
benefit from inpatient psychiatric treatment.
Changes to your medications include: aspirin 81 mg daily.
Followup Instructions:
Please follow per psychiatry recommendations.
Completed by:[**2189-7-24**]"
2954,"anicteric, no epistaxis or rhinorrhea
NECK: supple
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Labs on admission [**2189-7-20**]:
WBC-9.2 RBC-4.60 Hgb-13.2* Hct-40.9 MCV-89 MCH-28.7 MCHC-32.3
RDW-12.7 Plt Ct-204
Neuts-78.0* Lymphs-16.6* Monos-4.6 Eos-0.4 Baso-0.3
PT-12."
2955,"There was a struggle and approx 1-2g were
able to be removed from his mouth. The patient became
increasingly agitated and was intubated by EMS, paralyzed with
vecuronium for agitation and brought to [**Hospital3 **]. At
[**Hospital1 487**] he was given a total of 14mg IV ativan and 20mg
vecuronium. His labs were remarkable for a positive tox screen
for cocaine and BZD. CPK was 252, CPK-MB: 8.4, MB/CK index:3.3,
trop I 0.04. His LFT were also elevated AST:234/ALT:242. ABG:
7.33/50.9/463/25. (unknown vent settings). He had elevated BP at
with SBP 200's and a CT-head was performed to r/o bleed that was
negative."
2956,"The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Brief Hospital Course:
#. Cocaine Overdose: Pt with massive ingestion of 14g of crack
cocaine. He was intubated in the field and transferred from
[**Hospital6 3105**]. He was given 14mg ativan total at the
OSH and 40mg valium in the ED. Pt underwent NG lavage and also
received activated charcoal and started on Golytely. CT-head was
negative at OSH."
2957,"BCx [**2189-7-20**] - NGTD
.
MRSA [**2189-7-20**] - NGTD
.
[**2189-7-20**] EEG: There was no evidence of discharging activity or
electrical
status. The tracing represented an anesthesized patient with
pre-central beta activity extending somewhat more posteriorly
and
representative of a benzodiazepine effect. One isolated instance
of
vertex activity that might have represented stage II sleep was
seen.
.
EKG on admission: Sinus rhythm at 94 bpm, normal axis, normal
intervals, rsr' pattern in V2. TW flattening in III/avF.
Otherwise no acute ST or T-wave changes.
.
EKG on transfer to floor: NSR 95bpm, nl axis and intervals, no
TWI or ST segment elevations or depressions
."
2958,"35* Hgb-12.8* Hct-38.8* MCV-89 MCH-29.4
MCHC-33.0 RDW-13.4 Plt Ct-177
Neuts-83.6* Lymphs-11.9* Monos-4.3 Eos-0.1 Baso-0.1
PT-13.7* PTT-32.9 INR(PT)-1.2*
Glucose-88 UreaN-6 Creat-0.7 Na-142 K-3.5 Cl-109* HCO3-24
AnGap-13
ALT-153* AST-131* LD(LDH)-435* CK(CPK)-3226* AlkPhos-68
TotBili-1.8*
CK-MB-27* MB Indx-0.8 cTropnT-0.03*
Calcium-7.6* Phos-3.1# Mg-2.3
.
[**2189-7-20**] 05:45AM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2189-7-20**] 05:45AM HCV Ab-NEGATIVE
."
2959,"6 PTT-28.9 INR(PT)-1.1
Glucose-113* UreaN-13 Creat-0.7 Na-141 K-3.7 Cl-108 HCO3-28
AnGap-9
ALT-206* AST-199* CK(CPK)-1799* AlkPhos-63 TotBili-1.2
CK-MB-41* MB Indx-2.3 cTropnT-0.19*
Albumin-3.6 Calcium-8.0* Phos-2.0* Mg-1.8
Serum tox: ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Urine tox: bnzodzp-POS (received at OSH), barbitr-NEG
opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG
.
Labs on transfer to floor [**2189-7-21**]:
WBC-15.0*# RBC-4."
2960,"KUB: No evidence of drug packing. NG terminates below the
diaphragm
.
[**2189-7-21**] CXR: Compared to [**2189-7-20**], the bilateral subtle basal
opacities have minimally improved. The opacity along the minor
fissure is no longer visible. No newly occurred focal
parenchymal opacity suggesting pneumonia. No pleural effusion,
unchanged size of the cardiac silhouette. Complete resolution of
RUL opacicity.
.
[**7-22**] ECHO: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal."
2961,"An NG tube was placed 3L lavage was performed. He
was given activated charcoal and GoLytley. He was transferred
to the the [**Hospital1 18**] ED intubated and paralyzed.
Past Medical History:
Back pain
Social History:
Lives with his wife and 4 year old son. Wife is currently 4
months pregnant. Works construction, but currently unemployed.
Per family, dealt drugs due to financial hardships. Family
denied tobacco/EtoH/other drug use.
Family History:
Mother with HTN
Physical Exam:
PE on transfer out of [**Hospital Unit Name 153**]:
Vitals: T:99.0 BP:127/79HR:98 RR:18 O2Sat:100% NC 1L
Vt: 600, RR:15, PEEP:5 FiO2: 40%
GEN: Arousable to voice, intermittently sedated, NAD, able to
follow commands
HEENT: R pupil 3mm-->2mm, sluggish, Prosthetic left eye."
2962,"7/32.9/1.2, CK / CKMB /
Troponin-T:3226/27/0.03, ALT / AST:153/131, Alk Phos / T Bili:68/1.8,
Amylase / Lipase:/19, Differential-Neuts:83.6 %, Lymph:11.9 %, Mono:4.3
%, Eos:0.1 %, Lactic Acid:1.5 mmol/L, Albumin:3.6 g/dL, LDH:435 IU/L,
Ca++:7.6 mg/dL, Mg++:2.3 mg/dL, PO4:3.1 mg/dL
Imaging: CXR:persistent bibasilar infiltrates, slightly improved from
yesterday.
Assessment and Plan
COCAINE ABUSE
POISONING / OVERDOSE, COCAINE
RISK FOR INJURY
ASPIRATION PNEUMONIA
RHABDOMYOLYSIS
==========================
Patient feeling much better although still has intermittent somnolence,
presumably still related to high doses of benzos that he received in
the past 48 hours. HR and BP stable.
Continue antibiotic for aspiration pneumonia.
Maintaining high urine output to avoid renal tubular damage. CPK
pending for today,
ICU Care
Nutrition: oral
Glycemic Control:
Lines:
18 Gauge - [**2189-7-20**] 12:29 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments: VAP bundle not indicated
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition :Transfer to floor
Total time spent: 30 minutes"
2963,"8 g/dL
177 K/uL
88 mg/dL
0.7 mg/dL
24 mEq/L
3.5 mEq/L
6 mg/dL
109 mEq/L
142 mEq/L
38.8 %
15.0 K/uL
[image002.jpg]
[**2189-7-20**] 02:50 AM
[**2189-7-20**] 05:45 AM
[**2189-7-20**] 05:53 AM
[**2189-7-20**] 05:25 PM
WBC
9.2
7.8
15.0
Hct
40.9
39.7
38.8
Plt
[**Telephone/Fax (3) 7562**]
Cr
0.7
0.7
0.7
TropT
0.19
0.09
0.03
TCO2
28
Glucose
113
113
88
Other labs: PT / PTT / INR:13."
2964,"3
C (101
Tcurrent: 37.2
C (98.9
HR: 100 (88 - 134) bpm
BP: 127/79(88) {112/60(73) - 137/87(96)} mmHg
RR: 24 (13 - 28) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 87.4 kg (admission): 82.3 kg
Total In:
4,543 mL
1,643 mL
PO:
360 mL
TF:
IVF:
4,543 mL
1,283 mL
Blood products:
Total out:
6,380 mL
2,350 mL
Urine:
5,780 mL
2,350 mL
NG:
Stool:
Drains:
Balance:
-1,837 mL
-707 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 374 (374 - 374) mL
PS : 5 cmH2O
RR (Spontaneous): 25
PEEP: 0 cmH2O
FiO2: 30%
SpO2: 100%
ABG: ///24/
Ve: 8."
2965,"9 L/min
Physical Examination
General Appearance: Well nourished, No(t) No acute distress, No(t)
Overweight / Obese, Thin, No(t) Anxious, Somnolent
Eyes / Conjunctiva: No(t) PERRL, Left prosthetic eye
Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)
NG tube, No(t) OG tube
Cardiovascular: (PMI Normal, Hyperdynamic), (S1: Normal, No(t) Absent),
(S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t)
Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t)
Diastolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),
(Breath Sounds: No(t) Clear : , Crackles : Few rales at right base,
No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent :
, No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,
No(t) Tender: , No(t) Obese
Extremities: Right: Absent edema, Left: Absent edema, No(t) Cyanosis,
No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand
Skin: Not assessed, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): X3, Movement: Purposeful, No(t) Sedated, No(t)
Paralyzed, Tone: Not assessed
Labs / Radiology
12."
2966,"Chief Complaint: Cocaine toxicity, fever, aspiration pneumonia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
Patient feeling much better today. Tmax yesterday was 101.
Has not required any valium since yesteday afternoon.
24 Hour Events:
EEG - At [**2189-7-20**] 09:38 AM
INVASIVE VENTILATION - STOP [**2189-7-20**] 01:45 PM
EKG - At [**2189-7-20**] 05:30 PM
History obtained from [**Hospital 31**] Medical records
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ampicillin/Sulbactam (Unasyn) - [**2189-7-21**] 12:00 AM
Ampicillin - [**2189-7-21**] 11:35 AM
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2189-7-21**] 08:00 AM
Heparin Sodium (Prophylaxis) - [**2189-7-21**] 08:00 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-7-21**] 12:04 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 38."
2967,"Demographics
Day of intubation:
Day of mechanical ventilation: 0
Ideal body weight: 0 None
Ideal tidal volume: 0 / 0 / 0 mL/kg
Airway
Airway Placement Data
Known difficult intubation: Unknown
Procedure location:
Reason:
Tube Type
ETT:
Position: cm at teeth
Route:
Type: Standard
Size: 8mm
Tracheostomy tube:
Type:
Manufacturer:
Size:
PMV:
Cuff Management:
Vol/Press:
Cuff pressure: 20 cmH2O
Cuff volume: mL /
Airway problems:
Comments:
Lung sounds
RLL Lung Sounds: Diminished
RUL Lung Sounds: Clear
LUL Lung Sounds: Clear
LLL Lung Sounds: Diminished
Comments:
Secretions
Sputum color / consistency: /
Sputum source/amount: /
Comments:
Ventilation Assessment
Level of breathing assistance:
Visual assessment of breathing pattern:
Assessment of breathing comfort:
Non-invasive ventilation assessment:
Invasive ventilation assessment:
Trigger work assessment:
Dysynchrony assessment:
Comments:
Plan
Next 24-48 hours:
Reason for continuing current ventilatory support:
Respiratory Care Shift Procedures
Transports:
Destination (R/T)
Time
Complications
Comments
Bedside Procedures:
Comments: Pt received from ER intub with OETT and placed on mech vent
as per Metavision. Lung sounds ess clear. ABGs stable; pt in NARD on
current vent settings. Pt transported from [**Hospital Ward Name **] without
incident. Cont mech vent support."
2968,"#. Respiratory Failure: Pt was intubated by EMS for air-way protection
following cocaine overdose. The patient was initally paralyzed with
vecuronium initially. In the ED, he was sedated with propofol and given
valium. ABG: 7.41/42/159/28. CXR did not show acute process. CMV,
Tidal Vol:600, PEEP:5, FiO2:40%, PIP:21.
- repeat ABG and adjust vent setting accordingly
- cont sedation with propofol and valium as above
- follow abg
.
#. NSTEMI: In the setting of cocaine overdose. No prior history of CAD
or risk factors per family. Likely ischemia in the setting of cocaine
overdose causing vasospasm and not acute thrombosis."
2969,"Pt also
received activated charcoal and started on Golytely. Pt tachycardic and
BP elevated at OSH, but controlled in the ED. CT-head was negative at
OSH. Tox screen neg at OSH other then cocaine and BZD.
- appreciate Tox recs ([**Month (only) 11**] consider consulting surgery for enterotomy
for uncontrollable hyperthermia, tachycardia and seizure)
- Valium 10-20mg q5-10mins for agitation
- cont GoLytely 2L per hour until GI tract clear (activated charcoal is
only affective within the first hr of ingestion per tox)
- Neuro eval for EEG (although unlikely status since pt given 14mg
ativan at OSH)
- cont IVF
- Urine and serum tox screen
- Monitor ECG
- trend CE and CK q8 initially
- trend BMP
- monitor temperatures of hyperthemia
- monitor VS: treat uncontrollable hypertension/tachycardia with
phentolamine 5-10mg every 5-10mins prn
."
2970,"His labs were remarkable for a positive tox screen for
cocaine and BZD. CPK was 252, CPK-MB: 8.4, MB/CK index:3.3, trop I
0.04. His LFT were also elevated AST:234/ALT:242. ABG:
7.33/50.9/463/25. (unknown vent settings). He had elevated BP at with
SBP 200's and a CT-head was performed to r/o bleed that was negative.
An NG tube was placed 3L lavage was performed. He was given activated
charcoal and GoLytley. He was transferred to the the [**Hospital1 1**] ED
intubated and paralyzed.
.
In the ED, VS: 98."
2971,"Pin-point right pupil not
reactive. Not moving ext, unable to elicit reflexes. Plantar reflex
downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Labs / Radiology
198 K/uL
13.2 g/dL
113 mg/dL
0.7 mg/dL
13 mg/dL
26 mEq/L
109 mEq/L
3.5 mEq/L
143 mEq/L
39.7 %
7.8 K/uL
[image002.jpg]
[**2185-12-19**]
2:33 A8/3/[**2188**] 02:50 AM
[**2185-12-23**]
10:20 P8/3/[**2188**] 05:45 AM
[**2185-12-24**]
1:20 P8/3/[**2188**] 05:53 AM
[**2185-12-25**]
11:50 P
[**2185-12-26**]
1:20 A
[**2185-12-27**]
7:20 P
1//11/006
1:23 P
[**2186-1-19**]
1:20 P
[**2186-1-19**]
11:20 P
[**2186-1-19**]
4:20 P
WBC
9."
2972,"Chief Complaint: Cocaine Overdose
HPI:
This is a 38 year-old male with no PMH presents with cocaine overdose.
The patient was confronted by the [**Last Name (un) **]/police during a drug deal and
proceeded to ingest 14-16 grams of powder cocaine. There is a question
as to whether he ingested multiple small bags or one large bag. There
was a struggle and approx 1-2g were able to be removed from his mouth.
The patient became increasingly agitated and was intubated by EMS,
paralyzed with vecuronium for agitation and brought to [**Hospital1 **]. At [**Hospital1 **] he was given a total of 14mg IV ativan and 20mg
vecuronium."
2973,"49/36/154/26/5
Ve: 8.5 L/min
PaO2 / FiO2: 385
Physical Examination
Vitals: T:99.0 BP:136/86 HR:98 RR:15 O2Sat:100%
Vt: 600, RR:15, PEEP:5 FiO2: 40%
GEN: Intubated, sedated, NAD
HEENT: Pinpoint right pupil, non-reactive. Prosthetic left eye.
anicteric, no epistaxis or rhinorrhea, ET/OG in place
NECK: cervical collar in place
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: sedated, not responsive to stimuli."
2974,"Timidor (per family it is for back pain)
Past medical history:
Family history:
Social History:
Back Pain
Mother with HTN
Lives with his wife and 4 year old son. Wife is currently 4 months
pregnant. Works construction, but currently unemployed. Family denied
tobacco/EtoH/other drug use.
Review of systems:
Unable to obtain
Flowsheet Data as of [**2189-7-20**] 07:19 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37.2
C (99
Tcurrent: 37.2
C (99
HR: 91 (91 - 98) bpm
BP: 124/72(84) {124/72(84) - 136/87(98)} mmHg
RR: 15 (10 - 15) insp/min
SpO2: 100%
Total In:
408 mL
PO:
TF:
IVF:
408 mL
Blood products:
Total out:
0 mL
900 mL
Urine:
300 mL
NG:
Stool:
Drains:
Balance:
0 mL
-492 mL
Respiratory
Ventilator mode: CMV/ASSIST
Vt (Set): 600 (600 - 600) mL
RR (Set): 15
PEEP: 5 cmH2O
FiO2: 40%
PIP: 22 cmH2O
Plateau: 19 cmH2O
SpO2: 100%
ABG: 7."
2975,"2
7.8
Hct
40.9
39.7
Plt
204
198
Cr
0.7
0.7
TropT
0.19
TC02
28
Glucose
113
113
Other labs: PT / PTT / INR:12.6/28.9/1.1, CK / CKMB /
Troponin-T:[**2185**]//0.19, ALT / AST:182/166, Alk Phos / T Bili:62/1.5,
Amylase / Lipase:/19, Differential-Neuts:78.6 %, Lymph:15.1 %, Mono:5.3
%, Eos:0.7 %, Lactic Acid:1.5 mmol/L, Albumin:3.6 g/dL, LDH:384 IU/L,
Ca++:7.7 mg/dL, Mg++:1.7 mg/dL, PO4:1.4 mg/dL
ECG: Sinus rhythm at 94 bpm, normal axis, normal intervals, rsr'
pattern in V2."
2976,"TW flattening in III/avF. Otherwise no acute ST or
T-wave changes.
.
Imaging:
KUB: No evidence of drug packing. NG terminates below the diaphragm
.
CXR: no acute process, NG at distal esophagus.
Assessment and Plan
COCAINE ABUSE
POISONING / OVERDOSE, COCAINE
RISK FOR INJURY
Assesment: This is a 38 year-old male with a history of
who presents
with massive cocaine overdose after ingestion of 14g crack cocaine.
.
Plan:
#. Cocaine Overdose: Pt with massive ingestion of 14g of crack cocaine.
He was intubated in the field and transferred from an OSH. He was given
14mg ativan total at the OSH and 40mg valium in the ED."
2977,"2 HR:112 BP:126/70 RR:15 O2%98%
CMV, Tidal Vol:600, PEEP:5, RR: 15 FiO2:40%, PIP:21. ABG:
7.41/42/159/28. Pt was started on propofol (45mcg/hr) and given 40mg
Valium total. He was given 1L NS. Tox was consulted and recommended
KUB to eval for drug packing, which was negative. He was continued on
IVF and 4L Golytely. Additionally, neuro consult was recommended for
EEG for concern for seizures.
.
On arrive pt is intubated and sedated. Spoke with family who was
unaware of his activities.
Patient admitted from: [**Hospital1 1**] ER
History obtained from Family / [**Hospital 380**] Medical records
Patient unable to provide history: Sedated
Allergies:
Last dose of Antibiotics:
Infusions:
Propofol - 45 mcg/Kg/min
Other ICU medications:
Other medications:
?"
2978,"Will hold on
heparin gtt given risk for intracraial bleed
- ASA 325mg
- lipitor 80mg
- Maintain HR <100 with valium, CCB if needed
- ECHO to eval wall motion
- cont to trend CE
- BB contraindicated
.
#. Transaminitis: Pt with elevated transaminitis. No prior for baseline
comparison. Possibly related to crack cocaine ingestion or adulterated
with other substance. Non-obstructive picture. Tylenol neg at OSH.
Possible ischemia related in the setting of cocaine over dose.
Otherwise, pt with underlying hepatitis also a possibility.
- will check serum tox and urine tox
- check hepatitis serologies
- cont to trend LFT
.
# FEN: IVF, replete lytes, NPO
.
# Access: 2 PIV
.
# PPx: subq heparin, PPI
.
# Code: FULL
.
# Dispo: ICU
.
# Comm: [**Name (NI) 7536**] (wife) [**Telephone/Fax (1) 7537**]
[**Doctor First Name 5018**]- [**Telephone/Fax (1) 7538**]
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2189-7-20**] 03:28 AM
Prophylaxis:
DVT: SQ heparin
Stress ulcer: PPI
VAP: HOB elevation, mouth care,
Comments:
Communication: Comments:
Code status: FULL
Disposition: ICU"
2979,"Admission Date: [**2190-10-20**] Discharge Date: [**2190-10-25**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Aortic stenosis/ regurgitation
Major Surgical or Invasive Procedure:
aortic valve replacement (21mm St. [**Male First Name (un) 923**] porcine) [**2190-10-20**]
History of Present Illness:
This 86 year old white female has known aortic stenosis with
progressive dyspnea on exertion and fatigue over 7 months. She
has previously undergone catheterization to demonstrate clean
coronaries, despite a prior anterior infaction in [**2173**]. She is
admitted now for valve replacement.
Past Medical History:
Coronary artery disease s/p AMI '[**73**]
Ischemic cardiomyopathy (EF 35-40%)
Aortic stenosis/insufficiency
Hypertension
Hyperlipidemia
Diverticulitis
Past Surgical History: Right hip replacement s/p
fracture(MVA)'[**78**]
Bowel resection(diverticular dz)-'[**72**]
Incisional hernia repair '[**73**]
Bilat cataract removal
Ovarian cyst removal"
2980,"Social History:
Race: Caucasian
Last Dental Exam: 1 month ago
Lives with: Husband
Occupation: Retired college professor/[**Male First Name (un) **]-Education([**University/College **])
Tobacco:Quit 40 yrs ago, previously smoked 1ppwk x20yrs
ETOH:1 drink every other month
Family History:
non-contributory
Physical Exam:
Pulse: 54 Resp: 16 O2 sat: 98%-RA
B/P Right: 160/72 Left:
Height: 65 in Weight: 176 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] MMM, normal oropharynx
Neck: Supple [x] Full ROM [x], no JVD or lymphadenopathy
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: [**2-20**] blowing murmur
Abdomen: Soft[x] non-distended[x] non-tender [x] +bowel
sounds[x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: minimal
Neuro: Grossly intact, A&O x3-MAE, nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+"
2981,"Brief Hospital Course:
Following admission she went to the Operating Room where aortic
valve replacement was undertaken. She operative note for
details. She weaned from bypass easily on Propofol alone. She
awoke anxious but intact, requiring nitroglycerin intravenously
for BP control. She was extubated on POD 1 and oral agents
(Valsartan and Lopressor). Diuresis towards her preoperative
weight was begun and she transferred to the floor on POD 2.
Physical Therapy worked with her for strength and mobility. CTs
and temporary pacing wires were removed per protocols. She had
a brief episode of atrial fibrillation in the 140s on POD 4,
which was well tolerated."
2982,"This was treated with IV Lopressor
and amiodarone with restoration of sinus rhythm. She remained
volume overloaded and was discharged to rehab on IV lasix for 1
week.
On POD 5 she was ready for discharge and went TO [**Hospital 38**] Rehab
a MWMC in [**Location (un) 1110**].
Medications on Admission:
Metoprolol ER 25 daily
Simvastatin 40 daily
Zetia 10 daily
NTG-sl-prn
Aspirin 325 daily
Diovan 320 daily
Fish Oil
Vitamin E 400IU daily
Vitamin D 500mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain."
2983,"4*#
MCV-87 MCH-29.9 MCHC-34.2 RDW-13.4 Plt Ct-122*#
[**2190-10-23**] 06:40AM BLOOD Glucose-113* UreaN-26* Creat-1.1 Na-138
K-4.2 Cl-103 HCO3-28 AnGap-11
[**2190-10-20**] 01:35PM BLOOD UreaN-10 Creat-0.7 Na-141 K-4.3 Cl-115*
HCO3-22 AnGap-8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 87732**] (Complete)
Done [**2190-10-20**] at 11:46:35 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2103-12-5**]
Age (years): 86 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: AVR
ICD-9 Codes: 786."
2984,"Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Aortic stenosis/reguritation
hypertension
s/p aortic valve replacement
s/p right total hip arthroplasty
ischemic cardiomyopathy
coronary artery disease
s/p colon resection for diverticular disease
s/p herniorraphy
s/p cataract extractions
hyperlipidemia
s/p ovarian cystectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema: 1+ bilateral LEs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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"
2985,"2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 1 tab(200mg) [**Hospital1 **] for two weeks then one tab(200mg)
daily."
2986,"I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 - 50 %).
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0."
2987,"8cm2). Moderate
(2+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on no inotropes.
Preserved biventricular systolic fxn.
There is a prosthetic aortic valve with no leak and no
regurgitation.
Mean residual gradient = 10 mmHg.
No MR. [**First Name (Titles) **] [**Last Name (Titles) **].
Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2190-10-20**] 13:01"
2988,"9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. psyllium Packet Sig: One (1) Packet PO BID (2 times a
day) as needed for constipation.
11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. furosemide 10 mg/mL Solution Sig: Four (4) Injection twice
a day for 1 weeks: 40mg IV lasix [**Hospital1 **] x 1 week, then re-evaluate.
13. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 1 weeks."
2989,"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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 6256**]) at [**Hospital1 **] on [**11-18**] at
9:00am Cardiologist:Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**] ([**Telephone/Fax (1) 6256**]) on
[**2190-12-20**] at 2:30pm
Please call to schedule appointments with:
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4640**] ([**Telephone/Fax (1) 20221**]) in [**3-22**] 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**
Completed by:[**2190-10-25**]"
2990,"Carotid Bruit: radiated murmur Right: Left:
Pertinent Results:
[**2190-10-22**] 02:10AM BLOOD WBC-13.1* RBC-3.41* Hgb-10.1* Hct-30.2*
MCV-89 MCH-29.7 MCHC-33.4 RDW-14.4 Plt Ct-126*
[**2190-10-24**] 06:20AM BLOOD Na-135 K-4.5 Cl-101
[**2190-10-23**] 06:40AM BLOOD WBC-10.0 RBC-3.32* Hgb-9.9* Hct-29.6*
MCV-89 MCH-29.9 MCHC-33.5 RDW-14.0 Plt Ct-122*
[**2190-10-20**] 12:30PM BLOOD WBC-6.9 RBC-2.57*# Hgb-7.7*# Hct-22."
2991,"05, 786.51, 424.1, 424.0
Test Information
Date/Time: [**2190-10-20**] at 11:46 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW-1: Machine: [**Doctor Last Name **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aortic Valve - Peak Gradient: *56 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 35 mm Hg
Aortic Valve - Valve Area: *0."
2992,"6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above."
2993,"Admission Date: [**2194-8-14**] Discharge Date: [**2194-8-22**]
Date of Birth: [**2133-12-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Diastolic Murmur, Vegetation on Aortic Valve
Major Surgical or Invasive Procedure:
[**2194-8-18**]
Aortic valve replacement with a St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue valve,
size 23 mm. Reference #[**Serial Number 13649**]. Serial #[**Serial Number 30122**].
Dental extractions (teeth number 23, 24, 25, 26).
History of Present Illness:
60M with a past medical history of hypertension, hyperlipidemia,
tobacco use, who presents with three weeks of dyspnea on
exertion."
2994,"Found to have a new diastolic murmur, an echo
demonstrated a vegetation on his aortic valve and 4+ aortic
regurgitation.
He was referred to cardiac surgery.
Past Medical History:
AORTIC REGURGITATION
-COPD (CHRONIC AIRWAY OBSTRUCTION)
-FATTY LIVER DISEASE -OVERWEIGHT
-HEMANGIOMA, HEPATIC
-ERECTILE DYSFUNCTION
-BENIGN PROSTATIC HYPERTROPHY, WITH OBSTRUCTION
-HYPERTENSION
-HYPERLIPIDEMIA
-GERD
-Hx of TOBACCO USE
Social History:
He quit smoking three years ago and reports a forty pack year
history.
drinks alcohol socially.
He lives alone and works as a manager of [**Company **] Airport.
Family History:
His brother died from complication of an aortic valve
replacement secondary to endocarditis. His uncle had an
abdominal aortic aneurysm."
2995,"Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Vitamin E 400 UNIT PO DAILY
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
17. Levofloxacin 500 mg PO Q24H Duration: 7 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
AORTIC REGURGITATION,COPD (CHRONIC AIRWAY OBSTRUCTION),FATTY
LIVER DISEASE,OVERWEIGHT HEMANGIOM HEPATIC,ERECTILE
DYSFUNCTION,BENIGN PROSTATIC HYPERTROPHY, WITH
OBSTRUCTION,HYPERTENSION, HYPERLIPIDEMIA,GERD, Hx of TOBACCO USE
Past Surgical History:Right shoulder surgery, hernia repair and
tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema- 1+ bilat edema"
2996,"The
infectious disease service will contact Mr. [**Known lastname 30123**] [**Last Name (Titles) 30124**] he
final results of his culture data. At teh time of discharge
there was no growth from the cultures taken and he was afebrile
with WBC 9.
The remainder of his hospital course was uneventful, by the time
of discharge on POD 4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home with VNA in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR."
2997,"Estimated left ventricular function is
unchanged from prebypass.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2194-8-20**]
10:21 AM
Final Report: In comparison with the study of earlier in this
date, the right chest tube has been removed. No evidence of
pneumothorax. Bibasilar opacification persists and intact
midline sternal wires are present.
Admission labs:
[**2194-8-14**] 04:25PM PT-11.8 PTT-31.6 INR(PT)-1.1
[**2194-8-14**] 04:25PM PLT COUNT-158
[**2194-8-14**] 04:25PM WBC-8.3 RBC-4.80 HGB-15.3 HCT-43.7 MCV-91
MCH-31."
2998,"1. Lisinopril 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Gemfibrozil 600 mg PO BID
5. Amlodipine 5 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
9. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
10. Vitamin E 400 UNIT PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Gemfibrozil 600 mg PO BID
3."
2999,"9 MCHC-35.0 RDW-12.9
[**2194-8-14**] 04:25PM cTropnT-<0.01
[**2194-8-14**] 04:25PM GLUCOSE-100 UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2194-8-14**] 04:30PM LACTATE-1.8
[**2194-8-14**] 11:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Discharge labs:
[**2194-8-22**] 06:15AM BLOOD WBC-9.0 RBC-3.78* Hgb-12.1* Hct-35.5*
MCV-94 MCH-31.9 MCHC-33.9 RDW-13.1 Plt Ct-159#
[**2194-8-22**] 06:15AM BLOOD Plt Ct-159#
[**2194-8-22**] 06:15AM BLOOD Glucose-122* UreaN-12 Creat-0."
3000,"Sternum stable, incision-CDI
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. 1+ bilat pedal edema
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: *4.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - Valve Area: *2."
3001,"[**Known lastname 30123**] was admitted and placed on IV Vancomycin and
Gentamicin for aortic valve endocarditis per the direction of
the infectious disease service. He was evaluated by cardiac
surgery for an aortic valve replacement and underwent a
pre-operative work-up including teeth extractions. The patient
was brought to the Operating Room on [**2194-8-18**] where the patient
underwent tissue aortic valve replacement (#23mm tissue). The
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
The patient remained stable in the immediate post-op period.
Anesthesia was reversed, the patient was neurologically intact
and he weaned from the ventilator and extubated."
3002,"Simvastatin 20 mg PO DAILY
4. Acetaminophen 325-650 mg PO Q4H:PRN pain/temp
5. Docusate Sodium 100 mg PO BID
6. Furosemide 20 mg PO DAILY Duration: 1 Weeks
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
7. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
8."
3003,"Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
3004,"Oxycodone-Acetaminophen (5mg-325mg) [**12-23**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg [**12-23**] tablet(s) by mouth
every four (4) hours Disp #*75 Tablet Refills:*0
9. Potassium Chloride 20 mEq PO DAILY Duration: 1 Weeks
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 20 mEq by mouth once a day Disp
#*7 Tablet Refills:*0
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
12. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
13."
3005,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2194-9-11**] 1:45, in the [**Hospital **] medical office building,
[**Doctor First Name **], [**Hospital Unit Name **]
Wound check: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2194-9-2**] 10:15
in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Infectious disease:The infectious disease doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 138**] [**Name5 (PTitle) **]
regarding your final data
Cardiologist: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2194-10-7**] 1:00
Please call to schedule appointments with your
Primary Care Dr.[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 798**] in [**3-27**] 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**
Completed by:[**2194-8-22**]"
3006,"Over the next
several hours he weaned from vasopressor support. On POD1 Beta
blockers were initiated and he was started on diuretics and
gently diuresed toward his preoperative weight. On POD1 the
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued per
cardiac surgery protocol without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. Per infectious disease service it was
recommended that he be discharged to home on a 2 week course of
ceftriaxone pending the results of his culture data. He declined
the recommendation from the infectious diseae service for IVAB
however, did agree to a 7 day course of po levoflox."
3007,"There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve is abnormal with a coaptation defect between
the right and left cusps seen best in long axis view, there is
question of leaftlet perforation. Severe (4+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**2194-8-18**] at
0930.
Postbypass:
There is a well seated bioprosthetic valve in the aortic
position with no perivalvular leak. There is no evidence of
aortic dissection."
3008,"Physical Exam:
ADMISSION:
VS: 98 138/65 70 18 97% RA
GENERAL: NAD, AxOx3.
HEENT: JVP unappreciable. Sclera anicteric. PERRL, EOMI. MMM
CARDIAC: RRR, normal S1, S2. [**3-26**] diasolic rumbling murmur
consistent with AI. No S3 or S4.
LUNGS: Poor aeration throughout, no basilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: no LE edema 2+ pulses
SKIN: no osler nodes, splinter hemmhorages, [**Last Name (un) **] lesions,
rash
Discharge:
VS: 98.2 86 126/80 18 94% RA
Wt 88.4kg
Gen: NAD
Neuro: A&O x3, MAE. nonfocal exam
Pulm: CTA-bilat
CV: RRR, no murmur."
3009,"9 Na-138
K-3.9 Cl-98 HCO3-31 AnGap-13
[**2194-8-21**] 06:05AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0
[**2194-8-18**] 10:05 am TISSUE AORTIC VALVE LEAFLET.
GRAM STAIN (Final [**2194-8-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2194-8-21**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2194-8-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2194-8-19**]):
NO FUNGAL ELEMENTS SEEN.
Brief Hospital Course:
Mr."
3010,"5 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Normal descending aorta
diameter. Complex (>4mm) atheroma in the descending thoracic
aorta.
AORTIC VALVE: Abnormal aortic valve. Severe (4+) AR. Eccentric
AR jet.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR."
3011,"TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. The patient appears to be in sinus rhythm. Results
Conclusions
Prebypass:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50-55%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated."
3012,"Admission Date: [**2147-11-20**] Discharge Date: [**2147-11-25**]
Date of Birth: [**2071-5-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
shortness of breath x 4-6 weeks
Major Surgical or Invasive Procedure:
cardiac catheterization with bare metal stent to the right
coronary artery
History of Present Illness:
Patient is a 76 year-old female with a past medical history of
diabetes who presented to her PCP's office earlier today with
worsening DOE x 4-6 weeks. An ECG done at the PCP's office
showed old inferior q waves with new ST elevations in II,III,
aVF."
3013,"Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
psoriatic arthritis
depression
NIDDM
Macular degeneration
PAST SURGICAL HISTORY:
Appendectomy, bilateral vein ligation, and right knee surgery.
s/p right breast partial masectomy [**10-7**]
Social History:
SOCIAL HISTORY: Pt lives alone, has daughter in [**Name (NI) 620**]. Was
previously independent. no history of smoking, alcohol, drugs,
as per OSH documentation; patient intubated here
Family History:
FAMILY HISTORY:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory."
3014,"0 x 12 mm).
Brief Hospital Course:
ASSESSMENT & PLAN:
76 year-old female with a past medical history of diabetes who
presented to her PCP's office with worsening DOE x 4-6 weeks,
found to have ST elevations in inferior leads and now s/p BMS to
mid-RCA, 3-vessel disease on cath.
.
# Acute systolic CHF: A post cath ECHO showed that the patient
had an EF of 15% with apical/septal/poterior AK and focal DK.
Also has 3+ TR and 1+MR. [**Name13 (STitle) 17221**] than being an acute change, her
poor heart function was though to be a more chronic progression
over thelast few months."
3015,"She was also started on spironolactone. The patient
should have a repeat ECHO in about one month to assess for any
changes in her heart failure now that she has been started on a
heart failure medication regimen.
.
# Inf MI: The patient was found to have old Q waves in the
inferior leads, as well as new ST elevations in II, III, and
aVF. The patient did not make troponins, with peak being 0.04.
She was taken to the cath lab and found to have a 100% occlusion
of the RCA, and a BMS was placed over this lesion."
3016,"Also found to
have right heart cath notable for a PCWP 31, PA oressures 54/32.
She was given 40 mg IV Lasix and transferred to the CCU
intubated. Right heart cath notable for a PCWP 31, PA oressures
54/32. She was given 40 mg IV Lasix and transferred to the CCU
intubated. The patient was extubated the next morning, and
diuresis was continued, and her respiratory status continued to
improve. The patient was discharged on torsemide, and was
instructed to follow up labs as an outpatient.
.
# HTN: The patient's home dose of lisinopril was increased from
2."
3017,"5 mg daily to 5 mg daily, and she was started on metoprolol
12.5 mg [**Hospital1 **], that was later transitioned to 50 mg of metoprolol
succinate daily. The patient was also started on spironlactone
12.5 daily.
.
# Diabetes type 2: The patient was taken metformin at home; it
was held during the hospitalization and she was kept on humalog
sliding scale. While in patient, she required minimal amounts
of insulin and A1c was found to be 6.4. She was discharged on
her home dose of metformin.
.
# Psoriatic Arthritis: The patient was continued on her home
dose of methotrexate."
3018,"She has a rheumatologist at NWH who
follows her.
.
# Depression/mood disorder: The patient is followed by
outpatient psychiatrist. Her lithium and effexor were initially
held, but then restarted after she was extubated. The patient
had a lithium level that was checked, which was normal.
..
Transitional Issues:
- the patient will need to have her lytes checked on [**12-1**] and
have her results faxed to her primary care doctor's office.
- the patient will need to have a repeat ECHO done, as she has
been started on medications for her heart failure.
Medications on Admission:
Lisinopril 2.5mg PO Daily
Metformin 850mg PO BID
Methotrexate 2."
3019,"Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
11. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please check basic metabolic profile on [**12-1**]. Please fax
results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 483**] at [**Hospital1 18**] [**Location (un) 620**].
13. methotrexate sodium 2.5 mg Tablet Sig: Six (6) Tablet PO
once a week.
Discharge Disposition:
Home With Service
Facility:
Care Group Home Care
Discharge Diagnosis:
Coronary Artery Disease
Myocardial Infarction, not acute
Acute Systolic Dysfunction
Discharge Condition:
Mental Status: Clear and coherent."
3020,"2* Cl-107 HCO3-21* AnGap-17
[**2147-11-20**] 11:31PM BLOOD Na-143 K-3.9 Cl-107
[**2147-11-21**] 03:58AM BLOOD Glucose-132* UreaN-15 Creat-0.9 Na-142
K-4.0 Cl-107 HCO3-23 AnGap-16
[**2147-11-21**] 02:00PM BLOOD Glucose-124* UreaN-14 Creat-1.0 Na-141
K-3.5 Cl-104 HCO3-23 AnGap-18
[**2147-11-20**] 05:14PM BLOOD CK-MB-7 cTropnT-0.01
[**2147-11-20**] 11:31PM BLOOD CK-MB-6
[**2147-11-21**] 03:58AM BLOOD CK-MB-5 cTropnT-0."
3021,"She also had
a 90% diag, 90% mid LAD, 90% mid Lcx. Other vessels not stented
because of distal nature of occlusions. The patient was started
on ASA 325 mg, as well as plavix 75 mg for at least one month.
Post procedure, the patient was continued on integrillin drip
for 18 hours. The patient was found to have an A1c of 6.4. Her
lipid panel showed TC 90, TG 100, HDL 38, and LDL of 32. The
patient was started on atorvastatin 80 mg daily.
.
# elevated wedge/respiratory status: Pt was increasingly
tachypneic prior to cath and was intubated, on assist control
with TV 450 cc, resp rate 16, PEEP 5, on 60% FIO2."
3022,"CV: S1 S2 Normal in quality and intensity RRR,
ABD: soft, non-tender, non-distended, BS normoactive.
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: alert, oriented, fair understanding of medical condition.
Pertinent Results:
Admission labs:
[**2147-11-20**] 05:14PM BLOOD WBC-10.3 RBC-3.68*# Hgb-11.2*# Hct-32.1*#
MCV-87 MCH-30.5 MCHC-35.0 RDW-14.1 Plt Ct-259
[**2147-11-20**] 11:31PM BLOOD Hct-27.9* Plt Ct-212
[**2147-11-21**] 03:58AM BLOOD WBC-7."
3023,"START taking aspirin 325mg (not baby) and clopidogrel every
day for at least one month and possibly longer to keep the stent
from clotting off
2. START taking metoprolol to lower your heart rate and help
your heart pump better.
3. Increase the lisinopril to lower your blood pressure and help
your heart pump better
4. START taking atorvastatin to lower your cholesterol
5. START taking spironolactone daily to help your heart pump
better
6. START taking torsemide daily to get rid of extra fluid
Please have electrolytes checked with your primary care
physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 483**]."
3024,"7 RBC-3.10* Hgb-9.7* Hct-27.3*
MCV-88 MCH-31.3 MCHC-35.4* RDW-14.2 Plt Ct-199
[**2147-11-21**] 02:00PM BLOOD WBC-8.3 RBC-3.81* Hgb-11.3* Hct-34.0*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.2 Plt Ct-250
[**2147-11-20**] 05:14PM BLOOD PT-15.0* PTT-93.7* INR(PT)-1.3*
[**2147-11-22**] 05:52AM BLOOD PT-14.3* INR(PT)-1.2*
[**2147-11-20**] 05:14PM BLOOD Glucose-141* UreaN-17 Creat-1.0 Na-142
K-3."
3025,"7 Rates-16/ Tidal V-450
PEEP-5 FiO2-100 pO2-332* pCO2-38 pH-7.35 calTCO2-22 Base XS--3
AADO2-346 REQ O2-62 -ASSIST/CON Intubat-INTUBATED
[**2147-11-20**] 06:53PM BLOOD Type-ART Temp-36.8 Rates-16/ Tidal V-450
PEEP-5 FiO2-60 pO2-135* pCO2-40 pH-7.37 calTCO2-24 Base XS--1
-ASSIST/CON Intubat-INTUBATED
D/C labs:
[**2147-11-24**] 07:35AM BLOOD WBC-11.6* RBC-4.23 Hgb-13.2 Hct-38.4
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.9 Plt Ct-250
[**2147-11-25**] 06:35AM BLOOD WBC-11."
3026,"Physical Exam:
Admission PE:
VS: 98.1 93/53 71 16 98% intubated on 60% FIO2
GENERAL: NAD, intubated
HEENT: NCAT
NECK: Supple
CARDIAC: RR, normal S1, S2. No m/r/g.
LUNGS: anterior lung fields clear to ausculation b/l
ABDOMEN: soft, nondistended, +BS
EXTREMITIES: no LE edema, warm, well perfused, with soft cast
on R leg
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
..
GENERAL: 76 yo F in no acute distress
HEENT: no lymphadenopathy, JVP non elevated
CHEST: crackles bibasilar, [**Month (only) **] from prior."
3027,"04*
[**2147-11-20**] 05:14PM BLOOD Calcium-9.2 Phos-5.0* Mg-1.7
[**2147-11-21**] 03:58AM BLOOD Calcium-8.8 Phos-3.4# Mg-1.9 Cholest-90
[**2147-11-21**] 02:00PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.7*
[**2147-11-21**] 11:00PM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
[**2147-11-21**] 03:58AM BLOOD %HbA1c-6.4* eAG-137*
[**2147-11-21**] 03:58AM BLOOD Triglyc-100 HDL-38 CHOL/HD-2.4 LDLcalc-32
[**2147-11-20**] 05:57PM BLOOD Type-ART Temp-36."
3028,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 10351**],
You had increasing shortness of breath at home that is from
congestive heart failure and an old heart attack. You had some
changes on your ECG and was transferred to [**Hospital1 18**] for a cardiac
catheterization. A stent was placed in your right coronary
artery and you have other blockages that were not fixed at this
time. You were started on aspirin and clopidogrel, Plavix, to
keep the stent from clotting off. Do not stop taking plavix or
aspirin for any reason unless Dr."
3029,"1 Phos-2.7 Mg-2.3
[**2147-11-23**] 05:30PM BLOOD Calcium-9.8 Phos-3.0 Mg-2.1
[**2147-11-24**] 07:35AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.1
Studies:
ECHO: [**2147-11-21**]
Left ventricular wall thicknesses are normal. The left
ventricular cavity is dilated. Overall left ventricular systolic
function is severely depressed (LVEF= 15 %) secondary to
extensive apical akinesis, inferior posterior akinesis, and
septal akinesis with focal dyskinesis. The right ventricular
free wall thickness is normal. Right ventricular chamber size is
normal. with borderline normal free wall function. [Intrinsic
right ventricular systolic function is likely more depressed
given the severity of tricuspid regurgitation."
3030,"This is consistent with the patient's
description of NHYA class [**3-2**] symptoms at home. The patient
initially had crackles on exam, that improved during the
hospitalization, as well as no peripheral edema. Initially the
patient was very tachypneic during the cath, and was intubated.
She also received 40 mg IV lasix at the time and made good
urine. Her respiratory status continued to improve as fluid was
taken off. The patient did no have an oxygen requirment on
discharge, and was sent home on Torsemide 40 mg daily. The
patient was also medically optimized for her CHF and started on
metoprolol, atorvastatin, and her home lisinopril dose was
increased."
3031,"] There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Cath [**2147-11-20**]
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe diastolic ventricular dysfunction.
3. Inferior wall STEMI.
4. Acute occlusion at the level of mid-RCA successfully treated
with a
bare metal Vision stent(3."
3032,"5mg tabs 6 tabs by mouth once weekly
Folic acid 1mg PO daily
Effexor 75mg PO TID
Lithium 300mg tabs, 2 tabs by mouth [**Hospital1 **] (1200mg total) (managed
by Dr. [**Last Name (STitle) 85917**]
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5."
3033,"An order for these blood tests will be
provided in your discharge paperwork.
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: FRIDAY [**2147-12-1**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 85918**], MD [**Telephone/Fax (1) 3070**]
Building: None [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: CARDIAC SERVICES
When: TUESDAY [**2147-12-26**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2147-11-27**]"
3034,"She was taken to BIDN, where labs at notable for CK 6.2
and trop 0.014 at noon today. On arrival to the ED there, her
initial vitals were 28-34, o2 sat 95% r/a, bp 151/94, hr 115,
and she was becoming increasingly dyspneic. She was started on
a heparin and integrillin gtt, given plavix 600 mg, aspirin 325,
metoprolol 5 IV, and transferred to [**Hospital1 18**] for urgent
catheterization.
.
In the cath lab, patient was increasingly tacypneic and was thus
intubated prior to the procedure. There was a 100% occlusion of
the RCA, and a BMS was placed over this lesion."
3035,"[**Last Name (STitle) **] tells you it is OK. You
risk having another heart attack if you do not take these
medicines. The plan is to treat you with medicines to help your
heart pump better and recover from the heart attack. Your heart
function is very weak after the heart attack and you will need
to take all of your medicines every day and check for any fluid
build up. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes
up more than 3 lbs.You also need to follow a low sodium diet.
.
We made the following changes to your medicines:
1."
3036,"She also had a
90% diag, 90% mid LAD, 90% mid Lcx. Right heart cath notable
for a PCWP 31, PA oressures 54/32. She was given 40 mg IV Lasix
and transferred to the CCU intubated.
.
On review of systems, she 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. She denies recent fevers, chills or
rigors. She 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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope."
3037,"1* RBC-4.24 Hgb-13.0 Hct-38.2
MCV-90 MCH-30.8 MCHC-34.1 RDW-13.7 Plt Ct-294
[**2147-11-23**] 05:30PM BLOOD Glucose-119* UreaN-22* Creat-1.0 Na-141
K-4.1 Cl-98 HCO3-32 AnGap-15
[**2147-11-24**] 07:35AM BLOOD Glucose-130* UreaN-25* Creat-1.0 Na-141
K-4.1 Cl-99 HCO3-35* AnGap-11
[**2147-11-25**] 06:35AM BLOOD Glucose-111* UreaN-35* Creat-1.1 Na-140
K-3.9 Cl-99 HCO3-33* AnGap-12
[**2147-11-21**] 03:58AM BLOOD CK(CPK)-89
[**2147-11-23**] 05:06AM BLOOD Calcium-9."
3038,"spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
8. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day."
3039,"Admission Date: [**2198-12-11**] Discharge Date: [**2198-12-19**]
Date of Birth: [**2147-9-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
R leg pain
Major Surgical or Invasive Procedure:
L3-L5 laminectomy, resection of an intradural tumor.
History of Present Illness:
51 Spanish speaking male with progressively worsening LBP and
R leg pain over the last 2months. Reports going to multiple ED's
with these symptoms and has just been given pain medication
without much relief. Today after having an outpt MRI he was sent
here with report of L3-L4 tumor."
3040,"Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: Take
while on Narcotic pain medications.
Discharge Disposition:
Home
Discharge Diagnosis:
L3-L4 intrathecal lesion, s/p resection
Discharge Condition:
Stable
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery you may shower
Three days after your surgery and get the wound wet, but do not
scrub the wound area."
3041,"decrease sensation in R leg.
Reflexes: B T Br Pa Ac
Right 2 2
Left 2 2
Toes downgoing bilaterally
Rectal exam normal sphincter control
3 beat clonus on L
Pertinent Results:
MRI LUMBAR SPINE ON ADMITION:
FINDINGS: A 13 x 42 mm irregularly enhancing mass is noted
within the thecal sac, centered at the L4 vertebral level. The
mass essentially fills the thecal sac and approximates the right
lateral dural margin. There is presumed splaying of the cauda
equina at this location. It is not possible to determine, given
the size of this lesion whether the mass arises from a
nerve rootlet."
3042,"Past Medical History:
None
Social History:
Unemployed at this time, lives with some friends,
denies smoking and ETOH
Family History:
Mother died due to cardiac related event
Physical Exam:
T:97.2 BP:158/92 HR:82 RR:18 O2Sats:94
Gen: WD/WN, comfortable, NAD.
HEENT:Atraumatic Pupils: 2.5->2 EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
Sensation: Intact to light touch however posterior portion of R
leg is hypersensitive and sl."
3043,"??????Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
??????Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
??????Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
??????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:"
3044,"?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in 10 days f removal of your
staples/sutures. If your sutures are under the skin, you will
not need to be seen until the follow up appointment.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in __4__weeks.
??????You will/will not need x-rays/CT-scan prior to your
appointment.
Completed by:[**2198-12-19**]"
3045,"An attempt was made to page you, but you were not available. The
neurosurgical
house staff was also paged, but did not respond as of the time
of this report.
Brief Hospital Course:
51 Spanish speaking male with progressively worsening LBP and
R leg pain over the last 2months. Reports going to multiple ED's
with these symptoms and has just been given pain medication
without much relief. Today after having an outpt MRI he was sent
here with report of L3-L4 tumor. On admition the pt. recieved a
full spine MRI to rule out mets, including a Cranial MRI."
3046,"Pt.
went to the OR with Dr. [**First Name (STitle) **] and underwent a lumbare
decompression and a complete resection of the intradural tumor.
Post operative course was uncomplicated and the patient is being
discharge home today. The patient has been directed to maintain
a strict bowel regimine given his difficulty moving his bowels.
Medications on Admission:
Vicodin 5-500 1 tab""prn, Neurontin
200mg HS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3."
3047,"There is a minimally bulging disc at the L2-3 and L3-4 levels.
There is also mild disc space narrowing at L2-3. At L5-S1, there
is a minimally bulging, mildly narrowed disc with type 2
degenerative endplate change oN either side of the disc.
There is no other overt lumbar spinal abnormality seen.
The visualized distal spinal cord, conus medullaris, and
remainder of the
cauda equina are normal.
CONCLUSION: Large intradural mass. The finding likely represents
a neoplasm.
A large schwannoma, as opposed to an ependymoma could be
considered. A drop metastasis seems less likely, as does an
inflammatory process."
3048,"??????If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
??????No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
??????Limit your use of stairs to 2-3 times per day.
??????Have a friend or family member check your incision daily for
signs of infection.
??????If you are required to wear one, wear your cervical collar or
back brace as instructed.
??????You may shower briefly without the collar or back brace; unless
you have been instructed otherwise."
3049,"Admission Date: [**2172-9-20**] Discharge Date: [**2172-9-23**]
Date of Birth: [**2090-11-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor First Name 2080**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD [**2172-9-21**]
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 87132**] is an 81 year old man with a history of CAD
s/p CABG, Afib on coumadin, s/p CVA [**2171**], s/p PPM, and DM2 who
presents with anginal chest pain with exertion in the setting of
multiple melanotic stools. Patient lives in [**State 760**] and was
visiting his daughter in [**Name (NI) 86**] the week."
3050,"GI team was consulted. He was transfused 2
units FFP and 2 units pRBC prior to transfer to the MICU.
.
On arrival to the MICU, he again denies any active chest pain.
He reports some right sided chest pressure and fatigue with
exertion which resolves with rest. He denies any recent
lightheadedness, shortness of breath, palpitations, abdominal
pain, diarrhea, vomiting, nausea, fever, chills. He denies use
of any etoh, NSAIDS, steroids. He reports his last colonoscopy
was over 10 years ago and was negative. He denies any history
of upper endoscopy or known GI ulcers. He later admits to
having a GI bleed during an admission in the [**2152**] for cardiac
angioplasty in the setting of anticoagulation or high dose
aspirin."
3051,".
Review of systems:
(+) Per HPI, nocturia, constipation
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied nausea,
vomiting, diarrhea, or abdominal pain. No recent change in
bladder habits. No dysuria.
Social History:
Social History: He lives in [**State 760**] and is currently visiting
a daughter in [**Name (NI) 86**] (who is the director of Atrius). He denies
tobacco, EtOH, drugs.
Family History:
non-contributory
Physical Exam:
Physical Exam: at time of discharge
VS: BP 145/64, HR 85, RR 20, O2 95% RA
General: Sleeping but arousable, appears well, no distress
HEENT: moist mucosa, oropharynx clear
Cards: irregularly irregular, no murmur, 2+ pitting LE symmetric
peripheral edema, no carotid bruit appreciated
Pulm: clear bilaterally, no w/r/c
Abd: soft, nontender, nondistended
Extremities: warm, lipoma on posterior neck, LE skin changes
consistent with chronic venous stasis, 2 healed ulcers on left
shin
Neuro/Psych: hard of hearing."
3052,"5 4.08* 10.6* 33.2* 81* 26.0* 32.0 17.7* 186
Glucose UreaN Creat Na K Cl HCO3 AnGap
164 22* 1.0 140 3.2* 103 29 11
EKG (no baseline comparision) EKG showed diffuse TWI in II, III,
aVF, V1-6, and ST depressions II, V4-6.
ENDOSCOPY ([**9-21**])
Findings:
Esophagus: Normal esophagus.
Stomach:
Mucosa: Small erosions of the mucosa were noted in the antrum.
Excavated Lesions A single 5 mm ulcer with visible vessel was
found in the antrum. There were stigmata of recent bleeding.
Three endoclips were successfully applied to the ulcer with
visible vessel at stomach antrum for the purpose of hemostasis."
3053,"Duodenum: Normal duodenum.
Impression: Ulcer in the antrum (endoclip)
Small erosions in the antrum
Otherwise normal EGD to third part of the duodenum
Recommendations: Please f/u hct closely and transfusion with
target hct>30, pt at high risk for rebleed
H.pylori serology: positive
Brief Hospital Course:
An 81 year-old man with HTN, CAD, DM and atrial fibrillation on
coumadin h/o pontine CVA s/p PPM in [**2171**] presented fatigue,
chest tightness, in setting of several dark, melanotic stools
and supratherapeutic INR.
# GI Bleed/acute blood loss anemia: Secondary to bleeding antral
ulcer in setting of supratherapetic INR (3."
3054,"6), + H.pylori
serology. On presention HCT: 19.6. During hospitalization
received total of 7units pRBC, 6units FFP, 5mg of vit K PO. Both
coumadin and ASA held. PPI gtt started, transition to IV.
Endoscopy performed on [**9-21**] and antral ulcer clipped. Biopsies
sent and H. pylori serologies sent. After clipping, serial HCTs
obtain, Hct stabilized with no further transfusion requirement.
Extensive discussion regarding patients ongoing management of
his CAD/afib while weighing GU bleeding risk. His outpatient PCP
was [**Name (NI) 653**] and agreed to manage issue with plan to hold
coumdin until follow-up. Prior to discharge, GI recommended
repeat endoscopy in 8weeks, oral PPI treatment [**Hospital1 **] until repeat
endoscopy, and re-initiation of ASA 81mg, Patient to obtain GI
doctor on return to NJ."
3055,".
#) H.pylori infection. H.pylori sent post endoscopy which
returned postive. Patient already on a [**Hospital1 **] PPI. Patient started
on Amoxicillin and Clarithromycin for 14day course.
.
#) Atrial fibrillation (CHADS: 5), h/o pontine stroke s/p PPM in
[**2162**]. Rate controlled on metoprolol and amlodipine. Coumadin
held. Patient informed of importance to follow-up with PCP next
week as his risk of CVA is high and anticoagulation is necessary
in future.
.
# CAD s/p CABG. Troponin bump to 0.08 likely represented demand
ischemia in the setting of poor oxygen delivery from anemia.
Troponin downtrended with repeat 0.05. Patient without anginal
symptoms while hospitalized."
3056,"Repeat EKGs without appreciable
changes.
.
# DM2, controlled with complications: Home byetta and metformin
initially held and patient maintained on an insulin sliding
scale with good effect.
Medications on Admission:
Medications at home:
Aspirin 81 mg
glucovance 500/500mg [**Hospital1 **]
Actose 30 mg
Byetta 10 mcg [**Hospital1 **]
Amlodipine 10 mg
Metoprolol 75 mg [**Hospital1 **]
Lipitor 10 mg
Klorcon 20 meq
Benicar/HCTZ 40mg/25mg
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day)."
3057,"4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
2 months.
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) as needed for H.pylori for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
6. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) as needed for H.pylori for 14 days.
Disp:*112 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Upper GI bleed: bleeding stomach ulcer
H."
3058,"pylori infection
SECONDARY DIAGNOSIS:
CAD
Atrial Fibrillation
Hypertension
Diabetes
Discharge Condition:
Mental status: clear and coherent
Ambulates without assistance
Discharge Instructions:
You presented to [**Hospital1 18**] with symptoms of fatigue, chest tightness
in setting of several dark, melanotic stools. On arrival your
blood counts were found to be low. Gastroenterologists were
consulted and they performed an endoscopy to look for a source
of bleed. During the procedure a gastric ulcer was found an
clipped. Biopsies were taken and testing was sent to look for an
infection known as H.pylori. Testing for H.pylori returned
positive and you were started on Antibiotics and a PPI to treat
infection."
3059,"CN II-XII intact. Strength 5/5
upper and lower extremites b/l. Gait stable.
Pertinent Results:
On admission:
[**2172-9-20**] 01:40PM WBC-12.3* RBC-2.53* HGB-6.3* HCT-19.8*
MCV-78* MCH-24.7* MCHC-31.6 RDW-20.4*
[**2172-9-20**] 01:40PM PT-35.5* PTT-30.6 INR(PT)-3.6*
[**2172-9-20**] 01:40PM GLUCOSE-330* UREA N-55* CREAT-1.2 SODIUM-142
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-28 ANION GAP-16
At discharge ([**9-23**])
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8."
3060,"Infection should resolve with 2 weeks of treatment.
During the course of your stay you received several units of
blood and your counts improved and at the time of discharge
counts were stable.
Due to the bleed, your anticoagulation was held. At time of
discharge aspirin 81mg was restarted. However, warfarin was not
restarted at time of discharge due to risk of bleeding. However
due to your high risk for stroke you will need additional
anticoagulation in the future.
Of note, you will need to follow up with GI for repeat endoscopy
in 8weeks
Changes to your medications:
Start:
Pantoprazole 40mg PO, take one pill by mouth twice daily until
your endoscopy in 8weeks
Amoxicillin, take four 250mg pills by mouth twice daily for
14days
Clarithromycin take two 250mg tablets by mouth twice daily for
14days
Stop:
Coumadin
Followup Instructions:
Will follow-up with internist office on Tuesday [**9-28**]
Will need GI follow-up in 8weeks.
Completed by:[**2172-9-24**]"
3061,"During the last few
days he had several black stools. He also started becoming more
fatigued with exertion and developed right sided chest pressure
with activity that resolved at rest. He presented to urgent
care today who recommended ED evaluation.
.
In ED VS were T 98.4 HR 78 BP 131/62 RR 18 SpO2 99%. Patient
denied any symptoms on arrival. EKG showed diffuse TWI in II,
III, aVF, V1-6, and ST depressions II, V4-6. Labs were notable
for Hct 19.5, WBC 12, Trop 0.05. Melanotic guaiac positive
stools on rectal exam. NG lavage showed a few coffee grounds
concerning for UGIB."
3062,"CRITICAL CARE ATTENDING ADDENDUM
I saw and examined Ms. [**Known lastname 11357**] with the ICU team, whose note from
today reflects my input.
Overnight events:
Hypotension esp with pain medications, but mentating and with good UOP
Substantial pain (similar to her chronic pain)
97/68 100.2 70 18 96%
-1.7L LOS. Making up to 200 cc urine per hour.
Clear heart sounds, no murmur
Clear lungs anteriorly
Soft abdomen
No edema
Meds: oseltamivir, fiorect, vanco, sqh, gabapentin, morphine, zosyn,
diazepam, senna
Labs, meds, and imaging reviewed
Assessment and Plan
26-year-old woman with severe scoliosis s/p T3-L1 thoractomy [**2049-10-28**].
Her post op course c/b pain and pneumonia; she was discharged on two
weeks of levofloxacin.
Hypotension
Even with low BPs, maintaining good UOP and mentation
BP and UOP presently adequate
Treating presumptively for sepsis, though a little uncertain
Check [**Last Name (un) 402**] stim
Influenza
On oseltamivir
Consult ID
Possible pneumonia
Difficult to exclude bacterial superinfection
Continue present rx
Had received adequate atypical coverage, but await ID recs
Pain control
Increase standing narcotic
Consult pain service
Increase bowel regimen
Maintain in ICU in hypotension
Pt is critically ill. Total time spent: 35 minutes."
3063,"Received 2 liters NS
without improvement. Tamiflu given
PMHx: migraine HA's
Bisaiodyl, colace, dliaudid, LVQ, MOrphine
NKDA
Former smoker
FHX unknown
96.6 82/56, P102, alert and oriented , ill appearing with 7/10 back
pain (unchanged
MM dry
Lungs CTA
CV: tachy, RR
Abd: soft, nontender, +bs
Back: large surgical scar, no fluctuance, no disproportionate
tenderness
Ext: no peripheral edema
CT Torso: small degree of atelect. Vs infiltrate at LLL; no intrabd.
process
WBC 4.2/62% PMN's
INR 1.3
Electrolytes: 132, 4.7, 7/0.7
lactate 1.4
Rx: vanco, Hep SQ, colace, neurontin
26 year old female admitted with fevers and hypotension."
3064,"Chief Complaint: Hypotension, fevers
HPI:
This is a 26 year old female with a history of severe scoliosis s/p
recent T3-T4 spinal fusion with thoracotomy (staged procedures on [**10-29**]
and [**11-1**]). Her post-operative course was complicated by development
of pneumonia and severe pain. She was discharge on [**11-12**] with plans
for a two week course of levofloxacin. Since discharge she followed up
with her orthopedic surgeon on [**2136-11-16**] and was told that her wound was
feeling well. On the day prior to presentation she developed fevers,
myalgias and diffuse left flank and back pain as well as body aches and
a dull frontal headache."
3065,"UA negative
and CT torso with a small amt of infiltrate. Largest contenders
viral/atypical given low WBC/lack of left shift/lack of end-organ
damage (n
l uop, n
l lactate) though recent surgery still raises
concern for hardware infxn
Vanc/zosyn/tamiflu, droplet precautions, urine Ag
Fluid resuscitate based on MAP, urine output- if unable to keep up with
fluids, may need CVL/pressors
F/u with Ortho regarding whether further imaging needed to exclude
hardware infection
Pt is critically ill. Total time spent: 45 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 618**] [**Last Name (NamePattern1) **], MD
on:[**2136-11-18**] 13:47 ------"
3066,"She denies photophobia or neck stiffness. She
has a cough which is worsening but non-productive. She has left sided
pleuritic chest pain which is slightly worsened over the past two
days. She denies sore throat or rhinorrhea. She has had mild gassy
abdominal pain and [**3-14**] stools per day but has been taking laxatives.
No nausea, vomiting or constipation. No dysuria or hematuria. No
rashes. No indwelling lines. No sick contacts.
In the ED, initial vs were: T: 102 P: 120 BP: 99/54 R: 20 O2 sat 97% on
RA. Labs were notable for a WBC count of 4."
3067,"Review of systems:
Constitutional: Fatigue, Fever
Ear, Nose, Throat: Dry mouth
Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,
Tachycardia, No(t) Orthopnea
Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze
Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, Diarrhea,
No(t) Constipation
Genitourinary: Foley
Musculoskeletal: No(t) Joint pain
Integumentary (skin): No(t) Jaundice, No(t) Rash
Endocrine: No(t) Hyperglycemia
Heme / Lymph: No(t) Anemia
Neurologic: Headache
Pain: [**9-20**] Worst
Pain location: Back
Flowsheet Data as of [**2136-11-18**] 09:49 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37."
3068,"I agree with Dr. [**Last Name (STitle) 1657**]
s note as
outlined above, including assessment and plan.
26 yo female with severe scoliosis s/p T3-L1 thoractomy [**2049-10-28**]. Post
op course c/b pain, PNA. Discharged on 2 weeks levaquin. This past
weekend, she developed diffuse mylagia/flank pain/HA/cough. Slight abd
pain. Diarrhea but on laxatives.
ED: 102 120 90/50 97% RA
Labs: WBC 4.3, 70% PMN, n'l lactate and LFT's
Pan-CT: previously seen PNA, mildly dist GB
US: no edema/[**Doctor Last Name **] sign
Received 3 liters fluid for SBP 80-90's
Vanc/zosyn/dilaudid
To floor initially- BP 82/56 and dropped to 70's."
3069,"She received an
additional 2 liters of normal saline without improvement. Blood
cultures were drawn and she received tamiflu. The decision was made to
transfer the patient to the MICU.
Patient admitted from: [**Hospital1 19**] [**Hospital1 158**]
History obtained from [**Hospital 15**] Medical records
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Hydromorphone (Dilaudid) - [**2136-11-18**] 07:00 AM
Other medications:
Medications:
Bisacodyl 10 mg PO daily:PRN
Colace 100 mg PO BID
Dilaudid 2-4 mg PO Q3H:PRN
Diazepam 5 mg PO Q6H:PRN
Levofloxacin 500 mg PO BID
Gabapentin 300 mg PO BID
Morphine 30 mg PO Q8H
Past medical history:
Family history:
Social History:
Migraine
s/p spinal fusion
Non-contributory
Occupation: Unemployed
Drugs: None
Tobacco: Remote
Alcohol: None
Other: Moved back in with Mom prior to procedure."
3070,"No appreciable change
since prior study from four days ago.
Microbiology: Blood cultures pending [**2136-11-18**]
Assessment and Plan
Assessment and Plan: This is a 26 year old female with recent spinal
surgery who presents with fevers, cough and hypotension.
Hypotension/Sepsis: Concern given the constellation of fevers,
tachycardia and hypotension that this represents sepsis. Currently
making good urine, mentating well and with normal lactate which argues
against end-organ malperfusion. Souce is unclear. Highest on the
differential would be blood stream versus hardware infection of the
back. She also has a left sided infiltrate on chest CT which is being
treated with levofloxacin but has persistent cough and pleuritic chest
pain."
3071,"Given myalgias and high fevers, influenza is on the
differential. Urinalysis is negative. She has complained of diarrhea
so clostridium difficle should also be considered. She received
vancomycin and zosyn in the emergency room for empiric coverage of
sepsis of unclear etiology. Heart rate now in the 90s with blood
pressures in the high 90s systolic after 5 liters of IVF. Unclear
baseline blood pressures, per nursing staff during her previous
hospitalization her baseline blood pressures were in the 90s but in
clinic it appears to be in the high 90s to 110s.
- normal saline boluses for UOP < 30 cc/hr, SBP < 90
- will need to consider central IV access if persistent hypotension
- close monitoring of urine output
- will follow blood cultures
- will send sputum, c."
3072,"0
Imaging: CT TORSO [**11-17**]: ? gall bladder wall edema, US maybe helpful.
post op changes decreased LLL pleural effusion and adjacent atx.
RUQ U/S [**11-18**]: Gall bladder sludge and mildly distended gb. No wall
edema. clinical correlation recommended.
Xray L-spine [**11-16**]: Spinal fusion rods traverse from approximately the
T1 level to the L3 level. There is a mild S-shaped scoliosis.
Morselized bone graft traverses the lower thoracic and upper lumbar
levels. Pedicle screws are present. Hardware appears intact. Lumbar
vertebral body height and alignment are maintained. Disc height is
grossly maintained. Visualized lungs are clear."
3073,"Abdomen: Tender to palpation on LUQ/LLQ, soft, non-distended, bowel
sounds present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Labs / Radiology
409
11.6
95
0.7
7
29
93
4.7
132
34.9
4.3
[image002.jpg]
Other labs: PT / PTT / INR:15.0/38.1/1.3, ALT / AST:19/37, Alk Phos / T
Bili:101/0.4, Amylase / Lipase:/22, Differential-Neuts:62.5,
Lymph:29.2, Mono:6.2, Eos:1.3, Lactic Acid:1.4, Ca++:8.4, Mg++:1.7,
PO4:4."
3074,"0
2.8
3.3
Hct
30.1
31.9
33.3
Plt
263
267
290
Cr
0.5
0.5
0.7
Glucose
94
100
225
Other labs: PT / PTT / INR:13.9/39.1/1.2, ALT / AST:[**12-1**], Alk Phos / T
Bili:81/0.4, Differential-Neuts:47.1 %, Band:0.0 %, Lymph:44.2 %,
Mono:5.6 %, Eos:2.1 %, Ca++:8.4 mg/dL, Mg++:1.7 mg/dL, PO4:4.4 mg/dL
Assessment and Plan
INEFFECTIVE COPING
FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)
HYPOTENSION (NOT SHOCK)
TACHYCARDIA, OTHER
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
Assessment and Plan: This is a 26 year old female with recent spinal
surgery who presents with fevers, cough and hypotension; influenza A+."
3075,"If continues low will insert arterial line for more
accurate measurement.
- Endocrine consult
-Manual measurement
-Arterial line if continuing low
Leukopenia: Patient WBC count on arrival 4.3, trending down. Today
slightly increased from 2.8 yesterday to 3.3 today. ID feels likely
secondary to marrow suppression from viral illness vs. beta lactam
exposure.
-D/c vanco & Zosyn
Spinal fusion: Per orthopedics her wound is healing well and is at low
risk for hardware infection; did not feel imaging was necassary
Vaginal Itching: Patient appears to have yeast infection. Will send
sample of discharge and give 150mg of fluconazole x1."
3076,"- she takes dulcolax 20mg [**Hospital1 7**] at home when she is constipated.
- endocrine recs: has low basal but appropriate response to stim. Could
be due to getting steroids with surgery or from narcotics use. Get ACTH
and basal cortisol tomorrow am, to differentiate primary vs secondary.
Fellow Subbu [**Numeric Identifier 11406**], we can call tomorrow with results to discuss.
- echo: >55%. Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant valvular
disease seen.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Piperacillin - [**2136-11-20**] 10:00 PM
Vancomycin - [**2136-11-20**] 11:33 PM
Infusions:
Other ICU medications:
Hydromorphone (Dilaudid) - [**2136-11-20**] 03:30 PM
Other medications:
Past medical history:
Family history:
Social History:
Occupation:
Drugs:
Tobacco:
Alcohol:
Other:
Review of systems:
Flowsheet Data as of [**2136-11-21**] 07:09 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36."
3077,"Patient states
improved now after 1 dose of fluconazole.
Pain: Pain has been difficult to control during recent
hospitalization. Per patient she takes morphine. Patient reports that
pain regimen yesterday worked well for her
- Consult pain service as this worked well for her on her prior
admission.
- PO dilaudid for breakthrough
- Pain service will come by today, talk about plan for weaning
FEN: replete electrolytes, regular diet
Prophylaxis: Subcutaneous heparin, bowel regimen with Dulcolax
Access: Peripherals, may need to consider central access if persistent
hypotension
Code: Full code
Communication: Patient and Mom [**Name (NI) **] [**Telephone/Fax (1) 11336**]
[**Name2 (NI) **]osition: Pending clinical improvement
if pressures stable to
floor late today or tomorrow.
ICU Care
Nutrition:
Glycemic Control:
Lines:
22 Gauge - [**2136-11-19**] 02:00 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:"
3078,"7 g/dL
225 mg/dL
0.7 mg/dL
3 mg/dL
34 mEq/L
99 mEq/L
3.5 mEq/L
140 mEq/L
33.3 %
3.3 K/uL
[image002.jpg]
[**2133-1-12**]
2:33 A11/9/[**2136**] 06:10 AM
[**2133-1-16**]
10:20 P11/10/[**2136**] 05:09 AM
[**2133-1-17**]
1:20 P11/11/[**2136**] 02:50 AM
[**2133-1-18**]
11:50 P
[**2133-1-19**]
1:20 A
[**2133-1-20**]
7:20 P
1//11/006
1:23 P
[**2133-2-12**]
1:20 P
[**2133-2-12**]
11:20 P
[**2133-2-12**]
4:20 P
WBC
3."
3079,"8
C (98.3
Tcurrent: 36.4
C (97.6
HR: 69 (61 - 108) bpm
BP: 85/44(53) {74/41(50) - 101/56(64)} mmHg
RR: 8 (8 - 24) insp/min
SpO2: 89%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 108 kg (admission): 62 kg
Total In:
2,240 mL
500 mL
PO:
1,040 mL
500 mL
TF:
IVF:
1,200 mL
Blood products:
Total out:
1,780 mL
300 mL
Urine:
1,780 mL
300 mL
NG:
Stool:
Drains:
Balance:
460 mL
200 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 89%
ABG: ///34/
Physical Examination
Gen: Lying in bed in NAD
HEENT: MMM, no lymphadenopathy
CV: RRR, no M/R/G
Lungs: decreased breath sounds at bases, poor inspiratory effort
[**Last Name (un) 61**]: NABS, soft, ND, NT
Extrem: no edema
Labs / Radiology
290 K/uL
10."
3080,"Recommended oseltamavir
(H1N1), ramantadine (for coverage of possible seasonal flu in addition
to H1N1). Currently afebrile
- f/u blood and sputum (has not yet produced enough sputum for sputum
culture)
- d/c vanc &zosyn
- continue tamiflu x5 day course
- Rimantadine 100mg PO BID x5 day course
- monitor fever curve and WBC count
Hypotension: Baseline from last hospitalization 90s-100s/60s. [**Last Name (un) **] stim
test result equivocal. ECHO shows normal function of heart, so not
concern for CHF due to flu. Will follow up on endocrine results. Also
concern for if this is a valid result. Will check with smaller BP cuff
and manual cuff."
3081,"Influenza: Initially concern was for sepsis with source being recent
surgical implants. Now the most likely source is her lungs, and a
possible bacterial superinfection of her influenza infection. [**11-19**] CXR
showed left-sided pleural effusion combined to left lower lobe area of
consolidation with air bronchograms (new), which is consistent with
PNA. She received vancomycin and zosyn in the emergency room for
empiric coverage of sepsis of unclear etiology. Blood cultures are
negative to date. ID was consulted and felt that CXR improved from
prior hospitalization when patient was aggressively treated for PNA, so
we do not need to treat that at this point."
3082,"TITLE:
Chief Complaint:
HPI:
ID: Can d/c Vanco & Zosyn ; continue daily CBC with differential. Not
neutropenic at this time. Lymphocytes rising. This suggests a viral
etiology to bone marrow suppression. Likely complicated by beta lactam
exposure. Would consider smear if not improving; would not treat
pneumonia at this time as feel CXR improved from previous admission
where she was treated for PNA.
- pain: mix-up w/ resident who didn't think he needed to come today.
Suggested based on prior recommendations switching to PO dilaudid,
adding extra dose of QHS gabapentin and making tylenol standing. She
was previously on a fentanyl patch but that wasn't covered by insurance
so she switched to MS Contin."
3083,"Name: [**Known lastname 12819**],[**Known firstname 1197**] Unit No: [**Numeric Identifier 12820**]
Admission Date: [**2136-11-18**] Discharge Date: [**2136-11-23**]
Date of Birth: [**2110-8-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1880**]
Addendum:
Anemia: Patient had a normocytic anemia. Iron studies showed
chronic inflammation. It is recommended that she have repeat
iron studies after her acute illness.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1881**] MD [**Last Name (un) 1882**]
Completed by:[**2136-11-23**]"
3084,"Admission Date: [**2136-11-18**] Discharge Date: [**2136-11-23**]
Date of Birth: [**2110-8-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
fever and hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 26 year old female with a history of severe scoliosis
s/p recent T3-T4 spinal fusion with thoracotomy (staged
procedures on [**10-29**] and [**11-1**]). Her post-operative course was
complicated by development of pneumonia and severe pain. She
was discharge on [**11-12**] with plans for a two week course of
levofloxacin."
3085,"Her
hypotension was thought to be related to the severe illness.
.
Pain: The pain service was consulted. Her gabapentin was
increased to three times daily. Her hydromorphone was also
increased. She received MS Contin three times daily.
.
Vaginal Yeast Infection: She was treated for a vaginal yeast
infection in the unit with fluconazole.
.
Post-op: Ortho was consulted. Her incisions were healing well.
.
Prophylaxis: She received subcutaneous heparin and a bowel
regimen.
.
Code: During the hospitalization she was a full code.
.
Medications on Admission:
Bisacodyl 10 mg PO daily:PRN
Colace 100 mg PO BID
Dilaudid 2-4 mg PO Q3H:PRN
Diazepam 5 mg PO Q6H:PRN
Levofloxacin 500 mg PO BID
Gabapentin 300 mg PO BID
Morphine 60 mg PO Q8H"
3086,"Disp:*45 Tablet Sustained Release(s)* Refills:*0*
9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain for 2 weeks: Do not drive while taking
this medicaiton as it can cause drowsiness.
Disp:*75 Tablet(s)* Refills:*0*
10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety/muscle spasm for 2 weeks.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary - Influenza
Hypotension
Secondary - Pain status post spinal fusion
Discharge Condition:
Afebrile, pain controlled.
Discharge Instructions:
You were admitted to the hospital with fevers and found to have
an influenza."
3087,"2. Your breakthrough dilaudid dose was increased to 4 mg every
3 hours as needed. Do not drive while taking this medication as
it can cause sleepiness.
3. You can take 5 mg of valium every 6 hours as needed for
muscle spasms.
4. Your gabapentin was increased to 300 mg in the morning and
afternoon and 600 mg every night.
5. You should continue taking colace 100 mg twice daily to
prevent constipation. If you become constipated, you can take
10 mg of bisacodyl or 2 tablets of senna as needed.
6. If you experience nausea you can take 10 mg of compazine
every 6 hour as needed.
Call your primary doctor, or go to the emergency room if you
experience fevers, chills, shortness of breath, inability to eat
and drink normally, or other concerning symptoms.
Followup Instructions:
You have an appointment scheduled with Dr. [**Last Name (STitle) 61741**] on Monday the
[**10-3**] at 4:20 PM. Please call the office at
[**Telephone/Fax (1) 68410**] if you have any questions.
You should follow up with the orthopedic doctors according to
their previous instructions."
3088,"2*
[**2136-11-22**] 08:50AM BLOOD Ret Aut-1.5
[**2136-11-23**] 06:10AM BLOOD Glucose-99 UreaN-3* Creat-0.5 Na-143
K-3.8 Cl-104 HCO3-30 AnGap-13
[**2136-11-21**] 02:50AM BLOOD ALT-11 AST-21 AlkPhos-81 TotBili-0.4
[**2136-11-17**] 06:45PM BLOOD Lipase-22
[**2136-11-23**] 06:10AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.8
[**2136-11-22**] 08:50AM BLOOD calTIBC-199* VitB12-566 Folate-15.2
Ferritn-288* TRF-153*
[**2136-11-19**] 06:10AM BLOOD TSH-2.2
[**2136-11-21**] 02:50AM BLOOD Cortsol-13."
3089,"No nausea,
vomiting or constipation. No dysuria or hematuria. No rashes.
No indwelling lines. Her mother and daughter have both been
sick with upper respiratory symptoms.
.
In the ED, initial vs were: T: 102 P: 120 BP: 99/54 R: 20 O2 sat
97% on RA. Labs were notable for a WBC count of 4.3 with 62%
neutrophils. She had a CT Torso which showed a left sided
infiltrate and some possible gallbladder wall edema. She
subsequently had a RUQ ultrasound which showed a mildly
distended gallbladder but no edema. LFTs were negative. She
received 3 liters of normal saline, vanocycin 1 gram IV x 1,
zosyn 4."
3090,"5. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
6. Rimantadine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*50 Tablet(s)* Refills:*0*
8. Morphine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day: Do not drive while
taking this medicaiton as it can cause drowsiness."
3091,"Since discharge she followed up with her
orthopedic surgeon on [**2136-11-16**] and was told that her wound was
healing well. On the day prior to presentation she developed
fevers, myalgias and diffuse left flank and back pain as well as
body aches and a dull frontal headache. She denies photophobia
or neck stiffness. She has a cough which is worsening but
non-productive. She has left sided pleuritic chest pain which
is slightly worsened over the past two days. She denies sore
throat or rhinorrhea. She has had mild gassy abdominal pain and
[**3-14**] stools per day but has been taking laxatives."
3092,"Mildly distended
gallbladder. Clinical correlation is recommended
.
Xray L-spine [**11-16**]: Spinal fusion rods traverse from
approximately the T1 level to the L3 level. There is a mild
S-shaped scoliosis. Morselized bone graft traverses the lower
thoracic and upper lumbar levels. Pedicle screws are present.
Hardware appears intact. Lumbar vertebral body height and
alignment are maintained. Disc height is grossly maintained.
Visualized lungs are clear. No appreciable change since prior
study from four days ago.
ECHO: The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%)."
3093,"5 gm IV x 1 and dilaudid 1 mg IV x 2. She was seen by
orthopedics who felt that her incisions appeared to be healing
well. She was admitted to the floor for further management.
.
On arrival to the floor her blood pressure was 82/56. She
received an additional 2 liters of normal saline without
improvement. Blood cultures were drawn and she received
tamiflu. The decision was made to transfer the patient to the
MICU.
Past Medical History:
Migraine
s/p spinal fusion
Scoliosis
Social History:
Moved back in with Mom prior to procedure. Former smoker.
Occasional ETOH."
3094,"[**2136-11-17**] 06:45PM BLOOD WBC-4.3# RBC-4.05* Hgb-11.6* Hct-34.9*
MCV-86 MCH-28.6 MCHC-33.2 RDW-15.0 Plt Ct-409
[**2136-11-23**] 06:10AM BLOOD WBC-3.9* RBC-3.60* Hgb-9.7* Hct-31.6*
MCV-88 MCH-27.0 MCHC-30.8* RDW-14.8 Plt Ct-254
[**2136-11-23**] 06:10AM BLOOD Neuts-40.6* Lymphs-48.6* Monos-6.6
Eos-3.9 Baso-0.4
[**2136-11-23**] 06:10AM BLOOD PT-13.6* PTT-39.3* INR(PT)-1."
3095,"On admission she was given normal saline fluid
boluses to help maintain adequate systolic blood pressure.
Although she appeared clinically well, she continued to have
blood pressures in the low 90's and high 80's. She was kept in
the unit for monitoring. An endocrine and cardiac assessment
were done to discover any potential underlying causes. She had
an echocardiogram which showed an EF of >55%. There was normal
global and regional biventricular systolic function. No
pulmonary hypertension or clinically-significant valvular
disease was seen. An endocrine workup included measurements of
ACTH and cortisol. She was transferred to the floor and
maintained a systolic blood pressure in the mid 90's."
3096,"Brief Hospital Course:
This is a 26 year old female with recent spinal surgery who was
admitted to the intensive care unit for fevers, cough and
hypotension, found to have Influenza. A brief description of her
hospital course according to problem is described below:
.
Fever/Myalgias: When the patient originally presented there was
concern that the constellation of fevers, tachycardia and
hypotension represented sepsis. She persistently had a good
urine output, mentated well and had a normal lactate. She
received vancomycin and zosyn in the emergency room for empiric
coverage of sepsis of unclear etiology and was initially
admitted to the ICU."
3097,"She was found to be influenza A positive.
She was started on oseltamivir and rimantidine. Her other
antibiotics were stopped after 48 hours. Ortho was consulted
and did not believe there was an infection in her hardware and
did not recommend surgery. She was continued on oseltamivir for
5 days. She had one dose of rimantadine remaining when she was
discharged. On the day of discharge she had one set of blood
cultures from admission that were still negative, but not
finalized.
.
Hypotension: During her previous hospitalization her baseline
blood pressures were in the 90s. In clinic records it was in the
high 90s to 110s."
3098,"Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day: Take 300 mg in the morning and afternoon and 600 mg at
night.
Disp:*120 Capsule(s)* Refills:*0*
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours): Do not take more than 3000 mg of tylenol in a 24 hour
period."
3099,"No illicits. Has a 6 year old daughter.
Family History:
N/C
Physical Exam:
Vitals: T:96.6 BP: 82/56 P: 102 R: 24 O2: 95 RA
General: Alert, oriented, somewhat somnolent, complaints of [**7-20**]
back pain which is improved from arriavl to the floor
HEENT: Sclera anicteric, Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Back: Well healed, slightly erythematous incision without
fluctuance or drainage extending from thoracic to lumbar spine.
Abdomen: Tender to palpation on LUQ/LLQ, soft, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
3100,"Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen."
3101,"Your blood pressure was low so you were initially
cared for in the Intensive Care Unit. However, you improved with
antiviral therapy and supportive care. Your blood pressures
have remained on the low side of normal. However, you have
remained asymptomatic and not far from your baseline blood
pressure.
You were found to have anemia or a low red blood cell count.
Please follow up with your primary care doctor about this.
You completed a course of Tamiflu and have one more tablet of
rimantadine which you should take the night of discharge.
Medication changes:
1. Your fentanyl patch was changed to morphine SR 60 mg three
times daily."
3102,"5
[**2136-11-17**] 06:45PM BLOOD HCG-<5
[**2136-11-17**] 06:45PM BLOOD CRP-13.0*
[**2136-11-21**] 02:50AM BLOOD ACTH - 27
[**2136-11-18**] 10:05 am Influenza A/B by DFA Source: Nasal swab.
**FINAL REPORT [**2136-11-18**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2136-11-18**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79838**] (COVERING FOR [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19840**]
[**Numeric Identifier 77608**]) ON
[**2136-11-18**] AT 1435.
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2136-11-18**]):
Negative for Influenza B."
3103,"Pertinent Results:
CT [**11-17**]: IMPRESSION: 1. Decreased left-sided pleural effusion
with adjacent atelectasis as compared to prior study.
2. Questionable pericholecystic fluid versus gallbladder wall
edema with
mildly distended gallbladder. Clinical correlation for
cholecystitis is
suggested. An ultrasound may be helpful in further evaluation.
3. 4.2 cm left illiac defect likely represent a bone graft donor
site, new since [**2135-10-12**].
4. Post-surgical changes of the spine.
5. 1.1-cm nodule in the right lobe of the thyroid gland.
Ultrasoud will be helpful for further evaluation.
6. sub-cm tracheal diverticulum, unchanged
.
RUQ U/S [**11-18**]: IMPRESSION: Gallbladder sludge with no definite
wall thickening or pericholecystic fluid."
3104,"Has felt fatigue recently, but she has attributed this to
stress over her divorce. Denies sinus tenderness, rhinorrhea or
congestion though endorses sore throat for about 2 weeks which
she has attributed to ""allergies."" 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.
Past Medical History:
- Morbid obesity
- Asthma (not on medication)
- Essential hypertension
- Chronic lower back pain following fall in [**2117**] (fell from a
fire escape that gave way; had two herniated disks, sacral
fracture, abdominal hematoma which required ""panniculectomy"" to
treat; chronic bursitis in hip and chronic pain are
consequences, though not on pain medication)
- History of abnormal LFTs (currently WNL)
- Impaired fasting glucose
- Rapid weight loss followed by weight re-gain a few years ago
- Domestic abuse by ex-husband
- [**Name (NI) **] apnea requiring CPAP
- ""Arrhythmia"" for which she takes atenolol (?"
3105,"The
transfusion was discontinued, and she received 50 mg of IV
diphenhydramine and 20 mg of IV famotidine. She became very
emotional (crying) and stated that this response reminded her of
a scary experience with her son's breathing when he was young
and that it had triggered her PTSD. After approximately 20-30
minutes hives began to resolve, and resolution was cmoplete by
one hour. She never developed objective evidence of respiratory
compromise. Emotional response was aided by one dose of IV
lorazepam, supportive listening by staff, and speaking with her
family on the phone.
# PTSD/ANXIETY/SOCIAL STRESS: Patient was very tearful when she
developed hives."
3106,"She reported flashbacks to when her son was ill
at [**Hospital3 1810**] years ago. She also was very concerned
about her on-going custody battle with her ex-husband and his
potential to use her hospitalization to claim custody of their
7-year old daughter. She received one dose of IV lorazepam
overnight on the night of admission, and was seen by social work
consult the following day. Required PO ativan as needed.
INACTIVE ISSUES:
# HYPERTENSION: The patient was generally normotensive with SBPs
ranging ~115-140 off of medication. Her home antihypertensives
were held on admission at the recommendation of hematology
(though chlorthalidone, lisinopril and atenolol have not been
commonly associated with thrombocytopenia, there have been case
reports of low platelets with chlorthalidone and captopril),
with a plan to restart one medication at a time once platelets
become stable."
3107,"# ""ARRHYTHMIA"": Patient reported a history of ""arrhythmia"" on
admission which she states is the reason she uses the atenolol.
The ""arrhythmia"" seems most likely due to palpitations from PVCs
based on limited documentation in [**Hospital1 **] primary care
and cardiology notes. She was monitored on telemetry in the ICU
and other than sinus bradycardia to the 50s with sleep, no
arrhythmias were noted. She remained asymptomatic.
# OSA: Patient reported using CPAP at home but did not know her
settings. She was seen by the respiratory therapist who selected
settings that resulted in good-quality sleep in-house per
patient report. She required continuous O2 monitoring per
hospital protocol, although she eventually requestd it be
removed."
3108,"Disp:*90 Tablet, Chewable(s)* Refills:*0*
6. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
7. prednisone 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Immune Thrombocytopenic Purpura
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive."
3109,"Given oral
lesions which are associated with intracranial hemorrhage, she
was admitted to the MICU for close monitoring overnight. A head
CT was done and read as negative for acute bleed. She received a
partial platelet transfusion on admission (stopped due to
development of hives as below). Further platelet transfusions
were not required. Platelet count trended up to 68 on
discharge. She was discharged on prednisone 150mg daily with
followup with heme.
# ALLERGIC REACTION: Patient began receiving a platelet
transfusion on arrival to ICU. About 10 minutes into the
transfusion, she developed hives on face, a ""heavy"" sensation in
her chest and subjective SOB (had normal RR, no wheezing, no
desaturation, no evidence of angioedema or stridor)."
3110,"Brother has [**Name (NI) 13808**] (carrier for hemochromatosis) and has had
bleeding/coagulopathy. No known FH of autoimmune disease or ITP.
Physical Exam:
On admission:
General: Alert, oriented, no acute distress. Periodically
tearful during interview.
Skin: Scattered petechiae over face, arms, legs, upper torso.
Ecchymoses on right arm at site of forearm BP cuff.
HEENT: Sclera anicteric, no conjunctival hemorrhage, MMM, EOMI,
PERRL. Hemorrhagic bullae on top center of tongue, under tongue,
left buccal mucosa.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, distant S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft/obese, non-tender, non-distended, bowel sounds
present, no clear organomegaly but difficult to palpate given
body habitus
GU: no foley
Ext: warm, well perfused, minimal LE edema but significant
adipose tissue on lower extremities
Neuro: No focal deficits appreciated; patient upset due to
stress/PTSD and unable to cooperate with full exam at this time"
3111,"PVCs per Atrius
records, unable to locate Holter study from [**2126**])
- ""Water weight"" problems (no known heart problems)
- Peripheral neuropathy in feet/hands of unclear etiology (has
been told related to swelling, B12 deficiency, carpal tunnel in
hands)
- PTSD related to her fall as well as to history of abuse by her
husband and other instances of high stress (son sick as a child)
Surgical history:
- Panniculectomy x 2
- Lipectomy (complicated by infection requiring two subsequent
procedures)
- C-sections x 2
Social History:
Currently lives with 7-year old daughter and periodically hosts
[**Name (NI) **] exchange students. 20-year old son lives with her part-time."
3112,"0 CALCIUM-9.2 PHOSPHATE-3.6
MAGNESIUM-1.8
[**2130-1-21**] 01:20PM WBC-7.3 RBC-4.57 HGB-14.4 HCT-40.1 MCV-88
MCH-31.4 MCHC-35.9* RDW-13.0
[**2130-1-21**] 01:20PM NEUTS-58.4 LYMPHS-33.3 MONOS-4.8 EOS-2.1
BASOS-1.4
[**2130-1-21**] 01:20PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2130-1-21**] 01:20PM PLT COUNT-5*
[**2130-1-21**] 01:20PM PT-11.6 PTT-31.6 INR(PT)-1.1"
3113,"She was therefore referred
into [**Hospital1 18**] for further evaluation.
She reports use of hydrocodone x 1 dose for musculoskeletal pain
about a week prior to presentation. Otherwise, she denies any
recent medication changes or over-the-counter/herbal
medications, including no other pain medications or antibiotics.
(There is a prescription for ophthalmic erythromycin ointment in
[**Hospital1 **] records from the end of [**Month (only) 404**], but patient
states she never filled this prescription as it was not needed.)
In the ED, initial VS were: T 99.3, HR 63, BP 143/90, RR 16, O2
sat 100% on RA. Hematology was contact[**Name (NI) **] and recommended 100 mg
PO prednisone and 1 unit platelets."
3114,"Microbiology:
- EBV IgM
- EBV IgG
- HIV 1&2 antibody:
Imaging:
CT HEAD W/O CONTRAST [**2130-1-21**]: No evidence of acute intracranial
process. No definite evidence of intracranial hemorrhage.
Brief Hospital Course:
46 yo F with morbid obesity and hypertension who presented with
petechial rash, found to have platelets of 0. Assumed to be ITP
and started on steroids.
ACTIVE ISSUES:
# THROMBOCYTOPENIA: Platelet count on admission was markedly
abnormal at 5, which explains the patient's petechial rash. She
is not known to have any chronic condition associated with low
platelets and has no history of similar symptoms. Differential
is broad and includes ITP, TTP, and pregnancy-related,
drug-induced, and viral causes (no history to support
genetic/congenital conditions)."
3115,"Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 59319**],
You were admitted to [**Hospital1 18**] with low platelets that were thought
to be due to a condition called Immune Thrombocytopenic Purpura.
You were given steroids which have increased your platelet
numbers. You will need to continue these steroids until the
hematologist asks you to taper them.
Medication Changes
Please START prednisone 150mg daily (until tapered by your
doctor)
Please START bactrim 1 DS tab daily for pneumonia prophylaxis
Please START famotidine 20mg daily for ulcer prophylaxis
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Location (un) 2274**] [**Location 1268**], Internal Medicine
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1701**]
Appt: [**2-3**] at 10:40am
Name: [**Last Name (LF) 349**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: [**Location (un) 2274**] [**Location (un) **], Oncology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
Appt: [**1-30**] at 3:30pm"
3116,"Medications on Admission:
- Atenolol 25 mg PO daily
- Chlorthalidone 25 mg PO daily
- Lisinopril 20 mg PO daily
- Cholecalciferol, Vitamin D3 2,000 unit PO daily (when
remembers)
- Vitamin B12 PO daily (when remembers)
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. calcium carbonate 400 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day."
3117,"She has been engaged in an expensive and drawn out custody
battle with her ex-husband for the past two and a half years,
whom she says has been physically abusive toward her and has
also threatened to kill her. Currently, she is in a
""quasi-relationship"" with a male partner, with whom she is
sexually active by oral/anal sex (no vagnial sex). Significant
social stress related to interactions with her ex-husband.
- Tobacco: Never-smoker
- Alcohol: None
- Illicits: None
Family History:
Father with diabetes and hypertension; mother with hypertension
and reduced EF, paternal grandfather and great uncles with CAD."
3118,"Admission Date: [**2130-1-21**] Discharge Date: [**2130-1-25**]
Date of Birth: [**2083-8-19**] Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Petechial rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 59319**] is a 46F with a history of mild asthma, obesity,
hypertension and chronic lower back pain who presents with a
petechial rash to body (starting on right hand, also noticed
spread to forehead) and tongue since yesterday. She also had
some bloody mucous with blowing her nose, but no gross
epistaxis. She went to her PCP's office this morning, where she
was seen in urgent care by [**Name8 (MD) **] NP; bloodwork there was notable
for platelets of zero and ESR of 36."
3119,"Serum hCG is negative which
rules out gestational cause. She had not used medications
(heparin, sulfonamides) commonly known to cause drug-induced
thrombocytopenia. Smear was negative for schistocytes, making
TTP unlikely. HCV, H pylori, EBV and HIV serologies were sent
and returned negative for acute infection. Given the absence of
other suggestive cause, the most likely etiology for the
patient's presentation was felt to be ITP. She was evaluated by
the hematology service, who recommended treatment with high-dose
prednisone (initial dose of 100 mg PO daily was increased to 150
mg PO daily given patient's body weight of ~375lbs and desire to
avoid use of IVIg, which could be dangerous in this patient if
used according to weight-based dosing guidelines)."
3120,"While in the ED, patient
developed a headache and was sent for head CT to rule out bleed
(negative preliminarily for bleed). Hematology recommended
frequent neuro checks overnight given the hemorrhagic bullae in
the mouth (sometimes associated with intracranial bleed), which
is the reason for ICU admission. Vitals on transfer were T98.7,
HR 62, RR 16, BP 123/76, 98% on RA.
.
On arrival to the MICU, she reports that her headache has
resolved. She feels dehydrated due to nothing to drink since
11AM, and also hungry. Otherwise, no complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain."
3121,"Pertinent Results:
Labs at [**Hospital1 **] [**2130-1-21**]:
- Antistreptolysin O titer (pending at time of admission)
- Smear from [**Hospital1 **] notable for zero platelets seen
- Chem-7, liver panel all WNL (except for glucose 111)
- Coags WNL
- CBC 6.5/13.8/41/0, normal differential
- ESR 36
Labs on admission to [**Hospital1 18**]:
[**2130-1-21**] 01:20PM GLUCOSE-89 UREA N-13 CREAT-0.8 SODIUM-142
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-24 ANION GAP-20
[**2130-1-21**] 01:20PM ALT(SGPT)-29 AST(SGOT)-28 LD(LDH)-255* ALK
PHOS-56 TOT BILI-0.4
[**2130-1-21**] 01:20PM ALBUMIN-4."
3122,"Admission Date: [**2148-8-17**] Discharge Date: [**2148-8-18**]
Date of Birth: [**2094-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 yo M with new diagnosis ([**7-/2148**]) of hepatitis B cirrhosis and
extensive HCC that invades the IVC and right atrium who was
found unresponsive by his family this afternoon. EMS was called
and fingerstick was 15. He received an amp of D50 by EMS and
woke up and was brought to the ED."
3123,"However, per ED resident, family
states patient is full code.
Spoke with hepatology fellow who reviewed CT scan and states
that patient has very minimal hepatic tissue left given
extensive tumor. He estimates the patient has days left to
live, that his elevated lactate is indicative of his significant
liver failure.
On arrival to the ICU patient is comfortable.
Past Medical History:
Cirrhosis [**3-12**] Hepatitis B
HCC
ESLD
Duodenal Ulcer e/p EGD [**7-/2148**]
Multilobar PE's - not on anticoagulation given on hospice and
recent UGIB
Social History:
Pt works as a machinist, used to smoke [**5-13**] cigarettes a day for
30+ years, quit 6/[**2148**]."
3124,"No EtOH, denies recreational drug use.
Pt emigrated to the US from [**Country 3992**] in the early 80s. Lives at
home with wife and two children, aged 8,11.
Family History:
Denies any family history of cancers.
Physical Exam:
On admission:
VS: BP:65/46 T:98 HR:80 RR:30 95% on 3L
Cachectic, acutely ill appearing M in mild respiratory distress
Skin Jaundiced
Dry MMM, clear OP, scleral icterus, temporal wasting
Regular rate
Lungs clear bilaterally but distant breath sounds
Grossly distended abd, tense, tympanic to percussion but no pain
on palpation. Unable to appreciated liver or spleen [**3-12**] ascites
1+ [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], oriented to person and place and year, + asterixis"
3125,"Pertinent Results:
LFT: ALT(SGPT)-283* AST(SGOT)-957* ALK PHOS-590* TOT BILI-17.6*
AMMONIA: 99*
LACTATE: 17.2*
CBC: WBC-17.1* RBC-2.71* HGB-7.5* HCT-25.9* MCV-96 MCH-27.8
MCHC-29.0* RDW-18.2*
COAGS: PT-28.2* PTT-55.5* INR(PT)-2.8*
MELD: 30
CXR: My read: Low lung volumes, no acute process
Brief Hospital Course:
53 yo M with relatively new diagnosis of hepatitis B and end
stage hepatocellular carcinoma on hospice admitted from ED after
presenting with unresponsiveness and a glucose to 15 at home."
3126,"Patient received dextrose and became responsive. He was
hypotensive to the 70's and admitted to the ICU. Per extensive
prior notes and in discussion with his wife, comfort was made
the focus given his grave prognosis. Hepatology was consulted
in the ED and stated that there was no treatment for this
patient given his end stage disease and that his tumor had
essentially eliminated any normal hepatic tissue.
The patient was made comfort measures only with the family at
the bedside and he was treated with iv morphine for pain and
dyspnea which were well controlled. He expired at 4:32am,
approxomately 3 hours after reaching the floor. The medical
examiner's office was notified and declined autopsy. The family
declined autopsy. ICU attending and patient's PCP were
notified.
Medications on Admission:
Morphine Concentrate Five (5) mg PO Q2H
Spironolactone 25 mg
Furosemide 20 mg qod
Prilosec 40 mg Capsule
Lorazepam 1 mg qid prn
Fentanyl 12 mcg/hr
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired"
3127,"In the ED, VS remarkable for BP's in the 70-80's, afebrile, hr
in 80's, on 3L nc (his baseline). Lacate was elevated at 17,
WBC was 17, hct was 25, fibrinogen 127, and INR 2.8. Tbili was
17. He was given vancomycin and zosyn. His CXR had low lung
volumes, but no other acute process. No paracentesis was done.
Received NS bolus.
Per recent discharge summary diagnosis of Hep B and HCC is quite
new. He was also diagnosed with a large R sided PE on that
admission. On review on notes, patient was discharged home on
hospice and was made DNR/DNI."
3128,"SICU
HPI:
54F pediatric nurse [**First Name (Titles) 622**] [**Last Name (Titles) 9818**] adenoCA s/p primary [**Last Name (Titles) 9818**]
tumor resection [**1-5**], now presenting to SICU with hypotension s/p
pleuroscopy/pleural bx/tunneled CT/talc pleurodesis for right malignant
effusion (1.5L). Procedure was performed for increasing dyspnea/cough
and O2 requirements. Effusion has been drained multiple times in
past. Pt has been hypotensive to 70s/40s in PACU desipte 3L IVF
boluses. Recieved 350 mcg fentanyl in procedure and oxycodone, toradol
in PACU. Unremarkable CT drainage volume in PACU.
Also of note pt has had self-reported poor PO fluid intake and N/V on
evening prior to procedure."
3129,"Improving
R effusion, L atelectasis, no PTX.
Microbiology: [**2139-7-30**] Pleural fluid GS no organisms, 3+ PMNs.
ECG: ST/105 on admission. No appearance of ST changes.
Assessment and Plan
HYPOTENSION (NOT SHOCK)
Assessment and Plan: 54F with advanced metastatic ovarian adenoCA with
hypotension s/p pleuroscopy procedures, resolving with hydration.
Likely hypovolemia-related. BPs near baseline and patient mentating
well at this time.
Neurologic: Follow mental status. Dilaudid/percocet po and IV for
breakthrough pain. Tylenol prn.
Cardiovascular: Monitor BPs. No pressors given thus far. IP contact[**Name (NI) **]
re: fluid restrictions/goals.
Pulmonary: Supplental O2, follow sats."
3130,"HEENT: PERRL, EOMI, MMs dry
Cardiovascular: (Rhythm: Regular), No appreciable M/R/G.
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : Mild coarse BS in right fields.)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Skin: Right CT to clean dressing
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities, Alert, pleasant and conversational
Labs / Radiology
134
11.7
105
0.8
23
5.2
19
108
136
35.7
5.3
[image002.jpg]
Other labs: PT / PTT / INR://1.2
Fluid Analysis / Other Labs: Pleural fluid WBC 517, RBC [**Numeric Identifier 9819**], PMN 57,
Lymph 26
Imaging: [**2139-7-30**] CXR: R CT at R apex, distal pleurx at R CPA."
3131,"Heparin 5000 UNIT SC TID Order date: [**7-30**] @ 1717
6. 1000 mL NS Bolus 1000 ml Over 30 mins Order date: [**7-30**] @ 1717 22.
Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL
Normal Saline followed by Heparin as above daily and PRN per lumen.
Order date: [**7-30**] @ 1717
7. 1000 mL NS
Continuous at 100 ml/hr for 1000 ml
Change to peripheral lock when taking POs Order date: [**7-30**] @ 1852 23.
Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e."
3132,"Chief complaint:
Hypotension, dyspnea
PMHx:
Asthma, Osteoporosis, GERD, h/o multiple PE [**2-2**] on lovenox preop, [**2130**]
DCIS left breast s/p lumpectomy, XRT, adjuvant. Stage IV ovarian
cancer status post TAH BSO, primary [**Year (4 digits) 9818**] carcinoma
Current medications:
1. IV access: Indwelling port (Portacath), heparin dependent Order
date: [**7-30**] @ 1717 17. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
Order date: [**7-30**] @ 1744
2. IV access: Peripheral line Order date: [**7-30**] @ 1717 18.
HYDROmorphone (Dilaudid) 0.125 mg IV Q3H:PRN breakthrough pain Order
date: [**7-30**] @ 1744
3. IV access: Indwelling port (Portacath), heparin dependent Location:
Left Order date: [**7-30**] @ 1717 19."
3133,"CT to pleurivac, Albuterol nebs
prn for asthma. Repeat CXR. Follow CT outputs. Discuss
anticoagulation postop plan with Thoracic team, was on lovenox preop.
Gastrointestinal / Abdomen: Regular diet, compazine prn
Nutrition: Regular diet, Clear liquids, Advance diet as tolerated ,
Encourage PO, supplementation as appropriate. Consider albumin if
large proteinaceous effusion drainage / continued clinical hypovolemia.
Renal: Foley, Borderline UOPs, follow with volume resuscitation.
Hematology: Postop CBC, monitor hemorrhagic O/P from chest tube.
Endocrine: RISS
Infectious Disease: Check cultures, Follow effusion
studies--protein/glucose/LDH pending.
Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest
tube - pleural , L Portacath, PIV, tunneled R chest tube to pleurivac,
R pleurix catheter capped
Wounds: Chest Tube dressing in situ
Imaging: AM CXR
Fluids: NS, 100 cc/h
Consults: CT surgery, Interventional Pulmonary
Billing Diagnosis: Post-op hypotension
ICU Care
Nutrition:
Glycemic Control:
Lines:
Indwelling Port (PortaCath) - [**2139-7-30**] 05:00 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP bundle:
Comments:
Communication: Comments:
Code status:
Disposition:
Total time spent:"
3134,"g. Portacath), heparin dependent: When de-accessing
port, instill Heparin as above per lumen. Order date: [**7-30**] @ 1717
8. 500 mL NS Bolus 500 ml Over 30 mins Order date: [**7-30**] @ 1717 24.
Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**7-30**] @ 1718
9. 500 mL NS Bolus 500 ml Over 30 mins Order date: [**7-30**] @ 1717 25.
Ketorolac 15 mg IV ONCE Duration: 1 Doses Order date: [**7-30**] @ 1717
10. Acetaminophen 500 mg PO Q6H:PRN Pain
Please give no more than 2gm per day Order date: [**7-30**] @ 1717 26.
Magnesium Sulfate IV Sliding Scale Order date: [**7-30**] @ 1718
11."
3135,"m.
Tmax: 35.8
C (96.5
T current: 35.8
C (96.5
HR: 119 (104 - 119) bpm
BP: 91/62(68) {84/49(57) - 105/67(73)} mmHg
RR: 25 (20 - 31) insp/min
SPO2: 90%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
3,420 mL
PO:
120 mL
Tube feeding:
IV Fluid:
300 mL
Blood products:
Total out:
0 mL
2,110 mL
Urine:
230 mL
NG:
Stool:
Drains:
Balance:
0 mL
1,310 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 90%
ABG: ////
Physical Examination
General Appearance: No acute distress, Cachectic, Appears older than
stated age."
3136,"Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB Order date: [**7-30**] @
1717 27. Pantoprazole 40 mg PO Q24H Order date: [**7-30**] @ 1717
12. Benzonatate 100 mg PO TID Order date: [**7-30**] @ 1717 28. Potassium
Chloride IV Sliding Scale Order date: [**7-30**] @ 1718
13. Calcium Carbonate 500 mg PO BID Order date: [**7-30**] @ 1717 29.
Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**7-30**] @ 1718
14. Calcium Gluconate IV Sliding Scale Order date: [**7-30**] @ 1718 30.
Prochlorperazine 10 mg IV Q6H:PRN nausea Order date: [**7-30**] @ 1717
15."
3137,"Heparin Flush (10 units/ml) 5 mL IV
PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL
Normal Saline followed by Heparin as above daily and PRN per lumen.
Order date: [**7-30**] @ 1717
4. 1000 mL NS
Continuous at 100 ml/hr for 1000 ml Start: After the current bolus is
done Order date: [**7-30**] @ 1717 20. Heparin Flush (100 units/ml) 5 mL IV
PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing
port, instill Heparin as above per lumen. Order date: [**7-30**] @ 1717
5. 1000 mL NS Bolus 1000 ml Over 30 mins Order date: [**7-30**] @ 1717 21."
3138,"Cepacol (Menthol) 1 LOZ PO PRN cough Order date: [**7-30**] @ 1717 31.
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.
Order date: [**7-30**] @ 1717
16. Docusate Sodium 100 mg PO BID:PRN Constipation Order date: [**7-30**] @
1717
24 Hour Events:
ICU consent obtained. Pt gently hydrated with 100cc/h NS and
encouraged po clears intake. BPs near baseline 90s/60s but borderline
UOPs ~30/h and D/W thoracic team
Post operative day:
0
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2139-7-30**] 08:56 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**41**] a."
3139,"Admission Date: [**2139-7-28**] Discharge Date: [**2139-7-31**]
Date of Birth: [**2084-12-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Right pleural effusion
Major Surgical or Invasive Procedure:
[**2139-7-30**] Pleuroscopy, Right pleural effusion drainage with
PleureX catheter placment.
History of Present Illness:
54 year old woman with history of right breast DCIS in [**2130**] and
primary peritoneal carcinoma with recurrent malignant right
pleural effusion requiring multiple thoracentesis. She presented
this time with progressive dyspnea
and reports that she is more SOB at rest."
3140,"She has also been
complaining of cough that has been significat to a point where
she vomited on one occasion. She denies any chest pain, fevers,
chills, night sweats, nausea, or vomiting.
Past Medical History:
1- Breast CA, DCIS ([**2130**]) status post radiation, lumpectomy,
and tamoxifen.
2- Asthma
3- Osteoporosis
4- GERD
5- Stage IV ovarian cancer status post TAH BSO, primary
peritoneal carcinoma
6- PE, on Lovenox
Family History:
Sister with a history of breast cancer at 61. She has another
sister with biliary cirrhosis and [**Doctor Last Name 17472**]
syndrome. She has another sister who is healthy. Her brother
died in his 40s of sepsis of unclear etiology."
3141,"C.) - 1 Capsule(s)
by mouth twice daily
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
Q6
hours as needed for nausea
SCALP PROSTHESIS - - Please provide patient with one scalp
prosthesis. ICD-9 183.0.
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
-
Tablet(s) by mouth
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider) - Dosage uncertain
IBUPROFEN - (Prescribed by Other Provider) - 200 mg Tablet -
Tablet(s) by mouth
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right pleural effusion
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2139-10-16**]"
3142,"A chest CT was done and revealed a right pleural
effusion. No pulmonary embolism was noted. On [**2139-7-28**]
interventional pulmonary was consulted. They recommended a
pleuroscopy with pleur ex catheter placement. Her Lovenox was
held. On [**2139-7-30**] she underwent Rigid fluoroscopy.Right pleural
biopsies. Talc pleurodesis. Insertion of a 24-French right chest
tube. Insertion of a right PleureX catheter. A total of 1400 mL
of bloody fluid was aspirated. She was transferred to the PACU
and found to be hypotensive with blood pressure in the 70s/40s.
Despite 3L IVF boluses she continued to be hypotensive and was
transferred to the SICU."
3143,"7* Plt Ct-257
[**2139-7-30**] Neuts-85.3* Lymphs-11.6* Monos-1.9* Eos-0.8 Baso-0.3
[**2139-7-31**] Glucose-140* UreaN-24* Creat-0.7 Na-137 K-4.3 Cl-111*
HCO3-17
[**2139-7-27**] Glucose-109* UreaN-21* Creat-0.7 Na-135 K-3.8 Cl-104
HCO3-23
[**2139-7-31**] CXR: The two right chest tubes, superior and inferior
are in unchanged location. The right basal atelectasis is
unchanged. There is no evidence of reaccumulation of pleural
effusion. There is no pneumothorax, although note is made that
multiple lines overlying the right apex and minimal amount of
pleural air can be undetected."
3144,"On [**2139-7-31**] she was tachycardia to the
130s despite IVF, episode of anxiety/desaturation with
increasing O2 requirements. An echocardiogram was done which
showed Markedly dilated RV with severe global systolic
dysfunction. Small and under filled LV with hyperdynamic syst
fxn. Moderate functional TR. Moderate pulmonary HTN. Bilateral
lower extremity Dopplers were negative for DVT. She went into
PEA arrest, she was coded without recovery.
Medications on Admission:
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth q
week take w/ 8 oz of water, do not eat for 30 minutes
afterwards,
and remain upright after taking medication
ENOXAPARIN [LOVENOX] - 100 mg/mL Syringe - 1 injection (100
units) once daily
MAGIC MOUTH WASH - (Prescribed by Other Provider) - Dosage
uncertain
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E."
3145,"The patient's
aunt on her father side had a colon cancer in her 60s. Her
mother died of ALS, but had a renal cell carcinoma, which was
treated completely with nephrectomy. She has two uncles on her
mother's side, one of whom had bladder cancer, another had
esophageal cancer. She had an aunt on her mother's side who had
esophageal cancer as well.
Pertinent Results:
[**2139-7-31**] WBC-9.3# RBC-3.53* Hgb-10.7* Hct-32.2* Plt Ct-94*
[**2139-7-27**] WBC-4.4# RBC-2.96* Hgb-8.6* Hct-26."
3146,"The Port-A-Cath catheter inserted through the left subclavian
vein terminates at the level of low SVC. The lungs are well
expanded and the
cardiomediastinal silhouette is stable.
[**2139-7-31**] Lower extremity doppler: There is normal spontaneous
phasic flow, compressibility, and augmentation in bilateral
lower extremities from the level of the common femoral veins
through the proximal calf.
IMPRESSION: No evidence of deep vein thrombosis in either lower
extremity.
[**2139-7-27**]: Chest CT:
1. No pulmonary embolus. No aortic dissection.
2. Mildly increased moderate right pleural effusion and
associated
atelectasis.
Brief Hospital Course:
Mrs. [**Known lastname 107418**] was admitted on [**2139-7-27**] for increased shortness of
breath."
3147,"42/47/204//5
PaO2 / FiO2: 510
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
131
[image002.jpg]
[**2145-11-19**] 07:06 PM
[**2145-11-20**] 04:00 AM
TCO2
32
Glucose
131
Other labs: Lactic Acid:1.8 mmol/L
Fluid analysis / Other labs: UA negative
Imaging: CXR [**11-19**]: worsening of R sided pleural effusion.
Microbiology: Blood cx: pending
Urine cx: pending
Assessment and Plan
DYSPNEA (SHORTNESS OF BREATH)
HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)
TACHYCARDIA, OTHER
77M with metastatic lung cancer and malignant pleural effusion,
presenting with inability to drain pleurex catheter and admitted to
MICU with respiratory distress."
3148,"- Check flu swab.
- Expectorated sputum for AFB and culture (unlikely to tolerate induced
sputum with current respiratory status).
- Obtain records re: past AFB workup, ?bronch in the past.
- Continued goals of care discussion, as most of above irreversible
unless able to tolerate chemotherapy. Discussed difficulties with
mechanical ventilation with patient and family (would be very difficult
to get off vent) - understood by patient and daughter and he wishes to
be DNR/DNI.
.
# Tachycardia. Sinus tach in low 100s at times, increasing to ~150s in
MAT vs. Afib. Likely related to primary pulmonary disease. Also
consider PE and infection as above."
3149,"TITLE:
Chief Complaint: Tachypnea
24 Hour Events:
None
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Metoprolol - [**2145-11-19**] 07:05 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2145-11-20**] 06:47 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.1
C (98.7
Tcurrent: 36.9
C (98.4
HR: 108 (89 - 134) bpm
BP: 124/75(86) {112/57(71) - 161/132(137)} mmHg
RR: 23 (20 - 33) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Height: 63 Inch
Total In:
1,124 mL
98 mL
PO:
60 mL
30 mL
TF:
IVF:
1,064 mL
68 mL
Blood products:
Total out:
420 mL
300 mL
Urine:
420 mL
300 mL
NG:
Stool:
Drains:
Balance:
704 mL
-203 mL
Respiratory support
O2 Delivery Device: Aerosol-cool
SpO2: 98%
ABG: 7."
3150,"- Palliative care consult.
- Can discuss again with onc re: any ability for palliative chemo.
- Supposed to resume XRT on Monday.
- pain control with MS Contin, morphine IV prn breakthrough
.
# Leukocytosis. In patient with pneumonia, malignancy. No fevers.
- Infectious workup as above.
- Send C.diff.
- Continue to trend.
.
FEN: 1L NS then reeval, replete electrolytes, regular diet, megace for
appetite stim.
Prophylaxis: [**Last Name (un) 9430**] (on at rehab)
Access: peripherals
Code: DNR/DNI
Communication: Patient and daughter [**Name (NI) 9426**] [**Telephone/Fax (1) 9431**]
[**Name2 (NI) 1531**]osition: pending clinical improvement
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2145-11-19**] 05:30 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:"
3151,".
# Respiratory distress. Likely multifactorial with lung malignancy,
postobstructive pneumonia and RUL atelectasis, malignant pleural
effusion. Also consider PE in differential given malignancy history
and immobility. Pericardial disease less likely with negative
ultrasound in ED, but still a consideration. Patient appears dry
without much evidence of pulmonary edema.
- Daily/?continuous drainage of pleural space.
- Check formal TTE.
- Will obtain LENIs for DVT eval; if positive -> filter. Risks of
anticoagulating for DVT or PE very high given location of mass and
proximity to pulmonary arterial system.
- Will continue antibiotics for postobstructive pneumonia, though
unlikely to be able to sterilize RUL given anatomy."
3152,"- Monitor on tele.
- Metoprolol 12.5 TID for now (given MAT), 5 IV working well initially
and can titrate PO if needed.
- Pain and dyspnea control.
.
# Pneumonia. Post obstructive most likely. s/p recent 7 day course of
levoflox and flagyl. Very difficult to sterilize given post
obstructive nature. Getting XRT to region; too ill for chemo at
present time. Also consider TB given risk factors as above.
- continue vanc and zosyn for now.
- expectorated sputum.
- continued goals of care discussion.
.
# Metastatic lung cancer. With known mets to spine; pleural disease.
Getting palliative XRT. Patient understands grave prognosis but has
hope of slowing down the cancer."
3153,"42/47/204//5
PaO2 / FiO2: 510
Physical Examination
Cachectic male lying in bed in NAD. Tachypneic with movement with
slight retractions. Decreased lung sounds on right except for crackles
at apex, left side relatively clear. Heart tachycardic but regular.
Abdomen soft, NTND. Small Grade 1 pressure ulcer on coccyx.
Extremities thin and wasted.
Labs / Radiology
131
[image002.jpg]
[**2145-11-19**] 07:06 PM
[**2145-11-20**] 04:00 AM
TCO2
32
Glucose
131
Other labs: Lactic Acid:1.8 mmol/L
Fluid analysis / Other labs: UA negative
Imaging: CXR [**11-19**]: worsening of R sided pleural effusion.
Microbiology: Blood cx: pending
Urine cx: pending
Assessment and Plan
DYSPNEA (SHORTNESS OF BREATH)
HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)
TACHYCARDIA, OTHER
77M with metastatic lung cancer and malignant pleural effusion,
presenting with inability to drain pleurex catheter and admitted to
MICU with respiratory distress."
3154,"- Monitor on tele.
- Metoprolol 12.5 TID for now (given MAT), 5 IV working well initially
and can titrate PO if needed.
- Pain and dyspnea control.
.
# Pneumonia. Post obstructive most likely. s/p recent 7 day course of
levoflox and flagyl. Very difficult to sterilize given post
obstructive nature. Getting XRT to region; too ill for chemo at
present time. Also consider TB given risk factors as above.
- continue vanc and zosyn for now.
- expectorated sputum.
- continued goals of care discussion.
.
# Metastatic lung cancer. With known mets to spine; pleural disease.
Getting palliative XRT. Patient understands grave prognosis but has
hope of slowing down the cancer.
- Palliative care consult.
- Can discuss again with onc re: any ability for palliative chemo.
- Supposed to resume XRT on Monday.
- pain control with MS Contin, morphine IV prn breakthrough
.
# Leukocytosis. In patient with pneumonia, malignancy. No fevers.
- Infectious workup as above.
- Send C.diff.
- Continue to trend.
.
FEN: 1L NS then reeval, replete electrolytes, regular diet, megace for
appetite stim.
Prophylaxis: [**Last Name (un) 9430**] (on at rehab)
Access: peripherals
Code: DNR/DNI
Communication: Patient and daughter [**Name (NI) 9426**] [**Telephone/Fax (1) 9431**]
[**Name2 (NI) 1531**]osition: pending clinical improvement"
3155,"TITLE:
Chief Complaint: Tachypnea
24 Hour Events:
None
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Metoprolol - [**2145-11-19**] 07:05 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2145-11-20**] 06:47 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.1
C (98.7
Tcurrent: 36.9
C (98.4
HR: 108 (89 - 134) bpm
BP: 124/75(86) {112/57(71) - 161/132(137)} mmHg
RR: 23 (20 - 33) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Height: 63 Inch
Total In:
1,124 mL
98 mL
PO:
60 mL
30 mL
TF:
IVF:
1,064 mL
68 mL
Blood products:
Total out:
420 mL
300 mL
Urine:
420 mL
300 mL
NG:
Stool:
Drains:
Balance:
704 mL
-203 mL
Respiratory support
O2 Delivery Device: Aerosol-cool
SpO2: 98%
ABG: 7."
3156,"- Check flu swab.
- Expectorated sputum for AFB and culture (unlikely to tolerate induced
sputum with current respiratory status).
- Obtain records re: past AFB workup, ?bronch in the past.
- Continued goals of care discussion, as most of above irreversible
unless able to tolerate chemotherapy. Discussed difficulties with
mechanical ventilation with patient and family (would be very difficult
to get off vent) - understood by patient and daughter and he wishes to
be DNR/DNI.
.
# Tachycardia. Sinus tach in low 100s at times, increasing to ~150s in
MAT vs. Afib. Likely related to primary pulmonary disease. Also
consider PE and infection as above."
3157,".
# Respiratory distress. Likely multifactorial with lung malignancy,
postobstructive pneumonia and RUL atelectasis, malignant pleural
effusion. Also consider PE in differential given malignancy history
and immobility. Pericardial disease less likely with negative
ultrasound in ED, but still a consideration. Patient appears dry
without much evidence of pulmonary edema.
- Daily/?continuous drainage of pleural space.
- Check formal TTE.
- Will obtain LENIs for DVT eval; if positive -> filter. Risks of
anticoagulating for DVT or PE very high given location of mass and
proximity to pulmonary arterial system.
- Will continue antibiotics for postobstructive pneumonia, though
unlikely to be able to sterilize RUL given anatomy."
3158,"Admission Date: [**2145-11-19**] Discharge Date: [**2145-11-23**]
Date of Birth: [**2068-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Increasing pleural effusion
Major Surgical or Invasive Procedure:
Pleurex catheter drainage
History of Present Illness:
77M with history of recently diagnosed metastatic NSCLC and
known malignant right effusion, presenting with enlarging
effusion at rehab, now admitted to MICU with tachypnea and
respiratory distress. He was diagnosed with lung cancer in
[**2145-8-31**] now follows with Dr. [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **] at [**Hospital 8**]
Hospital."
3159,"Notes continued numbness and weakness in
his lower extremities since his acute cord compression. +lower
extremity edema x few weeks. + weight loss.
Past Medical History:
1. Nonsmall Cell Lung Cancer with metastatic disease to the
spine
- s/p T7-L1 laminectomy, decompression, fusion, and tumor
debluking and fusion for acute cord compression on [**2145-10-15**]
- Primary Oncologist Dr. [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **]
2. H/o C diff colitis in [**2145-9-30**]
3. COPD
4. Atrial fibrillation
Social History:
Originally from [**Country 651**], immigrated to the US > 10 years ago; was
living with his son and daughter until discharge yesterday
(discharged to rehab in [**Hospital1 392**])."
3160,"Worked as a factory worker in
[**Country 651**]. Previous history of heavy tobacco use (at least 1PPD x 50
years); not currently smoking. No known TB contacts.
Family History:
No family history of malignancy
Physical Exam:
Vitals: T: 99.2 BP: 128/59 P: 76 R: 26 SaO2: 97 RA
General: Cachectic male, alert, oriented, moderately tachypneic
with some accessory muscle use.
HEENT: PERRL, sclera anicteric, MM slightly dry, oropharynx view
poor but appears clear
Neck: supple, JVD low at 1-2 ASA.
Lungs: Decreased breath sounds on right, few rales, somewhat
rhonchorous with ?pleural rub. Left relatively clear. No
wheezes."
3161,"# Shortness of Breath: He has baseline shortness of breath due
to persistent malignant effusion and post-obstructive pneumonia
secondary to mass. Resolved with drainage of pleurex catheter.
This should be drained daily after discharge. Information
provided to nursing director at [**Hospital 392**] rehab by interventional
pulmonary service and video is sent with patient. Please call
[**Telephone/Fax (1) 3020**] if any questions or concerns regarding drainage.
# Pneumonia/Hypoxia: Patient completed a course for
post-obstructive pneumonia and other than leukocytosis as below
has no other signs or symptoms of infection. Has been C. diff
negative during this admission. UA negative, CXR without new
findings, C."
3162,"Follow up scheduled
with oncology service as per discharge paperwork.
# Leukocytosis: C. diff negative, CXR unchanged other than
effusion, UA negative and blood cultures no growth to date.
Patient remained afebrile and non-toxic appearing, though
chronically ill. [**Month (only) 116**] be secondary to malignancy.
# Tachycardia: Sinus tach vs MAT. No clear Afib history and he
was intermittently irregular making MAT more likely (though
difficult to appreciate p waves when accelerated rhyhtm). Rate
controlled with metoprolol which was increased to 37.5 mg three
times daily.
# Prophylaxis: Continued on fondaparinux, ppi
# Code status: DNR/I
# Communication: Liping (daughter) [**Telephone/Fax (1) 84933**], [**Name (NI) **] (son)
[**Telephone/Fax (1) 84934**]"
3163,"12. Catheter Drainage
Please drain Pleurex catheter daily after discharge. For any
questions or if it is felt that it can be drained less often,
please contact the Interventional Pulmonary office at [**Hospital1 18**] at
[**Telephone/Fax (1) 3020**].
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1)
nebulization Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis:
Non-small cell lung cancer
Malignant pleural effusion
Secondary Diagnosis:
COPD
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Sleepy but arousable
Activity Status: Bedbound"
3164,"Discharge Instructions:
You were admitted to the hospital to have your Pleurex catheter
drained. You experienced an episode of shortness of breath and
were initially admitted to the medical intensive care unit.
Your catheter was drained three times while you were in the
hospital.
You also had a fast heart rate (atrial fibrillation). We
increased your metoprolol from 25 mg three times daily to 37.5
mg three times daily.
It is important that you go to your follow-up appointments as
scheduled.
Please take all your other medications as you were prior to
hospitalization.
Please also read the aftercare instructions regarding the
radiation therapy of your chest."
3165,"In [**Month (only) 359**] he developed acute cord compression and had
decompression on [**2145-10-15**]. Discharged to rehab. He was
readmitted to [**Hospital1 18**] from [**Date range (1) 56568**] for shortness of breath
with new finding of large right sided pleural effusion and a RUL
post obstructive pneumonia; mass abutting RUL bronchus and PA.
During last admission he underwent thoracentesis and, later,
pleurex catheter placement on [**11-17**]. Pleural fluid positive for
malignant cells, AFB smear negative. Also initiated palliative
XRT to RUL. IP did not feel mass was amenable to stenting. Notes
in discharge summary state that patient was DNR/DNI at
discharge."
3166,"Discharge Medications:
1. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
2. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
3. Roxanol Concentrate 20 mg/mL Solution Sig: 0.25 ml PO q3h as
needed for pain.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Guaifenesin 100 mg/5 mL Liquid Sig: [**5-9**] mL PO every six (6)
hours as needed for cough.
6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO three
times a day."
3167,"IMPRESSION: Normal left ventricular cavity size with mild global
hypokinesis c/w diffuse process (toxin, metabolic, etc.). Mild
pulmonary artery systolic hypertension.
[**2145-11-20**] Bilateral lower extremity ultrasound:
Peroneal veins not visualized. No evidence of deep venous
thrombosis.
[**2145-11-21**] Chest Xray
There is essentially no change in chest findings with right
upper lobe
complete opacification, right pleural effusion, ground-glass
opacity and
mass-like consolidation in the right lower lobe, nodular opacity
projecting in the left upper lobe and peribronchial
abnormalities in the left lower lobe or due to patient's known
non-small cell lung cancer."
3168,"IP saw patient and drained 550 cc fluid from
patient's pleurex catheter. A bedside ultrasound was obtained
showing no pericardial effusion. Patient was given vancomycin
and zosyn. Attempts were made to contact interpreter but this
was not possible - could not confirm DNR status and seemed to
suggest that patient was full code.
In the MICU, patient interviewed with an interpreter. Notes he
gets dyspneic at times but no different lately. Actually denies
shortness of breath currently. + cough, productive of white
sputum, denies hemoptysis. No CP, no pleuritic pain. Notes
occasional palpitations. No fevers/chills. Endorses thirst and
general poor PO intake."
3169,"Medications on Admission:
- Morphine SR 15 mg Q12H
- Acetaminophen 325 mg Q6H as needed for pain, fever.
- roxanol 0.25 ml Q3H prn pain
- Omeprazole 40 mg DAILY
- Guaifenesin 100 mg/5 mL: 5-10 MLs PO Q6H as needed for cough.
- Benzonatate 100 mg TID
- Megestrol 400 mg/10 mL : Twenty (20) ml PO once a day.
- Fondaparinux 2.5 mg Subcutaneous once a day.
- Albuterol Sulfate [**1-1**] nebs Q4H prn shortness of breath or
wheeze.
- Catheter Drainage Please drain IP catheter three times/wk
- Docusate Sodium 100 mg twice a day.
- Senna 8.6 mgTwo (2) Tablet PO twice a day"
3170,"95* HGB-11.9* HCT-37.7*
MCV-95 MCH-30.1 MCHC-31.5 RDW-17.1*
[**2145-11-18**] 06:15AM PLT COUNT-332
[**2145-11-19**] 04:20PM CK-MB-3
[**2145-11-19**] 04:20PM cTropnT-<0.01
[**2145-11-19**] 04:20PM GLUCOSE-109* UREA N-18 CREAT-0.5 SODIUM-144
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-31 ANION GAP-12
[**2145-11-19**] 07:06PM LACTATE-1.8
[**2145-11-19**] 07:06PM TYPE-ART PO2-204* PCO2-47* PH-7.42 TOTAL
CO2-32* BASE XS-5
Studies:
[**2145-11-20**] Echo:
The left atrium and right atrium are normal in cavity size."
3171,"There are no new lung abnormalities.
Cardiomediastinal contours are unchanged. Right apical chest
tube remains in place. Spinal hardware is present. There is no
pneumothorax.
Brief Hospital Course:
77 year old male with metastatic lung cancer and malignant
pleural effusion admitted for pleural catheter drainage.
# Pleurex catheter drainage: He initially presented to the
emergency room after a radiation oncology appointment and
inability to drain pleurex at rehab facility. Per son, this was
likely due to not accessing pleurex catheter appropriately. In
total, patient has had approximately 2500 cc of fluid removed
during his stay. He was initially admitted overnight to the
MICU after experiencing shortness of breath, tachypnea and
hypoxia in the emergency room; however, this quickly resolved."
3172,"CV: tachycardic, irregularly irregular, no murmurs, rubs,
gallops appreciated
Abdomen: soft, thin, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Suprapubic area feels slightly ?firm though nontneder. +TTP over
lower right anterior ribs.
Ext: warm, well perfused, [**1-1**]+ LE edema, symmetric bilaterally.
No calf tenderness.
Neuro: A/O x 3. CN II-XII intact, UE strength and sensation
grossly intact. Reports LE numbness bilaterally. LE strength
impaired - cannot lift R leg off bed, L can be lifted very
slightly.
Pertinent Results:
Admission Labs:
[**2145-11-18**] 06:15AM WBC-15.8* RBC-3."
3173,"7. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Twenty (20)
mL PO once a day.
8. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
9. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
[**1-1**] Nebulizations Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
10. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation."
3174,"The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild
global left ventricular hypokinesis (LVEF = 45 %). Systolic
function of apical segments is relatively preserved suggesting a
non-ischemic etiology. 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) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial anterior pericardial effusion."
3175,"Followup Instructions:
You have the following appointments scheduled:
Neurosurgery
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD
Phone: [**Telephone/Fax (1) 1669**]
Date/Time: [**2145-12-1**] 11:45am
Thoracic Hematology/Oncology
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD
Phone: [**0-0-**]
Date/Time: [**2145-12-2**] 10:30am
and
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2145-12-2**] 10:30am
Interventional Pulmonology:
MD: [**First Name8 (NamePattern2) **] [**Doctor Last Name **] of interventional pulmonology
Day & Time: [**2145-12-8**] at 8:30 AM (Xray at 8:00 am)
Phone: [**Telephone/Fax (1) 3020**]
Special Instructions: You need a chest X-ray before this
appointment. Please show up at the [**Location (un) 10043**] of the clinical
center at 8:00am on [**2145-12-8**] for a chest radiograph. Afterward
your interventional pulmonology appointment is on the [**Location (un) 19201**] of the connected [**Hospital Ward Name 121**] building."
3176,"Patient was discharged to [**Hospital 392**] Rehab. At rehab this morning it
was discovered that there were not appropriate supplies to drain
pleurex. Had his usual session XRT this AM. He also had CXR
which was read as complete R sided opacification. When arrived
back at rehab, he was sent to the ED due to inability to drain
the effusion.
In the ED, initial vs were: T96.8 70 146/88 22 96% on 15L O2.
HRs have since been in the 130s - not clear if HR 70 truly
accurate. Has been tachypneic to 30s. CXR performed with finding
of interval increase in pleural effusion and R lung base
opacificition."
3177,"diff negative as above, blood cultures are no
growth to date and patient ruled out for flu, parainfluenza,
adenovirus and RSV. Tachypnea and hypoxia improved as above
with drainage of pleurex. LENIs negative as well making PE
less likely. He was given a few doses of vancomycin and
cefepime while in the intensive care unit, but these were
discontinued upon transfer to the floor.
# Stage IV NSCL and Malignant effusion: Known mets to spine and
malignant effusion. Already undergoing palliative xrt, last dose
today. Too debilitated for chemo at this time. We continued
pain control as per prior to admission."
3178,"Likely this represents an angina equivalent which is
exacerbated by her other pulmonary issues (effusion, COPD, asthma). To
cath tomorrow.
.
# PUMP: Pt c systolic CHF c EF of 45-55% on TTE in [**5-8**], BNP this
admission 8434. While on the floor, pt with hypotensive episode and
SBP to 70's that responded to total of 1L IVF. EKG remained
unchanged. Given recent c.cath with small dissection to OM1,
hemopericardium or retroperitoneal bleed were of concern given relative
hypotension. In addition, on admission, pt underwent thoracentesis of
L sided pleural effusion and removal of 1.5L possibly causing fluid
shifts and relative hypotension."
3179,"Pt also with small apical post thoracentesis pneumothorax;
IP following patient on the floor and considering pleurex drain.
- plan IP procedure Monday.
.
# Anemia: improved from baseline on admission.
- Monitor Hct as above
.
# UTI: pt c 6-10 WBCs on UA s/p foley placement, started empirically on
Ciprofloxacin on floor for UTI.
- continue cipro 500 [**Hospital1 **] for now
- f/u UCx from [**7-24**]
- d/c foley
.
# DM: d/ced rosiglitazone given CHF.
- hold oral [**Doctor Last Name **] until she is returned home
- RISS
-FS QAC/HS
.
FEN: Cardiac diet/Diabetic diet
PROPHYLAXIS: pneumoboots, Hep SQ on hold for now until bleed ruled out,
colace, MOM prn
-[**Name2 (NI) 222**] management with tylenol prn
CODE: full
DISPO: Stable for return to [**Hospital Unit Name 7343**] Care
Nutrition:
Glycemic Control:
Lines:
22 Gauge - [**2155-7-25**] 10:51 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
3180,"6 g/dL
134 mg/dL
0.9 mg/dL
29 mEq/L
4.4 mEq/L
13 mg/dL
105 mEq/L
140 mEq/L
33.9 %
6.0 K/uL
[image002.jpg]
[**2155-7-26**] 02:14 AM
[**2155-7-26**] 08:04 AM
WBC
6.0
Hct
29.7
33.9
Plt
482
Cr
0.9
TropT
0.04
Glucose
134
Other labs: PT / PTT / INR:14.0/45.1/1.2, CK / CKMB /
Troponin-T:38//0.04, Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL
Assessment and Plan
73F c 3VD and AAA, as well as DM, COPD and MMP now p/w increasing DOE
after failed CABG."
3181,"TITLE:
Chief Complaint:
24 Hour Events:
EKG - At [**2155-7-25**] 11:[**Street Address(2) 7342**]
Allergies:
Sulfa (Sulfonamide Antibiotics)
Unspecified [**Doctor First Name **]
Flagyl (Oral) (Metronidazole)
Diarrhea;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Ranitidine (Prophylaxis) - [**2155-7-26**] 08:00 AM
Heparin Sodium (Prophylaxis) - [**2155-7-26**] 08:00 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2155-7-26**] 09:07 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.5
C (99."
3182,"5
Tcurrent: 36.8
C (98.2
HR: 94 (87 - 120) bpm
BP: 107/57(69) {94/45(61) - 116/74(79)} mmHg
RR: 25 (17 - 25) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
150 mL
1,000 mL
Urine:
150 mL
1,000 mL
NG:
Stool:
Drains:
Balance:
-150 mL
-1,000 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ///29/
Physical Examination
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: Dry), (Teeth, gums and
palette: WNL)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Jugular veins: Not visible), (Thyroid: WNL)
Back / Musculoskeletal: (Chest wall structure: Midline sternotomy
incision well healed but slightly tender to palpation)
Respiratory: (Effort: WNL), (Auscultation: Abnormal, Decreased breath
sounds 2/3 up lung fields on left and diminished at right lung base
without wheezes or crackles)
Cardiac: (Rhythm: Regular, Tachycardic), (Palpation / PMI: WNL),
(Auscultation: S1: WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (foley catheter in place)
Femoral Artery: (Right femoral artery: Groin site without hematoma,
minimal tenderness to palpation, No bruit), (Left femoral artery: No
bruit)
Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and
station: not assessed), (Edema: Right: 0, Left: 0)
Skin: ( WNL)
Labs / Radiology
482 K/uL
9."
3183,"# CORONARIES: 3VD on cath from [**5-8**], s/p recent attempted CABG but pt
unable to tolerate bypass, now s/p c.cath with POBA to OM1
-to cath in the am
-continue asa/plavix post procedure for 6 weeks
-continue Rosuvastatin
.
# RHYTHM: sinus in the 100s while on the floor pre-procedure and now
slightly more tachycardic to 110's which may represent blood loss or
dehydration
- continue to monitor on tele for now
- resume beta blocker to keep HR closer to 80 if BP tolerates
.
# COPD and asthma: continue home meds -- fluticasone, salmeterol,
albuterol/atrovent nebs.
.
# Pleural effusion: consistent with exudate based on Light's criteria;
s/p drainage on admission with improvement in effusion visualized on
repeat CXR."
3184,"[**Name2 (NI) **] potential etiologies of
hypotension could include dehydration, or less likely medication effect
from meds received in the cath lab. Pt currently asymptommatic but
tachycardic to 115. Hct stable 32.2-->33.4 on the floor. CT
abdomen/pelvis without evidence of RP bleed or hematoma around femoral
vessels. Bedside echo without evidence of significant pericardial
effusion and no gross change in LV function from prior study.
- Holding metoprolol for now until BP improves
- Follow Hct Q8 hours
- Active T&C
- IVF boluses as needed to maintain SBP>90
- Monitor on tele
- F/[**Location **] CT abdomen/pelvis read
- Monitor femoral groin site for signs of hematoma
."
3185,"Likely this represents an angina equivalent which is
exacerbated by her other pulmonary issues (effusion, COPD, asthma). To
cath tomorrow.
.
# PUMP: Pt c systolic CHF c EF of 45-55% on TTE in [**5-8**], BNP this
admission 8434. While on the floor, pt with hypotensive episode and
SBP to 70's that responded to total of 1L IVF. EKG remained
unchanged. Given recent c.cath with small dissection to OM1,
hemopericardium or retroperitoneal bleed were of concern given relative
hypotension. In addition, on admission, pt underwent thoracentesis of
L sided pleural effusion and removal of 1.5L possibly causing fluid
shifts and relative hypotension."
3186,"# CORONARIES: 3VD on cath from [**5-8**], s/p recent attempted CABG but pt
unable to tolerate bypass, now s/p c.cath with POBA to OM1
-to cath in the am
-continue asa/plavix post procedure for 6 weeks
-continue Rosuvastatin
.
# RHYTHM: sinus in the 100s while on the floor pre-procedure and now
slightly more tachycardic to 110's which may represent blood loss or
dehydration
- continue to monitor on tele for now
- resume beta blocker to keep HR closer to 80 if BP tolerates
.
# COPD and asthma: continue home meds -- fluticasone, salmeterol,
albuterol/atrovent nebs.
.
# Pleural effusion: consistent with exudate based on Light's criteria;
s/p drainage on admission with improvement in effusion visualized on
repeat CXR."
3187,"Pt also with small apical post thoracentesis pneumothorax;
IP following patient on the floor and considering pleurex drain.
- plan IP procedure Monday.
.
# Anemia: improved from baseline on admission.
- Monitor Hct as above
.
# UTI: pt c 6-10 WBCs on UA s/p foley placement, started empirically on
Ciprofloxacin on floor for UTI.
- continue cipro 500 [**Hospital1 **] for now
- f/u UCx from [**7-24**]
- d/c foley
.
# DM: d/ced rosiglitazone given CHF.
- hold oral [**Doctor Last Name **] until she is returned home
- RISS
-FS QAC/HS
.
FEN: Cardiac diet/Diabetic diet
PROPHYLAXIS: pneumoboots, Hep SQ on hold for now until bleed ruled out,
colace, MOM prn
-[**Name2 (NI) 222**] management with tylenol prn
CODE: full
DISPO: Stable for return to [**Hospital Unit Name 7343**] Care
Nutrition:
Glycemic Control:
Lines:
22 Gauge - [**2155-7-25**] 10:51 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
3188,"[**Name2 (NI) **] potential etiologies of
hypotension could include dehydration, or less likely medication effect
from meds received in the cath lab. Pt currently asymptommatic but
tachycardic to 115. Hct stable 32.2-->33.4 on the floor. CT
abdomen/pelvis without evidence of RP bleed or hematoma around femoral
vessels. Bedside echo without evidence of significant pericardial
effusion and no gross change in LV function from prior study.
- Holding metoprolol for now until BP improves
- Follow Hct Q8 hours
- Active T&C
- IVF boluses as needed to maintain SBP>90
- Monitor on tele
- F/[**Location **] CT abdomen/pelvis read
- Monitor femoral groin site for signs of hematoma
."
3189,"6 g/dL
134 mg/dL
0.9 mg/dL
29 mEq/L
4.4 mEq/L
13 mg/dL
105 mEq/L
140 mEq/L
33.9 %
6.0 K/uL
[image002.jpg]
[**2155-7-26**] 02:14 AM
[**2155-7-26**] 08:04 AM
WBC
6.0
Hct
29.7
33.9
Plt
482
Cr
0.9
TropT
0.04
Glucose
134
Other labs: PT / PTT / INR:14.0/45.1/1.2, CK / CKMB /
Troponin-T:38//0.04, Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL
Assessment and Plan
73F c 3VD and AAA, as well as DM, COPD and MMP now p/w increasing DOE
after failed CABG."
3190,"TITLE:
Chief Complaint:
24 Hour Events:
EKG - At [**2155-7-25**] 11:[**Street Address(2) 7342**]
Allergies:
Sulfa (Sulfonamide Antibiotics)
Unspecified [**Doctor First Name **]
Flagyl (Oral) (Metronidazole)
Diarrhea;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Ranitidine (Prophylaxis) - [**2155-7-26**] 08:00 AM
Heparin Sodium (Prophylaxis) - [**2155-7-26**] 08:00 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2155-7-26**] 09:07 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.5
C (99."
3191,"5
Tcurrent: 36.8
C (98.2
HR: 94 (87 - 120) bpm
BP: 107/57(69) {94/45(61) - 116/74(79)} mmHg
RR: 25 (17 - 25) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
150 mL
1,000 mL
Urine:
150 mL
1,000 mL
NG:
Stool:
Drains:
Balance:
-150 mL
-1,000 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ///29/
Physical Examination
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: Dry), (Teeth, gums and
palette: WNL)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Jugular veins: Not visible), (Thyroid: WNL)
Back / Musculoskeletal: (Chest wall structure: Midline sternotomy
incision well healed but slightly tender to palpation)
Respiratory: (Effort: WNL), (Auscultation: Abnormal, Decreased breath
sounds 2/3 up lung fields on left and diminished at right lung base
without wheezes or crackles)
Cardiac: (Rhythm: Regular, Tachycardic), (Palpation / PMI: WNL),
(Auscultation: S1: WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (foley catheter in place)
Femoral Artery: (Right femoral artery: Groin site without hematoma,
minimal tenderness to palpation, No bruit), (Left femoral artery: No
bruit)
Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and
station: not assessed), (Edema: Right: 0, Left: 0)
Skin: ( WNL)
Labs / Radiology
482 K/uL
9."
3192,"En route
to the CCU, the patient was given an additional 500cc IVF bolus with
improvement of her SBP to the low 100's and the patient continued to
feel well with no symptoms of chest pain or shortness of breath.
Past medical history: CAD, s/p MI in [**2131**]
CHF (EF 45-50%)
Diabetes
Hyperlipidemia
Neuropathy
Sciatica
Asthma
Bursitis of the right shoulder
Rotator cuff tear, right shoulder
Dry eyes
H/O recurrent bronchitis
Seasonal allergies
GERD
H/O Proteinuria in the past
Squamous cell ca of the lip s/p resection
Tonsillectomy
S/P uvula removal
Diverticulitis
CAD Risk Factors
CAD Risk Factors Present
Diabetes mellitus, Dyslipidemia
CAD Risk Factors Absent
Hypertension, Family Hx of CAD, Family Hx of sudden cardiac death
(Tobacco: Yes), (Quit: Yes), (Cigarettes: 1 packs / day x 80 yrs)
Cardiovascular Procedural History
PCI: Most recent: [**2155-7-25**]
There is no history of:
CABG: Grafts: Not tolerated
Pacemaker / ICD
Allergies:
Sulfa (Sulfonamide Antibiotics)
Unspecified [**Doctor First Name **]
Flagyl (Oral) (Metronidazole)
Diarrhea;
Current medications: MEDICATIONS ON TRANSFER:
Aspirin 81 mg PO DAILY Start: In am
Clopidogrel 75 mg PO DAILY Start: In am
Ciprofloxacin HCl 500 mg PO Q12H
Rosuvastatin Calcium 20 mg PO DAILY
Gabapentin 300 mg PO Q12H
Acetaminophen 325 mg PO Q6H:PRN pain
Duloxetine 30 mg PO DAILY Start: In am
Milk of Magnesia 30 mL PO Q6H:PRN constipation
Insulin SC (per Insulin Flowsheet)
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
Albuterol 0."
3193,"# RHYTHM: sinus in the 100s while on the floor pre-procedure and now
slightly more tachycardic to 110's which may represent blood loss or
dehydration
- continue to monitor on tele for now
- resume beta blocker to keep HR closer to 80 if BP tolerates
.
# COPD and asthma: continue home meds -- fluticasone, salmeterol,
albuterol/atrovent nebs.
.
# Pleural effusion: consistent with exudate based on Light's criteria;
s/p drainage on admission with improvement in effusion visualized on
repeat CXR. Pt also with small apical post thoracentesis pneumothorax;
IP following patient on the floor and considering pleurex drain.
- f/u with IP in AM regarding possibility of drain if pt remains
hemodynamically stable overnight
.
# Anemia: improved from baseline on admission.
- Monitor Hct as above
.
# UTI: pt c 6-10 WBCs on UA s/p foley placement, started empirically on
Ciprofloxacin on floor for UTI.
- continue cipro 500 [**Hospital1 **] for now
- f/u UCx from [**7-24**]
.
# DM: d/ced rosiglitazone given CHF.
-RISS
-FS QAC/HS
.
FEN: Cardiac diet/Diabetic diet
PROPHYLAXIS: pneumoboots, Hep SQ on hold for now until bleed ruled out,
colace, MOM prn
-[**Name2 (NI) 222**] management with tylenol prn
CODE: full
DISPO: CCU"
3194,"The patient was hemodynamically stable
following her intervention and returned to the floor. However, while
on the floor the patient was noted to be hypotensive down to a systolic
in the 70s and slightly more tachycardic to the low 100's (baseline
80's-90's). After an initial 500cc IVF bolus, the patient's SBP
improved to the 100's but one hour later she was noted to have an SBP
in the 70s once again. Given her recent cardiac catherization there
was concern for possible pericardial tamponade so a bedside TTE was
performed which showed no significant pericardial effusion."
3195,"5-1mm of slowly upsloping
ST segment depression was seen in the inferior leads and V2-V6 at peak
infusion and in early recovery period; returning to baseline later in
recovery. The rhythm was sinus with rare isolated APBs and VPBs. The
blood pressure response to infusion was flat with an appropriate heart
rate response.
Cardiac Cath: (Date: [**2155-7-25**]), Initial angiography with a calcified
tortuous OM1
lesion to 90% and a longer 90% diagonal lesion. Access was quite
difficult. We used a micropuncture set to get access in RFA but had to
use a Glidewire to negotiate the tortuous iliacs and aorta."
3196,"TITLE:
Date of service: [**2155-7-26**]
Initial visit, Cardiology service: CCU
Presenting complaint: (Other: Hypotension, tachycardia)
History of present illness: In brief, Ms. [**Known lastname **] is a 73 year old woman
who has a history of coronary artery disease s/p a myocardial
infarction in [**2131**] and a large abdominal aortic aneurysm. Of note,
approximately two months ago, the patient was undergoing pre-op
evaluation and evaluation of chest pain prior to repair of a 6.6 cm AAA
when she was noted to have an abnormal office EKG. Following this, the
patient underwent dobutamine stress test and was found to have
upsloping ST segment depressions during the study, subsequently
undergoing cardiac catherization on [**2155-6-13**] that revealed 3VD (mid LAD
occlusion, 90% LCx, 100% Ostial RCA lesion)."
3197,"We
ultimated were able to get into ascending aorta and exchanged for a
Amplatz wire and then put up a 6F 90cm Shuttle sheath.
2. Limited hemodynamics with BP 123/67 with HR 82 in sinus.
3. POBA of OM1 with 2.25mm balloon resulting in dissection with good
flow.
Assessment and Plan
73F c 3VD and AAA, as well as DM, COPD and MMP now p/w increasing DOE
after failed CABG. Likely this represents an angina equivalent which is
exacerbated by her other pulmonary issues (effusion, COPD, asthma). To
cath tomorrow.
.
# PUMP: Pt c systolic CHF c EF of 45-55% on TTE in [**5-8**], BNP this
admission 8434."
3198,"The patient proceeded to
CABG earlier this month but was unable to tolerate placement on bypass,
and therefore was not revascularized and was maintained on medical
therapy for her 3VD.
.
Two days prior to this admission, the patient presented to outpatient
cardiology clinic complaining of dyspnea, and worsening DOE, which was
felt to be an anginal equivalent. Given her symptoms, she was admitted
to [**Hospital1 5**] for further evaluation. On admission the patient was found to
have a large left sided pleural effusion which was drained and found to
be exudative. She then underwent repeat elective cardiac catherization
on [**2155-7-25**], however, cardiac catherization was complicated by a small
sprial dissection of the OM1."
3199,"CT
abdomen/pelvis without evidence of RP bleed or hematoma around femoral
vessels. Bedside echo without evidence of significant pericardial
effusion and no gross change in LV function from prior study.
- Holding metoprolol for now until BP improves
- Follow Hct Q8 hours
- Active T&C
- IVF boluses as needed to maintain SBP>90
- Monitor on tele
- F/[**Location **] CT abdomen/pelvis read
- Monitor femoral groin site for signs of hematoma
.
# CORONARIES: 3VD on cath from [**5-8**], s/p recent attempted CABG but pt
unable to tolerate bypass, now s/p c.cath with POBA to OM1
-to cath in the am
-continue asa/plavix post procedure for 6 weeks
-continue Rosuvastatin
."
3200,"083% Neb Soln 1 NEB IH Q4H:PRN SOB
Docusate Sodium 100 mg PO BID
Fexofenadine 60 mg PO BID
Heparin 5000 UNIT SC TID
Ranitidine 150 mg PO BID
Cardiovascular ROS
Cardiovascular ROS Signs and Symptoms Present
SOB, DOE
Cardiovascular ROS Signs and Symptoms Absent
Murmur, Rheumatic fever, Chest pain, PND, Orthopnea, Edema,
Palpitations, Syncope, Presyncope, Lightheadedness, TIA / CVA,
Pulmonary embolism, DVT, Claudication, Exertional buttock pain,
Exertional calf pain
Cardiovascular ROS Details: Pt w/symptoms of SOB/DOE on admission but
not currently
Review of Systems
Signs and symptoms present
Black / red stool, Myalgias
Organ system ROS normal
Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,
Hematology / Lymphatic, Genitourinary, Musculoskeletal, Integumentary,
Neurological, Psychiatric, Allergy / Immune
Signs and symptoms absent
Recent fevers, Chills, Rigors, Cough, Hemoptysis, Bleeding during
surgery, Joint pains
ROS Details: Pt with history of black stools while on iron
supplementation."
3201,"While on the floor, pt with hypotensive episode and
SBP to 70's that responded to total of 1L IVF. EKG remained
unchanged. Given recent c.cath with small dissection to OM1,
hemopericardium or retroperitoneal bleed were of concern given relative
hypotension. In addition, on admission, pt underwent thoracentesis of
L sided pleural effusion and removal of 1.5L possibly causing fluid
shifts and relative hypotension. [**Name2 (NI) **] potential etiologies of
hypotension could include dehydration, or less likely medication effect
from meds received in the cath lab. Pt currently asymptommatic but
tachycardic to 115. Hct stable 32.2-->33.4 on the floor."
3202,"Trace pericardial
effusion. No retroperitoneal bleed, free fluid, or free air. No
hematoma near right femoral vessels.
Tests
ECG: (Date: [**2155-7-25**]), Sinus tachycardia, Q waves in II, III, aVF, poor
R wave progression, no ischemic ST segment changes
Stress Testing: (Date: [**5-8**]), (Protocol: Dobutamine), The patient was
infused with 15 and 30mcg/kg/min of Dobutamine at infusion time of 4.75
minutes. The test was stopped due to reaching the target submaximal
heart rate. The patient reported a lower RLQ discomfort [**4-8**] during
infusion. This symptom resolved after the Dobutamine was terminated. In
the presence of baseline changes, between 0."
3203,"Pt also complaining of left upper arm myalgias
Social History
(Alcohol: No), (Recreational drug use: No)
Family history: Non-contributory
Physical Exam
Date and time of exam: [**2155-7-25**]
Vital signs: per R.N.
BP right arm:
98 / 53 mmHg
supine
T current: 99.5 C
HR: 105 bpm
RR: 19 insp/min
O2 sat: 100 % on Supplemental oxygen: 2L NC
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: Dry), (Teeth, gums and
palette: WNL)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Jugular veins: Not visible), (Thyroid: WNL)
Back / Musculoskeletal: (Chest wall structure: Midline sternotomy
incision well healed but slightly tender to palpation)
Respiratory: (Effort: WNL), (Auscultation: Abnormal, Decreased breath
sounds 2/3 up lung fields on left and diminished at right lung base
without wheezes or crackles)
Cardiac: (Rhythm: Regular, Tachycardic), (Palpation / PMI: WNL),
(Auscultation: S1: WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (foley catheter in place)
Femoral Artery: (Right femoral artery: Groin site without hematoma,
minimal tenderness to palpation, No bruit), (Left femoral artery: No
bruit)
Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and
station: not assessed), (Edema: Right: 0, Left: 0)
Skin: ( WNL)
Labs
Outside / other labs: CT Abdomen/Pelvis [**2155-7-25**]:
Stable supra and infrarenal aortic aneurysms."
3204,"Admission Date: [**2155-7-23**] Discharge Date: [**2155-7-31**]
Date of Birth: [**2081-12-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Flagyl
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Ms. [**Known lastname **] is a 73 year old woman who has a history of chest
coronary artery disease s/p a myocardial infarction in [**2131**] and
a large abdominal aortic aneurysm. A recent cardiac
catheterization revealed 3VD. Admitted for CABG last month but
was unable to tolerate placement on bypass. In her cardiologists
office today, she was unable to walk 10 feet and had no breath
sounds in her left lung base, thus she is admitted for ?"
3205,"pleural
effusion and for possible coronary catheterization as she could
not tolerate CABG.
.
ROS: as above. Also, pt has had syncope while straining to have
a bowel movement on several occasions. Pt does c/o black stools
which she attributes to taking iron supplements.
.
Pt denies chest pain, PND, HA, fevers, night sweats, joint pain,
myalgias, bloody stool, dysuria.
Past Medical History:
Abdominal aortic aneurysm, diabetes mellitus, myocardial
infarction in [**2131**], Diverticulitis, Neuropathy, Sciatica,
Asthmatic, Bronchitis, Bursitis Rt shoulder, Rotator cuff tear,
Dry eyes
Social History:
Ms. [**Known lastname **] is a former smoker who quit 17 yrs ago, with an 80
pack/yr history."
3206,"FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. POBA of OM1""
Brief Hospital Course:
73F c 3VD and AAA, as well as DM, COPD and MMP now p/w
increasing DOE. Pt does have large L pleural effusion s/p cabg
which was drained on [**2155-7-24**], but has been reaccumulating since
then. Pt also had cath on [**7-25**] which resulted in a dissected
Lcx. She was admitted to the unit for hypotension on [**7-25**], rp
bleed and pericardial effusion ruled out and hypotension
resolved c IVF and decreased bblocker. c/o L shoulder pain which
seems msk in origin (reproducible by pressing on her shoulder
and reproducible with abduction of shoulder)
."
3207,"The ST depressions were attributed to demand [**3-3**]
tachycardia. Pt was continued on rosuvastatin.
.
# PUMP: Pt c systolic CHF c EF of ~40%. Her metoprolol was
decreased from 25 [**Hospital1 **] to 12.5 [**Hospital1 **] as her blood pressures were
consistently in the 90s on the higher dose. Of note, pt has
hypotensive for several hours on the day following her first
thoracentesis (pericardial eff and RP bleed were ruled out) and
pt responded well to 1LNS.
.
# RHYTHM: Pt was in sinus rhythm and monitored on telemetry
throughout her admission. Her rate was usually in the high 90s.
.
# L PLEURAL EFFUSION: Pt was found to have a large left pleural
effusion believed to be [**3-3**] her recent CABG."
3208,"She received
diagnostic/therapeutic thoracentesis on admission which
reaccumulated over ~36 hours. Pt recieved a second thoracentesis
on [**7-28**] with a small amount of reaccumulation, but less than the
first time. Both samples were sent for analysis and were found
to be exudative which is consistent with post-cabg pleural
effusion. Fluid was also sent for cytology, which is pending. Pt
was started on lasix 20 to try to limit reaccumulation, which
she tolerated well.
.
# COPD/asthma-continued home COPD/asthma medicines. Pt did
occasionally recieve albuterol nebs with good result.
.
# L SHOULDER PAIN: Pt had some left shoulder pain which
developed after her first thoracentesis and radiated to her
elbow, likely musculoskeletal in origin (though pt was ruled out
for MI again when she had this pain)."
3209,"She will follow up with
her PCP [**Last Name (NamePattern4) **] 1 week.
.
# OSTEOPENIA: Pt was found to be osteopenic by cxr, and was
started on calcium and vitamin D. She may benefit from a dexa
scan as an oupatient.
.
# ANEMIA: improved from baseline, trended throughout her
admission. Felt to likely be [**3-3**] her MMP.
.
# continued rest of home meds (allergy meds, neuropathic pain
meds)
.
# DM: d/ced rosiglitazone and started on ISS as inpt. Her blood
sugars were found to be in the 140s to 150s so rarely recieved
coverage with humalog. She can restart her rosiglitizone.
.
#PT consulted and believed she would benefit from [**Hospital 98**] rehab."
3210,"19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
20. Tylenol #3 300/30 1-2 tabs PO q6h prn pain
21. Ranitidine 150 [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
Academy Manor of [**Location (un) 7658**]
Discharge Diagnosis:
Primary diagnoses: pleural effusion, coronary artery disease,
CHF
Secondary diagnoses: AAA, diabetes, dyslipidemia, neuropathy,
sciatica, asthma, COPD, seasonal allergies, GERD
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital because of shortness of
breath. We found that you had a fluid accumulation in your chest
(called a pleural effusion) which can happen after heart
surgery."
3211,"# CORONARIES: 3VD on cath from [**5-8**], attempted CABG but pt could
not tolerate bypass. Now s/p cath on [**7-25**] c no stents,
dissection of left circumflex. She was ruled out for MI. She was
continued on aspirin and started on plavix, but the plavix was
discontinued as patient did not recieves stents and may need
thoracentesis or pleurex tube in the next few weeks. Pt had
episode of nausea and lightheadedness which was similar to her
prior MI in [**2130**] on [**2155-7-30**] depressions in V4-V6.
She was ruled out for MI, and the EKG had normalized by the next
day."
3212,"We drained it twice and will continue to watch it. You
also have some coronary disease. We tried to put a stent in one
of your coronary arteries during a procedure called coronary
catheterization, but we were not able to do that. Lastly, you
had some left arm pain after the procedures to drain fluid in
your lungs, this was treated with percocet. Please mention this
to Dr [**Last Name (STitle) **] if it has not resolved by your appointment.
AT REHAB (these instructions are for REHAB not for PATIENT):
Please monitor vital signs at least 4 times daily. Please
contact Dr [**Name (NI) **] at [**Telephone/Fax (1) 17382**] for SBP < 90."
3213,"Tyelenol #3
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
2. Formoterol Fumarate 12 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation twice a day.
3. loratidine Sig: One (1) 10mg once a day.
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-31**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO once a day."
3214,"She denies drinking alcohol or illicits. She
lives with her daughter.
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION:
VS: T=99.4...BP=98/58 (R), 130s systolic on L
...HR=102...RR=20...O2 sat= 99% RA
GENERAL: 73F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP does not appear elevated.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were mildly labored, no accessory muscle use."
3215,".
FEN: diabetic cardiac diet
.
PROPHYLAXIS: heparin sc 5000 TID, colace, senna prn
.
Daughter's cell is [**Telephone/Fax (1) 82228**]
CODE: full
Medications on Admission:
Formoterol Fumarate 12 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation twice a day.
loratidine Sig: One (1) 10mg once a day.
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops
Ophthalmic PRN (as needed) as needed for dry eyes.
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO once a day.
Duloxetine 30 mg Capsule, Delayed Release(E."
3216,"tot prot 3.6 (blood tpro 5), glucose
117, LDH 193 (blood LDH 250), amylase 47, alb 2.5
Cath [**2155-7-24**]: ""1. Planned PCI. Access was quite difficult. We
used a
micropuncture set to get access in RFA but had to use a
Glidewire to
negotiate the tortuous iliacs and aorta. We ultimated were able
to get
into ascending aorta and exchanged for a Amplatz wire and then
put up a
6F 90cm Shuttle sheath.
2. Limited hemodynamics with BP 123/67 with HR 82 in sinus.
3. POBA of OM1 with 2.25mm balloon resulting in dissection with
good
flow."
3217,"13. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 7 days.
Disp:*25 Tablet(s)* Refills:*0*
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day)."
3218,"Please keep O2
saturations >90%.
Please check chem-7 on on [**8-1**]. Please also check a chest
xray on Friday [**8-1**]. Please fax results to Dr [**Last Name (STitle) **] at
[**Telephone/Fax (1) 17382**].
ONCE YOU GO HOME (FOR PATIENT):
Please adhere to the medicine list that they give you when you
go. You will go to rehab on a water pill (called lasix) but you
may not need it by the time you go home. We did start you on
calcium and vitamin D for your bones, please do continue to take
those when you are at home."
3219,"7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
9. Nizatidine 150 mg Capsule Sig: One (1) Capsule PO once a day.
10. Budesonide 180 mcg/Inhalation Aerosol Powdr Breath Activated
Sig: [**1-31**] Inhalation at bedtime.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Aspirin 81 mg Tablet Enteric coated, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily)."
3220,"Please weigh yourself every morning, call your doctor if your
weight changes by > 3 lbs.
Adhere to 2 gm sodium diet
Please do not drink more than 2 liters of fluid per day.
Followup Instructions:
Please see your primary care doctor, Dr [**Last Name (STitle) **], on Wednesday
[**8-6**] at 11:45am
You have an appointment to see your lung doctor, Dr [**Last Name (STitle) 70216**], on
Tuesday [**8-26**] at 4:15pm
You have an appointment to see your cardiologist, Dr [**Last Name (STitle) **], at
1:45 on Wednesday, [**8-13**]
You have an appointment to see your cardiac surgeon at [**Hospital1 18**], Dr
[**First Name (STitle) **] R. [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2155-8-7**] 2:30
You have an appointment to see your vascular surgeon at [**Hospital1 18**],
Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2155-8-22**] 10:45
Completed by:[**2155-7-31**]"
3221,"Reduced breath
sounds at L base.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
palpable. EXTREMITIES: No c/c. No femoral bruits. Mild pitting
edema L>R (s/p recent L saphenous v removal). c/o some numbness
on the lateral side of her L leg. feet cool
SKIN: thoracotomy site and saphenous v site healing well.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
on discharge:
140 | 102 | 15
---------------136
4.3 | 30 | 0.9
5.3>29.7<463
INR 1
albumin 3.3
Pleural fluid: WBC 400, RBC [**Numeric Identifier **], PMNs 15, lymphs 30, monos 19,
eos 16, macrophages 14."
3222,"C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Nizatidine 150 mg Capsule Sig: One (1) Capsule PO once a day.
Budesonide 180 mcg/Inhalation Aerosol Powdr Breath Activated
Sig: [**1-31**] Inhalation at bedtime.
Metoprolol Tartrate 25 mg [**Hospital1 **]
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours)."
3223,"Admission Date: [**2195-1-19**] Discharge Date: [**2195-1-26**]
Date of Birth: [**2123-9-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2195-1-19**] Aortic Vavlve Replacement (23mm [**Company 1543**] Mosaic Ultra
porcine)/ Coronary artery bypass graft x2 (Left internal mammary
artery to Left anterior descending, Saphenouse vein graft to
obtuse marginal)/reduction aortoplasty
History of Present Illness:
71 year old female with hypertension began to notice significant
shortness of breath toward the end of [**Month (only) **]/early [**Month (only) 359**]
[**2194**] while on vacation."
3224,"She was seen at a walk in clinic and
prescribed inhalers with plans for follow up with her local MD.
Cardiac cath showed 2V CAD after echo showing aortic stenosis.
Referred for surgery.
Past Medical History:
Hypertension
chronic renal insufficiency ( baseline creat 1.5)
chronic systolic heart failure
Aortic stenosis
Depressed LVEF
Depression
Osteoarthritis- right ankle
Asthma
Kidney stones s/p surgery
Gastroesophageal reflux disease
Peptic ulcer disease
Past Surgical History:
s/p benign Left breast lumpectomy
Laser surgery of right eye x 2
Remote back surgery
Social History:
Lives with:husband
Occupation:retired
Tobacco:quit 8 years ago, 1-2ppdx 20years
ETOH:Patient had been drinking 3 glasses of wine and one beer a
day."
3225,"13. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Aortic stenosis and coronary artery disease s/p Aortic valve
replacement/coronary artery bypass graft x2
Past medical history:
Hypertension
Depression
Osteoarthritis- right ankle
Asthma
Kidney stones s/p surgery
Gastroseophageal reflux disease
Peptic ulcer disease"
3226,"[**Last Name (STitle) **]. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU in
stable condition on titrated phenylephrine and propofol drips.
Later that day she was weaned from sedation, awoke
neurologically intact and extubated. She was weaned from drips
over next 2 days. PICC placed for access on post-op day two.
Initially post-op she was confused but cleared slowly over
couple days. Chest tubes and pacing wires were removed per
protocol. She was transferred to the floor on post-op day three
to begin increasing her activity level. Gently diuresed toward
her preop weight and Beta blockade titrated."
3227,"She continued to
make good progress and was cleared for discharge to [**Hospital **] in [**Hospital1 3597**] NH via ambulance for the safest method of
transport on post-op day seven with the appropriate medications
and follow-up appointments.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth every morning
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - 250 mcg-50 mcg/Dose Disk with Device - twice a day
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth every morning
PERPHENAZINE-AMITRIPTYLINE - (Prescribed by Other Provider) - 2
mg-25 mg Tablet - 1 Tablet(s) by mouth every evening"
3228,"The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The aortic regurgitation jet is eccentric, directed toward the
anterior mitral leaflet. 7. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. 8. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results. POST-CPB: On infusion of
phenylephrine briefly. AV pacing, then a pacing. Well-seated
bioprosthetic valve in the aortic position. Trivial central AI,
gradient now 11 peak, 6 mean. Preserved biventricular systolic
function with LVEF now 40 %."
3229,"Aortic diameter now measures 3.8 in
the ascending aorta. Contour of the aorta is preserved post
decannulation. I certify that I was present for this procedure
in compliance with HCFA regulations.
[**2195-1-19**] 11:25AM BLOOD WBC-7.8 RBC-2.69*# Hgb-8.3*# Hct-24.0*#
MCV-89 MCH-30.7 MCHC-34.4 RDW-14.2 Plt Ct-185
[**2195-1-26**] 04:11AM BLOOD WBC-8.2 RBC-3.34* Hgb-9.9* Hct-30.1*
MCV-90 MCH-29.8 MCHC-33.0 RDW-14.3 Plt Ct-207
[**2195-1-19**] 11:25AM BLOOD PT-13."
3230,"8* PTT-48.3* INR(PT)-1.2*
[**2195-1-19**] 10:39PM BLOOD PT-12.4 PTT-38.7* INR(PT)-1.0
[**2195-1-19**] 12:28PM BLOOD UreaN-38* Creat-1.5* Na-137 K-4.6 Cl-108
HCO3-25 AnGap-9
[**2195-1-26**] 04:11AM BLOOD Glucose-117* UreaN-33* Creat-1.4* Na-142
K-4.4 Cl-101 HCO3-33* AnGap-12
[**2195-1-19**] 10:41PM BLOOD Mg-3.1*
[**2195-1-22**] 03:13AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.8
Brief Hospital Course:
Mrs. [**Known lastname 1968**] was a same day admit and on [**1-19**] underwent surgery
with Dr."
3231,"Medications - OTC
PYRIDOXINE [VITAMIN B-6] - (Prescribed by Other Provider) - 100
mg Tablet - 1 Tablet(s) by mouth daily
VITAMIN E - (Prescribed by Other Provider) - 400 unit Capsule -
1 Capsule(s) by mouth daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5."
3232,"Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
No Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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
Surgeon: Dr. [**Last Name (STitle) **] [**2195-2-19**] 1:00 [**Telephone/Fax (1) 170**]
Plaese call your
PCP/cardiologist:Dr. [**Last Name (STitle) 32668**] to schedule an appointment to
be seen in [**5-5**] 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**
Completed by:[**2195-1-26**]"
3233,"Carotid Bruit Right/Left: transmitted murmur
Pertinent Results:
[**2195-1-19**] Echo: PRE-CPB:1. The left atrium is mildly dilated. No
thrombus is seen in the left atrial appendage. 2. No atrial
septal defect is seen by 2D or color Doppler. 3. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is top normal/borderline dilated. 4.
Right ventricular chamber size is normal. with normal free wall
contractility. 5. The ascending aorta is moderately dilated. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. 6. The aortic valve
is bicuspid."
3234,"She has had none in 3 weeks.
Family History:
Mother and father died from a CVA, brother had CVA
Physical Exam:
Pulse:66 Resp:14 O2 sat:97/RA
B/P Right:104/60 Left:108/66
Height:5' Weight:131 lbs
General:
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 II/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x] R pretibial incision
Neuro: Grossly intact
Pulses:
Femoral Right: dressing Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2"
3235,"thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. perphenazine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime))."
3236,"Given Vanc/Zosyn.
Past Medical History:
-ALL - [**2147**], treated with Vincristine, prednisone,
Methotrexate, Adriamycin (total 450 mg/m2), 6MP and
L-Asparaginase, and cranial XRT. Bone marrow relapse [**2150**]
treated with COAP, stopped secondary to toxicity. Reinduced with
Prednisone, L-Asparaginase and oral Methotrexate in [**2151**] and
underwent allogeneic bone marrow transplant with whole body
radiation.
-Small bowel perforation - [**2167**]
-Pulmonary fibrosis and left lobe transplant - [**2170**],
complicated by pericardial and pleural effusion
-Staph aureus bronchitis - [**2171**]
-Left mainstem bronchomalacia, s/p stent placement [**2176**]
-Chronic sinus tachycardia
-Dyspnea on exertion and with lying supine
-G-tube placement
-Esophageal strictures - s/p multiple dilations
-Moderate MR ([**3-12**])
-Basal Cell Ca (Back - upper chest)
-Edentulous with full dentures due to major dental work (now
missing her lower dentures, as described above)
."
3237,"No subcutaneous fluid collection about G-tube
insertion site.
Brief Hospital Course:
This is a 40-year-old woman with a history of ALL, s/p BMT [**2151**]
complicated by radiation therapy-related pulmonary fibrosis
requiring LLL lung transplant from her father [**5-/2171**] (on no
immunosuppresants), further complicated by L main stem bronchus
stenosis s/p metal stent placement [**9-/2176**] requiring serial
debridements over the years who on [**2182-12-9**] had bronchoscopy with
debridement/cryotherapy and EGD with esophageal dilatation and
presents [**2182-12-11**] with hypercarbic respiratory failure.
# RESPIRATORY FAILURE: One day prior to admission, patient
underwent IP stenting, debridement and re-opening of stenosis as
well as esophageal manipulation."
3238,"She underwent bronchoscopy on [**12-24**] for evaluation of
stent patency (was patent). Lower extremity dopplers on [**12-20**]
were negative for DVTs. Percutaneous Tracheostomy was placed on
[**12-27**] and ventilator setting were slowly weaned. Prior to
transfer, patient was doing well on trach collar. She
occasionally required suctioning for mucus plugging.
.
# LEUKOCYTOSIS: Trended down once antibiotics changed to Vanco
and Cefepime on [**12-22**]. All repeat cultures NGTD. Only culture
pending is a B-glucan.
.
# HYPOTENSION: Patient had hypotension requiring neosynephrine.
This was felt to be secondary to infection/sepsis, sedation and
PEEP. Pressors were weaned off on [**12-26**] and she remained
hemodynamically stable with MAP> 55-60."
3239,".
#. RIGHT GOING HEMATOMA: Small hematoma at sight of prior
femoral line.
.
# ELEVATED LIVER ENZYMES: with mixed pattern of hepatocellular
injury and cholestasis. DDx is resolving shock, drug toxicity
and also acalculous cholecystitis. Per US on [**12-13**], Ms. [**Known lastname 27785**]
is status-post cholecystectomy. Enzymes are trending down.
.
# MALNUTRITION WITH COAGULOPATHY, ANEMIA, AND HYPOCALCEMIA: A
G-tube was placed and Ms. [**Known lastname 27785**] was started on Nutren
Pulmonary TFs. These were supplemented with MCT. Banana flakes
were added for diarrhea; c.diff was negative.
.
# ANEMIA: Hematocrit basically remained stable throughout
hospitalization. Patient was guaiac positive from below
intermittently, though unclear source."
3240,"Ms. [**Name14 (STitle) 34709**] was
maintained on an H2 blocker.
.
# ANXIETY AND NIGHTMARES: Amitryptyline 20 qhs.
.
# ABDOMINAL PAIN: Ms. [**Known lastname 27785**] complained of abdominal pain
around the site of her G-tube. An ultrasound was performed on
[**12-31**], which was negative for subcutaneous fluid collection
about G-tube insertion site.
.
# POSITIVE B-GLUCAN: B-glucan was positive during admission.
There are multiple reasons for a positive B-glucan aside from
fungal infection. Ms. [**Known lastname 27785**] was [**Doctor Last Name **] exceptionally well on
vancomycin and cefepime and as such, fungal coverage was not
started. If patient does poorly, she will need to be
re-evaluated with fungal infection on the differential."
3241,"25. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**]
Discharge Diagnosis:
1. Pneumonia
2. Respiratory failure
3. Tracheostomy and G-tube placement
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:
Dear Ms. [**Known lastname 27785**],
It was a pleasure taking care of you on this admission. You
came to the hospital with a bad pneumonia. We treated you with
antibiotics and you improved. A bronchoscopy revealed a patent
stent."
3242,"It was difficult to wean you from the ventilator so we
ended up putting in a tracheostomy. You are doing very well
with the trach, and hopefully you will continue to wean at
rehab.
.
Please see the attached updated medication list.
.
Please keep all of your follow-up appointments.
.
Return to the hospital if you develop worsening shortness of
breath, chest pain, nausea, vomiting, diarrhea, headache,
fevers, chills, or any other concerning signs or symptoms.
Followup Instructions:
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2183-1-13**] at 6:45 AM ARRIVAL
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5072**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage"
3243,"19. diphenhydramine HCl 50 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for itching.
20. lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for anxiety, insomnia.
21. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours).
22. fentanyl citrate (PF) 50 mcg/mL Solution Sig: One (1)
Injection Q4H (every 4 hours) as needed for breakthrough pain.
23. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
24. heparin lock flush (porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port."
3244,"8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dryness.
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
10. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
12. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain or fever.
13. medium chain triglycerides 7.7 kcal/mL Oil Sig: Fifteen (15)
ML PO BID (2 times a day)."
3245,"PAST SURGICAL HISTORY:
1- Surgical Debridement of thigh abcess from IM pentamidine [**2152**]
2- Appendectomy [**2163**]
3- Laparoscopy to remove ovarian cysts [**2162**]
4- S.P Small bowel perforation complicated with candidal and
bacterial paeritonitis requiring antifungals and antibiotics
5- Cholecystectomy
6- Pulmonary fibrosis S/P living related donor from father [**Name (NI) 25730**]
transplant)
7- Post pericardiotomy syndrome [**2170**]
8- L MS bronchomalacia
9- Bilat SAH
10- Ilesotomy and enterococcus fistula and reversed 10 months
later at [**Hospital1 112**]
11- Closing of enterocutaneous fistula and ostomy [**2174**]
12- S/P port placement for IV access [**9-7**]
13- LMS granuloma debridement and mitomycin
14- Esophageal dilatation [**2-11**] - [**7-11**]
15- Debridement of granulation tissue around stent
[**88**]- Pneumothorax post bronchoscopy with stent granulation tissue"
3246,"Pertinent Results:
Labs on admission:
.
[**2182-12-11**] 07:18AM WBC-25.3* RBC-3.03* HGB-9.1* HCT-27.6* MCV-91
MCH-30.0 MCHC-32.9 RDW-14.0
[**2182-12-11**] 07:18AM NEUTS-83* BANDS-6* LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2182-12-11**] 07:18AM PT-15.1* PTT-25.5 INR(PT)-1.3*
[**2182-12-11**] 07:24AM LACTATE-0.7
[**2182-12-11**] 04:12PM GLUCOSE-66* UREA N-8 CREAT-0.2* SODIUM-142
POTASSIUM-4.3 CHLORIDE-115* TOTAL CO2-21* ANION GAP-10
."
3247,"14. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. 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.
17. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
18. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours)."
3248,"Medications on Admission:
Per records, unable to be reconciled
amitriptyline 20 mg daily, carvedilol 6.25 mg [**Hospital1 **], codeine
sulfate 15 mg q4-6h prn cough, estradiol 10 mcg vaginal
suppository 3x weekly, estradiol-levonorgestrel 0.045-0.015
mg/24 hr TD weekly, cholecalciferol 1,000U daily, medium chain
triglycerides (7.7 kcal/mL) 1 tbsp TID (pt cannot afford med
yet), Nutren Pulmonary Lacfree 3 cans daily, polyvinyl alcohol
drops prn, Vit K 100mcg daily
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation."
3249,"Admission Date: [**2182-12-11**] Discharge Date: [**2183-1-1**]
Date of Birth: [**2142-12-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Tetanus / Morphine
/ Cefoxitin / Codeine / Lactose
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Bronchoscopy
G-tube placement
History of Present Illness:
This is a 40-year-old with history of ALL s/p allo BMT [**2151**], c/b
radiation-induced pulmonary fibrosis, underwent left lower lobe
transplant [**2170**], this was c/b left mainstem bronchomalacia, s/p
stenting, recently s/p bronchoscopy on [**2182-12-9**] for cryo to
granulation tissue now presenting with respiratory distress."
3250,"debridement
Social History:
Patient lives independently and has fantastic family support.
She helps take care of her 2-year-old nephew and 1-month-old
niece 5 days/week. She has never smoked. She does not drink
alcohol on a regular basis.
Family History:
Parents are both living. Father (66; aortic stenosis); Mother
(65 years; smoking, hyperlipidemia). She has 3 siblings (one
brother has a history of testicular cancer). She has no
children.
Physical Exam:
VS: Afebrile, 130, 100/58, 34, 100% on AC
Gen: Petite woman, appears older than stated age, sedated
HEENT: left pupil>right pupil, both reactive, no icterus, MMM
Neck: Supple, no cervical LAD, no supraclavicular LAD
Heart: tachycardic, no m/r/g
Pulm: Coarse & diffuse bronchial breath sounds and rhonchi
bilateral anteriorly
Chest: left chest port in place
Abd: soft, flat, NT/ND, no hepatosplenomegaly
Ext: 2+ pulses, warm, no cyanosis or edema
Neuro: Sedated, does not respond to noxious stimuli
Skin: No rashes"
3251,"The patient
was transfered to the [**Hospital1 18**] ED for further management.
.
At the [**Hospital1 18**] ED, the pt's initial vitals were 98.3 92 126/72 18
100% NRB. Patient was found to have worsening shortness of
breath, was tachypneic to 30s with ABG: 7.18/85/166. The pt was
intubated and bronchoscopy was performed. ABG after intubation
showed: 7.00/99/196. Vent changed with decreased volume and
increased rate. Blood pressures dropped after being sedated. An
A line and CVL (femoral) were placed. Sedation stopped with
improvement in blood pressures. Two liters IVF given. Patient
was started on neosynephrine with mild improvement in blood
pressures."
3252,"3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-5**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
4. amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
8. white petrolatum-mineral oil 56."
3253,"On admisison, Ms. [**Known lastname 27785**] had
impressive multi-focal infiltrates suggestive of overwhelming
pneumonia, likely the result of recent manipulations. Patient
was started on broad spectrum antibiotics (initially Vanc/
zosyn/ levoflox/ tobramycin/ tamiflu-->subsequently
Naf/Cipro/zosyn/Azithro then Naf/Vanc/Cipro/Azithro); her final
antibiotic regimen includes VANCOMYCIN and CEFEPIME. She will
finish a 14-day course of vancomycin and cefepime on [**2183-1-6**].
.
Ms. [**Known lastname 27785**] was eventually extubated on [**12-20**] however, became
increasingly tachycardic and tachypneic with RR of 40 and was
unable to speak in full sentances. Ms. [**Known lastname 27785**] was re-intubated
on [**12-21**]."
3254,".
ECHO [**2182-12-23**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**1-5**]+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild moderate mitral regurgitation. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function."
3255,".
History was obtained from medical records. On [**2182-12-9**], the
patient underwent bronchoscopy for cryotherapy debridment of the
metallic left main stent under rigid bronchoscopy followed by
esophageal dilation via thoracic surgery. Her post operative
course was complicated by respiratory distress and profound
bronchospasm, which responded to positive pressure noninvasive
ventilation and albuterol nebs. The patient was monitored
overnight, and discharged on [**2182-12-10**]. The patient presented to
an OSH ED on [**2182-12-11**] early am complaining of SOB that had
started the prior evening. At OSH ED the pt was noted to have a
pneumonia, and received levoquin 750mg and 500cc NS."
3256,"CT CHEST/ABDOMEN/PELVIS [**2182-12-22**]
1. Interval improvement in right lower lobe consolidation,
however
development of patchy consolidations and ground-glass opacities
throughout
almost the entire left lung. Ground-glass opacity also involves
the right
lower lobe and right upper lobe. The differential diagnosis is
broad, as
findings are nonspecific, and includes infection, edema and
hemorrhage.
2. No specific signs of empyema, however, superinfection of
simple pleural
effusions cannot be excluded.
3. No abdominal fluid collection.
4. Decompressed distal descending and sigmoid colon. No clear
wall thickening.
5. Trace abdominal ascites.
6. Mild perirectal stranding. The differential diagnosis
includes proctitis and third spacing in the setting of fluid
overload."
3257,"Department: WEST PROCEDURAL CENTER
When: MONDAY [**2183-1-13**] at 7:30 AM [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2183-1-13**] at 8:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5072**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2183-1-13**] at 8:00 AM
With: WPC ROOM TWO [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
NOTE: NOTHING TO EAT OR DRINK AFTER MIDNITE BEFORE THESE APPTS
ON [**2183-1-13**]. YOU WILL ALSO BE HAVING A FLEXIBLE BRONCHOSCOPY ON
THIS DAY. ANY QUESTIONS, CALL DR [**Last Name (STitle) **]."
3258,"Compared with the prior study (images reviewed) of [**2181-3-6**], the
findings are similar.
.
CLINICAL IMPLICATIONS:
Based on [**2179**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
G-TUBE PLACEMENT [**2182-12-25**]:
Successful uncomplicated placement of 12 French Wills-[**Doctor Last Name 12433**]
gastrostomy feeding tube. The tube can be used after 24 hours
and needs to be left to
gravity drainage overnight.
.
LENIS [**2182-12-20**]:
No evidence of deep vein thrombosis in either leg.
.
ABDOMINAL ULTRASOUND [**2182-12-31**]: No ascites in all four
quadrants."
3259,"Admission Date: [**2182-12-9**] Discharge Date: [**2182-12-10**]
Date of Birth: [**2142-12-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Tetanus / Morphine
/ Cefoxitin / Codeine / Lactose
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
[**2182-12-9**]:
EGD with dilation and left main stem cryoablation of granulation
tissue.
History of Present Illness:
Ms [**Known lastname 27785**] is a 39-year-old woman with a complicated medical
history including acute lymphocytic leukemia at age 4, status
post bone marrow transplant, radiation therapy complicated by
lung fibrosis requiring living donor lung transplant from her
father."
3260,"carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO twice a
day.
5. Vagifem 10 mcg Tablet Sig: One (1) tab Vaginal three times
per week.
6. Climara Pro 0.045-0.015 mg/24 hr Patch Weekly Sig: One (1)
patch Transdermal as directed.
7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
8. vitamin K 100 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Left main stem stenosis
Esophageal stricture
PAST MEDICAL HISTORY:
1- ALL since age 4
2- S/P Bone marrow transplant, and lung transplant from
radiation
fibrosis."
3261,"The both of them were donated by her father.
3- Pneumocystis Jiroveci Pneumonia in [**2152**]
4- Herpes Simplex 2 (oral)
5- TMJ Ankylosis with small oral opening
6- Bilateral cataracts
7- Esophagel stricture
8- LL pneumonia ([**2179-3-7**])
9- Intestinal Adhesions
10- Basal Cell Ca (Back - upper chest)
11- Edentulous with full dentures due to major dental work (now
missing her lower dentures, as described above).
PAST SURGICAL HISTORY:
1- Surgical Debridement of thigh abcess from IM pentamidine [**2152**]
2- Appendectomy [**2163**]
3- Laparoscopy to remove ovarian cysts [**2162**]
4- S.P Small bowel perforation complicated with candidal and
bacterial paeritonitis requiring antifungals and antibiotics
5- Cholecystectomy
6- Pulmonary fibrosis S/P living related donor from father [**Name (NI) 25730**]
transplant)
7- Post pericardiotomy syndrome [**2170**]
8- L MS bronchomalacia
9- Bilat SAH
10- Ilesotomy and enterococcus fistula and reversed 10 months
later at [**Hospital1 112**]
11- Closing of enterocutaneous fistula and ostomy [**2174**]
12- S/P port placement for IV access [**9-7**]
13- LMS granuloma debridement and mitomycin
14- Esophageal dilatation [**2-11**] - [**7-11**]
15- Debridement of granulation tissue around stent
[**88**]- Pneumothorax post bronchoscopy with stent granulation tissue
debridement."
3262,"PAST SURGICAL HISTORY:
1- Surgical Debridement of thigh abcess from IM pentamidine [**2152**]
2- Appendectomy [**2163**]
3- Laparoscopy to remove ovarian cysts [**2162**]
4- S.P Small bowel perforation complicated with candidal and
bacterial paeritonitis requiring antifungals and antibiotics
5- Cholecystectomy
6- Pulmonary fibrosis S/P living related donor from father [**Name (NI) 25730**]
transplant)
7- Post pericardiotomy syndrome [**2170**]
8- L MS bronchomalacia
9- Bilat SAH
10- Ilesotomy and enterococcus fistula and reversed 10 months
later at [**Hospital1 112**]
11- Closing of enterocutaneous fistula and ostomy [**2174**]
12- S/P port placement for IV access [**9-7**]
13- LMS granuloma debridement and mitomycin
14- Esophageal dilatation [**2-11**] - [**7-11**]
15- Debridement of granulation tissue around stent
[**88**]- Pneumothorax post bronchoscopy with stent granulation tissue
debridement."
3263,"She was brought in
for rigid bronch and cryoablation of left main stem granulation
tissue.
The patient also has esophageal stricture requiring past EGD
with dilation. Given dysphagia, the patient was also brought in
for combined EGD with dilation.
Past Medical History:
PAST MEDICAL HISTORY:
1- ALL since age 4
2- S/P Bone marrow transplant, and lung transplant from
radiation
fibrosis. The both of them were donated by her father.
3- Pneumocystis Jiroveci Pneumonia in [**2152**]
4- Herpes Simplex 2 (oral)
5- TMJ Ankylosis with small oral opening
6- Bilateral cataracts
7- Esophagel stricture
8- LL pneumonia ([**2179-3-7**])
9- Intestinal Adhesions
10- Basal Cell Ca (Back - upper chest)
11- Edentulous with full dentures due to major dental work (now
missing her lower dentures, as described above)."
3264,"vitamin K 100 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation q 4 hours prn as needed for shortness
of breath or wheezing.
Disp:*1 2* Refills:*0*
2. amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. Guaifenesin AC 10-100 mg/5 mL Liquid Sig: Ten (10) ML PO q 6
hours prn as needed for cough: do not drive while on this as it
may cause drowsiness. Take stool softeners to avoid
constipation.
Disp:*250 ML(s)* Refills:*0*
4."
3265,"9 Plt Ct-475*#
[**2182-12-9**] 10:42PM BLOOD Neuts-95.0* Lymphs-2.5* Monos-1.7*
Eos-0.4 Baso-0.3
[**2182-12-9**] 10:42PM BLOOD Glucose-72 UreaN-9 Creat-0.3* Na-134
K-3.9 Cl-99 HCO3-26 AnGap-13
[**2182-12-9**] 10:42PM BLOOD Calcium-7.9* Phos-2.3* Mg-1.7
CXR [**2182-12-10**]:
FINDINGS: As compared to the previous radiograph, the
pre-existing left
parenchymal opacities have slightly decreased in severity. The
right upper
lobe opacity is unchanged. There is no evidence of pneumothorax.
CXR [**2182-12-9**]:"
3266,"Social History:
Lives at home alone, with family that can help her. No smoking.
Physical Exam:
VS on day of discharge.
T 97.8, HR 90's SR , BP 95/45, RR 18 94% RA
Physical Exam on discharge:
Gen: pleasant in NAD
Neuro: alert and oriented x 4 without deficits
Lungs: wheezes t/o
CV: Fast RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: warm, without edema
Pertinent Results:
[**2182-12-9**] 10:42PM BLOOD WBC-21.0*# RBC-3.04* Hgb-9.1* Hct-27.4*
MCV-90 MCH-30.1 MCHC-33.4 RDW-13."
3267,"She was given albuterol for wheezing per the
pulmonary team with a script for guaifenesin with codeine for
cough. Her home medications were resumed.
Medications on Admission:
amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO twice a day.
Vagifem 10 mcg Tablet Sig: One (1) tab Vaginal three times per
week.
Climara Pro 0.045-0.015 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal as directed.
Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day."
3268,"She
recovered in the PACU, but over the evening developed
respiratory distress, therefore was admitted under Thoracic
surgery and stayed in PACU with Bipap. Her respiratory status
improved with bipap, albuterol, and morphine. She was observed
and in the morning, after examination by IP attending Dr. [**Last Name (STitle) **]
and the Thoracic surgery service, and review of chest xray, the
patient was deemed stable for discharge home. The patient was
ambulating oxygenating mid 90's on RA, stating she felt much
improvement from the evening without shortness of breath. She
was tolerating a regular meal without dysphagia. She did not
have any pain."
3269,"FINDINGS: As compared to the previous radiograph, there is
minimal
improvement with better ventilation of both lungs and minimal
regression of both the right upper lobe and the left lower lobe
opacity. No parenchymal opacities have newly occurred. The size
of the cardiac silhouette is unchanged. There is no evidence of
pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname 27785**] was taken to the operating room on [**2182-12-9**] by Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **] where she underwent EGD with dilation for her
esophageal stricture and rigid bronchoscopy with cryoablation of
the granulation tissue surrounding the left main stem stent."
3270,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr. [**First Name (STitle) **] or Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you experience:
fevers, chills, nightsweats, shakes, difficult or painful
swallowing, shortness of breath or cough.
Resume all home medications.
Given is a script for albuterol which will help you if you have
wheezing or a tight airway with shortness of breath. If used and
your breathing does not improve call us.
Followup Instructions:
Followup with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] in two weeks. Please obtain
a chest xray 30 minutes before your visit. You should here from
our office in the next few days regarding your appointment time,
if not call [**Telephone/Fax (1) 2348**].
Completed by:[**2182-12-11**]"
3271,"This was further complicated by left main stem stenosis
requiring metal stent placement 5 years ago. Since then she has
been requiring repeated bronchoscopies for stent evaluation,
clean out and granulation tissue removal. She was last seen by
interventional pulmonary service in [**2182-5-4**]. After that time
she
had been doing OK in terms of her breathing, but about one month
ago she started having dry cough, and then dyspnea on exertion,
both of which have been worsening, which prompted her consult
with us today. Her cough is worse at night, and is not
productive. Her dyspnea is currently with mild to moderate
exertion, like going up one flight of stairs."
3272,"Past medical history:
Family history:
Social History:
1. History of Cholecystitis s/p Cholecystotomy tube at [**Hospital1 3633**] - 4 years
ago
2. History of ampullary stenosis s/p sphincterotomy and ERCP in [**8-4**]
3. Depression
4. Raynaud's
5. Polysubstance Abuse- Past history of IV drug use with heroin and
cocaine (none in many years). Continues to drink alcohol, up to one
pint of vodka daily, less recently. Continues to smoke tobacco - [**12-2**]
PPD
6. Hepatitis C Infection
7. Presumed Cirrhosis c/b grade 1 esophageal varices (EGD [**7-9**])
8. Chronic Anemia
9. Chronic Abdominal Pain
10."
3273,"- Appreciate GI consult, plan for EGD in the am.
- Pantoprazole 40 mg IV bid.
- Active type and screen.
- Adequate access - will need a CVL as she has very difficult access.
# Abdominal pain: She has had persistent abdominal pain for multiple
weeks and previous hospitalizations and workup has been unrevealing.
Differential includes SBP, gastritis, esophagitis, biliary source,
diverticulitis (less likely given its characteristics).
- Diagnostic paracentesis to rule out SBP.
- Workup of pneumobilia/gallbladder source of pain as above.
- EGD in the am.
- Prn morphine for pain control.
# Hep C Cirrhosis: Patient is followed at the liver center. Has known
portal gastropathy and grade I esophageal varices.
# Alcohol abuse: Patient continued to drink alcohol and has the smell
of alcohol on her currently.
- folate, thiamine, MVI
- CIWA q4h with ativan prn for CIWA > 10
- SW consult
ICU Care
Nutrition: NPO, IVF prn
Glycemic Control:
Lines:
18 Gauge - [**2186-9-6**] 05:33 PM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU"
3274,".
Notably she has been admitted with concern for GI bleed multiple times
in the past 4 months. She was admitted in [**5-9**] with an upper GI
bleed. At that time she underwent an EGD which showed 3 cords of
nonbleeding grade I esophageal varices. She was transfused, her Hct
remained stable and she was discharged on a PPI to follow up with the
liver clinic. She was seen in the liver clinic on [**6-12**] and was started
on nadolol. On her follow up visit on [**7-24**] her Hct was found to be
decreased to 24 from 35 in [**Month (only) 807**]."
3275,"8 Cl 100 Bicarb 24 BUN 14 Cr 0.5 Glu 84
ALT 16 AST 57 AP 105 T bili 0.6 Lipase 47 Albumin 3.4
.
WBC 5.7 Hct 18.1 Plt 313
Hct baseline in mid to high 20's
N 71.1% L 21.5% M 6.5% E 0.4%
.
Peripheral smear: Hypochr: 3+ Anisocy: 1+ Poiklo: 1+ Macrocy:
OCCASIONAL Microcy: OCCASIONAL Polychr: OCCASIONAL Schisto: OCCASIONAL
Plt-Est: Normal
.
Micro: None
.
Images:
Abd/pelvis CT: Prelim
Interval improvement in colitis, now w/moderate fecal loading.
Cirrhotic liver with trace ascites. No acute abnormalities. No focal
collection or abscess."
3276,"4. Pantoprazole 40 mg po bid
5. Docusate Sodium 100 mg po bid
6. Lactulose 10 gram/15 mL Syrup 30 ML PO Q6H prn constipation.
7. Sucralfate 1 gram Tablet PO four times a day.
8. Thiamine HCl 100 mg po daily
9. Folic Acid 1 mg po daily
10. Alum-Mag Hydroxide-Simeth 200-200-20 mg Tablet 1 PO four times a
day as needed for constipation.
11. Tramadol 50 mg Tablet 1 Tablet PO twice a day.
12. Vancomycin 125 mg PO Q6H for 9 days (starting from [**2186-8-29**]).
Patient states she has only been taking methadone, omeprazole, and
motrin prn."
3277,"Lumbar Stenosis
11. Lumbar Disk Herniation
12. History of an upper GI Bleed
13. History of C.diff colitis in [**10-4**]
14. History of facial cellulitis in [**5-6**]
15. History of alcoholic pancreatitis
16. s/p sexual assault in [**2180**] while hospitalized at a
psychiatric institution
Denies a family history of GI disease or GI bleeding.
Occupation: Not currently working.
Drugs: Had previous used IV drugs but states she hasn't done so for at
least 15 years.
Tobacco: . Smokes [**4-6**] cig/day (has smoked for 30 years, but recent cut
back).
Alcohol: Was drinking 1 pint of vodka per day up until 4 weeks ago when
she cut back for her health."
3278,"Smells somewhat alcholic.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD to the madible, no LAD
Lungs: Breathing comfortably. Inspiratory crackles at the bases
bilaterally, otherwise clear.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, bowel sounds present, fluid wave present. Tenderness
to palpation throughout, worse in the center of her abdomen, but upon
percussion jumps when the RUQ is percussed. No rebound or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.
No asterixis present.
Skin: a few spider angioma over her chest
Labs / Radiology
[image002.jpg]
Labs:
Na 133 K 3."
3279,"TITLE:
Chief Complaint: Abdominal pain, continued bloody diarrhea
HPI:
Ms [**Known lastname 8339**] is a 47 yo female with pmh of Hep C with presumbed cirrhosis
and history of grade I esophageal varices, ETOH abuse, with a recent
admissions for C.diff colitis and continued abdominal pain and bloody
diarrhea admitted to the [**Hospital Unit Name 1**] due to concern for a GI bleed, also seen
to have air in her biliary tree on CT. The patient states she has had
two months of constant, diffuse abdominal pain which she describes as
an achy, bloaty feeling. Currently she states the pain is sharp over
her RUQ, but achy everywhere else."
3280,"Drank 4 drinks the day prior to admission
and a couple the day of admission. Denies a history of withdrawal.
Other: She lives with a roomate in [**Location (un) 590**].
Review of systems:
(+) Admits to a frontal HA for the last week.
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denied cough. No dysuria. Denied arthralgias.
Flowsheet Data as of [**2186-9-6**] 08:12 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36.9
C (98.5
Tcurrent: 36.9
C (98.5
HR: 84 (84 - 95) bpm
BP: 109/65(76) {96/60(68) - 109/71(78)} mmHg
RR: 13 (13 - 17) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 67 Inch
Total In:
375 mL
PO:
TF:
IVF:
Blood products:
375 mL
Total out:
0 mL
950 mL
Urine:
950 mL
NG:
Stool:
Drains:
Balance:
0 mL
-575 mL
Respiratory
SpO2: 97%
Physical Examination
General: Middle-aged woman, alert, appropriate, in no acute distress."
3281,"At that time she also reported BRBPR
as well as recent melena and was admitted. She received PRBC on
admission and then had a stable Hct without active bleeding. She
underwent an EGD on [**7-27**] which again showed varies and additionally an
esophagitis as well as portal hypertensive gastropathy and Gastric
antral vascular ectasia.
.
She was then hospitalized from [**8-4**] to [**8-7**] with abdominal pain. A CT
abd/pelvis showed pancolitis and she was found to be C. diff positive.
She was discharged on po flagyl. Per OMR documentation she did not
finish the course of flagyl and was hospitalized at [**Hospital1 3633**] in mid [**Month (only) **]
for continued abdominal pain and dark stools."
3282,"She also had an NG lavage which showed a
few small clots, but the fluid was otherwise clear w/ bile tinge.
.
On arrival to the [**Hospital Unit Name 1**] she states her abdominal pain is currently
[**6-9**]. She denies recent bowel movement.
Patient admitted from: [**Hospital1 19**] ER
History obtained from [**Hospital 15**] Medical records
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
(per recent discharge summary)
1. Methadone 40 mg po daily
2. Senna 8.6 mg 1-2 Tablets PO BID:prn constipation.
3. Bisacodyl 5 mg tab, 2 prn constipation."
3283,"She was again admitted
to [**Hospital1 19**] from [**8-22**] to [**8-29**] with persistent abdominal pain and bloody
stools. She was transfused initially and then her Hct remained stable,
although she continued to have dark stools. She was discharged on po
vanco. She was scheduled to follow up with GI for a repeat endoscopy
on [**9-1**], but missed the appointment.
.
In the ED, initial vs were: T 98.6 HR 100 BP 101/58 RR 20 Sat 96% on
RA. She was found to have a Hct of 18.1. Patient was given 40 mg IV
pantoprazole. She underwent an abd/pelvis CT which showed interval
improvement in her colitis, however there was concern for small amount
of air in her biliary tree."
3284,"The partial focality of her abdominal pain in
the RUQ makes a biliary source of her pain concerning.
- Appreciate surgery consult. Will f/u recs.
- F/u abdominal US results to look for evidence of cholelithiasis and
to assess the patency of the portal vein.
# Acute blood loss anemia/GI bleed: Most likely due to an upper source
given that she has had melena. Unlikely to be secondary to varices as
she would have a much brisker bleed and hemeatemesis. She received 1
unit PRBC in the ED.
- Will transfuse another two units of PRBC and check a post-transfusion
Hct."
3285,"Additionally, was called with concern for a
small amount of air in her biliary tree.
Assessment and Plan
47 yo female with pmh of Hep C with presumbed cirrhosis and history of
grade I esophageal varices, ETOH abuse, with a recent admissions for
C.diff colitis and continued abdominal pain and bloody diarrhea
admitted to the [**Hospital Unit Name 1**] due to concern for a GI bleed, also seen to have
air in her biliary tree on CT.
# Pneumobilia: The patient does have a history of ERCP in [**2180**],
however it is unclear that an ERCP 5 years ago could leave persistent
air in her biliary tree."
3286,"The pain gets up to [**8-10**]. The pain
occasionally goes to her back. Nothing makes it better. Was having
black stools previously, but has not had a bowel movement in two days.
She thought over the past few days her dark stool had been improving.
Admits to associated nausea, subjective fevers/chills; denies vomiting
in the last couple of months. Due to her pain she states she's had
decreased po intake. Also has generalized weakness and DOE which has
been worsening slowly. Admits to subjective fevers, chills,
palpitations, and night sweats for a week. No sick contacts. Denies
CP."
3287,"Admission Date: [**2186-9-6**] Discharge Date: [**2186-9-6**]
Date of Birth: [**2139-5-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Abdominal pain, continued bloody diarrhea
Major Surgical or Invasive Procedure:
transfusion of 1 unit of PRBC
History of Present Illness:
Ms [**Known lastname 106028**] is a 47 yo female with pmh of Hep C with presumbed
cirrhosis and history of grade I esophageal varices, ETOH abuse,
with a recent admissions for C.diff colitis and continued
abdominal pain and bloody diarrhea admitted to the [**Hospital Unit Name 153**] due to
concern for a GI bleed, also seen to have air in her biliary
tree on CT."
3288,"(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denied cough. No dysuria. Denied
arthralgias.
Past Medical History:
1. History of Cholecystitis s/p Cholecystotomy tube at [**Hospital1 336**] - 4
years ago
2. History of ampullary stenosis s/p sphincterotomy and ERCP in
[**8-4**]
3. Depression
4. Raynaud's
5. Polysubstance Abuse- Past history of IV drug use with heroin
and cocaine (none in many years). Continues to drink alcohol, up
to one pint of vodka daily, less recently. Continues to smoke
tobacco - [**12-2**] PPD
6. Hepatitis C Infection
7. Presumed Cirrhosis c/b grade 1 esophageal varices (EGD [**7-9**])"
3289,"Brief Hospital Course:
47 yo female with pmh of Hep C with presumbed cirrhosis and
history of grade I esophageal varices, ETOH abuse, with a recent
admissions for C.diff colitis and continued abdominal pain and
bloody diarrhea admitted to the [**Hospital Unit Name 153**] due to concern for a GI
bleed, also seen to have air in her biliary tree on CT.
# Pneumobilia: The patient does have a history of ERCP in [**2180**],
however it is unclear that an ERCP 5 years ago could leave
persistent air in her biliary tree. The partial focality of her
abdominal pain in the RUQ makes a biliary source of her pain
concerning."
3290,"Surgery was consulted and recommended obtaining a
RUQ US. This was done and was pending when she left AMA.
# Acute [**Year (4 digits) **] loss anemia/GI bleed: Most likely due to an upper
source given that she has had melena. Unlikely to be secondary
to varices as she would have a much brisker bleed and
hemeatemesis. She received 1 unit PRBC in the ED. Plan was to
transfuse an additional 2 units and for EGD in the am, however
she left AMA before this could be done.
The patient became very angry when she was told she was NPO.
She stated that she was extremely hungry and that she would
leave our hospital if we didn?"
3291,"Folic Acid 1 mg po daily
10. Alum-Mag Hydroxide-Simeth 200-200-20 mg Tablet 1 PO four
times a day as needed for constipation.
11. Tramadol 50 mg Tablet 1 Tablet PO twice a day.
12. Vancomycin 125 mg PO Q6H for 9 days (starting from [**2186-8-29**]).
Patient states she has only been taking methadone, omeprazole,
and motrin prn.
Discharge Medications:
Patient left against medical advice before paperwork could be
completed.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic [**Month/Day/Year **] loss anemia
Upper GI bleed
Hepatitis C cirrhosis
Pneumobilia
Alcohol abuse
Discharge Condition:
Hemodyndamically stable.
Discharge Instructions:
Patient left Against Medical Advice before paperwork could be
completed.
Followup Instructions:
Patient left Against Medical advice before paperwork could be
completed.
Completed by:[**2186-9-6**]"
3292,"Also has generalized weakness and DOE which has been
worsening slowly. Admits to subjective fevers, chills,
palpitations, and night sweats for a week. No sick contacts.
Denies CP.
.
Notably she has been admitted with concern for GI bleed multiple
times in the past 4 months. She was admitted in [**5-9**] with an
upper GI bleed. At that time she underwent an EGD which showed
3 cords of nonbleeding grade I esophageal varices. She was
transfused, her Hct remained stable and she was discharged on a
PPI to follow up with the liver clinic. She was seen in the
liver clinic on [**6-12**] and was started on nadolol."
3293,"6 Lipase 47 Albumin 3.4
WBC 5.7 Hct 18.1 Plt 313
Hct baseline in mid to high 20's
N 71.1% L 21.5% M 6.5% E 0.4%
Peripheral smear: Hypochr: 3+ Anisocy: 1+ Poiklo: 1+ Macrocy:
OCCASIONAL Microcy: OCCASIONAL Polychr: OCCASIONAL Schisto:
OCCASIONAL
Plt-Est: Normal
Images:
Abd/pelvis CT: Prelim
Interval improvement in colitis, now w/moderate fecal loading.
Cirrhotic liver with trace ascites. No acute abnormalities. No
focal collection or abscess. Additionally, was called with
concern for a small amount of air in her biliary tree.
RUQ US: read was pending when the patient left AMA"
3294,"6 HR 100 BP 101/58 RR 20 Sat
96% on RA. She was found to have a Hct of 18.1. Patient was
given 40 mg IV pantoprazole. She underwent an abd/pelvis CT
which showed interval improvement in her colitis, however there
was concern for small amount of air in her biliary tree. She
also had an NG lavage which showed a few small clots, but the
fluid was otherwise clear w/ bile tinge.
.
On arrival to the [**Hospital Unit Name 153**] she states her abdominal pain is
currently [**6-9**]. She denies recent bowel movement.
.
Review of sytems:
(+) Admits to a frontal HA for the last week."
3295,"Drank 4 drinks
the day prior to admission and a couple the day of admission.
Denies a history of withdrawal. Denies current drug use. Had
previous used IV drugs but states she hasn't done so for at
least 15 years.
Family History:
Denies a family history of GI disease or GI bleeding.
Physical Exam:
Vitals: T 98.5 P 85 BP 106/71 R 14 Sat 98% on RA
General: Middle-aged woman, alert, appropriate, in no acute
distress. Smells somewhat alcholic.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD to the madible, no LAD
Lungs: Breathing comfortably."
3296,"Per her
nurse, the nurse had been looking through her purse to identify
valuables that could be secured and found klonopin, which would
have to be removed from the room; the patient became agitated
when she was informed of this and then decided to leave AMA. I
discussed with her the risks of leaving when her [**Year (4 digits) **] counts
were so low (she had only received 1 unit of PRBC so far) and
when it was unclear if the air in her biliary tree was
clinically significant. The risks I discussed included loss of
consciousness, further bleeding, worsening clinical status and
death."
3297,"Inspiratory crackles at the bases
bilaterally, otherwise clear.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, bowel sounds present, fluid wave present.
Tenderness to palpation throughout, worse in the center of her
abdomen, but upon percussion jumps when the RUQ is percussed.
No rebound or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No asterixis present.
Skin: a few spider angioma over her chest
Pertinent Results:
Na 133 K 3.8 Cl 100 Bicarb 24 BUN 14 Cr 0.5 Glu 84
ALT 16 AST 57 AP 105 T bili 0."
3298,"The patient states she has had two months of
constant, diffuse abdominal pain which she describes as an achy,
bloaty feeling. Currently she states the pain is sharp over her
RUQ, but achy everywhere else. The pain gets up to [**8-10**]. The
pain occasionally goes to her back. Nothing makes it better.
Was having black stools previously, but has not had a bowel
movement in two days. She thought over the past few days her
dark stool had been improving. Admits to associated nausea,
subjective fevers/chills; denies vomiting in the last couple of
months. Due to her pain she states she's had decreased po
intake."
3299,"She stated she understood the risks and that she planned
to go to a different hospital to get care. She signed the AMA
form and left.
Medications on Admission:
(per recent discharge summary)
1. Methadone 40 mg po daily
2. Senna 8.6 mg 1-2 Tablets PO BID:prn constipation.
3. Bisacodyl 5 mg tab, 2 prn constipation.
4. Pantoprazole 40 mg po bid
5. Docusate Sodium 100 mg po bid
6. Lactulose 10 gram/15 mL Syrup 30 ML PO Q6H prn constipation.
7. Sucralfate 1 gram Tablet PO four times a day.
8. Thiamine HCl 100 mg po daily
9."
3300,"?????t feed her. It was explained to
her that the reason she was NPO was due to concern for an acute,
serious process in her stomach (due to the air seen in her
biliary system on CT). She stated she understood the risk of
eating while she may be bleeding and may need a procedure to her
abdomen, but she still wanted to eat. Upon discussion with our
team including our attending, we agreed to let her eat a few
crackers if she would stay. A few minutes later she declared
she wanted to leave AMA to go to another hospital."
3301,"diff positive. She was discharged on po flagyl. Per OMR
documentation she did not finish the course of flagyl and was
hospitalized at [**Hospital1 336**] in mid [**Month (only) **] for continued abdominal pain
and dark stools. She was again admitted to [**Hospital1 18**] from [**8-22**] to
[**8-29**] with persistent abdominal pain and bloody stools. She was
transfused initially and then her Hct remained stable, although
she continued to have dark stools. She was discharged on po
vanco. She was scheduled to follow up with GI for a repeat
endoscopy on [**9-1**], but missed the appointment.
.
In the ED, initial vs were: T 98."
3302,"8. Chronic Anemia
9. Chronic Abdominal Pain
10. Lumbar Stenosis
11. Lumbar Disk Herniation
12. History of an upper GI Bleed
13. History of C.diff colitis in [**10-4**]
14. History of facial cellulitis in [**5-6**]
15. History of alcoholic pancreatitis
16. s/p sexual assault in [**2180**] while hospitalized at a
psychiatric institution
Social History:
She lives with a roomate in [**Location (un) **]. She is not currently
working. Smokes [**4-6**] cig/day (has smoked for 30 years, but
recent cut back). Was drinking 1 pint of vodka per day up until
4 weeks ago when she cut back for her health."
3303,"On her follow
up visit on [**7-24**] her Hct was found to be decreased to 24 from 35
in [**Month (only) **]. At that time she also reported BRBPR as well as recent
melena and was admitted. She received PRBC on admission and
then had a stable Hct without active bleeding. She underwent an
EGD on [**7-27**] which again showed varies and additionally an
esophagitis as well as portal hypertensive gastropathy and
Gastric antral vascular ectasia.
.
She was then hospitalized from [**8-4**] to [**8-7**] with abdominal pain.
A CT abd/pelvis showed pancolitis and she was found to be C."
3304,"Chest X-ray did not have any acute processes or changes.
On arrival to the MICU, patient's vital signs were T 98.0 F, HR
93, BP 146/84, and oxygen saturation 99% in room air.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Oncologic History (include past therapies, surgeries,
etc):(1) [**12/2090**] Diagnosed with Breast Cancer on left breast and
had a lumpectomy and pathology showed ER+, Progesterone neg,
HER2/Neu and treated with Adriamycin, Cytoxan and Taxol followed
by radiation and tamoxifen,
(2) [**2098**] Diagnosed with metastatic breast cancer to the lungs,
liver, [**Year (4 digits) 500**] and rib and started on Taxol, bevacizumab, Xeloda
and Lupron,
(3) [**5-/2104**] Had an MI and bevacizumab was stopped."
3305,"Past Medical History:
Recurrent UTI's
Hypertension
Proteinuria (d/t Avastin)
Immunocompromised state
Coronary artery disease, s/p BMS to LCx
Hyperlipidemia
Headaches
Social History:
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
-Married with 4 children, husband (lawyer) is HCP
-Architect by trade
Family History:
Mother- lung cancer. Father- prostate and [**Name2 (NI) 499**] cancer. Paternal
GM- breast cancer. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION EXAMINATION:
Vital Signs: T 98.0 F, HR 93, BP 146/84, and O2 saturation 99%
in room air
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
Cardiovascular: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding"
3306,"Pt was
transitioned from Morphine IV to Morphine Sulfate IR 15-30 mg PO
Q4H in preparation for discharge. This oral morphine seemed to
control her pain well and pt was satisfied with pain control
regimen.
(3) Leukocytosis: Patient received neulasta [**8-8**]. Likely
secondary to this. No evidence of infection (unchanged chest
X-ray, normal CSF, normal urinalysis, denies fever, chills, or
nightsweat). Patient's oncologist informed who believes this is
most likely secondary to Neulasta and dexamethasone. This was
trended.
(4) Metastatic Breast Cancer: Patient is s/p lumpectomy with
chemo and radiation therapy. Metastatic disease to lung, [**Month/Year (2) 500**],
brain, leptomeningeal disease."
3307,"Current chemo regimen includes
intrathecal cytarabine, zoledronic acid, paclitaxel,
bevacixumab. Outpatient oncologist was informed. Dexamethasone
taper from CyberKnife to cerebellar lesions was continued; this
should be 2mg [**2105-8-12**], 1mg [**2105-8-13**], 0.5mg [**2105-8-14**], then stop.
Chemotherapeutic regimen was held while hospitalized which she
will resume as directed by primary oncologist.
(5) CAD s/p MI with Stent:
- continued ASA, crestor
- Plavix on hold for possible blood patch, this was restarted as
the pain service does not want to pursue a blood patch.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR."
3308,"1. Clopidogrel 75 mg PO DAILY
2. Cyclobenzaprine 10 mg PO BID:PRN pain
3. Gabapentin 600 mg PO TID
4. Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR Monday, Wednesday,
Friday
5. traZODONE 50 mg PO HS:PRN insomnia
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Excedrin Migraine *NF* (aspirin-acetaminophen-caffeine)
250-250-65 mg Oral [**Hospital1 **]
8. calcium *NF* unknown Oral daily
9. Dexamethasone 2 mg PO DAILY Duration: 3 Days Start: In am
2 mg on [**2105-8-12**]
1 mg on [**2105-8-13**]
0.5 mg on [**2105-8-14**] then STOP
Tapered dose - DOWN"
3309,"She has a slight increasein right palpebral
fissure and closure of her left eyelid is slightly weaker than
the right. Facial sensation is intact bilaterally. Her hearing
is intact bilaterally. Her tongue is midline. Palate goes up
in the midline. Sternocleidomastoids and upper trapezius are
strong. Motor Examination: She does not have a drift. Her
muscle strengths are [**4-18**] at all muscle groups, except for
weakness in the flexor digitorum of the right foot at 4/5. Her
muscle tone is normal. Her reflexes are absent throughout. Her
ankle jerks are absent. Her right toe is down while the left is
up."
3310,"0* Hct-34.0*
MCV-111* MCH-35.8* MCHC-32.2 RDW-17.0* Plt Ct-160
[**2105-8-13**] 07:00AM BLOOD WBC-12.0* RBC-2.96* Hgb-10.6* Hct-31.4*
MCV-106* MCH-35.6* MCHC-33.7 RDW-17.4* Plt Ct-191
[**2105-8-14**] 05:20AM BLOOD WBC-17.9* RBC-2.95* Hgb-10.4* Hct-31.2*
MCV-106* MCH-35.2* MCHC-33.2 RDW-17.3* Plt Ct-193
[**2105-8-12**] 06:00AM BLOOD Neuts-94.1* Lymphs-3.0* Monos-2.1 Eos-0.5
Baso-0."
3311,"You were admitted because of loss of consciousness. You
received many tests and the good news is that you had no
documented seizure activity.
You will require close follow up with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 84166**] to refill the presciption on oral
morphine, the pain medication started during this admission. Do
not drink alcohol with this medication. Do not operate heavy
machinary or drive while taking this medication. You will also
have follow-up with your oncologists, Dr. [**Last Name (STitle) 724**] and Dr. [**First Name (STitle) **].
Please see below for appointments that have already been made
for you."
3312,"5 Na-133
K-5.5* Cl-99 HCO3-21* AnGap-19
[**2105-8-10**] 04:50PM BLOOD Prolact-7.7
[**2105-8-10**] 08:12PM BLOOD Lactate-1.3
[**2105-8-10**] 04:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2105-8-10**] 04:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2105-8-10**] 04:35PM URINE UCG-NEGATIVE
[**2105-8-10**] 08:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2* Polys-10
Lymphs-90 Monos-0
[**2105-8-10**] 08:00PM CEREBROSPINAL FLUID (CSF) TotProt-70*
Glucose-61"
3313,"3
Brief Hospital Course:
[**Known firstname **] [**First Name8 (NamePattern2) 7635**] [**Known lastname 54865**] is a 54-year-old woman with breast
cancer and extensive mets s/p lumpectomy, chemoterhapy and
radiation therapy with intrathecal liposomal cytarabine and
CyberKnife radiosurgery treatment for leptomeningeal disease
admitted after loss of consciousness concerning for seizure.
(1) Syncope: Patient presented s/p LOC with fall. Differential
diagnosis includes seizure, syncope, infection, intracranial
mass. Description of episode, LOC without immediate recovery is
more consistent with seizure than syncope. Pertinent negatives
include normal CSF, CT scan unchanged without any acute bleed or
midline shift. Episode seems less likely to be syncope given
association with headache, however she was placed on telemetry."
3314,"No events were found. She had orthostatics which showed an
18mmg difference between systolic blood pressures standing and
sitting, and was given a fluid bolus of 1L. EEG for 20 minute
showed short runs of sharp waves concerning for seizure
activity, and so 24-hour EEG was recommended. Urine and blood
cultures were sent. The 24 hour EEG study was undertaken and no
seizure activity was noted. Patient denied any seizure activity
or loss of consciousness. She was started on valproic Acid to
prevent further seizures which she will take once discharged.
(2) Headache: Patient with 1-2 months of headaches that are
increasing in frequency and now associated with loss of
consciousness and vomiting."
3315,"MICROBIOLOGY:
Blood cultures [**2105-8-10**]:
Urine culture [**2105-8-10**]:
CSF culture [**2105-8-10**]: pending, gram stain negative
IMAGING:
CT Head w/o contrast [**2105-8-10**]:
1. No acute intracranial process.
2. Unchanged mild left mastoid air cell opacification.
Chest X-Ray [**2105-8-10**]:
No acute intrathoracic process.
Other labs:
[**2105-8-11**] 04:30AM BLOOD WBC-56.5* RBC-3.17* Hgb-11.3* Hct-33.1*
MCV-105* MCH-35.7* MCHC-34.1 RDW-17.4* Plt Ct-155
[**2105-8-12**] 06:00AM BLOOD WBC-20.9*# RBC-3.06* Hgb-11."
3316,"Etiology unclear. Differential
includes metastatic disease, migraine, tension, post LP,
medication side effect. Patient has a history of migraine
headaches prior to diagnosis of breast cancer. CT scan ruled
out acute bleed or midline shift. CSF with no evidence of
infection. She was started on morphine 2-5 mg q 4hrs prn pain
with continuation of gabapentin prn and cyclobenzaprine as
needed. Pain service was consulted who recommended no blood
patch as was considered a possibility as an outpatient. They
did recommend IV caffeine, however, this is not available
currently, as well as continuing morphine and encouraging good
fluid intake, which minimalization of position changes."
3317,"Sensory examination is intact to touch and proprioception;
there is no glove-stocking or radicular pattern of sensation
loss. Coordination examination does not reveal appendicular
dysmetria. Gait and stance are deferred.
DISCHARGE EXAMINATION:
Vital Signs: Tm 97.6 F, BP 136/76, HR 82, RR 20, O2 saturation
100% in room air
General: NAD, resting comfortably in bed
Skin: Warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
Cardiovascular: RRR, S1/S2, no murmers, gallops, or rubs
Lungs: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
Abdomen: Non-distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Extremities: Moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
Pulses: 2+ DP pulses bilaterally"
3318,"[**First Name8 (NamePattern2) **]
[**Name (STitle) **]
(12) MRI of the brain on [**2105-4-27**] showed a mass at the right
Meckel's cave and this would explain the numbness and pain at
the V2 and V3 distribution of her trigeminal nerve on the right
side of her face. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] did CyberKnife radiosurgery
procedure on [**2105-5-6**] to [**2105-5-8**].
(12) Cardiac: [**2104-6-14**] had a mid-LAD MI. She underwent cardiac
catheterization on [**2105-6-16**] that revealed 2 vessel CAD; a stent
to one vessel and medications adjusted.
CURRENT TREATMENT PLAN:Taxol D1, D15, Avastin D1 and D15, lupron
D15, faslodex D15, Depocyt (liposomal cytarabine) every two
weeks, Xeloda 2 weeks with 1 week off, and zometa every 9 weeks."
3319,"(4) [**5-/2104**] Developed left hip pain
(5) [**2105-2-16**] Pelvic and lumbar MRI showed possible
leptomeningeal disease manifesting as thickened cauda equina,
(6) lumbar puncture on [**2105-2-20**] that showed positive cytology
for malignant cells,
(7) head MRI on [**2105-2-23**] that was normal,
(8) MRI of the cervical and thoracic spine showing
leptomeningeal metastasis at T1-2 level,
(9) started external beam irradiation to C1-T2 and T12-sacrum
on [**2105-2-26**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**],
(10) lumbar puncture on [**2105-2-20**] showed 8 WBC, 215 RBC, 119
protein, 35 glucose, and postive cytology for malignant cells,
and
(11) placement of Ommaya reservoir on [**2105-3-18**] by Dr."
3320,"Admission Date: [**2105-8-10**] Discharge Date: [**2105-8-14**]
Date of Birth: [**2051-8-1**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Lumbar puncture on [**2105-8-10**]
History of Present Illness:
[**Known firstname **] [**First Name8 (NamePattern2) 7635**] [**Known lastname 54865**] is a 54-year-old woman with breast
cancer and extensive metastasess (liver, lung, [**Last Name (LF) 500**], [**First Name3 (LF) **],
leptomeningeal), s/p lumpectomy, chemoterhapy and radiation
therapy with intrathecal liposomal cytarabine, and CyberKnife
radiosurgery treatment. Her current chemotherapy regimen
includes intrathecal liposomal cytarabine, zoledronic acid,
paclitaxel, and bevacixumab."
3321,"Genitourinary: No foley
Extremities: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neurological Examination: Her Karnofsky Performance Score is
60. She is awake, alert, and oriented times 3. She is able to
respond to questions appropriately. Her language is fluent with
good comprehension. Her recent recall is good. Cranial Nerve
Examination: Her pupils are equal and reactive to light, 4 mm
to 2 mm on the right and 3 mm to 2 mm on the left. Extraocular
movements are full; there is a few beats of possibly physiologic
nystagmus on right gaze. Visual fields are full to
confrontation."
3322,"They were associated with
changes in peripheral vision, and posterior occipital pain and
neck pain with left sided trigeminal pain and tingling.
The patient denies any fever, chills, nightsweat, diarrhea,
chest pain, palpitations, cough, dyspnea, frequency, urinary
urgency, or sick contacts.
In the ED, initial vital signs were: T 97.8 F, HR 86, BP 121/69,
RR 14, and oxygen saturation 99% in room air. She had another
episode in the ED where she was unresponsive briefly and then
recovered. Laboratory data were notable for WBC 65, lactate
1.3, unremarkable CSF profile, and normal urinalysis. Head CT
preliminary reported no acute intracranial hemorrhage, edema,
mass, mass effect, or large vascular territorial infarction."
3323,"calcium *NF* 0 unknown ORAL DAILY
15. Aspirin 81 mg PO DAILY
16. Morphine Sulfate IR 15-30 mg PO Q4H:PRN pain RX *morphine 15
mg [**12-15**] tablet(s) by mouth every 4 hours Disp #*270 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Loss of consciousness
Secondary diagnosis:
Metastatic breast cancer
Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 54865**],
It has been a pleasure taking care of you here at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]."
3324,"Medication changes have been made during this admission. Please
see the accompanying chart regarding medication changes.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) 6382**] [**Last Name (NamePattern1) 84166**]
When: Thursday [**2105-8-20**] at 10:00 AM
Address: [**Apartment Address(1) 107061**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2105-8-21**] at 11:00 AM
With: PADDY [**Name8 (MD) **], RN [**Telephone/Fax (1) 9644**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2105-8-21**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 **] MRI (MOBILE)
When: MONDAY [**2105-8-31**] at 11:55 AM
With: MRI [**Telephone/Fax (1) 590**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: HEMATOLOGY/ONCOLOGY-SC
When: [**2105-9-4**] at 10:30a
With: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Building: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage"
3325,"Discharge Medications:
1. Cyclobenzaprine 10 mg PO BID:PRN pain
2. Dexamethasone 4 mg PO BID please give at 0800 and 1400
RX *dexamethasone 4 mg 1 (One) tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. Gabapentin 600 mg PO TID
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR Monday, Wednesday,
Friday
6. traZODONE 50 mg PO HS:PRN insomnia
7. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace]
100 mg 1 (One) capsule(s) by mouth Twice daily Disp #*60 Capsule
Refills:*0
8. Famotidine 20 mg PO Q12H RX *famotidine 20 mg 1 (One)
tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0
9."
3326,"Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1
(One) tablet(s) by mouth every eight hours Disp #*90 Tablet
Refills:*0
10. Senna 1 TAB PO BID:PRN constipation RX *sennosides [senna]
8.6 mg 1 (One) tablet by mouth twice daily Disp #*60 Capsule
Refills:*0
11. Valproic Acid 250 mg PO Q8H RX *valproic acid (as sodium
salt) 250 mg/5 mL (5 mL) 5 Milliliter by mouth every eight hours
Disp #*450 Milliliter Refills:*0
12. Clopidogrel 75 mg PO DAILY
13. Excedrin Migraine *NF* (aspirin-acetaminophen-caffeine) 250
mg ORAL [**Hospital1 **]
14."
3327,"Neurological Examination: CN II-XII intact, sensation decreased
in lower extremity b/l, 5/5 strength in upper and lower
extremity
Pertinent Results:
ADMISSION LABS:
[**2105-8-10**] 04:50PM BLOOD WBC-67.0*# RBC-3.11* Hgb-11.4* Hct-33.2*
MCV-107* MCH-36.8* MCHC-34.5 RDW-17.4* Plt Ct-142*
[**2105-8-10**] 04:50PM BLOOD Neuts-95* Bands-5 Lymphs-0* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2105-8-10**] 04:50PM BLOOD PT-11.3 PTT-27.1 INR(PT)-1.0
[**2105-8-10**] 04:50PM BLOOD Glucose-104* UreaN-14 Creat-0."
3328,"Patient presents after having
episode of loss of consciousness. She was at home in New
[**Location (un) **] when she felt a headache and dizziness. She decided
to lay down in bed and her husband then heard a bang and found
her on the floor, she was confused for 3 to 4 minutes and had
two episodes of vomiting and then recovered. Patient has been
having severe headaches over the past 1-2 months that are
thought to be due in part to bevacizumab, liposomal cytarabine,
or both. The headaches originally came on with changes in
position, however over the past two days they have come on every
30 minutes and last 2-5 minutes."
3329,"Potential for nutrition risk. Patient being monitored. Current
intervention if any, listed below:
Comments:
42M w/remote h/o lap chole c/b common hepatic biliary stricture c/b PTC
external biliary drain into R anterior biliary duct [**11-19**] and R
lobectomy [**12-22**].
Pt on regular diet, tol well.
If po
s decline, pls c/s for recs on nutrition support.
Pge w/ questions/concerns #[**Numeric Identifier 526**]
15:24"
3330,"Admission Date: [**2161-12-22**] Discharge Date: [**2161-12-31**]
Date of Birth: [**2119-9-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Right hepatic duct stricture.
Major Surgical or Invasive Procedure:
[**2161-12-25**] right lobectomy for common hepatic stricture
History of Present Illness:
42M with remote h/o lap chole previously p/w [**Month/Day/Year 5283**] pain, s/p ERCP
[**11-18**] showing R hepatic biliary stricture, thougt to be
postsurgical; s/p PTC external biliary drain into R anterior
biliary duct [**11-19**], PTC repositioned [**11-30**]."
3331,"Bile cultures grew
out sparse Lactobacillus. Discharged from hospital [**12-3**] on 21 d
course of Augmentin. Returned [**12-10**] with diarrhea, [**Month/Year (2) 5283**] abd pain,
nausea, po intolerance with 7 pound wt loss
Past Medical History:
Bile duct stricture
depression and anxiety.
ERCP [**2161-11-18**] showing R hepatic biliary stricture
PTC external biliary drain into R anterior biliary duct
[**2161-11-19**], PTC repositioned [**2161-11-30**]
chronic back pain s/p fall down stairs 1 yr prior
PSH: lap chole [**2145**], L4-5/L5-S1 fusion [**10-5**]
[**2161-12-22**] R hepatic lobectomy with cholangiogram for R duct
biliary stricture, benign"
3332,"Social History:
The patient's relatives are from [**Name (NI) 11660**]
islands. He lives in RI. He is not currently working. He does
smoke cigarettes
one pack per day for 13 years. He does not consume alcohol. He
is married. His wife has suffered from Lupus for many years and
recently completed a lengthy chemotherapy course. He and his
wife have been financially stressed. Has been staying with his
daughter in [**Name (NI) 1474**], MA
Family History:
Family history is significant for cancer and diabetes in his
mother and father as well. There is no family history of spinal
disorders."
3333,"6 RBC-2.49* Hgb-8.0* Hct-22.9*
MCV-92 MCH-32.1* MCHC-34.9 RDW-13.5 Plt Ct-307
[**2161-12-30**] 06:53AM BLOOD WBC-4.6 RBC-2.53* Hgb-8.1* Hct-24.2*
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.8 Plt Ct-363
[**2161-12-30**] 06:53AM BLOOD Glucose-105 UreaN-6 Creat-0.6 Na-142
K-3.8 Cl-105 HCO3-32 AnGap-9
Brief Hospital Course:
On [**2161-12-22**] he underwent right hepatic lobectomy with
cholangiogram for right hepatic duct stricture. Surgeon was Dr."
3334,"[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see operative report for details. Postop,
he was sent to the SICU given excessive pain management needs.
APS followed him. He was treated with vanco and zosyn for 24
hours then remained afebrile until pod 2 when he had a temp of
101.2. This was attributed to atelectasis. He was encouraged to
use the incentive spirometer and was assisted oob. Temperature
decreased. He was transferred out of the SICU on [**12-26**].
Bile was noted in his JP. On [**12-28**], JP fluid bilirubin was 3.1.
LFTs improved with the exception of the alk phos which which
increase slightly from 96 to 123."
3335,"Discharge Disposition:
Home
Discharge Diagnosis:
Biliary stricture
acute and chronic pain
Discharge Condition:
Good
Discharge Instructions:
1. Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if fever,
chills, nausea, vomiting, worsening abdominal pain, jaundice
(yellowing of whites of eyes or skin)or diarrhea/constipation
2. No driving while taking pain medication
3. No heavy lifting for four weeks
4. You may shower, but no baths.
5. Empty and record volume of fluid from drain.
Followup Instructions:
Please call Dr.[**Name (NI) 670**] office to schedule a follow-up
appointment.
Please also follow up with your primary care doctor.
Completed by:[**2162-1-1**]"
3336,"7 cm.
A lumen is identified within the specimen. The specimen is
bisected and frozen for intraoperative frozen section diagnosis.
Frozen section diagnosis by Dr. [**Last Name (STitle) **] reads: ""Right hepatic duct:
Bile duct with edema, mild chronic and acute inflammation, and
focal epithelial hyperplasia with mild atypia. No definitive
carcinoma seen, final diagnosis pending permanent sections."" The
specimen is entirely submitted as follows: A = frozen section
remnant, B = remaining tissue.
Part 2 is additionally labeled ""liver, right lobe."" It consists
of a right lobe of liver weighing 772 grams and measuring 18 x
12.2 x 6 cm. The anterior and superior and posterior surface of
this right liver lobe is smooth and peritoneal with a rough area
measuring 1 x 1 cm near the lateral edge which is consistent
with cautery."
3337,"His diet was advanced slowly and tolerated. He was drinking [**3-1**]
Ensures per day.He was ambulatory and vital signs remained
stable. Of note, his hct slowly trended down from 35.3 on pod 0
to 22.9 on pod 6. This stablized at 24 on pod 7 and 8.
Incision was clean, dry and intact without redness. JP drainage
averaged 200cc of bile tinged fluid. He was discharged with the
JP and was instructed to record volume of outputs. He was
declared safe for discharge home with a st. cane by PT.
Pathology was as follows: I. Right hepatic duct (A-B):"
3338,"Pertinent Results:
[**2161-12-22**] 04:58PM BLOOD WBC-15.6*# RBC-3.85* Hgb-12.2* Hct-35.3*
MCV-92 MCH-31.7 MCHC-34.5 RDW-13.5 Plt Ct-391
[**2161-12-23**] 03:38AM BLOOD WBC-12.9* RBC-3.72* Hgb-11.7* Hct-35.1*
MCV-95 MCH-31.5 MCHC-33.3 RDW-13.3 Plt Ct-291
[**2161-12-25**] 04:11AM BLOOD WBC-8.8 RBC-2.84* Hgb-9.2* Hct-27.1*
MCV-95 MCH-32.5* MCHC-34.1 RDW-13.4 Plt Ct-190
[**2161-12-28**] 05:30AM BLOOD WBC-4."
3339,"6. Morphine 30 mg Tablet Sustained Release Sig: Three (3) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*42 Tablet Sustained Release(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Diazepam 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours)
as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*"
3340,"His complaint posopt op was
pain control. Initially postop, this was controlled with an
epidural that was ineffective. The epidural meds were then split
with a dilaudid pca and a bupivicaine epidural that was later
discontinued on pod 3. Oxycontin was then added at 45mb [**Hospital1 **] and
prn oxycodone. This was ineffective in controlling his pain.
Oxycontin was switched to MS contin 90mg [**Hospital1 **] with oxycodone
breakthru. PCA was discontinued. He required supplemental break
thru iv dilaudid for [**Hospital1 5283**] pain.
On [**12-29**], an abdominal CT was done to evaluate his pain. This
showed a small-to-moderate amount of fluid about the liver and
at the resection bed with free air presumed to be post-surgical."
3341,"Medications on Admission:
tylenol, colace, valium 1 [**Hospital1 **], nicotine patch, paxil 30', senna,
MS Contin 30mg q 12 hours, oxycodone 2-3 tabs q 4 hours prn
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO q8H PRN as
needed for pain."
3342,"1. Chronic inflammation with focal glandular regeneration and
fibrosis.
2. No tumor.
II. Liver, right lobe (C-J):
1. Area of chronic inflammation with bile duct epithelial
regeneration and marked fibrosis.
2. No tumor.
3. Moderate steatosis and mild portal mononuclear cell
inflammation, without intracellular hyalin.
Clinical: Bile duct stricture, pain.
Gross: The specimen is received fresh from the O.R. in two
parts, both labeled with ""[**Known lastname 16651**], [**Known firstname **]"" and the medical
record number.
Part 1 is additionally labeled ""right hepatic duct."" It consists
of one piece of brown soft tissue measuring 1.0 x 0.8 x 0."
3343,"There is a rough surface on the medial edge of the
specimen which measures 14 x 7 cm and has cautery marks. There
are associated staples throughout this rough edge and there are
no discernable structures. A portion of this area is inked in
black at the potential margin. The specimen is serially
sectioned medially to laterally at 5 mm intervals to reveal a
surpentuous white area which contains a tubular structure. This
area measures 4.5 x 3 cm and is firm. The specimen is
represented as follows; C-D = shaved inked margin, E-I =
representation of white firm area inferior to superior, J =
normal liver parenchyma."
3344,"He was given on ceftriaxone, levo
(vanco ordered but not received in ED). He was given tylenol for
fever. VS prior to transfer were T: 101.4, 91, RR 50, BP:
114/60, 98% on trach mask.
.
On arrival to the MICU, patient was tachypneic.
Past Medical History:
- Bilateral PEs on coumadin (diagnosed [**2176-11-25**])
-Subarchnoid hemorrhage [**1-17**] aneurysm and s/p VP shunt placement,
tracheostomy and PEG placement
-Hyptertension
-Hyperlipidemia
-TIA
-? Prior thalamic bleed
Social History:
widowed, lives in rehab, has 2 adult daughters
Family History:
non-contributory
Physical Exam:
Admission:
Vitals: T: 97 BP: 118/44 P: 91 R: 31 18 O2: 97% onm 50% trach
mask
General: trach in place, opens eyes occasionally, not following
commands
HEENT: whitish plaque over tongue, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: tachypneic, clear to auscultation bilaterally, no
wheezes, rales, ronchi, sl."
3345,"Active Issues:
# Healthcare Associated Pneumonia:
Likely secondary to aspiration event from tube feeds. He was
initially started on vanco, cefepime and levofloxacin (day
1=[**12-9**]). Levofloxacin was stopped [**12-10**], and he will be
continued on vancomycin and cefepime through PICC line for total
8 day course, through [**2176-12-17**]. Vanc trough on [**12-11**] was 16.
PICC line can be d/c'd once IV antibiotics are completed. (Of
note, only received 1 dose of levofloxacin due to low suspicion
for resistant GNR infection. If pt worsens after discharge
would recommend restarting levofloxacin for double coverage.)
He was evaluated by speech & [**Last Name (LF) **], [**First Name3 (LF) **] family request, who
confirms that patient should remain NPO, everything per G-tube."
3346,"# Multiple Pulmonary Emboli:
Patient had RUL,RLL, LUL and left lingula lobar and segmental
pulmonary emboli at last hospitalization 12/12-19/11 and was
started on coumadin with lovenox bridge. INR supratherapeutic on
admission. He was given 5 mg vitamin K to lower INR when it
peaked at 7. Elevated INR likely related to metronidazole and
levofloxacin use. He was restarted on warfarin dose 2.5mg on
[**2176-12-11**], and his INR on discharge was 2.3. His INR should be
monitored frequently while on metronidazole (see attached
sheet).
# C. diff:
Diagnosed [**12-2**] at rehab and started on oral metronidazole which
was continued during this admission."
3347,"No further diarrhea by
time of admission here on [**12-8**]. He should continue
metronidazole 500mg Q8 hours until 2 weeks after completion of
IV antibiotics for HCAP (until [**1-1**]).
# ARF:
Presented with acute renal failure (creatinine elevated to 1.1
from baseline 0.5), likely prerenal [**1-17**] infection, which
resolved with hydration. On discharge his creatinine was 0.4.
His losartan was held during hospitalization and should be
restarted on discharge.
# UTI: UA consistent with UTI. Foley was placed during admission
[**10/2176**], and family understands the benefit in setting of sacral
ulcers. He was treated with vancomycin and cefepime as above for
pneumonia."
3348,"Chronic Issues:
# Hx SAH: Patient was admitted on [**10-28**] w SAH and IVH now s/p
ACOM coiling, VP shunt placement, tracheostomy and PEG
placement. Had repeat MRI/MRA per neurosurg recs, will be
contact[**Name (NI) **] by Dr. [**First Name (STitle) **] (neurosurg) as outpatient regarding
these results.
# Hypertension: Pt's home losartan held during hospitalization
for ARF, should be restarted on discharge.
Transitional issues:
- INR should be monitored closely while on metronidazole (was
supratherapeutic on admission and warfarin held, restarted
[**12-11**])
- Would recheck WBC if respiratory status worsens, if increasing
consider restarting levofloxacin
- Should continue IV vanc/cefepime until [**12-18**], can d/c PICC once
antibiotic course complete
- Should continue PO metronidazole until 2 weeks after
completing IV antibiotics for c diff infection
- Dr."
3349,"[**First Name (STitle) **] (neurosurgery) will contact patient as outpatient
with results of MRI. If he is not contact[**Name (NI) **] within a few days,
please contact his office at ([**Telephone/Fax (1) 88**].
- Pt maintained DNR/DNI status throughout hospitalization
Medications on Admission:
Vitamin D3 800 units PO DAILY (Daily).
Calcium carbonate 200 mg calcium (500 mg) PO TID (3 times a
day).
Albuterol nebs Q6H prn tachypnea
Chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]
Esomeprazole 40 mg po daily
Acetaminophen 650 mg PO Q6H as needed for pain or fever.
Multivitamin
Warfarin
Losartan 50 mg po once a day
Metronidazole 500 mg po q8h (started [**12-2**])"
3350,"10. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
[**Month/Day/Year **]: One (1) Capsule, Delayed Release(E.C.) PO once a day.
11. multivitamin Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
12. losartan 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 8**]
Discharge Diagnosis:
Hospital-acquired pneumonia
Urinary tract infection
Clostridium difficile infection
Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to [**Hospital1 18**] because of pneumonia. You were
started on IV antibiotics, which you should continue at your
rehab facility until [**12-18**]."
3351,"IMPRESSION:
1. Decreased intraventricular hemorrhage.
2. Resolved subarachnoid hemorrhage. No new hemorrhage.
3. Unchanged ventriculomegaly with a right frontal approach
ventriculostomy
catheter.
4. Bifrontal ACA distribution infarcts superimposed on chronic
microvascular
ischemic changes within the periventricular white matter.
CT Chest [**2176-12-8**]
TECHNIQUE: MDCT-acquired 5-mm axial images of the chest were
obtained prior to and following the uneventful administration of
100 cc of intravenous contrast. Coronal and sagittal
reformations were performed at 2-mm slice thickness. Additional
right and left oblique reconstructions were performed for
further evaluation of the pulmonary vasculature.
FINDINGS: The thyroid is normal. The patient is status post
tracheostomy
(2:28)."
3352,"The ventricles are enlarged though stable in size.
There has been interval decrease in blood products seen layering
posteriorly within the occipital horns of lateral ventricles
(2:16). Previously seen subarachnoid hemorhage no longer
visualized. No acute hemorrhage or large vascular territorial
infarction is seen.
Focal hypodensities along the periventricular white matter
(2:20, 21) and
within a large area along the ACA territory bilaterally (2:10)
are unchanged, compatible with encephalomalacia and chronic
microvascular
ischemic disease.
There is no acute fracture. A large scalp lipoma overlying the
left calvarium (2:19) is again seen. There is mild mucosal
thickening within the right ethmoid air cells."
3353,"Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
2. acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. metronidazole 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q8H (every
8 hours) for 19 days: Take until 2 weeks after completion of IV
antibiotics (until [**1-1**]).
4. warfarin 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Once Daily at 4
PM."
3354,"diminished at bilateral bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: not following commands, withdrawing to pain
Pertinent Results:
Admission labs:
[**2176-12-8**] 09:00PM BLOOD WBC-14.0*# RBC-4.03*# Hgb-12.5*#
Hct-37.8*# MCV-94# MCH-31.0 MCHC-33.1 RDW-14.0 Plt Ct-457*#
[**2176-12-8**] 09:00PM BLOOD Neuts-85.2* Lymphs-9.0* Monos-5.3 Eos-0.3
Baso-0.2
[**2176-12-8**] 09:00PM BLOOD PT-54."
3355,"5. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Year (2) **]: 1000 (1000) mg
Intravenous Q 12H (Every 12 Hours) for 5 days: Continue until
[**2176-12-17**].
6. cefepime 2 gram Recon Soln [**Month/Day/Year **]: Two (2) gram Injection Q12H
(every 12 hours) for 5 days: Continue until [**2176-12-17**].
7. Vitamin D-3 400 unit Capsule [**Month/Day/Year **]: Two (2) Capsule PO once a
day.
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Month/Day/Year **]: One (1) Tablet, Chewable PO three times a day.
9. chlorhexidine gluconate 0.12 % Mouthwash [**Month/Day/Year **]: Fifteen (15) mL
Mucous membrane twice a day."
3356,"A ventriculoperitoneal shunt transverses along the right
chest wall (2:31).
The heart is mildly enlarged. There is no pericardial effusion.
Moderate
atherosclerotic calcifications are seen throughout the thoracic
aorta which is normal in caliber. No intramural or intramural
hematoma is detected. There is no dissection.
Previously seen bilateral pulmonary emboli are no longer
visualized to the
subsegmental levels, although evaluation of the lower segmental
and
subsegmental branches is limited due to patient motion.
There is persistent moderate right basilar atelectasis with air
bronchograms (3:56, 58); an early consolidation in this region
cannot be excluded. A trace right pleural effusion is decreased
in size."
3357,"A blood gas done at rehab showed pH 7.52, CO2, 30,
O2 76. INR was 3.8 on coumadin which was held today.
In the ED, initial VS were: 98.8 94 116/78 20 96%, RR ranging
from 30s to 50s. Physical exam was notable for mental status
that was not responsive to voice but withdrawing to pain, 2+
reflexes, EOMI, PERRL. Lungs were distant but diffuslely CTAB in
setting of tachypnea. Labs were signifcant for leukocytosis to
14, lactate 2.2, INR 5.5. CT head showed no new ICH. CTA chest
showed decreased clot burden, new patchy infiltrates on left,
stable opacities on the right."
3358,"[**First Name (STitle) **] within the
next few days regarding these results. If you do not hear from
Dr. [**First Name (STitle) **] or his staff, please contact his office at ([**Telephone/Fax (1) 18865**]. It was a pleasure taking care of you at [**Hospital1 18**] and we
wish you a speedy recovery.
Followup Instructions:
You will be contact[**Name (NI) **] by Dr. [**First Name (STitle) **] (neurosurgery) regarding the
results of your brain MRI. At this time you do not need to
follow up in his clinic. If you do not hear from Dr. [**First Name (STitle) **] or
his staff, please contact his office at ([**Telephone/Fax (1) 88**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]"
3359,"9* PTT-51.8* INR(PT)-5.5*
[**2176-12-8**] 09:00PM BLOOD Glucose-159* UreaN-55* Creat-1.1 Na-138
K-4.4 Cl-105 HCO3-24 AnGap-13
[**2176-12-8**] 09:00PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
[**2176-12-8**] 09:16PM BLOOD pO2-86 pCO2-31* pH-7.50* calTCO2-25 Base
XS-1 Comment-GREEN TOP
[**2176-12-8**] 09:16PM BLOOD Lactate-2.2*
CT Head [**2176-12-8**]
FINDINGS: The patient is status post ACOM aneurysm coiling. A
right frontal approach ventriculostomy catheter terminates
within the anterior [**Doctor Last Name 534**] of the right lateral ventricle,
unchanged in position in comparison to [**2176-11-27**]
examination."
3360,"Scattered opacity is new in the left lower lobe
posteriorly(3:52), concerning for aspiration and/or early
pneumonia. The left upper lobe remains clear. There is no
pneumothorax.
OSSEOUS STRUCTURES: There is no acute fracture. No concerning
blastic or
lytic lesions are identified.
IMPRESSION:
1. Interval resolutino of pulmonary emboli.
2. New left lower lobe opacity concerning for pneumonia or
aspiration.
3. Interval decrease in trace right pleural effusion.
Brief Hospital Course:
Primary Reason for Hospitalization:
84M with recent admission for SAH secondary to aneursym s/p
coiling, intraventricular shunt, trach and PEG ([**Date range (1) 91301**]),
and bilateral PEs (12/12-15/11) presenting from rehab with
tachypnea and found to have pneumonia, likely secondary to
aspiration."
3361,"Admission Date: [**2176-12-8**] Discharge Date: [**2176-12-12**]
Date of Birth: [**2092-6-5**] Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is 84 male w/PMHx recent SAH + aneurysm clipping, VP
shunt placement, trach and PEG ([**Date range (1) 91301**]), multiple
subsegmental PE (admitted from 12/12-15/11), who presents from
rehab w/ progressively worsening tachypnea and respiratory
distress. His RR was elevated to the 40s-60s. He was given an
albuterol neb without improvement. Patient is non-verbal at
baseline, but per facility report he has been less responsive
than usual."
3362,"You were also started on an
oral antibiotic (metronidazole) for an intestinal infection
called C diff. You should continue to take metronidazole until 2
weeks after you complete your IV antibiotics for pneumonia.
While you were here, your INR was elevated so your coumadin was
held. You were restarted on your coumadin at 2.5 mg by mouth
daily. You should continue to have your INR level monitored
regularly at your rehab facility.
You were also seen by the neurosurgery service while you were
here because of your history of a brain hemorrhage. You had an
MRI of your brain, and you will hear from Dr."
3363,"Admission Date: [**2196-8-15**] Discharge Date: [**2196-8-26**]
Date of Birth: [**2145-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Hypoxemia, leukocytosis, and hypotension
Major Surgical or Invasive Procedure:
Paracentesis x5
Esophagogastroduodenoscopy
Colonoscopy
History of Present Illness:
51M with ETOH cirrhosis c/b refractory ascites requiring large
volume [**Doctor First Name 4397**] q 1-2 weeks and h/o multiple variceal bleeds with
grade [**1-6**] varices initially presented to RIH [**2196-8-5**] to replace
NGT and was found to have hyponatremia Na 120."
3364,"On the floor, his
NGT was replaced, and his hyponatremia was treated with fluid
restriction. Four days after admission on [**2196-8-9**], he developed
BRBPR and hematemesis with hypotension SBP 70s. Emergent EGD
revealed acute bleed from grade 2 varix which was banded and
severe esophagitis. He received a total of 5 units PRBCs, 4
units FFP, octreotide drip x 5 days and IV PPI [**Hospital1 **]. He was
intubated for airway protection and on pressors transiently for
approximately 2 days. RIJ placed [**2196-8-9**]. His HCT remained stable
and he had no further episodes of bleeding. Labs significant for
leukocytosis WBC 30."
3365,"Ulcer in the gastroesophageal
junction. Food in the whole stomach. Granularity, erythema,
congestion, abnormal vascularity and mosaic appearance in the
whole stomach compatible with portal hypertensive gastropathy.
Successful endoscopic placement of 10Fr [**Last Name (un) **]-jejunal feeding
tube to 130 cm from the nares. Successful placement of 10Fr
[**Last Name (un) **]-pharyngeal Bridle. Otherwise normal EGD to third part of
the duodenum
.
[**8-24**] Colonoscopy- Angioectasia in the sigmoid colon. Stool in
the hepatic flexure and ascending colon. Non-bleeding rectal
varices were noted. No significant lesions were identified,
although a small polyp could not be excluded at the hepatic
flexure due to the presence of stool."
3366,"Otherwise normal
colonoscopy to cecum
.
Discharge Labs:
[**8-26**]: WBC 7.2 Hgb 9.6* Hct 27.9* MCV 101* Plt 115
[**8-26**]: Gluc 158* BUN 42* Crt 1.4* Na 135 K 4.4 Cl 105 HCO3 20*
[**8-26**]: ALT 23 AST 46* AKP 157* TB 1.6*
Brief Hospital Course:
51yo man with EtOH cirrhosis c/b refractory ascites s/p his 3rd
episode of variceal bleed and banding who presents from outside
hospital with resolving pneumonia, ongoing hypoxia .
.
#Hypoxia: Patient presented from outside hospital with oxygen
requirement s/p treatment for a pneumonia. CXRs were repeated
and showed resolving pneumonia."
3367,"5) during this admission from baseline 0.8-0.9. This
was attributed to poor volume status due to bleeding and
diuresis in the OSH. He responded partially to albumin, but
creatinine on discharge remained stable around 1.3. Other
contributing factors may be increased intra-abdominal pressure
secondary to ascites vs. hepatorenal syndrome. Would recommend
further evaluation and consideration of treatment for
hepatorenal syndrome.
.
# Anemia - Patient's anemia was likely multifactorial and
related to acute bleed and cirrhosis. Received 2 units
transfusion in the MICU without active bleeding throughout his
[**Hospital1 18**] hospitalization. Hct remained stable, guaiac negative, and
patient was supplemented with B12 and folate."
3368,"Hemolysis labs
were negative.
.
#Hyponatremia: History of hyponatremia to 120 at admission to
OSH. This was attributed to the hemodynamics of his cirrhosis
and recurrent ascites. Patient was fluid restricted and became
slightly hypernatremic once tube feeds were started. Fluid
restriction was removed and sodium normalized.
.
# Hyperglycemia- Patient became hyperglycemic (sugars in the
160s -180s) with tube feeds. He was started on an insulin
sliding scale and typically received 8 units of sliding scale
insulin daily. We recommend that this be followed up in the
outpatient setting and patient evaluated further for diabetes
and oral anti-hyperglycemics considered. During rehab stay, can
consider a regular insulin sliding scale if sugars remain
elevated."
3369,"13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Alcoholic cirrhosis
Esophageal varices
Hepatic encephelopathy
Hypoxia
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 18**]. You were
transferred to this hospital from [**Hospital 44256**], where
you were you bled from your esophageal varices (blood vessels in
your throat) and were treated for a pneumonia."
3370,"Occ exp wheezes
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: Soft, non-tender, distended with positive fluid wave,
bowel sounds present, no rebound tenderness or guarding, +
splenomegaly
GU: foley draining dark yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. peripheral wasting.
Skin: Multiple spider angiomata on torso. GYnecomastia
Neuro: + resting tremor. No asterixis
.
On discharge:
VS Tm 97.7 Tc 96.7, BP 100/56 (91-105/56-75), HR 91 (79-91), 20,
95%RA
Wt 79.4 kg
General: Alert, oriented and appropriate
HEENT: Sclera icteric, poor dentition
Lungs: CTAB, no rhonchi, rales, or wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, distended, + fluid wave, bowel sounds
present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema."
3371,"His persistent hypoxia was
attributed to the resolving treated pneumonia, transpulmonary
shunting (TTE on [**8-16**] consistent with this), likely smoking
related parenchymal lung disease, deconditioning with poor
clearance of upper airway secretions and restriction from large
volume ascites. Patient was treated with aggressive pulmonary
toilet (chest physical therapy, incentive spirometry), frequent
nebulizer treatments and large volume paracenteses (3 L on [**8-17**] L on [**8-19**] L on [**8-23**] L on [**8-26**]) with marked improvement.
On discharge, patient was breathing comfortably on room air.
Follow Up:
We recommend that his nebulizer treatments be continued as
needed in the outpatient setting and the patient be encouraged
to mobilize and use an incentive spirometer."
3372,"1* CALCIUM-8.4 PHOSPHATE-3.6
MAGNESIUM-2.1
[**2196-8-15**] 10:19PM WBC-15.7*# RBC-2.99* HGB-10.0* HCT-30.5*
MCV-102* MCH-33.5* MCHC-32.8 RDW-17.7*
[**2196-8-15**] 10:19PM NEUTS-87.2* LYMPHS-4.8* MONOS-5.4 EOS-2.3
BASOS-0.3
[**Hospital1 18**] Admission labs:
[**2196-8-15**] 10:19PM BLOOD WBC-15.7*# RBC-2.99* Hgb-10.0* Hct-30.5*
MCV-102* MCH-33.5* MCHC-32.8 RDW-17.7* Plt Ct-135*
[**2196-8-15**] 10:19PM BLOOD Neuts-87."
3373,"Transplant Workup:
[**2196-8-22**] 10:16AM BLOOD AMA-NEGATIVE
[**2196-8-22**] 10:16AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2196-8-22**] 10:16AM BLOOD IgG-872 IgA-523* IgM-69
Micro:
[**8-15**] Blood cx- No growth
[**8-16**] C. diff- negative
[**8-16**] Peritoneal fluid - GS negative; cx- no growth
[**8-16**] Sputum- GRAM STAIN: >25 PMNs and <10 epithelial cells/100X
field. 2+ (1-5 per 1000X FIELD): YEAST(S). 1+ (<1 per 1000X
FIELD): GRAM POSITIVE ROD(S). Cx- respiratory flora
[**8-17**] Blood cx- no growth
[**8-17**] Urine cx- no growth
[**8-19**] Blood cx- no growth
[**8-19**] Urine cx- no growth
[**8-24**] Peritoneal fluid- GS negative, cx prelim negative"
3374,"Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Please take enough to have [**2-4**] bowel movements
daily.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily)."
3375,"Studies:
[**8-16**] TTE- Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is moderately dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion. With injectin of aerated saline, there are
2 bubbles in the LV within 3 heart beats and a flurry of
contrast after 6-7 beats. This is most consistent with
transpulmonary shunting, although with several early bubbles, a
concurrent PFO cannot be excluded."
3376,"IMPRESSION: Likely transpulmonary shunting. Normal biventricular
systolic function.
.
[**8-23**] CXR- #1. Bibasilar atelectasis and small effusions. 2.
Dobbhoff tube coiled in the stomach.
.
[**8-23**] CXR #2- Left PICC line ends at the junction of the
brachiocephalic veins. Lung volumes remain very low, but the
clearing of opacification at the left lung base suggest that
this was largely atelectasis. Mild interstitial abnormality and
plate-like scarring in the right lung are unchanged. Heart size
is normal. Feeding tube coils in the upper stomach and passes
out of view. No pneumothorax or appreciable pleural effusion.
Heart size normal.
.
[**8-23**] EGD- Varices at the lower third of the esophagus and
gastroesophageal junction."
3377,".
# FEN: Patient was given a low sodium diet and was evaluated by
nutrition specialists who restarted him on tube feeds. He was
also supplemented with ensure, thiamine, folate, cyanocobalamin,
and a multivitamin. His tubefeeds and vitamins should be
continued on discharge.
Medications on Admission:
Home Meds:
- albuterol inhaler 2puffs PO daily
- Vitamin D2 50,000 units PO weekly
- Lasix 80mg daily (on hold since [**7-4**] due to hyponatremia)
- Lactulose 15ml PO TID
- Prevacid 15mg PO daily
- Spironolactone 200mg PO daily (on hold since [**7-4**] due to
hyponatremia)
- Folic acid 0.4mg PO daily
.
Medications (from OSH records):
CefePIME 1 g IV Q12H
Vancomycin 1000 mg IV Q 12H
Pantoprazole 40 mg IV Q12H
Furosemide 40 mg IV BID
Lactulose 30 mL PO/NG TID
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN Constipation
Multivitamins 10 mL IV Q24H
FoLIC Acid 1 mg PO/NG DAILY
Thiamine 100 mg IV DAILY
Nicotine Patch 14 mg TD DAILY"
3378,"8. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing."
3379,".
On the floor, the pt is comfortable and in no acute distress. He
complains of abdominal fullness and discomfort, like he ""needs a
tap"", and feels as if this has affected his breathing. He
reports cough productive of white phlegm and SOB which he feels
is secondary to abdomen. His last paracentesis was more than 2
weeks prior, and he usually gets tapped every week (8-9L). He
denies current fever or chills and denies change in baseline
tremor.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache, change in vision.
Denies or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness."
3380,"We have made the following changes to your home medications:
- please START taking nadolol 20 mg daily
- please START taking rifaximin 550 mg twice daily
- please START taking sucralfate 1 g four times daily
- please START taking pantoprazole 40 mg daily
- please STOP taking prevacid
- please CHANGE your dose of lactulose to 30 mL three times
daily
- please CHANGE your dose of folic acid to 1 g daily
- please START taking cyanocobalamin
- please START taking thiamine
You may continue to take albuterol and vitamin D as you were
previously.
Please follow up for your pulmonary function tests (another
component of your liver transplant workup) and your appointment
with Dr. [**Name (STitle) 23173**] as below.
We wish you a speedy recovery.
Followup Instructions:
Please follow up for your pulmonary function tests and your
appointment with Dr. [**Name (STitle) 23173**]:
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2196-9-2**] 10:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2196-9-2**] 10:00
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2196-9-2**] 11:40
Completed by:[**2196-8-26**]"
3381,"While you were at the [**Hospital1 18**], we helped improve your lung
function with frequent nebulizer treatments and chest physical
therapy. We also performed an endoscopy to examine your varices
and a colonoscopy as part of your liver transplant evaluation.
You were re-evaluated by a nutritionist who felt that you would
benefit from continued additional caloric intake via a feeding
tube. Please continue to take your tubefeeds at home as the
additional nourishment will help build your strength. Your blood
sugars were slightly elevated during this hospitalization- we
recommend that you discuss this with your primary care doctor
for further management."
3382,"He was given lactulose and
rifaximin which were titrated to his mental status. He had some
encephelopathy during his ICU admission, but this resolved
shortly after his transfer to the floor with aggressive
lactulose treatment. He underwent diagnostic paracentesis in the
MICU (negative for SBP) and several therapeutic paracenteses
([**8-17**]- 3L, [**8-19**] 10L, [**8-23**] 3L, [**8-26**] 4L) which were also negative
for SBP. Patient was appropriately repleted with albumin
post-tap.
.
As part of his transplant evaluation patient underwent
echocardiogram w/ bubble study which showed transpulmonary
shunting with supine room air ABG pO2 57, though the patient had
no orthodeoxia."
3383,"peripheral wasting.
Skin: Multiple spider angiomas on torso. gynecomastia, caput
Neuro: A and Ox3, no asterixis
Pertinent Results:
OSH Labs:
- [**2196-8-15**] - Na139 K4.0 Cl11 HCO32 BUN40 Cr1.08 Glu132. AST51
ALT43 ALKphos 146 TBILI2.8 Alb2.6 WBC12.2 Hct28.1 Plt90.
[**2196-8-15**] 10:19PM GLUCOSE-179* UREA N-49* CREAT-1.3* SODIUM-137
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
[**2196-8-15**] 10:19PM ALT(SGPT)-42* AST(SGOT)-52* LD(LDH)-226 ALK
PHOS-164* AMYLASE-118* TOT BILI-2.0*
[**2196-8-15**] 10:19PM LIPASE-100*
[**2196-8-15**] 10:19PM ALBUMIN-3."
3384,"2* Lymphs-4.8* Monos-5.4 Eos-2.3
Baso-0.3
[**2196-8-15**] 10:19PM BLOOD PT-16.5* PTT-35.0 INR(PT)-1.5*
[**2196-8-15**] 10:19PM BLOOD Glucose-179* UreaN-49* Creat-1.3* Na-137
K-4.1 Cl-106 HCO3-21* AnGap-14
[**2196-8-15**] 10:19PM BLOOD ALT-42* AST-52* LD(LDH)-226 AlkPhos-164*
Amylase-118* TotBili-2.0*
[**2196-8-15**] 10:19PM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.6 Mg-2.1
[**2196-8-18**] 01:55PM BLOOD Hapto-71
[**2196-8-16**] 05:07AM BLOOD VitB12-GREATER TH Folate-GREATER TH"
3385,"Denies nausea, vomiting, diarrhea,
constipation, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
- Alcoholic cirrhosis
- s/p umbilical hernia repair in [**2196-3-3**]
- COPD?
Social History:
Previously lived in [**Hospital1 789**], RI, but now living with his
brother in [**Name (NI) 50909**], RI. Currently on SSDI, used to work at a
medical supply company. Single, never married, no children.
Stopped EtOH 1 year ago. Prior smoker, 1 PPD since age 16,
stopped 2 months ago, now using the nicotine patch. No h/o IVDU
or intranasal cocaine. History of marijuana in past, none
currently."
3386,"Cx were negative but he was noted to have
bilateral airspace disease on CXR so was treated for VAP with
Vanco cefepime currently Day [**5-10**]. Ongoing hypoxia with 3-4L O2
requirement was felt to be due to resolving infection as well as
volume overlaod so he was diuresed with IV Lasix, recently 40mg
IV BID. Hyponatremia resolved with Na 139 at time of transfer.
He was also started on TPN [**2196-8-13**].
.
He is being trasnferred to [**Hospital1 18**] for continuity of care and
ongoing trasnplant evaluation. VS on transfer: 105/75 93 97.7 27
94%3L."
3387,".
# Alcoholic cirrhosis: Patient with history of alcoholic
cirrhosis c/b refractory ascites (typically gets taps every two
weeks) and variceal bleeds x3, now s/p banding in OSH. Patient
was initially continued on octreotide drip and IV PPI.
Octreotide was d/c-ed and patient was transitioned to oral PPI.
He was started on nadolol which was titrated to 20 mg daily
given limited blood pressure room. Patient underwent EGD to
assess his variceal status after banding which showed an ulcer
in the GE junction and 3 cords of grade I bands in the lower
third of the esophagus. He was started on sucralfate in addition
to his standing nadolol and PPI."
3388,"Family History:
- mother died at age of 70 due to complications from
a fractured hip; she had osteoporosis and hypertension.
- father - stroke.
-The patient has 7 siblings.
-brother died in [**Name (NI) 39447**] at 26 and 1 brother who died last year of a
brain
aneurysm at the age of 50. The patient states that the rest of
his remaining siblings are alive, well and healthy.
- no history of liver disease or liver cancer in his family.
Physical Exam:
On admission:
Vitals: T: P96 BP166/69 RR29 93% on 4L NC
General: Alert, oriented to place and month and year, not date,
no acute distress
HEENT: Sclera icteric + sublingual icterus, MM dry, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral rhonchi R>L mid lung field and anterior lung
fields bilaterally."
3389,"Cardiology was consulted and felt that there was
no need for further pre-transplant workup- should the patient
develop cardiac symptoms they recommended possible CTA of the
coronaries. Patient also underwent colonoscopy which showed
angioectasia in the sigmoid colon and non-bleeding rectal
varices. [**Doctor First Name **] (negative), anti-smooth muscle (negative) and IgG
(nl), IgA (c/w alcoholic cirrhosis), and IgM (negative) were
sent.
Follow Up:
Patient will require PFTs in the outpatient setting and f/u with
his transplant hepatologist - these are scheduled for [**9-2**].
.
#. [**Last Name (un) **]: Patient's creatinine was elevated around 1.3 (and as
high as 1."
3390,"Admission Date: [**2155-10-6**] Discharge Date: [**2155-10-24**]
Date of Birth: [**2093-1-13**] Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
Open left tib/fib fracture s/p motorcycle accident
Major Surgical or Invasive Procedure:
[**2155-10-6**]
1. Irrigation and debridement of left tibia open fracture.
2. Application of multiplanar external fixator, left lower
extremity.
3. Closed reduction left tibia and fibula fracture.
4. Application of negative pressure dressing to the left lower
extremity.
.
[**2155-10-10**]
1. Application of manual stress, exam under stress fluoroscopy,
right ankle."
3391,"2. Closed reduction of right distal fibular fracture.
.
[**2155-10-10**]
Irrigation and debridement of skin, subcutaneous tissue, muscle
and fascia.
.
[**2155-10-15**]
1. Washout debridement, open fracture down to and inclusive of
bone
2. Operative stabilization, left tibial shaft fracture with
plate and screws.
3. Insertion non biodegradable antibiotic delivery device, left
tibia.
.
[**2155-10-15**]
History of Present Illness:
Mr. [**Known lastname 24927**] is a 62 year-old male status-post motor cycle crash
on [**2155-10-6**]; he was unhelmeted at the time and was
driving 40-50 mph, and swerved to avoid a car passing into his
[**Male First Name (un) **], and colliding into a tree."
3392,"He was brought in by
helicopter, with GCS 15, noting pain on his right shoulder, back
and side, and left lower extremity.
Past Medical History:
-Afib s/p ablation x4, not currently on rate/rhythm control meds
-throat cancer s/p XRT/chemo
-hiatal hernia
-chronic LBP
-transient occasional bilatateral foot numbness
-hx of vertigo
.
PSH: -previous ORIF of right ankle
-hiatal hernia repair
Social History:
Denied smoking or drinking history.
Family History:
Non contributory
Physical Exam:
PE upon admission [**2155-10-6**]:
Vitals:
Gen: AOx3, in discomfort but no acute distress
CV: tachycardic but regular rhythm
Resp: Nonlabored breathing, decreased chest sounds on right
Abd: Soft
Pelvis: Stable
LLE: ~15 cm laceration on the anterior aspect of his left lower
leg, approximately at the midshaft tibia level."
3393,"4. No intra-abdominal injury.
5. Possible fracture of the right third metatarsal. Correlate
with foot films if clinically warranted.
.
Radiology Report TIB/FIB (AP & LAT) LEFT PORT Study Date of
[**2155-10-6**] 12:25 PM
IMPRESSION: Open and extensively comminuted fractures of the mid
tibia and
proximal fibula, with displacement and angulation as described
above. Please refer to subsequent CT for further detail.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-6**] 2:29
PM
IMPRESSION: Placement of two right chest tubes. Increased right
pneumothorax, now moderate-to-large with evidence of tension.
This was paged to Dr."
3394,"[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2155-10-6**] at 2:50 p.m.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-6**] 4:00
PM
IMPRESSION: Interval re-expansion of the right lung with
residual right lower lung atelectasis. No residual pneumothorax
identified.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-6**] 5:54
PM
FINDINGS: In comparison with the earlier study of this date,
there again are two chest tubes on the right with no appreciable
pneumothorax. Decreasing subcutaneous gas along the right
lateral chest wall. There is some improvement in aeration at the
right base, though bibasilar opacifications are consistent with
atelectasis."
3395,"13. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Left open tibiofibular fracture, grade IIIB.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
CARE OF YOUR LEFT LOWER EXTREMITY FLAP:
* Please monitor incision lines closely for signs of infection:
opening of the incision, increased redness, increased pain, if
you have a fever greater than 101, swelling of the tissues
around the incision line, drainage of
green/yellow/grey/white/thick drainage, increased pain at the
incision line, or increased warmth."
3396,"[**Name (NI) 2989**] office immediately.
* It is important to elevate your left leg on several pillows
while in bed or chair to help decrease swelling. You should
always have an ace wrap in place to the left lower extremity
extending from toes up to the mid thigh, except when changing
dressings or showering.
Followup Instructions:
Please follow-up in the [**Hospital 9696**] clinic, with Dr. [**Last Name (STitle) **]
(you will be seeing his nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]),
next TUESDAY ([**10-28**]) at 9AM. You will need to arrive at 8:40AM
to have xrays taken before your appointment. Dr.[**Name (NI) 8091**]
clinic is located at [**Hospital3 **] Medical Center, [**Hospital Ward Name 516**],
[**Hospital Ward Name 23**] Center, [**Location (un) 551**]. Please call [**Telephone/Fax (1) 1228**] if you have
any questions.
Please follow up in the Hand Clinic next TUESDAY ([**10-28**]), after
you are discharged home or to another facility. You must call
([**Telephone/Fax (1) 2007**] to make an appointment.
.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] ([**Telephone/Fax (1) 36264**]
Completed by:[**2155-10-30**]"
3397,".
Radiology Report LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST
Study Date of [**2155-10-6**] 8:05 PM
FINDINGS: Multiple fluoroscopic images of the left lower leg
demonstrate
placement of external fixation pins within the proximal tibial
shaft and
within the calcaneus. Please refer to the operative note for
additional
details. The total intraservice time was 16.1 seconds.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-6**] 8:45
PM
FINDINGS: In comparison with the study of earlier in this date,
there is no evidence of appreciable pneumothorax.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-7**]
10:01 AM
IMPRESSION: Bibasilar atelectasis with little change from
[**2155-10-6**]
."
3398,"0
[**2155-10-10**] 05:07AM BLOOD Plt Ct-131*
[**2155-10-11**] 06:30AM BLOOD Plt Ct-171
.
Chemistry:
[**2155-10-7**] 02:18AM BLOOD Glucose-191* UreaN-21* Creat-0.7 Na-136
K-5.3* Cl-104 HCO3-24 AnGap-13
[**2155-10-7**] 01:45PM BLOOD Glucose-166* UreaN-24* Creat-0.8 Na-134
K-4.6 Cl-101 HCO3-26 AnGap-12
[**2155-10-8**] 01:50AM BLOOD Glucose-140* UreaN-24* Creat-0.7 Na-132*
K-4.6 Cl-99 HCO3-28 AnGap-10
[**2155-10-8**] 06:09PM BLOOD Glucose-131* UreaN-20 Creat-0."
3399,"Hematology:
[**2155-10-7**] 02:18AM BLOOD WBC-10.6 RBC-3.44* Hgb-10.9* Hct-31.3*
MCV-91 MCH-31.8 MCHC-35.0 RDW-12.5 Plt Ct-150
[**2155-10-8**] 01:50AM BLOOD WBC-9.3 RBC-2.55*# Hgb-8.2* Hct-23.1*#
MCV-90 MCH-32.3* MCHC-35.8* RDW-12.6 Plt Ct-123*
[**2155-10-8**] 11:56AM BLOOD WBC-8.8 RBC-2.68* Hgb-8.6* Hct-24.7*
MCV-92 MCH-32.0 MCHC-34.7 RDW-12.5 Plt Ct-164
[**2155-10-8**] 06:09PM BLOOD WBC-5."
3400,"His remaining CT
scans were then performed, which demonstrated the above
injuries, with no visceral injuries. He was concomitantly
evaluated by Orthopedics for his left open tibia-fibular
fracture, his wound was irrigated, and the leg splinted. He
received gentamicin, a tetanus shot and ancef at this time.
He was then taken emergently to the operating room by the
orthopedic surgery service for irrigation and debridement of
left tibia open fracture, application of external fixator,
closed reduction left tibia and fibula fracture and placement of
VAC dressing, and was then tranferred to the ICU for further
care.
After extubation, the patient noted right foot pain, with
original CT scans demonstrating a questionable fracture."
3401,"Right
foot films on [**2155-10-9**] showed fractures of metatarsals [**1-31**]
with a question of fracture of the base of the lisfranc
ligament. Orthopedics was notified of this finding, with further
management by their service. Plastics/Reconstructive Surgery was
also consulted intra-operatively for a possible washout and flap
for his left lower extremity wound: reader is referred to both
orthopedics and plastics summaries on respective management.
Neuro: pain control was obtained with a dilaudid PCA
supplemented by a lidocaine patch and MS [**First Name (Titles) **] [**Last Name (Titles) **] in the early
postoperative period. He was transferred to the floor soon after
ORIF of the left tibia-fibular fracture and was managed with
morphine IR, MS [**First Name (Titles) **] [**Last Name (Titles) **], and morphine IV as well as lidocaine
patch."
3402,"Medications on Admission:
tramadol prn
Discharge Medications:
1. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units sc Injection TID (3 times a day).
4. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
3403,"050*
[**2155-10-6**] 04:32PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2155-10-6**] 04:32PM URINE HOURS-RANDOM
[**2155-10-6**] 08:45PM PLT COUNT-191
[**2155-10-6**] 08:45PM WBC-14.2* RBC-3.68* HGB-11.8* HCT-34.9*
MCV-95 MCH-32.0 MCHC-33.7 RDW-12.2
[**2155-10-6**] 08:45PM CALCIUM-7.8* PHOSPHATE-3.5 MAGNESIUM-1.6
[**2155-10-6**] 08:45PM GLUCOSE-171* UREA N-18 CREAT-0.7 SODIUM-139
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
."
3404,"Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-8**] 5:14
AM
IMPRESSION: AP chest compared to [**10-6**] through 11.
Right upper chest tube is the only support device visible. There
is no
pneumothorax or large right pleural effusion despite multiple
displaced right rib fractures. Bibasilar atelectasis is severe.
The heart is at least moderately enlarged. There is no pulmonary
edema.
.
Radiology Report LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT
IN O.R. Study Date of [**2155-10-8**] 3:34 PM
FINDINGS: Multiple fluoroscopic images of the left lower
extremity
demonstrate interval placement of intramedullary rod with
multiple associated screws fixating a complex fracture involving
the mid shaft of the tibia."
3405,"Pleural effusion cannot be excluded.
Cardiomediastinal silhouette is unchanged.
There is interval improvement of pulmonary edema.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-11**] 7:45
AM
Bibasilar areas of atelectasis are present, unremarkable. Upper
lungs are
clear. Heart size and mediastinum are within normal limits. No
definitive
evidence of pneumothorax is seen. Rib fractures are better seen
on the prior examination than on the current study.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-12**] 7:32
AM
FINDINGS: There is no evidence of pneumothorax.
Cardiomediastinal contours
are stable in appearance. Persistent bibasilar atelectasis,
minimally
improved at the left lung base, with associated persistent
moderate elevation of left hemidiaphragm and either a small left
pleural effusion or pleural thickening."
3406,"Post-procedure, the
right chest tube was discontinued and patient had multiple
surveillance chest xrays indicating the resolution of the right
pneumothorax but the post-procedureal development of bibasilar
areas of atelectasis. Patient was encouraged to get out of bed
to chair for extended periods and to use his incentive
spirometer frequently. He was utilizing albuterol and atrovent
nebulizer treatments around the clock.
.
On [**2155-10-15**], the patient returned to the OR for a free flap to
his left lower extremity defect. When wound VAC dressing was
removed, the left lower extremity about the wound site appeared
very unstable;particularly, the proximal fragment was not being
well-supported by the nail and was very mobile causing
deformity."
3407,"Inferior and posterior calcaneal spurs
are seen and there are degenerative changes
involving the tarsal bones.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-10**] 4:09
PM
IMPRESSION:
1. Increased pulmonary vascular congestion with worsening
pulmonary edema and stable bilateral small pleural effusions.
2. Stable tiny right apical pneumothorax with unchanged position
of right
pleural tube.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2155-10-10**] 6:05
PM
Right apical pneumothorax is small. The right chest tube is not
clearly seen on the current study: removed? Multiple right rib
fractures are noted. Bibasal atelectases are present, left more
than right."
3408,"6
[**2155-10-6**] 12:22PM LACTATE-2.4*
[**2155-10-6**] 12:22PM PO2-39* PCO2-67* PH-7.28* TOTAL CO2-33* BASE
XS-2 COMMENTS-GREEN TOP
[**2155-10-6**] 04:32PM URINE MUCOUS-RARE
[**2155-10-6**] 04:32PM URINE GRANULAR-15* HYALINE-16*
[**2155-10-6**] 04:32PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
[**2155-10-6**] 04:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-10-6**] 04:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1."
3409,"Heme: Hct were trended daily and dropped to 21 at midnight on
[**10-9**]. He was transfused 2u pRBCs and his hct has remained
stable since.
ID: Ancef/Gent were administered for 3 days for empiric coverage
given open tib/fib fracture per orthopedics. He is currently on
cefazolin per ortho.
Prophylaxis:
DVT: boots and enoxaparin were employed daily
Stress ulcer: PO famotidine was administered
.
On [**2155-10-10**], the patient was admitted to the Plastic and
Reconstructive Surgery service status post left lower extremity
debridement and wound vac placement in preparation for planned
free flap to left lower extremity defect."
3410,"He remained neurologically intact throughout.
CVS:the patient remained hemodynamically stable. He was
continued on telemetry on the floor and remained in sinus
rhythm.
Pulm:the R chest tube was kept on suction for 48 hours with good
lung re-expansion. Incentive spirometry and pulmonary toilet
were encouraged. Prior to transfer, he was maintaining O2 sats
at 93-95% on RA with additional oxygen requirement.
Recommendations were made to remove the chest tube after washout
with the Plastics service on [**2155-10-10**].
GI/FEN: the patient was kept on a regular diet, which he
tolerated well.
GU: a foley catheter was initially placed for UOP monitoring and
was further managed by the plastics service when he was
transferred on [**2155-10-10**]"
3411,"8 MCHC-35.9* RDW-14.3 Plt Ct-131*
[**2155-10-10**] 09:35AM BLOOD Hct-25.1*
[**2155-10-11**] 06:30AM BLOOD WBC-6.1 RBC-2.76* Hgb-8.8* Hct-25.5*
MCV-92 MCH-31.8 MCHC-34.5 RDW-14.5 Plt Ct-171
.
Coags:
[**2155-10-7**] 02:18AM BLOOD Plt Ct-150
[**2155-10-8**] 01:50AM BLOOD Plt Ct-123*
[**2155-10-8**] 11:56AM BLOOD Plt Ct-164
[**2155-10-8**] 06:09PM BLOOD Plt Ct-110*
[**2155-10-10**] 05:07AM BLOOD PT-12.1 PTT-28.1 INR(PT)-1."
3412,"2. No fracture of the cervical spine. There is moderate spinal
degenerative change which results in mild central canal and more
prominent neural foraminal narrowing. If there is concern for
cord injury, MRI is more sensitive for its detection.
.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2155-10-6**] 12:24 PM
IMPRESSION:
1. Right tension pneumothorax. These findings were relayed to
the trauma
team, led by Dr. [**First Name (STitle) **], urgently.
2. Numerous right rib fractures, many segmental, raising concern
for flail
chest. Right scapula fracture. Left first rib fracture.
3. Comminuted compound left tibia and fibular diaphyseal
fractures, without vascular injury."
3413,"ADDENDUM AT ATTENDING REVIEW: There is a semilunar region of
calcific density adjacent to the inner table of of the squamosal
portion of the left temporal bone, measuring up to 14mm along
its base and 3mm in maximal thickness, seen on images 27-31,
series 3 The finding could represent a calcified meningioma.
There is negligible mass effect exerted by this lesion upon the
contiguous brain convexity surface.
.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2155-10-6**]
12:23 PM
IMPRESSION:
1. Moderate-size pneumothorax with posterior rib fractures and
gas tracking up the subcutaneous tissues of the neck
posteriorly."
3414,"He was admitted to [**Hospital1 18**] ACS service on [**2155-10-6**].
Two chest tubes were placed in the emergency room and one was
taken out shortly after because of incorrect placement. There
was a concern for tension pneumothorax with complete collapse of
the right lung shown on CT-scan; during scanning, the patient
developed shortness of breath with O2sats in high 80s, and was
brought back to the trauma bay for stabilization whereupon he
underwent a second chest tube placement on the right. A repeat
portable CXR was obtained, which demonstrated no improvement.
Dr. [**Last Name (STitle) 853**], trauma surgery attending, was able to re-place the
first chest tube with relief in the patient's symptoms with
maintenance of stable O2sats in the high 90s."
3415,"When tolerating oral intake, the patient was
transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Patient had standing
albuterol and atrovent nebulizers around the clock. He was
encouraged to cough and deep breathe and use his incentive
spirometer, frequently.
.
GI/GU: Pre and post-operatively, the patient was given IV fluids
for hydration and until tolerating oral intake. His diet was
advanced when appropriate, which was tolerated well. He was also
started on a bowel regimen to encourage bowel movement."
3416,"The tibia is
exposed with fracture fragments visible. He has +1 DP and PT
pulses. SILT on s/s/sp/dp/t and he fires [**Last Name (un) 938**]/FHL.
Pertinent Results:
ADMISSION LABS:
[**2155-10-6**] 12:00PM FIBRINOGE-260
[**2155-10-6**] 12:00PM PLT COUNT-184
[**2155-10-6**] 12:00PM PT-12.8 PTT-24.6 INR(PT)-1.1
[**2155-10-6**] 12:00PM WBC-9.8 RBC-4.59* HGB-14.5 HCT-42.8 MCV-93
MCH-31.6 MCHC-33.9 RDW-12.1
[**2155-10-6**] 12:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-10-6**] 12:00PM LIPASE-24
[**2155-10-6**] 12:00PM estGFR-Using this
[**2155-10-6**] 12:00PM UREA N-17 CREAT-0."
3417,"Foley
was removed. Intake and output were closely monitored.
.
ID: The patient was maintained on IV cefazolin every 8 hours.
The patient's temperature was closely watched for signs of
infection.
.
Prophylaxis: The patient received subcutaneous heparin
post-operatively. Patient was given 121.5 mg of aspirin, daily,
to maintain the vascular integrity of the flap. In addition,
patient was placed on a Kinair bed for the post-operative period
of mandatory bedrest to protect skin integrity. A pneumoboot
was placed on the RLE at all times while patient in bed.
.
At the time of discharge on [**10-24**], the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled."
3418,"6 Na-132*
K-4.6 Cl-98 HCO3-30 AnGap-9
[**2155-10-10**] 05:07AM BLOOD Glucose-107* UreaN-9 Creat-0.4* Na-135
K-3.7 Cl-98 HCO3-33* AnGap-8
[**2155-10-11**] 06:30AM BLOOD Glucose-157* UreaN-11 Creat-0.5 Na-137
K-4.0 Cl-98 HCO3-31 AnGap-12
[**2155-10-7**] 02:18AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.0
[**2155-10-7**] 01:45PM BLOOD Calcium-7.9* Phos-2.4* Mg-1.9
[**2155-10-8**] 01:50AM BLOOD Calcium-7.6* Phos-2."
3419,"Ortho service was called and came to washout the
wound, plate the fracture and replace the cement spacer. Once
this was complete, the Plastic service proceeded with
reconstruction of the LLE utilizing a left ALT flap. The
patient tolerated the procedure well and stayed overnight in the
Post Anesthesia Care Unit for hourly 'flap checks'.
.
Neuro: Post-operatively, the patient received a Morphine PCA for
breakthrough pain in addition to his standing MS Contin 30mg PO
Q12h with good effect and adequate pain control. He was also
given Toradol IV x 3 days and tylenol 650 mg Q6h for additional
pain control."
3420,"There is also a fracture involving
the mid shaft of the fibula with butterfly fragments. Please
refer to the operative note for additional details.
.
Radiology Report CHEST (PA & LAT) Study Date of [**2155-10-9**] 3:14 PM
Cardiomediastinum is unchanged with cardiomegaly, elevation of
the left
hemidiaphragm is stable. Bibasilar atelectases have improved.
Right apical
chest tube remains in place. There is a new or newly apparent
small right
apical pneumothorax. There are small bilateral pleural
effusions.
.
Radiology Report FOOT AP,LAT & OBL RIGHT Study Date of [**2155-10-9**]
3:15 PM
IMPRESSION:
1. Fractures at the base of the second, third and fourth
metatarsal bones."
3421,"3* Mg-2.0
[**2155-10-8**] 06:09PM BLOOD Calcium-7.5* Phos-2.5* Mg-1.8
[**2155-10-10**] 05:07AM BLOOD Calcium-7.7* Phos-2.0* Mg-1.8
[**2155-10-11**] 06:30AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9
.
RADIOLOGY:
Radiology Report TRAUMA #3 (PORT CHEST ONLY) Study Date of
[**2155-10-6**] 11:58 AM
Slightly displaced right sixth through eighth posterolateral rib
fractures, with moderate right pneumothorax. This was paged to
Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2155-10-6**] at 1:12 p.m.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2155-10-6**]
12:22 PM
IMPRESSION: No acute intracranial injury."
3422,"* You may shower with incisions/sutures. Let the warm water run
over the incisions, pat all areas dry with a clean towel, and
keep open to air but as clean and dry as possible. If the
incisions become irritated, you may apply a dry sterile gauze
dressing to the incision line. Please follow-up with Dr. [**First Name (STitle) 1022**] for
questions related to this most current surgery.
* Continue to monitor the flap. This should remain warm and a
similar color to the rest of your skin. If you notice that these
areas are changing in color to: red, purplish, blue, black, or
pale please call Dr."
3423,"No widening between the first and second
metatarsals, but the possibility of fractures at the Lisfranc
ligament insertion sites cannot be excluded.
2. Deformity of the distal tibia and fibula, not fully evaluated
on this
film.
3. Question small avulsion fracture along the dorsum of talus.
.
Radiology Report ANKLE (AP, MORTISE & LAT) RIGHT PORT Study Date
of [**2155-10-10**] 9:30 AM
FINDINGS: No previous images. There are old healed fractures of
the lower
shafts of the tibia and fibula with no residual portion of a
metallic pin just superior to the fracture region of the tibia.
Considering the degree of previous injury, the ankle mortise is
rather well maintained."
3424,"8 RBC-2.57* Hgb-8.2* Hct-23.1*
MCV-90 MCH-32.0 MCHC-35.5* RDW-13.6 Plt Ct-110*
[**2155-10-9**] 12:06AM BLOOD Hgb-7.6* Hct-21.0*
[**2155-10-9**] 05:07AM BLOOD Hgb-8.2* Hct-22.6*
[**2155-10-9**] 09:45AM BLOOD Hgb-8.8* Hct-24.6*
[**2155-10-9**] 08:10PM BLOOD Hct-23.3*
[**2155-10-10**] 03:44AM BLOOD Hct-23.1*
[**2155-10-10**] 05:07AM BLOOD WBC-5.4 RBC-2.66* Hgb-8.5* Hct-23.6*
MCV-89 MCH-31."
3425,"7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
10. aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily) for 21 days.
11. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours)."
3426,"Known right rib
fractures are again visualized.
.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2155-10-13**]
3:59 PM
IMPRESSION:
1. No right lower extremity DVT.
2. No DVT in the left common femoral, superficial femoral, or
popliteal vein.
Nonvisualization of left calf veins secondary to bandage
material.
.
Brief Hospital Course:
Mr [**Known lastname 24927**] was admitted [**2155-10-6**] after suffering a motorcycle
collision vs tree while riding his bike unhelmeted. He suffered
the following injuries: open comminuted L tib-fib fracture, R
ptx, R scapular fx, and bilateral rib fx (right [**3-4**] and left 1st
rib."
3427,"Admission Date: [**2158-8-10**] Discharge Date: [**2158-8-16**]
Date of Birth: [**2087-12-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
abnormal EKG
Major Surgical or Invasive Procedure:
[**2158-8-10**] Coronary bypass grafting x4 with left internal mammary
artery to left anterior descending coronary artery, with
extended patch angioplasty, reverse saphenous vein graft from
the aorta to the first obtuse marginal coronary artery; reverse
saphenous vein graft from the aorta to the second obtuse
marginal coronary; reverse saphenous vein graft from the aorta
to the posterior descending coronary artery, Endoscopic left
greater saphenous vein harvesting."
3428,"He is overall very sedentary. He has been overweight and
has never exercised. He fell down a couple stairs last week and
injured his left foot. He still has localized swelling. An XRAY
did not reveal any fracture. He is still having difficulty
getting around secondary to the pain. He was referred for
cardiac catheterization and was found to have coronary artery
disease. He is now referred to cardiac surgery for
revascularizaiton.
Past Medical History:
? Silent MI
Type 2 DM - most recent HbA1c 7.6 in [**2158-5-17**] on insulin for 5
years
HTN
Hypercholesterolemia
Obesity
Bladder and Renal Stones/Hematuria
Prostate CA s/p XRT therapy
CKD stage II"
3429,"Biventricular
function is unchanged. No new valvular abnormalities are seen.
The aorta is intact after removal of the bypass cannula.
ekg
Atrial fibrillation. Left axis deviation. Poor R wave
progression and lack
of R waves in the anterolateral leads suggestive of prior
myocardial
infarction. Small R waves in the inferior leads suggest possible
inferior
myocardial infarction. Compared to the previous tracing of
[**2158-8-11**] atrial
fibrillation is new and there is modest J point elevation in
leads III and aVF raising the possibility of an acute process.
Suggest clinical correlation and repeat tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 0 124 422/425 0 -58 90"
3430,"One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
units Subcutaneous as directed: 58 unit am, 32 units at night.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)."
3431,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] on [**9-19**] at 1:15 pm
Cardiologist Dr [**First Name (STitle) **] on [**9-5**] at 2:15pm
Please call to schedule appointment with primary care physician
after discharge from rehab Dr [**Last Name (STitle) 84032**] [**Telephone/Fax (1) 28612**]
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2-2.5
First draw [**8-18**] Friday
Please check INR monday and wednesday and friday for two weeks
then decrease as instructed by physician
Coumadin to be managed by rehab physician based on INR results
and then please arrange for continued management with primary
care physician
Completed by:[**2158-8-16**]"
3432,"1 Cl-104 HCO3-30 AnGap-13
[**2158-8-13**] 09:10AM BLOOD Glucose-172* UreaN-46* Creat-2.0* Na-136
K-4.8 Cl-101 HCO3-27 AnGap-13
[**2158-8-10**] 02:36PM BLOOD UreaN-18 Creat-1.3* Na-141 K-5.3* Cl-112*
HCO3-22 AnGap-12
[**2158-8-14**] 05:45AM BLOOD ALT-7 AST-25 LD(LDH)-282* AlkPhos-55
Amylase-45 TotBili-0.6
[**2158-8-16**] 07:30AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.6
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery."
3433,"0-2.5 for atrial fibrillation .
18. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Atrial fibrillation
Chronic kidney disease stage II
Diabetes mellitus type 2
Hypertension
Hypercholesterolemia
Obesity
Prostate cancer
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol and ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema +2 lower extremity
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon."
3434,"CXR [**8-15**]
COMPARISON: [**2158-8-12**].
FINDINGS: Upright PA and lateral views of the chest show
improvement of a
small left pleural effusion. There is an unchanged tiny right
pleural
effusion. Left retrocardiac atelectasis is stable. No change in
mild
cardiomegaly. No pneumothorax or focal consolidation to suggest
pneumonia. A right IJ sheath has been removed.
IMPRESSION: Improved, now small, left pleural effusion.
[**2158-8-16**] 07:30AM BLOOD WBC-11.1* RBC-3.42* Hgb-10.6* Hct-30.9*
MCV-90 MCH-31.0 MCHC-34.3 RDW-13.7 Plt Ct-336#
[**2158-8-10**] 02:36PM BLOOD WBC-19."
3435,"No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
PRE-BYPASS: The left atrium and right atrium are normal in
cavity size. No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%)."
3436,"History of Present Illness:
70 year old male without any previous known cardiac disease, who
was found to have an abnormal EKG during preoperative workup for
Bladder and Kidney stones. He was sent for an echo which
revealed low-normal systolic function with
an EF of 50-55%. He was sent for a Persantine Stress which
revealed a large previous infarct in the anterior and
anteroseptal walls extending from the mild LV to the apex with
mild peri-infarct ischemia. He does report 2 very brief
episodes of a gurgling sensation around his breast bone several
months occur. Each episode lasted only seconds, occurred while
lying down, with no associated symptoms, and resolved on its
own."
3437,"Carotid Bruit Right: None Left: None
Pertinent Results:
Echocardiogram
Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: 2."
3438,"See operative report
for further details. Post operatively he was taken to the
intensive care unit for management. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact
and was extubated without complications. Of note he initially
was in complete heart block requiring epicardial pacing but his
rhythm recovered and went into atrial fibrillation. He was
treated with amiodarone, which converted back to sinus rhythm.
Betablockers were held and he was continued on amiodarone with
intermittent short burst of atrial fibrillation. He was started
on coumadin for anticoagulation due to ongoing episodes of
atrial fibrillation. Physical therapy worked with him on
strength and mobility."
3439,"10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: twice
a day for one week then decrease to daily .
11. Zaroxolyn 5 mg Tablet Sig: One (1) Tablet PO once a day for
5 days: give with am lasix .
12. Outpatient Lab Work
please check bun, Cr Magnesium, potassium on [**8-18**] due to lasix
and continue twice a week with diuresis
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever, pain."
3440,"Look at
your incisions daily for redness or drainage
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**]."
3441,"Social History:
SOCIAL HISTORY: He lives with his wife in [**Name (NI) 5028**]. He is
retired, used to be a delivery person. He has two adult
children. He does not use any assistive devices.
TOBACCO: never
ETOH: rare
Drugs: none
Family History:
Father died of heart disease in his 70's. Father also diabetic.
Mother died in her 50's of peritonitis.
Physical Exam:
Admission Physical Exam
Pulse:80 Resp:18 O2 sat:99/RA
B/P Right:171/87 Left:160/83
Height:5'[**56**]"" Weight:276 lbs
General:
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [x] Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Palp Left: palp
DP Right: Palp Left: dop
PT [**Name (NI) 167**]: Palp Left: dop
Radial Right: Plap Left: Palp"
3442,"15. Insulin
Regular before each meal
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 2 Units
160-199 mg/dL 4 Units 4 Units 4 Units 4 Units
200-239 mg/dL 6 Units 6 Units 6 Units 6 Units
240-279 mg/dL 8 Units 8 Units 8 Units 8 Units
16. Insulin NPH
please give 30 units with breakfast and 18 units with dinner
17. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
pleae give 5mg on [**8-17**] then check INR [**8-18**] for further dosing
based on INR goal INR 2."
3443,"1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *2.6 cm2 >= 3.0 cm2
Mitral Valve - Pressure Half Time: 53 ms
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.67
Mitral Valve - E Wave deceleration time: 182 ms 140-250 ms
LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA."
3444,"Good (>20
cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low
normal LVEF.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3)."
3445,"4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Telemetry
To monitor rhythm due to atrial fibrillation and post operative
heart block
7. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
8. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
please give 400 mg twice a day until [**8-22**] then decrease to 400 mg
once a day until [**8-29**], then decrease to 200 mg once a day until
follow up with cardiologist ."
3446,"On post opeerative day five he was
started on low dose betablockers which he tolerated. He
continued to do well and was ready for discharge to rehab on
telemetry on post operative day six to [**Hospital6 **].
Medications on Admission:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2
times a day) for 5 days: Please swab in nose for 5 days before
surgery. .
Disp:*1 tube* Refills:*0*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:"
3447,"There is apical
hypokinesis. The remaining left ventricular segments contract
normally. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified
in person of the results at time of surgery.
POST-BYPASS: The patient is on no inotropes."
3448,"2*# RBC-4.34* Hgb-13.7* Hct-37.9*
MCV-87 MCH-31.7 MCHC-36.3* RDW-13.4 Plt Ct-206
[**2158-8-16**] 07:30AM BLOOD Plt Ct-336#
[**2158-8-16**] 07:30AM BLOOD PT-15.9* INR(PT)-1.4*
[**2158-8-15**] 05:05PM BLOOD PT-14.5* INR(PT)-1.3*
[**2158-8-10**] 12:30PM BLOOD PT-14.3* PTT-31.1 INR(PT)-1.2*
[**2158-8-10**] 12:30PM BLOOD Fibrino-292
[**2158-8-16**] 07:30AM BLOOD Glucose-109* UreaN-36* Creat-1.6* Na-142
K-5."
3449,"SICU
HPI:
[**Age over 90 **]F s/p fall with small L parietal SAH & R hip fx.
Chief complaint:
PMHx:
PMH: HTN, hyperchol, CAD s/p CABG, Afib, CHF, PVD s/p LE stents,
restless leg, TR/MR
[**Name13 (STitle) **] medications:
24 Hour Events:
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2136-2-21**] 08:53 PM
Infusions:
Diltiazem - 5 mg/hour
Other ICU medications:
Hydromorphone (Dilaudid) - [**2136-2-22**] 09:06 AM
Metoprolol - [**2136-2-23**] 02:39 AM
Other medications:
Flowsheet Data as of [**2136-2-23**] 05:57 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**38**] a."
3450,"m.
Tmax: 37.1
C (98.7
T current: 36.9
C (98.4
HR: 95 (95 - 123) bpm
BP: 140/84(97) {84/41(54) - 140/84(97)} mmHg
RR: 17 (14 - 62) insp/min
SPO2: 99%
Heart rhythm: AF (Atrial Fibrillation)
Total In:
2,001 mL
659 mL
PO:
120 mL
Tube feeding:
IV Fluid:
1,881 mL
659 mL
Blood products:
Total out:
573 mL
125 mL
Urine:
573 mL
125 mL
NG:
Stool:
Drains:
Balance:
1,428 mL
534 mL
Respiratory support
O2 Delivery Device: None
SPO2: 99%
ABG: ////
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Irregular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
144 K/uL
9."
3451,"4 g/dL
143 mg/dL
0.8 mg/dL
32 mEq/L
4.4 mEq/L
24 mg/dL
108 mEq/L
143 mEq/L
27.4 %
7.8 K/uL
[image002.jpg]
[**2136-2-20**] 02:39 AM
[**2136-2-20**] 07:56 PM
[**2136-2-21**] 01:41 AM
[**2136-2-21**] 09:22 AM
[**2136-2-21**] 10:24 AM
[**2136-2-21**] 06:20 PM
[**2136-2-22**] 03:29 AM
[**2136-2-23**] 01:16 AM
WBC
7.2
10.7
11.7
7.9
7.8
Hct
31.1
27.7
28.8
28."
3452,"7
28.3
27.4
Plt
146
172
169
127
144
Creatinine
0.9
1.0
1.0
0.8
Troponin T
<0.01
0.14
0.26
0.23
Glucose
162
113
98
143
Other labs: PT / PTT / INR: 13.7/ 28.6/ 1.2, CK / CK-MB / Troponin
T:160/7/0.23, Ca:7.7 mg/dL, Mg:2.1 mg/dL, PO4:1.9 mg/dL
Assessment and Plan
PLAN:[**Age over 90 **] year old female s/p fall with hip fracture, small SAH
NEUO: Morphine/Diluadid prn. hold plavix x 1 week as per NS for SAH
(stable)."
3453,"CVS: Pt with post operative Afib with rvr and rate demand ischemia
overnight. Echo shows good cardiac function. Pt weened off of diltiazem
drip and transitioned to 50 mg PO lopressor. C/s cardiology - NSTEMI
from demand, continue asa and restart plavix when appropriate.
PULM: IS, pulm toilet
GI: nectar liquid and ground soft
RENAL: restart lasix today as h/o home loop diuretic dependent.
HEME: f/u HCT, goal HCT 30 given extensive cardiac history and NSTEMI
ENDO: RISS, goal FS<150.
ID: No issues.
TLD: Foley, left subclavian CVL
IVF: 75 cc/hr NS
CONSULTS: Neurosurg, Trauma [**Doctor First Name **], Ortho
BILLING DIAGNOSIS: SAH
ICU CARE:
GLYCEMIC CONTROL: RISS
PROPHYLAXIS: famotidine, Lovenox
COMMUNICATIONS:
ICU Consent: in chart
CODE STATUS: full
DISPOSITION: ICU
Lines:
20 Gauge - [**2136-2-21**] 05:44 PM
Multi Lumen - [**2136-2-22**] 03:00 AM
Total time spent: 35 min"
3454,"Admission Date: [**2136-2-19**] Discharge Date: [**2136-2-24**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
CC:[**CC Contact Info 6576**]
Major Surgical or Invasive Procedure:
[**2-20**] ORIF of Rt Hip
History of Present Illness:
HPI:[**Age over 90 **]F s/p mechanical fall from standing, no LOC, no syncope.
Transferred from OSH for small traumatic Lt occipital SAH and R
hip fx
PMx: CAD s/p CABG x3 in [**2112**], Systolic CHF, EF approx 30-40%,
Chronic AF, not on coumadin [**1-2**] fall w/SDH [**11/2134**]; Cardiac
valvular HD, moderate to severe MR [**First Name (Titles) **] [**Last Name (Titles) **], HTN, hyperlipidemia,
Restless legs syndrome, Hypothyroidism, PVD - L RAS, treated
medically; PVD s/p b/l revascularization w/ acute occlusion of R
LE s/p atherotomy w/stent [**2134**]"
3455,"Hypercholesterolemia
6. Coronary artery disease
7. Gait disturbance
8. Subarachnoid hemorrhage.
9. Hearing loss, which has gotten worse since the torsemide.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
PE:
VS: 97.7 64 160/98 12 100% RA
HEENT PERRLA, EOMI, TMs clear, no evidence of facial trauma
CV: Irregular, 2+ femoral pulses
Resp: eaqual bilateral breath sounds, no crepitus or contusion
GI: Abd softt/NT/ND
GU: No blood at ureteral meatus
Musculoskeletal: RLE externally rotated and shortened, obvious
defomity, tender, sensation intact to light touch, good cap
refill"
3456,"Repeat CT demonstrated stable small SAH and plain
films of the pelvis confirmed Rt hip fracture. she was
transferred to the Trauma ICU in stable condition. The remainder
of her discharge will be done by systems:
Neuro: The patient had a repeat Head CT on [**2135-2-20**] which showed
stable SAH. Neurosurgery recommended holding her plavix for 7
days, no need for seizure prophylaxis. She was AOx3 with some
episodes of confusion likely [**1-2**] dementia. Her neurological exam
remained stable throughout the remainder of her hospital stay.
CV: The patient has a h/o chronic Afib, post operatively she
went into AF w/ RVR with a rate in the 120s, she was hypotensive
and required Neo for BP suppory She was ruled out for MI, her
troponins were mildly elevated 0."
3457,"2. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9."
3458,"[**Last Name (STitle) 6577**]
[**Telephone/Fax (1) 1669**] for a follow-up appt in 1 mos
Medications on Admission:
ATENOLOL 50'', CLOPIDOGREL 75', LEVOTHYROXINE 62.5' (125 mcg [**12-2**]
tab QD), LISINOPRIL 20'', SLN 0.3 PRN chest pain, KCl SR 10 mEq
2 tabs' ROPINIROLE 0.25' HS, SIMVASTATIN 10', TORSEMIDE - 20 mg
2 tab qAM, 1 tab q PM PRN SOB; tylenol 500 1 tab TID PRN;
ARTIFICIAL TEARS 0.4 % Drops - 2 qtt [**Hospital1 **] PRN, ASA', CALCIUM
CARBONATE 500', DOCUSATE SODIUM 100'', ERGOCALCIFEROL 400'',
MULTIVITAMIN '
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed."
3459,"She is to restart her plavix on [**2136-2-25**]
Resp: The patient used incentive spirometer, and good pulmonary
toilette was give. She had nebulizer treatments as needed
GI: The patient's diet was slowly advanced, she was seen by
speech and swallow [**1-2**] to some difficulty swalloing. She was
cleared for a Soft (dysphagia); Thin liquid diet on discharge
GU: The patient had some low UOP in the setting of her AF w/ RVR
and hypovolemia. Her UOP improved and she was restarted on her
home regimen of Torsemide prior to discharge
Heme: The patient was placed on Lovenox for DVT prophylaxis"
3460,"Pertinent Results:
[**2136-2-24**] 01:11AM BLOOD WBC-9.4 RBC-2.98* Hgb-9.9* Hct-28.0*
MCV-94 MCH-33.4* MCHC-35.5* RDW-15.0 Plt Ct-191
0
[**2136-2-24**] 01:11AM BLOOD Glucose-94 UreaN-25* Creat-0.8 Na-142
K-3.2* Cl-100 HCO3-35* AnGap-10
[**2136-2-21**] 01:41AM BLOOD CK-MB-8 cTropnT-0.14*
[**2136-2-21**] 09:22AM BLOOD CK-MB-9 cTropnT-0.26*
[**2136-2-21**] 06:20PM BLOOD CK-MB-7 cTropnT-0.23*
Brief Hospital Course:
The patient was transferred from OSH to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**]
[**Last Name (NamePattern1) **] Hospital, she was seen in the Trauma Bay by Trauma
Surgery, Neurosurgery and Orthopedic Surgery were also
consulted."
3461,"Discharge Diagnosis:
Multi trauma: Lt occipital SAH, Rt intertrochanteric fracture
Discharge Condition:
Stable
Discharge Instructions:
Please do not drink alcohol or operate heavy machinery while
takig this medication
You may weight bear as tolerated on your Rt leg
Please follow-up with your PCP regarding this admission, your
medications for your heart have been changed please be sure to
discuss these changes with your PCP
Please restart your Plavix tomorrow [**2136-2-25**]
Followup Instructions:
Please follow-up with Orthopedics Dr. [**Last Name (STitle) 1005**] [**Telephone/Fax (1) 1228**] in
2weeks for a follow-up appointment
Please follow-up with Neurosurgery Dr. [**Last Name (STitle) 6577**]
[**Telephone/Fax (1) 1669**] for a follow-up appt in 1 mos
Completed by:[**2136-2-24**]"
3462,"Endocrine: The patient continued on her home dose of
Levothyroxine
Prior to discharge the patient was doing well. She was
neurologically intact. Her heart rate was irregular, her lungs
were CTAB, her abdomen was soft/NT/ND, Her Rt hip incision was
clean dry and intact. She was tolerating a disphagia diet
without difficulty and her pain was well controlled. She was
discharged to extended care facility with plans for follow-up as
follows:
Please follow-up with Orthopedics Dr. [**Last Name (STitle) 1005**] [**Telephone/Fax (1) 1228**] in
2weeks for a follow-up appointment
Please follow-up with Neurosurgery Dr."
3463,"[**Last Name (un) 1724**]:
ATENOLOL 50'', CLOPIDOGREL 75', LEVOTHYROXINE 62.5' (125 mcg
[**12-2**] tab QD), LISINOPRIL 20'', SLN 0.3 PRN chest pain, KCl SR 10
mEq 2 tabs' ROPINIROLE 0.25' HS, SIMVASTATIN 10', TORSEMIDE -
20 mg 2 tab qAM, 1 tab q PM PRN SOB; tylenol 500 1 tab TID PRN;
ARTIFICIAL TEARS 0.4 % Drops - 2 qtt [**Hospital1 **] PRN, ASA', CALCIUM
CARBONATE 500', DOCUSATE SODIUM 100'', ERGOCALCIFEROL 400'',
MULTIVITAMIN '
Social Hx:no EtOH, no tobacco
Past Medical History:
1. Congestive heart failure (As above)
2. Hypertension.
3. Hypothyroidism.
4. Atrial fibrillation: Not on coumadin [**1-2**] fall risk
5."
3464,"Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain."
3465,"26 maximally. She was started
on a Dilt gtt for rate controlHer Hct was 27 and she reecieved 1
unit of PRBC. She has an ECHO which demonstrated EF > 55% w/
mild LVH, Rt ventricular cavity dilated with normal free wall
contractility and moderate TR. Cardiology was consulted and
felt that the troponin leak was likely [**1-2**] demand ischemia. They
recommended continuing on ASA, beta blockade, rate control, and
statin, restarting plavix when able. They did not recommend
anticogulation given her fall risk. The patient was weaned off
pressors, she was transitioned from Dilt gtt to a po regimen of
Dilt 45mg QID and Lopressor 75 TID with adequate rate control."
3466,"16. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
17. Torsemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
18. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
19. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
20. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) inj
Subcutaneous Q24H (every 24 hours) for 4 weeks: 30mg SC Q24hrs
for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]"
3467,"hold plavix x 1 week as per NS for SAH
(stable).
CVS: afib.? rate demand ischemia overnight. Diltiazem gtt (wean as
tolerated/change to po if tolerated) for rate control. Wean
phenylephrine as tolerated. Home meds as tolerated. continue to cycle
cardiac enzymes. Lasix dependent. Would get TTE today.
PULM: IS post operatively
RENAL: on lasix as h/o home loop diuretic dependant.
HEME: transfused 1 unit prbcs very slowly, follow HCT, goal HCT 30
given ectensive cardiac history
ENDO: RISS, goal FS<150.
ID: No issues.
Lines / Tubes / Drains: Foley
Wounds: Dry dressings
Imaging:
Fluids: D5 1/2 NS, Potassium Chloride
Consults: Trauma surgery, Ortho
Billing Diagnosis: Arrhythmia, Post-op hypotension, Multiple injuries
(Trauma)
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2136-2-19**] 10:23 PM
16 Gauge - [**2136-2-20**] 10:25 PM
Prophylaxis:
DVT: LMW Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 32 minutes"
3468,"5 mcg/Kg/min
Diltiazem - 10 mg/hour
Other ICU medications:
Morphine Sulfate - [**2136-2-20**] 10:02 AM
Metoprolol - [**2136-2-20**] 10:37 PM
Diltiazem - [**2136-2-21**] 12:40 AM
Furosemide (Lasix) - [**2136-2-21**] 02:56 AM
Hydromorphone (Dilaudid) - [**2136-2-21**] 04:22 AM
Other medications:
Flowsheet Data as of [**2136-2-21**] 06:20 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**38**] a.m.
Tmax: 37.3
C (99.1
T current: 35.8
C (96.5
HR: 70 (69 - 115) bpm
BP: 110/43(57) {65/41(46) - 149/80(96)} mmHg
RR: 16 (16 - 34) insp/min
SPO2: 99%
Heart rhythm: AF (Atrial Fibrillation)
Total In:
1,654 mL
656 mL
PO:
60 mL
Tube feeding:
IV Fluid:
1,488 mL
413 mL
Blood products:
107 mL
243 mL
Total out:
772 mL
305 mL
Urine:
722 mL
305 mL
NG:
Stool:
Drains:
Balance:
882 mL
351 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 99%
ABG: /// 31/
Physical Examination
General Appearance: No acute distress, very thin
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)
Respiratory / Chest: (Breath Sounds: Diminished: @ bases)
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3, x 2), Follows simple
commands, (Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
169
10."
3469,"2
98
1.0
31
4.8
31
109
146
28.8
11.7
[image002.jpg]
[**2136-2-20**] 02:39 AM
[**2136-2-20**] 07:56 PM
[**2136-2-21**] 01:41 AM
WBC
7.2
10.7
11.7
Hct
31.1
27.7
28.8
Plt
146
172
169
Creatinine
0.9
1.0
1.0
Troponin T
<0.01
0.14
Glucose
162
113
98
Other labs: PT / PTT / INR: 13.7/ 28.6/ 1.2, CK / CK-MB / Troponin
T:146/8/0.14, Ca:7.6, Mg:2.1, PO4:3.2
Assessment and Plan
ATRIAL FIBRILLATION (AFIB), HYPOTENSION (NOT SHOCK), IMPAIRED SKIN
INTEGRITY, SUBARACHNOID HEMORRHAGE (SAH), HIP FRACTURE (FEMORAL NECK
FRACTURE, FEMUR)
Assessment and Plan: [**Age over 90 **] year old female s/p fall with hip fracture,
small SAH
NEUO: Morphine/Diluadid prn."
3470,"Levothyroxine Sodium 22.
Lisinopril 23. Magnesium Sulfate
24. Metoprolol Tartrate 25. Morphine Sulfate 26. Multivitamins 27.
Nitroglycerin SL 28. Ondansetron
29. Phenylephrine 30. Potassium Chloride 31. Potassium Phosphate 32.
Ropinirole 33. Simvastatin
34. Sodium Chloride 0.9% Flush 35. Vitamin D
24 Hour Events:
Patient went to OR for pinning of right hip. Post operatively patient
with low urine output, rapid afib, ? ekg changes. Started on esmolol
gtt, however could not control HR well, so switched to diltiazem.
Phenylephrine started for BP control. 1 unit of Prbcs administered,
followed by 20mg IV lasix.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2136-2-20**] 11:39 PM
Infusions:
Phenylephrine - 1."
3471,"TSICU
HPI:
[**Age over 90 **]F s/p fall with small L parietal SAH & R hip fx.
Chief complaint:
mutiple trauma, post operative hypotension
PMHx:
HTN, hyperchol, CAD s/p CABG, Afib, CHF, PVD s/p LE stents, restless
leg, TR/MR
[**Name13 (STitle) **] medications:
1. 2. 1000 mL LR 3. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 4.
Acetaminophen 5. Aspirin 6. Atenolol
7. Calcium Carbonate 8. Calcium Gluconate 9. CefazoLIN 10. Diltiazem
11. Diltiazem 12. Docusate Sodium
13. Enoxaparin Sodium 14. Famotidine 15. Furosemide 16. Furosemide 17.
Furosemide 18. HYDROmorphone (Dilaudid)
19. Hydrochlorothiazide 20. Insulin 21."
3472,""" Interview limited as she is hard of hearing and
also intermittently awake. Of note, the patient declines any
blood until her daughter arrives.
Her daughter confirms that the patient did not receive a stent
at [**Hospital3 **], her diagnosis of PE was uncertain. Critical
care consent reviewed and signed.
ROS: Denies chest pain, abdominal pain, active nausea, diarrhea,
constipation, BRBPR, melena, hematochezia.
Past Medical History:
- CAD s/p MI in [**2118**]; NSTEMI [**2124-11-17**]
- COPD
- History of TB s/p Rx
- Anemia
- Colon CA
- Hiatal Hernia
- Recurrent Falls
- R malleolar Fx (Admission c/b sepsis and hypotension- tubed
and on pressors)
- Hx of Enterobacter UTIs
- ?"
3473,"#. Atrial Fibrillation with Rapid Ventricular Rate: The patient
was admitted with a sustained rate of 120s-130s in atrial
fibrillation and a history of paroxysmal atrial fibrillation.
She spontaneously converted to sinus rhythm with fluid and blood
rescuscitation with a period of transient hypotension that
resolved. Her beta blocker was held while admitted to the MICU.
.
Several days into her course patient spontaneously converted
back into atrial fibrillation with rapid rate, accompanied by
worsening dyspnea and pulmonary edema. Rate was controlled with
IV metoprolol which was later converted to PO metoprolol, which
was later uptitrated for better rate control. Rate was well
controlled on this regimen."
3474,".
Given CHADS 1 and recent GI bleed (as well as h/o recurrent
falls), the decision was made not to anticoagulate, coumadin is
discontinued.
# Pulmonary edema: In the setting of afib with RVR, patient
develoepd pulmonary edema. She was diuresed gently with 10 mg IV
lasix boluses and was approximately 2 L net negative over the
next 24 hours with improvement in dyspnea and oxygenation. If
she becomes SOB again, we strongly recommend considering fluid
overload with potential treatment with low-dose lasix (as well
as consideration of aspiration).
#. Leukocytosis with bacteruria: The patient had a rapidly
rising WBC with Left shift but no bands, positive U/A (recent
Enterobacter infection) and ?"
3475,"On room air at discharge.
.
#. CAD/Recent NSTEMI: Patient was on ASA, Plavix and metoprolol
after recent NSTEMI, no percutaneous intervention or hardware
present. Troponin elevated here, but with normal CK/CK-MB, and
the troponin remained flat. With impaired GFR and recent NSTEMI
this may represent old MI, renal failure or MI within the last 7
days. EKG was not revealing of ST changes. Decided to
discontinue plavix in setting of GI bleed and risk > benefit.
Did restart 162mg enteric-coated ASA.
#. Dysphagia: Patient had witnessed aspiration event. Evaluated
by speech & swallow. Placed on dysphagia diet. Concern for
aspiration continues."
3476,".
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Hematemesis
Atrial fibrillation with [**Hospital 5509**]
Hospital-acquired pneumonia
Dysphagia
Pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the hospital with vomiting blood. This
resolved on its own, without any procedure other than medical
management. Gastreoenterology was consulted and monitored your
course."
3477,"Mild aortic and
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
.
[**1-4**] ECG:
Atrial fibrillation with rapid ventricular response. Diffuse
ST-T wave changes that are non-specific. Compared to the
previous tracing of [**2109-10-15**] atrial fibrillation is new.
.
[**1-4**] abdominal x-ray:
IMPRESSION: No evidence of bowel obstruction or perforation.
.
[**1-8**] CXR:
As compared to the previous radiograph, there is a minimal
improvement with reduction of the bilateral pleural effusions
and minimal
improvement in ventilation of the right lung. Otherwise, the
radiograph is
unchanged, unchanged size of the cardiac silhouette.
.
[**1-5**] ankle x-ray:
There is again seen a bimalleolar fracture with a transversely
oriented
fracture line to the medial malleolus and obliquely oriented
fracture line to the distal fibula."
3478,"3. Large hiatal hernia.
.
[**1-4**] Echo:
The left atrium is mildly 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 valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mildly dilated right ventricle with preserved global
and regional biventircular systolic function."
3479,"Admission Date: [**2125-1-4**] Discharge Date: [**2125-1-9**]
Service: MEDICINE
Allergies:
Nystatin / Tetracycline
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
L Femoral Line placement and then removal.
History of Present Illness:
This [**Age over 90 **] year old lady was found at [**Hospital 100**] Rehab to have an
episode of vomiting of undigested food followed by 5 episodes
coffee ground emesis in the setting of a supratherapeutic INR on
Warfarin for PE and plavix for CAD. She was given Compazine PR,
and Coumadin has been held since [**1-3**]. At that time per ED Call
in, she denied chest pain, dyspnea or abdominal pain."
3480,"ASA restarted, Plavix and
Warfarin held at time of transfer out of the ICU. PPI converted
from drip to bolus and the patient was able to advance her diet
without issue. Based on risk/benefit ratio (CHADS = 1), are
holding plavix and coumadin, but continuing aspirin on
discharge. Patient without stent or hardware, so also has
presumed history of pulmonary embolism, no clear indication for
plavix even in setting s/p NSTEMI. As such, given concern for
bleed greater than benefit of antiplatelet, we have discontinued
plavix. Opted to continue aspirin however. Hematocrit stable,
after initial drop, through rest of ICU stay as well as on the
floor."
3481,"4* Mg-1.9
Brief Hospital Course:
A [**Age over 90 **] year old admitted to the MICU from [**Hospital 100**] Rehab with coffee
ground emesis in the setting of a supratherapeutic INR.
#. Hematemesis: The patient was admitted after 4-5 episodes of
coffee grounds emesis without hemodynamic instability, on
Aspirin, Plavix and Warfarin for a recent NSTEMI and ? PE during
a [**Month (only) 404**] admission to [**Hospital3 **]. Her INR was elevating
to [**2-19**], likely due to a Ciprofloxacin interaction without a
concomittant dosage change.
GI Consulted, no EGD necessary. 1 unit pRBCs transfused
although the patient only experienced a drop in hematocrit
consistent with fluid hydration."
3482,"5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation every [**2-20**]
hours as needed for wheeze/sob.
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain: Do not exceed 4gm/day.
7. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO QPM.
8. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10) mL
PO once a day.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lactobacillus Acidophilus Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day."
3483,"11. Maalox 200-200-20 mg/5 mL Suspension Sig: Three (3)
suspensions PO twice a day.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as needed as needed for chest pain.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Cefepime 1 gram Recon Soln Sig: One (1) gram Recon Soln
Injection Q24H (every 24 hours) for 2 doses: To be given on [**1-10**]
and [**1-11**]."
3484,"3 PRN chest pain
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for HR<60 or SBP <110. If HR is elevated
and blood pressure can tolerate, consider uptitration of this
medication.
3. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulization
Inhalation Q6H (every 6 hours) as needed for wheeze/sob.
5. Albuterol Sulfate 2."
3485,"She has
resided at [**Hospital 100**] Rehab MACU [**2124-12-6**]-since [**2124-12-30**], Floor
[**2124-12-31**]-Present after a Rt ankle fracture from [**Hospital3 **]
hospital. She was recently on Cipro for a UTI.
In the ED, initial VS: 98.5 138 101/71 20 93. The patient was
found to be in rapid Afib (rate 130s) with a non-tender abdomen
and guaiac negative; unsuccessful NG lavage. She was given NS
and 1 unit FFP and Vitamin K 10mg IV x1 for elevated INR.
Femoral line and peripheral placed, T&S obtained, started on
Protonix Bolus/Gtt."
3486,"Cast removed
by ortho. With ankle brace in place upon discharge.
# Had femoral line originally in setting of GI bleed, then
removed.
# CODE: DNR/DNI dated [**1-2**] in chart (Confirmed with daughter)
# CONTACT: Daughter [**Name2 (NI) 111377**] [**Name2 (NI) 111378**] Home [**Telephone/Fax (1) 111379**],
Cell: [**Telephone/Fax (1) 111380**]
Medications on Admission:
ASA 325mg PO Daily
Clopidogrel 75mg PO daily
Metoprolol 12.5mg PO BID
Bumetanide 1mg PO daily
Albuterol/Ipratropium
Acetaminophen 650mg PO TID
Mirtazapine 7.5mg PO QPM
Megestrol 400mg PO daily
Famotidine 20mg PO daily
Lactobacillus 1 tab PO Daily
Maalox 15mL PO BID
Bisacodyl 10mg PR daily
Senna 2 tabs PO Daily
NTG 0."
3487,"Given an elevated WBC count, cough, CXR
appearance and infected appearing U/A, the patient was started
on Vanc/Zosyn and admitted to the ICU.
With the assistance of a translator, the patient reports that
she is currently comfortable but for dry mouth. She has a cough
but is unsure of its duration and is unsure if she has had
fevers. She recalls that she was nauseated and vomiting last
night and was nauseous earlier today but is without nausea or
abdominal pain at this time. She denies any bleeding and bloody
stools. She denies chest pain and reports that her breathing is
""bad as usual."
3488,"PNA on CXR. She received
Vanc/Zosyn in the ED presumably for a PNA but was converted to
Vanc/Cefepime/Cipro then Vanc/Cefepime. No clear source
identified initially. Given persistence of WBC prior to leaving
the ICU, repeat cultures were sent, and CXR showed worsening
infiltrates. To continue to cover hospital-acquired pneumonia
(including pseudomonas), she was continued on cefepime only -
planning for 8 day course, so 2 days more of once daily
antibiotics (cefepime) at rehab.
#. Hypoxia/COPD: The patient has an O2 requirement that was
initially likely secondary to COPD and/or pneumonia (see above).
Nebulizers were continued."
3489,"of PE, currently anticoagulated
Social History:
Russian speaking. Currently at [**Hospital 100**] Rehab, habits unknown.
Daughter involved in her care.
Family History:
nc
Physical Exam:
Vitals - T: 99.2 BP: 104/50 HR: 125 RR: 23 02 sat: 98% 2L
GENERAL: Elderly, ill appearing, intermittently awake but easily
arousable
HEENT: JVP~ 7cm
CARDIAC: S1 & S2 rapid and irregular
LUNG: Rhonchi in all fields, R>L, bibasilar dull breath sounds,
not using accessory muscles
ABDOMEN: Nontender or distended
EXT: R cast in place, L femoral line oozing from insertion site.
NEURO: Oriented while awake
********
On discharge, rhonchi and rales present. R leg with brace."
3490,".
#. ? PE: The patient has an uncertain history of PE based on
elevated PA pressure from [**Hospital3 5097**], no confirmatory test
performed per HebReb records and daughter. [**Name (NI) 227**] uncertainty
(and CHADS = 1) and her current high bleeding risk, we
discontinued coumadin and let her INR drift down.
#. R bimallelor fracture: Spoke with Orthopedics Dr. [**Last Name (STitle) 57141**]
[**Telephone/Fax (1) 111375**]; [**Telephone/Fax (1) 111376**] (Cell) from [**Hospital3 **]. The
patient is due for cast removal, but must have an Aircast Ankle
brace to replace it until ~ [**2125-1-16**]. Patient is Bed to Chair
and Touch Down Weight Bearing per her orthopedist."
3491,".
You were on coumadin for atrial fibrillation and for a presumed
pulmonary embolism, but given your history of falls and your
gastrointestinal bleed on this admission, it is felt that the
risk of bleed outweighs the benefit of stroke prevention, and so
we have discontinued your coumadin.
.
You were found to be aspirating, so your diet was changed per
speech & swallow recommendations.
.
You had evidence of a pneumonia, so you are being empirically
treated, and you have 2 more days of IV antibiotics to finish
your course.
Followup Instructions:
Please see your primary care physician after you leave from
[**Hospital 100**] Rehab.
Completed by:[**2125-1-9**]"
3492,"Your blood level (hematocrit) remained stable after the
initial admission decrease.
.
You had an irregular heartbeat (atrial fibrillation) that became
rapid (rapid ventricular response) on 2 occasions, and responded
to fluid resuscitation as well as diuresis. After that, with
medication, your heart rate control has improved.
.
You had some fluid on your lungs, and diuresis with low-dose
lasix improved your respiratory status. If you have more
shortness of breath, consideration to give another one-time low
lasix would be important.
.
You were on medications for a presumed pulmonary embolism
(plavix and aspirin) but we feel that given you had a bleed,
your risk of bleed outweighs the benefits, and so we are
discharging you solely on aspirin, and not on plavix anymore."
3493,"Pertinent Results:
Admission Labs:
[**2125-1-4**] 03:50AM WBC-21.2* RBC-4.12* HGB-12.7 HCT-38.7 MCV-94
MCH-30.8 MCHC-32.8 RDW-16.1*
[**2125-1-4**] 03:50AM CK-MB-NotDone cTropnT-0.10*
[**2125-1-4**] 03:50AM CK(CPK)-74
[**2125-1-4**] 03:50AM GLUCOSE-141* UREA N-51* CREAT-1.1 SODIUM-144
POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-26 ANION GAP-19
[**2125-1-4**] 03:57AM LACTATE-2.2* K+-3.8
[**2125-1-4**] 10:40AM ALBUMIN-3.3* CALCIUM-8.7 PHOSPHATE-3."
3494,"3
MAGNESIUM-1.9
[**2125-1-4**] 10:40AM GLUCOSE-131* UREA N-48* CREAT-1.1 SODIUM-145
POTASSIUM-3.2* CHLORIDE-106 TOTAL CO2-27 ANION GAP-15
[**2125-1-4**] 07:43PM HCT-31.8*
.
Imaging:
CHEST, SINGLE AP VIEW: The heart is mildly enlarged. A calcified
right
fibrothorax, with calcified pleural densities and volume loss in
the right
upper lobe, are similar in appearance. Bilateral pleural
effusions with
bibasilar opacities are new. A large hiatal hernia appears
larger.
IMPRESSION:
1. Mild cardiomegaly.
2. Calcified right fibrothorax, with new small bilateral pleural
effusions
with associated atelectasis of the adjacent lower lobes."
3495,"The ankle mortise is grossly
preserved. There is some bridging callus however the fracture
lines are still visualized. There is generalized soft tissue
swelling about the ankle. No additional fractures are seen.
.
Discharge labs:
[**2125-1-9**] 07:50AM BLOOD WBC-11.9* RBC-3.68* Hgb-10.6* Hct-33.9*
MCV-92 MCH-28.8 MCHC-31.3 RDW-15.9* Plt Ct-228
[**2125-1-9**] 07:50AM BLOOD Glucose-114* UreaN-34* Creat-0.7 Na-146*
K-3.5 Cl-107 HCO3-32 AnGap-11
[**2125-1-9**] 07:50AM BLOOD Calcium-9.3 Phos-2."
3496,"11
CXR: CM
U/A +LE, mod WBC, bacteria
Problem list
GI bleed/acute blood loss anemia
Leukocytosis
Afib
Hypotension
1. GI bleed with acute blood loss anemia- likely upper GI source, and
precipitated by increasing INR in the context of recent abx
On protonix, bowel rest, serial hct's, transfusion; off coumadin
GI to see, though no immediate plans for EGD
2. Hypotension /: multifactorial with hypovolemia/GI bleed; may also
have cardiogenic component given rapid afib. Plan resuscitation with
blood transfusion/fluids
3. Leukocytosis: concerning for infection. Specific cause unclear,
though lungs/urine most likely. On vanc/cefipime/cipro to cover
HAP/UTI. F/u cultures and check CDiff
4. NSTEMI: troponin still elevated. Has recent hx of NSTEMI, though
recent elevations more likely due to demand phenomenon with GI bleed
and rapid afib. Off ASA/Plavix for now, consider resuming once bleeding
stopped.
5. Possible hx of [**Name (NI) 13442**] unclear documentation. Off anticoagulation while
bleeding, will need to sort out previous w/u.
Daughter updated at bedside.
Pt is critically ill.
Total time spent: 70 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 618**] [**Last Name (NamePattern1) **], MD
on:[**2125-1-4**] 13:13 ------"
3497,"GI consult
Leukocytosis: ? just related to GI bleed, vs superimposed infection,
sent C.diff, urine culture, blood culture. Treat with
vanco/cefepime/cipro.
Elevated troponin: likely some demand in the context of tachycardia,
willl hold plavix and aspirin, trend markers and serial EKGs.
Afib: will continue volume resuscitation if thi sdoesnot help her HR
then will load with amiodarone and start a drip.
PE: presumptting holding coumadn in setting of hemodynamically
significant GI bleed
bleeding femoral line site: apply pressure dressing.
? tamponade: will measure pulsus.
fracture: one acute issues resolve cast canbe removed and aircast
should be placed instead.
ICU Care
Nutrition:
Comments: NPO
Glycemic Control:
Lines / Intubation:
Multi Lumen - [**2125-1-4**] 08:00 AM
20 Gauge - [**2125-1-4**] 08:02 AM
Comments:
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: DNR / DNI
Disposition: ICU
Total time spent: 40 minutes
Patient is critically ill
------ Protected Section ------
I saw and examined the pt, and was physically present with the ICU team
for the key portions of services provided."
3498,"Abdominal: oozing left groin line
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
377 K/uL
31.0 %
10.0 g/dL
131 mg/dL
1.1 mg/dL
48 mg/dL
27 mEq/L
106 mEq/L
3.2 mEq/L
145 mEq/L
25.1 K/uL
[image002.jpg]
[**2125-1-4**] 08:10 AM
[**2125-1-4**] 10:40 AM
WBC
25.1
Hct
31.0
Plt
377
Cr
1.1
Glucose
131
Other labs: PT / PTT / INR:18.0/26.1/1.6, CK / CKMB / Troponin-T:42//,
ALT / AST:20/21, Alk Phos / T Bili:43/0."
3499,"Chief Complaint: GI bleed, tachycardia and hypotension.
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
[**Age over 90 **] yo F with coffee ground emesis x5 episodes last night. Recently
admitted to StE for Right maleolar fracture that was casted, course
complicated by Hypoxia, NSTEMi, enterobacter UTI, that was medically
managment, there was also high concern for PE and she was
anticoagulated empirically for this although no confirmatory test was
done. Aparently was also started on cipro recenlty for UTI,a nd INR
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 13430**] setting."
3500,"3
C (99.2
Tcurrent: 37.3
C (99.2
HR: 126 (118 - 133) bpm
BP: 92/57(64) {88/48(58) - 115/62(72)} mmHg
RR: 21 (19 - 28) insp/min
SpO2: 97%
Heart rhythm: AF (Atrial Fibrillation)
Total In:
1,581 mL
PO:
TF:
IVF:
81 mL
Blood products:
Total out:
0 mL
260 mL
Urine:
60 mL
NG:
100 mL
Stool:
Drains:
Balance:
0 mL
1,321 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 97%
ABG: ///27/
Physical Examination
General Appearance: No acute distress
Cardiovascular: (S1: Normal), (S2: Normal), JVP elevated
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Breath Sounds: No(t) Crackles : , Diminished:
bases, Rhonchorous: ), no accessory muscle use."
3501,"I agree with Dr.[**Name (NI) 13441**]
note above, including assessment and plan. I would add:
[**Age over 90 **] yo female with coffee grds emesis 4-5 times over the past day; INR
[**2-19**]'s in the context of cipro for a UTI
Recent admission to [**Hospital3 1004**] with ankle fx; course complicated by
sepsis/hypotension, NSTEMI medically managed- sent out on asa/plavix,
coumadin for possible PE
ED: afib 130's
guiac negative
unit ffp, vit K, protonix, vanc/zosyn
PMHx: COPD, colon CA, p. afib
Rx: ASA, plavix, metoprolol
INR 1.6
Hct38-->31
troponin 0.1-->0."
3502,"8, Fibrinogen:450 mg/dL, Lactic
Acid:2.0 mmol/L, Albumin:3.3 g/dL, LDH:202 IU/L, Ca++:8.7 mg/dL,
Mg++:1.9 mg/dL, PO4:3.3 mg/dL
Fluid analysis / Other labs: U/a positive
Imaging: bilateral small pleural effusion, could not exclude
pericardial effusion due to increase in cardio/pericardio silouette.
Assessment and Plan
Hypotension/shock: hemorrhagic from uppper GI bleed, vs concomitant
superimprosed sepsis. continue fluid and red cell resuscitation. goal
U/O >30cc/hr.
GI bleed: holding coumadin, s/p Vit K and FFP, transfuse, f/u hct
closely. Consider platelet transfusion."
3503,"P/w tachycardia to the 150 in Afib, started on
protonix drip, started on vanco and zosyn for wbc 21, + u/a nad
abnormal CXR.
Patient admitted from: [**Hospital1 19**] ER
Allergies:
Nystatin
Unknown;
Tetracycline
Unknown;
Last dose of Antibiotics:
Infusions:
Pantoprazole (Protonix) - 8 mg/hour
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
COPD
Colon cancer
Recent NSTEMI
old TB
Diastolic heart failure
paroxysmal Afib
non contributory
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: as in HO note
Review of systems:
Flowsheet Data as of [**2125-1-4**] 12:37 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**26**] AM
Tmax: 37."
3504,"Admission Date: [**2161-5-16**] Discharge Date: [**2161-5-23**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
respiratory failure and septic shock
Major Surgical or Invasive Procedure:
central venous catheter placement
History of Present Illness:
88 y/o Russian male with Alzheimer's dementia, remote latent TB
treated w/rifampin and pyrazadine in [**2153**], AF on coumadin, HTN
sent in from [**Hospital 100**] Rehab for dyspnea, fever, and hypoxia. On
the day prior to presentation ([**2161-5-15**]) he was noted to be tired
and weak, and he fell. He has not complained of respiratory
symtpoms."
3505,"A second IV was placed and he
was started on vancomycin, cefepime, and levofloxacin.
Past Medical History:
- COPD (unclear history, always a nonsmoker)
- HTN (active)
- AF on coumadin (active)
- colon cancer [**2152**] (inactive)
- dementia (AO x 1 at baseline)
- history of TB, found to have 10mm PPD in [**2153**], had a negative
CXR so treated in [**2153**] for 9 months for latent TB. CXR repeat in
[**2156**] looked increased density at the bases
- BPH (active)
- GERD (active)
Social History:
lives at [**Hospital 100**] Rehab
Family History:
No family history of TB.
Physical Exam:
On Admission:
GEN: pleasantly demented, AOx2 (knew he was in a hospital)
comfortable but tachypneic, NAD, pulling at lines
HEENT: PERRL, anicteric, MMM, no jvd,
RESP: Right basilar rales and reduced breath sounds, otherwise
clear."
3506,"**FINAL REPORT [**2161-5-22**]**
WOUND CULTURE (Final [**2161-5-22**]): No significant growth.
.
5 sets of blood cultures pending, all no growth to date
Brief Hospital Course:
88 year-old Russian-speaking M with Dementia, suspected COPD,
AFib on Coumadin, HTN who presented with dyspnea, hypoxia, and
fever, s/p MICU course for treatment of respiratory failure and
septic shock likely secondary to healthcare-associate pneumonia,
transferred to the Medicine floor for continued management,
which was complicated by delerium and subsequent uretheral
injury from self-discontinuation of foley placement. Also found
to have VRE bacteremia for which he was started on 14 days of
Linezolid."
3507,".
# Acute respiratory distress/Healthcare Associated Pneumonia:
Presentation with dyspnea, fever, bandemia, hypoxia, and CXR
findings all consistent with acute pneumonia. Given his
residence at [**Hospital 100**] Rehab, he was started on Vancomycin,
Cefepime, and Levofloxacin. TB felt unlikely given the rapid
acuity of symptoms and lack of other more subacute
constitutional symptoms. Moreover, patient had documented
adequate treatment of latent TB (with negative CXR) in [**2153**].
Additional processes, such as pulmonary embolism, seemed
unlikely given his therapeutic INR. Patient was treated with
Bipap and appeared to improve, but on hospital day #2, he was
tachypneic to the 30s, somnolent and working very hard to breath
so he was intubated and placed on ARDS net ventilation."
3508,"Once
stable he was 12L positive and diuresis with IV Lasix was
initiated. He responded well to Lasix 20mg IV and was extubated
on [**5-19**] without complication. Diuresis was continued until his
volume status was optimized. An echocardiogram showed normal
systolic function. He completed a 7 day course of broad
antibiotics.
.
# Severe sepsis: Patient presented with pneumosepsis and
elevated lactate up to 9. His lactate trended down to 2 after
6L IVF in the ED. His pressures maintained MAP >60 until the
patient was intubated when he became hypotensive. A central
line was placed and he was started on Levophed."
3509,"He was given
bolus fluids for CVP <10 and weaned off pressors. He was put on
Vanc/Levo/Cef for presumed HAP. He did have BCx positive for
GPCs after resolution of sepsis, which were ultimately speciated
to VRE (Vancomycin Resistant Enterococcus). His central venous
catheter was removed. He was started on a 14 days course of PO
Linezolid 600 mg twice daily, which should continue until
[**2161-6-3**]. Surveillence blood cultures have shown no growth to
date. These are still pending and should be followed up on.
.
# Delerium: Likely secondary to toxic/metabolic encephalopathy
from infection in a patient with underlying dementia."
3510,"We
attempted to minimize unecessary lines and tubes, provide
frequent orientation, and avoid aggravating
medications/sedatives.
.
# Atrial fibrillation: Rate controlled without medications. On
Coumadin for anticoagulation. His INR was elevated at 3 (likely
secondary to antibiotics and poor nutrition), so Coumadin has
been held at discharge. His INR should be monitored and Coumadin
re-started once necessary.
.
# BPH/Urinary Obstruction: Tamsulosin held on admission during
severe sepsis, but re-started upon transfer to the floor. The
patient self-discontinued his foley and had subsequent traumatic
injury resulting in blood clots that would cause painful
obstruction. A foley was placed and will need to remain until he
is healed and a voiding trial can be attempted."
3511,"Frequent
irrigation should be provided to prevent blood clots.
.
# [**Last Name (un) **]: Mild, but eGFR of 40 on admission with elevated BUN.
Creatinine improved from 1.1 to 0.8 after IVF resuscitation in
the MICU, but increased after diuresis. 1.2 at discharge, which
should be monitored in the future.
.
# Suspected COPD: Patient continued on nebulizer treatement.
.
# Microcytic Anemia: Remained relatively stable throughout the
admission. He required no blood products.
Medications on Admission:
- warfarin 3 mg daily
- aspirin 325 mg daily
- flomax 0.4 mg daily
- senna 17.2mg PO HS
- trazodone 12.5mg PO HS
- albuterol nebs 0."
3512,"6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for shortness of breath, wheezing.
7. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 11 days: last day [**2161-6-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
health-care associated pneumonia
bacteremia
toxic/metabolic encephalopathy
urinary obstruction
.
dementia
anemia
atrial fibrillation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)."
3513,"Discharge Instructions:
Dear Mr. [**Known lastname 55195**],
You were initially admitted to the intensive care unit (ICU) for
treatment of your difficulty breathing, which was likely
secondary to a pneumonia. You were given medications and you
improved. You were also found to have a bacteria in your blood,
for which you will continue to take an antibiotic for after
discharge.
.
Your INR was elevated from the antibiotics you are receiving.
Today the level was 3. We are holding your Coumadin (3 mg
daily), but this will need to be re-started once the level
falls.
.
Additionally, when you were confused you pulled out your foley,
which caused an injury and subsequent blood clots. You will be
discharged with the foley, which will be removed once you heal.
.
-Please START Linezolid 600 mg by mouth twice daily for a total
of 14 days (last day [**2161-6-3**])
-Please HOLD Coumadin for now until labwork shows INR falls
below 2.5
Followup Instructions:
A physician at your facility will be taking care of your needs.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]"
3514,"3 (29%
bands), INR 2.2. Bcx pending. CXR showing right sided pneumonia.
EKG showing ST 125, LAD, first degree AV delay, no ischemic
changes. Patient was given vancomycin, zosyn, combivent x 3,
tylenol. Only received 1L IVF. His vitals on transfer - 96 on
10L, RR 27, and his access was 1 PIV.
.
On the unit, he was tachypneic, but appeared comfortable and
denied any symptoms. He had a few episodes of relative
hypotension to the 80s-90s systolic. His oxygenation improved to
low-mid 90s on 5L. His lactate rose to 9. He was given 2L of LR
and his lactate trended down to 6."
3515,"083%
- tylenol 650mg PO PRN pain
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for Pain."
3516,"No wheezes.
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx2. [**4-7**] symmetric strength throughout upper and lower
extremities. No pronator drift., downgoing toes,
1+DTR's-patellar and biceps.
.
On Discharge:
GEN: alert, comfortable, no increased work of breathing
HEENT: sclera anicteric. MMM
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: limited by cooperation. bibasilar rales
Abd: +BS, soft, NT, ND
GU: + foley
Extremities: warm, +SCDs
Neuro/Psych: face symmetric, moves all extremites"
3517,"Pertinent Results:
Admission:
[**2161-5-16**] 06:00AM BLOOD WBC-10.3 RBC-5.53 Hgb-14.2 Hct-43.4
MCV-79* MCH-25.6* MCHC-32.6 RDW-14.8 Plt Ct-177
[**2161-5-16**] 06:00AM BLOOD Neuts-62 Bands-29* Lymphs-5* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0
[**2161-5-16**] 06:00AM BLOOD PT-23.7* PTT-36.7* INR(PT)-2.2*
[**2161-5-16**] 06:00AM BLOOD Glucose-172* UreaN-27* Creat-1.1 Na-140
K-5.0 Cl-104 HCO3-19* AnGap-22*
[**2161-5-16**] 06:00AM BLOOD cTropnT-0."
3518,"01 proBNP-1255*
[**2161-5-17**] 04:25AM BLOOD Calcium-7.6* Phos-1.8* Mg-1.4*
.
Discharge:
[**2161-5-23**] 06:00AM BLOOD WBC-11.4* RBC-4.95 Hgb-12.4* Hct-38.5*
MCV-78* MCH-25.1* MCHC-32.3 RDW-15.5 Plt Ct-367
[**2161-5-23**] 06:00AM BLOOD PT-30.3* PTT-34.4 INR(PT)-3.0*
[**2161-5-23**] 06:00AM BLOOD Glucose-112* UreaN-21* Creat-1.2 Na-146*
K-3.5 Cl-105 HCO3-27 AnGap-18
[**2161-5-23**] 06:00AM BLOOD Calcium-8.8 Phos-2."
3519,"3* Mg-2.3
.
[**2161-5-17**] 10:08 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2161-5-17**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
SINGLY IN PAIRS.
RESPIRATORY CULTURE (Final [**2161-5-19**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
.
[**2161-5-19**] 1:55 pm BLOOD CULTURE Source: Line-Rt CVL.
Blood Culture, Routine (Preliminary): ENTEROCOCCUS
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ R
LEVOFLOXACIN---------- R
VANCOMYCIN------------ R
Anaerobic Bottle Gram Stain (Final [**2161-5-20**]):
GRAM POSITIVE COCCI IN CHAINS.
.
[**2161-5-20**] 3:07 pm CATHETER TIP-IV Source: Rt IJ."
3520,"Overnight at 0100 he dropped to below 90% and placed
on 2LNC. He had respiratory distress, was given nebulizer and
tylenol without improvement. Later, his O2 sat dropped to 70 on
2L, and he was switched to NRB with 15L, then 96%. Temp was
99.6, given albuterol, but respirations increased to 37. Two
other people were ruled out for flu on the floor. Urine
legionella is pending.
.
In the ED, initial VS - 101, 125 (AF), 148/70, 32, 94% 15L NRB.
Exam notable for tachypnea, 94% on NRB, diffuse rhonchi. Labs
notable for lactate 5.8, Cr 1.1, bicarb 19, wbc 10."
3521,"Admission Date: [**2149-7-16**] Discharge Date: [**2149-7-22**]
Date of Birth: [**2070-5-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Flagyl
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Hypotension, atrial fibrillation with rapid ventricular
response, acute kidney injury
Major Surgical or Invasive Procedure:
TEE (Transesophageal Echocardiogram) with DC cardioversion
[**2149-7-18**]
History of Present Illness:
Ms. [**Known lastname 7594**] is a 79 y/o female with rheumatic heart disease s/p
porcine MVR (bioprosthetic mitral valve, on coumadin), moderate
aortic insufficiency, atrial fibrillation with rapid ventricular
response which has been poorly controlled during recent
hospitalization (was recently chemically cardioverted into NSR),
and recent treatment for enterococcal bacteremia and
endocarditis for 4 weeks at the end of [**Month (only) 116**] to the early part of
this month, who initially presented to [**Hospital3 7569**] for ?"
3522,"She was
supratherapeutic at this dose with an INR at discharge of 3.5.
Warfarin was held on [**7-21**] and [**7-22**]. The increased response to
warfarin is likely due to poor PO intake as well as increase in
amiodarone dosage. She will require INR checks daily while in
rehab until a new stable regimen can be ascertained. She should
be re-started on warfarin at 1mg daily after her INR is less
than 3.0. Goal INR [**2-20**]. Patient should follow-up with
cardiologist Dr. [**Last Name (STitle) 11493**] in 2 weeks.
.
# Diffuse rash with oral lesions: This was felt to be erythema
multiforme due to metronidazole per [**Location (un) **] dermatology consult."
3523,"[**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **] who saw her at [**Location (un) **].
.
# Acute kidney injury: Pt has an unclear baseline, though per
records had recent [**Last Name (un) **] secondary to gent toxicity. Cr on
presentation to [**Location (un) **] was 1.8 and improved to 1.5 on transfer,
and was 1.2 at the time of discharge from [**Hospital1 18**]. [**Month (only) 116**] have been
pre-renal component, as she improved with normalization of
volume status and cardiac output. Urine studies were all normal
(urine sediment, urine electrolytes, smear for eosinophils).
Renal function should be monitored in outpatient setting."
3524,".
# Leukocytosis: The WBC decreased from 20.1 on admission to 8.7
on discharge. The patient remained afebrile and there was no
evidence of infection on chest x-ray, blood culture, TTE, TEE,
or U/A. The etiology was likely steroids vs. stress response.
Urine cultures were positive for Pseudomonas sensitive to
ciprofloxacin however the UA was negative for LE and nitrites
and she was asymptomatic so no treatment was indicated at this
time. However if she becomes symptomatic antibiotic
sensitivities are included in this report above.
.
# Hypertension: After cardioversion the patient maintained blood
pressures consistently over 140/90 and therefore she was started
on losartan 50mg [**Hospital1 **] and amlodipine 5mg daily."
3525,"Also on
metoprolol succnate 50mg daily. Based on the home medication
list that we have, she was not previously taking any
anti-hypertensives. Her worsening hypertension may be explained
by treatment with steroids or alternatively because her cardiac
output improved after cardioversion. Her blood pressure may
normalize as steroids are tapered therefore she may need
adjustment to her anti-hypertensive regimen. She should have BP
checked daily and she was advised to follow-up with her
cardiologist Dr. [**Last Name (STitle) 11493**] in 2 weeks.
.
# Acute on Chronic Diastolic Heart Failure: The patient had an
episode of pulmonary edema on evening prior to transfer to [**Hospital1 18**]
and was on 6L NC."
3526,"No
intervention was instituted at this time, particularly given her
side effect to flagyl.
.
# Hypothyroidism: Her synthroid was continued, and her TSH was
wnl.
.
# ? Hx of Depression: The patient was taking sertraline 50mg
daily at home. This was discontinued at the outside hospital and
it was not reinstituted after transfer to [**Hospital1 18**]. I was not able
to find the rationale for discontinuing the medication in the
records we have. The patient reports that she had been started
on it several months ago and therefore it does not appear that
it was related to the patient's rash. Regardless, she does not
currently meet criteria for major depressive disorder and the
patient states that she would prefer to not take it."
3527,"She was transferred to [**Hospital1 18**] for management of
afib with rvr for which she underwent successful DC
cardioversion.
.
ACTIVE ISSUES:
.
# Afib with RVR: The precipitant of her afib was unclear, but
may have been related to her volume status or recent infection.
She was on amiodarone, metoprolol, and diltiazem, and was
difficult to rate control. She was successfully DC cardioverted
on [**2149-7-18**] after a TTE and TEE were negative for thrombus.
After the cardioversion the diltiazem drip was able to be
discontinued and she was discharged on metoprolol succinate 50mg
daily and amiodarone 200mg daily. She was anticoagulated with
heparin for the cardioversion and was then switched to her
previous home dose of warfarin 2mg daily."
3528,"Respirations were unlabored, no accessory muscle
use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pedal edema.
SKIN: Diffuse erythematous, non-blanching maculopapular rash
over the trunk, upper and lower extremities. No bullae. No
[**Last Name (un) **] lesions, osler nodes, or spliter hemmorhages.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Admission labs:
[**2149-7-16**] 06:51PM BLOOD WBC-20.1* RBC-3.88* Hgb-12.5 Hct-35.6*
MCV-92 MCH-32.1* MCHC-35.1* RDW-15.1 Plt Ct-385
[**2149-7-16**] 06:51PM BLOOD Neuts-93* Bands-1 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-16**] 06:51PM BLOOD PT-36."
3529,"She reports cough, but
no productive sputum. HR reportedly increasing to 138 bpm at
times.
Review of systems:
(+) Per HPI. Reports 20 lb weight loss since [**Month (only) 958**].
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea or congestion. Denies productive cough, shortness of
breath. Denies chest pain, chest pressure, palpitations, or
weakness. Denies vomiting, diarrhea, constipation, abdominal
pain, or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias.
Past Medical History:
- rheumatic heart disease s/p porcine MVR at [**Hospital2 **] [**Hospital3 6783**]
- moderate AI
- atrial fibrillation, until recently had been chemically
cardioverted to NSR."
3530,"Disp:*4 Tablet(s)* Refills:*0*
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. Magic Mouthwash
Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN mouth pain
16. Warfarin
To be restarted at 1mg daily when INR <3
17."
3531,"Well seated, normal
functioning mitral valve bioprosthesis. Depressed biventriular
systolic function. Aortic regurgitation.
Patient is at high risk for developing intracardiac thrombus
post cardioversion.
.
EKG [**2149-7-16**]: atrial fibrillation at 99, mild right axis
deviation, normal intervals, no pathologic Q waves, non-specific
ST changes precordially
.
URINE CULTURE (Final [**2149-7-19**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
.
SENSITIVITIES: MIC expressed in MCG/ML
______________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S"
3532,"Please continue to take all other medications as you were
previously prescribed.
Remember to let all of your doctors know that [**Name5 (PTitle) **] are allergic
to Flagyl (metronidazole).
Followup Instructions:
Name: [**Last Name (LF) 11493**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**] MD
Address: [**Apartment Address(1) 28703**], [**Location (un) **],[**Numeric Identifier 28704**]
Phone: [**Telephone/Fax (1) 11650**]
***We were unable to schedule a follow up appointment with Dr.
[**Last Name (STitle) 11493**]. The office is closed until [**7-28**]. Please contact them
at that time to schedule a follow up to your hospital stay. You
will need an appointment within 2 weeks of your discharge."
3533,"-Please monitor BP and adjust antihypertensive regimen
accordingly. Losartan increased from 50mg daily to 50mg [**Hospital1 **] on
[**2149-7-22**].
-Please monitor electrolytes and renal function at least twice
weekly, as patient has recently been started on new blood
pressure medications and is recovering from acute kidney injury.
-Patient will need PCP, [**Name10 (NameIs) 2086**], and dermatology follow-up.
It is important that she see dermatology within the next [**1-19**]
weeks for follow-up of erythema multiforme.
-PT at rehab
-Please monitor nutrition, and continue Boost milkshakes and
Ensure pudding supplements (or equivalent) with meals until
patient's oral intake improves."
3534,"She was treated with almost 1 month of
Vanc/Gent (PCN allergic). This was stopped 3 days prior to the
planned course, as she developed ARF. All subsequent blood
cultures at the OSH and [**Hospital1 18**] were negative. She did exhibit any
stigmata of endocarditis during her admission and TTE and TEE
were negative.
.
# Rheumatic heart disease s/p porcine MVR: Her goal INR is
2.0-3.0. Her INR was 3.5 at the time of discharge. She should be
restarted on warfarin 1mg daily once INR <3.
.
INACTIVE ISSUES:
.
# ? diverticulitis: AT [**Hospital1 18**] her abdominal exam was benign."
3535,"[**Known lastname 7594**], it was a pleasure taking care of you while you
were at [**Hospital1 18**]. You were transferred to [**Hospital1 18**] for management of
atrial fibrillation. You underwent a successful procedure
(cardioversion) which restored your normal rhythm. You were
also continued on a medication (amiodarone) that will help
prevent atrial fibrillation in the future.
You had fluid that backed up into your lungs while you were in
the abnormal heart rhythm, and the fluid back-up improved while
you were here.
We also continued medications for your rash. Our dermatologists
here recommended adding a topical steroid swish and spit
solution to help control the pain from the lesions in your
mouth."
3536,"Discharge Medications:
1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. triamcinolone acetonide 0.025 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): apply to affected areas. Talk to
your dermatologist about when to stop. .
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain."
3537,"7. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritis.
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Disp:*2 * Refills:*2*
10. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: Take 2 pills (20mg total) on [**2149-7-23**]. Take 1 pill (10mg) on
[**2149-7-24**] 1 and 1 pill on [**2149-7-25**], and then stop ."
3538,"The transmitral gradient is
normal for this prosthesis. No mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. IMPRESSION: Suboptimal image quality. No
definite vegetations seen
.
TEE ([**2149-7-18**]): The left atrium is dilated. Moderate to severe
spontaneous echo contrast but no thrombus is seen in the body of
the left atrium and left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No
spontaneous echo contrast or thrombus is seen in the right
atrium or right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler."
3539,"(for rash)
5. Hydroxyzine 25 mg every 6 hours as needed for itching
6. Triamcinolone Acetonide 0.025% Ointment. Apply twice daily to
affected areas. Talk your dermatologist about when to stop using
this.
7. Sarna Lotion (camphor-menthol 0.5-0.5 %) apply every 6 hours
as need for itching.
8. ""Magic Mouthwash"" (Maalox/Diphenhydramine/Lidocaine) 15-30 mL
every 6 hours as needed for mouth pain
9. Dexamethasone Oral Solution (0.1mg/1mL) use 1 tsp to swish
and spit up to three times a day as needed for mouth/tongue pain
10. Senna as needed for constipation"
3540,"***
Name: HELD,[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] DERMATOLOGY
Address: 190 [**Location (un) **], RD. [**Apartment Address(1) 89392**], [**Location (un) **],[**Numeric Identifier 28704**]
Phone: [**Telephone/Fax (1) 89393**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within
1 week. You will be called with the appointment. If you have not
heard from the office within 2 days or have any questions,
please call the number above.
After you are discharged from rehab, you will need to follow-up
with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 63998**]. Please call
[**Telephone/Fax (1) 25685**] to schedule an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]"
3541,"It is improving on steroids. Prednisone was tapered as follows:
60 mg x 3 days, 40 mg x 2 days, 20 mg x 2 days, 10 mg x 2 days,
then stop. On discharge ([**2149-7-22**]) she was given the 1st day of
20mg. For pruritus, triamcinolone, sarna, and atarax were
continued. The patient continues to have oral lesions,
predominantly on the tongue that cause pain with eating. She was
given a maalox/benadryl/lidocaine mouthwash QID and a
dexamethasone swish and spit TID which provided some symptomatic
relief. The patient was advised to follow up within 1 week with
Dr."
3542,"CXR at that time showed bilateral pulmonary
vascular congestion. TTE here shows low-normal EF of 50%.
Patient with history of diastolic dysfunction, and episode of
afib with RVR likely contributed to acute dCHF exacerbation.
She diuresed well with IV lasix. CXR prior to discharge showed
no pulmonary edema and she did not have any clinical evidence of
heart failure. She did not require any diuretics at the time of
discharge. Was discharged on metoprolol and losartan. Will
follow-up with cardioolgy.
.
# Recent enterococcus endocarditis: Per review of OSH records,
the patient originally presented to [**Location (un) **] in may of this year
with 1 month of weakness and fatigue, and was found to have
enterococcus bacteremia."
3543,"The rash was felt to be c/w
erythema multiform per dermatology. There was no airway
compromise, but she did report some difficulty swallowing. She
was kept on IV steroids, which was changed to oral prednisone on
date of transfer. Rash and erythema improved per dermatology
team. Reportedly, her SBP was in the 80s, and she was
resuscitated with IVF. HR was in the 130s-140s on arrival to
OSH.
She also had acute renal failure on admission to the OSH. She
was continued on mIVF. Cr on presentation to [**Location (un) **] was 1.8 and
improved to 1.5 on transfer."
3544,"There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm. The right ventricular free
wall thickness is normal. The right ventricular cavity is
dilated with depressed free wall contractility. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild to
moderate ([**1-19**]+) aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The prosthetic mitral valve
leaflets are mildly thickened."
3545,"grade II diastolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Skin: diffuse erythematous, non-blanching rash over the trunk,
upper and lower extremities, no bullae
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
VS: T= 97.3-99.5, BP=151-183/80-91, HR=53-59, RR=18, O2sat=99%
on RA
Weight: 47.7kg(S)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Lips cracked and dry. Numerous lesions on tongue.
NECK: Thin
CARDIAC: RRR, normal S1, S2.
LUNGS: CTAB."
3546,"7* PTT-35.5* INR(PT)-3.7*
[**2149-7-16**] 06:51PM BLOOD Glucose-161* UreaN-29* Creat-1.6* Na-133
K-3.5 Cl-99 HCO3-20* AnGap-18
[**2149-7-16**] 06:51PM BLOOD ALT-20 AST-18 LD(LDH)-374* AlkPhos-69
TotBili-0.6
[**2149-7-16**] 06:51PM BLOOD Albumin-3.5 Calcium-7.5* Phos-1.9*
Mg-1.5* Iron-48
[**2149-7-16**] 06:51PM BLOOD calTIBC-182* Ferritn-685* TRF-140*
[**2149-7-16**] 06:51PM BLOOD TSH-1.7
.
OSH ([**Location (un) **]) results per phone: INR's [**Month (only) 116**]: 26- 2."
3547,"0; 23-2.5;
19-5.2; 16-3.9; 12-1.8; 9-1.8; 6-1.9; 4-2.5; 2-3.5; [**5-15**]-1.8.
.
LABS AT DISCHARGE:
[**2149-7-22**] 06:45AM BLOOD WBC-8.7 RBC-3.73* Hgb-11.8* Hct-34.2*
MCV-92 MCH-31.7 MCHC-34.5 RDW-15.3 Plt Ct-345
[**2149-7-22**] 06:45AM BLOOD PT-34.7* INR(PT)-3.5*
[**2149-7-22**] 06:45AM BLOOD Glucose-95 UreaN-25* Creat-1.2* Na-131*
K-3.8 Cl-99 HCO3-21* AnGap-15
[**2149-7-22**] 06:45AM BLOOD Calcium-7."
3548,"- enterococcus endocarditis treated with almost 1 month of
Vanc/Gent (PCN allergic), which was stopped 3 days early
- breast cancer s/p mastectomy
Social History:
intermittently at rehab and was only at home for 2 weeks prior
to ICU stay at [**Location (un) **]. Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is HCP. Phone
[**Telephone/Fax (1) 89391**].
- [**Name2 (NI) 1139**]: denies
- Alcohol: rare
- Illicits: denies
Family History:
dad with [**Name (NI) 4278**]. 5 brothers had cancer as well. No
significant CAD.
Physical Exam:
MICU admission:
Vitals: T: 97.7 BP: 136/83 P: 95 R: 18 O2: 95% 4L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, unable to visualize posterior
oropharynx due to dry and cracked lips
Neck: supple, JVP not elevated, no LAD
Lungs: crackles anteriorly and at bases, no wheezing
appreciated, no accessory muscle use
CV: tachycardic, irregular rhythm, mechanical valve click, ?"
3549,"You should also follow-up with dermatology at [**Location (un) **]
Dermatology.
The following medication changes were made:
STOP TAKING:
1. Metronidazole (Flagyl)
2. Sertraline (Zoloft)
3. Potassium
4. Milk of magnesia
DOSE CHANGES:
1. Amiodarone increased from 100mg every other day to 200mg
daily
NEW MEDICATIONS:
1. Metoprolol Succinate 50mg Daily (for blood pressure and
control of heart rate)
2. Losartan 50mg Twice Daily (for blood pressure)
3. Amlodipine 5mg Daily (for blood pressure)
4. Prednisone: Take 2 pills (20mg) on [**2149-7-23**]. Take 1 pill (10mg)
on [**2149-7-24**] and 1 pill (10mg) on [**2149-7-25**]."
3550,"LV systolic function appears
depressed. Right ventricular chamber size is normal with global
free wall hypokinesis. There are simple atheroma in the aortic
arch and descending thoracic aorta. The aortic valve leaflets
(3) are mildly thickened. Trace aortic regurgitation is seen. A
well-seated bioprosthetic mitral valve prosthesis is present.
The mitral prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients. Trivial mitral regurgitation
is seen. The tricuspid valve leaflets are moderately thickened.
The estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion. IMPRESSION: Prominent
spontaneous echo contrast but no thrombus in the body of the
left atrium and left atrial appendage."
3551,"dehydration vs. orthostatic hypotension. She reports that she
""almost passed out"" and was ""dizzy"" at times. She reports ""loss
of balance"" and ""inability to get up."" During admission, she was
treated with IVF and fludrocortisone for the hypotension. She
had CT abdomen and pelvis for mild abdominal pain. She was felt
to have ? diverticulitis for which she was started on flagyl. On
her labs, she was noted to be in acute renal failure. The [**Last Name (un) **]
was felt to be in part due to gentamycin, and this was
discontinued. They continued the IV vancomycin. She was
discharged home.
She presented on [**7-13**] for a generalized rash over her body,
swollen lips, and some lesions in her mouth felt to be due to
the recently started flagyl."
3552,"Her atrial fibrillation is
reportedly poorly controlled, and she remains on IV amiodarone,
now transitioned to oral amiodarone, along with metoprolol and
diltiazem gtt. Initial plan was for electrical cardioversion,
but daughter requested transfer to a tertiary medical center for
this.
Additionally, the patient had an episode of pulmonary edema on
evening prior to transfer. She reported that it was ""hard to
breathe."" This was suspected to be from poorly controlled heart
rate and perhaps mIVF. CXR showed bilateral pulmonary vascular
congestion. She diuresed well with 40 mg IV lasix (-1800 cc
since then). She was initially on 6L NC."
3553,"[**2149-7-16**] 6:51 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2149-7-22**]**
Blood Culture, Routine (Final [**2149-7-22**]): NO GROWTH.
[**2149-7-16**] 8:45 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2149-7-22**]**
Blood Culture, Routine (Final [**2149-7-22**]): NO GROWTH.
Brief Hospital Course:
Ms. [**Known lastname 7594**] is a 79 y/o female with rheumatic heart disease s/p
porcine MVR, moderate AI and atrial fibrillation. In [**Month (only) 116**] she was
treated for enterococcus endocarditis with Vancomycin and
Gentamicin which were discontinued due to ARF, and was later
admitted to [**Location (un) **] for metronidazole induced
bronchoconstriction, rash, and hypotension as well as [**Last Name (un) **] and
afib with RVR."
3554,"However,
there is no contra-indication to her resuming another
anti-depressant in the future.
.
# Nutrition: Patient has limited PO intake secondary to pain
from oral lesions (in setting of erythema multiforme),
particularly with very hot and very cold foods as well as spicy
foods. She was able to tolerate ensure/boost pudding. Can
continue on dexamethasone swish and spit and
maalox/diphenhydramine/lidocaine mouthwash as needed for oral
pain
.
LABS PENDING AT THE TIME OF DISCHARGE: None
.
TRANSITIONAL ISSUES:
-Please monitor INR daily and restart warfarin at 1mg daily when
INR <3. Please trend INR and adjust warfarin dose accordingly
(goal [**2-20**])."
3555,"dexamethasone 0.5 mg/5 mL Solution Sig: Five (5) ML PO TID
(3 times a day) as needed for mouth/tongue pain: swish and spit.
18. losartan 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
life care of [**Hospital3 **]
Discharge Diagnosis:
Primary diagnoses:
Atrial fibrillation with rapid ventricular response
Acute kidney injury
Erythema multiforme
Acute on chronic diastolic heart failure
Hypertension
Secondary Diagnoses:
Rheumatic heart disease s/p porcine mitral valve replacement
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms."
3556,"9* Phos-3.0 Mg-2.1
[**2149-7-16**] 06:51PM BLOOD calTIBC-182* Ferritn-685* TRF-140*
[**2149-7-16**] 06:51PM BLOOD TSH-1.7
.
OTHER RELEVANT STUDIES:
.
Images: CXR at OSH - no acute cardiopulmonary process
.
CXR [**2149-7-16**]: Heart size is enlarged with left ventricular
configuration. Mediastinal silhouette is unremarkable. There are
multifocal opacities noted, with some perihilar and upper lung
redistribution as well as both basal involvement. There are also
bilateral pleural effusions, right more than left. There is no
pneumothorax. The findings are worrisome for a combination of
pulmonary edema given the perihilar and upper lobar distribution
as well as multifocal infection giving relatively focal and
patchy character of the finding."
3557,"Correlation with prior imaging
as well as assessment after diuresis is recommended. Surgical
clips are projecting over the right axilla and no right breast
identified, suggesting that the patient can be after right
mastectomy, please correlate with clinical history.
.
CXR [**2149-7-20**]: CHEST, PA AND LATERAL: The heart is somewhat
enlarged. There is no evidence of failure. The lung fields are
clear. The costophrenic angles are sharp. There has been a
marked improvement in the overall appearances since the prior
chest x-ray of [**7-17**]. IMPRESSION: Mild cardiomegaly, otherwise
normal chest.
.
TTE [**2149-7-17**]: The left atrium is elongated."
3558,"Patient may continue to use
dexamethasone swish and spit and
maalox/diphenhydramine/lidocaine mouthwash as needed for oral
pain.
.
-Code status: Full
-Contact: Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is HCP, home phone
[**Telephone/Fax (1) 89391**].
Medications on Admission:
Medications at home:
-patient unsure, and states that these have frequently changed
going from home to rehab
.
Medications on transfer:
-synthroid 88 mcg daily
-Kdur 20 meq daily
-amiodarone 200 mg daily (on IV amiodarone until this AM)
-triamcinolone ointment [**Hospital1 **]
-prednisone 60 mg daily (plan for 60 mg x 3 days, 40 mg x 2
days, 20 mg x 2 days, 10 mg x 2 days, then stop)
-nystatin 5 mL swish and swallow qid x 5 days
-colace 100 mg [**Hospital1 **]
-lopressor 25 mg q6 per cardiology
-IV diltiazem gtt"
3559,"Admission Date: [**2153-6-11**] Discharge Date: [**2153-6-19**]
Service: MEDICINE
Allergies:
Azulfidine / Penicillins / Aspirin / Allopurinol / Dilantin /
Tegretol / Keppra / Trileptal
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Fungal UTI, Infected Renal Calculus, Acute Renal Failure,
Septicemia
Major Surgical or Invasive Procedure:
Percutaneous Nephrostomy Tube
History of Present Illness:
88 year old female transferred from [**Hospital3 **] with
chief complaint of persistent acidosis in spite of more
aggressive treatment of UTI. On [**5-27**] Urine culture grew
Klebsiella pneumonea and E.Coli. She received 10 days
ciprofloxacin PO.
On [**6-8**] they started ceftriaxone IV. On [**6-11**] ordered for
Vancomycin but did not receive (remote [**11/2152**] U/C MRSA)."
3560,"ED Course: Labs consistent with metabolic acidosis, ARF. She got
IVF and IV Vancomycin. Her urine cultures at that time grew out
yeast.
Past Medical History:
1) Ulcerative colitis, status post colostomy in [**2132**]
2) Hypertension
3) Chronic renal insufficiency (baseline 1.4-2.0)
4) Osteoarthritis
5) History of Seizures, on topiramate
6) Atrial fibrillation, on amiodarone
7) Urge incontinence, on tolterodine
8) Bilateral cataracts
9) History of microscopic hematuria
10) Nephrolithiasis
11) Depression
12) Renal cysts
Social History:
Lives at [**Hospital 100**] Rehab. Smoked 2 packs per week many years ago.
No smoking currently, no etoh, no IVDU."
3561,"The plan is 6 weeks of bictra then followup CT, with plan that
if stone is dissolving then continue current therapy, but if
not, then patient will require intervention, likely lithotripsy.
# Acute Renal Failure on CKD Stage III:
- This is likely multifactorial given her obstructing renal
calculus. It improved with the nephrostomy and hydration. At
time of discharge she was at her baseline.
- Given decision of what to do with the stone, a renal scan was
performed as above.
# Metabolic Acidosis: in setting of ARF
- IV hydration with bicarb drip with resolution in ICU
# Hypoxemia: developed mild O2 requirement while on floor (was
also getting IVF)."
3562,"Reports of hypoxia at rehab, this had
resolved by time of discharge and was likely due to septicemia.
# Seizure disorder:
- cont topiramate 50 [**Hospital1 **]
- cont neurontin for now (Neurontin may also be contributing to
her lethargy in the setting of ARF), however this can be
addressed by Dr. [**Last Name (STitle) **] at [**Hospital1 1501**].
# Atrial fibrillation: Continued amiodarone 200, (deemed not a
candidate for coumadin in past, not on ASA given vaginal
bleed/epistaxis). Well controlled.
# Access: Midline
.
#. Code - DNR/DNI (ok to intubate in case of status epilepticus)
.
#. Communication - [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (daughter) is [**Name (NI) 3508**] cell
[**Telephone/Fax (1) **]."
3563,"6. Sodium Citrate-Citric Acid 500-300 mg/5 mL Solution Sig:
Thirty (30) ML PO TID (3 times a day).
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous once a day as needed for line flush.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Fungal UTI
Pyelonephritis
Renal Calculi
Septicemia - Fungal
Leukocytosis
Stage III Chronic Kidney Disease
Epilepsy
Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
You are being discharged with a very large kidney stone in
place, along with a nephrostomy tube in place to drain the urine
around the stone."
3564,"5. Hyperdense gallbladder material, possibly sludge.
PORTABLE ABDOMEN Study Date of [**2153-6-14**] 8:04 AM
IMPRESSION: Air in loops of small and large bowel without
evidence for ileus or obstruction. There is no free air given
limitation of supine technique.
RENAL SCAN Study Date of [**2153-6-15**]
IMPRESSION: Differential renal function demonstrated with the
left kidney
performing 18% of total renal function and the right performing
82%. There is a large renal pelvis on the right, but there is
prompt washout from the pelvis after administration of lasix.
INTRO CATH TO PELVIS FOR DRAINAGE AND INJ Study Date of [**2153-6-15**]
6:23 PM
IMPRESSION:
1."
3565,"7 MCHC-32.3 RDW-15.5 Plt Ct-279
[**2153-6-14**] 06:20AM BLOOD WBC-9.2 RBC-3.54* Hgb-10.7* Hct-33.3*
MCV-94 MCH-30.4 MCHC-32.3 RDW-15.8* Plt Ct-325
[**2153-6-13**] 09:52AM BLOOD WBC-9.4 RBC-3.99* Hgb-12.1 Hct-36.8
MCV-92 MCH-30.3 MCHC-32.9 RDW-16.1* Plt Ct-387
[**2153-6-12**] 06:25AM BLOOD WBC-9.8 RBC-3.33* Hgb-10.4* Hct-31.4*
MCV-95 MCH-31.3 MCHC-33.1 RDW-16."
3566,"Medications on Admission:
Ceftriaxone IV 1 GM daily
Topiramate 50mg [**Hospital1 **]
tylenol
Amiodarone 200mg daily
Remeron 15mg QHS
Artificial Tears
Gabapentin 1600mg TID
Psyllium 1 scoop tid
Cholecalciferol 1000unit daily
Discharge Medications:
1. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO TID (3
times a day).
5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days."
3567,"2* Plt Ct-353
[**2153-6-11**] 07:52PM BLOOD WBC-9.9 RBC-3.71* Hgb-11.1* Hct-35.3*
MCV-95 MCH-30.0 MCHC-31.5 RDW-15.7* Plt Ct-443*
[**2153-6-11**] 06:50PM BLOOD WBC-10.9 RBC-3.90*# Hgb-11.8*# Hct-37.4#
MCV-96 MCH-30.3 MCHC-31.6 RDW-15.6* Plt Ct-421
[**2153-6-17**] 07:53AM BLOOD Neuts-90.7* Lymphs-5.7* Monos-2.9 Eos-0.6
Baso-0.1
[**2153-6-16**] 03:50AM BLOOD Neuts-94.1* Lymphs-2."
3568,"8* Monos-2.9 Eos-0.1
Baso-0
[**2153-6-19**] 06:25AM BLOOD PT-17.2* PTT-41.6* INR(PT)-1.5*
[**2153-6-18**] 09:15AM BLOOD PT-16.8* PTT-44.0* INR(PT)-1.5*
[**2153-6-17**] 07:53AM BLOOD PT-17.9* PTT-44.5* INR(PT)-1.6*
[**2153-6-15**] 05:35PM BLOOD PT-17.5* INR(PT)-1.6*
[**2153-6-19**] 06:25AM BLOOD Glucose-105 UreaN-41* Creat-1.7* Na-137
K-3.6 Cl-102 HCO3-20* AnGap-19
[**2153-6-18**] 09:15AM BLOOD Glucose-88 UreaN-36* Creat-1."
3569,"Brief Hospital Course:
[**Hospital Unit Name 153**] [**Date range (1) 30784**] - Pt was admitted to the [**Hospital Unit Name 153**] s/p left
percutaneous nephrostomy due to high risk of hemodynamic
instability with active infection and markedly elevated WBC. Pt
was recieved to the unit with stable vitals and no complaints.
she was placed on IV fluids and monitered. There were no
overnight events, electrolytes were replaced and she was
transferred back to the floor with stable vital signs and
improvement in WBC.
# Septicemia, Fungal UTI, Obstructing Renal Calculus,
Leukocytosis
- Cultures of the urine, including from the percutaneous
nephrostomy tube have repeatedly grown yeast, and although never
speciated clinical there was impressive effect from diflucan,
with resolution of her leukocytosis."
3570,"We are trying to dissolve the stone with a
medication. This medication can affect your electrolytes, so
will need to be closely monitored.
You will need a cat scan in 6 weeks to assess.
You need to eat carefully, as you have a high-risk of aspirating
food into your lung which can cause pneumonia.
You are going on a medication called Fluconazole which is an
antibiotic to treat the infection you had in the kidney. You
must complete the course of this medication.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2153-9-11**] 10:30
CT Scan Pelvis with/without contrast in 6 weeks with results to
urology"
3571,"03* Hgb-9.0* Hct-29.4*
MCV-97 MCH-29.7 MCHC-30.6* RDW-15.9* Plt Ct-288
[**2153-6-18**] 09:15AM BLOOD WBC-16.5* RBC-3.11* Hgb-9.5* Hct-29.7*
MCV-95 MCH-30.7 MCHC-32.1 RDW-15.6* Plt Ct-276
[**2153-6-17**] 07:53AM BLOOD WBC-26.3* RBC-2.97* Hgb-9.1* Hct-28.1*
MCV-95 MCH-30.5 MCHC-32.3 RDW-15.8* Plt Ct-269
[**2153-6-16**] 03:50AM BLOOD WBC-29.9* RBC-2.89* Hgb-8.6* Hct-27."
3572,"Large stone in the left renal collecting system.
2. Dilatation of the upper pole calices, containing pus.
3. Uncomplicated ultrasound and fluoroscopically guided left
nephrostomy tube placement.
PORTABLE ABDOMEN Study Date of [**2153-6-16**] 5:11 AM
ABDOMEN, SUPINE AND UPRIGHT: Comparison is made to the two days
earlier.
A left-sided percutaneous nephrostomy tube has been placed since
the prior
study. A nasogastric tube terminates in the stomach, but a
leading sidehole is likely within the distal esophagus.
Advancement of the tube by several centimeters would lead to
more optimal placement. There is moderate persistent distention
of small bowel loops, little changed since both films from the
prior day, and non-specific as to etiology."
3573,"CHEST (PORTABLE AP) Study Date of [**2153-6-12**] 5:46 PM
IMPRESSION: No pneumonia or evidence of CHF.
CT PELVIS W/O CONTRAST Study Date of [**2153-6-13**] 3:05 PM
IMPRESSION:
1. Extensive bilateral nephrolithiasis, most severe on the left
with a
staghorn calculus and consequent obstruction, overall similar to
an ultrasound done one day earlier.
2. Marked atherosclerotic calcification.
3. Prominent loops of small bowel and collapsed ileum entering
the ileostomy. Recommend close monitoring of ostomy output for
signs of possible partial small bowel obstruction.
4. Small hepatic hypodensities likely cysts and hyperdensities,
possibly
calcified granulomas."
3574,"Also
noted to have CO2: 12 (had been 16-20 lately). ABG at HRC
7.31/27/94, HCO2 13.6/total CO2 14.4. She has not had any fever
in past week but continued to have dysuria, malaise and failure
to thrive.
She was recently ([**Date range (1) 32334**]/09) admitted to [**Hospital1 18**] for epistaxis &
vaginal bloody discharge on ASA; now off ASA and no more
epistaxis/?vaginal blood. Also has had ARF at HR responding to
IVF. Vaginal U/S that admit (patient declined vaginal u/S)
showed bilateral renal calculi- largest right 1.2 cm with
prominent renal pelvis and no hydronephrosis."
3575,"0 Cl-100 HCO3-11* AnGap-21*
[**2153-6-11**] 06:50PM BLOOD Glucose-112* UreaN-37* Creat-3.2*#
Na-130* K-4.2 Cl-99 HCO3-14* AnGap-21*
[**2153-6-18**] 09:15AM BLOOD ALT-33 AST-34 AlkPhos-116 TotBili-0.4
[**2153-6-15**] 03:15PM BLOOD ALT-34 AST-128* LD(LDH)-454* AlkPhos-89
TotBili-0.5
[**2153-6-14**] 06:20AM BLOOD ALT-17 AST-28 AlkPhos-75 Amylase-91
TotBili-0.2
[**2153-6-14**] 06:20AM BLOOD Lipase-33
[**2153-6-19**] 06:25AM BLOOD Calcium-9.7 Phos-2."
3576,"NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2153-6-16**]): NO CAMPYLOBACTER
FOUND.
[**2153-6-14**] 3:13 pm URINE Source: Catheter.
**FINAL REPORT [**2153-6-15**]**
URINE CULTURE (Final [**2153-6-15**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2153-6-11**] 7:52 pm BLOOD CULTURE
**FINAL REPORT [**2153-6-17**]**
Blood Culture, Routine (Final [**2153-6-17**]): NO GROWTH.
RENAL U.S. Study Date of [**2153-6-12**] 2:04 PM
IMPRESSION:
1. Bilateral extensive nephrolithiasis, appearing greatest on
the left as
above with evidence of left renal obstruction. No right
hydronephrosis.
2. Suboptimal assessment of the urinary bladder."
3577,"7* Na-136
K-3.6 Cl-105 HCO3-19* AnGap-16
[**2153-6-17**] 07:53AM BLOOD Glucose-105 UreaN-33* Creat-1.7* Na-140
K-3.7 Cl-109* HCO3-20* AnGap-15
[**2153-6-16**] 03:50AM BLOOD Glucose-125* UreaN-32* Creat-2.0* Na-139
K-3.1* Cl-107 HCO3-20* AnGap-15
[**2153-6-14**] 06:20AM BLOOD Glucose-107* UreaN-36* Creat-2.5* Na-134
K-4.3 Cl-98 HCO3-23 AnGap-17
[**2153-6-11**] 07:52PM BLOOD Glucose-106* UreaN-37* Creat-3.0* Na-128*
K-4."
3578,"[**2153-6-16**] 10:08 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2153-6-17**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2153-6-17**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
URINE NEPHROSTOMY TUBE (CUP).
**FINAL REPORT [**2153-6-17**]**
GRAM STAIN (Final [**2153-6-16**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
URINE CULTURE (Final [**2153-6-17**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2153-6-15**] 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED."
3579,"1*
MCV-94 MCH-29.9 MCHC-31.8 RDW-16.0* Plt Ct-273
[**2153-6-15**] 05:35PM BLOOD WBC-39.7* RBC-3.08* Hgb-9.5* Hct-29.2*
MCV-95 MCH-31.0 MCHC-32.7 RDW-15.4 Plt Ct-297
[**2153-6-15**] 03:15PM BLOOD WBC-37.5* RBC-3.19* Hgb-9.9* Hct-31.0*
MCV-97 MCH-30.9 MCHC-31.8 RDW-15.8* Plt Ct-287
[**2153-6-15**] 01:20PM BLOOD WBC-41.0*# RBC-3.31* Hgb-10.2* Hct-31.5*
MCV-95 MCH-30."
3580,"5* Mg-2.3
[**2153-6-18**] 09:15AM BLOOD Albumin-2.7* Calcium-9.3 Phos-2.3* Mg-2.4
[**2153-6-12**] 08:45AM BLOOD Vanco-15.5
[**2153-6-15**] 03:54PM BLOOD Type-[**Last Name (un) **] pH-7.52* Comment-GREEN TOP
[**2153-6-15**] 03:54PM BLOOD Lactate-2.9*
[**2153-6-11**] 08:10PM BLOOD Glucose-105 Lactate-2.2* Na-137 K-4.1
Cl-104 calHCO3-11*
[**2153-6-14**] 03:13PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2153-6-13**] 09:51AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1."
3581,"Daughters: [**Name2 (NI) **] [**Telephone/Fax (3) 94605**]
[**Doctor First Name **] [**Telephone/Fax (1) 94606**], [**Telephone/Fax (1) 94607**]
Family History:
non contributory
Physical Exam:
VSS: 98, 78, 22, 127/72, 96/RA
GEN: appears lethargic, drowsy, although answers appropriately
Pain: 0/0
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: diffuse tenderness, colostomy bag present draining copius
clear fluid
EXT: - CCE
Nephrostomy CDI
Midline CDI
NEURO: lethargic, open eyes to commands, able to communicate,
oriented atleast x2; able to lift all extremities
Pertinent Results:
[**2153-6-19**] 06:25AM BLOOD WBC-10.1 RBC-3."
3582,"She had a brief stay in the
ICU, but rapidly improved. Initially in the [**Hospital Unit Name 153**] she was started
on cefepime, vancomycin, mtronidazole and floconazole, but
nothing other than yeast was ever isolated, so other than
diflucan these were stopped.
- Urology was consulted and a percutaneous nephrostomy tube was
inserted. After insertion, the urology team was deciding between
a nephrectomy versus lithotripsy. Both of these would be high
risk in this patient. It was noted that the stone appears
radiolucent on xray, so there is a thought this is a uric acid
stone; the patient was started on bicitra to dissolve the stone."
3583,"BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2153-6-15**] 3:15 pm BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
[**2153-6-15**] 3:48 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2153-6-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2153-6-16**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2153-6-14**] 5:06 pm STOOL CONSISTENCY: WATERY
**FINAL REPORT [**2153-6-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2153-6-15**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
FECAL CULTURE (Final [**2153-6-16**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND."
3584,"016
[**2153-6-11**] 08:00PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2153-6-14**] 03:13PM URINE Blood-LG Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2153-6-13**] 09:51AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2153-6-11**] 08:00PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2153-6-14**] 03:13PM URINE RBC-0 WBC->1000* Bacteri-MOD Yeast-NONE
Epi-0
[**2153-6-13**] 09:51AM URINE RBC-42* WBC->1000* Bacteri-NONE
Yeast-NONE Epi-0
[**2153-6-11**] 08:00PM URINE RBC-0 WBC->50 Bacteri-MOD Yeast-NONE
Epi-0"
3585,"Admission Date: [**2160-8-16**] Discharge Date: [**2160-9-5**]
Date of Birth: [**2094-12-30**] Sex: F
Service: SURGERY
Allergies:
Halothane / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Perforated Bowel
Major Surgical or Invasive Procedure:
Exploratory laparotomy, ileocecectomy, low anterior resection
with an ileostomy and mucous fistula, and bladder repair.
History of Present Illness:
65 F h/o DM-2, refractory Crohn's diagnosed in [**2158**] p/w severe
abdominal pain. She has a history of Crohn's colitis and is
currently undergoing pre-operative planning for surgical
intervention with Dr. [**Last Name (STitle) 1120**] on the Colorectal Surgery service."
3586,"After 3 liters of IVF her SBP is now 117 and the
levophed is being weaned. Her lactate is down to 4.
She was diagnosed with Crohn's in [**2158**] and was started on
infliximab for about one year but lost response. She developed
a perianal fistula on [**5-/2159**] which has been healing. She has
also been tried on Humira, cyclosporine, mesalamine and
prednisone without success.
She recently presented to the ED with similar complaints on
[**2160-6-30**] and had a WBC of 34. She was admitted to GI and
underwent colonoscopy which revealed a polypoid lesion 2-3 cm in
diameter at 25 cm into sigmoid colon."
3587,"Biopsies obtained
revealed a degenerating crypt consistent with her diagnosis of
Crohn's. On [**2160-7-2**] she underwent CT ABD which revealed adjacent
stranding
containing small foci of extraluminal air consistent with
contained perforation, with stranding extending anteriorly with
loops of small bowel suggestive of fistula formation. She was
treated with IV antibiotics in house and prednisone and
discharged with a 2 week course of antibiotics and prednisone.
She is currently not taking any medications for her Crohn's and
reports being off steroids for approximately 3 weeks.
Past Medical History:
Crohn's Disease
Anemia
Benign Hypertension
Osteoarthritis
Hyperlipidemia
Type 2 Diabetes
Morbid obesity
Chronic knee pain
Murmur (never told she needed ABx prophylaxis)
Adrenal Adenoma"
3588,"16. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Please have INR check [**2160-9-5**], goal INR is [**2-6**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Bowel Perforation, Crohn's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after having emergency surgery
to treat a bowel perforation caused by Crohn's Disease. You were
very sick at this time and the procedure was very complicated."
3589,"And the results will be
passed on to Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 9125**].
Provider: [**Name10 (NameIs) 326**] UPPER GI (TCC) RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2160-9-15**] 9:30
Please call to make an appointment to see Dr. [**Last Name (STitle) 9125**] in clinic
on [**2160-9-15**], call ([**Telephone/Fax (1) 26017**] to make an appointment.
*** Dr. [**Last Name (STitle) 9125**] is operating on the morning on [**2160-9-15**] at [**Hospital1 18**]
and his office will be calling the rehabilitation hospital to
set up a follow-up arrangment***
Completed by:[**2160-9-5**]"
3590,"14 days after
blood cultures came back negative for E. coli her antibiotics
were narrowed to only vancomycin and fluconazole after which her
WBC continued to decrease. The patient was tolerating a regular
diet at this time with supplements at each meal and had adequate
stool and gas output from the ileostomy. The mucus fistula
continued to produce a small amount of mucus. The mucus fistula
was flushed periodically with normal saline and covered with a
dry sterile dressing. The patient was followed closely by the
wound/ostomy nursing team. On post-operative day 13 the wound
was assessed by the chief surgical resident and attending and
noted to have necrotic fat and fibrinous tissue to the suture
closure at the abdominal fascia."
3591,"WBC curve: 32.4 ([**8-16**])->33 ([**8-17**])->24.2 ([**8-18**])->27.4
([**8-19**])->43.5 ([**8-20**])-> 42.7 ([**8-20**])->37.2 ([**8-21**])->24.7 ([**8-23**])->22
([**8-24**])->24.8 ([**8-26**])->28.8 ([**8-27**]) ->22 ([**8-28**])-> 19.4 ([**8-30**])->
15.9 ([**9-2**])-> 13.8 ([**9-3**])-> 13.6 ([**9-4**])
PTT 56.9 ([**2160-8-27**])
INR 2.7 ([**2160-8-30**])
INR 6.4 ([**2160-8-31**])
INR 7.8 ([**2160-9-1**])
INR 7.9 ([**2160-9-3**])
INR 5.8 ([**2160-9-4**])
INR 2."
3592,"Social History:
No smoking, drinking, or illicit drug use, has 2 children, lives
with husband, works as a secretary in high school. No travel hx
over the past 2 years.
Contact is husband, [**Name (NI) 4468**]: [**Telephone/Fax (1) 82157**]
Family History:
No history of IBD or other autoimmune diseases.
Physical Exam:
VS: 97.5, 93, 108/65, 20, 99% RA, Blood Glucose= 114
Gen: Appears uncomfortable, AOx3
HEENT: EOM-I, Dry mucous membranes, neck soft, trachea midline
CVS: RRR
Pulm: no resp distress
Abd: Obese, firm and distended. Extremely TTP throughout
especially LUQ and LLQ. Voluntary guarding, no rebound."
3593,"The VAC therapy will continue with dressing
changes every three days. The dressing will be changed by the
nurses at the rehabilitation facility. Ther are multiple
pressure ulcers on your bottom, it is important to stay clean
and the nurses at the rehabilitation center will apply dressings
During your hospital stay, you developed a blood clot in your
lung. You were started on the medication coumadin for treatment
of this clot. You will need to continue this medication for
approximately 6 months. The purpose of this medication is to
thin the blood to prevent further clot formation. The INR level
of your blood needs to be monitored frequently and in your case,
it will need to be monitored closely as you have been very
sensitive to this medication."
3594,"Rectum: deferred, pt having severe abdominal discomfort
LE: 2+ edema b/l with skin changes c/w chronic venous
insufficiency
Abdominal Wound: Approximately 12 inches in length,
approximately 5cm at inferior portion of the wound, red beefy
granulation tissue in subcutaneous space, facia exposed with
suture however wound closing, small area grey/yellow sloughing
tissue along fascia at base of wound.
Mucus fistula: Retracted with some grey exudate, it is not
expected to drain a large amount
Illeostomy: stoma retracted, good liquid stool output, please
see wound/ostomy nurse page 2.
Pertinent Results:
[**2160-8-16**] fluid cx: E.coli, Klebsiella, C."
3595,"On exam her
legs continue to have significant venous congestion, but the
global edema has decreased significantly over her hospital
course. And her peripheral access improved.
During the patient's stay on the inpatient unit, the patient
verbalized feelings of anxiety and was observed to have a flat
affect which was gradually improving at the end of her hospital
stay. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 28528**], NP had discussions at length with the
patient and the patient's husband about initiating
anti-depressant therapy with Celexa. Because of the elevated INR
and the patients apprehension to this therapy the medication was
not initiated."
3596,"The wound was debrided at the
bedside and packed with a moist to dry saline dressing for 3
days for continued mechanical debridement and then the VAC
dressing was replaced on post-op day 16. On post-op day 19, on
VAC change, the wound had good granulation tissue.
Antibiotic/antifungal therapy was discontinued on [**2160-9-4**]
On post-op day 10 the abdominal JP drain was putting out minimal
drainage and was discontinued. On post-op day 14 the patient
underwent a cystogram to evaluate the bladder repair and was
found to have a continued bladder [**Date Range 3564**]."
3597,"3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal skin infection.
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours)."
3598,"On the last day of hospitalization , the patient
verbalized that she would like to attempt to deal with the
anxiety and mood on her own but would reach out to the care
providers at the [**Hospital **] hospital regarding this therapy
if she decided it was needed.
Upon discharge, the patient was evaluated by the clinical nurse
specialist and she was found to have adequate access for
peripheral blood draws for her INR monitoring. The central line
in the upper left chest was removed. The VAC dressing was taken
down prior to discharge with the intent that it will be
reapplied on her arrival to the rehabilitation facility."
3599,"She
continued to have leukocytosis and a mini-BAL was performed
which later grew yeast. At that point her antibiotic coverage
was broadened to vancomycin/ciprofloxacin/flagyl/fluconazole.
The patient was transferred from the surgical intensive care
unit to the inpatient floor on [**2160-8-25**] on intravenous
ciprofloxacin/metrodiazole. The patients lab values and fever
curve were closely monitored and the patient was noted to have a
consistently elevated white blood cell count. In an effort to
determine the cause of this consistently elevated white blood
cell count the blood cultures were drain, peritoneal fluid from
the [**Location (un) 1661**]/[**Location (un) 1662**] drain was sent for culture, the patients
sputum was cultured, and patient was sent for a CT scan of her
torso and abdomen to rule out intra-abdominal abscess."
3600,"Because of severe deconditioning, physical therapy was consulted
on transfer from the ICU to the inpatient floor and they
recommended that when ready for discharge, she should go to
rehab and that in the meantime she should be out of bed to chair
with [**Doctor Last Name 2598**] every day, which she has generally been compliant
with.
Due to the extensive volume requirement she had on admission due
to her hypotension and SIRS she became very edematous and her
weight was 113 kg on admission. With diuresis as she improved
her weight decreased to 95 kg on post-op day 16."
3601,"The
patients INR on [**2160-9-4**] was 5.8 and the patient was again given
10mg of vitamin K orally, also on [**2160-9-4**] the patient concluded
her antibiotic/antifungal therapy which may have contributed to
this elevated INR. The patient's INR on [**2160-9-5**] was 2.6 and it
was determined that the patient could receive her first dose of
Warfarin 3mg and be discharged to her selected rehabilitation
hospital for INR checks and warfarin therapy. Her goal INR is
[**2-6**].
The gram stain of the peritoneal fluid showed coagulase negative
staphylococcus and at this time the patient vancomycin and
fluconazole were added to her antibiotic regimen."
3602,"The ileostomy will
produce loose stool becuase it is the small intestine however
the amount of stool produced should be between 500-1200cc daily.
If it is less than 500cc or more than 1200cc please call the
office for assistance. If it is greater than 1200cc in one day
there is a risk that you could become dehydrated. You are
currently taking immodium to help reduce the stool output and
you may continue this therapy at rehab. Eat small frequent
meals, continue your boost suppplementation, and stay well
hydrated. Please continue the bowel regimen of immodium and
metamucil wafers. As your output decreases the staff at the
rehabilitaion facility can titrate your bowel regimen as needed."
3603,"The Foley catheter and
the suprapubic JP drain were left in place. On post-op day 16
the JP drain fluid was found to have a creatinine level of 2.9,
consistent with bladder [**Date Range 3564**]. Urology recommended continued
bladder decompression with the Foley catheter for an additional
14 days when a repeat cystogram will be obtained, this test is
ordered to take place on [**2160-9-16**] in the [**Hospital Ward Name 23**] building on the
[**Hospital Ward Name **] at 930 in the morning. Dr. [**Last Name (STitle) 9125**] is operating that
day at [**Hospital1 18**] will eb in touch with the rehabilitation hospital
to set up a follow-up appointment arrangement."
3604,"9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
15. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO TID W/MEALS (3
TIMES A DAY WITH MEALS)."
3605,"At the rehabilitation hospital,
they will monitor your coumadin therapy and regulate the dose as
needed. When you are home, your primary care provider will need
to do this. You will take 3 mg of coumadin daily at 4pm. You
will have an INR monitored on [**2160-9-6**]. Your goal INR is [**2-6**]. You
will need to take the coumadin daily for 6 months.
Continue your physical therapy as prescribed by a physical
therapist with a goal of walking. No heavy lifting for 2 months,
no bathing or swimming for 6 months after surgery.
You should monitor your bowel function."
3606,"Two [**Doctor Last Name **] drains were placed.
The abdominal wound was irrigated, closed with suture at the
facia and left open given significant obesity and gross
contamination. The patient was admitted from the operating room
to the surgical intensive care unit. The patient was intubated
and monitored closely by the surgical and intensive care unit
teams.
In the ICU a wound VAC was placed, which was changed every three
days by the surgical team. Her intraoperative fluid culture
grew E. coli and klebsiella and her post-op blood culture grew
E. coli and she was started on IV ciprofloxacin/Flagyl."
3607,"They may call Dr. [**Last Name (STitle) **] as needed.
We have talked about starting the antidepressant Celexa to help
you with your mood and motivation. At this time you have decided
to continue to cope with your anxiety on your own. Please talk
with the [**Last Name (NamePattern4) 4113**] at the rehabilitation hospital about starting this
medication if you feel you need continued help. Please reach out
to your family and other support systems.
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) **] in 2 weeks. Call
[**Telephone/Fax (1) 160**] to make this appointment.
Cystogram ordered for [**2160-9-15**] to access bladder [**Last Name (LF) 3564**], [**First Name3 (LF) **] take
place on the [**Hospital Ward Name **] of [**Hospital1 18**]."
3608,"The perforation of your bowel required significant resection and
an ostomy was created from your small intestine to give your
colon a chance to heal. Also, a mucus fistula was made. You
should continue to care for the mucus fistula as well as the
ostomy as you have [**Doctor First Name **] instructed by the wound/ostomy nursing
team. The large surgical wound in your abdomen was left open to
prevent a large wound infection, your abdomen had a large amount
of contamination during the procedure. This has been treated
with VAC therapy and debriedment and has showed signs of
improvment, the wound has decreased in size and has healthy
tissue formation."
3609,"She now p/w [**10-12**] sharp abdominal pain involving her lower
abdomen and back. She reports this started 1 day ago as a
typical Crohn's flare in her LLQ but has progressed and is not
worse than any previous flare. She has had associated nausea
without emesis. She has not had any changes in bowel function
and denies fevers or chills. She has been unable to tolerate
anything except clear liquids. In the ED her WBC is 32 and she
has a lactate of 6.4. She is hypotensive with SBP in 80's and
is currently receiving IVF resuscitation and was started on
levophed."
3610,"She
recieved 3mg of Warafrin prior to discharge on [**2160-9-5**].
Medications on Admission:
Atenolol 50mg daily
Diphenoxylate-atropine prn
Ezetimibe 10mg daily
Lasix 20mg daily
Metformin 50mg [**Hospital1 **]
Niacin SR 500mg daily
Omeprazole 20mg daily
Prochlorperazine Maleate prn
Risedronate 35 qwk
Ergocalciferol 1000mg daily
Multivitamin daily
Percocet prn
Imodium PRN
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
as written units Injection ASDIR (AS DIRECTED).
2. Regular Insulin Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119mg/dL 0 Units 0 Units 0 Units 0 Units
120-159mg/dL 2 Units 2 Units 2 Units 2 Units
160-199mg/dL 4 Units 4 Units 4 Units 4 Units
200-239mg/dL 6 Units 6 Units 6 Units 6 Units
240-279mg/dL 8 Units 8 Units 8 Units 8 Units
280-319mg/dL 10 Units 10 Units 10 Units 10 Units
320-359mg/dL 12 Units 12 Units 12 Units 12 Units
360-399mg/dL 14 Units 14 Units 14 Units 14 Units"
3611,"The CT
torso/abdomen showed no obvious intra-abdominal or intrapelvic
abscess with filling defects within the segmental and
subsegmental branches of the right lower lobe pulmonary arteries
is concerning for PE. Because of dry cough, shortness of breath
with exertion, and atelectasis the patient was started on
standing Combivent nebulizing treatments.
For treatment of the patient's pulmonary embolism a heparin drip
[**2160-8-27**] was initiated and the patient was started on 5mg of
Warfarin on [**2160-8-28**] to bridge her to an INR of [**2-6**]. The
patient's INR level on [**2160-8-29**] was 1."
3612,"5 and the patient recieved
5mg of Warfarin. On [**2160-8-30**] the patient's INR value was 2.7 and
the heparin drip was discontinued and the patient received 3mg
of Warfarin. The patient's INR value on [**2160-8-31**] was 6.4. At this
time the Warfarin was held and the patients INR continued to
climb with a value of 7.3 on the afternoon of [**2160-8-31**], 7.8 on
[**2160-9-1**], 7.7 on [**9-2**], and 7.9 on [**2160-9-3**]. On [**2160-9-3**] it was
decided to reverse the INR with 10 mg of Vitamin K orally."
3613,"perfringens,
Bacteroides: pan-sensitive
[**2160-8-16**] BCx: E.coli, pan-sensitive
[**2160-8-22**] sputum Cx: Gstain: 2+ GPC, 4+ PMNs, Cx: yeast
[**2160-8-23**] echo: LV syst fx depr (EF<30%), mild AO valve stenosis,
sm effusion
[**2160-8-25**] echo: LV systdysfx (EF<30%), apex mildly aneurysmal, no
pericardial effusion
[**2160-8-26**] drain Cx: g stain: 2+ PMNs, Cx: coag neg staph
[**2160-8-27**] CT thorax: seg R lower PE, new thrombus R subclav
partially occlusive, no abscess
[**2160-8-29**] cystogram: contrast [**Month/Day/Year 3564**] demonstrated at the dome of the
bladder"
3614,"6 ([**2160-9-5**])
Brief Hospital Course:
65yo F with Crohn's disease with a known contained abscess in
the pelvic inlet who
was scheduled for elective surgery in the near future, presented
with acutely worsened abdominal pain and hypotension requiring
large volume fluid resuscitation and vasopressors. Her CT scan
was consistent with a bowel perforation and she was taken to the
OR for exploratory laparotomy, ileocecostomy, low anterior
resection with an ileostomy,mucous fistula by Dr. [**Last Name (STitle) **] and a
bladder repair with Dr. [**Last Name (STitle) 9125**]. The case was complicated as
documented in the operative note and there was a bladder
laceration repaired by urology."
3615,"Admission Date: [**2185-7-7**] Discharge Date: [**2185-7-11**]
Date of Birth: [**2126-8-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
PPD placement
History of Present Illness:
58 yo M with PMH significant for chronic back pain, history of
splenectomy, and EtOH use presents with increased shortness of
breath and productive cough, found to be in respiratory
distress.
.
Per patient, he has had productive cough for the past 1.5 weeks.
It started with a dry cough which progressed to coughing
""spells"" that would last thirty minutes at time."
3616,"6 P:76 BP:117/76 RR:18 O2sat94%
3L Nasal Cannula. He was noted to be uncomfortable and
somnolent, with slurred speech and scattered rhonchi on lung
exam. Labs notable for leukocytosis of 11.6 without bands. CXR
was suggestive of multifocal pneumonia. VBG was 7.36/55/65 and
he was started on BiPAP for the hypercarbia, with FiO2 40, PEEP
6, and PP 15. ABG soon after initiation of BiPAP was 7.39/51/399
and patient was noted to be less somnolent and answering
questions. Patient initially treated with azithromycin with nebs
but then received vancomycin and ceftriaxone after the CXR
finding as well as 125 mg of methylprednisolone."
3617,"Social History:
Patient is a retired construction worker and [**Country 3992**] veteran.
Divorced from wife. Mother is health care proxy.
- alcohol: reports drinking 1 pint of vodka ""every ten years"".
also reported twice over past month to another physician. [**Name10 (NameIs) **]
admitted to drinking for 2 days (""several pints"") prior to
admission.
- tobacco: 2 cigarettes/day
- illictis: denied IV drug use. reports marijuana use as a
teenager
Family History:
Father died of congestive heart failure.
Physical Exam:
Vitals: T:96.7 BP: 125/75 P:65 R:16 O2sat: 93% 2L NC
General: middle-age man, sitting up in bed, breathing easily
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: (limited by patient cooperation) dry crackles, no obvious
wheezing, no accessory muscle use
CV: Slow and regular, 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 or
edema."
3618,"Brief Hospital Course:
58 yo M with chronic back pain, splenectomy, and alcohol abuse
presents with cough and shortness of breath from multifocal
pneumonia.
.
# Multifocal pneumonia: Etiology is most likely
community-acquired pneumonia. Given the possible alcohol use,
aspiration pneumonia considered to be possible. Influenza is
less likely, late for the season. Patient does potentially have
TB exposure risk from outreach program with other veterans. In
addition, since he does not have a spleen, need to have clinical
suspicion for infection with encapsulated organism. The
hypercarbia that he initially had in the ED was likely due to
decreased respiratory rate due to somnolence, which was likely
from combination of alcohol and methadone use."
3619,".
# Chest pain: Etiology most likely pleurisy from pneumonia. EKG
unremarkable. Cardiac enzymes normal. Pt was given NsAIDS for
pain prn and monitored on telemetry.
.
# Back pain/extremity pain. h.o multiple prior fxs, Raynauds per
pt- Chronic issue. methadone from methadone clinic. Pt was
given his home dose of 110mg daily.
Habit OPCO - Methadone / Opioid Treatment
[**Location (un) 13107**], [**Location (un) 669**], [**Numeric Identifier 13108**]
[**Telephone/Fax (1) 10953**]
Methadone dose: 110 mg every morning,
When leaves, he will need d/c summary and e/o last dose.
.
# Alcohol abuse: Patient endorses 1.5 pints of beer intake per
day, last drink >24 hours ago."
3620,"However, story is consistently
changing and unreliable. PCP notes, prior admissions for ETOH
withdrawal and seizures. Denied prior history of seizures or
delirium tremens, but PCP confirms seizures. Exam is notable for
tremors and agitation. Pt has a macrocytosis. Pt now admits to
several days of several pints with h.o ""grand mal"" withdrawal
seizures. Pt was placed on a CIWA scale and given valium for
signs of withdrawal. He was given thiamine and folate, but he
refused taking these medications on discharge. Urine/serum tox
screens positive for methadone and benzos. Pt consistently
asked for valium for his ""cough""."
3621,".
#hyperkalemia-unclear etiology. s/p kayexylate. Resolved.
.
#mild transaminitis-likely related to ETOH intake. Monitored
and trended downward.
.
#thrombocytosis-likely reactive given current state of
inflammation.
-trend/monitor.
.
FEN: cardiac, heart healthy. replete electrolytes, regular diet
.
Prophylaxis: Subcutaneous heparin
.
Access: peripherals
.
Code: Full
.
Communication: Patient, called PCP, [**Name Initial (NameIs) 13109**].
.
Medications on Admission:
(per patient):
- methadone 110 mg po qd
Discharge Medications:
1. methadone
methadone 110mg daily
2. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
3. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days."
3622,"Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
multifocal pneumonia
ETOH withdrawal
chronic pain
transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with shortness of breath and coughing and
found to have a bilateral pneumonia. For this, you were started
on antibiotic therapy and your symptoms improved. In addition,
you were evaluated for tuberculosis and PPD was negative, as
well as AFB smears were negative. You also revealed recent ETOH
intake and were found to have alcohol withdrawal during
admission. You mentioned that you have several sources that can
help you with help for this matter. Please continue to seek
help.
.
Medication changes:
1. antibiotics for 3 days (total of 7 days)
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 13110**] to
schedule a follow up after discharge."
3623,"Urine legionella
negative. CXR shows improvement after 1 day of antibiotic
therapy. Pt states recent HIV and PPD testing at PCPs office.
However, PCP has not seen pt in >1year. Pt was initally placed
on vanco, ceftriaxone, and azithromycin. However, as clinical
suspicion for MRSA PNA was low, vanco was discontinued. He will
be discharged on azithromycin and cefpodoxime. Pt refused
pneumonvax vaccination. PPD was placed and was read negative on
[**2185-7-11**]. Sputum was sent for PCP, [**Name10 (NameIs) **] pending. AFB was negative
x 3 on preliminary smear (AFB culture pending). Respiratory
viral screen did not have sufficient sample, but viral culture
was also sent (still pending)."
3624,"EKG [**7-7**]-Artifact is present. Sinus rhythm. The Q-T interval is
prolonged.
Compared to the previous tracing of [**2170-10-16**] there is no
significant change.
.
CXR [**7-7**]-PA AND LATERAL VIEWS OF THE CHEST: Heart size is normal.
Mediastinal contours are unremarkable. Ill-defined opacities
noted diffusely within the left lung, but also within the right
lung base, findings concerning for multifocal pneumonia. No
pleural effusion or pneumothorax is identified. Wedge
compression deformity of a mid thoracic vertebral body is
unchanged.
IMPRESSION: Findings concerning for multifocal pneumonia.
.
[**7-8**] CXR-
The relative hyperlucency of the right upper lung suggests
emphysema, even
though lung volumes are not particularly large."
3625,"He reports
""yellow, green, and brown"" sputum production. He noted
subjective fevers, but no night sweats, or weight loss. Endorses
substernal chest pain that has been constant for the past 1.5
weeks worsens with cough. No nausea, vomiting, diarrhea, joint
pain, or rash.
.
Of note, patient spends his days at an outreach program for
people with substance abuse, depression, and PTSD at the
Veteran's Hospital. Denied any recent travels or sick contact.
Reports that his most recent HIV/viral hepatitis tests were
performed one year ago and they were negative.
.
In the ED, initial vs were: T:97."
3626,"No asterexia.
Neuro: CN II-XII grossly intact. Alert and oriented x3.
Pertinent Results:
[**2185-7-7**] 05:05PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2185-7-7**] 05:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-TR
[**2185-7-7**] 05:05PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
[**2185-7-7**] 05:05PM URINE CastHy-1*
[**2185-7-7**] 05:05PM URINE Mucous-OCC
.
[**2185-7-8**] 05:07AM BLOOD WBC-8.7 RBC-3.80* Hgb-12."
3627,"8 Na-136
K-3.8 Cl-97 HCO3-27 AnGap-16
[**2185-7-9**] 05:45AM BLOOD Lipase-22
[**2185-7-7**] 01:45PM BLOOD Lipase-15
[**2185-7-7**] 01:45PM BLOOD cTropnT-<0.01
[**2185-7-7**] 09:26PM BLOOD Ethanol-NEG
[**2185-7-7**] 01:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2185-7-7**] 05:16PM BLOOD Type-ART pO2-399* pCO2-51* pH-7.39
calTCO2-32* Base XS-5
[**2185-7-7**] 03:27PM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-55* pH-7.36
calTCO2-32* Base XS-3 Comment-GREEN
."
3628,"8 PTT-26.7 INR(PT)-1.1
[**2185-7-8**] 05:07AM BLOOD Plt Ct-456*
[**2185-7-8**] 05:07AM BLOOD PT-12.5 PTT-25.9 INR(PT)-1.1
[**2185-7-7**] 01:45PM BLOOD Plt Smr-NORMAL Plt Ct-479*
[**2185-7-9**] 05:45AM BLOOD Glucose-72 UreaN-13 Creat-0.7 Na-141
K-4.4 Cl-101 HCO3-31 AnGap-13
[**2185-7-8**] 07:30PM BLOOD Na-138 K-5.4* Cl-100
[**2185-7-8**] 05:07AM BLOOD Glucose-160* UreaN-12 Creat-0.7 Na-139
K-5.4* Cl-101 HCO3-30 AnGap-13
[**2185-7-7**] 01:45PM BLOOD Glucose-106* UreaN-12 Creat-0."
3629,"7* Hct-41.0
MCV-108* MCH-33.4* MCHC-30.9* RDW-14.4 Plt Ct-456*
[**2185-7-7**] 01:45PM BLOOD WBC-11.6* RBC-3.99* Hgb-13.4* Hct-41.1
MCV-103* MCH-33.5* MCHC-32.5 RDW-14.9 Plt Ct-479*
[**2185-7-8**] 05:07AM BLOOD Neuts-80.7* Lymphs-14.0* Monos-4.6
Eos-0.5 Baso-0.2
[**2185-7-7**] 01:45PM BLOOD Neuts-70 Bands-0 Lymphs-17* Monos-7 Eos-2
Baso-0 Atyps-2* Metas-1* Myelos-1*
[**2185-7-7**] 01:45PM BLOOD Hypochr-OCCASIONAL Anisocy-1+
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2185-7-9**] 05:45AM BLOOD Plt Ct-537*
[**2185-7-9**] 05:45AM BLOOD PT-12."
3630,"What was a
diffuse
interstitial pulmonary abnormality on [**7-7**] has substantially
cleared with only a small residual at the lung bases, right
greater than left in less than 24 hours. This was pulmonary
edema even though heart size was never enlarged nor was there
substantial pleural effusion.
.
MICROBIOLOGY:
[**2185-7-10**] SPUTUM ACID FAST SMEAR-NEG; ACID FAST
CULTURE-PENDING INPATIENT
[**2185-7-9**] SPUTUM ACID FAST SMEAR-NEG; ACID FAST
CULTURE-PENDING INPATIENT
[**2185-7-8**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-PENDING; Respiratory Viral Antigen
Screen-PENDING INPATIENT
[**2185-7-8**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY; Immunoflourescent test for Pneumocystis
jirovecii (carinii)-PRELIMINARY; ACID FAST SMEAR-NEG; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2185-7-8**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; ACID FAST CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL INPATIENT
[**2185-7-7**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2185-7-7**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2185-7-7**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2185-7-7**] BLOOD CULTURE Blood Culture, Routine-PENDING"
3631,"EKG was
unremarkable. Vitals signs prior to transfer were HR:54
BP:131/81 RR:18 O2sat:99% on BiPAP.
.
On the floor, patient was off BiPAP, with O2 sat in the mid-90s
on 2L NC. He was alert and oriented, slightly tremulous, but in
no distress.
.
Review of sytems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea. Denied
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
- splenectomy [**2154**] - after injury
- shot in the left arm in [**Country 3992**]
- chronic back pain with methadone use"
3632,"Admission Date: [**2140-5-2**] Discharge Date: [**2140-5-6**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Complex left cystic adnexal mass, bilateral cystic adnexal
masses, and left colon cancer.
Major Surgical or Invasive Procedure:
Laparoscopic left colectomy
Laparoscopic bilateral salpingo-oophorectomy
History of Present Illness:
A [**Age over 90 **]-year-old woman who presented with symptoms of obstruction
who was found to have descending colon cancer as well as ovarian
cyst. The risks and benefits including but not limited to
infection, bleeding, leak, the need for more procedures, hernia,
pneumonia, death and heart attack were discussed."
3633,"The patient
consented and agreed.
Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Postural dizziness
Social History:
Patient lives alone independently, daughter lives in [**Name (NI) 760**]
and son in [**Name (NI) 8447**]. Daughter-in-law lives close by and
frequently visits the patient. She is very active and frequently
does yard work on her own.
Physical Exam:
General: Appears well, ambulating the floor independently,
toelrating a regular diet, +flatus, appropriate amount of pain.
VS: Tmac: 99.0 Tcurrent: 97.7 HR: 59 BP: 129/71 RR:16 SaO2:98
RA'
General: A&Ox3
Cardiac: RRR
Lungs: CTA bil
Abdominal: soft, nontender, nondistended, no rebound/gaurding
Wound: CD&I, all laparoscopic sites covered with staples"
3634,"8 Na-140
K-3.8 Cl-102 HCO3-30 AnGap-12
[**2140-5-4**] 05:30AM BLOOD Phos-2.5*# Mg-2.1
[**2140-5-3**] 04:06AM BLOOD Calcium-7.7* Phos-4.3 Mg-2.2
[**2140-5-2**] 10:06PM BLOOD Mg-2.2
[**2140-5-2**] 09:25AM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.7# Mg-2.7*
Brief Hospital Course:
[**Hospital Unit Name 13533**]:
[**Age over 90 **] yo F was admitted to the [**Hospital Unit Name 25503**] 0 s/p laparoscopic left
colectomy and b/l salpingooothecectomy complicated by
subcutaneous emphysema."
3635,"subcutaneous emphysema thought to be
likely secondary to intraoperative CO2 insulfation . On transfer
she had hypercarbic respiratory failure. Her respiratory
acidosis improved with change of ventilator settings and
respiratory alkalosis was induced; vent settings were changed
again to correct this. Sedation was weaned overnight and patient
was extubated in the morning. Patient was made DNR/DNI in
discussion with her daughter. [**Name (NI) **] from now on will be
determined by general surgery and gyn/oncology. The patient was
extubated on post-operative day one. She was transferred to the
inpatient floor after extubation.
.
PENDING ON TRANSFER: Blood cultures
The patient was transferred to the inpatient unit from the [**Hospital Unit Name 153**]
in stable condition."
3636,"Medications on Admission:
Nicardipine 20 daily
Enteric coated aspirin 325 daily
Valsartan 320 daily
Atorvastatin 10 daily
Metoprolol XL 50 daily
MVI
Stool softener QID
Discharge Medications:
1. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. nicardipine 20 mg Capsule Sig: One (1) Capsule PO once a day.
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 7 days: do not take more than 4000mg of tylenol
daily, do not drink alcohol while taking tylenol."
3637,"Miralax 17 gram Powder in Packet Sig: One (1) packet PO
every other day as needed for constipation: Please take if
constipated.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Complex left cystic adnexal mass,
bilateral cystic adnexal masses, and left colon cancer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a Left laparoscopic
colectomy and bilateral salpingo-oophrectomy for surgical
management of your adnexal masses and left colon cancer."
3638,"You have [**3-11**] laparoscopic surgical incisions on your abdomen
which are closed with internal surtures and staples. These are
healing well however it is important that you monitor these
areas for signs and symptoms of infection including: increasing
redness of the incision lines, white/gree/yellow/malodorous
drainage, increased pain at the incision, increased warmth of
the skin at the incision, or swelling of the area. Please call
the office if you develop any of these symptoms or a fever.
Youmay go to the emergency room if your symptoms are severe. You
may shower, pat the incisions dry with a towel do not rub."
3639,"Disp:*42 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain for 5 days: Please call the office if you
feel the need to take this medication. Do not drink alcohol or
drive a car while taking this medciation.
Disp:*10 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10."
3640,"Pertinent Results:
[**2140-5-4**] 05:30AM BLOOD WBC-12.4* RBC-2.97* Hgb-9.5* Hct-29.4*
MCV-99* MCH-32.1* MCHC-32.5 RDW-14.6 Plt Ct-216
[**2140-5-3**] 04:06AM BLOOD WBC-14.6*# RBC-2.86* Hgb-9.3* Hct-27.7*
MCV-97 MCH-32.5* MCHC-33.5 RDW-14.5 Plt Ct-228
[**2140-5-2**] 10:06PM BLOOD Hct-27.6*
[**2140-5-2**] 09:25AM BLOOD WBC-9.2# RBC-3.38* Hgb-11.2* Hct-32.7*
MCV-97 MCH-33.1* MCHC-34."
3641,"You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next 2-3 days. After anesthesia it is not
uncommon for patient??????s to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are explected however, if you notice that you are passing bright
red blood with bowel movments or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe."
3642,"You should take
a half tablet only if needed. If you find thta you are having
abdominal pain requiring you to use pain medications please call
Dr.[**Name (NI) 10065**] office. Do not drink a car or drink alcohol if
taking narcotic pain medicaitons.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr.
[**Last Name (STitle) **].
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. FOr a short time you will have visiting nurses check
on you at home. Good luck!
Followup Instructions:
Please call the colorectal surgery office at [**Telephone/Fax (1) 160**] to
make an appointment for your first post-operative check with Dr.
[**Last Name (STitle) **] 3 weeks after your discharge from the hospital.
Please call and make an appointment with your primary care
provider to have you staples removed in 7 days.
Completed by:[**2140-5-6**]"
3643,"The
small incisions may be left open to the air. Your staples will
be removed at your post-operative appointment with Dr. [**Last Name (STitle) **].
Please no baths or swimming for 6 weeks after surgery unless
told otherwise by Dr. [**Last Name (STitle) **].
You may continue to take tylenol for pain. Please do not take
more than 4000mg of tylenol [**Last Name (LF) **], [**First Name3 (LF) **] not drink alcohol while
taking tylenol. You will be given a small amount of the
medication oxycodone for pain, please take only as needed as you
have not taken this medication in the hospital."
3644,"You
have recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
[**Name2 (NI) 19605**] these results they will contact you before this time.
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor your bowel function closely."
3645,"She progressed well without any acute
event. [**2140-5-4**] she was started on a clear liquid diet which she
tolerated well and her Foley catheter was removed. She was able
to void spontaneously. The subcutaneous emphysema from the
operating room continued to steadily improve. The patient was
cleared by physical therapy to be discharged home with services.
The patient has a supportive family and this discharge plan was
realistic. The patient continued to ambulate independently and
on [**2140-5-5**] passed flatus and tolerated a regular diet. The
patient was discharged home on post-operative day four in stable
condition."
3646,"If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. Please follow the bowel regimen prescribed for you, you
have been prescribed the medication miralax which is a powder
that you may take every other day as needed for constipation. If
you notice that you are developing loose stools you make take
away one bowel medication at a time. If you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonges loose stool, or
constipation."
3647,"1 RDW-14.3 Plt Ct-307
[**2140-5-3**] 04:06AM BLOOD Plt Ct-228
[**2140-5-2**] 09:25AM BLOOD Plt Ct-307
[**2140-5-2**] 09:25AM BLOOD PT-12.4 PTT-22.9 INR(PT)-1.0
[**2140-5-4**] 05:30AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-136
K-3.8 Cl-103 HCO3-25 AnGap-12
[**2140-5-3**] 04:06AM BLOOD Glucose-132* UreaN-11 Creat-0.6 Na-140
K-4.4 Cl-107 HCO3-23 AnGap-14
[**2140-5-2**] 10:06PM BLOOD Na-140 K-3.3 Cl-104
[**2140-5-2**] 09:25AM BLOOD Glucose-104* UreaN-12 Creat-0."
3648,"Admission Date: [**2161-11-18**] Discharge Date: [**2161-11-22**]
Date of Birth: [**2100-1-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2161-11-18**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] tissue) via
minamally invasive approach
History of Present Illness:
Mr [**Known lastname **] had aortic stenosis diagnosed approximately 2 years
ago upon routine preop evaluation prior to prostatectomy. He was
noted to have bicuspid aortic valve with peak gradient of 86mmHg
and mean gradient of 52mmHg with a valve area calculated at
0."
3649,"7cm2 on most recent echo in [**2161-3-15**]. He has had a lifelong
heart murmur.On questioning of his symptoms he and his wife have
noticed him to have more shortness of breath on going up a
flight of stairs. However he's able to walk on the flat for
quite sometime (1-2 hours) without issues. He further denies any
chest pain, pressure or dizziness or syncope. Noted to have PVCs
recently.
Past Medical History:
- Aortic stenosis
- Prostate ca s/p resection
- ***diffuculty with intubation due to abnormal airway requiring
laser guidance when having prostate surgery ****
- skin CA
- cellulitis LUE [**2-20**]- healed well after abx
- bilat."
3650,"Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month AND off all narcotics
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns
Followup Instructions:
Please schdeule the following appointments
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] in [**3-17**] weeks
Dr. [**First Name (STitle) **] in [**2-13**] weeks
Wound check on [**Hospital Ward Name 121**] 6 on Friday [**11-27**].
Completed by:[**2161-11-22**]"
3651,"C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8."
3652,"Possible cleft in the posterior mitral leaflet. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2161-11-18**] at
1030am
Post bypass: Patient is V paced and receiving an infusion of
phenylephrine. Biventricular systolic function is unchanged.
Bioprosthetic valve seen in the aortic position. Valve appears
well seated and the leaflets move well. Mild mitral
regurgitation persists.
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit and on [**2161-11-18**] he was brought to
the operating room where he underwent an aortic valve
replacement via a minimally invasive approach."
3653,"[**Last Name (STitle) 914**], Mr. [**Known lastname **] was sent home
on 7 days of keflex and will return for a wound check on friday.
Medications on Admission:
None
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E."
3654,"Please see
operative note for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. On post-operative day one
he was transferred to the telemetry floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. He was evaluated by physical therapy and cleared for
discharge to home on POD#4.
Of note, the areas along Mr. [**Known lastname 515**] sternal incision and
previous pacer wire site were slightly pink without draiange or
tenderness. Per request of DR."
3655,"ing herniorrhaphies
Social History:
Occupation: Retired High School Principal
Last Dental Exam:6 months ago
Lives with: wife
[**Name (NI) **]:Caucasian
Tobacco: never
ETOH: 2-3 beers per day
Family History:
non-contrib.
Physical Exam:
Pulse: 72 Resp:12 O2 sat:98% RA
B/P Right:126/70 Left: 130/68
Height: 5'[**63**]"" Weight:182#
General:NAD; tan and fit-appearing
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]injected sclera;OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] bigeminy
Murmur 3/6 SEM radiates throughout precordium to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ hypoactive; no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact; nonfocal exam; MAE [**6-16**] strengths
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+"
3656,"Carotid Bruit :murmur radiates to both carotids
Pertinent Results:
[**2161-11-18**] Echo: Prebypass: A left-to-right shunt across the
interatrial septum is seen at rest. A small secundum atrial
septal defect is present. There is mild symmetric left
ventricular hypertrophy. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Trace aortic regurgitation is seen."
3657,"Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA ofCape Cod
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Past medical history:
Prostate ca s/p resection
- ***diffuculty with intubation due to abnormal airway requiring
laser guidance when having prostate surgery ****
- skin CA
- cellulitis LUE [**2-20**]- healed well after abx
- bilat. ing herniorrhaphies"
3658,"Admission Date: [**2144-3-16**] Discharge Date: [**2144-3-21**]
Date of Birth: [**2096-11-6**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
Cerebral Angiogram ([**2144-3-20**])
History of Present Illness:
Mr [**Known lastname 110267**] is a 47 year old man with HTN and daily etoh
abuse who woke up at 7am who presents as a transfer from an OSH
following a seizure and an IPH. Today the patient was awoken
around 7:20 am per his wife with worse HA of his life."
3659,"His vitals at that time were T 98.7 / pulse
127,
resp 20, BP 144/81. Patient was given Keppra 1 g at OSH, 2 mg
of
ativan and 5 mg of diazepam and 4 mg of zofran and transferred
for further management.
Past Medical History:
broken leg
sleep apnea?
HTN
No surgeries
Social History:
Lives at home wiht his wife / works as a mechanic for a Dodge
dealership. He has three children 12, 11 and 6 who are all at
home with him. He has a 15-20 pack year of tobacco. Daily Etoh
12-18 beers per day / does not recall history of DT's."
3660,"BRIEF ICU COURSE:
Patient was initially admitted to the NeuroICU for close
monitoring. Neurological exam shows unequal, reactive pupils
(L>R) but otherwise, nonfocal exam. Noncontrast head ct showed a
3 cm left temporal bleed with mild surrounding vasogenic edema
and localized mass effect, but no midline shift and basal
cisterns intact. Etiology for bleed unlikely to be hypertensive
given location and only mildly elevated BP at OSH. Underlying
structural lesion is possible, especially since there appears to
be prominent vasculature on CTA. Venous thrombosis was also
considered.
.
#Left Temporoparietal Intraparenchymal Hemorrhage: The patient
underwent and MRI/MRV to further delineate an underlying
mass/lession (see full report above)."
3661,"#ETOH: Per report from wife patient had been drinking up to 18
beers/day. Patient was placed on CIWA while in the unit and
received only minimal doses. He clinically did not go into
withdrawl. The CIWA was kept upon transfer to the floor but he
did not require any BZD's. LFT's were WNL, with no transminitis,
and liver synthetic function was normal. Patient was given
thiamine, folic acid, and multivitamin while in the hospital.
#HTN: Patient initially had goal SBP<160 with PRN hydralazine.
He was on lotrel (5 amlodipine, 40 benezepril) at home. He had
this restarted upon arrival to the floor and acheived good
control with this."
3662,"DO NOT SMOKE with
patch.
Disp:*60 Patch 24 hr(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain: do not take more than 4000mg in 24
hours. .
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Left Temporal Intraparenchymal Hemorrhage
Secondary Diagnosis: Hypertension, Tobacco Use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 110267**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were sent to
the hospital after having had a seizure and a terrible headache."
3663,"[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the contact information
will be provided below.
Also, the Neurosurgery team would like for you to follow-up and
get a repeat scan of your head in a month. Please see below.
We made the following changes to your medications:
START Keppra 1000mg take one tablet by mouth twice daily
(continue to take this until your follow-up with Dr. [**Last Name (STitle) **]
START Tylenol (Acetaminophen) take one to two 500mg tablets
every 8 hours as needed for headache
START Nicotine Patch (transdermal) 14mg apply once every 24
hours as needed for cigarette craving"
3664,"3. Mild peripheral enhancement along the hematoma, likely
represents reactive changes. No evidence of underlying mass
lesion in this study.
4. Opacification of the left mastoid sinus. Please correlate
clinically for signs of infection. Cortical venous sinus
thrombosis cannot be excluded in this study.
.
[**2144-3-21**] Cerebral Angiogram:
PRELIMINARY REPORT PRIOR TO DISCHARGE:
Mr. [**Known firstname **] [**Known lastname 110267**] underwent diagnostic cerebral angiography
which was unremarkable. There is no evidence of vascular
malformation or aneurysm in the intracranial circulation.
.
LABS AT DISCHARGE:
[**2144-3-21**] 05:30AM BLOOD WBC-6.3 RBC-4.30* Hgb-13.3* Hct-39."
3665,"You were admitted to the Neurology service, and a scan was
performed of your head that showed a bleed in the left side of
your brain. While it is still unclear exactly what caused the
bleed, the most likely cause is your high blood pressure. You
had a study of your blood vessels of the brain which was
reassuring, but did not help to reveal a potential cause for the
bleed in your brain.
Your seizure that you had was most likely due to the bleed in
the brain. For this reason we are starting you on an
anti-seizure medication known as Keppra."
3666,"Attentive, able to name DOW 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 0/3 at 5 minutes. The pt. had good
knowledge of current events. There was no evidence of apraxia
or
neglect. Calculation was intact (answers seven quarters in
$1.75)
.
-Cranial Nerves:
I: Olfaction not tested.
II: Left eye 5 mm to 3 mm, R eye 4 mm to 3mm and brisk."
3667,"He had
been drinking all weekend, and the wife assumed it was a ""hang
over"" and he called in to work. Around noon he was sleeping on
the couch and she took the kids to the pool. However, she
forgot
something and returned around 1 pm. She hurt a loud grunt and
walked over to find her husband with his head deviated to the
left and rigid. This lasted less than a minute and he was
somnolent afterwards. EMS was notified and he was brought over
to [**Hospital3 15402**] and was reportedly lethargic but answering
questions
appropriately and a noncontrast head ct showed a 3 cm left
temporal bleed."
3668,"-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 dysmetria on FNF or HKS bilaterally.
At transfer out of NeuroICU:
Neuro: 1 mm of anisicoria (L > R), R hand may be slightly slower
on RAMs than L hand. Otherwise normal.
Pertinent Results:
LABS ON ADMISSION:
[**2144-3-16**] 04:35PM WBC-11.2* RBC-4.88 HGB-14.9 HCT-45.6 MCV-93
MCH-30."
3669,"There is no evidence of
pleural
effusion or pneumothorax. Normal size of the cardiac silhouette.
In the lung parenchyma, there is no evidence of a mass or
pulmonary nodules. The hilar and mediastinal contours are
unremarkable.
.
[**2144-3-17**] Repeat Head CT:
Stable left temporal parenchymal hematoma with associated small
subdural hematomas along the left tentorium and left temporal
lobe, unchanged from [**2144-3-16**]. There is mild associated mass
effect with no evidence of herniation.
.
[**2144-3-17**] MRI/MRV:
1. Left temporoparietal intraparenchymal hematoma, with left
hemispheric and left tentorial subdural hematoma, not
significantly changed.
2. No evidence of venous sinus thrombosis."
3670,"You should continue to take your
blood pressure medication, and reduce your sodium intake to
help control your blood pressure. In addition, smoking is a
large risk factor for having a stroke, and if you were to quit
it would greatly reduce your risk. For this reason we are
presribing you a patch known as the nicotine patch to help you
fight off the craving. DO NOT smoke while you have the nicotine
patch in place. There are other medications as well that can be
used to help you quit smoking (bupropion and welbutrin), you
should discuss this with your primary care provider."
3671,"You will need to
continue this until your follow up with the Neurology team (Dr.
[**Last Name (STitle) **]. Please see below for your scheduled appointment.
Because you had a seizure, it will be important that you DO NOT
drive for the next 6 months. In addition to this please avoid
dangerous activities such as climbing. Also, do not take baths
or swim as you are at an increased risk for drowning if you were
to have a seizure.
In addition, we discussed with you the risk factors for your
bleed in the brain. There are several things you can do to
reduce your risk of stroke."
3672,"8*
MCV-93 MCH-30.9 MCHC-33.4 RDW-12.4 Plt Ct-196
[**2144-3-21**] 05:30AM BLOOD Glucose-108* UreaN-9 Creat-0.7 Na-138
K-4.3 Cl-102 HCO3-29 AnGap-11
[**2144-3-21**] 05:30AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 110267**] is a 47 year old man with HTN and daily etoh abuse
who woke up at 7am with worse HA of life at noon found by wife
in a likely complex partial seizure with secondary
generalization (loud vocalization left head deviation and then
tonic rigidity) that self resolved in about 1 minute."
3673,"4 eAG-108
.
LFT's
[**2144-3-17**] 04:22AM BLOOD ALT-24 AST-37 LD(LDH)-174 AlkPhos-45
TotBili-0.7
.
[**2144-3-16**] CTA Head and Neck:
IMPRESSION:
1. Left temporal parenchymal hemorrhage with associated small
subdural
hematoma. Mass effect is mild with effacement of the left
ambient cistern and compression of the ventricle of the left
temporal [**Doctor Last Name 534**]. No intraventricular extension.
2. No evidence of vascular malformation or aneurysm.
3. Cystic lucency in right anterior alveolar process of maxilla
for which
differential considerations include chronic abcess and clinical
correlation should be performed.
.
[**2144-3-16**] Portable CXR:
FINDINGS: The lung volumes are normal."
3674,"[**Name10 (NameIs) **],
sometimes heavy drinking of alcohol can cause problems with your
blood clotting. The Social Work team has provided you options
about certain programs that can help you with your alcohol
intake.
Social work has also provided you with information on programs
to help with your alcohol use, in addition, for your wife to
have support as well.
Also, due to the location of your bleed you were noted to have
issues associated with your memory. You were seen by
Occupational Therapy who has recommended a full neurocognitive
evaluation before you return to work. Please call to setup an
appointment with Dr."
3675,"5 MCHC-32.6 RDW-13.4
[**2144-3-16**] 04:35PM PLT COUNT-197
[**2144-3-16**] 04:35PM PT-9.9 PTT-25.3 INR(PT)-0.9
[**2144-3-16**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2144-3-16**] 04:35PM UREA N-13 CREAT-0.7
[**2144-3-16**] 04:43PM GLUCOSE-120* NA+-139 K+-4.1 CL--99 TCO2-26
.
STROKE RISK FACTORS:
[**2144-3-17**] 04:22AM BLOOD Triglyc-96 HDL-66 CHOL/HD-3.3
LDLcalc-136*
[**2144-3-17**] 04:22AM BLOOD %HbA1c-5."
3676,"TRANSITIONAL ISSUES:
1) Continue Keppra until follow up with Neurology (Dr. [**Last Name (STitle) **]
2) Repeat MRI in about 1 month, f/u with Nsurg
3) Continued monitoring of blood pressure control per PCP
4) Discussion of continued tobacco cessation with PCP
Medications on Admission:
Lotrel (almodipine 5, benzepril 40)
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
2. amlodipine-benazepril 5-40 mg Capsule Sig: One (1) Capsule PO
once a day.
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) as needed for nicotine withdrawal:
apply when you feel the craving for cigarette."
3677,"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. + asterixis bl, postural tremur (high freq, low
amp)
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
."
3678,"Followup Instructions:
You will need to follow-up with your primary care provider [**Last Name (NamePattern4) **]
[**12-2**] weeks. Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Monday [**3-23**] to
setup an appointment. You should discuss your smoking cessation
and your blood pressure medication. The phone number is
[**Telephone/Fax (1) 39454**].
You need to follow up with Dr. [**First Name (STitle) **] from Neurosurgery in 1
month. You will need an MRI/MRA prior to this appt. Appt can be
made by calling [**Telephone/Fax (1) 1669**].
You will need a formal neuro-cogntive evaluation to evaluate for
your safety to return to work. Please call to setup an
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 1703**].
Department: NEUROLOGY
When: WEDNESDAY [**2144-5-13**] at 2:00 PM
With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]"
3679,"There was no evidence of
venous sinus thrombosis or mass, and the previously identified
bleed was deemed stable. Our colleagues in Neurosurgery were
consulted and a cerebral angiogram was performed but did not
identify any pertinent vascular abnormalities. The patient due
to initial presentation of seizure (likely secondary to
temporoparietal bleed) was placed on Keppra 1000mg [**Hospital1 **] without
any notable seizure events. He will continue this as an
outpatient. The patient had his stroke risk factors evaluated,
HBA1c WNL, and LDL of 136. He did not require starting of a
statin as this has been shown to increase the risk of bleeding."
3680,"The patient did have noticeable memory deficits on cognitive
evaluation with occupational therapy. It has been recommended to
the patient to schedule an appointment with Dr. [**First Name (STitle) **]
(behavioral Neurology) in order to receive a full cognitive
evaluation prior to returning to work. As to the etiology of the
stroke, it is possible that is HTN related although the location
is not necessarily specific for this. Patient will have a follow
up MRI in about one month, and follow-up with Neurosurgery and
Neurology to help delineate if there is another underlying
lesion that was not identified on current studies."
3681,", smokes
MJ
ocassionally, no coccaine and no heroin use.
Family History:
does not believe there is a history of strokes or
seizures
Physical Exam:
At admission:
O: T: af BP:150 / 82 HR: 109 R 11 O2Sats100 on 2 l
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
-Mental Status: Alert, oriented x 2, stated it was ""[**2140-1-30**]""."
3682,"He will continue his home Lotrel as he
received
#Tobacco Use: Patient has been a lifelong smoker. We discussed
that this was a risk factor for stroke. He was given a nicotine
patch while in hospital. He will discuss cessation options
(including welbutrin or chantix) with his PCP. [**Name10 (NameIs) **] was given
a prescription for nicotine patches.
# Social issues: The patient's wife was uncomfortable coping
before baseling and more worried after her husband's stroke.
Social work was consulted and helped provide resources to Mr.
[**Known lastname 110267**] regarding alcohol cessation, in addition the patient's
wife was given support resources as well."
3683,"Admission Date: [**2157-12-16**] Discharge Date: [**2157-12-21**]
Date of Birth: [**2102-10-7**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2157-12-18**]
1. Open treatment fracture-dislocation, thoracic spine.
2. Bilateral laminotomy T9, T10, T11.
3. Posterolateral fusion T9-T10, T10-T11.
4. Posterolateral instrumentation T9, T10, T11.
5. Application of iliac crest bone graft for fusion
augmentation.
6. Application of local autograft for fusion augmentation.
7. Application of allograft for fusion augmentation.
History of Present Illness:
HPI: 55 yo F who fell backwards off of a [**Location (un) 453**] balcony onto
a
concrete slab."
3684,"Pt was leaning backwards on a rail at a
restaurant
when the rail gave way and she fell approximately 7 feet onto a
concrete slab. Pt recalls the entirety of the event and denies
LOC. She does recall striking the back of her head on the
concrete. She describes immediate pain in the middle of her back
after the fall and was unable to stand because of it. She denies
any numbness or tingling in her extremities and denies any
incontinence following her fall. Pt was taken to an OSH where
she
was found to have multiple posterior rib fxs (6th-8th on L, 9th
on R), a T10 compression fx w/ impringement on the thecal sac."
3685,"Pt
was subsequently transfered to the [**Hospital1 18**] for further evlauation
and Spine surgery consultation.
On presentation to the [**Name (NI) **], pt was stable and complaining of
severe pain throughout her mid back. While in the trauma bay her
O2 saturation decreased to high 80s on NC and a nonrebreather
was
required. At that point she was tachypnic into the 30s. She was
admitted to the TSICU for close observation, respiratory
support,
and pain control. Ortho Spine was consulted for further
evaluation of her spinal fractures
Past Medical History:
Past Medical History: anxiety - gerd
Social History:
Social History: Denies Alcohol and Smoking"
3686,"4 PTT-21.4* INR(PT)-1.0
[**2157-12-16**] 01:15AM GLUCOSE-119* UREA N-18 CREAT-0.7 SODIUM-137
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
Brief Hospital Course:
55 year old female who presented to the Acute Care Service
after a fall from a porch landing on her back. Initially, she
was seen at an outside hospital where she was reported to have
multiple rib fractures and a thoracic compression fracture.
Upon admission to the Acute Care Service, she was evaluated by
Ortho-spine who recommended TLSO brace. She had blood work done
and further imaging of her back, chest, and head."
3687,"8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-15**]
Tablets PO Q6H (every 6 hours) as needed for pain.
10. insulin regular human 100 unit/mL Solution Sig: [**2-23**] units
Injection four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
S/P Fall
1. posterior L 6-8th rib fx
2. posterior R 7-9th rib fx
3. severely comminuted compression fx T10
4. compression fx T7
5."
3688,"L transverse fx T7-11
6. acute blood loss anemai
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair, pt has TLSO brace when out of bed
Discharge Instructions:
You are being discharged after you were admitted for a fall in
which you sustained back and rib fractures. You were taken to
the operating room for a laminectomy and fusion. You are now
preparing for discharge with the following instructions:
Your injury caused posterior right and left rib fractures
which can cause severe pain and subsequently cause you to take
shallow breaths because of the pain."
3689,"Pertinent Results:
[**2157-12-16**]: Cat scan of spine:
IMPRESSION:
1. Burst fracture of T10 vertebral body, with outward
displacement of
multiple fracture fragments with associated laminar fractures on
both sides of the posterior arch of T10. Bone along the
posterior margin of T10 vertebral body is displaced into the
spinal canal.
2. Compression of the superior endplate of the T7 vertebral body
with intact posterior arch point.
3. Transverse fractures of left T7, 8, 9, 10 and 11.
4. Fractures of the left 5th, 6th and 7th ribs and right 9th
posterior ribs.
5. Developing atelectasis in bilateral lungs as well as possible
bilateral
pleural effusions"
3690,"3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
5. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours) as needed for itching/insomnia.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain: as needed."
3691,"Alternatively,
the increased signal in the T4 vertebra could be due to
degenerative change.
4. No evidence of high-grade spinal cord compression or
intrinsic spinal cord signal abnormalities
[**2157-12-17**]: cat scan of the head:
IMPRESSION: No acute intracranial process
[**2157-12-17**]: Chest x-ray:
FINDINGS: In comparison with the study of [**12-16**], there is some
increased
opacification at the right base consistent with atelectasis and
fluid in the pleural space. Retrocardiac atelectasis is again
seen. The multiple rib fractures are better visualized on the CT
scan. Top normal or slightly
enlarged cardiac silhouette is again noted."
3692,"[**2157-12-15**]: Cat scan of abdomen and pelvis:
IMPRESSION:
1. Bilateral dependent pleural effusion with some hyperdensity
within the
pleural effusion which may represent a component of hemothorax.
2. Adjacent compressive atelectasis.
3. Bilateral rib fractures as detailed above.
4. Fractures of the left 7, 8, 9, 10,11 transverse processes.
5. Burst fracture of T10 vertebral body with posterior arch
involvement and
retropulsion of the components of the fracture fragment into the
vertebral
canal.
6. Fracture of the anterior superior endplate of T7 with no
obvious arch
involvement
[**2157-12-15**]: Chest x-ray:
PORTABLE AP CHEST RADIOGRAPH: In the interim since the most
recent chest
radiograph there is increased inflation of the left lung."
3693,"Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2157-12-16**]
Temp:afeb HR:100 BP:131/83 Resp:36 O(2)Sat:99 Normal
Constitutional: Immob
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent; no deficits
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae"
3694,"She is tolerating a regular diet.
She has been out of bed with the TLSO brace. Her pain is
controlled with oxycodone. She was evaluated by Physical Therapy
Service and rehab was recommended with the hopes of improving
her mobility and returning home.
After an uneventful post op course she was discharged to rehab
on [**2157-12-21**] and will follow up with Dr. [**Last Name (STitle) 1007**] in 2 weeks.
Medications on Admission:
Medications: Omeprazole
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation."
3695,"* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing."
3696,"She had an episode of oxygen desaturation upon admission, and
for this reason was admitted to the Trauma Intensive Care unit
for neuro-checks, pulmonary toilet and pain management. She was
placed on log-roll precautions until she was fitted for her TLSO
brace.
She was taken to the Operating room on [**12-18**] where she had a
T10 posterior corpectomy and a T9-T11 fusion. During her
operative procedure, she did receive blood for a liter blood
loss. She was extubated in the recovery room.
Her post-operative course has been stable. She is afebrile and
her vital signs are stable."
3697,"Bilateral pleural effusions are still noted, left greater than
right. Rib fractures are better visualized on the adjacent chest
CT. Cardiac silhouette is top normal.
[**2157-12-16**]: MR thoracic spine:
IMPRESSION:
1. Worst fracture of T10 vertebra with retropulsion and likely
disruption of the anterior and posterior longitudinal ligaments
with retropulsion causing mild spinal stenosis.
2. Moderate compression of T7 vertebra with probable disruption
of the
posterior longitudinal ligament and mild retropulsion in the mid
portion in contact with the anterior aspect of the spinal cord.
3. Disc herniation at T3-4 level indenting the anterior aspect
of the spinal cord with subtle increased signal in the T4
vertebra, likely due to mild compression injury."
3698,"No definite
pulmonary vascular congestion
[**2157-12-18**]: T-spine:
FINDINGS AND IMPRESSION: AP and lateral intraoperative images
of the
thoracolumbar spine. At approximately T10, a compression
fracture is noted. Status post posterior spinal fusion from
approximately T9-T11. .
[**2157-12-16**] 01:15AM WBC-9.5 RBC-3.67* HGB-11.4* HCT-33.8* MCV-92
MCH-30.9 MCHC-33.6 RDW-12.9
[**2157-12-16**] 01:15AM NEUTS-86.9* LYMPHS-9.3* MONOS-3.2 EOS-0.1
BASOS-0.5
[**2157-12-16**] 01:15AM PLT COUNT-257
[**2157-12-16**] 01:15AM PT-12."
3699,"* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus )
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1007**] in 2 weeks. You can schedule
this appointment by calling #[**Telephone/Fax (1) 1228**].
Please follow up with the Acute Care Service in 2 weeks, you can
schedule this appointment by calling #[**Telephone/Fax (1) 600**]
Completed by:[**2157-12-21**]"
3700,"Around 5pm she had some home-made chicken soup
with beans, and about an hour later developed the pain and
distention. She describes the pain as crampy and wave-like in a
band across her lower abdomen. She has not had any nausea,
vomiting, or diarrhea. She has had difficulty with diarrhea
since her ileostomy reversal, and recently started taking
metamucil and Immodium.
Past Medical History:
Rectal Adenocarcinoma
Osteoporosis
Arthritis
Carotid Endarterectomy
Hysterectomy
Peptic Ulcer Disease
H. Pylori treated
Venous Insuffieciency
PSH: Carotid Endarterectomy, Hysterectomy, Robotic LAR w/
diverting loop ileostomy ([**2116-10-22**]), ileostomy take-down
[**2116-12-15**], left upper lobectomy [**2116-8-31**]"
3701,"Social History:
Widow. Retired radiolgoy tech
Tobacco: quit many years ago. ETOH social
Family History:
Mother died age [**Age over 90 **] old age
Father died age 86 bladder CA
Physical Exam:
On Discharge: Patient doing well, ambulating with assist of
nurse/aide and walker. OOB to chair. Patient tolerating
food/liquids, and PO meds per speech and swallow. No respirtory
distress.
Vitals- 98.3, 97.5, 95, 131/60, 20, 98% RA
Gen- NAD, A+O x3, Left PICC line in place
Cardiac- RRR, holosystolic [**3-8**] murmur, no bruits or gallops,
normal S1/S2
Resp- CTAB, no crackles, no wheezing, stridor dramatically
improved from original episode."
3702,"Please
refer to the operative note for more details on the procedure.
Neuro: During her stay and post-operatively, the patient
received IV morphine as needed along with IV Tylenol, all with
good effect and adequate pain control. When tolerating oral
intake and clears by speech and swallow to take pills orally,
the patient was transitioned to oral pain medications.
CV: The patient was more or less stable from a cardiovascular
standpoint; She was intermittently tachycardic on the floor
prior to surgery and in the [**Hospital Unit Name 153**] after which was successfully
managed with IV Lopressor (please refer to the [**Hospital Unit Name 153**] course
below)."
3703,"Occasional hypertension was successfully treated with
hydralazine. Vital signs were routinely monitored. The patient
was transitioned to home dose of Metoprolol and the patient's
blood pressure was adequately controlled.
Pulmonary: The patient had some pulmonary issues during her
hospital stay. Post operatively, she had some desaturation on RA
(to the 80's) as well as increasing stridor. A CXR was
concerning for possible aspiration vs hospital acquired
pneumonia and she was started on a 10 day course of
levofloxacin. ENT was consulted for the apparent upper
respiratory obstructive stridor and it was found that her left
vocal cord was non functional from a previous injury (possibly
during the CEA) and the right vocal cord was not functioning
well which is what likely contributed to the stridor."
3704,"Prior to
that, she was only having minimal flatus and bowel movements
with aggressive suppository treatments. She was kept NPO the
whole time. Post-operatively, the patient was also kept NPO for
a while aggressive awaiting return of bowel function. NGT tube
was removed on POD 2 due to very low output. A PICC line was
placed on POD 3 and TPN was initiated shortly thereafter. She
had bowel sounds throughout this whole time and abdominal
distention was improving. On POD 6 she began passing flatus. Due
to the possible aspiration pneumonia and vocal cord issues, a
speech and swallow study was ordered before advancing her diet."
3705,"She failed this study. The next day, a video swallow study was
ordered which she passed and was allowed to start a diet with
many aspiration precautions in place. She was advanced to sips
on POD 7 which was tolerated well with no coughing or gagging.
However, the next day she stopped passing flatus and had some
abdominal distention and was thus made back to an NPO status.
Her distention and obstipation continued to worsen and a KUB was
obtained which showed colonic ileus. The patient was given
bisacodyl suppositories in the mornings. On [**2116-2-5**] the patient
was passing flatus and having bowel movements."
3706,"Her diet was
advanced from clear liquids to full liquids which were tolerated
well. On [**2117-2-5**] was advanced to ground mechanical soft diet with
ensure supplements. Because of prolonged NPO status the patient
was started on TPN and was followed closely by inpatient
nutrition. The patient was to be discharged on TPN cycled
overnight with intention of tapering TPN as her PO intake
increased. Please see speech and swallow note attached to
discharge paperwork. The patient will need continued speech
therapy during her rehabilitation hospital stay.
Due to urinary retention in the beginning, a Foley was placed.
It was removed on HD 8."
3707,"It was again replaced on HD 9/POD1 for
close urine output monitoring given respiratory status and
desire to keep from fluid overload. It was removed on POD 5. She
had no urinary issues since and has been making adequate urine
on her own throughout the rest of her stay. Intake and output
were closely monitored.
ID: refer to the antibiotic regimen mentioned above in the
pulmonary section.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. The heparin was then administered in the TPN.
[**Hospital Unit Name 153**] course:
#Stridor: patient was scoped by ENT who noted sluggish vocal
cords and recommended steroids."
3708,"She received 3 doses of
dexamethasone, racemic epinephrine nebs and ipratropium nebs
with some improvement in symptoms. She was kept on face mask in
the ICU and her O2 sat was stable. On repeat scope, she was
noted to have paralyzed left vocal cord with interval
improvement in right vocal cord. Left vocal cord paralysis
suspected to be chronic issue related to past surgeries. Right
vocal cord was hyperkinetic, likely stunning related to
intubation. Her stridor improved with time.
#Healthcare acquired pneumonia: After patient's stridor
improved, she was noted to have continued O2 requirement and
repeat CXR showed a new RLL consolidation and she was started on
treatment for HCAP with vancomycin and cefepime on [**2117-1-25**]."
3709,"#Tachycardia: patient intermittently in sinus tachycardia,
thought to be multifactorial including pain and anxiety. PE
considered given recent surgery, however patient hemodynamically
stable. Less likely hypovolemia given adequate UOP. Given her
NPO status, her home metoprolol was converted to IV and
patient's tachycardia responded well to metoprolol. Her pain was
controlled with IV morphine prn and her anxiety was controlled
with Ativan prn.
# Nutrition: As patient was NPO due to stridor and
post-operative from abdominal surgery, a PICC line was placed
and TPN was initiated.
At the time of discharge on [**2116-2-6**] the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled."
3710,"8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1) Small bowel obstruction due to adhesions.
2) Stridor r/t vocal cord injury.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel
obstruction. This obstruction was managed conservatively with
nasogastric tube decompression and intravenous hydration.
However, you developed acute abdominal pain which required Dr."
3711,"Previous bibasilar
atelectasis, quite
severe on the right, has entirely resolved. There is no
pulmonary edema.
Small residual bilateral pleural effusions are smaller still.
Heart size is normal. There is no pneumothorax. A left PIC line
ends in the mid left
brachiocephalic vein. Findings are most consistent with severe
bronchospasm as a cause of respiratory insufficiency. The larynx
and subglottic trachea are not evaluated by this study.
KUB [**2117-1-31**]
There is disproportionate distention of the large bowel with
respect to small bowel with abrupt change in caliber in the
large bowel at the proximal sigmoid. Since there is formed stool
in the rectum, this could be functional, such as a developing
colonic ileus."
3712,"8* Hct-31.8*
MCV-88 MCH-27.1 MCHC-30.7* RDW-15.2 Plt Ct-344
[**2117-1-23**] 05:31AM BLOOD WBC-11.5* RBC-3.82* Hgb-10.2* Hct-33.9*
MCV-89 MCH-26.8* MCHC-30.2* RDW-15.5 Plt Ct-410
[**2117-1-24**] 03:06AM BLOOD WBC-12.9* RBC-3.45* Hgb-9.3* Hct-29.6*
MCV-86 MCH-27.1 MCHC-31.5 RDW-15.8* Plt Ct-427
[**2117-1-25**] 03:34AM BLOOD WBC-14.9* RBC-3.25* Hgb-8.7* Hct-27.5*
MCV-85 MCH-26."
3713,"This incision can be left open to air or covered with a
dry sterile gauze dressing if it begins to drain. If the
incision begins to drain, please call Dr. [**Last Name (STitle) **] at the
colorectal surgery office. Please monitor the incision for signs
and symptoms of infection including: increasing redness at the
incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run over
the incision line and pat the area dry with a towel, do not rub."
3714,"6 Na-130*
K-3.8 Cl-92* HCO3-31 AnGap-11
[**2117-1-20**] 06:20AM BLOOD Glucose-123* UreaN-12 Creat-0.5 Na-131*
K-3.6 Cl-93* HCO3-27 AnGap-15
[**2117-1-21**] 06:45AM BLOOD Glucose-118* UreaN-11 Creat-0.4 Na-135
K-3.2* Cl-99 HCO3-26 AnGap-13
[**2117-1-22**] 04:55AM BLOOD Glucose-118* UreaN-10 Creat-0.5 Na-135
K-3.8 Cl-100 HCO3-26 AnGap-13
[**2117-1-22**] 03:59PM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-137
K-3."
3715,"Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2117-3-24**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], PA [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2117-3-24**] at 3:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2117-3-24**] at 3:00 PM
With: DR. [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) **] [**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:[**2117-2-5**]"
3716,"[**Last Name (STitle) **] to preform an exploratory laparotomy, lysis of
adhesionss, and repair serosal defects. These adhesions were
thought to be causing the obstruction. Prior to this procedure
you were noted to have a possible aspiration pneumonia on chest
Xray for which you were treated with a full course of
Levofloxacin intravenously. After the additional surgery, you
developed airway difficulty called Stidor. The ENT doctors
followed [**Name5 (PTitle) **] as well as speech and swallow. You have damage to
your vocal cords which will be followed by ENT as an outpatient
and may require an injection. You should continue to follow a
Regular Mechanical soft diet and follow chin tuck instructions
given to you by the speech and swallow team."
3717,"1* Phos-1.9* Mg-1.8
[**2117-1-27**] 06:40AM BLOOD Calcium-8.6 Phos-3.6# Mg-2.0
[**2117-1-29**] 06:04AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1
[**2117-1-30**] 09:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2
[**2117-1-26**] 05:55AM BLOOD Triglyc-179*
[**2117-1-23**] 06:57PM BLOOD Type-ART FiO2-35 pO2-123* pCO2-43 pH-7.37
calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2117-1-25**] 11:57AM BLOOD Type-ART O2 Flow-37 pO2-123* pCO2-47*
pH-7."
3718,"You were evaluated
multiple times at the bedside by the speech and swallow team and
you will be reevaluated at the rehab to progress your diet
further after the repeat study of your vocal cords. Your bowel
function has taken an extended period of time to return and you
should continue to eat small frequent meals of ground food.
Because you are not going to be able to meet your caloric needs
right away from food alone, you will be discharged to rehab with
an order for TPN and this will be gradually decreased overtime
and eventually stopped. You will be discharged to rehab today."
3719,"There are focally dilated loops
of small bowel, likely
mid-to-distal ileum, which when compared to the prior study,
appear more
dilated. 2. Again noted is atherosclerotic calcification of the
abdominal aorta, focal low-attenuation lesion in the dome of the
liver, loculated left pleural effusion. 3. Compared to the prior
study, there is increased opacity in the left lower lobe.
Findings are consistent with an inflammatory or infectious
etiology. Aspiration should also be considered.
CXR [**2117-1-18**]
The NG tube tip is in the proximal stomach and should be
advanced. Current
study demonstrates interstitial pulmonary edema, moderate in
severity."
3720,"Albuterol and ipratropium nebulizer treatments were given every
6 hours. All vital signs were routinely monitored. The patient
was taken to the [**Hospital **] clinic for LEMG on [**2116-2-4**] which showed left
vocal fold paralysis and right vocal fold paresis. The ENT
attending recommended reassessment of motion this week, if no
changes would recommend observation given that her symptoms are
stable. If symptoms worsen or limit her, will consider L. vocal
fold
Botox injection vs. temporary suture lateralization. The ENT
team was comfortable with diet per speech and swallow and
primary teams.
GI/GU: Due to no improvement and in fact worsening obstructive
picture, the pt ended up having an ex-lap on HD 8."
3721,"The pt was
transferred to the [**Hospital Unit Name 153**] on POD 1 for respiratory precautions in
case of deterioration and need for intubation. Antibiotic
coverage was broadened on POD 3 to include vancomycin and Zosyn
due to a worsening CXR. Racemic epinephrine and Decadron
improved her symptoms. She never needed to be intubated and
eventually was satting well on RA. Please refer to the ICU
course below for more details. She was transferred back to the
floor on POD4 with markedly improved stridor and dyspnea.
Thereafter, her saturations and vitals remained stable despite
occasional subjective dyspnea while supine. ENT was following
throughout and noted improvement in the right vocal cord."
3722,"The [**Hospital3 2558**] in [**Location (un) **] is very close to the hospital
and if there is any issue, you can be brought back to the
hospital easily. Please continue to participate in speech and
physical therapy.
Please monitor your bowel function closely. You have had a bowel
movement and are passing gas however, you have required
assistance to do this by a suppository. You should not have
prolonged constipation. Some loose stool and passing of small
amounts of dark, old appearing blood are expected however, if
you notice that you are passing bright red blood with bowel
movements or having loose stool without improvement please call
the office or go to the emergency room if the symptoms are
severe."
3723,"43 calTCO2-32* Base XS-6
[**2117-1-25**] 11:07PM BLOOD Type-ART pO2-75* pCO2-46* pH-7.49*
calTCO2-36* Base XS-10
[**2117-1-23**] 06:57PM BLOOD Lactate-0.6
[**2117-1-25**] 11:07PM BLOOD Glucose-120* Lactate-0.7 Na-132* K-3.5
Cl-91*
IMAGING:
KUB [**2117-1-15**]
No bowel obstruction or free air
CT ABD [**2117-1-15**]
IMPRESSION:
1. Striking fecal loading within the colon, without obstruction.
2. A focally dilated loop of small bowel in the mid abdomen
contains contrast and fecalized contents. There is also slowed
motility, though a stricture or ischemia are not excluded on
this study."
3724,"Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please call the colorectal surgery office at [**Telephone/Fax (1) 160**] to
make a follow-up appointment for 7-14 days after discharge with
Dr. [**Last Name (STitle) **]. Please call this number with any questions or
concenrns.
Please have speech and swallow follow-up and evaluate patient
depending on ENT reevaluation and advize on advancing diet to
avoid aspiration.
Dr. [**Last Name (STitle) 51039**] from ENT [**Telephone/Fax (1) 41**] [**2-1**] wks, His office will also
be in touch with the rehabilitaion hospial."
3725,"Medications on Admission:
caltrate +D, metoprolol 12.5"", mvi, metamucil"", oxycodone
prn, immodium prn
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: please refer
to insulin sliding scale order Injection ASDIR (AS DIRECTED):
Please see sliding scale attatched. Please administer only while
on TPN. Patient does not take insulin at baseline.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. ipratropium bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing."
3726,"If you are taking narcotic pain medications there is a
risk that you will have some constipation. Please take an over
the counter stool softener such as Colace, and if the symptoms
does not improve call the office. If you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonged loose stool, or
constipation.
You have a long vertical incision on your abdomen. The staples
have been removed, steri-strips applied, and the incision is
intact."
3727,"Please see above for details. PICC is
ready for use.
EMG Study Date of [**2117-2-3**]
Clinical Interpretation: Abnormal study. There is
electrophysiologic evidence for a chronic neurogenic lesion
involving the left recurrent laryngeal nerve with incomplete
reinnervation. Evidence for synkinesis is also present. The
right recurrent laryngeal nerve is normal.
Brief Hospital Course:
The patient was admitted to the colorectal surgery service on
[**2117-1-15**] for a small bowel obstruction and had an exploratory
laparotomy with lysis of adhesions on HD 8 after medical
management failed. There were no complications from the
procedure and the patient tolerated the procedure well."
3728,"Abd- flat non-distended, soft, midline incision closed with
steri-strips without signs of infection, no redness/drainage or
other sign of infection.
ext- warm, no edema
Pertinent Results:
[**2117-1-15**] 01:00AM BLOOD WBC-9.4 RBC-4.00* Hgb-10.8* Hct-33.5*
MCV-84 MCH-27.1 MCHC-32.2 RDW-16.0* Plt Ct-323
[**2117-1-18**] 05:59AM BLOOD WBC-20.2*# RBC-4.04* Hgb-11.0* Hct-33.9*
MCV-84 MCH-27.3 MCHC-32.4 RDW-16.0* Plt Ct-314
[**2117-1-19**] 06:55AM BLOOD WBC-12."
3729,"The
presence of a small right pleural effusion cannot be excluded.
CXR [**2028-1-26**]
IMPRESSION: Interval decrease in right basal opacity after
diuresis though
the residual remains concerning for pneumonia.
Video Swallow [**2117-1-29**]
Fluoroscopic video oropharyngeal swallow evaluation was
performed in
collaboration with the speech and swallow therapist. Thin
barium, thick
barium, and barium-coated cookie were administered. There is
penetration with thin barium; however, no frank aspiration was
observed. For more details, please refer to speech and swallow
therapist note in the medical record.
CXR [**2117-1-30**]
IMPRESSION: AP chest compared to [**1-22**] through [**1-27**]:
Lungs are severely hyperinflated."
3730,"The
left mediastinal shift is unchanged. Loculated left pleural
effusion has
slightly increased in the interim. Bibasal opacities might
reflect areas of infection, although they potentially could
reflect interstitial edema as well. Evaluation of the patient
after diuresis is highly recommended.
KUB [**2117-1-22**]
IMPRESSION:
1. Partial small bowel obstruction which is essentially
unchanged from prior; however, the amount of retained enteric
contrast has slightly decreased. 2. Unconventional position of
an NG tube should be correlated to functioning. No findings to
suggest free air.
CXR [**2028-1-23**]
FINDINGS: Unchanged small loculated effusion on the left with
decreasing
extent of the retrocardiac atelectasis."
3731,"No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
exercise with Dr. [**Last Name (STitle) **].
You will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication."
3732,"8* MCHC-31.7 RDW-15.5 Plt Ct-388
[**2117-1-24**] 03:06AM BLOOD PT-17.9* PTT-33.8 INR(PT)-1.7*
[**2117-1-25**] 03:34AM BLOOD PT-14.1* PTT-29.8 INR(PT)-1.3*
[**2117-1-15**] 01:00AM BLOOD Glucose-123* UreaN-17 Creat-0.7 Na-132*
K-4.8 Cl-96 HCO3-27 AnGap-14
[**2117-1-18**] 05:59AM BLOOD Glucose-133* UreaN-19 Creat-0.7 Na-135
K-3.9 Cl-95* HCO3-35* AnGap-9
[**2117-1-19**] 06:55AM BLOOD Glucose-115* UreaN-15 Creat-0."
3733,"2
[**2117-1-18**] 05:59AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.6
[**2117-1-19**] 06:55AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.1
[**2117-1-20**] 06:20AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.9
[**2117-1-21**] 06:45AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.0
[**2117-1-22**] 04:55AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.9
[**2117-1-25**] 03:34AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
[**2117-1-25**] 09:25PM BLOOD Mg-2.7*
[**2117-1-26**] 05:55AM BLOOD Calcium-8."
3734,"Admission Date: [**2117-1-15**] Discharge Date: [**2117-2-5**]
Date of Birth: [**2036-4-6**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Constipation, nausea, SBO
Major Surgical or Invasive Procedure:
exploratory laparascopy, lysis of adhesions, primary repair
serosal defects, rigid sigmoidoscopy
History of Present Illness:
80F with history of rectal CA s/p LAR and ileostomy take-down
[**2116-12-15**], presents with acute onset of low abdominal pain and
distention for the past 6 hours. She reports she has been doing
very well recently, and had a normal bowel movement around 1pm
today."
3735,"4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 7 days: Do not administer more than 4000mg of
Tylenol in 24 hours.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp<100 or HR<65.
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain for 7 days: hold for increased sedation or
RR<12."
3736,"Leftward displacement of the rectum raises the
possibility of an adjacent pelvic fluid collection, but it does
not directly compress the rectum or sigmoid. If there is concern
for hematoma or pelvic infection, CT scanning would be required.
Maximum caliber of the right colon is 9 cm in the cecum and
there is preservation of normal haustral architecture and no gas
in the wall of the colon. There is no pneumoperitoneum.
[**Numeric Identifier 4684**] FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE Study Date of
[**2117-2-2**] 1:07 PM
IMPRESSION: Uncomplicated exchange of left-sided venous catheter
for a 5
French 38 cm PICC with its tip at the mid SVC, under
fluoroscopic guidance."
3737,"8 Cl-105 HCO3-23 AnGap-13
[**2117-1-25**] 09:25PM BLOOD Glucose-829* UreaN-18 Creat-0.4 Na-110*
K-6.3* Cl-83* HCO3-23 AnGap-10
[**2117-1-25**] 11:13PM BLOOD Glucose-119* UreaN-22* Creat-0.5 Na-135
K-3.9 Cl-99 HCO3-28 AnGap-12
[**2117-1-26**] 05:55AM BLOOD Glucose-109* UreaN-19 Creat-0.4 Na-133
K-6.5* Cl-98 HCO3-31 AnGap-11
[**2117-1-29**] 06:04AM BLOOD Glucose-100 UreaN-18 Creat-0.4 Na-138
K-4.0 Cl-103 HCO3-31 AnGap-8
[**2117-1-21**] 03:15PM BLOOD CK(CPK)-12*
[**2117-1-24**] 03:06AM BLOOD ALT-8 AST-14 CK(CPK)-57 AlkPhos-57
TotBili-0."
3738,"No pulmonary edema. No
newly
appeared focal parenchymal opacities. Borderline size of the
cardiac
silhouette. Unchanged course of the nasogastric tube.
UExt US [**2117-1-24**]
IMPRESSION: No DVT in the left upper extremity. Findings were
discussed in
person with Dr. [**Last Name (STitle) **] at 12:15 p.m. on [**2117-1-24**].
CXR [**2117-1-25**]
FINDINGS: As compared to the previous radiograph, the left
pleural effusion has mildly increased. There is increasing
subsequent atelectasis in the left retrocardiac lung areas.
Newly appeared is a right lower lobe opacity, likely
representing a combination of pneumonia and pulmonary edema.
Unchanged borderline size of the cardiac silhouette."
3739,"Note is made on this study of atherosclerotic SMA
disease. 3. New hypodense collection anterior to the liver
measures 1.6 cm, and is new compared with 6/[**2116**]. This may be a
small postsurgical fluid collection. This is too small for
intervention. Follow up MRI or PET CT may be of utility for
further evaluation. 4. Mild ascites and mesenteric edema, which
may be reactive to relatively recent surgery. 5. The low rectal
anastomosis appears intact, without surrounding fluid collection
to suggest leak.
CT Abd [**2117-1-18**]
IMPRESSION:
1. Compared to the prior study, the amount of fecal loading
within the colon has improved."
3740,"9* RBC-3.49* Hgb-9.4* Hct-29.4*
MCV-84 MCH-27.1 MCHC-32.2 RDW-15.4 Plt Ct-261
[**2117-1-20**] 06:20AM BLOOD WBC-13.8* RBC-3.95* Hgb-10.6* Hct-33.9*
MCV-86 MCH-26.7* MCHC-31.1 RDW-15.6* Plt Ct-325
[**2117-1-21**] 06:45AM BLOOD WBC-11.0 RBC-3.57* Hgb-9.6* Hct-29.8*
MCV-83 MCH-26.9* MCHC-32.3 RDW-15.3 Plt Ct-293
[**2117-1-22**] 03:59PM BLOOD WBC-9.4 RBC-3.61* Hgb-9."
3741,"Admission Date: [**2157-2-20**] Discharge Date: [**2157-3-4**]
Date of Birth: [**2089-2-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
OSH transfer for pneumococcal meningitis and cerebritis
Major Surgical or Invasive Procedure:
Stereotactic Burr hole drainage of subdural empyema.
History of Present Illness:
68M with PMH of DM, HTN, HL, CAD s/p distant MI, who is
transferred from [**Hospital **] Hospital, where he presented on [**2157-2-13**]
with fever, cough, and sore throat. He was initially treated for
pneumonia with ceftriaxone and azithromycin."
3742,"On the afternoon of
admission, he was noted to be acutely aphasic, with word finding
difficulty. There was concern for acute stroke. Neurology was
consulted, he was transferred to the ICU, and a stat head CT was
performed. Given that he was also febrile with an elevated WBC
count to 27 with 27% bands, an LP was performed. This revealed
7800 WBCs with 94% polys, a glucose of 5, and a protein of 447.
He was initially covered with vanc/CTX/ampicillin/acyclovir. CSF
and blood cultures from [**2-13**] grew strep pneumo. ID was consulted,
and recommended PCN G and rifampin, which were started on
[**2157-2-13**]."
3743,"CAD - s/p MI in [**2138**], [**2151**] tx with angioplasty
2. HTN - currently managed w/ toprol XL 200mg
3. DM2 - managed on glucophage 1000mg [**Hospital1 **], glyburide 3.75
4. Hyperlipidemia - on lipitor 40mg
5. S/p ORIF for R zygomatic fx, and orbital fx with 2 plate
insertion
6. Atypical pneumonia in [**2144**], complicated by bronchocentric
granulomatosis and cold agglutinins hemolytic anemia
7. Cystic pancreatic disease
8. BPH s/p TURP
9. Appendicitis s/p appendectomy
10. S/p bladder polypectomy
Social History:
Mr. [**Known lastname 410**] is a retired immunologist at the [**Hospital3 328**] whose
research interest was in monoclonal antibodies."
3744,"Small
low-density extra-axial collection layers dependently, and
appears slightly more dense in comparison to [**2156-2-26**]. Effacement
of the underlying sulci is unchanged.
There is no hydrocephalus or shift of normally midline
structures. No
intracranial hemorrhage is identified. [**Doctor Last Name **]-white matter
differentiation
remains normally preserved.
Complete opacification of the right mastoid air cells persist.
Brief Hospital Course:
68M with PMH of DM, HTN, CAD s/p MI, who is transferred from an
OSH with resolving pneumococcal meningitis and new neurological
deficits, found to have mastoiditis, cerebritis, and subdural
empyema.
.
# Meningitis: Mr. [**Known lastname 410**] was treated with IV Ceftriaxone 2mg IV
q12, in addition to 50mg [**Hospital1 **] Metronidazole upon arrival."
3745,"Metoprolol was
started at 25 mg [**Hospital1 **] and titrated up to 50 mg tid, with the
discharge goal of home dosing of 200mg qd.
.
#Diabetes - Mr. [**Known lastname 410**] was initially covered under a sliding
scale. When full diet was resumed, his glucose values were in
the high 200s. Medication was changed to pt's home PO metformin
and glyburide, with modest effect. Hyperglycemia thought to be
resultant of stress and illness.
.
#CAD, hx of MI - Stable, no events. Continued statin. Given
possibility of intervention, ASA was held throughout the stay.
.
#Anemia - Pt was down from baseline of 47.7 in [**2155**] to 37."
3746,"Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary: Streptococcus pneumoniae meningitis, cerebritis, and
mastoiditis.
Secondary:
Diabetes Mellitus, Type II, non-insulin dependent
Coronary artery disease
HTN
Discharge Condition:
Stable.
Discharge Instructions:
You were transferred from [**Hospital **] Hospital with an infection of
your brain and your mastoid bone. While you were here, you
received intravenous antibiotics, anti-seizure medication, and
repeated imaging of your brain. The medicine, [**Hospital 1083**]
disease, and neurosurgery teams decided that having surgical
drainage of the [**Hospital 1083**] collection around your brain would
best help clear the infection.
You were started on the following NEW medications, all of which
you will continue:
1."
3747,"Disp:*1 1* Refills:*2*
5. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 13 days: Do not consume alcohol while taking this
medication.
Disp:*40 Tablet(s)* Refills:*0*
7. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours) for 13 days."
3748,"Neurosurgical Follow-Up Appointment Instructions
??????Please return to the office [**2157-3-11**] for removal of your sutures
and a wound check. This appointment can be made with the Nurse
Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????You have an appointment with Dr. [**Last Name (STitle) **] on [**2157-3-15**] at 9a at [**Hospital Unit Name **], [**Hospital Unit Name **]
If you have any questions please call ([**Telephone/Fax (1) 88**]
??????You are scheduled for an MRI of the brain with and without
gadolinium contrast on [**3-15**] at 730 am in the [**Hospital Ward Name 517**]
Basement.
Completed by:[**2157-3-4**]"
3749,"OSH IMAGING:
[**2-13**] CT-A:
no evidence of PE. Calcified right costophrenic sulcus plaque
with associated.
.
[**2-15**] Head CT without contrast
new small amound of hypodense fluid in the right frontal
subdural space/ While this may represent a subdural hygroma,
given the patient's h/o bacterial meningitis, a subdural empyema
should be considered. Complete opacification of the right
mastoid air cells with fluid int he right middle ear, as seen
previously.
.
[**2157-2-15**] Temporal Bone CT
bilateral cerumen plugs, extensive opacifiaction of the right
mastoid air cells, antrum, and middle ear suggesting
otomastoiditis. No bony destruction."
3750,"No
interval change in opacification of right mastoid air cells and
middle ear
cavity.
""
.
[**2-28**] MR [**Name13 (STitle) 430**]:
""Stable appearance since [**2157-2-22**]. Evidence of right
mastoiditis with adjacent subdural empyema, extensive dural
enhancement,
leptomeningeal enhancement, and no evidence of infarction or
sinus
thrombosis. ""
.
CBC:
[**2157-2-20**] 11:14PM WBC-14.5*# RBC-3.88* HGB-13.0*# HCT-35.7*#
MCV-92 MCH-33.4* MCHC-36.3* RDW-13.1
[**2157-2-20**] 11:14PM NEUTS-87.7* LYMPHS-9.3* MONOS-1.9* EOS-1.0
BASOS-0
[**2157-2-20**] 11:14PM PLT COUNT-399#
[**2157-3-3**] 04:50AM 7."
3751,"Disp:*26 IV Piggyback* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: Please do not exceed 4 grams per day. .
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Headache: Please do not drink or drive
while taking this medication.
Disp:*50 Tablet(s)* Refills:*0*
12. PICC Line Care
Saline flush 10cc SASH PRN
Heparin flush 10u/ml 3cc SASH PRN"
3752,"8.
Because of history of cold agglutinin hemolysis, patient was
worked up for anemia. Haptoglobin was within normal limits.
Iron labs were consistent with anemia of inflammation, with
normal MCV, lower transferrin, and lower TIBC.
On [**3-2**] he was brought to the OR by Dr. [**Last Name (STitle) **] for a
steriotactic burr hole placement and washout of subdural
empyema. He tolerated the procedure and was transferred to the
floor where he ambulated with nursing and tolerated a regular
diet. He was then safe to be d/c'd home with services and follow
up appointment
Medications on Admission:
Home Meds:
Lipitor 40 mg
ASA 650 mg daily
Glucophage 1000mg [**Hospital1 **]
Glyburide 3."
3753,"75mg [**Hospital1 **]
Toprol XL 200 mg
MVI
.
Transfer Meds:
Rifampin
Keppra 250mg po bid ([**2-20**] - )
RISS
Floxin otic gtt to right ear [**Hospital1 **]
PCN G 4 million units q4h IV
metformin 1000mg [**Hospital1 **]
tylenol q4h prn prn
metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Ciprofloxacin 0.3 % Drops Sig: 4-10 Drops Ophthalmic TID (3
times a day): Right ear only."
3754,"He and his wife
live in [**Name (NI) 1439**], MA. He has at least one son and one daughter.
Daughter is an OB/Gyn at [**Hospital1 18**]. Denies EtOH. Tob use: 20 pack
year hx, d/c in [**2136**].
Family History:
Non-contributory
Physical Exam:
Upon transfer to medical service:
VS: 98.9 120/54 106 w/ PVCs 24 95RA
Gen: Well-nourished elderly man, lying in bed, talking to son,
not SOB, in pain, or otherwise distressed.
HEENT: H: R eye palpabral fissure slightly smaller than L (9mm
vs. 12mm), no signs of trauma. E: PERRLA 3mm->2mm, conjunctiva
not pale, anicteric."
3755,"Metronidazole was replaced with Clindamycin following a seizure,
but was changed back to metronidazole following the start of
levetiracem. Since his transfer here, Mr. [**Known lastname 410**] has remained
afebrile, with a WBC trending down. Clinically, Mr. [**Known lastname 410**]
improved dramatically over the course of his stay to the point
where no neurological deficits can be noted noted. He has no
meningeal signs at present.
.
#Cerebritis - Empyema was followed serially by CT and MR imaging
without any change over his stay. There was no involvement of
the sinuses. The decision was made on [**2156-2-29**] by medicine,
neurosurgery, and ID to surgically drain the fluid collection
via stereotactic biopsy."
3756,"2. Ear, Nose and Throat - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**]
[**Apartment Address(1) 96381**], [**Location (un) 55**]
[**3-8**] @ 10:15 am, Tuesday
[**Telephone/Fax (1) 2349**]
4. PCP
[**2157-3-8**] at 10am
Dr [**First Name4 (NamePattern1) 449**] [**Known lastname 410**]
[**Location (un) **], [**Location (un) **], MA.
Because of the antibiotic ceftriaxone can interfere with your
liver on rare occassion, you will need your liver enzymes tested
once per week. Please have blood drawn and tested for LFTs each
week and send the results to the [**Location (un) 1083**] disease clinic at
FAX number [**Telephone/Fax (1) 11959**]."
3757,"CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
*******You may resume your Asprin on [**2157-3-12**]******
Followup Instructions:
Please be sure to follow up with the following physicians:
1. [**Date Range **] Disease - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)
[**2157-3-22**] 11:30am"
3758,"Hypoactive bowel sounds. Liver percussed at 8cm. No renal
bruits.
Back: No spinal tenderness. No CVA tenderness. No paraspinal
tenderness.
Ext: No edema, erythema. WWP.
Neuro: AAOx3. Gives identifiers without prompting. Able to name
past 2 presidents only. Can multiply 6x7. Cannot subtract 17
from 81. Able to talk briefly about his research. Three word
recall intact at 2min. Full strength (unable to break) in
deltoids, biceps, triceps, IPs, and gastrocs, bilaterally. R
does seem slightly stronger however. Able to hold pen in L
hand, but trouble re-capping. Dysmetria w/ finger to nose on
the L. CN II: Lower left quadrant cut bilaterally."
3759,"PICC line at jxn of SVC and RA.
.
[**2-21**] CT Head w/ and w/o contrast:
""1. Right otomastoiditis.
2. Unchanged small right parietal subdural collection,
concerning for a
subdural empyema.
3. Persistent cortical swelling in the right parietal, posterior
frontal, and temporal lobes, compatible with known cerebritis.""
.
[**2-21**] CT Orbits, Sella w/ contrast:
""Findings compatible with severe right otomastoiditis with
possible coalescence of the mastoid septae. There is also
thinning and demineralization of the tegmen tympani. Would
recommend MRI with skull base protocol to assess for meningeal
extension of infection.
Additionally, there is a tiny subdural collection on the
right, again
recommend MRI for further evaluation and to exclude a subdural
empyema."
3760,"Ceftriaxone 2 g IV Q12H
2. Metronigazole (Flagyl) 500 mg PO Q8H
3. Ciprofloxicin Ear Drops
4. Levitracetam 1g PO BID
The first medication will be given through the picc line in your
arm. A visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 5050**] this. The flagyl will be
an oral medication, in the same amount, to be taken three times
a day. [**Last Name (Titles) **] disease will determine the length of your
antibiotics.
Because of the antibiotic ceftriaxone can interfere with your
liver on rare occassion, you will need your liver enzymes tested
once per week. Please have blood drawn and tested for CBCs,
Chem 7, and LFTs each week and send the results to the
[**Last Name (Titles) 1083**] disease clinic at ([**Telephone/Fax (1) 1353**]."
3761,"He was followed by neurology and ID. He steadily
improved and was transferred out fo the ICU on [**2157-2-15**]. An MRI
performed [**2157-2-16**] showed right cerebral meningeal enhancement c/w
his h/o meningitis, as well as concern for mastoiditis
(non-communicating with the meninges). There was no evidence of
abscess or hemorrhage, but a small frontal hygroma vs. subdural
empyema. Nsurg was consulted, and there was NTD per them.
On [**2-19**], ENT performed a right myringotomy, and a copious amount
of seromucoid purulent material was aspirated; tubes were
placed. Per his report, later that day he developed tingling of
both upper extremities and the LLE, as well as left hand
weakness and general poor coordination."
3762,"If you should become febrile, confused, lose bowel or bladder
function, have a strong headache, experience any loss in vision,
or lose conciousness, please return to the emergency room
immediately.
You will need follow-up appointments with your PCP, [**Name10 (NameIs) **]
Disease, Neurology, Neurosurgery, and ENT.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days."
3763,"III, IV,
VI:EOMS intact. (son notes no ptosis as compared to baseline) V:
Sensation intact to light touch. VII/VIII: Face symmetric aside
from eyes as mentioned above. Hearing intact to snaps, not light
rustle. IX/X: coughs. XII:SCM intact, trap intact. XII:tongue
midline.
Upon Discharge:
c/o sl. HA controlled
A&Ox3, PERRL, follows commands, 5/5 strength, wound C/D/I
Pertinent Results:
FROM OUTSIDE HOSPITAL PRIOR TO TRANSFER:
MICRO:
[**2-13**] CSF HSV PCR: negative
[**2-13**] CSF gram stain: GPCs in P+C, culture neg
[**2-13**] BCx + pansenstive strep PNA
[**2-13**] UCx: <10,000 CFU, mixed flora
No right ear fluid cultures sent from OR on [**2-19**]
."
3764,"9 4.12* 13.5* 37.6* 91 32.8* 36.0* 13.7
328
Coags:
[**2157-2-20**] 11:14PM PT-15.2* PTT-33.9 INR(PT)-1.3*
[**2157-3-3**] 04:50AM 16.2* 33.7 1.4*
Chem 7:
[**2157-2-20**] 11:14PM GLUCOSE-114* UREA N-15 CREAT-0.8 SODIUM-133
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-24 ANION GAP-15
[**2157-3-3**] 04:50AM 128* 18 1.0 139 4.1 101 28 14
LFTs:
[**2157-2-27**] 06:17AM 29 18 186 66 0.3
Head CT [**3-3**]
There is a new posterior parietal burr hole, and pneumocephalus
overlying the left posterior frontal and parietal lobes."
3765,"?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen
etc.
-You haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to."
3766,"E: Slightly tender to palpation. No
drainage appreciated. N: No signs of epistaxis. T: Moist
mucous membranes, no erythema or exudate.
Neck: Soft, supple. No LAD at pre/post auricular, ant/post
cervical, submandibular, supraclavicular nodes. No carotid
bruits. No mastoid tenderness.
CV: Tachycardic, reg rhythm with nl S1, S2. No m/r/g. Pulses 2+
in all 4 extremities (DP and PT on feet). No splinter
hemorrhages.
Lungs: Nl excursion on inspiration. No dullness to percussion.
No tactile fremitus. Lungs clear to auscult, bilat and ant/post.
No crackles, wheezes or rhonchi. Diaphragms symmetric.
Abd: Soft, non-tender. Slightly distended, but not tympanic."
3767,"""
.
[**2-22**] MR [**Name13 (STitle) 430**] w/ and w/o contrast, MRV Head:
""1. Unchanged small right parietal subdural empyema.
2. Right cortical edema consistent with cerebritis is again
seen. New mild
slow diffusion suggests interval worsening.
3. Mild right-sided leptomeningeal enhancement, consistent with
meningitis.
4. Right otomastoiditis again seen.
5. No evidence of venous sinus thrombosis. ""
.
[**2-24**] CT Head:
""No significant change from prior studies, with unchanged right-
sided subdural collection, consistent with previously
characterized subdural empyema. Persistent opacification of
right mastoid air cells and middle ear cavity. ""
.
[**2-26**] CT Head:
""Stable examination demonstrating unchanged right subdural
collection consistent with previously characterized subdural
empyema."
3768,"Neurology was
re-consulted, and exam revealed left sided neglect and poor
coordination without frank dysmetria. A repeat MRI was
performed, the preliminary report of which showed evidence of
cerebritis. Plans were initiated tranfer him to the [**Hospital1 18**] neuro
ICU, but they refused. He was instead accepted by the MICU.
Prior to transfer, rifampin was resumed, and keppra was begun
for seizure ppx. His temp was 100.2 and he was hemodynamically
stable.
On arrival to the [**Hospital1 18**] MICU, he complained of nausea. He
endorsed ongoing numbness in his hands and feet since
yesterday's ear operation.
Past Medical History:
PMH:
1."
3769,".
[**2-16**] MRI Brain:
extra-axial collection right cerebral hemisphere suggestive of
meningeal enchancement c/w clinical hx of bacterial meningitis.
No abscess or hemorrhage is seen.Non-aeration of mastoid air
cells with fluid signal c/w mastoiditis. However, this does not
appear to have broken through the subjacent meninges. Normal
venous sinuses.
.
[**2-16**] B/L carotid U/S:
< 20% ICA stenosis on both sides
.
[**2-16**] TTE
LVEF 40-45%, with inferior and posterior akinesis. Normla RV. 2+
MR, 1+ TR. Negative bubble study.
.
[**2-17**] CXR
fibrosis and scarring at the right base, small right pleural
effusion."
3770,".
# Mastoiditis- Patient has ear tubes bilaterally that have
drained minimally. He has remained afebrile since his arrival
and w/o pain. Hearing remains sensitive to loud snaps only. He
continues on Ciprofloxicin ear drops 0.3% Ophth Soln 4-10 drops
to the right ear.
.
# Seizure - Patient had a single generalized, tonic clonic
seizure in the MICU on [**2156-2-20**] while on Keppra 500mg.
Metronidazole was stopped temporarily and the patient was loaded
with additional Keppra. Pt has not seized since MICU stay. He
remains on Keppra, now tritrated up to 1g for neurosurgical
intervention.
.
# HTN - Mr. [**Known lastname 410**] was never hypotensive during his stay and his
pressures largely ranged in the 130s sytolic."
3771,"Admission Date: [**2169-7-9**] Discharge Date: [**2169-7-13**]
Date of Birth: [**2108-1-8**] Sex: F
Service: NEUROLOGY
Allergies:
Dilaudid (PF) / Zofran
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
right sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms [**Known lastname **] is a 61 year old LEFT handed female who presents
from an OSH s/p tPA after sudden onset of right sided weakness.
Patients husband states that she was driving to go shopping
however returned home at 2:20 pm on [**7-9**]. He states she was
complaining that the right side of her face felt 'warm and
numb."
3772,"9 kg) after discussion with
the stroke fellow and patients family.
Past Medical History:
HTN, GERD, diverticulitis, lymphocytic colitis
Social History:
Married, has 1 daughter. Smokes [**1-17**] PPD, [**2-16**] glasses of wine
daily, denies drugs. Works as special needs teacher.
Family History:
mother had stroke in her 60's
Physical Exam:
ADMISSION EXAM:
Temp: 98 HR: 87 BP: 134/87 Resp: 16 O(2)Sat: 99 Normal
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."
3773,"There was an inconsistent right hemianopia, right arm drift and
decreased right sided sensory loss, but all extremities drifted
and could not cooperate with full strength exam. The patient
also complained of a severe throbbing headache. She had been
having increasing throbbing headaches over the past 6 months,
but particularly worse over the past 1-2 weeks, associated with
nausea, seeing red flashing spots, and photophobia.
The patient was admitted to the neuro ICU for post-tPA protocol.
Head CT/CTA: no acute infarct, vascular stenosis. Brain MRI:
normal.
Toxic-metabolic workup including tox screens were negative.
Blood pressure was allowed to autoregulate with goal SBP
140s-180s."
3774,"Medications on Admission:
HCTZ 25 mg daily, omeprazole 20 mg daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Complicated Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro deficits: Halting speech and labile mood. Giveway
weakness of R side - downward drift of R arm and does not bear
weight on the R leg when standing."
3775,"-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: unable to formally test, but no obvious dysmetric
movements
DISCHARGE EXAM: awake, alert, oriented to person, place and
date. Mild right nasolabial fold flattening, though has
symmetric smile. Has give-way weakness on the right greater than
left. Light touch and proprioception intact throughout.
Pertinent Results:
[**2169-7-9**] 05:10PM BLOOD WBC-6.5 RBC-4.26 Hgb-14.6 Hct-40.3 MCV-95
MCH-34.3* MCHC-36.3* RDW-12."
3776,"There were no arrhythmias on cardiac telemetry.
Patient was ruled out for MI.
The patient was ultimately thought to have a complicated
migraine, with functional overlay. Her headache was controlled
with Ultram, IVF, antiemetics. She actually noted significant
improvement with IV Reglan and IVF. Her neuro exam improved
gradually back to normal except for giveway weakness throughout,
more on R than L. She was started on verapamil for migriane
prophylaxis. Her home HCTZ was D/Ced.
Given her weakness and difficulty walking, patient was
recommended to be discharged to rehabilitation facility.
Patient will be following up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] as
outpatient."
3777,"Echo: Suboptimal image quality due to body habitus. No cardiac
source of embolism seen. Left and right ventricular systolic
function are probably normal. No significant valvular
abnormality. Borderline elevation of pulmonary artery systolic
pressures. Negative bubble study.
CT head 24hrs post tPA:
No acute intracranial process.
Brief Hospital Course:
61 year old LEFT handed female presented from OSH s/p tPA after
sudden onset of right facial numbness and generalized weakness.
She had been given tPA on the [**Location (un) **] over to [**Hospital1 18**].
Upon arrival to [**Hospital1 18**] her NIHSS was 9 and was signifant for
inability to follow commands, oriented but slow to respond."
3778,"III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation decreased on right.
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.
Right arm with significant drift, was able to sustain the left
arm antigravity. Right leg was unable to lift antigravity with
about a 3 at the IP. left leg with significant drift.
-Sensory: decreased senstion to light touch and noxious on the
right leg, arm, and face."
3779,"'
He sat her down and went to call an ambulance because he noticed
her speech became slurred. At that point she became
unresponsive
and would not open her eyes. EMS arrived and she was taken to
an
OSH. No seizure activity was detected. Patient was brought to an
outside hospital where she was found to be hypertensive to the
210s systolically. She also had a negative noncontrast CT. Med
flight was called for transfer to [**Hospital1 18**] ED for further care and
en route patient was started on TPA (Patient was given a bolus
and then started
on a drip on her right based on 70."
3780,"CTA Head and neck:
1. No evidence of an acute intracranial process or evidence of a
flow-limiting stenosis.
2. 12-mm low-density left thyroid nodule with some
calcifications may be
assessed with ultrasound if not performed earlier.
3. Minor soft plaques at the carotid bifurcation.
MR head:
Diffusion images demonstrate no acute infarction. Gradient
images
demonstrate no hemorrhage. There is no intracranial mass or mass
effect. The ventricles and sulcal configuration are age
appropriate. The [**Doctor Last Name 352**]-white matter differentiation is normal.
The brain stem, cerebellum and
craniocervical junction are normal. Mucosal thickening is seen
in the
bilateral ethmoid air cells."
3781,"S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language dysarthric but fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. She did not have her glasses and was unable
to read but could name large letters. Initially was only
following midline commands but later followed appendicular
commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. On visual fields she did not
consistently visualize the right visual field, however
inconsistently reacted to threat on the right."
3782,"Discharge Instructions:
You came to the hospital with symptoms of right facial numbness
folllowed by difficulty speaking and episode of fainting. There
was concern for an acute stroke, so you received IV tPA, while
en route to [**Hospital3 **]. While here, you had brain imaging,
including CT of the head and blood vessels and MRI. The imaging
was all normal and there was no evidence of stroke. You were
initially admitted to the ICU after receiving the clot busting
medication, just for monitoring; there was no complications
after receiving the medication. As there was no stroke and you
did have a headache (and recent headache symptoms consistent
with migraines), your symptoms are most likely due to a
complicated migraine."
3783,"7 Plt Ct-255
[**2169-7-11**] 01:40AM BLOOD Glucose-91 UreaN-8 Creat-0.6 Na-139 K-3.7
Cl-108 HCO3-23 AnGap-12
[**2169-7-10**] 05:23PM BLOOD ALT-20 AST-18 LD(LDH)-202 CK(CPK)-46
AlkPhos-52 TotBili-0.5
[**2169-7-9**] 05:10PM BLOOD cTropnT-<0.01
[**2169-7-10**] 05:23PM BLOOD CK-MB-2 cTropnT-<0.01
[**2169-7-9**] 05:10PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2
[**2169-7-10**] 05:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG"
3784,"For this reason, you were started on a
medication called Verapamil to help prevent future migraines.
Followup Instructions:
Please ask your PCP for referral to follow-up with the
neurologist who oversaw your care during this admission:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2169-8-28**] 2:30
[**Hospital Ward Name 23**] Building ([**Hospital1 18**]), [**Location (un) **]
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2169-10-30**] 5:15
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge
from rehab.
Completed by:[**2169-7-13**]"
3785,"Admission Date: [**2172-5-8**] [**Year/Month/Day **] Date: [**2172-5-14**]
Date of Birth: [**2091-10-3**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Quinolones
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80F with history of COPD on home O2 who was found to have a UTI
a week ago and started on Macrodantin by her urologist. She took
3 days of Macrodantin and felt very nauseated and dizzy. On [**5-7**]
while walking to the bathroom, she fell and started complaining
of hip pain."
3786,"Past Medical History:
COPD, CO2 retainer on home oxygen 2 liters, GERD, DVT 6 years
ago, spinal stenosis, CHF, hypertension, osteoporosis, anxiety,
bladder cancer, UTI, and shingles.
PSH: varicose vein ligation, hysterectomy, IVC filter [**2172-5-7**]
Family History:
Noncontributory
Physical Exam:
Upon admission:
Afebrile, BP 111-141/48-70, HR 88-101, RR 19-29, Sat 89-98% on
4L
General: Elderly Caucasian Female with pursed lip breathing,
mild tacypnea
Pulmonary: Inspiratory crackles noted at the bases but overall
is markedly improved from yesterday.
Cardiac: RR, nl S1 S2, systolic ejection murmur noted over
sternum, no rubs or gallops appreciated
Abdomen: distended, soft, non-tender, tympanetic to percussion
Extremities: No edema noted in lower extremities
Neurologic: Alert, oriented x 3."
3787,"[**Location (un) **] Diagnosis:
s/p Fall
Pelvic fractures:
Left comminuted sacral fracture
Inferior right sacral fracture
Left superior pubic ramus fracture
Left comminuted ischiopubic fracture
Urinary tract infection
Secondary diagnosis:
COPD on home oxygen
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
You were hospitalized following a fall; you sustained multiple
fractures of your pelvis which did not require any operations.
The Physical therapists are recommending that you go to rehab.
You may weight bear as tolerated on your lower extremities.
Followup Instructions:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP orthopedics for
your pelvic fractures; call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
Completed by:[**2172-5-14**]"
3788,"Four people at [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] rehab helped her up
and put her back into bed. She denied any loss of consciousness,
blurry vision, chest pain, shortness of breath. A CT scan done
showed multiple pelvic fractures, a question of a pulmonary
embolism in the RLL and a bladder pollyp. She had seen her
urologist one week prior for cystoscopy for hematuria. At [**Last Name (un) 1724**]
she had an IVC filter placed [**2172-5-7**] as well as a PICC line. Her
Urine Cx from [**2172-5-4**] was ESBL E.Coli for which she has been
treated with Imipenem/Cilistatin."
3789,"9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection [**Hospital1 **] (2 times a day).
14. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day)."
3790,"Able to relate history without
difficulty. Cranial nerves II-XII intact.
.
Pertinent Results:
[**2172-5-8**] 08:48PM GLUCOSE-108* UREA N-20 CREAT-0.5 SODIUM-140
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12
[**2172-5-8**] 08:48PM ALT(SGPT)-31 AST(SGOT)-21 ALK PHOS-60 TOT
BILI-0.4
[**2172-5-8**] 08:48PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-2.2*
MAGNESIUM-2.2
[**2172-5-8**] 08:48PM WBC-18.2* RBC-3.51* HGB-10.4* HCT-31.7*
MCV-90 MCH-29.5 MCHC-32.7 RDW-15."
3791,"20. Oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q4H (every 4
hours) as needed for pain.
21. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
22. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) MG Recon
Soln Intravenous Q12H (every 12 hours): Stop date [**2172-5-18**].
23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] at [**Location (un) 1821**]"
3792,"1
[**2172-5-8**] 08:48PM NEUTS-93.8* LYMPHS-2.8* MONOS-2.3 EOS-0.9
BASOS-0.2
[**2172-5-8**] 08:48PM PLT COUNT-178
[**2172-5-8**] 08:48PM PT-11.7 PTT-27.5 INR(PT)-1.0
CT: 1. Pelvic fractures: comminuted fx of left sacrum extending
into the first sacral arch. A second nondisplaced fx in the
inferior right sacral ala. Proximal left superior pubic ramus fx
and a comminuted fx of the left ischiopubic ramus. 2. Possible
thrombus in two pulmonary vessels of the right lower lobe. It is
unclear if these vessels are arteries or veins."
3793,"She required IV Lasix for diuresis which improved overall
respiratory function. Her home medications, including her home
oxygen, for her COPD were continued.
Orthopedics was consulted for her pelvic fractures. These
injuries did not require operative intervention; her weight
bearing status was as tolerated by patient without restriction.
Her pain regimen includes standing Tylenol, Ultram and prn
Oxycodone. She is also on a bowel regimen.
She is currently continuing treatment of her UTI with Meropenem;
stop date is [**2172-5-18**].
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay.
Medications on Admission:
Advair 250/50 b."
3794,"15. K Phos Di & Mono-Sod Phos Mono 250 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
16. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day)."
3795,"i.d., Spiriva INH, dilt 240 daily, Ativan 0.5
b.i.d. p.r.n., Neurontin 300 b.i.d., Protonix 40 daily, Tylenol,
Celexa 10 daily, Colace 100 b.i.d., prednisone 5 daily, Mucinex
600 b.i.d., calcium 600, vitamin D 400, omeprazole 20, MiraLax,
senna 2tabs q.h.s., bisacodyl suppository as needed, milk of
magnesia 30 mL
[**Month/Day/Year **] Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day)."
3796,"3. Small
bilateral pulmonary effusions with adjacent consolidations. 4. 1
cm bladder polyp.
CXR:
FINDINGS: In comparison with the study earlier in this date,
there is little change in the appearance of the heart and lungs.
Again, there is
hyperexpansion of the lungs with coarse interstitial markings
that could
reflect chronic pulmonary disease, elevated pulmonary venous
pressure, or
both. Bilateral pleural effusions or scarring with probable
bibasilar
atelectasis. Again, the possibility of supervening pneumonia
cannot be
definitely excluded.
Brief Hospital Course:
She was admitted to the Trauma service. She required ICU
admission for tenuous respiratory status given her history of
COPD."
3797,"3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation."
3798,"Admission Date: [**2168-2-13**] Discharge Date: [**2168-2-17**]
Date of Birth: [**2104-8-29**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / Diphenhydramine
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stents x2 to the left
circumflex artery and the left main coronary artery
History of Present Illness:
This is a 63 year old man with a history of CAD s/p 2 vs 3v
CABG, HL who presented to the ED with chest pain while walking
his dog today. He reported that prior to walking his dog at
5:10pm he was showering and developed SOB and dizzyness."
3799,"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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
- CABG: LIMA to LAD, SVG to PDA
3. OTHER PAST MEDICAL HISTORY:
CAD s/p 2 vessel CABG, LIMA to LAD, SVG to PDA, [**2157**] at [**Hospital1 2025**]
Temporal lobe epliepsy
ADHD
Psoriasis
Appendectomy
Hyperlipidemia
Social History:
- Tobacco history: never
- ETOH: rarely
- Illicit drugs: never
Lives with wife, [**Name (NI) **], in [**Location (un) **]
Has 2 sons works as department head at [**Hospital3 **]"
3800,"Family History:
- No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death
- Mother: lupus, cardiac disease died in 70's from MI
- Father: MI x2, died at age 55 from MI
- strong family h/o HL including both parents and eldest son.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T= 97.8 BP= 115/71 HR=82 RR=16 O2 sat= 97% on 2L
GENERAL: NAD. Oriented x3. anxious.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line."
3801,"These demonstrated appropriate
augmentation of all left ventricular segments.
IMPRESSION: Average functional exercise capacity (submaximal
workload as patient is s/p STEMI). No diagnostic ECG changes in
the absence of 2D echocardiographic evidence of inducible
ischemia to achieved workload.
Brief Hospital Course:
HOSPITAL COURSE: 63 year old man with a history of CAD s/p CABG
who presented to the ED with chest pain while walking his dog
and was found to have an inferior STEMI. Received BMS
implantation to native LCX and LM.
# Inferior STEMI: The patient presented with STE of II,III, and
avF and STD depression in V2-V5."
3802,"Pt was discharged
on ASA, plavix, metoprolol, lisinopril, sl ntg, imdur and
rosuvastatin. Creatinine was stable despite contrast load.
# Hyperlipidemia: on rosuvastatin at home, switched to high dose
atorvastatin hwile an inpatient given STEMI. Changed to
rosuvastatin 40 at discharge.
# Hyperglycemia: BS moderately elevated on routine labs. Pt
states his blood sugar has been elevated at times but A1C has
been nl. A1c was normal on recheck.
# Temporal lobe epliepsy- per patient develops flushing,. We
continued depakote 250mg 5 times daily (qAM, qNoon, qPM, and 2
tabs qHS). He remained well controlled.
# ADHD: we continued venlafaxine and held strattera due to risk
of adverse cardiovascular outcomes."
3803,"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*
10. Outpatient Lab Work
Please check Chem-7 on Friday [**2168-2-19**] with results to Dr.
[**Last Name (STitle) 96196**] at Phone: [**Telephone/Fax (1) 96197**]
Fax: [**Telephone/Fax (1) 96198**]
11. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hyperlipidemia
Temporal Lobe epilepsy
Coronary Artery disease
Obstructive Sleep Apnea"
3804,"GENERAL: 63 YO M in no acute distress
HEENT: 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.
EXT: wwp, no edema. DPs, PTs 2+. right groin with no ecchymosis
or hematoma, angioseal palpated.
NEURO: Speech clear. 5/5 strength in U/L extremities. gait WNL.
SKIN: no rash
PSYCH: alert, mildly anxious, appears tired, cooperative.
Pertinent Results:
LABS ON ADMIT:
[**2168-2-13**] 06:30PM BLOOD WBC-10.7 RBC-4.92 Hgb-15."
3805,"11. Limited resiting hemodynamics revealed normal systemic
arterial
blood
pressure with a central aortic blood pressure of 126/77.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease with a 95%
thrombotic LCx
lesion thought to the cause of the patient's acute STEMI.
2. Patent LIMA to LAD.
3. Patent SVG to RCA.
4. No other grafts demonstrated on aortography.
2. Successful direct stenting of the Cx with a BMS.
3. Successful direct stenting of the LMCA with a BMS.
4. Successful closure of the right femoral arteriotomy site with
an
Angioseal VIP device.
8. Normal central aortic blood pressure."
3806,"This level of exercise
represents an average exercise tolerance for age (submaximal
test obtained as the patient is s/p STEMI). In response to
stress, the ECG showed no diagnostic ST-T wave changes (see
exercise report for details). There were normal blood pressure
and heart rate responses to stress.
Resting images were acquired at a heart rate of 69 bpm and a
blood pressure of 104/59 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Doppler
demonstrated no aortic stenosis, aortic regurgitation or
significant mitral regurgitation or resting LVOT gradient.
Echo images were acquired within 45 seconds after peak stress at
heart rates of 120-97 bpm."
3807,"The RCA was totally occluded in its mid segment.
2. Selective venous conduit angiography demonstrated a patent
SVG to
distal RCA graft.
3. Non-selective arterial conduit angiography demonstrated a
patent LIMA
to LAD with a kink in its midcourse.
4. Supravalvular aortography did not demonstrate any additional
grafts.
5. Primary PCI was delayed due to difficulty in locating the
patient's
prior bypass grafts and therefore determining the culprit artery
(no
reports of the anatomy were available and the patient stated
that he had
3 grafts despite our ability to only locate 2), and because
patient
agitation due to a paradoxical reaction to fentanyl caused a
delay in
the ability to safely carry out the procedure."
3808,"Graft angiography revealed a patent
SVG to RCA/PDA, and a patent LIMA to LAD. The third vein graft
was not found despite non-selective power injection of the
aortic root, and was thought to likely be a SVG to OM that was
occluded. Subsequent reports from [**Hospital1 2025**], revealed that he only had
a 2-vessel CABG (per cath report from [**2164**]). The LCX lesion was
thought to the the culprit given its appearance, and this was
opened with a BMS. After this lesion was opened the patient
converted into AIVR which lasted about 5 minutes. Given that LM
had a 70% ostial stenosis, it was decided that the patient would
benefit from increased coronary inflow, and a BMS was also
placed in the LM."
3809,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack and was brought to [**Hospital1 18**] for a cardiac
catheterization. The catheterization showed that your grafts
from the operation were open and had good blood flow but there
was a clot in your left circumflex artery that was causing the
heart attack. You received a bare metal stent but also needed a
bare metal stent in your left main artery to increase blood flow
to the area. You will need to take plavix for at least one year
and possibly longer to prevent the stent from clotting off."
3810,"In the cath lab, his native
coronary angiography demonstrated a 70% ostial LM lesion, a
totally occluded mid LAD, a 95% thrombotic appearing mid LCX
lesion, LM had a 70% ostial stenosis and a totally occluded mid
RCA. Graft angiography revealed a patent SVG to RCA/PDA, and a
patent LIMA to LAD. A BMS was placed to the LCX and LM. He had
several episodes of [**2165-12-8**] resting CP in the two days after the
intervention that were relieved with sublingual nitroglycerin. A
submaximal stress echo was performed which demonstrated no
evidence of ischemia by ECG or echocardiogram."
3811,"Do
not stop taking Plavix or aspirin or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr.
[**Last Name (STitle) 96196**] says it is OK. This is extremely important to prevent
another heart attack. An echocardiogram was done that showed
that your heart function is normal. You had some chest pain
after the cathererization which was treated with nitroglycerin
but this did seem to cause any damage to your heart. Your stress
test was negative. You will have nitroglycerin tablets to take
at home. Please take this for any chest pain that is similar to
the pain of your heart attack."
3812,"You can take one pill, wait 5
minutes, then take another pill if you still have chest pain.
Call 911 if you still have chest pain after 2 [**Last Name (STitle) 4319**] of
nitroglycerin. Call Dr. [**Last Name (STitle) 96196**] if you use any nitroglycerin at
all. You can also call the heartline to talk to a cardiologist
or NP here who can help you with your symptoms.
You received a lot of contrast during your catheterization. This
can sometimes affect your kidney function. So far, you have not
had any changes in your kidney function but please get blood
drawn on Thursday to check again."
3813,"8 Na-143 K-4.7 Cl-105
HCO3-30 AnGap-13
[**2168-2-15**] 06:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9
ECG [**2168-2-13**]:
Normal sinus rhythm. Intra-atrial conduction abnormality.
Diffuse ST-T wave abnormalities. Inferior ST segment elevation.
Anterolateral ST segment depression. Consider acute inferior
myocardial infarction.
CATH [**2168-2-13**]:
1. Selective native coronary angiography in this right dominant
system
demonstrated severe 3 vessel and left main coronary artery
disease. The
LMCA had a 70% ostial lesion. The LAD was totally occluded in
its mid
segment. The LCx had a 95% thrombotic appearing lesion in its
mid
segment."
3814,"No pathologic valvular abnormality seen.
SUBMAXIMAL STRESS [**2168-2-17**]:
No anginal symptoms with nonspecific ST segment changes.
Attaining a submaximal level of 7 METs indicates an average
exercise
tolerance for his age, however patient could have attained
higher level
of work. Appropriate hemodynamic response to exercise. Echo
report sent
separately.
STRESS ECHO [**2168-2-17**]:
The patient exercised for 9 minutes and 0 seconds according to a
Modified [**Doctor First Name **] treadmill protocol (7 METS) reaching a peak heart
rate of 125 bpm and a peak blood pressure of 134/40 mmHg. The
test was stopped because of fatigue."
3815,"RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. old midline scar well healed
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB on anterior exam,
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.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3,
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+"
3816,"After both interventions, the patient's chest
pain and prior ECG changes resolved. He was transferred to the
CCU for close monitoring in good condition.
Of note, the patient had significant confusion during the
cardiac cath, asking repetitively where was and how he had
arrived in the cath lab. The patient noted a prior history of
mental status changes with benadryl, and it was unclear if the
patient??????s mental status changes in the cath lab were the result
of the fentanyl and versed that he received.
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."
3817,"0 Hct-41.4
MCV-84 MCH-30.4 MCHC-36.2* RDW-12.5 Plt Ct-194
[**2168-2-13**] 06:30PM BLOOD PT-10.2 PTT-29.5 INR(PT)-0.9
[**2168-2-13**] 06:30PM BLOOD Fibrino-292
[**2168-2-13**] 06:30PM BLOOD Glucose-103* UreaN-22* Creat-0.8 Na-142
K-4.2 Cl-104 HCO3-26 AnGap-16
[**2168-2-13**] 11:02PM BLOOD CK(CPK)-645*
[**2168-2-14**] 05:38AM BLOOD CK(CPK)-922*
[**2168-2-14**] 01:55PM BLOOD CK(CPK)-726*
[**2168-2-14**] 03:30PM BLOOD CK(CPK)-638*
[**2168-2-13**] 06:30PM BLOOD cTropnT-<0."
3818,"6. Start taking nitroglycerin as described above to treat chest
pain.
7. Stop taking Strattera, this is not good for your heart. You
can talk to your physician about an alternative.
8. Start taking imdur, this will prevent chest pain. Talk to Dr.
[**Last Name (STitle) 96196**] if the lightheadedness does not improve in a few days.
Followup Instructions:
Name: JUDGE,[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: AMBULATORY PRACTICE OF THE FUTURE
Address: [**Location (un) 96199**] [**Apartment Address(1) 12836**], [**Location (un) **],[**Numeric Identifier 10614**]
Phone: [**Telephone/Fax (1) 96200**]
Appointment: WEDNESDAY [**2-24**] AT 12PM
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern4) 4094**]: CARDIOLOGY
Location: [**Hospital6 **]
Address: [**Street Address(2) 12266**], YAWKEY CENTER 5800, [**Location (un) **],[**Numeric Identifier 18228**]
Phone: [**Telephone/Fax (1) 96197**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 96196**]
within 1 month. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**"
3819,"4. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
5. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablet* Refills:*0*
8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9."
3820,"ECHO [**2168-2-15**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function."
3821,"TRANSITONAL ISSUES: Followup with PCP and cardiologist was
arranged. Dr [**Last Name (STitle) 96196**] was made aware of hopsital course.
Medications on Admission:
ASA 325
Crestor 10mg Daily
Depakote 250mg tablets 1 tablet qAM, 1 tablet qNoon, 1 tablet
qPM, 2tablets pHS
Effexor XR 150mg daily
Strattera 100mg daily
Discharge Medications:
1. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO qHS ().
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
3822,"01
[**2168-2-13**] 11:02PM BLOOD CK-MB-97* MB Indx-15.0* cTropnT-1.36*
[**2168-2-14**] 05:38AM BLOOD CK-MB-137* MB Indx-14.9* cTropnT-2.67*
[**2168-2-14**] 01:55PM BLOOD CK-MB-100* MB Indx-13.8* cTropnT-2.11*
[**2168-2-14**] 03:30PM BLOOD CK-MB-87* MB Indx-13.6* cTropnT-1.85*
[**2168-2-15**] 06:15AM BLOOD CK-MB-21* MB Indx-8.4* cTropnT-1.67*
[**2168-2-16**] 05:45AM BLOOD CK-MB-5
[**2168-2-13**] 06:30PM BLOOD Calcium-9.8 Phos-2."
3823,".
We made the following changes to your medicines:
1. Continue aspirin forever, talk to Dr. [**Last Name (STitle) 96196**] before you stop
the aspirin for any reason.
2. Increase the Crestor to 40 mg to lower your cholesterol
3. Start taking metoprolol to lower your heart rate and help
your heart recover from the heart attack
4. Start taking lisinopril to lower your blood pressure and help
your heart recover from the heart attack.
5. Start taking Clopidogrel (Plavix) to keep the stents from
clotting off and causing another heart attack. Do not stop this
medicine unless you talk to Dr [**Last Name (STitle) 96196**] first."
3824,"6. Successful direct stenting of the Cx with a 3.0x12mm
INTEGRITY
stent. Final angiography revealed no residual stenosis, no
angiographically apparent dissection and TIMI III flow (see PTCA
comments).
7. Successful direct stenting of the LMCA with a 4.5x18mm ULTRA
stent.
Final angiography revelaed no residual stneosis, no
angiographically
aparent dissection and TIMI III flow (see PTCA comments).
8. Patient went into AIVR post stenting of the Cx lesion. Rhythm
lasted
five minutes, and patient remained hemodynamically stable
throughout.
9. Successful closure of the 6 French right femoral arteriotomy
site
with a 6 French Angioseal VIP device with good resultant
hemostasis."
3825,"2* Mg-2.0
[**2168-2-13**] 11:02PM BLOOD Valproa-85
[**2168-2-13**] 06:41PM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-33* pH-7.51*
calTCO2-27 Base XS-3 Comment-GREEN-TOP
[**2168-2-13**] 06:41PM BLOOD Glucose-94 Lactate-2.3* Na-142 K-4.2
Cl-100
[**2168-2-13**] 06:41PM BLOOD freeCa-1.12
LABS on DC:
[**2168-2-17**] 06:45AM BLOOD WBC-8.8 RBC-4.38* Hgb-13.6* Hct-37.9*
MCV-87 MCH-31.0 MCHC-35.9* RDW-12.7 Plt Ct-178
[**2168-2-17**] 06:45AM BLOOD UreaN-19 Creat-0."
3826,"Subsequently, while walking his dog he developed SOB, [**9-14**] SS
chest pain and paramedics were called. On the ride to [**Hospital1 18**], his
pain started radiating to his left arm. A 12-lead ECG
demonstrated inferior ST elevations and ST depressions in the
lateral and precordial leads.
In the ED, initial vital signs were the following: HR: 83 BP:
118/75 Resp: 18 O(2)Sat: 100 Normal. He was given ASA 325 mg,
Plavix 600 mg, heparin 5000 units IV, as well as 125 mg IV
solumedrol, and 50 mg IV famotidine (for contrast allergy) and
taken emergently to the cath lab where native coronary
angiography demonstrated a 70% ostial LM lesion, a totally
occluded mid LAD, a 95% thrombotic appearing mid LCX lesion, and
a totally occluded mid RCA."
3827,"2. Small bilateral pleural effusions are slightly increased from [**2188-4-21**].
Bibasilar atelectasis. Increased lingular opacity is incompletely imaged and
is probably atelecatsis, less likely infection. Dense mitral annular
calcifications.
3. Cirrhosis, large nonhemorrhagic ascites, unchanged from [**2188-4-21**].
Interval fixation of left femoral fracture. Dialysis catheter ends in inferior
right atrium.
4. Small stones or sludge layering in gallbladder.
-MAgarwal discussed with Dr. [**Last Name (STitle) 15163**] by phone at 10:51pm [**2188-5-7**] at time of
discovery.
______________________________________________________________________________
FINAL REPORT
INDICATION: 80-year-old female with dropping hematocrit.
COMPARISON: Comparison is made with portable AP chest radiographs from [**5-7**], [**2188**] and CT chest, abdomen and pelvis without contrast [**2188-4-21**]."
3828,"There is no evidence of
intrahepatic or extrahepatic biliary dilatation. Layering sludge and stones
are seen within the gallbladder, but is otherwise unremarkable with no
evidence of inflammatory changes. The spleen, pancreas and adrenal glands are
normal. The spleen is mildly enlarged measuring 12.5 cm representing interval
decrease in size (previously 14.3 cm). The kidneys are unremarkable on this
non-contrast study. There are several foci of punctate calcification, which
can represent non-obstructing stone or more likely arterial calcifications.
There is no evidence of obstruction or hydronephrosis. Small stable
calcification is seen in segment VII of the liver, likely representing old
granulomatous disease."
3829,"There is a large 4.4 x 10.3
cm hematoma medial to metallic prosthesis in the left acetabulum within the
medial left proximal thigh. Hematoma appears to extend to the mid femur with
CC span of 8.4 cm. No obvious hardware complications are seen.
BONE WINDOWS: There is a displaced fracture of the lateral sixth rib which
appears to have undergone slight interval sclerosis. There are multiple other
old rib fractures seen. Stable degenerative changes are seen along the lower
lumbar spine. Moderate-to-severe degenerative changes are stable and seen in
the mid-to-low thoracic spine."
3830,"IMPRESSION:
1. Large hematoma measuring approximately 4.4 x 10.3 (TRV) x 8.4 (CC) cm in
the medial left thigh with adjacent left femoral metallic hardware, placed
after prior study.
2. Large volume non-hemorrhagic ascites, slightly decreased from previous
study.
3. Stable bilateral pleural effusion with associated bibasilar atelectasis.
Possible area of new consolidation in the left lower lobe.
4. Dialysis catheter terminates within the inferior right atrium as before.
(Over)
[**2188-5-7**] 9:06 PM
CT ABD & PELVIS W/O CONTRAST Clip # [**Clip Number (Radiology) 66797**]
Reason: eval for bleed
Admitting Diagnosis: SEPSIS
______________________________________________________________________________
FINAL REPORT
(Cont)"
3831,"Moderate coronary
calcification and extensive mitral annular calcification is observed. No
pericardial effusion is identified. There is mild prominence of pulmonary
vasculature suggestive of pulmonary vascular congestion and/or heart failure.
CT ABDOMEN WITHOUT CONTRAST: Moderate-volume ascites is seen, somewhat
increased from [**Month (only) 4155**] study, and is simple-fluid density and does not represent
hemorrhage. The liver is atrophic and macronodular consistent with history of
(Over)
[**2188-5-7**] 9:06 PM
CT ABD & PELVIS W/O CONTRAST Clip # [**Clip Number (Radiology) 66797**]
Reason: eval for bleed
Admitting Diagnosis: SEPSIS
______________________________________________________________________________
FINAL REPORT
(Cont)
cirrhosis. No focal lesions are observed."
3832,"[**2188-5-7**] 9:06 PM
CT ABD & PELVIS W/O CONTRAST Clip # [**Clip Number (Radiology) 66797**]
Reason: eval for bleed
Admitting Diagnosis: SEPSIS
______________________________________________________________________________
[**Hospital 4**] MEDICAL CONDITION:
80 year old woman with hct drop
REASON FOR THIS EXAMINATION:
eval for bleed
CONTRAINDICATIONS for IV CONTRAST:
renal failure;renal failure
______________________________________________________________________________
WET READ: MDAg WED [**2188-5-7**] 10:52 PM
1. No retroperitoneal hematoma. 4.4 x 10.2 cm hematoma in the medial left
thigh adjacent to new fixation (2:89) extending to at least the mid thigh
(inferior aspect of the study), although full evaluation limited by streak
artifact from hardware."
3833,"There is no retroperitoneal or mesenteric
lymphadenopathy. There is no free air. The aortoiliac vessels and splenic
artery are heavily calcified, SMA and celiac trunk appear patent.
CT PELVIS WITHOUT CONTRAST: Evaluation of this region is limited secondary to
extensive streak artifact from bilateral metallic hip prosthesis. Within
these limitations, the rectum and distal sigmoid colon appear normal course
and caliber. Foley catheter is seen in place with a decompressed bladder,
which appears otherwise unremarkable. Uterus appears normal in size and
contour. Extensive free fluid is seen in the pelvis of the same density as
abdominal ascites, not concerning for hemorrhage."
3834,"TECHNIQUE: Multidetector CT-acquired axial images from the base of the lungs
to the mid thigh were acquired without IV or oral contrast. Sagittally and
coronally reformatted images were generated.
DLP: 657.57 mGy-cm.
CT LUNG BASES WITHOUT CONTRAST: There is mild bilateral pleural effusion with
associated atelectasis and area of new consolidation in the left lower lobe
(2:3). There is moderate cardiomegaly with interval increase as compared to
[**4-21**] study. Seen terminating within the right atrium is a dialysis
catheter unchanged in the position. Previously seen left IJ catheter
terminates out of field of view of this study."
3835,"Admission Date: [**2188-5-7**] Discharge Date: [**2188-5-17**]
Date of Birth: [**2107-11-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Diagnostic paracentesis [**2188-5-7**]
Diagnostic paracentesis [**2188-5-12**]
History of Present Illness:
This is an 80 -year-old female with history of left hip fracture
s/p ORIF [**4-23**], and subsequent admission from [**4-29**] to [**5-5**] for
NSTEMI treated medically, who was transferred to the ED today
from her nursing home where she was noted to have SBPs in the
70s."
3836,"She was subsequently transferred to [**Hospital1 18**] ED
.
In the ED, initial VS were 60 76/52 20 99. She triggered for
hypotension and received 2LIVF in the ED. UA showed >180 wbc
and many bacteria and she was given zosyn for UTI. Bloodwork
was significant for Hct of 23.0, down from 37.6 on discharge
[**5-5**]. She was given 2 U PRBC with improvement to 29.9. Concern
was for variceal bleed, and she was loaded with protonix and
placed on ggt. She was intubated for airway protection and
liver was consulted and did an upper endsocopy (once in the
MICU) which showed no concern for bleed."
3837,"She is intubated and sedated, not answering
questions
.
Review of systems: Unable to obtain [**3-6**] intubation and sedation
Past Medical History:
-CHF--EF 35%
-NSTEMI [**5-/2188**] treated medically
-Hep C cirhosis- CHILD B - complicated with esophageal varices
sp
banding, SBP/ascites in [**11/2187**]
-DM II dx at age 55
-HTN
-HL
-ESRD on HD since [**2187-11-3**](possible from Hep C, had attempted
renal bx), thought to be [**3-6**] DM
-GERD
-Anemia
-Uterine polyps
-Left hip fracture s/p ORIF [**2188-4-23**]
Social History:
No drugs, pts family feels she got Hep C in the hospital setting
while in the [**Location (un) 3156**]."
3838,"Patient may have ongoing
abdominal pain, specifically with eating, however, she is not a
candidate for ERCP or other intervention on sludge/biliary
stones.
With aggressive bowel regimen, patient had several good
well-formed bowel movements and nausea/abdominal pain improved.
She continued to have regular bowel movements with bowel regimen
during admission.
In addition, EGD on admission noted candidiasis in the
esophagus. Patient was started on clotrimazole troche po QID
for 2 weeks.
# Cirrhosis: Secondary to Hep C. Patient with known varices not
actively bleeding on EGD on admission. Diagnostic paracentesis
negative for SBP on [**5-7**] and [**5-12**]."
3839,"Nadolol was held briefly then
restarted once pressures stabilized. Patient was initially on
cefepime given concern for septic shock causing hypotension,
then changed to ciprofloxacin for SBP prophylaxis (bactrim not
restarted given pancytopenia). Patient had a therapeutic
paracentesis on the day prior to discharge with 4L of fluid
removed and albumin given.
# Bradycardia: High 30s while in the ICU, but resolved once
patient was off of neosynephrine. Heart rate stable for the
remainder of admission.
# Chronic renal failure: On dialysis M/W/F. She continued
dialysis during her hospitalization. Patient was hypotensive
during dialysis which limited the amount of fluid that could be
removed during each session."
3840,"# CHF: EF 35% on last admission, with EF 55% during this
admission. Carvedilol 12.5mg po BID and lisinopril 10mg po daily
were not restarted given normal blood pressure, and low blood
pressures with dialysis.
# CAD: Recent NSTEMI treated medically with aspirin and plavix.
Both were held in setting of hematoma, acute blood loss.
Troponins were monitored daily as were EKG given nonspecific
symptoms of nausea/abdominal pain and lethargy. Troponins
trended down and were 0.15 at time of discharge. EKG remained
stable throughout admission. Notably, QTc was prolonged at
470-490. Aspirin was restarted once hematocrit stabilized.
Plavix was held at time of discharge given risk for bleed."
3841,"17. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
18. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
19. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Nasal twice a day as needed for cold symptoms.
20. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
21. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
# Acute blood loss
# Hypovolemic shock"
3842,"Secondary diagnosis:
# Cirrhosis
# End stage renal disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Partial weightbearing on left
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission.
You were admitted because of low blood pressures, which occurred
because of a large bleed at the site of your hip fracture
repair. You were given blood and your blood pressure improved.
In addition, you had severe constipation causing abdominal pain
and nausea, which improved with a bowel regimen.
You had multiple paracentesis to investigate the fluid in your
abdomen, which did not show any infection."
3843,"6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
untis Injection three times a day.
12. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS)."
3844,"Lives in rehab. Has 2 children, 4
grandchildren.
-Tobacco history: never
-ETOH: denies
-Illicit drugs: never
Family History:
Mother with DM2 and MI. 2 brothers died of heart problems (one
definitely from MI). No history of strokes.
Physical Exam:
Admission Physical Exam:
Vitals: VS are 97.3 69 100/51 100% on AC 450/14/5/80%.
General: intubated, sedated, not responding to verbal or
physical stimuli
HEENT: Intubated. PERRLA, MMM
Neck: supple, JVP not elevated, no LAD
CV: bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation anteriorly,
Abdomen: Distended, no tenderness appreciated. Normal BS.
GU: foley
Ext: warm, well perfused, 2+ pulses."
3845,"6 to 23.0. Initial
concern was for variceal bleed given her history of varices.
However, she was scoped by hepatology with EGD showing no bleed.
CT showed 4x10cm hematoma over the left medial aspect of the
thigh/groin, likely source of acute blood loss, thought to be
exacerbated by recent treatment with aspirin/plavix/sc heparin
for NSTEMI. She had a coagulopathy (PTT is >100 and INR is 1.5)
thought to be a combination of her subcutaneous heparin and
cirrhosis which were corrected. Her hematocrit responded
appropriately to transfusion, and she received a total of 4U
PRBCs.
Pressures were initially supported in the ICU with pressors,
which were weaned following IVF and blood resuscitiation."
3846,"Rectal showed brown
stool and G+. BPs came up to SBPs in the 90s with fluids/blood,
though she did require push of norepinepherine for low systolics
peri-intubation
Of note, trop was elevated at 0.3 but this is actually
downtrending from her prior level of 0.41 during last admission
and imrpoved to 0.26 on recheck. Given her history of SBP,
diagnostic para was done showing only 65 wbc. Renal saw the pt
in the ED is following though felt no need for dialysis tonight
(MWF at baseline).
.
On arrival to the MICU, VS are 97.3 69 100/51 100% on AC
450/14/5/80%."
3847,"2. There is no evidence for retroperitoneal hematoma or
intraperitoneal
hemorrhage. A large volume ascites is non-hemorrhagic.
3. Cirrhotic liver with splenomegaly.
4. Cholelithiasis without evidence for cholecystitis.
5. 1.3 cm hypodense lesion in the tail of the pancreas most
likely represents an IPMN. In the patient's age group, no
further followup is necessary.
Brief Hospital Course:
80 yof with history of HepC cirrhosis, with known varices,
recent admissions for for hip fracture s/p ORIF and NSTEMI
treated medically, admitted from rehab for hypotension, found to
have significant Hct drop.
# Hypotension/Hct drop: Hct down from 37."
3848,"She
was not continued on subcutaneous heparin for same reason
# Anemia/thrombocytopena: Related to both end stage renal and
end stage liver diseases. Platelets were variable during
admission, but current level in the 40-60s likely represents new
baseline. Hematocrit varied, as above, with volume shifts
related to dialysis, but baseline was around 27-28.
# Transitional issues
- started ciprofloxacin for SBP prophylaxis in place of bactrim
- started nadolol for esophageal varices
- started clotrimazole troche QID for [**Female First Name (un) **], continue x 2
weeks through [**2188-5-28**]
- bowel regimen: senna/colace/miralax and lactulose to ensure
daily stools
- carvedilol and lisinopril held on discharge; if hypertensive,
should restart
- dialysis monday, wednesday, friday at [**Hospital3 2005**]."
3849,"15*
Microbiology:
Peritoneal fluid [**5-12**]-
GRAM STAIN (Final [**2188-5-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH
Peritoneal fluid [**5-7**]-
GRAM STAIN (Final [**2188-5-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE: NO GROWTH.
ANAEROBIC CULTURE: NO GROWTH.
Blood culture [**5-7**]- pending, NGTD x 2
Urine culture [**5-7**]- YEAST. >100,000 ORGANISMS/ML
Imaging:
CT abd/pelvix [**5-7**]-
1. Large hematoma measuring approximately 4.4 x 10.3 (TRV) x 8.4
(CC) cm in the medial left thigh with adjacent left femoral
metallic hardware, placed after prior study."
3850,"You had 4L removed
prior to admission to make you feel better.
You were continued on dialysis throughout admission.
The following changes were made to your medication regimen:
- STOP plavix
- STOP omeprazole
- START ranitidine
- START nadolol to prevent bleeding from your esophagus
- STOP bactrim
- START ciprofloxacin for prevention of infection in your
abdominal fluid
- START clotrimazole to treat the fungal infection in your
throat
- STOP carvedilol as your blood pressure has been well
controlled off
- STOP lisinopril as your blood pressure has been well
controlled off
Followup Instructions:
Department: LIVER CENTER
When: MONDAY [**2188-6-9**] at 10:30 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage"
3851,"C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): please hold for loose stools.
14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q8H PRN ()
as needed for pain.
15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
16. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
3852,"5. sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
8. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day) for 2 weeks.
9. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. bisacodyl 5 mg Tablet, Delayed Release (E."
3853,"2. Large volume non-hemorrhagic ascites, slightly decreased from
previous study.
3. Stable bilateral pleural effusion with associated bibasilar
atelectasis. Possible area of new consolidation in the left
lower lobe.
4. Dialysis catheter terminates within the inferior right atrium
as before.
TTE [**5-10**]- The left atrium is moderately dilated. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
normal free wall contractility. The diameters of aorta at the
sinus, ascending and arch levels are normal."
3854,"The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**2-4**]+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Small, hypertrophied left ventricle with
hyperdynamic systolic function. Mild to moderate mitral
regurgitation. Moderate pulmonary hypertension.
Lower extremity venous doppler [**5-11**]-
1. No evidence of DVT in the visualized veins
2. Subcutaneous edema of the calf, but calf veins not
visualized.
3. Loculated fluid in the left groin proably represents seroma
after hip surgery."
3855,"There is a large hematoma
of the medial left thight and groin. incision site on the
posterior thigh c/d/i with staples
Neuro: intubated and sedated, not responding to stimuli
Discharged Physical Exam:
Pertinent Results:
Admission labs:
WBC 5.3 Hgb 6.9 Hct 23.0 Plts 65
NEUTS-80.6* BANDS-0 LYMPHS-15.0* MONOS-3.3 EOS-0.9 BASOS-0.2
Trop-T 0.3
GLUCOSE-254* UREA N-56* CREAT-4.2* SODIUM-133 POTASSIUM-4.1
CHLORIDE-98 TOTAL CO2-24 ANION GAP-15
LACTATE-3.5*
Urinalysis: RBC->182* WBC->182* BACTERIA-MANY YEAST-MANY EPI-8
BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5."
3856,"PO DAILY (Daily).
19. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
21. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release
Sig: One (1) Capsule, Extended Release PO twice a day.
3. insulin glargine 100 unit/mL Solution Sig: Ten (10) Units
Subcutaneous qAM.
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
3857,"Given initial concern for septic shock, patient was started
on vancomycin and cefepime. Cefepime was continued on transfer
to floor and discontinued as patient had no signs of infection.
On transfer to the floor, blood pressures remained stable,
but were labile during hemodialysis preventing large fluid
removal. Hematocrit varied with fluid shifts with dialysis.
She was quaiac positive, but had no evidence of variceal
bleeding and was hemodynamically stable. She received epo with
dialysis and 1U PRBC during dialysis on day of discharge.
# Abdominal pain/nausea: Patient had complaints of abdominal
pain and nausea on transfer to the floor from ICU."
3858,"RUQ ultrasound [**5-12**]-
1. Cirrhosis with splenomegaly consistent with portal
hypertension.
Moderate-to-large ascites.
2. Patent portal vein.
3. Sludge in the gallbladder without evidence of gallstones. No
biliary obstruction. Gallbladder wall edema is noted, but
compatible with underlying liver disease and third spacing.
HIDA scan [**5-13**]- Acute cholecystitis is unlikely given
gallbladder filling. Delayed gallbladder filling only after
morphine administration may indicate a chronic cholecystis.
CT abd/pelvis [**5-15**]-
1. Stable hematoma in the left adductor muscles at the level of
the ischial tuberosity. Please note that the previously noted
hematoma in the left thigh at the level of the inferior aspect
of the plate in the femur is not depicted on this examination."
3859,"5 LEUK-LG
Pertinent labs:
PF4 antibody negative
Discharge labs:
[**2188-5-15**] 05:58AM BLOOD WBC-4.4 RBC-2.80* Hgb-8.5* Hct-27.7*
MCV-99* MCH-30.4 MCHC-30.8* RDW-21.8* Plt Ct-43*
[**2188-5-11**] 04:52AM BLOOD Neuts-69.4 Lymphs-23.6 Monos-5.3 Eos-1.3
Baso-0.3
[**2188-5-15**] 05:58AM BLOOD Plt Ct-43*
[**2188-5-15**] 05:58AM BLOOD Glucose-192* UreaN-20 Creat-2.4* Na-136
K-3.4 Cl-100 HCO3-30 AnGap-9
[**2188-5-14**] 07:00AM BLOOD cTropnT-0."
3860,"Given recent
NSTEMI, EKG and troponin were checked and showed no acute
changes, and downtrending troponin. She had not had a bowel
movement in several days and KUB confirmed that she had
significant constipation. In addition, given elevated
Tbili/alkphos and amylase, concern for cholecystitis,
pancreatitis or choledocholithiasis. RUQ showed biliary sludge
without gallstones and normal size of common bile duct. HIDA was
negative for acute cholecystitis but did show delayed filling
suggesting chronic cholecystitis. In addition, a paracentesis
was repeated which did not show evidence of spontaneous
bacterial peritonitis. Pain was thought to be due to biliary
sludge and resolved spontaneously."
3861,"- left leg is partial weight bearing only secondary to hip
surgery
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
4. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to shoulder."
3862,"On day of discharge, she had an
extra session of ultrafiltration. She was continued on sevelamer
and nephrocaps.
# Left hip fracture s/p ORIF [**2188-4-23**]: In total required 4 units
of pRBCs for hematoma in left hip. Aspirin and plavix were held
on admission; aspirin restarted once hematocrit stabilized.
Surgical site was intact without signs of wound dehiscence.
Staples were removed at 2 week mark. Patient continued to work
with physical therapy upon transfer to the floor. Repeat CT
scan prior to discharge showed interval improvement in hematoma.
# DM: Continued home glargine 10 units daily with insulin
sliding scale."
3863,"13. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 5X/WEEK (MO,TU,TH,FR,SA): Take 5 times a week, after
dialysis on dialysis days.
15. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO ASDIR:
Titrate to [**3-7**] BM daily. .
16. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap"
3864,"Admission Date: [**2106-10-29**] Discharge Date: [**2106-11-5**]
Date of Birth: [**2041-4-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
R parietal mass
Major Surgical or Invasive Procedure:
Crainiotomy for tumor resection
History of Present Illness:
This is a 65-year-old gentleman who initially
presented with left hand numbness as well as tingling
associated with difficulty placing his hand in space. His
work-up ultimately included MRI of the head that revealed a
right parietal mass, as well as a small contrast enhancing
region in the left cerebellum consistent with metastasis."
3865,"Work-up revealed a left upper lung mass as well. The patient
presents for a combined mediastinoscopy as well as a right
craniotomy for tumor resection. The mediastinoscopy will be
separately dictated by Dr. [**Last Name (STitle) **].
Past Medical History:
HTN
Hypercholesterolemia
BPH (prostate bx 18 mo ago negative)
Seasonal allergies
Social History:
Tobacco: remote 25 pack yr smoking history
Alcohol: 2 beers per night
Illicits: denies, no IVDA.
No herbal remedies.
Family History:
Father - died of CHF aged 89
Mother - died of a stroke aged 73 (also had rheumatoid
arthritis)
4 Siblings:
Non-identical twin siblings: brother has ulcerative colitis and"
3866,"His neurologic
status continued to improve. By POD2, he was consistently
coherent and without episodes of confusion.
Routine post-op serum electrolyte check revealed that he was
hyponatremic (Na 132) and was started on fluid restriction and
salt tabs. The restriction and salt tab was tapered
subsequently. By the time of discharge, his Na was 133 without
fluid restriction or salt taps.
The patient has a history of Prostatic Hypertrophy and had
voiding difficulties post-op. The urology service was called
and a foley was placed. Per urology recommendation, the patient
will go home with the Foley and a leg bag."
3867,"Discharge Disposition:
Home With Service
Facility:
Southshore VNA
Discharge Diagnosis:
Brain Tumor
Discharge Condition:
Stable
Discharge Instructions:
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**First Name (STitle) **] TO BE SEEN IN [**3-30**] WEEKS.
YOU WILL NOT NEED AN MRISCAN OF THE BRAIN WITH and WITHOUT
CONTRAST which will be arranged by the Brain tumor [**Date Range **]. Other
appointments that are scheduled for you are as follow:
[**2106-11-16**] 01:00p Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] A.
South Campus [**Hospital Ward Name **] CENTER, [**Location (un) **] UROLOGY
[**2106-11-15**] 09:30a Dr."
3868,"Vasogenic
edema in the right cerebral hemisphere has decreased in extent
compared to [**2106-10-11**]. A 4 mm enhancing mass in the
left cerebellar hemisphere is unchanged. A left parietal
development venous anomaly is again seen. No new enhancing
lesions are seen. The ventricles are normal in size.
MRI [**10-29**]: Head Accounting for differences in head angulation and
positioning, there is slight increase in the right parietal lobe
mass but with decrease in the surrounding edema. The right
frontal lobe lesion currently measures 2.2 cm CC x 2.7 cm AP x
2.5 cm TV dimensions compared to prior measurements of 2."
3869,"[**Last Name (STitle) **],[**First Name3 (LF) **] [**Hospital **] [**Hospital **]
South Campus [**Hospital Ward Name **] CENTER, [**Location (un) **] NEUROLOGY UNIT
Phone:[**Telephone/Fax (1) 44**]
[**2106-11-11**] 09:30a [**Last Name (LF) **],[**First Name3 (LF) **] MULTI-SPECIALTY
South Campus [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] MULTI-SPECIALTY
THORACIC UNIT-CC9
[**2106-11-11**] 09:30a Hematology/Oncology: Dr. [**First Name (STitle) **],[**First Name3 (LF) **] J.
South Campus [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
This urology appointment was made for you to address your
urinary retention, if you are unable to make this appointment
please call the office to re-schedual.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2106-11-16**] 1:00PM
Below are appointments that were in the system and are reminders
for you.
Provider: [**Name10 (NameIs) 13644**],NURSE [**First Name (Titles) 13644**] [**Last Name (Titles) **] Date/Time:[**2106-11-18**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2106-12-29**] 9:30
Completed by:[**2106-11-9**]"
3870,"Disp:*7 Tablet(s)* Refills:*0*
9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO please
follow directions below: qid x 3days
tid x 3days
[**Hospital1 **] x 4days
qc x2 4days
.
Disp:*33 Tablet(s)* Refills:*1*
11. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*"
3871,"Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day: take 30 min after a
meal daily.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
7 days."
3872,"He will follow up
with the urology service after discharge.
The patient took in adequate POs and he worked well with PT/OT
and was cleared for home with PT services. His left hand
coordination had significantly improved by the time of
discharge.
Medications on Admission:
Flomax
Lisinopril
Simvastatin
ASA
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tamsulosin 0.4 mg Capsule, Sust."
3873,"sister has diverticulitis
One sister died of AML aged 55
A brother has OA
Physical Exam:
A&Ox3, PERRL, follows commands, tongue midline, smile symmetric,
no pronator drift. Strength is full [**5-31**]. Poor coordination of
his left hand (baseline)
Pertinent Results:
MRI [**10-31**]:There is a new right frontal/parietal craniotomy.
Subacute blood
products are present at the site of the resected right frontal
mass. There is hyperemia and mild linear enhancement along the
medial and superior margins of the surgical cavity. There is a
small right subdural collection, a small right epidural
collection, and a small right subgaleal collection."
3874,"7 Na-134
K-4.7 Cl-97 HCO3-27 AnGap-15
[**2106-10-31**] 07:15AM BLOOD Phenyto-10.0
[**2106-11-4**] 06:45AM BLOOD WBC-9.0 RBC-3.92* Hgb-11.1* Hct-31.9*
MCV-81* MCH-28.3 MCHC-34.7 RDW-14.9 Plt Ct-151
[**2106-11-4**] 06:45AM BLOOD Plt Ct-151
[**2106-11-4**] 06:45AM BLOOD Glucose-99 UreaN-18 Creat-0.6 Na-133
K-4.1 Cl-101 HCO3-26 AnGap-10
[**2106-11-4**] 06:40AM BLOOD Phenyto-8.4*
Brief Hospital Course:
On [**10-29**] Mr."
3875,"2 x 1.7
x 2.0 cm. There is less mass effect on the ventricles.
There is also a subtle enhancing lesion in the left cerebellum
adjacent to
the tentorium. Ventricles and sulci are unchanged in size and
configuration. There is no acute ischemia.
[**2106-10-30**] 02:55AM BLOOD WBC-19.4*# RBC-4.45* Hgb-12.4* Hct-36.2*
MCV-81* MCH-27.8 MCHC-34.1 RDW-14.2 Plt Ct-186
[**2106-10-30**] 02:55AM BLOOD PT-12.3 PTT-22.0 INR(PT)-1.0
[**2106-10-30**] 02:55AM BLOOD Glucose-179* UreaN-27* Creat-0."
3876,"[**Known lastname **] [**Last Name (Titles) 1834**] a R Parietal Crani for tumor
resection. During that time he [**Last Name (Titles) 1834**] a biopsy of his LUL by
Thoracics. He tolerated both procedures well and was trasferred
to the floor where he was neurologically stable. He did have LUE
ataxia and alt. proprioception which was at his baseline during
that time.
He did have confusion during the night on a couple of occasions
and on [**11-1**] had a fall and hit head. There was a sm. amount of
new blood on CT however pt was neurologically stable. Subsequent
CTs revealed no evidence of hematoma expansion."
3877,"SICU
HPI:
65M w/new mass lesions LUL and [**Doctor Last Name 414**] w/edema no shift.admission exam
LUE ataxia, alt proprioception. S/P mediastinoscopy and crni with
pariet lobe resection
Chief complaint:
Brain Mass
PMHx:
HTN, Dyslipidemia, BPH
Current medications:
20 mEq Potassium Chloride / 1000 mL D5NS 2. Docusate Sodium 3.
Famotidine 4. Gentamicin 5. HYDROmorphone (Dilaudid)
6. Heparin 7. Influenza Virus Vaccine 8. Labetalol 9. Phenytoin 10.
Phenytoin 11. Potassium Phosphate
12. Senna 13. Vancomycin
24 Hour Events:
ARTERIAL LINE - START [**2106-10-29**] 06:44 PM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Gentamicin - [**2106-10-30**] 02:00 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2106-10-29**] 10:00 PM
Other medications:
Flowsheet Data as of [**2106-10-30**] 07:55 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a."
3878,"m.
Tmax: 36.7
C (98.1
T current: 36.6
C (97.8
HR: 68 (67 - 84) bpm
BP: 111/52(71) {111/52(71) - 164/90(118)} mmHg
RR: 13 (10 - 24) insp/min
SPO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Total In:
700 mL
788 mL
PO:
Tube feeding:
IV Fluid:
700 mL
788 mL
Blood products:
Total out:
1,110 mL
770 mL
Urine:
1,110 mL
770 mL
NG:
Stool:
Drains:
Balance:
-410 mL
18 mL
Respiratory support
O2 Delivery Device: None
SPO2: 94%
ABG: ///27/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
186 K/uL
12."
3879,"admission exam LUE ataxia, alt proprioception. S/P
mediastinoscopy and crni with pariet lobe resection
Neurologic: Neuro checks Q: 2 hr, Pain controlled
Cardiovascular: stable
Pulmonary: stable
Gastrointestinal / Abdomen:
Nutrition: Regular diet
Renal: Foley
Hematology:
Endocrine:
Infectious Disease: vanc/gent
Lines / Tubes / Drains: Foley
Wounds:
Imaging:
Fluids:
Consults: Neuro surgery
Billing Diagnosis: Post-op complication
ICU Care
Nutrition:
Glycemic Control: Comments: stable
Lines:
Arterial Line - [**2106-10-29**] 06:44 PM
18 Gauge - [**2106-10-29**] 06:44 PM
16 Gauge - [**2106-10-29**] 06:44 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status:
Disposition: Transfer to floor
Total time spent: 31 minutes"
3880,"4 g/dL
179 mg/dL
0.7 mg/dL
27 mEq/L
4.7 mEq/L
27 mg/dL
97 mEq/L
134 mEq/L
36.2 %
19.4 K/uL
[image002.jpg]
[**2106-10-30**] 02:55 AM
WBC
19.4
Hct
36.2
Plt
186
Creatinine
0.7
Glucose
179
Other labs: PT / PTT / INR:12.3/22.0/1.0, Ca:8.2 mg/dL, Mg:2.3 mg/dL,
PO4:4.8 mg/dL
Assessment and Plan
.H/O HYPERTENSION, BENIGN, PULMONARY NODULE (LUNG NODULE), [**Last Name **]
PROBLEM - ENTER DESCRIPTION IN COMMENTS
Parietal Mass, .H/O DYSLIPIDEMIA (CHOLESTEROL, TRIGLYCERIDE, LIPID
DISORDER)
Assessment and Plan: 65M w/new mass lesions LUL and [**Doctor Last Name 414**] w/edema no
shift."
3881,"SICU
HPI:
65M w/new mass lesions LUL and [**Doctor Last Name 414**] w/edema no shift.admission exam
LUE ataxia, alt proprioception. S/P mediastinoscopy and crni with
pariet lobe resection
Chief complaint:
Brain Mass
PMHx:
HTN, Dyslipidemia, BPH
Current medications:
20 mEq Potassium Chloride / 1000 mL D5NS 2. Docusate Sodium 3.
Famotidine 4. Gentamicin 5. HYDROmorphone (Dilaudid)
6. Heparin 7. Influenza Virus Vaccine 8. Labetalol 9. Phenytoin 10.
Phenytoin 11. Potassium Phosphate
12. Senna 13. Vancomycin
24 Hour Events:
ARTERIAL LINE - START [**2106-10-29**] 06:44 PM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Gentamicin - [**2106-10-30**] 02:00 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2106-10-29**] 10:00 PM
Other medications:
Flowsheet Data as of [**2106-10-30**] 07:55 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a."
3882,"4 g/dL
179 mg/dL
0.7 mg/dL
27 mEq/L
4.7 mEq/L
27 mg/dL
97 mEq/L
134 mEq/L
36.2 %
19.4 K/uL
[image002.jpg]
[**2106-10-30**] 02:55 AM
WBC
19.4
Hct
36.2
Plt
186
Creatinine
0.7
Glucose
179
Other labs: PT / PTT / INR:12.3/22.0/1.0, Ca:8.2 mg/dL, Mg:2.3 mg/dL,
PO4:4.8 mg/dL
Assessment and Plan
.H/O HYPERTENSION, BENIGN, PULMONARY NODULE (LUNG NODULE), [**Last Name **]
PROBLEM - ENTER DESCRIPTION IN COMMENTS
Parietal Mass, .H/O DYSLIPIDEMIA (CHOLESTEROL, TRIGLYCERIDE, LIPID
DISORDER)
Assessment and Plan: 65M w/new mass lesions LUL and [**Doctor Last Name 414**] w/edema no
shift."
3883,"admission exam LUE ataxia, alt proprioception. S/P
mediastinoscopy and crni with pariet lobe resection
Neurologic: Neuro checks Q: 2 hr, Pain controlled
Cardiovascular: stable
Pulmonary: stable
Gastrointestinal / Abdomen:
Nutrition: Regular diet
Renal: Foley
Hematology:
Endocrine:
Infectious Disease: vanc/gent
Lines / Tubes / Drains: Foley
Wounds:
Imaging:
Fluids:
Consults: Neuro surgery
Billing Diagnosis: Post-op complication
ICU Care
Nutrition:
Glycemic Control: Comments: stable
Lines:
Arterial Line - [**2106-10-29**] 06:44 PM
18 Gauge - [**2106-10-29**] 06:44 PM
16 Gauge - [**2106-10-29**] 06:44 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status:
Disposition: Transfer to floor
Total time spent: 31 minutes"
3884,"m.
Tmax: 36.7
C (98.1
T current: 36.6
C (97.8
HR: 68 (67 - 84) bpm
BP: 111/52(71) {111/52(71) - 164/90(118)} mmHg
RR: 13 (10 - 24) insp/min
SPO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Total In:
700 mL
788 mL
PO:
Tube feeding:
IV Fluid:
700 mL
788 mL
Blood products:
Total out:
1,110 mL
770 mL
Urine:
1,110 mL
770 mL
NG:
Stool:
Drains:
Balance:
-410 mL
18 mL
Respiratory support
O2 Delivery Device: None
SPO2: 94%
ABG: ///27/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
186 K/uL
12."
3885,"He was discharged home on [**2155-5-30**].
Yesterday
he developed some nausea, limiting his PO intake, which
progressed to emesis this morning of thin yellow-green fluid.
Reports mild abdominal pain, described as a tightness across his
upper abdomen in the region of the incision. + flatus yesterday
but not today. Last BM was yesterday. Denies fevers or chills.
Past Medical History:
PMHx: Diet-controlled DM, HTN.
.
PSHx: [**2155-4-22**] ERCP with sphincterotomy and stent placement,
[**2155-4-24**] EUS.
Social History:
Works at Shaws as produce manager. Married with children and
grandchildren. No tobacco use history, 1 drink EtOH/month, no
recreational drugs."
3886,"8* 8.4 - 10.3 mg/dL
PERFORMED AT WEST STAT LAB
Phosphate 4.5 2.7 - 4.5 mg/dL
PERFORMED AT WEST STAT LAB
Magnesium 1.9 1.6 - 2.6 mg/dL
Brief Hospital Course:
The patient was discharged home on [**2155-5-30**] s/p Whipple
resection and SMV reconstruction. On [**2155-6-1**] patient was
readmitted to the General Surgical Service with c/o
nausea/vomiting and decreased PO intake. On admission in ED,
patient continue to have active and continuous emesis of thin
yellow-fluid. Patient was tachycardic with HRmax 130s, chest
xray revealed aspiration pneumonia."
3887,"Patient was intubated for
airway protection and transferred in ICU for observation and
treatment.
Neuro: The patient received propofol and fentanyl for sedation
while intubated. After extubation, patient's pain was controlled
with IV Dilaudid with good effect and adequate pain control.
When tolerating oral intake, the patient was transitioned to
oral pain medications. Currently patient taking Tylenol for pain
control.
CV: On admission patient was tachycardic, after he was hydrated
patient HR returned to [**Location 213**] sinus rhythm. Patient heart rate
was monitored with telemetry during hospitalization. The patient
remained stable from a cardiovascular standpoint; vital signs
were routinely monitored."
3888,"Pulmonary: On admission patient had active emeses, and chest xr
revealed aspiration pneumonia. Patient was intubated and
transferred in ICU. On [**6-2**] patient was extubated, he was
required 3-4 L of O2 via n/c for O2 Sats > 92%. Patient was
transferred on the floor, where he continue to be monitored for
O2 Sats. He continue require 2L O2, his O2 Sats 95-97%. Last
chest pa/lat demonstrated that pulmonary edema has markedly
improved and now mild; bibasilar consolidations larger on the
left side and consistent with pneumonia; there is no
pneumothorax. Patient was started on Vancomycin and Zosyn on
admission, late Erythromycin was added to his treatment."
3889,"Patient
currently stable from pulmonary standpoint, he will continue ABX
treatment after discharge.
GI/GU/FEN: Patient was made NPO on admission and started on TPN.
His diet was advanced to clears on HD # 8. Patient will continue
TPN on discharge. His diet will be advanced slowly within 2
weeks to fulls, with no solid food allowed until follow up with
Dr. [**Last Name (STitle) **] (Surgery). Electrolytes were routinely followed, and
repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. On admission patient's
WBC was elevated, but currently WNL."
3890,"Patient remained afebrile
during hospitalization. Blood, urine and sputum cultures were
negative.
Endocrine: Patient has a history of diet controlled diabetes.
After TPN was started, patient's BS was continue to increase and
required increased TPN insulin, standing insulin order and high
sliding scale for BS control. Currently patient's FS between
90s-200s. Patient will require close blood sugar monitor when
his TPN will started to wean off.
Hematology: The patient's complete blood count was examined
routinely, his Hct was stable low (23.1-24.6). On [**6-5**] patient
received one unit of RBC, after transfusion Hct was 24."
3891,"15. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Pancreatic adenocarcinoma with SMV thrombosis
2. Delayed gastric emptying
3. Aspiration PNA
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 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."
3892,"Admission Date: [**2155-6-1**] Discharge Date: [**2155-6-11**]
Date of Birth: [**2098-12-11**] Sex: M
Service: SURGERY
Allergies:
Percocet / Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Abdominal pain
2. Nausea/vomiting
3. Poor PO intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 56 y/o M s/p Whipple resection + SMV reconstruction
[**5-14**] for
pancreatic ca with SMV thrombosis ([**Doctor Last Name **] and [**Doctor Last Name **]),
with post-operative course marked by delayed gastric emptying,
requiring NGT reinsertion on POD 7 until POD 11. The remainder
of his post-op course was notable for small wound infection
treated by opening up each corner of the incision and packing
with WTD dressings."
3893,"He is only sexually active with his wife.
Family History:
Father had IDDM and HTN, brother with DM, HTN
Physical Exam:
On Admission:
97.9 102 145/89 22 96 on RA
A&Ox3, active and continuous emesis of thin yellow-fluid without
wretching, fatigued appearing
CTAB with diminished breath sounds BL bases
RRR
soft, minimally tender without rebound or guarding, min
distended. incision c/d/i with each corner showing clean
granulation bed without surrounding erythema, re-packed with WTD
gauze.
WWP, wearing [**Male First Name (un) **] stockings BL (precludes examination for edema)
NGT placed uneventually at bedside via R nare, no resistance
encountered, no coughing or aspiration, volumous output of __cc
of thin yellow-green fluid."
3894,"Avoid lifting
weights greater than [**5-5**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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.
*If you have staples, they will be removed at your follow-up
appointment."
3895,"*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is 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.
PICC line care:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site."
3896,"6. On
[**6-6**] patient received one more unit of RBC, his Hct was 29.2
after second transfusion. After blood transfusions, patient
reported increase of energy and patient's O2 requirements
decreased from 5L to 3L.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible. There was concern for a
LUE DVT during his stay b/c of some swelling at and around the
PICC site, but an ultrasound was performed that showed no clot
and the swelling improved with elevation.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs."
3897,"*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Please call your doctor or nurse practitioner if you experience
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."
3898,"On Discharge:
VS: 98.2, 66, 121/79, 18, 99% 2L n/c
Gen: Fatigued appearing, comfortably sitting on bed in NAD
CV: RRR
Lungs: diminished bilateraly on bases L > R
Abd: Soft, normal tenderness around incision. Incision open on
both corners and packed with moist-to-dry gauze dressing, middle
portion with steri strips and c/d/i.
Ext: LUE PICC
Pertinent Results:
[**2155-6-1**] 11:00AM WBC-13.9* RBC-3.70* HGB-10.8* HCT-32.5*
MCV-88 MCH-29.2 MCHC-33.3 RDW-15.1
[**2155-6-1**] 11:00AM NEUTS-90.3* LYMPHS-4."
3899,"Report Comment:
Source: Line-PICC
RENAL & GLUCOSE
Glucose 150* 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
PERFORMED AT WEST STAT LAB
Urea Nitrogen 26* 6 - 20 mg/dL
PERFORMED AT WEST STAT LAB
Creatinine 0.7 0.5 - 1.2 mg/dL
PERFORMED AT WEST STAT LAB
Sodium 135 133 - 145 mEq/L
PERFORMED AT WEST STAT LAB
Potassium 4.4 3.3 - 5.1 mEq/L
PERFORMED AT WEST STAT LAB
Chloride 105 96 - 108 mEq/L
PERFORMED AT WEST STAT LAB
Bicarbonate 24 22 - 32 mEq/L
PERFORMED AT WEST STAT LAB
Anion Gap 10 8 - 20 mEq/L
CHEMISTRY
Calcium, Total 7."
3900,"2. Stable partial thrombosis of the right anterior portal vein.
3. Small locules of free air inferior to the gallbladder fossa,
may reflect
residual postoperative air. There is no associated fluid or
collection.
4. Essentially resolved fluid collections previously seen
adjacent to the
Roux jejunal loop as well as inferior to the liver.
5. Moderate gastric distention, though contrast passes freely
through the
small and large bowel without evidence for obstruction.
6. Moderate free fluid in the pelvis.
7. Massive bilateral lower lobe consolidations, concerning for
aspiration
[**2155-6-2**] CHEST PA:
IMPRESSION:
1. Left PICC ends in the lower SVC."
3901,"37 TOTAL CO2-26
BASE XS-0 COMMENTS-GREEN TOP
RADIOLOGY:
[**2155-6-1**] ECG:
Sinus tachycardia. rate 130. Possible anteroseptal myocardial
infarction of indeterminate age. Possible inferior myocardial
infarction of indeterminate age. Non-specific lateral
repolarization changes consistent with myocardial ischemia.
Compared to the previous tracing of [**2155-5-25**] normal sinus rhythm
has given way to sinus tachycardia and lateral repolarization
changes consistent with myocardial ischemia are new.
[**2155-6-1**] CHEST XRAY:
IMPRESSION:
1. Bilateral lower lobe opacities most compatible with
aspiration pneumonia.
2. No pneumoperitoneum.
[**2155-6-1**] CT ABD:
IMPRESSION:
1. Post-Whipple changes, with stable narrowing of the SMV just
proximal to
the splenic vein insertion into the portal vein."
3902,"3. Insulin Regular Human 100 unit/mL Solution Sig: 4-32 units
Injection as directed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Erythromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
3903,"The patient was tolerating a clear
fluid diet and TPN, ambulating with stand by assist, voiding
without assistance, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
ASA 325', norvasc 10', losartan 25', indapamide 2.5', lipitor
10', protonix 40', reglan 10''', colace 100''prn, senna
8.6''prn, dilaudid 2-4q4:prn, tylenol prn
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q4H (every 4 hours).
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime."
3904,"[**2155-6-2**] 5:15 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2155-6-4**]**
GRAM STAIN (Final [**2155-6-2**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2155-6-4**]):
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
[**2155-6-4**] 4:01 pm URINE Source: CVS.
**FINAL REPORT [**2155-6-5**]**
URINE CULTURE (Final [**2155-6-5**]): NO GROWTH.
[**2155-6-10**] 04:46
Report Comment:
Source: Line-PICC
COMPLETE BLOOD COUNT
White Blood Cells 9.3 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3."
3905,"* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] (PCP) in [**1-29**] weeks after
discharge
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2155-6-20**] 11:30 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
Completed by:[**2155-6-11**]"
3906,"No post-procedural
complications
detected.
2. Bibasal consolidations and bilateral small pleural effusions
are unchanged since the previous study.
[**2155-6-5**] CHEST PA/LAT:
Mild cardiomegaly is stable. Bibasilar consolidations larger on
the left side are consistent with pneumonia. Pulmonary edema has
markedly improved, now mild. There is no pneumothorax. Small
bilateral pleural effusions are larger on the right side.
[**2155-6-9**] LUE US:
IMPRESSION: No thrombus is identified in the deep veins of the
left upper limb.
MICRO:
[**2155-6-1**] 6:50 pm BLOOD CULTURE
**FINAL REPORT [**2155-6-7**]**
Blood Culture, Routine (Final [**2155-6-7**]): NO GROWTH."
3907,"1* MONOS-5.3 EOS-0.1
BASOS-0.2
[**2155-6-1**] 11:00AM PLT COUNT-651*
[**2155-6-1**] 11:00AM GLUCOSE-154* UREA N-15 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14
[**2155-6-1**] 11:00AM ALT(SGPT)-21 AST(SGOT)-17 CK(CPK)-20* ALK
PHOS-126 AMYLASE-19 TOT BILI-1.0
[**2155-6-1**] 11:00AM LIPASE-17
[**2155-6-1**] 05:18PM TYPE-ART PO2-62* PCO2-39 PH-7.47* TOTAL
CO2-29 BASE XS-4 INTUBATED-NOT INTUBA COMMENTS-15L NRB
[**2155-6-1**] 05:01PM TYPE-[**Last Name (un) **] PO2-97 PCO2-44 PH-7."
3908,"25* 4.6 - 6.2 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 9.5* 14.0 - 18.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 28.6* 40 - 52 %
PERFORMED AT WEST STAT LAB
MCV 88 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 29.2 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 33.3 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 14.9 10.5 - 15.5 %
PERFORMED AT WEST STAT LAB
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count [**Telephone/Fax (3) 83797**] K/uL
PERFORMED AT WEST STAT LAB
[**2155-6-10**] 04:46"
3909,"10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. 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.
12. Reglan 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours.
13. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
twice a day for 4 days.
14. Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 4 days."
3910,"Patient denies fevers, but reports chills over the
past few days. She denies diarrhea. Her stools are formed and
regular. She denies any hematochezia or melena. She denies ever
having this type of abdominal pain in the past. She stopped
taking majority of her medications a few days ago as she was
concerned it may contribute to her pain.
Past Medical History:
PAD, Hypertension, Hyperlipideia, Thalasemia, Gout
PSH:
Left Lower Extremity Bypass [**2180**](appears to be fem-PT), revision
in [**2187**]; Right Lower Extremity Bypass [**2185**] (appears to be
fem-AT); BLE angio - [**2192-10-17**]; cholecystectomy; hysterectomy
Social History:
Currently smokes [**11-26**] ppd, former 1 ppd for last 50 years,
denies EtOH or illicit drugs"
3911,"**FINAL REPORT [**2192-12-7**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2192-12-7**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
[**2192-12-9**] 11:15 am URINE Source: CVS.
**FINAL REPORT [**2192-12-10**]**
URINE CULTURE (Final [**2192-12-10**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2192-12-20**] EGD: A single superficial non-bleeding 5 mm ulcer was
found in the duodenal bulb. This ulcer had a clean base and was
not bleeding. There were two adherent clots adjacent to the
ulcer, one proximal and one distal. The distal clot was removed
with aggressive washing and suctioning, and no underlying lesion
could be identified."
3912,"The proximal clot remained adherent despite
aggressive washing. One endoclip was successfully applied to the
proximal adherent clot for the purpose of hemostasis.
[**2192-12-20**] Flexible Sigmoidoscopy: The previously seen single
pedunculated 2 cm polyp was found in the distal sigmoid colon at
20cm. The polyp was not bleeding.
Poor bowel prep
[**2192-12-16**] 08:43AM HEPARIN DEPENDENT ANTIBODIES POSITIVE
-
[**2192-11-23**] 09:42PM HEPARIN DEPENDENT ANTIBODIES Negative
Brief Hospital Course:
Ms. [**Known lastname 6515**] was admitted with abdominal pain and non occlusive
SMA thrombus. She was put on a heparin gtt, plavix and aspirin
325mg. SHe was transfused for a low hct."
3913,"Please have your blood pressure checked several times per week.
Follow up with PCP regarding restarting your blood pressure meds
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Abdominal pain/ Mesenteric ischemia
-Left Brachial artery emboli
-GI bleed/ Erosive gastritis
-Heparin Induced Thrombocytopenia
Secondary:
Bilateral Lower extremity ischemia with pain
HTN
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of [**Name10 (NameIs) **] and Endovascular Surgery
Endovascular Discharge Instructions
You were admitted with abdominal pain and had a complicated
hospital course. You had mesenteric ischemia and had a stent
placed in your superior mesenteric artery through a brachial
(arm) sheath."
3914,"After the procedure you were found to have a blood
clot in your brachial artery, and had to have that surgically
removed. You then had an exploratory laparoscopy to evaluate for
dead bowel. You had no evidence of this. You remained in the
hospital and were carefully anticoagulated. You had concern for
GI bleeding and had an endoscopy and colonoscopy by the GI team.
The egd (upper scope) showed erosive esophagitis which was
thought to be the cause of bleeding. The colonoscopy showed a
polyp in the sigmoid colon which was removed, and diverticulosis
in the sigmoid colon. You were started on several new
medications including carafate and omeprazole."
3915,"2* Phos-4.2 Mg-1.9
Discharge:
[**2192-12-27**] 06:46AM BLOOD WBC-7.3 RBC-3.25* Hgb-10.2* Hct-30.0*
MCV-92 MCH-31.4 MCHC-34.0 RDW-19.9* Plt Ct-304
[**2192-12-27**] 06:46AM BLOOD PT-33.5* PTT-45.6* INR(PT)-3.3*
[**2192-12-27**] 06:46AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9
Other pertinent labs:
[**2192-11-23**] 4:59 pm MRSA SCREEN SOURCE:NASAL SWAB.
**FINAL REPORT [**2192-11-26**]**
MRSA SCREEN (Final [**2192-11-26**]): No MRSA isolated.
[**2192-12-6**] 5:25 am SEROLOGY/BLOOD CHEM # 60812J [**12-6**] 5:25AM."
3916,"If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
HEMATOLOGY:
[**2193-1-18**] 1030am
[**Telephone/Fax (1) 91089**]
[**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
PCP/INR FOLLOW UP:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Fax: [**Telephone/Fax (1) 6808**]
She will follow your INR and your CBC 2 x week for your GI
bleed. Please go to get your labs drawn tomorrow, [**2192-12-28**].
Your goal INR is 3-3.5
[**Month/Day/Year **] SURGERY:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2193-1-22**]
8:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2193-1-22**] 9:15
GASTROENTEROLOGY:
[**1-22**] 11am
[**Hospital Unit Name 1825**] - [**Hospital Ward Name 516**] [**Location (un) 453**]
([**Telephone/Fax (1) 2233**]
Completed by:[**2192-12-27**]"
3917,"She continued to make steady
progress , tolerating a regular diet, ambulating and voiding
when her foley was removed. Her coumadin was restarted with an
INR goal of 3.0-3.5 . She continued to make progress but on [**12-2**]
reported seeing blood on her toilet paper, after a bowel
movement and was found to be guiac positive. Her h/h had fallen
and she was transfused for a hct of 25 on [**12-3**]. She responded
appropriately but on [**12-4**] her hct was down to 25.1. She
received 1 unit prbc without much of a response and got another
1 unit."
3918,"We therefore did a: Brachial artery cutdown with
thrombectomy and primary repair. ACS then did an exploratory
laparoscopy and found no evidence of bowel ischemia. Their ports
were closed and the patient was monitored closely. She had
respiratory distress and was re-intubated and taken to the
CVICU. Given her hypercoaguable state, heme was involved and she
was started on an argatroban gtt. She was extubated on [**11-25**] and
did well. She was transfused again for a falling hct. She
remained hemodynamicaly stable and was transfered to the VICU
and [**Month/Day (4) 8337**] a clear diet on [**11-25**]."
3919,"C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for pain.
13. BLOOD PRESSURE MONITORING
We stopped all of your BP meds (valsartan/hctz and toprol xl)."
3920,"She remained on an argatroban gtt until her
true INR was >3.0 . On [**2192-12-27**] she was stable from a medical and
surgical standpoint. Her true INR wasd 3.3 and she was not
having any melena or other GI symptoms.
At the time of discharge, Ms. [**Known lastname 6515**] was hemodynamically stable,
mentating and ambulating at baseline, and with a stable
hematocrit. Her INR is therapeutic and she is scheduled for very
close monitoring of her h/h and INR with her PCP. [**Name10 (NameIs) **] will also
have her BP monitored, and discuss restarting meds with her PCP."
3921,"Her surgical issues were stable and
the decision was made to transfer the patient to the medicine
team for further monitoring and treatment.
On [**12-14**], we were called to the bedside by night merit team for
persistent hypotension to the 70s. Reviewing vitals flowsheets
places her BP in the 100 systolic range, though she repeatedly
dropped into the upper 80s throughout the day. As of 2300, her
BP slipped into the 70s, though she continued to mentate
normally without lightheadedness, chest pain or pressure. She
has been having daily melenotic stools for the past few days.
Her bp meds were stopped and she received a liter of NS and her
fourth pRBC transfusion of the day with improvement of her SBP
to 100-105."
3922,"History of Present Illness:
62 year old female with history of severe bilateral PVD, s/p
bilateral lower extremity angio with occluded fem-PT bypasses
bilaterally, now presenting
to the ED w/abdominal pain of 5 days duration. We are consulted
for an evaluation of mesenteric ischemia. Patient reports sudden
onset of severe abdominal 5 days ago. The pain has remained high
in intensity and constant. Patient has been unable to tolerate
food. She had no episodes of frank emesis, but reports retching
and some ""yellow secretion"". The pain is located in the
mid-abdomen radiates to substernal region and to flanks and
lower back."
3923,"right p p d d
left p p d d
Pertinent Results:
Admission:
[**2192-11-20**] 12:35PM BLOOD WBC-8.4 RBC-2.41* Hgb-9.7* Hct-29.4*
MCV-122* MCH-40.2* MCHC-33.0 RDW-16.9* Plt Ct-347
[**2192-11-20**] 12:35PM BLOOD PT-31.5* PTT-43.7* INR(PT)-3.1*
[**2192-11-20**] 12:35PM BLOOD Glucose-143* UreaN-38* Creat-1.9* Na-141
K-3.6 Cl-103 HCO3-26 AnGap-16
[**2192-11-20**] 12:35PM BLOOD ALT-13 AST-12 AlkPhos-65 TotBili-0.2
[**2192-11-21**] 04:23AM BLOOD Calcium-8."
3924,"After consulting with GI, decision made to transfer
to MICU6 for endoscopy in the AM. She has undergone 18 red cell
transfusions this admission. Her current INR was 4.3. In the
MICU, the patient continued to have melena, but otherwise
hemodynamically stable. An EGD was performed that showed
friability and erythema of the esophagus, stomach and duodenum.
Cautery was used to stop bleeding from the duodenal bulb. After
EGD, the patient cotninued to have melena. She was maintained on
her coumadin, plavix, aspirin, and heparin. The patient was then
transfered to the VICU for further management.
Ms. [**Known lastname 6515**] remained hemodynamically stable following transfer to
the VICU."
3925,"????? Elevate your leg above the level of your heart (use [**12-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication"
3926,"????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-1**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office."
3927,"The
patient had been receiving full heparin drip and was fully
anticoagulated as well as having a therapeutic INR on Coumadin,
as well as being on full-dose aspirin and Plavix prior to the
presentation in the operating room. This led to our decision to
not rebolus her with more heparin. However, due to the nature
of the clot that was seen on the wire upon exchange to the
5-French short sheath, and then upon attempt to flush the short
sheath we were not able to draw back, there was significant
concern for a clot in the brachial
artery."
3928,"Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
VS: 97.7 100 131/78 18 100% RA
CV: RRR, no murmur
pulm: CTA b/l
abd: obese, + BS, tender especially in the RLQ, also reports
subjective pain in the mid abdomen, but not fully evident on
exam
guaiac positive
extremities: minimal lower extremity edema
Pulses:
Fem [**Doctor Last Name **] AT DP PT
R palp dop dop faint dop dop
L palp dop dop NS dop
Discharge Exam:
(per progress note)
VS: 100.1 98 88 151/76 20 99% ra
Gen: Obese female, alert and oriented x 3,
Card: RRR
Lungs: CTA bilat
Abd: obese, soft, no m/t/o
Extremities: warm, mild lower extremity edema
Pulses: Rad Fem DP PT"
3929,"What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?"
3930,"Your INR will continue to be followed by the Atrius anti-coag
team. You will follow up with Gastroenterology, [**Name10 (NameIs) **] surgery
and hematology.
Medications:
?????? Take Aspirin 325mg daily
?????? Take Plavix 75mg once daily.
Take Coumadin daily as directed - your INR goal is now
3.0 - 3.5
Do not stop Aspirin/Plavix/or Coumadin unless your [**Name10 (NameIs) **]
Surgeon instructs you to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?"
3931,"Her pain resolved and
she was started on sips with close monitoring. On [**11-24**] her
pain increased and she had a stat CTA which showed an unchanged
appearance of SMA thrombus and no direct or indirect evidence of
mesenteric ischemia. She was then pre-op'd and consented and
taken to the angio suite where she had:
1. Ultrasound-guided puncture of left brachial artery.
2. Catheterization of aorta.
3. Abdominal aortogram with mesenteric angiography.
4. Selective catheterization of superior mesenteric artery.
5. Balloon angioplasty and stent of proximal superior
mesenteric artery.
At completion of the procedure, upon removal of the wire, it
was noted there was extensive clot seen on the wire."
3932,"By this point she was having melena and her hct
continued to fall. GI was consulted on [**12-4**]. She was prepped
appropriately and had an EGD on [**12-5**] which showed erosive
gastritis in the stomach body and antrum. Then on [**12-6**] she had
colonoscopy which showed a 20 mm polyp which was treated with an
endoloop. Her h/h was stable for several days, and her INR was
therapeutic and discharge planning was initiated. On [**12-11**], her
hct was drifting down. She was transfused appropriately but
didn't respond appropriately. She was still having melena. GI
was monitoring the patient."
3933,"[**Name10 (NameIs) **] will be followed by her PCP, [**Name10 (NameIs) 1106**] surgery, hematology
and GI. She has been instructed regarding her post-discharge
plans and verbally expressed understanding and agreement with
these plans.
Medications on Admission:
Hydroxyurea 1000mg daily
Valsartan/HCTZ 320/25 daily
Crestor 10mg daily
KCL 10mEq daily
Metoprolol ER 50mg po daily
Folic Acid 1mg po daily
Neurontin 600mg po TID
[**Name10 (NameIs) **] 81mg po daily
Pletal 100mg po BID
Coumadin 5mg po Daily
Discharge Medications:
1. hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)."
3934,"Her hematocrit was routinely monitored and she was
transfused as needed for Hcts in the low - mid 20s. Given the
persistence of her melena, however, she underwent flexible
sigmoidoscopy and EGD on [**2192-12-20**], the results of which were
notable only for a nonbleeding polyp in the sigmoid colon
(previously seen on prior [**Last Name (un) **]) as well as some friability of
the duodenum which was clipped and injected with epinephrine.
Following this procedure, Ms. [**Known lastname 6515**] [**Last Name (Titles) 8337**] her diet well.
She was transfered to the [**Last Name (Titles) 1106**] floor where she was monitored
for another week."
3935,"3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
6. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
call PCP for refills.
Disp:*30 Tablet(s)* Refills:*0*
7. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E."
3936,"Admission Date: [**2192-11-20**] Discharge Date: [**2192-12-27**]
Date of Birth: [**2130-8-8**] Sex: F
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
OPERATIONS PERFORMED [**2192-11-23**]:
1. Ultrasound-guided puncture of left brachial artery.
2. Catheterization of aorta.
3. Abdominal aortogram with mesenteric angiography.
4. Selective catheterization of superior mesenteric artery.
5. Balloon angioplasty and stent of proximal superior
mesenteric artery.
6. Brachial artery cutdown with primary repair
[**2192-11-23**]: Exploratory Laparoscopy
[**2192-12-5**]: EGD
[**2192-12-6**]: Colonoscopy
[**2192-12-15**]: EGD
[**2192-12-20**]: EGD and Sigmoidoscopy"
3937,"Lung sounds
RLL Lung Sounds: Rhonchi
RUL Lung Sounds: Ins/Exp Wheeze
LUL Lung Sounds: Ins/Exp Wheeze
LLL Lung Sounds: Rhonchi
Secretions
Sputum color / consistency: Yellow / Thick
Sputum source/amount: Expectorated / Small
Comments: sputum collected & sent.
Ventilation Assessment
Non-invasive ventilation assessment: Pt placed on NIV with small full
face mask for short time upon arrival in ICU d/t decreased
saturations. Decision to return to cool mist (high flow) by team & us
NIV intermittently if pt unable to maintain SpO2 > 85%.
Invasive ventilation assessment:
Plan:
Bronchodilation, pulmonary toilet, encourage deep breathing & coughing,
NIV if indicated."
3938,"She had fevers 101 at home,
+flatus,+Vomiting.
Chief complaint:
Respiratory failure
PMHx:
GERD, COPD, Achalasia
PSH:s/p Nissen, s/p re-do/release Nissen, L foot surgery, [**Doctor Last Name 6633**]
myotomy/takedown Nissen/Toupet fundoplication [**2103-5-8**]
Current medications:
1. 1000 mL LR 2. Albuterol 0.083% Neb Soln 3. Albuterol 0.083% Neb Soln
4. Calcium Gluconate 5. Docusate Sodium (Liquid)
6. Furosemide 7. HYDROmorphone (Dilaudid) 8. Heparin 9. Ipratropium
Bromide Neb 10. Lorazepam 11. Magnesium Sulfate
12. Piperacillin-Tazobactam Na 13. Potassium Chloride 14. Vancomycin
24 Hour Events:
NASAL SWAB - At [**2103-5-12**] 12:58 PM
NON-INVASIVE VENTILATION - START [**2103-5-12**] 01:30 PM
SPUTUM CULTURE - At [**2103-5-12**] 03:24 PM
BLOOD CULTURED - At [**2103-5-12**] 03:45 PM
ARTERIAL LINE - START [**2103-5-12**] 03:45 PM
[**5-12**]: Transfer to TICU for Low sat low 80's, improved w/ nebs and
chest PT to mid 80's
Allergies:
Aspirin
Wheezing; swell
Last dose of Antibiotics:
Vancomycin - [**2103-5-12**] 08:03 PM
Piperacillin/Tazobactam (Zosyn) - [**2103-5-12**] 09:44 PM
Infusions:
Other ICU medications:
Lorazepam (Ativan) - [**2103-5-12**] 03:45 PM
Heparin Sodium (Prophylaxis) - [**2103-5-12**] 04:28 PM
Furosemide (Lasix) - [**2103-5-12**] 09:07 PM
Hydromorphone (Dilaudid) - [**2103-5-12**] 10:08 PM
Other medications:
Flowsheet Data as of [**2103-5-13**] 05:21 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**05**] a."
3939,"Now back w/ SOB, ? PNA
Neurologic: Neuro checks Q: 4 hr, Dilaudid PRN, Intermittent episode of
lethargy and confusion when she is hypoxic
Cardiovascular: HD stable, sinus tachycardia likely secondary to
hypoxemia
Pulmonary: Hx of COPD, 32 year hx of smoking, transferred to ICU
hypoxic mid 70's with dyspnea, Respiratory status improved w/ Neb's,
chest PT. Per primary team no Cpap given her recent [**Doctor Last Name 6633**] myotomy
surgery, cxr right basilar consolidation which likely represents
combination of effusion, atelectasis and possibly infection. Minimal
left basilar atelectasis. Cont gentle diuresis with Albumin for
pulmonary edema.
Gastrointestinal / Abdomen: s/p [**Doctor Last Name 6633**] myotomy, redo fundoplication,
NPO and NO NG or OG tube per primary team, PE consistent w/ rebound and
tenderness."
3940,"Ct scan OSH c/w Pneumoperitoneum and free fluid close the
left Liver [**Last Name (LF) **], [**First Name3 (LF) 77**] primary team c/w postop course changes
Nutrition: NPO
Renal: Foley, Adequate UO, Creatinine stable, Diurese as above with
small lasix dose.
Hematology: Post op anemia stable
Endocrine: RISS, BS<150
Infectious Disease: Check cultures, Afebrile, WBC trending down 11
today, we will monitor closely continue course of Zosyn and Vancomycin
for post-op Pneumonia
Lines / Tubes / Drains: Foley, A-line, PIV, Foley
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: Gen Surgery
Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op);
Pneumonia; Post-op complication
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2103-5-12**] 01:02 PM
20 Gauge - [**2103-5-12**] 01:02 PM
Arterial Line - [**2103-5-12**] 03:45 PM
22 Gauge - [**2103-5-13**] 03:18 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 34 minutes
Patient is critically ill"
3941,"m.
Tmax: 38.2
C (100.7
T current: 36.8
C (98.3
HR: 102 (102 - 133) bpm
BP: 93/60(68) {86/54(62) - 109/73(82)} mmHg
RR: 27 (19 - 38) insp/min
SPO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 45 kg (admission): 45.6 kg
Total In:
5,673 mL
245 mL
PO:
Tube feeding:
IV Fluid:
1,673 mL
245 mL
Blood products:
Total out:
1,860 mL
1,480 mL
Urine:
1,860 mL
1,480 mL
NG:
Stool:
Drains:
Balance:
3,813 mL
-1,235 mL
Respiratory support
O2 Delivery Device: Aerosol-cool
Ventilator mode: CPAP
Vt (Spontaneous): 400 (400 - 400) mL
PS : 0 cmH2O
RR (Spontaneous): 27
PEEP: 5 cmH2O
FiO2: 95%
PIP: 6 cmH2O
SPO2: 99%
ABG: 7."
3942,"45/41/62/27/3
Ve: 7.5 L/min
PaO2 / FiO2: 103
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: Wheezes : L>R, Rhonchorous :
Bilateral)
Abdominal: Tender: tender to palpation w/ rebound
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
17
11.2 K/uL
322 K/uL
10.7 g/dL
123 mg/dL
0.7 mg/dL
27 mEq/L
3.7 mEq/L
8 mg/dL
100 mEq/L
137 mEq/L
31."
3943,"SICU
HPI:
47 yo F s/p take down of prior Nissen fundoplication, [**Doctor Last Name 6633**]
myotomy, and partial fundoplication on [**5-8**], returning today in
transfer from an OSH with complaints of abdominal pain and
dyspnea. She was discharged to home on [**5-10**] after an unremarkable
hospital course. She was transferred from an OSH after she was
seen there with the complaints listed above. A CT scan was
performed there, which noted a possible PNA, no PE, as well as
free air and fluid in the upper abdomen that was concerning for a
leak versus normal postoperative changes."
3944,"5 %
[image002.jpg]
[**2103-5-12**] 01:16 PM
[**2103-5-12**] 04:06 PM
[**2103-5-12**] 06:44 PM
[**2103-5-12**] 10:21 PM
[**2103-5-13**] 01:29 AM
[**2103-5-13**] 01:49 AM
WBC
11.2
Hct
31.5
Plt
322
Creatinine
0.7
TCO2
24
23
25
28
29
Glucose
136
123
Other labs: PT / PTT / INR:13.3/28.4/1.1, Differential-Neuts:85.2 %,
Lymph:10.3 %, Mono:4.1 %, Eos:0.3 %, Ca:8.8 mg/dL, Mg:1.6 mg/dL,
PO4:3.5 mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), RESPIRATORY FAILURE, ACUTE
(NOT ARDS/[**Doctor Last Name 76**])
Assessment and Plan: 47 yo F s/p [**Doctor Last Name 6633**] myotomy, redo fundoplication
s/p d/c ([**5-10**])."
3945,"A CT scan was
performed there, which noted a possible PNA, no PE, as well as
free air and fluid in the upper abdomen that was concerning for
a
leak versus normal postoperative changes. She denies any fevers,
but does feel chilled. She has baseline dyspnea, but this is a
bit worse today. Her pain has been poorly controlled with oral
elixir oxycodone. Her pain is mostly centered in her epigastrum.
She denies significant dysphagia at this time. She is passing
flatus. She does feel a bit bloated.
Past Medical History:
PMH: GERD, COPD, Achalasia
PSH: s/p Nissen, s/p re-do/release Nissen, L foot surgery,
[**Doctor Last Name **]
myotomy/takedown Nissen/Toupet fundoplication [**2103-5-8**]"
3946,"Social History:
32 pack-year tobacco history. Social EtOH. Denies illicit
drug use. Works as a supervisor.
Family History:
NC
Physical Exam:
PE: 98.0 81 90/61 18 88% 6LO2
Gen: NAD. A&Ox3.
HEENT: Anicteric. Tacky mucosal membranes.
Neck: No JVD. No LAD. No TM.
CV: RRR.
Pulm: Bibasilar rhonchi.
Abd: Soft. Mildly distended. TTP epigastrum. +BS. Incisions
c/d/i.
DRE: Deferred.
Ext: Warm and well perfused. No peripheral edema.
Neuro: Motor and sensation grossly intact.
Pertinent Results:
11.5
14.6 >-----< 258
35.6
PT: 12.6 PTT: 22.9 INR: 1.1
Lactate:1.0"
3947,"02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: please crush pills .
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Respiratory distress/ insufficiency
Aspiration Pneumonia
Achalasia status post fundoplication x2 with revision and
takedown.
Discharge Condition:
Stable, good pain control, normal oxygenation, modified diet
Discharge Instructions:
**DO NOT EAT BREAD, CRACKERS, OR POTATO CHIPS**
You are being discharged from the hospital in stable condition
with good pain control. It is essential for you to stay on top
of your pain with the prescribed pain medications as taught in
the hospital. You should also make sure to limit your diet to
the foods discussed in the hospital, avoiding potato chips,
bread, and other larger foods. Make sure to chew thoroughly.
Please call your doctor's office or return to the emergency room
with any of the following
*severe intractable abdominal pain
*significant vomiting / intractable nausea
*fever > 101.2
*Chest pain or shortness of breath
Do not drive while taking narcotic pain medications.
Followup Instructions:
Please call Dr.[**Name (NI) 1482**] office for follow up in 2 weeks.
[**Telephone/Fax (1) 2981**]
Completed by:[**2103-5-18**]"
3948,"Disp:*600 cc* Refills:*2*
4. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) mL PO every
six (6) hours as needed for pain.
Disp:*100 mL* Refills:*0*
5. Famotidine 40 mg/5 mL Suspension Sig: 2.5 mL PO twice a day
for 4 weeks.
Disp:*200 mL* Refills:*0*
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*25 Suppository(s)* Refills:*0*
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
8. Ipratropium Bromide 0."
3949,"132 102 19
-------------< 98
5.6 19 0.7
Ca: 8.0 Mg: 2.1 P: 3.0
ALT: 24 AP: 65 Tbili: 0.4 Alb: 3.1
AST: 42 Lip: 10
CTA Torso (OSH): Reviewed with Dr. [**Last Name (STitle) **] and radiology
resident,
Dr. [**Last Name (STitle) **]. No official read placed. Bibasilar pulmonary
consolidation, atelectasis versus PNA. R>L pleural effusions.
Free air and fluid collection around L lobe of the liver, which
likely represents normal postoperative changes. No PE.
[**5-13**] CXR: Extensive consolidation in the left lung has improved
at the base, worsened in the suprahilar region, and on the right
previously collapsed right lower lobe has re-expanded and is
severely consolidated, findings that suggest widespread
aspiration pneumonia."
3950,"She was transferred from the ICU on [**5-16**] and her
pain regimen was adjusted, she was moved to a regular diet, and
ambulated around the floor. She was discharged in very stable
condition with her pain under control on a normal diet with
modifications.
Discharge Medications:
1. Hydromorphone 1 mg/mL Liquid Sig: [**1-24**] mL PO Q4H (every 4
hours) as needed for pain.
Disp:*80 mL* Refills:*0*
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*2*
3. Colace 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day for
4 weeks."
3951,"Gastric and colonic distention and
pneumoperitoneum are also still present. Dr. [**Last Name (STitle) 81827**] was paged.
Brief Hospital Course:
The patient was admitted [**5-12**] to the ICU due to respiratory
distress. She was started on Vancomycin/Zosyn for presumptive
pneumonia with poor saturations. She was given nebulizers and
20mg IV lasix x 4 for fluid offloading. She improved
significantly and was able to transfer from the ICU without
significant event.
She received a KUB for increasing abdominal pain which was
notable for increased large bowel distension. She ultimately had
2 large bowel movements with significant improvement of her
abdominal pain."
3952,"Admission Date: [**2103-5-12**] Discharge Date: [**2103-5-18**]
Date of Birth: [**2055-7-1**] Sex: F
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Abdominal pain, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 yo F s/p take down of prior Nissen fundoplication, [**Doctor Last Name **]
myotomy, and partial fundoplication on [**5-8**], returning today in
transfer from an OSH with complaints of abdominal pain and
dyspnea. She was discharged to home on [**5-10**] after an
unremarkable
hospital course. She was transferred from an OSH after she was
seen there with the complaints listed above."
3953,"Admission Date: [**2183-7-14**] Discharge Date: [**2183-7-18**]
Date of Birth: [**2135-7-18**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
47F who is s/p fall from second story window and hit scaffolding
on the way down. There was +EtOH. She was transferred from an
OSH, where her hct was initially 33. CT showed liver laceration
with active extravasation, small spleen laceration, bilateral
rib fractures, and small pneumothorax. She received 2L LR, 1u
pRBC."
3954,"Past Medical History:
PMH: depression
PSH: wisdom teeth extraction, lap sterilization
Social History:
Lives with husband and 17 year old daughter.
+ETOH abuse
Family History:
Non-contributory
Physical Exam:
On admission:
HR: 138 BP: 112/73 Resp: 24 O(2)Sat: 100% RA Normal
Constitutional: Somnolent
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
No septal hematoma. TMs clear bilaterally. No hemotympanum.
Trachea midline.
Chest: Airway intact, breath sounds equal but diminished
bilaterally. Chest wall stable, no crepitus.
Cardiovascular: DPs palpable but weak bilaterally. Regular
Rate and Rhythm. FAST negative.
Abdominal: Abdomen mildly distended and tense.
Rectal: Normal rectal tone, no gross [**First Name3 (LF) **]."
3955,"A focus of arterial enhancement
along the lateral aspect of segment II is equivocal for
pseudoaneurysm versus active bleed. No definite active
extravasation is detected.
2. Moderate hemoperitoneum surrounding the liver appears
minimally changed since [**2183-7-13**].
3. Low-grade splenic laceration with slightly increased
neighboring [**Name2 (NI) **] products since [**2183-7-13**].
4. Multiple minimally displaced right rib fractures.
5. Minimally displaced lower sternal fracture. Trace epicardial
gas has
decreased since the prior CT examination.
5. Small left hemothorax and moderate bibasilar atelectasis is
new since [**2183-7-13**].
[**2183-7-4**] Chest X-ray
IMPRESSION:
No acute intrathoracic process although the CT of the torso
performed the same day at an outside hospital shows right-sided
rib fractures and small bilateral pneumothoraces."
3956,"She is being
discharged home with follow up scheduled in [**Hospital 2536**] clinic.
Medications on Admission:
Lexapro 20 mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Escitalopram Oxalate 20 mg PO DAILY
4. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
watch for RR less than 12
RX *hydromorphone 2 mg [**12-30**] tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
s/p fall
*Grade IV liver laceration
*Grade I spleen laceration
*Bilateral anterior [**7-6**] rib fractures, right posterior [**8-7**] rib
fractures
*Small apical bilateral pneumothoraces
*Acute [**Month/Day (3) **] loss anemia"
3957,"Extr/Back: Pelvis stable
Skin: Diaphoretic. Abrasions over entire abdomen and left
flank.
Neuro: Follows commands, GCS 13. MAE=
Psych: Somnolent
On Discharge
T 98.2 HR: 79 BP: 128/69 Resp: 18 O(2)Sat: 94% RA
Constitutional: AAOx3
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Chest: Airway intact, breath sounds equal but diminished
bilaterally. Chest wall stable, no crepitus.
Cardiovascular: DPs 2+ Regular Rate and Rhythm.
Abdominal: NBS,soft,nondistendded,nontender
Neuro: grossly intact
Pertinent Results:
CT ABD W&W/O C Study Date of [**2183-7-15**] 8:22 PM
IMPRESSION:
1. High-grade liver laceration."
3958,"5
LEUK-NEG
[**2183-7-14**] 12:57AM URINE RBC-4* WBC-2 BACTERIA-NONE YEAST-OCC
EPI-1
[**2183-7-14**] 12:57AM URINE MUCOUS-RARE
[**2183-7-14**] 12:57AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2183-7-14**] 12:57AM ASA-NEG ETHANOL-156* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-7-14**] 12:57AM LIPASE-92*
[**2183-7-14**] 12:57AM UREA N-14 CREAT-0.9
[**2183-7-14**] 12:58AM GLUCOSE-164* NA+-145 K+-4.1 CL--111* TCO2-20*
[**2183-7-14**] 03:38AM PT-11."
3959,"[**2183-7-14**] 12:57AM WBC-23.2* RBC-3.90* HGB-12.0 HCT-37.0 MCV-95
MCH-30.7 MCHC-32.3 RDW-12.9
[**2183-7-14**] 12:57AM PLT COUNT-340
[**2183-7-14**] 12:57AM PT-11.0 PTT-25.9 INR(PT)-1.0
[**2183-7-14**] 12:57AM FIBRINOGE-228
[**2183-7-14**] 12:57AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.030
[**2183-7-14**] 12:57AM URINE [**Month/Day/Year 3143**]-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5."
3960,"Her pain medications were changed to oral, and her
pain continued to be well controlled and she was able to perform
incentive spirometry. She did not have increased pain with
eating or ambulating relating to her liver laceration.
Occupational therapy evaluated the patient for loss of
consciouness who determined her safe for discharge home but
recommended outpatient follow up with cognitive neurology, which
was set up prior to discharge.
On [**2183-7-18**] Ms. [**Known lastname 112114**] is afebrile with stable vital signs. Her
hematocrit is stable at 34.5. She is tolerating a regular diet
and her pain is well controlled on an oral regimen."
3961,"9 PTT-26.0 INR(PT)-1.1
[**2183-7-18**] 02:28PM [**Month/Day/Year 3143**] Hct-34.5*
Brief Hospital Course:
Ms. [**Known lastname 112114**] was admitted to the TSICU on [**2183-7-14**] under the
Acute Care Surgery service for close monitoring. She was
tachycardic and mildly hypotensive upon arrival and she was
transfused another unit of pRBC. She eventually stabilized and
her hematocrit was serially monitored. It remained stable at 38
for the day. Her pain was controlled with fentanyl and IV
dilaudid. She was alert and responsive. Her cardiovascular and
pulmonary status were closely monitored and she remained stable."
3962,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to hospital after fall out of a window. You
sustained multiple injuries including an injury to your liver, a
small injury to your spleen, and broken ribs on both sides.
You sustained an injury to your liver/spleen. You should go to
the nearest Emergency department if you suddenly feel dizzy or
lightheaded, as if you are going to pass out. These are signs
that you may be having internal bleeding from your liver/spleen
injury.
Your liver/spleen injury will heal in time."
3963,"It is important that
you do not participate in any contact sports or any other
activity for the next 6 weeks that may cause injury to your
abdominal region.
Avoid aspirin products, NSAID's such as Advil, Motrin,
Ibuprofen, Naprosyn, or Coumadin for at least 1-2 weeks unless
otherwise directed as these can cause bleeding internally.
You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medicine as directed to stay ahead of
the pain otherwise you won't be able to take deep breaths."
3964,"Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Thefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2183-7-31**] at 3:45 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.
Department: COGNITIVE NEUROLOGY UNIT
When: MONDAY [**2183-8-11**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage"
3965,"If
the pain medication is too sedating, take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain."
3966,"She was initially NPO while we monitored for active bleed. A CTA
showed increased hematoma around the liver and spleen although
no areas of active extravasation. However, her hematocrit was
slowly trending down to 28 and then stabilized. She did not
complain of any belly pain and she was not tachycardic. She was
ready for transfer out of the ICU on HD 3.
On the floor she remained hemodynamically stable with no
evidence of active bleeding. Her hematocrits were trended and
remained stable. On HD4 her diet was advanced as tolerated and
her activity status was changed from bedrest to activity as
tolerated."
3967,"Admission Date: [**2131-12-24**] Discharge Date: [**2131-12-27**]
Date of Birth: [**2058-2-4**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen
Attending:[**Doctor First Name 1402**]
Chief Complaint:
ASA desensitization
Major Surgical or Invasive Procedure:
Cardiac catheterization ([**2131-12-24**])
Intubation ([**2131-12-25**])
History of Present Illness:
The pt is a 73-yo man w/ severe COPD and recently-diagnosed
cardiomyopathy with EF 30% who presented to OSH on [**2131-12-21**]
with complaints of increasing SOB, DOE, orthopnea, PND, chest
tightness, and wheezing. He denied any chest pain, palpitations,
lightheadedness, syncope, lower extremity edema, fevers, chills,
cough, or sputum production."
3968,"1
[**2131-12-24**] 08:26PM BLOOD Glucose-106* UreaN-26* Creat-0.9 Na-141
K-4.7 Cl-103 HCO3-31 AnGap-12
[**2131-12-26**] 05:31AM BLOOD LD(LDH)-333*
[**2131-12-26**] 05:31AM BLOOD cTropnT-0.08*
[**2131-12-24**] 08:26PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.3
.
.
ECG ([**2131-12-24**]): Sinus rhythm with atrial premature beats and
possible first beat being a ventricular premature beat. Left
bundle-branch block. No previous tracing available for
comparison.
.
CARDIAC CATH ([**2131-12-24**]):
1. Selective coronary angiography of this left dominant system
revealed
one vessel coronary artery disease."
3969,"He completed the protocol
overnight, but approximately 1 hour after completion he suffered
from acute-onset of severe respiratory distress with chest
tightness and wheezing, consistent with anaphylaxis. He was
treated with steroids, H1- and H2-blockers, as well as
treatments directed at his COPD, CHF, and anxiety, with no
improvement, so he was intubated for respiratory failure. He was
extubated later that day with significant improvement. He was
seen by the Allergy consult service, who felt that this was
consistent with anaphylaxis, and recommended repeat
desensitization after a couple weeks if needed. He is stable for
discharge.
.
#. Acute on chronic systolic CHF - The patient was recently
diagnosed with a cardiomyopathy of unknown etiology, and was
being treated for acute on chronic systolic heart failure prior
to transfer."
3970,"Disp:*60 Capsule(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Digoxin 125 mcg Tablet Sig: ([**12-28**]) One-Half Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours.
Disp:*1 Inhaler* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Aspirin allergy: anaphylaxis
2. Non-ischemic cardiomyopathy (EF 15%)
3. Coronary artery disease
4. Severe COPD
5. Atrial fibrillation
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for cardiac catheterization, and you
were found to have a blockage in one of the arteries of your
heart."
3971,"4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Puff Inhalation twice a day.
Disp:*1 Diskus* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Puff Inhalation once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)."
3972,"9 L/min/m2.
3. Left vetriculography was deferred.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate pulmonary hypertension.
3. Moderate diastolic dysfunction.
4. Elevated RVEDP
.
CXR ([**2131-12-24**]):
1. Hazy opacity in the lingula and left lower lobe, concerning
for early pneumonia versus asymmetric edema.
2. Cardiomegaly. Mild vascular congestion with interstitial
edema.
3. Right retrocardiac density, atelectasis versus pneumonia. PA
and lateral views are recommended for better assessment of this
area.
.
TTE ([**2131-12-25**]):
The left atrium is normal in size. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thicknesses are
normal."
3973,"No abdominial bruits.
EXTREMITIES: WWP, no c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2131-12-24**] 08:26PM BLOOD WBC-8.2 RBC-4.02* Hgb-11.8* Hct-35.0*
MCV-87 MCH-29.4 MCHC-33.8 RDW-15.0 Plt Ct-293
[**2131-12-24**] 08:26PM BLOOD Neuts-84.6* Lymphs-9.4* Monos-5.9 Eos-0.1
Baso-0
[**2131-12-24**] 08:26PM BLOOD PT-12.7 PTT-25.9 INR(PT)-1."
3974,"He is being discharged off of anticoagulation.
.
# COPD - The patient has a history of severe COPD, with mild
wheezes on exam on admission. This was significantly worsened
after his intubation for anaphylaxis as above, so he was treated
with IV Solu-Medrol and then quickly transitioned to Prednisone
for a rapid taper. He was otherwise continued on Advair,
Spiriva, and nebulizers as needed, and showed significant
improvement by discharge.
Medications on Admission:
HOME MEDICATIONS:
- Plavix 75mg PO daily
- Nexium 40mg PO daily
- Lisinopril 10mg PO daily
- Toprol XL 37.5mg PO daily
- Salmeterol 50mcg 1puff INH [**Hospital1 **]
- Spironolactone 25mg PO daily
- Tiotropium 18mcg 1puff INH daily
- Docusate 100mg PO daily
."
3975,".
Past Medical History:
- severe COPD / bronchial asthma
- cardiomyopathy w/ EF 30-35%, cause unknown
- suspected TIA
- h/o recent pneumonia
- LBBB on ECG
- nephrolithiasis
- s/p cataract surgery
- s/p hernia repair
Social History:
Lives with his wife, fairly independent until symptomatic w/
SOB.
-Tobacco history: x15-20years, Quit smoking: [**2104**]
-ETOH: Quit in [**2105**].
-Illicit drugs: None.
Family History:
Mother had a stroke, Father had CAD. No early CAD.
Physical Exam:
VS: T = 97.6 F, BP = 125/93, HR = 94, RR = 22, O2 sat = 97% 2L
NC
GENERAL: WA middle-aged man in NAD. Oriented x3. Mood, affect
appropriate."
3976,"You should follow-up with your primary
care doctor and your cardiologist within 1 week.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You should call your doctor or return to the Emergency Room for
any concerning symptoms, including:
- chest pain, shortness of breath, wheezing, palpitations
- allergic reaction
- leg swelling, feeling faint
- fevers or chills
- any other concerning symptoms.
Followup Instructions:
You should follow-up with your cardiologist at home within 1
week.
You should follow-up wiht your PCP (Dr. [**Last Name (STitle) 77512**] within [**12-28**]
weeks.
You should discuss blood thinners with your cardiologist for
your atrial fibrillation."
3977,".
TRANSFER MEDICATIONS:
- Plavix 75mg PO daily
- Lisinopril 10mg PO daily
- Advair Diskus 250/50 1puff INH [**Hospital1 **]
- Guaifenesin syrup 200mg QID PRN
- SL NTG PRN
- Tylenol PRN
- Nexium 40mg PO daily
- Solu-Medrol 60mg IV daily
- Tiotropium 18mcg 1puff INH daily
- Spironolactone 25mg PO daily
- Toprol XL 37.5mg PO daily
- Lasix 20mg IV BID
- Xopenex nebs PRN
Discharge Medications:
1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day."
3978,"HEENT: NC/AT. Sclera anicteric. PERRL/EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10cm. No LAD or thyromegaly.
CARDIAC: PMI located in 5th intercostal space, non-displaced.
RRR w/ freq APCs and PVCs. Normal S1, S2. +[**2-1**] HSM at apex. No
r/g, thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
mildly labored, tachypneic, no accessory muscle use. +Bibasilar
crackles and scattered wheezes, prolonged expiratory phase.
ABDOMEN: +BS, soft/NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation."
3979,"Moderate mitral regurgitation. Mild pulmonary
hypertension.
.
CT Abdomen/Pelvis ([**2131-12-26**]):
1. There is no evidence of a retroperitoneal hematoma.
2. Marked asymmetric enlargement of the proximal right thigh
musculature, consistent with the patient's history of a known
hematoma.
3. Small left greater than right pleural effusions with
associated compressive atelectasis of the posterior lung bases.
4. Cholelithiasis.
5. Extensive colonic diverticulosis without evidence of
diverticulitis.
.
Femoral Vascular U/S ([**2131-12-26**]):
FINDINGS: There is no evidence of pseudoaneurysm or A-V fistula,
as questioned. There is a large right groin/thigh hematoma as
seen on CT, measuring at least 13."
3980,"Since you are allergic to Aspirin, you were admitted to
the CCU for Aspirin desensitization. At the end of the
desensitization you had an anaphylactic reaction that required
intubation. You were extubated quickly and have done well since.
You do have an exacerbation of your COPD (chronic lung disease)
and are being treated for it with steroids. You will need to
continue to take your medications as prescribed below. You also
have atrial fibrillation but were not treated with blood
thinners because you were not on this medication at home. You
should discuss starting blood thinners (Coumadin) with your
cardiologist at home."
3981,"He was treated as an acute on
chronic CHF exacerbation with diuresis as well as a COPD
exacerbation with steroids and nebulizers. He was seen by
Cardiology and Pulmonology consults, and repeat TTE showed an
LVEF of 20-25% with global LV hypokinesis and chamber
dilatation, and the possibility of an apical thrombus could not
be ruled out. He was started on weight-based heparin gtt and
transferred to the [**Hospital1 18**] Cardiac Cath Lab for catheterization.
Catheterization here showed diffuse 20-30% stenosis with
mid-vessel 80% stenosis of the LAD and mild luminal
irregularities with mid-vessel 60% eccentric stenosis of the
LCx."
3982,"The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = [**10-9**] %).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated left ventricular cavity with severe global
hypokinesis. Preserved right ventricular cavity size and
systolic function."
3983,"The LMCA had no
angiographically
apparent disease. The LAD had diffuse 20-30% lesions throughout
with a
mid vessel 80% stenosis. The Lcx had mild luminal irregularities
with a
mid vessel 60% eccentric stenosis. The RCA was small and
nondominant
without any angiographically apparent stenosis.
2. Resting hemodynamics revealed elevated right sided filling
pressures
with an RVEDP of 17 mmHg. There was moderate pulmonary
hypertension with
a pulmonary artery pressure of 47/21 mmHg. There were moderately
elevated left sided filling pressures with a PCWP mean of 24
mmHg. There
was normal central aortic pressures of 126/77 mmHg. The cardiac
index
was normal at 2."
3984,"On transfer, he was still mildly fluid overloaded,
so diuresis was continued with Lasix and spironolactone. Repeat
TTE here revealed EF 15% with global LV dysfunction and no
wall-motion-abnormalities to suggest ischemic cardiomyopathy. He
is being discharged on Lasix and spironolactone, as well as a
beta-blocker and an ACE-inhibitor.
.
#. Coronary artery disease - The patient underwent cardiac
catheterization that showed a left-dominant system, an LAD with
diffuse 20-30% lesions throughout and mid-vessel 80% stenosis,
and a LCx with mild luminal irregularities and mid-vessel
eccentric 60% stenosis. He was admitted for the aspirin
desensitization protocol as above, but given his anaphylaxis he
is not being discharged on aspirin."
3985,"0 cm in greatest dimension.
IMPRESSION: No evidence of pseudoaneurysm of AVF. Large right
groin/thigh hematoma.
.
Brief Hospital Course:
The patient is a 73-year-old man with severe COPD and
recently-diagnosed cardiomyopathy with EF 30%, who presented to
an OSH on [**2131-12-21**] with symptoms of acute on chronic systolic
heart failure, transferred to [**Hospital1 18**] for cardiac catheterization
to assess for ischemic cardiomyopathy, which showed LAD disease.
He was admitted to the CCU for aspirin desensitization with plan
for repeat cardiac catheterization and PCI.
.
#. Aspirin desensitization - The patient was admitted to the CCU
overnight for aspirin desensitization."
3986,"Given his ASA allergy, he is admitted to the CCU for ASA
desensitization and investigation of viability of the
anteroapical wall in anticipation of probable PCI of the LAD
lesion.
.
On arrival to the CCU: VS - Temp 97.6F, BP 125/93, HR 94, R 22,
SaO2 97% 2L NC. He complains of mild left groin pain at the
catheterization site.
.
ROS: He acknowledges a prior history of TIA but denies any
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains, hemoptysis, black
stools or red stools. All of the other review of systems were
negative."
3987,"It was also suggested that
he would need a viability study to assess for antero-apical
myocardial viability in preparation for a potential PCI of his
mid-LAD lesion, but his TTE showed no wall-motion-abnormalities
to suggest ischemia as the reason for his cardiomyopathy, so
there was felt to be no indication for viability study at this
time. He is being discharged home on Plavix, beta-blocker, and
lisinopril.
.
# ? Apical thrombus - The patient was transferred to [**Hospital1 18**] for
evaluation for apical thrombus as the TTE done at OSH was unable
to properly assess the apex. He was transferred on an IV heparin
gtt, but TTE here showed no evidence of apical thrombus, so this
was discontinued."
3988,"# RHYTHM: NSR w/ LBBB and frequent APCs and PVCs.
- monitor on telemetry
- electrolyte repletion
.
# ASA allergy: Pt w/ CAD on cardiac cath today. Given plan for PCI in
future, will need to be on ASA. Pt has ASA allergy w/ anaphylaxis,
admitted to CCU for desensitization.
- ASA desensitization per protocol
- PRN Epinephrine, Benadryl, Solu-Medrol, Pepcid
.
# ? Apical thromus: OSH TTE unable to adequately assess apex for
thrombus.
- IV heparin gtt, weight-based protocol
- viability study w/ MRI vs. Thallium+TTE to eval for presence of
thrombus
- anticipate transition to coumadin
.
# COPD: Pt w/ severe COPD, was being treated as COPD exacerbation at
OSH prior to transfer."
3989,"He was started on weight-based heparin gtt and transferred
to the [**Hospital1 5**] Cardiac Cath Lab for catheterization. Catheterization here
showed diffuse 20-30% stenosis with mid-vessel 80% stenosis of the LAD
and mild luminal irregularities with mid-vessel 60% eccentric stenosis
of the LCx. Given his ASA allergy, he is admitted to the CCU for ASA
desensitization and investigation of viability of the anteroapical wall
in anticipation of probable PCI of the LAD lesion.
.
On arrival to the CCU: VS - Temp 97.6F, BP 125/93, HR 94, R 22, SaO2
97% 2L NC. He complains of mild left groin pain at the catheterization
site."
3990,"TITLE:
Chief Complaint: ASA desensitization
HPI:
The pt is a 73-yo man w/ severe COPD and recently-diagnosed
cardiomyopathy with EF 30% who presented to OSH on [**2131-12-21**] with
complaints of increasing SOB, DOE, orthopnea, PND, chest tightness, and
wheezing. He denied any chest pain, palpitations, lightheadedness,
syncope, lower extremity edema, fevers, chills, cough, or sputum
production. He was treated as an acute on chronic CHF exacerbation with
diuresis as well as a COPD exacerbation with steroids and nebulizers.
He was seen by Cardiology and Pulmonology consults, and repeat TTE
showed an LVEF of 20-25% with global LV hypokinesis and chamber
dilatation, and the possibility of an apical thrombus could not be
ruled out."
3991,"- continue Advair, Spiriva
- change from Solu-Medrol to Prednisone taper
- PRN albuterol/ipratropium nebs
.
# GERD: continue home PPI.
.
# FEN: Regular (heart-health, low-Na) diet, NPO p MN, replete lytes PRN
.
# ACCESS: PIVs
# PROPHYLAXIS:
- DVT ppx with IV heparin gtt
- Pain managment with Tylenol
- Bowel regimen
# CODE: Presumed full
# DISPO: CCU
.
ICU Care
Nutrition:
Comments: Regular (heart-health, low-Na) diet, NPO p MN, replete lytes
PRN.
Glycemic Control: Blood sugar well controlled
Lines:
20 Gauge - [**2131-12-24**] 05:58 PM
Prophylaxis:
DVT: (Systemic anticoagulation: Heparin gtt)
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU"
3992,"Patient admitted from: Transfer from other hospital, Cardiac cath lab
History obtained from [**Hospital 19**] Medical records
Allergies:
Aspirin
Anaphylaxis;
Ibuprofen
Shortness of br
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
HOME MEDICATIONS:
- Plavix 75mg PO daily
- Nexium 40mg PO daily
- Lisinopril 10mg PO daily
- Toprol XL 37.5mg PO daily
- Salmeterol 50mcg 1puff INH [**Hospital1 **]
- Spironolactone 25mg PO daily
- Tiotropium 18mcg 1puff INH daily
- Docusate 100mg PO daily
.
.
TRANSFER MEDICATIONS:
- Plavix 75mg PO daily
- Lisinopril 10mg PO daily
- Advair Diskus 250/50 1puff INH [**Hospital1 **]
- Guaifenesin syrup 200mg QID PRN
- SL NTG PRN
- Tylenol PRN
- Nexium 40mg PO daily
- Solu-Medrol 60mg IV daily
- Tiotropium 18mcg 1puff INH daily
- Spironolactone 25mg PO daily
- Toprol XL 37."
3993,"6 F, BP = 125/93, HR = 94, RR = 22, O2 sat = 97% 2L NC
GENERAL: WA middle-aged man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL/EOMI. Conjunctiva pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10cm. No LAD or thyromegaly.
CARDIAC: PMI located in 5th intercostal space, non-displaced. RRR w/
freq APCs and PVCs. Normal S1, S2. +[**1-31**] HSM at apex. No r/g, thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp mildly
labored, tachypneic, no accessory muscle use."
3994,"All of the other review of systems were negative.
Flowsheet Data as of [**2131-12-24**] 08:33 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36.4
C (97.6
Tcurrent: 36.4
C (97.6
HR: 98 (84 - 98) bpm
BP: 129/95(103) {125/93(102) - 129/95(103)} mmHg
RR: 16 (16 - 28) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 65 Inch
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
0 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 97%
Physical Examination
VS: T = 97."
3995,".
OSH TTE (report):
1. Technically limited study due to poor parasternal windows.
2. LV chamber size mildly dilated. Severe global HK of LV. EF estimated
at 20-25%. Apical clot cannot be excluded.
3. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2315**], RA normal.
4. RV chamber size and systolic function WNL.
5. Focal aortic leaflet calcification, no AS, trace AR.
6. Mild mitral annular regurgitation, mitral valve leaflets mildly
thickened, mild subvalvular thickening of mitral valve, moderate MR.
7. Mild TR, RVSP calculated at 37mmHg, mild pulmonary HTN.
8. Pericardium normal.
9. Aortic root normal.
.
OSH Chest CTA (report): No evidence of pulmonary embolus."
3996,"Findings
consistent with COPD. New left greater than right pleural effusions
with scattered areas of atelectasis. Mild pericardial effusion
increased since prior study. Pertinent findings likely result of
congestive changes.
ECG: ECG - NSR, LBBB, LVH.
Telemetry - NSR w/ freq APCs and PVCs.
Assessment and Plan
CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)
ASSESSMENT / PLAN: 73-yo man w/ severe COPD and recently-diagnosed
cardiomyopathy w/ EF 30%, who presented to OSH on [**2131-12-21**] w/ symptoms
of acute on chronic systolic heart failure, transferred here for
cardiac catheterization that showed LAD disease, now admitted to CCU
for ASA desensitization and viability study."
3997,".
# CORONARIES: Cardiac catheterization today showed left-dominant
system, LAD with diffuse 20-30% lesions thoroughout with mid-vessel 80%
stenosis, and LCx with mild luminal irregularities with mid-vessel
eccentric 60% stenosis.
- continue Plavix, lisinopril
- short-acting beta-blocker given ASA desensitization protocol
- ASA desensitization as below
- viability study to assess for antero-apical myocardial viability, for
potential PCI of mid-LAD lesion
.
# PUMP: Recently diagnosed with cardiomyopathy of unknown cause. OSH
TTE showed EF 20-25% with global LV HK and chamber dilation. Responded
to diuresis at OSH prior to transfer, but still overloaded by symptoms
and exam.
- diuresis with Lasix IV boluses
- cont Spironolactone, BB, ACE-I
- viability study to assess for antero-apical myocardial viability, for
potential PCI of mid-LAD lesion
."
3998,"The
RCA was small and nondominant without any angiographically apparent
stenosis.
.
HEMODYNAMICS: Resting hemodynamics revealed elevated right sided
filling pressures with an RVEDP of 17 mmHg. There was moderate
pulmonary hypertension with a pulmonary artery pressure of 47/21 mmHg.
There were moderately elevated left sided filling pressures with a PCWP
mean of 24 mmHg. There was normal central aortic pressures of 126/77
mmHg. The cardiac index was normal at 2.9 L/min/m2.
.
pCXR: (wetread) Mild congestive heart failure. Left lower lobe hazy
opacity may represent early infiltrate versus edema. Repeat exam after
treatment recommended. Remote right rib fractures."
3999,"Recommend conventional catheter angiography to rule
out a high flow lesion prior to surgery.
2. Interval placement of right ventriculostomy tube.
Brief Hospital Course:
25M admitted with large L cerebellar mass with obstructive
hydrocephalus. On [**11-9**] he had a third ventriculostomy which was
done without difficulty. Pt was monitored in the PACU overnight
and transferred to step down for observation. Neurologically the
patient was stable and does not have any deficits. Currently he
is neurologically intact and safe fdor discharge. Will return
for surgical resection.
Medications on Admission:
None
Discharge Medications:
1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours)."
4000,"Ativan 1 mg Tablet Sig: One (1) Tablet PO on call to MRI for
1 doses: take medication one hour prior to your scheduled MRI on
[**2128-11-19**].
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Cerebellar Mass
Obstructive hydrocephalus
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation."
4001,"Head CTA [**11-10**]:
IMPRESSION:
1. Left cerebellar mass, unchanged.
2. Lateral ventricles appear slightly smaller than on prior scan
indicating
working ventriculostomy.
3. No evidence of high flow feeding vessel to the mass, but
there is a
possibility that the mass effect of the hematomas are
compressing these
vessels. There is prominence of the right PICA. These findings
together are
suspicious and merit investigation with catheter angiogram.
MRI Spectroscopy Head [**11-10**]:
IMPRESSION:
1. Centrally enhancing large 5.0 cm left cerebellar mass. The
spectroscopy
failed due to susceptibility artifact from hemorrhage within the
lesion. While there is no increased flow on perfusion imaging,
this may be due to tamponade effect of the hemorrhagic
components."
4002,"IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-31**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin on right side, slightly slower on left
upper and lower extremities
On Discharge:
Neurologically intact, no focal deficits, denies HA.
Pertinent Results:
Labs on Admission:
[**2128-11-8**] 04:15AM BLOOD WBC-6.9 RBC-4.40* Hgb-13."
4003,"Differential diagnostic considerations include
hemangioblastoma, hemorrhagic ependymoma or a vascular lesion
likely
cavernoma. An angiogram can be performed to assess the
vascularity of this
lesion.
Head CT [**11-9**]:
NON-CONTRAST HEAD CT: There has been no interval change in the
size and mass effect of the complex, multilocular and
hemorrhagic left cerebellar
hemispheric mass measuring 3.5 (AP) x 5.1 cm (TRV). The mass
contains
multiple foci of calcification. No definite new focus of
bleeding is noted.
The degree of mass effect and effacement of the 4th ventricle,
as well as the secondary hydrocephalus is unchanged, and there
is no transependymal
migration of CSF."
4004,"He went to an outside hospital where a
head CT revealed an approximately 4 x 5 cm left cerebellar mass
with resulting effacement of the fourth ventricle and
enlargement of lateral and third ventricles. He was transferred
to [**Hospital1 18**] for higher level of care.
Past Medical History:
Remote Asthma; since resolved
Social History:
lives at home with family; he denies tobacco use, and admits to
EtOH use approximately once per month
Family History:
Non-contributory
Physical Exam:
On Admission:
O: T:98.1 BP: 144/89 HR:82 R 16 O2Sats 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-28**] bilaterally EOMs intact
Neck: Supple."
4005,"9* Hct-38.8*
MCV-88 MCH-31.7 MCHC-35.9* RDW-13.1 Plt Ct-211
[**2128-11-8**] 04:15AM BLOOD Neuts-63.7 Lymphs-26.5 Monos-6.7 Eos-2.5
Baso-0.5
[**2128-11-8**] 04:15AM BLOOD Plt Ct-211
[**2128-11-8**] 05:18AM BLOOD PT-12.3 PTT-26.4 INR(PT)-1.0
[**2128-11-8**] 04:15AM BLOOD UreaN-16 Creat-1.0 Na-139 K-3.8 Cl-104
HCO3-28 AnGap-11
[**2128-11-9**] 09:25PM BLOOD Calcium-10.2 Phos-2.9 Mg-2."
4006,"?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return on Friday [**11-19**] for resection of your mass.
- You will need to have an MRI on the morning of [**11-19**] at 5:30am
-MRI is located in the CLINICAL CENTER BASEMENT OF [**Hospital Ward Name **]
- Please do not eat or drink after midnight on [**11-19**] (Thursday
night into Friday morning) except for small sips of water to
take your medications. Anything more than small sips with your
medication will result in your case being delayed or cancelled.
- You will have your sutures removed during the scheduled
hospitalization.
- please take your dose of valium one hour prior to your
scheduled MRI time.
Completed by:[**2128-11-15**]"
4007,"Admission Date: [**2128-11-8**] Discharge Date: [**2128-11-15**]
Date of Birth: [**2103-11-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Significantly worsened headaches and nausea/vomiting
Major Surgical or Invasive Procedure:
[**11-9**]: Third Ventriculostomy
History of Present Illness:
Mr. [**Known lastname 14502**] is a 25 y/o male in previously good health who began
to notice new-onset headaches during weightlifting sessions
about a month ago. At rest he did not have any symptoms, but
yesterday his headaches were significantly more pronounced and
he had nausea/vomiting."
4008,"Disp:*48 Tablet(s)* Refills:*0*
2. Ultram 50 mg Tablet Sig: One (1) Tablet PO q6 PRN as needed
for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: you must take
this medication while you are on the dexamethasone to prevent
ulcers.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5."
4009,"We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage."
4010,"0
Labs on Discharge:
[**2128-11-14**] 04:00PM BLOOD WBC-11.5* RBC-4.45* Hgb-14.3 Hct-39.4*
MCV-89 MCH-32.1* MCHC-36.3* RDW-13.2 Plt Ct-236
[**2128-11-15**] 07:05AM BLOOD PT-11.8 PTT-23.0 INR(PT)-1.0
[**2128-11-14**] 04:00PM BLOOD Glucose-122* UreaN-29* Creat-1.0 Na-134
K-4.3 Cl-101 HCO3-25 AnGap-12
[**2128-11-14**] 04:00PM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2
Imaging:
MRI Head [**11-8**]:
IMPRESSION:
Extremely large hemorrhagic mass in the left cerebellum causing
obstructive
hydrocephalus."
4011,"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.
Recall: [**3-29**] objects at 5 minutes.
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, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice."
4012,"She has had chills, and developed a
cough, but did not measure her temperature.
Past Medical History:
aortic stenosis
coronary artery disease
diabetes mellitus
gastroesophageal reflux disease
hypertension
Social History:
Tobacco history: Quit smoking 3 weeks prior to presentation
was smoking [**2-5**] ppd recently (down from 1 ppd); smoked approx
30-40 years
ETOH Denies
Cares for her husband with [**Name (NI) 2481**].
Family History:
Brother had an MI at 42. Positive FHx of HTN.
Physical Exam:
PHYSICAL EXAMINATION on Admission:
62"" 142#
VS: T= BP=125/76 HR=92 RR=30 O2 sat=88% on 6L NC
GENERAL: Elderly woman in mild respiratory distress."
4013,"Brief Hospital Course:
Presented to emergency department tachypneic to 32-40 while on
BiPaP and hypotension. She was admitted and transferred to the
CCU at which time she was chest pain free; vitals on transfer to
the CCU T 98.0, HR 83, BP 105/63, RR 30, 100% on bipap. She was
actively diuresed and put out over 4L with significant
improvment in pulmonary edema seen on CXR and concomitant
improvement in respiratory status. Given severity of AS and
resent exacerbation, pt was evaluated for AVR and felt to need
valve replacement. Pre-op work-up intiated and she underwent
repeat CXR, carotid ultrasound and cardiac catheterization."
4014,"20. Outpatient Lab Work
Chem BUN/Cr, Potassium and Magnesium twice a week while on Lasix
21. heart monitor
Telemetry to monitor rhythm due to atrial fibrillation rate
controlled
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Aortic stenosis s/p AVR
Coronary artery disease s/p CABG
Mitral regurgitation s/p MV repair
Post operative atrial fibrillation
Non ST elevation myocardial infarction
Gastroesophageal reflux disease
Hypertension
Discharge Condition:
Alert and oriented x3 UE strength 5/5 LE RE [**4-8**] LE [**5-9**]
Ambulating with walker and assistance few feet unsteady gait
Incisional pain managed with acetaminophen prn
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage steri strips
Edema trace lower extremities"
4015,"3 K-3.8
[**2146-10-22**] 10:40PM BLOOD freeCa-1.13
.
ECG Study Date of [**2146-10-23**]
Sinus rhythm. There is slurring of the upstroke of the QRS
complex consistent with pre-excitation. Compared to the previous
tracing voltage for left ventricular hypertrophy is slightly
less.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 158 116 392/437 58 19 41
.
Cardiac Cath Study Date of [**2146-10-24**]
COMMENTS: 1. Coronary angiography in this right dominant
system
demonstrated two vessel disease. THe LMCA had no
angiographically
apparent disease. The LAD had a 80% proximal stenosis."
4016,"6 MCHC-31.7 RDW-16.3* Plt Ct-336
[**2146-10-27**] 03:21AM BLOOD Neuts-88.2* Lymphs-8.9* Monos-2.5 Eos-0.2
Baso-0.2
[**2146-11-2**] 05:12AM BLOOD Plt Ct-336
[**2146-11-2**] 05:12AM BLOOD PT-13.9* INR(PT)-1.2*
[**2146-11-2**] 05:12AM BLOOD Glucose-135* UreaN-21* Creat-0.6 Na-138
K-4.0 Cl-102 HCO3-25 AnGap-15
[**2146-10-28**] 04:00AM BLOOD ALT-29 AST-45* LD(LDH)-333* AlkPhos-83
Amylase-26 TotBili-0.6
[**2146-10-23**] 04:30AM BLOOD CK-MB-10 MB Indx-8."
4017,"History of Present Illness:
72 year old female with an extensive smoking history presents
with one day of intermittent left chest pain and worsening
shortness of breath. Was comfortable when EMS arrived, but on
transport, her breath sounds became less clear with crackles to
the mid lung fields and she became tachypneic. Was given 6
sprays of NG, 40mg of Lasix, 4mg of morphine and put on BiPaP.
Highest SBP is reported but not documented at 180. While on
BiPaP she was tachypneic to 32-40. She admits to eating some
sausage today prior to feeling short of breath. Also, she visits
her husband at a long term care facility and said that many
people had ""colds"" there."
4018,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Wednesday [**11-16**] @ 1:45 pm [**Hospital Ward Name **] 2A
Cardiologist:Dr. [**Last Name (STitle) **] [**11-28**] @ 10:20 AM
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] in [**5-9**] weeks [**Telephone/Fax (1) 250**]
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2.0-2.5
First draw day after discharge Friday [**2146-11-4**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease to twice a week
Rehab physician to dose coumadin while at rehab
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2146-11-2**]"
4019,"Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
4020,"10. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please give 400 mg twice a day for six days, decreased
to 400mg once a day for seven days, then 200 mg daily until
follow up with cardiologist .
12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): 75 mg three times a day ."
4021,"Admission Date: [**2146-10-23**] Discharge Date: [**2146-11-2**]
Date of Birth: [**2074-8-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2146-10-25**] Coronary artery bypass grafting x2 with the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein graft to the posterior descending artery.
Mitral valve repair with [**Company 1543**] CG Future annuloplasty ring,
size 26 mm, model #638R. Aortic valve replacement with a St.
[**Male First Name (un) 923**] Epic tissue valve model #ESP100-21-00.
[**2146-10-24**] cardiac catheterization"
4022,"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 ~20 (at her earlobe).
CARDIAC: Normal rate regular rhythm. [**4-9**] LUSB
crescendo/decrescendo murmur, and [**3-12**] holosystolic low pitch
murmur.
LUNGS: No chest wall deformities. Resp were mildly labored, with
accessory muscle use. Diffuse crackles bilaterally with
decreased breath sounds at the bases. Wheezes bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ pitting edema
SKIN: Warm, dry. No lesions
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+"
4023,"3 Phos-4.4 Mg-1.1*
[**2146-10-23**] 11:13AM BLOOD Albumin-4.0 Calcium-9.0 Phos-4.4 Mg-2.4
[**2146-10-24**] 02:57AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.9
[**2146-10-23**] 03:19PM BLOOD %HbA1c-6.1* eAG-128*
[**2146-10-22**] 10:40PM BLOOD pH-7.35 Comment-GREEN TOP
[**2146-10-23**] 12:33AM BLOOD pO2-92 pCO2-35 pH-7.36 calTCO2-21 Base
XS--4 Comment-TRAUMA
[**2146-10-22**] 10:40PM BLOOD Glucose-230* Lactate-2.4* Na-125* K-4.0
Cl-91* calHCO3-20*
[**2146-10-23**] 12:33AM BLOOD Lactate-1."
4024,"Cardiac catheterization revealed coronary artery disease.
On [**2146-10-25**] she was brought to the operating room and underwent
aortic valve replacement and coronary artery bypass graft
surgery. She received vancomycin for perioperative antibiotics
and was trasnfered to the intensive care unit for post operative
management. She remained intubated, as she remained lethargic
and unable to protect airway. She was transfused two units of
packed red blood cells for anemia due to blood loss and
hemodilution. She was extubated on POD 3, by this time she had
been weaned from inotropic and vasopressor support. Beta
blocker was initiated and she was gently diuresed toward the
preoperative weight."
4025,"She did develop post-op atrial
fibrillation and was treated with amiodarone, beta blocker and
anti-coagulation for a goal INR 2-2.5. Additionally, she
developed bilateral weakness of upper and lower extremities.
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 8 she remained weak, ambulating few
feet with walker and assistance. She was discharged to [**Hospital 100**]
rehab MACU on telemetry due to continued atrial fibrillation."
4026,"Pertinent Results:
[**2146-10-22**] 10:32PM BLOOD WBC-12.4* RBC-3.78* Hgb-11.8* Hct-34.5*
MCV-91 MCH-31.1 MCHC-34.0 RDW-14.2 Plt Ct-212
[**2146-10-23**] 04:30AM BLOOD WBC-11.5* RBC-3.56* Hgb-11.0* Hct-32.2*
MCV-91 MCH-31.0 MCHC-34.3 RDW-14.3 Plt Ct-201
[**2146-10-24**] 02:57AM BLOOD WBC-8.0 RBC-3.49* Hgb-10.9* Hct-30.9*
MCV-89 MCH-31.1 MCHC-35.1* RDW-14.3 Plt Ct-187
[**2146-10-22**] 10:32PM BLOOD Neuts-67."
4027,"4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day): stop when INR > 1.8.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily)."
4028,"8 Lymphs-26.9 Monos-3.5 Eos-1.2
Baso-0.6
[**2146-10-22**] 10:32PM BLOOD Plt Ct-212
[**2146-10-22**] 10:32PM BLOOD PT-11.9 PTT-25.0 INR(PT)-1.0
[**2146-10-23**] 04:30AM BLOOD Plt Ct-201
[**2146-10-24**] 02:57AM BLOOD PT-13.3 PTT-38.2* INR(PT)-1.1
[**2146-10-24**] 02:57AM BLOOD Plt Ct-187
[**2146-10-22**] 10:32PM BLOOD Glucose-236* UreaN-8 Creat-0.7 Na-123*
K-4.1 Cl-94* HCO3-19* AnGap-14
[**2146-10-23**] 04:30AM BLOOD Glucose-95 UreaN-9 Creat-0."
4029,"THe
LCx had
minimal diffuse disease. The RCA had a 90% stenosis in the
mid-portion.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
.
CHEST (PRE-OP PA & LAT) Study Date of [**2146-10-24**]
FINDINGS: There has been marked interval improvement in
pulmonary edema.
Cardiomediastinal and hilar contours are within normal limits.
Minimally
increased pulmonary vasculature and blunting of the costophrenic
angles
remain. No focal consolidation or pneumothorax. There are low
lung volumes.
IMPRESSION:
1. Marked interval improvement in pulmonary edema.
[**2146-11-2**] 05:12AM BLOOD WBC-11.0 RBC-3.22* Hgb-9.2* Hct-29.1*
MCV-90 MCH-28."
4030,"7 Na-128*
K-4.4 Cl-94* HCO3-22 AnGap-16
[**2146-10-23**] 11:13AM BLOOD Glucose-124* UreaN-10 Creat-0.6 Na-128*
K-4.1 Cl-94* HCO3-21* AnGap-17
[**2146-10-23**] 04:30AM BLOOD CK(CPK)-118
[**2146-10-23**] 11:13AM BLOOD ALT-21 AST-29 LD(LDH)-213 AlkPhos-62
TotBili-0.4
[**2146-10-22**] 10:32PM BLOOD cTropnT-0.04*
[**2146-10-22**] 10:32PM BLOOD proBNP-1210*
[**2146-10-23**] 04:30AM BLOOD CK-MB-10 MB Indx-8.5* cTropnT-0.08*
[**2146-10-23**] 04:30AM BLOOD Calcium-9."
4031,"Medications on Admission:
ATORVASTATIN 40 mg PO daily
HYDROCHLOROTHIAZIDE 25 mg PO daily
LISINOPRIL 60 mg PO daily
METFORMIN 1,000 mg PO BID
PANTOPRAZOLE - 40 mg PO BID
SUCRALFATE 1 gram Q6H
ASPIRIN 81 mg PO daily
CALCIUM CARBONATE-VITAMIN D3
OMEGA-3 FATTY ACIDS
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain."
4032,"15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
18. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
19. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: please give 2 mg on [**11-3**] thrusday - then check INR [**11-4**]
for further dosing -
had received 2mg on [**11-1**] and [**11-2**] at [**Hospital1 18**] ."
4033,"5* cTropnT-0.08*
[**2146-10-22**] 10:32PM BLOOD proBNP-1210*
[**2146-11-2**] 05:12AM BLOOD Phos-2.6* Mg-1.6
[**2146-10-23**] 03:19PM BLOOD %HbA1c-6.1* eAG-128*
PA AND LATERAL VIEWS OF THE CHEST:
REASON FOR EXAM: Status post AVR and MVR repair and CABG.
Comparison is made with prior studies [**10-30**].
Moderate cardiomegaly is stable. Now mild to moderate pulmonary
edema has
markedly improved. Small-to-moderate bilateral pleural effusions
are
decreased associated with adjacent atelectasis. Left PICC tip is
in the upper
to mid SVC. Sternal wires are aligned."
4034,"Admission Date: [**2198-12-27**] Discharge Date: [**2199-1-1**]
Date of Birth: [**2123-2-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
arterial line placement
History of Present Illness:
History limited as patient intubated and family not present at
time of exam. This is a 75 yo F with metastatic (brain/bone)
transitional cell CA of bladder, here from [**Hospital 100**] Rehab with
tachypnea (RR 40-42), hypoxia (70s%), tachycardia (119-128),
hypotension (62/40), temp 98. CXR at rehab felt to be consistent
with bilateral PNA."
4035,"CXR not
overly impressive, getting CT torso prior to transfer. Current
VS: 110-120s 110/70 100%. In the ICU, she is intubated and
sedated.
Past Medical History:
1. Right intertrochanteric hip fracture on [**2198-11-8**], status
post
[**11-9**] intramedullary nail placed at [**Hospital1 18**].
2. Chronic leg ulcers, improving.
3. History of Raynaud's phenomenon, stable.
4. History of skin cancer, basal cell, removed [**11-27**], stable.
5. Anxiety, stable.
6. Osteoporosis.
7. Dementia.
8. H/o C. diff infection.
9. Transitional cell CA with mets to brain and bone.
10. A fib with RVR, bursts of SVT: in setting of post-op pain
from hip fracture"
4036,"Please correlate
clinically to assess for acute infection.
3. Partial left mastoid air cell opacification.
Brief Hospital Course:
Hospital course: Mrs. [**Known lastname 19704**] is a 75-year-old female with
metastatic transitional cell carcinoma of the bladder who
presented with hypoxic respiratory failure that was likely
multifactorial in setting of tumor burden and possible
multifocal pneumonia although aspiration is a consideration, and
hemodynamic instability requiring aggressive volume
resuscitation, pressor support with norepinephrine, and
intubation. The patient had last been treated for cancer, but
her regimen has been on hold since [**Month (only) **] secondary to a hip
fracture with subsequent poor performance status and medical
issues related to her rehabiliation and chronic medical
conditions."
4037,"Imaging revealed further metastasis with suggested
brain involvement, new retroperitoneal lymphadenopathy,
worsening bone metastases, new liver metastases, and possible
multifocal lung metastatis although pneumonia was a
consideration. Patient was extubated on [**2199-1-1**] per family
desire to pursue comfort care given progressively worsening
clinical status and died on [**2199-1-1**] at 12:35 PM.
# Hypoxic respiratory failure:
Her respiratory failure was thought to be secondary to either
multifocal pneumonia or worsening metastasis from underlying
malignancy. PE was excluded in setting of recent hip fracture
s/p repair. She was intubated and required support throughout
her hospitalization. She was treated broadly with vancomycin (IV
and PO), cefepime, ciprofloxacin, metronidazole for both
anaerobic and pulmonary infections in addition to C."
4038,"diff given
leukocytosis. Microbiology did not suggest infectious etiology.
Patient was extubated on [**2199-1-1**] per family desire to pursue
comfort care given progressively worsening status and died on
[**2199-1-1**] at 12:35 PM.
.
# Septic shock:
Patient was hypotensive on presentation and required high-volume
resuscitation, pressor support with levophed. Etiology was
thought to be septic process although high tumor burden could
have caused destabilization and no overt evidence in favor of
septic process. She was empirically covered with aforementioned
antimicrobials for infection although her blood, sputum, and
urine cultures were not suggestive of infection. Patient
subsequently switched to phenylephrine as having episodes of
hypotension associated with atrial fibrillation with rapid
ventricular response."
4039,".
# Atrial fibrillation: Patient likely developed atrial
fibrillation in setting of acute illness and secondary to
cardiostimulatory pressor. She was controlled with lopressor. On
her last day of hospitalization, her episodes were causing
severe hemodynamic instability.
.
# Anemia: Patient noted to be anemic. Likely secondary to
overwhelming systemic illness with marrow suppression with no
evidence of acute blood loss. Hemolysis and DIC labs did not
suggest such processes.
# Acute oliguric renal failure
Her renal function declined likely secondary to pre-renal
processes from poor perfusion leading to acute tubular necrosis.
Tumor lysis syndrome in setting of burden was thought to be less
likely."
4040,"# Transaminitis
Patient noted to have elevated liver function tests thought to
be secondary to liver metastasis and worsened by underling
systemic process.
# Metabolic acidosis
Patient developed marked acidosis likely to underlying
inflammatory process.
# Thrombocytopenia with coagulopathy
Patient noted to develop thrombocytopenia likely multifactorial
etiology with marrow suppression, drug side effect from
antibiotics (no known heparin usage). For coagulopathy, there
was a concern for DIC as above.
Medications on Admission:
APAP 975mg TID
Ca carbonate 650mg [**Hospital1 **]
Enoxaparin 40mg daily
Folic acid 1mg daily
Lactobacillus 2 tab [**Hospital1 **]
Loratadine 10mg daily
Metoprolol 12.5 mg [**Hospital1 **]
Albuterol neb q6h prn
Bisacodyl 10mg PR prn
Ipratropium neb q4h prn
Magnesium hydroxide 30ml daily prn
Morphine sulfate 15mg q6h prn
Senna 2 tabs daily prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Transitional cell carcinoma, metastatic, multi-organ
dysfunction syndrome, respiratory failure
Secondary: atrial fibrillation, anemia, renal failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]"
4041,"5*
[**2198-12-27**] 09:30PM BLOOD Albumin-1.8* Calcium-6.6* Phos-3.9 Mg-1.6
[**2198-12-27**] 10:22PM BLOOD Type-ART PEEP-5 FiO2-100 pO2-378* pCO2-37
pH-7.24* calTCO2-17* Base XS--10 AADO2-323 REQ O2-57
Intubat-INTUBATED Vent-CONTROLLED
[**2198-12-27**] 09:41PM BLOOD Glucose-67* Lactate-6.4* Na-136 K-4.9
Cl-111
[**2198-12-27**] 09:41PM BLOOD Hgb-7.1* calcHCT-21
[**2198-12-28**] 05:35AM BLOOD freeCa-1.11*
.
B. Day of Expiration
[**2199-1-1**] 06:00AM BLOOD WBC-39."
4042,"5* RBC-4.06* Hgb-11.6* Hct-38.0
MCV-94 MCH-28.5 MCHC-30.5* RDW-19.8* Plt Ct-37*
[**2199-1-1**] 06:00AM BLOOD Glucose-77 UreaN-59* Creat-1.5* Na-132*
K-4.8 Cl-106 HCO3-12* AnGap-19
[**2199-1-1**] 06:00AM BLOOD ALT-88* AST-354* LD(LDH)-5755*
AlkPhos-1818* TotBili-5.7*
[**2199-1-1**] 06:00AM BLOOD Albumin-1.6* Calcium-8.5 Phos-4.4 Mg-2.0
[**2199-1-1**] 06:00AM BLOOD Vanco-25.8*
[**2199-1-1**] 06:12AM BLOOD Type-ART Temp-36."
4043,"Social History:
Formerly worked in an administrative role at [**Hospital1 18**] in Pathology.
Former smoker. Lives with daughter, [**Name (NI) 6480**].
Family History:
Mother died of pancreatic CA.
Physical Exam:
Exam on Admission:
General: Intubated and sedated, NAD
HEENT: ETT in place
Lungs: Coarse breath sounds anteriorly with slightly crackles on
left
CV: Tachycardic, regular rhythm, no murmurs, rubs, gallops
Abdomen: +BS. soft, non-tender, mildly distended. +hepatomegaly
~6cm below costal maragin.
Ext: warm, well perfused, 2+ pulses, 1+ pitting edema at upper
thighs, R thigh without tense compartments or apparent
ecchymosis, ankles wrapped in gauze
Pertinent Results:
I. Labs"
4044,"0 pO2-90 pCO2-27*
pH-7.24* calTCO2-12* Base XS--14
[**2199-1-1**] 06:12AM BLOOD Lactate-4.2*
[**2199-1-1**] 06:12AM BLOOD freeCa-1.21
II. Microbiology
[**2198-12-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2198-12-28**] Influenza A/B by DFA DIRECT INFLUENZA A
ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL;
Respiratory Viral Culture-FINAL INPATIENT
[**2198-12-28**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2198-12-27**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2198-12-27**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2198-12-27**] URINE URINE CULTURE-FINAL"
4045,"A. Admission
[**2198-12-27**] 09:30PM BLOOD WBC-15.0* RBC-2.27* Hgb-6.7* Hct-22.1*
MCV-97 MCH-29.6 MCHC-30.4* RDW-18.5* Plt Ct-169
[**2198-12-27**] 09:30PM BLOOD Neuts-88.6* Lymphs-8.0* Monos-2.8 Eos-0.3
Baso-0.3
[**2198-12-27**] 09:30PM BLOOD Plt Ct-169
[**2198-12-27**] 09:30PM BLOOD Glucose-70 UreaN-47* Creat-1.4* Na-136
K-4.8 Cl-108 HCO3-13* AnGap-20
[**2198-12-27**] 09:30PM BLOOD ALT-16 AST-44* LD(LDH)-774* AlkPhos-1086*
TotBili-2."
4046,"3. New bilateral small pleural effusions.
4. New liver metastases involving both lobes.
5. New retroperitoneal lymphadenopathy.
6. Worsening bone metastases.
7. Retroperitoneal soft tissue mass decreased in size.
.
CT Head:
1. No evidence of acute intracranial findings. Grossly unchanged
right
cavernous sinus mass, extending along the tentorium. MRI would
be more
sensitive for posterior fossa abnormalities and reassessment of
metastatic
disease, particularly if brainstem and cranial nerve involvement
is suspected.
2. Complete right mastoid opacification and middle ear
opacification. Given concern for perineural tumor spread from
the right cavernous sinus, this finding may relate to
obstruction of drainage by the skull base mass."
4047,"Given evidence of worsening perfusion with
oliguria and upward trend of lactate, she was subsequently
placed back on levophed with minimal effect and continuing
deterioration until her death. It was unclear if her
deterioration was due mostly to a septic picture or worsening
malignancy.
.
# Metastatic transitional cell cancer: Patient was noted to have
worsening metastasis on imaging as above. She had received
treatment in the past, which was limited of recent by a fall
with resultant hip fracture and subsequent poor performance.
Oncology was involved during her hospitalization indicating that
further therapy would likely only worsen her condition in the
setting of an already poor prognosis."
4048,"She was given IV levofloxacin and referred
to the ED.
.
On arrival to the ED, initial VS were: 101 140 86/74 30 95% NRB.
She is on her 4th L of IVF. She was given vanc/zosyn here. EKG
showed sinus tach at 130 bpm, T wave flattening diffusely. She
was intubated with etomidate and succinylcholine, given
phenylephrine bolus prior to intubation. She had a L femoral
line placed in nonsterile conditions, later pulled with a clean
R IJ placed. Currently on norepinephrine, had 5L IVF. Going to
give RBCs for hct 19. Has guaiac pos dark brown stool."
4049,"III. Radiology
A. CXR
1. Endotracheal tube in satisfactory position as above.
2. At least two patchy foci, one in the right infrahilar region
and one in
the retrocardiac left lower lobe, which may represent foci of
aspiration or
early-developing multifocal pneumonia.
3. Subtle pulmonary vascular indistinctness may indicate early
pulmonary
edema
4. Compression fracture of a lower thoracic vertebral body of
indeterminate
acuity.
5. Small pleural effusions.
B. CT Torso with Contrast:
1. No evidence of PE.
2. Multifocal opacities within both lungs are new and while they
may
represent multifocal pneumonia in light of the other findings,
metastatic
disease is also a consideration."
4050,"Admission Date: [**2152-10-25**] Discharge Date: [**2152-11-7**]
Date of Birth: [**2135-1-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p Motor Vehicle Crash
Major Surgical or Invasive Procedure:
Exploratory laparotomy ([**2152-10-25**])
.
Right Lower Extremity procedures including:
([**10-25**])
1. Irrigation and debridement down to and inclusive of bone
open tibia shaft fracture.
2. Fasciotomies right leg.
3. Placement of external fixator across tibia.
4. Placement of the external fixator across femur.
5. Closed reduction with traction of left tibia fracture."
4051,"7* RDW-15.6*
[**2152-10-25**] 03:37PM PLT COUNT-113*
[**2152-10-25**] 03:37PM PT-16.9* PTT-38.8* INR(PT)-1.5*
[**2152-10-25**]
FINDINGS: No previous studies available for a direct comparison.
There is a fracture involving the proximal femur with multiple
fracture lines
extending from the lesser trochanter as well as to the proximal
to mid
diaphysis of the right femur. External fixation pins are seen
within the
proximal femur and within the distal femur. A single frontal
view of the
lower leg shows a compound fracture along the fibula as well as
a complex
fracture involving the mid shaft of the tibia."
4052,"Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
- Right tibial fracture (open)
- Right femoral fracture (closed)
- Left lateral leg wound
- Complex lip laceration
- Cardiac contusion with AVNRT
- Right middle lung contusion
- Non-operative facial fractures
- Dental fractures & tooth loss
Discharge Condition:
Stable vital signs. Pain controlled with medication. Tolerating
a regular diet.
Discharge Instructions:
You sustained fractures to your right leg for which you
underwent multiple operations. Per these injuries, please return
to the Emergency Department or see your own doctor right away if
any problems develop, including the following:
* Swelling, pain or redness getting worse."
4053,"Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. RV function
depressed.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal mitral valve supporting structures. Normal LV inflow
pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized."
4054,"His tachycardia
persisted requiring several trigger events. Cardiology involved
the EPS service who recommended to continue with the Lopressor
and recommended adding Flecainide. The tachycardia did improve
with this regimen. He will require outpatient follow up with [**Hospital **]
clinic for further studies.
His Heparin was changed to Lovenox for which he will continue
post discharge until discontinued by Orthopedics in follow up.
Social work was closely involved with patient and his family
throughout his entire hospital stay.
Physical and Occupational therapy were consulted and worked with
him regularly to prepare him for home as there was no insurance
in place and so rehab placement was not a feasible option."
4055,"No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with depressed free wall contractility. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is no pericardial
effusion.
IMPRESSION: Mildly dilated and hypokinetic right ventricle. This
may be due to right ventricular contusion."
4056,"* Pain not much better within 3 days.
* Fingers or toes become pale (whiter) or become dark or
blue.
* Numbness, tingling or coldness of your fingers or toes.
* Loss of movement.
* Rubbing sensation, burning or soreness of your skin,
especially under a cast.
* Chest pain, shortness of breath or trouble breathing.
* Fever or shaking chills.
* Headache, confusion or any change in alertness.
* For any other concerning symptoms that are concerning to
you
In the course of your stay, you were diagnosed with an abnormal
heart rhythm and were treated for it. Please call your doctor or
return to the emergency room if any of the following problems
develop:
* [**Name2 (NI) **] are having new symptoms that your doctor doesn?"
4057,"Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days."
4058,"As the FAST
examination was positive and free-fluid was noted in the abdomen
on CT the patient was taken to the operating room emergently for
an exploratory laporatomy.
Past Medical History:
None
Social History:
Lives with parents.
2 ppd smoker, etoh, no drugs
Family History:
Noncontributory
Physical Exam:
Upon admission:
134 15 100% CMV 50%/500/15/5
Gen: intubated sedated
HEENT: partial thickness laceration to upper lip ~2cm long on
left face
lateral to philtral columns. Crosses the white roll.
Full thickness laceration to lower lip near the midline through
mucosa and skin. violates the [**Location (un) 67019**] border."
4059,"There were no
intraoperative complications. He was taken back to the operating
room by Orthopedics on [**10-26**] for removal of external fixation,
right tibia; irrigation and debridement open fracture, right
tibia down to and including the bone; intermedullary nailing of
right tibia with Synthes pin
#10 X 345 mm nail; removal of external fixator, right femur;
intramedullary nail fixation with Gamma nail #11 x 125 x400 mm,
90 mm lag screw. On [**10-30**] he was again taken back to the
operating room for closure right lower extremity fasciotomies
both
medially and laterally.
Because of his multiple facial injuries there was concern for
fractures."
4060,"He
made significant gains and was eventually cleared for safe
discharge to home with his parents.
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Enoxaparin 40 mg/0.4 mL Syringe Sig: 0.4 ML's Subcutaneous
DAILY (Daily) for 4 weeks.
Disp:*30 ML's* Refills:*0*
4. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
5."
4061,"Plastic Surgery was consulted who initially requested
CT scan of the face but because of hemodynamic instability the
facial CT was deferred until [**10-29**]. No fractures were identified.
His extensive lip laceration was irrigated and sutured.
Postoperatively he was taken to the Trauma ICU where he remained
sedated and vented. His tachycardia persisted. He underwent an
ECHO which revealed EF >55% with mildly dilated and hypokinetic
right ventricle which was likely due to right ventricular
contusion. Normal left ventricular systolic function. No LVOT
obstruction or significant valvular lesion was seen. Cardiology
was consulted and recommended continued beta blockade.
He was eventually weaned and extubated and would later be
transferred to the regular nursing unit."
4062,"1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.9 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 2.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A ratio: 1.25
Mitral Valve - E Wave deceleration time: 242 ms 140-250 ms
TR Gradient (+ RA = PASP): *33 mm Hg <= 25 mm Hg"
4063,"IMPRESSION:
1. No fracture identified.
2. Absence of the left central and lateral incisors. Please
correlate
clinically to determine whether this is acute.
3. Mucosal thickening of all sinuses, with small air-fluid
levels in the
maxillary and sphenoid sinuses. However, no underlying fracture
is
identified. This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3827**] on
[**2152-10-30**] at
11:45 a.m.
Brief Hospital Course:
He was admitted to the Trauma service. Because he was in shock
upon arrival he was taken immediately to the operating room for
an exploratory laparotomy which was negative. Orthopedics was
consulted because of his extremity fractures; he was taken to
the operating room on [**10-25**] for irrigation and debridement down
to and inclusive of bone open tibia shaft fracture on right;
fasciotomies right leg; placement of external fixator across
tibia placement of the external fixator across femur, right;
closed reduction with traction of tibia fracture; closed
reduction with traction of right femur."
4064,"Coronal reformatted images
were
prepared.
[**2152-10-29**]
FINDINGS: No definite facial fractures identified. There is
mucosal
thickening and aerated debris within ethmoid sinuses
bilaterally, and mucosal
thickening of the maxillary sinuses, left greater than right,
with small
air-fluid levels in the maxillary sinuses. However, no
underlying facial
fracture is identified. There are also air-fluid levels within
the sphenoid
sinus.
There is absence of the left ninth left upper frontal teeth (9,
10, and 11)
(central and lateral incisors). The nasal septum is deviated
slightly toward
the left. There is also slight mucosal thickening of the frontal
sinuses
bilaterally."
4065,"Normal left
ventricular systolic function. No LVOT obstruction or
significant valvular lesion seen.
[**2152-10-28**]
IMPRESSION: No DVT in both lower extremities.
[**2152-10-28**] TIB/FIB XRAY
1. Right grade 3 open tibia shaft fracture, status post
four-compartment
fasciotomy.
2. Right closed femoral shaft fracture.
3. Left lateral leg wound
4. Complex fascial laceration. Information from the patient's
chart
indicates that he has a full thickness laceration to the lower
lip near the
midline through the mucosa and skin, and there is concern for
facial fractures
given mechanism of injury.
COMPARISON: None.
TECHNIQUE: Contiguous axial images were obtained through the
paranasal
sinuses, facial bones, and mandible."
4066,"Forehead lac closed with staples wound is non-draining, well
approximated. Small hematoma present.
No periorbital echymosis/edema. Midface with moderate
instability.
Neck: cervical collar
Cor: Tachy
Chest: clear
Abd: soft
Extr: deformity RLE
Pertinent Results:
[**2152-10-25**] 03:37PM GLUCOSE-110 UREA N-8 CREAT-0.7 SODIUM-138
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-24 ANION GAP-7*
[**2152-10-25**] 03:37PM CALCIUM-7.0* PHOSPHATE-4.0 MAGNESIUM-1.5
[**2152-10-25**] 03:37PM WBC-6.1 RBC-3.42*# HGB-10.9*# HCT-29.7*
MCV-87 MCH-31.8 MCHC-36."
4067,"* If you have numbness, pins-and-needles or pain in the area of
your injury.
Followup Instructions:
Please follow-up with the following [**Hospital1 18**] departments:
- Orthopedic Surgery within 1 week following discharge at ([**Telephone/Fax (1) 15940**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP for removal of your sutures
and staples.
- Plastic Surgery within 1 week following discharge at ([**Telephone/Fax (1) 59430**].
- Trauma Surgery in around 2 weeks following discharge at ([**Telephone/Fax (1) 41065**].
- Follow up with your primary Dentist for your teeth issues; you
will need to call for an appointment.
- You have indicated that you would like to follow up with an
Electrophysiologist closer to your home. If you'd like you may
follow up with Cardiac Electrophysiology here at [**Hospital1 771**] in [**7-2**] weeks at ([**Telephone/Fax (1) 80498**] with Dr.
[**Last Name (STitle) 80499**].
Completed by:[**2152-12-5**]"
4068,"?????t know
about or your palpitations get worse
* You have trouble breathing while resting
* You have new or worsening swelling in your feet or ankles
* You have any questions or concerns about your illness or
medicine
* Chest pain, tightness, or pressure that lasts more than a few
minutes
* Feeling very short of breath
* Feeling faint, or too dizzy to stand up
* Sudden onset of weakness or numbness (loss of feeling) in your
arms or legs
* Watch carefully for signs of infection at your surgical sites
and wounds: redness, warmth, increasing pain, swelling, drainage
of pus (thick white, yellow or green liquid) or fevers."
4069,"6. Closed reduction with traction of right femur.
.
([**10-26**])
1. Removal of external fixation, right tibia.
2. Irrigation and debridement open fracture, right tibia down to
and including some of the bone.
3. Intermedullary nailing of right tibia with Synthes pin #10 X
345 mm nail.
4. Removal of external fixator, right femur.
5. Intramedullary nail fixation with Gamma nail #11 x 125 x
400 mm, 90 mm lag screw.
.
([**10-30**])
1. Closure right lower extremity fasciotomies both medially and
laterally.
History of Present Illness:
17yo M unrestrained passenger in high speed auto crash with
prolonged extrication. Transfered to [**Hospital1 18**] from referring
hopsital tachycardic to the 150's and hypotensive despite having
received 9 liters of IVF, 4u PRBC's, and FFP."
4070,"External fixation
hardware
limits evaluation of the entire tibia.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Done [**2152-10-25**] at 9:00:00 AM
Left Atrium - Long Axis Dimension: 2.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.5 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1."
4071,"Admission Date: [**2150-1-10**] Discharge Date: [**2150-1-18**]
Date of Birth: [**2097-6-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Cellcept / Zosyn
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
52 year old female with ESRD on HD with recent admission for VRE
bacteremia, admitted to MICU for sepsis evaluation, transferred
to the floor, readmitted to MICU for afib with RVR, then
transferred to the floor once hemodynamically stable. She
initially presented with fever to 101 after HD on [**1-10**] treated
with 650mg of Tylenol at rehab, rechecked at 101."
4072,"Also of note, she
has been on Dapsone for PCP prophylaxis as well as Gancyclovir
for CMV viremia.
.
On arrival to the ED, her vitals were: T 99.8 BP 93/60 HR 120
RR22 98%RA. Labs were done which showed WBC 4 with 8% bandemia,
Lactate 4.8. CXR was negative, U/A not done as pt is anuric.
Blood cultures were drawn. EKG showed sinus tachycardia with
flattening laterally. She was given 2L IVF and Vanc/Imipenem for
empiric coverage of an unclear source given her history. A CVL
was offered but the patient refused so an EJ was placed."
4073,"Diff [**10/2149**]
- Paroxysmal atrial fibrillation
- NSVT
- hx of Hypertension
- Hyperthyroidism
- s/p bilateral knee surgeries and R ACL repair
Social History:
Single, currently at [**Hospital 671**] rehab. Denies tobacco, ETOH, and
drugs.
Family History:
Mother and brother both with diabetes and [**Name (NI) 2091**], both deceased.
Physical Exam:
Vitals - T: 97.7 BP: 125/69 HR: 81 RR: 26 02 sat: 100% RA
GENERAL: Ill appearing female, in NAD
HEENT: O/P Clear, MMM
NECK: No LAD, left tunneled HD line in place, no erythema or
tenderness over area
CARDIAC: RRR, nl S1S3, no m/r/g
LUNG: Clear bilaterally, mild scatered wheezing
ABDOMEN: Soft, NT, ND, +BS
EXT: No clubbing, edema, warm and well pefused, 2+ DP/PT pulses
bilatearlly
NEURO: Alert and oriented x3"
4074,"08*
[**2150-1-13**] 05:23PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2150-1-16**] 03:30AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2150-1-16**] 06:40AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2150-1-16**] 03:50PM BLOOD CK-MB-NotDone cTropnT-0.04*
Brief Hospital Course:
52 year old female with ESRD on HD, recent VRE bacteremia, CMV
Viremia, SLE presented with fever and hypotension, developed
Afib with RVR as well as labile t wave inversion, now
hemodynamically stable.
# EARLY SEPSIS: Patient presented with fevers, hyotension,
tachycardia and a lactate of 4.8. In addition, her WBC was 4."
4075,"She was
unable to receive a PICC on that side [**12-30**] this thrombus (and not
on the right [**12-30**] presence of fistula). She was maintained on
warfarin with goal [**12-31**] and should continue anticoagulation until
resolution of the thrombus or indefinitely.
.
# CMV viremia: Patient has been treated with valganciclovir.
This was briefly stopped out of concern for myelosuppression but
subsequently restarted per ID. Plan is for her to f/u with
outpatient ID with Dr. [**First Name (STitle) **] on [**2150-1-21**] regarding need to
continue this treatment.
.
# Atrial fibrillation with RVR: On [**1-13**] patient was transferred
to MICU for afib with RVR and hypotension."
4076,"15. Epoetin Alfa 2,000 unit/mL Solution Sig: at dialysis
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
Primary diagnoses:
Fever
Atrial fibrillation
VRE bacteremia on treatment
.
Secondary diagnoses:
ESRD on HD
SLE
LUE venous thrombus
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
It was a pleasure to be involved in your care, Ms. [**Known lastname 6357**].
You were admitted to [**Hospital1 69**]
because of fever and hypotension. You were then found to have a
type of arrhythmia called ""atrial fibrillation with rapid
ventricular response""."
4077,"==================
DISCHARGE LABS
==================
[**2150-1-18**] 06:00AM BLOOD WBC-2.1* RBC-2.50* Hgb-7.1* Hct-23.2*
MCV-93 MCH-28.4 MCHC-30.6* RDW-21.4* Plt Ct-147*
[**2150-1-18**] 06:00AM BLOOD Plt Ct-147*
[**2150-1-18**] 06:00AM BLOOD PT-21.2* PTT-24.9 INR(PT)-2.0*
[**2150-1-18**] 06:00AM BLOOD Glucose-75 UreaN-8 Creat-2.5*# Na-143
K-3.3 Cl-103 HCO3-35* AnGap-8
[**2150-1-18**] 06:00AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.3*
==================
CARDIAC ENZYMES
=================="
4078,"She was treated with
digoxin load and PRN PO metoprolol. She will continue on digoxin
0.125mg 3/week and metoprolol 12.5 [**Hospital1 **] as an outpatient, with
holding parameters for SBP<95 or HR<55.
.
# Nausea: Patient had repeated bouts of nausea accompanied by
tachycardia in the 120-140 and hypotension that resolved with
ondansetron. This appears to occur after HD and may be related
to volume depletion. She also often gets nausea after eating.
Patient repeatedly denied SOB or chest discomfort. Repeated
cardiac enzymes were negative.
.
# Anticoagulation: Patient should continue on coumadin with goal
INR [**12-31**].
.
# Code status: Full Code"
4079,"[**2150-1-10**] 11:24PM BLOOD CK(CPK)-13*
[**2150-1-11**] 05:41AM BLOOD LD(LDH)-443* CK(CPK)-17* TotBili-0.4
DirBili-0.1 IndBili-0.3
[**2150-1-13**] 11:37AM BLOOD CK(CPK)-15*
[**2150-1-13**] 05:23PM BLOOD CK(CPK)-10*
[**2150-1-16**] 03:30AM BLOOD CK(CPK)-47
[**2150-1-16**] 06:40AM BLOOD CK(CPK)-50
[**2150-1-16**] 03:50PM BLOOD CK(CPK)-56
[**2150-1-10**] 11:24PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2150-1-11**] 05:41AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2150-1-13**] 11:37AM BLOOD CK-MB-NotDone cTropnT-0."
4080,"Compared to the previous tracing of [**2149-12-27**]
ventricular
premature beats are not seen on the current tracing. Otherwise,
no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
112 138 86 334/425 59 3 144
.
Cardiology Report ECG Study Date of [**2150-1-11**] 1:11:50 AM
Sinus rhythm. Short P-R interval. ST-T wave abnormalities. Since
the previous tracing of [**2150-1-10**] ST-T wave abnormalities are less
prominent at a slower rate.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 148 88 386/435 65 -16 70
."
4081,"However, after speaking with
ID valganciclovir was restarted. During hospitalization,
antibiotics were narrowed to daptomycin. Patient will need to
complete 4 week course of Daptomycin for VRE bacteremia in
setting of known thrombus that is possibly seeded. She will
receive Daptomycin when she receives HD. The renal team has
arranged for her to get the medication at HD. The last dose will
be on [**2150-1-26**].
.
# T Wave Inversions: Patient's T waves were upright at the time
of admission. She then developed inverted T waves in V3-V6, I,
II, aVF, and intermittently/biphasic in V2 (see attached EKGs
copied from [**Hospital1 18**]), with repeated negative cardiac enzymes."
4082,".
In the MICU, the patient was started on daptomycin, imipenem
switched to meropenem and vanc continued. Her hypotension
resolved with IVF. She remained afebrile with stable vital
signs.
.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, cough, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- VRE Bacteremia, treated Linezolid
- ESRD due to SLE, s/p cadaveric renal transplant [**8-/2147**]
complicated by FSGS and transplant failure [**7-/2149**], now on HD
- SLE, followed by Dr.[**Last Name (STitle) **] in Rheumatology
- Hypotension (started on midodrine [**11-5**])
- Septic shock [**10/2149**]
- CMV viremia [**10/2149**]
- Acute uncomplicated diverticulitis [**10/2149**]
- hx of C."
4083,"Possible LVH. Extensive ST-T changes may be due to
hypertrophy and/or ischemia. T wave inversion in I, II, and aVF;
biphasic T wave in V2, T wave inversion in V3-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
121 160 84 334/[**Medical Record Number 99130**] -154
.
Cardiology Report ECG Study Date of [**2150-1-16**] 17:07:36 PM
*At rest, asymptomatic*
Sinus rythm. Extensive ST-T changes may be due to hypertrophy
and/or ischemia. T wave inversion in I, II, and aVF; biphasic T
wave in V2, T wave inversion in V3-V6."
4084,"However, after treatment with
zofran and resolution of nausea, her heart rate remained in the
120s, which argues against that theory.
.
# Low Blood Pressure: Patient's baseline systolic blood pressure
is 100s to 110s, though was noted to occasionally be in the 90s,
which responded to small IVF boluses (250-300cc). It was thought
to be secondary to volume shifts and possibly be exacerbated by
autonomic instability. She should continue on Midodrine 10mg
TID.
.
# ESRD on HD s/p failed transplant: Patient was continued on HD
and maintained on Prednisone.
.
# Venous thrombus: Patient was noted to have a complete
thrombosis of the left AV [**Month/Year (2) **], left cephalic vein and left
subclavian vein, and partial thrombosis of left brachiocephalic
vein with extension to SVC on her previous admission."
4085,"9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 1230**]y (450)
mg Intravenous at dialysis: The last dose on [**2150-1-26**].
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
12. Insulin Regular Human 100 unit/mL Cartridge Sig: sliding
scale Injection QACHS.
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
goal INR [**12-31**].
14. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
4086,"Left ventricular hypertrophy. Extensive ST-T
changes probably due to ventricular hypertrophy. T wave
inversion in I, II, aVF, upright in V2, inverted in V3-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 144 88 398/457 24 -17 -169.
.
Cardiology Report ECG Study Date of [**2150-1-17**] 9:54:46 AM
*Nauseous*
Sinus tachycardia. Left ventricular hypertrophy. Extensive ST-T
changes probably due to hypertrophy and/or ischemia. T wave
inversion in I, II, aVF, upright in V2, inverted in V3-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 146 84 424/424 1 -18 -162
."
4087,"Medications on Admission:
Aspirin 325 mg daily
Pantoprazole 40 mg daily
Prednisone 5 mg Tablet daily
Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,TH).
Midodrine 10mg TID
Linezolid 600 mg [**Hospital1 **] until [**1-19**]
Oxycodone 5 mg q6 prn
Injection q dialysis.
Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous QACHS.
Warfarin 2.5 mg daily
Dapsone 100 mg daily
Zofran 4 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
Atovaquone 1500 daily
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2."
4088,"Cardiology Report ECG Study Date of [**2150-1-13**] 8:19:24 AM
Sinus rhythm. Since the previous tracing earlier on [**2150-1-13**],
atrial
fibrillation is no longer present. There is marked Q-T interval
prolongation and there are inferolateral T wave inversions.
Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 160 88 448/472 63 -3 -114
.
Cardiology Report ECG Study Date of [**2150-1-15**] 9:37:40 AM
Sinus tachycardia. Diffuse ST-T wave changes. Cannot rule out
myocardial
ischemia. Compared to the previous tracing of [**2150-1-13**] QTc
interval prolongation has improved."
4089,"Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 152 80 414/449 21 -19 -169
.
Cardiology Report ECG Study Date of [**2150-1-17**] 16:22:36 PM
*During dialysis, asymptomatic*
Possible ectopic atrial rythm. Left ventricular hypertrophy.
Extensive ST-T changes may be due to ventricular hypertrophy. T
wave inversion in I, II, aVF, V2-V6. In V2 T wave inversions are
deep and symmetric.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
98 126 82 380/446 -35 -6 -161
.
Cardiology Report ECG Study Date of [**2150-1-17**] 17:34:12 PM
*Post dialysis, back to floor, asymptomatic*
Sinus rythm."
4090,"Otherwise, previously
described multiple abnormalities are present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 148 86 362/433 6 -12 -173
.
Cardiology Report ECG Study Date of [**2150-1-15**] 20:21:24 PM
*After 9 beats of NSVT*
Sinus rythm with PACs. Extensive ST-T changes may be due to
myocardial ischemia. T wave inversion in I, II, aVF, V2-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 118 86 412/450 -17 1 -128
.
Cardiology Report ECG Study Date of [**2150-1-16**] 9:30:44 AM
*At the time, patient was nauseous*
Sinus rythm."
4091,"0
but with an 8% bandemia. She has had a number of infections
recently in the setting of immunosuppression. The differential
was broad including line infection (new HD line placed on [**12-31**]),
pneumonia (CXR without obvious infiltrate), CMV Viremia (viral
load [**12-29**] negative), UTI, C. Diff (recent infection [**11-5**] but
without any symptoms to suggest this). Patients BP/HR improved
after administration of 2L IVF, and broad coverage with
Meropenem (GN coverage) plus Daptomycin (GP coverage) as well as
PO Vanc, given bandemia. BCx, C.Diff cx, and CMV viral load were
also obtained and were negative."
4092,"Then
she developed more deeply inverted T waves in V2 that were deep
and symmetrical during HD on [**1-17**] that then turned upright. It
was not clear that the T wave inversions were rate related.
Cardiology was [**Month/Year (2) 4221**]. The ddx included: ischemia,
Takotsubo's, or a cerebral processes, however rapid resolution
of the T waves made the later two less likely. She denied chest
discomfort though she occasionally had nausea. She did not have
any neurological symptoms. Patient has no LVH on prior ECHOs to
invoke repolarization changes. Recommend performing persantine
study to r/o ischemia as an outpatient, not initiated as an
inpatient given difficulty to instigate intervention in this
setting with recent bacteremia and RUE thrombus."
4093,"Cardiology Report ECG Study Date of [**2150-1-12**] 3:16:38 PM
Sinus rhythm. Since the previous tracing baseline artifact is
different. There is probably no significant change in previously
noted findings.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 140 90 414/457 59 -12 62
.
Cardiology Report ECG Study Date of [**2150-1-13**] 5:18:08 AM
Probable atrial fibrillation with rapid ventricular response.
Since the
previous tracing of [**2150-1-12**] atrial fibrillation is new. There is
a single wide complex beat, probably ventricular, which is also
new.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
145 0 84 318/466 0 -10 -142
."
4094,"Pertinent Results:
==================
ADMISSION LABS
==================
[**2150-1-10**] 07:40PM
WBC-4.0 RBC-2.84* Hgb-7.8* Hct-25.1* MCV-88 MCH-27.4 MCHC-31.0
RDW-18.3* Plt Ct-92*
Neuts-52 Bands-8* Lymphs-30 Monos-8 Eos-0 Baso-0 Atyps-2*
Metas-0 Myelos-0
Hypochr-3+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL
Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
Plt Smr-LOW Plt Ct-92*
Glucose-170* UreaN-10 Creat-3.0*# Na-137 K-4.3 Cl-97 HCO3-24
AnGap-20
CK(CPK)-13*
Calcium-7.6* Phos-1.8*# Mg-1."
4095,"Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO Q TUES, THURS,
SAT ().
8. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO WED, SAT
()."
4096,"3, and noted
have some chills by the nurse. She was subsquently sent to the
ED.
.
The patient reports feeling well overall the days prior to
admission. She denies any N/V, cough, shortness of breath, sore
throat, rhinnorhea, or abdominal pain. She reports a good
appetite. She does complain that the rehab was not dosing her
antibiotics appropriately and was only giving her Linezolid once
daily until she corrected them a few days ago.
.
Of note, the patient was recently admitted on [**3-11**] for VRE
Bacteremia and was treated with Linezolid for a planned 4 week
course; she subsequently had her HD lined removed, underwent a
line holiday and then a new line was placed."
4097,"3*
Glucose-164* Lactate-4.8* Na-137 K-4.2 Cl-96* calHCO3-27
UPRIGHT AP VIEW OF THE CHEST: Left-sided dual-lumen central
venous catheter tip terminates within the mid SVC. The cardiac
silhouette is normal in size. The mediastinal and hilar
contours are within normal limits. The lungs are clear without
focal consolidation. Pulmonary vascularity is normal. No pleural
effusion or pneumothorax is present. The osseous structures are
unremarkable. IMPRESSION: No acute cardiopulmonary abnormality.
==============
EKGs
==============
Cardiology Report ECG Study Date of [**2150-1-10**] 7:14:44 PM
Sinus tachycardia with baseline artifact. Non-specific
anterolateral
ST-T wave changes."
4098,"You were in the medical ICU twice during
this admission. For your fever, we did not find any source of
infection, and your antibiotics was changed from linezolid to
datpomycin because your blood counts went down on linezolid.
You will receive daptomycin on the days of your dialysis, and
you will finish it on [**2150-1-26**]. You were treated for
atrial fibrillation with two medications, digoxin and
metoprolol.
Please note that your medications have been changed:
Please continue daptomycin until [**2150-1-26**]
We have added digoxin
We have added metoprolol
We also added simvastatin
Please continue to take coumadin
Please continue to take valganciclovir until when you are seen
in the infectious disease clinic next week ([**2150-1-21**])
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2150-1-21**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2150-1-30**] 1:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2150-6-18**] 10:00"
4099,"In the mean
time, patient is medically managed for coronary artery disease;
she is on aspirin and small dose of beta-blocker. Simvastatin
was added during this admission.
.
# Tachycardia: In addition to atrial fibrillation which is
currently controlled, she had multiple episodes of regular
tachycardia. EKG revealed sinus tach. In terms of the
etiologies of sinus tachycardia, she had evidence of volume
depletion, especially after HD, which likely led to low systolic
blood pressures in the 90s and sinus tachycardia. Sinus
tachycardia invariably improved/resolved after gentle IVF
(250cc-500cc NS). She also experienced nausea during some
episodes of tachycardia, raising the question whether the
tachycardia is due to discomfort."
4100,"Admission Date: [**2125-11-26**] Discharge Date: [**2125-12-7**]
Date of Birth: [**2065-1-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
A 60 year old male with PMH HTN, COPD, and Alcoholism presented
to the [**Hospital1 18**] ED with dyspnea and cough and was admitted to the
ICU for hypoxia.
History obtained primairly from ExWife who is at bedside. She
reports that for the past month, the patient has been having
worseing dyspnea on exertion. Two days prior to admission, she
reports that he had increasing sputum production and dyspnea, he
was somnolent and spent >16 hours sleeping each day."
4101,"Initial ABG showed 7.31/69/76/36 on 15L (unclear O2 delivery) he
was placed on BiPAP with 50% FiO2 repeat ABG showed
7.33/65/74/36.He was given Albuterol and ipratropium nebulizer
treatements, 500mg Azithromycin, Ceftriaxone 1g IV, and
Methylprednisolone 125mg IV x1.
ABG shortly prior to transfer showed 7.39/55/58/35. Vitals on
transfer BP157/72 RR24 SaO293% on BiPAP PEEP of 8
On arrival to the ICU, initial vitals were BP 127/70 HR:80 RR:19
90% on a 50% ventimask. He was agitated, pulling at lines and
his foley and demanding to get out of bed."
4102,"He stated that his
last alcoholic drink was 2 days ago which his ExWife confirmed.
Review of systems:
(+) Per HPI
(-) Denies changes in sputum color. Denies fever. Denies chest
pain, chest pressure. Unable to perform further ROS due to
agitation.
Past Medical History:
Alcoholism since [**33**]'s, Denies withdrawl history, denies history
of seizures
COPD
Hypertension
Social History:
- Tobacco: 120-160 pack years (3-4 packs daily x 40 years)
currently smoking 3 packs daily.
- Alcohol: currently drinking 2 bottles of wine + large mixed
drink daily
Family History:
Mother: [**Name (NI) 2481**] Coronary artery disease
Father: Leukemia
Physical Exam:
Admission Exam:
Vitals: T:96."
4103,"9 Na-141
K-3.4 Cl-94* HCO3-38* AnGap-12
[**2125-12-5**] 06:45AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8
Studies pending at Discharge:
None
Brief Hospital Course:
Mr. [**Known lastname 103584**] is a 60 y/o male with a history of hypertension,
chronic obstructive pulmonary disease, probable alcoholic
cirrhosis, and alcohol abuse/dependence admitted with pneumonia
and hypoxemic respiratory failure. Hospital course was notable
for alcohol withdrawal, encephalopathy, and acute diastolic
heart failure.
#Hypoxemic respiratory failure/Pneumonia/Severe exacerbation of
chronic obstructive pulmonary disease:
Chest X-ray was consistent with left lower lobe pneumonia and
patient was requiried ICU admission and intubation."
4104,"He was also
given steroids for exacerbation of COPD and was able to be
extubated. He completed his antibiotic course of Ceftriaxone and
azithromycin during his hospitalization and was discharged off
supplemental oxygen. He was also started on maintenance
Tiotropium and inhaled fluticasone on discharge.
#Acute diastolic heart failure:
Patient was felt to be volume overloaded on admission and was
diuresed with improvement in pulmonary edema and oxygen
requirement. Since he has had poor PCP follow up in the past and
was felt to have heart failure exacerbation due to infection,
which was treated prior to discharge, he was not discharged on
diuretics."
4105,"Echocardiogram showed mild symmetric LVH, preserved
LVEF, and mild RV dilation.
#Alcohol withdrawal/encephalopathy/Cirrhosis:
Patient became delirious and agitated following extubation and
this was felt to be due to alcohol withdrawal and benzodiazepine
withdrawal. He was treated with Haldol and tapering doses of
benzodiazepines and his mental status returned to [**Location 213**] prior
to discharge. Although he had imaging consistent with cirrhosis,
he was not felt to have hepatic encephalopathy. Abdominal
ultrasound showed probable cirrhosis but no ascites. He was
counseled on importance of abstaining from alcohol and was given
folate and thiamine. He was maintained on CIWA protocol while on
the medical floor."
4106,"fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing: please have pharmacist teach you how to use
this.
Disp:*1 * Refills:*0*
6. Calcium 500 + D Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Community Acquired Pneumonia
COPD exacerbation
Acute on Chronic Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr."
4107,"Portal blood flow is towards the liver. No
focal defects are seen within the liver. The gallbladder is free
of stones. The liver itself is enlarged. Both right and left
kidneys are normal. Spleen could not be identified suggesting
that it is not enlarged. Pancreas and aorta are hidden by
overlying bowel gas. There is no ascites.
IMPRESSION: Abnormal liver more consistent with cirrhosis than
fatty infiltrate. No ascites.
Discharge Labs:
[**2125-12-6**] 07:00AM BLOOD WBC-9.2 RBC-4.38* Hgb-14.0 Hct-43.6
MCV-100* MCH-32.0 MCHC-32.1 RDW-14.7 Plt Ct-194
[**2125-12-6**] 07:00AM BLOOD Glucose-104* UreaN-13 Creat-0."
4108,"Discharge Exam:
Physical Exam:
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT
NECK - no JVD appreciated
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c trace edema
NEURO - awake, A&Ox3, moving all extremities
Pertinent Results:
Admission Labs:
[**2125-11-26**] 01:05AM BLOOD WBC-9.7 RBC-4.31* Hgb-14.0 Hct-44.0
MCV-102* MCH-32.4* MCHC-31.8 RDW-15.3 Plt Ct-233
[**2125-11-26**] 01:05AM BLOOD Neuts-76* Bands-0 Lymphs-15* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-8*
[**2125-11-26**] 01:05AM BLOOD Plt Ct-233
[**2125-11-26**] 01:05AM BLOOD PT-15."
4109,"On the day
of admission, she noted confusion, though he usually speaks with
her in English, he began only speaking in Hindi which she does
not speak.
In the ED initial vitals were 98.7, 107, 125/68, 40 and 70 on
RA, he was triggered for hypoxia. Initial labs were remarkable
for HCT 44.0, WBC 9.7 PMN 76%, INR 1.4, Cr 1.1, Lactate 2.6, BNP
3272. Chest xray showed BL (L>R) pleural effusions and pulmonary
edema. According to the report, exam was remarkable for
abdomiinal distention however ultrasound examination failed to
identify ascitic fluid collection."
4110,"# Transitional issues:
Patient was discharged with PCP follow up of COPD, probable
cirrhosis, diastolic heart failure, and alcohol abuse.
Medications on Admission:
Symbicort 80/4.5 prescribed but not using
Vitamin D (Dose unknown)
Vitamin B12 (Dose unknown)
Folate (Dose unknown)
Calcium (Dose unknown)
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 Cap(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4."
4111,"You will need to follow with a liver
specialist.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital **] MEDICAL PHYSICIANS, P.C.
Address: [**University/College 808**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 823**]
**Please contact your Primary Care Physician for [**Name Initial (PRE) **] follow up
appointment from your hospital stay. It is recommended you
follow up with Dr [**First Name (STitle) 807**] within 1 week for a FULL PHYSICAL.**
**Also please speak with your PCP about the need to follow up
with a Liver specialist, Heart specialist, Lung specialist**
Completed by:[**2125-12-9**]"
4112,"2* PTT-28.3 INR(PT)-1.3*
[**2125-11-26**] 01:05AM BLOOD Glucose-96 UreaN-11 Creat-1.1 Na-140
K-4.6 Cl-100 HCO3-32 AnGap-13
[**2125-11-26**] 01:05AM BLOOD ALT-24 AST-55* CK(CPK)-58 AlkPhos-176*
TotBili-0.7
[**2125-11-26**] 01:05AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-2372*
[**2125-11-26**] 01:05AM BLOOD Albumin-2.9*
[**2125-11-26**] 01:05AM BLOOD TSH-3.5
[**2125-11-26**] 01:05AM BLOOD Free T4-1.0
[**2125-11-26**] 01:18AM BLOOD Lactate-2."
4113,"[**Known lastname 103584**],
You were admitted to the hospital for shortness of breath and
cough and you were found to have pneumonia. You were admitted to
the intensive care unit and a breathing tube was placed. You
were treated with antibiotics and your symptoms improved. You
were transferred to the medicine floor and continued to improve.
During your hospital stay, you underwent an ultrasound of your
liver which shows liver disease. It is very important that you
stop drinking alcohol, as this can further damage your liver and
make you very sick. It is also important that you quit smoking,
as this can increase your risk for developing pneumonia."
4114,"No aortic regurgitation is seen. The mitral valve
leaflets are not well seen. No mitral regurgitation is seen.
Tricuspid regurgitation is present but cannot be quantified. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
prominent fat pad.
CXR [**2125-11-26**]:
IMPRESSION:
1. Bibasilar consolidation, left greater than right, and
moderate left
pleural effusion, may represent infection in the appropriate
clinical setting.
2. Moderate cardiomegaly and/or pericardial effusion. Mild
pulmonary edema.
LE Ultrasound [**2125-11-26**]:
IMPRESSION:
No left or right lower extremity DVT.
RUQ Ultrasound [**2125-11-27**]:
The liver is echogenic and shows some irregularity of outline
more suggestive of cirrhosis than fatty liver, though either
could be the cause."
4115,"Please try to avoid salt as much as
possible in your diet. Please also weigh yourself every morning
before breakfast, as we discussed. If you are gaining more than
3 lbs, it is likely fluid weight, so you should call Dr. [**Name (NI) 30283**] office, and he may need to start you on a medication
called furosemide so that you can urinate out the extra fluid.
3.) You were also found to have cirrhosis of the liver, likely
because of the alcohol you have been drinking over the years.
Please try to stop drinking alcohol, as this can cause further
harm to your liver."
4116,"You
primary care doctor can help you with this.
It is very important you follow up with your primary care doctor
regarding your multiple medical conditions. Please go to your
scheduled appointments. You need to have your primary care
doctor set up home physical therapy services.
Please check your weights each morning and if you notice greater
than 3 pound weight gain, please call your primary care doctor
immediately, as this can represent worsening heart failure.
The following changes were made to your medications:
- Please START tiotropium inhaler daily -- this is to help with
your lungs because you have emphysema
- Please STOP Symbicort
- Please START fluticasone inhaler -- this is also for your
lungs
- Please START thiamine vitamins"
4117,"9 BP:127/70 P:80 R:19 O2:92 30% 10/2 BiPAP
General: Overewight male. Agitated, oriented to
person/place/year speaking in [**12-31**] word sentences
HEENT: Sclera anicteric fair dentition
Neck: full supple, JVP not elevated, no LAD
Lungs: Poor air movement, right sided wheezes, decreased breath
sounds on the left base.
CV: Distant Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: Distended, soft, non-tender, bowel sounds normoactive,
unable to assess shifting dullness
GU: Foley in place
Ext: Non pitting edema to mid calf BL, warm, hyperpigmentation
of anterior shin BL consistent with peripheral vascular disease"
4118,"Please be sure to schedule a followup appointment with your
primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 807**].
Dr. [**First Name (STitle) 807**] may set you up with a liver specialist, a lung
specialist, and a heart specialist.
1.) You likely have Emphysema from smoking so much, so you will
need to start the inhalers, as listed below. You will also need
to have pulmonary function tests when you are feeling back to
normal.
Please try to cut back as much as possible on your smoking to
make it easier to quit.
2.) You were also found to have diastolic heart failure, which
means that you can build up fluid easily in your lungs and legs
if you eat extra salt."
4119,"6*
[**2125-11-26**] 09:00PM BLOOD freeCa-1.13
Notable studies:
ECHO [**2125-11-26**]:
Poor image quality. The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Regional left
ventricular wall motion is normal. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with normal free wall contractility. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. The
aortic valve is not well seen. There is no aortic valve
stenosis."
4120,"Nuclear imaging was notable for a moderate to
large sized, severe inferolateral posterolateral defect which
remains fixed.(unchanged from prior MIBI). Given the patient's
progression in symptoms, he has now been referred for outpatient
cardiac catheterization. He was found to have three vessel
disease upon cardiac catheterization today and is now referred
to cardiac surgery for revascularization.
Past Medical History:
Coronary artery disease s/p Inferior Myocardial Infarction age
52
Benign Prostatic Hypertrophy s/p TURP
Seizure disorder since age 16; last episode about 20 yrs ago
Inferior Myocardial Infarction age 52
Hypertension
Hyperlipidemia
Rheumatic fever as a child age 14
Macular Degeneration
s/p Hernia repair
s/p Left Knee surgery- ACL
s/p Right Torn rotator cuff repaired"
4121,"16. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
please assess edema status as therapy continues.
17. Coumadin 2 mg Tablet Sig: One (1) Tablet PO daily dosing per
rehab provider: [**Name10 (NameIs) **] INR 2.0-2.5 for A Fib; dose today [**4-29**]
only is 2 mg; all further dosing per rehab provider.
18. ENSURE shakes to be encouraged
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4/
cystoscopy
postop A Fib
LUE vein clot
Past medical history:
Benign Prostatic Hypertrophy s/p TURP
Seizure disorder since age 16; last episode about 20 yrs ago
Inferior Myocardial Infarction age 52
Hypertension
Hyperlipidemia
Rheumatic fever as a child age 14
Macular Degeneration
s/p Hernia repair
s/p Left Knee surgery- ACL
s/p Right Torn rotator cuff repaired"
4122,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on Thurs [**5-21**] @ 1:15 pm
Cardiologist: Dr. [**Last Name (STitle) **] on [**5-12**] @ 2:15 pm
f/u with outpatient urologist Dr. [**Last Name (STitle) 365**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1408**] in [**4-21**] 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**
***Coumadin daily for A Fib
target INR 2.0 - 2.5
first draw tomorrow [**4-30**]
please arrange for coumadin f/u prior to discharge from rehab
Completed by:[**2172-4-29**]"
4123,"Social History:
Race: Caucasain
Last Dental Exam: 1 year ago
Lives with: Wife
Occupation: Family Lawyer
[**Name (NI) 1139**]: quit in [**2125**]
ETOH: occassional small glass of wine
Family History:
Father with MI at age 52, Paternal uncle MI at age 53, Maternal
uncles with [**Name2 (NI) **]
Physical Exam:
Pulse:54 Resp:18 O2 sat:99/RA
B/P Right:170/71 Left:167/75
Height:5'8.5"" Weight:180 lbs
General:NAD, alert and cooperative
Skin: Dry [s] intact [s]
HEENT: PERRLA [s] EOMI [s]
Neck: Supple [s] Full ROM [s]
Chest: Lungs clear bilaterally [s]
Heart: RRR [s] Irregular [] No Murmur
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: +2 Left:+2
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:+2 Left:+2"
4124,"Medications - OTC
ASPIRIN [ASPIRIN [**Hospital1 **]] - (Prescribed by Other Provider) -
81 mg Tablet, Chewable - 2 Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN WITH IRON-MINERAL [CENTRUM] - (Prescribed by Other
Provider) - Dosage uncertain
VIT A,C & E-NIAC-B2-LUT-MN-GLU [EYE-VITE] - (Prescribed by
Other Provider) - Dosage uncertain
Discharge Medications:
1. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day: hold for
K+ > 4.5.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months."
4125,"Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema [**1-19**]+ pitting
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
4126,"5* PTT-30.9 INR(PT)-1.3*
[**2172-4-29**] 04:35AM BLOOD Glucose-112* UreaN-26* Creat-0.9 Na-139
K-4.2 Cl-103 HCO3-30 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 97345**] was a same day admit and on [**4-22**] was brought to the
operating room where he underwent a coronary artery bypass graft
x 3. Please see operative report for surgical details. While in
the OR urology place a Foley under cystoscopy for a false
passage which is to remain in place for 5 days. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition."
4127,"He was found to have an occluded RCA, a
60% LAD lesion and some disease in the marginal vessel. He has
been managed medically since then and had been doing well until
this past year when he started to experiencing progressive
dyspnea with exertion. He describes shortness of breath which
occurs when he walks outside about one block or after climbing 2
flights of stairs. He denies any dyspnea at rest. He had a
stress MIBI done on [**2172-3-17**] at Dr.[**Name (NI) 9388**] office. He exercised
for 6.5 minutes to a heart rate of 100bpm. No significant EKG
changes noted."
4128,"Mild to moderate ([**1-19**]+) mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**4-22**]/2011at 1530.
Post bypass: Immediately post bypass there was severe mitral
regurgitation associated with elevated PA pressures. Dr [**Last Name (STitle) **]
aware of findings. With time the mitral regurgitation settled to
2+. The LVEF= 50%. Aorta is intact post decannulation.
[**2172-4-29**] 04:35AM BLOOD WBC-12.3* RBC-3.18* Hgb-10.1* Hct-29.0*
MCV-91 MCH-31.6 MCHC-34.6 RDW-14.2 Plt Ct-243
[**2172-4-22**] 07:33PM BLOOD PT-14."
4129,"10. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
11. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
13. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day)."
4130,"He continued to make steady progress and was discharged to
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Rehab on POD #7.
Target INR 2.0-2.5 for A Fib.
All f/u appts were advised.
NO BP cuffs on L arm
Pt should attempt to void every 2-3 hours and then re-attempt in
15 min if not successful.
Medications on Admission:
ATENOLOL [TENORMIN] - (Prescribed by Other Provider) - 25 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
DIVALPROEX [DEPAKOTE] - (Prescribed by Other Provider) - 250 mg
Tablet, Delayed Release (E.C.) - 2 (Two) Tablet(s) by mouth
three times a day
FELODIPINE - 10 mg Tablet Extended Release 24 hr - 1 Tablet(s)
by mouth once a day - No Substitution
ISOSORBIDE MONONITRATE - 30 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day - No Substitution
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once a day
PHENYTOIN SODIUM EXTENDED [DILANTIN EXTENDED] - (Prescribed by
Other Provider) - 100 mg Capsule - 2 (Two) Capsule(s) by mouth
twice a day
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
SOLIFENACIN [VESICARE] - (Prescribed by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth daily"
4131,"Admission Date: [**2172-4-22**] Discharge Date: [**2172-4-29**]
Date of Birth: [**2097-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2172-4-22**] Coronary artery bypass grafting x4/ cystoscopy
Left internal mammary artery graft to left anterior
descending; reverse saphenous vein to the marginal branch,
ramus intermedius branch, diagonal branch.
History of Present Illness:
75 year old gentleman has a history of a prior inferior
infaction at age 52 in approximately [**2149**] that was managed
medically. In [**2162**], he had a cardiac catheterization which
showed multivessel CAD."
4132,"3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. phenytoin sodium extended 200 mg Capsule Sig: One (1) Capsule
PO twice a day."
4133,"Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. His seizure
medications were restarted. He was started on beta-blockers and
diuresed towards pre-op weight. He transferred to the step-down
floor for further care. Chest tubes and epicardial pacing wires
were removed per protocol. On [**2172-4-25**] he remained hypertensive
and amlodipine was re-started in addition to lisinopril with
hydralazine prn. Urology was reconsulted for leakage around
foley. He tolerated a cardiac diet. Pain was well controlled
with oral analgesics. He was followed by physical therapy who
recommended rehab. He went into brief bursts of A Fib as well
as developing a LUE vein thrombus and was started on coumadin."
4134,"Carotid Bruit Right: none Left:none
Pertinent Results:
[**2172-4-22**] Echo: Prebypass: No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened."
4135,"Ht: 66
(estimated)
Admit wt: 75kg
116% IBW/ BMI = 26.6
Previous wt [**4-25**]) 78.6kg
Diet: regular; NPO for procedure
Meds/Labs: noted
Potential for nutrition risk. Patient being monitored. Current
intervention if any, listed below:
80 YO male with right hemidiaphragm paralysis, COPD, bronchiectais and
tracheal malacia with stent placed in [**2144**]. Presented with low grade
fevers, increased cough from pulmonary rehab to outside hospital.
Transferred to [**Hospital1 5**] for further management. (+) focal findings on
x-ray, no evidence of fibrosis on CT scan and it is more suggestive of
bronchiectasis and tracheal malacia. Patient currently off floor for
replacement of [**Location (un) 6045**] cannula trach (originally placed [**5-30**]).
Patient was taking small amount of po
s; NPO for procedure.
Recommendations:
1. resume regular diet when medically feasible
2. lytes and BS management
3. Will follow up to check diet advancement and po
s; page if
questions *[**Numeric Identifier 606**]"
4136,"He recalls
breathing worsened day prior to admission. Denies any chest discomfort,
abdominal discomfort, diarrhea, dysuria.
Allergies:
Opioid Analgesics
Confusion/Delir
Sulfa (Sulfonamides)
Unknown;
Tetanus
Unknown;
Benzodiazepines
Confusion/[**Hospital 6307**]
Rehab meds
Levofloxacin 500mg daily 5/11start
Saline nebs QID between dunebs
Duonebs QID
Mucomyst 10% 4cc nebs TID
Omeprazole 20 daily
Velafaxine XR 37.5 daily
Warfarin 6mg daily
Neurontin 400mg TID
Lisinopril 5mg daily
Lidoderm patch
Folate, Colace, Guiafenesin, Mag Oxide, Miconazole
Past medical history:
Family history:
Social History:
COPD with recent exacerbations in [**12-24**] and [**2-26**].
pulmonary fibrosis ([**9-/2146**]: FVC: 49%, FEV1: 59%, restrictive
pattern)
tracheobronchomalacia s/p Y stent 3 years ago
PVD s/p right femoral artery bypass
HTN
sleep apnea on bipap: 12 inspiratory/6 expiratory
renal artery stenosis
chronic kidney disease
Parkinsonism
coronary atherosclerosis (stress test [**4-/2147**]: No anginal type
symptoms or ischemic EKG changes, 57% Max HR achieved)
hyperlipidemia
depression/ anxiety
pulmonary nodule
paralyzed right hemidiaghragm per daugther's report
H/O PNA in [**2147**], requiring intubation
H/O R foot cellulitis
DJD
s/p spinal surgery with hardware
n/c
Occupation: retired
Drugs:
Tobacco: remote history, 20 pack years
Alcohol:
Other:
Review of systems:
See HPI
Flowsheet Data as of [**2148-5-28**] 12:49 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37."
4137,"2. Fever
Suspect due pulmonary infection, as above. No diarrhea to suggest C
diff, UA without evidence of UTI. Other noninfectious causes such as PE
seem less likely.
- Pulmonary workup as above
- UA/UCX, blood cultures
.
3. Acute on chronic renal failure
Labs suggestive of a pre-renal picture in setting of diuresis, poor PO
- Hold on further diuresis
- Urinalysis, urine electrolytes
- Follow urine output, renally dose meds
- Hold lisinopril
.
4. HTN
Holding lisinopril in setting of elevated Cr. Continue diltiazem.
.
5. Parkinsons
Continue home Sinemet
.
6. PVD s/p stent
Continue home warfarin, ASA, statin. Will discuss need for warfarin
with vascular.
.
7. Depression/Anxiety
Continue duloxetine
.
8. Hyperlipidemia
Continuing home statin
ICU Care
Nutrition:
Comments: regular diet, NPO after midnight for ?bronch
Glycemic Control: Blood sugar well controlled
Lines:
20 Gauge - [**2148-5-28**] 12:00 PM
Comments: place 2nd PIV
Prophylaxis:
DVT: (Systemic anticoagulation: Coumadin)
Stress ulcer: PPI
VAP: HOB elevation
Communication: with Daughter
[**Name (NI) 156**] status: Full code
Disposition: ICU"
4138,"7
C (99.8
Tcurrent: 37.7
C (99.8
HR: 102 (101 - 103) bpm
BP: 123/64(79) {106/54(64) - 123/64(79)} mmHg
RR: 24 (24 - 28) insp/min
SpO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
500 mL
PO:
TF:
IVF:
500 mL
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
500 mL
Respiratory
O2 Delivery Device: Aerosol-cool
SpO2: 97%
ABG: 7.43/38/150//1
PaO2 / FiO2: 300
Physical Examination
Vitals 99.8 102 123/64 24 97% on 50% facemask
General Mildly tachypneic, but able to converse
HEENT Sclera anicteric, dry MM
Neck No JVD
Pulm Bilateral rales minimal on R, coarse on L
CV Mildly tachy regular S1 S2 no m/r/g appreciated
Abd Soft nontender +bowel sounds nontender
Extrem Warm no edema palpable distal pulses
Neuro Alert and awake, following commands
Lines/tubes/drains Foley, PIV
Labs / Radiology
CBC 13>31<267 N 86 no bands
Chem 134/4."
4139,"Chief Complaint: dyspnea
HPI:
Mr. [**Known lastname **] is an 80M with COPD, pulmonary fibrosis, and h/o TBM s/p
tracheal stent [**2144**] who presents with respiratory distress. Of note he
was recently admitted to the medical service [**Date range (1) 6306**] with increased
respiratory distress, felt at that time to be due to mucous plugging.
He received ceftriaxone and azithromycin during this admission, which
were stopped prior to discharge and respiratory status was improved by
discharge. Patient developed increased cough [**5-27**] and started on
levofloxacin as an outpatient without significant improvement. He was
initially evaluated at an OSH where vitals were 98."
4140,"6/96/25/33/1.5<96 prior Cr [**4-25**] was 1.2
CK 106, Tropn 0.03
BNP 972
INR 2.6 PTT 33
UA no wbc
Blood cx pending
Sputum gram stain + cx pending
ABG 7.43 38 150 26, lactate 0.9 on 50% facemask
CXR official read pending - elevated R hemidiaphram, L CP angle not
well seen with possible infiltrate, increased vascularity
.
EKG SR @114, nl axis, RBBB +PVCs similar to prior
poor baseline
[**2145-1-18**]
2:33 A5/12/[**2148**] 11:02 AM
[**2145-1-22**]
10:20 P
[**2145-1-23**]
1:20 P
[**2145-1-24**]
11:50 P
[**2145-1-25**]
1:20 A
[**2145-1-26**]
7:20 P
1//11/006
1:23 P
[**2145-2-18**]
1:20 P
[**2145-2-18**]
11:20 P
[**2145-2-18**]
4:20 P
TC02
26
Assessment and Plan
This 80M with COPD, pulmonary fibrosis, Parkinsons, and TBM s/p
stenting returns with increased respiratory distress."
4141,"8 88 115/47 24 95%
on 4L. Given 40mg lasix - apparently without benefit. CBC there with
WBC 11.6, 19% bands per OSH records. He was transferred to [**Hospital1 5**] for
further management.
.
In the ER, vitals were 100.9 114 148/76 98% 3L -> 100% on BiPAP. Exam
with rhonchi with supraclavicular retractions. CXR showing mild
pulmonary edema. Given vanco, ctx in ED. Respiratory attempted
secretions but too thick. IP called - stent is in same place, plan for
scope in MICU. Started on BIPAP and admitted to MICU for further care.
.
On evaluation in the ICU, pt reports SOB is improved."
4142,".
1. Dyspnea
History concerning for possible pneumonia given fever and cough. His
CXR shows no clear infiltrate, which raises the possibility of an
atypical bacterial infection or viral pneumonia such as influenza. In
the setting of recent hospitalization and rehab, health care associated
pathogens much be addressed and could have been easily missed with
recent ceftriaxone, azithromycin. In setting of Parkinsons, may be
prone to aspiration. Other possibilities include recurrent mucous
plugging, COPD exacerbation. He certainly may have an element of HF.
ACS, PE seems less likely.
- Gram stain and culture of sputum, DFA with respiratory viral panel
- Urine legionella antigen, blood cultures
- Empiric vancomycin and Zosyn, plus levoflox (recently got azithro)
- Continue bronchodilators, mucomyst nebs
- Chest PT
- Check ABG
- PA/Lat CXR when stabilizes
- Hold on further diuresis for now
- Recheck BNP
- Consider swallow eval
."
4143,"CXR showing
mild pulmonary edema. Given vanco, ctx in ED, respiratory
attempted secretions but too thick. IP called - stent is in same
place, plan for scope in MICU. Started on BIPAP and admitted to
MICU for further care.
.
On evaluation in the ICU, pt reports SOB is improved. He recalls
breathing worsened day prior to admission. Denies any chest
discomfort, abdominal discomfort, diarrhea, dysuria.
Past Medical History:
- COPD with recent exacerbations in [**12-24**] and [**2-26**].
- Pulmonary fibrosis ([**9-/2146**]: FVC: 49%, FEV1: 59%, restr
pattern)
- Tracheobronchomalacia s/p Y stent in [**2144**]
- PVD s/p right femoral artery bypass
- OSA on bipap: 12 inspiratory/6 expiratory
- renal artery stenosis
- chronic kidney disease
- Parkinsonism
- coronary atherosclerosis (stress test [**4-/2147**]: No anginal type"
4144,"symptoms or ischemic EKG changes, 57% Max HR achieved)
- HTN
- hyperlipidemia
- depression/ anxiety
- pulmonary nodule
- paralyzed right hemidiaghragm per daugther's report
- H/O PNA in Fall [**2146**], requiring intubation
- H/O R foot cellulitis
- DJD
- s/p spinal surgery with hardware
Social History:
No currrent EtOH or tobacco. Prior smoking history was 50 years
ago, smoked for 1 ppd for 20 years. Normally lives at home but
was in rehab before coming in for this admission. Daughter is
very involved in his care and is a respiratory therapist.
Family History:
Denies family history of pulmonary problems.
Physical Exam:
On admission:
Vitals 99."
4145,"Pt evaluated w video speech and swallow, showed
Dysphagia Outcome
Severity Scale (DOSS) rating of level 5, mild dysphagia,
recommended repeat instrumental evaluation at rehab prior to
upgrading patient's diet or if patient continues to improve.
Tracheostomy capped on discharge, which the pt is tolerating
well. Oxygenating on room air > 93%.
.
# tracheostomy site: it was felt patient had a tracheostomy site
infection, was initiated on vancomycin on [**5-29**], with plan to
complete 10d course, to end [**6-8**].
.
# Acute renal failure: Cr 1.5 up from recent baseline of Cr ~1.
Likely prerenal in the setting of diuresis, poor PO intake and
acute processes (infection)."
4146,"Lisinopril was held until Cr
resolved to baseline. Cr=1 on discharge.
.
# HTN: SBP varied in the 100-160 range given acute
hospitalization. Mostly in the 130s on discharge on home regimen
(diltiazem, lisinopril).
.
# Anemia: normocytic, likely [**2-19**] ACD and possibly acute losses
from procedures. Stable at baseline Hct ~30 on discharge.
.
# PVD s/p stent: Coumadin held for tracheostomy, restarted on
[**2148-6-3**], will need INR monitoring and adjustments in dosing.
Patient's coumadin was initially held, then restarted [**6-3**] at
7.5mg. This will need to be followed at rehab, with goal inr 2
to 3."
4147,"- continue home ASA, statin
- continue coumadin - will need inr check until therapeutic
.
# Parkinson's dz: stable, continued home carbidopa/levodopa on
discharge.
.
# Hyperlipidemia: stable, continued home statin.
.
# Depression/Anxiety: stable, continued home venlafexine.
.
CODE STATUS: FULL
Communication: Daughter [**Name (NI) 1785**] ([**Telephone/Fax (1) **])
Medications on Admission:
Levofloxacin 500mg daily
Saline nebs QID between dunebs
Duonebs QID
Mucomyst 10% 4cc nebs TID
Omeprazole 20 daily
Velafaxine XR 37.5 daily
Warfarin 6mg daily
Neurontin 400mg TID
Lisinopril 5mg daily
Lidoderm patch
Folate, Colace, Guiafenesin, Mag Oxide, Miconazole
Discharge Medications:
1. Vancomycin in Dextrose 1 gram/250 mL Solution Sig: One (1)
Intravenous once a day for 4 days: to complete 10 d course,
began on [**5-29**], to end [**6-8**]."
4148,"25. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): will taper over next 14 days. see paperwork for taper
plan.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
health-care associated pneumonia
acute exacerbation of chronic obstructive pulmonary disorder
mucous plugging
.
peripheral vascular disease, s/p stenting
anemia
hypertension
Discharge Condition:
improved
Discharge Instructions:
You were admitted to the hospital for respiratory distress. We
think that it was likely caused by a combination of factors
including a lung infection, exacerbation of your COPD, and
possible mucous plugging in your airways. We treated you with
antibiotics, nebulizers, steroids, and tracheostomy."
4149,".
# DYSPNEA: Likely multifactorial from combination of HCAP
(fever, cough, infiltrate on CXR [**5-29**], leukocytosis), acute
exacerbation of COPD from infection (given wheezing, O2
requirement), possible recurrent mucous plugging given extensive
baseline pulmonary disease/bronchiectasis. Acute on chronic
systolic CHF exacerbation (LVEF 40% [**5-/2147**], mild pulm edema on
CXR at OSH) and aspiration in the setting of Parkinson's dz also
considered, esp w witnessed aspiration of chicken broth as
inpatient. ACS/PE seemed less likely, cardiac enzymes negative.
Sputum grew GNRs and Proteus, for which Meropenem was started
for a 10-day course ([**Date range (1) 51975**]). Blood cxs negative."
4150,"Bronchoscopy was performed and pt taken to the OR for
tracheostomy and T-tube placement for suctioning. Necrotic skin
was seen around the incision, hence vancomycin was started for a
10-day course ([**Date range (1) 72760**]). The COPD exacerbation was treated
with prednisone initially with 40mg, with plan for taper over 15
days. Taper should begin on [**6-5**] at 20mg through [**6-7**], then
10mg on [**6-8**] to [**6-10**], then 5mg on [**6-11**] to [**6-13**], then 2mg [**6-14**] to
[**6-16**], then 1mg [**6-17**] to [**6-19**]. Patient was also treated with
bronchodilators/acetylcysteine nebs and supplemental oxygen as
needed."
4151,"14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until more fully functional at
rehab. course to be decided by MD.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
16. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: do not exceed 4g/d.
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous [**Hospital1 **] (2 times a day).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation."
4152,"Admission Date: [**2148-5-28**] Discharge Date: [**2148-6-4**]
Date of Birth: [**2068-1-6**] Sex: M
Service: MEDICINE
Allergies:
Opioid Analgesics / Sulfa (Sulfonamides) / Tetanus /
Benzodiazepines
Attending:[**First Name3 (LF) 9415**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
tracheostomy ([**Location (un) **] button and T-stent placement)
History of Present Illness:
Mr. [**Known lastname **] is an 80M with COPD, pulmonary fibrosis, and h/o TBM s/p
tracheal stent [**2144**] who presents with respiratory distress. Of
note he was recently admitted to the medical service [**Date range (1) 12721**]
with increased respiratory distress, felt at that time to be due
to mucous plugging."
4153,"MICRO:
Blood cx - NEGATIVE
Sputum cx - sparse GNRs, rare Proteus
Urine Cx - NEGATIVE
Urinary Legionella Ag - negative
Resp viral screen: ADENO,PARAINFLUENZA 1,2,3 INFL A,B AND RSV -
NEGATIVE
.
EKG SR @114, nl axis, RBBB +PVCs similar to prior poor baseline
.
RADIOLOGY:
CXR ([**5-28**]):
1. Mild CHF.
2. Tracheal stent appears to lie slightly to the left relative
to the
tracheal contour. A CT of the chest is suggested to exclude a
tracheal stent migration.
.
CXR ([**5-29**]):
Evolving airspace change, particularly in the right mid zone
suggestive of
pneumonia. Generalized peribronchial cuffing suggestive of
left heart decompensation."
4154,"1 MCHC-33.9 RDW-16.2* Plt Ct-267
[**2148-5-30**] 02:37AM BLOOD Neuts-89.8* Lymphs-6.0* Monos-4.1 Eos-0.1
Baso-0
[**2148-6-4**] 05:16AM BLOOD PT-13.8* PTT-30.3 INR(PT)-1.2*
[**2148-6-4**] 05:16AM BLOOD Plt Ct-225
[**2148-5-30**] 02:37AM BLOOD PT-18.0* PTT-27.1 INR(PT)-1.6*
[**2148-5-29**] 01:16PM BLOOD PT-24.9* PTT-34.7 INR(PT)-2.4*
[**2148-5-28**] 07:00AM BLOOD PT-26.5* PTT-32.8 INR(PT)-2."
4155,"8 102 123/64 24 97% on 50% facemask
General Mildly tachypneic, but able to converse
HEENT Sclera anicteric, dry MM
Neck No JVD
Pulm Bilateral rales minimal on R, coarse on L
wheezy bilaterally
CV Mildly tachy regular S1 S2 no m/r/g appreciated
Abd Soft nontender +bowel sounds nontender
Extrem Warm no edema palpable distal pulses
Neuro Alert and awake, following commands
Lines/tubes/drains Foley, PIV
Pertinent Results:
LABS ON ADMISSION:
[**2148-5-28**] 07:00AM BLOOD WBC-13.0* RBC-3.65* Hgb-10.6* Hct-31.3*
MCV-86 MCH-29.1 MCHC-33."
4156,"Your
condition has improved.
.
If you have fevers, chills, shortness of breath, chest pain,
abdominal pain, or any other concerning symptoms, please call
your physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Please follow up with your providers:
1. Dr [**First Name (STitle) 75120**] [**First Name (STitle) **] (primary care): [**2148-6-17**] @ 2pm - [**Telephone/Fax (1) 75119**].
2. Dr [**Last Name (STitle) **] (pulmonary): [**Hospital **] CLINIC INTERVENTIONAL PULMONARY
(SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2148-7-8**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2148-7-8**]
10:30
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2148-7-8**] 10:00"
4157,"03*
[**2148-6-4**] 05:16AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.9
[**2148-5-28**] 07:00AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.7 Cholest-144
[**2148-5-28**] 07:00AM BLOOD Triglyc-63 HDL-48 CHOL/HD-3.0 LDLcalc-83
[**2148-5-29**] 01:16PM BLOOD Vanco-5.0*
[**2148-5-29**] 09:43AM BLOOD Type-ART pO2-73* pCO2-38 pH-7.42
calTCO2-25 Base XS-0
[**2148-5-29**] 09:43AM BLOOD Lactate-0.7
Brief Hospital Course:
In brief, Mr [**Known lastname **] is an 80M w COPD (on home Bipap)), pulmonary
fibrosis, and tracheobronchomalacia s/p Y-stent in [**2146**], PVDz
s/p LE stenting on Warfarin, Parkinson's dz, and recent
admissions for similar complaints, who was admitted with
increased respiratory distress, s/p MICU stay."
4158,".
CXR ([**5-31**]):
FINDINGS: New tube overlies the proximal trachea and may reflect
a
tracheostomy tube. Preexisting Y-stent within the trachea and
main bronchi
appear unchanged. Interval worsening of pulmonary edema as well
as slight
progression in degree of right lower lobe atelectasis with
associated
elevation of right hemidiaphragm. Probable adjacent small right
pleural
effusion. No pneumothorax or pneumomediastinum.
.
CXR ([**6-1**]):
FINDINGS: Tracheostomy tube and Y-stent remain in place in the
airways.
Interval improvement and pulmonary edema which is nearly
resolved, as well as improving aeration at the right lung base
with some residual minor atelectasis remaining as well as a
persistent elevation of right hemidiaphragm."
4159,"9 RDW-16.2* Plt Ct-267
[**2148-5-28**] 07:00AM BLOOD Neuts-85.5* Lymphs-8.8* Monos-4.2 Eos-0.9
Baso-0.6
[**2148-5-28**] 07:00AM BLOOD PT-26.5* PTT-32.8 INR(PT)-2.6*
[**2148-5-28**] 07:00AM BLOOD Glucose-96 UreaN-33* Creat-1.5* Na-134
K-4.6 Cl-96 HCO3-25 AnGap-18
[**2148-5-28**] 07:00AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.7 Cholest-144
[**2148-5-28**] 07:00AM BLOOD Triglyc-63 HDL-48 CHOL/HD-3.0 LDLcalc-83
."
4160,"He received ceftriaxone and azithromycin
during that admission, which were stopped prior to discharge and
respiratory status was improved by discharge. Patient developed
increased cough [**5-27**] and started on levofloxacin as an
outpatient without significant improvement. He was initially
evaluated at an OSH where vitals were 98.8 88 115/47 24 95% on
4L. Given 40mg lasix - apparently without benefit. CBC there
with WBC 11.6, 19% bands per OSH records. He was transferred to
[**Hospital1 18**] for further management.
.
In the ER, vitals were 100.9 114 148/76 98% 3L -> 100% on BiPAP.
Exam with rhonchi with supraclavicular retractions."
4161,"Minimal patchy
opacity at the left base also likely represents atelectasis,
accompanied by a small pleural effusion.
.
[**2148-6-4**] 05:16AM BLOOD WBC-11.7* RBC-3.63* Hgb-10.4* Hct-31.7*
MCV-88 MCH-28.6 MCHC-32.7 RDW-16.3* Plt Ct-225
[**2148-5-31**] 04:52AM BLOOD WBC-17.0* RBC-3.30* Hgb-9.8* Hct-28.1*
MCV-85 MCH-29.6 MCHC-34.7 RDW-16.6* Plt Ct-251
[**2148-5-28**] 07:00AM BLOOD WBC-13.0* RBC-3.65* Hgb-10.6* Hct-31.3*
MCV-86 MCH-29."
4162,"LABS ON DISCHARGE:
...
.
URINE:
[**2148-5-28**] 03:12PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2148-5-28**] 03:12PM URINE RBC-0-2 WBC-[**12-6**]* Bacteri-NONE
Yeast-NONE Epi-0-2
[**2148-5-28**] 03:12PM URINE Eos-NEGATIVE
[**2148-5-28**] 03:12PM URINE Hours-RANDOM UreaN-334 Creat-35 Na-78
[**2148-5-28**] 07:00AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2148-5-28**] 07:00AM URINE RBC-0-2 WBC-0 Bacteri-RARE Yeast-NONE
Epi-[**3-21**]
."
4163,"20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing, sob.
21. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for neck pain for 7 days: in lieu of
lidocaine patch if not working.
22. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
23. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
24. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM."
4164,"2. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 4 days: to end 10d course on
[**6-8**], start date [**5-29**].
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust."
4165,"6*
[**2148-6-4**] 05:16AM BLOOD Glucose-87 UreaN-25* Creat-0.9 Na-139
K-4.3 Cl-103 HCO3-29 AnGap-11
[**2148-5-29**] 04:15AM BLOOD Glucose-146* UreaN-33* Creat-1.4* Na-137
K-4.1 Cl-102 HCO3-23 AnGap-16
[**2148-5-29**] 04:15AM BLOOD CK(CPK)-95
[**2148-5-28**] 03:23PM BLOOD CK(CPK)-127
[**2148-5-28**] 07:00AM BLOOD CK(CPK)-106
[**2148-5-29**] 04:15AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2148-5-28**] 03:23PM BLOOD CK-MB-5 cTropnT-0.03*
[**2148-5-28**] 07:00AM BLOOD CK-MB-6 proBNP-972*
[**2148-5-28**] 07:00AM BLOOD cTropnT-0."
4166,"Release 24 hr PO DAILY (Daily).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Trifluridine 1 % Drops Sig: One (1) Drop Ophthalmic Q4H
(every 4 hours).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 7
days.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
4167,"Admission Date: [**2128-4-8**] Discharge Date: [**2128-4-13**]
Date of Birth: [**2061-7-1**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
perirectal abscess
Major Surgical or Invasive Procedure:
drainage of perirectal abscess on [**4-8**]
History of Present Illness:
66M transferred from [**Hospital1 18**] [**Location (un) 620**] with 4 weeks of
perirectal pain and purulent drainage from his rectum. Patient
didnt go to the ED before with the hope that this would resolve,
but pain has been steady and worsening during the past 3 days.
The purulent drainage started 3 weeks ago, associated with
fevers, chills and diaphoresis, and it has been increasing
during
the past week."
4168,"Patient went to [**Location (un) **] ED and was found to have
a
T 102.2, a WBC of 12 and Glucose of 490 requiring insulin
boluses. Here on arrival with new onset of A.Fib with RVR up to
150s.
Past Medical History:
HTN, CHF, DM, GERD
Social History:
Smoker of 1 1/5 packs a day for 30 years. Drinks
EtOH occasionally.
Family History:
mother had [**Name2 (NI) 499**] cancer in the 60s.
Physical Exam:
ON DISCHARGE:
Vitals: 98.8 77 154/80 18 96% RA
GEN: A&O, NAD
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds
RE: drainage coming out of the rectum around penrose drain."
4169,"No
erythema. Slightly TTP (appropriate). no fluctuant masses
Ext: No LE edema, LE warm and well perfused dependent rubor
Pertinent Results:
CT pelvis [**4-12**]:
1. Interval perirectal abscess drainage without residual fluid
collection. The drain remains in place.
2. Mild-to-moderate proctocolitis.
3. Chondroid lesion in the right iliac bone which has a benign
appearance and might represent an enchondroma. If the patient
complains of regional pain this could be further evaluated with
MRI to exclude a more aggressive lesion
Brief Hospital Course:
Mr. [**Known lastname 17811**] was admitted to the ACS surgery service for [**Known lastname **]
of the perirectal abscess."
4170,"The CT showed that the abscess was adequately drained.
Cardiology was consulted for assistance in [**Last Name (un) **] of the
paroxysmal atrial fibrillation. They recommended continuation of
home Metoprolol XL 100mg PO daily, anti-coagulation for
paroxysmal AF, [**Doctor Last Name **] of Heart Monitor on discharge, f/u with
cardiology in [**3-24**] weeks, continuing ASA, ACEI and statin for
CHF.
He was discharged in good condition, tolerating a regular diet,
afebrile, ambulating, pain well controlled.
Medications on Admission:
furosemide 40 mg daily, omeprazole 20 mg daily, simvastatin 40
mg daily, metoprolol succinate ER 100 mg daily, actos 45 mg Tab
daily, aspir-81 81 mg daily, lisinopril 40 mg daily, glipizide
20 mg [**Hospital1 **]"
4171,"On [**4-8**] he underwent an I/D of the
large perirectal abscess and placement of a penrose drain.
Intraop he was in afib with RVR and was transferred to the ICU
for [**Month/Year (2) **]. The following day, he was hemodynamically stable
and was in NSR with betablocker so he was transferred to the
floor. He was put on broad spectrum antibiotics. He was also
having significant hyperglycemia requiring insulin boluses.
[**Last Name (un) **] was consulted for glycemic control. Also, nutrition was
consulted for diabetic diet education. The atrial fibrillation
recurred postoperatively after a brief period in NSR. A CT scan
was obtained to rule out ongoing infection/undrained perirectal
abscess."
4172,"7. insulin syringes (disposable) 1 mL Syringe Sig: syringe
Miscellaneous four times a day.
Disp:*100 syringes* Refills:*12*
8. insulin safety needles (disp) 29 x [**12-21**] Needle Sig: needle
Miscellaneous four times a day.
Disp:*100 needle* Refills:*2*
9. glucometer Sig: glucometer four times a day.
Disp:*1 glucometer* Refills:*0*
10. test strips Sig: for glucometer four times a day.
Disp:*100 test strips* Refills:*2*
11. Lantus 100 unit/mL Cartridge Sig: Twenty Six (26) units
Subcutaneous at bedtime.
Disp:*30 cartridge* Refills:*2*
12. Humalog KwikPen Subcutaneous
13. insulin sliding scale
check blood glucose 4 times a day."
4173,"Take 26 units of lantus every
night.
Blood glucose 100-160 take 10 units of Humalog
Blood glucose 161-200 take 13 units of Humalog
Blood glucose 201-240 take 16 units of Humalog
Blood glucose 241-280 take 19 units of Humalog
Blood glucose 281-320 take 22 units of Humalog
Blood glucose 321-360 take 25 units of Humalog
Blood glucose >360 seek medical attention
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
perirectal abscess
diabetes
paroxysmal atrial fibrillation
Discharge Condition:
MS: intact. Alert and oriented x 3
Ambulating
Discharge Instructions:
-You have a perirecatal abscess."
4174,"A penrose drain was placed to
facilitate drainage of the abscess and allow for it to heal
properly. The penrose drain will be removed in surgery clinic.
In order to ensure that this heals well, you must control your
diabetes and see a primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of the
diabetes. You also developed atrial fibrillation or an irregular
heart rate. Cardiology wants you to have a heart monitor and
start anticoagulation. You should follow up with them for
[**Last Name (Titles) **] of the atrial fibrillation.
Followup Instructions:
-Follow up with a primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of diabetes
and atrial fibrillation
-Follow up with Cardiology for [**Last Name (Titles) **] of atrial fibrillation
in [**3-24**] weeks. Call for an appointment [**Telephone/Fax (1) **]
-Follow up in [**Hospital 2536**] clinic in [**12-21**] weeks. Call for an appointment.
[**Telephone/Fax (1) 600**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]"
4175,"Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day."
4176,"Admission Date: [**2164-9-19**] Discharge Date: [**2164-9-30**]
Date of Birth: [**2082-8-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fatigue/DOE/CHF
Major Surgical or Invasive Procedure:
[**2164-9-24**] - 1. Aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna
aortic valve bioprosthesis. 2. Coronary artery bypass grafting
x2, left internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein single graft from the
aorta to the posterior descending coronary artery.3. Concomitant
right carotid endarterectomy performed by Dr. [**Last Name (STitle) **] and
dictated separately."
4177,"[**2164-9-20**] - Cardiac catheterization
History of Present Illness:
82 year old woman with complex past medical history including
PVD, aortic stenosis, and mitral regurgitation who has been
experiencing worsening fatigue, dyspnea on exertion, and
congestive heart failure. She has had several failed
catheterizations secondary to severe PVD (femoral, radial,
brachial). SHe is now admitted for cardiac catheterization and
surgical management of her valvular and coronary artery disease.
Past Medical History:
Dyslipidemia
Hypertension
aortic stenosis
Mitral regurgitation
PVD
COPD
Depression
Osteoporosis
Chronic systolic dysfunction
Social History:
Sheis retired. She is edentulous and therefore will not require
dental clearance. She is a 55-pack year history of smoking."
4178,"Diagnsotic catheterization on [**2164-9-20**]
showed 80% mid and distal LAD, 60% mid LCX, and a complicated
99% calcified proximal RCA lesion. An aortogram was performed at
the end of the procedure and revealed severe aorto-iliac disease
extending into her Profunda and Superficial femoral arteries
bilaterally. Also on [**2164-9-20**] patient had carotid duplex scans
that revealed severe 80-99% right ICA stenosis, 60-69% left ICA
stenosis and a high-grade left external carotid artery stenosis.
The vascular surgery service was consulted who recommended a
concommittant right carotid endarterectomy. As she had right
upper quadrant tenderness, a right upper quadrant ultrasound was
obtained which showed a dilated common bile duct which was not
an uncommon finding after cholecystectomy."
4179,"10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p AVR/CABG
Carotid Disease - s/p Right CEA
PMH: PVD, HTN, Hyperlipidemia, History of MI, MR, CHF(chronic,
systolic), COPD"
4180,"She initially required atrial
pacing for an underlying junctional rhythm/sinus node
dysfunction, for which beta blockade was initially withheld. She
otherwise maintained stable hemodynamics and transferred to the
SDU on postoperative day two. On POD 5 the patient developed
atrial fibrillation. She was treated with lopressor 5mg IVP and
started on lopressor 12.5mg PO. Approximately one hour after
initiation of therapy, the patient converted to sinus rhythm,
with a long (22second) conversion pause. The patient's nurse
was in the room, witnessed this long pause, and chest
compressions were initiated. The patient came to immediately.
Follow up CXR reveals no rib fractures."
4181,"No other
abnormalities were seen. On [**2164-9-24**], Ms. [**Known lastname 7568**] was taken to the
operating room where she underwent an aortic valve replacement
with a 21-mm [**Doctor Last Name **] Magna aortic valve bioprosthesis, two
vessel coronary artery bypass grafting and a concomitant right
carotid endarterectomy performed by Dr. [**Last Name (STitle) **]. Please see
operative notes from both vascular and cardiac surgery for
details. Postoperatively she was transferred to the cardiac
surgical intensive care unit for further monitoring. Within 24
hours, Ms. [**Known lastname 7568**] [**Last Name (Titles) 5058**] neurologically intact and was extubated.
She was transfused with PRBCs for postoperative anemia and to
maintain hematocrit near 30%."
4182,"She had mild clubbing. Her head was normocephalic and
atraumatic. Pupils were equally, round, and reactive to light.
Sclerae were anicteric. Oropharynx was benign. She was
edentulous. Her neck was supple with full range of motion and
no
JVD. Carotid bruits were present on both sides. She had
bibasilar crackles left greater than right and barrel chest
consistent with COPD. Heart was regular in rate and rhythm with
a grade III/VI systolic ejection murmur and grade I/VI diastolic
murmur with S1 and S2 tones present. She had right upper
quadrant tenderness today in the office with mild hepatomegaly."
4183,"0
LEUK-NEG
[**2164-9-19**] 09:34PM PT-13.7* PTT-25.4 INR(PT)-1.2*
[**2164-9-19**] 09:34PM WBC-6.9 RBC-3.07* HGB-9.6* HCT-29.3* MCV-96
MCH-31.3 MCHC-32.8 RDW-17.8*
[**2164-9-19**] 09:34PM ALT(SGPT)-19 AST(SGOT)-24 ALK PHOS-69 TOT
BILI-0.3
[**2164-9-19**] 09:34PM GLUCOSE-127* UREA N-41* CREAT-1.3* SODIUM-140
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
[**2164-9-19**] Abdominal U/S
Status post cholecystectomy. Common bile duct is dilated, which
is not an uncommon finding after cholecystectomy."
4184,"The patient remained
stable in normal sinus rhythm for the next 24 hours. She was
discharged in good condition to rehab on POD 6.
Medications on Admission:
ASA 81', zocor 40', protonix 40', toprol xl 25', hctz 25',
boniva 150 monthly, calcium, vit d, tylenol, duragesic patch 25
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Simvastatin 40 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)."
4185,"Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please call ([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. OK to shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-12**] weeks. [**Telephone/Fax (1) 74598**]
Completed by:[**2164-9-30**]"
4186,"4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours)."
4187,"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 moderately thickened. There is moderate to severe
aortic valve stenosis (area 0.8-1.0cm2). Moderate (2+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet.
6. Mild to moderate ([**1-11**]+) mitral regurgitation is seen.
Posterior leaflet appears slightly restricted, jet is central.
7. There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced."
4188,"1. A well-seated bioprosthetic valve is seen in the Aortic
position with normal leaflet motion and gradients (mean gradient
= 7 mmHg). No aortic regurgitation is seen.
2. LV function is unchanged.
3. MR is mild.
4. Other findings are unchanged.
[**2164-9-21**] Carotid duplex ultrasound
1. 80-99% right ICA stenosis.
2. 60-69% left ICA stenosis.
3. High-grade left external carotid artery stenosis.
[**2164-9-20**] Cardiac Catheterization
Showed 80% mid and distal LAD, 60% mid LCX, and a complicated
99% calcified proximal RCA lesion.
Brief Hospital Course:
Patient was admitted to the hospital on [**9-19**] for
pre-operative workup."
4189,"[**2164-9-24**] ECHO
PRE-BYPASS:
1. The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild regional
left ventricular systolic dysfunction with inferior basal
hypokinesis. Overall left ventricular systolic function is low
normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the ascending aorta."
4190,"She quit smoking last year. She does not use any alcohol at
this time. She is widowed and speaks only Greek.
Family History:
She has two sisters with hypertension but no premature coronary
disease.
Physical Exam:
On examination, her heart rate was 68. Respiratory rate was 12.
Blood pressure on the right was 134/50 not taken on the left due
to recent brachial artery attempts at catheterization. She was
5
feet tall weighing 110 pounds. Overall, she appeared to be
quite
frail elderly woman in no apparent distress. She was using a
cane to ambulate. Skin was warm and dry without any cyanosis or
edema."
4191,"Her extremities were warm and well perfused with very trace
peripheral edema and a little bit of mild clubbing on the left.
She had some ecchymosis of her abdomen from Heparin shots in the
hospital. She had noted varicosities. She was alert and
oriented x3 moving all extremities. Gait slow and steady using
the cane with 4/5 strength. She had 2+ bilateral femoral pulses
with a bruit present in her left femoral artery, trace DP
bilateral pulses, 1+ bilateral in the PTs, and 2+ bilateral
radial pulses.
Pertinent Results:
[**2164-9-19**] 08:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5."
4192,"Admission Date: [**2177-2-28**] Discharge Date: [**2177-3-18**]
Service: MEDICINE
Allergies:
Amiodarone / Lopressor / Aspirin / dofetilide
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
DC-CARDIOVERSION X 2
History of Present Illness:
Mrs [**Known lastname 4643**] is a pleasant 87F with hx of intermittent vertigo on
Meclizine, afib on coumadin, recent UTI tx'd with bactrim, now
presenting to the ED for vertigo. Pt states that 4 days ago she
noticed hematuria, which prompted her to go to her PCP, [**Name10 (NameIs) **] which
point she was given bactrim for a UTI. She never had dysuria or
frequency."
4193,"On arrival to the ICU, pt is comfortable. She states that her
breathing is slightly labored however she denies SOB, cough, CP.
She does feel slightly nauseous and weak all over. She does
not currently feel vertiginous, however states that it comes on
suddenly and she was recently feeling nauseous.
Past Medical History:
- Paroxysmal atrial fibrillation on Coumadin.
- Echo in [**2176-8-2**]: LVEF of 60-65%.
- R septic knee: hospitalized from [**2175-2-5**] to [**2175-2-10**] during which
she underwent arthrocentesis then I&D and washout on [**2175-2-5**]
followed by 14 day-course of ceftriaxone
- Breast cancer status post lumpectomy in [**2162-7-4**], also
with six weeks of radiation therapy."
4194,"- Chronic low back pain followed at the Pain Clinic.
- History of asthma: Spirometry: Mixed obstructive and
restrictive ventilatory defect. Since [**2171-5-7**], there is no
significant change in spirometry. Since [**2166-12-18**] TLC has
decreased 1.33L (28%).
- Exercise treadmill test echocardiogram in [**2162-8-3**] without
evidence of angina or ischemia after four minutes,
mild-to-moderate mitral regurgitation.
- Sick sinus syndrome with a DDI pacemaker placed.
- Herpes zoster in [**2168-3-5**].
- Hypertension
- ? Alzheimer's dementia
- recent rib fractures
Social History:
Pt lives at home with sister who was recently placed in rehab,
has home health aids."
4195,"Ambulates with a walker. Quit smoking 10
years ago after almost a decade of smoking, no ETOH, no
illicits. She has 6 children, she previously worked for the
phone company and at [**Last Name (un) 59330**]. One of her daughters is a nurse.
Family History:
Father died of heart disease.
Mother died of CVA.
Sister: Died of emphysema at age 59.
Physical Exam:
Admission Exam:
Vitals: T:94.4 BP:152/57 P:65 R:20 O2: 98% on 2 L NC
General: Aaox3, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: RIJ in place, fresh blood under dressing
Lungs: tachypnic, clear to auscultation bilaterally, mild
crackles in L base
CV: Distant heart sounds, irregular rate, unable to appreciate
any murmurs."
4196,"Anterior ST-T wave changes are more
pronounced. Clinical correlation is suggested.
Brief Hospital Course:
HOSPITAL COURSE: Pleasant 87 yo female presenting with
dizziness, hypotension concerning for sepsis initially requiring
pressors in the ICU, who was then called out to the cardiology
service with volume overload, AFIB and severe TR w/ RV
dilation. Underwent DCCV but continued to be in afib and had to
be transferred to the CCU for respiratory distress where she was
diuresed and then transferred back to the cardiology floor. She
was discharged to [**Hospital1 **] (LTAC).
ACTIVE ISSUES:
# Septic Shock: The pt was hypotensive on admission requiring
pressors with signs of end organ damage including acute renal
failure and shock liver."
4197,"Echo was then obtained, which showed severe
tricuspid regurgitation with complete lack of coaptation of
tricuspid leaflets. It was thought that this was likely the
cause of her shock, in addition to the infectious component that
had instigated her acute presentation (although no infectious
source was isolated during her hospital course). Therefore she
was gently diruresed with IV lasix back to her dry weight. She
continued to have intermittent respiratory difficulty likely [**3-6**]
COPD and fluid overload, which was alleviated with nebs and IV
lasix.
# Atrial fibrillation: On coumadin, supratherapeutic INR on
admission (see below). EKG initially showed intermittent pacing
with evidence of pacer spikes on t-waves."
4198,"125 every
other day. However, dig was also dc/ed and the pt was dc/ed on
verapamil alone with HR in 70s and 80s. The pacemaker was
changed from DDIR to VVI w/ a lower HR threshold of 50 bpm.
# Acute renal failure: Creatinine elevated to 1.9 on
presentation, up from previous baseline of 0.7-0.8 one year
prior. Etiology thought to be ATN vs hypotension/shock. Her
initial course was complicated by hyperkalemia with associated
widening of QRS and [**Last Name (LF) 5937**], [**First Name3 (LF) **] she was given kayexalate, insulin +
D50, and calcium gluconate."
4199,"Creatinine peaked at 2.9 with
minimal urine output, however renal function improved with
continued fluid resuscitation and support with pressors. Towards
the end of her stay she had another Cr spike (1.8 from 1.1)
which improved with gentle fluid resusciation. Her Cr at dc was
1.5.
# Dyspnea: Patient became acutely dyspneic after cardioversion
from Afib. She was transferred to the CCU for closer
monitoring. In the CCU, she was placed on a nitro gtt and
diuresed with lasix boluses. Her SOB was however multifactorial
but primarily d/t fluid overload vs COPD vs severe thoracic
kyphosis as she responded to both lasix and nebs."
4200,"Peaked at 9.7. No signs of bleeding,
so she was not given any reveral agents. Etiology of acute rise
presumed to be liver dysfunction in the setting of
hypotension/shock. However, pt has a hx of labile INR. Recieved
Vitamin K in the CCU and had hematuria which persisted a few
days after resolution of supratherpeutic INR. She was bridged
back to therapeutic range with lovenox. INR managment remained
challenging throughout her stay. At the time of dc her INR was
3.5 so her coumadin of 0.5 mg was held.
# Hematuria: pt continued to have gross hematuria."
4201,"Unrelated to
INR levels. Was worked up in the past w/ cystoscopy showing
bilateral diverticuli. She has been set up for follow up appt
with urologist for cystoscopy. Renal u/s done here was normal.
# Transaminitis: AST/ALT in the 400s on presentation, likely
due to acute injury from hypoperfusion (shock liver) vs.
congestive hepatopathy. Alkaline phosphatase and bili remained
within normal limits, supports this hypothesis. Transaminases
rose to the thousands prior to coming down after resolution of
sepsis.
# Anemia: Normocytic, near recent baseline of 34.3 on
presentation. Despite high INR, no signs of acute bleedn other
than known prior hematuria that continued intermittently
througout her stay."
4202,"Likely [**3-6**] chronic hematuria vs low marrow
production. Her retic count was normal, and SPEP was also
normal.
INACTIVE ISSUES:
# Dementia: stable; contined home meds mirtazepine and aricept
# GERD: continue home ranitidine
TRANSITIONAL ISSUES: Patient has a variety of specialist appts
that need to be followed up with. In case that she develops
dyspnea and does not respond to duonebs, IV lasix 40mg should be
given. Verapamil dose can be increased to 240 [**Hospital1 **] if rate
control or blood pressure managment becomes problem[**Name (NI) 115**]. Pt's
INR on the day of DC was 3.5 so her warfarin dose of 0."
4203,"5 tablets daily or as directed
-Tramadol 50 mg Oral Tablet [**2-3**] tab po qhs
-Loperamide (IMODIUM A-D) 2 mg Oral Tablet Take 1 tablet now,
then 1 tablet each 4 hrsfter each unformed stool as needed;
available over the counter
-? meclizine, dosage unknown
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
ATRIAL FIBRILLATION
ACUTE ON CHRONIC DIASTOLIC HEART FAILURE
HYPERTENSION
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]"
4204,"5 mg was
held. Please restart warfarin at 1 mg after the INR is in
therapuetic range.
Medications on Admission:
-Sulfamethoxazole-Trimethoprim 800-160 mg Oral Tablet TAKE 1
TABLET TWICE A DAY FOR 10 DAYS
-Lorazepam 0.5 mg Oral Tablet TAKE 1 TABLET AT BEDTIME
-Mirtazapine 15 mg Oral Tablet TAKE 1 TABLET AT BEDTIME
-Verapamil SR 12 HR 240 mg Oral Tablet Extended Release [**2-3**] po
QAM, and 1 po Qpm
-Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation
HFA Aerosol Inhaler Take 1 to 2 inhalations every 4 to 6 hours
as needed; rinse mouthpiece at least once a week
-Donepezil (ARICEPT) 10 mg Oral Tablet Take 1 tablet daily at
bedtime
-Lisinopril 40 mg Oral Tablet Take 1 tablet daily
-Flecainide 100 mg Oral Tablet [**Hospital1 **]
-Metoprolol Tartrate 50 mg Oral Tablet QD WITH ONE 25 MG TABLET
[**Hospital1 **]
-Metoprolol Tartrate 25 mg Oral Tablet 1 TABLET WITH 50 MG
TABLET [**Hospital1 **]
-Fluticasone (FLOVENT HFA) 110 mcg/Actuation Inhalation Aerosol
Use 1 inhalation by mouth twice daily and rinse your mouth
thoroughly afterward
-Furosemide 20 mg Oral Tablet TAKE ONE TABLET DAILY
-Ranitidine HCl 75 mg Oral Tablet Take 1 tablet twice daily;
available over the counter
-Warfarin 1 mg Oral Tablet Take 1."
4205,"[**2177-3-1**] TTE (Focused views): IMPRESSION: Limited transthoracic
echocardiography. Unable to assess regional wall motion
abnormalities due to limited study, but overall systolic
function of the left ventricle is probably normal. Severe
tricuspid regurgitation with failure of tricuspid leaflet
coaptation. Mild mitral regurgitation. Unable to fully assess
aortic valve.
Compared with the findings of the prior report (images
unavailable for review) of [**2173-4-12**], the tricuspid regurgitation
is now severe. If clinically indicated, a complete transthoracic
examination with Doppler is recommended.
[**2177-3-4**] Portable TTE: Compared with the prior study (images
reviewed) of [**2177-3-1**], estimated pulmonary artery systolic
pressure is now higher."
4206,"Today she felt vertiginous and lightheaded and
therefore presented to the ED. Pt states that he vertigo comes
on out of the blue, is not positional or worse with changing
positions. She states that she feels thirsty but has had normal
PO intake over the last several days. Of note, her UA from 4 d
PTA showed leuks, blood, few bacteria, creatinine was 0.87.
Urine cx showed mixed gram positive flora.
In the ED inital vitals were 98.7 60 92/68 (b/l 120/80) 18 100%
10L Non-Rebreather, which was rapidly weaned. Venous gas showed
7."
4207,"8
Baso-0.5
[**2177-2-28**] 07:15PM BLOOD PT-36.3* PTT-37.6* INR(PT)-3.5*
[**2177-2-28**] 07:10PM BLOOD Glucose-156* UreaN-31* Creat-1.9*#
Na-131* K-5.9* Cl-96 HCO3-17* AnGap-24*
[**2177-2-28**] 07:15PM BLOOD CK(CPK)-116
[**2177-2-28**] 07:15PM BLOOD CK-MB-2 proBNP-4420*
[**2177-2-28**] 07:20PM BLOOD cTropnT-<0.01
[**2177-3-1**] 03:57AM BLOOD CK-MB-2 cTropnT-<0.01
[**2177-3-1**] 03:57AM BLOOD Calcium-8.0* Phos-7.1*# Mg-2.1 Iron-44
[**2177-2-28**] 08:21PM BLOOD pO2-51* pCO2-48* pH-7."
4208,"Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: cool ext, thready pulses, no clubbing, cyanosis or edema
Skin: no rashes, L nipple scarred
Neuro: CNs [**3-16**] intact, moves all ext freely
Discharge Examination:
VS: Tc 98.0 BP 107-128/49-57 HR 69-79 RR 18 O2 96% on RA.
Wt: 66.4<--69.4<--69.6<--70.4<--70.1<--69.1<--70.3 kg.
GEN: pleasant elderly woman, NAD, AOX3. Looks a bit tired and
described some dizziness
CV: nl s1 + s2. Systolic mumur, most loudly auscultated in LUSB."
4209,"Cardiac silhouette is enlarged, accompanied by
pulmonary vascular engorgement. Previously reported multifocal
pulmonary opacities have partially cleared with residual
opacities mostly in the perihilar regions. This likely reflects
improving pulmonary edema. More confluent opacity in left
retrocardiac region has only slightly improved and is likely due
to a combination of atelectasis and effusion. Small right
pleural effusion has decreased in size.
[**2177-3-17**] EKG: Atrial fibrillation with controlled ventricular
response. Intermittent pacer spikes which do not capture
non-specific anterior and inferior ST-T wave changes. Modest Q-T
interval prolongation. Compared to tracing #1 ventricular paced
beats are absent."
4210,"However, the pt has a hx of not tolerating Amio
which was dc/ed and the pt underwent DCCV after transfer to the
floor. However, pt reverted back to AFIB and had to go to the
CCU for resp distress. QT prolongation prevented dofelitide from
being continued, and metoprolol was dc/ed as it was thought to
be worsening bronchospasm. At the time of discharge she was put
on a higher dose of verapamil (280 [**Hospital1 **]). DCCV was performed
again and she continued to be in afib. Flecainide was dc/ed due
to likely underlying CAD and was switched to digoxin 0."
4211,"Cardiology/EP consult
was obtained, and on pacemaker interrogation was noted to have
elevated thresholds above programmed output of leads leading to
intermittent capture. PPM was reprogrammed with higher output
and higher HR to 80s with appropriate capture. HR was increased
to improve cardiac output to more closely match physiologic
demand in setting of shock. She was started on dofetilide, but
this was discontinued due to QT prolongation. She was then
started on amiodarone and metoprolol. In the ICU, verapamil was
increased to 60mg TID and metoprolol was maintained at 50mg [**Hospital1 **].
In this setting, home lisinopril was held to give blood
pressure room."
4212,"RESP: pt has poor air entry; otherwise ctab. Some crackles in
left base.
EXTREMITIES: 2+ pulses in all 4 extremities. No peripheral
edema. Pt has a grade 1 stress ulcer on her left ankle.
Complaining of pain in ankle.
NEURO: AOX3, but does get confused intermittently. No neuro
deficits.
Pertinent Results:
Admission Labs:
[**2177-2-28**] 07:15PM BLOOD WBC-11.1* RBC-3.89* Hgb-11.6* Hct-35.9*
MCV-92 MCH-29.8 MCHC-32.3 RDW-13.8 Plt Ct-320
[**2177-2-28**] 07:15PM BLOOD Neuts-84.9* Lymphs-9.8* Monos-3.9 Eos-0."
4213,"[**2177-3-2**] LIVER OR GALLBLADDER US (SINGLE ORGAN) :
1. Cholelithiasis without evidence of cholecystitis.
2. Patent portal vein. Prominent hepatic veins likely due to
vascular
congestion.
3. Possible right renal fullness seen on partial views of right
kidney. If
indicated, this could be evaluated with renal ultrasound.
Renal U/s [**2177-3-12**]: Somewhat limited study however both kidneys
are within normal limits with good cortical thickness, no
hydronephrosis or mass lesions identified. The bladder is fully
decompressed around the Foley catheter.
[**2177-3-17**] CXR: Central venous catheter and permanent pacemaker
remain unchanged in position allowing for positional differences
of the patient."
4214,"26* calTCO2-23 Base
XS--5 Comment-GREEN TOP
[**2177-2-28**] 07:26PM BLOOD Lactate-5.3*
Discharge Labs:
[**2177-3-18**] 06:35AM BLOOD WBC-8.4 RBC-2.96* Hgb-8.5* Hct-26.7*
MCV-90 MCH-28.6 MCHC-31.6 RDW-14.5 Plt Ct-589*
[**2177-3-18**] 06:35AM BLOOD PT-36.3* INR(PT)-3.5*
[**2177-3-18**] 06:35AM BLOOD Glucose-83 UreaN-13 Creat-1.5* Na-138
K-3.6 Cl-94* HCO3-36* AnGap-12
[**2177-3-18**] 06:35AM BLOOD CK-MB-3 cTropnT-<0."
4215,"01
[**2177-3-17**] 02:06PM BLOOD CK-MB-3 cTropnT-<0.01
[**2177-3-18**] 06:35AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.6
[**2177-3-16**] 10:00PM BLOOD Ret Aut-2.6
[**2177-3-16**] 10:00PM BLOOD PEP-NO SPECIFI
Micro:
Blood cultures: NGTD
Urine culture: NGTD
Stool: -ve
Imaging:
[**2177-3-1**] CXR: Persistent low lung volume. Pulmonary edema has
resolved. Pacer leads are in standard position. Right IJ
catheter tip is in the upper right atrium. There is no evident
pneumothorax. Bilateral pleural effusions are small. Bibasilar
atelectases have improved on the left."
4216,"She was also
started on Fluticasone-Salmeterol Diskus (500/50). Torsemide was
started for po diuresis as she failed po lasix diuresis.
Lisinopril was restarted at 5mg. Her 02 requirement went up to
3L but she was comfortable on RA on dc. At discharge she was
stable on RA but patient prone to having acute episodes of
dyspnea that were alleviated with duonebs and IV lasix 40mg (if
the pt appeared overloaded on exam).
# Fluctuating INR: Pt presented on coumadin for Afib (INR goal
[**3-7**]); INR 3.5 on presentation in the ED but rapidly rose to 6.2
upon arrival in the ICU."
4217,"26/48/51. Triggered for hypotension (reportedly 50/30),
central line placed, pt given 500 ccs NS, bedside echo showed
adequate pump funx, no effusion. CVP reportedly 22. Labs were
notable for lactate of 5.3, creatinine 1.9, gap of 16. She was
given zofran, levofloxacin for possible PNA, and started on a
norepi gtt for hypotension. CXR showed central venous catheter
terminating at the cavoatrial junction, mild pulmonary vascular
congestion, l-sided pleural effusion. Line was pulled back.
BPs improved to 100s, no O2 requirement. VItals on transfer
were 98.7 64 17 97/67 100% on 2L NC."
4218,"Lactate was 5.3 on admission and rose
rapidly throughout her first day in the ICU peaking at 9. The
pt had a recent hx of UTI and there was a concern for urosepsis,
so she was started on broad antibiotics with vancomycin and
zosyn and receieved a 7 day course. On exam, however, she was
cold and clamped down peripherally, more concerning for a
cardiogenic process. Additionally, ECG was showing only
intermittent capture of pacemaker. Cardiology/EP was consulted,
and her pacemaker was interrogated and adjusted to improve
cardiac output in setting of shock and acidosis (see Atrial
Fibrillation below)."
4219,"Admission Date: [**2106-4-7**] Discharge Date: [**2106-4-15**]
Date of Birth: [**2023-7-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Levaquin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2106-4-8**] Aortic valve replacement and ascending aorta replacement
History of Present Illness:
This is an 82 year old male with known atrial fibrillation,
thoracic aortic aneurysm and aortic regurgitation. He has a
history of bactermia and possible endocarditis with aortic
regurgitation. Has been medically managed until now but is
developing worsening symptoms of shortness of breath. He is
admitted today for heparin bridge for an aortic valve
replacement."
4220,"Past Medical History:
Aortic regurgitation
Dilated aorta
Congestive heart failure
History of strep bacteremia ?endocarditis [**2104-3-27**]
Atrial fibrillation
Hypercholesterolemia
Hypertension
Prostate cancer [**2097**] s/p XRT c/b proctitis
Kidney stone
Gynecomastia
DVT or Thrombophlebitis [**2098**]
H Pylori s/p pylera
Vitamin D deficiency
Radiation enteritis/proctitis with occasional episodes of GI
bleeding
Macular Degeneration
s/p Hernia repair
s/p Prostatectomy
s/p Retinal laser
s/p Prostate Implant
Social History:
Race: Caucasian
Last Dental Exam: Dental clearance [**2106-1-13**]
Lives with: Wife
Occupation: Retired Military; retired VP Stop & Shop
Cigarettes/Tobacco: Denies, never a smoker
ETOH: < 1 drink/week [] [**2-2**] drinks/week [X] >8 drinks/week []
Illicit drug use: Denies"
4221,"endocarditis [**2104-3-27**]
Atrial fibrillation
Hypercholesterolemia
Hypertension
Prostate cancer [**2097**] s/p XRT c/b proctitis
Kidney stone
Gynecomastia
DVT or Thrombophlebitis [**2098**]
H Pylori s/p pylera
Vitamin D deficiency
Radiation enteritis/proctitis with occasional episodes of GI
bleeding
Macular Degeneration
s/p Hernia repair
s/p Prostatectomy
s/p Retinal laser
s/p Prostate Implant
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema +1
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon."
4222,"Follow-up appointments arranged.
Medications on Admission:
Atenolol 75mg [**Hospital1 **]
Digoxin 125mcg daily
Prednisone 5mg daily
Torsemide 20mg daily
Coumadin 4mg daily- stopped on [**2106-4-2**]
Vitamin D-3 daily
Discharge Medications:
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*1*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily)."
4223,"Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
4224,"Prednisone 5
mg was restarted which he has been taken for several years. His
pain was well controlled with acetaminophen and low-dose
narcotics. He was seen by physical therapy for strength and
mobility. On POD # 6 he was noted to have plebitis of left
upper extremity possibley related to amiodarone infusion. He was
started on PO keflex. In light of starting the antibiotic his
INR bumped slight and his coumadin was adjusted. This will need
to be monitored closely while he continues on the antibiotic. He
has continued to make steady progress and was ready for
discharge on POD #7."
4225,"Please see operative note for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Later this day he was
weaned from sedation, awoke neurologically intact and extubated.
He was started on beta-blockers, diuretics and gently diuresed
towards his pre-op weight. On post-op day one he was transferred
to the step-down floor for further care. Chest tubes and
epicardial pacing wires were removed per protocol. On POD2 he
developed rapid atrial fibrillation, loaded with IV/PO
amiodarone. His beta-blocker was titrated for rate control.
His Coumadin was restarted for his history of DVT."
4226,"Disp:*14 Tablet(s)* Refills:*0*
14. Demadex 20 mg Tablet Sig: One (1) Tablet PO once a day:
start lower dose in 0ne week [**2106-4-25**].
Disp:*30 Tablet(s)* Refills:*2*
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain, fever.
Disp:*30 Tablet(s)* Refills:*0*
16. warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 1 doses: take 3mg total for today only.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic regurgitation and dilated aorta s/p aortic valve
replacement and ascending aorta replacement
Past medical history:
Congestive heart failure
History of strep bacteremia ?"
4227,"Carotid Bruit Right: - Left: -
Pertinent Results:
Echo [**2106-4-8**]: PRE-BYPASS: 3D multiplanar reconstructions were
used for aortic root measurements. No spontaneous echo contrast
is seen in the body of the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. There is
mild left ventricular hypertrophy. The left ventricular cavity
is moderately dilated. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %). Right ventricular chamber size is
normal. with normal free wall contractility. The aortic root is
moderately dilated at the sinus level."
4228,"Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
7. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9."
4229,"A
tube graft is visualized in the ascending aorta. The study is
otherwise unchanged from prebypass.
IMPRESSION: Moderately dilated aortic sinuses measuring 5.0 cm
without effacement of the sinotubular junction. Ascending aorta
is moderately dilated to 4.8 cm and tapers down to 4.0 cm
distally. The aortic valve is trileaflet with poor coaptation.
Severe aortic regurgitation without aortic stenosis is seen.
Moderate mitral regurgitation is seen.. Mildly depressed LV
function.
.
[**2106-4-12**] 05:15AM BLOOD WBC-9.3 RBC-2.95* Hgb-9.8* Hct-30.2*
MCV-103* MCH-33.3* MCHC-32.5 RDW-14."
4230,"The ascending aorta is
moderately dilated. There are complex (>4mm) atheroma in the
aortic arch. The descending thoracic aorta is mildly dilated.
There are complex (>4mm) atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. There is no aortic
valve stenosis. Severe (4+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results at time of
surgery.
POST-BYPASS: LV systolic function appears improved to normal
(LVEF 55%) RV systolic function remains normal. There is a well
seated, well functioning bioprosthesis in the aortic position."
4231,"2
CXR [**4-12**]:
Mild bilateral pleural effusions are unchanged from prior.
Bibasilar
opacities , a combination of pleural effusions and atelectasis
have increased
on the right and minimally improved on the left. The upper lungs
are clear.
There is no pneumothorax. Widened mediastinum has improved.
Cardiomegaly has
improved. Sternal wires are aligned.
Brief Hospital Course:
Mr. [**Known lastname 3094**] was admitted one day before surgery for routine
work-up and Heparin since he was on Coumadin for atrial
fibrillation. On [**2106-4-8**] he was brought to the operating room
where he underwent an aortic valve replacement and ascending
aorta replacement."
4232,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2106-5-12**] 3:15
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2106-4-20**] 10:30
Cardiologist: Dr. [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) 2912**] [**2106-5-6**] @ 2:30PM
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] [**Telephone/Fax (1) 19196**] in [**4-1**] weeks
Coumadin for DVT
Goal INR: 2.0-3.0
First draw day after discharge:
Results to phone fax: Dr.[**Name (NI) 16259**] office [**Telephone/Fax (1) 25001**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2106-4-15**]"
4233,"polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**12-28**]
Drops Ophthalmic PRN (as needed) as needed for eye irritation.
Disp:*1 * Refills:*0*
10. atenolol 50 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
Disp:*60 Tablet(s)* Refills:*2*
11. atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
12. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*40 Capsule(s)* Refills:*0*
13. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
10 days: then decrease to 20mg daily."
4234,"7 Plt Ct-98*
[**2106-4-15**] 05:44AM BLOOD Hct-29.8*
[**2106-4-12**] 05:15AM BLOOD PT-14.7* INR(PT)-1.4*
[**2106-4-12**] 05:15AM BLOOD Plt Ct-98*
[**2106-4-13**] 04:50AM BLOOD PT-15.8* INR(PT)-1.5*
[**2106-4-14**] 05:20AM BLOOD PT-19.3* INR(PT)-1.8*
[**2106-4-15**] 05:44AM BLOOD PT-25.0* INR(PT)-2.4*
[**2106-4-15**] 05:44AM BLOOD UreaN-25* Creat-1.0 Na-136 K-4.1 Cl-104
[**2106-4-14**] 05:20AM BLOOD Mg-2."
4235,"Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: 70 AF Resp: 18- O2 sat: 99%
B/P Right: 131/57 Left: -
Height: 5'[**04**]"" Weight: 200 lbs
General: Well-developed elderly male sitting in NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X- left surgical pupil] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [] Irregular [X] Murmur [X] grade [**2-1**]
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema Trace chronic RLE
swelling after DVT
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+"
4236,"CVICU
HPI:
HD2 POD 1-ASD closure
Ejection Fraction:60
Hemoglobin A1c:6.0
Pre-Op Weight:182 lbs 82.56 kgs
Baseline Creatinine:0.9
TLD:Rt IJ :Day2
Foley:Day2
PMH: ASD, HTN, obesity, NIDDM, hyperlipidemia, remote duodenal ulcer
osteopenia, PHTN
PSH: bil. shoulder [**Doctor First Name 213**], tonsillectomy, TAH, L knee [**Doctor First Name 213**], bil. breast
bxs, L thumb [**Doctor First Name 213**].
[**Last Name (un) **]: ambien 10', atenolol 100', celexa 20', fosamax 70 QTue,
omeprazole 20', metformin 500"", lisinopril 20', simvastatin 40'
Current medications:
Acetaminophen 5. Aspirin EC 6. Aspirin 7. Calcium Gluconate 8.
Chlorhexidine Gluconate 0."
4237,"43 L/min) / (2.9 L/min/m2)
SVR: 768 dynes*sec/cm5
SV: 87 mL
SVI: 44 mL/m2
Total In:
4,487 mL
148 mL
PO:
Tube feeding:
IV Fluid:
4,487 mL
148 mL
Blood products:
Total out:
1,315 mL
365 mL
Urine:
1,010 mL
165 mL
NG:
Stool:
Drains:
Balance:
3,172 mL
-217 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: Standby
Vt (Set): 550 (550 - 550) mL
Vt (Spontaneous): 102 (102 - 102) mL
PS : 5 cmH2O
RR (Set): 15
RR (Spontaneous): 0
PEEP: 0 cmH2O
FiO2: 40%
PIP: 0 cmH2O
SPO2: 92%
ABG: 7."
4238,"Endocrine: Lantus (R), wean insulin gtt
Infectious Disease: Periop Vanco
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: CT surgery
Billing Diagnosis: Post-op hypotension
ICU Care
Nutrition:
Glycemic Control: Insulin infusion
Lines:
Arterial Line - [**2173-11-2**] 10:58 AM
Triple Introducer - [**2173-11-2**] 10:59 AM
PA Catheter - [**2173-11-2**] 11:00 AM
20 Gauge - [**2173-11-2**] 11:00 AM
Prophylaxis:
DVT:
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 33 minutes
Patient is critically ill"
4239,"12% Oral Rinse
9. Dextrose 50% 10. Docusate Sodium 11. Docusate Sodium (Liquid) 12.
Furosemide 13. Glycopyrrolate
14. Insulin 15. Ketorolac 16. Ketorolac 17. Magnesium Sulfate 18.
Metoclopramide 19. Milk of Magnesia
20. Morphine Sulfate 21. Neostigmine 22. Nitroglycerin 23. Omeprazole
24. Oxymetazoline 25. Phenylephrine
26. Pneumococcal Vac Polyvalent 27. Potassium Chloride 28. Propofol 29.
Simvastatin 30. Sodium Chloride 0.9% Flush
31. Sodium Chloride 0.9% Flush 32. Sodium Chloride Nasal 33. Vancomycin
24 Hour Events:
OR RECEIVED - At [**2173-11-2**] 10:35 AM
ARTERIAL LINE - START [**2173-11-2**] 10:58 AM
TRIPLE INTRODUCER - START [**2173-11-2**] 10:59 AM
INVASIVE VENTILATION - START [**2173-11-2**] 11:00 AM
PA CATHETER - START [**2173-11-2**] 11:00 AM
EKG - At [**2173-11-2**] 11:15 AM
NASAL SWAB - At [**2173-11-2**] 11:26 AM
mrsa
INVASIVE VENTILATION - STOP [**2173-11-2**] 03:06 PM
Post operative day:
POD#1 - ASD repair
Allergies:
Penicillins
Rash;
Sulfa (Sulfonamide Antibiotics)
?"
4240,"tremors;
Cephalosporins
Rash;
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
itchy;
Last dose of Antibiotics:
Vancomycin - [**2173-11-2**] 08:00 PM
Infusions:
Phenylephrine - 0.2 mcg/Kg/min
Insulin - Regular - 1 units/hour
Other ICU medications:
Insulin - Regular - [**2173-11-2**] 03:49 PM
Morphine Sulfate - [**2173-11-3**] 05:30 AM
Furosemide (Lasix) - [**2173-11-3**] 05:30 AM
Other medications:
Flowsheet Data as of [**2173-11-3**] 06:11 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**75**] a.m.
Tmax: 37.9
C (100.2
T current: 37.7
C (99.9
HR: 64 (60 - 88) bpm
BP: 101/48(64) {85/46(60) - 139/72(97)} mmHg
RR: 18 (14 - 24) insp/min
SPO2: 92%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
CVP: 17 (3 - 19) mmHg
PAP: (43 mmHg) / (22 mmHg)
CO/CI (Thermodilution): (4."
4241,"8
0.9
TCO2
25
25
25
25
Glucose
73
91
156
158
168
161
124
90
92
Other labs: PT / PTT / INR:14.1/28.1/1.2, Fibrinogen:192 mg/dL, Lactic
Acid:3.1 mmol/L, Mg:1.8 mg/dL
Assessment and Plan
SEPTAL DEFECT, ATRIAL (ASD)
Assessment and Plan: 66yoW s/p ASD closure. [**11-2**]
Neurologic: Pain controlled, Percocet prn.
Cardiovascular: Aspirin, Discontinue PA monitor, Post-op hypotension
--> Wean neo gtt for MAP > 60; Consult vascular regarding right hand
with possible embolus from a-line .
Pulmonary: OOB / IS
Gastrointestinal / Abdomen: standard bowel regimen
Nutrition: Advance diet as tolerated
Renal: Foley, Adequate UO, Mild oliguria overnight --> improved with
volume and
Hematology: Mod anemia post-op --> cont to follow."
4242,"39/40/129/24/0
Ve: 7 L/min
PaO2 / FiO2: 322
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities; Numbness and slightly cool right hand after
a-line d/c
d; +cap refill buy mild cyanosis.
Labs / Radiology
278 K/uL
9.0 g/dL
92 mg/dL
0."
4243,"9 mg/dL
24 mEq/L
4.8 mEq/L
24 mg/dL
101 mEq/L
134 mEq/L
26.7 %
13.0 K/uL
[image002.jpg]
[**2173-11-2**] 10:57 AM
[**2173-11-2**] 11:58 AM
[**2173-11-2**] 02:13 PM
[**2173-11-2**] 02:51 PM
[**2173-11-2**] 04:00 PM
[**2173-11-2**] 05:00 PM
[**2173-11-2**] 05:09 PM
[**2173-11-2**] 06:00 PM
[**2173-11-2**] 11:25 PM
[**2173-11-3**] 03:30 AM
WBC
13.0
Hct
27.9
26.1
26.7
Plt
278
Creatinine
0."
4244,"Admission Date: [**2173-11-2**] Discharge Date: [**2173-11-6**]
Date of Birth: [**2107-3-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalosporins /
Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mild DOE
Major Surgical or Invasive Procedure:
[**2173-11-2**] - Closure of Atrial Septal Defect
History of Present Illness:
66 yo female with ASD found on echo for murmur [**9-2**]. Recently
TEE confirms a large secundum ASD with anatomy unfavorable for
percutaneous closure.Referred for surgery.
Past Medical History:
Atrial septal defect
Hypertension
obesity
diabetes mellitus 2
hyperlipidemia
remote duodenal ulcer
osteopenia
Pulmonary hypertension
Social History:
Race:Caucasian
Last Dental Exam:summer [**2172**]
Lives alone
Occupation:secretary
Tobacco:quit 25 years ago- approx 10 PYHx
no recr."
4245,"Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]
Discharge Diagnosis:
Atrial septal defect s/p closure
Hypertension
obesity
Diabetes mellitus
hyperlipidemia
remote duodenal ulcer
osteopenia
Pulmonary Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with ultram prn
Wound-healing well, no erythema or drainage
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"
4246,"drug use
ETOH:rarely
Family History:
Family History:father died of MI at 79
Physical Exam:
Pulse:76 reg B/P Right: 148/84 Left: 152/84 Resp: O2
sat:
Height: 5'1"" Weight:188#
General:NAD
Skin: Dry [x] [**Year (4 digits) 5235**] [x]
HEENT: PERRLA [] EOMI [x]ptosis left upper lid;anicteric sclera
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [ x]
Heart: RRR [x] Irregular [] Murmur- 1-2/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]: obese, no HSM/CVA tenderness, healed abd scar
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None []mild spider veins
Neuro: Grossly [**Year (4 digits) 5235**]; nonfocal exam, MAE [**3-30**] strengths
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: NP Left: NP
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left:none"
4247,"There has been a linear suture closure of the ASD. No residual
flow.
Normal biventricular systolic fxn. No AI, no MR.
[**First Name (Titles) **] [**Last Name (Titles) 5235**].
pre-op
[**2173-11-2**] 07:35AM HGB-10.9* calcHCT-33
[**2173-11-2**] 07:35AM GLUCOSE-118* LACTATE-1.4 NA+-135 K+-4.4
CL--100
[**2173-11-2**] 09:54AM FIBRINOGE-192
[**2173-11-2**] 09:54AM PT-14.9* PTT-24.7 INR(PT)-1.3*
[**2173-11-2**] 09:54AM PLT COUNT-251
[**2173-11-2**] 10:49AM UREA N-31* CREAT-0.9 CHLORIDE-106 TOTAL
CO2-23
post-op
[**2173-11-5**] 06:00AM BLOOD WBC-8."
4248,"She was taken directly to
the operating room where she underwent closure of her atrial
septal defect. Please see operative note for details. She
tolerated the operation well and postoperatively she was taken
to the intensive care unit for monitoring. She was
hemodynamically stable in the immediate post operative period,
she awoke neurologically [**Date Range 5235**] and was extubated. She was
started on beta blockade, statin and aspirin. On POD 1 she
experienced right hand numbness which resolved over the day.
Vascular evaluated her for this complaint and recommended
conservative management with warm compresses. She was then
transferred to the step down unit for further recovery."
4249,"Pertinent Results:
[**2173-11-2**] ECHO
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
A large secundum atrial septal defect is present, measuring 1.8
cm square. Left to right flow.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic [**Month/Day/Year 5236**].
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. Physiologic
mitral regurgitation is seen (within normal limits).
There is no pericardial effusion.
Post-CPB:
Patient is AV-Paced, on low dose phenylephrine."
4250,"2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day)."
4251,"8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours for 1 months.
11. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO Q tues.
14. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day."
4252,"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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] on [**2172-12-9**] -9am @[**Hospital1 **] MC [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 83692**] in [**11-27**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6254**] in [**11-27**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2173-11-6**]"
4253,"7 RBC-3.24* Hgb-9.3* Hct-28.3*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.0 Plt Ct-196
[**2173-11-5**] 06:00AM BLOOD Plt Ct-196
[**2173-11-2**] 10:49AM BLOOD PT-14.1* PTT-28.1 INR(PT)-1.2*
[**2173-11-5**] 06:00AM BLOOD UreaN-24* Creat-0.9 K-4.7
[**11-4**] CXR
Smalll bilateral pleural effusions R>L
Elevated R hemidiaphram
Brief Hospital Course:
Ms. [**Known lastname 174**] was admitted to the [**Hospital1 18**] on [**2173-11-2**] for surgical
repair of her atrial septal defect."
4254,"She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. The remainder of her post
operative course was uneventful. On post-operative day 4 she was
discharged to [**Hospital 3548**] [**Hospital 3549**] Rehabilitation Center in [**Location (un) 1110**].
Medications on Admission:
ambien 10 mg daily
atenolol 100 mg daily
celexa 20 mg daily
fosamax 70 mg Q Tuesday
omeprazole 20 mg daily
metformin 500 mg [**Hospital1 **]
lisinopril 20 mg daily
simvastatin 40 mg daily
Discharge Medications:
1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day."
4255,"CVICU
HPI:
HD2 POD 1-ASD closure
Ejection Fraction:60
Hemoglobin A1c:6.0
Pre-Op Weight:182 lbs 82.56 kgs
Baseline Creatinine:0.9
TLD:Rt IJ :Day2
Foley:Day2
PMH: ASD, HTN, obesity, NIDDM, hyperlipidemia, remote duodenal ulcer
osteopenia, PHTN
PSH: bil. shoulder [**Doctor First Name 213**], tonsillectomy, TAH, L knee [**Doctor First Name 213**], bil. breast
bxs, L thumb [**Doctor First Name 213**].
[**Last Name (un) **]: ambien 10', atenolol 100', celexa 20', fosamax 70 QTue,
omeprazole 20', metformin 500"", lisinopril 20', simvastatin 40'
Current medications:
Acetaminophen, Aspirin EC, Docusate Sodium, Furosemide, Insulin,
Ketorolac, Metoclopramide, Milk of Magnesia, Morphine Sulfate,
Omeprazole, Phenylephrine, Simvastatin, Vancomycin
24 Hour Events:
Extubated without incident, weaning neo
Post operative day:
POD#1 - ASD repair
Allergies:
Penicillins
Rash;
Sulfa (Sulfonamide Antibiotics)
?"
4256,"39/40/129/24/0
Ve: 7 L/min
PaO2 / FiO2: 322
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), + Loud Rub
Respiratory / Chest: (Breath Sounds: Diminished: at bases)
Abdominal: Soft, Non-distended, Non-tender, Hypoactive BS
Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities
Labs / Radiology
278 K/uL
9.0 g/dL
92 mg/dL
0.9 mg/dL
24 mEq/L
4.8 mEq/L
24 mg/dL
101 mEq/L
134 mEq/L
26."
4257,"7 %
13.0 K/uL
[image002.jpg]
[**2173-11-2**] 10:57 AM
[**2173-11-2**] 11:58 AM
[**2173-11-2**] 02:13 PM
[**2173-11-2**] 02:51 PM
[**2173-11-2**] 04:00 PM
[**2173-11-2**] 05:00 PM
[**2173-11-2**] 05:09 PM
[**2173-11-2**] 06:00 PM
[**2173-11-2**] 11:25 PM
[**2173-11-3**] 03:30 AM
WBC
13.0
Hct
27.9
26.1
26.7
Plt
278
Creatinine
0.8
0.9
TCO2
25
25
25
25
Glucose
73
91
156
158
168
161
124
90
92
Other labs: PT / PTT / INR:14."
4258,"tremors;
Cephalosporins
Rash;
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
itchy;
Last dose of Antibiotics:
Vancomycin - [**2173-11-2**] 08:00 PM
Infusions:
Phenylephrine - 0.2 mcg/Kg/min
Insulin - Regular - 1 units/hour
Other ICU medications:
Insulin - Regular - [**2173-11-2**] 03:49 PM
Morphine Sulfate - [**2173-11-3**] 05:30 AM
Furosemide (Lasix) - [**2173-11-3**] 05:30 AM
Other medications:
Flowsheet Data as of [**2173-11-3**] 07:47 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**75**] a.m.
Tmax: 37.9
C (100.2
T current: 37.8
C (100
HR: 68 (60 - 88) bpm
BP: 104/63(77) {85/46(60) - 139/72(97)} mmHg
RR: 23 (14 - 24) insp/min
SPO2: 93%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
CVP: 18 (3 - 19) mmHg
PAP: (44 mmHg) / (25 mmHg)
CO/CI (Thermodilution): (4."
4259,"43 L/min) / (2.9 L/min/m2)
SVR: 726 dynes*sec/cm5
SV: 88 mL
SVI: 45 mL/m2
Total In:
4,487 mL
167 mL
PO:
Tube feeding:
IV Fluid:
4,487 mL
167 mL
Blood products:
Total out:
1,315 mL
735 mL
Urine:
1,010 mL
535 mL
NG:
Stool:
Drains:
Balance:
3,172 mL
-568 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: Standby
Vt (Set): 550 (550 - 550) mL
Vt (Spontaneous): 102 (102 - 102) mL
PS : 5 cmH2O
RR (Set): 15
RR (Spontaneous): 0
PEEP: 0 cmH2O
FiO2: 40%
PIP: 0 cmH2O
SPO2: 93%
ABG: 7."
4260,"1/28.1/1.2, Fibrinogen:192 mg/dL, Lactic
Acid:3.1 mmol/L, Mg:1.8 mg/dL
Assessment and Plan
66 yo female s/p ASD closure
Neurologic: Neuro checks Q: 8 hr, Pain control with dilaudid and
toradol
Cardiovascular: Aspirin, Statins, Discontinue PA monitor, Wean neo and
start beta blockers as tolerated
Pulmonary: Monitor Chest tube output, Enc DB/IS/OOB
Nutrition: Advance diet as tolerated
Renal: Foley, Lasix to run negative, Crea stable
Hematology: ASA, Hct stable
Endocrine: RISS, Insulin drip, Transition from insulin gtt - restart
home DM meds once po intake improves
Infectious Disease: Afebrile, Perio abx
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Fluids: KVO
Consults: P.T.
ICU Care
Glycemic Control: Regular insulin sliding scale, Insulin infusion
Prophylaxis:
Stress ulcer: H2 blocker
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: Transfer to floor"
4261,"Admission Date: [**2198-5-21**] Discharge Date: [**2198-5-26**]
Date of Birth: [**2160-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Palpitations and increasing fatigue
Major Surgical or Invasive Procedure:
[**2198-5-21**] Mitral valve repair (36mm CG future ring)
History of Present Illness:
37 year old gentleman, known to our service (please see H&P from
[**6-20**]) who is originally from [**Country 2784**] and was found to have a
heart murmur on exam 6 years ago. He was found to have mitral
regurgitation which was subsequently followed by serial
echocardiograms by multiple physicians as he moves frequently."
4262,"Recent Echo on [**2198-4-24**] revealed moderate/severe mitral
valve bileaflet prolapse involving all anterior segment and all
posterior scallops with moderate to severe (3+) mitral
regurgitation.
Past Medical History:
Mitral valve regurgitation s/p mitral valve repair
Past medical history:
- Hypertension
- Non-sustained ventricular tachycardia
- Anxiety
- ? syncopal event [**5-21**]
- + PPD [**2181**], negative CXR
Social History:
Race: Caucasian
Last Dental Exam: 6 months ago
Lives with: College roommate
Contact: [**Name (NI) **] [**Last Name (NamePattern1) 89423**] Phone # [**Telephone/Fax (1) 89424**]
Occupation: He is a CEO of a series of call centers called the
VTW Company. This involves a lot of both national and
international travel."
4263,"Potassium Chloride 10 mEq PO DAILY Duration: 5 Days
RX *potassium chloride 10 mEq once a day Disp #*5 Tablet
Refills:*0
9. Magnesium Oxide 400 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Mitral valve regurgitation s/p mitral valve repair
Past medical history:
- Hypertension
- Non-sustained ventricular tachycardia
- Anxiety
- ? syncopal event [**5-21**]
- + PPD [**2181**], negative CXR
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema- none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon."
4264,"Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later this day he was weaned from sedation,
awoke neurologically intact and extubated. Post-operatively his
rhythm was junctional/brady requiring pacing. Nodal agents were
held. He subsequently developed atrial fibrillation with slow
ventricular response. He remained hemodynamically stable. He
was started on Sotalol and beta-blocker was held. Rhythm
converted to Sinus. He 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."
4265,"His echocardiogram last year showed moderate to severe mitral
valve prolapse with 3+ mitral regurgitation. A cardiac MRI was
obtained which showed bileaflet mitral valve prolapse with
moderate mitral regurgitation. The LVEF was mildly depressed at
48%. The effective forward LVEF was moderately depressed at 35%.
He is symptomatic with mainly fatigue however he does note
occasional palpitations.
When we saw him in [**2196**] surgery was recommended but cardiology
decided to postpone surgery and treat his ventricular ectopy in
hopes to improve his LV systolic function and dimensions. Holter
monitor study in [**2197-12-10**] still showed significant amount of
ectopy, and he has persistent symptoms due to this, albeit less
frequent."
4266,"There is moderate/severe posterior leaflet mitral
valve prolapse, worst at P2. The entire anterior leaflet
prolapses as well, but to a lesser degree than the posterior
leaflet. An eccentric, anteriorly directed jet of moderate to
severe (3+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time
of surgery.
POST-BYPASS: The patient is AV paced. The patient is on an
epinephrine infusion. Left ventricular function remains
depressed, with an LVEF = 35%."
4267,"Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use: None
ETOH: < 1 drink/week [] [**1-16**] drinks/week [X] >8 drinks/week []
Illicit drug use-none
Family History:
N0n-contrib for Premature coronary artery disease. Two older
brothers, one with hypertension, the other with no known cardiac
disease. His mother has asthma and his father died of cancer.
There is no family history of sudden cardiac death.
Physical Exam:
Pulse: 80 Resp: 16 O2 sat: 100%
B/P Left: 114/80
Height: 5'[**96**]"" Weight: 225
General: Well-developed male 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 [X] grade 236 late systolic
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 [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+"
4268,"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
on POD#5 in good condition with appropriate follow up
instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Lisinopril 30 mg PO DAILY
2. Magnesium Oxide 400 mg PO DAILY
3. Sotalol 80 mg PO BID
Theragran-M premier 1 tab daily
Discharge Medications:
1. Lisinopril 30 mg PO DAILY
hold for SBP<95 and notify HO
RX *lisinopril 20 mg once a day Disp #*60 Tablet Refills:*1
2."
4269,"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: [**2198-6-5**] 10:00 in the
[**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Surgeon: Dr. [**Last Name (STitle) **] [**2198-6-28**] at 1:00pm in the [**Hospital **] medical office
building, [**Doctor First Name **], [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2198-6-15**] at 10:20a
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-15**] 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**
Completed by:[**2198-6-5**]"
4270,"Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
4271,"Sotalol 80 mg PO BID
RX *sotalol 80 mg once a day Disp #*30 Tablet Refills:*1
3. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
4. Aspirin EC 81 mg PO DAILY Start: POD #1
RX *aspirin 81 mg once a day Disp #*30 Tablet Refills:*1
5. Furosemide 10 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg once a day Disp #*5 Tablet Refills:*0
6. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *hydromorphone 2 mg every four (4) hours Disp #*60 Tablet
Refills:*0
7. Ibuprofen 400 mg PO Q8H:PRN pain
RX *ibuprofen 200 mg every six (6) hours as needed Disp #*120
Tablet Refills:*1
8."
4272,"Lateral wall motion remains
unchanged from prebypass. Right ventricular function appears
mildly depressed. There is a mitral annuloplasty ring in place.
Trace mitral regurgitation is seen. There is a mean gradient of
4mmHg across the mitral valve at a cardiac output of 5.6 L/min.
There is no systolic anterior motion of the mitral valve and no
increased LVOT gradient. The aorta is intact post-decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname 89425**] was a same day admit and brought directly to
the operating room where he underwent a mitral valve repair.
Please see operative note for surgical details."
4273,"Carotid Bruit Right: - Left: -
Pertinent Results:
[**2198-5-21**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is mild regional left
ventricular systolic dysfunction with basal to mid inferior and
inferoseptal hypokinesis. There is mild to moderate global left
ventricular hypokinesis. Overall left ventricular systolic
function is moderately depressed (LVEF= 35-40 %). 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 stenosis or aortic
regurgitation."
4274,"Admission Date: [**2190-7-11**] Discharge Date: [**2190-7-12**]
Date of Birth: [**2108-10-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Aspiration of foreign body
Major Surgical or Invasive Procedure:
Flexible bronchoscopy for retrieval of duckbill prosthesis
device.
History of Present Illness:
81M with alzheimers dementia, laryngeal ca, trach many years
ago. Was in his usual state of health, but today was putting in
his pacimmune valve, and accidentally aspirated his duckbill
voice piece into his left main.
In the ED:
Pt's vitals unimpressive with 97."
4275,"9, hr 126, 15, 124/92, 96% RA
Na= 143, K=4.3, Cl = 107, CO2 = 23
BUN = 16, Cr = 1.3
Lipase = 37
7.0>14.3/43.9<161
INR = 1.0
fibrinogen 319
Pt was given 0.5mg ativan. IP was able to remove the voice piece
with a flexible bronchoscope. However, afterwards, pt was
tachycardic to 130s with sbps to 150/83 and rr 21. On arrival to
the MICU, pt is on room air. He cannot talk because he does not
have the proper material for his trach mask.
Past Medical History:
tracheostomy 20 years a go for throat cancer
dementia
gerd
Medications:
namenda 20 mg qday
nexium 40mg PO once day
multivitamin
tylenol
aspercreme
thera tears"
4276,"Left basal
opacity is seen, which could reflect an early aspiration event.
No priors are available for comparison. There is no pleural
effusion or pneumothorax. Heart is moderately enlarged.
IMPRESSION: Left basilar opacity could reflect atelectasis or
aspiration.
Brief Hospital Course:
81M with laryngeal cancer, alzheimer's dementia, s/p aspiration
of duckbill voice piece to L main.
# Aspirated duckbill voice piece/airway obstruction: The
duckbill transesophageal prosthesis was removed without
complication by Interventioal Pulmonology service. The patient
was subsequently seen by speech and language pathology who was
able to refit the patient with his 16 french, 16mm TEP
prosthesis."
4277,"Speech and language recommended that the patient be
fit with an indwelling devide to avoid this complication in the
future. At time of discharge, they agreed to do this at [**Hospital1 **] where he has been followed at for years.
#alzheimers: continue with namenda
#GERD: nexiuim
# Code: Full
Transitional: Placement of indwelling TEP prosthesis.
Medications on Admission:
namenda 20 mg qday
nexium 40mg PO once day
multivitamin
tylenol
aspercreme
thera tears
Discharge Medications:
1. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Exelon 4.6 mg/24 hour Patch 24 hr Sig: One (1) Transdermal
once a day."
4278,"Pertinent Results:
[**2190-7-11**] 02:25PM WBC-7.0 RBC-4.52* HGB-14.3 HCT-43.9 MCV-97
MCH-31.7 MCHC-32.7 RDW-14.0
[**2190-7-11**] 02:25PM PLT COUNT-161
[**2190-7-11**] 02:25PM PT-10.7 PTT-26.1 INR(PT)-1.0
[**2190-7-11**] 02:33PM GLUCOSE-105 NA+-143 K+-4.3 CL--107 TCO2-23
[**2190-7-11**] 02:25PM UREA N-16 CREAT-1.3*
[**7-11**] CXRay:
Portable semi-upright radiograph of the chest was obtained.
Tracheostomy tube is noted. The patient is rotated."
4279,"3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Tylenol 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. Thera Tears 0.25 % Dropperette Sig: One (1) Ophthalmic once
a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Foreign body aspiration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 112092**]
You were admitted to the ICU because your duckbill lanryngeal
piece was dislodged. We had interventional Pulmonology remove
the piece from your lungs and had our speech pathologist replace
a new piece.
You are now safe to go home.
We have not made any changes to your home medications
Followup Instructions:
please follow up with your primary care doctor and Speech
pathologist to help manage your new device.
Name: [**Last Name (LF) 112093**], [**Name8 (MD) **], NP
Address: [**Location (un) 112094**], [**Location (un) **],[**Numeric Identifier 10768**]
Phone: [**Telephone/Fax (1) 81522**]
When: Tuesday, [**7-20**], 3:30 PM
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2190-7-20**]"
4280,"Social History:
lives with wife, demented
Family History:
noncontributory
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: bronchial breath sounds in upper airway, but otherwise
clear
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred."
4281,"Admission Date: [**2176-7-15**] Discharge Date: [**2176-7-30**]
Date of Birth: [**2142-4-8**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Tetraplegia
Major Surgical or Invasive Procedure:
[**2176-7-15**] C5 corpectomy with C4-C6 fusion
[**2176-7-17**] Percutaneous tracheostomy
[**2176-7-25**] [**Month/Day/Year 282**] tube
History of Present Illness:
This is a 34-year-old male who dove into a pool and never
resurfaced. He was taken to an OSH where he was found to have
sustained a C5 burst fracture with incomplete spinal cord injury
at C5."
4282,"ABG:
[**2176-7-23**] 03:16PM BLOOD Type-ART pO2-146* pCO2-41 pH-7.41
calTCO2-27 Base XS-1
[**2176-7-24**] 02:49AM BLOOD Type-ART pO2-163* pCO2-46* pH-7.42
calTCO2-31* Base XS-5
.
Micro: all culture data negative for bacterial pathogens.
Brief Hospital Course:
Mr. [**Known lastname 174**] was transferred to [**Hospital1 18**] after sustaining a C5 burst
fracture with spinal cord involvement after diving into a pool.
He was taken emergenty to the operating room for decompression.
.
Neuro: On admission his sensory level was only intact above the
nipple line. He went to the operating room for an emergent C5
corpectomy with C4-C6 fusion."
4283,"8* Hct-34.4*
MCV-92 MCH-31.4 MCHC-34.3 RDW-13.6 Plt Ct-195
[**2176-7-18**] 02:03AM BLOOD WBC-12.2* RBC-3.36* Hgb-10.7* Hct-30.3*
MCV-90 MCH-31.8 MCHC-35.1* RDW-12.9 Plt Ct-177
[**2176-7-22**] 03:14AM BLOOD WBC-9.4 RBC-3.02* Hgb-9.4* Hct-27.9*
MCV-92 MCH-31.1 MCHC-33.8 RDW-13.0 Plt Ct-246
[**2176-7-23**] 02:00AM BLOOD WBC-11.2* RBC-3.10* Hgb-9.4* Hct-28.3*
MCV-91 MCH-30."
4284,".
Endo: His blood sugars were well controlled on sliding scale
insulin.
Medications on Admission:
None
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) neb Inhalation every six (6) hours as needed for SOB.
3. Baclofen 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a day)
as needed for muscule spasm.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain."
4285,".
ID: He did spike fevers to 103 with no obvious source. He was
started on broad spectrum antibiotics. Culture data has all
been negative. His WBC count became elevated and there was a
questionable LLL infiltration. He underwent bronchoscopy with
BAL. All of these cultures have been negative. His
leukocytosis resolved. He received a total of 9 days of
vancomycin. He was started on Cipro and will continue this for
5 more days.
.
Heme: His hematocrit has remained stable. Vascular surgery was
consulted for a potential IVC filter placement. They did not
recommend an IVC filter at this time and that he should continue
on subcutaneous heparin."
4286,"11. Lorazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
12. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000)
units Injection TID (3 times a day).
13. Ibuprofen 100 mg/5 mL Suspension [**Month/Day (2) **]: 400-800 mg PO Q6H
(every 6 hours) as needed for pain,fever.
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**12-1**] Sprays Nasal
QID (4 times a day) as needed for dry nares."
4287,"He was taken to the operating room for emergent
decompression.
Past Medical History:
None
Social History:
Positive ETOH
Family History:
Noncontributory
Physical Exam:
Afebrile, VSS
No distress, alert, communicative
PERLA, EOMI, anicteric
Tracheostomy site clean
RRR, lungs clear
Abdomen soft, nontender, [**Last Name (LF) 19973**], [**First Name3 (LF) 282**] tube site clean
Ext: warm, well perfused, gross upper arm movement
Pertinent Results:
WBC trend:
[**2176-7-15**] 01:16AM BLOOD WBC-15.0* RBC-4.54* Hgb-14.6 Hct-40.7
MCV-90 MCH-32.1* MCHC-35.9* RDW-13.5 Plt Ct-219
[**2176-7-15**] 07:24AM BLOOD WBC-13."
4288,"4 MCHC-33.4 RDW-13.0 Plt Ct-265
[**2176-7-24**] 02:15AM BLOOD WBC-11.5* RBC-3.23* Hgb-9.8* Hct-29.3*
MCV-91 MCH-30.4 MCHC-33.6 RDW-13.3 Plt Ct-251
[**2176-7-25**] 02:57AM BLOOD WBC-16.2* RBC-3.51* Hgb-10.9* Hct-31.9*
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.6 Plt Ct-298
[**2176-7-26**] 03:20AM BLOOD WBC-18.2* RBC-3.58* Hgb-11.1* Hct-32.2*
MCV-90 MCH-31.2 MCHC-34.7 RDW-13."
4289,"He was initially unable to move
any extremity but now is able to move his arms grossly. He
should continue physical and occupational therapy.
.
Cardiovascular: He initially required vasopressor support for
spinal shock. This was able to be weaned off. He is now
hemodynamically stable.
.
Pulmonary: Due to his level of spinal cord injury, he required
pecutaneous tracheostomy. He is currently on pressure support
and being actively weaned to trach mask.
.
GI: He failed a speech and swallow evaluation and a [**Hospital1 282**] tube was
placed. He is currently tolerating tube feeds at a goal rate.
.
GU: He had no genitourinary issues and has adequate urine
output."
4290,"7 Plt Ct-307
[**2176-7-27**] 01:04AM BLOOD WBC-13.7* RBC-3.09* Hgb-9.6* Hct-28.1*
MCV-91 MCH-30.9 MCHC-34.0 RDW-13.7 Plt Ct-311
[**2176-7-28**] 01:59AM BLOOD WBC-10.0 RBC-3.09* Hgb-9.4* Hct-28.1*
MCV-91 MCH-30.3 MCHC-33.4 RDW-13.8 Plt Ct-281
[**2176-7-29**] 02:28AM BLOOD WBC-8.7 RBC-3.49* Hgb-10.7* Hct-32.4*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.5 Plt Ct-290
."
4291,"22. DiphenhydrAMINE 25 mg IV Q6H:PRN itchy
23. HYDROmorphone (Dilaudid) 1-3 mg IV Q3H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
C5 burst fracture with spinal cord involvement
Tetraplegia
Discharge Condition:
Fair
Discharge Instructions:
Call your surgeon or return to the ED if you experience:
- fever > 101.5
- chills
- problems with your tracheostomy
- problems with your [**Location (un) 282**] tube
- inability to tolerate tube feeds
.
Continue daily trach care.
Continue daily [**Location (un) 282**] care.
.
Stay in your cervical collar for a total of 6 weeks.
.
Continue ciprofloxacin for 5 more days to complete a 10 day
course for pneumonia.
.
Continue pressure support ventilation as needed. Wean to trach
mask as tolerated.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] in 4 weeks. Call his office at
([**Telephone/Fax (1) 2007**] to schedule your appointment.
Follow up in the Trauma clinic in 4 weeks. Call the clinic at
([**Telephone/Fax (1) 22750**] to schedule your appointment."
4292,"1* RBC-4.40* Hgb-13.7* Hct-39.6*
MCV-90 MCH-31.1 MCHC-34.6 RDW-13.6 Plt Ct-175
[**2176-7-15**] 04:56PM BLOOD WBC-18.7* RBC-4.70 Hgb-14.7 Hct-43.2
MCV-92 MCH-31.4 MCHC-34.1 RDW-13.5 Plt Ct-239
[**2176-7-16**] 01:00AM BLOOD WBC-22.9* RBC-4.60 Hgb-14.2 Hct-41.6
MCV-91 MCH-30.8 MCHC-34.0 RDW-13.6 Plt Ct-310
[**2176-7-17**] 02:07AM BLOOD WBC-11.8* RBC-3.76* Hgb-11."
4293,"5. Bisacodyl 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
6. Midodrine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
7. Amitriptyline 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day) as needed for neuropathic pain & depression.
8. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: [**12-1**] PO BID (2 times a
day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for cosntipation."
4294,"16. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Day (2) **]: One (1) Appl Topical
TID (3 times a day) as needed for itching/rash.
17. Triamcinolone Acetonide 0.025 % Cream [**Month/Day (2) **]: One (1) Appl
Topical QID (4 times a day).
18. Pregabalin 25 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO TID (3
times a day).
19. Ciprofloxacin 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
20. Ondansetron 4 mg IV Q8H:PRN Nausea
21. 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."
4295,"1 mg/dL, Mg:1.7 mg/dL,
PO4:3.1 mg/dL
Assessment and Plan
CVA (STROKE, CEREBRAL INFARCTION), ISCHEMIC
Assessment and Plan: 59yM s/p TPA and clot retrieval of large [**Country 2032**]/MCA
Neurologic: Q1 hour neuro checks, CT if change in mental status. MRI
for when stable. Sedation with propofol as needed but lighten in
preparation for extubation; CT at 9 AM.
Cardiovascular: tolerate BP 120-185, labetalol for HTN and fluid and
pressors if persistent hypotension
Pulmonary: tolerating CPAP/PS on minimal settings, has cough & gag,
proceed with extubation today after imaging
Gastrointestinal / Abdomen: NPO, S&S eval after extubation
Nutrition: NPO
Renal: UOP adequate, NS @ 100
Hematology: Hct stable, recent TPA, no new stick for 48 hours if
possible."
4296,"m.
Tmax: 37.1
C (98.8
T current: 37.1
C (98.8
HR: 81 (55 - 87) bpm
BP: 154/73(100) {109/51(72) - 176/141(149)} mmHg
RR: 23 (12 - 23) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
1,547 mL
572 mL
PO:
Tube feeding:
IV Fluid:
547 mL
572 mL
Blood products:
Total out:
1,185 mL
440 mL
Urine:
1,185 mL
440 mL
NG:
Stool:
Drains:
Balance:
362 mL
132 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 600 (600 - 600) mL
Vt (Spontaneous): 577 (507 - 1,601) mL
PS : 8 cmH2O
RR (Set): 12
RR (Spontaneous): 24
PEEP: 5 cmH2O
FiO2: 60%
RSBI: 46
PIP: 13 cmH2O
Plateau: 17 cmH2O
SPO2: 98%
ABG: 7."
4297,"Will cont plavix
Endocrine: RISS
Infectious Disease: no issues
Lines / Tubes / Drains: Foley, ETT
Wounds:
Imaging: f/u MRI this AM, repeat CT today
Fluids: NS
Consults: Neuro surgery, Neurology
Billing Diagnosis: CVA
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2131-2-1**] 07:15 PM
18 Gauge - [**2131-2-1**] 07:15 PM
20 Gauge - [**2131-2-1**] 07:15 PM
Prophylaxis:
DVT: Boots (TPA)
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent: 33
Patient is critically ill"
4298,"39/40/229/24/0
Ve: 10.9 L/min
PaO2 / FiO2: 573
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Neurologic: Follows simple commands, (Responds to: Verbal stimuli,
Tactile stimuli), Moves all extremities, Sedated
Labs / Radiology
227 K/uL
13.6 g/dL
88 mg/dL
0.7 mg/dL
24 mEq/L
3.8 mEq/L
10 mg/dL
112 mEq/L
140 mEq/L
38.5 %
12.4 K/uL
[image002."
4299,"SICU
HPI:
59yM s/p fall with left hemiparesis brought to [**Hospital6 5579**]. CTA
showed [**Country 2032**] origin stenosis and terminal occlusion. IVtPA was
administered ~2hr 45 min after initial event, and pt was transferred to
[**Hospital1 **] where he underwent [**Hospital1 5589**] clot retrieval from [**Country 2032**]/MCA.
Chief complaint:
Fall, stroke
PMHx:
hyperlipidemia
Current medications:
1. 1000 mL NS 2. Atorvastatin 3. Clopidogrel 4. Famotidine 5. Insulin
6. Influenza Virus Vaccine
7. Labetalol 8. Propofol
24 Hour Events:
ARTERIAL LINE - START [**2131-2-1**] 07:15 PM
MAGNETIC RESONANCE IMAGING - At [**2131-2-2**] 05:11 AM
s/p clot retrieval
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Propofol - 15 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2131-2-1**] 09:00 PM
Other medications:
Flowsheet Data as of [**2131-2-2**] 07:01 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**33**] a."
4300,"jpg]
[**2131-2-1**] 05:35 PM
[**2131-2-1**] 07:55 PM
[**2131-2-1**] 08:06 PM
[**2131-2-1**] 09:05 PM
[**2131-2-1**] 10:13 PM
[**2131-2-2**] 02:37 AM
[**2131-2-2**] 02:38 AM
WBC
11.5
12.4
Hct
46
40.3
38.5
Plt
235
227
Creatinine
0.7
0.7
Troponin T
<0.01
TCO2
23
23
23
25
Glucose
101
90
89
88
88
Other labs: PT / PTT / INR:14.5/30.9/1.3, CK / CK-MB / Troponin
T:79//<0.01, Lactic Acid:0.8 mmol/L, Ca:8."
4301,"Subjective: Per pt
s daughter, pt usually drinks a pot of coffee in the
a.m., and then only eats one large meal at night. Pt
s weight was
stable.
Objective
Height
Admit weight
Daily weight
Weight change
BMI
170 cm
75 kg
74.7 kg ([**2131-2-3**] 12:00 AM)
26
Ideal body weight
% Ideal body weight
Adjusted weight
Usual body weight
% Usual body weight
67.1 kg
112%
77.3kg
97%
Diagnosis: CVA
PMH : hyperlipidemia, tobacco
Food allergies and intolerances:
Pertinent medications: RISS, Famotidine, others noted
Labs:
Value
Date
Glucose
87 mg/dL
[**2131-2-3**] 01:54 AM
Glucose Finger Stick
117
[**2131-2-3**] 10:00 AM
BUN
9 mg/dL
[**2131-2-3**] 01:54 AM
Creatinine
0."
4302,"Calories: 1800-2100 (BEE x or / 24-28 cal/kg)
Protein: 90-105 (1.2-1.4 g/kg)
Fluid: per team
Estimation of previous intake: Adequate
Estimation of current intake: Adequate
Specifics:
59 y.o. M presented to OSH with L-sided weakness, slurred speech and
facial droop. Pt found to have critical carotid stenosis. Pt received
tPA and then MERCI clot removal with carotid stent placed [**2-1**]. Pt was
extubated, but too lethargic to tolerate a S/S evaluation. NGT placed
for enteral feeds until pt able to take po
s. Current TF order will
meet 100% of pt
s needs.
Medical Nutrition Therapy Plan - Recommend the Following
1) Continue advancing to TF goal, as ordered.
2) Monitor lytes and BG with advancing TF.
3) S/S eval when pt more alert/awake.
Following
please page with ?
s #[**Numeric Identifier 2337**]"
4303,"5 mg/dL
[**2131-2-3**] 01:54 AM
Ionized Calcium
1.19 mmol/L
[**2131-2-1**] 08:06 PM
Magnesium
1.7 mg/dL
[**2131-2-3**] 01:54 AM
Triglyceride
126 mg/dL
[**2131-2-2**] 02:37 AM
WBC
12.5 K/uL
[**2131-2-3**] 01:54 AM
Hgb
13.0 g/dL
[**2131-2-3**] 01:54 AM
Hematocrit
37.5 %
[**2131-2-3**] 01:54 AM
Current diet order / nutrition support: TF: Replete with Fiber @
75cc/hr (1800kcal, 112g protein)
GI: soft, +bowel sounds, +semi-formed stool
Assessment of Nutritional Status
Adequately nourished
Estimated Nutritional Needs based on adm wt."
4304,"8 mg/dL
[**2131-2-3**] 01:54 AM
Sodium
138 mEq/L
[**2131-2-3**] 01:54 AM
Potassium
3.7 mEq/L
[**2131-2-3**] 01:54 AM
Chloride
107 mEq/L
[**2131-2-3**] 01:54 AM
TCO2
23 mEq/L
[**2131-2-3**] 01:54 AM
PO2 (arterial)
229 mm Hg
[**2131-2-2**] 02:38 AM
PCO2 (arterial)
40 mm Hg
[**2131-2-2**] 02:38 AM
pH (arterial)
7.39 units
[**2131-2-2**] 02:38 AM
CO2 (Calc) arterial
25 mEq/L
[**2131-2-2**] 02:38 AM
Calcium non-ionized
8.6 mg/dL
[**2131-2-3**] 01:54 AM
Phosphorus
2."
4305,"Paramedics were [**Name (NI) 653**], and he was brought to [**Hospital3 **], where his NIHSS ranged between [**10-13**]; CT head did not
show any bleeding. CTA showed [**Country **] origin stenosis and
terminal occlusion. After discussion with stroke service at [**Hospital1 **],
IVtPA was administered ~2hr 45 min after initial event, and pt
was transferred to [**Hospital1 **] for possible endovascular therapy.
Past Medical History:
HL
Social History:
tobacco: 1PPd
Family History:
NC
Physical Exam:
Admit Exam
VS: T 96.3 HR 63 BP 127/82 RR 18 Sat 99 % on RA
PE: General NAD
HEENT AT/NC, MMM no lesions
Neck Supple, no bruits
Chest CTA B
CVS RRR, no m/r/g
ABD soft, NTND, + BS"
4306,"2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
5. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right Stoke from CC stenosis and ICA clot
Discharge Condition:
Improved
Discharge Instructions:
You were admitted because you had a stoke. You had a procedure
to help open up the blood vessels which were blocked. You will
need physical and occupational therapy and will be discharged to
a facility where that will be ongoing.
Followup Instructions:
[**Hospital 4038**] clinic with Dr. [**First Name (STitle) **] - ([**Telephone/Fax (1) 7394**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]"
4307,"slow, but present withdrawal to noxious in LLE. extinction to
DSS on L.
Coordination: Finger-nose-finger intact on R. unable on L.
Pertinent Results:
[**2131-2-1**] 10:13PM TYPE-ART PO2-194* PCO2-41 PH-7.34* TOTAL
CO2-23 BASE XS--3
[**2131-2-1**] 09:05PM CK(CPK)-79
[**2131-2-1**] 09:05PM CK-MB-NotDone cTropnT-<0.01
[**2131-2-1**] 07:55PM GLUCOSE-90 UREA N-11 CREAT-0.7 SODIUM-142
POTASSIUM-4.7 CHLORIDE-114* TOTAL CO2-22 ANION GAP-11
[**2131-2-1**] 07:55PM PLT COUNT-235
[**2131-2-1**] 07:55PM PT-14."
4308,"MRI [**2-2**]: Right basal ganglia infarct with blood products
indicative of
hemorrhage. Mild mass effect on the right lateral ventricle.
Several tiny
areas of additional infarcts are seen in the posterior division
of the right middle cerebral artery territory.
MRA: No significant abnormalities on MRA of the head in the
arteries
around the circle of [**Location (un) 431**]. The right middle cerebral artery
demonstrates
flow signal on the current study indicating improvement since
the previous
cerebral angiogram of [**2131-2-1**].
CXR [**2-3**]: Previously concerning findings relating to the right
hilum and
right apex appear less apparent and likely relate to question of
interstitial features in the interim."
4309,"Motor: Normal bulk and tone on R. L: with decreased tone. LUE
movement only to noxious.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 0 1 0 0 0 1 0
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
4+ 5- 4- 3 3 5-
5 5 5 5 5 5
Reflex: 3+ in UE and patella on L. 2+ on R. toes down
bilaterally.
Sensation: brisk withdrawal on R. withdrawal in UE as above."
4310,"2* PTT-31.1 INR(PT)-1.2*
[**2131-2-1**] 07:55PM WBC-11.5* RBC-4.53* HGB-13.6* HCT-40.3 MCV-89
MCH-30.1 MCHC-33.8 RDW-13.8
[**2131-2-1**] 03:20PM GLUCOSE-102 UREA N-15 CREAT-1.1 SODIUM-139
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2131-2-1**] 03:20PM WBC-15.8* RBC-5.40 HGB-16.4 HCT-48.3 MCV-90
MCH-30.4 MCHC-34.0 RDW-13.6
[**2131-2-1**] 03:20PM cTropnT-<0.01
CT [**2-1**]: 1."
4311,"Admission Date: [**2131-2-1**] Discharge Date: [**2131-2-5**]
Date of Birth: [**2071-2-17**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
MERCI clot retreival
History of Present Illness:
59 yo RH man who presents after fall. He was heard to fall
at 11:30 am by his daughter who lives on the floor under his.
She went up to investigate and found him lying awake on the
bathroom floor with left sided weakness, unable to get up."
4312,"Brief Hospital Course:
Pt was taken to angio upon arrival with placement of carotid
stent and MERCI clot retrieval. He tolerated the procedure
well. He had a stroke risk factor work-up with A1c, FLP, ECHO
all of which were unremarkable. His stroke is likely secondary
to carotid disease. He had a CXR initially concerning for PNA
and was started on azithromycin. F/U CXR was improved. He had
a speech/swallow evaluation on [**2-5**] which cleared him for ground
solids, nectar thick liquids.
Medications on Admission:
Lipitor
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily)."
4313,"NEUROLOGICAL
MS:
General: alert, yawning throughout, but able to maintain
arousal
with frequent verbal stimulation. follows simple commands
briskly. oriented to self, place, date, age. able to name
frequent objects - trouble with hammock and cactus. repetition
intact.
CN:
II,III: VFFTC to threat, pupils 4-2 mm bilaterally to light,
optics discs sharp and flat
III,IV,V: R gaze preference but EOMI, no ptosis. Normal
saccades/pursuits
V: sensation intact to LT/temp
VII: significantly decreased NLF excursion on L
VIII: hears finger rub bilaterally
IX,X: voice normal, palate elevates symmetrically
[**Doctor First Name 81**]: SCM/trapezeii [**5-1**] bilaterally
XII: tongue protrudes to L."
4314,"No gross acute hemorrhage. However, evaluation for
small areas of hemorrhage are limited due to contrast from prior
CT study. To correlate with the initial study. 2. Large area of
perfusion deficit in the right middle cerebral artery territory,
including the centrum semiovale, temporal lobe, and the basal
ganglia and internal capsule, with the area of infarction, on
the medial aspect, and area of reversible ischemia in the
periphery. 3. Possible occlusion of the right internal carotid
artery termination and the middle cerebral artery, which can be
better evaluated on the CT head and CTA, done earlier, which are
not available for at the present dictation."
4315,"Admission Date: [**2119-1-5**] Discharge Date: [**2119-1-6**]
Date of Birth: [**2064-5-4**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Ultram
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
Mr. [**Known lastname 23189**] is a 54M with DM, cirrhosis c/b portal hypertensive
gastropathy and grade I esophageal varices who presents with
melena x2-3 days. Seem by PCP, [**Name Initial (NameIs) **]+ on exam.
He initially had constipation, no diarrhea, hematochezia,
hemoptysis or coffee-ground emesis. He has mid-abdominal
non-radiating ""gassy"" and ""burning"" discomfort x months which
has been nonprogressive."
4316,"Past Medical History:
Decompensated EtOH cirrhosis
- c/b Esophageal varices, grade 1 on [**2118-5-25**] EGD
DM
Fibromyalgia
Social History:
Last drink 10months ago. Current smoker 1ppd x20+ years. Denies
illicit drug use.
Family History:
Multiple family members with DM. No bleeding problems or [**Name2 (NI) 499**]
CA.
Physical Exam:
Vitals 98.3 96 119/66 18 99RA
General Pleasant middle aged man in no distress
HEENT Sclera anicteric, MMM
Neck No JVD
Pulm Lungs with poor air movement at bases, occasional wheeze
CV Tachycardic regular S1 S2 no m/r/g
Abd Soft nontender +bowel sounds +hepatomegaly
Extrem Warm no edema full peripheral pulses
Derm +palmar erythema and spider angiomas
Neuro Alert and awake, no asterixis"
4317,"2 Phos-3.1 Mg-2.2
CXR [**2119-1-5**]:
FINDINGS: No previous images. The cardiac silhouette is within
normal limits and there is no vascular congestion or pleural
effusion. No evidence of acute pneumonia. Tracheal air column
appears to be within normal limits.
Upper Endoscopy [**2119-1-6**]:
Impression: Grade II esophagael varices.
Erythema and petechiae in the stomach body compatible with
portal gastropathy. Otherwise normal EGD to third part of the
duodenum
Recommendations: Start nadolol 20 mg once a day.
Prilosec 20 mg once a day.
Bleeding likely secondary to portal gastropathy; no active
bleeding at present."
4318,"Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day.
9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Eighty
Five (85) Units Subcutaneous qam & qpm.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Upper GI Bleed, not hemodynamically significant
2. Cirrhosis
3. Portal Hypertension
Discharge Condition:
Hemodynamically stable & comfortable
Discharge Instructions:
You have been admitted to the hospital because of dark stools
that were caused by a small bleed in your belly. While you were
here the GI doctors looked with [**Name5 (PTitle) **] endoscope and found the site
of old bleeding that is now healed. It is likely that the
aspirin and aleve that you recently tried for pain may have
contributed to this bleed."
4319,"In the future, please take only
tylenol for headaches, and then no more than 8 pills or 2 grams
in a day.
Please call your doctor or 911 for worsening stomach
pain/bleeding, chest pain, shortness of breath or any other
medical concern.
New Medicines:
Your GI doctors would [**Name5 (PTitle) **] [**Name5 (PTitle) **] to take:
Nadolol 20mg by mouth daily to prevent bleeds.
Prilosec 20mg by mouth daily to prevent bleeds.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2119-1-19**] 10:15
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]"
4320,"3. Diabetes Mellitus: Patient was contined on home insulin.
4. History of alcohol abuse: Patient denies recent use.
Medications on Admission:
Insulin Sliding Scale
NPH 80 units qam and qpm
Ipratropium Bromide MDI 2 PUFF IH QID PRN
Lidocaine 5% Patch 1 PTCH TD DAILY
Albuterol Inhaler [**12-30**] PUFF IH Q4H:PRN
Ursodiol 300 mg PO TID
Cholestyramine 4 gm PO DAILY
Zolpidem Tartrate 5 mg PO HS:PRN
Discharge Medications:
1. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
DAILY (Daily).
2. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation three times a day as needed for shortness of breath
or wheezing."
4321,"He denies any recent EtoH or NSAID use.
He did recently have a URI with nasal congestion and sore
throat. He did take 81mg ASA x2 for a headache. No prior GIB.
Felt a little lightheaded today, slightly thirsty. No fever,
chills, sweats. No confusion.
In the ED, 97.6 108 139/77 18 99 RA. On rectal had black stool
guiac+. Has 16 and 18 PIVs. Received 40mg IV protonix, 50mcg
octreotide bolus then 50mcg/hr drip. Discussed with liver, plan
to scope tonight. In the ED, no further gross bleeding and BPs
have been stable. Currently 103 133/70 16 100% on RA."
4322,"Pertinent Results:
[**2119-1-6**] 03:17AM BLOOD WBC-5.7 RBC-3.22* Hgb-10.7* Hct-29.5*
MCV-92 MCH-33.1* MCHC-36.2* RDW-15.3 Plt Ct-211
[**2119-1-6**] 11:12AM BLOOD Hct-33.7*
[**2119-1-6**] 03:17AM BLOOD PT-13.6* PTT-40.5* INR(PT)-1.2*
[**2119-1-6**] 03:17AM BLOOD Glucose-138* UreaN-7 Creat-0.7 Na-139
K-3.5 Cl-107 HCO3-27 AnGap-9
[**2119-1-5**] 02:12PM BLOOD ALT-44* AST-55* AlkPhos-197* TotBili-0.6
[**2119-1-5**] 05:26PM BLOOD Calcium-9."
4323,"Brief Hospital Course:
A 54 year old man with a history of alcohol cirrhosis & varices
presented with hemodynamically stable melena.
1. Melena: The patient was started on Protonix IV & Octreotide
drip while in the emergency room. He remained hemodynamically
stable throughout his admission to the MICU. Endoscopy per GI
show erosive gastropathy currently healing, likely exacerbated
by recent aspiring ingestion. GI was comfortable with his
discharge on Nadolol & Prilosec with follow up.
2. Cirrhosis with ascites: Patient was started on Ceftriaxone
for Spontaneous Bacterial Peritonitis prophylaxis. He remained
cogent without signs of encephalopathy. His aldactone was held
while admitted due to bleeding concern."
4324,"3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
8."
4325,"# Chest Pain- Anginal pain in setting of severe 3v CAD and NSTEMI.
Patient was transferred to CCU for excalating chest pain with increased
ST depressions in V4-V6. He is currently chest pain free. S/p PCI with
BMS x 2 to LCx on [**1-25**]. Plan for PCI to RCA on [**1-27**].
- ASA 325 mg PO daily
- Plavix 75 mg PO Daily
- atorvastatin 80 mg PO qhs
- metoprolol 50mg PO BID, consider uptitration as tolerated by
hemodialysis.
- lisinopril 5mg PO daily, held on HD days
- Heparin IV
- morphine prn pain
- nitro gtt, titrated to pain relief
- plan for PCI Thursday
# COPD: Stable
- albuterol/ipratropium PRN
# ESRD- patient with history of ESRD likely [**1-31**] hypertension and
diabetes receives dialysis m,w,f."
4326,"6
146
30.0
9.0
[image002.jpg]
[**2152-1-24**] 03:26 AM
[**2152-1-24**] 10:54 AM
[**2152-1-24**] 04:39 PM
[**2152-1-25**] 04:05 AM
[**2152-1-25**] 08:52 PM
[**2152-1-26**] 04:07 AM
[**2152-1-26**] 08:00 AM
[**2152-1-26**] 01:26 PM
[**2152-1-26**] 10:43 PM
[**2152-1-27**] 05:43 AM
WBC
7.8
10.5
10.7
14.4
9.0
Hgb
9.7
11.5
11.2
11.0
10.6
Hct (Serum)
27.5
33.0
31.7
29.4
30."
4327,"Scheduled for dialysis today.
- sevalemer to TID with meals
- nephrocaps
- renal recs: re fistula / dialysis access needle (pt request blunted
needle)
# Pump
Clinical heart failure, ejection fraction preserved, so
presumed acute on chronic diastolic CHF. improves with fluid removal
on HD.
- f/u fluid status after HD, currently stable
- patient already on beta blocker, lisinopril
# Diabetes - Patient is reportedly diabetic however no outpatient
diabetic medications listed. HgA1C 5.8%
- insulin sliding scale
- continue to monitor
# Hyperlipdemia - patient with history of hyperlipedemia. Recent lipid
panel with LDL 65.
- continue lipitor 80 mg PO daily
# Carotid stenosis s/p L carotid endarterectomy
- cont statin, aspirin
# Anemia
Chronic disease, stable.
- transfuse for Hct < 30 based on NSTEMI (would prefer to give to
patient when in dialysis)
#. FEN: Follow and replete electrolytes. Cardiac, diabetic, renal
diet.
#. Access: PIV
#. PPx: Heparin IV, colace, senna, PPi.
#. Code: Full Code
#. Dispo: consider transfer back to floor after staged PCI"
4328,"0
Plt
157
211
209
218
200
INR
1.1
1.2
1.6
1.3
1.2
PTT
39.3
57.4
56.4
87.1
56.9
38.1
39.8
41.6
Na+
137
138
137
136
K + (Serum)
3.9
4.0
5.0
4.9
Cl
99
99
99
102
HCO3
23
30
22
23
BUN
69
39
57
63
Creatinine
11.6
8.2
10.0
9.9
Glucose
100
97
179
142
146
CK
158
CK-MB
20
Troponin T
2.18
Assessment and Plan
80 year old male with MMP who presents for vascular procedure with SMA
stenting for mesenteric ischemia, having NSTEMI post procedure, found
to have extensive CAD not amenable to surgery, with plans for staged
[**Hospital 3657**] transferred to CCU for persistent chest pain."
4329,"5 kg
Intake: 114 mL
Output: 0 mL
Fluid balance: 114 mL
Gen: elderly male in NAD. Alert, oriented, conversant.
HEENT: moist MM
Neck: supple, JVP not elevated
CV: regular, no audible murmur
Chest: Left greater than right sided crackles, less crackles
Abd: Soft, NT, ND. No HSM or tenderness. No abdominial bruits.
Ext: Warm, trace pedal edema. No femoral bruits. Warm extremities
with palpable distal pulses. R groin echhymoses, stable nontender. L
groin small hematoma, NT, no bruits, L arm eccymoses, apparently
rsolving; right wrist tender at base of thumb, but less than yesterday
Skin: warm, no rash
Labs
200
10."
4330,"TITLE:
History of Present Illness
Date: [**2152-1-27**]
Initial visit
Events / History of present illness: - glucose levels well controlled
- HD with 2.5kg of fluid removed
- in evening had abdominal discomfort, then 3 loose BMs, trace gauaic
positive (has hemorrhoids)
- NPO for cath tomorrow
Medications
Unchanged
Physical Exam
BP: 126 / 52 mmHg
HR: 73 bpm
RR: 18 insp/min
Tmax C last 24 hours: 36.6 C
Tmax F last 24 hours: 97.8 F
T current C: 36.6 C
T current F: 97.8 F
O2 sat: 92 % on Room air
Previous day:
Intake: 616 mL
Output: 20 mL
Fluid balance: 596 mL
Today:
Weight: 74."
4331,"Admission Date: [**2152-1-18**] Discharge Date: [**2152-1-29**]
Date of Birth: [**2071-8-8**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Superior mesenteric artery stenosis, NSTEMI
Major Surgical or Invasive Procedure:
1. Ultrasound-guided puncture of left brachial artery.
2. Introduction of catheter into aorta.
3. Abdominal aortogram.
4. Selective first order catheterization of celiac artery.
5. Celiac artery angiogram.
6. Selective first order catheterization of the superior
mesenteric artery.
7. Superior mesenteric arteriogram.
8. Primary stenting of superior mesenteric artery.
9. Pressure measurement across the superior mesenteric
artery.
10. percutaneous coronary intervention x 3 with placement of
drug-eluting stents
11."
4332,"hemodialysis
History of Present Illness:
80 year old male with MMP including DMII, hyperlipedemia, CRF,
COPD who presented with intestinal angina and was admitted by
vascular surgery for possible stenting. As per the patient his
abdominal symptoms occurred only when he was at dialysis about
[**3-1**] of the way through. Patient was also having symptoms of
abdominal cramping. Both of these sytmpoms were felt to be
related to poor abdominal blood floor. Paitent was admitted to
vascular surgery and underwent routine angiogram on [**2152-1-18**] with
stent placement to SMA. Patient appparently in the PACU had very
difficult to control pain requiring multiple nitroglycerins with
some relief."
4333,"Patient
also endorses chest pain with exertion that occurs when patient
walks just a few steps. Patient states this pain improves with
rest. Patient also endorses sleeping sitting up as he feels
uncomfortable if he is lying down flat. Patient states that
sometimes he sleeps upright in a chair because it is more
comfortable. IN addition, patient endorses + PND. Denies current
lower extremity swelling although he states that he previously
has had bilateral lower extremity swelling.
Past Medical History:
CAD
HTN
DMII - insulin dependent
hyperlipedemia
CRF - HD M/W/F
COPD- home O2 2L at night
Carotid stenosis s/p LCEA
CHF, dialstolic
Paget's disease
b/l total knee replacement
removal of neck cyst in [**2080**]"
4334,"difficile toxin A & B by EIA.
MRSA SCREEN (Final [**2152-1-27**]): No MRSA isolated.
Blood Culture, Routine (Final [**2152-1-27**]): NO GROWTH
====================================
Reports-
Cath [**2152-1-20**]
COMMENTS:
1. Coronary angiography of this right dominant system revealed
three
vessel CAD. The LMCA had mild luminal irregularities. The LAD
was a
tortuous vessel with a 95% calcified mid vessel lesion. The LCx
had a
99% mid vessel lesion. The RCA serial 90% proximal and mid
vessel
lesions.
2. Hemodynamic evaluation revealed severely elevated right and
left
sided filling pressures. The pulmonary arterial systolic
pressure was
severely elevated at 65mm Hg."
4335,"Tx.Imparied Renal fxn, soy 0.08 gram-1.8 kcal/mL ( 1 by
mouth TID)
Omega 3- fatty acids 1 capsule at bedtime
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min as needed for chest pain.
3. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily)."
4336,"He
will have PCP and cardiology follow up.
Medications on Admission:
Albuterol 90 1-2 puffs IHH q 6 hours PRN
Albuterol nebs PRN
Ipratropium 0.2 mg/ml 0.02% solution, 1 q 6 PRN
Ipratropium-albuterol [**12-31**] q 6 hours PRN
Metoprolol Tartate 50 mg PO daily
Nitro PRN
Omeprazole 20 mg PO daily
Oxygen 2L at night
Ranitidine 300 mg PO q hs
Sevelamer 2400 mg PO QID
Simvastatin 20 mg PO daily
Temazepam 30 mg PO qhs PRN
Acetominophen 650 mg PO q 6 PRN
Aspirin 81 mg PO daily
Docusate 100 mg PO PRN
MVI
Nut."
4337,"Social History:
Social history is significant for the absence of current tobacco
use. Pt quit smoking 4 years ago. Prior to that patient smoked
[**12-31**] pack of cigarettes from age 6 on = 35 year pack smoking
history. There is no history of alcohol abuse. Patient states he
drinks socially.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - Temp 97.6, P 70, BP 133/72, R 18, 97% on RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate recieving dialysis.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI."
4338,"8* MCHC-35.4* RDW-14.8 Plt Ct-185
[**2152-1-20**] 07:00AM BLOOD PT-14.0* PTT-32.4 INR(PT)-1.2*
[**2152-1-20**] 07:00AM BLOOD Glucose-85 UreaN-43* Creat-7.2*# Na-140
K-4.0 Cl-97 HCO3-30 AnGap-17
[**2152-1-19**] 05:40AM BLOOD WBC-11.9* RBC-3.36* Hgb-11.0* Hct-31.7*
MCV-94 MCH-32.8* MCHC-34.8 RDW-14.7 Plt Ct-177
[**2152-1-20**] 07:00AM BLOOD PT-14.0* PTT-32.4 INR(PT)-1.2*
[**2152-1-19**] 05:40AM BLOOD Glucose-114* UreaN-67* Creat-9."
4339,".
# Hyperlipdemia - Patient with history of hyperlipedemia. Lipid
panel showed LDL 65 on 20 mg atorvastatin as an outpatient.
Given NSTEMI, he was changed to atorvastatin 80mg.
.
# Carotid stenosis s/p LCEA: Statin and ASA were continued.
.
# Anemia - Normocytic and hematocrit of 28 in the setting of
chronic renal failure. Iron panel consistent with anemia of
chronic disease. Also with decreased EPO production. Goal Hct
>30 given NSTEMI and angina; no transfusion was required.
# COPD - on 2L NC at night PRN at home, continued while in
patient. Will resume use at home.
He was discharged home with home safety evaluation planned."
4340,"Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
primary:
Non-ST elevation myocaridal infarction
Periphrial vascular disease s/p stenting to Superior mesenteric
artery
secondary:
Chronic renal failure, end stage on hemodialysis
hypertension
Diabetes mellitus, type II
hyperlipedemia
COPD
Chronic heart failure, diastolic
Carotid stenosis s/p LCEA
Paget's disease
Discharge Condition:
stable, free of chest pain
Discharge Instructions:
You came to the hospital for a procedure to open the artery to
your intestine which was done successfully. While in the
hospital you had a heart attack and had 2 procedures to place
stents in the arteries to the heart."
4341,"Nitro drip was titrated to pain
relief. ASA, Plavix, atorvastatin, metoprolol, and lisinopril
were continued. He underwent staged PCI with 2 bare metal
stents to the LCx and then another PCI with two bare metal
stents to the RCA. He will need continued plavix tx for at
least 1 month. Per pt request he will follow up with his
cardiologist by his home.
.
#.ESRD- Patient had a history of ESRD likely [**1-31**] hypertension
and diabetes, on MWF dialysis. On [**1-21**] he became hypotensive
during HD and was only able to have 1 L removed. Because he had
elevated R heart pressures on cath, the plan was made to
undertake ultrafiltration with the plan to remove more fluid and
prevent pulmonary edema."
4342,"1* PTT-34.4 INR(PT)-1.3*
[**2152-1-29**] 07:25AM BLOOD Glucose-91 UreaN-35* Creat-6.8*# Na-138
K-4.0 Cl-98 HCO3-30 AnGap-14
[**2152-1-28**] 05:30AM BLOOD CK(CPK)-24*
[**2152-1-29**] 07:25AM BLOOD Calcium-9.7 Phos-4.7*# Mg-1.6
Micro
[**2152-1-28**] 5:37 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT [**2152-1-28**]**
GRAM STAIN (Final [**2152-1-28**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2152-1-27**]):
Feces negative for C."
4343,"Disp:*30 Cap(s)* Refills:*0*
6. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed for insomnia.
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, headache, fever.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB."
4344,"12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for sob, wheezing.
13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
16. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO at bedtime."
4345,"3- Vagal reaction requiring Dopamine infusion.
FINAL DIAGNOSIS:
1. Successful rotablation, PTCA and stenting of the proximal-mid
RCA
with two overlapping Driver BMS.
2. partially successful deployment of
an 8 French Angioseal.
3. Vagal reaction secondary to groin compression requiring
Dopamine
infusion.
4. Consider CT scan to r/o retroperitoneal hemorrhage if
dopamine
requirement persists or significant hematocrit drop.
======================================
Cardiology Report ECG Study Date of [**2152-1-20**] 2:37:12 PM
Baseline artifact. Sinus rhythm with borderline P-R interval
prolongation.
predominantly inferolsateral ST segment depressions. Since the
previous tracing of [**2152-1-19**] atrial premature beats are no longer
seen."
4346,"3
[**2152-1-20**] 07:00AM BLOOD Calcium-9.9 Phos-5.1* Mg-1.8
[**2152-1-21**] 04:10PM BLOOD calTIBC-168* VitB12-414 Folate-8.1
Ferritn-1505* TRF-129*
[**2152-1-21**] 04:10PM BLOOD Triglyc-184* HDL-27 CHOL/HD-4.8
LDLcalc-65
[**2152-1-21**] 04:10PM BLOOD %HbA1c-5.8
Discharge labs-
[**2152-1-29**] 07:25AM BLOOD WBC-10.4 RBC-2.98* Hgb-9.6* Hct-28.3*
MCV-95 MCH-32.3* MCHC-34.0 RDW-15.1 Plt Ct-215
[**2152-1-28**] 05:30AM BLOOD PT-15."
4347,"Patient ruled in with NSTEMI with troponins
peaking to 0.89 and CK- MB to 34. Cardiology was consulted and
patient underwent cardiac catherization and was found to have
3VD. C-surgery was consulted and pt was deemed not a surgical
candidate for CABG, thus it was decided that pt would undergo
staged PCI. Plan current was for staged PCI to begin on Monday.
On transfer patient denies any current symptoms. Denies current
chest pain, abdominal pain, or shortness of breath. Patient has
severly depressed exercise tolerance. Patient states he can
barely walk a few feet without getting short of breath."
4348,"Conjunctiva
non-injfected.
Neck: Difficult to assess JVP given positioning.
CV: RR, normal S1, S2. distant. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. fine crackels at the
bases, no wheezes or rhonchi.
Abd: Soft, NT, ND. No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission labs-
[**2152-1-20**] 07:00AM BLOOD WBC-9.7 RBC-3.29* Hgb-11.1* Hct-31.4*
MCV-96 MCH-33."
4349,"Mean PCWP was elevated at 31 mm
Hg.
Systemic arterial pressures were elevated at 132 mm Hg. Cardiac
index
was preserved at 3.94 l/min/m2.
3. Left ventriculography revealed no mitral regurgitation.
LVEF was
60% with normal regional wall motion.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severely elevated biventricular filling pressures.
3. Pulmonary arterial systolic hypertension.
=========================================
Cath [**2152-1-25**]
COMMENTS:
1- Successful stenting of the mid LCX with two overlapping
Microdriver
BMSs (2.5x18 and 2.5x8 mm). Final anfiography revealed 0%
residual
stenosis with TIMIn III flow and no dissection or distal emboli."
4350,"3*# Na-137
K-4.7 Cl-95* HCO3-25 AnGap-22*
[**2152-1-19**] 01:30AM BLOOD CK(CPK)-24*
[**2152-1-19**] 05:40AM BLOOD CK(CPK)-63
[**2152-1-19**] 04:40PM BLOOD CK(CPK)-223*
[**2152-1-19**] 01:30AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2152-1-19**] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2152-1-19**] 04:40PM BLOOD CK-MB-34* MB Indx-15.2* cTropnT-0.89*
[**2152-1-25**] 08:52PM BLOOD CK-MB-20* MB Indx-12.7* cTropnT-2.18*
[**2152-1-21**] 04:10PM BLOOD ALT-10 AST-15 LD(LDH)-145 CK(CPK)-38
AlkPhos-58 TotBili-0."
4351,"Afte that he had his regular HD, with
good results. He has an appointment to restart his MWF HD after
discharge. Sevalamer was continued; nephrocaps were started.
.
#. Pump - Patient had evidence clinically of heart failure by
history with PND, dyspnea on exertion as well as previous
history of lower extremity edema, although ventrigulograph done
with cath showed normal EF and wall motion. On arrival to the
ccu, patient appeared euvolemic to slightly overloaded. ACEI and
beta blocker were continued.
.
# Diabetes - Patient was not on outpatient medications. Sliding
scale was instituted. Pt was discharged on diabetic diet. He
will f/u with his PCP."
4352,"You are now on several
medications to help keep the arteries to your heart open. It is
important that you take your plavix and aspirin every day.
Please keep your follow up appointments
Clopidogrel was added.
The following medication changes were made:
Lisinopril was added.
Metoprolol was increased.
Atorvastatin was increased.
Your sevelamer should be taken three times daily with meals.
Nephrocaps have been added.
Please return to the emergency department if you have chest
pain, shortness of breath, high fevers and chills, or other
symptoms that are concerning to you.
Please follow the wound care instructions provided to you for
your groin."
4353,"Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 [**Telephone/Fax (3) 73455**]/411 78 76 40
=======================================
Brief Hospital Course:
80 year old male with MMP who presents for vascular procedure
with SMA stenting for mesenteric ischemia, having NSTEMI post
procedure, found to have extensive CAD not amenable to surgery,
now status post staged PCI.
NSTEMI: On [**2152-1-19**], patient had an NSTEMI (ruled in with
troponins positive) and required increasing amounts of
nitroglycerin. Patient had unstable angina though he remained
hemodynamically stable. Patient underwent a cardiac
catheterization with which showed extensive cardiac disease (The
LAD had a 95% calcified mid vessel lesion."
4354,"2- Failed attempt to cross the LAD into the diagonal.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the mid LCX with two overlapping bare
metal
stents.
3. Failed attempt to cross the LAD lesion.
=========================================
Cath [**2152-1-27**]
COMMENTS:
1- Sucecssful rotablation, PTCA and stenting of the proximal-mid
RCA
with two overlapping Driver BMSs (3.5x15 and 3.5x24 mm). Final
angiography revealed 0% residual stenosis and no dissection or
distal
emboli.
2- Partially successful deployment of an 8 French Angioseal
closure
device to the left CFA with limited bleeding that responded to
compression."
4355,"The LCx had a 99%
mid vessel lesion. The RCA serial 90% proximal and mid vessel
lesions.) He was evaluated for CABG and thought not to be a
candidate given multiple medical problems including PVD and
Renal failure on HD. Instead, staged PCI was planned and
medical therapy optimized including ASA, clopidogrel, and
heparin gtt until PCIs were completed. Because he had
persistent chest pain and ST depressions v4-v6 despite nitro gtt
after catheterization, he was transferred to the CCU while
awaiting the procedures.
.
On arrival to the ccu he was chest pain free but continued to
have nitermittent symptoms."
4356,"Followup Instructions:
Please resume dialysis on Monday, [**1-31**].
Please also follow up as below:
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26225**] ([**Telephone/Fax (1) 73456**] on Tues.
[**2-8**] at 3pm.
.
Please follow up with your cardiologist Dr. [**First Name (STitle) 1557**] ([**Telephone/Fax (1) 73457**] on Tuesday [**2-15**] at 2:30 pm.
.
Please follow up with Vascular Surgery:
VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-2-10**] 10:45
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-2-10**]
11:30
Completed by:[**2152-1-29**]"
4357,"Tolerated fluid removal without any
problems yesterday.
-- [**Name2 (NI) 3690**] to TID with meals
- nephrocaps
- renal recs: re fistula / dialysis access needle (pt request blunted
needle)
# Pump
Clinical heart failure, ejection fraction preserved, so
presumed acute on chronic diastolic CHF. improves with fluid removal
on HD.
- f/u echo read
- patient already on beta blocker, lisinopril
# Diabetes - Patient is reportedly diabetic however no outpatient
diabetic medications listed. HgA1C 5.8%
- insulin sliding scale
- continue to monitor
# Hyperlipdemia - patient with history of hyperlipedemia. Recent lipid
panel with LDL 65.
- continue lipitor 80 mg PO daily
# Carotid stenosis s/p L carotid endarterectomy
- cont statin, aspirin
# Anemia
Chronic disease, stable.
- transfuse for Hct < 30 based on NSTEMI (would prefer to give to
patient when in dialysis)
#. FEN: Follow and replete electrolytes. Cardiac, diabetic, renal
diet.
#. Access: PIV
#. PPx: Heparin IV, colace, senna, PPi.
#. Code: Full Code
#. Dispo: consider after stages PCI"
4358,"3
7.8
10.5
10.7
14.4
Hgb
10.0
9.7
11.5
11.2
11.0
Hct (Serum)
28.8
30.3
27.5
33.0
31.7
29.4
Plt
171
157
211
209
218
INR
1.3
1.2
1.1
1.2
1.6
PTT
105.9
50.8
101.2
40.5
39.3
57.4
56.4
87.1
56.9
Na+
139
136
137
138
137
136
K + (Serum)
3.8
3.9
3.9
4.0
5.0
4.9
Cl
99
100
99
99
99
102
HCO3
28
26
23
30
22
23
BUN
39
51
69
39
57
63
Creatinine
7."
4359,"# Chest Pain- Anginal pain in setting of severe 3v CAD and NSTEMI.
Patient was transferred to CCU for excalating chest pain with increased
ST depressions in V4-V6. He is currently chest pain free.
- ASA 325 mg PO daily
- Plavix 75 mg PO Daily
- atorvastatin 80 mg PO qhs
- metoprolol 50mg PO BID, consider uptitration as tolerated by
hemodialysis.
- lisinopril 5mg PO daily
- Heparin IV
- morphine prn pain
- nitro gtt, titrated to pain relief, currently off
- plan for PCI today
# COPD: Stable
- albuterol/ipratropium PRN
# ESRD- patient with history of ESRD likely [**1-31**] hypertension and
diabetes receives dialysis m,w,f."
4360,"8
9.3
11.6
8.2
10.0
9.9
Glucose
141
154
100
97
179
142
CK
28
158
CK-MB
20
Troponin T
2.18
ABG: / / / 23 / Values as of [**2152-1-26**] 04:07 AM
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
ANEMIA, CHRONIC
CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)
RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)
80 year old male with MMP who presents for vascular procedure with SMA
stenting for mesenteric ischemia, having NSTEMI post procedure, found
to have extensive CAD not amenable to surgery, with plans for staged
[**Hospital 3657**] transferred to CCU for persistent chest pain."
4361,"Alert, oriented, conversant.
HEENT: moist MM
Neck: supple, JVP not elevated
CV: regular, no audible murmur
Chest: Left greater than right sided crackles, less crackles
Abd: Soft, NT, ND. No HSM or tenderness. No abdominial bruits.
Ext: Warm, trace pedal edema. No femoral bruits. Warm extremities
with palpable distal pulses. R groin echhymoses, stable nontender. L
arm eccymoses, apparently rsolving; right wrist tender at base of
thumb, but less than yesterday
Skin: warm, no rash
Labs
218
11.0
142
9.9
23
4.9
63
102
136
29.4
14.4
[image002.jpg]
[**2152-1-22**] 01:37 PM
[**2152-1-22**] 10:09 PM
[**2152-1-23**] 04:32 AM
[**2152-1-23**] 03:40 PM
[**2152-1-24**] 03:26 AM
[**2152-1-24**] 10:54 AM
[**2152-1-24**] 04:39 PM
[**2152-1-25**] 04:05 AM
[**2152-1-25**] 08:52 PM
[**2152-1-26**] 04:07 AM
WBC
9."
4362,"TITLE:
`
History of Present Illness
- cath --> BMS x 2 to LCx, plan for RCA intervention on [**1-27**]
- had chest pain during cath, came back on increased nitro gtt
- increased beta blocker to 50 mg TID 2/2 HR 80s
- post-cath check NL (venous sheath left in for access)
Medications
Unchanged
Physical Exam
BP 121/59, HR 65, RR 18, O2 Sat 98% on 2L
Tmax C last 24 hours: 36.8 C
Tmax F last 24 hours: 98.2 F
T current C: 36.2 C
T current F: 97.2 F
Previous day:
Weight: 74.3 kg
Intake: 864 mL
Output: 0 mL
Fluid balance: 864 mL
Today:
Intake: 100 mL
Output: 0 mL
Fluid balance: 100 mL
Gen: elderly male in NAD."
4363,"#. Pump - patient with evidence clinically of heart failure by history.
No recent echo in our system. Patient with history of PND, dyspnea on
exertion as well as previous history of lower extremity edema. On exam,
patient is saturating well on room air, with fine crackels at the lung
bases bilaterally.
- echo
- patient already on beta blocker, lisinopril
.
# Diabetes - Patient is a diabetic however no outpatient diabetic
medications listed.
- tight insulin sliding scale
- consider [**Last Name (un) 294**] consult if needed
.
# Hyperlipdemia - patient with history of hyperlipedemia without
documented lipid panel in our system. Given NSTEMI would benefit from
high dose statin
- lipitor 80 mg PO daily
- check lipid panel
.
# Carotid stenosis s/p LCEA - cont statin, aspirin
.
# Anemia - Normocytic and hematocrit of 28 in the setting of chronic
renal failure. Iron panel consistent with anemia of chronic disease.
Also withdecreased EPO production.
- transfuse for Hct < 30 based on NSTEMI (would prefer to give to
patient when in dialysis)
.
#. FEN: Follow and replete electrolytes. Cardiac, diabetic, renal
diet.
.
#. Access: PIV
.
#. PPx: Heparin IV, colace, senna, PPi.
.
#. Code: Full Code
.
#. Dispo: consider after stent placement next week."
4364,"On [**1-22**], the patient was
reporting persistent chest pain, and EKG showed increased ST
depressions in V4-V6. Given his increased frequency of chest pain and
ekg changes he was transferred ot the CCU for closer monitoring.
.
On transfer to the CCu the patient denied any current symptoms. Denied
current chest pain, abdominal pain, or shortness of breath. Patient has
severly depressed exercise tolerance. Patient states he can barely walk
a few feet without getting short of breath. Patient also endorses chest
pain with exertion that occurs when patient walks just a few steps.
Patient states this pain improves with rest."
4365,"Tx.Imparied Renal fxn, soy 0.08 gram-1.8 kcal/mL ( 1 by mouth TID)
Omega 3- fatty acids 1 capsule at bedtime
Medications on transfer:
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
Lisinopril 5 mg PO DAILY
Acetaminophen 650 mg PO Q6H:PRN pain, headache, fever
Metoprolol Tartrate 50 mg PO BID
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing
Morphine Sulfate 1-2 mg IV Q4H:PRN chest pain
Aspirin 325 mg PO DAILY
Nitroglycerin 0.25-0.6 mcg/kg/min IV DRIP TITRATE TO chest pain
Atorvastatin 80 mg PO DAILY
Omeprazole 20 mg PO DAILY
Bisacodyl 10 mg PO/PR DAILY:PRN
Clopidogrel 75 mg PO DAILY
Senna 1 TAB PO BID
Docusate Sodium 100 mg PO BID
Heparin IV per Weight-Based Dosing Guidelines
Temazepam 30 mg PO HS:PRN
Insulin SC
sevelamer HYDROCHLORIDE 2400 mg PO QID
Cardiovascular ROS
Cardiovascular ROS Signs and Symptoms Present
Chest pain, SOB, DOE, PND, Orthopnea, Edema
Cardiovascular ROS Signs and Symptoms Absent
Murmur, Rheumatic fever, Palpitations, Syncope, Presyncope,
Lightheadedness, Pulmonary embolism, DVT, Claudication, Exertional
buttock pain, Exertional calf pain
Review of Systems
Organ system ROS normal
Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,
Hematology / Lymphatic, Genitourinary, Musculoskeletal, Integumentary,
Neurological, Psychiatric, Allergy / Immune
Signs and symptoms absent
Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,
Bleeding during surgery, Joint pains, Myalgias
Social History
(Recreational drug use: No)
Family history: Non-contributory
Physical Exam
Date and time of exam: [**2152-1-22**] 1400
General appearance: awake, alert, obese
Vital signs: per R."
4366,"N.
Height: 63 Inch, 160 cm
BP right arm:
116/45 / mmHg
Weight: 75 kg
T current: 97.9 C
HR: 81 bpm
RR: 14 insp/min
O2 sat: 97 % on Room air
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and
palette: WNL)
Neck: (Jugular veins: Not visible), (Thyroid: WNL)
Back / Musculoskeletal: (Chest wall structure: WNL)
Respiratory: (Effort: WNL), (Auscultation: Abnormal, crackles at bases)
Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:
WNL, S3: Absent, S4: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Hepatosplenomegaly: No)
Genitourinary: (WNL)
Extremities / Musculoskeletal: (Digits and nails: WNL), (Dorsalis pedis
artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+,
Left: 1=), (Edema: Right: 0, Left: 0)
Skin: ( WNL)
Labs
171
10."
4367,"The LCx had a
99% mid vessel lesion. The RCA serial 90% proximal and mid vessel
lesions.
2. Hemodynamic evaluation revealed severely elevated right and left
sided filling pressures. The pulmonary arterial systolic pressure was
severely elevated at 65mm Hg. Mean PCWP was elevated at 31 mm Hg.
Systemic arterial pressures were elevated at 132 mm Hg. Cardiac index
was preserved at 3.94 l/min/m2.
3. Left ventriculography revealed no mitral regurgitation. LVEF was
60% with normal regional wall motion.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severely elevated biventricular filling pressures.
3. Pulmonary arterial systolic hypertension."
4368,"The LMCA had mild luminal irregularities. The LAD was a
tortuous vessel with a 95% calcified mid vessel lesion. The LCx had a
99% mid vessel lesion. The RCA serial 90% proximal and mid vessel
lesions.
2. Hemodynamic evaluation revealed severely elevated right and left
sided filling pressures. The pulmonary arterial systolic pressure was
severely elevated at 65mm Hg. Mean PCWP was elevated at 31 mm Hg.
Systemic arterial pressures were elevated at 132 mm Hg. Cardiac index
was preserved at 3.94 l/min/m2.
3. Left ventriculography revealed no mitral regurgitation. LVEF was
60% with normal regional wall motion."
4369,"Patient appparently in the PACU had very difficult to control pain
requiring multiple nitroglycerins with some relief. Patient ruled in
with NSTEMI with troponins peaking to 0.89 and CK- MB to 34. Cardiology
was consulted and patient underwent cardiac catherization [**1-20**] and was
found to have 3VD. C-surgery was consulted and pt was deemed not a
surgical candidate for CABG, thus it was decided that pt would undergo
staged PCI. Plan current was for staged PCI to begin on Monday.
.
On the cardiology floor the patient reported persistent chest pain,
which was exacerbated when his nitroglycerin was weaned off and
resolved with increased nitroglycerin."
4370,"- ASA 325 mg PO daily
- Plavix 75 mg PO Daily
- atorvastatin 80 mg PO qhs
- metoprolol 50mg PO BID
- lisinopril 5mg PO daily
- Heparin IV
- morphine prn pain
- nitro gtt, titrated to pain relief
- consider ranolazine
.
#.ESRD- patient with history of ESRD likely [**1-31**] hypertension and
diabetes receives dialysis m,w,f. Became hypotensive during HD
yesterday and was only able to remove 1L. Recent cath report showing
elevated right and left heart pressures, and ideally patient would
undergo further CVVH over the weekend to remove fluid and prevent
pulmonary edema.
-UF over the weekend.
-change sevalemer to TID with meals
."
4371,".
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severely elevated biventricular filling pressures.
3. Pulmonary arterial systolic hypertension.
Assessment and Plan
ASSESSMENT AND PLAN: 80 year old male with MMP who presents for
vascular procedure with SMA stenting for mesenteric ischemia, having
NSTEMI post procedure, found to have extensive CAD not amenable to
surgery, with plans for staged PCI beginning [**Hospital 3626**] transferred to CCU
for persistent chest pain.
.
#. Chest Pain- Anginal pain in setting of severe 3v CAD and NSTEMI.
Patient was transferred to CCU for excalating chest pain with increased
ST depressions in V4-V6. He is currently pain free on presentation to
CCU."
4372,"There is no history of:
CABG
Pacemaker / ICD
Allergies:
Iodine
Anaphylaxis; ca
Current medications: OUTPATIENT MEDICATIONS:
Albuterol 90 1-2 puffs IHH q 6 hours PRN
Albuterol nebs PRN
Ipratropium 0.2 mg/ml 0.02% solution, 1 q 6 PRN
Ipratropium-albuterol [**12-31**] q 6 hours PRN
Metoprolol Tartate 50 mg PO daily
Nitro PRN
Omeprazole 20 mg PO daily
Oxygen 2L at night
Ranitidine 300 mg PO q hs
Sevelamer 2400 mg PO QID
Simvastatin 20 mg PO daily
Temazepam 30 mg PO qhs PRN
Acetominophen 650 mg PO q 6 PRN
Aspirin 81 mg PO daily
Docusate 100 mg PO PRN
MVI
Nut."
4373,"Date of service: [**2152-1-22**]
Initial visit, Cardiology service: CCU
History of present illness: 80 year old male with MMP including DMII,
hyperlipedemia, CRF, COPD who presented with intestinal angina and was
admitted by vascular surgery for possible stenting. As per the patient
his abdominal symptoms occurred only when he was at dialysis about [**3-1**]
of the way through. Patient was also having symptoms of abdominal
cramping. Both of these sytmpoms were felt to be related to poor
abdominal blood flow. Patient was admitted to vascular surgery and
underwent routine angiogram on [**2152-1-18**] with stent placement to SMA."
4374,"Admission Date: [**2179-8-16**] Discharge Date: [**2179-8-20**]
Service: MEDICINE
Allergies:
morphine
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
dizziness and vomitting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
OUTPATIENT CARDIOLOGIST: [**Last Name (LF) 1270**], [**Name8 (MD) **] MD
.
PCP:
.
CHIEF COMPLAINT: Dizziness and vomiting
.
.
HISTORY OF PRESENTING ILLNESS:
Pt is a [**Age over 90 **] y/o female with history of ?bradycardia, LE swelling,
CKD, HTN, HL, hypothyroidism, RA who was transferred to [**Hospital1 18**]
for pacemaker placement s/p symptomatic bradycardia. Per OSH
(Good Sumaritan) records, she was in usual state of health until
this evenning when she developed acute onset dizziness while
washing her dishes when she fell and EMS was caled."
4375,"CHF
Bradycardia- had been evaluated by cardiologist who recommended
no intervention as patient was asymptomatic. Unclear if history
3. OTHER PAST MEDICAL HISTORY:
CKD
ANEMIA
GERD
Rheumatoid arthritis
MEDICATIONS:
hydrochlorothiazide - in OMR, not on OSH records
25 mg tablet
0.5 (One half) Tablet(s) by mouth once a day [**2179-4-9**]
isosorbide mononitrate [Imdur]
60 mg tablet extended release 24 hr
1 Tablet(s) by mouth once a day
levothyroxine [Synthroid]
25 mcg tablet
1 Tablet(s) by mouth once a day [**2179-2-12**]
nitroglycerin [Nitrostat]
0.3 mg tablet, sublingual
1 Tablet(s) sublingually 5 minutes [**2178-12-11**]"
4376,"4* INR(PT)-1.0
Brief Hospital Course:
ASSESSMENT AND PLAN
This is a [**Age over 90 **] y/o female with PMHx of HTN, HL, questionable
history of bradycardia and CHF, also with CKD who presented to
[**Hospital3 **] hospital with near syncope found to be in 3rd degree
heart block/Aflutter with evidence of lateral STEMI .
She was transferred here for consideration of pacemaker
placement.
ACUTE ISSUES
# Afib with Junctional escape/complete heart block: Per son and
attending, this had happened in the past and pt had not been
symptomatic. ECG changes indicated likely completed STEMI that
could be contributing to bradycardia vs acute on chronic
process."
4377,"Patient felt dizzy when walking with physical therapy.
At this point in time it was decided to not place a pacemaker.
# Completed STEMI: Trop peak was 1.5 at the outside hospital.
She was treated with heparin for 2 days as ACS treatment. She
was also given aspirin and plavix. Her beta blocker wa held
because of slow heart rate. She was not brought to cath lab
because it was believed this was a completed MI. On [**8-18**] her
CKMB was down to 4 and trop down to .32.
# Right arm hematoma: Patientn came home with a right arm
hematoma."
4378,"She did not recall how she got this though it is
possible it was related to when she fell before coming in.
During hospital stay the hematoma got larger and we consulted
vascular and hand surgery for their input. They could obtain an
ulnar pulse on doppler and recommended the patient be monitored
and there was no need to do any surgery at this time. We did
further imaging which showed a brachial artery dissection with
no fractures in any of the bones in her arm. We gave her
tramadol and tylenol for pain while she was uncomfortable.
#Vertigo: On [**8-20**] patient started feeling vertigo."
4379,"She described
a dizziness like the room is spinning sensation. She said it was
worse when turning her head. We felt this was either Meuniere's
vs benign position veritgo vs a small stroke involving the
brainstem. We started her on meclizine on day of discharge and
ordered a soft collar to prevent neck movements.
# HTN: Her SBPs were in the 160s-170s. We stopped her home hctz
and started amlodipine. She was also on captopril which was
changed to her home benazepril at discharge. Her goal SBP Is
140.
CHRONIC ISSUES.
# Hypothryoidism: TSH nl. We continued home levothyroxine
# HLD: stable We continued home simvastatin"
4380,"Aspirin 325 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Docusate Sodium 100 mg PO BID:PRN constipation
hold for loose stools
11. Heparin 5000 UNIT SC TID
D/C once pt is mobile
12. Meclizine 12.5 mg PO TID
13. Senna 1 TAB PO BID:PRN constipation
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. benazepril *NF* 40 mg ORAL DAILY
Hold SBP < 100
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Completed STEMI
Acute on chronic diastolic congestive Heart failure
Acute on chronic kidney function
Atrial Fibrillation with complete heart block
Vertigo
Hypertension
Right arm hematoma"
4381,"Hydrochlorothiazide 25 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN angina
9. benazepril *NF* 40 mg Oral daily
Discharge Medications:
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Nitroglycerin SL 0.3 mg SL PRN angina
3. Pantoprazole 40 mg PO Q24H
4. PredniSONE 5 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Acetaminophen 650 mg PO TID
7. Amlodipine 5 mg PO DAILY
Hold for SBP < 100
8."
4382,"6 BP=143/61 HR= 45 3rd degree AV block RR=20 O2 sat=99%
GENERAL: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 9 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Slow rate, normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: Crackles auscultated in left lower lobe
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: [**1-25**]+ edema bilateral lower extremities, R>L."
4383,"Brady @ 0054 [**2179-8-17**]
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 9.1 Mg: 2.1 P: 3.0
94
12.6 12.3 201
34.5
PT: 10.8 PTT: 42.4 INR: 1.0
EKG:
-In house: Rate 40, 3rd degree AV block, Axis 80, No ST changes
seen on this EKG.
-OSH- STE in Leads aVL and I with reciprocal changes in v5 and
v6. Ventricular escape takes over in 09:56:36 PM EKG.
.
2D-ECHOCARDIOGRAM:
EF 60-65%, normal systolic function, right atrium mildly
dilated, trace AR, no AS, Pulmonary HTN present with RVSP 67"
4384,"REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
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:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
?"
4385,"They
have all agreed that it is resolving on it's own. Please be sure
to keep it elevated. You have new dizziness that may have been
caused by a very small stroke. You are now on aspirin and plavix
for your heart that may also help to prevent further strokes.
Your vertigo should go away as you recover.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: FRIDAY [**2179-9-24**] at 11:00 AM
With: [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], MD [**0-0-**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**]
Campus: OFF CAMPUS Best Parking: On Street Parking
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]"
4386,"Her exam at OSH was notable for BP systolic 160s both upper
extremities, bradycardia, crackles in left base, 2+ pitting
edema in LE bilaterally, and skin tear on left elbow with
brusing and echhymoses. Labs WBC 11.3, hct 38.5, plt 225,000,
INR 0.9 PTT 30. Na 137 K3.7, Cl94, bicarb 29, AG 14. BUN/Cr
71/2.2. glu 250 and Ca 9.6. Cl 73, peak MB 14, peak TropI
1.55.
EKG with Aflutter 5:1 conduction block. 1mm STE in I, 2mmSTE in
aVL with reciprocal ST depressions in II, II, avF, V5 and V6."
4387,"# GERD/Hiatal hernia
-Pantoprazole 40 mg daily
#HL
-Simvastatin 20 mg daily
TRANSITIONAL ISSUES
#veritgo: patietn should follow up with PCP
#[**Name10 (NameIs) **] hematoma showed be followed up with vascular surgery if
does not resolve.
#hypertension: we started amlodipine during hosptial stay and
discontinued her home thiazide. Her SBPs were in the 140's.
#Bradycardia with heart block: should be followed up with
outpatient cardiologist in terms of if patient will need a
pacemaker in the future.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Furosemide 20 mg PO ONCE Duration: 1 Doses
2."
4388,"Also ""new LBBB"". CXR with enlarged cardiac silhouette. CT
Chest showed cardiac enlargement with small pericardial
effusion, large hiatal hernia, small right pleural effusion.
ECHO showed EF 60-65%, normal systolic function, right atrium
mildly dilated, trace AR, no AS, Pulmonary HTN present with RVSP
67
On arrival to CCU the patient appeared well and was conversant,
alert and oriented x3. She did describe some chest pain on her
lower right sternum which only was present during moving. The
pain was felt to be internal and non-radiating. She denied
nausea, dizziness, shortness of breath, but did endorse a cough
which is new."
4389,"pantoprazole [Protonix]
40 mg tablet,delayed release (DR/EC)
simvastatin [Zocor]
20 mg tablet
1 Tablet(s) by mouth once a day
Benzapril 40 mg daily
Lasix 20 mg daily
Prednisone 5 mg daily
ALLERGIES: Morphine years ago, does not remember her reaction
Social History:
SOCIAL HISTORY
Lives in [**Hospital3 **] home, lately increased dependence on
ambulatory aid. 1 son [**Name (NI) **] [**Name (NI) **] involved in her care
-Former smoker, [**3-28**] ppd 45 years, quit in [**2144**]
-No etoh or illicits
Family History:
FAMILY HISTORY:
Mother and father died in 80s, father from CAD, sister cancer,
mother unknown
Physical Exam:
PHYSICAL EXAMINATION:
VS: T=97."
4390,"[**2179-8-16**] 11:16PM GLUCOSE-144* UREA N-56* CREAT-1.6* SODIUM-140
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-31 ANION GAP-15
[**2179-8-16**] 11:16PM estGFR-Using this
[**2179-8-16**] 11:16PM CK(CPK)-165
[**2179-8-16**] 11:16PM CALCIUM-9.1 PHOSPHATE-3.0 MAGNESIUM-2.1
[**2179-8-16**] 11:16PM WBC-12.6* RBC-3.69* HGB-12.3 HCT-34.5* MCV-94
MCH-33.3* MCHC-35.6* RDW-13.4
[**2179-8-16**] 11:16PM PLT COUNT-201
[**2179-8-16**] 11:16PM PT-10.8 PTT-42."
4391,"No LOS or
headache. On route developed chest pain radiating to her back
and got aaspirin 325 and nitro once. In the ambulance she was
noted to be diaphoretic, pale, nausea with vomiting and
dizzzines. The initial EKG showed junctional bradycardia in
40s. A subsequent 12 lead EKG demonstrated aflutter with 5:1
conduction with rates between 49 and 52. In the ED Code STEMI
was activated given STE in I and aVL and patient determined to
be medically managed and NOT taken to cath lab. She was sent
for CT chest to r/o aortic dissection and after put on heparin
drip, asa, nitro drip, morphine, and continued on her home dose
of lasix, hydrochlorothiazide, and home benazepril was changed
to lisinopril (unknown dose)."
4392,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a fall before you arrived here and your heart rate was
found to be very slow. You had a heart attack before you came
and you have been started on medicines to help your heart
recover. Your heart rate has been slow for a long time so a
pacemaker was not placed. You had some fluid overload and was
given diuretics to remove the fluid. A large bruise developed
over your upper and lower right arm and you were seen by a
vascular surgeon, a rheumatologist and a plastic surgeon."
4393,"Ecchymosis on L elbow
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+
.
Pertinent Results:
11:16p
140 98 56 144 AGap=15
3.9 31 1.6
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
estGFR: 30/36 (click for details)
CK: 165 MB: 10 MBI: 6.1 Trop-T: 0.52
Comments: CK(CPK): New Reference Interval As Of [**2177-1-27**];Upper
Limit (97.5th %Ile) Varies With Ancestry And Gender
(Male/Female);Whites 322/201 Blacks 801/414 Asians 641/313
cTropnT: Reported To And Read Back By
cTropnT: J."
4394,"He didn't
restart it and on Saturday morning (5days post operatively,)upon
getting out of bed became SOB. He was unable to catch his
breath but had no chest pain or pressure. He went to [**Hospital1 3325**] and his troponins were elevated (4.58 highest). ASA,
Plavix and a Heparin infusion were started and he became symptom
free. His troponins drifted down also. Catheterization
showed the following 3 vessel disease: total occulsion RCA, 90%
OM and LCx stenosis, 60-70% mid LAD stenosis.
Past Medical History:
Coronary artery disease Diabetes
Dyslipidemia
Hypertension
Sleep apnea - uses nasal CPAP
Chronic back pain
s/p [**Hospital1 **];lateral rotator cuff surgery, 2nd on L
s/p c-spine fusion
s/p transurethral reection of prostate
s/p Appendectomy"
4395,"1* eAG-157*
Brief Hospital Course:
He underwent the usual preoperative work up and Plavix washout
was allowed. On [**3-17**] he was taken to the Operating Room where
surgery was performed. See operative note for details. He did
well and was extubated easily. He was diuresed towards his
preoperative weight and beta blockade was begun. He was
sensitive to lopressor and was bradycardic to the 40s and 50s,
although remained assymptomatic. Losartan was resumed for
hypertension.
He was placed on Lantus and sliding scale human regular insulin
in place of the Levemir he generally takes, with good effect.
Mobilizationn was somewhat problem[**Name (NI) 115**] as he had both sternal
precautions and limitations due to his shoulder repair recently."
4396,".
Carotid U/S [**3-14**]: 1. 40-59% stenosis in the bilateral internal
carotid arteries with moderate heterogenous plaques in the
proximal internal carotid arteries, right more than left.
2. Bidirectional parvus tardus flow in the right vertebral
artery, which may indicate proximal stenosis.
.
PFTs [**3-15**]:
SPIROMETRY 1:42 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.93 4.47 65
FEV1 2.08 3.06 68
MMF 1.24 2.83 44
FEV1/FVC 71 68 104
LUNG VOLUMES 1:42 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 6."
4397,"04 6.95 87
FRC 3.71 3.94 94
RV 2.66 2.48 107
VC 3.42 4.47 76
IC 2.33 3.01 78
ERV 1.04 1.47 71
RV/TLC 44 36 124
He Mix Time 1.75
DLCO 1:42 PM
Actual Pred %Pred
DSB 14.68 25.74 57
VA(sb) 5.48 6.95 79
HB 13.50
DSB(HB) 15.17 25.74 59
DL/VA 2.77 3.70 75
.
TTE [**3-15**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with focal hypokinesis of
the basal inferior wall."
4398,"Physical Therapy worked with him and a regimen for mobilization
was worked out (he uses a cane for balance at home).
Follow up appointments with all providers were arranged and
restrictions and precautions discussed with the patient. He was
discharged to [**Hospital 98323**] Rehab on POD 6.
Medications on Admission:
Sertraline 100mg QD
Pantoprazole 40mg [**Hospital1 **]
Remeron 45mg QHS
Metoprolol tartate 25mg [**Hospital1 **]
Metformin 1000mg [**Hospital1 **]
Losartan 100mg [**Hospital1 **]
Levemir insluin 70units [**Hospital1 **]
Novolog insulin sliding scale
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. aspirin 81 mg Tablet, Delayed Release (E."
4399,"Carotid Bruit Right: 0 Left:0
Pertinent Results:
Cardiac Cath [**3-13**]:
1) Selective coronary angiography of this right-dominant system
demonstrated significant 3-vessel coronary artery disease. The
LMCA had
20% distal stenosis. The LAD had long 60% proximal stenosis and
70%
mid-vessel stenosis. The LCx had a 90% stenosis at its origin
and 90%
proximal stenosis. The RCA was completely occluded proximally,
with the
distal vessel territory being filled with left-to-right
collaterals.
2) Limited resting hemodynamics revealed systemic arterial
normotension,
with a central aortic pressure of 121/56 mmHg.
3) The right femoral arteriotomy site was successfully closed
with a
Perclose device."
4400,"C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day): until mobile, then stop.
15. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 98323**] health center
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass graft x 4
s/p myocardial infarction
insulin dependent diabetes mellitus
Dyslipidemia
Hypertension
Sleep apnea - uses nasal CPAP
Chronic back pain
s/p bilateral rotator cuff surgery, 2nd on L [**3-5**]
s/p c-spine fusion
s/p transurethral resection of prostate
s/p Appendectomy"
4401,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2152-4-20**] at 1:30pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**]([**Telephone/Fax (1) 5315**]) on [**2152-4-10**] at 2pm
Please call to schedule appointments with:
Primary Care: Dr. [**Last Name (STitle) 98324**] [**Name (STitle) 5311**]([**Telephone/Fax (1) 5317**]) in [**4-13**] weeks
orthopedics:Dr. [**Last Name (STitle) 98325**] as instructed
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2152-3-23**]"
4402,"Social History:
Retired electrician. Lives with fiancee. Has three dtrs.
-[**Name2 (NI) 1139**] history: currently 1ppd, 50 pack year hx
-ETOH: denies
-Illicit drugs: denies
Family History:
Mother died of heart disease in her 80s. Brother with DM and
emphysema. Father died with ulcerative colitis in his 40s.
Physical Exam:
VS: 98.3 125/62 55 16 94%RA
General: NAD
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] ___0__
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left:2
DP Right: 1 Left:1
PT [**Name (NI) 167**]: 1 Left:1
Radial Right: 2 Left:2"
4403,"Admission Date: [**2152-3-13**] Discharge Date: [**2152-3-23**]
Date of Birth: [**2085-10-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2152-3-13**] left heart catheterization, coronary angiogram
[**2152-3-17**] Coronary artery bypass graft
x4(LIMA-LAD,SVG-PDA,SVG-DG,SVG-OM)
History of Present Illness:
This 66 year old white male with known coronary disease, had
rotator cuff surgery a week prior to admission. He was told to
hold ASA prior to surgery but not when to restart it."
4404,"The remaining segments contract
normally (LVEF = 55-60 %). The right ventricular cavity size and
systolic function are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w CAD. Preserved ejection fraction. Mild mitral regurgitation.
.
[**2152-3-22**] 04:56AM BLOOD WBC-5.9 RBC-3.10* Hgb-9."
4405,"Admission Date: [**2133-11-11**] Discharge Date: [**2133-11-17**]
Date of Birth: [**2095-8-2**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Keflex
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Left parapharyngeal mass
Major Surgical or Invasive Procedure:
On [**2133-11-12**]:
1. Facial nerve monitoring.
2. Laryngeal nerve monitoring.
3. Transcervical resection of left glomus vagale tumor.
4. Transcervical resection of left carotid body tumor.
5. Left Mastoidectomy with sigmoid decompression
History of Present Illness:
The patient is a 38 yo female with bilateral carotid body tumors
and a
large left skull base paraganglioma/left vagus glomus tumor. 3D
CT angiogram [**2133-8-31**] demonstrated a glomus vagale 4."
4406,"She underwent
preoperative embolization which was successful for an upper
portion of the tumor, however, a
separate portion which was smaller and inferior could not be
embolized adequately. In addition to this tumor, she has a
contralateral carotid body tumor.
Past Medical History:
Left vagal glomus tumor, as above
Bilateral carotid body tumors, as above
Hypertension.
Gastroesophageal reflux.
Head injury [**2130**].
question of history of [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease.
Social History:
She is employed as an executive administrator and is married.
She currently smokes and has for 22 years. She has six to eight
alcoholic drinks per month."
4407,"GI: In light of vagus nerve resection secondary to the tumor,
she was initially kept NPO pending further evaluation. An NGT
was placed on POD #1 and she was started on continuous tube feed
diet with Replete with fiber @ 60 cc/hr. Nutrition was
consulted who agreed with plan. Speech/swallow was consulted on
POD #4 and she underwent a video floroscopic examination to
evaluate pharyngeal swallowing mechanism and aspiration. She had
decrease mobility of the left side of her pharynx with some
pooling on the left side, but this was compensated for by head
turn to left, chin tuck and hand pressure to left neck."
4408,"Disp:*350 ML(s)* Refills:*0*
3. Tube feeding supplies
Tube feeding tansfusion pump
Tube feeding transfusion supplies
4. Suction machine
Suction machine for suctioning of excess oral secretions
5. Tube feeding: replete with fiber
Rx: Replete with fiber nutrition supplement
patient to received 80 ml/hr x 14 hours daily.
Dispense: 1 month supply.
Refill: 3 months
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care
Discharge Diagnosis:
1. Glomus vagale left neck/skull base.
2. Carotid body tumor left neck.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Seek immediate medical attention for fever >101."
4409,"Regarding her cranial nerve exam, post-operatively, she was
noted to have some weakness with tongue movement to the left
(left CN XII) as well as paralysis of the left true vocal cord,
deceased peristalysis of left pharyngeal wall with some pooling
of secretions on that side which was anticipated given intra-op
resection of the left vagus nerve. As a result of anticipated
difficulty with POs, an NGT was placed on POD #1; on POD #4,
after evaluation by speech and swallow, a diet was initiated
with compensatory maneuvers (see below) for her nerve deficits.
Pain was initially controlled with IV dilaudid while she was
NPO."
4410,"She was
cleared for a pureed, moist thin food with thin liquid diet,
which she tolerated. She was instructed on signs/symptoms to
look for in terms of aspiration. She was discharged with a plan
to continue on cycled tube feeds nocturnally with replete with
fiber @ 80 cc/hr x 14 hrs and and diet as above with oral
nutrition supplements as tolerated. She is to follow-up with
Nutrition and Speech/Swallow as an outpatient.
GU: The patient voided throughout admission without signs of
retention or UTI.
Heme: The patient ambulated frequently and was given SCH for DVT
prophylaxis during admission."
4411,"Endo: no issues
ID: The patient recieved perioperative antibiotic prophylaxis
with clindamycin until the drain was removed. Her wound
remained clean, intact and with erythema or signs of infection.
She was afebrile throughout her hospital stay.
Wound: The patient had a neck drain in place, which was removed
on POD#3 as it met output criteria. Her neck incision is closed
with sutures which will be removed as an outpatient. Her wound
remained clean, dry and intact.
Patient is being discharged [**2133-11-17**], POD #5, to home with VNA
services: afebrile, tolerating regular tube feeding via NGT with
pureed, moist food with thin liquid oral diet, pain well
controlled on oral/per tube medication, voiding, and ambulating
well."
4412,"Call Speech and swallow to schedule
follow-up in [**2-14**] weeks. Follow-up with your PCP [**Last Name (NamePattern4) **] [**2-14**] weeks.
Followup Instructions:
1. Call Dr.[**Name (NI) 20390**] office at [**Telephone/Fax (1) 41**] to make
follow up appointment to be seen in 1 week.
2. Call Dr.[**Name (NI) 37129**] office at [**Telephone/Fax (1) 2349**] to schedule a
follow-up appointment in 1 week.
2. Call Speech and swallow team at [**Telephone/Fax (1) 3731**] to schedule
follow-up in [**2-14**] weeks.
4. Call Nutrition at [**Telephone/Fax (1) 3681**] to schedule a follow-up
appointment in [**2-14**] weeks as you are weaning off of Tube feeds
and taking more POs to adjust your tube feed requirements.
5. Follow-up with your PCP [**Last Name (NamePattern4) **] [**2-14**] weeks. Please have you HR and
Blood pressure checked at this time.
Completed by:[**2133-11-17**]"
4413,"Patient will follow-up with Dr. [**Last Name (STitle) 1837**] and Dr.
[**Last Name (STitle) 3878**] in 1 week, nutrition and speech and swallow in [**2-14**] weeks
as well as her primary care physician [**Last Name (NamePattern4) **] [**2-14**] weeks.
Medications on Admission:
Tylenol prn
Discharge Medications:
1. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) 650 mg PO
Q6H (every 6 hours) as needed for pain: PO or via NGT.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain: PO or via NGT."
4414,"4* RDW-12.8
[**2133-11-11**] 09:01PM PLT COUNT-251
[**2133-11-11**] 09:01PM PT-12.8 PTT-25.0 INR(PT)-1.1
Brief Hospital Course:
The patient is a 38 year old woman with history of bilateral
carotid body tumors and left glomus vagale who was admitted
pre-operatively on [**2133-11-11**]. She had undergone pre-operative
embolization, which she tolerated without issue. She was taken
to the OR on [**2133-11-12**] for left mastiodectomy, sigmoid
decompression, transcervical resection of left glomus vagale
tumor and resection of left carotid body tumor with facial and
laryngeal nerve monitoring."
4415,"5, chills,
increased redness, swelling or discharge from incision, chest
pain, shortness of breath, or anything else that is troubling
you. OK to shower. No strenuous exercise or heavy lifting until
follow up appointment, at least. Do not drive or drink alcohol
while taking narcotic pain medications. Narcotic pain
medications may cause constipation, if this occurs take an over
the counter stool softener. Resume all home medications.
Call Dr.[**Name (NI) 20390**] office at [**Telephone/Fax (1) 41**] and Dr. [**Name (NI) 71084**] office at [**Telephone/Fax (1) 2349**] to make follow up appointment
to be seen in 1 week."
4416,"After NGT placement on POD1, she was transitioned to pain
medications through the NGT with good effect.
CV: She had elevated BP to SBP 160-180 in the initial
post-operative days which were attributed to pain and
hemodynamic re-adjustment after carotid body removal. Her blood
pressure normalized by POD #5. She was instructed to follow-up
with PCP as an outpatient to have her blood pressure monitored.
Resp: The patient had oxygen saturations >95% throughout
admission. She demonstrated good cough and was able to control
her oral secretions. She used suctioning as needed to help with
any excess oropharyngeal secretions and arrangement were made
for suction machine at home."
4417,"1x 2.2x
1.8cm
that extends from below the region of the carotid bifurcation
and
up to the skull base. It does not enter the jugular foramen.
She also has a small carotid body tumor on the contralateral
side
that is 1.7x 1.3x 2.1cm. An octreotide scan had tracer uptake
in
the area of the left glomus vagale. However, the carotid body
tumor had no uptake. The SPECT/CT images also demonstrate a
5-mm
nodule in the left anterior lung without evidence of tracer
uptake. The patient carries the SDHD gene. She has been tested
and found to have normal plasma normetanephrine, an undetectable
calcitonin, and a normal ionized calcium."
4418,"Family History:
Postive for FH of paragangiomas and pheochromocytomas. Brother
treated for
malignant paraganglioma. + SDHD gene
Physical Exam:
On admission:
97.4, 66, 117/73, 20, 99% on room air
NAD, A&Ox3
EOMI, PERRL
CNII-XII intact, face symmetric
Full neck ROM, soft, no LAD
OC/OP: Clear, no lesions, uvula midline
CV: RRR, no murmurs
Lungs CTAB
Abdomen soft, NTND
Extremities warm and well perfused, faint peripheral pulses in
lower extremities bilaterally.
Pertinent Results:
[**2133-11-11**] 09:01PM WBC-16.0* RBC-3.58* HGB-11.2* HCT-31.5*
MCV-88 MCH-31.1 MCHC-35."
4419,"For details, please see separately
dictated note by Dr. [**Last Name (STitle) 3878**] and Dr. [**Last Name (STitle) 1837**]. The patient
tolerated procedure without complications. She was taken to the
ICU for first 24 hours for monitoring of neurological status,
which remained stable, and was thereafter transfered to the
floor. The details of her hospital course are reviewed below by
ststems:
Neuro: Postoperatively, the patient was taken to the ICU for
closer monitoring of her vital signs and neurological function,
given the proximity of the surgery to the carotid artery. Her
exam remained stable and she was transfered to the floor on POD
1."
4420,"Admission Date: [**2149-11-23**] Discharge Date: [**2149-12-8**]
Date of Birth: [**2097-6-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Cellcept / Zosyn
Attending:[**First Name3 (LF) 6734**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Tunneled Hemodialysis Line Placement
History of Present Illness:
This is a 52 yo female with ESRD on HD, s/p failed renal
transplant, who was discharged 1.5 wks ago for septic shock
thought due to CMV viremia and diverticulitis, who presented
yesterday to [**Hospital1 18**] with a fever to 104.
To summarize her recent history, she was admitted [**Date range (1) 99101**]/[**2148**]
with ARF leading to her graft failure, found to also have CMV
viremia and C."
4421,"Has some diarrhea that pt notes as chronic
and unchanged. Makes small amt urine and confirms dysuria,
frequency, urgency. Denies vomiting, CP, SOB, cough, sputum,
wheezing, HA, vision changes, confusion.
Past Medical History:
- ESRD due to SLE, s/p cadaveric renal transplant [**8-/2147**]
complicated by FSGS and transplant failure [**7-/2149**], now on HD
- SLE, followed by Dr.[**Last Name (STitle) **] in Rheumatology
- Hypotension (started on midodrine [**11-5**])
- Septic shock [**10/2149**]
- CMV viremia [**10/2149**]
- Acute uncomplicated diverticulitis [**10/2149**]
- hx of C. Diff
- Paroxysmal atrial fibrillation
- NSVT
- hx of Hypertension
- Hyperthyroidism
- s/p bilateral knee surgeries and R ACL repair"
4422,"PICC line was removed and cultures were negative. Her
fevers were felt secondary to clot burden. She was discharged
on empiric vancomycin to be given with each HD treatment for a
total of four weeks. She was discharged on vancomycin taper for
c difficile and prophylaxis as mentioned above in addition to
the vancomycin with dialysis.
Pancytopenia: Patient has a history of pancytopenia of unclear
cause. Differential diagnosis considered includes drug reaction
from zosyn, CMV viremia versus lupus related. Her blood counts
were stable from recent admission and were trended. CMV viral
load was negative.
Renal transplant: Complicated by graft FSGS and ESRD on HD."
4423,"Hyperglycemia: Attributed to corticosteroid therapy. She was
treated with a humalog sliding scale.
Paroxysmal atrial fibrillation: In sinus rhythm on discharge 10
days ago and currently. Not on warfarin. She was continued on
aspirin.
.
Dispo - Discharged to rehab following resolution of abdominal
pain, diarrhea, fever work up, and tunneled line placement.
Medications on Admission:
HOME MEDICATIONS: (from d/c summary dated [**2149-11-14**])
- Atovaquone 1500mg (10ml) PO daily
- Aspirin 325mg PO daily
- Pantoprazole 40mg PO Q24hrs
- B Complex-Vitamin C-Folic Acid 1mg capsule PO daily
- Midodrine 10mg PO TID
- Ciprofloxacin 500mg PO Q24hrs - ended [**11-16**]
- Flagyl 500mg PO Q8hrs - ended [**11-16**]
- Tacrolimus 2mg PO Q12hrs
- Ganciclovir 110mg IV QHD
- Heparin 5000units SQ TID
- Insulin glargine 2units SQ QHS
- Insulin NPH 4units SQ QAM
- Insulin Humalog sliding scale
- Prednisone 10mg PO daily
- Zofran 4mg IV Q8hrs PRN nausea
- Epogen 15000units QHD
- Bisacodyl 5-10mg PO daily PRN constipation"
4424,"10. insulin
glargine 2 U SQ qhs
NPH 4 U SQ qAM
11. Vancomycin 1000 mg IV HD PROTOCOL
please check trough prior to each dose
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
1. Clostridium difficile colitis
2. Fistula Repair
3. Chronic Kidney Disease
Discharge Condition:
Stable for discharge. On room air, ambulating with assistance.
Resolved diarrhea and abdominal pain, intermittent continued low
grade fevers.
Discharge Instructions:
Dear Ms [**Known lastname 6357**],
It was a pleasure caring for you while you were in the hospital."
4425,"Social History:
Single, currently at [**Hospital 671**] rehab. Denies tobacco, ETOH, and
drugs.
Family History:
Mother and brother both with diabetes and [**Name (NI) 2091**], both deceased.
Physical Exam:
Vitals: T 101.2 BP 105/49 HR 113 RR 18 O2sat 98RA
GENERAL: NAD, AAOx3, appropriate, comfortable
HEENT: NCAT, EOMI, aniceteric sclerae, MMM
NECK: No JVD
CARDIAC: RRR, no m/r/g
LUNG: CTAB
ABDOMEN: NABS. Soft, ND, exquisitely TTP with in LUQ/LLQ with +
rebound and grimacing, pain with bed movement, no significant
guarding, graft palpable in RLQ without TTP
EXT: Warm and dry, 2+ DP pulses, AVF in LUE."
4426,"9* MCV-94 MCH-27.1
MCHC-28.7* RDW-17.3* Plt Ct-182
Neuts-41* Bands-8* Lymphs-37 Monos-11 Eos-0 Baso-2 Atyps-1*
Metas-0 Myelos-0
BLOOD PT-11.9 PTT-25.3 INR(PT)-1.0
BLOOD Glucose-89 UreaN-17 Creat-4.2* Na-145 K-3.7 Cl-105 HCO3-32
AnGap-12
Brief Hospital Course:
52 yo female with ESRD on HD, recent admission for septic shock
from diverticulitis vs CMV, here with fever and hypotension.
Hypotension/Fevers: Patient presented with evidence of septic
physiology with fevers and hypotension, along with abdominal
pain and diarrhea."
4427,"You were first admitted to the hospital because of pain in your
abdomen that was caused by Clostridium difficile. Because of
this infection, you developed pain in your abdomen, fevers, and
your blood pressure was low. During dialysis, your blood
pressure fell even further. To treat you, we started you on
antibiotics for the infection and your pain and fevers improved.
You will need to continue to take these antibiotics for several
more weeks. The course of antibiotics is described below.
.
During your hospital stay, your fistula on your left arm also
stopped working. Because you needed dialysis, we placed a new
line (called a tunneled line) that will allow us to continue
dialysis."
4428,"Was given vanco/zosyn/flagyl and admitted.
On arrival to HD today, she was tachycardic to 130s, apparently
sinus rhythm. HD was stopped after 1 hour due to progressive
tachycardia to the 160s, with fever to 103.2, despite running
her volume even. After stopping HD, she became hypotensive to
SBP 60s, with preserved mental status. After 1L IVF, her BP
improved to 86/44 with HR 107. Temp improved to 100.3 after
acetaminophen. Currently c/o nausea and fatigue, no resting abd
pain but 10/10 L sided abd pain with palpation. Also c/o fevers,
no chills or sweats."
4429,"It is unclear when
ganciclovir was restarted, but by [**11-2**], she was on ganciclovir
with HD dosing. She became hypotensive on [**11-6**] with mild
abdominal pain, sent to [**Hospital1 18**] and admitted to MICU on
norepinephrine. She was treated with stress-dose steroids,
empiric PO vancomycin, IV vancomycin, IV zosyn and IV
gancyclovir. CT abd/pelvis showed uncomplicated sigmoid
diverticulitis. All other culture data and infectious workup
(including c. diff toxin negative x 3) was unrevealing as to
another source of infection. She was started on midodrine for
persistent hypotension to 70-80s systolic. Also was
progressively pancytopenic, though to be from pip-tazo."
4430,"Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): To be administered during dialysis and
dosed according to the [**Hospital1 18**] Epoetin Alfa P&T Guidelines. .
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily)."
4431,"Cortisol stim test was performed which was negative.
Her hypotension was responsive to fluid boluses. She was
continued on midodrine. On the floor she was found to have a
positive c diff toxin. She was started on vancomycin taper with
resolution of her abdominal pain and diarrhea. Fevers abated.
She was covered with valgancyclovir for CMV prophylaxis and
atovaquone for PCP [**Name Initial (PRE) 1102**]. Towards the end of her
hospitalization, her fevers reappeared without accompanying
hypotension. Pan culture revealed no organism repeatedly. Her
left arm at the fistula site was painful and ultrasound revealed
extensive clot burden. Transplant surgery did not feel
immediate correction was required; a tunneled line was placed
for HD."
4432,"diff colitis. She was discharged on IV
ganciclovir until 2 negative CMV VLs, and transitioned to oral
valganciclovir secondary ppx to continue for 3 mos from her
admission. How this was discontinued is unclear: possibly on
[**10-10**] due to neutropenia, and outside records note negative CMV
VL on [**10-18**]. She was also at [**Hospital 3278**] Medical Center from
[**Date range (1) 23929**] septic shock due to pseudomonas bacteremia,
completing a course of ?zosyn on [**10-27**].
On [**10-27**] pt began having fevers. A CMV viral load was rechecked
(970) and repeat VL of 4059 on [**11-2**]."
4433,"Cultures revealed negative blood cultures,
urine culture positive for klebsiella 10-100,000 colonies and
positive clostridium difficle. She had a CT of the abdomen
which revealed diverticulitis. CXR did not show evidence of
pneumonia. She was initially started on broad spectrum
antibiotics with vancomycin and cefepime and this was
transitioned to PO vancomycin and tigacycline for coverage of
clostridium difficle as well as IV Gancyclovir given her history
of CMV viremia. Her hypotension resolved with 1 liter of normal
saline. She also received stress dose steroids given her
history of long term steroid use. She was transitioned to the
floor."
4434,"She
received stress dose steroids as above in the setting of sepsis.
She was followed by the renal consult and transplant services.
She was continued on tacrolimus 1 mg [**Hospital1 **] (decreased from 2 mg
[**Hospital1 **]) and atovaquone for prophylaxis. She received hemodialysis
treatments three times a week as per her home schedule. Given
her clotted fistula towards the end of her hospitalization, a
tunneled HD line was placed as mentioned above. Transplant
surgery will see her in outpatient follow up for consideration
of placement of new fistula on the right arm. Her tacrolimus
was discontinued at time of discharge given that she does not
require tacrolimus any longer secondary to graft failure."
4435,"The transplant surgeons want to create a new fistula
for you to use, and you have a follow up appointment set up with
them as an outpatient to arrange this. We also decided to
continue you on antibiotics to be given during dialysis to treat
the possibility of infection in the area of the fistula.
.
The medication changes we made during this hospitalization were:
1. We started you on oral vancomycin. You should continue to
take this with the following regimen:
(a) take 125 mg daily by mouth for one week ([**2149-12-8**] - [**2149-12-14**])
(b) then take 125 mg every other day for one week ([**2149-12-15**] -
[**2149-12-21**])
(c) then take 125 mg every third day for two weeks ([**2149-12-22**] -
[**2150-1-4**])
2."
4436,"6. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO as below:
One (1) Capsule PO every twenty-four(24) hours: Starting [**12-8**], take 125 mg daily for one week ([**12-8**]- [**12-14**]) (b) then take
125 mg every other day for one week ([**Date range (1) **]) (c) then take
125 mg every third day for two weeks ([**Date range (1) 97009**]/10).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a
day: One (1) Tablet PO 2X/WEEK (TU,TH)."
4437,"You can take 5 mg of the prednisone every day instead of 10
mg.
3. You will be receiving vancomycin intravenously with
hemodialysis until [**2150-1-1**] to complete a 4 week course.
4. You should take vangancyclovir 450 mg twice a week with
dialysis.
5. You can take oxycodone 5 mg as needed every 6 hours for pain.
6. You should stop taking gancyclovir IV.
7. You should stop taking tacrolimus.
.
Please keep the follow up appointments scheduled for you below.
Followup Instructions:
1) You have an appointment with a transplant infectious disease
doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], on [**12-23**] at 930 AM. Please call
[**Telephone/Fax (1) 673**] if you have any other questions.
2) You have an appointment with your kidney doctor, Dr. [**First Name (STitle) **]
[**Name (STitle) **] on [**2149-12-18**] at 9:40 AM. If you have any questions,
his phone number is [**Telephone/Fax (1) 673**].
.
3) You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from
transplant surgery at 1:40 PM on [**2149-12-25**]. If you
have any questions regarding this appointment, please call
[**Telephone/Fax (1) 673**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]"
4438,"1* PTT-29.8 INR(PT)-1.3*
[**2149-11-25**] 09:00AM BLOOD Plt Smr-LOW Plt Ct-144*
Chemistries:
[**2149-11-23**] 12:40PM BLOOD Glucose-96 UreaN-24* Creat-5.9*# Na-147*
K-4.2 Cl-108 HCO3-27 AnGap-16
[**2149-11-25**] 09:00AM BLOOD Glucose-130* UreaN-30* Creat-5.1* Na-143
K-4.0 Cl-106 HCO3-26 AnGap-15
[**2149-11-23**] 12:40PM BLOOD ALT-15 AST-12 AlkPhos-57 TotBili-0.3
[**2149-11-24**] 12:45PM BLOOD Calcium-7.4* Phos-2.7 Mg-1.7
[**2149-11-24**] 07:30AM BLOOD Vanco-19."
4439,"No edema.
Pertinent Results:
Hematology:
[**2149-11-23**] 12:40PM BLOOD WBC-2.4* RBC-3.37* Hgb-9.5* Hct-32.6*
MCV-97 MCH-28.3 MCHC-29.2* RDW-17.1* Plt Ct-97*
[**2149-11-25**] 09:00AM BLOOD WBC-4.1 RBC-3.70* Hgb-10.3* Hct-35.4*
MCV-96 MCH-27.8 MCHC-29.0* RDW-17.0* Plt Ct-144*
[**2149-11-23**] 12:40PM BLOOD Neuts-51 Bands-20* Lymphs-12* Monos-13*
Eos-2 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2149-11-25**] 09:00AM BLOOD Neuts-67 Bands-2 Lymphs-20 Monos-8 Eos-0
Baso-0 Atyps-1* Metas-1* Myelos-1*
[**2149-11-23**] 12:40PM BLOOD Plt Smr-VERY LOW Plt Ct-97*
[**2149-11-24**] 12:12PM BLOOD PT-15."
4440,"She was
discharged on PO cipro and flagyl for diverticulitis, 10 mg
daily prednisone, with her tacrolimus decreased to 2mg [**Hospital1 **]. Also
discharged on IV ganciclovir, planning to switch to oral after 2
negative VLs, although stopped at some point in rehab.
While in rehab, BPs had remained normotensive. Yesterday am, she
awoke nauseated and febrile, with a temp of 104.0. Blood
cultures (2 sets) were sent from rehab. Also c/o LLQ pain. In
the ED, her Tmax was 102, with BP 142/82. CT abd showed
diverticulitis similar to prior. UA was positive. CXR improved
from prior."
4441,"CXR [**2149-11-24**]:
Since interval examination from [**2149-11-11**], there has been
improvement in left lower lobe atelectasis and removal of a
central venous catheter. The lungs are clear with no signs of
pneumonia or congestive heart failure. No pleural effusions or
pneumothorax. The cardiomediastinal silhouette is stable in
size.
Microbiology:
Blood cultures [**2149-11-23**], [**2149-11-24**] - pending
Urine culture [**2149-11-23**] - 10,000-100,000 Klebsiella
Clostridium Difficle [**2149-11-23**] - positive
CMV Viral Load [**2149-11-24**] - negative
Discharge Labs:
Hematology:
BLOOD WBC-2.7* RBC-2.85* Hgb-7.7* Hct-26."
4442,"5
[**2149-11-23**] 12:47PM BLOOD Lactate-1.0
Imaging:
CT Abdomen and Pelvis [**2149-11-23**]:
1. Extensive diverticulosis with diverticulitis of the sigmoid
colon and
distal descending colon, similar in extent when compared to the
most recent study of [**2149-11-7**]. No evidence of
perforation or abscess formation.
2. Mild enhancement of the transplanted kidney in the right
lower quadrant, which is similar in appearance to the prior
study. No evidence of perinephric fluid collection or abscess.
3. Persistently dilated pancreatic duct may be related to
ampullary stenosis or IPMN. As noted previously, if not already
performed, consultation with the Pancreas Center may assist in
evaluation."
4443,"Attending Physician: [**Name10 (NameIs) 242**]
Referral date: [**2149-11-24**]
Medical Diagnosis / ICD 9: ESRD /
Reason of referral: Eval & treat
History of Present Illness / Subjective Complaint: 52 yo F recently
d/c'd [**11-14**] after hospitalization for septic shock, CMV viremia, and
diverticulitis. Now readmitted from rehab with nausea and fever c/w
diverticulitis. Hospital course has been c/b tachycardia and
hypotension while in HD and was transferred to icu for observation.
Past Medical / Surgical History: ESRD due to SLE s/p renal transplant
[**9-3**] and c/b failure [**8-6**], now on HD; c.diff, PAF, NSVT, h/o HTN,
hyperthyroidism, s/p B knee surgeries
Medications: aspirin, tylenol, oxycodone, vancomycin, midodrine
Radiology: CXR [**11-23**]- Significant diverticulosis with diverticulitis
mainly of the sigmoid colon and distal descending colon
Labs:
35."
4444,"4
10.3
144
4.1
[image002.jpg]
Other labs:
Activity Orders: ok for OOB per icu team
Social / Occupational History: lives with her sister and sister's
family
Living Environment: lives in single-level home with steps to enter
Prior Functional Status / Activity Level: I pta, no DME. More recently
using a RW at rehab for short distance ambulation
Objective Test
Arousal / Attention / Cognition / Communication: alert and oriented,
pleasant and cooperative
Aerobic Capacity
HR
BP
RR
O[2] sat
RPE
Rest
82
120/58
18
Activity
130
148/78
22
96% on RA
Recovery
82
138/75
18
Total distance walked: 0
Minutes:
Pulmonary Status: lungs cta, non-labored breathing, no cough noted
Integumentary / Vascular: R PICC, tele, foley
Sensory Integrity: B LE's intact to light touch
Pain / Limiting Symptoms: denies pain
Posture: mildly obese
Range of Motion
Muscle Performance
B LE's WNL
RLE grossly [**3-2**]
LLE grossly [**1-30**]
Motor Function: no abnormal movement patterns
Functional Status:
Activity
Clarification
I
S
CG
Min
Mod
Max
Gait, Locomotion: sit-to-stand on 2nd attempt able to attain full
upright standing, able to move feet minimally, unable to take steps or
ambulate."
4445,"Rolling:
T
Supine /
Sidelying to Sit:
T
Transfer:
Sit to Stand:
T
Ambulation:
Stairs:
Balance: S static sitting, min A static/dynamic standing balance. No
gross LOB with mobility.
Education / Communication: Reviewed PT [**Name (NI) **], safety and d/c planning.
Communicated with nsg re: status.
Intervention:
Diagnosis:
1.
Impaired functional mobility
2.
Impaired balance
3.
Impaired endurance
4.
Impaired strength
Clinical impression / Prognosis: 52 yo F with ESRD and diverticulitis
p/w above impairments a/w deconditioning. She is most limited by
general weakness a/w hospitalization and is well below her baseline
level. Given her recent progress made in rehab since previous
admission, anticipate good rehab potential to return to independent
function. PT to continue to follow to progress as able at acute level.
Goals
Time frame: 1 week
1.
CG bed mobility, min A sit-to-stand, assess gait
2.
No LOB with mobility
3.
Ambulate >/= 30' with stable HDR, tolerate OOB daily
4.
Tolerate daily strengthening
5.
6.
Anticipated Discharge: Rehab
Treatment Plan:
Frequency / Duration: 2-3x/wk
bed mobility, transfers, ambulation, balance, endurance, strengthening,
education, d/c planning
T Patient agrees with the above goals and is willing to participate in
the rehabilitation program."
4446,"Past medical history:
Family history:
Social History:
- ESRD due to SLE, s/p cadaveric renal transplant [**8-/2147**] complicated
by FSGS and transplant failure [**7-/2149**], now on HD
- SLE, followed by Dr.[**Last Name (STitle) 8105**] in Rheumatology
- Hypotension (started on midodrine [**11-5**])
- Septic shock [**10/2149**]
- CMV viremia [**10/2149**]
- Acute uncomplicated diverticulitis [**10/2149**]
- hx of C. Diff
- Paroxysmal atrial fibrillation
- NSVT
- hx of Hypertension
- Hyperthyroidism
- s/p bilateral knee surgeries and R ACL repair
Mother and brother both with diabetes and [**Name (NI) 1661**], both deceased.
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Single, currently at [**Hospital 4201**] rehab."
4447,"Soft, ND, exquisitely TTP with in LUQ/LLQ with + rebound
and grimacing, pain with bed movement, no significant guarding, graft
palpable in RLQ without TTP
EXT: Warm and dry, 2+ DP pulses, AVF in LUE. No edema.
[**Year (4 digits) 610**] / Radiology
98
75 mg/dL
4.7 mg/dL
21 mg/dL
25 mEq/L
106 mEq/L
3.8 mEq/L
143 mEq/L
34.1
3.3
[image002.jpg]
[**2145-11-29**]
2:33 A12/28/[**2148**] 12:45 PM
[**2145-12-3**]
10:20 P
[**2145-12-4**]
1:20 P
[**2145-12-5**]
11:50 P
[**2145-12-6**]
1:20 A
[**2145-12-7**]
7:20 P
1//11/006
1:23 P
[**2145-12-30**]
1:20 P
[**2145-12-30**]
11:20 P
[**2145-12-30**]
4:20 P
Cr
4."
4448,"- Renal following, follow recs and continue HD
- Steroids as above
- Cont tacrolimus, now decreased from 2mg [**Hospital1 **] to 1mg [**Hospital1 **]
- Cont atovaquone for PCP [**Name Initial (PRE) 1694**]
# Hyperglycemia: Attributed to corticosteroid therapy. Some low sugars
this am, so will avoid long-acting insulin for now.
- Cont HISS and monitor fingersticks
# Paroxysmal atrial fibrillation: In sinus rhythm on discharge 10 days
ago and currently. Not on warfarin.
- Continue ASA
# ACCESS: [**Last Name (LF) 1200**], [**First Name3 (LF) 116**] obtain 2nd [**First Name3 (LF) 1200**], CVC may be needed if BPs drop
# CONTACT: [**Name (NI) **], [**Name (NI) **] blood cx from [**11-23**]: call [**Telephone/Fax (1) 10103**]
ICU Care
Nutrition:
Comments: NPO
Glycemic Control:
Lines:
18 Gauge - [**2149-11-24**] 12:56 PM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: ICU"
4449,"Abdominal exam is concerning, so will involve
surgery.
- Awaiting surgery recs
- Appreciate ID recs
- Stop IV vanco and cefepime, as no clear source being covered
- Cont PO vancomycin for C diff, IV ganciclovir pending CMV VL
- Per ID, adding tigecycline as adjunct for C diff (would also likely
cover UTI if present)
- NPO for now
- Trend CBC with diff, lactate
- Follow up blood, urine, stool cultures, CMV VL
# Pancytopenia: [**Month (only) 11**] be due to recent pip-tazo vs CMV vs lupus-related.
Stable compared with recent admisison.
- Avoid pip-tazo
- Await CMV VL
- Trend CBC
# Renal transplant: Complicated by graft FSGS and ESRD on HD."
4450,"7
Glucose
75
Other [**Year (4 digits) **]: PT / PTT / INR:15.1/29.8/1.3, Lactic Acid:1.3 mmol/L,
Ca++:7.4 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL
Imaging: CXR [**11-23**]: No acute cardiopulmonary process.
CT ABD/PELVIS [**11-23**]:
1. Extensive diverticulosis with diverticulitis of the sigmoid colon
and distal descending colon, similar in extent when compared to the
most recent study of [**2149-11-7**]. No evidence of perforation or
abscess formation.
2. Mild enhancement of the transplanted kidney in the right lower
quadrant, which is similar in appearance to the prior study."
4451,"Denies tobacco, ETOH, and
drugs.
Review of systems:
Flowsheet Data as of [**2149-11-24**] 02:01 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 38.4
C (101.2
Tcurrent: 38.4
C (101.2
HR: 97 (97 - 110) bpm
BP: 93/51(60) {91/47(58) - 105/55(64)} mmHg
RR: 20 (16 - 23) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Total In:
45 mL
PO:
TF:
IVF:
45 mL
Blood products:
Total out:
0 mL
20 mL
Urine:
20 mL
NG:
Stool:
Drains:
Balance:
0 mL
25 mL
Respiratory
O2 Delivery Device: None
SpO2: 97%
ABG: ///25/
Physical Examination
GENERAL: NAD, AAOx3, appropriate, comfortable
HEENT: NCAT, EOMI, aniceteric sclerae, MMM
NECK: No JVD
CARDIAC: RRR, no m/r/g
LUNG: CTAB
ABDOMEN: NABS."
4452,"How this was discontinued is unclear:
possibly on [**10-10**] due to neutropenia, and outside records note negative
CMV VL on [**10-18**]. She was also at [**Hospital **] Medical Center from [**Date range (1) 10102**]
septic shock due to pseudomonas bacteremia, completing a course of
?zosyn on [**10-27**].
On [**10-27**] pt began having fevers. A CMV viral load was rechecked (970)
and repeat VL of 4059 on [**11-2**]. It is unclear when ganciclovir was
restarted, but by [**11-2**], she was on ganciclovir with HD dosing. She
became hypotensive on [**11-6**] with mild abdominal pain, sent to [**Hospital1 1**] and
admitted to MICU on norepinephrine."
4453,"Upon transfer
to the ICU after 1L IVF and IV hydrocortisone, BP much improved.
Mentating well throughout.
- Give another 1L IVF and monitor vitals closely
- Cont stress dose steroids (hydrocort 50mg IV q8h) for now, convert to
PO if BPs remain stable
- Cont midodrine
- Cont abx as discussed below
# Fevers: UA dirty, but hard to interpret in ESRD patient who is
olgio-anuric. CXR clear, blood cx pending from rehab and ED yesterday
and from HD today. Source is most likely her diverticulitis seen on CT.
Has known positive C diff, but also consider CMV (viral load pending)
involving the colon."
4454,"She was treated with stress-dose
steroids, empiric PO vancomycin, IV vancomycin, IV zosyn and IV
gancyclovir. CT abd/pelvis showed uncomplicated sigmoid diverticulitis.
All other culture data and infectious workup (including c. diff toxin
negative x 3) was unrevealing as to another source of infection. She
was started on midodrine for persistent hypotension to 70-80s systolic.
Also was progressively pancytopenic, though to be from pip-tazo. She
was discharged on PO cipro and flagyl for diverticulitis, 10 mg daily
prednisone, with her tacrolimus decreased to 2mg [**Hospital1 **]. Also discharged
on IV ganciclovir, planning to switch to oral after 2 negative VLs,
although stopped at some point in rehab."
4455,"After
stopping HD, she became hypotensive to SBP 60s, with preserved mental
status. After 1L IVF, her BP improved to 86/44 with HR 107. Temp
improved to 100.3 after acetaminophen. Currently c/o nausea and
fatigue, no resting abd pain but 10/10 L sided abd pain with palpation.
Also c/o fevers, no chills or sweats. Has some diarrhea that pt notes
as chronic and unchanged. Makes small amt urine and confirms dysuria,
frequency, urgency. Denies vomiting, CP, SOB, cough, sputum, wheezing,
HA, vision changes, confusion.
Patient admitted from: [**Hospital1 1**] [**Hospital1 192**]
History obtained from [**Hospital 31**] Medical records
Allergies:
Bactrim Ds (Oral) (Sulfamethoxazole/Trimethoprim)
Exfoliative [**Doctor Last Name **]
Cellcept (Oral) (Mycophenolate Mofetil)
Rash;
Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)
Myelosuppressio
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
HOME MEDICATIONS: (from d/c summary dated [**2149-11-14**])
- Atovaquone 1500mg (10ml) PO daily
- Aspirin 325mg PO daily
- Pantoprazole 40mg PO Q24hrs
- B Complex-Vitamin C-Folic Acid 1mg capsule PO daily
- Midodrine 10mg PO TID
- Ciprofloxacin 500mg PO Q24hrs - ended [**11-16**]
- Flagyl 500mg PO Q8hrs - ended [**11-16**]
- Tacrolimus 2mg PO Q12hrs
- Ganciclovir 110mg IV QHD
- Heparin 5000units SQ TID
- Insulin glargine 2units SQ QHS
- Insulin NPH 4units SQ QAM
- Insulin Humalog sliding scale
- Prednisone 10mg PO daily
- Zofran 4mg IV Q8hrs PRN nausea
- Epogen 15000units QHD
- Bisacodyl 5-10mg PO daily PRN constipation
TRANSFER MEDS:
Notable for PO vanc (not yet received), IV ganciclovir (not yet
received), IV vanc, IV cefepime."
4456,"No
evidence of perinephric fluid collection or abscess.
3. Persistently dilated pancreatic duct may be related to ampullary
stenosis or IPMN. As noted previously, if not already performed,
consultation with the Pancreas Center may assist in evaluation.
Assessment and Plan
52 yo female with ESRD on HD, recent admission for septic shock from
diverticulitis vs CMV, here with fever and hypotension.
# Hypotension: Known baseline low BPs, for which midodrine was started
at last admission. Of note, patient received her dose late today.
However, patient was run even at HD, was tachycardic with fevers and
bandemia on [**Last Name (LF) **], [**First Name3 (LF) **] concern for impending septic shock."
4457,"Cardiology
eval reveals a poor surgical candidate and requested an cardiac
cath prior ro surgical consideration. The patient was cleared
for
neurosurgical intervention. The patient had initially opted to
undergo a stereotactic biopsy of the lesion. He now wishes to
have a discussion with regards to the relative merits of
craniotomy versus stereotactic biopsy.
Since last seen in clinic, the patient has no new complaints.
Past Medical History:
- HTN
- HL
- CAD s/p CABG, currently a plan for elective cardiac
catheterization for unstable angina
- BPH
Social History:
quit smoking several yrs ago, Rx heavy smoker
Ex alcoholic, No drugs, Lives with family, owns a restaurant."
4458,"MR HEAD W/ CONTRAST Study Date of [**2193-1-18**] 5:50 AM ******
CT HEAD W/O CONTRAST of [**2193-1-18**]
IMPRESSION: Expected postoperative appearance of the brain
status post recent resection of right parietal hemorrhagic
lesion.
MRI Brain [**2193-1-19**]
IMPRESSION:
1. Postoperative changes in the right parietooccipital region
with blood
products and pneumocephalus. Small areas of residual enhancement
seen
posterior to the surgical cavity.
2. New right posterior cerebral artery infarct.
3. Findings were communicated to neurosurgery at the time of
interpretation of this study on [**2193-1-19**].
Brief Hospital Course:
This is a 65year old male who is on Plavix and ASA with a hx of
a triple bypass 21
years ago who reports a sudden onset of headache accompanied by
nausea on [**2192-12-9**]."
4459,"Work up revealed a right parietal mass
measuring 4 x 6 x 4 cm with rim contrast enhancement. Cardiology
eval reveals a poor surgical candidate and requested an cardiac
cath prior to surgical consideration. This was worked up
outpatient and then the patient was cleared for neurosurgical
intervention.
The patient was electively admitted on [**2193-1-18**] for a right sided
craniotomy for resection of tumor. The patient was transfused
with platelets intraop as he was on aspirin at home. The
patient was extubated post operatively and recovered in the
surgical intensive unit. He was placed on decardon 4mg every 6
hours."
4460,"A physical therapy consult was ordered for the patient.
A post operative head CT was consistent with stable post
operative changes.
On [**1-19**] the patient was neurologically well except for a left
hemi-anopsia. He was out of bed to the chair and tolerating a PO
diet. A post operative MRI was consistent with small residual
enhancement. He remained on an insulin drip with difficult to
control blood sugars.
On [**1-20**] the patient was again stable and was able to be weaned
off of the insulin gtt. decadron was tapered.
On [**1-21**] the patient was seen by physical therapy and cleared for
discharge home with services."
4461,"He was restarted on aspirin and a
[**Last Name (un) **] Diabetes consult was requested for assistance with blood
sugar management and discharge planning. Insulin and PO
medication adjustments were made and the patient was cleared for
discharge to home with services.
Medications on Admission:
.
Discharge Medications:
.
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily)."
4462,"3
CL--97*
[**2193-1-18**] 10:46AM HGB-12.1* calcHCT-36 O2 SAT-97
[**2193-1-18**] 10:46AM freeCa-1.11*
[**2193-1-18**] 09:17AM TYPE-ART RATES-10/ TIDAL VOL-700 O2-30
PO2-121* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2193-1-18**] 09:17AM GLUCOSE-255* LACTATE-2.3* NA+-130* K+-3.7
CL--96*
[**2193-1-18**] 09:17AM HGB-11.2* calcHCT-34 O2 SAT-97
[**2193-1-18**] 09:17AM freeCa-1.08*
Tissue: RIGHT PARIETAL MASS, Study Date of [**2193-1-18**]"
4463,"1mg Q6hrs on [**1-22**] then discontinue.
Disp:*7 Tablet(s)* Refills:*0*
16. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
17. insulin lispro 100 unit/mL Solution Sig: One (1) as directed
Subcutaneous QAC.
Disp:*1 as directed* Refills:*2*
18. insulin safety needles (disp) 29 x [**12-16**] Needle Sig: One (1)
syringe Miscellaneous QAC.
Disp:*90 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
right parietal mass
Discharge Condition:
Mental Status: Clear and coherent."
4464,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication."
4465,"CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Your sutures are dissolvable and do not need to be removed.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2193-1-28**]
@ 9:30 AM. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
?????? Please call for a follow up appointment at [**Last Name (un) **] in 2
weeks with Dr. [**Last Name (STitle) 15279**] or first available attending. You should
also make an appointment with the diabetes educator at [**Last Name (un) **]
for the same date
for insulin teaching. These appointments can be made by calling
[**Telephone/Fax (1) 2378**].
?????? You should follow up with your PCP [**Name Initial (PRE) 176**] 7 days of
discharge.
Completed by:[**2193-1-22**]"
4466,"Family History:
NC
Physical Exam:
On the day of admission: On examination, the patient is awake,
alert, and approriate. VFF.EOMI. FS. T/U midline. Hearing + SS
symmetric. MA4E with good
strength. No drift. Normal gait
On the day of discharge:
non-focal except left hemi-anopsia which is improving compared
to immediate post op
Pertinent Results:
[**2193-1-18**] 02:36PM GLUCOSE-406*
[**2193-1-18**] 12:33PM GLUCOSE-360* UREA N-28* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
[**2193-1-18**] 12:33PM estGFR-Using this
[**2193-1-18**] 12:33PM CALCIUM-8."
4467,"Admission Date: [**2193-1-18**] Discharge Date: [**2193-1-21**]
Date of Birth: [**2127-3-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
elective admit for craniotomy
Major Surgical or Invasive Procedure:
[**2193-1-18**]: right craniotomy for resection of tumor
History of Present Illness:
65M who is on Plavix and ASA with a hx of a triple bypass 21
years ago who reports a sudden onset of headache accompanied by
nausea on [**2192-12-9**]. Work up revealed a right parietal mass
measuring 4 x 6 x 4 cm with rim contrast enhancement."
4468,"C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
13. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
14. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO taper for 2
days: 2mg Q6hrs on [**1-21**]."
4469,"?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You were on Aspirin, prior to your injury, and this was
restarted on [**2193-1-21**]. You were also on plavix prior to your
surgery. This should NOT be restarted until after it is
discussed at your follow up appointment.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit. DO NOT drive until you are
cleared.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to."
4470,"5. terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-16**]
Tablets PO Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. bisacodyl 5 mg Tablet, Delayed Release (E."
4471,"4 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2193-1-18**] 12:33PM WBC-5.5 RBC-3.82* HGB-11.6* HCT-33.4* MCV-87
MCH-30.5 MCHC-34.9 RDW-13.6
[**2193-1-18**] 12:33PM PLT COUNT-160
[**2193-1-18**] 12:33PM PT-12.1 PTT-18.4* INR(PT)-1.0
[**2193-1-18**] 10:46AM TYPE-ART TIDAL VOL-830 O2-25 PO2-127*
PCO2-30* PH-7.49* TOTAL CO2-23 BASE XS-1 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2193-1-18**] 10:46AM GLUCOSE-270* LACTATE-3.9* NA+-133* K+-4."
4472,"Admission Date: [**2117-1-16**] Discharge Date: [**2117-1-23**]
Date of Birth: [**2037-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
intraosseous access removal
HD line placement
CVVH
History of Present Illness:
Mr. [**Known lastname **] is a 79 yo M w/hx of CAD s/p MI X 2, DM, CHF EF 35-40%,
afib, stage IV diabetic nephropathy (Cr 3.0) who presented to
the ED after a witness unresponsive episode. Per the family, he
was walking down the street and had a wittness loss of
consciousness."
4473,".
Per [**Hospital1 18**] ED report, he had presented to [**Hospital 4199**] hospital in
Vfib, then became asystolic. After the initial resuscitation he
had 2 additional asystolic arrests in the [**Last Name (un) 4199**] ER.
.
In the [**Hospital1 18**] ED, initial vitals were T98.2 HR75, BP149/106, RR32
100% on the vent. The post-arrest consult team was called and
recommended cooling him to 33-34 degrees and weaning his
propofol to fentanyl/versed. A R femoral line was placed, he was
given 1L IVF and had a head, chest, abdomen CT done without
contrast. He was kept on dopamine, propofol and amiodarone."
4474,"Systolic Left Ventricular Heart Failure, EF 35-40% (echo
[**12-15**])
3. Hypertension
4. Diabetes Mellitus Type 2
5. Diabetic Nephropathy - Chronic kidney disease stage IV,
baseline creatinine 3.0
6. Atrial Fibrillation - on Coumadin
7. Gout
8. Prostate cancer - T1C, NX, [**Doctor Last Name **] score 5+5, s/p XRT [**2107**]
Social History:
Unable to obtain as patient is intubated and sedated. Per OMR,
no tobacco, alcohol or drug use. Confirmed with family.
Family History:
Unable to obtain. Per OMR, there is no family history of
premature coronary artery disease or sudden death.
Physical Exam:
VS: T=36.4 BP 134/83 HR 90 RR 20 99% on AC 550x20 100% FiO2,
PEEP 5
GENERAL: Intubated and sedated."
4475,"g.,
pulmonary embolism, bronchospasm, etc.
Brief Hospital Course:
79yo M w/hx of CAD s/p MI X 2, CHF, DM, Stage IV CKD who
presents s/p cardiac arrest.
.
# CARDIAC ARREST: There was little information about the events
of the hours that preceded his admission. We know that he had a
witnessed syncopal episode; he may have been in asystole at an
OSH. The etiology of the cardiac arrest was likely [**2-9**]
hyperkalemia. He underwent Artic Sun cooling protocol at [**Hospital1 18**],
which was complicated by persistent bradycardia to the 20's.
Therefore, Arctic sun was terminated after 6 hours."
4476,"He was
placed on Epinephrine, Isoproteronol & Dopamine and his HR
eventually rebounded. His pressors were slowly weaned.
Neurology was consulted regarding his neurological prognosis.
Based on his EEG result, non-arousal, and lack of brainstem
reflexes except for overbreathing on the ventilator, Neurology
suggested that meaningful recovery from the neurological
standpoint is very unlikely. Serial family meetings were held,
and the family decided to withdraw care on [**2117-1-23**] at 10am.
Following extubation, patient expired 40 minutes later at
10:40am on [**2117-1-23**].
.
# ANOXIC BRAIN INJURY: Neurology was consulted on admission and
patient was placed on a 48 hour EEG per protocol."
4477,"P er
examination, the patient demonstrated no brainstem function,
save for a respiratory rate that exceeded the ventilator
settings. Over the next few days, he did demonstrate the
presence of a gag reflex as well as a questionable R-sided
pupillary constriction and corneal reflex, but despite being off
pressors and sedation, he did not exhibit further cortical
function. EEG's demonstrated some e/o encephalopathy. Serial
family meetings were held, and the family decided to withdraw
care on [**2117-1-23**] at 10am. Following extubation, patient expired
40 minutes later at 10:40am on [**2117-1-23**].
.
# RESPIRATORY FAILURE: Patient was placed on a ventilator s/p
cardiac arrest."
4478,"His chest CT demonstrated mild pulmonary edema.
Sputum culture from [**1-18**] and [**1-21**] grew out Moraxella for which
he was covered with ceftriaxone. He remained intubated with
stepwise decrements in his degree of pressure support.
Following extubation, patient expired 40 minutes later at
10:40am on [**2117-1-23**].
.
# ANURIC RENAL FAILURE: Patient with known CKD, baseline Cr 3.0.
On admission, patient was anuric, likely due to ATN s/p shock
and poor perfusion despite receiving several liters of IVF's at
the OSH and in the ED. His electrolytes and acid/base status
was stabilized after he was placed on CVVH."
4479,"His CVVH filter was
clotted off on [**1-18**]. Given that his his UOP improved and his
electrolytes were stable off CVVH, and because of his poor
prognosis, CVVH was discontinued. His electrolytes were stable
during the rest of the hospitalization.
.
# CONGESTIVE HEART FAILURE: EF of 35-40% in [**12-15**], down to
30-35% on repeat TTE on [**2117-1-18**], likely further impaired by the
cardiac arrest. Patient with mild pulmonary edema on chest CT,
but intubated since admission. His ACE was held given renal
insufficiency and his fluid status was managed as above.
.
# Leukocytosis: Patient presented with leukocytosis & grossly
positive U/A, but elevated WBC may also be due to stress
response to cardiac arrest."
4480,"He was started on Ceftriaxone 1g IV
q24H on [**1-17**]. Sputum cx was positive for Moraxella & blood
cultures demonstrated coag negative staph. Vancomycin was added
on [**1-19**].
.
# DMII: Patient was continued on Lantus with regular insulin
sliding scale.
Medications on Admission:
Allopurinol 300 mg Tablet
Atorvastatin 80 mg Tablet
Calcitriol 0.25mg PO qday
Carvedilol 12.5mg PO BID
Lasix 80mg PO BID
Humalog dose unknown
Hydralazine 10mg PO BID
Lantus 33 units in the AM
Imdur 30mg PO q24H
Warfarin 2mg daily except Wednesday, 1 mg on Wednesday
Aspirin 81mg PO qday
Colace 100mg PO qday PRN constipation
MVI
Senna 2 tabs daily PRN constipation
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired"
4481,"12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
.
[**2117-1-16**] 11:25 pm BLOOD CULTURE Source: Line-mlc.
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
STUDIES:
.
CXR ([**2117-1-16**]): Cardiomegaly with mild congestive heart failure.
Endotracheal tube and nasogastric tube in standard positions.
.
CT spine ([**2117-1-16**]):
1. No acute fracture or malalignment of the cervical spine.
2. Pulmonary edema and right pleural effusion, partially imaged.
3. Multilevel degenerative changes, worst at C4-C5, which
predisposes the patient to cord injury."
4482,"HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP unable to be assessed due to cervical collar.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: 2+ peripheral edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas."
4483,"He
was given 1mg Atropine for bradycardia to 35During transfer to
the floor, he became bradycardic. External pacer pad were placed
and his dopamine was increased from 15mcg/kg to 20mcg/kg. He was
briefly externally paced and given additional an additional 1mg
of Atropine. On arrival to the CCU he was not being paced and
his dopamine was back down to 15mcg/min. CT scan showed a
sternal fracture and mediastinal hematoma.
.
ROS unable to be obtained as the patient is intubated and
sedated.
Past Medical History:
1. Coronary artery disease,
-s/p MI [**2100**], cath showing occluded OM1
-s/p AMI [**2105**] with stent to proximal LAD 80% lesion, 70% D1, 70%
OM1 with circ occluded after OM1
2."
4484,"Mild prominence of the ventricles and
cerebral sulci is likely related to age-appropriate atrophy.
IMPRESSION: No acute intracranial abnormality. Sinus disease, as
noted above.
.
CT chest, abdomen, pelvis ([**2117-1-16**]):
IMPRESSION:
1. Mildly displaced transversefracture of the mid sternum likely
involves the medial aspect of the anterior left third rib with
associated substernal anterior mediastinal hematoma.
2. Mild pulmonary edema with bilateral small pleural effusions
with associated atelectasis.
3. 1.9 cm right renal hypodense lesion, likely a complex cyst. A
renal ultrasound is recommended further evaluation.
4. Gallbladder wall edema and trace perihepatic ascites, likely
related to heart failure."
4485,"9 cTropnT-1.34*
[**2117-1-17**] 03:29AM BLOOD CK-MB-41* MB Indx-4.7 cTropnT-1.19*
[**2117-1-17**] 01:41PM BLOOD CK-MB-38* MB Indx-4.1 cTropnT-1.25*
[**2117-1-16**] 03:40PM BLOOD Albumin-3.5 Calcium-9.0 Phos-5.5* Mg-3.0*
[**2117-1-17**] 03:29AM BLOOD Triglyc-103 HDL-21 CHOL/HD-3.1 LDLcalc-24
MICROBIOLOGY:
.
RESPIRATORY CULTURE ([**1-18**] and [**1-21**])
MORAXELLA CATARRHALIS.
[**2117-1-18**] 5:14 pm BLOOD CULTURE Source: Line-aline.
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0."
4486,"3* Na-134
K-4.6 Cl-104 HCO3-21* AnGap-14
[**2117-1-16**] 03:40PM BLOOD ALT-465* AST-572* CK(CPK)-881*
AlkPhos-141* TotBili-1.4
[**2117-1-16**] 09:35PM BLOOD ALT-385* AST-493* CK(CPK)-1141*
AlkPhos-123 TotBili-1.9*
[**2117-1-17**] 03:29AM BLOOD ALT-317* AST-304* CK(CPK)-870*
AlkPhos-106 TotBili-1.2
[**2117-1-17**] 01:41PM BLOOD CK(CPK)-936*
[**2117-1-16**] 03:40PM BLOOD cTropnT-0.64*
[**2117-1-16**] 03:40PM BLOOD CK-MB-35* MB Indx-4.0
[**2117-1-16**] 09:35PM BLOOD CK-MB-45* MB Indx-3."
4487,"EMS was called and he was taken to [**Hospital 4199**]
hospital. On arrival (11:20am) he was in asystole. He was given
Epi X 3 and Atropine X 1. He then went into Vfib and shocked
(200 joules). He then went into Afib and became bradycardic.
Dopamine was started. He regained a perfusing rhythm at 11:35am.
He was given Calcium chloride, Magnesium, Amiodarone 300mg IV X
1 and bicarb during the resuscitation at [**Last Name (un) 4199**]. He later had
another episode of VT at 12:40 and an amiodarone gtt was
started. He was transferred to the [**Hospital1 18**] ED."
4488,".
ECHO [**2117-1-18**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the inferior and inferolateral walls,
distal anterior wall and distal lateral wall. There is an apical
left ventricular aneurysm. The remaining walls contract well
(LVEF 30-35%). No masses or thrombi are seen in the left
ventricle. The right ventricular cavity is moderately dilated
with moderate global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen."
4489,"PULSES:
Right: Carotid 2+ Femoral dopplerable DP dopplerable
Left: Carotid 2+ Femoral dopplerable Popliteal dopplerable
Pertinent Results:
ADMISSION LABS:
[**2117-1-16**] 03:40PM BLOOD WBC-13.3* RBC-5.40 Hgb-15.7 Hct-49.7
MCV-92 MCH-29.0 MCHC-31.6 RDW-16.8* Plt Ct-216
[**2117-1-16**] 03:40PM BLOOD Neuts-86.1* Lymphs-5.9* Monos-7.8 Eos-0.1
Baso-0.2
[**2117-1-16**] 03:40PM BLOOD PT-30.1* PTT-44.2* INR(PT)-3.0*
[**2117-1-16**] 09:35PM BLOOD Glucose-276* UreaN-69* Creat-3."
4490,"Consider MRI for further
evaluation if clinically indicated.
.
Non-contrast head CT ([**2117-1-16**]): NON-CONTRAST HEAD CT: There is no
intracranial hemorrhage, mass effect, or [**Doctor Last Name 352**]-white matter
differentiation abnormality. The ventricles and extra-axial
spaces are appropriate for age. Intracranial carotid artery
atherosclerotic calcifications are moderate-to-severe. Mucosal
secretions within the nasal passages, nasopharynx, and
opacification of the ethmoid sinus air cells are noted, at least
partially related to recent intubation. There is mucosal
thickening in bilateral maxillary, frontal, and sphenoid
sinuses, mild in degree. Imaged mastoid air cells are clear.
There is no fracture."
4491,"The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Significant pulmonic regurgitation is seen. The pulmonary
artery systolic pressure could not be quantified (but pulmonary
artery systolic hypertension is suggested). There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderate regional left
ventricular systolic dysfunction consistent with multivessel
CAD. Right ventricular cavity enlargement with free wall
hypokinesis. Mild mitral regurgitation.
Compared with the findings of the prior study (images reviewed)
of [**2116-1-6**], left ventricular function has further
deteriorated and the right ventricular cavity is more dilated
with new free wall hypokinesis.
Is there a history to suggest a primary pulmonary process (e."
4492,"He had
a stress test on [**2126-5-18**] that was positive and was referred for
a
cardiac catheterization. He was found to have left main disease
and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Coronary Artery Disease, s/p CABG this admission
Alcohol abuse (last drink 1 year ago)
Wernicke's encephalopathy
Multiple falls with injury/fractures (left humerus and
shoulder)-
has only had 1 fall in the last year since arriving at the
nursing home
Hypertension
COPD
GERD
Current Smoker
Social History:
Lives with:Lives at nursing home due to financial issues
Contact:[**Name (NI) 17**] [**Name (NI) **] (sister) Phone# [**Telephone/Fax (1) 83483**]
Occupation:does not currently work
Cigarettes: Smoked no [] yes [x] last cigarette [**2126-6-6**]
Hx:currently smokes 8 cigarettes a day x 2 years and history of
3ppd x 50 years
Other Tobacco use:none
ETOH: none in the past year, history of alcohol abuse
Illicit drug use:none"
4493,"Family History:
Sister with
[**Name2 (NI) **] placed at age of 50
Physical Exam:
Pulse:59 Resp:16 O2 sat:99/RA
B/P Right:156/77 Left:142/70
Height:5'[**24**]"" Weight:131 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs wheezes bilaterally [x]
Heart: RRR [x] Irregular [x] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese
Extremities: Warm [x], well-perfused [] Edema +2
Varicosities: +1 Chronic venous stasis
Neuro: Grossly intact []
Pulses:
Femoral Right: cath site Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2"
4494,"Disp:*65 Tablet(s)* Refills:*0*
12. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days."
4495,"5
mg-3 mg (2.5 mg base)/3 mL Solution for Nebulization - 1 (One)
unit dose vial inhaled three times a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once
a
day
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 (One) Tablet(s) sub lingually every 5 minutes up
to 3 times as need for chest pain
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth at bedtime
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E."
4496,"6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain."
4497,"**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:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**2126-7-3**] at 1pm in the [**Hospital **] medical office
building
Cardiologist: Dr. [**First Name8 (NamePattern2) 20204**] [**Last Name (NamePattern1) **] [**2126-6-25**] at 10:20 am
[**Telephone/Fax (1) 33529**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 60013**] [**Telephone/Fax (1) 37824**]- make appointment for
4-5 weeks
Completed by:[**2126-6-11**]"
4498,"Admission Date: [**2126-6-6**] Discharge Date: [**2126-6-11**]
Date of Birth: [**2062-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfasalazine
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2126-6-7**]
Coronary artery bypass grafting x4, with the
left internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the obtuse
marginal artery and a reverse saphenous vein Y-graft to the
ramus intermedius artery and the first diagonal artery.
History of Present Illness:
64 year old male complains of
exertional chest pain and tightness in the last 3 months."
4499,"C.) - 1 (One) Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
(One) Capsule(s) by mouth once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
4500,"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 4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to RosCommon at [**State 83484**]in [**Location 1268**] in good condition with appropriate follow
up instructions.
Medications on Admission:
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
(One) Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
(One) Tablet(s) by mouth once a day
IPRATROPIUM-ALBUTEROL - (Prescribed by Other Provider) - 0."
4501,"7 Na-132*
K-4.7 Cl-97 HCO3-28 AnGap-12
[**2126-6-7**], Intra-op TEE
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on no inotropes."
4502,"17. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 10
days.
Discharge Disposition:
Extended Care
Facility:
Roscommon [**Hospital 1268**] Extended Care Center
Discharge Diagnosis:
Alcohol abuse (last drink 1 year ago), Werneke's encephalopathy,
multiple falls with injury/fractures (left humerus and
shoulder), Hypertension, COPD, GERD, Current Smoker, s/p
ORIF(humerus) [**7-/2124**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with cane
Incisional pain managed with oral anagesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema [**12-9**]+ pitting edema"
4503,"Admission Date: [**2106-7-9**] Discharge Date: [**2106-7-20**]
Date of Birth: [**2045-2-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Kiwi (Actinidia Chinensis) / Cipro I.V. / Nsaids
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Lethargy, N/V
Major Surgical or Invasive Procedure:
L burr hole craniotomy for evacuation of SDH
History of Present Illness:
61yo M with multiple medical problems including cirrhosis
(reportedly on transplant list) and RUE DVT on lovenox, s/p MVC
[**2106-6-25**] with SDH at that time, discharged to nursing facility on
[**7-5**]. Woke this morning feeling lethargic; + HA; + n/v.
Presented to the ED, where a repeat head CT was performed which
showed acute on subacute subdural hematoma overlying the left
frontotempoparietal convexity with 3 mm midline shift to the
right."
4504,"Basilar cisterns patent.
Past Medical History:
1. Cirrhosis secondary to PSC and hepatic sarcoid, previously
decompensated with hepatic encephalopathy. No hx of SBP,
+varices, + variceal bleed [**4-/2106**], undergoing transplant work-up
at [**Hospital1 **]
2. Sarcoidosis (pt states this is resolved)
3. Type 2 diabetes.
4. Obesity.
5. Hypertension (pt states this is resolved)
6. Dyslipidemia.
7. Meralgia paraesthetica.
8. Recurrent thrombophlebitis - most recent bilateral LE dvt
[**11/2105**]
Social History:
Mr. [**Known lastname 13751**] has retired from his teaching position last [**Month (only) 956**],
previously taught history. Denies recent etoh. Denies IVDU. The
patient has a 30-pack-year history of smoking but quit 20 years
ago."
4505,"Cirrhotic liver. No focal liver lesions visualized
on this limited exam.
2. Patent portal veins with stable reversal of flow consistent
with portal hypertension. No recanalization of the paraumbilical
vein, splenomegaly, or ascites.
Head CT [**7-15**]: No significant change from [**2106-7-13**]. No new
hemorrhage.
Brief Hospital Course:
Mr [**Known lastname 13751**] is 61yoM with h/o PSC cirrhosis c/b variceal bleed,
hepatic encephalopathy, recent UE DVT treated with Lovenox, b/l
LE DVTs, t2DM, s/p [**Known lastname 8751**] on [**2106-6-25**] with right tib/fib fx, left
wrist fx, s/p ORIF, C7fx, discharged [**2106-6-30**], readmitted [**2106-7-10**]
with acute on subacute SDH"
4506,"He
was then transferred to the hepatology service
He was found to have Bilateral sup. fem and popliteal DVTs.
Given SDH's, systemic anti-coagulation was not indicated.
Heme-onc was consulted and recommended against IVC filter.
Decided to use heparin 5000units SQ TID until he is fully
ambulating.
His hepatic encephalopathy was treated w/ lactulose and
rifaximin, and he improved.
# Cirrhosis: Secondary to PSC, complicated by variceal bleeds in
past. Continues on lactulose, rifaximin, furosemide, nadolol.
Active T&S kept while inpatient.
.
# Acute on chronic subdural hematoma: Patient s/p evacuation
with burr hole placement on [**2106-7-11**]."
4507,"Head CTs showed no
re-accumulation. Started on phenytoin for seizure prophylaxis,
and will continue on this till NSGY f/u in [**Month (only) 216**]. If he
develops severe headaches and neurologic deficits, he should be
re-evaluated immediately.
.
#Fracture left wrist and right ankle: s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8751**], [**First Name3 (LF) **] f/u with
ortho (Dr [**Last Name (STitle) **] in 2 weeks time
.
# C7 fracture: f/u with neurosurgery in 8 weeks, w/ CT C and T
spine at that time. Should continue in neck brace until then.
.
#Shingles: located on his back. Completed a 7 day total course
of acyclovir
."
4508,"OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 Capsule(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
7. Rifaximin 550 mg PO BID
8. Sucralfate 1 gm PO TID
9. Multivitamins 1 TAB PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. HydrOXYzine 25 mg PO BID:PRN anxiety
12. Omeprazole 40 mg PO DAILY
13. Rosuvastatin Calcium 5 mg PO DAILY
14. Ursodiol 500 mg PO TID
15. Phenytoin (Suspension) 100 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subdural hematoma
lethargy
hepatic encephalopathy
OSA
hypertension
cirrhosis
Shingles
Diabetes mellitus type 2"
4509,"Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr [**Known lastname 13751**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for a bleed in your head, for which you had a procedure. You
were also found to have blood clots. You should not receive
high-dose anti-coagulation ever again, though we are sending you
out on low-dose anti-coagulation. You also had altered mental
status from your liver disease (hepatic encephalopathy), which
was treated with medications."
4510,"9* Calcium-9.5 Phos-2.5* Mg-2.0
Discharge labs
[**2106-7-18**] 09:20AM BLOOD WBC-4.1 RBC-3.40* Hgb-11.5* Hct-35.1*
MCV-103* MCH-33.8* MCHC-32.7 RDW-16.5* Plt Ct-145*
[**2106-7-17**] 06:50AM BLOOD PT-15.5* PTT-41.5* INR(PT)-1.5*
[**2106-7-18**] 09:20AM BLOOD Glucose-272* UreaN-10 Creat-1.1 Na-137
K-4.3 Cl-109* HCO3-20* AnGap-12
[**2106-7-16**] 03:43PM BLOOD ALT-22 AST-67* LD(LDH)-281* AlkPhos-418*
TotBili-2."
4511,"?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
Department: LIVER CENTER
When: THURSDAY [**2106-7-22**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2106-8-3**] at 9:40 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"
4512,"Department: ORTHOPEDICS
When: TUESDAY [**2106-8-3**] at 10:00 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
[**2106-8-23**] 02:00p [**Last Name (LF) **],[**First Name3 (LF) **] L.
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
NEUROSURGERY WEST (NHB)
[**2106-8-23**] 01:15p XCT [**Apartment Address(1) 9394**] [**Hospital Ward Name **]
CC [**Location (un) **], [**Location (un) **]
RADIOLOGY
[**2106-8-23**] 01:00p XCT [**Apartment Address(1) 9394**] [**Hospital Ward Name **]
CC [**Location (un) **], [**Location (un) **]
RADIOLOGY
[**2106-8-5**] 10:00a PODIATRY,[**Doctor Last Name 722**]
BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX), [**Location (un) **]
[**Hospital 1947**] CLINIC (SB)
Create Visit Summary
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]"
4513,"Lives alone in walk up apartment. Still smokes marijuana.
Currently undergoing transplant evaluation at [**Hospital1 498**].
Family History:
Mother with diabetes and CAD. Father with diabetes, brother and
sister with diabetes, white coat hypertension in maternal
family, paternal grandmother with cervical cancer and breast
cancer. No other cancers noted. No other heart disease.
Physical Exam:
Admission exam
O: T: 98.9 BP: 111/52 HR: 66 R 16 O2Sats 100%
Gen: WD/WN, lethargic, NAD.
HEENT: Pupils: 4->3 EOMs intact, no nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused."
4514,"No abnormal movements,
tremors. Strength full power [**5-22**] throughout. No pronator drift.
Strength exam limited by external fixator on RLE and cast on LUE
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Normal
Toes downgoing bilaterally
Handedness Right
Discharge exam
Vitals: Tm/c 98.7 72 114/64 20 100%ra FBS 191
GENERAL: Awake, laying in bed, coherent but confused on some
questions. Looks better than he has in previously days
HEENT: Sclera icteric, PERRL, C-collar in place
CV: Normal rate, regular rhythm, no m/r/g
PULM: Lungs CTA b/l posteriorly
ABD: Soft, nontender, nondistended, NABS
EXT: Right ankle with external fixator, b/l pedal edema; left
wrist with well-healing scar from ORIF
NEU: no asterixis, AAOx2, coherent but confused on some
questions."
4515,"0*
[**2106-7-18**] 09:20AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.6
Head CT [**7-9**]
1. Acute on subacute/chronic subdural hematoma overlying the
left
frontoparietotemporal convexity with 3 mm of midline shift to
the right.
Basilar cisterns are patent. No hydrocephalus.
2. Large bulging parotid glands with less fat than usual.
Correlate with
physical exam and clinical picture, consider normal variant
versus a chronic inflammatory process; the appearance is
unchanged however.
Head CT [**7-10**]
Stable appearance of acute-on-chronic left subdural collection
as
described above.
RUE doppler ultrasound
No DVT
RUQ U/S: 1."
4516,"Neuro:
Mental status: Awake, lethargic, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, but not 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, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally."
4517,"Moves all extremities, sensation intact, EOMI, PERRL.
Pertinent Results:
Admission labs
[**2106-7-9**] 05:45PM BLOOD WBC-4.4 RBC-3.68* Hgb-12.2* Hct-37.9*
MCV-103* MCH-33.3* MCHC-32.3 RDW-18.2* Plt Ct-224#
[**2106-7-9**] 05:45PM BLOOD PT-14.0* PTT-48.4* INR(PT)-1.3*
[**2106-7-9**] 05:45PM BLOOD Glucose-158* UreaN-11 Creat-1.2 Na-136
K-4.0 Cl-102 HCO3-27 AnGap-11
[**2106-7-9**] 05:45PM BLOOD ALT-22 AST-57* AlkPhos-365* TotBili-2.7*
[**2106-7-9**] 05:45PM BLOOD Albumin-2."
4518,"Pt was admitted to the neurosurgery service for further
observation and care. He was admitted to the ICU for strict SBP
control and q1 neuro checks. His repeat CT head on [**7-10**] appeared
stable. He was found to have mild RUE weakness on exam and he
was planned for the OR for burr hole craniotomies on [**7-11**]. On
[**7-11**] he underwent L burr hole craniotomy without complication.
Post operatively he returned to the SICU for further care. On
post op exam he was non focal and CT head showed no acute
hemorrhage. He continued to have altered mental status, and was
thought to have an exacerbation of hepatic encephalopathy."
4519,"#CODE: Full
#CONTACT: [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 12528**] [**Telephone/Fax (1) 102546**]
.
# TRANSITIONAL ISSUES
1. Needs to be on heparin sq TID on discharge for DVT ppx
2. Needs to wear c-collar until neurosurgery f/u.
Medications on Admission:
enoxaparin
lasix 20qD
hydroxyzine
Lantus
lactulose PRN
nadolol 20 qD
omeprazole
rifaximin 550 [**Hospital1 **]
crestor
sucralfate
Discharge Medications:
1. Heparin 5000 UNIT SC TID
2. Furosemide 20 mg PO DAILY
hold for SBP<100
3. Glargine 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Lactulose 60 mL PO TID
5. Nadolol 20 mg PO DAILY
6."
4520,"?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound was closed with sutures/staples. You may wash your
hair only after sutures and/or staples have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**]."
4521,"Admission Date: [**2100-9-29**] Discharge Date: [**2100-10-5**]
Date of Birth: [**2037-6-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Septic Shock
Major Surgical or Invasive Procedure:
endotrachial intubation (at outside hospital)
History of Present Illness:
Ms. [**Known lastname 40750**] is a 63 year old female with a pmh of CAD, HLD, DMII,
and asthma, who presented to an OSH after feeling generally
unwell for 4 days. She reported getting a ""bug bite"" 4 days
prior to admission, and it began to itch 2 days prior to
admission."
4522,".
Other studies: CT head no acute process, no bleed. CTA negative
for PE. CXR clear.
.
On the floor, she is intubated. Unresponsive
Past Medical History:
Hypertension
Prior hyperlipidemia
Diabetes Type 2
Asthma
Arthritis
[**8-11**] Arthroscopic right knee surgery
Left knee replacement
Hysterectomy
Cholecystectomy
Appendectomy
Umbilical hernia repair
Prior heavy ETOH, quit > 20 years ago
Social History:
(Obtained from OSH records) Lives with husband, has 2 children.
- Tobacco: Denied
- Alcohol: Denied
- Illicits: Denied
Family History:
unobtainable
Physical Exam:
Admission Exam:
General: intubated, not responding
HEENT: dry MM
Neck: JVP not elevated, no LAD
Lungs: Rhonchorus BS bilaterally, no wheezes, dimished breath
sounds on left."
4523,"both cerebral hemispheres and the infratentorial compartment,
likely related to known MSSA endocarditis. The largest region of
infarction, involving the right temporoparietal lobe
demonstrates evidence of early cortical ""pseudolaminar
necrosis,"" but there is no evidence of hemorrhagic conversion at
this time.
Brief Hospital Course:
63 year old female with a history of asthma, CAD, DMII
presenting from an OSH with septic found to have MSSA
endocarditis.
.
Septic Shock: MSSA bacteremia (OSH with 4/4 bottles of blood
cultures positive) and E. coli in the urine. She was on
vancomycin and Unasyn at the OSH, with an increasing WBC. She
was started on Vancomycin, meropenem, clindamycin here and
tapered to nafcillin and ceftriaxone based on Cx data from OSH."
4524,"They decided to withdraw care and focus on
comfort. The patient was extubated the evening of [**2100-10-3**]. She
passed away on [**2100-10-5**].
.
Medications on Admission:
Meds at Home:
Viocdin prn
Diltiazem ER 240 daily
Lisinopril 10mg daily
Metoprolol 25 daily
Isosorbide 20mg PO 3 times a day
Aspirin 81mg
Serevent 2 puffs [**Hospital1 **]
Flovent 2 puffs [**Hospital1 **]
NPH Humulin 55 units in the morning, 10 units HS
Labetalol 200mg [**Hospital1 **]
Albuterol nebs prn
.
On Transfer:
Unasyn 3g IV Q6H
Vanco 1250 Q18H
Albuterol Q4
ASA 81mg
Flovent 220mcg [**Hospital1 **]
Fondaparinux 25mg SQ Q24
Tylenol 650 mg Q4H prn
Albuterol Nebs Q2 prn
Neosynephrine
Levophed
Insulin SSI
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Methicillin-sensitive staphylococcus aureas endocarditis, with
septic embolization to brain, resulting in neurologic
devastation, and death secondary to respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none"
4525,"Troponin was positive 0.06 -> 0.32. WBC 14.2-> 15.9, H/H
11.2/32.3, ESR 82, Na 129, K 3.4, Glucose 123. Her blood
pressures dropped and she was started on Neo/Levo, with
pressures responding to 90s/60s, 3L of IV fluid were given. A
total of 485cc of UOP, BUN 19->38, Cr. 1.2-> 1.9. She desatted
to 80s, CPAP, 6L with sats in the high 90s. Her husband and son
were at the bedside prior to transfer. ABG: 7.07, 49, 59 ->
7.16, 37, 72, she appeared hypoxic and was desatting to the 70s
to 80s on CPAP and was intubated prior to transfer."
4526,"5* Lymphs-7.8* Monos-3.4 Eos-0.1
Baso-0.3
[**2100-9-29**] 03:42AM BLOOD PT-16.0* PTT-35.0 INR(PT)-1.4*
[**2100-9-29**] 02:23PM BLOOD Fibrino-732*
[**2100-9-29**] 03:42AM BLOOD Glucose-212* UreaN-43* Creat-1.9* Na-129*
K-5.1 Cl-100 HCO3-15* AnGap-19
[**2100-9-29**] 03:42AM BLOOD ALT-1568* AST-2451* CK(CPK)-389*
AlkPhos-133* TotBili-0.3
[**2100-9-29**] 03:42AM BLOOD CK-MB-4 cTropnT-0.07* proBNP-[**Numeric Identifier 72396**]*
[**2100-9-29**] 03:42AM BLOOD Calcium-7."
4527,"Surveillance Cx here negative. She was been weaned off of
pressors. TEE showed a large vegetation with 4+ mitral
regurgitation with mitral prolapse. Her transaminitis from
admission was felt to be due to shock liver, and trended down
during her ICU stay. Renal failure was felt to be most likely
due to ATN.
.
Endocarditis: Large veg, mobile with MR [**First Name (Titles) **] [**Last Name (Titles) 50935**]. Thoracic
surgery following, but did not plan to take pt for surgery
during current acute illness. Has not been responding to
commands or pain concerning for neurologic deficits, even when
sedation off. She failed SBTs given irregular breathing patterns
of tachypnea alternating with apnea."
4528,"3* Phos-4.6* Mg-1.9
[**2100-9-29**] 03:42AM BLOOD Cortsol-86.3*
[**2100-9-29**] 03:54AM BLOOD Lactate-2.2*
.
TEE [**2100-9-30**]
Large mitral valve vegetation with possible abscess cavity vs.
perforation and severe mitral regurgitation.
.
CT Head [**2100-10-2**]
Limited study. Multiple intracranial areas of low density of
uncertain chronicity, subacute versus chronic, without
associated hemorrhage. Though septic emboli are often associated
with hemorrhage, the diffuse distribution of these abnormalities
is compatible with embolic infarcts. MRI is recommended for
further evaluation.
.
MRI [**2100-10-3**]
Extensive late acute-early subacute embolic infarction involving"
4529,"CV: Normal rate, distant heart sounds, difficult to appreciate
with rhonchi and ventilated breath sounds.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool extremities, no edema. Right forearm with erythema and
3cm of firmness
Neuro: Intubated, off sedation, not responsive to painful
stimuli, sluggish pupilary response
Discharge exam: deceased
Pertinent Results:
Admission Labs:
[**2100-9-29**] 03:42AM BLOOD WBC-21.8* RBC-4.11* Hgb-11.8* Hct-35.4*
MCV-86 MCH-28.7 MCHC-33.2 RDW-14.4 Plt Ct-288
[**2100-9-29**] 03:42AM BLOOD Neuts-88."
4530,"CT scan showed lesions that
could be septic emboli. Pupillary exam shows dilation then
constriction and then downward gaze. + Babinski sign. MRI was
done and showed midbrain lesions as well as A large right
parietal stroke and L occipital stroke. Neuro was consulted;
felt that her neurologic prognosis was very poor. Give location
of stroke, if she had any recovery, she would almost certainly
be blind. Her chance for any meaningful recovery overall was
extremely poor. This was discussed with the family, who
expressed that [**Known firstname **] would not want to live if it could not be a
meaningful life."
4531,"She treated herself with Benadryl, without relief,
and 24 hours prior to admission she had chills, temp to 102.5,
and general weakness. Her FS were [**Location (un) 1131**] ""High."" She was taken
to [**Hospital6 17032**].
.
At the OSH, her Tmax reached 104.2, 96.6 on transfer rectally
she was cooled with cooling blanket. She was started on Unasyn,
Vanco, and had a urine culture positive for GNRs, blood cultures
grew 4/4 bottles of GPCs in pairs and clusters. She was
progressively agitated and pulling at lines and was given 2mg
ativan and 2mg of morphine. CTA was done and it was negative."
4532,"Admission Date: [**2107-10-10**] Discharge Date: [**2107-10-15**]
Date of Birth: [**2043-9-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography
Endotracheal intubation
Peripherally inserted central catheter placement on [**10-14**]
History of Present Illness:
Ms. [**Known lastname 9449**] is a 64yo F with history of atrial fibrillation on
warfarin, mild mental retardation and history of CVA with left
sided paralysis who was transferred to [**Hospital1 18**] for urgent [**Hospital1 **] in
setting of elevated liver enzymes and concern for cholangitis."
4533,"0) that was unremarkable without
evidence of cholangitis or biliary obstruction. She received
ceftriaxone 1g IV and ampicillin 2g IV during [**Hospital1 **]. Patient
remained intubated after the procedure and was transferred to
the [**Hospital Unit Name 153**] for further management. In the [**Hospital Unit Name 153**], she is intubated
and sedated. She squeezes right hand to command but does not
squeeze on left. She does not open eyes to command.
Past Medical History:
Mental retardation
History of embolic CVA, now with left hemiplegia
Hypertension
Depression
Chronic CHF of unknown etiology
h/o alcohol abuse, sober since [**2091**]
s/p ASD repair"
4534,"Social History:
She lives in a nursing home. Patient quit smoking years ago and
quit drinking alcohol in [**2091**]. No illicit drug use. She is
wheelchair bound at home.
Family History:
Unable to obtain.
Physical Exam:
ADMISSION:
VS: 99.2 65 105/55 16 94%PSV FiO2 0.4
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, ET in mouth
Neck: supple, JVP elevated to angle of mandible, no LAD
Lungs: Clear to auscultation bilaterally anteriorly with coarse
vent sounds, no wheezes, rales, rhonchi appreciated
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, no grimace to palpation, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Squeezes hand on right to command, not on left; will not
open eyes or follow other commands"
4535,"There had been a question of
whether she would be having a cholecystectomy but per the OSH
this was not planned or necessary. Increased dose to 5mg from
2.5mg for subtherapeutic INR. She will need close monitoring of
her INR and adjustments of coumadin dosing until it stabilizes.
# Hypertension: Lisinopril was initially held as patient was
being diuresed with IV lasix. After diuresis was stopped,
lisinopril was restarted at home dose.
# Urinary tract infection: Final urine culture negative. OSH
records report UTI. Continued her on cefepime for biliary tract
infection which was adequate treatment for an uncomplicated UTI.
# Prophylaxis: Patient received heparin products during this
admission."
4536,"Please fax results to Dr. [**Last Name (STitle) 47367**].
19. Outpatient Lab Work
Chem7 on [**2107-10-20**]. Please fax results to Dr. [**Last Name (STitle) 47367**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6598**] Manor Extended Care Facility - [**Location (un) 6598**]
Discharge Diagnosis:
Primary diagnoses:
1. Hypoxic respiratory failure secondary to
healthcare-associated pneumonia
2. Pulmonary edema
3. Liver function test elevations secondary to presumed
cholangitis with biliary stent placement
Secondary Diagnoses:
Hypertension
Mental retardation
Chronic congestive heart failure
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair."
4537,"0 RBC-3.68* Hgb-11.6* Hct-34.1*
MCV-93 MCH-31.6 MCHC-34.0 RDW-14.2 Plt Ct-185
[**2107-10-11**] 04:15AM BLOOD PT-18.1* PTT-29.6 INR(PT)-1.6*
[**2107-10-10**] 01:12PM BLOOD Glucose-140* UreaN-17 Creat-0.8 Na-143
K-3.3 Cl-104 HCO3-26
[**2107-10-10**] 01:12PM BLOOD ALT-165* AST-85* AlkPhos-222* Amylase-49
TotBili-1.9*
[**2107-10-10**] 01:12PM BLOOD Lipase-40
[**2107-10-10**] 01:12PM BLOOD proBNP-3344*
[**2107-10-10**] 01:12PM BLOOD Calcium-8."
4538,"Patient was tachypneic to 20-30s while awaiting [**Hospital1 **] and
intubated to protect her airway for the procedure. She became
hypoxic to 70s% during induction and remained intubated after
the procedure.
Per records, patient presented to [**Hospital3 6592**] on [**10-5**] with
epigastric pain. She was found to have elevated LFTs (initially
only mildly elevated, see below for details) and had an
abdominal ultrasound and CT which showed possible stones in the
gallbladder without common bile duct dilation. She also was
diagnosed with a UTI but had a negative urine culture. While at
the OSH, she had a CXR on [**10-8**] that showed cardiomegaly without
pulmonary edema and questionable left lower lung atelectasis."
4539,"IMAGING:
[**10-11**] Transthoracic Echocardiogram (TTE)
IMPRESSION: Surgical repair of a probable ostium secundum ASD
with residual left-to-right interatrial shunting. Dilated right
ventricle with preserved systolic function and mild pulmonary
hypertension. Normal left ventricular systolic function.
Recommend a cardiac MRI for more precise definition of
congenital anatomic abnormalities and quantification of
intracardiac shunting. Findings discussed with Dr. [**Last Name (STitle) **] at
1410 hours on the day of the study.
[**10-10**] [**Month/Year (2) **] Images
IMPRESSION: Placement of common bile duct stent. Normal
appearing bile ducts.
Brief Hospital Course:
Ms. [**Known lastname 9449**] is a 64yo F with history of mental retardation,
atrial fibrillation and CVA with left hemiplegia who was
transferred to [**Hospital1 18**] for [**Hospital1 **] and intubated for respiratory
distress likely secondary to volume overload & pneumonia;
successfully extubated on [**10-13**]."
4540,"You
will need to continue taking antibiotics through [**2107-10-17**].
3. You urine cultures were negative, but we had received a
report that they were positive at [**Hospital3 **]. We treated
this with the same antibiotics that we used to treat your
pneumonia.
4. We restarted your coumadin at a higher dose because your INR
was too low. You will need to have your INR checked every other
day and you coumadin dose adjusted as needed. The antibiotics
may be affecting your coumadin dosing.
5. We made the following changes to your medications:
STARTED cefepime (last dose on [**10-17**])
STARTED vancomycin (last dose on [**10-17**])
INCREASED warfarin dose to 5mg (adjust as necessary based on
INR)
STARTED Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC
6. It is important that you take all of your medications as
prescribed.
7. It is important that you follow up with your primary care
doctor.
Followup Instructions:
Date/Time: [**2107-12-15**] at 12:00PM
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD
Phone:[**Telephone/Fax (1) 463**]
It is important that you follow up with your primary doctor (Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47367**]) at [**Hospital 6598**] [**Hospital 731**] Nursing Home (tel: [**Telephone/Fax (1) 88487**])."
4541,"# Code status: Presumed full code.
Medications on Admission:
Acetaminophen 650mg qhs
Acetaminophen 650mg q4-6 PRN
Dulcolax suppository 10mg PR daily PRN
Refresh Tear 1 gtt OU 4XD
Celexa 40mg daily
Colace 100mg [**Hospital1 **]
Flonase 2 sprays each nostril daily
Lasix 40mg daily
Lisinopril 10mg qdaily
Milk of Magnesia 30 mL daily PRN constipation
MVI
Mylanta 30 mL q6 PRN gastric upset
Coumadin 2.5mg daily
Lorazepam 1mg q6 PRN anxiety
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever: Do not exceed 4 grams/day.
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)."
4542,"3. Refresh Tears 0.5 % Drops Sig: One (1) DROP IN EACH EYE
Ophthalmic four times a day.
4. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays in each nostril Nasal once a day.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Hold for loose stools.
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: adjust dose based on INR checks every other day.
7. 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."
4543,"Discharge Instructions:
1. You were transfered from [**Hospital3 6592**] to have a procedure
called an [**Hospital3 **]. You had a biliary stent placed during this
procedure and will need a repeat [**Hospital3 **] in 2 months as below.
Your INR should be less than 1.5 at that time if possible.
2. You were admitted to the intensive care unit after your [**Hospital3 **]
for difficulty breathing. You required a breathing tube, also
known as intubation. We removed the tube on [**10-13**]. You were
treated for healthcare-associated pneumonia with antibiotics and
we gave you medicine to help remove fluid from your body."
4544,"Lasix was held on [**10-14**] due to agressive diuresis,
but redosed on the morning of discharge based on exam and repeat
chest x-ray. She should resume her usual home dose of oral
lasix on [**10-16**].
# LFT abnormalities: Her [**Month/Year (2) **] was unremarkable and did not show
any frank pus from the biliary system s/p stent placement. Will
need repeat [**Month/Year (2) **] for stent removal in 2 months (appointment has
already been scheduled). LFTs trended down during admission.
# Atrial fibrillation and h/o CVA: Coumadin was restarted when
it was clear that the patient would not be undergoing any other
procedure during this admission."
4545,"14. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
once a day as needed for constipation.
15. Mylanta 200-200-20 mg/5 mL Suspension Sig: [**10-19**] mL PO every
six (6) hours as needed for gastric upset.
16. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety: This medication can make you
sleepy. Do no drink alcohol, drive or operate machinery after
taking this medication.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
18. Outpatient Lab Work
Please check INR every other day until level is stable between
[**2-2**] on three checks and patient has completed antibiotic course."
4546,"7 Na-139
K-3.5 Cl-103 HCO3-31 AnGap-9
[**2107-10-15**] 04:02AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.0
MICROBIOLOGY:
[**2107-10-11**] 4:16 am SPUTUM (Source: Endotracheal)
GRAM STAIN (Final [**2107-10-11**]): >25 PMNs and <10 epithelial
cells/100X field. NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2107-10-13**]): NO GROWTH.
[**2107-10-11**] 4:15 am URINE (Source: Catheter)
URINE CULTURE (Final [**2107-10-12**]): NO GROWTH.
[**2107-10-11**] 4:16 am BLOOD CULTURE (Source: Venipuncture)
Blood Culture, Routine (Pending):
[**2107-10-10**] 1:12 pm MRSA SCREEN (Source: Nasal swab)
MRSA SCREEN (Final [**2107-10-12**]): No MRSA isolated."
4547,"DISCHARGE:
VS: Tmax 98.1, Tcurrent 97.9, BP 154/97, HR 63, RR 25, O2 sat
94% RA
GEN: A+Ox3
HEENT: Sclerae anicteric, PERRL, EOMI
NECK: supple, JVD not appreciated no LAD
LUNGS: Bibasilar rales, no wheezes or rhonchi
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace peripheral edema
NEURO: limited by cognitive impairment (mild MR), moving BLE,
LUE contracted (stable), moving RUE, face symmetric, CN II-XII
w/o focal deficit
Pertinent Results:
ADMISSION LABS:
[**2107-10-10**] 01:12PM BLOOD WBC-7."
4548,"She also had a nuclear medicine cardiology scan with EF noted to
be 90% and ""technically it was not ideal"" but no evidence of
ischemia. There is also an echo report that comments on normal
EF, moderately dilated LA, evidence of ASD repair although ""not
clear if patch is still intact or not"", moderate MR, moderate TR
and RVSP is 51mmHg. Patient received two doses of 5mg vitamin K
the day prior to transfer to [**Hospital1 18**]. She was transferred to [**Hospital1 18**]
for [**Hospital1 **] before a possible cholcystectomy.
At [**Hospital1 18**], she underwent [**Hospital1 **] with biliary stenting (no
sphincteromy given INR 2."
4549,"# Respiratory distress: Patient was tachypneic to 20-30s while
awaiting [**Month/Year (2) **] and intubated to protect her airway for the
procedure. She became hypoxic to 70s% during induction and
remained intubated after the procedure. Respiratory distress
likely caused by CHF exacerbation secondary to volume overload,
in addition to healthcare-associated pneumonia (BNP 3344). CXR
was concerning for infiltrate or pulmonary edema. Echo with EF
>55% with mild pulmonary hypertension. Treated with vancomycin
and cefepime for HCAP with a planned 8-day course (D1=[**10-10**],
last day [**10-17**]). She was treated with IV lasix for her volume
overload."
4550,"9 Phos-2.9 Mg-1.7
[**2107-10-10**] 12:43PM BLOOD Type-ART pO2-158* pCO2-43 pH-7.39
calTCO2-27 Base XS-1
[**2107-10-10**] 12:43PM BLOOD Lactate-1.2
[**2107-10-10**] 11:06PM BLOOD O2 Sat-99
DISCHARGE LABS:
[**2107-10-15**] 04:02AM BLOOD WBC-5.4 RBC-3.60* Hgb-11.2* Hct-33.9*
MCV-94 MCH-31.2 MCHC-33.1 RDW-14.2 Plt Ct-179
[**2107-10-15**] 04:02AM BLOOD PT-16.4* PTT-29.1 INR(PT)-1.5*
[**2107-10-15**] 04:02AM BLOOD Glucose-142* UreaN-11 Creat-0."
4551,"8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H
(every 12 hours) for 3 days.
Disp:*12 grams* Refills:*0*
10. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 3 days.
Disp:*6 grams* Refills:*0*
12. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day: Hold for loose stools.
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day."
4552,"Admission Date: [**2195-4-19**] Discharge Date: [**2195-4-24**]
Service: MEDICINE
Allergies:
Niacin / Lovastatin
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Intubation
Arterial line placement [**2195-4-19**]
History of Present Illness:
87 yo F wtih a history of COPD on chronic steroids, Dementia
(nonverbal baseline), and recent admission for pneumonia
requiring intubation, influenza and UTI who was BIBA from [**Hospital 100**]
Rehab for worsening dyspnea and productive cough. Duration is
unclear, and patient unable to provide history. Today she was
found to be 87% on 4L at 10 pm, and came up to 98% on NRB."
4553,"EKG
showed sinus tachycardia with peaked t waves, but K was normal.
WBC was elevated at 22. She received 1litres of fluid. Prior to
transfer, VS were 98.4, 101, 92/58, 14, 100%.
.
Of note, patient was admitted [**4-6**] to [**4-13**] with influenza, hcap
and UTI. She required intubation in the ICU and was treated with
oseltamivir, azithro, vanco and meropenem. During this hospital
stay family was reluctant to change code status because
daughter/hcp was away on vacation.
.
In the MICU, patient is intubated and sedated.
.
Review of systems:
limited by patient being on ventilator. appears comfortable"
4554,"17. Rib fractures.
18. Actinic keratoses.
19. Posterior vitreous detachment.
20. Hypertension.
21. History of vertigo.
22. Headaches with negative workup in the past.
Social History:
Former criminal lawyer. [**Name (NI) **] 3 children. Quit smoking 30 years
ago; previously was heavy smoker. No alcohol, illicit drug use.
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
T: 98.4 BP: 115/76 P: 100
450 cc RR 16 PEEP 5 FiO2 100%
General: Sedated, not withdrawing to sternal rub
[**Name (NI) 4459**]: Sclera anicteric, MMM, oropharynx clear, [**Name (NI) 2994**]
[**Last Name (un) **]: Macular [**Last Name (un) **] on back bilaterally, extending to left flank"
4555,"4 Na-139
K-3.4 Cl-99 HCO3-33* AnGap-10
[**2195-4-24**] 05:36AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
Brief Hospital Course:
87 yo F wtih a history of COPD on chronic steroids, dementia
(nonverbal at baseline), and recent admission for pneumonia
requiring intubation and influenza who was admitted from [**Hospital 100**]
Rehab for worsening dyspnea and productive cough secondary to
new pneumonia.
# Respriratory failure: Pt with LLL opacity on CXR suggestive of
pneumonia. Given her recent influenza, she was was covered for
MRSA with vancomycin. Pt also with history of ESBL and was
started on meropenem (Day 1=[**4-19**])."
4556,"Dementia: Patient non-verbal at baseline. Passed swallow
evaluation and was restarted on dysphagia diet.
Anemia: Patient??????s recent HCT baseline around 28-31. During this
hospitalization, her HCT stable around 23-25 and was 26 at time
of discharge. Likely hemodilutional component in setting of IVF
in addition to likely marrow suppresion in setting of acute
illness.
Pending Labs:
-Blood cultures from [**4-19**]
Transition of care:
-FULL code, verified by family
-Pneumonia: will need to complete course of meropenem
-Aspiration: family aware of pt's aspiration risk.
-Anemia: would trend HCT while outpatient. HCT stable and
trending up while inpatient."
4557,"7. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: Do not give more then 3g/day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. meropenem 500 mg Recon Soln Sig: One (1) Intravenous every
six (6) hours for 3 days: Take through [**2195-4-26**] for total 7 day
course.
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
11. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization
Sig: One (1) Inhalation every six (6) hours as needed for
shortness of breath or wheezing: prn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Hospital Acquired Pneumonia
chronic obstructive pulmonary disease- acute exacerbation
Contact dermatitis [**Name2 (NI) **]
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
Please make sure to see your primary care doctor within the week
after leaving rehab."
4558,"Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
T 97.5, BP 105/58, HR 58, RR 22, 100%2L, 2 BM yesterday and 1 BM
this AM
Gen: nad, comortable, confused, dementia, alert
Cardiac: RRR< no mrg
Pulm: few scattered crackled in lower lung bases bilaterally, no
wheezing or rhonchi
Abd: soft, non distended, non tender
Ext: no pedal edema, warm"
4559,"MICRO:
[**4-19**] Blood cx x2: pending
[**4-19**] Urine cx x2: yeast
[**4-19**] Sputum:
SPUTUM Source: Endotracheal.
**FINAL REPORT [**2195-4-22**]**
GRAM STAIN (Final [**2195-4-19**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2195-4-22**]):
RARE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
YEAST. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones."
4560,"01
[**2195-4-23**] 09:37AM BLOOD Phos-2.4* Mg-1.7
[**2195-4-19**] 03:01AM BLOOD calTIBC-230* Ferritn-85 TRF-177*
[**2195-4-20**] 06:11PM BLOOD Vanco-11.4
Discharge Labs:
[**2195-4-24**] 05:36AM BLOOD WBC-6.1 RBC-3.24* Hgb-8.4* Hct-26.4*
MCV-82 MCH-26.0* MCHC-31.8 RDW-17.9* Plt Ct-244
[**2195-4-20**] 03:30AM BLOOD Neuts-86.2* Lymphs-8.6* Monos-4.7 Eos-0.2
Baso-0.2
[**2195-4-24**] 05:36AM BLOOD Glucose-151* UreaN-6 Creat-0."
4561,"Pt was initialy closely
monitored in the MICU where she was intubated. Her pulmonary
status improved and she was extubated on [**4-20**]. Pt's fevers
improved and her leukocytosis resolved (WBC 22->6). For possible
COPD exacerbation, she was continued on prednisone 20mg daily.
She will taper down to 10mg daily in 3 days. CXR showed some
signs of pulmonary edema, esp in the setting of getting IVF
while in the MICU, and she was diursed with IV lasix (10-20mg
daily for 2 days). Sputum culture notable for rare growth of
coag positive aureus, MSSA plus some rare GNR."
4562,"Pertinent Results:
ADMISSION LABS:
[**2195-4-19**] 01:00AM BLOOD WBC-22.2*# RBC-3.85* Hgb-10.0* Hct-30.8*
MCV-80* MCH-25.9* MCHC-32.4 RDW-17.6* Plt Ct-367#
[**2195-4-19**] 01:00AM BLOOD Neuts-87* Bands-1 Lymphs-4* Monos-7 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2195-4-19**] 01:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL
[**2195-4-19**] 01:00AM BLOOD PT-12.1 PTT-20.0* INR(PT)-1.0
[**2195-4-19**] 01:00AM BLOOD UreaN-19 Creat-0."
4563,"[**2195-4-23**] 09:37AM BLOOD WBC-7.0 RBC-3.19* Hgb-8.4* Hct-25.5*
MCV-80* MCH-26.4* MCHC-33.0 RDW-18.4* Plt Ct-275
[**2195-4-20**] 03:30AM BLOOD Neuts-86.2* Lymphs-8.6* Monos-4.7 Eos-0.2
Baso-0.2
[**2195-4-23**] 09:37AM BLOOD Plt Ct-275
[**2195-4-23**] 09:37AM BLOOD Glucose-198* UreaN-6 Creat-0.3* Na-138
K-3.5 Cl-101 HCO3-30 AnGap-11
[**2195-4-20**] 03:30AM BLOOD AST-13 AlkPhos-63 TotBili-0.3
[**2195-4-19**] 05:59PM BLOOD CK-MB-3 cTropnT-<0."
4564,"Reccoment CBC check on [**2195-3-29**].
If HCT continues to decrease, would reccomend anemia workup.
Medications on Admission:
# prednisone 20 mg daily
# morphine 4 mg Q2 H prn
# Albuterol prn
# vitamin d 1000 U
# Ipratropium neb Q4H
# Dulcolax suppository
# Miralax 17 g daily
# Ativan 0.25 mg Q4H prn
# Aspirin 81 mg daily
# Tylenol 650 mg suppository
# albuterol neb q6H
# ipratropium neb Q6H
# senna 17.2 mg daily
# zinc oxide topical
.
per last d/c summary
# albuterol sulfate prn
# aspirin 81 mg daily
# bisacodyl 10 mg pr
# Vitamin D 1,000 unit daily
# ipratropium bromide 0.02 % Solution Q4H
# polyethylene glycol 3350 17 gram daily
# prednisone 40 mg x 3 days, 30 mg x 3 days, 20 mg x 3 days, 10
mg ongoing
# acetaminophen 650 mg prn
# docusate sodium 100 mg [**Hospital1 **]"
4565,"6
[**2195-4-19**] 03:01AM BLOOD Glucose-276* UreaN-20 Creat-0.6 Na-133
K-4.5 Cl-99 HCO3-27 AnGap-12
[**2195-4-19**] 01:00AM BLOOD ALT-22 AST-16 LD(LDH)-254* AlkPhos-78
[**2195-4-19**] 03:01AM BLOOD CK(CPK)-43
[**2195-4-19**] 01:00AM BLOOD Lipase-36
[**2195-4-19**] 03:01AM BLOOD CK-MB-2 cTropnT-0.03*
[**2195-4-19**] 01:00AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.8 Mg-1.8
[**2195-4-19**] 01:09AM BLOOD pH-7.34* Comment-GREEN TOP
[**2195-4-19**] 01:09AM BLOOD Glucose-258* Lactate-3."
4566,"0* Na-137 K-4.5
Cl-99* calHCO3-28
[**2195-4-19**] 01:09AM BLOOD Hgb-10.4* calcHCT-31 O2 Sat-96 COHgb-1.4
MetHgb-0
[**2195-4-19**] 01:09AM BLOOD freeCa-1.12
[**2195-4-19**] 05:47AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025
[**2195-4-19**] 05:47AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2195-4-19**] 05:47AM URINE RBC-2 WBC-6* Bacteri-FEW Yeast-NONE
Epi-<1
[**2195-4-19**] 05:47AM URINE CastHy-1*
[**2195-4-19**] 05:47AM URINE Mucous-RARE"
4567,"Past Medical History:
1. End-stage Alzheimers Dementia, non-verbal
2. COPD, FEV1 81% in [**2190**]
3. Pulmonary nodules
4. ?CAD ?MI in [**2171**]; normal dipyridamole thallium in [**2173**].
5. Osteoarthritis
6. Cataracts.
7. Chronic back pain and hip pain
8. Hearing loss
9. Varicose veins
10. Heart murmur
11. Breast cancer in the left breast back in [**2183**] treated with
radiation and tamoxifen, which was later changed to Arimidex.
12. Osteopenia with history of atraumatic vertebral fracture.
13. Abnormal endometrial, worked up by OB/GYN in the past.
14. Hypercholesterolemia.
15. Status post cholecystectomy in [**2164**].
16. Status post umbilical hernia repair."
4568,"She had a PICC
placed for antibiotic course of treatment for presumed HCAP.
Vancomycin was stopped on [**2195-4-23**] (completed 5 day course) and
she will continue meropenem for total 7 day course (through
[**2195-4-26**]).
Aspiration Concern: Pt had speech and swallow video study and
passed. She was restarted on dysphagia diet of pureed solids and
nectar think liquids. Explained to pt's family that she is at
risk for aspiration.
[**Year (4 digits) **]: Patient with [**Year (4 digits) **] in dependent areas on back (flank
regions bilaterally) and part of stomach. Crosses midline so
unlikely Zoster. Likely to be contact dermatitis as [**Year (4 digits) **] existed
prior to antibiotic administration."
4569,"Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING:
[**4-19**] CXR:
IMPRESSION: Mild interstitial edema with a left lower lobe
opacity, which
could represent an underlying pneumonia. Mitral annular
calcifications.
[**4-21**] Video Swallow;
Penetration without aspiration of thin barium. No aspiration
with any administered preparations."
4570,"Discharge Medications:
1. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
In the next 3 days, can taper to 10mg daily and continue 10mg.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
at bedtime as needed for constipation.
4. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
once a day."
4571,"She
was given atrovent neb, albuterol neb, and morphine 4 mg SL
without much effect. Prior to transfer VS were 99.8 (rectal),
118/76, 104, 42, 95% RA.
.
On arrival to the ED, patient was intubated. Patient had a CXR
consistent with interstitial edema versus infection, stable
since prior study. She was treated with vancomycin, and ordered
for zosyn but this was not given prior to transfer. She received
propafol, etomidate 30 mg IV x1 and succinylcholine 120 mg IV x1
peri-intubation. After intubation she was started on fentanyl
and versed drips. On transfer, VS were 98.4, 99, 99/61, with
vent settings of TV 450 cc, RR 16, PEEP 5, 100% FiO2."
4572,"Admission Date: [**2129-9-20**] Discharge Date: [**2129-9-23**]
Date of Birth: [**2102-6-6**] Sex: M
Service: MEDICINE
Allergies:
Fentanyl
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
27year old male with Hajdu-[**Location (un) 2987**] Syndrome, (bone disorder) with
restrictive lung disease from severe scoliosis and COPD (current
smoker) at home on 4L O2 by nasal cannula and then SIMV by
ventilator at night presenting to ED with increased SOB x 2days
and increasing secretions. Patient was recently admitted to
[**Hospital1 18**] with right olecranon osteomyelitis."
4573,"No
microbiologic evidence of bacteria from sputum, Legionella
antigen negative. Thought likely secondary to Enterococcus
bacteremia, and cipro, cefepime were discontinued. Patient's
symptoms subjectively improved.
# R Olecranon Osteomyelitis: Increased vancomycin dose initially
due to low trough, then switched to daptomycin after
consultation with ID as clinically no improvement. Presumably
no response to vancomycin.
# Enterococcal bacteremia: Initial blood cultures grew
Enterococcus and coag neg Staph. Patient was continued on
daptomycin and after extensive discussion with ID the decision
was made to continue antibiotic treatment via his picc. The
risks of removing the picc were high as the patient has
difficult iv access and requires a long course of iv
antibiotics."
4574,"C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
22. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
23. Bactrim DS q day [This was accidentally omitted from
patient's discharge medications but he was taking this in-house
and should be taking this at home.]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Enterococcal bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive."
4575,"Patient also was supposed to have been taking Bactrim DS daily
for PCP prophylaxis as he is on chronic daily prednisone;
however this was not on his home medication list.
Discharge Medications:
1. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection once
a day.
Disp:*1 month's supply* Refills:*2*
2. Outpatient Lab Work
Please check CBC/diff, BUN/Cr, ESR, CRP, CK and fax to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1419**]
3. Daptomycin 500 mg Recon Soln Sig: One (1) vial Intravenous
once a day: Give at 5pm.
Disp:*1 month's supply* Refills:*2*
4."
4576,"11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q12H (every 12 hours).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
16. Albuterol Sulfate 2."
4577,"No wheezing.
tachypneic but not in acute distress.
CV: tachycardic and regular 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, edema
Pertinent Results:
[**2129-9-20**] 01:09PM LACTATE-0.9
[**2129-9-20**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2129-9-20**] 01:00PM WBC-9.3 RBC-3.85* HGB-10.2* HCT-31.7* MCV-83
MCH-26."
4578,"The patient will follow up with ID on an
outpatient basis (as he was doing prior to admission for his
osteomyelitis.)
# Chronic obstructive/restrictive pulmonary disease: Continued
on home dose of prednisone 15mg daily and bactrim prophylaxis
with prn nebs and chest PT. Home regimen of trach mask collar
and SIMV at night was continued.
# Hajdu-[**Location (un) 2987**] Syndrome: Home pain medications were continued
including methadone, morphine, baclofen, gabapentin, and
ibuprofen (with holding parameters for somnolence). Bowel
regimen prn constipation.
Medications on Admission:
MSIR 60mg QID
Methadone 40mg TID
Baclofen 40mgs QAM, 20mg at 11am 20mg at 7pm
Gabapentin 800mg TID
Motrin 800mg TID with food
Lorazepam 1mg HS
Singulair daily
Omprazole daily
Prednisone 15mg daily (given 60mg in ED)
Atrovent neb Q4H PRN
Albuterol [**Doctor First Name **] Q4H PRN
Pulmicort neb [**Hospital1 **]"
4579,"5* MCHC-32.1 RDW-13.9
[**2129-9-20**] 01:00PM GLUCOSE-128* UREA N-17 CREAT-0.4* SODIUM-138
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-34* ANION GAP-12
[**2129-9-20**] 01:00PM NEUTS-94.8* LYMPHS-4.1* MONOS-0.7* EOS-0.3
BASOS-0.1
Micro:
GRAM STAIN (Final [**2129-7-30**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2129-8-1**]):
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. PREDOMINATING
ORGANISM.
SENSITIVITIES: MIC expressed in
MCG/ML"
4580,"Osteomyelitis, right olecranon (pressure-related)
3. Chronic obstructive/restrictive lung disease
4. h/o multiple pneumonias, including Pseudomonas pna and VAP
Social History:
Lives at home with his grandparents and brother. [**Name (NI) **] a Home
Health Aide.
- Tobacco: active tobacco use ([**5-16**] cigarettes a day)
- Alcohol: denies
- Illicits: denies
Family History:
Mother and brother with [**Location (un) 86059**] syndrome.
Physical Exam:
Vitals: T: 98.2 BP: 135/92 P:108 R: 24 O2: 99% on 40% trach mask
General: Alert, oriented, no acute distress, small stature with
marked [**Last Name (un) 2043**] abnormalities of extremities and back.
HEENT: Sclera anicteric, dry MM, oropharynx clear, trach in
place without erythema around site
Neck: supple, JVP not elevated
Lungs: Rales right middle lobe but left side clear."
4581,"Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. We
think this was because your infection in the arm was not treated
enough and you felt sicker than usual which made you too weak to
cough well. Your antibiotics were switched to daptomycin (from
vancomycin). We left in your PICC line because it was very
difficult to place and putting in a new one would be riskier
than treating your infection through the line. You should
continue to follow along with your infectious disease doctor as
you were.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-9-28**] 9:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-10-28**] 10:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2129-9-23**]"
4582,"9 HR:122 BP:109/79 RR:22 O2Sat:98
on 5L trach mask. Reportedly received cefepime and/or levoquin
in the ED for history of pseudomonal VAP since already on
Vancomycin for osteomyelitis was covered for MRSA. Also takes
prednisone at home and got 60mg in the ED for ?COPD
exacerbation.
.
VS prior to transfer: T 99 HR 108 BP 124/72 RR 20 O2 97% on 5L
trach mask.
.
On the floor, patient complained of SOB and requested nebulizer
treatments. He denied chest pain, dysuria, N/V/abdominal
pain/diarrhea.
Past Medical History:
1. Hajdu-[**Location (un) 2987**] Syndrome
2."
4583,"5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Budesonide 1 mg/2 mL Suspension for Nebulization Sig: One
(1) neb Inhalation twice a day.
21. Omeprazole 20 mg Capsule, Delayed Release(E."
4584,"He has been treated
for 1.5 weeks with vancomycin for this infection. Since then he
reports very little improvement in the infection.
Patient has history of ventilator-associated pneumonia with
resistant pseudomonas in recent cultures (sensitive only to
tobramycin but treated with cefepime with good result) and
reports that over the last few days he has had increasing SOB
worse than baseline. In addition he has had increasing
secretions. He thinks he may also have been having fevers
(low-grade). No sick contacts but says this feels like his prior
PNAs so he came to ED.
.
VS on arrival to the ED: T:98."
4585,"_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 2 S
.
Images:
CXR (wet read): limited study secondar to pt body
habitus/scoliosis; RML consolidation - may represent aspiration
vs PNA
.
EKG: Sinus tachycardia with <1mm STE I avl slightly worse than
prior and TWI III.
Brief Hospital Course:
# Respiratory distress/SOB: Afebrile, no leukocytosis and no
evidence of pneumonia on chest xray (although exam difficult due
to patient anatomy.) Initially started on cipro, cefepime for
history of Pseudomonas pneumonia. Continued on vanco for
osotemyelitis and home vent settings for night/day."
4586,"Morphine 30 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Methadone 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
6. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO QAM (once a day
(in the morning)).
7. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TWICE DAILY AT
11AM AND 7PM ().
8. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
9. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours): WITH FOOD.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24
Hours)."
4587,"Admission Date: [**2128-8-27**] Discharge Date: [**2128-9-4**]
Date of Birth: [**2061-7-1**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 11784**]
Chief Complaint:
aphasia and right hemiparesis
Major Surgical or Invasive Procedure:
IV tPA and MERCI device
History of Present Illness:
The patient is a 67 year old right handed man with a past
medical
history significant for a.fib (not on Coumadin - for unclear
period of time, possible not since [**2122**]), HTN, HLD, DM - on
insulin, heavy smoking history who presents with a sudden onset
of right sided weakness, determined to have a LMCA syndrome at
an
OSH, given tPA and sent to [**Hospital1 18**] for further evaluation."
4588,"There NIH scale was reported to be 21.
Here on examination he continued to have severe deficits, given
a
stroke scale of 23. He had a CTA which showed a persistent L
MCA
clot and he was taken to the angio suite for intervention.
Past Medical History:
- afib w RVR, only on ASA not on Coumadin (unclear if ever was)
- CHF
- HTN
- DM on insulin
- peri-rectal abscess treated a few months ago
Social History:
Lives by himself in [**Location (un) **]. He is not employed. He has a long
40 year x 3ppd smoking history, etoh use and uses pain pills
that are not his according to his daughter."
4589,"No previous tracing
available for comparison.
.
CT BRAIN PERFUSION [**2128-8-27**]: IMPRESSION: 1. Left M1 cutoff with
increased MTT thoughout the left M1 territory. The perfusion
studies are limited and evaluation for mismatch and territory at
risk is not possible. This was discussed with Dr. [**Last Name (STitle) 88862**] of
the stroke service and Dr. [**Last Name (STitle) **] of Interventional
Neuroradiology, and the patient was brought for an
interventional procedure. 2. Ground glass opacities throughout
the visualized lung apices are non-specific and if clinically
indicated might be better evaluated with chest CT. 3.
Mediastinal lymphadenopathy.
.
59 DISTINCT PROCEDURAL SERVICE [**2128-8-27**]: FINDINGS:
."
4590,"The patient also was placed on statin therapy for control of his
LDL levels.
.
*)INFECTIOUS DISEASE: Patient had pneumonia and E. coli positive
UTI which were controlled with broad spectrum antibiotics
including Vancomycin 100mg, Tobramycin 740 mg, and Cefepime 2 g
IV.
.
*)ENDOCRINE: Patient was placed on an insulin sliding scale
during this hospitilzation due to history of DM2 and per stroke
protocol.
Time of Death: 3:30pm on [**9-4**].
Medications on Admission:
- ASA 81
- Omeprazole 20mg qd
- Toprol 100mg
- Zocor 40mg qd
- Lisinopril 40mg
- Insulin
Discharge Medications:
N/A, pt expired on [**9-4**].
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: L MCA stroke
Secondary: Atrial Fibrillation
Discharge Condition:
N/A pt expired.
Discharge Instructions:
N/A Pt expired peacefull with family at bedside at 3:30pm on
[**9-4**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was called to perform the death
prounouncement. Please see physical exam section for further
details.
Followup Instructions:
N/A pt expired"
4591,"RIGHT INTERNAL CAROTID ARTERY INJECTION, PREPROCEDURE: There is
complete proximal M1 occlusion with distal collateral flow
provided by ACA branches and scant leptomeningeal collaterals.
.
LEFT INTERNAL CAROTID ARTERY INJECTION, POST-PROCEDURE: The left
internal carotid artery and its distal branches are patent with
the exception of a proximal M2 branch, which demonstrates
sluggish flow indicating more distal occlusion. Lenticulostriate
luxury perfusion is noted. The anterior cerebral artery is
widely patent and provides collateral flow to the left cerebral
hemisphere.
.
IMPRESSION: Successful left MCA M1 division thrombectomy using a
combination of 10 mg of IV TPA and a Merci retrieval device."
4592,"There is residual sluggish flow and distal occlusion within a
proximal M2 branch.
.
PORTABLE CXR [**2128-8-27**]: FINDINGS: The tip of the endotracheal
tube projects 3.8 cm above the carina. The tip of the
nasogastric tube is projecting over the stomach. Mild bilateral
areas of atelectasis. No overt pulmonary edema. Low lung
volumes. The presence of minimal pleural effusions cannot be
excluded. The size of the cardiac silhouette is at the upper
range of normal.
PORTABLE CXR [**2128-9-4**]: FINDINGS: The position of the various
lines and tubes is unchanged. Cardiac size is within normal
limits. The lung fields are clear."
4593,"Heart: no heartbeat.
Extremities: cool extremities.
Skin: pale.
Pertinent Results:
ADMISSION LABS:
[**2128-8-27**] 01:30PM WBC-11.5* RBC-4.71 HGB-12.4* HCT-36.7*
MCV-78* MCH-26.4* MCHC-33.8 RDW-15.4
[**2128-8-27**] 01:37PM GLUCOSE-348* NA+-134 K+-3.2* CL--95* TCO2-26
[**2128-8-27**] 05:07PM CALCIUM-7.5* PHOSPHATE-3.9 MAGNESIUM-1.6
[**2128-8-27**] 05:07PM CK-MB-2 cTropnT-<0.01
.
ADMISSION IMAGING:
ECG [**2128-8-27**]: Atrial fibrillation with a rapid ventricular
response. Non-specific ST-T wave changes."
4594,"42
calTCO2-23 Base XS--1
.
Brief Hospital Course:
*)NEURO: Patient was admitted [**2128-8-27**] s/p large left MCA stroke
with resultant aphasia and right sided weakness. He received TPA
at an OSH and was transferred to the [**Hospital1 18**] for interventional
angiography which was able to partially recanalize his posterior
vessels. He was intubated for protection of his airway and cared
for in the NICU. The rest of his care proceeded according to the
stroke protocol including continued anticoagulation with ASA and
heparin and appropriate imaging. Over the course of his
hospitalization, the patient exhibited anisocoria (left 3nn,
right 2mm, only reactive on left), eyes that were closed at
baseline and he did not open them spontaneously, with symmetric
grimace to pain in upper extremities."
4595,"He exhibited no
spontaneous movements. At the decision of his family, he was
terminally extubated the afternoon of [**9-4**] and died peacefully
within 40 minutes of his extubation with his family at the
bedside. They denied autopsy.
.
*)PULM: Following admission for acute left MCA stroke, patient
was intubated for protection of his airway. He was never able to
be successfully extubated during the course of his
hospitalization. At the decision of his family, he was
terminally extubated the afternoon of [**9-4**].
.
*)CARDIO: During this hospitalization, the patient exhibited
atrial fibrilation which was controlled with Amiodarone 200 mg
and hypertension which was controlled with labetolol 10 mg IV."
4596,".
-Motor: Normal bulk, tone throughout.
Right arm - minimal effort against gravity, slight withdrawal to
pain (flexor), no movement in hand, leg slight withdrawal to
pain
no effort against gravity. Left arm/leg moving spontaneously
appear full
.
-Sensory: Decreased on right side to painful stim, o/w appears
grossly intact
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was mute bilaterally.
.
-Coordination and gait: not tested
.
.
PHYSICAL EXAMINATION UPON PRONOUNCIATION OF DEATH:
Gen: Elderly male lying in bed. Unresponsive.
HEENT: Pupils unreactive bilaterally.
Lungs: no breath sounds."
4597,"There is no evidence of
failure.
.
LABS ON DAY OF EXPIRATION:
[**2128-9-4**] 02:17AM BLOOD WBC-11.7* RBC-3.93* Hgb-10.0* Hct-32.3*
MCV-82 MCH-25.4* MCHC-30.9* RDW-15.7* Plt Ct-415
[**2128-9-4**] 02:17AM BLOOD PT-16.3* PTT-29.4 INR(PT)-1.4*
[**2128-9-4**] 02:17AM BLOOD Glucose-172* UreaN-26* Creat-1.0 Na-152*
K-3.6 Cl-124* HCO3-21* AnGap-11
[**2128-9-4**] 02:17AM BLOOD Calcium-7.9* Phos-1.3* Mg-2.0
[**2128-9-4**] 02:17AM BLOOD Osmolal-321*
[**2128-9-3**] 03:32AM BLOOD Type-ART pO2-170* pCO2-34* pH-7."
4598,"The story is not clear (he was unable to provide details and the
family was not present for the event). He was apparently in his
usual state of health and went out for a drive. Per report (not
clear how this was obtained) he felt ill and pulled over to the
side of the road. He was found by the fire service at ~11:30-40
to have right sided weakness and unable to speak and was taken
to
[**Hospital1 **]-[**Location (un) 620**]. He was in the window and was given tPA after
consultation with tele-service. He got 81mg of tPA at ~1:50pm
and transferred here."
4599,"No nuchal rigidity
Pulmonary: Lungs clear anteriorly
Cardiac: [**Last Name (un) 3526**] [**Last Name (un) 3526**]
Abdomen: soft, NT/ND, obese
Extremities: mild erythema on both calves, likely venous stasis
.
Neurologic:
-Mental Status: Alert, aphasic, occasionally would curse, not
following commands although did squeeze hands and open eyes on
command one time.
.
-Cranial Nerves:
I: Olfaction not tested.
II: Left eye fixed, appears surgical, right eye 2mm reactive,
R field cut
III, IV, VI:Left visual pref, cannot get him to cross midline to
right
VII: right facial droop, lower half of face
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline."
4600,"[**First Name4 (NamePattern1) **] [**Known lastname 17811**] (ex
wife) c:[**Telephone/Fax (1) 88858**] h:[**Telephone/Fax (1) 88859**]. [**First Name4 (NamePattern1) 1457**] [**Known lastname 17811**] ([**Last Name (un) **])
[**Telephone/Fax (1) 88860**]. [**First Name4 (NamePattern1) 50269**] [**Last Name (NamePattern1) 284**] ([**Last Name (un) **]) c: [**Telephone/Fax (1) 88861**]
Family History:
Mother with CA, father who fell and had cerebral hemorrhage
secondary to etoh in his 40s.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: T: 98 P:95 R: 16 BP:119/76 SaO2: 95
General: Awake, moaning, no following commands, obese
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated."
4601,"A 2.0 soft Merci retriever was then placed, and over a period of
five minutes, gentle traction was applied and thrombectomy was attempted. A
3.0 firm Merci retriever was then placed across the occluded portion of the
left M1 segment, and two further attempts were performed with the application
of gentle traction over a period of 5 minutes. Angiogram following these
attempts demonstrated a patent M1 segment of the left internal carotid artery,
distal M2 branches remained patent, however, a more proximal M2 branch
demonstrated slow flow, signifying more distal occlusion. Approximately 5 mg
of TPA was infused into this M2 branch."
4602,"The catheter was then removed,
followed by removal of the sheath over a wire. Hemostasis was achieved using
(Over)
[**2128-8-27**] 2:17 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 12512**]
Reason: inetervention for stroke
Contrast: OPTIRAY Amt: 160
______________________________________________________________________________
FINAL REPORT
(Cont)
an angioseal device and manual compression. The patient was brought to the ICU
intubated.
FINDINGS:
RIGHT INTERNAL CAROTID ARTERY INJECTION, PREPROCEDURE: There is complete
proximal M1 occlusion with distal collateral flow provided by ACA branches and
scant leptomeningeal collaterals.
LEFT INTERNAL CAROTID ARTERY INJECTION, POST-PROCEDURE: The left internal
carotid artery and its distal branches are patent with the exception of a
proximal M2 branch, which demonstrates sluggish flow indicating more distal
occlusion. Lenticulostriate luxury perfusion is noted. The anterior cerebral
artery is widely patent and provides collateral flow to the left cerebral
hemisphere.
IMPRESSION: Successful left MCA M1 division thrombectomy using a combination
of 10 mg of IV TPA and a Merci retrieval device. There is residual sluggish
flow and distal occlusion within a proximal M2 branch."
4603,"COMPARISON: CTA head [**2128-8-27**].
OPERATORS:
Dr. [**First Name8 (NamePattern2) 1617**] [**Name (STitle) 291**], attending.
Dr. [**First Name4 (NamePattern1) 106**] [**Last Name (NamePattern1) 785**], resident.
[**First Name4 (NamePattern1) 823**] [**Last Name (NamePattern1) 824**], NP.
ANESTHESIA: General anesthesia was provided by the staff anesthesiologist.
TECHNIQUE: The procedure was explained to the patients daughter and written
informed consent was obtained. A preprocedure timeout confirmed the patient
identity and the procedure to be performed. The patient was brought to the
neuro interventional suite, and the bilateral groins were prepped and draped
in the usual sterile fashion. Using a 19-gauge single wall needle, the right
common femoral artery was accessed, and an 8 French sheath was placed over a
[**Last Name (un) 52**] wire."
4604,"[**2128-8-27**] 2:17 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 12512**]
Reason: inetervention for stroke
Contrast: OPTIRAY Amt: 160
********************************* CPT Codes ********************************
* [**Numeric Identifier 1155**] PRIMARY MECH THROMBECTOMY ART/ [**Numeric Identifier 285**] SEL CATH 3RD ORDER [**Last Name (un) 286**] *
* -51 MULTI-PROCEDURE SAME DAY [**Numeric Identifier 287**] SEL CATH 2ND ORDER *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 288**] CAROTID/CEREBRAL BILAT *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 4205**] CAROTID/CERVICAL UNILAT *
* -59 DISTINCT PROCEDURAL SERVICE *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
67 year old man with left MCA stroke needs interventions
REASON FOR THIS EXAMINATION:
inetervention for stroke
______________________________________________________________________________
FINAL REPORT
CLINICAL INFORMATION: 67-year-old male with a left MCA occlusion."
4605,"Using the [**Last Name (un) 52**] wire and a 4 French Berenstein 2 catheter,
the left common carotid artery was selected and an angiogram was performed.
This demonstrated complete occlusion of the M1 segment of the left middle
cerebral artery. The 4 French Berenstein catheter was therefore exchanged for
an 8 French Merci balloon catheter which was parked in the cervical left
internal carotid artery. Then, using a gold tip Glidewire and a Merci
emergency microcatheter, the thrombus in the left M1 division was reached, and
crossed. At this point, approximately 5 mg of TPA was infused into the
thrombus."
4606,"A
family member took his pulse and found him to be in the 20's, so
brought him to the ED.
.
There his vitals were hr 31, 110/68, 18, 100% RA. He was found
to have elevated INR, hypokalemic and repleted. EKG showing
sinus bradycardia with intermittent ventricular escape beats and
Vpaced beats. He is admitted to CCU for pacer interrogation and
monitoring.
.
ROS is positive as above and also with worsening postural
hypoTN, which he ascribes to the Parkinson's meds, and lost of
taste, also attributed to Parkinson's meds
.
ROS is negative for f/c/ns, CP, SOB, diaphoresis, cough, PND,
orthopnea, syncope"
4607,"Past Medical History:
1. Myxomatous mitral valve disease status post mitral valve
repair with an annuloplasty ring at the [**Hospital 3340**] Clinic in
[**2098**].
2. Postoperative nonsustained VT status post single chamber
[**Company 1543**] ICD generator, changed in [**2108**].
3. Atrial fibrillation, was previously on Amiodarone but now on
Dronedarone and also Coumadin
4. Nonischemic dilated cardiomyopathy with an ejection fraction
of 30-40%
5. Parkinson disease, recently initiated on Aricept and
carbidopa
6. Progressive orthostasis with dizziness upon standing.
7. Small ASD or PFO not felt to be clinically significant
Social History:
Lives at home with wife and two daughters
[**Name (NI) 1139**] Use: Never smoker
Alcohol Abuse: No history of alcohol abuse."
4608,"5* Mg-2.4 Iron-64
[**2110-5-21**] 10:22PM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7
Cardiac Enzymes
[**2110-5-22**] 04:21AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2110-5-21**] 10:22PM BLOOD cTropnT-<0.01
Brief Hospital Course:
60 y/o M with a history of myxomatous mitral valve disease s/p
annuloplasty '[**98**], paroxysmal atrial fibrillation, h/o
postoperative NSVT s/p ICD placement, and h/o nondilated
cardiomyopathy who presents with lightheadedness and
near-syncope in the context of recent undefined illness and
weight loss, found to be bradycardic and admitted to CCU for
further management."
4609,".
#. Presyncope/NSVT: Pt had pacer evaluated by EP, which showed
a few episodes of NSVT which seem to correlate temporally with
his symptoms. Also with runs of ventricular bigeminy with 1st
QRS complex paced and second complex a wide complex PVC, other
strips show bigeminy without pacing. Runs of sinus rhythm with
junctional vs ventricular escape beats are also seen. Patient
was followed closely by the EP service. Possible etiology of
NSVT could be due to hypokalemia. Patient had potassium
aggressively repleted. Prior to discharge, his potassium level
was 4.2, for which he was repleted with an extra 40 mEq of
potassium for goal of 4."
4610,"5. Patient was continued on
dronedarone. Metoprolol was stopped. Lisinopril decreased to 5
mg daily. Patient will also start daily potassium
supplementation. He will follow up closely in device clinic
where he will have repeat CBC, lytes, and INR checked.
.
#. Failure to thrive: patient has had recent weight loss,
decrease in appetite, overall fatigue and malaise. Sinamet is
the most recent addition to his outpatient medications. His
neurologist did not think that these symptoms are due to
sinamet, although sinamet may cause some nausea, the treatment
of which would be to take an extra 25mg of carbidopa along with
his sinamet."
4611,"This was discussed with patient and a prescription
for carbidopa was provided to be taken as needed for nausea.
.
#. Pancytopenia: the etiology of this is unclear. His
medications were reviewed with no offending medications found.
His neurologist did not think that this was being caused by any
of his parkinson's meds. He will have a repeat CBC drawn on his
next visit at device clinic to follow up.
.
#. Acute renal failure - patient on admission had creatinine of
1.3 which trended down to baseline of 1.0 with gentle IV fluids.
.
#. Supratherapeutic INR - patient's albumin was normal which
suggests not a synthetic problem."
4612,"LFT's also normal. Patient
had warfarin held during this admission, but on discharge his
INR was back within therapeutic range of 2.0-3.0 at 2.9. He
will be restarted on warfarin as an outpatient, and will have
INR checked on his next visit to device clinic for further
management of his warfarin dosing.
.
#. Parkinson's - patient was continued on sinamet and azilect
Medications on Admission:
Warfarin 1 mg or 5 mg daily (? med list unclear)
Metoprolol tartrate 50mg PO bid
Lisinopril 5mg po daily (vs 20mg daily by medication list)
Dronedarone 400mg po BID
Azilect (Rasagiline) 1mg daily
Carbidopa/Levodopa 25/100 tid
Flomax 0."
4613,"Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Presyncope/NSVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
lightheadedness. You were admitted to the cardiac intensive
care unit for close monitoring. The electrophysiology service
evaluated you on this admission and changed some of the setting
on your pacemaker. They found brief episodes of abnormal rhythm
when they interrogated your pacemaker. You will need to
continue taking dronedarone.
We contact[**Name (NI) **] your neurologist in regards to your parkinson's
medications: sinemet and resegaline."
4614,"4mg qhs
Ambien 10 mg qhs prn
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO twice a day.
4. AZILECT 1 mg Tablet Sig: One (1) Tablet PO daily ().
5. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime)."
4615,"7. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
8. Carbidopa 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
Disp:*90 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
10. Outpatient Lab Work
Please draw a CBC, Chemistry 10, PT, PTT, and INR drawn on
[**2110-5-27**] and have results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 3341**]"
4616,"Admission Date: [**2110-5-21**] Discharge Date: [**2110-5-23**]
Date of Birth: [**2050-3-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Lightheadedness, slow pulse
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Dr. [**Known lastname 3339**] is a 60 yoM with a history of myxomatous mitral
valve disease s/p annuloplasty '[**98**], paroxysmal atrial
fibrillation currently on Dronedarone and Coumadin, h/o
postoperative NSVT s/p ICD placement, and h/o nondilated
cardiomyopathy with EF who presents with lightheadedness and
near-syncope in the context of recent undefined illness and
weight loss."
4617,"It does not appear that
they are the causes of your appetite or weight loss. Sinemet
can cause nausea, and the treatment to that is to take an
additional 25mg of carbidopa along with the sinemet
You will also need to continue warfarin. Your INR on discharge
is 2.9. Please continue to have your INR checked periodically
in order to manage your warfarin dosage.
You will need to have your labs checked again. Please have a
CBC, Chem 10, and an INR checked on [**5-27**].
Your medications have changed. Please make note of the
following changes:
- please STOP taking metoprolol
- please DECREASE your lisinopril dosage to 5 mg daily
- new: Potassium chloride 20 mEq daily
- you are being given a prescription for carbidopa."
4618,"No drugs
Family History:
FH:
h/o colon CA
Physical Exam:
96.5 72 116/74 15 99% RA
Pleasant middle aged male in no distress, good historian.
JVD not elevated, no hepatojugular reflux noted
Lungs CTAB no w/c/r/r, good air movement, no accessory muscle
use, breathing comfortably on room air
RRR, no murmurs appreciated, heart sounds soft S1 S2, no S3 S4
Abd obese NT ND
No BLE edema noted but hyperpigmented macules noted
2+ bilateral radial pulses noted
CN 2-12 intact, no facial droop or dysarthria, spontaneously
moving all four extremities, no focal lesions noted."
4619,"You can
take one tablet along with your sinamet, three times a day, as
needed if you are experiencing nausea that you think may be due
to the sinamet.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2110-5-27**]
9:00
Dr.[**Name (NI) 1565**] office will contact you for an additional follow
up appointment in approximately 6 weeks' time. If you do not
hear back from them soon, please call [**Telephone/Fax (1) 3342**] to make the
appointment.
Please continue to follow up with your neurologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]"
4620,"Pertinent Results:
CHEST (PORTABLE AP) Study Date of [**2110-5-21**] 10:47 PM
IMPRESSION: No acute intrathoracic process.
CBC
[**2110-5-23**] 06:45AM BLOOD WBC-4.1 RBC-4.09* Hgb-11.9* Hct-35.0*
MCV-86 MCH-29.2 MCHC-34.1 RDW-13.7 Plt Ct-180
[**2110-5-22**] 04:21AM BLOOD WBC-3.4* RBC-3.90* Hgb-11.7* Hct-33.2*
MCV-85 MCH-29.9 MCHC-35.2* RDW-13.8 Plt Ct-145*
[**2110-5-21**] 10:22PM BLOOD WBC-4.3 RBC-4.22* Hgb-12.3* Hct-35."
4621,"1 Na-140 K-4.7
Cl-106 HCO3-28 AnGap-11
[**2110-5-22**] 04:21AM BLOOD Glucose-83 UreaN-13 Creat-1.2 Na-142
K-3.1* Cl-106 HCO3-28 AnGap-11
[**2110-5-21**] 10:22PM BLOOD Glucose-98 UreaN-14 Creat-1.3* Na-142
K-3.1* Cl-102 HCO3-30 AnGap-13
[**2110-5-23**] 06:45AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
[**2110-5-22**] 01:33PM BLOOD Calcium-8.7 Phos-2.2* Mg-2.1
[**2110-5-22**] 04:21AM BLOOD Calcium-8.5 Phos-2."
4622,"9*
MCV-85 MCH-29.0 MCHC-34.1 RDW-13.7 Plt Ct-201
Coags
[**2110-5-23**] 06:45AM BLOOD PT-29.5* PTT-32.6 INR(PT)-2.9*
[**2110-5-22**] 04:21AM BLOOD PT-38.3* PTT-37.2* INR(PT)-4.0*
[**2110-5-21**] 10:22PM BLOOD PT-39.3* PTT-33.2 INR(PT)-4.1*
Chemistry
[**2110-5-23**] 01:28PM BLOOD K-4.2
[**2110-5-23**] 06:45AM BLOOD Glucose-90 UreaN-9 Creat-1.0 Na-142 K-4.0
Cl-107 HCO3-29 AnGap-10
[**2110-5-22**] 01:33PM BLOOD Glucose-93 UreaN-9 Creat-1."
4623,".
Pt reports history of 25lb weight loss in the past 6 weeks that
he attributes to losing his sense of taste due to his
Parkinson's meds. He denies any further focal symptoms during
this time frame. Then, today he was not feeling well while at
work in the ED here at [**Hospital1 18**]. He had been feeling lightheaded
all day. He went home then relates that he was laying on the
couch watching TV with his daughter and may have passed out for
some time, the only thing he remembers is his daughter waking
him up. He is unsure if he actually lost consciousness or not."
4624,"Admission Date: [**2171-5-6**] Discharge Date: [**2171-5-15**]
Date of Birth: [**2100-7-11**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior L3-S1 fusion
Anterolateral T12-L3 fusion
Posterior T9-S1 fusion
History of Present Illness:
Ms. [**Known lastname **] has a long history of back pain due to scoliosis.
She presents for surgical intervention.
Past Medical History:
HLD, HTN, depression, hypothyroidism
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles"
4625,"Oxycodone SR (OxyconTIN) 20 mg PO Q12H
13. Pravastatin 20 mg PO DAILY
14. Senna 1 TAB PO BID:PRN Constipation
15. traZODONE 25 mg PO HS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Scoliosis
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around."
4626,"Post-operatively she was transfered to the T/ICU for hemodynamic
monitoring. Her course was uneventful. Postoperative HCT was
low and she was transfused PRBCs. She was kept NPO until bowel
function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#4 from the third procedure.
She was fitted with a TLSO brace for out of bed. Physical
therapy was consulted for mobilization OOB to ambulate. Hospital
course was otherwise unremarkable. On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet."
4627,"If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead."
4628,"Pertinent Results:
[**2171-5-12**] 01:39AM BLOOD WBC-7.9 RBC-3.74* Hgb-11.2* Hct-34.3*
MCV-92 MCH-29.9 MCHC-32.6 RDW-13.6 Plt Ct-210
[**2171-5-10**] 12:04AM BLOOD WBC-6.7 RBC-3.57* Hgb-10.9* Hct-31.7*
MCV-89 MCH-30.6 MCHC-34.4 RDW-14.5 Plt Ct-148*
[**2171-5-8**] 11:47PM BLOOD WBC-4.5 RBC-3.57* Hgb-11.0* Hct-31.0*
MCV-87 MCH-30.9 MCHC-35.6* RDW-14.0 Plt Ct-157
[**2171-5-12**] 01:39AM BLOOD Glucose-131* UreaN-11 Creat-0."
4629,"4 Na-136
K-3.6 Cl-100 HCO3-30 AnGap-10
[**2171-5-10**] 12:04AM BLOOD Glucose-118* UreaN-8 Creat-0.4 Na-143
K-3.8 Cl-107 HCO3-32 AnGap-8
[**2171-5-8**] 06:14PM BLOOD Glucose-199* UreaN-7 Creat-0.6 Na-141
K-3.2* Cl-104 HCO3-26 AnGap-14
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2171-5-6**] and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details."
4630,"-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days."
4631,"You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity as tolerated in brace
Treatments Frequency:
Please continue to change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2171-5-14**]"
4632,"Medications on Admission:
Amlodipine
Citalopram
Dexilant
Levothyroxine
Losartan Potassium
Pravastatin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q 8H pain
2. Amlodipine 10 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Citalopram 20 mg PO DAILY
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Heparin 5000 UNIT SC BID
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. OxycoDONE (Immediate Release) 5-15 mg PO Q3H:PRN pain
hold if somnolent, rr < 12, sat < 92
12."
4633,"The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T12-L3 anterior release with as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Hospital day #3 she underwent a posterior
T9-L1 posterior fusion."
4634,"Admission Date: [**2190-1-30**] Discharge Date: [**2190-2-4**]
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
CC:[**CC Contact Info 111485**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]yo woman with h/o dementia who was noted by NH
to be acting strangely. Although at baseline she has
""nonsensical speech,"" for the last few days, she was seen
moaning and holding her head in her hands. Her vital signs were
noted to be normal. Labs revealed Na of 175. At her NH, she is
listed as DNR/DNI/DNH, but a discussion was had with the
patient's daughter, and decision was made to send her to [**Hospital1 18**]
for treatment."
4635,".
In the ED, initial VS were: 98.0 107/71 78 17 98%. She was awake
but not verbal and not following commands. She appeared
comfortable. Labs revealed a Na of 177 and Cr of 2.4. She was
given ceftriaxone for a positive UA. Renal was contact[**Name (NI) **] and
suggested 1/2NS at 100cc/hr. She was then sent to the ICU for
further care.
.
Upon arrival to the ICU, she is sleeping comfortably but
rousable.
Past Medical History:
Dementia: at baseline has ""non-sensical speech,"" incontinent,
wheelchair-bound
Alzheimer's disease
CKD with baseline Cr 1.3-1."
4636,"7 (in [**2188**])
HTN
Hyperlipidemia
UTIs
Hiatal hernia
Osteoarthritis
Possible sacral ulcer
Social History:
Lives at [**Hospital **] [**Hospital **] Nursing Home: [**Telephone/Fax (1) 62338**], where she
was placed in [**2185**]. No further history available at present.
Family History:
Not contributory
Physical Exam:
97.7 148/47 76 22 91% 2L
Light yellow urine in Foley.
Sleeping comfortably in bed, rouses minimally when she is being
examined and moans or shifts position.
Pupils are small b/l, right has some surgical changes. Sclera
are non-icteric.
Resists oral exam, but lips are moist.
Neck is supple. No thyroid enlargement or nodule."
4637,"This can also be further evaluated
with a PA and lateral view.
Brief Hospital Course:
[**Age over 90 **] year old woman with h/o dementia who was found to have severe
hypernatremia and acute renal failure resulting in altered
mental status/delirium. Her hypernatremia was due to poor access
to free water in this demented elderly woman with impaired
thirst and LASIX TREATMENT. She had no evidence of central or
nephrogenic DI. Her free water deficit at admission was 7.6-9.2L
(depending on whether her water is 50-60% of her body weight).
She was corrected with D5W and [**2-6**] normal saline for
conservative management."
4638,"On [**2-2**], she was switched back to D5W
because of slowed correction. A picc line was placed for better
access and ease of blood draws given need for close monitoring
of electrolytes. Her sodium on discharge was 147. She will
receive additional IV fluids for 24 hours and then oral
hydration of 1500 ML/ Hour. Her delirium/altered mental status
was from her hypernatremia, dehydration, UTI, ARF, and abnormal
mental status at baseline. Per daughter, the patient has
nonsensical speech at baseline. Her mental status improved back
to baseline over the course of her hospitalization. The
patient's creatinine was increased to 2."
4639,"4 at admission (baseline
Cr 1.3-1.7. Her renal function improved to baseline with IV
fluid rehydration given for hypernatremia correction. Lisinopril
was initially held and then restarted on [**2-2**] when renal
function at baseline. She received Ceftriaxone for 5 days for
UTI and urine culture grew proteus mirabilis and MORGANELLA
MORGANII. She will receive Bactrim and Augmentin for additional
3 days. Her Foley was discontinued on discharge. She had
hypertensive urgency but no emergency. Lasix was stopped and
should NOT be resumed. She received Lisinopril and Norvasc for
HTN treatment. She may remain hypertensive at NH but no evidence
from radpi reduction of BP woith IV medications unless emergency
(end organ damage)."
4640,"1 MONOS-3.4 EOS-3.1
BASOS-1.2
[**2190-1-30**] 06:55PM WBC-10.3 RBC-4.62 HGB-13.7 HCT-45.9 MCV-99*#
MCH-29.8 MCHC-30.0* RDW-14.1
[**2190-1-30**] 06:55PM GLUCOSE-200* UREA N-127* CREAT-2.4*
SODIUM-177* POTASSIUM-4.9 CHLORIDE-GREATER TH TOTAL CO2-19*
[**2190-1-30**] 09:00PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2190-1-30**] 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7."
4641,"0
LEUK-MOD
[**2190-1-30**] 09:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018
[**2190-1-30**] 09:59PM LACTATE-1.4
[**2190-1-30**] 10:54PM GLUCOSE-138* LACTATE-1.9 NA+-182* K+-4.9
CL--148* TCO2-18*
Discharge Labs:
Microbiology:
[**1-30**] Urine Culture: PROTEUS MIRABILIS. >100,000
ORGANISMS/ML..
[**1-30**] Blood Culture: NGTD
Imaging:
CXR [**2190-1-30**]:
1. Lucency projecting over the left hemithorax, question
elevated left
hemidiaphragm versus herniation of intra-abdominal contents.
Correlation with a lateral radiograph is recommended.
2. Apparent widening of the mediastinum, most likely related to
patient
positioning and technique."
4642,"7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 3 days.
11. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Severe hypernatremia
Delirium
UTI
Uncontrolled hypertension without emergency
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Bedbound
Discharge Instructions:
Severe hypernatremia related to impaired thirst and decreased
oral hydration. The patient needs constant stimulation for oral
hydration with a goal of >1500 ML of daily FLUIDS. She also
needs supervision for feeding.
Followup Instructions:
Follow up with PCP : [**Name10 (NameIs) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 608**]"
4643,"She was initially NPO except for medications
given poor mental status. She had a speech and swallow
evaluation that showed aspiration of thin liquids. She had a
repeat speech and swallow eval when sodium normalized and she
was able to have thickened liquids.
# Code: DNR/DNI BUT SHOULD BE HOSPICE AT SOME POINT
.
# Comm: Daughter [**First Name4 (NamePattern1) 1785**] [**Known lastname **] (cell) [**Telephone/Fax (1) 111486**]; (home)
[**Telephone/Fax (1) 111487**]. Need to clarify goals of care with daughter.
Medications on Admission:
(per NH sheet):
ASA 81mg daily
Lisinopril 20mg daily
Simvastatin 40mg daily
Furosemide 20mg daily
Darvocet 100/650mg TID
Prilosec 40mg daily
Calcium with vitamin D 600/200 daily
Colace 100mg daily
Senna
MVI
Metamucil
Flovent 110mcg 2 puffs
Duoneb 0."
4644,"5/3mg Q4H
Spiriva 18mcg
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipatoin.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain."
4645,"S1, S2, RRR, +3/6 systolic murmur at apex, radiates to axilla.
Lungs are clear b/l with good air movement, although somewhat
diminished at bases. No wheeze or crackles.
Abd: +BS, soft, NT and not distended.
Skin: No bruising or rash noted.
Neuro: Minimally rousable. Moves all extremities during exam.
Some increased tone with cogwheeling in the LUE. Has pneumoboots
in place.
Ext: Feet are warm, well-perfused. DPs palpable b/l.
.
Pertinent Results:
Admission Labs:
[**2190-1-30**] 06:55PM PT-12.5 PTT-29.6 INR(PT)-1.1
[**2190-1-30**] 06:55PM NEUTS-74.3* LYMPHS-18."
4646,"5/3mg Q4H
Spiriva 18mcg
Past medical history:
Family history:
Social History:
Dementia: at baseline has ""non-sensical speech,"" incontinent,
wheelchair-bound
Alzheimer's disease
CKD with baseline Cr 1.3-1.7 (in [**2188**])
HTN
Hyperlipidemia
UTIs
Hiatal hernia
Osteoarthritis
Possible sacral ulcer
PCP: [**First Name8 (NamePattern2) 2379**] [**Last Name (NamePattern1) 10077**] [**Telephone/Fax (1) 10078**]
Not contributory
Lives at [**Hospital 1792**] [**Hospital **] Nursing Home: [**Telephone/Fax (1) 10079**], where she was
placed in [**2185**]. No further history available at present.
Review of systems:
Flowsheet Data as of [**2190-1-31**] 04:16 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36."
4647,"- contact [**Name (NI) 122**] for further information as to her baseline
- treat hypernatremia and likely UTI
- avoid sedating meds
- monitor for delirium
# Acute renal failure: baseline Cr 1.3-1.7, current Cr 2.4
Suspect that patient is dehydrated, and lasix and lisinopril may have
contributed to the toxicity of her prerenal state. She received 1L of
NS in the ED.
- recheck Cr in AM
- send urine lytes
- hold lisinopril
# Possible UTI:
- continue ceftriaxone started in the ED (day 1 = [**1-30**])
- f/u urine culture
- patient's foley was placed in ED; will leave in for now given
hypernatremia
# Macrocytosis: check folate and B12
# Abnormal CXR:
Noted to possibly have widened mediastinum and possible hiatal hernia
on recent CXR.
- recheck PA/lat CXR in AM
# HTN:
- hold lisinopril and lasix for now given ARF
- continue ASA
# Hyperlipidemia: continue statin
# FEN: NPO except meds for now until mental status better; IVF as
above
# PPx: subQ heparin [**Hospital1 **] given size and age; famotidine while NPO
# Access: PIV
# Code: DNR/DNI (paperwork in chart)
# Comm: Daughter [**First Name4 (NamePattern1) 919**] [**Known lastname **] (cell) [**Telephone/Fax (1) 10080**]; (home)
[**Telephone/Fax (1) 10081**]. Need to clarify goals of care with daughter.
# Dispo: eventually to floor vs NH depending on goals of care"
4648,"In the ED, initial VS were: 98.0 107/71 78 17 98%. She was
awake but not verbal and not following commands. She appeared
comfortable. Labs revealed a Na of 177 and Cr of 2.4. She was given
ceftriaxone for a positive UA. Renal was contact[**Name (NI) **] and suggested 1/2NS
at 100cc/hr. She was then sent to the ICU for further care.
Upon arrival to the ICU, she is sleeping comfortably but rousable.
Allergies:
Levaquin (Oral) (Levofloxacin)
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
(per NH sheet):
ASA 81mg daily
Lisinopril 20mg daily
Simvastatin 40mg daily
Furosemide 20mg daily
Darvocet 100/650mg TID
Prilosec 40mg daily
Calcium with vitamin D 600/200 daily
Colace 100mg daily
Senna
MVI
Metamucil
Flovent 110mcg 2 puffs
Duoneb 0."
4649,"TITLE:
Chief Complaint: ""not acting herself""
Reason for ICU admission: Hypernatremia to 182
HPI:
Ms. [**Known lastname **] is a [**Age over 90 **]yo woman with h/o dementia who was noted by NH to be
acting strangely. Although at baseline she has ""nonsensical speech,""
for the last few days, she was seen moaning and holding her head in her
hands. Her vital signs were noted to be normal. Labs revealed Na of
175. At her NH, she is listed as DNR/DNI/DNH, but a discussion was had
with the patient's daughter, and decision was made to send her to [**Hospital1 1**]
for treatment."
4650,"5
C (97.7
Tcurrent: 36.5
C (97.7
HR: 72 (72 - 76) bpm
BP: 120/41(60) {120/41(60) - 148/47(127)} mmHg
RR: 18 (17 - 22) insp/min
SpO2: 92%
Heart rhythm: SR (Sinus Rhythm)
Height: 60 Inch
Total In:
1,165 mL
PO:
TF:
IVF:
165 mL
Blood products:
Total out:
0 mL
100 mL
Urine:
100 mL
NG:
Stool:
Drains:
Balance:
0 mL
1,065 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 92%
Physical Examination
97.7 148/47 76 22 91% 2L
Light yellow urine in Foley.
Sleeping comfortably in bed, rouses minimally when she is being
examined and moans or shifts position."
4651,"Labs / Radiology
177 mEq/L
[image002.jpg]
CXR [**1-30**] (dictated):
Elevation of the left hemidiaphram vs hiatal hernia. Recommend lateral
view. No consolidation, pneumonia, or pulm edema. Possible widening
of mediastinum, which may be due to technique.
Assessment and Plan
A/P: [**Age over 90 **]yo woman with h/o dementia found to have hypernatremia and
acute renal failure in the setting of altered mental status.
# Hypernatremia:
Likely due to poor access to free water in this demented elderly
woman. Other possibilities include central or nephrogenic DI, though
these are considerably less likely. Her free water deficit is 7."
4652,"6-9.2L
(depending on whether her water is 50-60% of her body weight). This
should be given over a 3 day period to correct her at 0.5mEq/hour.
Thus, D5W at just over 100cc/hr should correct her at the appropriate
rate. Per renal recs, we will start with 1/2 NS and monitor serial
sodiums so as not to correct her too quickly
- 1/2 NS at 100cc/hr, adjust prn
- monitor Q4H serum sodium for now
- appreciate input from renal
- check Posm, Uosm, UNa
# Altered mental status:
Most probably from her hypernatremia and dehydration superimposed on
abnormal mental status at baseline."
4653,"Pupils are small b/l, right has some surgical changes. Sclera are
non-icteric.
Resists oral exam, but lips are moist.
Neck is supple. No thyroid enlargement or nodule.
S1, S2, RRR, +3/6 systolic murmur at apex, radiates to axilla.
Lungs are clear b/l with good air movement, although somewhat
diminished at bases. No wheeze or crackles.
Abd: +BS, soft, NT and not distended.
Skin: No bruising or rash noted.
Neuro: Minimally rousable. Moves all extremities during exam. Some
increased tone with cogwheeling in the LUE. Has pneumoboots in place.
Ext: Feet are warm, well-perfused. DPs palpable b/l."
4654,"Admission Date: [**2152-2-29**] Discharge Date: [**2152-3-5**]
Date of Birth: [**2093-9-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 2412**] is a 58 year old female with a medical history
significant for hypertension, diabetes, chronic back pain and
depression who presented to the ED today after a mechanical fall
at a train station. She hit her face after tripping while
carrying heavy bags. She did not lose consciousness. She scraped
her face, and otherwise felt fine per report."
4655,"Vitals on transfer BP: 170/99 HR 48 RR 11 Sat O2
99%3L.
In the ICU she received 2 liters of IV fluids and her sodium
improved to 129. She was also noted to have a bradycardia to the
40s. All of her sedating medications were held and her mental
status slowly improved.
Past Medical History:
- Depression
- Chronic Back Pain requiring 3 previous back surgeries
- Hypertension
- Type 2 Diabetes
Recent Hospitalizations at Other Hospitals:
1. [**Hospital 1474**] Hospital ([**0-0-**])
- Admitted for syncope. Underwent head CT, echocardiogram,
carotid doppler ultrasounds that were all unrevealing. Her
symptoms were then attributed to Fentanyl patches and other
sedating medications."
4656,"2. [**Hospital 1474**] Hospital ([**0-0-**])
- Admitted after being found down in her home with vomit in her
mouth. Reuired Bipap for respiratory support. She had a normal
EEG during this admission. Her presentation was attributed to
pneumonia and a COPD exacerbation.
3. [**Hospital3 10377**] Hospital ([**2152-5-17**])
- Admitted for delirium. She underwent MRI/MRA (revealed old
lacunar infarcts), head CT, chest CT, RPR, TSH, B12, [**Doctor First Name **], RF,
and infectious work-up that were all negative. She was thought
to have delirium from opioids and bezodiazepines.
4. [**Hospital3 10377**] Hospital ([**0-0-0**])
- Admitted for delirium. She underwent a head CT and was
ultimately diagnosed with a UTI."
4657,"5. [**Hospital 1474**] Hospital ([**145-7-18**])
- Admitted for somnolence. Found to have an elevated ammonia
and underwent multiple imaging studies and serology tests for
liver dysfunction. She improved with lactulose and was diagnosed
with new crytogenic liver dysfunction.
Social History:
- Tobacco: 1.5 packs per day
- Alcohol: Social (3 drinks, once a month)
- Illicits: None
Family History:
Not relevant to the current admission.
Physical Exam:
EXAM ON ADMISSION:
Vitals: T: 97 BP: 163/72 P: 49 R: 11 O2: 94%
General: Lethargic, somnolent, awakes to loud voice and sternal
rub,
HEENT: Sclera anicteric, dry MM, oropharynx clear, bruising on
her nose, bilateral eyes, and chin
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation with scant soft crackkles, no
wheezes, rales, ronchi
CV: Bradycardic and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: PERRL, Lethargic, oriented to place, + asterixis,
hyporeflexive"
4658,"Her bradycardia was from accidental ingestion of both
Toprol and metoprolol for hypertension and resolved with holding
Toprol. Her hyponatremia was thought to be from hypovolemic
hyponatremia and not thought to be causing her delirium. All of
her symptoms were attributed to drug-induced delirium. She
improved with holding Risperdal and methadone and decreasing her
gabapentin and clonazepam. At discharge she was ambulatory with
minimal back pain on reduced doses of gabapentin, ibuprofen, and
Tylenol.
Management of chronic medical problems outlined below:
1. Chronic low back pain
- discharged off methadone and on decreased doses of gabapentin
and clonazepam
- she will follow-up in her pain clinic for repeat epidural
steroid injections in a few weeks
- we arranged for visiting nurses to assist with medication
changes and to discard unprescribed medications"
4659,"7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for back pain.
10. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Drug-induced delirium from methadone, clonazepam, and gabapentin
Bradycardia from accidental combination of metoprolol and Toprol
Hyponatremia
Fall
Chronic low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive."
4660,"On arrival to the hospital, the patient was unable to provide a
detailed history due to confusion. However, her granddaughter
was with her at the station and reported the patient was quite
confused before and after the fall. In conversations with her
husband, he mentions that Ms. [**Known lastname 2412**] has bad back pain and has
had multiple recent injections and medication changes for this.
Notably, she was started on methadone approximately 3 weeks
prior to admission. Her gabapentin was also recently increased.
In reviewing her medications with her husband, it was also noted
that she had pill bottles of both metoprolol 6."
4661,"2. Hyponatremia
- thought to be from hypovolemic hyponatremia but still had a
low sodium at discharge
- this will be repeated on [**3-7**] and the results faxed to her
PCP
[**Name Initial (PRE) **] if hyponatremia persists she should have an evaluation for
SIADH and causes of SIADH given her smoking history
3. Nicotine abuse
- likely has undiagnosed COPD with an element of chronic
hypoxia (room air sats 95% while hospitalized)
- received smoking cessation counseling while here
4. Hypertension and Cerebrovascular disease
- blood pressure at goal <130/80 on lisinopril 40 and
metoprolol 6.25 twice daily. Toprol was discontinued given
bradycardia on arrival."
4662,"6 Free T4-0.86*
- [**2152-2-29**] 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABORATORY STUDIES:
[**2152-3-5**] 06:45AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-130*
K-3.7 Cl-94* HCO3-27 AnGap-13
[**2152-3-3**] 01:46PM BLOOD VitB12-[**2092**]*
[**2152-3-4**] 06:40AM BLOOD Ammonia-41
Imaging:
[**2152-2-29**] CT HEAD: There is no evidence of acute hemorrhage, large
acute territorial infarction, or large masses. There are focal
hypodensities, one near right caudate head nucleus (2:15) and
second within the anterior limb of the right internal capsule
(2:14) compatible with old ischemic events."
4663,"Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 2412**],
You were admitted with confusion and a fall. We think this was
all from your medications, especially your gabapentin
(Neurontin) and methadone. Please change your medications as
below:
- decrease clonazepam to 0.5mg at night
- stop risperidone
- decrease gabapentin to 400mg three times daily
- stop methadone
- stop Toprol XL
- restart metoprolol 6.25mg twice daily
The medications that we stopped/decreased are causing you to be
confused and fall. You can die from falls such as this and it is
important that you find other ways to treat your back pain.
You should also stop smoking. It is the most important thing you
can do for your health. Please follow-up with Dr. [**Last Name (STitle) **] to
review all of these medication changes. Your visiting nurses
will also check a sodium level on [**3-7**] and send the results to
Dr. [**Last Name (STitle) **].
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 1955**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Location (un) 58843**], [**Location (un) **],[**Numeric Identifier 90192**]
Phone: [**Telephone/Fax (1) 34002**]
Appointment: Monday [**2152-3-13**] 2:30pm"
4664,"Brief Hospital Course:
Ms. [**Known lastname 2412**] is a 58 F with chronic low back pain on multiple
different medications, notably methadone (recently started),
gabapentin (recently increased), and clonazepam. She was
admitted on [**2152-2-29**] with delirium, a mechanical fall with facial
injuries, bradycardia, and hyponatremia. Of note, this is her
6th hospitalization to various hospitals since [**3-/2151**] with
similar symptoms (see past medical history in this discharge
summary for details).
She was initially admitted to the ICU as she was somnolent and
bradycardic on arrival. She was not intubated and her mental
status slowly improved over the next 96 hours with supportive
care."
4665,"The visiting nurses will discard her
Toprol to prevent accidental co-administration of these 2
beta-blockers.
- of note, she had evidence of lacunar infarcts on her head CT
and her blood pressure should be carefully monitored. She should
continue her statin and start an aspirin as an outpatient if she
has no contraindications.
5. Type 2 diabetes
- restarted on Januvia at discharge
6. Depression and Other medication changes
- continued on fluoxetine
- she reported being on risperidone for hospital-associated
delirium during one of her 6 recent admissions. She has no other
indication for antipsychotic medications and this was
discontinued given her problems with medication side effects."
4666,"Again seen are lacunes in the right caudate head and anterior
limb of the right internal capsule. Ex-vacuo diliation of the
frontal [**Doctor Last Name 534**] of the right lateral ventricle is again noted. Mild
prominence of the sulci is consistent with age-related
involutional changes. The visualized portions of the paranasal
sinuses and mastoid air cells are well aerated. The imaged
osseous structures are unremarkable. IMPRESSION: 1. No evidence
of intracranial hemorrhage or acute large vascular territorial
infarction. If there is continued concerned for parenchymal
changes, MR could be performed if not contraindicated. 2.
Unchanged lacunes involving the right caudate head and anterior
limb of the right internal capsule."
4667,"Pertinent Results:
ADMISSION LABORATORY STUDIES:
[**2152-2-29**] 07:15PM BLOOD WBC-9.0 (Neuts-71.2* Lymphs-19.4
Monos-5.6 Eos-3.3 Baso-0.4) RBC-4.06* Hgb-12.1 Hct-36.4 MCV-90
MCH-29.9 MCHC-33.3 RDW-14.8 Plt Ct-203 Plt Ct-203
[**2152-2-29**] 07:15PM BLOOD Glucose-97 UreaN-8 Creat-0.6 Na-120*
K-3.9 Cl-85* HCO3-28 AnGap-11 ALT-19 AST-25 AlkPhos-52
TotBili-0.3 Calcium-8.4 Phos-4.0 Mg-1.6 Osmolal-246*
- [**2152-2-29**] 07:15PM BLOOD TSH-2."
4668,"25mg twice daily
and Toprol 50mg daily at home. She had no recent illness or
infections.
In the ED, she was at times somnolent, and confused, lighting a
cigarette while in the ED. Her initial vs were: T 97.4 HR 50 BP
119/84 RR 18 Sa O2 95%. Patient was given 500cc of saline and a
Tdap booster shot. She had a head CT that showed no acute
hemorrhage and focal hypodensities at the right basal ganglia,
likely old ischemic foci. They were going to send her home, but
she was a little bit lethargic and somnolent. Chem 7 showed
sodium of 120."
4669,"25mg twice daily
Januvia 50mg daily
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
2. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily)."
4670,"To Do:
- repeat electrolytes on [**3-7**] and possible evaluation for
hyponatremia
- continued smoking cessation counseling and consideration of
evaluation of COPD
- recheck blood pressure and titrate up to goal <130/80
- start aspirin
She has follow-up arranged with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on [**3-13**].
There were no tests pending at discharge.
Medications on Admission:
Clonazepam 1mg at bedtime
Metoprolol 6.25mg twice daily and Toprol 50mg daily (has both
pill bottles at home)
Ibuprofen three times daily
Methadone 5mg three times daily (started approximately 2 weeks
ago)
Lisinopril 40mg daily
Pantoprazole 40mg daily
Fluoxetine 80mg daily
Simvastatin 40mg daily
Gabapentin 800mg four times daily (recently increased)
Risperidone 0."
4671,"There is associated
ex vacuo dilatation of the right frontal [**Doctor Last Name 534**] of the lateral
ventricle. The remaining ventricles and sulci are normal in size
and configuration. There is no shift of midline structures.
Osseous structures appear normal. IMPRESSION: No acute
intracranial process.
[**2152-3-1**] PA AND LATERAL VIEWS OF THE CHEST: Cardiac size is top
normal. There are low lung volumes. There is crowding of the
vasculature but no area of focal pneumonia. There is no
pneumothorax or pleural effusion. Mild degenerative changes are
in the thoracic spine.
[**2152-3-2**] CT HEAD: There is no evidence of intracranial
hemorrhage, edema, shift of normally midline structures,
hydrocephalus, or acute large vascular territorial infarction."
4672,"diff colitis at that time and was
discharged to home with po vancomycin. Patient now s/p autologous stem
cell transplant [**12/2175**], currently day 41 post transplant.
.
.
Other Past Medical History:
1. Diabetes mellitus, type II (diagnosed 10-11 years ago), treated with
oral meds until chemotherapy, now on ISS.
2. High-grade prostatic intraepithelial neoplasia (prostate biopsy
[**2175-8-26**], no treatment [**2-6**] ""no cancer"")
3. Diffuse large B-cell lymphoma ([**1-/2175**]), s/p CHOP x 8 cycles and
R-ICE two cycles
4. Renal cell carcinoma, s/p L nephrectomy ([**1-/2175**])
5. Eczema (severe) - no recent exacerbations
."
4673,"4. Enhancing nodule within the left nephrectomy surgical bed concerning
for recurrence.
5. Multiple pathologically enlarged lymph nodes within the
retroperitoneum, unchanged.
6. Focal areas of wall thickening involving the cecum and sigmoid
colon. Dedicated visualization with colonoscopy is recommended given
history of lymphoma.
7. Persistant splenic vein thrombosis.
Assessment and Plan
Mr. [**Known lastname **] is a 60 yo male with relapsed DLBCL d+16 of nitrogen mustard
therapy with persistent neutropenic and asplenic fevers and progressive
respiratory failure.
.
1. Respiratory failure. Unclear etiology of rapidly worsening hypoxic
respiratory failure. Patient on broad spectrum antibiotics recently
broadened yesterday from vanco/zosyn/vori to dapto/zosyn/leavquin/vori
yesterday."
4674,"Given ongoing fevers and JP drain positive
for enterococcus, concerning for abscess versus colonization. Switched
from vanco to dapto yesterday.
- continue dapto
- surgery following
.
7. Gylcemic control.
- regular ISS given steroid use
.
FEN: IVF boluses as needed, replete electrolytes, tube feeds
.
Prophylaxis: pneumoboots given thrombocytopenia
.
Access: peripherals, picc
.
Code: Full, confirmed with patient, wife
.
Communication: Patient, wife
.
Disposition: pending clinical improvement of respiratory failure and
hypotension requiring pressors
..
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2176-3-23**] 02:28 PM
20 Gauge - [**2176-3-23**] 08:44 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Need for restraints reviewed
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU"
4675,"Responded to IVFs and
intubation.
- monitor on tele
- tylenol for fevers
- ivfs as needed, though currently euvolemic
.
4. DLBCL. Patient with refractory DLBCL. Now day +16 of nitrogen and
counts are slowly recovering.
- transfuse to Hct of 25, Plts > 30
- continue neupogen
- BMT following
- daily CBC with diff/ anc
.
5. Fevers. Ongoing neutropenic and asplenic fevers. Only localizing
symptoms is respiratory distress. Additionally, enterococcus growing
from JP drain at splenectomy site (though not clear if this is
colonization of the drain).
- empiric broad spectrum antibiotics given immunocompromized state
- ID following
- f/u cultures
- thoracics consult for possible vats
.
6. Abdominal collections."
4676,"Micro:
Urine legionella
Blood cultures x 2 - [**3-22**] - NGTD
RSV - negative
JP drain with enteroccus
CMV viral load - undetectable
BAL - [**3-21**] - negative for legionella, grain stain negative, culture
positive for commensal respiratory flora, PCP negative, fungal culture
negative, AFB negative
Stool culture [**3-19**] - C. diff negative.
.
Images:
CXR - [**2176-3-23**].
FINDINGS: As compared to the previous radiograph, an endotracheal tube
has been inserted. The tip of the tube projects 3 cm above the carina.
New placement of a nasogastric tube, correct position in the proximal
part of the stomach. No evidence of complications, notably no
pneumothorax."
4677,"0 g/dL
121 mg/dL
1.1 mg/dL
12 mg/dL
10 mEq/L
104 mEq/L
5.1 mEq/L
133 mEq/L
24.8 %
0.7 K/uL
[image002.jpg]
[**2172-1-6**]
2:33 A3/20/[**2176**] 06:43 PM
[**2172-1-10**]
10:20 P3/20/[**2176**] 07:05 PM
[**2172-1-11**]
1:20 P3/20/[**2176**] 10:33 PM
[**2172-1-12**]
11:50 P
[**2172-1-13**]
1:20 A
[**2172-1-14**]
7:20 P
1//11/006
1:23 P
[**2172-2-6**]
1:20 P
[**2172-2-6**]
11:20 P
[**2172-2-6**]
4:20 P
WBC
0."
4678,"21/29/195/10/-15
Ve: 14.2 L/min
PaO2 / FiO2: 488
Physical Examination
Vitals: T: 102.9 BP: 105/63 P: 140 sinus R: 35 O2: 97% on NRB
General: Alert, oriented, in respiratory distress, using accesssory
muscles, requires breaths every [**3-7**] words
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: crackles [**2-7**] the way up lungs bilaterally without wheezes
CV: tachycardic, regular, 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
Labs / Radiology
39 K/uL
8."
4679,"At the time of this diagnosis, he was also diagnosed with
a renal cell carcinoma for which he underwent unilateral left complete
nephrectomy and this was thought to be curative therapy. In late [**Month (only) **]
[**2175**], he again felt febrile and repeat CT of the abdomen revealed new
or increased adenopathy in the left internal and external iliac groups,
the largest area being 24 mm. He also had some liver lesions, which
were suspicious for metastatic disease (lymphoma versus renal cell
carcinoma) and splenomegaly. He was transferred to [**Hospital1 19**] where he
underwent a CT of the torso showing multiple abnormally enlarged lymph
nodes in the retroperitoneum,extending to the left common and external
iliac chains to the left inguinal ring, highly concerning for recurrent
lymphoma."
4680,"His therapy was complicated by encephalopathy. He developed asterixis,
negative myoclonus, inattentiveness and somnolence after the second
dose of ifosfamide and third dose was delayed by one day. His third
dose resulted in similar signs. This was cleared within 24 hours, the
somnolence improved dramatically
within 24 hours as well. He was discharged after this cycle on
[**2175-8-26**]. He was readmitted with febrile neutropenia secondary to C.
difficile colitis on [**2175-9-4**], treated with oral vancomycin and flagyl,
and discharged on [**2175-9-11**]. He was readmitted on [**2175-9-25**] for his second
cycle of R+ICE, but found to have c."
4681,"4
C (102.9
Tcurrent: 34
C (93.2
HR: 76 (76 - 146) bpm
BP: 93/58(73) {93/44(2) - 115/74(90)} mmHg
RR: 11 (11 - 35) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 69 Inch
Total In:
4,439 mL
PO:
TF:
IVF:
3,757 mL
Blood products:
472 mL
Total out:
0 mL
670 mL
Urine:
670 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,769 mL
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 550 (550 - 550) mL
RR (Set): 14
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
PIP: 19 cmH2O
Plateau: 18 cmH2O
SpO2: 99%
ABG: 7."
4682,"Chief Complaint:
Chief Complaint: hypoxic respiratory failure
Reason for MICU transfer: hypoxemic respiratory failure requiring
intubation
HPI:
Mr. [**Known lastname **] is a 54 yo male male with DLBC lymphoma undergoing nitrogen
mustard d+16 therapy with persistent neutropenic fevers, who has
developed worsening respiratory status over the past few days. He has
been evaluated by pulmonary including a bronch on [**3-21**] which was thus
far been negative. He was requriing 2LNC until yesterday and had
worsening of his respiratory status over the last 24 hours and
increasing oxygen requirements. He trigged today at 1PM for hypoxia
with O2Sat of 95% on NRB and worsening tachycardia (sinus) to 140s."
4683,"There are multiple ill-defined liver lesions, very
symptomatic metastatic disease and small volume ascites. There is a
thin band of enhancing soft tissue in the
left nephrectomy bed, worrisome for locally recurrent renal cell
carcinoma and a cluster of central lobular nodules in the left upper
lobe measuring up to 7 mm in size. There was also a 4-mm right lower
lobe pulmonary nodule seen. Biopsy of a left iliac lymph node showed
involvement by diffuse large B-cell lymphoma. The MIB fraction was
approximately 90%. CD20 was not immunoreactive and this was thought to
be due to previous therapy with rituximab and therefore he was started
on ICE without Rituxan due to the lack of CD20 positivity in the cells."
4684,"7
Hct
24.8
Plt
39
Cr
1.1
TC02
13
12
Glucose
121
Other labs: PT / PTT / INR:15.5/38.4/1.4, Differential-Neuts:44.0 %,
Band:0.0 %, Lymph:36.0 %, Mono:20.0 %, Eos:0.0 %, Lactic Acid:3.3
mmol/L, Ca++:7.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.4 mg/dL
Labs:
ABG on NRB: 7.39 \ 26 \ 101 \ 16
Lactate 4.3
.
.. \ 7.8 /
0.5 ----- 62
.. / 23.9 \
.
132 | 102 | 11 /
--------------- 86
4.2 | 20 | 1.0 \
.
Ca 7.3
Mg 1.8
Phos 2.0
.
ALT 18
AST 61
AP 792
LDH 212
."
4685,"5 g IV Q8H
Allopurinol 200 mg PO/NG DAILY
Magnesium Sulfate Replacement (Oncology) IV Sliding Scale
Pantoprazole 40 mg PO Q12H
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q4H:PRN pain
Docusate Sodium 100 mg PO BID
Ondansetron 4 mg IV Q8H:PRN nausea
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN congestion
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Past medical history:
Family history:
Social History:
Past Oncologic History:
ONCOLOGIC HISTORY (per primary oncologist's note, Dr. [**Last Name (STitle) **] [**Name (STitle) 363**]):
[**Known firstname **] [**Known lastname **] is a 59-year-old man who was diagnosed with a diffuse
large B-cell lymphoma in [**2175-1-5**] and received 8 cycles of CHOP
plus Rituxan."
4686,"DDx is infectious (viral, less likely bacterial or PCP in
setting of negative cultures), DAH, ARDS lymphoma.
- continue dapto/zosyn/levaquin/vori
- start bactrim for empiric PCP therapy
[**Name Initial (PRE) **] [**Name Initial (PRE) **]/u BAL results from yesterday
- thoracics consult for VATs
- repeat bronch now that he is intubated
- empiric steroids
.
2. Hypotension. Patient developed hypotension following intubation.
Had low urine output initially which improved with fluid boluses.
- neo to keeps MAPS > 65 due to marked tachcyardia
- follow UOP
- fluid boluses as need to keep MAPs> 65 and to wean pressors
.
3. Tachycardia. Patient with sinus tachycardia to 140s in setting of
respiratory distress, fevers, and hypovolemia."
4687,"Past surgical hisory:
1. Pyloric stenosis correction as neonate [**2116**]
2. Vasectomy - complicated by infection, treated with
antibiotics [**2148**]
3. Left nephrectomy for renal cell carcinoma [**2175**]
Family History:
Mother with ?Leukemia. Father with lung cancer, deceased.
.
Social History:
Patient denies tobacco, alcohol, or drug use. He is married with 3
children. Lives with wife, two daughters and grandson. [**Name (NI) **] worked
as a computer technician, has not worked in one year.
Occupation:
Drugs:
Tobacco:
Alcohol:
Other:
Review of systems:
Flowsheet Data as of [**2176-3-23**] 11:48 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**78**] AM
Tmax: 39."
4688,"The lung volumes have slightly increased, presumably
because of initiated ventilation. The extent of the bilateral
parenchymal opacities is unchanged.
.
CT abdomen/pelvis. [**2176-3-22**].
IMPRESSION:
1. Marked interval progression of bilateral ground-glass opacity and
tree-in-[**Male First Name (un) **] opacities in the lung bases with small bilateral pleural
effusions concerning for worsening infectious disease process.
2. Interval decrease in fluid collection within the left upper quadrant
with drain in appropriate position. Other areas of small amount of
fluid within the perihepatic space along the right paracolic gutter are
now identified.
3. Mild gallbladder distention, unchanged. Periportal edema, similar in
appearance."
4689,"He
reports difficulty breathing, but denies cough.
.
Of note, patient's hospitalization has been complicated by
thrombocytopenia requiring splenectomy in [**Month (only) **]. He has had daily
neutropenic & asplenic fevers for the past week to 104. His has had
stable tachycardia in the 120s. Patient was treated with nitrogen
mustard 16 days ago and his counts are beginning to recover.
Allergies:
Ifosfamide
Mental status c
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2176-3-23**] 07:00 PM
Levofloxacin - [**2176-3-23**] 09:14 PM
Infusions:
Fentanyl (Concentrate) - 150 mcg/hour
Midazolam (Versed) - 3 mg/hour
Phenylephrine - 1.5 mcg/Kg/min
Other ICU medications:
Pantoprazole (Protonix) - [**2176-3-23**] 09:14 PM
Other medications:
Home Medications:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth every 12 hrs
Levamir 24u SQ qPM
Novolog Sliding Scale
."
4690,"Transfer Meds:
Sulfameth/Trimethoprim DS 1 TAB PO/NG Q6H d1 = [**3-23**]
Midazolam 0.5-2 mg/hr
Fentanyl Citrate 25-100 mcg/hr IV DRIP
Immune Globulin Intravenous (Human) 25 g IV d1 = [**3-23**]
MethylPREDNISolone Sodium Succ 60 mg IV Q8H d1 = [**3-23**]
DiphenhydrAMINE 25 mg PO/IV PRN Prior to blood products
Potassium Phosphate Replacement (Oncology) IV Sliding Scale
Levofloxacin 750 mg PO/NG Q24H day 1 = [**3-22**]
Daptomycin 400 mg IV Q24H Day 1 = [**3-22**]
Acetaminophen 650 mg PO/NG Q6H:PRN fever
Voriconazole 200 mg PO Q12H
Loperamide 2 mg PO/NG QID:PRN diarrhea
Filgrastim 300 mcg SC Q24H
Caphosol 30 mL ORAL QID:PRN mouth care
Clotrimazole 1 TROC PO QID:PRN thrush
Piperacillin-Tazobactam 4."
4691,"LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)-Will need future
treatment planning in light of current clinical worsening.
Methylpred
GCSF
SEPSIS WITHOUT ORGAN DYSFUNCTION-This is in neutropenic patient with
asplenic status and with significant and persistent insult seen with
VRE only positive cultures seen. Unfortunately the source here remains
to be clearly defined with possible VRE and with possible pulmonary
source being considered.
-Daptomycin/Zosyn/Levoflox to continue
-Levophed weaned to off and will continue to favor pressors over fluids
ACUTE RESPIRATORY FAILURE-He has PIP=21, Pplat=16 and PEEP=5 all with
good oxygenation and this is much less consistent with ARDS given P/F
ratio being favorable and this morning would make diagnosis consistent
with [**Doctor Last Name 11**]."
4692,"8 cmH2O/mL
SpO2: 94%
ABG: 7.37/39/109/22/-2
Ve: 10.2 L/min
PaO2 / FiO2: 273
Physical Examination
Head, Ears, Nose, Throat: Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),
(Breath Sounds: Diminished: )
Abdominal: Soft, Non-tender, Bowel sounds present
Skin: Not assessed
Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
8.4 g/dL
48 K/uL
104 mg/dL
1.1 mg/dL
22 mEq/L
3."
4693,"2
1.1
1.1
1.1
TCO2
17
23
26
21
23
Glucose
[**Telephone/Fax (3) 14093**]04
Other labs: PT / PTT / INR:18.0/33.2/1.6, ALT / AST:25/87, Alk Phos / T
Bili:575/0.6, Differential-Neuts:69.0 %, Band:0.0 %, Lymph:23.0 %,
Mono:8.0 %, Eos:0.0 %, Lactic Acid:2.2 mmol/L, Albumin:2.2 g/dL,
LDH:446 IU/L, Ca++:7.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.0 mg/dL
Fluid analysis / Other labs: AG-11
Imaging: CXR-ETT and OGT in good position, increase in pulmonary edema
R>L seen over past 48 hours
Microbiology: Blood Culture--no growth to date
Sputum--not seen
JP drain--VRE seen on swab
Assessment and Plan
68 yo male with relapse diffuse large b-cell lymphoma who is s/p
splenectomy and now admitted with sepsis and respiratory failure in the
setting of fever and neutropenia."
4694,"5
C (97.7
Tcurrent: 36.5
C (97.7
HR: 65 (47 - 81) bpm
BP: 87/53(65) {72/43(52) - 117/73(87)} mmHg
RR: 20 (14 - 20) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 78.8 kg (admission): 73.3 kg
Height: 69 Inch
CO/CI (Fick): (69.8 L/min) / (37 L/min/m2)
Mixed Venous O2% Sat: 93 - 93
Total In:
6,985 mL
1,252 mL
PO:
TF:
IVF:
5,366 mL
1,222 mL
Blood products:
1,279 mL
Total out:
2,700 mL
430 mL
Urine:
2,700 mL
430 mL
NG:
Stool:
Drains:
Balance:
4,285 mL
822 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 550 (550 - 550) mL
RR (Set): 20
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI Deferred: Hemodynamic Instability
PIP: 24 cmH2O
Plateau: 17 cmH2O
Compliance: 45."
4695,"1 mEq/L
21 mg/dL
112 mEq/L
145 mEq/L
24.9 %
0.3 K/uL
[image002.jpg]
[**2176-3-24**] 03:53 AM
[**2176-3-24**] 04:22 AM
[**2176-3-24**] 08:15 AM
[**2176-3-24**] 09:18 AM
[**2176-3-24**] 12:07 PM
[**2176-3-24**] 12:25 PM
[**2176-3-24**] 03:23 PM
[**2176-3-24**] 07:55 PM
[**2176-3-24**] 11:04 PM
[**2176-3-25**] 03:35 AM
WBC
0.3
0.1
0.2
0.3
Hct
24.7
25.6
26.2
24.9
Plt
26
59
30
13
48
Cr
1."
4696,"This may be related to overall sepsis picture but patient
also with some hydrostatic edema noted. We do have concern for
possible infectious source in the lungs but with bronchoscopy negative
to date.
-Will move to PSV today
-Will continue to support with antibiotics and look to return to
capacity for spontenous breathing trial and move to extubation with
volume status optimized
-We see little evidence of acute active bacterial pneumonia at this
time.
-So
move to PSV this morning, look to keep I/O even and wean off
pressors and minimize sedation.
-Follow up BAL cultures
ICU Care
Nutrition: PO intake
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2176-3-23**] 02:28 PM
Arterial Line - [**2176-3-23**] 06:24 PM
20 Gauge - [**2176-3-23**] 08:44 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 45"
4697,"Chief Complaint: Respiratory Failure
Sepsis
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
-Patient started on Daptomycin for VRE seen from tube site
-Patient remains with levophed requirement through to this morning.
History obtained from Medical records
Allergies:
Ifosfamide
Mental status c
Last dose of Antibiotics:
Daptomycin - [**2176-3-24**] 12:04 PM
Bactrim (SMX/TMP) - [**2176-3-24**] 04:28 PM
Voriconazole - [**2176-3-24**] 07:45 PM
Levofloxacin - [**2176-3-24**] 08:26 PM
Piperacillin/Tazobactam (Zosyn) - [**2176-3-25**] 02:35 AM
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2176-3-24**] 07:45 PM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: No(t) Fever
Flowsheet Data as of [**2176-3-25**] 09:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**78**] AM
Tmax: 36."
4698,"DDx is infectious (viral, less likely bacterial or PCP in
setting of negative cultures), DAH, ARDS lymphoma.
- continue dapto/zosyn/levaquin/vori
- start bactrim for empiric PCP therapy
[**Name Initial (PRE) **] [**Name Initial (PRE) **]/u BAL results from yesterday
- thoracics consult for VATs
- repeat bronch now that he is intubated
- empiric steroids
.
2. Hypotension. Patient developed hypotension following intubation.
Had low urine output initially which improved with fluid boluses.
- neo to keeps MAPS > 65 due to marked tachcyardia
- follow UOP
- fluid boluses as need to keep MAPs> 65 and to wean pressors
.
3. Tachycardia. Patient with sinus tachycardia to 140s in setting of
respiratory distress, fevers, and hypovolemia."
4699,"Responded to IVFs and
intubation.
- monitor on tele
- tylenol for fevers
- ivfs as needed, though currently euvolemic
.
4. DLBCL. Patient with refractory DLBCL. Now day +16 of nitrogen and
counts are slowly recovering.
- transfuse to Hct of 25, Plts > 30
- continue neupogen
- BMT following
- daily CBC with diff/ anc
.
5. Fevers. Ongoing neutropenic and asplenic fevers. Only localizing
symptoms is respiratory distress. Additionally, enterococcus growing
from JP drain at splenectomy site (though not clear if this is
colonization of the drain).
- empiric broad spectrum antibiotics given immunocompromized state
- ID following
- f/u cultures
- thoracics consult for possible vats
.
6. Abdominal collections."
4700,"There are multiple ill-defined liver lesions, very
symptomatic metastatic disease and small volume ascites. There is a
thin band of enhancing soft tissue in the
left nephrectomy bed, worrisome for locally recurrent renal cell
carcinoma and a cluster of central lobular nodules in the left upper
lobe measuring up to 7 mm in size. There was also a 4-mm right lower
lobe pulmonary nodule seen. Biopsy of a left iliac lymph node showed
involvement by diffuse large B-cell lymphoma. The MIB fraction was
approximately 90%. CD20 was not immunoreactive and this was thought to
be due to previous therapy with rituximab and therefore he was started
on ICE without Rituxan due to the lack of CD20 positivity in the cells."
4701,"diff colitis at that time and was
discharged to home with po vancomycin. Patient now s/p autologous stem
cell transplant [**12/2175**], currently day 41 post transplant.
.
.
Other Past Medical History:
1. Diabetes mellitus, type II (diagnosed 10-11 years ago), treated with
oral meds until chemotherapy, now on ISS.
2. High-grade prostatic intraepithelial neoplasia (prostate biopsy
[**2175-8-26**], no treatment [**2-6**] ""no cancer"")
3. Diffuse large B-cell lymphoma ([**1-/2175**]), s/p CHOP x 8 cycles and
R-ICE two cycles
4. Renal cell carcinoma, s/p L nephrectomy ([**1-/2175**])
5. Eczema (severe) - no recent exacerbations
."
4702,"4
C (102.9
Tcurrent: 34
C (93.2
HR: 76 (76 - 146) bpm
BP: 93/58(73) {93/44(2) - 115/74(90)} mmHg
RR: 11 (11 - 35) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 69 Inch
Total In:
4,439 mL
PO:
TF:
IVF:
3,757 mL
Blood products:
472 mL
Total out:
0 mL
670 mL
Urine:
670 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,769 mL
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 550 (550 - 550) mL
RR (Set): 14
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
PIP: 19 cmH2O
Plateau: 18 cmH2O
SpO2: 99%
ABG: 7."
4703,"He
reports difficulty breathing, but denies cough.
.
Of note, patient's hospitalization has been complicated by
thrombocytopenia requiring splenectomy in [**Month (only) **]. He has had daily
neutropenic & asplenic fevers for the past week to 104. His has had
stable tachycardia in the 120s. Patient was treated with nitrogen
mustard 16 days ago and his counts are beginning to recover.
Allergies:
Ifosfamide
Mental status c
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2176-3-23**] 07:00 PM
Levofloxacin - [**2176-3-23**] 09:14 PM
Infusions:
Fentanyl (Concentrate) - 150 mcg/hour
Midazolam (Versed) - 3 mg/hour
Phenylephrine - 1.5 mcg/Kg/min
Other ICU medications:
Pantoprazole (Protonix) - [**2176-3-23**] 09:14 PM
Other medications:
Home Medications:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth every 12 hrs
Levamir 24u SQ qPM
Novolog Sliding Scale
."
4704,"Given ongoing fevers and JP drain positive
for enterococcus, concerning for abscess versus colonization. Switched
from vanco to dapto yesterday.
- continue dapto
- surgery following
.
7. Gylcemic control.
- regular ISS given steroid use
.
FEN: IVF boluses as needed, replete electrolytes, tube feeds
.
Prophylaxis: pneumoboots given thrombocytopenia
.
Access: peripherals, picc
.
Code: Full, confirmed with patient, wife
.
Communication: Patient, wife
.
Disposition: pending clinical improvement of respiratory failure and
hypotension requiring pressors
..
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2176-3-23**] 02:28 PM
20 Gauge - [**2176-3-23**] 08:44 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Need for restraints reviewed
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU"
4705,"Past surgical hisory:
1. Pyloric stenosis correction as neonate [**2116**]
2. Vasectomy - complicated by infection, treated with
antibiotics [**2148**]
3. Left nephrectomy for renal cell carcinoma [**2175**]
Family History:
Mother with ?Leukemia. Father with lung cancer, deceased.
.
Social History:
Patient denies tobacco, alcohol, or drug use. He is married with 3
children. Lives with wife, two daughters and grandson. [**Name (NI) **] worked
as a computer technician, has not worked in one year.
Occupation:
Drugs:
Tobacco:
Alcohol:
Other:
Review of systems:
Flowsheet Data as of [**2176-3-23**] 11:48 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**78**] AM
Tmax: 39."
4706,"5 g IV Q8H
Allopurinol 200 mg PO/NG DAILY
Magnesium Sulfate Replacement (Oncology) IV Sliding Scale
Pantoprazole 40 mg PO Q12H
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q4H:PRN pain
Docusate Sodium 100 mg PO BID
Ondansetron 4 mg IV Q8H:PRN nausea
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN congestion
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Past medical history:
Family history:
Social History:
Past Oncologic History:
ONCOLOGIC HISTORY (per primary oncologist's note, Dr. [**Last Name (STitle) **] [**Name (STitle) 363**]):
[**Known firstname **] [**Known lastname **] is a 59-year-old man who was diagnosed with a diffuse
large B-cell lymphoma in [**2175-1-5**] and received 8 cycles of CHOP
plus Rituxan."
4707,"4. Enhancing nodule within the left nephrectomy surgical bed concerning
for recurrence.
5. Multiple pathologically enlarged lymph nodes within the
retroperitoneum, unchanged.
6. Focal areas of wall thickening involving the cecum and sigmoid
colon. Dedicated visualization with colonoscopy is recommended given
history of lymphoma.
7. Persistant splenic vein thrombosis.
Assessment and Plan
Mr. [**Known lastname **] is a 60 yo male with relapsed DLBCL d+16 of nitrogen mustard
therapy with persistent neutropenic and asplenic fevers and progressive
respiratory failure.
.
1. Respiratory failure. Unclear etiology of rapidly worsening hypoxic
respiratory failure. Patient on broad spectrum antibiotics recently
broadened yesterday from vanco/zosyn/vori to dapto/zosyn/leavquin/vori
yesterday."
4708,"At the time of this diagnosis, he was also diagnosed with
a renal cell carcinoma for which he underwent unilateral left complete
nephrectomy and this was thought to be curative therapy. In late [**Month (only) **]
[**2175**], he again felt febrile and repeat CT of the abdomen revealed new
or increased adenopathy in the left internal and external iliac groups,
the largest area being 24 mm. He also had some liver lesions, which
were suspicious for metastatic disease (lymphoma versus renal cell
carcinoma) and splenomegaly. He was transferred to [**Hospital1 19**] where he
underwent a CT of the torso showing multiple abnormally enlarged lymph
nodes in the retroperitoneum,extending to the left common and external
iliac chains to the left inguinal ring, highly concerning for recurrent
lymphoma."
4709,"His therapy was complicated by encephalopathy. He developed asterixis,
negative myoclonus, inattentiveness and somnolence after the second
dose of ifosfamide and third dose was delayed by one day. His third
dose resulted in similar signs. This was cleared within 24 hours, the
somnolence improved dramatically
within 24 hours as well. He was discharged after this cycle on
[**2175-8-26**]. He was readmitted with febrile neutropenia secondary to C.
difficile colitis on [**2175-9-4**], treated with oral vancomycin and flagyl,
and discharged on [**2175-9-11**]. He was readmitted on [**2175-9-25**] for his second
cycle of R+ICE, but found to have c."
4710,"7
Hct
24.8
Plt
39
Cr
1.1
TC02
13
12
Glucose
121
Other labs: PT / PTT / INR:15.5/38.4/1.4, Differential-Neuts:44.0 %,
Band:0.0 %, Lymph:36.0 %, Mono:20.0 %, Eos:0.0 %, Lactic Acid:3.3
mmol/L, Ca++:7.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.4 mg/dL
Labs:
ABG on NRB: 7.39 \ 26 \ 101 \ 16
Lactate 4.3
.
.. \ 7.8 /
0.5 ----- 62
.. / 23.9 \
.
132 | 102 | 11 /
--------------- 86
4.2 | 20 | 1.0 \
.
Ca 7.3
Mg 1.8
Phos 2.0
.
ALT 18
AST 61
AP 792
LDH 212
."
4711,"0 g/dL
121 mg/dL
1.1 mg/dL
12 mg/dL
10 mEq/L
104 mEq/L
5.1 mEq/L
133 mEq/L
24.8 %
0.7 K/uL
[image002.jpg]
[**2172-1-6**]
2:33 A3/20/[**2176**] 06:43 PM
[**2172-1-10**]
10:20 P3/20/[**2176**] 07:05 PM
[**2172-1-11**]
1:20 P3/20/[**2176**] 10:33 PM
[**2172-1-12**]
11:50 P
[**2172-1-13**]
1:20 A
[**2172-1-14**]
7:20 P
1//11/006
1:23 P
[**2172-2-6**]
1:20 P
[**2172-2-6**]
11:20 P
[**2172-2-6**]
4:20 P
WBC
0."
4712,"Transfer Meds:
Sulfameth/Trimethoprim DS 1 TAB PO/NG Q6H d1 = [**3-23**]
Midazolam 0.5-2 mg/hr
Fentanyl Citrate 25-100 mcg/hr IV DRIP
Immune Globulin Intravenous (Human) 25 g IV d1 = [**3-23**]
MethylPREDNISolone Sodium Succ 60 mg IV Q8H d1 = [**3-23**]
DiphenhydrAMINE 25 mg PO/IV PRN Prior to blood products
Potassium Phosphate Replacement (Oncology) IV Sliding Scale
Levofloxacin 750 mg PO/NG Q24H day 1 = [**3-22**]
Daptomycin 400 mg IV Q24H Day 1 = [**3-22**]
Acetaminophen 650 mg PO/NG Q6H:PRN fever
Voriconazole 200 mg PO Q12H
Loperamide 2 mg PO/NG QID:PRN diarrhea
Filgrastim 300 mcg SC Q24H
Caphosol 30 mL ORAL QID:PRN mouth care
Clotrimazole 1 TROC PO QID:PRN thrush
Piperacillin-Tazobactam 4."
4713,"Micro:
Urine legionella
Blood cultures x 2 - [**3-22**] - NGTD
RSV - negative
JP drain with enteroccus
CMV viral load - undetectable
BAL - [**3-21**] - negative for legionella, grain stain negative, culture
positive for commensal respiratory flora, PCP negative, fungal culture
negative, AFB negative
Stool culture [**3-19**] - C. diff negative.
.
Images:
CXR - [**2176-3-23**].
FINDINGS: As compared to the previous radiograph, an endotracheal tube
has been inserted. The tip of the tube projects 3 cm above the carina.
New placement of a nasogastric tube, correct position in the proximal
part of the stomach. No evidence of complications, notably no
pneumothorax."
4714,"21/29/195/10/-15
Ve: 14.2 L/min
PaO2 / FiO2: 488
Physical Examination
Vitals: T: 102.9 BP: 105/63 P: 140 sinus R: 35 O2: 97% on NRB
General: Alert, oriented, in respiratory distress, using accesssory
muscles, requires breaths every [**3-7**] words
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: crackles [**2-7**] the way up lungs bilaterally without wheezes
CV: tachycardic, regular, 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
Labs / Radiology
39 K/uL
8."
4715,"Chief Complaint:
Chief Complaint: hypoxic respiratory failure
Reason for MICU transfer: hypoxemic respiratory failure requiring
intubation
HPI:
Mr. [**Known lastname **] is a 54 yo male male with DLBC lymphoma undergoing nitrogen
mustard d+16 therapy with persistent neutropenic fevers, who has
developed worsening respiratory status over the past few days. He has
been evaluated by pulmonary including a bronch on [**3-21**] which was thus
far been negative. He was requriing 2LNC until yesterday and had
worsening of his respiratory status over the last 24 hours and
increasing oxygen requirements. He trigged today at 1PM for hypoxia
with O2Sat of 95% on NRB and worsening tachycardia (sinus) to 140s."
4716,"The lung volumes have slightly increased, presumably
because of initiated ventilation. The extent of the bilateral
parenchymal opacities is unchanged.
.
CT abdomen/pelvis. [**2176-3-22**].
IMPRESSION:
1. Marked interval progression of bilateral ground-glass opacity and
tree-in-[**Male First Name (un) **] opacities in the lung bases with small bilateral pleural
effusions concerning for worsening infectious disease process.
2. Interval decrease in fluid collection within the left upper quadrant
with drain in appropriate position. Other areas of small amount of
fluid within the perihepatic space along the right paracolic gutter are
now identified.
3. Mild gallbladder distention, unchanged. Periportal edema, similar in
appearance."
4717,"SEPSIS WITHOUT ORGAN DYSFUNCTION: Neutropenic and asplenic host on
broad spectrum antibiotics, ID following. Continues on levophed.
ACUTE ON CHRONIC RESPIRATORY FAILURE: Continues broad spectrum
antibiotics including bactrim for PCP, [**Name10 (NameIs) **] BAL negative for PCP, [**Name10 (NameIs) **]
other culture data on the BAL. Given reticulonodular appearance on
imaging of lungs agree that lung biopsy may be informative albeit high
risk in this patient. Will need to address with oncology team as far
as pros/cons given overall prognosis given his underlying
malignancy. RR increased on the ventilator given persistent
metabolic acidosis, bicarb drip off and will repeat ABG to reassess."
4718,"HYPERGLYCEMIA: Increased blood sugars on steroids. RISS. [**Month (only) 51**] need
insulin drip if unable to adequately control.
METABOLIC ACIDOSIS: Secondary to lactic acidosis in setting of
sepsis, improving with volume; GI losses, and with elevated sugars on
steroids will check for ketones albeit less likely.
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2176-3-23**] 02:28 PM
20 Gauge - [**2176-3-24**] 12:15 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Need for restraints reviewed
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 50 minutes
Patient is critically ill"
4719,"3
Hct
24.8
24.7
Plt
39
51
26
59
Cr
1.1
1.2
TCO2
13
12
12
13
15
17
Glucose
121
252
Other labs: PT / PTT / INR:16.7/45.8/1.5, ALT / AST:25/87, Alk Phos / T
Bili:575/0.6, Differential-Neuts:44.0 %, Band:0.0 %, Lymph:36.0 %,
Mono:20.0 %, Eos:0.0 %, Lactic Acid:4.4 mmol/L, Albumin:2.2 g/dL,
LDH:446 IU/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL, PO4:4.4 mg/dL
Imaging: CXR: ETT in good position, diffuse alveolar infiltrates,
reticulonodular appearance
Microbiology: Blood cultures NGTD
Legionella ag negative
BAL negative for PCP
Assessment and [**Name9 (PRE) 171**]
LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID): Transfuse to keep
hct >25, transfuse plts to keep counts >30."
4720,"Chief Complaint: Acute on chronic respiratory failure
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
60 yo man with DLBC lymphoma s/p auto SCT and recently nitrogen mustard
therapy who presents to ICU with worsening pulmonary infiltrates,
hypoxemia, and respiratory distress.
24 Hour Events:
PICC LINE - START [**2176-3-23**] 02:28 PM
placed [**2176-3-20**] 0927
INVASIVE VENTILATION - START [**2176-3-23**] 03:43 PM
FEVER - 102.9
F - [**2176-3-23**] 02:34 PM
Transfused 1 u pRBCs last night
Transfused platelets this am
Suctioned for modest amount of thick tan secretions
High residuals
Patient unable to provide history: Sedated, Intubated
Allergies:
Ifosfamide
Mental status c
Last dose of Antibiotics:
Levofloxacin - [**2176-3-23**] 09:14 PM
Piperacillin/Tazobactam (Zosyn) - [**2176-3-24**] 02:00 AM
Bactrim (SMX/TMP) - [**2176-3-24**] 02:00 AM
Infusions:
Fentanyl (Concentrate) - 150 mcg/hour
Midazolam (Versed) - 3 mg/hour
Norepinephrine - 0."
4721,"03 mcg/Kg/min
Other ICU medications:
Pantoprazole (Protonix) - [**2176-3-23**] 09:14 PM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Genitourinary: Foley
Heme / Lymph: Anemia
Pain: No pain / appears comfortable
Flowsheet Data as of [**2176-3-24**] 09:52 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**78**] AM
Tmax: 39.4
C (102.9
Tcurrent: 37
C (98.6
HR: 80 (66 - 146) bpm
BP: 85/55(65) {85/44(2) - 122/74(93)} mmHg
RR: 15 (9 - 35) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Height: 69 Inch
CO/CI (Fick): (214."
4722,"25/37/121/14/-10
Ve: 7.8 L/min
PaO2 / FiO2: 303
Physical Examination
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Breath Sounds: Crackles : dependently)
Abdominal: Soft, Non-tender, No(t) Bowel sounds present, JP drains
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,
Tone: Not assessed
Labs / Radiology
8."
4723,"4 L/min) / (113.8 L/min/m2)
Mixed Venous O2% Sat: 95 - 96
Total In:
4,482 mL
2,952 mL
PO:
TF:
IVF:
3,726 mL
2,150 mL
Blood products:
546 mL
592 mL
Total out:
670 mL
1,680 mL
Urine:
670 mL
1,680 mL
NG:
Stool:
Drains:
Balance:
3,812 mL
1,272 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 550 (450 - 550) mL
RR (Set): 14
RR (Spontaneous): 5
PEEP: 5 cmH2O
FiO2: 40%
RSBI Deferred: Hemodynamic Instability
PIP: 21 cmH2O
Plateau: 13 cmH2O
SpO2: 95%
ABG: 7."
4724,"2 g/dL
59 K/uL
252 mg/dL
1.2 mg/dL
14 mEq/L
5.0 mEq/L
17 mg/dL
106 mEq/L
138 mEq/L
24.7 %
0.3 K/uL
[image002.jpg]
[**2176-3-23**] 06:43 PM
[**2176-3-23**] 07:05 PM
[**2176-3-23**] 10:33 PM
[**2176-3-23**] 11:47 PM
[**2176-3-24**] 12:29 AM
[**2176-3-24**] 01:48 AM
[**2176-3-24**] 02:57 AM
[**2176-3-24**] 03:53 AM
[**2176-3-24**] 04:22 AM
[**2176-3-24**] 08:15 AM
WBC
0.7
0."
4725,"Clinician: Attending
Chief Complaint: Respiratory Failure-Hypoxemic
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
STOOL CULTURE - At [**2176-3-27**] 02:30 PM
-Patient with acute onset of abdominal pain overnight with tenderness
on exam
-Lactate had decreased to 2.6
-PSV titrated up to [**8-11**] and he had evolution of worsening hypercarbia
and persistent hypoxemia with ABG->
7.36/55/67
-Patient was negative 3 liters across past 24 hours History obtained
from Medical records
Patient unable to provide history: Sedated
Allergies:
Ifosfamide
Mental status c
Last dose of Antibiotics:
Daptomycin - [**2176-3-27**] 12:30 PM
Levofloxacin - [**2176-3-27**] 07:44 PM
Voriconazole - [**2176-3-28**] 08:00 AM
Piperacillin/Tazobactam (Zosyn) - [**2176-3-28**] 09:46 AM
Infusions:
Fentanyl - 100 mcg/hour
Midazolam (Versed) - 2 mg/hour
Other ICU medications:
Morphine Sulfate - [**2176-3-28**] 05:00 AM
Fentanyl - [**2176-3-28**] 05:30 AM
Midazolam (Versed) - [**2176-3-28**] 05:30 AM
Pantoprazole (Protonix) - [**2176-3-28**] 08:00 AM
Furosemide (Lasix) - [**2176-3-28**] 08:00 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Gastrointestinal: Abdominal pain
Flowsheet Data as of [**2176-3-28**] 10:16 AM
Vital signs Hemodynamic monitoring Fluid balance 24
hours Since [**78**] AM
Tmax: 37."
4726,"1 cmH2O/mL
SpO2: 97%
ABG: 7.52/39/122/28/8
Ve: 11.3 L/min
PaO2 / FiO2: 244
Physical Examination
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),
(Breath Sounds: Diminished: )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended,
Tender: MId-line, firm area to the right of incision
Extremities: Right lower extremity edema: 2+, Left lower extremity
edema: 2+
Skin: Not assessed
Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
[**2176-3-27**] 12:33 PM [**2176-3-27**] 03:13
PM [**2176-3-27**] 03:40 PM [**2176-3-27**] 06:05
PM [**2176-3-27**] 08:50 PM [**2176-3-28**] 03:00
AM [**2176-3-28**] 03:16 AM [**2176-3-28**] 05:13
AM [**2176-3-28**] 07:34 AM [**2176-3-28**] 07:45 AM
WBC
0."
4727,"6
C (99.7
Tcurrent: 37.4
C (99.4
HR: 66 (63 - 113) bpm
BP: 126/62(84) {105/51(70) - 141/72(97)} mmHg
RR: 20 (14 - 22) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 80.1 kg (admission): 73.3 kg
Height: 69 Inch
Total In: 3,549 mL 1,332
mL
PO:
TF: 95 mL 37 mL
IVF: 3,134 mL 570
mL
Blood products:
Total out: 6,763
mL 1,195 mL
Urine: 6,620 mL 1,195
mL
NG: 140 mL
Stool:
Drains: 3 mL
Balance: -3,214
mL 137 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 550) mL
Vt (Spontaneous): 544 (332 - 544) mL
PS : 10 cmH2O
RR (Set): 20
RR (Spontaneous): 0
PEEP: 8 cmH2O
FiO2: 50% RSBI: 34
RSBI Deferred: Agitated
PIP: 24 cmH2O
Plateau: 19 cmH2O
Compliance: 48."
4728,"5
0.4
Hct
25.7
23.9
Plt
21
7 34
Cr
1.2
1.1
TCO2 29 29 32
29 33 32
33
Glucose
151
180
Other labs: PT / PTT / INR:18.0/35.9/1.6, ALT / AST:14/27, Alk Phos / T
Bili:378/0.7, Amylase / Lipase:24/15, Differential-Neuts:52.0 %,
Band:0.0 %, Lymph:26.0 %, Mono:22.0 %, Eos:0.0 %, Lactic Acid:2.6
mmol/L, Albumin:2.4 g/dL, LDH:229 IU/L, Ca++:7.6 mg/dL, Mg++:1.5 mg/dL,
PO4:2.0 mg/dL
Imaging: CXR-Mild improvement in dependent edema but is very mild."
4729,"ETT
in good position. No free air
Microbiology: Micro--no new positive results on cultures
-B-glucan--positive now
Assessment and Plan
Patient with lymhoma--recurrent and now admitted with hypoxemic
respiratory failure which based on clinical course if most likely
related to idiopathic pneumonitis as we have no evidence of acute
infection within the lungs with the exception of maringal positive
B-glucan. He has evolved some abdominal discomfort across the night
with relatively non-focal exam but consistent tenderness. Reassuringly
patient does have decrease in lactate.
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 11**])-
-Will hold lasix today given need for contrast on scan
-Will continue on A/C support
-Dapto/Zosyn/Voriconazole
-Steroids taper for 40mg today
ABDOMINAL PAIN-
-CT scan with contrast at this time
-Concern for collection or hernia raised
-Contrast to be given as we do need detailed examination
will provide
hydration and mucormyst
-Surgery consulted and will re-address with surgery following study
completion and will monitor exams in the interim.
LYMPHOMA (CANCER, MALIGNANT NEOPLASM, LYMPHOID)-
-Continue with treatment Rx
-Transfuse for PLT <10
-Continue to follow WBC count
SEPSIS WITHOUT ORGAN DYSFUNCTION
Additional issues to be addressed as defined in the housestaff note of
this date.
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2176-3-23**] 02:28 PM
Arterial Line - [**2176-3-23**] 06:24 PM
20 Gauge - [**2176-3-28**] 09:58 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 45 minutes
Total time spent: 45 minutes"
4730,"Admission Date: [**2176-1-29**] Discharge Date: [**2176-4-3**]
Date of Birth: [**2116-2-11**] Sex: M
Service: MEDICINE
Allergies:
Ifosfamide
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
[**2176-2-2**]: Bone marrow aspiration and biopsy.
[**2176-2-20**]: Open splenectomy, exploratory laparotomy, lysis of
adhesions
[**2176-3-13**]: Drainage of splenectomy bed
History of Present Illness:
This is a 59 yom with hx of DM2, High-grade prostatic
intraepithelial neoplasia, Renal cell carcinoma, s/p L
nephrectomy ([**1-/2175**]), Diffuse large B cell lymphoma ([**1-/2175**]),
s/p CHOP x 8 cycles and R-ICE two cycles now s/p ASCT day 41
post transplant who presents from home with fevers."
4731,"CXR done
showed no acute abnormality. 2L IVF given. Blood cultures
drawn and patient sent to the floor for further management.
Past Medical History:
1. Diabetes mellitus, type II (diagnosed 10-11 years ago),
treated with oral meds until chemotherapy, now on ISS.
2. High-grade prostatic intraepithelial neoplasia (prostate
biopsy [**2175-8-26**], no treatment [**2-6**] ""no cancer"")
3. Diffuse large B-cell lymphoma ([**1-/2175**]), s/p CHOP x 8 cycles
and R-ICE two cycles
4. Renal cell carcinoma, s/p L nephrectomy ([**1-/2175**])
5. Eczema (severe) - no recent exacerbations
6. h/o C. difficile colitis (just completed PO Vanc course)
7."
4732,"Pneumonia, ~[**2172**] - did not require hospitalization; treated
with Z-pack x 2
.
Past surgical hisory:
1. Pyloric stenosis correction as neonate [**2116**]
2. Vasectomy - complicated by infection, treated with
antibiotics [**2148**]
3. Left nephrectomy for renal cell carcinoma [**2175**]
.
--------------------
.
ONCOLOGIC HISTORY (per primary oncologist's note, Dr. [**Last Name (STitle) **] [**Name (STitle) 410**]):
[**Known firstname 449**] [**Known lastname **] is a 59-year-old man who was diagnosed with a
diffuse large B-cell lymphoma in [**2175-1-5**] and received 8
cycles of CHOP plus Rituxan. At the time of this diagnosis, he
was also diagnosed with a renal cell carcinoma for which he
underwent unilateral left complete nephrectomy and this was
thought to be curative therapy."
4733,"In late [**2175-7-5**], he again felt
febrile and repeat CT of the abdomen revealed new or increased
adenopathy in the left internal and external iliac groups, the
largest area being 24 mm. He also had some liver lesions, which
were suspicious for metastatic disease (lymphoma
versus renal cell carcinoma) and splenomegaly. He was
transferred to [**Hospital1 18**] where he underwent a CT of the torso
showing multiple abnormally enlarged lymph nodes in the
retroperitoneum,extending to the left common and external iliac
chains to the left inguinal ring, highly concerning for
recurrent lymphoma. There are multiple ill-defined liver
lesions, very symptomatic metastatic disease and small volume
ascites."
4734,"His therapy was complicated by encephalopathy. He developed
asterixis, negative myoclonus, inattentiveness and somnolence
after the second dose of ifosfamide and third dose was delayed
by one day. His third dose resulted in similar signs. This was
cleared within 24 hours, the somnolence improved dramatically
within 24 hours as well. He was discharged after this cycle on
[**2175-8-26**]. He was readmitted with febrile neutropenia secondary
to C. difficile colitis on [**2175-9-4**], treated with oral vancomycin
and flagyl, and discharged on [**2175-9-11**]. He was readmitted on
[**2175-9-25**] for his second cycle of R+ICE, but found to have c."
4735,"diff
colitis at that time and was discharged to home with po
vancomycin.
.
Other oncologic history:
- ? Prostate cancer - biopsy on [**2174-8-26**] revealed high-grade
prostatic intraepithelial neoplasia
- Renal cell carcinoma - diagnosed [**1-/2175**] after routine work-up
including CT scan; s/p nephrectomy (considered curative)
.
Other active problems:
- Pancytopenia
- Findings on CT [**2175-8-14**] concerning for locally recurrent renal
cell carcinoma, recurrent lymphoma (retroperitoneal nodes
extending down int/ext iliac chains), lesions in liver (? renal,
? lymphoma mets)
Social History:
Married, lives with wife [**Name (NI) **] in [**Location (un) **], [**State 350**]. Two
daughters (one works as nurse and lives with him), one son."
4736,"5. Mildly increased size of a left paraaortic lymph node.
6. Abnormal marrow signal, possibly related to iron deposition
but marrow
infiltration by lymphoma, post-treatment changes, or marrow
reconversion are not excluded.
[**2176-2-13**] CT TORSO W/CONTRAST:
1. Slight increase in size of subcentimeter mediastinal lymph
nodes, soft tissue thickening in the left nephrectomy bed, and
soft tissue nodules/lymph node in the left paraaortic
region,potentially concerning for recurrence of disease.
2.The spleen has increased by 4 cm in its length since [**1-31**], concerning for worsening of patient's lymphoma.
3. Two stable pulmonary nodules as described."
4737,"2. Interval decrease in fluid collection within the left upper
quadrant with drain in appropriate position. Other areas of
small amount of fluid within the perihepatic space along the
right paracolic gutter are now identified.
3. Mild gallbladder distention, unchanged. Periportal edema,
similar in appearance.
4. Enhancing nodule within the left nephrectomy surgical bed
concerning for recurrence.
5. Multiple pathologically enlarged lymph nodes within the
retroperitoneum, unchanged.
6. Focal areas of wall thickening involving the cecum and
sigmoid colon.
Dedicated visualization with colonoscopy is recommended given
history of
lymphoma.
7. Persistant splenic vein thrombosis.
[**2176-3-23**] Portable CXR: As compared to the previous radiograph,
the bilateral parenchymal opacities have further increased in
extent and severity."
4738,"The distribution and morphology of the
opacities would be consistent with diffuse infection, or
vascular permeability edema. Increasing retrocardiac
atelectasis, no evidence of pleural effusions.
Brief Hospital Course:
59 year old male with a history of Type II DM, high-grade
prostatic intraepithelial neoplasia, renal cell carcinoma s/p L
nephrectomy ([**1-/2175**]), diffuse large B-cell lymphoma ([**1-/2175**])
s/p autologous SCT admitted for febrile neutropenia.
#. Febrile neutropenia: There was initially no clear source
based on cultures or imaging. He was started on vancomycin,
cefepime, levoquin, and tamiflu. Nasopharyngeal swab and culture
were negative for viral infection, so the tamiflu was
discontinued."
4739,"Bronchoscopy
was performed which was negative x 2. Bactrim was stopped, but
he was otherwise continued on broad spectrum antibiotics.
Thoracic surgery declined to perform a VATS biopsy given
patients comorbidities.
#. Abdominal pain: The patient complained of the acute onset of
abdominal pain on [**3-28**]. CT abd/pel showed small peri-pancreatic
fluid accumulations. Concern was raised regarding whether or not
this was a leak secondary to his surgery. Surgery recommended
watchful waiting.
#. Acute Renal Failure: His creatinine on admission was elevated
from baseline creatinine. This was though to be likely due to
dehydration and increased insensible loss. He was given IVF in
the emergency department and on the floor and his creatinine
returned to baseline."
4740,"The fluid did have a very elevated amylase
level which suggested pancreatic fistula/injury during the
surgery. A drain was left in place, and it continued to collect
about 20-80 cc of fluid/day, one month later.
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth every 12 hrs
Levamir 24u SQ qPM
Novolog Sliding Scale
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
1. Febrile neutropenia
2. Chronic thrombocytopenia and splenomegaly.
3. Acute renal failure
4. Large B cell lymphoma
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2176-4-4**]"
4741,"Numerous
pulmonary macrophages, bronchial cells, lymphocytes and
benign-appearing squamous cells.
[**2176-3-22**] Portable CXR: Widespread ground-glass opacities are
present throughout both lungs with some associated reticular,
micronodular, and linear opacities. Heart size and pulmonary
vascularity have not appreciably changed. Correlation with chest
CT of [**2176-3-19**] demonstrates widespread abnormalities which
have apparently progressed. Observed findings are likely due to
an evolving infection, either viral or pneumocystis.
[**2176-3-22**] CT Abd/Pelvis: 1. Marked interval progression of
bilateral ground-glass opacity and tree-in-[**Male First Name (un) 239**] opacities in the
lung bases with small bilateral pleural effusions concerning for
worsening infectious disease process."
4742,"[**2176-2-5**] Liver/Gallbladeer U/S:
1. Cholelithiasis again noted within contracted gallbladder.
Possible sludge also. No biliary obstruction.
2. Normal liver exam on ultrasound. Again previously seen lesion
in the liver on CT of [**2175-8-14**] is not visualized on ultrasound.
[**2176-2-11**] MRI ABDOMEN W/O & W/CONTRAST:
1. No abnormality identified to explain patient's persistent
fevers. No fluid collections seen.
2. Diffuse low signal intensity within the liver and spleen is
consistent with iron deposition secondary to hemosiderosis.
3. Massive splenomegaly.
4. Enhancing linear soft tissue noted within the left
nephrectomy bed which is unchanged from the recent CT, and again
remains concering for disease recurrence."
4743,"Ultimately, he could
continued to spike fevers with hypotension despite negative
cultures. Antibiotics were being changed to meet this fever
curve, with the last major addition being daptomycin on [**4-3**].
Despite this, his CXR continued to reveal new opacities. This
together with his fevers and history of recurrent lymphoma
presenting with fevers, comfirmed a primary role for lymphoma.
On [**4-4**], a family meeting was held wherein the patient would be
made DNR and a transition to comfort care was initiated. He
passed shortly thereafter
#. Respiratory distress: As above, the patient had worsening
opacities on chest films and CT scans, concerning for infection."
4744,"#. Cholestasis Transaminitis: Patient developed an elevated
alkaline phosphatase, bilirubin, and GGT following initiation of
antibiotic therapy. Azithromycin was stopped and the LFTs
improved. There was no sign of hepatitic candidiasis. He later
again had elevated transaminitis and elevated alk phos with a
normal bilirubin. Tylenol was kept to a minimum and hepatotoxic
drugs were stopped. It was felt that his elevated LFTs may be
due to his recurrent lymphoma.
#. Diffuse large B-cell lymphoma: He is s/p autologous SCT. He
was started on antibiotics on admission but after his infectious
work-up was negative they were discontinued given concern for
drug fever."
4745,"4. Small amount of free fluid in the pelvis, which is new, but
not specific.
5. No intra-abdominal or pelvic collections.
[**2176-2-13**] Head CT W/O CONTRAST: No acute intracranial process. No
midline shift.
[**2176-2-18**] CT ABDOMEN W/O CONTRAST:
1. No significant change in appearance of the right adrenal
gland with no evidence of high attenuation to suggest
spontaneous active adrenal hemorrhage.
2. Overall no significant interval change in appearance of the
abdomen with the previously noted soft tissue thickening in the
left nephrectomy bed and left periaortic region stable, though
incompletely characterized on this non-contrast examination."
4746,"After his bronchoscopy on [**3-21**], the patient was breathing
comfortably and satting well, intermittently wearing 1-2 liters
by nasal cannula. The following day, he was found to be
tachypnic, and ABG revealed PO2 of 69. On the morning of [**3-23**],
he triggered for worsening hypoxia, tachypnea, and tachycardia.
He was placed on a non-rebreather mask. ABG revealed O2 of ~100,
while on the NRB. Stat chest x-ray revealed worsening opacities.
He was transferred to the [**Hospital Unit Name 153**] for further management. On
arrival patient was tachypneic and tachycardic, and was
intubated and placed on mechanical ventilation."
4747,"He was extubated on POD#1,
and later transferred to the floor. Post-operative pain was
controlled with the a Dilaudid PCA. JP amylase was sent in the
evening of POD#6; the JP was discontinued on POD#7 as the output
and amylase level were low. Around POD 20-21, he began to
complain of left-sided abdominal pain. CT abdomen/pelvis was
done which showed an fluid collection at the splenectomy site
with an enhancing rim and there was concern for infection given
his recent fevers. This collection was drained by
interventional radiology and gram stain and culture were
negative to date."
4748,"[**Last Name (STitle) 35852**]"".
Half-sister (by his mother) with diabetes, obesity and poor
self-care, is deceased. Daughter and two other children are
well.
Physical Exam:
On Admission:
VS: Temp 97.7, BP 90/56, HR 93, RR 18 98% RA
GEN: Caucasian male in NAD, lying in bed comfortably
HEENT: NCAT, no sinus tenderness, dry MM, OP clear
NECK: no LAD
CV: +S1/S2, no M/R/G, RRR
PULM: CTAB, no wheezes crackles or ronchi
ABD: +BS, NT/ND, no gaurding
LIMBS: no C/C/E, +2 pulses, left great toe bandaged appears
soupy
SKIN: no rashes"
4749,"Patient
states he felt febrile this afteroon so he took his temperature
and noted it to be elevated to 100.6. He called his oncologist
who then referred him to the ED. The patient reports +fatigue
over the past few days, +body aches today. He also reports
+rhinorrhea with clear discharge. He denies any recent cough,
sore throat, ear pain, sore throat, headache, CP, SOB, N/V,
diarrhea, abdominal pain, dysuria, hematuria, urinary frequncy,
back pain, rashes, sick contacts or recent travel.
.
In the ED V/S: Temp 100.6, BP 124/62, HR 120, RR 20 99% RA.
Patient received Cefepime 2gm IV x 1, Flu swab sent."
4750,"3. Splenomegaly with spleen measuring up to 22 cm.
[**2176-3-1**]: CT Chest/Abd/Pelvis:
1. New subtle ground-glass opacities in the bilateral lungs
predominantly in the bases. Although findings are nonspecific,
differential diagnosis includes edema, infection, or drug
reaction.
2. Status post splenectomy with a small amount of fluid within
the posterior splenectomy bed and mesenteric stranding. While
these findings may represent post-surgical change, and
underlying infection is not excluded. Splenic vein thrombus
which does not cross the midline. Portal vein patent.
3. Interval increase in some of mediastinal and retroperitoneal
lymph nodes.
4. Stable 3 mm left lower lobe nodule and tree-in-[**Male First Name (un) 239**] opacity."
4751,"4 PTT-26.0 INR(PT)-1.0
MICRO:
IMAGING:
[**2176-1-31**] TORSO CT W/CONTRAST:
1. No pathologically enlarged mediastinal, mesenteric or
retroperitoneal lymphadenopathy that would be concerning for
recurrence, with marked interval improvement of previously noted
lymphadenopathy in retroperitoneum and left pelvic region as
seen on CT from [**2175-8-14**].
2. Previously noted band of enhancing soft tissue in left
nephrectomy bed on examinations from [**2175-8-14**] and [**2175-10-23**] is
incompletely evaluated on this non-contrast examination with no
gross enlargement.
3. Slight thickening of the cecum. It is unclear if this is from
underdistention, typhlitis, or infection/inflammation."
4752,"Pertinent Results:
On Admission:
[**2176-1-29**] 08:51PM LACTATE-1.0
[**2176-1-29**] 08:35PM GLUCOSE-85 UREA N-26* CREAT-1.7* SODIUM-140
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
[**2176-1-29**] 08:35PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2176-1-29**] 08:35PM WBC-2.3* RBC-2.63* HGB-8.9* HCT-25.2* MCV-96
MCH-33.9* MCHC-35.3* RDW-21.0*
[**2176-1-29**] 08:35PM NEUTS-56 BANDS-1 LYMPHS-23 MONOS-16* EOS-0
BASOS-0 ATYPS-4* METAS-0 MYELOS-0
[**2176-1-29**] 08:35PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2176-1-29**] 08:35PM PLT SMR-VERY LOW PLT COUNT-24*
[**2176-1-29**] 08:35PM PT-12."
4753,"Was
a motor mechanic but could not tolerate the eczema. For the last
thirty-five years he has worked as a computer technician, at
first with [**Month (only) **]. Currently on disability. Smoked until [**2144**] (11.5
ppd x 13 years) and does not presently drink (x 14 years),
although did have history of heavy EtOH use.
Family History:
Father died from mesothelioma (worked in fire department and as
janitor, smoked), and had a pace-maker. Mother had diabetes and
breast cancer, still alive with ""lazy blood cancer"". OSH
documents describe his mother's ""myelodysplastic syndrome, 5q
minus syndrome and low-grade lymphoma involving bone marrow as
well as monoclonal gammopathy consulted by Dr."
4754,"General
surgery was consulted, and the patient underwent splenectomy on
[**2176-2-20**] (see below for course with general surgery). He was
initially afebrile but again developed fevers on [**2-28**]. CT torso
on [**2-29**] showed new subtle ground-glass opacities bilaterally,
predominantly in the bases. He received pentamidine on [**3-2**] for
PCP [**Name Initial (PRE) 1102**]. Blood, urine, stool, and mycolytic cultures
continued to be negative. Repeat CT's on [**3-19**] and [**3-22**] showed
worsening intrapulmonary processes, reported as likely
infectious. Antibiotic coverage was broadened to include
daptomycin, zosyn, voriconazole, levaquin, and bactrim. The
patient underwent bronchoscopy/bronchoalveolar lavage on [**3-21**]
and repeat on [**2176-3-24**], both negative for organisms or PCP;
bactrim was then discontinued on [**3-24**]."
4755,"He had a PET/CT, as above. After splenectomy on
[**2-20**], splenic tissue showed involvement by non-Hodgkin lymphoma,
diffuse large B-cell type. He was restarted on rituxan and
steroids on [**2-29**]. He had a BM biopsy on [**2176-3-5**] which showed
diffuse involvement by his known lymphoma. He underwent treated
with nitrogen mustard on [**2176-3-7**].
#. Post-operative Splenectomy Course: On [**2176-2-20**], the patient
underwent open splenectomy, exploratory laparotomy, and lysis of
adhesions. After a brief, uneventful stay in the PACU, the
patient was transferred to the TICU overnight and intubated. The
patient was hemodynamically stable."
4756,"The only culture positive
data was from his JP drain fluid, which grew enteroccoccus; ID
felt this was more consistent with colonization than infection,
but the patient was nonetheless continued on Daptomycin. He was
tranfused PRBCs and platelets to keep his HCt above 25 and his
platelets above 10. Sputum culture on [**3-25**] grew GNRs, likely
respiratory flora, but given persistent fevers, ID recommended
changing levofloxacin to gentamicin, and zosyn to meropenem.
CXR and CT chest were consistent with progression of the
patient's underlying lymphoma, and although he continued to be
treated for infectious source, B lymphoma symptoms were also
considered as contributing to his fevers."
4757,"5. Multiple tiny lung nodules and peribronchovascular nodular
opacities,
similar to that seen on [**2176-3-1**].
[**2176-3-13**]: Chest Xray: There is no pneumothorax. Cardiomediastinal
contours are normal. The lungs are clear. There is no pleural
effusion. Drain projects in the left upper quadrant.
[**2176-3-19**]: Non-contrast chest CT: 1. Diffuse infectious process,
likely viral in origin, with small bilateral pleural effusions.
2. Slight increase in mediastinal lymphadenopathy.
3. Soft tissue nodular thickening in the left nephrectomy bed,
incompletely evaluated due to the lack of IV contrast.
[**2176-3-21**] BAL Cytology: NEGATIVE FOR MALIGNANT CELLS."
4758,"He continued to have fevers to 103 so micafungin
was added for fungal coverage while invasive marker of fungal
infection were sent. Bone marrow biopsy on [**2-2**] did not show
disease recurrence. There was concern for hepatic candidiasis
given increased alk phos but hepatic MRI was negative. He
continued to spike fevers to 103 degrees, with no positive
culture data. PET/CT on [**2-16**] showed a massive, FDG avid spleen
(22cm up 4cm since [**2176-1-31**]) and some FDG-avid nodes, concerning
for disease recurrence. He required daily platelet and blood
tranfusions, thought to be [**2-6**] to splenic consumption."
4759,"5. Enhancing tissue within the left nephrectomy bed very
suspicious for RCC recurrence.
[**2176-3-5**]: Bone Marrow Biopsy: HYPERCELLULAR MARROW WITH EXTENSIVE
INVOLVEMENT BY PATIENT'S KNOWN DIFFUSE LARGE B-CELL LYMPHOMA.
[**2176-3-8**]: Chest Xray: No active disease in the chest.
[**2176-3-4**]: Liver ultrasound: The liver has a normal echotexture
without focal hepatic lesions. There is no intra- or
extra-hepatic biliary duct dilatation. The common bile duct is
normal measuring 4 mm. There are multiple small non-obstructing
gallstones. The portal vein is patent with normal hepatopetal
flow. The patient is status post splenectomy."
4760,"There is no
ascites.
[**2176-3-12**]: CT chest/abd/pelvis:
1. Interval organization of fluid within the splenectomy bed,
now with
enhancing rim. infection is not excluded by imaging. Splenic
vein thrombus has not propagated; portal vein remains patent.
2. Subtle diffuse ground-glass opacities in bilateral lungs with
lower lobe predominance, similar to that seen on [**2176-3-1**].
Findings again nonspecific, with differential including
inflammatory or infectious processes.
3. Status post left nephrectomy and adrenalectomy. Stable
enhancing soft
tissue within the left nephrectomy bed.
4. Minimal if any increase in size of retroperitoneal and
mediastinal lymph nodes."
4761,"There is a thin band of enhancing soft tissue in the
left nephrectomy bed, worrisome for locally recurrent renal cell
carcinoma and a cluster of central lobular nodules in the left
upper lobe measuring up to 7 mm in size. There was also a 4-mm
right lower lobe pulmonary nodule seen. Biopsy of a left iliac
lymph node showed involvement by diffuse large B-cell lymphoma.
The MIB fraction was approximately 90%. CD20 was not
immunoreactive and this was thought to be due to previous
therapy with rituximab and therefore he was started on ICE
without Rituxan due to the lack of CD20 positivity in the cells."
4762,"Subjective; Patient intubated and sedated, on droplet precautions.
Objective
Height
Admit weight
Daily weight
Weight change
BMI
175 cm
73.3 kg
23.8
Ideal body weight
% Ideal body weight
Adjusted weight
Usual body weight
% Usual body weight
72.6 kg
101%
77.3kg ([**2176-1-29**])
95%
Diagnosis: Fever
PMHx:
Diabetes mellitus, type II (diagnosed 10-11 years ago), treated with
oral meds until chemotherapy, now on ISS.
High-grade prostatic intraepithelial neoplasia (prostate biopsy
[**2175-8-26**])
Diffuse large B-cell lymphoma ([**1-/2175**]), s/p CHOP x 8 cycles and R-ICE
two cycles
- metastatic disease to spleen and lymph nodes
- s/p autologous stem cell transplant [**12-12**]
Renal cell carcinoma, s/p L nephrectomy ([**1-/2175**])
Eczema (severe)
Pyloric stenosis correction as neonate [**2116**]
Vasectomy - complicated by infection, treated with antibiotics [**2148**]
Left nephrectomy for renal cell carcinoma [**2175**]
C difficile colitis [**8-12**]
treated with oral vanco and flagyl
Food allergies and intolerances: none noted
Pertinent medications: Fentanyl, Versed, Sodium Bicarb, Norepinephrine,
RISS, ABx, others noted
Labs:
Value
Date
Glucose
252 mg/dL
[**2176-3-24**] 03:53 AM
Glucose Finger Stick
335
[**2176-3-24**] 06:14 AM
BUN
17 mg/dL
[**2176-3-24**] 03:53 AM
Creatinine
1."
4763,"2 mg/dL
[**2176-3-24**] 03:53 AM
Sodium
138 mEq/L
[**2176-3-24**] 03:53 AM
Potassium
5.0 mEq/L
[**2176-3-24**] 03:53 AM
Chloride
106 mEq/L
[**2176-3-24**] 03:53 AM
TCO2
14 mEq/L
[**2176-3-24**] 03:53 AM
PO2 (arterial)
91 mm Hg
[**2176-3-24**] 09:18 AM
PCO2 (arterial)
42 mm Hg
[**2176-3-24**] 09:18 AM
pH (arterial)
7.33 units
[**2176-3-24**] 09:18 AM
CO2 (Calc) arterial
23 mEq/L
[**2176-3-24**] 09:18 AM
Albumin
2.2 g/dL
[**2176-3-24**] 03:53 AM
Calcium non-ionized
7."
4764,"5 mg/dL
[**2176-3-24**] 03:53 AM
Phosphorus
4.4 mg/dL
[**2176-3-24**] 03:53 AM
Magnesium
1.8 mg/dL
[**2176-3-24**] 03:53 AM
ALT
25 IU/L
[**2176-3-24**] 03:53 AM
Alkaline Phosphate
575 IU/L
[**2176-3-24**] 03:53 AM
AST
87 IU/L
[**2176-3-24**] 03:53 AM
Total Bilirubin
0.6 mg/dL
[**2176-3-24**] 03:53 AM
WBC
0.3 K/uL
[**2176-3-24**] 03:53 AM
Hgb
8.2 g/dL
[**2176-3-24**] 03:53 AM
Hematocrit
24.7 %
[**2176-3-24**] 03:53 AM
Current diet order / nutrition support: Tube Feed order: Nutren
Pulmonary @ 40mL/hr (1440kcals, 65g protein)
GI: abd soft, hypoactive bowel sounds, OGT clamped
Assessment of Nutritional Status
At risk for malnutrition
Patient at risk due to: prolonged hospitalization, SCT, reccurent
cancer, now intubated
Estimated Nutritional Needs
Calories: 1830-2200 (25-30 cal/kg)
Protein: 88-110 (1."
4765,"2-1.5 g/kg)
Fluid: per team
Calculations based on: Admit weight
Estimation of previous intake: Inadequate
Estimation of current intake: Inadequate
Specifics:
60 y.o. Male with Diffuse large B-cell lymphoma s/p auto SCT [**12-12**] and
recent nitrogen mustard therapy, transferred to the ICU with rapidly
worsening respiratory status, now intubated, sedated and on pressor
support. Patient was followed by nutrition prior to ICU transfer and
had been eating with a poor to fair appetite, receiving CIB shakes to
help supplement intake. Team wants tube feeding recommendations now
that patient is intubated. Agree with tube feeds as patient is at high
nutrition risk. Current tube feed order will underfeed patient,
therefore recommend increasing goal rate.
Medical Nutrition Therapy Plan - Recommend the Following
Recommend tube feed goal of Nutren Pulmonary @ 52mL/hr
(1872kcals, 85g protein). Start at 10mL/hr and advance rate by 10mL
q4-6hrs as tolerated to goal.
Monitor tolerance with abd exam and residual checks q4hrs.
Monitor lytes and renal function
patient may need a renal
formula if renal function worsens or lytes become elevated.
Following - #[**Numeric Identifier 2337**]
11:35"
4766,"During this time,
he also developed a pneumothorax, confirmed on CXR, and a chest
tube was placed. Post-op, he was admitted to the TSICU. On
[**2112-5-23**], orthopedics took the patient back to the OR for I&D of
left thigh and leg and closure, after which he was admitted to
the floor. On [**2112-5-24**], the pneumothorax resolved and the chest
tube was removed. On [**2112-5-26**], the patient was discharged home
after consultation with PT.
Medications on Admission:
None.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Continue while on narcotics."
4767,"Discharge Disposition:
Home
Discharge Diagnosis:
s/p jetski crash
Left femur fracture
Non-displaced left fibular fracture
Compartment syndrome of left lower extremity
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
You may bear weight as toelrated on your left leg.
It is important that you walk several times during the day to
help with circulation and to minimize risks of developing blood
clots.
You have been prescribed Lovenox injections by Orthopedics; this
is a blood thinner to help prevent blood clots.
Return to the Emergency room if you develop any fevers, chills,
shortness of breath, increased pain, swelling in your calf,
nausea, vomitng, diarrhea and/or any other symptoms that are
concerning to you.
Followup Instructions:
Follow-up in Orthopaedic Trauma Clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
NP in 2 weeks. Call [**Telephone/Fax (1) 1228**] to schedule an appointment.
Completed by:[**2112-5-27**]"
4768,"Admission Date: [**2112-5-19**] Discharge Date: [**2112-5-26**]
Date of Birth: [**2094-4-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Jetski accident.
Major Surgical or Invasive Procedure:
[**5-20**]: s/p Left femoral nail placement
[**5-20**]: left femur and tibia compartment release and vac placement
[**5-23**]: I&D and wound closure
History of Present Illness:
The patient is a 17-y.o. male who was involved in a jetski
accident and sustained left femur fracture.
Past Medical History:
None.
Social History:
Non-contributory."
4769,"[**2112-5-19**]: XR femur/tib/fib showed comminuted displaced fracture
through the upper femoral diaphysis with mild varus angulation.
Brief Hospital Course:
On [**2112-5-20**], the patient underwent fixation of the femur by
intramedullary nail. Shortly post-op, while in the PACU, he
experienced a significant increase in pain and swelling in the
left femur and was returned to the OR for four-compartment
fasciotomy. A large hematoma was evacuated from underneath the
vastus and the muscles remained viable. The compartments felt
softer, though still with some swelling, and the wound was
closed with assistance from two VAC sponges."
4770,"2. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day.
5. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) MG
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*30 MG* Refills:*0*"
4771,"Family History:
Non-contributory.
Pertinent Results:
[**2112-5-19**] 07:45PM FIBRINOGE-186
[**2112-5-19**] 07:45PM PT-15.0* PTT-25.9 INR(PT)-1.3*
[**2112-5-19**] 07:45PM PLT COUNT-391
[**2112-5-19**] 07:45PM WBC-27.0* RBC-4.40* HGB-13.4* HCT-39.1*
MCV-89 MCH-30.5 MCHC-34.3 RDW-12.7
[**2112-5-19**] 07:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2112-5-19**] 07:45PM LIPASE-42
[**2112-5-19**] 07:45PM UREA N-15 CREAT-1.2
[**2112-5-19**] 08:03PM freeCa-1."
4772,"08*
[**2112-5-19**] 08:03PM HGB-13.9* calcHCT-42 O2 SAT-75 CARBOXYHB-2
MET HGB-0
[**2112-5-19**] 08:03PM GLUCOSE-178* LACTATE-2.0 NA+-140 K+-3.7
CL--101 TCO2-25
[**2112-5-19**] 11:08PM LACTATE-1.7
[**2112-5-19**]: CXR showed clear lungs.
[**2112-5-19**]: CT head showed no abnormalities.
[**2112-5-19**]: CT chest showed lung contusion.
[**2112-5-19**]: CT abdomen showed no abnormalities.
[**2112-5-19**]: CT pelvis showed contusion and edema of the left
obturator internus and vasti muscles.
[**2112-5-19**]: CT C-spine showed no fracture."
4773,"Hemodynamically stable
Pulmonary: on NC O2 @ 3 lpm, satting well. Cont IS, wean O2 as
tolerated. CT on water seal, tolerated well. [**Month (only) 11**] be able to DC CT
today or tomorrow- discuss with trauma team
Gastrointestinal / Abdomen: reg diet, NPO for surgery today; H2B, bowel
regimen
Nutrition: NPO, for OR today
Renal: Foley, Adequate UO, received lasix 10 mg yesterday & diuresed
well.
Hematology: stable anemia, T&C for 2 U PRBCS for OR today, transfuse 2
U now before going to OR, rpt Hct after transfusion
Endocrine: RISS, no acute issues
Infectious Disease:
Lines / Tubes / Drains: Foley, Chest tube - pleural , PIV
Wounds: Wound vacuum, vac x2
Imaging:
Fluids: KVO
Consults: Trauma surgery, Ortho
Billing Diagnosis: Multiple injuries (Trauma)
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2112-5-20**] 11:11 PM
18 Gauge - [**2112-5-23**] 02:29 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
Total time spent:"
4774,"1 g/dL
101 mg/dL
0.8 mg/dL
34 mEq/L
3.8 mEq/L
5 mg/dL
101 mEq/L
140 mEq/L
25.7 %
7.2 K/uL
[image002.jpg]
[**2112-5-20**] 11:06 PM
[**2112-5-21**] 01:26 AM
[**2112-5-21**] 02:00 AM
[**2112-5-21**] 05:07 AM
[**2112-5-21**] 08:00 AM
[**2112-5-21**] 11:55 AM
[**2112-5-21**] 08:09 PM
[**2112-5-22**] 01:06 AM
[**2112-5-22**] 06:18 PM
[**2112-5-23**] 02:08 AM
WBC
9.3
7.6
7."
4775,"TSICU
HPI:
18 yo male s/p jetski accident w/left femur fracture, ?ischial fracture
vs acetabular fracture. Went to OR for ORIF in morning of [**5-19**], cont
pain and swelling L thigh--? OR for fasciotomy in evening of [**5-19**]. Post
op with tachycardia and hypoxia --> L ptx on cxr. CT placed.
Chief complaint:
left femur fx
PMHx:
none
Current medications:
24 Hour Events:
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2112-5-21**] 08:59 AM
Infusions:
Other ICU medications:
Furosemide (Lasix) - [**2112-5-22**] 11:52 AM
Famotidine (Pepcid) - [**2112-5-22**] 07:55 PM
Hydromorphone (Dilaudid) - [**2112-5-23**] 02:28 AM
Other medications:
Flowsheet Data as of [**2112-5-23**] 06:17 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**14**] a."
4776,"m.
Tmax: 37.4
C (99.4
T current: 37
C (98.6
HR: 96 (96 - 121) bpm
BP: 121/65(78) {121/61(78) - 145/89(101)} mmHg
RR: 24 (12 - 32) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 71.2 kg (admission): 70.6 kg
Height: 66 Inch
Total In:
2,320 mL
82 mL
PO:
1,560 mL
Tube feeding:
IV Fluid:
760 mL
31 mL
Blood products:
52 mL
Total out:
7,160 mL
2,020 mL
Urine:
6,070 mL
1,620 mL
NG:
Stool:
Drains:
1,000 mL
400 mL
Balance:
-4,840 mL
-1,938 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 100%
ABG: ///34/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
140 K/uL
9."
4777,"2
Hct
20.2
26.6
25.1
20.7
26.0
25.4
26.7
25.7
Plt
168
104
120
140
Creatinine
0.9
0.8
0.7
0.8
Glucose
140
138
132
108
133
101
Other labs: PT / PTT / INR:12.6/30.2/1.1, CK / CK-MB / Troponin
T:4545//, Fibrinogen:284 mg/dL, Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.6
mg/dL
Assessment and Plan
PNEUMOTHORAX, TRAUMATIC, TACHYCARDIA, OTHER, [**Hospital **] HOSPITAL
ACQUIRED (PROCEDURE RELATED, BAROTRAUMA), TRAUMA, S/P, PAIN CONTROL
(ACUTE PAIN, CHRONIC PAIN)
Assessment and Plan:
Neurologic: Neuro checks Q: 4 hr, Increased oxycontin dose to 20 mg [**Hospital1 **]
plus has prn percocet & IV hydromorphone for breakthrough pain; to OR
today for I&D left leg w/ poss closure; if pain severe post-op would
consider doing LE block for pain control
Cardiovascular: mild tachycardia has been improving; CTA was neg for
PE."
4778,"[**2112-5-19**] 8:09 PM
FEMUR (AP & LAT) LEFT; TIB/FIB (AP & LAT) LEFT Clip # [**Clip Number (Radiology) 68640**]
Reason: trauma eval
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
20M s/p trauma
REASON FOR THIS EXAMINATION:
trauma eval
______________________________________________________________________________
FINAL REPORT
INDICATION: 18 year-old male post jet ski collision.
COMPARISON: Pelvic films performed concurrently.
AP femur: There is a comminuted transverse fracture through the upper femoral
diaphysis with mild varus angulation of the distal fragment and distraction
laterally by one- quarter shaft width.
AP tibia/fibula: A fracture through the lateral malleolus is better evaluated
on ankle films performed concurrently. No other fracture is identified.
IMPRESSION:
1. Comminuted displaced fracture through the upper femoral diaphysis with
mild varus angulation.
2. Fracture through the lateral malleolus is not well seen on this limited AP
view. No other fractures identified."
4779,"There
is no free fluid in the pelvis.
(Over)
[**2112-5-19**] 8:08 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # [**Clip Number (Radiology) 68639**]
CT PELVIS W/CONTRAST
Reason: trauma eval
Field of view: 36 Contrast: OPTIRAY Amt: 130
______________________________________________________________________________
FINAL REPORT
(Cont)
BONE WINDOWS: There is a transverse fracture through the left superior pubic
ramus. In addition, an ossific corticated density is noted adjacent to the
left 10th thoracic transverse process and may be related to old trauma. No
other fractures are identified. No suspicious osteosclerotic or osteolytic
lesions are present.
IMPRESSION:
1. Probable small pulmonary contusions in the left lower lobe and right lung
base.
2. Left superior pubic ramus fracture with associated contusion and edema of
the left obturator internus muscle.
3. Contusion and edema of the left vasti muscles, likely related to known
femur fracture evaluated on dedicated femur radiographs.
4. Corticated ossific density adjacent to the left 10th thoracic transverse
process likely related to old trauma."
4780,"The non-opacified stomach and loops of small and large bowel
are unremarkable. There is no free air or fluid in the abdomen. No mesenteric
or retroperitoneal lymphadenopathy is present.
CT PELVIS WITH IV CONTRAST: The urinary bladder is collapsed around a Foley
catheter. Small locules of gas in the anterior portion of the bladder are
likely related to Foley catheter placement. The distal ureters, prostate,
seminal vesicles, sigmoid colon and rectum are unremarkable. There is no free
fluid in the pelvis. Contusion and edema of the left obturator internus and
vasti muscles is noted. There is no pelvic or inguinal lymphadenopathy."
4781,"Coronal and
sagittal reformats were displayed.
CT CHEST WITH IV CONTRAST: Patchy opacity in the left lower lobe (2:26 - 28)
and right lung base (2:40) likely corresponds to parenchymal contusion. There
is no associated rib fracture or pneumothorax. The lungs are elsewhere clear
without mass or pleural effusion. The heart and great vessels are
unremarkable without pericardial effusion. There is no aortic injury. There
is no axillary, mediastinal or hilar lymphadenopathy. Residual thymic tissue
is noted.
CT ABDOMEN WITH IV CONTRAST: The liver, gallbladder, pancreas, spleen and
adrenal glands are unremarkable. The kidneys enhance and excrete contrast
symmetrically."
4782,"[**2112-5-19**] 8:08 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # [**Clip Number (Radiology) 68639**]
CT PELVIS W/CONTRAST
Reason: trauma eval
Field of view: 36 Contrast: OPTIRAY Amt: 130
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
20 year old man with trauma
REASON FOR THIS EXAMINATION:
trauma eval
No contraindications for IV contrast
______________________________________________________________________________
WET READ: [**First Name9 (NamePattern2) 614**] [**Doctor First Name 141**] [**2112-5-19**] 9:27 PM
Probable left lung and small right base contusion with no rib fx. Ossific
density corticated adjacent to left 10th thoracic transverse process, may be
related to old trauma."
4783,"Transverse fracture of the left superior pubic ramus.
Contusion and edema of left obturator internus and vasti muscles.
WET READ VERSION #1 [**First Name9 (NamePattern2) 614**] [**Doctor First Name 141**] [**2112-5-19**] 9:25 PM
Probable left lung and small right base contusion with no rib fx. Ossific
density corticated adjacent to left 10th thoracic transverse process, may be
related to old trauma. Transverse fracture of the left superior pubic ramus.
______________________________________________________________________________
FINAL REPORT
INDICATION: 20-year-old male with trauma.
COMPARISON: No prior study available for comparison.
TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen
and pelvis after administration of 130 cc IV Optiray contrast."
4784,"Small parenchymal pulmonary opacities in the left lower lobe are
again consistent with pulmonary contusion. Right upper lobe nodular/ground
glass opacities may be inflammatory or infectious.
No residual pneumothorax is seen, although subcutaneous emphysema tracks
around the site of the left chest tube, which apparently terminates just
superior to the left lung apex.
The heart, aorta, and great vessels appear normal. Although not tailored for
the purpose, limited axial images of the upper abdomen appear unremarkable.
IMPRESSION:
1. No evidence of PE.
2. New bilateral pleural effusions with subsegmental atelectasis.
3. Pulmonary opacities in the left lung base posteriorly consistent with
contusion.
4. Inflammatory/infectious right upper lobe opacities.
(Over)
[**2112-5-21**] 10:18 AM
CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # [**Clip Number (Radiology) 68493**]
Reason: r/o PE
Admitting Diagnosis: S/P JET SKI ACCIDENT
______________________________________________________________________________
FINAL REPORT
(Cont)"
4785,"______________________________________________________________________________
FINAL REPORT
HISTORY: 18-year-old male status post trauma with known pulmonary
contusions, pneumothorax on the left with left chest tube. Evaluate for
pulmonary embolus.
COMPARISON: CT torso [**2112-5-19**].
TECHNIQUE: Axial imaging was performed from the thoracic inlet to the
diaphragm following the uneventful administration of intravenous contrast.
Multiplanar reformations were provided.
CTA CHEST WITH IV CONTRAST: There is no pulmonary embolism. Bilateral
pleural effusions, small to moderate on the right, and small on the left, have
developed since two days ago. There is resulting compressive subsegmental
atelectasis. Fluid is also seen along the right major fissure posteriorly
(2:44)."
4786,"[**2112-5-21**] 10:18 AM
CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # [**Clip Number (Radiology) 68493**]
Reason: r/o PE
Admitting Diagnosis: S/P JET SKI ACCIDENT
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
18 year old man with tachycardia, hypoxia, s/p trauma
REASON FOR THIS EXAMINATION:
r/o PE
No contraindications for IV contrast
______________________________________________________________________________
PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT [**2112-5-21**] 12:31 PM
No PE. Subsegmental atelectasis w/ pleural effusions (R > L) increased since
two days ago. Left chest tube extends just beyond left lung apex. Basilar
opacities again seen which may represent small contusions."
4787,"Admission Date: [**2201-6-23**] Discharge Date: [**2201-6-29**]
Date of Birth: [**2138-12-24**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
[**2201-6-23**]: s/p left total hip revision
History of Present Illness:
62 year old man with [**First Name9 (NamePattern2) 3262**] [**Last Name (un) 3263**] cirrhosis c/b Grade 1 esophageal
varices and past GIB's, Crohn's s/p ileostomy, COPD, HTN,
pancytopenia, GERD, depression, avascular necrosis [**1-7**] chronic
prednisone use s/p L hip replacement with massive osteolysis of
pelvis/acetabulum and proximal femur, extended femoral osteotomy
(clamshell) with multiple open reduction and internal fixations
who is admitted to the ICU for monitoring after 3rd attempt of
total hip replacement."
4788,".
The patient was previously discharged on [**2201-4-20**] s/p total
resection arthroplasty on [**2201-4-2**]. Post-operatively, the patient
was noted to be confused coming out of the OR and overnight. He
was initially transferred to ICU post surgery because of
hypotension and was on pressors with subsequent normalization of
blood pressures. Post-op course was also complicated by
hepatic/toxic-metabolic encephalopathy, cleared with rifaximin
and lactulose, and by acute kidney injury.
Past Medical History:
Past Medical History:
- HTN
- dyslipidemia
- ascending aortic aneurysm, not involving the coronary vessels
- bicuspid aortic valve
- EtOH cirrhosis c/b esophageal varices and bleeding: baseline
liver enzymes ALT 21, AST 30, ALK 190, TBili 1."
4789,"2
- pancytopenia: baseline WBC 1.7, Hgb 12.3, Hct 35.8, Plt 54
- thrombocytopenia
- Crohn's disease s/p ileostomy
- prostate cancer
- kyphosis
- COPD
- GERD
- squamous cell carcinoma s/p resection
- avascular necrosis of left hip secondary to prednisone
- depression
- baseline BUN 15, Cr 1.0
.
Past Surgical History:
- squamous cell carcinoma excisions x 3 forehead ([**10/2199**])
- L distal radius ORIF ([**2196**])
- partial colectomy with transverse colostomy and mucous fistula
- mucous fistula takedown
- left wrist surgery
- left hip replacement (20 years ago)
- avascular necrosis of left hip secondary to
Crohn's/prednisone,
- Complex complete resection arthroplasty of failed left total
hip replacement; extended femoral osteotomy (clamshell) with
multiple open reduction and internal fixation cerclage wires"
4790,".
# Crohn's disease - Stable, not having diarrhea. Continued with
azathioprine when taking POs.
.
# HTN - Initially held lisinopril for now pending fluid shifts
and post op hypotension.
.
# COPD - Documented h/o COPD in OMR but on no home medications.
# Ascending aortic aneurysm: Stable on recent Echo. VS were
monitored.
.
# Depression: Home duloxitine was continued.
2. Asymptomatic post-operative anemia - POD 2 Hct 21.1 ->
Transfused 2 units PRBCs
3. Medicine consult for co-management
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#2. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1."
4791,"Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
Failed left total hip replacement
Post-operative anemia due to blood loss
Chronic pancytopenia
*Anticipated length of stay < 30 days*
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns."
4792,"7* RBC-2.66* Hgb-9.2* Hct-25.5*
MCV-96 MCH-34.8* MCHC-36.2* RDW-18.9* Plt Ct-83*
[**2201-6-25**] 06:20AM BLOOD WBC-1.5*# RBC-2.15* Hgb-7.5* Hct-21.1*
MCV-98 MCH-35.0* MCHC-35.6* RDW-19.3* Plt Ct-51*
[**2201-6-26**] 12:30AM BLOOD WBC-1.8* RBC-2.68* Hgb-9.0* Hct-25.4*
MCV-95 MCH-33.7* MCHC-35.5* RDW-18.6* Plt Ct-43*
[**2201-6-26**] 06:25AM BLOOD WBC-1.2* RBC-2.71* Hgb-9."
4793,"Lactulose
was started after the patient was extubated. His home nadolol
was initially held [**1-7**] low BP, but this was restarted after
extubation.
.
# Pancytopenia - History of thrombocytopenia [**1-7**] cirrhosis as
well as pancytopenia, (which on previous workup by Heme/Onc was
felt to medication, portal sequestration). Macrocytic anemia
consistent with history of alcohol and cirrhosis. CBC was
monitored with a goal of keeping platelets > 10 or 50 if acute
bleeding. Through his course in the [**Hospital Unit Name 153**], the patient had an
active type and screen. No transfusions were required
post-operatively in the [**Hospital Unit Name 153**]."
4794,"The foley was removed on POD#2 and the patient was
voiding independently thereafter. The surgical dressing was
changed on POD#2 and the surgical incision was found to be clean
and intact without erythema or abnormal drainage. The patient
was seen daily by physical therapy. Labs were checked throughout
the hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign."
4795,"Social History:
He is retired from the Department of Social Services, former
widower, has a girlfriend.
- Tobacco: Previous use
- Alcohol: Prior history of alcohol abuse, no longer drinking in
22 months per pt, family and PCP.
[**Name Initial (NameIs) **] [**Name11 (NameIs) 3264**]: denies
Family History:
Positive for hemophilia but not affecting this patient, although
he does have thrombocytopenia.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND, ostomy RLQ, hernia LLQ
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* 5/5 strength
* SILT, NVI distally
* Toes warm"
4796,"2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily to
prevent this side effect. Call your surgeons office 3 days
before you are out of medication so that it can be refilled.
These medications cannot be called into your pharmacy and must
be picked up in the clinic or mailed to your house."
4797,"9* MCHC-35.4* RDW-18.8* Plt Ct-42*
[**2201-6-23**] 08:43PM BLOOD Neuts-88.5* Bands-0 Lymphs-3.9* Monos-7.0
Eos-0.5 Baso-0.1
[**2201-6-24**] 03:39AM BLOOD Neuts-89.0* Bands-0 Lymphs-4.2* Monos-6.2
Eos-0.1 Baso-0.5
[**2201-6-27**] 07:20AM BLOOD Neuts-80.2* Lymphs-9.1* Monos-7.6 Eos-2.5
Baso-0.5
[**2201-6-23**] 08:43PM BLOOD Glucose-140* UreaN-14 Creat-0.7 Na-138
K-4.6 Cl-113* HCO3-19* AnGap-11
[**2201-6-24**] 03:39AM BLOOD Glucose-119* UreaN-16 Creat-0."
4798,"8 Na-138
K-4.4 Cl-112* HCO3-19* AnGap-11
[**2201-6-25**] 06:20AM BLOOD Glucose-135* UreaN-17 Creat-0.9 Na-140
K-3.6 Cl-109* HCO3-24 AnGap-11
[**2201-6-26**] 06:25AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-141
K-3.3 Cl-109* HCO3-25 AnGap-10
[**2201-6-27**] 07:20AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-142
K-3.4 Cl-108 HCO3-24 AnGap-13
[**2201-6-28**] 06:05AM BLOOD Glucose-134* UreaN-12 Creat-0.9 Na-140
K-3."
4799,"Pertinent Results:
[**2201-6-23**] 11:30AM BLOOD Hgb-12.5* Hct-34.4* Plt Ct-53*
[**2201-6-23**] 06:00PM BLOOD Hgb-9.7* Hct-27.6* Plt Ct-85*#
[**2201-6-23**] 08:43PM BLOOD WBC-1.9* RBC-3.36* Hgb-11.5* Hct-33.2*
MCV-99* MCH-34.2* MCHC-34.6 RDW-18.3* Plt Ct-62*
[**2201-6-24**] 03:39AM BLOOD WBC-3.4*# RBC-3.01* Hgb-10.6* Hct-29.3*
MCV-97 MCH-35.2* MCHC-36.2* RDW-19.2* Plt Ct-84*
[**2201-6-24**] 04:07PM BLOOD WBC-3."
4800,"6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
10. azathioprine 50 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
11. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 3 weeks.
Disp:*21 syringe* Refills:*0*
12. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice
a day for 3 weeks: AFTER completing Lovenox, take as directed
with food."
4801,"Medications - OTC
CALCIUM - (Prescribed by Other Provider) - Dosage uncertain
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - Dosage uncertain
MAGNESIUM OXIDE - (Prescribed by Other Provider) - 400 mg
Tablet
- 6 Tablet(s) by mouth three times a day
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (Prescribed by Other
Provider) - 20 mg Tablet, Delayed Release (E.C.) - two Tablet(s)
by mouth daily
.
Medications on transfer to ICU:
-Lisinopril 10 mg PO/NG DAILY
-Acetaminophen 650 mg PO Q6H
-Milk of Magnesia 30 ml PO BID:PRN Constipation
-Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
-Multivitamins 1 CAP PO DAILY
-CefazoLIN 2 g IV Q8H (2 hrs post-op)
-Nadolol 40 mg PO DAILY
-Calcium Carbonate 500 mg PO TID
-OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN Pain Start: In
am
Begin after PCA has been d/c [**6-24**]
-Docusate Sodium 100 mg PO BID
-Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
-Duloxetine 60 mg PO DAILY
-Omeprazole 20 mg PO DAILY
-Enoxaparin Sodium 40 mg SC DAILY Start: In am
Begin on [**6-24**] wednesday
-Senna 1 TAB PO BID
-FoLIC Acid 1 mg PO/NG DAILY
-Vitamin D 400 UNIT PO DAILY Order date: [**6-23**] @ 1103
-HYDROmorphone (Dilaudid) 0."
4802,"12 mg IVPCA Lockout Interval: 6
minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s)
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
4803,"Disp:*42 Tablet(s)* Refills:*0*
13. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Take while on strong pain medication.
Disp:*2700 ML(s)* Refills:*2*
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Hold for confusion.
Disp:*50 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
daily CBC with diff at rehab until his WBC counts increase. If
he were to become neutropenic or show signs of infection, would
recommend stopping Azathioprine. Would transfuse PRN for goal
plt >10 and Hct > 21."
4804,"Please
allow an extra 2 days if you would like your medication mailed
to your home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks."
4805,"Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: TOUCHDOWN weight bearing on the operative
extremity. POSTERIOR and TROCHANTER OFF precautions. No
strenuous exercise or heavy lifting until follow up appointment.
Physical Therapy:
LLE TOUCHDOWN weight bearing
Posterior AND trochanter off precautions
Mobilize
Treatments Frequency:
Dry sterile dressing daily as needed for drainage
Wound checks
Ice as tolerated
Staple removal POD 17 - replace with steristrips
TEDs
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2201-7-24**] 11:00
Completed by:[**2201-6-28**]"
4806,"The patient's weight-bearing status is TOUCHDOWN weight bearing
on the operative extremity with POSTERIOR and TROCHANTER OFF
precautions.
Mr. [**Known lastname 3265**] is discharged to rehab in stable condition.
Medications on Admission:
MEDICATIONS AT HOME:
AZATHIOPRINE - (Prescribed by Other Provider) - 50 mg Tablet -
2-1/2 Tablet(s) by mouth once daily
DULOXETINE [CYMBALTA] - (Prescribed by Other Provider) - 60 mg
Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once daily
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet -
one
Tablet(s) by mouth daily
NADOLOL - (Prescribed by Other Provider) - 40 mg Tablet - one
Tablet(s) by mouth daily
OXYCODONE [OXYCONTIN] - (Prescribed by Other Provider) - 20 mg
Tablet Extended Release 12 hr - 1 Tablet(s) by mouth twice daily
OXYCODONE-ACETAMINOPHEN [ROXICET] - (Prescribed by Other
Provider) - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth every 4-6
hours as needed for pain
SODIUM CHLORIDE - (Prescribed by Other Provider) - - 4 mg
daily
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth once a day
."
4807,"8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for three (3)
weeks to help prevent deep vein thrombosis (blood clots). After
completing the lovenox, please take Aspirin 325mg TWICE daily
for three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air."
4808,"6 Cl-108 HCO3-24 AnGap-12
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. ICU Course:
# s/p left hip replacement: Patient tolerated the procedure
well per Ortho although he did have significant blood loss and
fluid shifts. He had a RIJ placed in the OR the postition of
which was confirmed on presentation to the [**Hospital Unit Name 153**]."
4809,"2* Hct-26.1*
MCV-97 MCH-33.9* MCHC-35.1* RDW-18.6* Plt Ct-42*
[**2201-6-27**] 07:20AM BLOOD WBC-1.3* RBC-2.79* Hgb-9.6* Hct-26.8*
MCV-96 MCH-34.3* MCHC-35.7* RDW-18.3* Plt Ct-43*
[**2201-6-27**] 07:20AM BLOOD WBC-1.3* RBC-2.79* Hgb-9.6* Hct-26.8*
MCV-96 MCH-34.3* MCHC-35.7* RDW-18.3* Plt Ct-43*
[**2201-6-28**] 06:05AM BLOOD WBC-1.3* RBC-2.79* Hgb-9.7* Hct-27.5*
MCV-99* MCH-34."
4810,"The
acute pain and the chronic pain services were consulted
regarding a lumbosacral block. It was decided that in place of a
lumbosacral block, the patient's Dilaudid PCA would be increased
to dose to .24/6m and his long-acting oxycontin PO 10 mg Q6H.
The patient was successfully extubated upon leaving the [**Hospital Unit Name 153**].
.
# EtOH Cirrhosis - Blood transfusions and insult of surgery
would contribute to higher likelihood of post-op hepatic
encephalopathy. Patient does have history of grade 1 varices as
well. Mental status was monitored through [**Hospital Unit Name 153**] course and the
patient did not have hepatic encephalopathy on exam."
4811,"Post-op Hct
stable at 33.2. He received ancef for 24 hours after the
procedure. Was intubated on admission to unit. He was cautiously
weaned from the vent and from Propofol given his prior history
of difficulty with extubation and altered mental status. Opiods
were avoided in management of the patient's pain. He was given
small fentanyl boluses for pain through the night. He was
extubated in the morning without difficulty. The JP drains
contained serosanginous fluid, and on POD1 the patient was
started on enoxaparin 40mg Sc daily. Pain management was an
issue given the patient's underlying hepatic dysfunction."
4812,"Admission Date: [**2157-5-27**] Discharge Date: [**2157-6-3**]
Date of Birth: [**2078-10-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Right rib pain secondary to submassive pulmonary embolus
Major Surgical or Invasive Procedure:
CT scan of chest, Echocardiogram
History of Present Illness:
78 year old female with PMhx dementia, GERD, remote DVT and
remote VA who was admitted with submassive pulmonary embolus.
Patient was in her usual state of health until the evening prior
to admission when she first noted right rib pain."
4813,"Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
hiatal hernia
GERD
? fast heart beat
Schizophrenia
CVA - remote > 10 years ago
DVT - noted [**9-13**] at time of femur and humerus fracture
Lt femur and humerus fracture in [**9-13**] after a fall
Urinary Incontinance
.
Past Surgical history:
Ex lap after car accident in [**2107**]
Lt partial thyroidectomy, found to be benign
Hysterectomy
Social History:
Lives at [**Location 1188**] house. Walks with a walker."
4814,"Brief Hospital Course:
78 y.o. F with remote CVA, remote DVT, admitted with large
bilateral pulmonary emboli, initially stable on floor but
required ICU stay for hypercarbic respiratory failure
# Hypercarbic Respiratory Failure: PCO2 on ABG with hypercarbic
respiratory failure. This was thought to be secondary to
decreased respiratory drive given oxygen supplementation,
possibly underlying COPD. AMS resolved with decreasing O2
supplementation from 3 L NC to 1 L NC. Patient without
documented history of COPD but has 25 pack year smoking history.
Her goal O2 sat 88-93%. Narcotic use and psychotropic
medications were avoided. Pt's mental status now appears back
to baseline, conversant, alert."
4815,"She was advised to perform incentive spirometry.
.
#pulmonary edema: Pt developed transiently in the ICU in the
setting of IVF for hypercalcemia. She was given additional 20mg
IV lasix with good effect.
.
# Hypercalcemia: Pt found to have hypercalcemia especially in
the setting of low albumin. PTH was high, phos tended to be on
the lower side. This makes primary hyperparathyroidism the most
likely. She was given lasix and IVF with good effect. Her
calcium and vit D supplementation were stopped. She should
continue this workup in the outpt setting.
.
# GERD: Pt given omeprazole as per outpt regimen.
.
# Hypertension: patient with a history of hypertension
maintained on outpatient beta blocker and lasix."
4816,"This was
continued.
.
# Schizophrenia: Pt with remote history but did act
appropriately during hospitalization. She was continued on her
olanzapine as per outpt regimen.
.
# Urinary incontinence - patient maintained on outpatient
Oxybuynin as this is chronic medication for her
Medications on Admission:
MOM PRN
Calcium Carbonate 2 tabs by mouth PRN heartburn
Artifical tears drops QID OU
Metoprolol tartrate 75 mg PO BID
Tramadol 25 mg PO BID
Vitamin D 400 Units PO BID
Tylenol 650 mg PO TID with ultram
Mirtazapine 15 mg PO qhs
Fleet enema PRN constipation
Dulcolax PRN constipation
Lasix 20 mg PO daily
Ocuvite 1 tab PO daily
Multivitamin 1 tablet PO daily
Prilosec 1 tablet PO daily
Zyprexa 2."
4817,"Discharge Diagnosis:
Primary:
1) Pulmonary embolism
2) Altered mental status - resolved, thought due to hypercarbia
3) Hypercalcemia with elevated PTH, possible primary
hyperparathyroidism
Secondary diagnosis:
Schizophrenia
hx DVT [**2153**]
Discharge Condition:
afebrile, vitals stable, sating low-mid 90's on 1L NC
Discharge Instructions:
You were admitted to hospital with right rib pain and found to
have a large blood clot in your lungs. You were given blood
thinning medications heparin and coumadin to prevent further
clot formation. Shortly after hospitalization, you were found
to be more confused, and were tranferred to Intensive care Unit
for observation. Your confusion resolved."
4818,"4.Your mirtazapine and tramadol were stopped secondary to
confusion, you should discuss with your PCP resuming these
medications.
5. oxygen as needed. Currently only requiring 1 liter.
Upon discharge, you will return to your residence at [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **]. Your are scheduled to follow up with your Primary Doctor
to further manage your pulmonary embolism, hyperparathyroidism
and other medical problems. Please return to the emergency
department immediately if you experience any increased
confusion, agitation, fever, chills, shortness of breath, chest
pain.
Followup Instructions:
Please make sure you follow up with your primary care physician
at [**Hospital3 4262**] group. Your former PCP was [**Name9 (PRE) 111220**] [**Name9 (PRE) **].
Please be sure to [**Name6 (MD) 138**] your NP[**First Name8 (NamePattern2) 111221**] [**Location (un) **] [**Telephone/Fax (1) 608**] at
[**Hospital3 4262**] to schedule a follow up within 1-2 weeks of
discharge.
.
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2157-7-6**]
10:45
.
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2157-7-6**] 11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]"
4819,"7 Na-140
K-4.4 Cl-104 HCO3-29 AnGap-11
[**2157-5-27**] 11:40AM BLOOD CK(CPK)-19*
[**2157-5-28**] 09:45AM BLOOD CK(CPK)-22*
[**2157-5-27**] 11:40AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-926*
[**2157-5-28**] 09:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2157-5-28**] 09:45AM BLOOD Calcium-10.0 Phos-2.0* Mg-1.9
[**2157-5-27**] 11:40AM BLOOD D-Dimer-[**2161**]*
[**2157-5-30**] 08:18AM BLOOD Type-ART FiO2-100 O2 Flow-2 pO2-77*
pCO2-66* pH-7.33* calTCO2-36* Base XS-5 AADO2-576 REQ O2-94
Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2157-5-27**] 11:47AM BLOOD K-4."
4820,"The pain was
so severe that she woke up from her sleep. She stated that she
sat in her chair overnight because of the pain. She was
transferred in from the [**Last Name (un) 1188**] house. Patient also reported
associated shortness of breath which began that evening as well.
Denied associated chest pain. The patient endorsed some mild
cough without sputum production. Patient reported that she had a
low grade temperature on arrival to the ED but stated that she
was unaware of any fever. Patient denied any recent surgery
other than cataract surgery in [**Month (only) 116**] of this year."
4821,"Your pain was
controlled with Tylenol. You were also found to have high level
of calcium, and it was determined that this was due to high
levels of Parathyroid hormone. You were given water pill Lasix
and IV fluids to lower the levels of blood calcium. Over the
course of your hospitalization, your pain became better
controlled, your breathing and oxygenation have improved.
During hospitalization, several of your medications were
changed.
1.Your calcium was stopped
2.Your vitamin D was stopped
3.You were started on a blood thinning medication, coumadin for
your blood clot for which you should likely take for a lifetime."
4822,"Please correlate clinically. Old rib
fractures at the left lung base.
Question of a nondisplaced rib fracture at the right mid rib. If
there is a clinical concern, designated rib film could be done
to evaluate this further.
.
CTA chest - IMPRESSION:
1. Bilateral pulmonary emboli. Large saddle embolus in the right
main
pulmonary artery and segmental left lower lobe branches with
associated
peripheral airspace opacification and small right pleural
effusion. Bowing of the intraventricular septum and increased
ratio of the right to left ventricle suggestive of possible
component of right heart strain.
2. Enlarged heterogenous appearance with multiple nodules noted
in the left thyroid lobe compatible with multinodular goiter."
4823,"5
[**2157-5-27**] 04:00PM BLOOD Lactate-0.9
[**2157-5-30**] 08:18AM BLOOD Glucose-113* Lactate-0.6 Na-138 K-4.2
Cl-99*
[**2157-5-30**] 08:18AM BLOOD freeCa-1.39*
.
Chest PA/Lateral - IMPRESSION: Prominence of bronchovascular
markings, more on the right, and at the lung bases. Prominence
of vascular markings at the hilum bilaterally. Attenuation at
the right costophrenic angle, and mildly at the left
costophrenic angle.
Findings could suggest congestion, bibasilar atelectasis,
pleural effusion, more on the right, and/or pneumonia especially
at the left lung base. Findings could also be seen in
interstitial lung disease."
4824,"Pertinent Results:
[**2157-5-27**] 11:40AM BLOOD WBC-15.4*# RBC-4.08* Hgb-12.1 Hct-36.0
MCV-88 MCH-29.6 MCHC-33.6 RDW-13.7 Plt Ct-114*#
[**2157-5-27**] 11:40AM BLOOD Neuts-84.7* Lymphs-9.3* Monos-5.7 Eos-0.1
Baso-0.2
[**2157-5-27**] 11:40AM BLOOD PT-12.2 PTT-24.7 INR(PT)-1.0
[**2157-5-27**] 11:40AM BLOOD Glucose-113* UreaN-14 Creat-0.8 Na-138
K-4.3 Cl-103 HCO3-28 AnGap-11
[**2157-5-30**] 07:15AM BLOOD Glucose-105 UreaN-13 Creat-0."
4825,"The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild pulmonary artery systolic hypertension."
4826,"Patient denied
any new immobilization or long plane flights. Patient was noted
to be tachycardic, got CTA in the ED which demonstrated
submassive PE. Patient got a dose of Lovenox. Patient was also
noted to be febrile and cultures were sent. Patient got morphine
down in the ED. In the ED: Vitals signs: T 100.6, HR 100, BP
120/75, 95% on RA
.
On the floor, CT scan was amended to demonstrate submassive PE
as described below.
.
Review of sytems:
(+) Per HPI
(-) Denied fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion."
4827,"# Altered Mental Status: Occurred in the setting of hypercarbia.
Head CT obtained on floor prior to ICU transfer which was
negative.
.
# Pulmonary emboli: large bilateral PE. CT exhibited evidence
of right heart strain but echo showed intact RV function. Pt
did not require thrombolytic therapy. She remained
coumadin/heparin gtt until INR therapeutic. Pt is currently in
the therapeutic range. Pt should have her INR checked in [**1-11**]
days.
.
# Right sided rib pain: Thought to be secondary to pleuritic
pain cause by pulmonary emboli. This pain made deep breathing
difficult. However, pain gradually resolved with standing
tylenol. She was written for morphine prn but did not require."
4828,"5 mg PO qhs
Oxybuynin 5 mg PO BID
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin 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. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM."
4829,"Minimal
linear atelectasis at left lung base.
.
CT head - CONCLUSION: Chronic findings unchanged since [**Month (only) **]
[**2154**]. No evidence of hemorrhage.
.
CXR-FINDINGS: In comparison with the study of [**5-28**], there is
little overall change. Continued small right pleural effusion
with adjacent atelectasis and minimal streaks of atelectasis at
the left base. Mild prominence of interstitial pattern without
evidence of acute focal pneumonia.
.
ECHO-The left atrium and right atrium are normal in cavity size.
The estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%)."
4830,"Has a niece who
lives in the area. Patient with remote 25 Pack year smoking
history, quit 50 years ago. Drinks only occasionally, no
history of IVDA or drug use
Family History:
CAD, brother and father
DM
Ovarian Cancer in mother
Physical Exam:
Vitals: T: 99.1 BP: 130/74 P: 108 R: 30 O2: 96% on 3L
General: Alert, oriented, tachypniec, tachycardic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: + fine crackles at right base
CV: tachycardic, hyperdynamic, nl s1/s2
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
4831,"3. Diffuse ground glass opacity and interlobular thickening
suggestive of
component of congestive heart failure.
4. Moderate in size sliding hiatal hernia.
5. Atherosclerotic disease involving the thoracic aorta.
6. Old left healed rib fractures.
7. 4mm right lower lobe subpleural pulmonary nodule. Recommend
clinical
correlation with risk factors, and if patient is high risk, a
dedicated chest CT can be obtained in 6 months for further
evaluation.
.
Portable chest - FINDINGS: The heart size is normal. Persistent
tortuosity of the thoracic aorta. Interval improvement in
interstitial pattern. Small right pleural effusion has possibly
increased in the interval with adjacent atelectasis."
4832,"8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-10**]
Drops Ophthalmic QID (4 times a day).
11. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO twice
a day.
12. oxygen
Oxygen via NC. 1L prn to keep sats >90%
13. Outpatient [**Name (NI) **] Work
Pt/PTT/INR
Calcium level
[**2157-6-5**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]"
4833,"4 and she remained HD stable without
tachycardia or hypotension. She was started on pantoprazole
drip. Liver was called and plan to scope patient tomorrow. She
was also started on ceftriaxone for PCP [**Name Initial (PRE) 31424**]. She was
sent to the MICU.
Currently, she denies any symptoms. Denies CP, SOB,
light-headedness. She reports abdominal distension leading to
SOB was worst symptom and this has resolved after having NG.
Past Medical History:
# Autoimmune hepatitis: [**Doctor First Name **]+, AMA-, [**Last Name (un) 15412**]+
# Cirrhosis:
# Rheumatoid Arthritis:
# Hep C: Genotype 3. most recent viral load undetectable.
# mulitple liver biopsies
# compartment syndrome in R arm s/p surgical decompression [**11-24**]
# herpes zoster
# C section in [**2175**]
# osteomyelitis [**2177**]
# Nephrolithiasis"
4834,"She missed 4 days of Lasix doses
so we will re-initiate her diuretic regimen as well as her other
home medications.
ACUTE ISSUES:
#. GIB: the patient had dark emesis and a lavage done at OSH
revealed blood. On EGD, non-bleeding grade I varices are
appreciated so unclear if this is source of bleed. We treated as
for GIB but we did not continue octreotide and PPI. Treatment
with ceftriaxone and converted to po Cipro 500mg [**Hospital1 **] for 7 days,
Nadolol 20mg daily. Patient's hematocrit remained stable around
33-35 and she remained hemodynamically stable
.
#. Autoimmune Hepatitis c/b cirrhosis, recurrent ascites."
4835,"Abdominal pain may be [**1-19**] ascites. Continued on home dose of
Lasix (of which she had missed 4 days of doses), Aldactone, home
dose of Imuran, Budesonide. Started on weekly vitamin D 50,000
on Wednesdays. The patient achieved relief of abdominal pain
with carafate and was also advised to use Tums for her pain. As
well, she was given tramadol for this pain.
.
#.Uncomplicated UTI: patient had asymptomic pyuria, urine
cultures show staph aureus coag positive. Sensitivities revealed
resistance to levofloxacin and so ciprofloxacin will not cover
her. She was given a 3 day course of Bactrim for UTI."
4836,"7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
8. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day as needed for abdominal pain for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 1 weeks.
Disp:*15 Tablet(s)* Refills:*0*
11. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days."
4837,".
#Patient eloped with 2 IV's in arms. She left without receiving
discharge paperwork but Rx were delivered.
.
CHRONIC ISSUES:
#. Cirrhosis. MELD was 15 on day of discharge. Patient will
continue to follow in transplant hepatology.
.
TRANSITIONAL CARE ISSUES:
CODE: Full
CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 73008**], [**Telephone/Fax (1) 72764**]
PENDING STUDIES: none
PATIENT ELOPED WITH IV'S INTACT.
Medications on Admission:
Imuran 50 mg once a day,
budesonide 3 mg one p.o. t.i.d.,
vitamin D 50,000 units once a week,
furosemide 20 mg once a day,
spironolactone 100 mg once a day,
calcium with vitamin D is on hold due to kidney stones,
iron 325 one three times a day"
4838,"8
Liver U/S [**6-12**]: 1. Nodular cirrhotic liver with splenomegaly and
ascites suggesting the
presence of portal hypertension. Patent main portal vein with
hepatopedal
flow.
2. New echogenic focus in the left lobe of the liver, measuring
1.3 cm in
greatest dimension. Further characterization with non-emergent
MRI is
recommended.
EGD [**6-12**]: Grade I Varices at the lower third of the esophagus
and gastroesophageal junction
Duodenal varices
Otherwise normal EGD to third part of the duodenum
Discharge Labs:
[**2180-6-14**] 01:15PM BLOOD WBC-8.4# RBC-2.97* Hgb-11.2* Hct-32.8*
MCV-111* MCH-37."
4839,"Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
gastrointestinal bleed
urinary tract infection
autoimmune liver disease
Cirrhosis
SECONDARY DIAGNOSIS:
hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
***patient eloped prior to delivery of paperwork***
Dear Ms. [**Known lastname 3321**],
It was a pleasure taking care of you. You were admitted to the
hospital for a gastrointestinal bleed. You did not receive a
transfusion and your blood levels are stable. You were also
found to have a urinary tract infection while you were in the
hospital."
4840,"Discharge Medications:
1. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
Disp:*30 Capsule(s)* Refills:*2*
2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. budesonide 3 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO TID (3 times a day).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day)."
4841,"You received an esophagogastroduodenoscopy while you
were in the hospital which did not reveal a source of your
bleeding.
Please note the following changes to your medications:
Please keep all of your follow up appointments.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: Wednesday [**2180-6-21**] at 10:45 AM
Location: [**Hospital3 **] PRIMARY CARE
Address: [**State **], 4TH FL, [**Location (un) **],[**Numeric Identifier 73009**]
Phone: [**Telephone/Fax (1) 4688**]
Department: TRANSPLANT
When: WEDNESDAY [**2180-6-21**] at 3:20 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: MONDAY [**2180-7-3**] at 1:40 PM
With: XMR [**Telephone/Fax (1) 327**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT
When: WEDNESDAY [**2180-8-30**] at 1:20 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage"
4842,"Discharge Physical Exam:
VSS, abdomen is distended, nontender, no fluid wave, no masses.
guiac positive stools. IV's present at time of elopement.
Pertinent Results:
Labs on admission:
===============================================================
WBC-6.9# RBC-3.24* Hgb-12.1 Hct-36.4 Plt Ct-51*
Neuts-76.7* Lymphs-14.6* Monos-5.8 Eos-2.1 Baso-0.7
PT-20.5* PTT-37.3* INR(PT)-1.9*
Glucose-97 UreaN-18 Creat-0.5 Na-137 K-4.7 Cl-112* HCO3-21*
AnGap-9
Albumin-2.4* Mg-1.9
Pertinent Labs and Studies:
Hct 36.4-->32."
4843,"Admission Date: [**2180-6-12**] Discharge Date: [**2180-6-14**]
Date of Birth: [**2148-11-12**] Sex: F
Service: MEDICINE
Allergies:
Nafcillin
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy
History of Present Illness:
31 y.o. female with history of autoimmune hepatitis complicated
by cirrhosis and recurrent ascites presenting with hematemesis
for one day. The patient reports on the morning of presentation
she woke up without significant abdominal pain or nausea but did
notice her abdomen was very distended. She then began to vomit
and had a paroxysm of vomiting where she had five episodes of
emesis each with about a half cup of dark blood per her report."
4844,"9* MCHC-34.2 RDW-16.1* Plt Ct-70*
[**2180-6-14**] 04:50AM BLOOD Glucose-160* UreaN-17 Creat-0.7 Na-133
K-4.4 Cl-103 HCO3-25 AnGap-9
[**2180-6-14**] 04:50AM BLOOD ALT-62* AST-67* AlkPhos-131* TotBili-1.8*
[**2180-6-14**] 04:50AM BLOOD PT-18.8* PTT-37.4* INR(PT)-1.7*
Brief Hospital Course:
31yo female with autoimmune liver disease presenting with UGIB
with bloody emesis x1 day, she is now s/p EGD which did not
reveal bleeding varices but did reveal small grade I varices in
the esophagus and the duodenum."
4845,"Social History:
Lives with mother in [**Name (NI) 14663**].
Smokes 5 cig/day (down from before) x 15 yrs. Has h/o ETOH and
drug abuse (heroin and cocaine) but clean since 9/[**2178**].
Has a 11 year old son [**Doctor First Name **] and a 3 year old daughter ([**Name (NI) **]
[**Name (NI) **]).
Mom is point person.
Family History:
Aunt w/ breast Ca.
No h/o autoimmune hepatitis, early colon CA, or Crohn/UC.
Physical Exam:
Physical Exam on Admission:
Vitals:
Tcurrent: 36.2 ??????C HR: 64 BP: 108/54(66) RR: 14 SpO2: 95%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
4846,"She called EMS and was brought to an OSH where she had an NG
passed that expelled a large amount of dark blood. Reports vary
and some sources (i.e. ED dash) said this was bright red blood
but after reviewing with patient it seems this was all maroon
with only flecks of dark red blood. Unfortunately, she vomited
out the NG tube. She was started on octreotide drip and
transferred to [**Hospital1 18**]. OSH Hct was 36.7.
In the ED VS: T 99.4, P 62, BP 122/75, RR 16, O2 97% 3L. On
arrival to [**Hospital1 18**] Hct was 36."
4847,"Chief Complaint:
24 Hour Events:
- Pt extubated without difficulty
- Pt will need permanent HD line at some point, will have to touch base
with renal in AM
Allergies:
Nsaids
Unknown;
Sulfa (Sulfonamide Antibiotics)
Unknown;
Last dose of Antibiotics:
Ceftriaxone - [**2181-1-8**] 06:47 PM
Ampicillin/Sulbactam (Unasyn) - [**2181-1-9**] 10:00 AM
Infusions:
Other ICU medications:
Furosemide (Lasix) - [**2181-1-10**] 12:48 PM
Heparin Sodium (Prophylaxis) - [**2181-1-10**] 08:29 PM
Pantoprazole (Protonix) - [**2181-1-10**] 10:00 PM
Dilantin - [**2181-1-10**] 10:13 PM
Fentanyl - [**2181-1-11**] 06:42 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2181-1-11**] 07:33 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 38."
4848,"6
C (101.4
Tcurrent: 36.2
C (97.2
HR: 88 (83 - 101) bpm
BP: 127/61(86) {80/41(54) - 145/69(96)} mmHg
RR: 19 (16 - 33) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 75.5 kg (admission): 69.5 kg
Height: 65 Inch
CVP: 6 (-1 - 10)mmHg
Total In:
390 mL
224 mL
PO:
TF:
60 mL
126 mL
IVF:
120 mL
38 mL
Blood products:
Total out:
713 mL
295 mL
Urine:
713 mL
295 mL
NG:
Stool:
Drains:
Balance:
-323 mL
-71 mL
Respiratory support
O2 Delivery Device: None
Ventilator mode: PSV/SBT
Vt (Spontaneous): 348 (348 - 348) mL
PS : 5 cmH2O
RR (Spontaneous): 28
PEEP: 0 cmH2O
FiO2: 35%
PIP: 6 cmH2O
SpO2: 94%
ABG: 7."
4849,"1
16.7
12.8
12.2
Hct
26.5
26.1
25.4
25.9
24.5
24.0
Plt
91
109
106
115
Cr
4.8
3.2
3.4
4.0
TCO2
16
18
19
19
Glucose
77
79
81
103
Other labs: PT / PTT / INR:17.0/37.2/1.5, CK / CKMB /
Troponin-T:784/7/0.15, ALT / AST:32/39, Alk Phos / T Bili:43/0.5,
Amylase / Lipase:44/13, Differential-Neuts:88.8 %, Lymph:6.7 %,
Mono:4.3 %, Eos:0.1 %, Fibrinogen:154 mg/dL, Lactic Acid:1.1 mmol/L,
Albumin:2."
4850,"4 g/dL, LDH:326 IU/L, Ca++:7.4 mg/dL, Mg++:1.9 mg/dL, PO4:4.7
mg/dL
Imaging: CXR: ET tube removed, otherwise no significant change
Microbiology: GRAM STAIN (Final [**2181-1-10**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.
Assessment and Plan
ICU Care
Nutrition:
Nutren 2.0 (Full) - [**2181-1-10**] 06:00 PM 20 mL/hour
Glycemic Control:
Lines:
Dialysis Catheter - [**2181-1-5**] 07:00 PM
Arterial Line - [**2181-1-5**] 07:00 PM
Multi Lumen - [**2181-1-5**] 09:00 PM
Prophylaxis:
DVT: SQ UF Heparin(Systemic anticoagulation: None)
Stress ulcer:
VAP:
Comments:
Communication: Patient discussed on interdisciplinary rounds , Family
meeting held , ICU consent signed Comments:
Code status: Full code
Disposition:Transfer to floor"
4851,"42/28/150/21/-4
Ve: 8.8 L/min
PaO2 / FiO2: 429
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
115 K/uL
8.4 g/dL
103 mg/dL
4.0 mg/dL
21 mEq/L
3.8 mEq/L
60 mg/dL
107 mEq/L
139 mEq/L
24.0 %
12.2 K/uL
[image002.jpg]
[**2181-1-8**] 10:53 PM
[**2181-1-9**] 03:42 AM
[**2181-1-9**] 03:58 AM
[**2181-1-9**] 11:40 AM
[**2181-1-9**] 01:54 PM
[**2181-1-9**] 09:00 PM
[**2181-1-10**] 04:30 AM
[**2181-1-10**] 04:55 AM
[**2181-1-10**] 12:57 PM
[**2181-1-11**] 03:46 AM
WBC
15."
4852,"COMPARISON: No previous exams for comparison.
FINDINGS: Grayscale, color and Doppler son[**Name (NI) 424**] of bilateral common femoral,
superficial, and popliteal veins were performed. There is extensive deep vein
thrombosis throughout the left common femoral, superficial, and popliteal
veins. There is no flow and these vessels do not compress. The right leg
demonstrates normal compression, flow and augmentation in all of the vessels.
IMPRESSION: Extensive deep vein thrombosis from the left popliteal through
the left superficial and common femoral veins. No deep vein thrombosis is
identified in the right leg.
These findings were conveyed to Dr. [**First Name (STitle) 4822**] [**Name (STitle) 3817**] at 2:15 p.m. [**2181-1-8**]."
4853,"[**2181-1-8**] 12:44 PM
BILAT LOWER EXT VEINS Clip # [**Clip Number (Radiology) 89348**]
Reason: please assess LLE and RLE for DVT.
Admitting Diagnosis: SUBDURAL HEMATOMA
______________________________________________________________________________
[**Hospital 3**] MEDICAL CONDITION:
85 year old man with extensive swelling of LLE, please assess LLE and RLE for
DVT.
REASON FOR THIS EXAMINATION:
please assess LLE and RLE for DVT.
______________________________________________________________________________
PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON [**2181-1-8**] 3:56 PM
Extensive DVT in the left leg. No DVT in the right leg.
______________________________________________________________________________
FINAL REPORT
INDICATION: 85-year-old man with swelling of the left lower extremity. Assess
for DVT."
4854,"jpg]
Fluid analysis / Other labs: 7.48/33/94
lactate 0.9
Imaging: CXR - more free abdominal air c/w [**2-1**], patchy bilat
infiltrates
ECG: ST 133, no ischemia
Assessment and Plan
free abdominal air and left psoas collection - abd CT now to assess
g-tube, surgery involved, on vanco + zosyn
tachycardia - looks sinus though may be a-tach, follow for now, gently
hydration
hypotension - resolved, likely related to abdominal process
foot ischemia - local wound care
DVT - IVC filter in place
CVA - no active issues though aphasic and bed bound
bladder outflow obstruction - foley replaced yesterday
UTI - on antibiotics
ICU Care
Nutrition:
Glycemic Control:
Lines / Intubation:
20 Gauge - [**2181-2-3**] 10:43 AM
Dialysis Catheter - [**2181-2-3**] 11:52 AM
Comments:
Prophylaxis:
DVT: IVC filter
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent: 39 minutes
Patient is critically ill"
4855,"4
C (99.4
Tcurrent: 37.4
C (99.4
HR: 122 (118 - 122) bpm
BP: 133/83(94) {127/83(94) - 133/86(96)} mmHg
RR: 25 (22 - 29) insp/min
SpO2: 100%
Total In:
221 mL
PO:
TF:
IVF:
221 mL
Blood products:
Total out:
0 mL
75 mL
Urine:
75 mL
NG:
Stool:
Drains:
Balance:
0 mL
146 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ///25/
Physical Examination
General Appearance: Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Absent), (Left DP pulse: Not
assessed)
Respiratory / Chest: (Breath Sounds: Diminished: )
Abdominal: Tender: , rigid, g-tube in place
Extremities: Right: 2+, Left: 3+, right gangrenous toes
Musculoskeletal: Muscle wasting
Skin: Not assessed
Neurologic: Follows simple commands, Responds to: Not assessed,
Movement: Not assessed, Tone: Not assessed
Labs / Radiology
328
31
17
[image002."
4856,"Chief Complaint: hypotensive, tachycardic
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
85M here since [**1-5**] - began with DVT, led to SDH and seizures
IVC filter placed
acute on chronic renal failure requiring HD
likely CVA
PEG placed 2 days ago - intermittant hypotension since, requiring IVF
CT showed intra-abd fluid collection near psoas and free air (more than
would be expected)
foley placed via cysto yesterday
febrile overnight while receiving blood
hypotensive this AM and transferred to ICU
Patient admitted from: [**Hospital1 19**] [**Hospital1 158**]
History obtained from HO
Patient unable to provide history: non-verbal
Allergies:
Nsaids
Unknown;
Sulfa (Sulfonamide Antibiotics)
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Lorazepam (Ativan) - [**2181-2-3**] 11:46 AM
Morphine Sulfate - [**2181-2-3**] 11:46 AM
Other medications:
see HO note
Past medical history:
Family history:
Social History:
thoracic and aoric aneurysm
bladder ca
TIA
CVA
PVD
ESRD
non-contributory
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: was living independently prior to this hospitalization
Review of systems:
Flowsheet Data as of [**2181-2-3**] 12:25 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37."
4857,"(Had TWI in I, aVL on [**1-1**] EKG).
Assessment and Plan
SUBDURAL HEMORRHAGE (SDH)
SEIZURE, WITHOUT STATUS EPILEPTICUS
HYPOTENSION (NOT SHOCK)
.
This is a 85 M w/ pmh of CRI, HTN, bladder cancer, DVT w/ IVC filter
transferred from OSH w/ SDH, seizures, acute on chronic renal failure,
hypotension.
.
# Respiratory failure: Intubated for airway protection. No respiratory
symptoms prior to intubation. [**Month (only) 51**] well have aspirated prior to
intubation in the context of seizures. Possible LLL infitrate on CXR
- continue ETT w/ CPAP
- will treat ? aspiration PNA w/ unasyn
.
# Hypotension: clearly relatively hypotensive as not on usual BP
regimen."
4858,"# Code: Was DNR/DNI. If underlying cause of AMS is not reversible, son
would want him to be [**Name (NI) 580**].
.
# Communication: Son
.
# Disposition: ICU for now
.
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Dialysis Catheter - [**2181-1-5**] 07:00 PM
Arterial Line - [**2181-1-5**] 07:00 PM
22 Gauge - [**2181-1-5**] 07:00 PM
Multi Lumen - [**2181-1-5**] 09:00 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Need for restraints reviewed
Comments:
Communication: Family meeting held Comments:
Code status: Full code
Disposition: ICU"
4859,"There is
a mild rightward shift of the anterior falx, septum pellucidum and
third ventricle. There is mild mass effect upon the left lateral
ventricle. No intraventricular hemorrhagic extension and no parenchymal
hemorrhage is identified. Prominence of the cerebral sulci is
compatible with age-related involutional change. Periventricular
regions of hypodensity are compatible with chronic microvascular
ischemic change. No fracture is identified. The paranasal sinuses and
mastoid air cells are well aerated. The orbits are unremarkable.
Endotracheal and nasogastric tubes are noted.
IMPRESSION: Large acute subdural hematoma along the convexity and
tentorium, with mass effect as described above.
Microbiology: MRSA screen, blood and urine cx pending
ECG: SR (90), LAD, LAFB, IVCD (LBBB morphology), AV-delay, 1/[**Street Address(2) 5298**]-depressions in V4-V6."
4860,"8 mg/dL, PO4:4.5
mg/dL
Imaging: [**1-5**] CXR: ETT extends into right mainstem bronchus and
repositioning is required. Retrocardiac atelectasis but no large
leftsided collapse or mediastinal shift. Right IJ catheter terminates
lower SVC. d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5297**] at 8pm.
.
[**1-6**] CT Head:
FINDINGS: A mixed but predominantly hyperdense collection overlies the
entire left cerebral hemisphere, measuring up to 19 mm in greatest
transverse dimension, and extending along the left tentorium. It is
consistent with a predominantly acute subdural hematoma. This exerts
mass effect upon the left hemisphere, predominantly in the frontal and
temporal lobes, with effacement
of the underlying cerebral sulci and mild left frontal edema."
4861,"Chief Complaint: Subdural Hematoma
HPI:
85M with prior DVT, HTN and CKD was admitted to NEBH with decreased
appetite and LE swelling. Found to have extensive DVT and acute on
chronic RF. Was started on heparin gtt and yesterday was noted to have
a right facial droop and increased dysarthria, R-sided weakness and
somnolence. He developed what appeared to be a R-sided seizure and
then a grand-mal seizure in the CT scanner at the OSH. He was
intubated for airway protection and transferred to [**Hospital1 19**] to the
neurosurgery service. He was noted to be hypotensive after intubation
(without sedation) prior to transfer and was started on neo."
4862,".
# Anemia: Hct 21 this am. Now only 26 after 2 U PRBC. Could be some
degree of hemodilution as received approx 2 L NS in the setting of
hypotension.
- continue q 4 hr hcts (transfuse for hct < 25)
- guiac stools
- if continues to drop, consider CT abdomen to eval for RP bleed
.
# Acute on chronic renal failure: Unclear baseline cr. No need for
urgent dialysis. No need for urgent dialysis today.
- appreciate renal recs.
.
# FEN: No IVF, replete electrolytes, regular diet
.
# Prophylaxis: Pneumoboots
.
# Access: R IJ dialysis cath placed at OSH, L IJ placed here on [**1-5**], R
art line placed at OSH on [**1-5**]
."
4863,"Labs / Radiology
140 K/uL
7.6 g/dL
156 mg/dL
3.6 mg/dL
55 mg/dL
21 mEq/L
108 mEq/L
4.2 mEq/L
140 mEq/L
26.0 %
16.4 K/uL
[image002.jpg]
[**2177-12-15**]
2:33 A1/23/[**2180**] 06:58 PM
[**2177-12-19**]
10:20 P1/23/[**2180**] 07:08 PM
[**2177-12-20**]
1:20 P1/24/[**2180**] 01:01 AM
[**2177-12-21**]
11:50 P1/24/[**2180**] 03:38 AM
[**2177-12-22**]
1:20 A1/24/[**2180**] 03:52 AM
[**2177-12-23**]
7:20 P1/24/[**2180**] 01:19 PM
1//11/006
1:23 P
[**2178-1-15**]
1:20 P
[**2178-1-15**]
11:20 P
[**2178-1-15**]
4:20 P
WBC
17."
4864,"45/31/171/21/0
Ve: 10.5 L/min
PaO2 / FiO2: 428
Physical Examination
General: Intubated and sedated, bites down on ETT
HEENT: Sclera anicteric, pinpoit pupils, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: cool feet bilaterally w/ eschar on R great toe, LLE swelling w/ +2
edema, not able to palpate pedal pulses; doplerable LLE dp/pt and R dp."
4865,"He fell and hit his head
about 1 week ago but his son noticed only a small cut and so did not
have him evaluated. Over the week prior to admission, he became unable
to walk and needed a wheelchair to get around.
.
Review of sytems:
(+) Per HPI, unable to obtain further as pt intubated
Patient admitted from: SICU/ Neurosurg ICU
History obtained from Family / [**Hospital 75**] Medical records
Patient unable to provide history: Encephalopathy
Allergies:
Nsaids
Unknown;
Sulfa (Sulfonamide Antibiotics)
Unknown;
Last dose of Antibiotics:
Piperacillin - [**2181-1-6**] 01:00 AM
Vancomycin - [**2181-1-6**] 01:30 AM
Infusions:
Other ICU medications:
Lorazepam (Ativan) - [**2181-1-6**] 12:25 PM
Other medications:
Home:
oxycodone
Calcitrol
Prilosec
Mentax
avocat
Flomax
Timoptic
Travatan
Dyazide
vitamin D
Vitamin B12
."
4866,"9% Flush 3 mL IV Q8H:PRN line flush Peripheral line:
Flush with 3 mL Normal Saline every 8 hours and PRN. Order date: [**1-5**]
@ [**2183**]
Influenza Virus Vaccine 0.5 mL IM ASDIR Follow Influenza Protocol
Document administration in POE Order date: [**1-5**] @ [**2175**]
Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central
Access-ICU: Flush with 10mL Normal Saline daily and PRN. Order date:
[**1-5**] @ 2124
Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: [**1-5**] @
[**2183**] 22. Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date: [**1-6**]
@ 0058
Past medical history:
Family history:
Social History:
HTN
thoracic and abdominal aortic aneurysm
h/o transitional cell bladder cancer
CKD
h/o lumbar laminectomy
tertiary hyperparathyroidism
BPH
DVT in the past, s/p IVC filter placement
bilateral cataracts s/p removal
glaucoma
s/p L TKR
?"
4867,"Corrected dilantin level elevated.
- check with neuro re dilantin dosing w/ ativan
- EEG
- appreciate neuro input
.
# Altered mental status: DDX from SDH vs from ativan vs from
post-ictal state. Was not given sedation for intubation. Unlikely
from uremia as BUN in 50s. No longer hypotensive. ? from
non-convulsive status epilepticus.
- EEG, continue dilantin
- Appreciate neurosurg and neuro recs
- treat for possible sepsis as above
.
# Large subdural hematoma: Per neurosurg, this is unlikely the cause of
his altered mental status. Per neurosurg, CT stable.
.
# DVT: H/o prior DVT w/ IVC filter. Developed SDH in the setting of
heparin ggt."
4868,"Admission Date: [**2181-1-5**] Discharge Date: [**2181-2-7**]
Service: MEDICINE
Allergies:
Nsaids / Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer from Neurosurg to MICU for Acute renal failure
Major Surgical or Invasive Procedure:
IVC Filter Placement
Central Line placement
Arterial Line placement
Hemodialysis
Intubation/Mechanical Ventilation
History of Present Illness:
85M with prior DVT, HTN and CKD was admitted to NEBH with
decreased appetite and LE swelling. Found to have extensive DVT
and acute on chronic RF. Was started on heparin gtt and
yesterday was noted to have a right facial droop and increased
dysarthria, R-sided weakness and somnolence."
4869,"Past Medical History:
HTN
thoracic and abdominal aortic aneurysm
h/o transitional cell bladder cancer
CKD
h/o lumbar laminectomy
tertiary hyperparathyroidism
BPH
DVT in the past, s/p IVC filter placement
bilateral cataracts s/p removal
glaucoma
s/p L TKR
?[**Name (NI) **] unclear per records
PVD ? Fem/[**Doctor Last Name **] bipass
Social History:
Was living independently prior to 2 weeks ago.
Physical Exam:
Admission Exam:
General: Intubated and sedated, bites down on ETT
HEENT: Sclera anicteric, pinpoit pupils, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: cool feet bilaterally w/ eschar on R great toe, LLE
swelling w/ +2 edema, not able to palpate pedal pulses;
doplerable LLE dp/pt and R dp."
4870,"Brief Hospital Course:
85 year old gentleman with CRI, HTN, Bladder CA and known R [**Hospital **]
transferred from NEBH with Subdural Hematoma, Seizures, and new
acute on chronic renal failure requiring dialysis. He was
transfered to our Neurosurgical service then MICU for evaluation
of altered mental status and sepsis.
# Altered mental status: AMS began with the development of a
SDH after treatment of extensive LLE DVT with a heparin gtt.
The patient was transfered to the MICU on [**1-8**].
Neurosurgery was the initial primary team (then consulting) and
based on family discussions and repeat head imaging no
intervention was performed."
4871,"#. Subdural hematoma: After discovery of an extensive DVT of
the LLE at an OSH, the patient was started on a heparin gtt. He
subsequently developed right facial droop and increased
dysarthria, R-sided weakness and somnolence. He developed what
appeared to be a R-sided seizure and then a grand-mal seizure in
the CT scanner at the OSH. He was intubated for airway
protection and transferred to [**Hospital1 18**] to the neurosurgery service.
He was noted to be hypotensive after intubation (without
sedation) prior to transfer and was started on neo. Heparin was
stopped due to head bleed and IVC Filter placed."
4872,"The patient
developed a subdural hematoma at the outside hospital presumed
secondary to heparin therapy for a DVT. Neurosurgery was the
initial primary team (then consulting) and based on family
discussions and repeat head imaging no intervention was
performed. The hematomas were stable on transfer. See below
for seizure treatment related to hematoma.
.
# Seizures: The patient developed right sided seizures likely
due to his subdural hematoma as confirmed by EEG and neuro
consult. The patient was started on ativan, dilantin, and keppra
for seizure control. He will be tapered off of dilantin,
transitioned to Keppra and the ativan held.
.
# Acute on Chronic renal failure: Acute on chronic kidney
failure likely due to contrast induced nephropathy, despite
pretreatment with IVF and bicarb."
4873,"The renal team will directly
contact the receiving rehab facility about dialysis information.
.
# Pneumonia: Gram [**Last Name (un) **] suggestive of infection treated with 7
days of Vanc/Zosyn followed by Unasyn with a resolution of white
count and no fevers early in the admission. He did have another
infection of unclear source which resulted in sepsis and a
second transfer to the MICU. See below for details of that
infection.
.
# Right toe eschar-unable to palpate, + Doppler pulses and
concern is for arterial insufficiency. Vascular
consulted-follow recs suggested nitropaste only, no intervention
given bleed and contraindication for heparin. Due to
intermittant hypotension, the nitropaste was discontinued."
4874,"He
went for catheterization, which demonstrated severe, diffuse
disease, not amenable to stenting. Due to prior SDH, patient
was not a candidate for anticoagulation. Prelim report on US
showed SFA occlusion with reconstitution distal to popliteal.
.
#. DVT: The patient was found to have extensive DVT and acute on
chronic RF. Was started on heparin gtt and subsequently
developed a SDH. The heparin was stopped and an IVC filter was
placed in [**Doctor Last Name 2434**]. He does not have signs of PE with good
oxygenation on room air.
.
# Hematuria: insetting of change of [**Last Name (un) 21655**] and [**Last Name (un) 21655**] care."
4875,"The patient remained persistently hypotensive
despite IVF and was transferred to the MICU for concern for
urosepsis. See below for MICU course.
.
# Anemia: Hct 25.5 in setting of hemodilution and hematuria-no
further hematuria overnight after foley replaced by urology.
Iron studies were obtained and were consistent with anemia of
chronic disease. The HCT remained stable.
.
# Thrombocytopenia: Resolved.
_____________________________________________
MICU admission [**Date range (1) 21656**]: Patient was transferred to MICU on
[**2-3**] for hypotension in the setting of concern for sepsis with a
possible complication of the G-tube placement. Imaging did not
show problems with the G tube placement and patient became
afebrile and resolved leukocytosis on vanc/zosyn/fluconazole."
4876,"Surgery followed and determined that the G tube was safe to use.
Pressures were MAP>60 and SBP in 90s, higher than pressures on
admission. Pressure throughout the course of hospitalization
have not been greater than SBP 110.
.
# Sepsis - his hypotension that resulted in transfer to the MICU
was likely urosepsis, although no organism was ever grown in
culture. Other sources could have been the intraabdominal fluid
collection, although surgery consulted and did not think it was
an infection. He responded to a course of vanco and zosyn and
should complete a two week course of the antibiotics. The end
date is [**2-12**]."
4877,"He quickly reached goal and did not
have high residuals.
.
# SVT - The day prior to discharge, the patient developed [**4-18**]
transient episodes of SVT with rates of 140. The episodes last
approximately 1-20 minutes and were asymptomatic to the patient.
He maintained a normal blood pressure during these episodes.
Most of the episodes broke with vagal manuevers or with a
spontaneous PVC. We started diltiazem for rate control at a
very low dose as to not drop his blood pressures. He tolerated
the diltiazem well and should be continued on it.
.
IN SUMMARY:
85 y/o M who presented after anticoagulated DVT resulted in SDH."
4878,"Also found to have old strokes, now with resultant
quadraparesis. Had seizures that were treated with keppra.
Also initially had a pneumonia, s/p treatment. While receiving
imaging during workup of these above issues developed acute on
chronic renal failure and started on HD, now due for Monday and
Thursday dialysis. Had workup of ischemic feet, showed diseased
vasculature, but no intervention done. No infection of necrotic
toes. Was recovering well but after G tube placement had
hypotension likely from sepsis of unclear etiology, although
urine most likely source. Has known yeast infection in bladder;
urology following and has permanent foley cath in."
4879,"10 Ng/Ml Suggests Acute Mi
Ca: 7.5 Mg: 1.9 P: 4.7
ALT: 32 AP: 46 Tbili: 1.1 Alb: 2.6
AST: 45 LDH: Dbili: TProt:
[**Doctor First Name **]: 44 Lip: 13
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Comments: Positive Tricyclic Results Represent Potentially Toxic
Levels;Therapeutic Tricyclic Levels Will Typically Have Negative
Results
TSH:1.5 Free-T4:1.1
Phenytoin: 14.7
PT: 13.7 PTT: 27.6 INR: 1.2
Fibrinogen: 351
.
Of note in microbiology,
pt only grew [**Female First Name (un) **] albicans in urine, otherwise all cultures
were negative without any obvious organism."
4880,"Moderate-to-severe periventricular white matter hypodensity is
consistent with chronic small vessel ischemic changes.
Atherosclerotic calcifications involve the cavernous carotids
and intracranial vertebral arteries bilaterally. The imaged
portions of the paranasal sinuses appear well aerated.
IMPRESSION: Evolving left cerebral convexity subdural hematoma
with unchanged minimal mass effect, stable compared to the CT
from [**1-18**].
.
MRI Head:
FINDINGS: Areas of slow flow and restricted diffusion are seen
in the right posterior parietal periatrial region with high
signal on diffusion images and low signal on ADC map indicative
of acute infarcts. Small acute infarcts are also seen in right
parietal and left frontal lobes."
4881,"8
.
Radiology Studies:
.
CT head on admission:
FINDINGS: A mixed but predominantly hyperdense collection
overlies the entire left cerebral hemisphere, measuring up to 19
mm in greatest transverse dimension, and extending along the
left tentorium. It is consistent with a predominantly acute
subdural hematoma. This exerts mass effect upon the left
hemisphere, predominantly in the frontal and temporal lobes,
with effacement of the underlying cerebral sulci and mild left
frontal edema. There is a mild rightward shift of the anterior
falx, septum pellucidum and third ventricle.
There is mild mass effect upon the left lateral ventricle. No
intraventricular hemorrhagic extension and no parenchymal
hemorrhage is
identified."
4882,"Pertinent Results:
Admission Labs:
[**2181-1-5**] 06:58PM BLOOD WBC-17.1* RBC-2.73* Hgb-8.5* Hct-24.1*
MCV-88 MCH-31.0 MCHC-35.1* RDW-16.9* Plt Ct-175
[**2181-1-5**] 06:58PM BLOOD Neuts-88.8* Lymphs-6.7* Monos-4.3 Eos-0.1
Baso-0.1
[**2181-1-5**] 06:58PM BLOOD PT-13.7* PTT-27.6 INR(PT)-1.2*
[**2181-1-5**] 06:58PM BLOOD Glucose-162* UreaN-51* Creat-3.6* Na-141
K-4.2 Cl-107 HCO3-21* AnGap-17
[**2181-1-5**] 06:58PM BLOOD ALT-32 AST-45* CK(CPK)-778* AlkPhos-46
Amylase-44 TotBili-1."
4883,"Prominence of the cerebral sulci is compatible with age-related
involutional change. Periventricular regions of hypodensity are
compatible with chronic microvascular ischemic change.
No fracture is identified. The paranasal sinuses and mastoid air
cells are
well aerated. The orbits are unremarkable. Endotracheal and
nasogastric
tubes are noted.
IMPRESSION: Large acute subdural hematoma along the convexity
and tentorium, with mass effect as described above.
.
CT Head on [**1-21**] for follow up:
FINDINGS: An evolving subdural hematoma along the left cerebral
convexity
again likely extends along the left tentorium cerebelli.
Minimal, 1 mm,
rightward midline shift is unchanged. Ventricular and sulcal
caliber is
unchanged and no new intracranial hemorrhage is identified."
4884,"The
patient also has a history of bladder cancer; urology saw
patient earlier in admission. Several U/As were positive for
yeast infection. The patient had a prolonged course of oral
fluconazole and topical miconazole. The yeast infection cleared
on subsequent U/A. But per urology recs, he is to complete a 14
day course of fluconazole. The end date of fluconazole is 11
days from day of discharge on [**2-17**]. He should not have his foley
changed once at rehab as it was placed with cystoscopy and is a
difficult change. He should follow up with urology in 2 weeks
after his fluconazole is completed for reevaluation of need for
foley."
4885,"Aneurysmal abdominal aorta at the diaphragmatic crura is
unchanged from prior study, with atherosclerotic changes.
The gallbladder appears dilated, though unchanged from the prior
study.
Again noted is prominence of the left psoas muscle, with an area
of
hypodensity, which may represent fluid collection, however,
infection cannot be excluded.
There is no evidence of bowel dilatation.
IVC filter is again noted. There are degenerative endplate
changes in the
thoracolumbar spine.
IMPRESSION:
1. No evidence for G-tube extravasation.
2. No interval change in enlargement of the left psoas muscle
with hypodense collection in the left flank. While this may
represent old hematoma, a loculated infected collection cannot
be excluded and intravenous contrast would be necessary for
additional evaluation."
4886,"Referral to vascular surgery for right leg BKA.
FINAL DIAGNOSIS:
1. Right SFA occlusion with severe infra-popliteal disease.
.
Renal US:
IMPRESSION: Probably no hydronephrosis.
.
CT abdomen and Pelvis Follow up:
FINDINGS
100 cc of contrast was administered through G-tube. There is no
contrast
extravasation. Extensive pneumoperitoneum is again noted.
However, this is
unchanged from the prior examination from the previous day.
There is bilateral pleural effusion, small in quantity, not
significantly
changed from the prior study. The unenhanced liver and spleen
appear
unremarkable. There is bilateral hydronephrosis and mild
hydroureter. This
is likely on the basis of the significant wall thickening seen
in the urinary bladder."
4887,"A subsequent TTE on [**1-23**] demonstrated regional left
ventricular systolic dysfunction consistent with coronary artery
disease. A left atrial/ [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] thrombus cannot be excluded
by TTE. If clinically indicated, a TEE would better assess for
this possibility. No significant change from prior. Carotid
ultrasound noted: Less than 40% stenosis in the right and left
internal carotid arteries. MRA was held due to concern for
acute on chronic renal disease. The patient was placed on ASA
to treat the embolic strokes after consultation with
neurosurgery.
for his QUADRAPARESIS: MRI of the C-spine: Multilevel
degenerative change is seen, with Moderate spinal stenosis at
C4-5 and mild-to-moderate spinal stenosis at C5-6 and C6-7 with
extrinsic indentation on the spinal cord, and postoperative
changes with posterior bony bar at C3-4 slightly indenting the
spinal cord."
4888,".
Lower Extremity Cath:
COMMENTS:
1. Access via LFA via 4F catheter.
2. Imaging of the distal aorta with a Omniflush catheter at L1
revealed
mild aortic disease with no renal artery stenosis. The iliacs
were very
tortuous on both sides but without flow limiting lesions. The
CFA's
were without lesions.
3. Imaging of the right leg with a Slip cath in the right SFA
revealed
a mid SFA 10cm occlusion. There was a high grade popliteal
lesion and
single vessel run off to the foot via a peroneal. There was
only very
faint filling of plantars and DP.
4."
4889,"3. Postoperative changes with posterior bony bar at C3-4
slightly indenting the spinal cord. Atrophic changes in the
spinal cord at C3-4 level.
.
ECHOs:
[**1-8**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
basal inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 50 %). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present."
4890,"He developed what
appeared to be a R-sided seizure and then a grand-mal seizure in
the CT scanner at the OSH. He was intubated for airway
protection and transferred to [**Hospital1 18**] to the neurosurgery service.
He was noted to be hypotensive after intubation (without
sedation) prior to transfer and was started on neo. An aline was
placed also prior to transfer.
.
This morning, the neurosurgery attending asked that the MICU
take over his care given the complexity of his medical problems.
.
On eval, he was intubated and sedated. Does not follow commands.
Not on sedation although received 2 mg of IV ativan within the
past 2 hours for possible seizure."
4891,".
16. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Month (only) **]: One (1)
Intravenous twice a day: through [**2-12**].
17. Insulin Lispro 100 unit/mL Solution [**Month (only) **]: Per sliding scale
Subcutaneous ASDIR (AS DIRECTED): Please see sliding scale.
18. Epoetin Alfa 10,000 unit/mL Solution [**Month (only) **]: At hemodialysis
Injection ASDIR (AS DIRECTED).
19. Verapamil 40 mg Tablet [**Month (only) **]: One (1) Tablet PO Q12H (every 12
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
-Deep venous thrombosis
-Subdural Hemorrhage
-Seizure disorder
-End Stage Renal Disease on Hemodialysis
-SVT treated with vagal maneuvers"
4892,"4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Hospital1 **]: One
(1) PO TID (3 times a day).
6. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for cough."
4893,"The patient was admitted with
temporary HD line in place after 3 days of HD. He was seen by
our renal service and dialyzed once through the temporary line
with no further indication for dialysis at the time of transfer.
The patient developed a fever of unknown origin, and the
temperary HD line was pulled due to concern that it would be
seeded by infection. He subsequently developed fluid overload,
resistent to medical therapy. Nephrology then saw him and
placed a permanent HD line, and received regular HD. He
develops moderated hypotension during HD but was otherwise
asymptomatic. The plan is to continue Monday and Thursday
dialysis indefinitely for now."
4894,"10. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Five Hundred (500) MG
PO BID (2 times a day).
14. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q48H (every
48 hours) for 11 days: Monitor for interaction with statin.
Watch for ck elevation or rhabdo. .
15. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
gram Intravenous HD PROTOCOL (HD Protochol): through [**2-12**]."
4895,"Changes of
cervical spondylosis are visualized, which are further evaluated
with cervical spine
MRI. Bilateral basal ganglia lacunes are seen.
IMPRESSION:
1. Small areas of restricted diffusion in the left frontal lobe,
right
parietal lobe, and left periatrial region suggestive of embolic
infarcts.
2. Left-sided subdural hematoma extending from frontal to
occipital region
with obliteration of adjacent sulci. No midline shift. Brain
atrophy and
small vessel disease.
.
MRI C-Spine
IMPRESSION:
1. Limited study due to motion. Multilevel degenerative change
is seen.
2. Moderate spinal stenosis at C4-5 and mild-to-moderate spinal
stenosis at C5-6 and C6-7 with extrinsic indentation on the
spinal cord."
4896,"There is subacute subdural hematoma identified extending from
frontal to
occipital region on the left with a maximum width of
approximately 1.5 cm to 2 cm at the convexity with indentation
on the sulci. Increased signal along the sulci may indicate
small amount of subarachnoid hemorrhage or stasis of the CSF
secondary to subdural. Small amount of subdural collection is
also seen along the left side of the tentorium. There is no
midline shift seen. Moderate to severe brain atrophy and
moderate changes of small vessel disease are identified. There
is no midline shift. Sagittal T2 images were obtained to
evaluate the brainstem, but are limited by motion."
4897,"Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary
Central Access-ICU: Flush with 10mL Normal Saline daily and PRN.
Order date: [**1-5**] @ 2124
Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:
[**1-5**] @ [**2183**] 22. Vancomycin 1000 mg IV ONCE Duration: 1 Doses
Order date: [**1-6**] @ 0058
Discharge Medications:
1. Latanoprost 0.005 % Drops [**Month/Year (2) **]: One (1) Drop Ophthalmic HS (at
bedtime).
2. Timolol Maleate 0.5 % Drops [**Month/Year (2) **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical QD (): Apply to mid
back."
4898,"He had a midline placed for abx
administration. He recovered quickly without any need for
pressure support. He was not dialyzed during this time because
of his hypotension, but has been dialyzed the last two days
prior to discharge and was run even. He maintained his BPs
during this time.
.
# Pneumoperitoneum on CT scan - during imaging while working up
his hypotension, CT revealed pneumoperitoneum around the G tube
placement. He had a benign abdomen exam and it was not thought
to be cause of his hypotension. His tube feeds were initially
held, but with surgery following along were restarted several
days prior to discharge."
4899,"Order date: [**1-6**] @ 0058
8. Calcium Gluconate 2 gm / 100 ml D5W IV ONCE Duration: 1 Doses
Order date: [**1-6**] @ 0428
Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**1-5**] @
[**2176**]
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **] Use only
if patient is on mechanical ventilation. Order date: [**1-5**] @
[**2114**]
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. Order
date: [**1-5**] @ [**2183**]
Influenza Virus Vaccine 0.5 mL IM ASDIR Follow Influenza
Protocol Document administration in POE Order date: [**1-5**] @ [**2175**]"
4900,"There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction c/w CAD (PDA distribution).
Dilated ascending and descending thoracic aorta. Mild pulmonary
artery systolic hypertension.
.
[**2-5**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the
inferior and inferolateral walls."
4901,"His neurologic status did improve
over time, but persistent deficits lead to subsequent neurologic
consultation. The following problems were addressed by the
neurology team:
for his ENCEPHALOPATHY: toxic-metabolic work up identified the
following possible etiologies: yeast UTI, PNA, R LE necrosis, L
DVT, ESRD on HD. His sedating medications were limited. A
repeat routine EEG demonstrated no evidence of subclinical sz
activity. MRI of the brain, however, demonstrated small areas
of restricted diffusion in the left frontal love, right parietal
love, and left periatal region suggestive of embolic infarcts;
improving SDH.
for his STROKES: MRI of the brain demonstrated actute embolic
infarcts."
4902,"Is being
treated with vanco and zosyn and fluconazole for sepsis. Had
SVTs treated with diltiazem.
.
So, once at rehab, he should continue his antibiotic course of
vanco, zosyn and fluconazole. He can start PT/OT. He should
follow up with neuro, urology and his PCP.
Medications on Admission:
oxycodone
Calcitrol
Prilosec
Mentax
avocat
Flomax
Timoptic
Travatan
Dyazide
vitamin D
Vitamin B12
.
On transfer:
Lorazepam 2 mg IV ONCE Duration: 1 Doses Order date: [**1-5**] @
[**2115**]
IV access: Temporary central access (ICU) Location: Left
Subclavian, Date inserted: [**2181-1-5**] Order date: [**1-5**] @ 2124
Lorazepam 1-5 mg IV Q4H seizure activity hold if oversedated
Order date: [**1-6**] @ 0820
1000 mL NS Continuous at 80 ml/hr Order date: [**1-5**] @ [**2183**]
Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses Order date:
[**1-6**] @ 0428
1000 mL NS Bolus 1000 ml Over 60 mins Order date: [**1-5**] @ 2250
Norepinephrine 0."
4903,"1
[**2181-1-5**] 06:58PM BLOOD CK-MB-5 cTropnT-0.12*
[**2181-1-6**] 03:38AM BLOOD CK-MB-6 cTropnT-0.14*
[**2181-1-6**] 01:23PM BLOOD CK-MB-7 cTropnT-0.15*
[**2181-1-5**] 06:58PM BLOOD Albumin-2.6* Calcium-7.5* Phos-4.7*
Mg-1.9
[**2181-1-5**] 06:58PM BLOOD Free T4-1.1
[**2181-1-5**] 06:58PM BLOOD TSH-1.5 [**2181-1-5**] 06:58PM BLOOD
Phenyto-14.7
[**2181-1-5**] 07:08PM BLOOD Type-ART pO2-306* pCO2-28* pH-7.48*
calTCO2-21 Base XS-0
[**2181-1-5**] 07:08PM BLOOD Lactate-1."
4904,"The remaining segments
contract normally (LVEF = 50 %). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2181-1-23**], a
prominent left pleural effusion is now identified and the
estimated pulmonary artery systolic pressure is lower. Left
ventricular wall motion is similar."
4905,"Atrophic changes in the spinal cord at C3-4 level.
The patient was transferred to the MICU minimally responsive to
stimuli on intermittent ativan. He was intubated for airway
protection and maintained on pressure support with minimal
requirements. His altered mental status was attributed to a
combination of new subdural hematoma, which remained stable
throughout admission, and resulting seizure activity. On
transfer he is responsive to questions with the appropriateness
of his garbled answers uncertain.
As treatment for the seizures, he was started on keppra and
should be continued on this until neurology follow up is
arranged. The dose is keppra 500 mg [**Hospital1 **]."
4906,"03-0.25 mcg/kg/min IV DRIP TITRATE TO SBP >
100mmHg Order date: [**1-5**] @ [**2183**]
500 mL NS Bolus 500 ml Over 30 mins Order date: [**1-5**] @ 2149
Pantoprazole 40 mg IV Q24H Order date: [**1-5**] @ [**2183**]
500 mL NS Bolus 500 ml Over 30 mins Order date: [**1-5**] @ 2149
Phenytoin 100 mg IV Q8H Hold am dose until trough level back.
Order date: [**1-5**] @ 2250
Acetaminophen 650 mg PR Q4H:PRN fever or pain Order date: [**1-5**]
@ [**2183**]
Piperacillin-Tazobactam Na 2.25 g IV ONCE Duration: 1 Doses
*Awaiting ID Approval* ID Approval is required for this order."
4907,".
Per his son who is at his bedside, he was doing well until about
2 months ago at which point they noticed a 15 pound weight loss
and hematuria. Bladder cancer was discovered and he had a
cystoscopic removal of tumor. 2 weeks ago, his son noted that he
was increasingly tired w/ decreased appetite and LE swelling. He
fell and hit his head about 1 week ago but his son noticed only
a small cut and so did not have him evaluated. Over the week
prior to admission, he became unable to walk and needed a
wheelchair to get around."
4908,"Here we treated you for your seizures. We found that they were
likley caused by a large subdural hematoma in your brain. You
also developed renal failure and needed to start hemodialysis.
He placed a Gtube in your stomach to feed you. We also needed
to treat you for a severe infection that caused your blood
pressure to get low. You were on antibiotics and improved. You
will now continue to recover at rehabilitation, complete your
course of antibiotics, and work on your strength.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please call [**Telephone/Fax (1) 164**] to make an appointment with Dr. [**Last Name (STitle) 770**]
- Urologist for follow-up 2 weeks after discharge.
Please call [**Telephone/Fax (1) 21657**] to make and appointment with Dr. [**Last Name (STitle) **]
(Neurology) for follow-up for 4-6 weeks after discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2181-2-7**]"
4909,"Discharge Condition:
Vital signs were stable, SBP occassionally drops to 80s but pt
is without change in mental status. Patient with G-tube in
place. Patient is communicative with non-verbal signs.
Afebrile. Completing course of antibiotics.
Discharge Instructions:
You were admitted initially at [**Hospital1 **]-[**Location (un) 620**] with decreased
appetite and leg swelling. You were found to have extensive DVT
and acute on chronic renal failure. You were later noted to have
right-sided weakness and somnolence, developed what appeared to
be a right-sided seizure and then a grand-mal seizure. You were
intubated for airway protection and transferred to [**Hospital1 18**]."
4910,"In setting of ARF, he does still make small amounts of
urine.
.
# Inability to swollow: Possibly multifactorial with left sided
SDH and acute embolic areas of infarction, in addition to severe
cervical spinal stenosis. Speach and swallow evaluation
occurred on more than one occasion, and he was unable to protect
his airway, and did not have a gag reflex. After a significant
amount of time with an NG tube, and multiple conversations with
the Son, her received a G-tube. He is receiving tube feeds and
reached his goal rate.
.
# Hypotension developed within two days of G-tube placement and
in the setting of penile instrumentation."
4911,"Etiology could be from
a number of cuases including bleeding in the setting of his
recent G-tube placement, hypovolemia, perhaps increased vagal
tone from bladder distention, sepsis from gangrenous foot, and
ACS. A CT of his abdomen demonstrated a fluid collection that
was not consistent with blood by [**Doctor Last Name **], but could not differentiate
between sterile fluid collection or an abscess without contrast.
The patient received fluid boluses, narcan to reverse the
potential effects of the 1mg of i.v. morphine the patient
received. In addition, the patient had blood and urine
cultures. The urine culture wa positive for bacteria and >50
WBCs, > 50 RBCs."
4912,"3. Again noted mild bilateral hydronephrosis, which is likely
secondary to
significant bladder wall thickening.
4. Unchanged pneumoperitoneum.
.
CT chest:
IMPRESSION: Dilated ascending aorta and thoracoabdominal
junction. Bilateral psoas hematoma, much larger on the left,
extending in the retroperitoneum.
.
Labs on Discharge:
CHMS ADDED 2253 [**2181-1-5**]
141 / 107 / 51 162 AGap=17
----------------
4.2 / 21 / 3.6
WBC 9.4, Hct 28.5, Plt 249
all have been stable over the last several days
estGFR: 16/20 (click for details)
CK: 778 MB: 5 Trop-T: 0.12
Comments: cTropnT: Called [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 21654**],303am,[**2181-1-6**]
cTropnT: Ctropnt > 0."
4913,"Admission Date: [**2130-2-7**] Discharge Date: [**2130-2-14**]
Date of Birth: [**2096-2-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
ABSCESS
Major Surgical or Invasive Procedure:
IR drainage of peri-J-pouch abscess
History of Present Illness:
34 yo man with h/o UC s/p lap total colectomy with end
ileostomy [**11-21**] with ileoanal J pouch and diverting colostomy
[**2130-1-18**] presents with 1 week nausea/vomiting and 3 days with
minimal UOP. Pt was recovering well post-op until 1 week ago
when
he began to feel nauseated and complained of rectal pain."
4914,"Pt denies fevers, but has had temperature drops (94.7 F at OSH).
Reports periods of shaking chills of [**4-23**] minute duration since
his surgery that may coincide with narcotic troughs. Denies
loose
output from ileostomy.
Past Medical History:
Crohn's Disease
migraine headaches.
disc operation.
Social History:
He does not smoke cigarettes. He drinks alcohol socially. He is
married and works as a lawyer for the department of labor.
Family History:
noncontributory
Physical Exam:
At discharge:
Gen: A and O x 3, NAD
V.S: 98.6, 80, 118/62, 18, 96% RA
CV: RRR, no m/r/g
Resp: LSCTA, NARD
Abd: soft, nt, nd, +BS, ostomy beefy red
Ext: c/c/e"
4915,"The
patient was made NPO with IV hydration and IV medications/abx. A
foley and NGT were placed. Labs indicated acute renal failure
and leukocytosis.
.
#.Severe Sepsis: Caused by abscess at site of J pouch detected
by CT. Patient with significant leukocytosis, thrombocytosis.
Received zosyn in the ED, unsure if he received vancomycin. Has
been hemodynamically stable. Lactate 0.7. ABX were continued and
surgery requested IR guided drainage of the abcess.
.
#.Acute Renal Failure. Baseline Cr. 1.0. presented with Cr 9.9.
UA without nitrites but with WBC and bacteria. Likely prerenal
from poor renal perfusion in setting of sepsis."
4916,"K is 5.1. Has
put out 4000cc of urine in ED, 1225 out of ostomy. Responsive to
fluid. ABG was obtained and renal was notifed. Naprosyn was held
and labs were trended (K, PO4, Cr)
.
#Leukocytosis: likely from abscess at J pouch.
.
#.Anemia: Baseline hematocrit ranges between 34-39.0. MCV 94
Possibly from GI bleeding in setting of colitis and surgeries,
may also be anemia of chronic disease. iron studies, B12,
Folate, Hemolysis labs-guaiac ostomy.
.
#.Thrombocytosis: Likely reactive from infection and
inflammatory disease, anemia. Monitor.
.
#.Transaminitis: with elevated alk phos, consistent with
cholestasis, may be due to sepsis."
4917,"Presented to clinic on [**2130-2-2**], rectum assessed w/o evidence of
abscess. Pt went home but still felt nauseated and had decreased
PO intake. Over the next 3 days, he only urinated once and noted
decrease in his ileostomy output by about 25%. Nausea continued
through day of presentation when the patient vomited brownish
fluid and felt ""he could no longer go on like this."" He
presented
initially to [**Hospital3 3583**], where labs where drawn and a KUB
was done. Labs suggested acute renal failure per patient, and
KUB
showed ""air in stomach."" Pt then transferred to [**Hospital1 18**] for
further
workup."
4918,"Medications on Admission:
Clonazepam 1mg TID, Naproxen 500mg q12h, Percocet 7.5/325 [**12-16**]
tab q4-6hrs prn, OxyContin 20mg [**Hospital1 **], atenolol 75mg daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO 1800 ().
3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours)."
4919,"Unsure of common bile dcut
dilation. will fractionate bilirubin. Wait for acute process to
resolve before pursuing other etiologies. CT showing stones but
no acute cholecystitis.
.
PPX:
-DVT ppx with pneumoboots, sub q heparin
-Bowel regimen colace, senna
-Pain management with dilaudid
.
[**2130-2-7**]:
-Had IR drainage of J-pouch abscess
-Cr steadily improved over course of the day and leukocytosis
and thrombocytosis improving on PM labs
-Got hydromorphone for pain with good effect
-PICC postponed as febrile
-APAP negative, iron studies c/w iron of chronic inflammation,
B12 elevated and folate normal
-Kept UOP > 100/hr.
.
The pt was admited to [**Hospital Ward Name **] 5."
4920,"0
[**2130-2-13**] 04:10AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.1
[**2130-2-7**] 10:33AM BLOOD calTIBC-217* VitB12-1669* Folate-11.5
Hapto-473* Ferritn-420* TRF-167*
.
Micro:
[**2-7**] blood: no growth final
[**2-7**] abscess: Multiple micro on Gram stain. MSSA Pan sensitive
and BETA STREPTOCOCCI, NOT GROUP A MODERATE GROWTH.
[**2-13**]: JP drain 4+ poly, 2+ GPC pairs/clusters
.
CT abd: 4x6cm abscess near J pouch
Brief Hospital Course:
The patient was admitted to the ICU for close assessment. A CT
scan of his abd/pelvis were ordered and indicated 4x6cm abscess
near J pouch, new gallstone without any secondary findings of
acute cholecystitis and no findings of bowel obstruction."
4921,"* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Drain:
-Please continue to empty drain twice a day or as needed.
-Please continue to record daily output from drain.
-Please continue to assess drain site for signs and sypmtoms of
infection.
-The visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] you will this.
.
PICC line-
-Please continue to administer antibiotics as ordered for the
next six days every 8 hrs.
-Please continue with PICC care as [**Name6 (MD) 48630**] by RN and
VNA/infusion company.
-Please continue to assess for signs and symptoms of infection.
Followup Instructions:
Scheduled Appointments :
1. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2130-2-20**] 1:30
[**Hospital Ward Name **] [**Location (un) 470**]
2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2130-2-21**] 3:00
NEITHER DICTATED NOR READY BY ME
Completed by:[**2130-2-14**]"
4922,"Pertinent Results:
[**2130-2-13**] 04:10AM BLOOD WBC-14.1* RBC-3.57* Hgb-10.9* Hct-33.1*
MCV-93 MCH-30.6 MCHC-33.0 RDW-13.8 Plt Ct-633*
[**2130-2-7**] 03:00AM BLOOD Neuts-82* Bands-2 Lymphs-8* Monos-4 Eos-1
Baso-0 Atyps-1* Metas-1* Myelos-1*
[**2130-2-13**] 04:10AM BLOOD Plt Ct-633*
[**2130-2-13**] 04:10AM BLOOD Glucose-81 UreaN-9 Creat-1.6* Na-139
K-4.4 Cl-101 HCO3-29 AnGap-13
[**2130-2-8**] 04:10AM BLOOD ALT-52* AST-36 LD(LDH)-121 AlkPhos-399*
TotBili-1."
4923,"Discharge Diagnosis:
Primary:
ABSCESS
.
Secondary:
PMH: ""abnormal heart rhythm"", acne, migraine, indeterminate
colitis
PSH: lap total colectomy, open proctectomy with ileo-anal pull
through, diverting ileostomy
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled oral medications.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing."
4924,"6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for 2 weeks: Please do not exceed
more than 4000 mg of acetaminophen in 24 hrs.
Disp:*45 Tablet(s)* Refills:*0*
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 6 days.
Disp:*6 * Refills:*0*
9. PICC Care
PICC line care per NEHT protocol
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA"
4925,"A PICC line was placed and he
was started on a regular diet which he tolerated well. His foley
was d/c'd and voided without any issues. IV fluids were d/c'd
and the Pt was continued on IV abx. Cultures were obtained from
the JP fluid and zosyn was started.
.
The patient will go home with 6 more days of IV zosyn, with [**Location (un) **] home therapies. He will have a CT and drain study on [**2-20**]
at 12:30 and follow up with Dr. [**Last Name (STitle) 1120**] on [**2-21**] at 3:00. Discharge
paperwork was reviewed with patient and all questions were
answered."
4926,"* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you."
4927,"These findings are highly suggestive of
an
enteric leak with abscess formation.
Microbiology: No new data.
ECG: Unremarkable.
Assessment and Plan
34 year old male with ulcerative colitis, s/p total colectomy [**11-21**], J
pouch w/ diverting ileostomy [**2130-1-18**], presenting with acute renal
failure, leukocytosis, and abscess at site of J pouch.
# Severe Sepsis: J pouch abscess as source.
Leukocytosis/thrombocytosis improving with IFV / abx. Received
vancomycin and zosyn in the ED. Hemodynamically stable.
- Continue vancomycin/Zosyn
- Drain to be placed in abscess by IR this afternoon.
# Acute Renal Failure. Baseline Cr. 1.0. presented with Cr 9."
4928,"He was given
Zosyn and 6L IVF, to which he put out 4000cc urine, 1225 out of
ostomy. Temperature increased to 101.3. Transferred to [**Hospital Unit Name 4**] for
further managment.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
1. Clonazepam 1mg TID
2. Naproxen 500mg q12h
3. Percocet 7.5/325 [**12-16**] tab q4-6hrs prn
4. OxyContin 20mg [**Hospital1 **]
5. atenolol 75mg daily
Past medical history:
Family history:
Social History:
Ulcerative colitis
S/p lap total colectomy with end ileostomy [**11-21**] ([**Doctor Last Name 132**])
S/p ileoanal J pouch and diverting ileostomy [**2130-1-18**] ([**Doctor Last Name 132**])
Migraine headaches
Disc operation
Non-contributory
Occupation: Lawyer for department of labor
Drugs: Denies
Tobacco: Denies
Alcohol: Social
Other: Married
Review of systems:
Constitutional: Fatigue, Fever
Gastrointestinal: Abdominal pain, Nausea, Emesis
Flowsheet Data as of [**2130-2-7**] 12:26 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
HR: 94 (93 - 94) bpm
BP: 134/42(64) {134/42(64) - 143/64(82)} mmHg
RR: 16 (15 - 27) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 72 Inch
Total In:
177 mL
PO:
TF:
IVF:
177 mL
Blood products:
Total out:
0 mL
5,275 mL
Urine:
NG:
450 mL
Stool:
Drains:
Balance:
0 mL
-5,098 mL
Respiratory
O2 Delivery Device: None
SpO2: 97%
ABG: ///19/
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Bowel sounds present, Tender:
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Labs / Radiology
1134 K/uL
32."
4929,"3 %
10.6 g/dL
92 mg/dL
5.1 mg/dL
45 mg/dL
19 mEq/L
100 mEq/L
4.9 mEq/L
133 mEq/L
19.6 K/uL
[image002.jpg]
[**2130-2-7**] 10:33 AM
WBC
19.6
Hct
32.3
Plt
1134
Cr
5.1
Glucose
92
Other labs: PT / PTT / INR:19.8/27.2/1.8, Ca++:8.4 mg/dL, Mg++:2.0
mg/dL, PO4:3.2 mg/dL
Imaging: Pelvis CT - Extraluminal rectal contrast is located within the
air- and fluid-containing
midline pelvic collection which appears centered along the most
superior
aspect of the surgical sutures."
4930,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
34y/o M w/ h/o UC s/o lap total colectomy [**11-21**], J pouch with diverting
ileostomy [**2130-1-18**], presenting with one week of N/V, 3 days of oliguria,
and decreased ostomy output. Initially presented to [**Hospital3 902**]
with acute renal failure per patient. Then transferred to [**Hospital1 5**] for
further workup. Here, he was found to have a creat of 10 and an
abscess/fluid collection at end of J pouch on pelvic CT."
4931,"9.
Likely prerenal from poor renal perfusion in setting of sepsis. Already
trending down with good UOP to IVF
- Follow creatinine / lytes
- Urine lytes / sediment
# Anemia: Blood loss from surgeries/colitis vs anemia of chronic
disease.
- Iiron studies, B12, Folate, Hemolysis labs.
- Active T&C
- PRBC prn
# Transaminitis: Likely related to sepsis. Has gallstone, but no
evidence of acute cholecystitis / cholangitis.
- Direct bili
- Follow until sepsis resolves
Other issues per resident note.
ICU Care
Nutrition:
Glycemic Control:
Lines / Intubation:
22 Gauge - [**2130-2-7**] 10:29 AM
Comments:
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 55 minutes"
4932,"9. Likely prerenal from poor renal perfusion in setting of sepsis.
Already trending down with good UOP to IVF.
- Follow creatinine / lytes / UOP
- Urine lytes / sediment
- Aggressive IVF
# Anemia: Blood loss from surgeries/colitis vs anemia of chronic
disease.
- Iiron studies, B12, Folate, Hemolysis labs.
- Active T&C
- PRBC prn
# Transaminitis: Likely related to sepsis. Has gallstone, but no
evidence of acute cholecystitis / cholangitis. INR elevated (liver vs
nutritional etiology).
- Direct bili
- Follow until sepsis resolves
- FFP / vitamin K for INR
- Check tylenol level (on percoset at home)
# FEN:
- NPO
- PICC line for TPN
Other issues per resident note.
ICU Care
Nutrition:
NPO
Glycemic Control:
Lines / Intubation:
PICC line ordered
22 Gauge - [**2130-2-7**] 10:29 AM
Comments:
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 55 minutes"
4933,"These findings are highly suggestive of
an
enteric leak with abscess formation.
Microbiology: No new data.
ECG: Unremarkable.
Assessment and Plan
34 year old male with ulcerative colitis, s/p total colectomy [**11-21**], J
pouch w/ diverting ileostomy [**2130-1-18**], presenting with acute renal
failure, leukocytosis, and abscess at site of J pouch.
# Severe Sepsis: J pouch abscess as source. Leukocytosis / reactive
thrombocytosis improving with IFV / abx. Received vancomycin and zosyn
in the ED. Hemodynamically stable.
- Continue vancomycin/Zosyn
- Drain to be placed in abscess by IR this afternoon.
# Oliguric Acute Renal Failure. Baseline Cr. 1.0. presented with Cr
9."
4934,"He was
given Zosyn and 6L IVF, to which he put out 4000cc urine, 1225 out of
ostomy. Temperature increased to 101.3. Transferred to [**Hospital Unit Name 4**] for
further managment.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
1. Clonazepam 1mg TID
2. Naproxen 500mg q12h
3. Percocet 7.5/325 [**12-16**] tab q4-6hrs prn
4. OxyContin 20mg [**Hospital1 **]
5. atenolol 75mg daily
Past medical history:
Family history:
Social History:
Ulcerative colitis
S/p lap total colectomy with end ileostomy [**11-21**] ([**Doctor Last Name 132**])
S/p ileoanal J pouch and diverting ileostomy [**2130-1-18**] ([**Doctor Last Name 132**])
Migraine headaches
Disc operation
Non-contributory
Occupation: Lawyer for department of labor
Drugs: Denies
Tobacco: Denies
Alcohol: Social
Other: Married
Review of systems:
Constitutional: Fatigue, Fever
Gastrointestinal: Abdominal pain, Nausea, Emesis
Flowsheet Data as of [**2130-2-7**] 12:26 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
HR: 94 (93 - 94) bpm
BP: 134/42(64) {134/42(64) - 143/64(82)} mmHg
RR: 16 (15 - 27) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 72 Inch
Total In:
177 mL
PO:
TF:
IVF:
177 mL
Blood products:
Total out:
0 mL
5,275 mL
Urine:
NG:
450 mL
Stool:
Drains:
Balance:
0 mL
-5,098 mL
Respiratory
O2 Delivery Device: None
SpO2: 97%
ABG: ///19/
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Bowel sounds present, Tender:
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Labs / Radiology
1134 K/uL
32."
4935,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
34y/o M w/ h/o UC s/o lap total colectomy [**11-21**], J pouch with diverting
ileostomy [**2130-1-18**], presenting with one week of N/V, 3 days of oliguria,
and decreased ostomy output. Initially presented to [**Hospital3 902**]
with acute renal failure (creat 10) per patient. Then transferred to
[**Hospital1 5**] for further workup. Here, he was found to have a creat of 7 and
an abscess/fluid collection at end of J pouch on pelvic CT."
4936,"3 %
10.6 g/dL
92 mg/dL
5.1 mg/dL
45 mg/dL
19 mEq/L
100 mEq/L
4.9 mEq/L
133 mEq/L
19.6 K/uL
[image002.jpg]
[**2130-2-7**] 10:33 AM
WBC
19.6
Hct
32.3
Plt
1134
Cr
5.1
Glucose
92
Other labs: PT / PTT / INR:19.8/27.2/1.8, Ca++:8.4 mg/dL, Mg++:2.0
mg/dL, PO4:3.2 mg/dL
Imaging: Pelvis CT - Extraluminal rectal contrast is located within the
air- and fluid-containing
midline pelvic collection which appears centered along the most
superior
aspect of the surgical sutures."
4937,"She
denied any other focal complaints such as chest pain, SOB,
abdominal pain, dysuria, nausea, vomiting, or diarrhea. She is
not sure how long she has been feeling sick, but thinks maybe a
few days.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
sinus tenderness, rhinorrhea, or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denied current arthralgias or myalgias.
Past Medical History:
# Diabetes Mellitus
# Dyslipidemia
# Hypothyroidism
# Hypertension
# Obstructive sleep apnea
# Anemia
# Osteoporosis
# Scoliosis -- s/p spinal fusion in [**2135**]
# Obesity
# Hip fracture ([**2-/2157**])
# Intracerebral hemmorhage
-- secondary to cavernous malformation"
4938,"2 & pan-cultured;
tolerated ~1L PO, NGT maintained for meds as pt has waxing /
[**Doctor Last Name 688**] MS.
[**2-18**]: LENIS negative, pelvic US ordered, CTH no new hemorrhage,
cdiff. Febrile but not cultured (cultured in the last 24h)
[**2-21**]: Afebrile for >24 hours.
Brief Hospital Course:
The patient is a 34 year old female with cognitive delay and DM2
not currently on hypoglycemic agents who presented to the ED
from her group home for unexplained hypoglycemia and fever.
Negative infectious workup, but new intracranial bleed found on
CT and MRI.
.
# Intraventricular Hemorrhage: CT head was obtained on [**2159-2-7**]
due to her persistent headache, lack of other localizing
symptoms, and history of cavernous malformations with
intracerebral bleeding."
4939,"She had
negative viral studies. Her fevers were treated symptomatically
with Acetaminophen 1000 mg PO Q6H PRN pain/fever. A full fever
work was in place. Multiple blood and urine cultures was taken
and NGTD. A CT scan of the torso was completed and was non
contributory. An MRI of the right hip was also completed and was
also non contributory. An LP was performed and was abnormal
secondary to interventricular blood and no organism on gram
stain. GPC's were isolated on urine [**2159-2-17**]. Her fever subsided
on Tylenol without antibiotics.
.
# Reported Hypoglycemia: It is unclear whether her reported
episode of hypoglycemia was a real event or an artifact from
glucometer malfunction."
4940,"She has a history of DM2, but has not
been on hypoglycemic agents recently. The rapid correction of
her hypoglycemia with oral sugar packets and sustained readings
in the 200s by EMS and in the ED is strange. Her shaking was
likely due to fever from an infection rather than hypoglycemia.
She was monitored with fingersticks QACHS and had hypoglycemia
protocol orders in place to treat any low readings. Her FBG was
121 on reaching the floor and has remained between 100 and 200
during her stay.
.
# UTI: Her UA on admission was positive and she received a dose
of Ceftriaxone in the ED."
4941,"Discharge Diagnosis:
Primary Diagnoses:
Central Fever seocndary to Interparanchymal hemorrhage with
interventricular extension.
Secondary Diagnoses:
Cavernous malformations
# Dyslipidemia
# Hypothyroidism
# Hypertension
# Obstructive sleep apnea
# Anemia
# Osteoporosis
# Scoliosis -- s/p spinal fusion in [**2135**]
# Obesity
# Hip fracture ([**2-/2157**]), s/p replacement?
# Intracerebral hemmorhage, -- secondary to cavernous
malformation; had a brain surgery at [**Hospital1 **] for bleeding
# Chronic seizures (on Depakote, Oxcarb, Neurontin)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for fevers and possible low
blood sugar levels. During your stay, your blood sugars
remained normal, but you continued to have fevers."
4942,"No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Back: No CVA tenderness. Well healed scar down midline of back.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. Digital cap refill <2 sec. No C/C. LE edema 1+
bilaterally. Distal pulses intact radial 2+, DP 2+.
Skin: No rashes, ulcers, or other lesions noted
Neuro: CN II-XII grossly intact. Moving all four limbs.
.
PHYSICAL EXAM ON DISCHARGE:
Alert, NAD
Pulmonary is clear to auscultation, CV: RRR no MRG. Abd: Soft
NT/ND.
Neuro: Alert. Oriented to self and hospital not year or month."
4943,"Admission Date: [**2159-2-4**] Discharge Date: [**2159-2-23**]
Date of Birth: [**2124-11-29**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Hypoglycemia, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 34 year old female with cognitive delay and DM2
not on hypoglycemics who presented to the ED from her group home
for unexplained hypoglycemia and fever. The group home staff
noted that she had a cough and body aches yesterday. This
morning, she was walking hunched over and using her cane."
4944,"LABS ON DISCHARGE:
.
- [**2-9**] CT Head: (compared to [**2159-2-7**]) mild increase IVH;
hyperdense lesion in the medial aspect of L lateral ventricle
likely a subependymal clot and appears diminished in size;
numerous b/l hyperdense lesions, likely cavernomas; prominent
sulci and markedly enlarged ventricles, likely developmental in
nature; hyper-pneumatized frontal sinuses and mucosal
thickening.
- [**2-9**] b/l LENIs: No evidence of DVT.
- [**2-12**] CT Torso: IMPRESSION: No apparent cause of pt's FUO; due
to sig artifact paraspinal and epidural space can only be
minimally evaluated; vascular variant in the chest inlet:
separate R & L SVC with absence of the left innominte vein."
4945,"Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. Depakote ER 500 mg Tablet Extended Release 24 hr Sig: Five
(5) Tablet Extended Release 24 hr PO at bedtime.
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day)."
4946,"3 prior to arrival at the hospital. She had
T 100.8 in the ED. Once on the floor, she was febrile to 104
with shaking chills, and continued to have intermittent fevers
during her stay. She denies any focal symptoms except headache,
but reportedly had cough and myalgias at her group home.
Influenza and respiratory viral swab was negative by DFA as well
as final cultures. Urine culture showed no growth and blood
cultures have been NGTD. She was found to have intraventricular
hemorrhage as above, which can be associated with persistent
fevers and likely explains her recent symptoms."
4947,"Social History:
Lives in group home at Bay Cove.
# Tobacco: Smokes 3 cigarettes/day
# Alcohol: None
# Drugs: None
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: T 102.4, BP 141/98, HR 95, RR 18, SpO2 100% on RA, Wt 90.5
kg
Gen: Young female in NAD. Oriented x3. Mood, affect pleasant.
HEENT: Well healed scar across right temporal area. Sclera
anicteric. Significant proptosis. PERRL. EOMI. MMM, OP benign.
Neck: Supple, full ROM, no meningismus. JVP just above clavicle
at 45 degrees. No cervical lymphadenopathy.
CV: Somewhat distant heart sounds. RRR with normal S1, S2. No
M/R/G."
4948,"Testing
initially showed evidence of a urinary tract infection, but
final culture results did not show any bacterial growth. You
received several doses of Ceftriaxone, an antibiotic, while the
results were pending. You were also tested for influenza and
several other viruses, but these tests were negative. Because
of your history of bleeding within the brain and your only other
symptom being headache, you had imaging of your head and this
showed a hemorrhage, this was stable with repeat imaging. You
had also imaging of your torso and hip which did not show a
source for your infection. We also were tested for possible
seizures and this did not demonstrate seizures."
4949,"After a full set of tests your fever was determined to be
secondary to your bleed.
Your fevers were treated with Acetaminophen and Ibuprofen, which
helped you feel better. None of your prior medications were
changed. You should continue taking your medications as
previously prescribed and as indicated on your discharge
medication sheet.
Followup Instructions:
Also please have your PCP [**Name9 (PRE) 14030**] you to your Neurologist.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14031**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2159-4-2**] 11:30
Provider: [**Name10 (NameIs) 14032**],[**Name11 (NameIs) 14033**] [**Location (un) **] IM (NHB)
Date/Time:[**2159-4-25**] 11:30
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2159-5-22**] 11:20
Completed by:[**2159-2-23**]"
4950,"6
[**2159-2-5**] 05:40AM BLOOD %HbA1c-6.2* eAG-131*
[**2159-2-4**] 02:40PM BLOOD TSH-2.8 T4-3.9*
[**2159-2-5**] 05:40AM BLOOD Valproa-54
.
URINALYSIS:
[**2159-2-4**] 03:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2159-2-4**] 03:50PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2159-2-4**] 03:50PM URINE RBC-0-2 WBC-[**11-18**]* Bacteri-RARE
Yeast-NONE Epi-0-2 RenalEp-0-2
[**2159-2-4**] 03:50PM URINE Hours-RANDOM UreaN-644 Creat-140 Na-50
K-36 Cl-48
[**2159-2-4**] 03:50PM URINE UCG-NEGATIVE Osmolal-453
."
4951,"0 Lymphs-25.7 Monos-9.8 Eos-0.2
Baso-0.3
[**2159-2-4**] 02:40PM BLOOD Glucose-109* UreaN-13 Creat-1.2* Na-137
K-4.0 Cl-104 HCO3-24 AnGap-13
.
OTHER RELEVANT LABS:
[**2159-2-5**] 05:40AM BLOOD ALT-18 AST-48* LD(LDH)-215 AlkPhos-48
TotBili-0.3
[**2159-2-5**] 05:40AM BLOOD Albumin-3.4* Calcium-9.1 Phos-2.8 Mg-2.4
Iron-57
[**2159-2-5**] 05:40AM BLOOD calTIBC-302 Hapto-261* Ferritn-379*
TRF-232
[**2159-2-5**] 05:40AM BLOOD Ret Aut-2."
4952,"Due to her intracranial
bleeding, her BP was controlled with goal SBP<140. She was
restarted on her home Lisinopril 5 mg PO daily and ordered for
Hydralazine 10 mg IV Q6H to be given for SBP>140.
.
# Diabetes Mellitus: She reportedly has a history of DM2, but is
not currently on medications. Her last HgbA1c was 5.5% on
[**2158-9-14**] and was 6.2% on admission. She was continued on a
diabetic diet during her stay. Her FBGs were occasionally
elevated during her stay into the 200s and she was started on a
Humalog sliding scale.
.
# Hypothyroidism: Her TSH on admission was normal at 2."
4953,"She was initially continued on
Ceftriaxone 1000 mg IV Q24H pending final urine culture results.
Her urine culture came back negative and Ceftriaxone was
discontinued after three doses had been given.
.
# Anemia / Thrombocytopenia: Her Hct on admission was 33.8,
which is lower than her recent baseline in the high 30s. She
has had a mild microcytic anemia in the past. Her MCV is
currently low normal at 84, but her RDW is high at 15.9. Her
platelets have also been low over at least the last few months.
This could potentially represent a medication effect.
Thrombocytopenia is a relatively common side effect of Valproic
acid, with a dose response."
4954,"The CT showed acute intraventricular
hemorrhage and enlarged ventricles. Neurosurgery consult was
called and an MRI/MRA was obtained. The MRI showed similar
findings as the CT as well as a possible new SAH at the right
vertex. No emergent or urgent neurosurgical intervention was
required at this time. She was restarted on her home Lisinopril
5 mg PO daily. She was transferred to Neurology for further
management. A repeat head CT was completed [**2159-2-18**] with no
interval changes.
.
# Fever: She reportedly developed shaking and agitation while at
her group home. She was also given Tylenol 1000 mg and later
noted to have T 100."
4955,"Anemia and pancytopenia have also
been associated with several of her other psych meds, but these
effects are rare. Her iron and hemolysis panels showed no
evidence of either iron deficiency or hemolysis.
.
# Creatinine Elevation: Her Cr on admission was 1.2, increased
slightly from a recent baseline around 0.9 (from [**2158-9-14**]). Her
Lisinopril 5 mg PO daily was held initially. Her Cr has since
returned to baseline, and her Lisinopril was restarted.
.
# Hypertension: Substituted Metoprolol tartrate 50 mg PO BID for
home succinate daily. Her Lisinopril 5 mg PO daily was
initially held as mentioned above."
4956,"- [**2-13**] MRI R Hip: Limited assessment of R hip due to THR;
evidence of mild greater trochanteric R bursitis and
tendinopathy w/out osteomyelitits; R adductor compartment edema
c/w muscle strain; avascular necrosis involving <30% of the
articular surface of L femoral head w/out articular surface
collapse.
- [**2-14**] TTE: EF 55-60%, no vegetation
- [**2-16**] CXR: NGT ends in / just beyond pylorus; lungs low in
volume but clear; no PTX; pt is s/p R upper rib rsxn; spinal
stabilization devices noted; heart size normal; no pleural
abnormality.
- [**2-16**] EEG: P
- [**2-17**] EEG: P
- [**2-18**] CTH: Decreased intraventricular hemorrhage, hemorrhage in
the splenium of the corpus callosum, and adjacent subarachnoid
hemorrhage
- [**2-18**] LENIS: negative for DVT
EVENTS:
[**2-16**]: Transferred to SICU
[**2-17**]: Intermittently lethargic; febrile to 103."
4957,"Sometimes coperates with examination, most of the time she does
not. Able to follow simple commands. Dyscongugate gaze with
exotropia of both eyes that switches. Perhaps a subtle INO with
the right eye. There is exophthalmos R>L. Face is symmetric.
She is moving all 4 extremities. Does not allow for formal
examination of the lower extremities.
Pertinent Results:
LAB RESULTS ON ADMISSION:
[**2159-2-4**] 02:40PM BLOOD WBC-8.8# RBC-4.03* Hgb-11.8* Hct-33.8*
MCV-84 MCH-29.4 MCHC-34.9 RDW-15.9* Plt Ct-124*
[**2159-2-4**] 02:40PM BLOOD Neuts-64."
4958,".
In the ED, she was noted to have proptosis and intial vitals T
100.8, BP 130/74, HR 96, RR 18, and SpO2 98% on RA. She
reported feeling okay and back to her baseline. Her UA showed
11-20 WBCs, rare bacteria, mod leukocyte esterase, and negative
nitrite. She was given a dose of Ceftriaxone in the ED for her
positive UA. Her CXR showed no evidence of pneumonia. She was
admitted to medicine for further workup and treatment.
.
On the floor, she reported current fever, chills, and headache.
She does report a mild cough and congestion recently."
4959,"8. senna 8.6 mg Capsule Sig: Two (2) Tablet PO at bedtime.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
11. Systane 0.4-0.3 % Drops Sig: One (1) Ophthalmic once a day.
12. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]"
4960,"She
has the cane from hip replacement one year ago, but does not use
it at baseline. The staff noted that she started to shake while
on the toilet. Her FBG was checked and was reportedly low on
the monitor (<20). She was given sugar packets, and when her
FBG was rechecked it was 180. She was also given Tylenol 1000
mg. Her temperature was noted to be 100.3 afterwards. EMS was
called and brought her to the ED. EMS found FBG 230, and her
FBG was 238 in triage. The group home staff was uncertain if
she received a flu shot this year."
4961,"8, but
her T4 was 3.9, which is somewhat low. The meaning of these
results is unclear in the setting of an acute illness and can be
readdressed as an outpatient. She was continued on
Levothyroxine 25 mcg PO daily during her stay.
.
# Neuro/Psych: She was continue on her home regimen of
psychiatric meds.
.
# GI Prophylaxis: Bowel regimen with Colace and Senna
.
# DVT Prophylaxis: She was initially kept on Heparin 5000 units
SC TID. This was discontinued after her intraventricular
hemorrhage was found. Pneumoboots were used therafter.
.
# Seizure history: No seizures here. She was on >24hr VEEG
without capture of events."
4962,"No changes to her medications (AEDs)
were made.
.
# Followup: She should follow up with her PCP. [**Name10 (NameIs) **] should be
re-referred to your neurology doctor.
--
.
Medications on Admission:
Metoprolol succinate 100 mg PO daily
Lisinopril 5 mg PO daily
Levothyroxine 25 mcg PO daily
Alendronate 70 mg PO weekly
Depakote ER 2500 mg PO QHS
Gabapentin 300 mg PO BID
Oxcarbazepine 300 mg PO BID
Risperidone 1 mg PO BID
Senna 8.6 mg 2 tabs PO QHS
Multivitamin 1 tab PO daily
Calcium-Vitamin D (600 mg-400 unit) 1 tab PO BID
Systane 1 drop each eye QAM"
4963,"Currently Cycle #6, Day 15 of 5FU/LV
Her low platelet count [**12-22**] cirrhosis has limited the number of
chemo options
.
Other Past Medical History:
- alcoholic cirrhosis (+ ETOH & + positive smooth muscle Ab. Hep
B and C negative), complicated by ascites and GI bleed. Grade I
esophageal and grade II rectal varices in [**2177**].
- RLE DVT a few months ago, due to thrombocytopenia got IVC
filter instead of systemic anticoagulation
- History of Alcohol Abuse: [**6-27**] had EtOH withdrawal seizure
- Diabetes, type II
- Hypertension
Social History:
Lives at home with a health aid who hels with her meds. (Per d/c
sumamry [**10/2179**]) - Patient lives alone in [**Location (un) 5871**], MA and
recently stopped working."
4964,"[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2180-9-18**] 9:36 PM
Imaging Lab
Brief Hospital Course:
Ms. [**Known lastname 64573**] is a 58yoF with h/o advanced cholangiocarcinoma
(on C14 of 5FU), EtOH cirrhosis c/b lower GIB in [**2177**] and upper
GIB in [**2178**] who presents with perineal skin
breakdown/desquamation/bleeding and hypotension.
.
# Perineal skin erosion: Improved with wound care and treatment
of [**Female First Name (un) **] infection. Upon presentation and inspection by GYN
did not appear to have internal involvement of vaginal vault or
rectum. Likely dermatologic side effect of 5-FU."
4965,"Wound culture
at OSH c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 64582**] superinfection. Fluconazole started
for planned 14 day course. Lidocaine jelly apppied PRN for pain.
- continue lidocaine jelly to wound.
.
# Hypotension: 80's-90's/40's-50's likely secondary to
cirrhosis. Per OMR BP is at her baseline (SBP 80's-90's last 3
months in clinic). Initially responsive to fluid boluses, but is
back to 80's s/p 6L NS. Abx (vanc/zosyn/azithro) were started
in the MICU for treatment of CAP, but have been discontinued
upon final read of CXR."
4966,"She is relatively leukopenic but not
neutropenic (ANC >1000). All cultures negative with exception
of [**Female First Name (un) **] in her wound.
.
# Cholangiocarcinoma: Per Dr.[**Name (NI) 22252**] note of [**9-13**], pt
appears to have disease progression on chemotherapy. Not a
candidate for second line chemo given her comorbidities.
.
# Cirrhosis: Stable. Given elevated lactulose to 70's, lactulose
changed from PRN to standing. Nadolol, lasix, and spironolactone
continued.
.
# Diabetes: Last A1c 8.5% on [**2180-9-13**]. Currently not on oral
hypoglycemics or insulin at home. ISS and lantus begun in house
and [**Last Name (un) **] consulted. Upon discharge Ms."
4967,"5 (One half) Tablet(s) by mouth once
a
day
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every 8
hours as needed for nausea, vomiting
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every 6 hours as needed for nausea, vomiting
SPIRONOLACTONE - (Dose adjustment - no new Rx) - 25 mg Tablet -
1 Tablet(s) by mouth DAILY (Daily)
Medications - OTC
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 2 Tablet(s) by mouth daily
THIAMINE HCL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY
(Daily)
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days."
4968,"[**Known lastname 64573**] was started
on lantus 50 units qhs and sliding scale.
.
# Goals of care: Per latest heme-onc notes, goal of care for
chemo is palliative. Pt currently wishes to remain Full Code,
unless there is little chance she could be revived. She is
refusing rehab/hospice that this point so focus has been on
getting her home with services that will ensure her safety as
much as possible.
Medications on Admission:
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth q week
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
LACTULOSE - 10 gram/15 mL Solution - 30 ml(s) by mouth three
times a day as needed for constipation
NADOLOL - 20 mg Tablet - 0."
4969,""" Denies subjective fevers/chills,
SOB, abdominal pain, nausea/vomiting, melena, hematochezia,
diarrhea/constipation.
.
In the MICU, she continued to have borderline pressures
70-90's/40-60's despite fluid administration. Per the patient,
these pressures are baseline for her. She recieved another
liter of NS while in the unit, but pressures remained
borderline.
Past Medical History:
Past Oncologic History (adapted from today's onc clinic note):
screening abdominal u/s [**2179-4-14**]: 1.7cm right liver lesion
Abdominal MRI [**2179-4-23**]: nodular, cirrhotic contour with a 1.8 x
2.5cm lesion in segment IV/VIII with peripheral enhancement,
1."
4970,"You were
admitted with a serious rash to your perineum likely caused by
the chemotherapy you have been taking for the past year. This
rash was complicated by an infection with yeast. You were also
treated with insulin to treat uncontrolled diabetes.
Medication Changes:
START fluconazole 200mg oral daily for 10 more days, continue
until [**2180-10-4**]
START lidocaine cream applied twice daily as needed for pain in
perineum
START Insulin Lantus 50 units at night
START Insulin Humolog according to sliding Scale
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2180-9-27**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage"
4971,"Admission Date: [**2180-9-17**] Discharge Date: [**2180-9-25**]
Date of Birth: [**2121-10-16**] Sex: F
Service: MEDICINE
Allergies:
Bactroban Nasal / Peanut
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Perineal Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 64573**] is a 58yoF with h/o advanced cholangiocarcinoma
(on C14 of 5FU), EtOH cirrhosis c/b lower GIB in [**2177**] and upper
GIB in [**2178**] who initially presented to [**Hospital1 **] with a perineal
bleed. Shet states that over the past 3-4 weeks she has had
pain/irritation in the perineal region, and has noticed
occasional streaks of blood on toilet paper."
4972,"no hepatosplenomegaly.
EXTREMITIES: Venous stasis changes, no clubbing/cyanosis/edema.
GU: Significant erythema and desquamation with bleeding around
labial folds and in perineal area. +tenderness. No vesicles, pus
or exudate. No blood visualized in vaginal vault.
NEURO: AAOx3, grossly intact
Upon discharge, perineum we re-epithelialization
Pertinent Results:
[**2180-9-17**] 09:50PM BLOOD WBC-1.6*# RBC-2.76* Hgb-10.1* Hct-30.0*
MCV-109* MCH-36.5* MCHC-33.5 RDW-17.2* Plt Ct-63*
[**2180-9-18**] 04:20AM BLOOD WBC-1.5* RBC-2.48* Hgb-8.8* Hct-26.5*
MCV-107* MCH-35."
4973,"In the ED at [**Hospital1 18**], initial VS were T 97.2, HR 70, BP 97/70, RR
24, O2 95%RA. Physical exam was notable for guaiac positive on
DRE. Labs were notable for WBC 1.6 (decreased from 4.9 on
[**9-13**]), Hct 30.0 (c/w baseline), plts 60. She received 3g IV
unasyn and 6L IV NS. She was admitted to MICU due to concern for
hypotension [**12-22**] ?GIB or sepsis.
.
On arrival to the MICU, initial vitals were T 97.1, HR 81, BP
111/56, O2 sat 97% on RA. She c/o pain in her perineal area, but
states that it is ""tolerable."
4974,"insulin glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
Disp:*qs for 1 month units* Refills:*2*
15. Humalog 100 unit/mL Solution Sig: 6 to 22 units
Subcutaneous qac: dose with each meal according to sliding
scale.
Disp:*qs for 1 months supply * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Metastatic Cholangiocarcinoma
Alcoholic Cirrhosis
DVT
Diabetes Mellitus II
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 64573**],
It was a pleasure taking care of you at [**Hospital1 18**]."
4975,"0 Na-136
K-4.1 Cl-105 HCO3-29 AnGap-6*
[**2180-9-20**] 06:00AM BLOOD Glucose-214* UreaN-12 Creat-1.0 Na-136
K-3.6 Cl-102 HCO3-30 AnGap-8
[**2180-9-21**] 05:50AM BLOOD Glucose-163* UreaN-12 Creat-1.0 Na-136
K-3.9 Cl-103 HCO3-30 AnGap-7*
[**2180-9-22**] 06:10AM BLOOD Glucose-255* UreaN-11 Creat-1.0 Na-133
K-3.9 Cl-101 HCO3-29 AnGap-7*
[**2180-9-23**] 06:00AM BLOOD Glucose-224* UreaN-12 Creat-0.9 Na-136
K-3."
4976,"Disp:*8 Tablet(s)* Refills:*0*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three
times a day as needed for constipation.
7. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea."
4977,"3
[**2180-9-24**] 05:34AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8
[**2180-9-17**] 10:04PM BLOOD Hgb-10.1* calcHCT-30
[**2180-9-17**] 10:04PM BLOOD Glucose-368* Lactate-2.5*
[**2180-9-18**] 04:35AM BLOOD Lactate-1.6
[**2180-9-18**] 04:35AM BLOOD Type-[**Last Name (un) **] Temp-36.7
Blood Culture, Routine (Final [**2180-9-23**]): NO GROWTH.
**FINAL REPORT [**2180-9-21**]**
GRAM STAIN (Final [**2180-9-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2180-9-21**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION."
4978,"Family History:
(Per d/c summary [**10/2179**]): [**Name (NI) **] sister diagnosed with
[**Name (NI) 4278**] lymphoma in her 30's, died in 40's from acute
leukemia. Her son was diagnosed with [**Name (NI) 4278**] lymphoma at 19,
he is currently in remission at age 33.
Physical Exam:
Vitals - T: 98.7 BP: 80/60 HR: 66 RR: 18 02 sat: 97% on RA
HEENT: PERRL, +scleral icterus, conjunctiva clear, oropharynx
without lesion or exudate, dry mucous membranes
LYMPH: no anterior/posterior cervical, occipital,
supraclavicular, axillary, or inguinal adenopathy
CARDIOVASCULAR: RRR nl S1 S2 no m/r/g
LUNGS: CTAB, no rhonchi, wheezes, or crackles
ABDOMEN: soft, nontender, nondistended with normal
active bowel sounds."
4979,"Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2180-9-27**] at 3:00 PM
With: [**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16901**], MD
Specialty: Endocrinology and Diabetes
When: Friday [**9-29**] at 12pm
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Please arrive at 12pm. You will have an eye exam at 12:30p, see
the doctor at 1pm and then at 2pm you will see a nurse educator.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]"
4980,"SPARSE
GROWTH.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2180-9-22**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**Known lastname **],[**Known firstname **] M [**Medical Record Number 64580**] F 58 [**2121-10-16**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2180-9-18**] 3:14
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. MED MICU [**2180-9-18**] 3:14 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 64581**]
Reason: Please eval for pna
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with h/o cholangiocarcinoma on
chemotherapy, presents with
hypotension
REASON FOR THIS EXAMINATION:
Please eval for pna
Final Report
CHEST RADIOGRAPH"
4981,"9 Cl-104 HCO3-28 AnGap-8
[**2180-9-24**] 05:34AM BLOOD Glucose-165* UreaN-11 Creat-0.8 Na-136
K-3.7 Cl-105 HCO3-28 AnGap-7*
[**2180-9-21**] 05:50AM BLOOD ALT-12 AST-21 LD(LDH)-170 AlkPhos-93
TotBili-1.9*
[**2180-9-22**] 06:10AM BLOOD ALT-14 AST-20 LD(LDH)-175 AlkPhos-112*
TotBili-1.4
[**2180-9-23**] 06:00AM BLOOD ALT-12 AST-23 LD(LDH)-170 AlkPhos-123*
TotBili-1.3
[**2180-9-24**] 05:34AM BLOOD ALT-17 AST-23 LD(LDH)-173 AlkPhos-125*
TotBili-1."
4982,"C1D8 was held due
to thrombocytopenia. Cr was elevated to 2.4.
[**2179-8-11**]: C1D1 of gemcitabine monotherapy, but again required
dose
hold C1D8 ([**2179-8-18**]) due to thrombocytopenia. We then discussed
[**2179-8-27**]: PORT placed . She
[**Date range (3) 64576**]: Cyberknife
[**2179-9-8**]: started 5FU/LV. She presented the same day with
increasing abdominal distention
[**2179-9-27**]: had missed a chemo appointment and presented with
volume overload, difficulty managing her medications, and caring
for herself at home. She was admitted [**Date range (3) 64577**].
[**Date range (1) 64578**]: Admitted for Cycle #2, Day 1 of infusional
5FU/LV."
4983,"9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed) as needed for pain.
13. lidocaine HCl 3 % Cream Sig: One (1) tsp Topical twice a day
as needed for pain: apply 1 tsp twice daily as needed to
affected area.
Disp:*1 tube* Refills:*0*
14."
4984,"At first she
thought it may have been vaginal or rectal blood, but then she
noticed that it appeared to be from her skin. On [**2180-9-13**] she
received Day 1 of Cycle 14 of 5FU. Since then the bleeding and
skin irritation increased. She presented to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the
advice of her CNA. There she was initially hypotensive with SBP
80s, improved with IVFs. Evaluation was notable for guaiac
positive, DRE, ?vaginal infection on pelvic exam, BG 528,
elevated LFTs, ANC 1000. CXR showed R base opacity stable from
prior films. She received IV flagyl 500 mg, 10U insulin IV and
was transferred to [**Hospital1 18**]."
4985,"0x1.2cm lesion in segment VIII
[**2179-5-12**]: biopsy of segment [**Doctor First Name 690**] lesion. Pathology revealed a
moderately-differentiated carcinoma, CK-7 (+), (-) for CD20,
CDX2, TTF-1, GCDFP & mammoglobin. These findings were felt to be
consistent with a primary pancreaticobiiary adenocarcinoma.
[**2179-6-1**]: exploratory laparotomy & segment [**Doctor First Name 690**]/II resection. On
pathology review margins were (+) microscopically.
These margins were on the middle hepatic vein posteriorly. Pt
was
not deemed resectable as she would require a left hepatic
lobectomy.
[**Date range (1) 61459**]/[**2178**]: admitted for SBP, delaying evaluation by
Radiation
Oncology.
[**2179-7-20**]: gemcitabine/cisplatin C1D1."
4986,"7* MCHC-33.4 RDW-17.2* Plt Ct-60*
[**2180-9-18**] 10:21AM BLOOD WBC-1.4* RBC-2.48* Hgb-9.0* Hct-26.6*
MCV-107* MCH-36.2* MCHC-33.7 RDW-17.3* Plt Ct-64*
[**2180-9-19**] 06:00AM BLOOD WBC-2.0* RBC-2.36* Hgb-8.7* Hct-24.6*
MCV-104* MCH-36.9* MCHC-35.5* RDW-17.6* Plt Ct-50*
[**2180-9-20**] 06:00AM BLOOD WBC-2.8* RBC-2.37* Hgb-8.7* Hct-24.6*
MCV-104* MCH-36.9* MCHC-35.4* RDW-17."
4987,"She used to work in customer service.
She is widowed, her husband died 13-15 years ago from lung
cancer, she cared for him at home when he died. She previously
drank [**4-25**] drinks daily, quit [**2178-6-20**]. Since returning home,
she has not had any alcohol. She has smoked 1 ppd x 40 years, is
currently smoking
although now down to 4-6 cigarettes/day. She 'knows' she can
quit and was encouraged to quit completely. Denies other drug
use. She is close with her sister and has close friends she
plays cards with.
- Tobacco: [**12-23**] cigarettes/day
- etOH: quit in [**2177**]
- Illicits: denies"
4988,"TECHNIQUE: Semi-erect portable radiograph of chest.
Comparisons were made with prior chest radiographs through
[**2178-8-29**],
with the most recent from [**2180-9-17**].
FINDINGS: Right-sided Port-A-Cath terminates at mid SVC.
Loculated pleural
effusion along the right lower chest, mild to moderate
non-locuated right
pleural effusions and associated right lower lung atelectasis
are unchanged
since [**2180-9-17**]. Left lung is clear. There is no left
pleural effusion.
Heart size, mediastinal and hilar contours are normal.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 16988**] [**Name (STitle) 16989**]
DR."
4989,"5* Plt Ct-46*
[**2180-9-21**] 05:50AM BLOOD WBC-3.1* RBC-2.37* Hgb-8.4* Hct-24.6*
MCV-104* MCH-35.6* MCHC-34.1 RDW-17.3* Plt Ct-34*
[**2180-9-22**] 06:10AM BLOOD WBC-3.3* RBC-2.41* Hgb-8.6* Hct-24.9*
MCV-104* MCH-35.7* MCHC-34.4 RDW-17.3* Plt Ct-41*
[**2180-9-23**] 06:00AM BLOOD WBC-4.0 RBC-2.32* Hgb-8.3* Hct-24.7*
MCV-107* MCH-36.0* MCHC-33.7 RDW-18.7* Plt Ct-40*
[**2180-9-24**] 05:34AM BLOOD WBC-4."
4990,"8 RBC-2.24* Hgb-8.1* Hct-23.9*
MCV-107* MCH-36.1* MCHC-33.8 RDW-20.3* Plt Ct-47*
[**2180-9-24**] 05:34AM BLOOD Neuts-76* Bands-0 Lymphs-13* Monos-6
Eos-4 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2180-9-17**] 09:50PM BLOOD Glucose-397* UreaN-24* Creat-1.0 Na-133
K-4.5 Cl-96 HCO3-29 AnGap-13
[**2180-9-18**] 04:20AM BLOOD Glucose-291* UreaN-20 Creat-0.8 Na-134
K-4.0 Cl-104 HCO3-27 AnGap-7*
[**2180-9-19**] 06:00AM BLOOD Glucose-273* UreaN-15 Creat-1."
4991,"Admission Date: [**2185-8-6**] Discharge Date: [**2185-8-10**]
Date of Birth: [**2133-5-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
wound infection/hematoma
Major Surgical or Invasive Procedure:
drainage of hematoma
History of Present Illness:
52yoM with Hep C and h/o IVDA, POD#11
s/p right ilioprofunda bypass with Dacron tube graft after found
to have occluded right fem-AK popliteal bypass, now presents
from
[**Hospital3 8544**] hypotensive (sbp 80s) with erythematous wound
and
2.2x1.8x4.0cm fluid collection within right groin incision per
CT
scan."
4992,"Disp:*60 Capsule(s)* Refills:*2*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a wound infection of your left groin with
presumed sepsis."
4993,"4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)."
4994,"Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*Keep your groin incision clean and dry after WoundVac dressing
placement.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 8343**] to schedule an
appointment.
Follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of your
blood pressure."
4995,"Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses.
Rectal: Abnormal: Guaiac positive.
Extremities: No RLE edema, No LLE Edema, No varicosities.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE DP: N. PT: D.
LLE DP: D. PT: D.
DESCRIPTION OF WOUND: right groin staple line intact; wound with
increased warmth, erythematous and tender with no drainage
expressible
Pertinent Results:
[**2185-8-6**] 02:15AM PLT COUNT-129*#
[**2185-8-6**] 02:15AM WBC-6.0 RBC-3.90* HGB-12.5* HCT-36.7* MCV-94
MCH-32."
4996,"PAST SURGICAL HISTORY: h/o fem-AK popliteal bypass, right
iliofemoral and profunda endarterectomy with Dacron patch
angioplasty ([**3-/2184**]), angiogram ([**2185-7-25**]) - occluded fem-AK [**Doctor Last Name **]
at proximal portion with reconstitution of flow at R profunda
femoris artery distally, s/p right ilioprofunda bypass with
Dacron tube graft ([**2185-7-26**])
Social History:
divorced
lives with mother and x-wife house
current tobacco use
former IV drug abuse, not at present- heroin
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline.
Nodes: No clavicular/cervical adenopathy."
4997,"*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location."
4998,"Echocardiogram showed normal ventricular
function and was negative for effusion and vegetation. On
hospital day 2, Levophed was weaned off.Creatinine declined to
1.0. Blood cultures were positive for GPC in clusters. Wound
culture grew MRSA. On hospital day 3, patient remained
hemodynamically stable and was subsequently transferred out of
the SICU to the floor. A Wound-Vac was placed over the right
groin site. Metoprolol 25 mg [**Hospital1 **] was added for hypertension with
improvement.
The day of discharge, Vac was removed for transfer and wound was
found to be granulating well. Patient was ambulating and
tolerating a regular diet."
4999,"The wound was incised and drained and you were
started on antibiotics. The wound culture suggested you were
infected with methicillin-resistant staph aureus (MRSA). We
started you on metoprolol 25 mg orally twice a day for
[**Location (un) **] of your blood pressure.
1) You should continue the antibiotics by mouth for 2 weeks.
2) A nurse will come to your home to change the dressing for the
Wound VAC. You should get daily wet-to-dry dressing changes
until the WoundVac arrives.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness."
5000,"*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids."
5001,"Reportedly, feeling well although noted groin incision
progressively ""red"" over past 2-3 days. He denies tenderness or
drainage from wound, fever/chills, nausea/vomiting,
numbness/tingling of extremities, or difficulty walking. On
presentation to OSH, found to be afebrile but hypotensive with
sbp 80s, with erythematous staple line, without dopplerable
right
lower extremity pulse, and reportedly with Cr 5.1. He was given
3L IVF, vancomycin and levofloxacin, and underwent CT lower
extremity prior to being transferred to [**Hospital1 18**] for further
evaluation and [**Hospital1 **].
Past Medical History:
PAST MEDICAL HISTORY: Hepatitis C, h/o CVA [**2180**], h/o adrenal
insufficiency, h/o IVDA, h/o tobacco use"
5002,"1* MCHC-34.1 RDW-13.9
[**2185-8-6**] 02:15AM ALT(SGPT)-240* AST(SGOT)-191* LD(LDH)-172 ALK
PHOS-72 AMYLASE-102* TOT BILI-0.5
[**2185-8-6**] 02:15AM GLUCOSE-115* UREA N-33* CREAT-3.7*#
SODIUM-133 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-21* ANION GAP-15
Brief Hospital Course:
In the ED, patient was hypotensive after 2 L fluid bolus and was
subsequently started on Levophed and admitted to the SICU.
Cipro, Flagyl, and vancomycin were started. Staples were removed
from the groin site and the wound was packed with significant
serous drainage noted."
5003,"Pain was well-controlled. Patient is
to be discharged on 2 weeks oral Bactrim/Cipro/Flagyl.
Medications on Admission:
lisinopril 10 mg daily, escitalopram 10 mg daily, colace 100 mg
[**Hospital1 **],simvastatin 10 mg daily, ASA 81 mg daily, plavix 75 mg daily
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
5004,"# Acute renal failure: Creatinine 2.7 on presentation (baseline 0.7).
Likely secondary to dehydration and poor perfusion in the setting of
sepsis.
- continue IVF and trend creatinine
- consider urine lytes if no improvement in am
- monitor UOP
- renally dose medications
- avoid nephrotoxins
.
# HTN: Blood pressure currently controlled. Will hold home
antihypertensives (metoprolol) until patient proves hemodynamic
stability.
.
# DM: Continue to monitor fsbs qid. Start sliding scale humalog.
- goal fsbs < 200 for optimal immune function
.
# Hypernatremia: Likely due to dehydration. Will continue to trend.
.
# Goals of Care: [**Name (NI) **] son is health care proxy and appears to be
under a great deal of stress regarding his role in his mother's care.
Patient has been seen in past by Palliative Care team.
- consult Palliative Care
.
# FEN: IVF, replete electrolytes, npo given patient's mental status
# Prophylaxis: Subcutaneous heparin
# Access: peripherals x 2
# Communication: Son
# Code: DNR/DNI/NO lines
# Disposition: ICU until am"
5005,"3 BP: 149/62P: 135 R:19 O2: 100% 2L NC
General: no acute distress, asleep, responds only to painful stimuli,
decorticate posture
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to angle of jaw no LAD
Lungs: Good air movement, crackles at bilateral bases, no wheezes,
rales, ronchi
CV: tachycardic, normal rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
.
Labs / Radiology
[**2161-3-9**] Blood cx: pending
."
5006,".
On the floor, patient is unresponsive to verbal stimuli. Per son, she
does not have a indwelling catheter at baseline. He does report
similar presentation to [**Hospital1 19**] last month during which she was diagnosed
with a UTI.
Patient admitted from: [**Hospital1 19**] ER
History obtained from Family / [**Hospital 75**] Medical records
Patient unable to provide history: Unresponsive
Allergies:
Penicillins
Unknown;
Depakote (Oral) (Divalproex Sodium)
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
1. Insulin Lispro 100 unit/mL Solution [**Hospital **]: per sliding scale
Subcutaneous three times a day.
2. Miconazole Nitrate 2 % Powder [**Hospital **]: One (1) Appl Topical TID
(3 times a day): apply to below breasts."
5007,"TITLE:
Chief Complaint: Altered Mental Status/ Fever
HPI:
Ms. [**Known firstname **] [**Known lastname 6509**] is a 75 year old woman with history of DM, advanced
Alzheimer's dementia (nonverbal), and schizophrenia. She presents to
the Emergency Department today from her nursing home after she was
found to be somnolent and febrile to 101.8 F.
.
In the ED, initial vs were: T 100 P 120 BP 111/86 R 16 O2 sat 99% 2L.
Chest x-ray was negative. Urinalysis was positive. Patient was given 4
L IV NS and acetaminophen for her persistent tachycardia. She was
started on empiric cefepime 2 g IV and vancomycin 1g IV for her UTI."
5008,"[**2161-3-9**] Urine cx: pending
.
Images:
.
[**2161-3-9**] CXR: (prelim) No acute cardiopulmonary process.
[image002.jpg]
Assessment and Plan
75 year old woman with history of DM2, advanced Alzheimer's dementia
(nonverbal), and schizophrenia who presents from her nursing home with
somnolence, fever, tachycardia and positive UA.
.
# Urosepsis: Patient presents with tachycardia, leukocytosis, altered
mental status and ARF in the setting of positive UTI and history of
urosepsis. Tachycardia responded well to 4 L IVF in the Emergency
Department.
- trend WBC and temps
- continue IVF boluses as needed for tachycardia
- continue empiric antibiotics
- follow up blood and urine cultures
- trend lactate
- remove foley when hemodynamically stable
- dose vanco per level given renal function
."
5009,"Bed bound.
Review of systems: Unable to assess given mental status
Flowsheet Data as of [**2161-3-10**] 03:04 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**62**] AM
Tmax: 38.5
C (101.3
Tcurrent: 38.5
C (101.3
HR: 118 (106 - 135) bpm
BP: 122/61(73) {122/61(73) - 149/62(83)} mmHg
RR: 16 (16 - 34) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
210 mL
PO:
TF:
IVF:
210 mL
Blood products:
Total out:
0 mL
120 mL
Urine:
20 mL
NG:
Stool:
Drains:
Balance:
0 mL
90 mL
Respiratory
SpO2: 100%
Physical Examination
Vitals: T: 101."
5010,"3. Metoprolol Tartrate 25 mg Tablet [**Hospital **]: 0.25 Tablet PO TID (3
times a day).
4 Multivitamins Tablet, Chewable [**Hospital **]: One (1) Tablet,
Chewable PO once a day.
5 Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Past medical history:
Family history:
Social History:
CVA with left sided residual deficits
DM2
Renal insufficiency
Hypercalcemia
HTN
GERD
Osteoarthritis
Anemia
Severe Alzheimer's
Schizophrenia
UTIs
Noncontributory
Occupation: unemployed
Drugs:
Tobacco:
Alcohol:
Other: Lives in nursing home x 5 years. Son in area, health care
proxy. Requires assistance for all ADLs."
5011,"TITLE:
I have seen and examined the patient with the resident. The patient
has dementia and is unable to provide any further history.
Overnight, she had a drop in hematocrit but otherwise no new problems.
Tm 100.4 P 82 BP 131/72 RR 14 Saturation: 98%
Gen: Awake, dementia (baseline)
HEENT: slightly dry mucous memranes
Chest: CTA bilaterally
Heart: S1 S2 reg
Abd: Soft, NT ND
Ext: no edema
Labs reviewed in metavision and most notable for hypernatremia (151),
renal insufficiency (Cr 2.0), glucose 340
Assessment:
1) Urosepsis
improved and now perfusing with normal blood pressure,
good urine output
2) Acute renal failure secondary to dehydration
3) Hypernatremia
4) Dementia
5) DNR/DNI
Plan:
1) Continue antibiotics
2) Change from normal saline to half-normal or LR given hypernatremia
3) Follow urine output/creatinine
4) Transfer to the floor
Time Spent: 30 minutes"
5012,"Admission Date: [**2161-3-9**] Discharge Date: [**2161-3-13**]
Date of Birth: [**2085-3-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Depakote
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
MICU HPI
Ms. [**Known firstname **] [**Known lastname **] is a 75 year old woman with history of DM,
advanced Alzheimer's dementia (nonverbal), and schizophrenia.
She presents to the Emergency Department today from her nursing
home after she was found to be somnolent and febrile to 101.8 F.
In the ED, initial vs were: T 100 P 120 BP 111/86 R 16 O2 sat
99% 2L."
5013,"Lactate
normalized and ARF improving with IV fluids, and pt started on
maintenance fluids for mild hyponatremia to 51. Mental status
noted to be slightly improved (responsive to verbal stimuli) but
not yet back to baseline.
.
Review of systems: Unable to assess given mental status.
.
Past Medical History:
CVA with left sided residual deficits
DM2
Renal insufficiency
Hypercalcemia
HTN
GERD
Osteoarthritis
Anemia
Severe Alzheimer's
Schizophrenia
UTIs (not in our system)
Social History:
Lives in nursing home x 5 years. Son in area, health care proxy.
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 101.3 BP: 149/62P: 135 R:19 O2: 100% 2L NC
General: no acute distress, asleep, responds only to painful
stimuli, decorticate posture
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to angle of jaw no LAD
Lungs: Good air movement, crackles at bilateral bases, no
wheezes, rales, ronchi
CV: tachycardic, normal rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding,
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
5014,"0 Leuks-MOD
[**2161-3-9**] 09:30PM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-MANY
Epi-0-2
[**2161-3-9**] Chest X ray:
COMPARISON: Multiple chest radiographs with the most recent from
[**2161-2-9**].
SINGLE FRONTAL VIEW OF THE CHEST: Lungs are clear with no
evidence of
pneumonia or congestive heart failure. There is no pneumothorax
or pleural
effusion. Heart, mediastinum, and hila are normal.
IMPRESSION: No acute intrathoracic abnormality.
Brief Hospital Course:
75 year old woman with history of DM2, advanced Alzheimer's
dementia (nonverbal), and schizophrenia who presents from her
nursing home with somnolence, fever, tachycardia, positive UA,
and acute renal failure."
5015,"Urosepsis: Patient presents with tachycardia, leukocytosis,
altered mental status and ARF in the setting of positive UTI and
history of urosepsis. Tachycardia responded well to 4 L IVF in
the Emergency Department. The patient was not on pressors. Pt
was started on Cefepime of which she received a couple days
before IV access was lost and unable to be re-established. She
remained afebrile and WBC's trended down, however given overall
grim prognosis of any functional recovery and overall poor
mental status (brainstem reflexes intact, however pt basically
unresponsive to environmental stimuli at baseline even before
admission), it was decided to make pt comfort measures only by
discussion with [**Hospital **] healthcare proxy (son [**Doctor First Name 892**], social work,
palliative care, and medical team."
5016,"She is being discharged back
to extended care facility and pt son stated that he will call
hospice team which had previously been involved. Oral narcotic
solution and Tylenol suppositories were given to address pain
and agitation.
Acute renal failure: Responded to IV fluids and trended down to
normal by time of discharge.
Medications on Admission:
1. Insulin Lispro 100 unit/mL Solution [**Doctor First Name **]: per sliding scale
Subcutaneous three times a day.
2. Miconazole Nitrate 2 % Powder [**Doctor First Name **]: One (1) Appl Topical TID
(3 times a day): apply to below breasts.
3. Metoprolol Tartrate 25 mg Tablet [**Doctor First Name **]: 0."
5017,"Discharge Diagnosis:
Sepsis from urinary tract infection
CVA with left sided residual deficits
DM2
Renal insufficiency
Hypercalcemia
HTN
GERD
Osteoarthritis
Anemia
Severe Alzheimer's
Schizophrenia
UTIs
Discharge Condition:
Comfort measures only
Discharge Instructions:
You were admitted to [**Hospital1 18**] with likely sepsis from a urinary
tract infection. You were resuscitated with IV fluids and
antibiotics however given your poor state of health it was
decided to make you comfort measures only. You are being
discharged back to your extended care facility.
All of your medicines were stopped and you were started on:
1. OxycoDONE-Acetaminophen Elixir [**4-27**] mL PO/NG Q2H:PRN pain
2. Acetaminophen 650 mg PR Q4H:PRN pain, agitation
These medicines are for your comfort only.
Followup Instructions:
No follow up is needed
Completed by:[**2161-3-13**]"
5018,"No BLE edema
Pertinent Results:
ADMISSION LABS
[**2161-3-9**] 10:20PM BLOOD WBC-10.6# RBC-4.23 Hgb-13.1# Hct-39.6#
MCV-94 MCH-31.1 MCHC-33.2 RDW-13.2 Plt Ct-153
[**2161-3-10**] 05:58AM BLOOD WBC-6.3 RBC-3.44* Hgb-10.6* Hct-32.2*
MCV-94 MCH-30.7 MCHC-32.8 RDW-13.2 Plt Ct-114*
[**2161-3-9**] 10:20PM BLOOD Neuts-87.4* Lymphs-8.3* Monos-3.0 Eos-0.7
Baso-0.5
[**2161-3-9**] 09:30PM BLOOD Glucose-282* UreaN-51* Creat-2."
5019,"Chest x-ray was negative. Urinalysis was positive.
Patient was given 4 L IV NS and acetaminophen for her persistent
tachycardia. She was started on empiric cefepime 2 g IV and
vancomycin 1g IV for her UTI.
On the floor, patient is unresponsive to verbal stimuli. Per
son, she does not have a indwelling catheter at baseline. He
does report similar presentation to [**Hospital1 18**] last month during
which she was diagnosed with a UTI.
Review of systems: Unable to assess given mental status.
FLOOR ACCEPTING TEAM HPI
Please see admit H&P for full details. Ms. [**Known firstname **] [**Known lastname **] is a 75
year old woman with history of DM, advanced Alzheimer's dementia
(nonverbal at baseline), schizophrenia, recent admit
[**Date range (1) 106956**] for AMS in setting of UTI who presented to the ED
from NH after being found somnolent and febrile to 101."
5020,"25 Tablet PO TID (3
times a day).
4 Multivitamins Tablet, Chewable [**Doctor First Name **]: One (1) Tablet,
Chewable PO once a day.
5 Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q2H (every 2 hours) as needed for pain.
2. Acetaminophen 650 mg Suppository [**Last Name (STitle) **]: One (1) Suppository
Rectal Q4H (every 4 hours) as needed for pain, agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]"
5021,"8 F.
.
In the ED, initial vs were: T 100, P 120, BP 111/86, R 16, O2
sat 99% 2L. CXR neg, U/A positive. Cr 2.7 (baseline 0.7).
Lactate 3.1. Pt given tylenol, cefepime 2g IV, vancomycin 1g IV,
and 4L IVF but was persistently tachycardic so admitted to the
MICU for urosepsis. No indwelling catheter at baseline.
.
In the MICU, patient was initially unresponsive to verbal
stimuli. her tachycardia improved with IV fluids, and VS
remained stable. Pt continued on vanc (dosed by level) and
cefepime; noted to have PCN allergy but tolerating fine."
5022,"7*#
Na-150* K-4.1 Cl-112* HCO3-22 AnGap-20
[**2161-3-10**] 05:58AM BLOOD Glucose-348* UreaN-41* Creat-2.0* Na-151*
K-3.7 Cl-124* HCO3-19* AnGap-12
[**2161-3-10**] 05:58AM BLOOD Calcium-9.0 Phos-1.5* Mg-1.5*
[**2161-3-9**] 09:39PM BLOOD Lactate-3.1* K-4.1
[**2161-3-10**] 06:12AM BLOOD Lactate-1.7
[**2161-3-9**] 09:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2161-3-9**] 09:30PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-250 Ketone-TR Bilirub-SM Urobiln-NEG pH-5."
5023,"FLOOR ACCEPTING TEAM PHYSICAL EXAM
96.7 96.7 160/72 (152-168) 72 (65-77) 16 100%RA
Elderly lady, chornically ill and debilitated appearing. She is
slumped over to the left. She doesn't respond to verbal stimuli
but responds minimally to sternal rub. Her eyes are open and she
looks around but not purposefully. She doesn't speak or even
make noises. She doesn't follow commands. Her L arm is flexed up
in the air and is very rigid and her hand is in decorticate
position.
Unable to listen to lungs posteriorly, from the anterior she is
loudly mouth breathing
S1 S2 clear RRR, no murmurs
Abd soft but unable to tell if tender
L arm as above, but R arm is not as rigid, able to be flexed and
extended."
5024,"Admission Date: [**2131-8-15**] Discharge Date: [**2131-9-6**]
Date of Birth: [**2108-7-3**] Sex: F
Service: MEDICINE
Allergies:
Vicodin / pears
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Easy bruising, malaise, bony pain, concern for leukemia
Major Surgical or Invasive Procedure:
Central line placement
LP with IT chemo x 2
History of Present Illness:
23yoF with h/o asthma and ADHD who is being admitted out of
concern for acute leukemia. She was in her USOH until [**7-12**] when
she presented to [**Hospital6 **] with intermittent, L-sided
chest pain. CXR was read as normal. She was treated for
bronchitis with azithromycin."
5025,"She is diaphoretic. She does
endorse worsening fatigue recently as well as intermittent
nausea. She understands that she may have leukemia.
Past Medical History:
ADHD
Asthma - uses albuterol 2x per week since age 13
Depression
Anxiety
Social History:
Lives in [**Location 10022**], MA with her grandmother and grandfather. She
is single. Works as a hairdresser and is going to school
studying massage.
tob: 0.5 ppd x 3 years (quit last Saturday)
EtOH: 1 beer per week
illicits: none
Family History:
Mother - epilepsy
[**Name (NI) **] Aunt: [**Name (NI) 4278**] lymphoma
Ma GPa: [**Name (NI) 2320**]
Father - doesn't know about father's health"
5026,"CD45 bright lymphocytes comprise 24% of total analyzed events.
B cells comprise 18% of lymphoid-gated events, are polyclonal,
and do not express aberrant antigens. T cells comprise 63% of
lymphoid-gated events, express mature lineage antigens, and have
a decreased helper-cytotoxic ratio of 0.7:1 (usual range in
blood 0.7-3.0).
INTERPRETATION
Immunophenotypic findings consistent with involvement by acute
lymphoblastic leukemia (pre B-ALL).
Please correlate with morphologic and cytogenetic findings (see
separate report). Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] notified on [**2131-8-16**].
BONE MARROW:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:"
5027,"0
[**2131-9-4**] 12:00AM BLOOD Fibrino-159
[**2131-9-6**] 12:10AM BLOOD Gran Ct-1205*
[**2131-9-6**] 12:10AM BLOOD Glucose-128* UreaN-18 Creat-0.6 Na-140
K-3.9 Cl-101 HCO3-29 AnGap-14
[**2131-9-6**] 12:10AM BLOOD ALT-189* AST-45* AlkPhos-92 TotBili-0.4
DirBili-0.2 IndBili-0.2
[**2131-9-6**] 12:10AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0
Brief Hospital Course:
Primary reason for hospitalization:
Patient is a 23yo female with history of ADHD and asthma who
presented at an outside hospital with a month of night sweats,
easy bruising, and fatigue and was found to have Acute
Lymphocytic Leukemia."
5028,"2. Atrial fibrillation: Patient experienced new onset atrial
fibrillation with RVR in the hospital after a placement of a
central line. CT showed potential area of leukemic infiltrate in
the right mediastinum. Patient's line was changed over the
wire, as irritation from the line was a likely explaination for
atrial fibrillation. She went to the ICU where she was placed on
a diltiazem drip. She converted to sinus rhythm following. He
home adderall was held.
Chronic Care:
1. Asthma: Patient was continued on home albuterol inhaler prn.
2. ADHD: Adderall was held because of its potential to cause
arryhthmias, and will be restarted as an oupatient when risk is
lower for arrythmias."
5029,"3. Depression: Patient was continued on home venlafaxine.
Transitions in Care:
Patient was given a follow-up appointment 2 days post-discharge
for IV chemotherapy and blood work, and given an appointment on
[**2131-9-14**] for further chemo and BM biopsy. She was instructed to
stop taking Lovenox >24 hours before the procedure. She will
need weekly AT and fibrinogen levels drawn.
Medications on Admission:
Albuterol prn
Adderall 30 mg [**Hospital1 **]
venlafaxine XR 75 mg qday
ibuprofen prn
Discharge Medications:
1. prednisone 10 mg Tablet Sig: 4.5 Tablets PO BID (2 times a
day) for 10 days.
Disp:*90 Tablet(s)* Refills:*0*
2."
5030,"Disp:*30 Tablet(s)* Refills:*0*
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*1*
8. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
ALL
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 91125**],
You were admitted to the hospital for chemotherapy for newly
diagnosed leukemia."
5031,"STOP taking Adderall until further instructed
8. STOP taking venlafaxine until further instructed
Please continue taking all other medications as previously
prescribed to you.
Please return to clinic as instructed to complete your course of
chemotherapy, and for scheduled bone marrow biopsy.
Followup Instructions:
[**2131-9-8**] at 10:30AM-Please go to your appointment at 7 [**Hospital Ward Name 1826**]
Outpatient Clinic for chemotherapy and labs.
[**2131-9-14**] at 9:30AM-Please go to you appointment at Dr. [**Last Name (STitle) **]'
office for bone marrow biopsy and lumbar puncture with
intrathecal chemotherapy.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]"
5032,"Physical Exam on Discharge:
Patient was afebrile on discharge.
HEART: RRR, no M/R/G
CHEST: occlusive dressing on wound from central line removal
Exam otherwise unchanged from admission
EXTREMITIES: no bruising or petechiae
Pertinent Results:
ADMISSION LABS
[**2131-8-15**] 04:00PM BLOOD WBC-12.8* RBC-3.55* Hgb-11.3* Hct-29.8*
MCV-84 MCH-31.9 MCHC-38.0* RDW-13.5 Plt Ct-21*
[**2131-8-15**] 04:00PM BLOOD Neuts-15* Bands-1 Lymphs-25 Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 Blasts-57* Other-0
[**2131-8-15**] 04:00PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2131-8-15**] 04:00PM BLOOD PT-13."
5033,"Occasional atypical
mitoses are seen in the neoplastic cells. Rare scattered
myeloid precursors, plasma cells and small erythroid islands are
seen.
BCR-ABL: Normal, see cytogenetics report for full description
TTE [**8-16**] The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF 70%). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). The
right ventricular cavity appears small, with normal free wall
contractility. There are complex (mobile) atheroma in the aortic
arch. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation."
5034,"She again presented to the ED on
[**7-14**] with similar complaints and began taking ibuprofen for the
pain. Over the course of the past month she has experienced
worsening sweating - at night and during the day, worsening
fatigue, bilateral arm heaviness, easy bruising, and petechial
rash on her arms and legs. She presented to [**Hospital6 33**]
with these complaints and CBC showed thrombocytopenia to 15 as
well as lymphocytosis. There was initially concern for ITP or
rickettsial infection, but peripheral blood was sent for flow
cytometry, which reportedly showed lymphoblasts.
.
At present, she complains of bilateral arm pain and pain in her
back between her shoulder blades."
5035,"The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
Impression: Suboptimal image quality. The right atrium and, to a
lesser extent, the right ventricle appear extrinsically
compressed. However, due to the technically suboptimal nature of
the acquired images, neither cardiac tamponade secondary to a
loculated pericardial effusion nor a soft tissue mass causing
right heart compression can be excluded on the basis of this
study. A cardiac CT scan or MRI is recommended for further
imaging of this abnormality.
CT chest [**8-16**]: IMPRESSION:
1."
5036,"Discharge Labs:
[**2131-9-6**] 12:10AM BLOOD WBC-2.2*# RBC-2.92* Hgb-8.9* Hct-25.0*
MCV-86 MCH-30.3 MCHC-35.4* RDW-14.1 Plt Ct-242
[**2131-9-6**] 12:10AM BLOOD Neuts-44* Bands-1 Lymphs-26 Monos-24*
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-2* NRBC-4*
[**2131-9-6**] 12:10AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Schisto-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**]
[**2131-9-6**] 09:54AM BLOOD PT-11.8 PTT-23.4 INR(PT)-1."
5037,"She tolerated it well with slight
intermittant symptoms of headache, throat pain and nausea.
Activated AT and fibrinogen levels were monitored and remained
within normal limits. She received enoxaparin for DVT
prophylaxis, and zofran and compazine for nausea. She was given
acyclovir and fluconazole for infection prophylaxis while
neutropenic and received a 10-day course of IV cefepime for
fever on admission that was culture-negative. Patient's
neutrophil count dropped with therapy but recovered. She was
discharged on day 20 of the protocol having regained her cell
counts to a granulocyte count of 1205. She was instructed to
follow up on day 22 next for IV vincristine"
5038,"7 LDLcalc-91
LDLmeas-66
[**2131-8-17**] 03:05PM BLOOD TSH-3.5
[**2131-8-17**] 03:05PM BLOOD HCG-<5
BCX, UCX, CSF GRAM STAIN: Negative
FLOW CYTOMETRY: RESULTS:
Cell marker analysis demonstrates that a majority of the cells
isolated from this peripheral blood are in the
CD45-dim-to-moderate, low side-scatter, 'blast gate'. Gating on
these cells demonstrates that these cells express immature
antigens CD34, HLA-DR, and TdT, lymphoid associated antigens
CD10, CD19 and CD20 along with CD71. They lack surface
immunoglobulin light chains kappa and lambda. They lack
T-associated antigens (CD3, CD5, CD2, CD7, CD4, CD8) and are
negative for myeloid associated antigens CD13, CD14, CD15, CD33,
CD117, CD11c, CD41, CD56, CD64 and Glycophorin A."
5039,"DIAGNOSIS:
Acute lymphoblastic leukemia, see note.
Note: The morphologic findings on this core biopsy specimen
combined with concurrent flow cytometry findings on peripheral
blood (S11-33319M) are consistent with the diagnosis of acute
lymphoblastic leukemia (pre-B-ALL). Please correlate with
cytogenetic findings (see separate report).
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes appear mildly
decreased in number, are normochromic with rare dacryocytes,
echinocytes, fragments, microcytes and nucleated red blood
cells noted. The white blood cell count appears mildly
increased. A majority of circulating cells are variably sized,
with moderately condensed to open chromatin, prominent nuclei,
round to slightly irregular nuclear contours, scant amounts of
basophilic cytoplasm and occasional coarse granules."
5040,"Physical Exam:
Physical Exam on admission:
VS - 100.0 111 120/88 20 96% on RA
GENERAL - overweight female w/ cold compress on forehead,
pleasant, a&ox3, diaphoretic, NAD
HEENT - wearing color contacts so difficult to assess pupils,
EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh
HEART - tachycardic, regular, no MRG, nl S1-S2
ABDOMEN - obese abdomen, NABS, soft/NT/ND, difficult to assess
for hepatosplenomegaly
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - petechial rash on arms and legs, tattoo on back,
extensive brusing on bilateral UE
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-10**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact"
5041,"acyclovir 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) unit
Subcutaneous DAILY (Daily): Last day is day 26 ([**2131-9-12**]).
Disp:*13 unit* Refills:*0*
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain."
5042,"Ascending, arch and descending thoracic aorta is normal in
morphology
without any element of calcification
2. No CT evidence of an extrinsic compression on the
atrium/right ventricle.
3. No pulmonary embolism
4. Focal opacity in the right upper lobe may represent either
infectious focus
or could be inflammatory give the clinical setting.
5. Mild splenomegaly
EKG [**8-17**]: Afib with RVR
[**8-16**] Echocardiogram: Impression: Suboptimal image quality. The
right atrium and, to a lesser extent, the right ventricle appear
extrinsically compressed. However, due to the technically
suboptimal nature of the acquired images, neither cardiac
tamponade secondary to a loculated pericardial effusion nor a
soft tissue mass causing right heart compression can be excluded
on the basis of this study."
5043,"A cardiac CT scan or MRI is
recommended for further imaging of this abnormality.
CSF:
[**2131-8-18**] 03:38PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-7* Polys-0
Lymphs-56 Monos-44
[**2131-8-18**] 03:38PM CEREBROSPINAL FLUID (CSF) TotProt-20 Glucose-62
LD(LDH)-17
[**2131-9-1**] 07:01PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-2
Lymphs-62 Monos-36
[**8-18**] immunophenotyping of CSF:
No aberrant cells are identified in this specimen using a
limited marker panel.
Due to paucicellularity the findings need to be interpreted with
caution. A concurrent cytospin specimen reveals mostly a
mixture of rare monocytes and small mature lymphocytes."
5044,"You completed the first stage of your
chemotherapy and are ready to go home to continue therapy as an
outpatient.
Please make the following changes to your medications:
1. START Acyclovir 400mg by mouth three times daily
2. START Enoxaparin 40mg by subcutaneous injection daily, and
STOP taking it after your dose on Wednesday, [**9-12**].
3. START Lorazepam 0.5-1mg by mouth every four hours as needed
for anxiety or nausea
4. START Omeprazole 20mg by mouth daily
5. START Prednisone 45mg by mouth twice daily through [**9-14**]
6. START Vitamin D3 400units by mouth daily
7."
5045,"She was transferred to [**Hospital **] [**Hospital **]
Medical Center for initiation of care.
Acute Care:
1. ALL: Patient had symptoms of night sweats, easy bruising,
fatigue and initially chest pain and was diagnosed with ALL at
OSH via flow cytometry. At our hospital the diagnosis was
confirmed via biopsy and flow cytometry, which were consistent
with pre-B cell ALL negative for the [**Location (un) 5622**] chromosome.
She underwent induction chemotherapy under experimental protcol
#06-254 ALL Adult Consortium trial. The protocol included PO
prednisone, and IV doxorubicin, cytarabine, vincristine, and
methotrexate. She also received intrathecal methotrexate,
cytarabine, and hydrocortisone. The protocol included
asparaginase as well."
5046,"Platelet
count appears significantly decreased. Differential shows 12%
neutrophils, 20% lymphocytes, 68% Blasts.
Aspirate Smear:
The aspirate material is not submitted due to dry tap.
Touch Imprints:
Touch imprints are adequate for evaluation. The smears are
hypercellular with sheets of small to medium sized cells, with
scant cytoplasm, smooth chromatin, prominent nucleoli and
slightly irregular nuclear contours, morphologically consistent
with blasts
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation and consists of
two bone marrow core biopsies composed of trabecular bone with
bone marrow elements, the overall cellularity is more than 95%
and consists almost entirely of a monotonous population of
variably-sized cells with round to regular nuclei, open
chromatin and scant amount of cytoplasm."
5047,"9* PTT-40.0* INR(PT)-1.2*
[**2131-8-15**] 04:00PM BLOOD Fibrino-727*
[**2131-8-15**] 04:00PM BLOOD Ret Aut-1.1*
[**2131-8-15**] 04:00PM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-130*
K-3.8 Cl-92* HCO3-29 AnGap-13
[**2131-8-15**] 04:00PM BLOOD ALT-24 AST-30 LD(LDH)-617* AlkPhos-85
TotBili-1.0
[**2131-8-15**] 04:00PM BLOOD Albumin-4.0 Calcium-9.6 Phos-5.6* Mg-1.6
UricAcd-5.1
[**2131-8-17**] 03:05PM BLOOD Triglyc-120 HDL-15 CHOL/HD-8."
5048,"Air filled, distended gastric
bubble.
Assessment and Plan
[**Age over 90 **] yo M, Russian speaking only, with dementia, CKD, BPH; presenting
after witnessed mechanical fall at rehab with comminuted left
intertrochanteric femoral fracture, pinned in ED with plan to go to OR
in AM.
.
# Left femur fracture: Had pin placed in ED, leg kept in traction
overnight. Ortho consult plan for operative fixation today. Given CKD,
age, poor mental status at baseline, patient is high operative risk
candidate for high risk surgery. Most recent cardiac assessment Echo
[**5-/2153**] with Ef 55%, mild symmetric left ventricular hypertrophy, mild
AR, MR & pulmonary artery hypertension."
5049,"- NPO post-MN given mental status, position
- Transfuse to Hct > 30, will re-check hematocrit today
- Post-pin films pending
- Pain management with standing Tylenol per rectum & PRN morphine
.
# Hypotension: Resolved prior to admission to the ICU. Possibly [**2-10**]
meds (Morphine IV multiple times), bleeding (no clear source though
abdomen is somewhat firm; CT negative), undiagnosed infection (CXR
prelim clear, U/A fairly unrevealing), cardiac event (flat troponins,
poor quality EKG). Most concerning features are new anemia, distended
abdomen and ?behavioral change if ambulating without walker.
- Final reads CT abdomen / pelvis, CXR
- Serial adominal exams
- Serial Hct, with transfusion goal: Hct 30
- Telemetry
- Repeat EKG
- If recurs, consider TTE, check random cortisol
- T&C x 4 units
."
5050,"# Abdominal distension: Unclear baseline. Unclear if TTP but some
element of voluntary guarding. Formal CT report pending, but large
amount of stool clearly visible in rectal vault. Prelim Abd/Pelvis
without concerning features for acute pathology.
- Serial abdominal exam
- Final read CT Abd/Pelvix
- Aggressive bowel regimen (give suppository today), consider
disimpaction if tenderness or distension worsens.
.
# Anemia: High normocytic. Sub-optimal response to blood transfusions
overnight. Goal Hct 30, given surgery. On B12 as outpatient. No
evidence of external bleeding; no hematoma over hip but thigh firmness
L>R this morning
- Serial Hct Q6H
- stool guaiac x 3
- maintain active type/screen, several units cross matched for OR
- Monitor thigh tension
will call Ortho to do compartment pressures
if concerning
."
5051,"# Leukocytosis: Elevated to 12.8 with resolution to 9 on multiple
repeat labs. Possible stress reaction, hemoconcentration or
undiagnosed infectious source. U/A unrevealing (few bacteria, negative
leuks/nitrites). CXR negative for consolidation, pneumothorax, or
pleural effusions.
- Final read CT abdomen / pelvis
- Monitor CBC
- Culture if spikes fever
.
# CKD: Unclear recent baseline creatinine. Most recent creatinine in
OMR was 2.1 in [**8-16**]. Electrolytes generally normal. FeNa 0.7%,
consistent with perfusion-related kidney injury. Improved from 1.9 on
admission to 1.7 this morning, after IV fluids overnight.
- Prior labs from [**Hospital 328**] Rehab RE: current baseline
- Renally dose medications
- Monitor BUN/creatinine
."
5052,"Chief Complaint:
24 Hour Events:
URINE CULTURE - At [**2156-2-28**] 10:14 PM
NASAL SWAB - At [**2156-2-28**] 10:14 PM
EKG - At [**2156-2-28**] 10:15 PM
- Head CT: No acute intracranial abnormality
- Hct: 34.9 -> 29.5 -> (1RBC) -> 29.8 -> (1RBC) -> 30.9
Patient unable to provide history: Language barrier
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Morphine Sulfate - [**2156-2-29**] 05:00 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2156-2-29**] 06:59 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**58**] AM
Tmax: 36."
5053,"# Dementia with behavioural disturbances: In behavioural unit at [**Hospital 328**]
Rehab.
- Continue Quetiapine 150 mg [**Hospital1 7**]
- Niece will visit today
try to orient patient and have family at
bedside as often as possible
.
# Depression / Anxiety: Unclear severity.
- Continue Citalopram 40 mg po daily
- Hold Lorazepam given increased narcotics, concern for impending
delirium
.
# Elevated troponin: Baseline compared to prior. EKG in MICU unchanged
from prior
.
# BPH: Foley in place, hold Terazosin given concern for hypotension.
.
# GERD: Continue PPI once advance beyond NPO. If continued HCT drop
would start IV PPI empirically for possible GI source.
.
# FEN: Maintenance IVF, replete electrolytes PRN, ice chips / NPO for
OR
# Prophylaxis: Pneumoboots given unclear source of blood loss, to OR in
AM; post-OR will need anticoagulant given high risk Orthopedics surgery
will reassess possibility of starting heparin SQ this afternoon if
hemodynamically stable
# Access: 18g x1, 16g x1
# Communication: Patient; HCP
# Code Status: DNR/DNI (per [**Hospital 328**] Rehab, copy in chart) but after
speaking with HCP [**Name (NI) 5564**] [**Name (NI) 13505**] [**Telephone/Fax (1) 13506**] (h), [**Telephone/Fax (1) 13507**] (w)
would like pt to be FULL CODE
# Disposition: ICU pending clinical improvement, post-operative course
ICU Care
Nutrition:
Glycemic Control:
Lines:
16 Gauge - [**2156-2-28**] 08:45 PM
18 Gauge - [**2156-2-28**] 08:45 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: DNR (do not resuscitate)
Disposition:"
5054,"No fracture of the cervical spine. 2. Reversal of
cervical lordosis between C4 and C7 narrows the spinal canal. 3.
Bilateral neural foraminal narrowing at multiple levels.
[**2-28**] Hip X-ray: Acute comminuted proximal left femur fracture involving
the lesser trochanter and extending to the subtrochanteric region.
[**2-28**] CT Abd/Pelvis (Preliminary Read): No acute intra-abdominal
findings: no free air or fluid, no hematoma. No bowel obstruction,
although rectum is distended with stool. 3mm nonobstructing renal
calculus (versus vascular calcification). Fluid-filled gallbladder
without wall thickening, pericholecystic fluid or other evidence of
cholecystitis.
[**2-28**] CXR: No acute intrathoracic process."
5055,"2
C (97.2
Tcurrent: 36.2
C (97.1
HR: 94 (87 - 105) bpm
BP: 150/82(98) {115/66(82) - 151/90(100)} mmHg
RR: 24 (20 - 32) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
781 mL
721 mL
PO:
TF:
IVF:
222 mL
530 mL
Blood products:
559 mL
191 mL
Total out:
105 mL
160 mL
Urine:
105 mL
160 mL
NG:
Stool:
Drains:
Balance:
676 mL
561 mL
Respiratory support
O2 Delivery Device: None
SpO2: 100%
ABG: ///20/
Physical Examination
General Appearance: Anxious, Speaking unintelligibly, likely in Russian
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,
Diminished: )
Abdominal: Soft, Bowel sounds present, Distended
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: 1+
Musculoskeletal: Left leg in traction, with pin through knee
Skin: Not assessed
Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
173 K/uL
10."
5056,"6 g/dL
179 mg/dL
1.7 mg/dL
20 mEq/L
4.6 mEq/L
37 mg/dL
116 mEq/L
143 mEq/L
30.9 %
9.8 K/uL
[image002.jpg]
[**2156-2-28**] 09:40 PM
[**2156-2-29**] 02:15 AM
WBC
9.8
Hct
29.8
30.9
Plt
173
Cr
1.7
Glucose
179
Other labs: PT / PTT / INR:13.6/22.7/1.2, Ca++:7.6 mg/dL, Mg++:1.9
mg/dL, PO4:3.4 mg/dL
Imaging: [**2-28**] CT Head: No acute intracranial abnormality.
[**2-28**] CT C-spine: 1."
5057,"Admission Date: [**2156-2-28**] Discharge Date: [**2156-3-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
femur fracture s/p fall
Major Surgical or Invasive Procedure:
[**2156-3-1**]: s/p open reduction internal fixation, left hip.
History of Present Illness:
[**Age over 90 **] y.o. Russian speaking M with HTN, CRI, dementia from [**Hospital 100**]
Rehab who was brought by ambulance to the ED s/p witnessed
mechanical fall (backed into chair and fell after getting up
without walker). Reportedly did not strike his head strike and
no LOC."
5058,"VS on transfer 97.3, 100,
136/86, 22, 100/2L. Upon admission to MICU, patient appears in
pain.
.
While in ED patient denied chest pain, pressure, fever,
chills/rigors, SOB, cough.
Past Medical History:
1. Hypertension.
2. Chronic renal insufficiency.
3. Benign prostate hypertrophy.
4. Dementia
5. Depression
6. Peptic ulcer disease
7. s/p hernia repair
Social History:
Lives in behavioral unit at [**Hospital 100**] Rehab. No tobacco, 'may have
up to one glass of wine per day'.
Family History:
non-contributory
Physical Exam:
On admission:
Vitals: 97.3, 100, 136/86, 22, 100/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
5059,"Brief Hospital Course:
[**Age over 90 **] yo M, Russian speaking only, with dementia, CKD, BPH
presented after witnessed mechanical fall at rehab and found to
have a comminuted left intertrochanteric femoral fracture
.
# Left femur fracture: Ortho was consulted in the ED and
consented patient for surgery and placed pin for traction. The
pt presented with Hct 34 (Baseline Hct 35.8 [**2156-1-14**]). He was
given Morpine 2mg IV, Morphine 4mg x 1, NS 2L, Haldol 5mg, and
1U PRBC. His post transfusion Hct dropped to 29 and he was
transfused a second unit without appropriate bump (Hct stayed at
29)."
5060,"Foley was placed. Given unclear source of bleeding and
hypotension on arrival, the patient was admitted to MICU for
closer monitoring. VS on transfer were 97.3, 100, 136/86, 22,
100/2L. Upon admission to MICU, the patient appeared in pain.
The patient's BP normalized after 2L. Hypotension was thought
secondary to morphine amdinistration in the ED. He was afebrile
with negative cardiac enzymes. It was unclear where his source
of bleeding was but the patient was guaiac negative. His thigh
had been firm and it was suspected that he may a hematoma there.
He remained hemodynamically stable and was thought appropriate
for transfer to medicine."
5061,"He should
follow up in two weeks in ortho clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
NP.
# Abdominal distension/ileus: In the MICU the patient was found
to have a mildly distended abdomen that was soft and non tender,
with an unclear baseline. It was noted in the records that the
patient required agressive bowel regimen at rehab it was thought
that he had chronic constipation and was given an aggressive
bowel regimen. After the patient went to the OR he developed a
post op ileus confirmed by KUB and had an NGT placed to suction.
He had a rectal tube placed for decompression but this failed."
5062,"On PO D# 4 he was started on PPN for nutrition. GI was
consulted and they felt this was a pseudoobstruction. They
recommended continued NG suction, avoiding narcotics and
anticholinergics, and changing his position every hour. He
should have a daily KUB and if his colon diameter is between
10-12 cm, surgery should be consulted because this is a surgical
emergency. It was 8.8cm on [**2156-3-7**], and unchanged on [**2156-3-8**].
NGT was taken off suction and patient had low residuals. NG was
discontinued per general surgery recs on [**2156-3-9**]. Receiving TPN.
Patient will need speech and swallow evaluation on admission to
rehab."
5063,"# UTI: In the SICU the patient was found to have a proteus uti.
His foley was changed and he was started on ceftriaxone on [**3-3**]
and should complete a 14 day course.
# CKD: The patient presented with Cr of 1.9. He had an unclear
baseline. His most recent creatinine in OMR was 2.1 on [**8-16**].
The rest of his electrolytes were normal. Urine lytes were
consistent with pre-renal azotemia. Over the course of
hospitlaization the patient's creatinine improved to 1.2. It
was 0.9 on discharge.
# Dementia with behavioural disturbances: The patient lives in
the behavioural unit at [**Hospital 100**] Rehab."
5064,"He is oriented x 1 a
baseline. Prior to the surgery the patient was functioning
below baseline per family members, taking [**Name2 (NI) 16910**] to recognize
them then normal. After the operation he remained verbally
unresponsive to family members and would not follow commands.
He was not given narcotics for worsening of his mental status.
The patient was continued on his home dose Quetiapine 150 mg
[**Hospital1 **].
# Depression / Anxiety: Unclear severity. The patient was
continued on his Citalopram 40 mg po daily.
# Elevated troponin: The patient was initially found to have an
elevated troponin compared to his baseline, however it did not
trend up and repeat EKG showed no changes so it was not thought
to be from ACS."
5065,"# BPH: The patient had a foley placed, His terazosin was
initially held in the ICU given concern for hypotension.
# Code Status: DNR/DNI (this was reversed temporarily for the
operation then DNR/DNI again)
Medications on Admission:
Morphine 4mg po Q4H PRN
Acetaminophen 650 mg Q4H PRN
Milk of Magnesia 30 mL po daily
Citalopram 40 mg po daily
Miralax 17gm po daily
Terazosin 2 mg po QPM
Quetiapine 150 mg po BID
Lorazepam 0.5 mg po BID PRN
Eucerin 1 application daily
Ferrous sulfate 325 mg po daily
Cyanocobalamin 1000 mcg daily
Sodium Fluoride 10 mL QHS Swish
Bisacodyl suppository 10 mg daily
Senna 2 tabs [**Hospital1 **]
Mirtazapine 15 mg QHS
Omeprazole 20 mg daily"
5066,"20. regular insulin sliding scale
21. Radiology
supine abdomen daily. if colon is over 10cm contact surgery.
22. Pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous
once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Left hip fracture.
2. Ileus/Pseudopbstruction
3. urinary tract infection
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You came to the hospital after you fell and were found to have a
left hip fracture. You required several blood transfusions and
went to the operating room to have your hip fixed."
5067,"7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) 17
grams/dose powder PO DAILY (Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical DAILY (Daily).
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks."
5068,"You remained
in the surgical intensive care unit for 4 days after your
operation. You developed a post operative ileus ([**Last Name **] problem
with your gut working) and you were not able to eat food for
several days. We gave you IV fluids and nutrition through your
vein.
Please go to your follow up appointment with the orthopedic
doctors (see below). They have also provided the following
special instructions after your surgery:
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
Activity:
-Continue to be full weight bearing on your left leg.
-You should not lift anything greater than 5 pounds."
5069,"08*
[**2156-2-28**] 12:00PM BLOOD ALT-25 AST-33 CK(CPK)-90 AlkPhos-105
TotBili-0.5
[**2156-3-8**] 05:10AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.2
.
Admission Imaging:
Hip X-ray IMPRESSION: Comminuted fracture proximal femur.
.
CT Pelvis / Pelvis W/O Contrast -- [**2156-2-28**]
** Preliminary **
Comminuted left intertrochanteric femoral fracture. No acute
intra-abdominal findings: no free air or fluid, no hematoma. No
bowel
obstruction, although rectum is distended with stool. 3mm
nonobstructing renal calculus (versus vascular calcification).
Fluid-filled gallbladder without wall thickening,
pericholecystic fluid or other evidence of cholecystitis."
5070,"He was transferred to the medicine
floor on [**2-29**] and taken for surgery on [**3-1**], where he underwent
ORIF of his left hip. He went to the SICU post-op to recover, as
he was transiently hypotensive during the procedure. His SICU
course included UTI and post op ileus (see below). On [**2156-3-4**]
he was called out to the medicine floor. He continued to have a
large amount of serous fluid drain from the traction wounds in
his knee. His Hct remained stable in the low 30s. Ortho
recommendations were to continue weight beairng as tolerated,
lovenox for DVT prophylaxis and tylenol for pain."
5071,"Pertinent Results:
Labs:
[**2156-2-28**] 12:00PM BLOOD WBC-12.8*# RBC-3.62* Hgb-11.4* Hct-34.9*
MCV-97 MCH-31.5 MCHC-32.6 RDW-12.8 Plt Ct-258
[**2156-2-28**] 12:00PM BLOOD Neuts-86.3* Lymphs-9.2* Monos-3.9 Eos-0.5
Baso-0.1
[**2156-2-28**] 02:32PM BLOOD PT-13.8* PTT-22.0 INR(PT)-1.2*
[**2156-2-28**] 03:00PM BLOOD ESR-16*
[**2156-2-28**] 12:00PM BLOOD Glucose-205* UreaN-40* Creat-1.9* Na-140
K-4.6 Cl-105 HCO3-23 AnGap-17
[**2156-2-28**] 12:00PM BLOOD ALT-25 AST-33 CK(CPK)-90 AlkPhos-105
TotBili-0."
5072,"5
[**2156-2-28**] 12:00PM BLOOD cTropnT-0.07*
[**2156-2-28**] 12:00PM BLOOD Lipase-40
[**2156-3-8**] 05:10AM BLOOD WBC-9.4 RBC-3.28* Hgb-10.1* Hct-30.5*
MCV-93 MCH-30.8 MCHC-33.1 RDW-16.3* Plt Ct-208
[**2156-3-8**] 05:10AM BLOOD PT-14.0* PTT-27.9 INR(PT)-1.2*
[**2156-3-8**] 05:10AM BLOOD Glucose-141* UreaN-37* Creat-1.2 Na-135
K-4.0 Cl-105 HCO3-28 AnGap-6*
[**2156-3-2**] 04:23AM BLOOD CK-MB-9 cTropnT-0."
5073,".
CT C-Spine W/O Contrast -- [**2156-2-28**]
** Preliminary **
No fracture. Marked degenerative changes with reversal of
lordosis in the mid c-spine resulting in moderate canal
narrowing.
.
CT Head W/O Contrast -- [**2156-2-28**]
** Preliminary **
No ICH or acute abnormality
.
Chest X-ray [**2156-2-28**]
** Preliminary **
Low lung volumes, marked deviation of trachea to the right,
otherwise lungs are normally aerated. Prior CXR with tracheal
deviation.
.
EKG: 120 BPM, ?sinus tachy cardia but very poor baseline, slight
LAD, no clear ST/TW changes but poor study. Compared to
[**2155-1-4**], similar axis.
ABDOMEN, [**3-7**]"
5074,"Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Quetiapine 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily)."
5075,"14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nauesa.
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 4 days: Last
dose [**2156-3-12**].
18. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical DAILY (Daily).
19. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime)."
5076,"Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
2 weeks (the week of [**2156-3-15**]) in the [**Hospital **] clinic with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to make this
appointment.
Completed by:[**2156-3-9**]"
5077,"Was noted to have left leg pain/deformity. Per report,
patient A & O x 0 at baseline. Was seen by staff physician and
given morphine. Initial ED VS 96.9, 112 irregular, 118/82, 18,
100/RA. Exam with left hip deformity, LLE shortening and
internal rotation, 1+ palpable distal pulses. Baseline Hct 35.8
([**2156-1-14**]). Given Morpine 2mg IV, Morphine 4mg x 1, NS 2L, Haldol
5mg, 1U PRBC. Foley placed. FAST negative per report but not
in ED documentation. Ortho consulted, consented patient for
surgery and placed pin, currently in traction. Given unclear
source of bleeding and hypotension on arrival, patient admitted
to MICU for closer monitoring."
5078,"HISTORY: Colonic pseudo-obstruction. Please measure colonic
diameter.
IMPRESSION: Three views of the abdomen show no appreciable
change in the
diameter of the widest part of the colon, the ascending, 84 mm
yesterday and 88 mm today. There is no appreciable wall
thickening or intramural emphysema to suggest ischemia.
Generalized gaseous distention is moderate throughout the GI
tract except for the stomach which is decompressed by a
nasogastric tube.
KUB ([**2156-3-8**])
1. Interval improvement in patient's colonic dilatation, with
scattered
air-filled loops of small and large bowel without evidence of
significant
dilatation. Air-fluid levels are identified on the decubitus
view."
5079,"Pt admitted to MICU for ? bleeding
and hypotension on arrival. There, given 2L IVF with improvement in
hypotension. He was afebrile with negative cardiac enzymes. Unclear
source of bleeding but the patient was guaiac negative. His thigh had
been firm and it was suspected that he may a hematoma there. He
remained hemodynamically stable. On [**3-1**], pt taken to OR for ORIF Left
Hip with TFN. Pt admitted to SICU postop intubated for further
management.
Chief complaint:
hip fracture
PMHx:
-- HTN
-- CRI
-- BPH
-- Alzheimer's Dementia - behavioral disturbances
-- Depression / Anxiety
-- h/o PUD
-- h/o hernia repair
-- Anemia NOS
-- GERD
-- Lumbar stenosis
Current medications:
1."
5080,"IV access: Peripheral line Order date: [**3-1**] @ 1016
16. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**3-1**] @ 1430
2. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS
Continuous at 100 ml/hr Order date: [**3-1**] @ 2358
17. Magnesium Sulfate IV Sliding Scale Order date: [**3-1**] @ 1658
3. Acetaminophen 650 mg PO/PR Q6H Order date: [**3-1**] @ 1016
18. Metoprolol Tartrate 5 mg IV ONCE MR1 Duration: 1 Doses Order date:
[**3-2**] @ 0522
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: [**3-1**] @
1016
19. Milk of Magnesia 30 mL PO/NG DAILY Order date: [**3-1**] @ 1016
5."
5081,"S/p 1 unit PRBC
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2156-3-2**] 04:40 AM
Infusions:
Other ICU medications:
Morphine Sulfate - [**2156-3-1**] 02:48 PM
Famotidine (Pepcid) - [**2156-3-2**] 12:49 AM
Other medications:
Flowsheet Data as of [**2156-3-2**] 05:29 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**58**] a.m.
Tmax: 37.5
C (99.5
T current: 36.3
C (97.4
HR: 88 (61 - 101) bpm
BP: 169/81(114) {108/50(68) - 173/89(121)} mmHg
RR: 16 (14 - 25) insp/min
SPO2: 99%
Heart rhythm: 1st AV (First degree AV Block)
Wgt (current): 72."
5082,"Cardiomediastinal contours are unchanged. Areas of
bibasilar atelectasis have developed as well as small bilateral pleural
effusions. Possibly distended loops of bowel are seen in
the imaged portion of the upper abdomen, but are incompletely evaluated
on this radiograph. Resolution of gastric distention.
Assessment and Plan
ANEMIA, OTHER, RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF,
CHRONIC KIDNEY DISEASE), PROSTATIC HYPERTROPHY, BENIGN (BPH),
GASTROESOPHAGEAL REFLUX DISEASE (GERD), DEMENTIA (INCLUDING
ALZHEIMER'S, MULTI INFARCT), DEPRESSION, TACHYCARDIA, OTHER, HIP
FRACTURE (FEMORAL NECK FRACTURE, FEMUR)
ASSESSMENT: [**Age over 90 **] yo M s/p fall with left subtroch femur fx s/p ORIF with
TFN."
5083,"Nutrition:
-- NGT in place
-- currently NPO
-- (when resumed diet: Nectar thick, Soft consistency)
Renal:
-- foley in place. Monitor UOP.
-- CKD: Unclear baseline. Cr 2.1 [**8-16**]. Current Cr 1.2
-- BPH: terazosin was on hold secondary to hypotension on admission
Hematology:
-- s/p 2 units PRBCs [**2-28**], 1 unit PRBC [**3-1**]
-- anemia: cont iron supplement and B12
-- Hct 32.5
Endocrine: RISS
ID:
-- periop ABX: ancef x 3 doses
-- leukocytosis on admission now resolved
-- f/u UCx
T/L/D: ETT, NGT, Aline, PIV, foley
Wounds: left hip
Imaging:
Fluids: D5 1/2 NS + 20meq KCL @ 100cc/hr
Consults: ortho, red west 3 surgery, geriatrics
Billing Diagnosis: hip fracture
Prophylaxis:
DVT: lovenox sc
Stress ulcer: H2B
VAP bundle: +
Comments: needs ICU consent
Communication: HCP [**Name (NI) 5564**] [**Name (NI) 13505**] [**Telephone/Fax (1) 13506**] (h), [**Telephone/Fax (1) 13507**] (w)
Code status:FULL
Disposition:SICU
Time spent: 35"
5084,"Ferrous Sulfate 325 mg PO/NG DAILY Order date: [**3-1**] @ 1016
28. Senna 1 TAB PO/NG [**Hospital1 7**]:PRN Constipation Order date: [**3-1**] @ 1016
14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:
[**3-1**] @ 1430
29. 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.
Order date: [**3-1**] @ 1016
15. Hydrocerin 1 Appl TP DAILY Order date: [**3-1**] @ 1016
24 Hour Events:
ARTERIAL LINE - START [**2156-3-1**] 01:28 PM
INVASIVE VENTILATION - START [**2156-3-1**] 01:35 PM
MULTI LUMEN - START [**2156-3-1**] 01:39 PM
[**3-1**] - ORIF Left Hip with TFN."
5085,"1
Hct
29.8
30.9
30.5
28.9
28.3
33.5
32.5
Plt
173
120
119
Creatinine
1.7
1.3
1.2
Troponin T
0.08
TCO2
20
20
21
Glucose
179
186
150
Other labs: PT / PTT / INR:13.6/27.4/1.2, CK / CK-MB / Troponin
T:/11/0.08, Ca:7.4 mg/dL, Mg:1.6 mg/dL, PO4:2.0 mg/dL
Imaging: [**3-1**] CXR - Endotracheal tube tip terminates about 3 cm above
the carina, nasogastric tube terminates in the stomach and a right
internal jugular vascular catheter tip terminates below the expected
level of the superior vena cava, right atrial junction, with no
pneumothorax."
5086,"Neurologic:
-- intubated and sedated with propofol gtt
-- moves all extremities
-- pain control: tylenol ATC, morphine prn
-- depression/anxiety: cont citalopram, mirtazapine
-- Dementia with behavioural disturbances: cont quetiapine
Cardiovascular:
-- on admission, trop 0.06 with negative CKMB. No EKG changes from
prior.
-- trops: 0.06 -> 0.08 (MB 11) --> f/u AM trop
-- hemodynamically stable
Pulmonary:
-- intubated postop. Wean to extubation after KUB .
Gastrointestinal / Abdomen:
-- NGT in place
-- abdominal distension on admission. Cont bowel regimen. Will check
KUB. If colonic distension, consider colonoscopy.
-- bowel regimen: bisacodyl prn, colace, milk of magnesia, senna,
polyethylene glycol
-- GERD: on PPI at home, currently on famotidine."
5087,"7 kg (admission): 67 kg
CVP: 13 (10 - 17) mmHg
Total In:
2,531 mL
655 mL
PO:
Tube feeding:
IV Fluid:
2,181 mL
655 mL
Blood products:
350 mL
Total out:
656 mL
209 mL
Urine:
286 mL
209 mL
NG:
Stool:
Drains:
Balance:
1,875 mL
446 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 14
RR (Spontaneous): 11
PEEP: 5 cmH2O
FiO2: 50%
PIP: 21 cmH2O
Plateau: 18 cmH2O
SPO2: 99%
ABG: 7.35/37/145/22/-4
Ve: 12.7 L/min
PaO2 / FiO2: 363
Physical Examination
General Appearance: No acute distress, intubated, sedated
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Firm,distended, Non-tender, Bowel sounds present, Distended
Left Extremities: (Edema: 1+), (Temperature: Warm)
Right Extremities: (Edema: 1+), (Temperature: Warm)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Responds to: Verbal stimuli), Moves all extremities,
Sedated
Labs / Radiology
119 K/uL
11."
5088,"0 g/dL
150 mg/dL
1.2 mg/dL
22 mEq/L
4.0 mEq/L
33 mg/dL
117 mEq/L
143 mEq/L
32.5 %
8.1 K/uL
[image002.jpg]
[**2156-2-28**] 09:40 PM
[**2156-2-29**] 02:15 AM
[**2156-2-29**] 07:23 AM
[**2156-2-29**] 02:37 PM
[**2156-3-1**] 03:02 PM
[**2156-3-1**] 03:16 PM
[**2156-3-1**] 06:02 PM
[**2156-3-1**] 10:51 PM
[**2156-3-2**] 04:23 AM
[**2156-3-2**] 04:49 AM
WBC
9.8
6.8
8."
5089,"TITLE:
SICU
HPI:
[**Age over 90 **]y Russian speaking M brought by ambulance from [**Hospital 328**] rehab to the ED
s/p witnessed mechanical fall (backed into chair and fell after getting
up without walker). Reportedly no head trauma or LOC. + left leg pain.
Exam with left hip deformity, LLE shortening and internal rotation, 1+
palpable distal pulses. Ortho consulted, placed pin and pt in traction.
In ED, Hct 34 (Baseline Hct 35.8 [**2156-1-14**]). He was transfused 1U PRBC.
Post transfusion Hct dropped to 29 and he was transfused a second unit
without appropriate bump (Hct 29)."
5090,"Subjective: Patient has dementia and is Russian-speaking. No family
or care takers available to interview.
Objective
Height
Admit weight
Daily weight
Weight change
BMI
170 cm
72.6 kg
74.4 kg ([**2156-3-4**] 12:00 AM)
23.1
Ideal body weight
% Ideal body weight
Adjusted weight
Usual body weight
% Usual body weight
67.1 kg
108%
unknown
Diagnosis: Left Femur Fracture
PMHx: -- HTN
-- CRI
-- BPH
-- Alzheimer's Dementia - behavioral disturbances
-- Depression / Anxiety
-- h/o PUD
-- h/o hernia repair
-- Anemia NOS
-- GERD
-- Lumbar stenosis
Food allergies and intolerances: none noted
Pertinent medications: Morphine, IV fluid, others noted
Labs:
Value
Date
Glucose
135 mg/dL
[**2156-3-4**] 03:43 AM
Glucose Finger Stick
145
[**2156-3-4**] 10:00 AM
BUN
27 mg/dL
[**2156-3-4**] 03:43 AM
Creatinine
1."
5091,"1-1.3 g/kg)
Fluid: per team
Calculations based on: Admit weight
Estimation of previous intake: Adequate
Estimation of current intake: Inadequate
Specifics:
[**Age over 90 **] y.o. Male s/p mechanical fall with left subtrochanteric femur
fracture, now s/p ORIF and nailing with TFN [**3-1**]. Patient
s post-op
course complicated by prolonged extubation and colonic ileus. Patient
is now extubated, but continues with NGT to suction with only small
amount of output. Patient has had minimal nutrition for ~5 days, so
once patient is ok to use gut, recommend a swallow evaluation. If
patient is unable to take po
s safely, recommend starting TPN if
indicated.
Medical Nutrition Therapy Plan - Recommend the Following
Monitor clinical progress
recommend swallow evaluation if
ileus resolved.
If patient is unable to take po
s, recommend goal of Boost
Glucose Control @ 70mL/hr (1780kcals/97g protein).
If TPN is needed, recommend starting Day 1 standard. Will
provide TPN goal as needed.
Multivitamin / Mineral supplement
Following - #[**Numeric Identifier 2337**]"
5092,"4 mg/dL
[**2156-3-4**] 03:43 AM
Phosphorus
2.3 mg/dL
[**2156-3-4**] 03:43 AM
Ionized Calcium
1.20 mmol/L
[**2156-3-3**] 06:23 PM
Magnesium
2.4 mg/dL
[**2156-3-4**] 03:43 AM
WBC
8.7 K/uL
[**2156-3-4**] 03:43 AM
Hgb
9.9 g/dL
[**2156-3-4**] 03:43 AM
Hematocrit
28.7 %
[**2156-3-4**] 03:43 AM
Current diet order / nutrition support: Diet: NPO
GI: NGT to low continuous suction, abd distended, hypoactive bowel
sounds
Assessment of Nutritional Status
At risk for malnutrition
Patient at risk due to: advanced age, Ileus, dementia
Estimated Nutritional Needs
Calories: 1742-[**2176**] (24-28 cal/kg)
Protein: 80-94 (1."
5093,"2 mg/dL
[**2156-3-4**] 03:43 AM
Sodium
134 mEq/L
[**2156-3-4**] 03:43 AM
Potassium
4.4 mEq/L
[**2156-3-4**] 03:43 AM
Chloride
109 mEq/L
[**2156-3-4**] 03:43 AM
TCO2
22 mEq/L
[**2156-3-4**] 03:43 AM
PO2 (arterial)
138 mm Hg
[**2156-3-3**] 06:23 PM
PCO2 (arterial)
37 mm Hg
[**2156-3-3**] 06:23 PM
pH (arterial)
7.37 units
[**2156-3-3**] 06:23 PM
pH (urine)
5.0 units
[**2156-2-28**] 09:39 PM
CO2 (Calc) arterial
22 mEq/L
[**2156-3-3**] 06:23 PM
Calcium non-ionized
7."
5094,"TITLE:
Chief Complaint: hip fracture
HPI:
[**Age over 90 **]y Russian speaking M brought by ambulance from [**Hospital 328**] rehab to the
ED s/p witnessed mechanical fall (backed into chair and fell after
getting up without walker). Reportedly no head trauma or LOC. + left
leg pain. Exam with left hip deformity, LLE shortening and internal
rotation, 1+ palpable distal pulses. Ortho consulted, placed pin and pt
in traction. In ED, Hct 34 (Baseline Hct 35.8 [**2156-1-14**]). He was
transfused 1U PRBC. Post transfusion Hct dropped to 29 and he was
transfused a second unit without appropriate bump (Hct 29)."
5095,"Current Cr 1.4
-- BPH: terazosin was on hold secondary to hypotension on admission
Hematology: -- s/p 2 units PRBCs [**2-28**], 1 unit PRBC [**3-1**]
-- anemia: cont iron supplement and B12
Infectious Disease: -- periop ABX: ancef x 3 doses
-- leukocytosis on admission now resolved
-- f/u UCx
Endocrine: -- RISS
Fluids: -- D5 1/2 NS + 20meq KCL @ 100cc/hr
Electrolytes: -- replete as needed
Nutrition: -- NGT in place
-- currently NPO
-- (when resumed diet: Nectar thick, Soft consistency)
General:
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2156-3-1**] 01:28 PM
Multi Lumen - [**2156-3-1**] 01:39 PM
Prophylaxis:
DVT: Boots(sc lovenox)
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Need for restraints reviewed
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 35 minutes
Patient is critically ill"
5096,"6 g/dL
186 mg/dL
1.3 mg/dL
20 mEq/L
3.2 mEq/L
35 mg/dL
117 mEq/L
142 mEq/L
28.3 %
6.8 K/uL
[image002.jpg]
[**2156-2-28**] 09:40 PM
[**2156-2-29**] 02:15 AM
[**2156-2-29**] 07:23 AM
[**2156-2-29**] 02:37 PM
[**2156-3-1**] 03:02 PM
[**2156-3-1**] 03:16 PM
[**2156-3-1**] 06:02 PM
WBC
9.8
6.8
Hct
29.8
30.9
30.5
28.9
28.3
Plt
173
120
Cr
1.7
1.3
TropT
0."
5097,"Docusate Sodium 100 mg PO BID Order date: [**3-1**] @ 1016
25. Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**3-1**] @ 1658
11. Enoxaparin Sodium 40 mg SC DAILY Order date: [**3-1**] @ 1016
26. Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation Order date:
[**3-1**] @ 1431
12. Famotidine 20 mg PO/NG Q24H Order date: [**3-1**] @ 1508
27. Quetiapine Fumarate 150 mg PO/NG [**Hospital1 7**] Order date: [**3-1**] @ 1016
13. Ferrous Sulfate 325 mg PO/NG DAILY Order date: [**3-1**] @ 1016
28. Senna 1 TAB PO/NG [**Hospital1 7**]:PRN Constipation Order date: [**3-1**] @ 1016
14."
5098,"CefazoLIN 1 g IV Q8H Duration: 3 Doses Order date: [**3-1**] @ 1016
21. Morphine Sulfate 2-4 mg IV Q6H:PRN pain Order date: [**3-1**] @ 1016
7. Citalopram Hydrobromide 40 mg PO/NG DAILY Order date: [**3-1**] @ 1016
22. Ondansetron 4 mg IV ONCE Duration: 1 Doses Order date: [**3-1**] @ 1016
8. Cyanocobalamin 1000 mcg PO/NG DAILY Order date: [**3-1**] @ 1016
23. Polyethylene Glycol 17 g PO/NG DAILY Order date: [**3-1**] @ 1016
9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Order date: [**3-1**]
@ 1430
24. Potassium Chloride IV Sliding Scale Order date: [**3-1**] @ 1658
10."
5099,"33/36/115/20/-6
Ve: 7.3 L/min
PaO2 / FiO2: 230
Physical Examination
General Appearance: Well nourished, intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube, NG tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,
Tone: Not assessed
Labs / Radiology
120 K/uL
9."
5100,"Small non-obstructing
right renal calculus. Atherosclerotic disease.
[**2-28**] CT Head - No acute intracranial abnormality.
[**2-28**] CXR - No acute intrathoracic process.
[**2-28**] Hip Xray - Acute comminuted proximal left femur fracture involving
the lesser trochanter and extending to the subtrochanteric region.
[**2-29**] Femur Xray - Comminuted fracture proximal femur
Assessment and Plan
ANEMIA, OTHER
RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY
DISEASE)
PROSTATIC HYPERTROPHY, BENIGN (BPH)
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)
DEPRESSION
TACHYCARDIA, OTHER
HIP FRACTURE (FEMORAL NECK FRACTURE, FEMUR)
Assessment And Plan: [**Age over 90 **] yo M s/p fall with left subtroch femur fx s/p
ORIF with TFN."
5101,"1000 mL LR Bolus 500 ml Over 30 mins Order date: [**3-1**] @ 1550
17. Magnesium Sulfate IV Sliding Scale Order date: [**3-1**] @ 1658
3. Acetaminophen 650 mg PO/PR Q6H Order date: [**3-1**] @ 1016
18. Milk of Magnesia 30 mL PO/NG DAILY Order date: [**3-1**] @ 1016
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: [**3-1**] @
1016
19. Mirtazapine 15 mg PO/NG HS Order date: [**3-1**] @ 1016
5. Calcium Gluconate IV Sliding Scale Order date: [**3-1**] @ 1658
20. Morphine Sulfate 2-4 mg IV Q4H:PRN Pain
Hold for oversedation or RR < 12 Order date: [**3-1**] @ 1016
6."
5102,"Pt admitted
to MICU for ? bleeding and hypotension on arrival. There, given 2L IVF
with improvement in hypotension. He was afebrile with negative cardiac
enzymes. Unclear source of bleeding but the patient was guaiac
negative. His thigh had been firm and it was suspected that he may a
hematoma there. He remained hemodynamically stable. On [**3-1**], pt taken
to OR for ORIF Left Hip with TFN. Pt admitted to SICU postop intubated
for further management.
Other medications:
1. IV access: Peripheral line Order date: [**3-1**] @ 1016
16. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**3-1**] @ 1430
2."
5103,"1
C (98.8
Tcurrent: 37.1
C (98.8
HR: 84 (61 - 84) bpm
BP: 148/68(98) {108/50(68) - 173/89(121)} mmHg
RR: 16 (14 - 16) insp/min
SpO2: 99%
Heart rhythm: 1st AV (First degree AV Block)
Total In:
2,364 mL
1,763 mL
PO:
60 mL
TF:
IVF:
2,113 mL
1,413 mL
Blood products:
191 mL
350 mL
Total out:
361 mL
620 mL
Urine:
361 mL
250 mL
NG:
Stool:
Drains:
Balance:
2,003 mL
1,143 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 14
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
PIP: 19 cmH2O
Plateau: 18 cmH2O
SpO2: 99%
ABG: 7."
5104,"08
TCO2
20
20
Glucose
179
186
Other labs: PT / PTT / INR:14.6/26.4/1.3, CK / CKMB /
Troponin-T:/11/0.08, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL
Imaging: [**2-28**] CT Cspine - No fracture of the cervical spine. Reversal
of cervical lordosis between C4 and C7 narrows the spinal canal. If
neurologic symptoms are referable to this level, MRI could be obtained
to evaluate the spinal cord. Bilateral neural foraminal narrowing at
multiple levels.
[**2-28**] Ct Abd/Pelv - Comminuted, impacted subtrochanteric fracture of the
left femur extending into the lesser trochanter, with superior
displacement of lesser trochanteric fragment."
5105,"Neurologic: -- intubated and sedated with propofol gtt
-- pain control: tylenol ATC, morphine prn
-- depression/anxiety: cont citalopram, mirtazapine
-- Dementia with behavioural disturbances: cont quetiapine
Cardiovascular: -- on admission, trop 0.06 with negative CKMB. No EKG
changes from prior.
-- trops: 0.06 -> 0.08 (MB 11) --> f/u AM trop
-- hemodynamically stable
Pulmonary: -- intubated postop. Wean to extubation.
Gastrointestinal: -- NGT in place
-- abdominal distension on admission. Cont bowel regimen.
-- bowel regimen: bisacodyl prn, colace, milk of magnesia, senna,
polyethylene glycol
-- GERD: on PPI at home, currently on famotidine.
Renal: -- foley in place. Monitor UOP.
-- CKD: Unclear baseline. Cr 2.1 [**8-16**]."
5106,"Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Order date:
[**3-1**] @ 1430
29. 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.
Order date: [**3-1**] @ 1016
15. Hydrocerin 1 Appl TP DAILY Order date: [**3-1**] @ 1016
Post operative day:
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2156-3-1**] 08:45 PM
Infusions:
Other ICU medications:
Morphine Sulfate - [**2156-3-1**] 02:48 PM
Past medical history:
Family / Social history:
-- HTN
-- CRI
-- BPH
-- Alzheimer's Dementia - behavioral disturbances
-- Depression / Anxiety
-- h/o PUD
-- h/o hernia repair
-- Anemia NOS
-- GERD
-- Lumbar stenosis
Flowsheet Data as of [**2156-3-1**] 09:25 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**58**] AM
Tmax: 37."
5107,"4
[image002.jpg]
Other labs: PT / PTT / INR:15/29/1.4
Imaging: None
Assessment and Plan
31yoF 31yoF with hx ckd stage 4, hd-dependant [**2-14**] to childhood reflux,
presents with epistaxis and anemia.
# epistaxis/acute blood loss anemia: Etiology of her epistaxis unknown,
no longstanding hx of nosebleeds; no hx of vonWillebrand's or
hemophilia. Issue currently exacerbated by uremia. Baseline hct unknown
but likely low given ESRD. Seen by ENT who feel most consistent with
arterial spasm. Anterior packing in place with no further active
bleeding apparent. Received DDAVP in ED.
- q6hr hct check
- 2uPRBCs now
- T/C 2 units
- appreciate ENT evaluation/input
- merocel in place x 5 days
- keflex for staph coverage
- afrin at bedside
- humidified air
- after the packing is removed, she should start nasal saline
sprays TID x10 days and apply a very small amount of bacitracin
to the left anterior nose [**Hospital1 **] x 7 days
- follow-up in [**Hospital **] clinic on day 5 (Thursday) for packing removal
# ESRD: [**2-14**] to childhood reflux, HD-dependant."
5108,"Chief Complaint: Epistaxis
HPI:
31yoF with hx ckd stage 4, hd-dependant [**2-14**] to childhood reflux,
presents with epistaxis and anemia. Pt had a spontaneous nosebleed,
which began yesterday, seen early at OSH yesterday ([**5-21**]), had packing
placed. Bleeding continued over course of day, returned to hospital 2
additional times for continued bleeding. Hct dropped from 22->16 at
OSH. Now sent from [**Hospital1 **] to [**Hospital1 5**] for further management as no ENT
available there.
.
In [**Hospital1 5**] ED, vital signs stable, sbp 140, hr 80s, on room air. Packing
in place, no active bleeding. Hct 16 on arrival here (stable from OSH)."
5109,"[**Last Name (STitle) 3482**]. I was present for delivery of all key services and agree with
Dr. [**Last Name (STitle) 3482**]
s note above. In addition, I would add/emphasize:
31F ESRD HD dependant 2ndry to childhood reflux, presents with
epistaxis and anemia. Epistaxis started spontaneously yesterday. No
h/o prior episodes. Presented to OSH x 3 with presumed anterior
epistaxis. Transferred to [**Hospital1 5**] for ENT availability for evaluation.
Hct 16 on presentation at [**Hospital1 5**]
had been 22 at last measure at OSH.
In ED: ENT evaluation-> anterior nasal packing applied (merocel).
Given DDAVP, pRBC x 2. Transferred to MICU for close monitoring given
falling hct and evidence of ongoing bleeding."
5110,"Patient initially refusing blood transfusions, [**2-14**] to ""fear of blood
products,"" vs. ""religious issues. ED resident discussed risk and
benefits, pt agreed to receive pRBCs. Two pIVs (20/18) placed. Blood
transfusion initiated in ED. Pt then had another episode of brisk nose
bleed in ED, seen by ENT who placed new merocel packing in L nostril.
Received DDAVP, ancef, ativan, and zofran. Pt was admitted to the MICU
for close monitoring.
Patient admitted from: [**Hospital1 5**] ER
History obtained from Family / [**Hospital 216**] Medical records
Patient unable to provide history: Encephalopathy
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
(per ED record, dosages unknown):
Atenolol
Procardia XL
Doxazosin
Renagel
Guaifenesin
Past medical history:
Family history:
Social History:
-CKD stage4 - [**2-14**] reflux as child, HD M/W/F
-HTN
-Anxiety
Non-contributory
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Unable to obtain from patient [**2-14**] mental status."
5111,"1, BP 133/73, HR 88, RR 16, SaO2 94% on RA
GENERAL: sleepy but arousable, NAD
HEENT: No scleral icterus. PERRLA/EOMI. packing in Left nostril with
evidence of dried blood, no active bleeding, OP clear, MMM. Neck NECK:
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial pulses.
NEURO: sleepy, alert and oriented x 3, moving all extremities
Labs / Radiology
159
95
8.0
132
23
95
5.3
135
16.4
5."
5112,"Afeb BP 130/70 R18 P90 Sat 95%RA
Resting comfortably in bed, NAD
Lungs CTAB
CV RRR s
Abd benign bs+
Hct 16
A/P
Anterior epistaxis
-murocel packing
-Keflex empiric coverage
-ENT following
-etiology unclear. [**Name2 (NI) **] hx. Uremia/plt function exacerbating factor
-serial hct
Anemia secondary to blood loss
-baseline hct not known though last measure at OSH 22
-cont transfuse
ESRD:
-HD dependent
-renal aware pt in house
-follow lytes, esp with blood product transfusion
Remainder of plan per note above.
Patient is critically ill.
Time spent on care: 35minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 174**] [**Last Name (NamePattern1) 911**], MD
on:[**2191-5-22**] 19:36 ------"
5113,"Significant uremia,
stable potassium, stable clinical mental status. Dialysis dates are
M/W/F. Getting blood products with volume and K. Not currently volume
overloaded.
- renal HD team is aware and will await their recs
- electrolyte check q12 until HD
- obtain further history from family when able to reach
# FEN: cardiac diet, keep mg>2, k >4 and <5, maintain adequate access
at 20 and 18.
# ppx: pneumoboots, ppi (renal failure and uremia)
# access: 2pIV's
# CODE STATUS: FULL
# DISPOSITION: MICU until bleeding and HCT stabilizes
# COMMUNICATION: with patient
- fiance [**Doctor First Name 92**] [**Telephone/Fax (1) 6258**] (attempted to call but no answer)
- will make further attempts to reach family to obtain ICU consent and
further history
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2191-5-22**] 07:15 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
------ Protected Section ------
Chart reviewed, patient examined, case discussed in detail with Dr."
5114,"Review of systems:
Limited [**2-14**] mental status. Denies pain.
Flowsheet Data as of [**2191-5-22**] 02:51 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36.9
C (98.4
Tcurrent: 36.9
C (98.4
HR: 88 (83 - 88) bpm
BP: 159/105(119) {124/67(84) - 159/105(119)} mmHg
RR: 23 (14 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
350 mL
PO:
TF:
IVF:
Blood products:
350 mL
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
350 mL
Respiratory
O2 Delivery Device: None
SpO2: 100%
Physical Examination
VS: T 98."
5115,"Admission Date: [**2191-5-22**] Discharge Date: [**2191-5-24**]
Date of Birth: [**2159-12-1**] Sex: F
Service: MEDICINE
Allergies:
Protamine Sulfate / Bactrim / Amoxicillin
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
Nasal Packing
History of Present Illness:
31yoF with hx ckd stage 4, hd-dependent [**2-14**] to childhood reflux,
presents with epistaxis and anemia. Pt had a spontaneous
nosebleed, which began yesterday, seen early at OSH yesterday
([**5-21**]), had packing placed. Bleeding continued over course of
day, returned to hospital 2 additional times for continued
bleeding. Hct dropped from 22->16 at OSH."
5116,"Received DDAVP, ancef, ativan, and zofran. Pt was admitted to
the MICU for close monitoring.
Past Medical History:
-CKD stage4 - [**2-14**] reflux as child, HD M/W/F
-HTN
-Anxiety
Social History:
Fiancee of 5 years, unclear about other social history
Family History:
NC
Physical Exam:
VS: T 98.1, BP 133/73, HR 88, RR 16, SaO2 94% on RA
GENERAL: sleepy but arousable, NAD
HEENT: No scleral icterus. PERRLA/EOMI. packing in Left nostril
with evidence of dried blood, no active bleeding, OP clear, MMM.
Neck NECK: Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g."
5117,"0* SODIUM-135
POTASSIUM-5.3* CHLORIDE-95* TOTAL CO2-23 ANION GAP-22
[**2191-5-22**] 05:20AM CALCIUM-10.2 PHOSPHATE-4.1 MAGNESIUM-2.4
[**2191-5-22**] 05:20AM WBC-5.4 RBC-1.66* HGB-5.4* HCT-16.4* MCV-99*
MCH-32.8* MCHC-33.1 RDW-17.5*
[**2191-5-22**] 05:20AM NEUTS-44.2* LYMPHS-49.8* MONOS-2.5 EOS-3.0
BASOS-0.5
[**2191-5-22**] 05:20AM PLT COUNT-159
[**2191-5-22**] 05:20AM PT-15.9* PTT-29.4 INR(PT)-1.4*
Brief Hospital Course:
31yoF 31yoF with hx ckd stage 4, hd-dependant [**2-14**] to childhood
reflux, presents with epistaxis and anemia."
5118,"Now sent from [**Hospital1 **]
to [**Hospital1 18**] for further management as no ENT available there.
.
In [**Hospital1 18**] ED, vital signs stable, sbp 140, hr 80s, on room air.
Packing in place, no active bleeding. Hct 16 on arrival here
(stable from OSH). Patient initially refusing blood
transfusions, [**2-14**] to ""fear of blood products,"" vs. ""religious
issues. ED resident discussed risk and benefits, pt agreed to
receive pRBCs. Two pIVs (20/18) placed. Blood transfusion
initiated in ED. Pt then had another episode of brisk nose bleed
in ED, seen by ENT who placed new merocel packing in L nostril."
5119,"4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for anxiety/agitation for 7 days.
Disp:*10 Tablet(s)* Refills:*0*
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 2 days.
Disp:*4 Capsule(s)* Refills:*0*
6. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
8. Guanfacine 1 mg Tablet Sig: One (1) Tablet PO at bedtime."
5120,"Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Epistaxis
.
Secondary:
Hypertension
End Stage Renal Disease on Hemodialysis
Discharge Condition:
Vitals signs stable, hematocrit stable, ambulating
Discharge Instructions:
You were admitted for a nose bleed that required you to have a
blood transfusion to keep your blood levels stable. You also
received dialysis as scheduled.
.
Nose bleed instructions: Do not manipulate the packing. No nose
blowing. Do not touch or manipulate the nose. Avoid long, hot
showers. Avoid drinking very hot liquids or eating spicy foods.
If active (bright red) bleeding is noted, spray copious amounts
of Afrin in and around the packing (which is like a sponge) and
hold pressure on the tip of nose for 15-20 minutes."
5121,".
Continue with dialysis as scheduled on Monday, Wednesday,
Friday.
.
If you develop any of the following, nose bleeding, chest pain,
shortness of breath, cough, fevers/chills, headache, dizziness,
nausea, vomiting or diarrhea, please call your primary care
doctor or go to your local emergency room.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] with ENT on Thursday
[**2191-5-26**] at 11:15. The office is located on [**Last Name (NamePattern1) **].
Suite 6E. Please arrive 15 minutes early to complete some
paperwork.
.
Also, please call to schedule an appointment with your primary
care doctor within the next week.
.
Continue with dialysis as scheduled on Monday, Wednesday,
Friday.
Completed by:[**2191-5-29**]"
5122,".
# epistaxis/acute blood loss anemia: Required short MICU stay
until bleeding stabilized. Etiology of her epistaxis unknown, no
longstanding hx of nosebleeds; no hx of vonWillebrand's or
hemophilia. Issue exacerbated by uremia. Baseline hct unknown
but likely low given ESRD. Seen by ENT who feel most consistent
with arterial spasm. Anterior packing in place with no further
active bleeding apparent. Received DDAVP in ED. Given 4 units
PRBC's, q6H hct check which was stable with transfusion and
epistaxis did not recur. Placed pt on keflex for staph coverage
and placed afrin at bedside. After the packing is removed, she
should start nasal saline, sprays TID x10 days and apply a very
small amount of bacitracin, to the left anterior nose [**Hospital1 **] x 7
days."
5123,".
# ESRD: [**2-14**] to childhood reflux, HD-dependant. Significant
uremia, stable potassium, stable clinical mental status.
Dialysis dates are M/W/F. Getting blood products with volume and
K. Not currently volume overloaded.
Medications on Admission:
Atenolol 100mg PO BID
Procardia XL 60mg PO daily
Doxazosin 2mg PO BID
Renagel 800mg TID with meals
Guanficine 1mg PO QHS
Discharge Medications:
1. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
DAILY (Daily) as needed for epistaxis.
Disp:*1 bottle* Refills:*0*
2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day)."
5124,"If bleeding
continues after that, please go to the emergency room.
.
Medications: Please continue with all your home medications as
previously prescribed. The following additions were made to
your regimen:
ADDED Keflex 500mg my mouth twice a day
ADDED Afrin to be used in nose if bleeding develops
.
You have an appointment with Dr. [**Last Name (STitle) **] with ENT on Thursday
[**2191-5-26**] at 11:15. The office is located on [**Last Name (NamePattern1) **].
Suite 6E. Please arrive 15 minutes early to complete some
paperwork.
.
Also, please call to schedule an appointment with your primary
care doctor within the next week."
5125,"LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: sleepy, alert and oriented x 3, moving all extremities
Pertinent Results:
[**2191-5-22**] 02:19PM GLUCOSE-85 UREA N-148* CREAT-8.9* SODIUM-135
POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-19* ANION GAP-23*
[**2191-5-22**] 02:19PM CALCIUM-10.0 PHOSPHATE-5.1* MAGNESIUM-2.3
[**2191-5-22**] 02:19PM HCT-19.6*
[**2191-5-22**] 05:25AM HGB-5.5* calcHCT-17
[**2191-5-22**] 05:20AM GLUCOSE-95 UREA N-132* CREAT-8."
5126,"Apache II score: 7, corresponding to a 7.6% mortality. Will
require repeat ERCP, given obstructive picture (elevated LFTs, CBD
measuring 11mm on US), GNR bacteremia, concern for evolving biliary
sepsis.
-NPO for bowel rest, plus expected ERCP and cholecystectomy
-IV morphine (2-4mg Q6H PRN) for pain control
-IVF (1L NS @ 150cc/hr) for fluid resuscitation
-ERCP tomorrow, per GI
-Cholecystectomy prior to hospital discharge
#) Biliary infection: Pt presented initially with fever and RUQ pain
[**3-13**] cholecystitis, diagnosed by RUQ ultrasound. Following a TBili bump
to 5.3 the following day, the picture became concerning for cholangitis
(class triad = fever, RUQ pain, jaundice), though pt was no longer
febrile."
5127,"Per
report, pt's Tn has been similarly elevated in the past. EKG normal in
ED. No prior.
-Cycle enzymes
-Repeat EKG
#) HTN: Pt treated with lisinopril and HCTZ at home. Currently
normotensive on floor.
-Hold home antihypertensives in setting of recent hypotension
-Anti-HTN support provided by diltiazem
#) Asthma: Stable. No evidence of reactive airways on exam.
-Nebulizers PRN
#) Diabetes: Presumed diet controlled, given no antiglycemics on
patient's home med regimen.
-ISS + hypoglycemia protocol
#) FEN:
-NPO, as above
-Replete lytes as necessary
ICU Care
Nutrition: NPO, as above
Glycemic Control: ISS + hypoglycemia protocl
Lines:
20 Gauge - [**2114-4-17**] 01:59 AM
Prophylaxis:
DVT: Subcutaneous heparin
Stress ulcer: PPI
Communication: [**Name (NI) **] (son) [**Telephone/Fax (1) 11880**]
Code status: Full code
Disposition: Pending ERCP, continued hemodynamic stability"
5128,"2 mg/dL,
Mg++:1.7 mg/dL, PO4:3.8 mg/dL
Assessment and Plan
Assessment and Plan: 73yF, Vietnamese-speaking only, hx of HTN and [**Hospital 5882**]
transferred from OSH with cholecystitis, gallstone pancreatitis,
possible cholangitis, now s/p unsuccessful ERCP complicated by A-fib
with RVR.
#) Gallstone pancreatitis. Attempt at treatment with early ERCP failed
[**3-13**] ampulla positioning within a diverticulum. CBD visualization was
not pursued because of the high risk of perforation with
sphincterotomy, also peri-procedure development of A-fib with RVR. Pt
now may have post-ERCP pancreatitis as well, given lipase bump to
1200s."
5129,"-Unasyn and Cipro for broad-spectrum coverage, as above
-Monitor HR, BP, UOP
#) A-fib with RVR: Paroxysmal A-fib. Most likely etiology is systemic
infection. Though pt has reported hx of CHF, there are no signs of
volume overload on exam or CXR. Rate conrol achieved with diltiazem
prior to arrival on floor. Pt spontaneously converted to NSR. CHADS
score of 3 (for CHF, HTN, DM), therefore anticoagulation technically
indicated, though would wait to establish recurrence before treating.
-Continue Diltiazem 30mg PO daily for rate control
#) Troponin leak: Tn was 0.55 at OSH, 0.07 on admission here."
5130,"8 g/dL
101 mg/dL
1.0 mg/dL
26 mEq/L
5.3 mEq/L
18 mg/dL
101 mEq/L
139 mEq/L
33.2 %
6.7 K/uL
[image002.jpg]
[**2114-4-17**] 02:01 AM
WBC
6.7
Hct
33.2
Plt
206
Cr
1.0
TropT
0.06
Glucose
101
Other labs: CK / CKMB / Troponin-T:388/5/0.06, ALT / AST:233/256, Alk
Phos / T Bili:166/4.1, Differential-Neuts:75.7 %, Lymph:19.2 %,
Mono:4.6 %, Eos:0.4 %, Albumin:3.2 g/dL, LDH:586 IU/L, Ca++:9."
5131,"2
C (99
Tcurrent: 37.2
C (99
HR: 63 (63 - 74) bpm
BP: 133/53(70) {105/45(59) - 136/54(72)} mmHg
RR: 21 (19 - 27) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Total In:
758 mL
PO:
TF:
IVF:
758 mL
Blood products:
Total out:
0 mL
655 mL
Urine:
NG:
Stool:
Drains:
Balance:
0 mL
103 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 97%
ABG: ///26/
Physical Examination
General: Obese Vietnamese woman, in no acute distress, sleeping
HEENT: PERRLA; sclerae anicteric; MMM; oropharynx clear; poor dentition
Neck: JVP @ 7cm
Lungs: Inspiratory crackles at R lung base, otherwise clear to
auscultation w/o wheezes
CV: RRR, nl S1, S2, [**4-14**] harsh early systolic murmur heard best at RUSB
Abdomen: Soft, obesely distended but not tympanitic, +BS, non-tender to
deep palpation without rebound or guarding
GU: Foley
Ext: Warm, well-perfused; DPs 2+ bilaterally; trace pedal edema
Labs / Radiology
206 K/uL
10."
5132,"Chief Complaint: Gallstone Pancreatitis
24 Hour Events:
Overnight: pt remained afebrile and hemodynamically stable with a
benign belly exam.
Tolerating IVF w/o signs of volume overload.
CXR demonstrated marked cardiomegaly without evidence of edema.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ampicillin/Sulbactam (Unasyn) - [**2114-4-17**] 03:20 AM
Infusions:
Other ICU medications:
Morphine Sulfate - [**2114-4-17**] 04:56 AM
Other medications:
Diltiazem
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2114-4-17**] 07:45 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**16**] AM
Tmax: 37."
5133,"GNR+ bacteremia may be [**3-13**] to this infection. The predisposing
source is presumably biliary obstruction [**3-13**] biliary calculi. Concern
is for biliary sepsis.
-Unasyn (Ampicillin-Sulbactam 1.5 g IV Q6H)
-Coinsider ciprofloxacin (Ciprofloxacin HCl 500 mg PO/NG Q12H) for
additional GNR coverage
-ERCP for re-establishment of biliary drainage
#) SIRS/Hypotension: Resolving. Over past two days, pt has been febrile
to 103, hypotensive, with a bandemia and a clear infectious source: the
biliary tree. However, pt presented to [**Hospital1 5**] ED with transient
hypotension that resolved without fluid resuscitation. Most likely
explanation for patient's hypotension in our ED is the diltiazem
administered for A-fib w/ RVR, though given the GNR bacteremia, plus
unresolved gallstone pancreatitis +/- cholangitis, concern for sepsis
remains high."
5134,"She had a rising T. bili
today to 5, so she was transferred to [**Hospital1 3494**] hopsital for
ERCP. During the ERCP, she was found to have a ampullary polyp.
She also developed A. fib with RVR to 140s, thoug her blood
pressure remained stable. She was sent to the [**Hospital1 3494**] ED
where she received diltiazem 10 mg IV boluses x 2 and then was
started on a diltiazem drip.
.
In the ED, initial vital signs were HR of 80 on diltiazem drip
at 10 mg/hour, BP 96/46, RR 18, 99% on 2l NC. She was given
unasyn for treatment of cholecystitis."
5135,"She was given morphine
for abdominal pain that she states is similar to prior episodes
of pancreatitis. She was given diltiazem 30 mg PO and diltiazem
drip was stopped as patient was in NSR. Additionally, she
expressed frustration with being transferred to multiple
hopsitals over the day and requested to leave AMA, however, she
was convinced to stay.
.
Upon arrival to the floor, patient reports mild epigastric pain
which is improved with morphine. She denies fevers, chills,
diarrhea, chest pain, chest pressure, weight loss, weight gain,
shortness of breath, cough.
Past Medical History:
Hypertension
Diabetes
Diastolic dysfunction
Asthma
Social History:
Patient lives alone, but her daughter is nearby and she
occasionally stays with her daughter."
5136,"Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The left
ventricular inflow pattern suggests impaired relaxation. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion
Brief Hospital Course:
Ms. [**Known lastname **] is a 72 year old female with HTN, diastolic CHF,
asthma, admitted to OSH with GNR bacteremia with cholesytitis,
cholangitis, and gallstone pancreatitis, transferred to [**Hospital1 18**]
following unsuccessful ERCP complicated by A."
5137,".
2. Cholecystitis/Cholangitis. Patient admitted to OSH with
elevated LFTs, abdominal pain, and [**Name (NI) 5283**] sono consistent with
cholecystitis. Given that LFTs were consistent with an
obstructive picture, an ERCP was performed on [**2114-4-17**]. Source of
GNR bacteremia was thought to be from a biliary source. The
patient was continued on antibiotics as above, and was
transferred to surgery once stable for further management. On
[**2114-4-19**] patient underwent laparoscopic cholecystectomy. Surgery
was done without complications. Post surgery patient was
continue on antibiotics. WBC was normal.
.
3. Pancreatitis. Likely sedcondary to gallstone pancreatitis.
She was initially hydrated with IVFs, kept NPO, and her pain
managed with morphine."
5138,"12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
1. Gallstone pancreatitis.
2. Cholecystitis/Cholangitis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
General Discharge Instructions:
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."
5139,".
6. Asthma. Continued home advair, and given prn nebs.
.
7. Diabetes. Kept on HISS and monitored fingersticks. On
discharge was started on Diabetic Diet with low carbohydrates.
She did not require exogenous insulin at discharge.
.
8. Diastolic CHF. Cardiomegaly on CXR. Echo demonstrated
elevated LV filling pressures with preserved EF (70-80%) and no
wall motion abnormalities. Per patient, she was told she had a
""large heart"" following her first pregnancy at age 26. During
hospitalization patient didn't demonstrate any symptoms of CHF
exacerbation. Lung x-ray was grossly normal, patient has trace
lower extremities edema. Patient denies SOB or DOE."
5140,"On Discharge:
VS: 98.1, 72, 140/88, 18, 94% RA
GENERAL: Awake and alert, NAD
HEENT: NC/AT, sclera icteric, neck supple, oropharynx clear
HEART: RRR with rare PACs
LUNGS: CTAB
ABDOMEN: Normal post surgical tenderness along incisions,
otherwise soft, non-distended. BS x 4.
GU: No Foley
EXT: Warm, positive peripheral pulses 2+, trace pedal edema.
Pertinent Results:
[**2114-4-16**] 07:40PM BLOOD WBC-8.0 RBC-3.89* Hgb-10.6* Hct-32.9*
MCV-85 MCH-27.1 MCHC-32.1 RDW-13.6 Plt Ct-201
[**2114-4-16**] 07:40PM BLOOD PT-12."
5141,"fib with RVR.
1. GNR bacteremia. Likely source of GNR bacteremia is
cholecysitis/cholangitis. Patient's BP remained stable though
patient was initially tachcyardic in setting of A. fib with RVR,
now resolved with diltiazem. Cultures done at OSH revealed
E.coli sensitive to Cipro & Unsasyn. She was continued on Unasyn
and Cipro for double GN coverage. Surgery co-managed this
patient, who underwent successful ERCP on [**2114-4-17**] during which a
gallstone was removed, resolving biliary obstruction. On [**2114-4-19**]
patient underwent laparoscopic cholecystectomy. Post surgery
patient's WBC was within normal range, patient was afebrile. She
was discharged home without any antibiotic coverage."
5142,"She denies alcohol or
tobacco use.
Family History:
There is no family history of liver, gallbladder, or pancreas
diseases.
Physical Exam:
On Admission:
Vitals: afebrile, HR 67, BP 124/42, 98% on 2LNC
General: no acute distress
HEENT: Sclera icteric, oropharynx clear
Neck: supple, JVP not elevated
Lungs: crackles at right base, otherwise clear
CV: Regular rate and rhythm, normal S1 + S2, +2/6 systolic
murmur at RUSB,
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, negative
[**Doctor Last Name **] sign
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace pedal edema"
5143,"7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
Inhalation four times a day as needed for shortness of breath or
wheezing.
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain."
5144,"Patient will
follow-up with cardiology as an outpatient.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a diabetic
regular diet, ambulating, voiding without assistance, and pain
was well controlled. She was discharged with VNA services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
Medications on admission:
Aspirin 81 mg PO qday
Lisinopril 20 mg PO qday
Singular 10 mg PO qday
Advair 250/50 [**Hospital1 **]
Hydrochlorothiazide 25 mg PO qday
ProAir HFA 90 two inalation [**Name6 (MD) **] [**Name8 (MD) **] rn
Prilosec 20 mg PO qday
Fosamax 70 mg PO qweek"
5145,"Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day."
5146,"1 RBC-4.04* Hgb-11.1* Hct-35.2*
MCV-87 MCH-27.4 MCHC-31.5 RDW-14.1 Plt Ct-298
[**2114-4-22**] 07:30AM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-141 K-4.1
Cl-107 HCO3-22 AnGap-16
[**2114-4-22**] 07:30AM BLOOD ALT-70* AST-38 AlkPhos-92 Amylase-49
TotBili-0.8
[**2114-4-22**] 07:30AM BLOOD Lipase-76*
[**2114-4-17**]: ECHOCARDIOGRAPHY
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%)."
5147,"Avoid lifting
weights greater than [**6-18**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**]
Date/Time:[**2114-5-14**] 1:00. [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
2. Please folow up with your PCP [**Last Name (NamePattern4) **] 2 weeks after discharge.
3. Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**2114-6-4**] 10:20 am. [**Hospital Ward Name 23**] 7, Cardiology
Completed by:[**2114-5-8**]"
5148,"With
Diltiazem 30mg PO [**Name9 (PRE) **] patient heart rate continue to be sinus
rhythm with occasional PACs. Patient was started on Aspirin 325
mg PO QDay and her Diltiazem was converted to Diltiazem ER 240mg
PO qday per cardiology recommendation. Patient will have a
follow up with cardiologist on [**2114-6-4**] regarding further A-fib
management.
.
5. HTN. Anti-hypertensives were held in the setting of
cholangitis/cholecystitis. Patient's BP was closly monitored
during hospital stay and her SBP was 120s-150s. Patient was
instructed to restart all her home anti-hypertensive medication
after discharge and follow up with her PCP for further
management."
5149,"Her lipase was downtrending. On [**2114-4-19**]
patient underwent laparoscopic cholecystectomy. Surgery was done
without complications. Post surgery patient's diet was advanced
slowly to regular/diabetic, patient tolerated diet well.
Patient's liver enzymes were normal prior disharge, her lipase
was slightly elevated.
.
4. A. fib with RVR. Paroxysmal and recurrent. Pt reports [**3-14**] yrs
of palpitations. Developed A.fib with RVR in setting of
procedure, which resolved initially after diltiazem drip and
continuation on diltiazem 30 PO [**Month/Day (3) **] but returned x5hrs on floor,
with spontaneous return to SR. Given patient's CHADS score of 3,
she may be a candidate for anticoagulation and should be
scheduled with PCP [**Name9 (PRE) 702**] to discuss this further."
5150,"Admission Date: [**2114-4-16**] Discharge Date: [**2114-4-23**]
Date of Birth: [**2042-2-7**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal pain, fevers, chills, and mid diarrhea.
Major Surgical or Invasive Procedure:
[**2114-4-17**]: ERCP with sphincterotomy, stone and biliary sludge
removal and pancreatic stent placement.
[**2114-4-19**]: Laparoscopic Cholecystectomy
History of Present Illness:
Ms. [**Known lastname **] is a 72 year old female who was admitted yesterday to
[**Hospital 8**] Hospital for abdominal pain, fevers, chills, and mid
diarrhea. She had a [**Hospital 5283**] which was concerning for cholecystitis
and she was treated with ertapenem."
5151,"5 PTT-24.1 INR(PT)-1.1
[**2114-4-16**] 07:40PM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-141
K-3.6 Cl-102 HCO3-27 AnGap-16
[**2114-4-16**] 07:40PM BLOOD ALT-241* AST-255* CK(CPK)-372*
AlkPhos-164* TotBili-5.2*
[**2114-4-17**] 02:01AM BLOOD Albumin-3.2* Calcium-9.2 Phos-3.8 Mg-1.7
[**2114-4-16**] 08:50PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-50 Bilirub-SM Urobiln-4* pH-5.0 Leuks-NEG
[**2114-4-16**] 08:50PM URINE RBC-[**12-29**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2114-4-22**] 07:30AM BLOOD WBC-5."
5152,"Admission Date: [**2163-8-14**] Discharge Date: [**2163-8-21**]
Date of Birth: [**2103-3-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
altered mental status, DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 year old gentleman with history of metastatic melanoma to the
brain and the liver, on decadron (higher dose compared to prior
admission; from 4 mg q 6 hr to 6 mg q 6 hr given gradual
weakness), presented with progressive worsening. [**Name (NI) **] wife
reports a steady decline over the last week, culminating on the
day admission with inability to walk or verbalize."
5153,"Patient was
seen by Dr. [**Last Name (STitle) 724**] in clinic on Monday, and LP was performed. This
LP showed no evidence of infection. Patient is not on
chemotherapy or radiation therapy at this time. Wife reports
that patient was able to function minimally over the past week
but since night prior to admission has really not been able to
walk or verbalize. He is able to follow commands and understand
everything that is spoken to him. Patient triggered on arrival
to ED for nursing concern.
Of note, he was previously admitted to [**Hospital1 18**] from [**Date range (1) 8767**] with
confusion that was attributed to cerebral edema from his head
metastases."
5154,"He carries a diagnosis of melanoma metastatic to the
head, lung, and liver. He was receiving treatment from Dr. [**First Name (STitle) **] at
[**Hospital1 3278**], including gamma-knife in [**2163-3-10**], and had multiple
similar admissions in [**Month (only) **] and [**Month (only) 205**] for confusion that improved
with pulse dexamethasone. Attempts to wean steroids were met
with worsening confusion. He and his wife chose to transfer care
to [**Hospital1 18**] for a second opinion from Dr. [**Last Name (STitle) 724**]. He follows in the
biologics clinic here, receiving off-label ipilimumab. He
received a huge bolus of dexamethasone (10mg at home, 10IV in
the ED) with improvement of his confusion, however his FSG
ascended into the 400s requiring insulin coverage."
5155,"[**First Name (STitle) **].
Torso CT was stable. He was admitted in [**2163-6-10**] twice at [**Hospital1 3278**]
for mental status changes responsive to steroids, presumably due
to edema surrounding known metastatic disease.
PAST MEDICAL HISTORY:
1. Status post traumatic neck injury in [**2160**]
after falling off a ladder, status post C-spine fusion;
2. history of chronic dysphagia from nutcracker esophagus
syndrome; 3. history of a frozen shoulder status post physical
therapy with
improvement in mobility
4. history of lentigo maligna of the right cheek.
5. Metastatic Melanoma as above
Social History:
The patient is married. He is a nonsmoker."
5156,"However, consider MR for better assessment.
NOTE:
A focus of increased density in the left frontal lobe anteriorly
at the vertex ( se 2a, im 25)- ? artifact/real correlate with
MRI for better assessment if not CI.
The study and the report were reviewed by the staff radiologist.
MRI BRACHIAL PLEXUS ([**2163-8-15**])
1. Progression of disease with significant increase in size of
lung
metastases since [**2163-7-10**]. The largest lung metastasis is a
cavitating
lesion in the left upper lobe. The known brain metastases were
incompletely
imaged at this time.
2. Edema within the supraspinatus and infraspinatus muscle
bellies at their
scapular origin - this is possibly secondary to myositis."
5157,"# IDDM: His sugars were initally difficult to control in the
ICU. [**Last Name (un) **] consult was placed. Patient's sugars remained in
the 300s-400s while on 25U lantus and ISS. His regimen was
being uptitrated when he was transferred to the floor. On the
floor, blood sugars remained labile, and patient had several AM
episodes of hypoglycemia. At [**Last Name (un) **] recommendation, patient's
insulin titrated to 30U qAM and 25U qHS of Lantus, as well as
QACHS sliding scale, with improved blood sugar control.
# Neurological deterioration: this has been ongoing problem for
which he was seen by Dr."
5158,"EMG was done, which
showed diffuse myopathy with no definitive inflammatory
features. Steroid taper was begun while patient on the floor,
with no confusion or change in mental status. If steroid wean
not feasible, PCP prophylaxis will have to be started.
# Pan-hypopituitarism: TSH/T4/[**Last Name (un) **]/Prolactin/Testosterone were
all found to be decreased during admission. Ddx includes
autoimmune endocrinopathy from ipilimumab or post-radiation
pituitary damage. Endocrinology was consulted. Patient was
started on thyroid hormone replacement and testosterone
replacement. No mineralocorticoid replacement was indicated at
this time.
# Dyspnea: Patient developed shortness of breath the evening of
[**8-13**] with desaturations."
5159,"Blood cultures
were repeatedly negative, so septic emboli felt to be less
likely. Infectious disease was consulted and initial fungal
studies were sent. Additional workup, including serial AFB
sputum cultures to rule out TB were recommended. However, the
patient and his family felt very strongly about going home.
Despite being advised to stay and continue work-up, they chose
to go home on levofloxacin on [**2163-8-21**].
# METASTATIC MELANOMA WITH HEAD METASTASES: Patient with
metastatic melanoma currently being treated with off label
ipilimumab. MRI of brachial plexus and CT of chest showed
probable progression of metastatic burden in lungs."
5160,"Outpatient Lab Work
Please check TSH, free thyroxine, T3 on [**2163-8-25**] and fax results
to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at Phone: [**Telephone/Fax (1) 3402**]; Fax: [**Telephone/Fax (1) 84154**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Diabetic ketoacidosis
Metastatic melanoma
Healthcare Associated Pneumonia
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:
Dear Mr. [**Known lastname **],
You were admitted to the hospital for progressive weakness and
were found to have very elevated blood sugar and a diabetic
ketoacidosis."
5161,"THYROID ULTRASOUND [**2163-8-18**]
FINDINGS: The right thyroid lobe measures 1.5 x 1.9 x 4.5 cm
and contains a
well-circumscribed, avascular, hypoechoic nodule measuring 0.3 x
0.2 x 0.2 cm
in the middle portion of the thyroid lobe. The remainder of the
thyroid gland
demonstrates homogeneous echogenicity and normal vascularity.
The left thyroid lobe measures 1.5 x 1.4 x 4.2 cm and
demonstrates homogeneous
echogenicity and normal vascularity without thyroid nodules.
No lymphadenopathy is identified in the neck.
IMPRESSION: Small right thyroid lobe nodule most likely
represents a colloid
cyst."
5162,"3. Unremarkable appearance of the brachial plexus. Metallic
hardware
artifact along the right side of the lower cervical spine (C6-7)
consistent
with prior fixation. Evaluation of cervical nerve roots would
be better
assessed on the cervical MRI performed [**2163-8-3**].
CXR ([**2163-8-14**])
1. No acute cardiopulmonary process. Known subcentimeter
pulmonary nodules
not well visualized.
2. Triangular opacity in peripheral left midlung likely
artifact. Consider
repeat CXR to confirm.
3. Stable pectus excavatum deformity.
CXR ([**2163-8-16**])
Small to moderate right pleural effusion is new, accompanying a
large region of interstitial infiltration in the right lower
lung, and growing
heterogeneous opacification of the left suprahilar lung."
5163,"You were treated with insulin, fluids and
electrolytes, and this resolved. During your hospitalization,
you were found to have a pneumonia and treated with antibiotics.
A chest CT [**2163-8-19**] showed new lung lesions. They may be related
to your melanoma, but we cannot rule out infection as a cause
including fungal or less likely myobacterial infection. Fungal
lab studies were sent. We discussed that work-up of these
lesions was not yet complete, and that further workup would
include sputum testing to rule out tuberculosis. However, you
and your family decided that it was important for you to go home
today."
5164,"Pertinent Results:
ADMISSION LABS
[**2163-8-14**] 02:00PM BLOOD WBC-10.6 RBC-4.03* Hgb-12.8* Hct-35.3*
MCV-88 MCH-31.7 MCHC-36.2* RDW-15.6* Plt Ct-273#
[**2163-8-14**] 02:00PM BLOOD Glucose-432* UreaN-31* Creat-0.5 Na-133
K-4.0 Cl-96 HCO3-7* AnGap-34*
[**2163-8-14**] 02:00PM BLOOD ALT-49* AST-14 AlkPhos-62 TotBili-0.7
[**2163-8-14**] 05:18PM BLOOD Calcium-8.3* Phos-1.6*# Mg-1.8
[**2163-8-14**] 02:33PM BLOOD Lactate-2.1*
IMAGING
CT HEAD WITHOUT CONTRAST ([**2163-8-14**])
FINDINGS:
Multiple supratentorial hyperdense lesions are again
demonstrated, compatible
with metastatic disease and are largely unchanged since CT exam
of [**2163-8-1**]."
5165,"Concentric needle electromyography (EMG) of selected right upper
extremity
muscles revealed short duration, polyphasic motor units, many of
which were
low-amplitude but some of which were normal amplitude, with
early recruitment
in deltoid, biceps, infraspinatus and first dorsal interosseous.
EMG of
deltoid also revealed increased insertional activity in the form
of occasional
positive sharp waves.
Concentric needle EMG of right tibialis anterior and vastus
lateralis revealed
short duration, mostly low-amplitude (some normal amplitude),
polyphasic motor
units with early recruitment.
IMPRESSION:
Abnormal study. There is electrophysiological evidence for a
generalized
myopathy without associated denervating (""inflammatory"")
features. The
absence of denervating features does not rule out an
inflammatory myopathy
(myositis), particularly in the setting of concomitant
glucorticoid use."
5166,"pitting edema at the
ankles bilaterally. pulses palpable +2 bilaterally.
NEURO: Alert and oriented x 3, CN II-XII intact, gait deferred.
LE weakness 3+/5 bilaterally. sensation intact bilaterally with
no sensory level in both UE's and LE's.
SKIN: vitiligo.
DISCHARGE EXAM
99.1 118-130/74-82 89-97 16 98/RA
BG 190 dinner, 199 HS, 95 AM
GENERAL: NAD, cushingoid appearance with moon fascies
CARDIAC: RRR S1/S2, no murmurs, gallops, or rubs
LUNG: crackles at the right base
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
SKIN: distal vitiligo"
5167,"Your outpatient oncology team will arrange for additional
infectious disease follow-up pending initial results.
Changes to your medications include:
- inject 30 units of insulin glargine (Lantus) subcutaneously in
the morning and 20 units of insulin glargine (Lantus)
subcutaneously at bedtime
- inject Humalog subcutaneously with meals per sliding scale
- take dexamethasone 4mg every 12 hours
- apply one 4mg Androderm patch to your skin each day (and
remove old patch)
- start levofloxacin 750mg daily for 5 more days
- start levothyroxine 88mcg daily
- oxycodone 5mg every 6 hours as needed for pain
- start docusate and senna as needed for constipation (because
oxycodone can cause constipation)"
5168,"No lymphadenopathy in the neck
CXR [**2163-8-19**]
IMPRESSION: Improving right pleural effusion. Worsening
interstitial edema.
Increase in perihilar opacity likely due to vascular engorgement
or lymph node
enlargement.
CT Chest [**2163-8-20**]
IMPRESSION:
1. Diffuse ground glass and solid nodular opacities with more
confluent
opacity at the right lung base are new from [**2163-7-12**]. Two
opacities have
central cavitation. The findings are concerning for infection,
including
fungal, and septic emboli. While these may represent markedly
increased
melanoma metastases, reassessment after treatment for infection
is
recommended.
2. Interlobular septal thickening at the right lung base is
unchanged from
[**2162-3-12**]."
5169,"Motor NCSs of the right ulnar nerve demonstrated normal distal
latency,
moderately reduced response amplitudes, normal conduction
velocity, and
slightly prolonged F-minimum latency.
Sensory NCS of the right median nerve was normal. Sensory NCS of
the right
ulnar nerve was normal. Sensory NCS of the right radial nerve
was normal.
Sensory NCS of the right lateral antebrachial cutaneous nerve
was normal.
Sensory NCS of the left lateral antebrachial cutaneous nerve
demonstrated
decreased response amplitude and normal conduction velocity.
Repetitive nerve stimulation at 3 Hz demonstrated no abnormal
decrement.
Stimulation of the right ulnar nerve, recording ADM, pre- and
post-10 seconds
of maximal voluntary contraction demonstrated no post-exercise
facilitation."
5170,"He drinks rare ETOH
and has no illicit drug use. He worked as a painting contractor
as well as real estate [**Doctor Last Name 360**].
Family History:
no history of melanoma
Physical Exam:
ADMISSION EXAM
98.1, HR 111, BP 135/80, RR 13, Sat 97%RA. FS 242
GENERAL: NAD, sitting in bed, speaking with very soft voice.
pleasant. moon face.
HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva, MM
relatively dry
CARDIAC: RRR,normal S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mild distention and tympany throughout, +BS, nontender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing."
5171,"3. Small, nonhemorrhagic bilateral pleural effusions.
Brief Hospital Course:
Active issues:
# DKA: Patient was noted to be insulin resistant on prior
admissions, this presentation is likely [**2-10**] increase in decadron
dosing. Possible that infection played a role in increasing
insulin resistance. Patient was started on insulin drip in the
ED, his anion gap decreased from 34 on admission to 17 by the
time he was on the floor. He was started on D51/2NS and
electrolytes were monitored Q6H and replaced as needed. His
mental status improved within several hours of insulin therapy
and he became responsive to questioning."
5172,"He was also tachycardic to the 100-110s.
His CXR at that time reflected a possible multilobar pneumonia
which was broadly covered as HCAP with vancomycin and cefepime.
His dyspnea improved, and by day of discharge he was satting
well on room air and had been afebrile for multiple days. Chest
CT on [**8-20**] showed diffuse ground glass and solid nodular
opacities with more confluent opacity at the right lung base,
with 2 lesions with central cavitation. These were felt to most
likely represent metastases, but infectious causes (including
fungal or mycobacterial infectious) were also a significant
concern given patient's high dose steroid use."
5173,"For example, an 8 x 10 mm left temporal lobe
hyperattenuating lesion
with surrounding edema is unchanged (2A:16). Left frontal 14 x
8 mm lesion is
also stable (2A:21). Bilobed focus of hyperattenuation in the
left
frontoparietal vertex is unchanged (2:23). Surrounding edema is
also noted.
There is no mass effect or shift of normally midline structures.
No new
lesions detected on the CT exam. Basal cisterns are patent. No
vascular
territorial infarction. Sulci and ventricles are unchanged in
size and
configuration. Imaged paranasal sinuses and mastoid air cells
are well
aerated. No fracture.
IMPRESSION:
In comparison to [**2163-8-1**] CT exam, there is no significant
change in
multiple hyperdenselesions, compatible with metastatic disease,
as described above."
5174,"[**Last Name (STitle) 724**] as an outpatient. LP was done,
which did not show any results c/w infection. Could be [**2-10**]
progressing metastatic disease (as shown on MRI [**2163-8-3**]) vs.
metabolic due to uncontrolled diabetes. Patient was at baseline
before being transferred to the floor. Dr. [**Last Name (STitle) 724**] saw the patient
in the ICU- he had suspicion that his recurrent AMS was
secondary to possible leptomeningeal spread and CNS infiltration
of the melanoma. No malignant cells were seen on LP [**8-5**] and
MRI C spine revealed no malignant leptomeningeal disease. A
finding of right arm weakness prompted MRI of the brachial plexi
which were neurologically unremarkable, but reflected a
worsening burden of pulmonary metastases."
5175,"In [**2161-9-9**], he [**Year (4 digits) 1834**] abdominal US to
evaluate abdominal pain which revealed small gallstones. There
were liver nodules noted consistent with hemangiomas. He
[**Year (4 digits) 1834**] a liver MRI on [**2162-3-11**], revealing a dominant liver
nodule concerning for possible metastatic disease. Torso CT
revealed lung nodules. On [**2162-3-18**], he [**Year (4 digits) 1834**] a brain MRI
revealing three brain lesions. On [**2162-3-22**], he [**Year (4 digits) 1834**] a
CT-guided liver biopsy confirming melanoma. He was subsequently
referred to [**Hospital 3278**] Medical Center to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for a gamma
knife evaluation."
5176,"They
remained elevated in the 300 range at the time of discharge- and
he was sent out on metformin with FSG testing supplies, and an
appointment with his [**Name8 (MD) 6435**] NP was established within a few days
of discharge to assess the need for insulin. He unfortunately
failed to followup, and his FSG were 300+ at home. 4-5 days
prior to admission he noted progressive weakness and decreased
strength of voice prompting ED presentation.
On admission to the [**Hospital Unit Name 153**], he had a glucose of 432 and an anion
gap of 30. He was treated with an insulin gtt, aggressive
hydration, and repletion of electrolytes."
5177,"It was a pleasure taking care of you during your hospitalization
and we wish you all the best going forward.
Followup Instructions:
You have a post-discharge appointment with Dr. [**First Name (STitle) **], Tan at
[**Last Name (un) **]. Please call [**Telephone/Fax (1) 25521**] if you have more questions.
Please call DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**] to see if they
would like to see you sooner than [**8-30**].
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-8-30**] at 3:00 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-8-30**] at 3:00 PM
With: [**Doctor First Name 10838**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call Dr [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 724**] for an appointment within 1-2 weeks
of discharge. [**Telephone/Fax (1) 1844**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2163-8-23**]"
5178,"Although there could be a component of pulmonary edema, it is
likely that there is bilateral pneumonia. A triangular opacity
in the periphery of the left upper lobe, new on [**8-14**] and
still present is either infection or infarction. Fullness in
both hila and the paratracheal regions of the mediastinum could
be due to vascular engorgement or lymph node enlargement.
Calcification of granulomatous lymph nodes is documented on the
[**2163-7-12**] torso CT. Heart size is normal.
EMG ([**2163-8-18**])
FINDINGS:
Motor nerve conduction studies (NCSs) of the right median nerve
demonstrated
normal distal latency, mildly reduced response amplitudes,
normal conduction
velocity, and normal F-minimum latency."
5179,"Transition issues:
- recheck TFTs [**2163-8-25**] and adjust dose of thyroid hormone
- Beta glucan, galactomannan, cryptococcal antigen, legionella
antigen
- sputum culture (including AFB) not done as inpatient;
mycobacterial infection cannot be decisively ruled out
Medications on Admission:
1. Dexamethasone 6 mg PO Q6H
2. LeVETiracetam 500 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Sodium Chloride 1 gm PO THREE TIMES A DAY (stopped given
lower extremity swelling)
5. Tamsulosin 0.4 mg PO HS
6. metformin 500 mg 1 tablet(s) by mouth twice a day
Discharge Medications:
1. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*56 Tablet Refills:*0
2."
5180,"Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine 88 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN severe pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*56 Tablet Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet
Refills:*0
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
12."
5181,"On arrival to the MICU, patient's VS were: 98.1, HR 111, BP
135/80, RR 13, Sat 97%RA. FS 242.
Review of systems:
(+) Per HPI, constipation
(-) Denies fever, chills, night sweats. Denies shortness of
breath, cough, dyspnea or wheezing. Denies chest pain, chest
pressure, palpitations. Denies abdominal pain, diarrhea, dark or
bloody stools. Denies dysuria, frequency, or urgency.
Past Medical History:
PAST ONCOLOGIC HISTORY: from OMR notes
In [**8-/2159**], Mr. [**Known lastname **] [**Last Name (Titles) 1834**] biopsy of a right cheek skin
lesion revealing lentigo maligna. He [**Last Name (Titles) 1834**] a wide local
excision with a focal positive margin with no further resection
at that time."
5182,"His gap subsequently
closed and basal/bolus SubQ insulin was started, guided by
[**Last Name (un) **] consult. FSG were still intermittently into the 300-400
range, and glargine was uptitrated as needed.
In the ED, T 98.4 HR 109 BP 142/96 RR 16 Sat100%RA. CT head was
done and per prelim report shwoed multiple hyperattenuating
supratentorial lesions with surrounding edema compatible with
metastatic disease, unchanged since [**2163-8-1**] CT exam. CXR did
not show acute process. UA was not suggestive of UTI. ALT was
notable to be 49 otherwise normal LFT. Lactate was 2.1. Serum
tox was negative."
5183,"LeVETiracetam 500 mg PO BID
3. Tamsulosin 0.4 mg PO HS
4. Omeprazole 20 mg PO DAILY
5. Testosterone 4 mg Patch 1 PTCH TD DAILY
RX *Androderm 4 mg/24 hour apply 1 new patch to skin and remove
old patch daily Disp #*30 Transdermal Patch Refills:*0
6. Levofloxacin 750 mg PO Q24H Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
7. Glargine 30 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *Lantus 100 unit/mL inject 30 units subcutaneously before
breakfast and 20 units subcutaneously qHS qAM and qHS Disp #*1
Vial Refills:*0
RX *Humalog 100 unit/mL inject subcutaneously per sliding scale
four times a day Disp #*1 Vial Refills:*0
RX *insulin syringe-needle U-100 31 gauge X [**5-25**]"" use as
directed QIDACHS Disp #*1 Box Refills:*0
8."
5184,"He [**Last Name (NamePattern1) 1834**] gamma knife treatment to three
brain lesions on [**2162-4-9**] with brain MRI one month later
revealing stability. He began off protocol ipilimumab on
[**2162-6-1**]. F/U brain MRI in early [**Month (only) 216**] showed several new small
brain lesions without associated edema. He had evidence of
regression in SQ nodules at this time so he was observed. F/U
brain MRI revealed resolution of the largest CNS lesion with
growth in some smaller lesions felt to be ipilimumab effect.
Torso CT revealed continued improvement in systemic disease. He
[**Month (only) 1834**] Gamma knife therapy to 5 lesions on [**2163-4-9**] by Dr."
5185,"No other filling defect or strictures were seen. A
final frontal radiograph was taken following drainage of the instilled barium,
and contrast was seen to have passed up to the splenic flexure with the
superior portion of the abdomen excluded from the field of view.
IMPRESSION:
1. Distal sigmoid volvulus with likely organoaxial rotation, and rectal tube
traversing the site of the volvulus.
2. Large ulcerated filling defect in the mid-portion of the sigmoid colon
with associated luminal narrowing, suggestive of an ulcerated mass, concerning
for malignancy.
These findings were discussed over the telephone with Dr. [**First Name4 (NamePattern1) 1036**] [**Last Name (NamePattern1) 2466**]
at the time of interpretation.
(Over)
[**2151-1-5**] 11:12 AM
COLON (BARIUM ENEMA) Clip # [**Clip Number (Radiology) 50660**]
Reason: therapeutic barium enema for volvulus
Admitting Diagnosis: VOLVULUS
______________________________________________________________________________
FINAL REPORT
(Cont)"
5186,"Under fluoroscopic observance, barium was instilled into the pre-existing
rectal tube under gravity. Contrast filled the dilated loop of sigmoid colon,
though did not pass caudal to an area near the rectosigmoid junction, ~15 cm
proximal to the anus. This area shows a twisting mucosal fold pattern,
consistent with sigmoid volvulus. More proximally, the lumen of the sigmoid
narrowed abruptly in the left lower quadrant near the tip of the rectal tube
and then reconstitutes in the left mid-abdomen, more proximally. At this area
of luminal narrowing, the mucosal fold pattern was disrupted laterally and a
central ulceration was seen within the filling defect, overall suggesting a
large ulcerated mass."
5187,"[**2151-1-5**] 11:12 AM
COLON (BARIUM ENEMA) Clip # [**Clip Number (Radiology) 50660**]
Reason: therapeutic barium enema for volvulus
Admitting Diagnosis: VOLVULUS
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
77 year old man with sigmoid volvulus. S/p colonoscopic decompression with
some improvement but volvulus likely still present.
REASON FOR THIS EXAMINATION:
therapeutic barium enema for volvulus
______________________________________________________________________________
FINAL REPORT
HISTORY:
Sigmoid volvulus.
TECHNIQUE:
Single contrast barium enema
COMPARISON:
Comparison is made to abdominal radiographs taken earlier the same day.
FINDINGS:
Initial frontal abdominal radiograph shows a dilated loop of sigmoid colon, to
~16 cm with a rectal tube in place, traversing the area of dilation and
terminating in the left lower quadrant near the more proximal sigmoid colon."
5188,"Admission Date: [**2151-1-5**] Discharge Date: [**2151-1-21**]
Date of Birth: [**2073-9-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted with abdominal distention and pain.
Major Surgical or Invasive Procedure:
Status Post Proximal jejunum resection and anastomosis of
deodunum to jejunum and sigmoid colectomy w/ end colostomy.
History of Present Illness:
77M, NH resident and wheelchair bound having onstipation,
increasing ab distension and mild pain for the past 2-3 days.
Afebrile, mild problems breathing, no CP/d/n/v. Never had
symptoms like this before."
5189,"At [**Hospital1 **] had AXR shows
significant
distension c/w sigmoid volvulus. Intubated for respiratory
protection do to tachypnea and low O2 sats for the transfer.
Past Medical History:
bipolar & schizophrenia (newer diagnoses), BPH, urnary
retention, neuromuscular disorder - wheelchair and NH bound
Social History:
Patient is wheelchair bound and lives in nursing home. Daughter
([**Doctor First Name **]) involved with care.
Family History:
Not applicable.
Physical Exam:
PE 98.2 100 121/76 18 100% ventilator (50% FIO2 PEEP 5)
intubated, sedated
decreased bs b/l
RRR
soft distended, tympanitic
no c/c/e
guiac neg
Pertinent Results:
[**2151-1-5**] 12:00AM BLOOD WBC-24."
5190,"4. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis: Gastric volvulus with mass of colon.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness."
5191,"Seen at OSH where XRays showed distended loops of bowel and
likely sigmoid colon volvulus. Tx with hydration. Became
tachypneic with RR 50 and hypoxic and was intubated. Transfer to
[**Hospital1 18**]. Sigmoid volvulus confirmed, and pt with leukocytosis of
24.3 with left shift, lactate of 4.8, and urinanalysis
consistent with UTI. To MICU. Decompression by GI but not
sustained. Question of mass found on barium enema. Pt extubated
and wish to have surgery. To OR [**1-6**] and is now s/p prox
jejunum resection and anastomosis of deod to jejunum and sigmoid
colectomy w/ end colostomy."
5192,"Postoperative course complicated by several days of ileus
requiring nasogastric tube and TPN. Currently patient on regular
diet with oral reglan. Ostomy is actively draining.
Patient will follow up with Dr. [**Last Name (STitle) **] in 2 weeks. He will be
discharged to nursing home/rehab today.
Medications on Admission:
flomax, mvi, colace, zcor, risperdal, senna
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection twice a day.
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime)."
5193,"Activity:
No heavy lifting of items [**10-21**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2151-2-5**] 3:15
Completed by:[**2151-1-20**]"
5194,"* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered."
5195,"3* RBC-4.23* Hgb-12.9* Hct-37.2*
MCV-88 MCH-30.5 MCHC-34.7 RDW-12.9 Plt Ct-491*
[**2151-1-8**] 03:09AM BLOOD WBC-14.5* RBC-2.95* Hgb-8.9* Hct-26.4*
MCV-89 MCH-30.2 MCHC-33.7 RDW-13.1 Plt Ct-292
[**2151-1-18**] 08:16AM BLOOD WBC-8.8 RBC-3.20* Hgb-9.8* Hct-28.0*
MCV-87 MCH-30.5 MCHC-34.9 RDW-13.7 Plt Ct-315
Brief Hospital Course:
77yo M, NH resident presented [**1-5**] with 1 day history of
abdominal pain and distension with 1 episode diarrhea day prior."
5196,"o. man with schizophrenia, neuromuscular d/o, presents with
sigmoid volvulus.
.
# Sigmoid volvulus: Surgery and GI consulted. Attempt being made for
decompression with sigmoidoscope. Surgery discussed surgical options
as well.
-scope in unit with successful decompression
-repeat abd x-ray
-IVFs (2 liter bolus)
-no need for abx for abdomen; giving cipro for UTI
-repeat lactate after bolus
-serial abd exams
.
# Respiratory failure. Unclear etiology. Could be due to sepsis [**2-7**]
abdominal infection vs atelectasis due to distended abdomen.
- repeat ABG, try to wean FI02 after procedure
- CXR no clear evidence infection
- f/u blood, sputum, and urine cultures
- treat UTI as below
- daily RSBI, spontaneous breathing trial when appropriate
- may be able to wean off vent once volvulus resolved
.
# UTI: positive UA, culture pending
- cipro IV BID emperically
.
# Hyperlipidemia: hold statin while NPO
.
# Schizoaffective d/o: hold risperdal while sedated. Restart when
awake.
.
# BPH: hold flomax while intubated
.
# FEN: NPO, IVF bolus
.
ICU Care
Nutrition: NPO
Glycemic Control:
Lines:
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Need for restraints reviewed
Comments:
Communication: Patient discussed on interdisciplinary rounds , Family
meeting held , ICU consent signed Comments: Communication - [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 3622**] (daughter) [**Telephone/Fax (1) 3623**]
Code status: DNR (do not resuscitate)
Disposition: ICU"
5197,"Chief Complaint: abd pain/distention
HPI:
77 y.o. male, lives in nursing home, presented with 1 day of abdominal
pain and distention. Had 1 episode diarrhea 1 day prior to admission
per family. At NH, foley was placed with no improvement. Was seen at
OSH ED, where CXR and Abd x-ray revealed distended loops of bowel and
likely sigmoid colon volvulus. He was given 1 L saline bolus, then
maintenance fluids at 100cc/hr. He was tachypeic, RR 50, and hypoxic,
91% on 100%FM. He was sedated with propofol and intubated prior to
transfer. Per report, given Cefoxitin at OSH prior to transfer."
5198,"At [**Hospital1 5**], initial vitals: T 99, BP 99/78, hr 104, rr 30, 93% on Fi02
80%. Abd xray/cxr confirmed the presence of sigmoid volvulus. Labs
reveal a leukocytosis of 24.3 with left shift, lactate of 4.8, troponin
of 0.02, and U/A consistent with UTI. GI and Surgery consulted. Pt's
daughter prefers a conservative approach, and patient admitted to MICU
with plan for GI to do sidmoidoscopy to relieve volvulus
Patient admitted from: ED
History obtained from Family / Friend
[**Name (NI) **] unable to provide history: Sedated
Allergies:
Last dose of Antibiotics:
Infusions:
Propofol - 50 mcg/Kg/min
Other ICU medications:
Other medications:
Famotidine
Ciprofloxacin 400 Q12
Hep SC
Past medical history:
Family history:
Social History:
Schizophrenia/Bipolar d/o
BPH
urnary retention,
neuromuscular disorder (daugher calls it ""spastic paralysis)
wheelchair and NH bound
NC
Occupation:
Drugs: no
Tobacco: no
Alcohol: no
Other: wheel chair bound, lives at [**Location **]
Review of systems: Could not obtain/sedated
Flowsheet Data as of [**2151-1-5**] 03:14 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Heart rhythm: ST (Sinus Tachycardia)
Total In:
19 mL
PO:
TF:
IVF:
19 mL
Blood products:
Total out:
0 mL
200 mL
Urine:
200 mL
NG:
Stool:
Drains:
Balance:
0 mL
-181 mL
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 450 (450 - 450) mL
RR (Set): 14
RR (Spontaneous): 1
PEEP: 5 cmH2O
FiO2: 100%
PIP: 37 cmH2O
Ve: 17."
5199,"9 L/min
Physical Examination
GEN: sedated, intubated
HEENT: NCAT
LUNGS: CTA b/l (anteriorly)
HEART: RRR, nl S1S2, no m/r/g
ABD: hypoactive BS, markedly distended. Pt sedated so tenderness could
not be assessed
EXT: no edema. 2+ DP pulses b/l
NEURO: sedated
Labs / Radiology
491
171
0.9
27
23
108
4.8
145
37.2
24.3
[image002.jpg]
INR 1.2
AST 35
ALT 21
ALP 106
Tbili 0.5
Lip 23
Imaging:
[**2151-1-5**] CXR: dilated loops of bowel. Low lung volumes, likely
atelectasis
[**2151-1-5**] Abd xray: dilated loops of bowel
Microbiology: Blood cx [**1-5**], Urine cx [**1-5**], sputum cx [**1-5**]: NGTD
ECG: NSR
Assessment and Plan
77 y."
5200,"H/O ABDOMINAL
PAIN (INCLUDING ABDOMINAL TENDERNESS), URINARY TRACT INFECTION (UTI)
Assessment and Plan: 77M POD4 s/p prox jejunum resection and
anastomosis of deod to jejunum and sigmoid colectomy w/ end colostomy.
Neurologic: off sedation, fent prn, haldol prn
Cardiovascular: hypotensive intermittantly, responded to fluid bolus,
lopressor 5 IV q6h
Pulmonary: extubated, stable
Gastrointestinal / Abdomen: Post-op ileus, s/p duod resection and
anastomosis to jejunum and sigmoid. NGT clamp trial
Nutrition: TPN, NPO
Renal: Adequate UO
Hematology: Hct stable
Endocrine: RISS
Infectious Disease: Flagyl x2doses and Cefaz x2doses postop; Cipro
([**1-5**]) x4 days for UTI; Sputum Cx.
Lines / Tubes / Drains: left Ailine, PIV, NGT, PICC
Wounds:
Imaging:
Fluids: D5 1/2NS 40K @ 150/hr, stop when TPN
Consults: General surgery
Billing Diagnosis: Post-op complication
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2151-1-10**] 12:14 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 35 minutes"
5201,"SICU
HPI:
77yo M, NH resident presented [**1-5**] w/ 1day h/o abd pain and distension
with 1 episode diarrhea day prior. Seen at OSH where XRays showed
distended loops of bowel and likely sigmoid colon volvulus. Tx w/
hydration. Became tachypneic w/ RR 50 and hypoxic and was intubated.
Transfer to [**Hospital1 5**]. Sigmoid volvulus confirmed, and pt w/ leukocytosis
of 24.3 with left shift, lactate of 4.8, and U/A consistent with UTI.
To MICU. Decompression by GI but not sustained. ?mass found on barium
enema. Pt extubated and wish to have surgery. To OR [**1-6**] and is now
s/p prox jejunum resection and anastomosis of deod to jejunum and
sigmoid colectomy w/ end colostomy
Chief complaint:
PMHx:
bipolar & schizophrenia (newer diagnoses), BPH, urnary
retention, neuromuscular disorder (?"
5202,"m.
Tmax: 36.9
C (98.4
T current: 36.2
C (97.1
HR: 65 (64 - 88) bpm
BP: 120/68(80) {104/58(69) - 125/74(85)} mmHg
RR: 14 (13 - 26) insp/min
SPO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 71.8 kg (admission): 70 kg
Total In:
3,951 mL
1,081 mL
PO:
Tube feeding:
IV Fluid:
3,951 mL
1,081 mL
Blood products:
Total out:
2,912 mL
2,050 mL
Urine:
1,212 mL
600 mL
NG:
1,400 mL
1,050 mL
Stool:
Drains:
Balance:
1,039 mL
-969 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 99%
ABG: ///24/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-tender, Distended
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: Follows simple commands, Moves all extremities
Labs / Radiology
410 K/uL
9."
5203,"spastic paralysis) - wheelchair and
NH bound
Current medications:
24 Hour Events:
PICC LINE - START [**2151-1-10**] 12:14 PM
ARTERIAL LINE - STOP [**2151-1-10**] 07:00 PM
UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At [**2151-1-10**]
07:30 PM
Post operative day:
POD#5 - colectomy
Allergies:
Last dose of Antibiotics:
Ciprofloxacin - [**2151-1-9**] 04:40 PM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2151-1-10**] 10:31 AM
Metoprolol - [**2151-1-11**] 03:03 AM
Other medications:
Flowsheet Data as of [**2151-1-11**] 07:58 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**54**] a."
5204,"2
9.8
Hct
26.4
30.5
27.7
28.0
Plt
292
410
397
410
Creatinine
0.5
0.5
0.5
0.6
0.5
0.5
TCO2
28
27
30
Glucose
115
115
97
127
124
118
120
Other labs: PT / PTT / INR:13.3/28.4/1.1, ALT / AST:25/65, Alk-Phos / T
bili:75/0.2, Lactic Acid:0.9 mmol/L, Albumin:2.6 g/dL, LDH:285 IU/L,
Ca:7.8 mg/dL, Mg:2.1 mg/dL, PO4:2.2 mg/dL
Assessment and Plan
DELIRIUM / CONFUSION, ELECTROLYTE & FLUID DISORDER, OTHER, HYPOTENSION
(NOT SHOCK), RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**]), ."
5205,"2 g/dL
120 mg/dL
0.5 mg/dL
24 mEq/L
3.9 mEq/L
15 mg/dL
113 mEq/L
141 mEq/L
28.0 %
9.8 K/uL
[image002.jpg]
[**2151-1-8**] 03:09 AM
[**2151-1-8**] 05:54 AM
[**2151-1-8**] 08:25 AM
[**2151-1-8**] 10:00 AM
[**2151-1-8**] 11:01 AM
[**2151-1-8**] 05:16 PM
[**2151-1-9**] 02:01 AM
[**2151-1-10**] 02:30 AM
[**2151-1-10**] 05:42 PM
[**2151-1-11**] 02:31 AM
WBC
14.5
18.3
11."
5206,"2/26.0/1.1, Lactic Acid:0.9 mmol/L,
Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:5.7 mg/dL
Imaging: Perinephritic fluid, fat stranding c/w rejection - R kidney.
CXR: mild L pleural effusion, vascular fullness, otherwise clear.
Assessment and Plan
RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), ACUTE
REJECTION:
- Anticipate low tacro level, and predominant rejection, but with
possible superimposed infection/UTI
- Treating with steroids
- Renal and transplant surgery following
- Needs phosphate binder
- Empiric antibiotics (ceftazidime for ease of dosing with HD)
HYPERTENSION, BENIGN
- On amlodipine, adding hydralazine.
HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)
now resolved post
HD.
Anemia
Fe studies, getting blood per renal.
ICU Care
Nutrition: Renal diet.
Glycemic Control:
Lines:
20 Gauge - [**2149-8-3**] 07:54 PM
Prophylaxis:
DVT: hep sc
Stress ulcer: ppi
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition : ICU
Total time spent:"
5207,"7
C (98
Tcurrent: 36.7
C (98
HR: 70 (65 - 85) bpm
BP: 201/83(108) {169/68(91) - 201/89(115)} mmHg
RR: 21 (16 - 27) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 70 Inch
Total In:
3,371 mL
919 mL
PO:
TF:
IVF:
346 mL
919 mL
Blood products:
Total out:
45 mL
43 mL
Urine:
45 mL
43 mL
NG:
Stool:
Drains:
Balance:
3,326 mL
876 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///24/
Physical Examination
GEN: Awake, alert, somewhat distant affect.
HEENT: MMM
PULM: Clear
BACK: No pain
ABD: Soft, NT, ND
EXT: RLE mildly > LLE
chronic per pt (after knee surgery)
Labs / Radiology
6."
5208,"8, BUN/Cr 121/14.7. EKG with mild peak Ts in V2 - got
hyperK treatment in ED. CT abd pelvis, with perinephric fat stranding,
got empiric levo/flagyl. Got high dose steroids per renal, and
transferred to MICU.
24 Hour Events:
- Increasing potassium to 7.4, EKG unchanged, but re-treated o/n with
Ca, insulin, glc.
- Renal notified, fistula patency verified and had short course HD
o/n.
- K corrected to 4.2, and Cr corrected to 9.
History obtained from Patient
Allergies:
Bactrim Ds (Oral) (Sulfamethoxazole/Trimethoprim)
Exfoliative [**Doctor Last Name **]
Cellcept (Oral) (Mycophenolate Mofetil)
Rash;
Last dose of Antibiotics:
Ceftriaxone - [**2149-8-3**] 10:27 PM
Infusions:
Other ICU medications:
Dextrose 50% - [**2149-8-3**] 09:31 PM
Insulin - Regular - [**2149-8-3**] 09:32 PM
Heparin Sodium (Prophylaxis) - [**2149-8-4**] 08:10 AM
Other medications:
Home: Tacro, Epo, Fe
Here: colace, methylpred, RISS, amlodipine, nitropaste, prograf
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2149-8-4**] 08:49 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
5209,"8 g/dL
112 K/uL
196 mg/dL
9.1 mg/dL
24 mEq/L
4.2 mEq/L
73 mg/dL
105 mEq/L
141 mEq/L
21.7 %
2.3 K/uL
[image002.jpg]
[**2149-8-3**] 08:19 PM
[**2149-8-3**] 08:22 PM
[**2149-8-3**] 10:47 PM
[**2149-8-4**] 03:32 AM
[**2149-8-4**] 05:56 AM
WBC
3.5
2.2
2.3
Hct
24.7
20.4
21.7
Plt
107
108
112
Cr
13.5
13.3
9.1
Glucose
153
171
196
Other labs: PT / PTT / INR:13."
5210,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
52F with SLE, HTN, s/p renal [**Last Name (un) 8147**] ( 2 years ago, maintained on
prograf), p/w acute LBP onset am of admission, as well as abdominal
fullness; otherwise had been well and taking immunsupp regimen as
directed (though cannot name renal MD or recall last visit). No F/C,
SOB/cough, CP, abd pain, N/V/C/D. No dysuria, hematuria. In ED, K
notable for 6."
5211,"Chief Complaint: acute renal failure, hypertension.
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
24 Hour Events:
New onset Afib responded to diltiazem. Hypertension s/p renal biospy
yesterday. s/p HD yesterday. PICC line placed.
History obtained from Patient
Allergies:
Bactrim Ds (Oral) (Sulfamethoxazole/Trimethoprim)
Exfoliative [**Doctor Last Name **]
Cellcept (Oral) (Mycophenolate Mofetil)
Rash;
Last dose of Antibiotics:
Ceftriaxone - [**2149-8-3**] 10:27 PM
Ceftazidime - [**2149-8-4**] 10:07 PM
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2149-8-4**] 10:21 AM
Metoprolol - [**2149-8-4**] 10:59 PM
Diltiazem - [**2149-8-5**] 12:00 AM
Other medications:
heparin s/c, colace, methylpred 500 iv q24, RISS, norvasc 10, tacro 12
[**Hospital1 **], protonix, hydral 25 q8, calcium acetate
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2149-8-5**] 09:27 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37
C (98."
5212,"6
Tcurrent: 36.4
C (97.6
HR: 68 (68 - 122) bpm
BP: 161/70(92) {122/62(81) - 188/82(106)} mmHg
RR: 14 (13 - 24) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 70 Inch
Total In:
1,823 mL
242 mL
PO:
TF:
IVF:
1,473 mL
242 mL
Blood products:
350 mL
Total out:
1,583 mL
20 mL
Urine:
83 mL
20 mL
NG:
Stool:
Drains:
Balance:
240 mL
222 mL
Respiratory support
O2 Delivery Device: RA
SpO2: 98%
ABG: ///28/
Physical Examination
General Appearance: Well nourished, No acute distress, Anxious
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent
Skin: Warm
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Labs / Radiology
7."
5213,"2 g/dL
103 K/uL
185 mg/dL
7.3 mg/dL
28 mEq/L
4.2 mEq/L
51 mg/dL
101 mEq/L
140 mEq/L
22.4 %
2.9 K/uL
[image002.jpg]
[**2149-8-3**] 08:19 PM
[**2149-8-3**] 08:22 PM
[**2149-8-3**] 10:47 PM
[**2149-8-4**] 03:32 AM
[**2149-8-4**] 05:56 AM
[**2149-8-4**] 10:59 PM
[**2149-8-5**] 04:53 AM
WBC
3.5
2.2
2.3
2.9
2.9
Hct
24.7
20.4
21.7
23.1
22."
5214,"4
Plt
107
108
112
109
103
Cr
13.5
13.3
9.1
6.7
7.3
Glucose
153
171
196
132
185
Other labs: PT / PTT / INR:13.2/26.0/1.1, Lactic Acid:0.5 mmol/L,
Ca++:7.6 mg/dL, Mg++:2.5 mg/dL, PO4:6.7 mg/dL
Imaging: CXR Right sided PICC, otherwise clear.
Assessment and Plan
HYPERTENSION, BENIGN:
Will continue to titrate up oral regimen, will control this better
prior to transferring to the floor.
RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)
of unclear etiology, f/u renal biopsy, f/u complement levels to assess
for lupus flare
HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)
resolved s/p HD
Atrial fibrillation:
brief run of A.fib, and now with peristent pleuritic chest pain, will
send cardiac enzymes, and complements to assess for lupus flare. Will
hold off on starting aspirin.
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2149-8-4**] 02:00 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :Transfer to floor
Total time spent: 30 minutes"
5215,"2/26.0/1.1, Lactic Acid:0.9 mmol/L,
Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:5.7 mg/dL
Imaging: Perinephritic fluid, fat stranding c/w rejection - R kidney.
CXR: mild L pleural effusion, vascular fullness, otherwise clear.
Assessment and Plan
RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), ACUTE
REJECTION:
- Anticipate low tacro level, and predominant rejection, but with
possible superimposed infection/UTI
- Treating with steroids
- Renal and transplant surgery following: awaits renal Bx today
- Needs phosphate binder
- Empiric antibiotics (ceftazidime for ease of dosing with HD)
HYPERTENSION, BENIGN
- On amlodipine, adding hydralazine.
HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)
now resolved post
HD.
Anemia
Fe studies, getting blood per renal.
ICU Care
Nutrition: Renal diet.
Glycemic Control:
Lines:
20 Gauge - [**2149-8-3**] 07:54 PM
Prophylaxis:
DVT: hep sc
Stress ulcer: ppi
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition : ICU , may leave if BP/ HR stable later today
Total time spent: 35 mins"
5216,"8 g/dL
112 K/uL
196 mg/dL
9.1 mg/dL
24 mEq/L
4.2 mEq/L
73 mg/dL
105 mEq/L
141 mEq/L
21.7 %
2.3 K/uL
[image002.jpg]
[**2149-8-3**] 08:19 PM
[**2149-8-3**] 08:22 PM
[**2149-8-3**] 10:47 PM
[**2149-8-4**] 03:32 AM
[**2149-8-4**] 05:56 AM
WBC
3.5
2.2
2.3
Hct
24.7
20.4
21.7
Plt
107
108
112
Cr
13.5
13.3
9.1
Glucose
153
171
196
Other labs: PT / PTT / INR:13."
5217,"7
C (98
Tcurrent: 36.7
C (98
HR: 70 (65 - 85) bpm
BP: 201/83(108) {169/68(91) - 201/89(115)} mmHg
RR: 21 (16 - 27) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 70 Inch
Total In:
3,371 mL
919 mL
PO:
TF:
IVF:
346 mL
919 mL
Blood products:
Total out:
45 mL
43 mL
Urine:
45 mL
43 mL
NG:
Stool:
Drains:
Balance:
3,326 mL
876 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///24/
Physical Examination
GEN: Awake, alert, somewhat distant affect.
HEENT: MMM
PULM: Clear
BACK: No pain
ABD: Soft, NT, ND
EXT: RLE mildly > LLE
chronic per pt (after knee surgery)
Labs / Radiology
6."
5218,"8, BUN/Cr 121/14.7. EKG with mild peak Ts in V2 - got
hyperK treatment in ED. CT abd pelvis, with perinephric fat stranding,
got empiric levo/flagyl. Got high dose steroids per renal, and
transferred to MICU.
24 Hour Events:
- Increasing potassium to 7.4, EKG unchanged, but re-treated o/n with
Ca, insulin, glc.
- Renal notified, fistula patency verified and had short course HD
o/n.
- K corrected to 4.2, and Cr corrected to 9.
History obtained from Patient
Allergies:
Bactrim Ds (Oral) (Sulfamethoxazole/Trimethoprim)
Exfoliative [**Doctor Last Name **]
Cellcept (Oral) (Mycophenolate Mofetil)
Rash;
Last dose of Antibiotics:
Ceftriaxone - [**2149-8-3**] 10:27 PM
Infusions:
Other ICU medications:
Dextrose 50% - [**2149-8-3**] 09:31 PM
Insulin - Regular - [**2149-8-3**] 09:32 PM
Heparin Sodium (Prophylaxis) - [**2149-8-4**] 08:10 AM
Other medications:
Home: Tacro, Epo, Fe
Here: colace, methylpred, RISS, amlodipine, nitropaste, prograf
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2149-8-4**] 08:49 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
5219,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
52F with SLE, HTN, s/p renal [**Last Name (un) 8147**] ( 2 years ago, maintained on
prograf), p/w acute LBP onset am of admission, as well as abdominal
fullness; otherwise had been well and taking immunsupp regimen as
directed (though cannot name renal MD or recall last visit). No F/C,
SOB/cough, CP, abd pain, N/V/C/D. No dysuria, hematuria. In ED, K
notable for 6."
5220,".
ARF/Acute rejection: High concern for acute rejection. Plan for
dialysis in AM. Renal and transplant surgery aware.
- 500mg IV daily solumedrol
- continue tacro 12.5mg daily
- follow daily tacro levels
- dialysis in AM
- f/u renal recs
- f/u transplant surgery recs
- send urine lytes, eos, alb/cr
- stat u/s of fistula
- monitor urine output
- ck VBG. If acidemia, give 3amp bicarb in D5W
-ceftriaxone for concern of infection though unlikely given clinical
picture
.
Hyperkalemia: Mild peaked T waves.
- monitor labs
- repeat EKG
- repeat calcium/insulin
- stat dialysis
.
SLE: stable; not currently on treatment
.
HTN: not currently on meds. Currently hypertensive.
- will monitor
.
Anemia:
-continue iron supplement
.
FEN: Management if lytes per dialysis and acute management of
hyperkalemia; renal diet
.
PPX: heparin SC
.
ACCESS: [**Last Name (LF) 1200**], [**First Name3 (LF) **] fistula
.
CODE: Full
.
CONTACT: Pt
.
DISPO: pending above
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2149-8-3**] 07:54 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer:
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status:
Disposition:"
5221,"Imaging: Renal US (wet read):
1. RI ranges 0.61 to 0.80 of the txp kidney
2. No hydronephosis. No perirenal fluid.
3. Large anterior subcutaneous fluid collection as noted in concurrent
CT.
.
CT Abd/pelvis: 1. No evidence of AAA. 2. No kidney stone. 3. RLL txp
kidney.Atrophic native kidneys. No hydronephrosis. 4. Perinephritic fat
stranding of the txp kidney, could represent acute rejection or
infectious process. Recommend obtain an UA.
5. Sigmoid diverticulosis. Fat stranding in the right colon,
likely extending from txp kidney fat standing.
Assessment and Plan
A/P: 52yo W with PMH of SLE, renal failure s/p transplant presents with
acute renal failure and likely rejection."
5222,"8
C (96.5
Tcurrent: 35.8
C (96.5
HR: 85 (79 - 85) bpm
BP: 170/74(95) {170/69(95) - 185/80(103)} mmHg
RR: 22 (16 - 22) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Height: 70 Inch
Total In:
3,334 mL
PO:
TF:
IVF:
309 mL
Blood products:
Total out:
0 mL
45 mL
Urine:
45 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,289 mL
Respiratory
O2 Delivery Device: None
SpO2: 94%
ABG: ///10/
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
107 K/uL
7."
5223,"7 g/dL
153 mg/dL
13.5 mg/dL
113 mg/dL
10 mEq/L
115 mEq/L
7.6 mEq/L
139 mEq/L
24.7 %
3.5 K/uL
[image002.jpg]
[**2145-11-29**]
2:33 A9/6/[**2148**] 08:19 PM
[**2145-12-3**]
10:20 P9/6/[**2148**] 08:22 PM
[**2145-12-4**]
1:20 P
[**2145-12-5**]
11:50 P
[**2145-12-6**]
1:20 A
[**2145-12-7**]
7:20 P
1//11/006
1:23 P
[**2145-12-30**]
1:20 P
[**2145-12-30**]
11:20 P
[**2145-12-30**]
4:20 P
WBC
3."
5224,"5
Hct
24.7
Plt
107
Cr
13.5
Glucose
153
Other labs: PT / PTT / INR:12.7/26.0/1.1, Lactic Acid:0.9 mmol/L,
Ca++:7.2 mg/dL, Mg++:2.3 mg/dL, PO4:7.1 mg/dL
Fluid analysis / Other labs: LABS:
141 113 121 estGFR: 3
----|----|-----< 141 Ca: 7.7 Mg: 2.5 P: 8.1
6.7 11 14.7 (last Cr 1.4 [**2-3**])
ALT: 7 AST: 12 AP: 82 Tbili: 0.2 Alb: 3.7 Lip: 114
3.9> 8.1< 107 FK: p (last level 10.6 on [**2-3**])
27
."
5225,"Chief Complaint: Flank pain/acute renal failure
HPI:
HPI: 52 yo F with SLE s/p renal tx 2 years ago presents with b/l LBP,
atraumatic. Started acutely this AM while watching television. Also c/o
abdominal fullness but no frank pain. No F/C/N/V/CP/SOB. Had been
feeling her usual self until this AM.
.
In the ED, VS: T98.4 BP 120/100 HR 86 100%RA. Labs were notable for K
6.8, BUN/cr 121/14.7. EKG showed mild peak Ts in lead V2. She received
2g calcium gluconate, 10U insulin, kayexalate and 2L NS."
5226,"She was given
4mg morphine for pain. CT abd/pelvis showed perinephric fat stranding.
She was given levo flagyl for empiric abx coverage. While in the ED,
she was seen by renal and transplant surgery with concern for acute
rejection. She was started on high dose IV steroids and transferred to
the MICU for further management.
.
Upon arrival stat labs were drawn, notable for increasing K to 7.4 with
no changes on EKG from prior. Patient had stat LUE U/S which
demonstrated patent fistula. She was started on dialysis.
Allergies:
Bactrim Ds (Oral) (Sulfamethoxazole/Trimethoprim)
Exfoliative [**Doctor Last Name **]
Cellcept (Oral) (Mycophenolate Mofetil)
Rash;
Last dose of Antibiotics:
Ceftriaxone - [**2149-8-3**] 10:27 PM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2149-8-3**] 09:31 PM
Dextrose 50% - [**2149-8-3**] 09:31 PM
Insulin - Regular - [**2149-8-3**] 09:32 PM
Other medications:
Past medical history:
Family history:
Social History:
SLE
HTN:
Hyperthyroidism
Occupation:
Drugs:
Tobacco:
Alcohol:
Other:
Review of systems:
Constitutional: Fatigue
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea,
No(t) Constipation
Flowsheet Data as of [**2149-8-3**] 11:49 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 35."
5227,"Admission Date: [**2149-8-3**] Discharge Date: [**2149-8-26**]
Date of Birth: [**2097-6-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Cellcept
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
52 yo F with SLE s/p renal tx 2 years ago presents with b/l LBP,
atraumatic. Started acutely this AM while watching television.
Also c/o abdominal fullness but no frank pain. No
F/C/N/V/CP/SOB. Had been feeling her usual self until this AM.
.
In the ED, VS: T98.4 BP 120/100 HR 86 100%RA."
5228,".
Brief Hospital Course:
A/P: 52yo W with PMH of SLE, renal failure s/p transplant
presents with acute renal failure and likely rejection.
.
# Acute Renal Failure: Mrs. [**Known lastname 6357**] presented to the ED with
hyperkalemia [**12-30**] acute renal failure in her transplant kidney.
Due to faliure of medical management of the hyperkalemia, Mrs.
[**Known lastname 6357**] underwent emergent dialysis via her previous left arm
fistula that remained patent by U/S. Renal transplant
ultrasound was normal except for large subcutaneous fluid
collection that was also noted on CT. On hospital day 1, there
was concern for rejection."
5229,"UA with no signs of urinary tract infection. On hospital day
3, plasmapheresis was empirically initiated. During her
plasmapheresis courses, calcium levels were noted to be low and
were repleted on an as needed basis. She received 4 sessions of
plasmapheresis, however due to development of fever and signs of
infection on hospital day 10 this was not continued. Urine
Protein/Creatinine ratio was monitored on a daily basis during
the initial part of admission peaking at 30.7 then trending down
to 1.7 after 2 weeks. Throughout admission, hemodialysis was
done on as needed basis with one 9-day period of no
hemodialysis."
5230,"G6PD testing was negative.
-Please send all lab work to Dr. [**Last Name (STitle) **] at [**Hospital1 18**]-
.
# Hemodialysis: Patient to receive T/Th/Sa dialysis as
outpatient. At dialysis, she should receive epogen. In
addition, she should have PTH, Vitamin D and Iron studies drawn
at dialysis. She should continue cinacalcet as outpatient and
vitamin D as follows (50,000 units weekly x 8 weeks, followed by
1000 units daily thereafter until replete.). Patient has a slot
at [**Hospital4 117**] [**Hospital5 **] [**Hospital6 **] after she leaves rehab.
.
# C. difficile infection - On day 10 of admission, patient was
noted to be febrile."
5231,"Difficile (had recieved one dose of ceftazadime on
admission). Adenovirus PCT, Toxo serology and stool O&P were
negative. Stool was positive for C. Diff and po vancomycin
started. Cefepime, flagyl and vancomycin were discontinued.
Patient had 2 more fevers over the first 48 hours of PO
vancomycin treatment then was afebrile. Of note, diarrhea
work-up was positive for CMV viral load in blood possibly
consistent with CMV colitis (see below). Patient should complete
a 14 day course of PO vancomycin to end on [**2149-9-2**].
.
# CMV viremia - patient had detectable CMV viral load during
diarrheal work-up."
5232,"She had mild peaked T waves
in V2. In the ED, she received 2 rounds of calcium, insulin and
was transferred to the ICU where medical management for
hyperkalemia was more effective, but she still required emergent
dialysis. After a short course of emergent dialysis there was
improvement in her electrolytes. Potassium was monitored closely
throughout her admission while she underwent intermittant
hemodialysis.
.
# Atrial fibrillation: Mrs. [**Known lastname 6357**] went into atrial
fibrillation with RVR on the evening of [**8-4**] after dialysis.
She had no prior history. Had some chest pain during episode and
was ruled out. The atrial fibrillation was converted with
metoprolol then Diltiazem IV and she had no further episodes on
telemetry."
5233,"She was continued on metoprolol for rate control and
hypertension. Hydralazine was discontinued. Echo showed a
mildly dilated left atrium and LVEH > 55%. TSH was WNL. After
one week, telemetry was discontinued.
.
# Hypertension: Mrs. [**Known lastname 6357**] was not previously on
anti-hypertensives prior to admission. On admission, she was
noted to be hypertensive and started on hydralazine and
amlodipine. After her episode of atrial fibrillation, she was
also on hydralazine. Hydralazine ws discontinued after 2 days
with good blood pressure control on metoprolol and amlodipine.
Blood pressure was monitored and stable throughout her hospital
course with some episodes of hypotension during dialysis."
5234,"Amlodipine was changed to be dosed after dialysis and metoprolol
reduced to 12.5mg [**Hospital1 **]. At discharge, amlodipine was
discontinued due to its tendency to cause lower extremity edema,
and b/c hypotension had limited her HD sessions. Metoprolol
should be continued and titrated up as needed for hypertension.
.
# SLE: stable; on prednisone for FSGS.
.
# Anemia - continued iron supplement, epogen with HD as above,
transfusions as needed.
.
# Access: PICC line in place. AV fistula functional for now,
but had difficulty during hospital stay.
.
# Diabetes: presented during hospital stay while on treatment
with high dose steroids. Was covered with glargine qhs, and
humalog sliding scale with meals."
5235,"Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
18. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO every
twelve (12) hours. Capsule(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) **]
Discharge Diagnosis:
Focal Segmental Glomerulosclerosis
Acute Renal Failure
End Stage Renal Disease
C. Diff Colitis
CMV Viremia
Discharge Condition:
Stable, AOx3, appropriate.
Discharge Instructions:
You were admitted to the hospital for evaluation of kidney
failure. You had a biopsy of your kidney that showed a reaction
known as FSGS or focal segmental glomerulosclerosis. This was
treated with high doses of steroids, and plasmapheresis."
5236,"11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
12. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week for 8 weeks.
13. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
15. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: to end on [**2149-9-2**].
16. Ganciclovir 120 mg IV Q24H Start: In am
Give after HD on dialysis days
17."
5237,"Patient had stat LUE U/S
which demonstrated patent fistula. She was started on dialysis.
Past Medical History:
S/P renal transplant
SLE followed by Dr.[**Last Name (STitle) **] in Rheumatology.
Hypertension.
History of hyperthyroidism.
PSH:LUE AVF
History of bilateral knee surgeries and ACL repair on the
right knee.
Social History:
Single, lives alone, but has family in the area
Denied smoking/etoh
Family History:
NC
Physical Exam:
VS: HR 75 BP 185/85 97% RA
GEN: African American female in NAD
HEENT: EOMI, PERRL
NECK: Supple
CHEST: CTABL, no w/r/r
CV: RRR, S1S2
ABD: Soft/NT/ND
EXT: LUE: fistula with bruit and palpable thrill
SKIN: NO rashes
NEURO: AAOx3, no focal deficits"
5238,"03*
[**2149-8-5**] 02:36PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2149-8-6**] 03:39AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2149-8-23**] 05:16AM BLOOD Calcium-9.6 Phos-4.6* Mg-2.4
[**2149-8-7**] 05:00AM BLOOD Calcium-6.3* Phos-8.8* Mg-2.6
[**2149-8-7**] 07:45PM BLOOD Calcium-6.8*
[**2149-8-8**] 06:48AM BLOOD Calcium-6.8* Phos-5.3*# Mg-2.0
[**2149-8-8**] 04:41PM BLOOD Calcium-7.2*
[**2149-8-14**] 05:10AM BLOOD VitB12-552 Folate-11.2 Hapto-95
Ferritn-304*
[**2149-8-4**] 03:32AM BLOOD calTIBC-181* Ferritn-925* TRF-139*
[**2149-8-5**] 09:54PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2149-8-5**] 09:54PM BLOOD ANCA-NEGATIVE B
[**2149-8-5**] 09:54PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 dsDNA-NEGATIVE
[**2149-8-5**] 09:54PM BLOOD PEP-NO SPECIFI IgG-1192 IgA-421* IgM-27*
IFE-NO MONOCLO
[**2149-8-5**] 04:53AM BLOOD C3-107 C4-25
[**2149-8-7**] 12:05PM BLOOD HIV Ab-NEGATIVE
[**2149-8-3**] 05:32PM BLOOD tacroFK-13."
5239,"This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
FEW RBC'S.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2149-8-18**]):
REPORTED BY PHONE TO G PARSOPAROU @ 3:54A [**2149-8-18**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
VIRAL CULTURE (Final [**2149-8-19**]):
VIRAL CULTURE DISCONTINUED DUE TO PRESENCE OF CLOSTRIDIUM
DIFFICILE
TOXIN."
5240,"5. Petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for for dry skin.
6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
9. Insulin Glargine 100 unit/mL Cartridge Sig: Two (2) units
Subcutaneous at bedtime.
10. Insulin Lispro 100 unit/mL Cartridge Sig: as per sliding
scale as per sliding scale Subcutaneous qACHS."
5241,"Labs were notable
for K 6.8, BUN/cr 121/14.7. EKG showed mild peak Ts in lead V2.
She received 2g calcium gluconate, 10U insulin, kayexalate and
2L NS. She was given 4mg morphine for pain. CT abd/pelvis showed
perinephric fat stranding. She was given levo flagyl for empiric
abx coverage. While in the ED, she was seen by renal and
transplant surgery with concern for acute rejection. She was
started on high dose IV steroids and transferred to the MICU for
further management.
.
Upon arrival stat labs were drawn, notable for increasing K to
7.4 with no changes on EKG from prior."
5242,"0*# Na-144
K-3.9 Cl-104 HCO3-29 AnGap-15
[**2149-8-14**] 05:10AM BLOOD Glucose-93 UreaN-42* Creat-5.4* Na-146*
K-3.5 Cl-108 HCO3-27 AnGap-15
[**2149-8-16**] 10:12AM BLOOD Glucose-103 UreaN-61* Creat-6.3* Na-144
K-3.9 Cl-107 HCO3-24 AnGap-17
[**2149-8-19**] 05:31AM BLOOD Glucose-96 UreaN-83* Creat-6.4* Na-141
K-4.4 Cl-105 HCO3-21* AnGap-19
[**2149-8-21**] 05:15AM BLOOD Glucose-158* UreaN-102* Creat-7.6* Na-137
K-5."
5243,"3* Cl-103 HCO3-24 AnGap-15
[**2149-8-22**] 06:13AM BLOOD Glucose-103 UreaN-64* Creat-5.8*# Na-139
K-5.2* Cl-100 HCO3-27 AnGap-17
[**2149-8-23**] 05:16AM BLOOD Glucose-120* UreaN-72* Creat-6.7* Na-136
K-5.3* Cl-99 HCO3-28 AnGap-14
[**2149-8-22**] 06:13AM BLOOD ALT-12 AST-15 AlkPhos-66 TotBili-0.5
[**2149-8-16**] 06:00AM BLOOD ALT-7 AST-14 LD(LDH)-520* AlkPhos-27*
TotBili-0.7
[**2149-8-3**] 01:30PM BLOOD Lipase-114*
[**2149-8-5**] 04:53AM BLOOD CK-MB-NotDone cTropnT-0."
5244,"She was started on solumedrol 500mg
IV qday for this concern pending biopsy results. Renal biopsy
showed no signs of rejection, but was consistent with rapidly
progressing FSGS. IV solumedrol was decreased from 500 to 100 mg
qday on day 3 then ultimately switched to Prednisone 60 mg qday
on day 5--which was continued throughout admission and continued
on discharge. Studies into the etioogy of the FSGS were
negative -- HIV negative, BK virius negative, ANCA negative,
compliment levels normal, Hepatitis serology negative, [**Doctor First Name **] 1:40,
parvo b19 and HTLV negative. Urine output was monitored as best
as possible, however patient was non-compliant with collection."
5245,".
[**2149-8-25**] 2:13 pm Immunology (CMV) Source: Line-picc.
CMV Viral Load (Pending):
[**2149-8-20**] 6:44 am Immunology (CMV) Source: Line-picc.
**FINAL REPORT [**2149-8-21**]**
CMV Viral Load (Final [**2149-8-21**]):
861 copies/ml.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
Time Taken Not Noted Log-In Date/Time: [**2149-8-19**] 1:27 pm
URINE Site: NOT SPECIFIED CHEM # 66381R [**8-19**].
**FINAL REPORT [**2149-8-22**]**"
5246,"2# RBC-3.11* Hgb-8.4* Hct-27.9*
MCV-90 MCH-27.0 MCHC-30.1* RDW-17.4* Plt Ct-160
[**2149-8-22**] 06:13AM BLOOD WBC-12.4* RBC-3.61* Hgb-9.6* Hct-32.0*
MCV-89 MCH-26.5* MCHC-29.9* RDW-16.6* Plt Ct-244
[**2149-8-22**] 06:13AM BLOOD Neuts-73* Bands-2 Lymphs-20 Monos-3 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-2*
[**2149-8-13**] 05:00AM BLOOD Neuts-86* Bands-0 Lymphs-11* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2149-8-16**] 10:12AM BLOOD PT-13."
5247,"6* Cl-115* HCO3-10* AnGap-22*
[**2149-8-3**] 10:47PM BLOOD Glucose-171* UreaN-117* Creat-13.3*
Na-141 K-7.2* Cl-115* HCO3-10* AnGap-23*
[**2149-8-4**] 03:32AM BLOOD Glucose-196* UreaN-73* Creat-9.1*# Na-141
K-4.2 Cl-105 HCO3-24 AnGap-16
[**2149-8-6**] 03:39AM BLOOD Glucose-179* UreaN-73* Creat-9.1*# Na-141
K-4.4 Cl-101 HCO3-26 AnGap-18
[**2149-8-7**] 05:00AM BLOOD Glucose-130* UreaN-94* Creat-10.6*#
Na-141 K-4.3 Cl-100 HCO3-25 AnGap-20
[**2149-8-11**] 04:56AM BLOOD Glucose-109* UreaN-58* Creat-7."
5248,"Patient was also complaining of LLQ
abdominal pain, but no other associated symptoms. At this time
patient was started empirically on cefepime and flagyl for
suspected diverticulitis given findings of sigmoid colon wall
thickening on CT Abdomen and pelvis. Blood and urine cultures
were drawn and negative. UA negative for UTI. CXR had no
interval change of right basalar atelectasis and patient was
asymptommatic. Patient continued to have fevers and vancomycin
added on hospital day 12. Additionally valgancyclovir and
atovoqoune were added at this time for prophylaxis while on high
dose steroids. Patient continued to be febrile and complained
of diarrhea, ID consult felt symptoms were most consistent for
C."
5249,"3
[**2149-8-5**] 09:54PM BLOOD HCV Ab-NEGATIVE
CXR [**2149-8-6**]: IMPRESSION: AP chest compared to [**2149-8-4**]:
.
Right PIC line can be traced only as far as the mid SVC. Left
lower lobe
consolidation, new since [**2149-8-3**], is unchanged since
[**2149-8-4**] could be pneumonia or atelectasis. Small right
pleural effusion and generalized vascular engorgement have
increased. Mild cardiomegaly stable. No pneumothorax.
.
CT A/P [**2149-8-13**]: IMPRESSIONS:
1. Colonic diverticulosis along the descending and sigmoid
colon, with area of pericolonic fat stranding in the left lower
quadrant, compatible with mild uncomplicated diverticulitis."
5250,"No
free air, free fluid, or fluid collection except for the seroma
in ant [**Last Name (un) 103**] wall.
.
2. Small bilateral pleural effusions are slightly increased
compared to
[**2149-8-3**], with associated adjacent atelectasis in the lung bases.
The study and the report were reviewed by the staff radiologist.
.
AC Fistulogram [**2149-8-15**]: IMPRESSION: Fistulogram demonstrating
dilated, tortuous and widely patent left cephalic venous outflow
from fistula, and no central stenosis or clot. Brisk inflow
across arterial anastomosis implies no stenosis there.
.
CT C/T/L Spine [**2149-8-23**]: IMPRESSION:
Given limitations of the image acquisition and the patient's
inability to
cooperate, there is no evidence for fracture or dislocation."
5251,"You
had some mild improvement in your kidney function but required
dialysis to replace your kidneys. You will need to continue on
dialysis until your kidney function improves. During your
hospital stay you also developed an infectious diarrhea known as
C. Diff. This diarrhea is treated with oral antibiotics such as
vancomycin. You were also treated for CMV infection which
occurs in patients on high doses of immunosuppression such as
yourself. Please continue to take all medications on discharge.
.
Please return to the hospital should you experience any fevers,
chills, night sweats, worsening diarrhea, or other symptoms
concerning to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-9-1**] 1:30
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-9-22**] 1:20
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]"
5252,"At the time of detection, patient had been
on valgancyclovir prophylaxis for 4 days. Initially, it was
felt to be viremia w/o end organ involvement, however due to
continued diarrhea on PO vancomycin for C. difficile infection,
treatment was changed from valgancyclovir to gancyclovir for
treatment of possible CMV disease. She should be continued on
IV ganciclovir for treatment of CMV viremia until she has 2
negative CMV viral loads separated by one week. (viral load
[**8-20**] 861, repeat viral load [**8-25**] pending).
.
# Hyperkalemia: Mrs. [**Known lastname 6357**] was diagnosed with elevated
potassium on admission to the ED."
5253,"URINE CULTURE (Final [**2149-8-22**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ =>32 R
[**2149-8-19**] 12:17 pm BLOOD CULTURE
**FINAL REPORT [**2149-8-25**]**
Blood Culture, Routine (Final [**2149-8-25**]): NO GROWTH.
[**2149-8-3**] 8:19 pm MRSA SCREEN
**FINAL REPORT [**2149-8-6**]**
MRSA SCREEN (Final [**2149-8-6**]): No MRSA isolated.
[**2149-8-17**] 9:47 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2149-8-19**]**
OVA + PARASITES (Final [**2149-8-18**]):
NO OVA AND PARASITES SEEN."
5254,"Medications on Admission:
Tacro 12mg [**Hospital1 **]
epo
iron
Vitamin D
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: not to exceed 4g tylenol per
day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain."
5255,".
CT Head: [**2149-8-23**]: IMPRESSIONS: Very limited study, particularly
through the skull base due to patient motion. The visualized
brain reevals no definite abnormality. If there remains concern
for acute intracranial pathological process, reimaging would be
recommended when the patient is able to be still for the exam.
.
NOTE AT ATTENDING REVIEW: The hyperdensity noted above likely is
minimal
hyperostosis frontalis interna, with a similar finding noted on
the right
side in an analogous locale.
.
CXR [**2149-8-22**]
IMPRESSION: Increased right basilar opacity which may represent
atelectasis or developing pneumonia. Improved left basilar
atelectasis.
The study and the report were reviewed by the staff radiologist."
5256,"Pertinent Results:
[**2149-8-3**] 01:30PM BLOOD WBC-3.9* RBC-3.20* Hgb-8.1* Hct-27.0*
MCV-84 MCH-25.2* MCHC-29.9* RDW-16.8* Plt Ct-107*
[**2149-8-10**] 06:10AM BLOOD WBC-2.9* RBC-2.98* Hgb-7.7* Hct-25.1*
MCV-84 MCH-25.9* MCHC-30.8* RDW-17.9* Plt Ct-83*
[**2149-8-14**] 05:10AM BLOOD WBC-3.9* RBC-2.52* Hgb-6.7* Hct-21.6*
MCV-86 MCH-26.5* MCHC-30.9* RDW-17.5* Plt Ct-75*
[**2149-8-20**] 06:44AM BLOOD WBC-10."
5257,"Patient will continue dialysis as outpatient, as
well as prednisone and tacrolimus. She should follow up with
Transplant nephrology as arranged. Should continue tacrolimus
with goal trough [**5-5**]. Dose was decreased to 4mg [**Hospital1 **] on day of
discharge for elevated trough 9.1. Please contact transplant
nephrology at [**Hospital1 18**] for dose adjustments. Please check tacro
levels on Thursday, [**2149-8-28**], and regularly there after.
She should continue prednisone at 60mg daily for now. She
should remain on GI prophylaxis, Ca/Vit D as ordered. Patient
should be considered for starting dapsone for PCP prophylaxis in
the future rather than atovaquone, but given h/o severe bactrim
allergy did not challenge with dapsone on this hospitalization."
5258,"1 PTT-30.8 INR(PT)-1.1
[**2149-8-16**] 06:00AM BLOOD QG6PD-10.0
[**2149-8-14**] 05:10AM BLOOD Ret Aut-3.0
[**2149-8-16**] 06:00AM BLOOD Ret Aut-2.2
[**2149-8-5**] 09:54PM BLOOD ACA IgG-5.6 ACA IgM-7.4
[**2149-8-5**] 09:54PM BLOOD Lupus-NEG
[**2149-8-3**] 01:30PM BLOOD Glucose-141* UreaN-121* Creat-14.7*#
Na-141 K-6.7* Cl-113* HCO3-11* AnGap-24*
[**2149-8-3**] 08:22PM BLOOD Glucose-153* UreaN-113* Creat-13.5*#
Na-139 K-7."
5259,"Chief Complaint:
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
52F with SLE, HTN, s/p renal [**Last Name (un) 8147**] ( 2 years ago, maintained on
prograf), p/w acute LBP onset am of admission, as well as abdominal
fullness; otherwise had been well and taking immunsupp regimen as
directed (though cannot name renal MD or recall last visit). No F/C,
SOB/cough, CP, abd pain, N/V/C/D. No dysuria, hematuria. In ED, K
notable for 6."
5260,"8, BUN/Cr 121/14.7. EKG with mild peak Ts in V2 - got
hyperK treatment in ED. CT abd pelvis, with perinephric fat stranding,
got empiric levo/flagyl. Got high dose steroids per renal, and
transferred to MICU.
24 Hour Events:
- Increasing potassium to 7.4, EKG unchanged, but re-treated o/n with
Ca, insulin, glc.
- Renal notified, fistula patency verified and had short course HD
o/n.
- K corrected to 4.2, and Cr corrected to 9.
History obtained from Patient
Allergies:
Bactrim Ds (Oral) (Sulfamethoxazole/Trimethoprim)
Exfoliative [**Doctor Last Name **]
Cellcept (Oral) (Mycophenolate Mofetil)
Rash;
Last dose of Antibiotics:
Ceftriaxone - [**2149-8-3**] 10:27 PM
Infusions:
Other ICU medications:
Dextrose 50% - [**2149-8-3**] 09:31 PM
Insulin - Regular - [**2149-8-3**] 09:32 PM
Heparin Sodium (Prophylaxis) - [**2149-8-4**] 08:10 AM
Other medications:
Home: Tacro, Epo, Fe
Here: colace, methylpred, RISS, amlodipine, nitropaste, prograf
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2149-8-4**] 08:49 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
5261,"7
C (98
Tcurrent: 36.7
C (98
HR: 70 (65 - 85) bpm
BP: 201/83(108) {169/68(91) - 201/89(115)} mmHg
RR: 21 (16 - 27) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 70 Inch
Total In:
3,371 mL
919 mL
PO:
TF:
IVF:
346 mL
919 mL
Blood products:
Total out:
45 mL
43 mL
Urine:
45 mL
43 mL
NG:
Stool:
Drains:
Balance:
3,326 mL
876 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///24/
Physical Examination
Labs / Radiology
6.8 g/dL
112 K/uL
196 mg/dL
9."
5262,"9 mmol/L,
Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:5.7 mg/dL
Imaging: Perinephritic fluid, fat stranding c/w rejection - R kidney.
CXR: mild L pleural effusion, vascular fullness, otherwise clear.
Assessment and Plan
RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD), ACUTE
REJECTION:
- Anticipate low tacro level, and predominant rejection, but with
possible superimposed infection/UTI
- Treating with steroids
- Renal and transplant surgery following
- Needs phosphate binder
- Empiric antibiotics (ceftazidime for ease of dosing with HD)
HYPERTENSION, BENIGN
- On amlodipine, adding hydralazine.
HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)
now resolved post
HD.
Anemia
Fe studies, getting blood per renal.
ICU Care
Nutrition: Renal diet.
Glycemic Control:
Lines:
20 Gauge - [**2149-8-3**] 07:54 PM
Prophylaxis:
DVT: hep sc
Stress ulcer: ppi
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition : ICU
Total time spent:"
5263,"1 mg/dL
24 mEq/L
4.2 mEq/L
73 mg/dL
105 mEq/L
141 mEq/L
21.7 %
2.3 K/uL
[image002.jpg]
[**2149-8-3**] 08:19 PM
[**2149-8-3**] 08:22 PM
[**2149-8-3**] 10:47 PM
[**2149-8-4**] 03:32 AM
[**2149-8-4**] 05:56 AM
WBC
3.5
2.2
2.3
Hct
24.7
20.4
21.7
Plt
107
108
112
Cr
13.5
13.3
9.1
Glucose
153
171
196
Other labs: PT / PTT / INR:13.2/26.0/1.1, Lactic Acid:0."
5264,"TITLE:
Chief Complaint: [**8-4**]
-Renal recs - Ceftaz started instead of ceftriaxone, continue tacro
12ng [**Hospital1 **] and follow levels, started phoslo
-1.5 liters removed with HD
-hydral 25 TID started for BP
-after HD started having afib with RVR to 140s, gave lopressor 5mg x 2,
and 250ml bolus, checked lytes and hct, gave calcium and mag, gave dilt
10mg x 1, pt then converted to sinus in 80s
-had renal bx, was given Desmopressin with procedure
-PICC line placed
-she was transfused 1 unit of RBCs in am on [**8-4**]
24 Hour Events:
PICC LINE - START [**2149-8-4**] 02:00 PM
Allergies:
Bactrim Ds (Oral) (Sulfamethoxazole/Trimethoprim)
Exfoliative [**Doctor Last Name **]
Cellcept (Oral) (Mycophenolate Mofetil)
Rash;
Last dose of Antibiotics:
Ceftriaxone - [**2149-8-3**] 10:27 PM
Ceftazidime - [**2149-8-4**] 10:07 PM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2149-8-4**] 08:10 AM
Pantoprazole (Protonix) - [**2149-8-4**] 10:21 AM
Metoprolol - [**2149-8-4**] 10:59 PM
Diltiazem - [**2149-8-5**] 12:00 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2149-8-5**] 07:40 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37
C (98."
5265,"Renal and transplant surgery are following. Pt was
started on steroids on admission.
- 500mg IV daily solumedrol
- continue tacro 12.5mg daily
- follow daily tacro levels
- dialysis as needed
- f/u renal recs
- f/u transplant surgery recs
- f/u on renal bx results
- monitor urine output
- ceftazidime for concern of infection though unlikely given clinical
picture
.
# Hyperkalemia: Mild peaked T waves on admission, K normalized with HD
yesterday
- monitor labs
- repeat EKG
- PRN dialysis
.
# SLE: thought to be stable, but if active could be inducing renal
faiure
- will check C3 and C4 levels
# Afib with RVR: new onset [**8-4**], HR to 140s, may have been secondary to
quick correction of potassium with HD or fluid shifts
- responds to dilt 10mg IV x 1, will give again if needed
- monitor lytes
- if reoccurs will consider anticoagulation/ASA therapy
."
5266,"# HTN: not currently on home meds. Was hypertensive on admission,
corrected with HD
- hydral PRN
- continue amlodipine
- will monitor
.
# Anemia:
- continue iron supplement
.
FEN: Management if lytes per dialysis and acute management of
hyperkalemia; renal diet
.
PPX: heparin SC
.
ACCESS: [**Last Name (LF) 1200**], [**First Name3 (LF) **] fistula
.
CODE: Full
.
CONTACT: Pt
.
DISPO: ICU for now
ICU Care
Nutrition: renal diet
Glycemic Control:
Lines:
PICC Line - [**2149-8-4**] 02:00 PM
Prophylaxis:
DVT: hep SQ
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU for now, likely can be called out later today if BP
stable"
5267,"6
Tcurrent: 36
C (96.8
HR: 70 (67 - 122) bpm
BP: 169/75(97) {122/62(81) - 201/89(112)} mmHg
RR: 14 (13 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 70 Inch
Total In:
1,823 mL
226 mL
PO:
TF:
IVF:
1,473 mL
226 mL
Blood products:
350 mL
Total out:
1,583 mL
20 mL
Urine:
83 mL
20 mL
NG:
Stool:
Drains:
Balance:
240 mL
206 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 100%
ABG: ///28/
Physical Examination
GEN: awake, polite
HEENT: clear OP
CV: RRR, no M
CHEST: CTA B
ABD: soft, NT, +BS
Ext: trace edema
Labs / Radiology
103 K/uL
7."
5268,"5
13.3
9.1
6.7
7.3
Glucose
153
171
196
132
185
Other labs: PT / PTT / INR:13.2/26.0/1.1, Lactic Acid:0.5 mmol/L,
Ca++:7.6 mg/dL, Mg++:2.5 mg/dL, PO4:6.7 mg/dL
Assessment and Plan
HYPERTENSION, BENIGN
RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)
HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)
A/P: 52yo W with PMH of SLE, renal failure s/p transplant presents with
acute renal failure and likely rejection.
.
# ARF/Acute rejection: High concern for acute rejection. Had renal bx
and HD yesterday."
5269,"2 g/dL
185 mg/dL
7.3 mg/dL
28 mEq/L
4.2 mEq/L
51 mg/dL
101 mEq/L
140 mEq/L
22.4 %
2.9 K/uL
[image002.jpg]
[**2149-8-3**] 08:19 PM
[**2149-8-3**] 08:22 PM
[**2149-8-3**] 10:47 PM
[**2149-8-4**] 03:32 AM
[**2149-8-4**] 05:56 AM
[**2149-8-4**] 10:59 PM
[**2149-8-5**] 04:53 AM
WBC
3.5
2.2
2.3
2.9
2.9
Hct
24.7
20.4
21.7
23.1
22.4
Plt
107
108
112
109
103
Cr
13."
5270,"Labs prior to transfer were 100.6 132
154/77 14 100%AC. Access was 18gauge x 2.
.
On arrival to the ICU, vital signs were 100.5 128 104/60 18 100%
on PS 8/5 60%FiO2. Patient was intubated, comfortable appearing
and very lethargic. Nursing reported pressence of copious light
brown secretions from ET tube.
.
Unable to complete review of systems given intubation.
Past Medical History:
PAST MEDICAL HISTORY
** none available per patient, have included past medical
history of [**Known firstname **] [**Known lastname **], the supposed identity of this patient **
- Atypical Chest Pain - cardiac catheterization [**4-24**] w/o
significant lesions, EF >55% ([**2180**]), pMibi [**2176**] negative
- Polysubstance abuse (EtOH, BZD, cocaine, heroin), w h/o DT and
withdrawal seizures, multiple detox admissions including 25-day
[**Location (un) 1475**] detox/incarceration
- Depression - prior suicide attempts
- Hypertension
- Hyperlipidemia
- DM - diet controlled
- DVT in prison treated with coumadin
- Hiatal hernia
- Barrett's Esophagus
- h/o HCV
- h/o PPD+ s/p isoniazid x9mo
- h/o Lyme disease
- s/p appendectomy"
5271,"Brief Hospital Course:
IMPRESSION: 60M with uncertain PMH history who presented with
lethargy and evidence of alcohol withdrawal seizures who was
intubated for airway protection and behavioral concerns. Patient
was successfully extubated and treated with pneumonia. Patient
eloped on [**2183-2-27**].
.
# DELIRIUM - During and after extubation, patient intermittently
very agitated, trying to get out of bed and punching staff
members - occasionally becoming physical. He was treated with
PRN IV Haldol for agitation and had an infectious and metabolic
work-up for causes of delirium which was unrevealing. Once
Precedex was weaned (see below), his mental status improved.
.
# ALCOHOL WITHDRAWAL SEIZURES - Patient with witness generalized
tonic-clonic seizure activity in the ED."
5272,".
# SINUS TACHYCARDIA - Likely multifactorial and secondary to
hypovolemia and presumed alcohol withdrawal with sympathetic
overdrive; no obvious sources of infection and afebrile. EKG on
admission reassuring, with improvement in his rate following
sedation. His electrolytes were aggressively repleted.
.
# THROMBOCYTOPENIA - Patient presented with worsening
thrombocytopenia that stabilized following admission. He
demonstrated no evidence of active bleeding. He was maintained
on heparin prophylaxis without issue. He had no evidence of
infection.
.
# IDENTIFICATION - Identification was confirmed as [**Known firstname **] [**Known lastname **]
after 3-days of his hospital stay. Once identification was
confirmed, his medication reconcilitation was performed. His
brother arrived to confirm his identification.
.
Medications on Admission:
** none available per patient, have included past medical
history of [**Known firstname **] [**Known lastname **], the supposed identity of this patient **
- Thiamine 100mg daily
- Aspirin 81mg daily
- Diltiazem 120mg QID
- Atorvastatin 10mg daily
- Isosorbide Mononitrate SR 30mg daily
- Omeprazole 20mg daily
- Folic Acid 1mg daily
- MVI
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Alcohol withdrawal seizure
Secondary Diagnosis: Aspiration pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
patient eloped.
Followup Instructions:
patient eloped."
5273,"9 Na-142
K-3.5 Cl-105 HCO3-27 AnGap-14
[**2183-2-26**] 03:54AM BLOOD ALT-49* AST-51* LD(LDH)-239 CK(CPK)-585*
AlkPhos-63 TotBili-0.7
.
IMAGING STUDIES:
.
[**2183-2-21**] CT C-SPINE W/O CONTRAST - No acute fracture or
malalignment is present. There is exaggeration of normal
cervical lordosis. NG tube and ET tube are partially imaged. The
thyroid gland is unremarkable. The partially imaged lung apices
show mild paraseptal emphysema. The partially imaged mastoid air
cells are well aerated.
.
[**2183-2-21**] CT HEAD W/O CONTRAST - Evaluation is limited due to
patient motion."
5274,"Within these limitations, no acute intracranial
hemorrhage, large vascular territory infarct, shift of midline
structures or mass effect is present. The ventricles and sulci
are normal in size and configuration. The visible paranasal
sinuses and mastoid air cells show minimal mucosal thickening in
the posterior ethmoidal air cells and the sphenoidal sinus.
.
[**2183-2-25**] CXR: The ET tube tip is 5 cm above the carina. The NG
tube tip is in the stomach. Heart size and mediastinum appear
unchanged. There is interval progression of widespread
multifocal opacities, highly concerning for multifocal
pneumonia, potential aspiration in origin. Small amount of
bilateral pleural effusion, left more than right, cannot be
excluded."
5275,"Father w DM,
mother w Breast Ca, HTN.
Physical Exam:
ADMISSION EXAM:
.
Vitals: 100.5 128 104/60 18 100% on PS 8/5 60%FiO2
General: Intubated, sedated, very lethargic, spontaneously
moving
HEENT: PERRL 2mm, sclera anicteric, MMM
Neck: Supple, no JVD, no LAD
Lungs: Coarse breath sounds bilaterally without no wheezes,
rales, rhonchi
CV: Tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, NT/ND, naBS
GU: + foley
Ext: WWP, 2+ DP/radial equal bilaterally, no cyanosis/edema
Derm: Scattered papules over extremities, corresponding w hair
folicles c/w folliculitis
.
DISCHARGE EXAM:
.
Vitals: Tm 101.5 Tc 99."
5276,"Multivitamin, folate
and thiamine were all started on admission.
.
# ACUTE RESPIRATORY CONCERNS - Intubation for behavioral issues,
ventilating well, with copious brown liquid being suctioned from
ET tube initially; given these findings, there was some concern
for aspiration in the setting of seizure or peri-intubation. He
had low grade temperatures without leukocytosis on admission
attributed to his withdrawal physiology. Given his increased
sedation requirements, he required mechanical ventilatory
support. His CXR did demonstrated some evidence of pulmonary
congestion and possible consolidation concerning for aspiration
pneumonitis vs. pneumonia. He was antibiosed with Vancomycin and
Cefepime for pneumonia coverage given his sputum culture gram
stain demonstrating gram positive cocci and gram negative rods;
speciating commensal organisms only."
5277,"Neurologic exam was
without deficits on admission and head CT imaging was
reassuring. Toxic ingestion, overdose and alcohol withdrawal
were all considered, with laboratory and physical evidence of
alcohol withdrawal seizure. No clear evidence of toxidrome on
laboratory and physical exam work-up. He remained intubated and
required intensive sedation with Midazolam and Propofol
infusions, as well as Fentanyl for comfort. Diazepam was started
via his OGT as well. We switched him to Precedex to promote
down-titration of his narcotics and benzodiazepines, and we were
able to transition him to PO Diazepam for withdrawal concerns.
His electrolytes were optimized, although he had some
intermittent episodes of non-sustained ventricular tachycardia
which were short-lived and asymptomatic."
5278,"Admission Date: [**2183-2-21**] Discharge Date: [**2183-2-27**]
Date of Birth: [**2128-9-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Truvada
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
[**2183-2-21**] - Rapid sequence intubation with mechanical ventilation
History of Present Illness:
60yo M with uncertain past medical history, who was BIBEMS after
experiencing a seizure. Patient called EMS after experiencing a
reported seizure. EMS found him standing outside, but became
combative and subsequently experienced a seizure while enroute
to [**Hospital1 18**]. FS at time of seizure was 150.
.
On presentation to [**Hospital1 18**] ED, initial vital signs were 134 130/64
13 100%."
5279,"2*
[**2183-2-21**] 11:00AM BLOOD Albumin-4.9
[**2183-2-21**] 08:55PM BLOOD Osmolal-277
[**2183-2-21**] 03:50PM BLOOD Type-ART Temp-37.8 pO2-108* pCO2-48*
pH-7.33* calTCO2-26 Base XS--1 -ASSIST/CON Intubat-INTUBATED
[**2183-2-21**] 11:25AM BLOOD Lactate-10.2*
[**2183-2-22**] 04:58AM BLOOD freeCa-1.04*
.
DISCHARGE LABS:
[**2183-2-26**] 03:54AM BLOOD WBC-4.5 RBC-3.76* Hgb-11.4* Hct-34.8*
MCV-93 MCH-30.4 MCHC-32.9 RDW-13.9 Plt Ct-160
[**2183-2-26**] 03:54AM BLOOD Glucose-107* UreaN-13 Creat-0."
5280,"[**2183-2-21**] 11:00AM BLOOD WBC-7.9 RBC-4.25* Hgb-13.3* Hct-39.8*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.2 Plt Ct-212
[**2183-2-21**] 11:00AM BLOOD PT-10.6 PTT-27.9 INR(PT)-1.0
[**2183-2-21**] 11:00AM BLOOD Glucose-193* UreaN-10 Creat-1.0 Na-135
K-3.9 Cl-92* HCO3-18* AnGap-29*
[**2183-2-21**] 11:00AM BLOOD ALT-50* AST-88* AlkPhos-71 TotBili-0.5
[**2183-2-21**] 08:55PM BLOOD Calcium-7.6* Phos-2.1* Mg-1."
5281,"Social History:
* none available per patient, have included past medical history
of [**Known firstname **] [**Known lastname **], the supposed identity of this patient * Drinks 2L
vodka daily for the last 30+ years. He also has a 30+ pack year
history. H/o IVDU - last heroin use 1 month ago. Current
cocaine/crack and crystal meth use. Had an ex-boyfriend
of 9 years, by whom he was abused. Ex-boyfriend currently in
prison for abuse, and patient feels safe.
Family History:
** none available per patient, have included past medical
history of [**Known firstname **] [**Known lastname **], the supposed identity of this patient **
Significant for premature coronary artery disease: father w MI
at 46 (4 [**Known lastname **] total), twin brother had MI at 43."
5282,"At that
time patient became combative, and was induced and intubated to
allow completion of medical workup. CXR was unremarkable, NCHCT
without acute intracranial process, and CT Cspine without acute
fracture. Patient was felt to have had seizure's [**1-23**] EtOH
withdrawal and was sedated on fentanyl/midazolam. Patient was
bolused with IV normal saline. Post-intubation ABG 7.33/48/108.
Repeat lactate returned 0.9 after 3LNS. ED course otherwise
notable for agitation requiring increasing of midazolam drip to
20mg/hr. He was given thiamine, folate and was admitted to [**Hospital Unit Name 153**]
for further management."
5283,"5, HR 70s, BP 120s/60s, RR 18, O2 95-97%
on RA
General: alert, oriented, speaking coherently, sitting up in a
chair and eating breakfast
HEENT: PERRL 2mm, sclera anicteric, MMM
Neck: Supple, no JVD, no LAD
Lungs: Coarse breath sounds bilaterally without wheezes, rales,
rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, NT/ND, naBS
Ext: WWP, 2+ DP/radial equal bilaterally, no cyanosis/edema
Derm: Scattered papules over extremities, not corresponding with
hair follicles ?????? some psoriatic appearing plaques and numular
plaque-like red lesions with scaling noted over groin and
proximal extremities
Pertinent Results:
ADMISSION LABS:
."
5284,"There is no pneumothorax.
.
[**2183-2-25**] EKG: Sinus rhythm. Low limb lead voltage. Since the
previous tracing of [**2183-2-21**] atrial premature beats are no longer
seen and the rate is slower. ST-T waves have improved.
.
MICROBIOLOGIC DATA:
.
[**2183-2-21**] Urine culture ?????? negative
[**2183-2-21**] Blood culture (x 2) ?????? negative
[**2183-2-21**] MRSA screen ?????? negative
[**2183-2-21**] Sputum ?????? 2+ GPC, 1+ GNRs, commensal growth
[**2183-2-25**] Sputum ?????? contaminated, culture cancelled
[**2183-2-25**] UCx ?????? negative
[**2183-2-25**] BCx pending
[**2183-2-26**] urine legionella antigen ?????? negative
[**2183-2-26**] UCx pending
[**2183-2-26**] BCx pending"
5285,"Exam was notable for cold extremities and wet
clothing, hematoma and abrasion over R parietal area . He was
lethargic and reported to be confused. Given lethargy, patient
was unable to provide any history at that time. He was
recognized as a patient who is frequently seen in the [**Hospital1 18**] ED
for intoxication with a history of withdrawal seizures (thought
to be named [**Name (NI) **] [**Known lastname **], MR [**Numeric Identifier 111312**]). Labs were notable for WBC
7.9 (N73), Hct 39.8, Cr 1.0, ALT/AST 50/88, lactate of 10.2,
unremarkable UA, negative serum and urine tox screens."
5286,"Admission Date: [**2106-11-19**] Discharge Date: [**2106-12-6**]
Date of Birth: [**2027-2-7**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Adenocarcinoma of the Proximal Colon
Major Surgical or Invasive Procedure:
1. Right colectomy.
2. Extensive enterolysis.
3. Exploratory laparotomy.
4. Washout and takedown and resection of failed ileocolic
anastomosis with end ileostomy.
History of Present Illness:
This patient is a 79-year-old male who presents with a history
of having anemia which was worked up and he was found to have a
tumor in cecum very near the ileocecal valve."
5287,"This was palpable
at the time surgery. Additionally he
had 2 polyps in the ascending colon. The highest one was distal
to the hepatic flexure. At surgery we found his hepatic flexure
was quite adherent to the gallbladder fossa. This was taken down
and we managed to get his colon over to
the level of his antecolic B2 where we resected. We actually
managed to get to the right branch of the middle colic artery.
This did require extensive enterolysis for approximately an hour
and half because of his previous
abdominal sepsis following coronary artery bypass graft in [**2093**].
He was doing well until yesterday when he developed a white
count and a fever overnight."
5288,"This morning he had some stool
expressing from his wound. He was
brought to surgery and there he was found to have fecal
peritonitis. He actually been taking diet and having flatus, but
no bowel movement yet prior to surgery. At surgery, the colonic
side of this ileocolic anastomoses was found to be disrupted,
but was not necrotic. It was determined that the entire colon
was open, and so therefore, it was felt it would probably be
best to just go ahead and oversew it and take down the
anastomoses and give him an end ileostomy, especially since
there was so much a fecal spillage."
5289,"This was
accomplished with some degree of difficulty because he had had a
preperitoneal bleed, I assume from closure, so we had some
abdominal wall hematoma, as well, which was removed.
Past Medical History:
CAD s/p CABG [**2093**]
Antrectomy and vagotomy [**2093**] with BillrothII then converted to
R-Y
GERD
HTN
Social History:
Lives at home with his wife. [**Name (NI) **] social support amongst family
members.
Family History:
Not elicited
Pertinent Results:
[**2106-11-19**] 06:01PM POTASSIUM-4.1
[**2106-11-19**] 06:01PM CK(CPK)-377*
[**2106-11-19**] 06:01PM CK-MB-5 cTropnT-<0.01
[**2106-11-19**] 06:01PM MAGNESIUM-1."
5290,"DIAGNOSIS:
Ileocolectomy:
1. Adenocarcinoma of the ascending colon, see synoptic report.
2. Two adenomas of the colon.
3. Fibrous obliteration, distal end of appendix.
4. Ileal segment, within normal limits.
ECG
Sinus rhythm with borderline A-V conduction delay
Consider left atrial abnormality
Left anterior fascicular block
Since previous tracing of [**2106-11-16**], ventricular ectopy absent
Brief Hospital Course:
Pt admitted to surgery for removal of adenocarcinoma proximal
colon. He had a colectomy of the R colon and an anastomis
performed to bring terminal ileum to the transverse colon. This
did require extensive enterolysis for approximately an hour and
half because of his previous abdominal sepsis following coronary
artery bypass graft in [**2093**]."
5291,"5*
[**2106-11-19**] 06:01PM HCT-39.0*
[**2106-11-19**] 05:09PM HGB-13.2* calcHCT-40
[**2106-11-19**] 04:24PM HGB-5.7* calcHCT-17
PORTABLE CHEST, [**2106-11-19**], 21:44
INDICATION: Hypertension and dyspnea.
FINDINGS:
CABG changes are evident. At the right upper lobe laterally,
there is some
linear reticular markings and a nodular feature is appreciated
projecting over
right anterior rib 3. The latter was shown to be a dense
calcification on
prior chest CT. That CT shows no definite correlate with the
reticular
markings visualized at the right upper lobe laterally, but
additional
reticular markings were seen in the right upper lobe anteriorly."
5292,"He did well for the first five
postoperative days until it was noted on POD 6 that pt had stool
expressing from his wound. He was brought to surgery and there
he was found to have fecal peritonitis. He was on a regular diet
and having flatus, but no bowel movement yet prior to the second
surgery. At surgery, the colonic side of this ileocolic
anastomoses was found to be disrupted, but was not necrotic. It
was determined that the entire colon was open, and so therefore,
it was felt it would probably be best to just go ahead and
oversew it and take down the anastomoses and give him an end
ileostomy, especially since there was so much a fecal spillage."
5293,"This was accomplished with some degree of difficulty because he
had had a preperitoneal bleed, I assume from closure, so we had
some abdominal wall hematoma, as well, which was removed. S/p
surgery pt did well and had wound vac placed over abdominal wall
where hematoma was removed. Pt continued to progress and was
discharged to home after receinf ileostomy care and setting up
services for wound vac changes.
Medications on Admission:
Atenolol 50mg Qdaily
Xanax 0.25 PRN
Omeprazole 20mg QDaily
MVN
ASA 81mg QDaily
Travatan Eye drops (Travoprost)
Discharge Medications:
1. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray
Mucous membrane PRN (as needed)."
5294,"Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Hydrocodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
Anastomotic failure with fecal peritonitis.
Adenocarcinoma of the right colon.
Discharge Condition:
Good
Discharge Instructions:
Call your surgeon or return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications."
5295,"The
pulmonary vascular markings are not distended, and the
costophrenic sulci are
sharply delineated. There is no focal consolidation. No
pneumothorax.
IMPRESSION: No focal consolidation. Reticular markings seen in
the right
upper lobe laterally should be followed with a subsequent film
to see if this
is evolving. Dense calcification presumably granuloma in the
superior aspect
of the right lower lobe laterally.
Pathology Report
SPECIMEN SUBMITTED: right colon.
Procedure date Tissue received Report Date Diagnosed
by
[**2106-11-19**] [**2106-11-19**] [**2106-11-23**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl
Previous biopsies: [**-8/3905**] GI BX'S, 3 JARS."
5296,"* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] and the Wound Care Clinic -
your appoinments are on the same day on [**2106-12-21**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2106-12-21**] 9:30
Wound care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10132**], NP. [**2106-12-21**] 10:45AM"
5297,"2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8."
5298,"Periop fluid balance 3L
in/150ml urine/EBL?, intermittent phenylephrine boluses, no cont
pressor gtt. Pt hospital course w/ paroxymal afib on rate control,
postop w/ PAF.
.
ISSUES:
1. periop Afib w/ RVR
Chief complaint:
arrhythmia
PMHx:
htn, cad s/p cabg [**2093**], gerd, colon ca
Current medications:
1. 2. 3. 4. 1000 mL LR 5. Amiodarone 6. Amiodarone 7. Calcium Gluconate
8. Ciprofloxacin 9. HYDROmorphone (Dilaudid)
10. Heparin 11. Insulin 12. Latanoprost 0.005% Ophth. Soln. 13.
Magnesium Sulfate 14. Metoprolol Tartrate
15. MetRONIDAZOLE (FLagyl) 16. Ondansetron 17. Pantoprazole 18.
Phenaseptic Throat Spray 19. Potassium Chloride
20. Sodium Chloride 0."
5299,"0 g/dL
145 mg/dL
0.6 mg/dL
28 mEq/L
3.4 mEq/L
14 mg/dL
103 mEq/L
137 mEq/L
23.8 %
11.7 K/uL
[image002.jpg]
[**2106-11-26**] 06:37 PM
[**2106-11-27**] 02:05 AM
[**2106-11-28**] 02:15 AM
[**2106-11-28**] 03:09 AM
WBC
17.4
16.5
11.6
11.7
Hct
32.5
31.2
24.5
23.8
Plt
533
514
420
429
Creatinine
0.6
0.7
0.6
Glucose
146
213
145
Other labs: PT / PTT / INR:15.6/28."
5300,"SICU
HPI:
HPI: 79 yo male w/ htn, cad s/p cabg [**2093**], gerd, colon ca s/p right
hemicolectomy [**11-19**], back to OR [**11-26**] for suspected leak --> ex lap,
abd washout, leak found, end ileostomy created. Periop fluid balance 3L
in/150ml urine/EBL?, intermittent phenylephrine boluses, no cont
pressor gtt. Pt hospital course w/ paroxymal afib on rate control,
postop w/ PAF.
.
ISSUES:
1. periop Afib w/ RVR
Chief complaint:
SICU
HPI:
HPI: 79 yo male w/ htn, cad s/p cabg [**2093**], gerd, colon ca s/p right
hemicolectomy [**11-19**], back to OR [**11-26**] for suspected leak --> ex lap,
abd washout, leak found, end ileostomy created."
5301,"m.
Tmax: 37.2
C (98.9
T current: 36.9
C (98.4
HR: 74 (65 - 91) bpm
BP: 131/47(68) {111/35(56) - 140/63(80)} mmHg
RR: 18 (8 - 22) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
CVP: 5 (-1 - 7) mmHg
Total In:
3,496 mL
689 mL
PO:
Tube feeding:
IV Fluid:
3,496 mL
689 mL
Blood products:
Total out:
1,505 mL
390 mL
Urine:
1,220 mL
340 mL
NG:
Stool:
Drains:
255 mL
50 mL
Balance:
1,991 mL
301 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 98%
ABG: ///28/
Physical Examination
General Appearance: No acute distress, Overweight / Obese
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Distended, Tender: appropriately post-operatively
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact), VAC to suction
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
429 K/uL
8."
5302,"8/1.4, Albumin:2.5 g/dL, Ca:7.3
mg/dL, Mg:2.0 mg/dL, PO4:2.0 mg/dL
Assessment and Plan
WOUND INFECTION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), CANCER
(MALIGNANT NEOPLASM), COLORECTAL (COLON CANCER), NAUSEA / VOMITING,
ATRIAL FIBRILLATION (AFIB)
Assessment and Plan: HPI: 79 yo male w/ htn, cad s/p cabg [**2093**], gerd,
colon ca s/p right hemicolectomy [**11-19**], back to OR [**11-26**] for suspected
leak --> ex lap, abd washout, leak found, end ileostomy created. Periop
fluid balance 3L in/150ml urine/EBL?, intermittent phenylephrine
boluses, no cont pressor gtt."
5303,"9% Flush 21. Sodium Chloride 0.9% Flush 22.
Sodium Chloride 0.9% Flush 23. Vancomycin
24 Hour Events:
[**11-27**] - placed vac on wound, amio gtt continued for OR tomorrow, A+Ox3 -
urine output appropriate - seems appropriately resuscitated
Post operative day:
POD#2 - colectomy
Allergies:
Penicillins
Hives;
Last dose of Antibiotics:
Vancomycin - [**2106-11-27**] 08:06 PM
Ciprofloxacin - [**2106-11-28**] 12:20 AM
Metronidazole - [**2106-11-28**] 04:24 AM
Infusions:
Amiodarone - 0.5 mg/min
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2106-11-27**] 08:25 PM
Pantoprazole (Protonix) - [**2106-11-27**] 08:26 PM
Hydromorphone (Dilaudid) - [**2106-11-28**] 01:54 AM
Metoprolol - [**2106-11-28**] 04:23 AM
Other medications:
Flowsheet Data as of [**2106-11-28**] 04:36 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a."
5304,"Pt hospital course w/ paroxymal afib on
rate control, postop w/ PAF.
Neurologic: Neuro checks Q: 4 hr, Neurologic: Neuro checks Q: 4 hr,
DILAUDID PRN FOR PAIN; phenergan/zofran for continued nausea without
productive emesis
Cardiovascular: Beta-blocker, Cardiovascular: Beta-blocker, AFIB IN
RATE CONTROL ON AMIO GTT
Pulmonary: Pulmonary: IS, IS/ OOB
Gastrointestinal / Abdomen: Post-op ileus, Gastrointestinal / Abdomen:
Post-op ileus, nausea s/p ex-lap/ end ileostomy
zofran
Nutrition: NPO
Renal: Foley, Adequate UO
Hematology: Serial Hct
Endocrine: RISS
Infectious Disease: Check cultures, Infectious Disease: Check cultures,
V/F/Cipro - broad coverage
Lines / Tubes / Drains: Foley, Lines / Tubes / Drains: Foley, triple
lumen,
Wounds: Dry dressings, Wounds: Dry dressings
Imaging: Imaging: no imaging needed today
Fluids: LR, @ 80 to reduce amount of resuscitative fluids overnight
Consults: General surgery
Billing Diagnosis: Post-op complication, Sepsis
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2106-11-26**] 07:03 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 32 minutes
Patient is critically ill"
5305,"Admission Date: [**2161-9-5**] Discharge Date: [**2161-9-16**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
s/p Arrest
Major Surgical or Invasive Procedure:
Intubated with endotracheal tube
History of Present Illness:
[**Age over 90 **]M with history of Afib on coumadin, PVD, hypothyroidism
admitted to [**Hospital1 18**] s/p arrest found to have small
intraventricular hemorrage, unclear etiology of arrest. Per
sister, who lives in apt below, patient has been in usual state
of health. She found him this am in bathtub with water running -
reported to be breating."
5306,"2 mg), levophed titrated
up, right femoral CVL placed. Large incontinence of stool.
Neurosurgery consulted and recommended no intervention at this
time with serial CT Head and managment of coagulopathy. Neuro
felt seizure unlikely the cause of shock. Due to acidosis,
started on bicarb gtt. Placed on Fentanyl/Versed for sedation.
Also recieved 18 units of Factor 9 to reverse coagulopathy and
4L IVF. After ROSC, he was moving all 4 extremities. Not cooled
due to ICH.
.
Most recent set of vitals prior to transfer: 127 143/69 100% on
vent 98.6F rectally.
Past Medical History:
Atrial Fibrillation
Hypertension
NIDDM - diet controlled
PVD
Hypothyroidism
CHF diagnosed in [**2156**], no known ischemic disease"
5307,"He was placed on
fentanyl/versed for sedation, given 18 u factor 9 to reverse
coagulopathy. Not cooled due to ICH. Decision was made to make
patient CMO. He was extubated and transferred to the medicine
service for futher care.
# Cardiac arrest: He achieved return of spontaneous circulation
in the ED. He was transferred to the ICU intubated on pressure
support with levophed for a MAP >60. Attempts were made to
determine the etiology of the arrest. He had an echocardiogram
which showed an ""ejection fraction of 25%, mildly dilated LA,
mild symmetric LVH, mid-distal anteroseptal and apical akinesis
and hypokinesis elsewhere, RV cavity dilated with moderate
global free wall hypokinesis, mild AR, mild MR, no pericardial
effusion."
5308,"Pt was extubated on
[**9-8**] and made comfort measures only.
.
# Hypotension: Unclear etiology of hypotension; echo showed
depressed ejection fraction so maybe cardiogenic in origin.
Unlikely to be hypovolemia given lack of bleeding source and
lack of response to aggressive fluid resucitation. Attempts were
made to place radial and femoral a-lines but were unsuccessful
due to peripheral arterial disease. IVF and levophed were used
to keep urine output >30cc/hr and a MAP >60. ACEI and BB were
held throughout.
.
# CHF/A-fib: Acuity of his CHF is unclear as discussed above.
His supratherapeutic INR was reversed in the setting of IVH and
his anti-coagulation was held."
5309,"His ACEI and BB were held in the
setting of hypotension.
.
# IVH: likely secondary to fall in the setting of
supratherapeutic INR. Bleed is not large enough to precipitate
PEA arrest. A CT head showed no interval change in
intraventricular hemorrhage in the temporal and occipital horns
of the left lateral ventricle. He received frequent neuro
checks. The neurosurgery team felt no need for intervention at
this time.
.
# AG metabolic acidosis and appropriate compensatory respiratory
alkalosis: AG likely due to lactic acidosis. No evidence of DKA
or other toxin exposures. He was given aggressive fluid
resuscitation and his lactate trended down throughout his MICU
stay."
5310,".
# [**Last Name (un) **]: Was likely to be pre-renal or ATN in the setting of
shock. We do not know the baseline status of his renal function.
His lisinopril and HCTZ were held throughout his stay. He was
given adequate fluid resucitation. On [**9-7**] he had a potassium
of 5.7. An EKG did not demonstrate peaked T-waves. He was given
30mg of kayexalate.
.
# DM - diet controlled with fingersticks qACHS, start gentle
insulin SS
.
# hypothydroidism - thyroid medication dosage not confirmed
prior to his status as being made CMO.
.
# Lung nodules - a CT demonstrate ground glass opacities and a
nodules that should be followed up in [**2-1**] months."
5311,""" Cardiac enzymes did not suggest massive new MI.
Bilateral LENIs did not show any DVTs. Cardiac arrhythmia
possible given hx of A-fib. A family meeting was held in which
the patient's code status was changed to DNR (no shocks or chest
compressions). It was determined that we would not further
escalate care or pursue more invasive measures such as a-line
placement or HD at this time. On [**9-7**] he passed SBT with a RSBI
of 23 and he was switched to pressure support. Upon further
discussion with the family, it was decided to palliatively
extubate. The palliative care team was made aware and will help
make patient as comfortable as possible."
5312,".
# Comfort measures only
The decision was made to make the patient CMO. He was extubated
and transferred to the medicine service. Palliative care was
consulted. Patient was made comfortable with morphine and
scopolamine and other comfort measures. He was admitted to
hospice care and expired on [**2161-9-16**].
Medications on Admission:
HCTZ
Lisinopril 2.5
Coumadin 4mg 6xweek/5mg 1xweek
Pravastatin 80 mg daily
Nifedipine (dose unknown)
Equate vision
Multivitamins
Trental 500 TID
ASA 81 mg daily
Synthroid - dose unknown
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
Completed by:[**2161-9-16**]"
5313,"3* Na-138
K-6.1* Cl-106 HCO3-12* AnGap-26*
[**2161-9-7**] 04:01PM BLOOD Glucose-200* UreaN-76* Creat-3.7* Na-137
K-5.6* Cl-105 HCO3-14* AnGap-24*
[**2161-9-8**] 05:22AM BLOOD ALT-1881* AST-1045* CK(CPK)-1113*
AlkPhos-40 Amylase-47 TotBili-2.9*
[**2161-9-6**] 05:50AM BLOOD CK-MB-60* cTropnT-1.95* proBNP-[**Numeric Identifier **]*
[**2161-9-6**] 06:30AM BLOOD TSH-0.31
[**2161-9-8**] 05:22AM BLOOD Vanco-7.6*
[**2161-9-7**] 01:13PM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-41 pH-7."
5314,"Social History:
Lives above sister, who is HCP.
[**Name (NI) 1139**]: none
Family History:
Non-contributory
Physical Exam:
Vitals: afebrile, 97 134/67 100% on vent AC 500/18 (breathing at
26)/50%/5
General: intubated/sedated, opens eyes intermittently, does not
respond to commands, withdrawal to pain
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, NT/ND
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
[**2161-9-8**] 05:22AM BLOOD WBC-19.2* RBC-3.94* Hgb-12."
5315,"2* Hct-35.7*
MCV-91 MCH-31.0 MCHC-34.2 RDW-15.6* Plt Ct-84*
[**2161-9-7**] 04:21AM BLOOD WBC-15.4* RBC-3.83* Hgb-11.9* Hct-36.4*
MCV-95 MCH-31.0 MCHC-32.6 RDW-15.1 Plt Ct-99*
[**2161-9-7**] 04:21AM BLOOD Neuts-80* Bands-12* Lymphs-5* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2161-9-8**] 05:22AM BLOOD Plt Ct-84*
[**2161-9-8**] 05:22AM BLOOD PT-21.6* PTT-42.0* INR(PT)-2.0*
[**2161-9-5**] 12:30PM BLOOD Fibrino-350
[**2161-9-8**] 05:22AM BLOOD Glucose-174* UreaN-86* Creat-4."
5316,"EMS arrived, AED with VT, had CPR, no
shock given. Loaded with amiodorone in the field, transferred to
Lawsrence [**Hospital1 107**]. At [**Hospital3 1443**], Febrile to 100.8,
recieved avalox for possible PNA and Rocephin for UTI. CT with
left intraventricular hemorrhage. Recieved Vitamin K for
elevated INR and fosphenytoin for seizure prophylaxis.
Transferred on propofol for comfort. Of note, no written report
of PEA arrest at OSH that was verbally reported in sign-out.
.
On arrival to [**Hospital1 18**], patient arrived hypotensive 60-70/30 with
HR 56. Propofol was discontinued, levophed started. He went into
PEA arrest at 1244, recieved epi 1 mg (?"
5317,"21*
calTCO2-17* Base XS--12
[**2161-9-7**] 01:13PM BLOOD Lactate-3.1*
[**2161-9-5**] 08:26PM BLOOD freeCa-1.02*
Brief Hospital Course:
[**Age over 90 **]M admitted to [**Hospital1 18**] s/p PEA arrest. He was found in his
bathrub with water running. Had CPR in the field with no shock
given, amiodarone given. At [**Hospital3 1443**] Hosp, he was
treated with avalox and rocephin for possible pneumonia and UTI
respectively. CT showed left intraventricular hemorrhage.
Transferred to [**Hospital1 18**] hypotensive. Started on levophed. Again
went into PEA arrest with epinephrine given, levophed titrated
up, bicarb given due to acidosis."
5318,".
# Apnea/hypoxemia. Likely related to narcatoics intraop and PCA. [**Month (only) 8**]
have sleep disordered breathing at home, though has never had any
formal sleep study. Currently, she has been weaned from CPAP-> face
mask -> nasal cannula without any further desats at night. Less likely
volume overload, no signs of consolidation to be suggestive of
infection. PE less likely as O2 requirements reducint. Apnea likely
combination of central/high narcotic use with morphine PCA from PACU
plus likely sleep disordered breathing.
- Continue to wean O2 as tolerated
- Outpatient sleep study
- Can make standing albuterol neb prn
.
# s/p TKR.
- Lovenox for prophylaxis."
5319,"- 3 doses of cefazolin post op.
- Oxycodone prn pain, tylenol, naproxen
.
# Leukocytosis: Patient has been afebrile. Will continue to monitor
for signs of infection. No evidence of consolidation on CXR. - - CIS
- 3 doses of cefazolin post op
# Anemia: Likely dilutional. Will continue to monitor for signs of
bleeding
- [**Hospital1 **] hct
- Guaic stools
# Diabetes.
- Insulin sliding scale.
.
# Hypertension.
- continue home valsartan, HCTZ.
# Hyperlipidemia:
- cont statin
.
FEN: No IVF, replete electrolytes, sips and advance as tolerated
Prophylaxis: lovenox, H2B
Access: peripherals
Code: Full
Communication: Patient
Disposition: pending clinical improvement
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2101-3-28**] 10:49 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
5320,"8 g/dL
120 mg/dL
0.7 mg/dL
27 mEq/L
4.3 mEq/L
14 mg/dL
102 mEq/L
137 mEq/L
34.3 %
14.1 K/uL
[image002.jpg]
_______________________________________________________________________
pH
7.32
pCO2
56
pO2
257
HCO3
30
BaseXS
1
[**2101-3-29**] 03:54 AM
WBC
14.1
Hct
34.3
Plt
207
Cr
0.7
Glucose
120
Other labs: Ca++:8.0 mg/dL, Mg++:1.6 mg/dL, PO4:3.9 mg/dL
Assessment and Plan
HYPERTENSION, BENIGN
HYPOXEMIA
[**Last Name 9**] PROBLEM - ENTER DESCRIPTION IN COMMENTS
51F with osteoarthritis, diabetes, hypertension, obesity, presenting
with periodic apneas and desaturations."
5321,"9
C (98.4
Tcurrent: 36.9
C (98.4
HR: 111 (84 - 111) bpm
BP: 158/64(86) {126/59(83) - 173/84(104)} mmHg
RR: 19 (13 - 21) insp/min
SpO2: 93%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
150 mL
549 mL
PO:
TF:
IVF:
150 mL
549 mL
Blood products:
Total out:
45 mL
430 mL
Urine:
45 mL
330 mL
NG:
Stool:
Drains:
100 mL
Balance:
105 mL
119 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 93%
ABG: ///27/
Physical Examination
CV: [**4-9**] SM, RR
Pulm: + bibasilar crackles
Abd: Soft NTND
Labs / Radiology
207 K/uL
11."
5322,"Chief Complaint:
24 Hour Events:
Overnight, patient was on CPAP untill 0130 am. She was then placed on
med conc 02 mask.
Respiratory therapy observed paradoxical breathing effort while
sleeping, but sats were okay.
Allergies:
Zomig (Oral) (Zolmitriptan)
Headache; low b
Last dose of Antibiotics:
Cefazolin - [**2101-3-28**] 11:00 PM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2101-3-29**] 06:54 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**03**] AM
Tmax: 36."
5323,"Admission Date: [**2101-3-28**] Discharge Date: [**2101-4-1**]
Date of Birth: [**2049-10-28**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Zomig
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
Right TKA
History of Present Illness:
51 y/o woman with increased right knee pain with walking.
Decision made to proceed with primary Right Total Knee
Arthroplasty.
Past Medical History:
HTN, asthma/allergies, diabetes.
Social History:
NC
Family History:
NC
Physical Exam:
Afebrile, All vital signs stable
General: NCAT, NAD
Pulm: lungs CTA bilaterally, no w/r/r
Card:s1/s2 clear no m/g/r"
5324,"083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): as per institution protocol.
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
OA right knee
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:
Keep the incision clean and dry. Please apply a dry sterile
dressing daily as needed for drainage or comfort.
If you have any shortness of breath, increased redness,
increased swelling, pain, or drainage, or have a temperature
>101, please call your doctor or go to the emergency room for
evaluation."
5325,"4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Albuterol Sulfate 2.5 mg /3 mL (0."
5326,"Abd: soft NT/ND, +BS
Ext: incision C/D/I calf nt nvi distally
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to [**Hospital1 18**] on [**2101-3-28**] for right total
knee replacement. Pre-operatively, she was consented and history
and physical performed. Intra-operatively, she was closely
monitored and remained stable. She tolerated the procedure well
without any difficulty. Post-operatively, she was transferred to
the PACU and it was determined that she should be observed in
the [**Hospital Unit Name 153**] overnight due to hypoxia. This was determined to be
related to overuse of narcotics. She was transferred to the
floor on the afternoon of [**3-29**] in stable condition."
5327,"On the
floor,she remained stable. Her pain was well controlled. She
progressed with physical therapy to improve her strength and
mobility. She continued to make steady progress. She was
discharged to a rehabilitation facility in stable condition.
Medications on Admission:
Diovan 160 QD, HCTZ 12.5 QD, Simvastatin 20mg QD, Motrin PRN
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 3 weeks.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)."
5328,"You may bear weight on your right leg.
Please resume all of the medications you took prior to your
admission unless discussed with your provider. [**Name10 (NameIs) **] all
medication as prescribed by your provider.
Continue to take your lovenox 40 mg daily for 3 weeks and then
start taking aspirin 325 mg daily for 3 weeks.
Feel free to call our office with any questions or concerns.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2101-4-12**] 1:00
follow up with sleep medicine service as directed
Completed by:[**2101-3-31**]"
5329,"Chief Complaint: desaturations, apneas
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
Tolerated the autoset here until early morning
Now on 3 L NC
Sitting up in chair
History obtained from Patient
Allergies:
Zomig (Oral) (Zolmitriptan)
Headache; low b
Last dose of Antibiotics:
Cefazolin - [**2101-3-29**] 09:11 AM
Infusions:
Other ICU medications:
Enoxaparin (Lovenox) - [**2101-3-29**] 08:43 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: Fatigue
Nutritional Support: NPO
Genitourinary: Foley
Heme / Lymph: Anemia
Pain: [**2-5**] Minimal
Flowsheet Data as of [**2101-3-29**] 11:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**03**] AM
Tmax: 36."
5330,"9
C (98.4
Tcurrent: 36.6
C (97.8
HR: 101 (84 - 111) bpm
BP: 146/74(92) {126/54(75) - 173/84(104)} mmHg
RR: 21 (13 - 21) insp/min
SpO2: 97%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
150 mL
1,013 mL
PO:
TF:
IVF:
150 mL
1,013 mL
Blood products:
Total out:
45 mL
1,250 mL
Urine:
45 mL
1,150 mL
NG:
Stool:
Drains:
100 mL
Balance:
105 mL
-237 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 97%
ABG: ///27/
Physical Examination
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, No(t) Bowel sounds present, Distended
Extremities: TEDS in place
Musculoskeletal: Unable to stand
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
11."
5331,"8 g/dL
207 K/uL
120 mg/dL
0.7 mg/dL
27 mEq/L
4.3 mEq/L
14 mg/dL
102 mEq/L
137 mEq/L
34.3 %
14.1 K/uL
[image002.jpg]
[**2101-3-29**] 03:54 AM
WBC
14.1
Hct
34.3
Plt
207
Cr
0.7
Glucose
120
Other labs: Ca++:8.0 mg/dL, Mg++:1.6 mg/dL, PO4:3.9 mg/dL
Assessment and Plan
RIGHT TKR: Pain meds changed to oxycodone and tylenol. On
lovenox. Cefazolin as per ortho service.
HYPOXEMIA: Improving now that she is less somnolent. CXR seems
slightly congested, good urine output, restarted HCTZ this morning.
Monitor I/Os.
APNEAS: Improved with minimizing narcotics. Was able to tolerate
autoset in the ICU, now weaned FiO2 to 2L nasal cannula this morning.
Patient needs a sleep evaluation as an outpatient given likely OSA.
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2101-3-28**] 10:49 PM
Prophylaxis:
DVT: LMW Heparin
Stress ulcer:
VAP:
Need for restraints reviewed
Comments:
Communication: Comments:
Code status: Full code
Disposition :Transfer to floor
Total time spent: 25 minutes"
5332,"Chief Complaint:
Chief Complaint: elective admission for TKR
Reason for MICU admission: apnea and desats
HPI:
51F with DM, obesity, osteoarthritis, POD#0 from R TKR, now admit to
[**Hospital Unit Name 4**] from floor with desaturations and periods of apnea. She had
planned procedure today, uncomplicated. To PACU at 12pm. Between
intraop and PACU course she received 5 L IVFs. Placed on morphine PCA
(13.5 mg total) and also had local nerve blocks at times. In PACU
requiring 6L NC to keep sats in mid 90s. Later placed on CPAP as
well. Noted to be apneic with sleeping with desats into 80s."
5333,"5 mg daily
valsartan 160 mg daily
vitamin D 400 mg daily
calcium carbonate 500 mg TID
multivitamin daily
albuterol nebs Q4H
Past medical history:
Family history:
Social History:
- Diabetes, diet controlled
- Hypertension
- Hyperlipidemia
- Asthma
- Osteoarthritis
- s/p arthroscopy of right knee [**2100-3-18**]
- s/p hysterectomy
- s/p rotator cuff repair
- s/p carpal tunnel surgery
Parents with CAD.
Smokes 5 cigarettes per day (though later endorses one pack daily);
notes with ?5PPD) No EtOH or drug use. Lives alone.
Review of systems:
(+) Per HPI. Also with recent cough x days. No sick contacts.
(-) Denies fever, chills, headache, sinus tenderness, shortness of
breath."
5334,".
# s/p TKR.
- Lovenox for prophylaxis.
- Cephalosporins as written post op.
- hold PCA for now, can try PO oxycodone if needed but want patient to
wake up more before giving.
.
# Diabetes.
- Insulin sliding scale.
.
# Hypertension.
- continue home valsartan, HCTZ.
.
FEN: No IVF, replete electrolytes, sips and advance as tolerated
Prophylaxis: lovenox, H2B
Access: peripherals
Code: Full
Communication: Patient
Disposition: pending clinical improvement
ICU Care
Nutrition: sips, advance as tolerate
Glycemic Control: insulin sliding scale
Lines:
20 Gauge - [**2101-3-28**] 10:49 PM
Prophylaxis:
DVT: lovenox
Stress ulcer: H2B
VAP:
Comments:
Communication: Comments:
Code status: full
Disposition: ICU for tonight"
5335,"Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Flowsheet Data as of [**2101-3-29**] 01:27 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**03**] AM
Tmax: 36.7
C (98
Tcurrent: 36.7
C (98
HR: 109 (84 - 109) bpm
BP: 145/75(93) {126/68(83) - 148/83(104)} mmHg
RR: 20 (13 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Total In:
150 mL
116 mL
PO:
TF:
IVF:
150 mL
116 mL
Blood products:
Total out:
45 mL
50 mL
Urine:
45 mL
50 mL
NG:
Stool:
Drains:
Balance:
105 mL
66 mL
Respiratory
SpO2: 96%
Physical Examination
General: Alert, oriented, no distress, breathing comfortably."
5336,"Denies respiratory symptoms at home
other than recent nonproductive cough. States she cannot sleep flat
but is unable to specify why (breathing or other reason). Denies
nighttime awakenings/choking, snoring. Endorses intermittent leg
edema.
Patient admitted from: [**Hospital1 5**] [**Hospital1 **]
History obtained from [**Hospital 19**] Medical records
Allergies:
Zomig (Oral) (Zolmitriptan)
Headache; low b
Last dose of Antibiotics:
Cefazolin - [**2101-3-28**] 11:00 PM
Infusions:
Other ICU medications:
Other medications:
Medications at home:
Diovan 160 mg daily -?taking
HCTZ 12.5 mg daily -?taking
Simvastatin 20 mg daily -?taking
calcium/vitamin D
Ibuprofen prn
.
Medications upon transfer:
morphine PCA - off
cefazolin 2 mg Q8H
tylenol 650 mg Q6H
Naproxen 500 mg [**Hospital1 **]
enoxaparin 40 mg daily
famotidine 20 mg [**Hospital1 **]
colace 100 mg [**Hospital1 **]
simvastatin 20 mg daily
HCTZ 12."
5337,"HEENT: Sclera anicteric, PERRL 3->2, MMM.
Neck: supple, JVD elevation difficult to assess given obesity.
Lungs: Clear to auscultation bilaterally, with rare posterior wheeze,
prolonged expiratory phase.
CV: Regular rate and rhythm, normal S1 + S2, distant overall.
Abdomen: slightly firm, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.
Brace over R TKR.
Neuro: Grossly intact.
Labs / Radiology
[image002.jpg]
pH
7.32
pCO2
56
pO2
257
HCO3
30
BaseXS
1
Type:Art
Micro: none
.
Images:
CXR: borderline cardiomegaly, no obvious infiltrates or edema."
5338,".
EKG: sinus tach at 112, NANI, no ischemic ST/T changes.
Assessment and Plan
51F with osteoarthritis, diabetes, hypertension, obesity, presenting
with periodic apneas and desaturations.
.
# Apnea/hypoxemia. Apnea likely combination of central/high narcotic
use with morphine PCA from PACU plus likely sleep disordered
breathing. Still having some apneic event while on [**Last Name (LF) **], [**First Name3 (LF) **]
probably not entirely obstructive in etiology. Patient still complains
of leg pain so given narcan not desirable though will keep in mind.
Hypoxia seems to be related to apneas, though will also consider other
etiologies, in particular volume overload given intraop IVFs, and
COPD/bronchospasm."
5339,"PE unlikely without chest pain. Severity of desats
difficult to measure - low 90s on sat monitoring but had ABG with paO2
>200.
- Monitor sats/respiratory efforts; may need stimulation overnight to
overcome effects of narcotics at first. Trying to avoid narcan
administration.
- Will continue on [**First Name3 (LF) **] as tolerated to eliminate obstructive
component.
- Consider diuresis given likely some effect of pulmonary edema in
hypoxia.
- Care with naproxen given volume status, consider dc if end up needing
to diurese.
- Consider carboxyhemoglobin/methemoglobin given discrepancies between
sats and paO2.
- Trial of nebs when off CPAP.
- Needs sleep followup as outpatient and/or inpatient."
5340,"She left
the PACU at about 8 pm on [**Hospital Unit Name **]. Again noted to be apneic at times
with sats in upper 80s even on [**Hospital Unit Name **]. Generally did not like the
[**Hospital Unit Name **] and kept removing. Unclear how much medications were playing a
role and how much obstructive/sleep disordered breathing factored.
Transferred to [**Hospital Unit Name 4**] for further monitoring and management.
.
In the [**Hospital Unit Name 4**], patient denies chest pain, shortness of breath, abdominal
pain. Complains of R knee pain and dry mouth. Asking to take off
bipap and have something to drink."
5341,"Has been
doing well since removal of PTC drains last week though notes
mild erythema at lateral drain site.
Past Medical History:
PMH: Ruptured GB c/b recurrent pericholecystic abscesses since
[**1-10**] treated with percutaneous cholecystostomy and multiple
biliary stents, hx CBD/R colonic fistula ([**5-11**]), R colectomy
[**5-11**], partial L nephrectomy for renal clear cell carcinoma
[**1-/2106**], right complete nephrectomy for [**Last Name (un) 42686**] tumor, HTN,
insulin-dependent DMII, PUD, PE/DVT ([**2099**], completed warfarin),
Gout, Hereditary spherocytosis s/p splenectomy, [**Last Name (un) 42686**] tumor s/p
R nephrectomy
PSH: Splenectomy ([**2057**]), R nephrectomy ([**2064**]), Right
hemicolectomy with ileal transverse colostomy anastomosis and
side-to-side gastrojejunostomy [**2105-5-28**], PTBD x 2 (removed last
wk, s/p gelfoam occlusion stent tracts)."
5342,"Resolution
of pulmonary edema since [**2106-4-22**].
Brief Hospital Course:
The patient was admitted to the Hepatobiliary Surgical Service
for evaluation and treatment of UGIB in the setting of known
biliary stents partially extruding through ampulla with
associated duodenal ulceration as well as portal hypertensive
gastropathy. Pt was admitted to the Surgical Intensive Care
Unit, placed on a PPI drip, Foley for hemodynamic monitoring and
serial Hematocrits. Angio was performed [**4-15**], and his GDA was
embolized. He was transfered to the floor [**4-16**] with stable HCT.
On the morning of [**4-17**] he was noted to have a lower HCT and
tachycardia with BRBPR and he was again transferred to the ICU
for management of an acute GI bleed."
5343,"He underwent repeat EGD,
which showed extensive clot in the stomach. Unable to ID source
of bleeding, though felt to be from duodenum. He then had
massive UGI bleed, receiving 12u PRBC and becoming unstable. He
then was taken to the operating [****], where a gastrotomy
was created, the stents were taken out through his pylorus, and
the duodenum was packed with surgicel. The abdomen was left
open. He received 34 units perioperatively, as well as profuse
amounts of FFP and cryo. he was taken back to OR for abdominal
closure [**4-20**] and then was transferred back to the floor."
5344,"5. Lantus 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous once a day.
6. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Use home scale.
7. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2* (NOT TAKING AS EXPLAINED ABOVE)
8. Carafate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*2*
9.. multivitamin with iron Tablet Sig: One (1) Tablet PO
once a day: Take separate from Cipro. [**Month (only) 116**] darken stool.
Discharge Medications:
None, pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Duodenal ulcer, gastric and esophageal varices
GI bleed
Discharge Condition:
N/A
Discharge Instructions:
None, pt expired
Followup Instructions:
None, pt expired
Completed by:[**2106-5-7**]"
5345,"Social History:
denies etoh, drugs or tobacco. LiVes alone. Works as a software
consultant in the energy industry. Social History: He works as a
software consultant. Never smoked or drank alcohol. He is
currently on leave from work and living with his mother. [**Name (NI) **]
denied any past exposures to hepatitis or HIV.
Family History:
Family History: He has no biological children. His family
history is significant for hereditary spherocytosis in his
mother and for diabetes mellitus. His father had prostate
cancer. pt states multiple family members have had their
gallbladders out but none were complicated procedures.
Physical Exam:
PE on Admission:
98."
5346,"7
[**2106-4-30**] 03:26AM BLOOD Lactate-1.1 K-4.4
[**2106-4-30**] 06:44PM BLOOD Lactate-3.5* K-4.9
[**2106-4-30**] 07:53PM BLOOD Glucose-229* Lactate-3.9* K-5.7*
[**2106-5-1**] 07:35AM BLOOD Glucose-357* Lactate-5.7*
MICRO:
[**4-16**] BCx x2: enterococcus and enterobacter, suscep to vanc and
[**Last Name (un) 2830**]
[**4-17**] blood cx x1: enterococcus
[**4-18**] blood cx: NG
[**4-18**] urine cx: neg
[**4-20**] urine cx: neg
[**4-21**] blood cx: NG
[**4-21**] blood cx x 2: NG
[**4-25**] blood cx: P
[**4-26**] blood cx: P"
5347,"5*
[**2106-4-15**] 03:41AM BLOOD WBC-13.7* RBC-2.71* Hgb-8.3* Hct-22.9*
MCV-85 MCH-30.8 MCHC-36.4* RDW-15.2 Plt Ct-296
[**2106-4-15**] 04:36PM BLOOD WBC-14.7* RBC-3.61*# Hgb-11.0*# Hct-30.5*
MCV-85 MCH-30.4 MCHC-36.0* RDW-15.2 Plt Ct-372
[**2106-4-16**] 07:25AM BLOOD WBC-17.2* Hct-33.4* Plt Ct-491*
[**2106-4-22**] 04:03PM BLOOD Hct-35.3*
[**2106-4-30**] 06:12PM BLOOD WBC-20.0* RBC-1."
5348,"On [**5-2**] he expired with family at the bedside and time of death
was called at 20:34.
[**5-2**]: [**Month/Day (4) 3225**]
Medications on Admission:
1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Take through [**2106-4-16**]."
5349,"He returns today with further bleeding, stating that
he had hematemeis and melena this morning, then became dizzy and
came in for evaluation. NGT lavage was performed with frankly
bloody fluid. Rectal exam performed with dark stool and visible
blood/guaiac positive. Was started on nadolol, carafate, and [**Hospital1 **]
PPI for GI bleeding at last d/c but has not initiated nadolol
due to a pharmacist thinking the nadolol was for HTN and might
possibly be redundant. He has been taking carafate and PPI. The
[**5-11**] admission also notable for surgical resection
choledochocolic fistula with right hemicolectomy, ileal
transverse colostomy anastomosis, side-to-side gastrojejunostomy
and biliary stenting for choledochocutaneous fistulae."
5350,"On [**4-30**] he came off pressors, and his HCT was stable. He was
started on TPN, however he required massive transfusion that
afternoon after copious hematemesis and melena with a HCT of 15.
He was transfued 22U PRBC, 2FFP, 2plts, 3000mcg factor 7
(40mcg/kg). He was scoped by GI, who placed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] - noting
possible bleed from both GE junction and duodenum/stomach. Given
his worsening metabolic acidosis, increasing lactate bicarb gtt
& phenylephrine gtt were restarted overnight. He was also
maintained on ARDS protocol on the vent. On [**5-1**] a family
meeting was held and, given the lack of surgical option and the
intractable bleeding, the decision was made to make the pt [**Name (NI) 3225**]."
5351,"He
remained there with a hct in the low 30s with no transfusions x
2 days. Of note, he was found to have enterococcus in his blood,
and so he stayed in house on the floor to receive antibiotics.
On [**4-27**] there was bilious staining noted on the vac. However, a
cholangiogram was not concerning for leak. [**4-27**] Hct was 32.8 and
the pt was asymptomatic all day. However, later in the evening
he vomited blood. At that time, his SBP was 100, HR 120 and the
Vac output became bloody from bilious. [**4-28**] he was transfered
again to the SICU for hematemesis--mixed dark and bright red
blood per mouth and rectum."
5352,"IMAGING:
- [**4-17**] Abd Duplex & GB U/S: Coarse echotexture of the liver,
without focal lesions. Extremely limited doppler study. Normal
hepatic vein Doppler. Normal left portal vein. Assessment of the
right portal vein is extremely limited on this study. Previously
seen small hepatic artery- right portal fistula is difficult to
evaluate in this study, please refer to the IR procedure report
on [**4-15**].
- [**4-17**] CTA: No active bleed, ?incr luminal flow in L-side
- [**4-21**] CXR: Continued enlargement of the cardiac silhouette with
pulmonary vascular congestion and layering pleural effusions.
Retrocardiac opacification @left lower lobe
- [**4-28**] CXR: NGT side port and tip within the stomach."
5353,"1
[**2106-4-18**] 07:11PM BLOOD Glucose-247* Lactate-1.7 Na-133* K-4.2
Cl-105
[**2106-4-18**] 07:58PM BLOOD Glucose-239* Lactate-2.3* Na-133* K-3.7
Cl-104
[**2106-4-18**] 08:35PM BLOOD Glucose-286* Lactate-6.0* Na-136 K-5.3
Cl-100
[**2106-4-19**] 02:06AM BLOOD Glucose-152* Lactate-3.4* K-3.6
[**2106-4-20**] 08:16AM BLOOD Lactate-1.4
[**2106-4-29**] 03:54PM BLOOD Glucose-316* Lactate-5.6*
[**2106-4-29**] 07:53PM BLOOD Glucose-273* Lactate-3.6* K-4."
5354,"2 123 104/60 20 100% Pain 0/10
Gen: Alert, oriented, pleasant, not in distress
CV: RRR, no murmurs
Resp: Lungs clear to auscultation
Abd: Soft, non-tender, non-distended with well-healed incision.
Drain removal site in RUQ non-infected with small hematogenous
oozing and 2cm of granulation tissue.
Rectal: dark stool/visible blood. guaiac positive.
Pertinent Results:
[**2106-4-14**] 07:30AM BLOOD WBC-17.5*# RBC-2.51*# Hgb-7.3*#
Hct-21.1*# MCV-84 MCH-29.1 MCHC-34.6 RDW-16.3* Plt Ct-477*
[**2106-4-14**] 10:03PM BLOOD Hct-28."
5355,"Admission Date: [**2106-4-14**] Discharge Date: [**2106-5-2**]
Date of Birth: [**2052-2-9**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Recurrent GI bleeding
Major Surgical or Invasive Procedure:
[**2106-4-18**] Exploratory laparotomy and open gastrotomy, removal of
biliary Wall stents, packing of duodenum
[**2106-4-18**] Coil and Gelfoam embolization of right hepatic artery
branch
pseudoaneurysm.
[**2106-4-15**] Coil embolization of the gastroduodenal artery.
History of Present Illness:
The pt is a 54yo man with history of recurrent GI bleeding
requiring an extended admission [**5-11**] (EGD noted esophagitis,
healed GEJ ulcer, gastritis, and duodenitis, was treated with
octreotide and protonix gtt) well as a more recent admission
last week during which EGD did not identify active source of
bleeding."
5356,"91*# Hgb-6.3*# Hct-17.6*#
MCV-92 MCH-33.2* MCHC-35.9* RDW-15.8* Plt Ct-162
[**2106-5-1**] 02:42AM BLOOD WBC-27.0* RBC-4.33* Hgb-14.0 Hct-38.4*
MCV-89 MCH-32.3* MCHC-36.4* RDW-14.5 Plt Ct-155
[**2106-5-1**] 12:26PM BLOOD WBC-13.7* RBC-3.32* Hgb-10.5* Hct-28.3*
MCV-85 MCH-31.6 MCHC-37.1* RDW-14.5 Plt Ct-103*
[**2106-4-14**] 11:01AM BLOOD Lactate-2.7*
[**2106-4-17**] 07:30PM BLOOD Lactate-1."
5357,"An NGT was placed but unable to
lavage due to thick stomach contents. He was monitored on Q2h
hcts and coags and transfused 3uPRBC overnight. HDS. On [**4-29**] he
had 900cc of emesis (dark red blood, most likely old blood) and
remained tachycardic, however his HCT initially remained stable
at 28.0. Later that day he had 600cc dark bloody emesis, RBCs &
FFP were given, trauma line was placed, and emergent endoscopy
was performed. This revealed grade II/III esophageal and gastric
varices. 10 RBC's & 8 FFP were given, as was Activated Factor
VII was administered and he required pressors for SBP support."
5358,"Endoscopy Impression [**2186-8-2**]: Erythema, congestion and erosion
in the antrum; Coffee-ground blood in the stomach;Ulcer in the
pylorus (biopsy)
Otherwise normal EGD to third part of the duodenum
Biopsies: SPECIMEN SUBMITTED: GI BX ( 3 JARS) [**2186-8-2**]
DIAGNOSIS:
A. Gastric ulcer biopsy: Focal chronic active gastritis with
erosion and a cluster of macrophages suggestive of poorly formed
granuloma. Special stain for H. pylori pending.
B. Terminal ileum: Focal active ileitis.
C. Sigmoid biopsies: Focal chronic active colitis.
Brief Hospital Course:
28 yo F with a past medical history of IBS, ADD presents with
abdominal pain and msk pain."
5359,"Biopsies showed Focal chronic active gastritis with
erosion and a cluster of macrophages suggestive of poorly formed
granuloma with H.pylori stain pending, focal active ileitis and
focal chronic active colitis. Patient was changed from IV
Solumedrol to PO prednisone for discharge and started on
protonix and mesalamine 2g [**Hospital1 **]. She will followup at [**Hospital1 41724**] in
[**Location (un) 7349**].
.
# Arthrlagias/Myalgias: Patient presented with arthralgias and
myalgias which worsened over first night of hospitalization. She
was treated with IV Dilaudid. She also developed a erythematous,
nodular rash on her legs and arms over the first night of her
admission; this rash started on her ankles and rapidly spread
over the course of 10 hours to her arms."
5360,"This rash resolved on
its own, without treatment, in the following 10 hours. This rash
was thought to be consistent with erythema nodosum, although the
time course was puzzling. The arthralgias and myalgias were also
thought to be extra-intestinal manifestations of IBD. CK 41, ESR
110.
.
# Hypotension: Patient was admitted to the ICU initially because
she was thought to be hypotensive with SBPs in 70s and 80s.
Patient given at least 6 L IVF in the ED/ICU and remained with
BP in the 90s. She was completely asymptomatic for hypotension
and otherwise hemodynamically stable. Patient continued to have
systolic blood pressures in 80s throughout hospitalization
without symptoms."
5361,".
# Anemia: Patient's baseline HCT is unknown. Admission HCT was
33.7, lowest HCT was 24.7, discharge 27. Given endoscopy showing
ulcer and colonoscopy showing melena, the patient likely bled
from her ulcer at some point. These studies indicate that there
is now no active bleeding and patient is competely
hemodynamically stable. Of note, iron, ferritin and TIBC were
all low, TSH was normal. There is likely a component of both
iron deficiency and anemia of chronic disease. We will not treat
with iron given GI symptoms. This should be followed up with
the patient's PCP.
Medications on Admission:
# Adderall 10 mg po BID - TID
# Loestrin daily"
5362,"Mesalamine 500 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*240 Capsule, Sustained Release(s)* Refills:*2*
6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Colitis secondary to Inflammatory Bowel Disase- Crohns
Hypotension
Anemia
Duodenal Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for severe abdominal pain and
musculoskeletal pain with a rash."
5363,"She did not have abdominal pain, nausea or vomiting at
this time. She did have three apthous ulcers- which she has had
in the past.
.
Approximately one week ago she developed subxiphoid abdominal
pain, dull, mild in nature, and nonradiating which she
attributed to heartburn- she had no relief with ranitidine with
no improvement. She says that the pain is much worse with
eating.
At around this same time she developed she developed bilateral
shin pain. At this point her diarrhea had improved somewhat- she
weas still having loose stools but much less frequently.
.
Four days prior to admission, patient presented to her
outpatient primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **], who advised an outpatient
CT abdomen which revealed transverse colitis, so she was started
on oral Cipro."
5364,"CXR was wnl. CT abdomen again revealed transverse colitis
with associated LAD. Exam revealed TTP diffusely, and was guaiac
negative. UCG was negative and lactate was 1.1. Pelvic exam was
performed and was reportedly normal, with GC and chlamydia sent.
Patient was initially going to the floor, but dropped to SBP 80s
and only improved to 88/40 with fluid resuscitation.
Past Medical History:
-IBS--Diagnosed as teenager, with occasional flares since. No
colonoscopy in the past.
-Pleurisy 7 yrs ago. Pain at that time different from this
recent presentation. Workup was negative
-ADD
Social History:
Lives in [**Hospital1 1281**] square in [**Location (un) 21601**]."
5365,"Admission Date: [**2186-7-30**] Discharge Date: [**2186-8-4**]
Date of Birth: [**2158-6-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
Flexible Sigmoidoscopy
Upper Endoscopy
History of Present Illness:
The patient is a 28 yo F with a past medical history of IBS and
ADD who presents with abdominal pain and musculoskeletal pain.
Patient was in her USOH when she developed diarrhea 2 weeks ago-
loose, brown, mucousy, nonbloody diarrhea [**4-6**] daily for several
days."
5366,"6 Na-138
K-4.1 Cl-107 HCO3-26 AnGap-9
[**2186-8-1**] 09:10AM BLOOD ALT-4 AST-9 AlkPhos-51 Amylase-48
TotBili-0.1
[**2186-8-1**] 09:10AM BLOOD Lipase-37
[**2186-8-3**] 06:40AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1
[**2186-8-1**] 09:10AM BLOOD calTIBC-202* TRF-155*
[**2186-8-1**] 09:10AM BLOOD TSH-3.0
[**2186-7-30**] 05:05PM BLOOD CRP-141.5*
[**2186-7-31**] 04:35AM BLOOD Lactate-0.7
CT Abd/pelvis [**7-30**]:
1. No acute abdominal pathology detected."
5367,"1 RDW-12.7
[**2186-7-30**] 05:05PM CRP-141.5*
[**2186-7-30**] 05:05PM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2186-7-30**] 05:05PM LIPASE-40
[**2186-7-30**] 05:05PM ALT(SGPT)-9 AST(SGOT)-9 CK(CPK)-20* ALK
PHOS-71 TOT BILI-0.4
[**2186-7-30**] 05:05PM GLUCOSE-77 UREA N-7 CREAT-0.7 SODIUM-135
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-21* ANION GAP-18
[**2186-7-30**] 05:40PM URINE RBC-0-2 WBC-[**4-7**] BACTERIA-NONE YEAST-NONE
EPI-[**4-7**]
[**2186-7-30**] 05:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5."
5368,"Abdominal pain worsened to [**11-12**] and was worse
with po intake. She denied nausea, vomitting, hematochezia, or
melena.
.
Two days ago her shin pain developed in diffuse myalgias and
arthralgias involving the ankles, knees, wrists, elbows and
shoulders- this was so bad that it was difficult to walk. She
denies any new rashes during this time and denies any swelling
in her joints or any edema. Also denies any sick contacts,
recent travel abroad, and new pets or exposure to animals. No
recent NSAID use. She denies eating any new or suspicious foods.
She denies any eye pain or visual changes with the exception of
slightly tender eyelid on R side."
5369,"The GI team found
that these studies were likely consistent with Crohns disease
(Inflammatory Bowel Disease) and the biopsies that they took
confirmed this. Of note, your musculoskeletal pain and rash are
also consistent with Crohns disease.
.
Of note, your hematocrit (blood levels) were low while you were
here. This was likely due partially to past bleeding from your
ulcer and partially due to receiving a lot of fluids. This could
also partially be due to iron deficiency, as your iron was low.
We suggest that your PCP follow up your iron levels at a later
point. We continued to follow your hematocrit here and it
remained stable upon discharge.
.
We will send you home with the following new medications to
treated Crohns disease:
1. Mesalamine 2 g twice daily
2. Prednisone 40 mg daily
3. Protonix 40 mg twice daily
4. Dilaudid 1 mg as need, max every 4 hours.
Followup Instructions:
You should plan to followup with IBD doctors [**First Name (Titles) **] [**Hospital1 1872**] in [**Location (un) 7349**]
as discussed. You should also followup with your primary care
doctor.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]"
5370,"Discharge Medications:
1. Loestrin 1.5/30 (21) 1.5-30 mg-mcg Tablet Sig: One (1) Tablet
PO daily (): Take according to previous prescription.
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5."
5371,"2. Normal appendix.
3. Numerous prominent mesenteric lymph nodes along the hepatic
flexure,
transverse mesocolon and ileocolic region. As per Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 26216**], [**First Name3 (LF) **]
resident physician, [**Name10 (NameIs) **] patient had transverse colitis diagnosed
on outside hospital CT four days ago. Given this history these
nodes may relate to underlying infectious or inflammatory
etiology. Recommend clinical correlation and GI
follow-up/evaluation. If no evidence of Crohn's
disease/inflammatory bowel disease, suggest repeat CT in [**4-8**]
months to assess for interval change of the lymph nodes.
Colonoscopy Impression [**2186-8-2**]:Stool in the transverse colon,
ascending colon and cecum;;Erythema and congestion in the
colon;v Normal mucosa in the colon; Otherwise normal colonoscopy
to terminal ileum"
5372,"You were initially sent to the
ICU because your blood pressure was low. There you were given IV
fluids. Your blood pressure increased slightly and you remained
stable and so it was determined that your blood pressure is
likely low at baseline. After leaving the ICU, your rash
worsened on your first night but resolved spontaneously. You
were treated with pain medications, started on antibiotics for
concern for possible infection and started on steroids out of
concern for IBD. You had a flexible sigmoidoscopy that showed
inflammation in your colon and you had an endoscopy which showed
an ulcer. The studies did not see any active bleeding but did
reveal stool with blood (melena) which indicates that you did
bleed at some point, likely from your ulcer."
5373,"Works as a fashion designer.
Denies tobacco use. Uses ethanol socially on the weekends,
usually less than 3-5 drinks per weekend. Denied IVDU. Reports
sexually active with men, uses barrier protection, and had
negative STI panel 6 months ago, but is unaware of what she was
tested for.
Family History:
First cousin with on Father's side with Crohn's. No UC. No SLE.
No FMF.
Physical Exam:
Vitals on admission: 98.5 97/65, 93, 100 RA, 5'5 and 54.9kg
General: Alert, oriented, in moderate pain, holding herself very
still.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild tenderness to palpation in epigastric region
with no rebound or guarding, non-distended, bowel sounds present"
5374,"Crohns seemed
most likely diagnosis, given family history of two first cousins
with several weeks of abdominal pain with myalgia/arthralgia and
rash (see below.) Patient was treated empirically with IV
Solumedrol because she was in severe pain and had a nodular
rash. She then underwent flexible sigmoidoscopy and endoscopy.
Flex sig showed erythema and congestion in the colon, Normal
mucosa in the colon and otherwise normal colonoscopy to terminal
ileum. Upper endoscopy showed erythema, congestion and erosion
in the antrum,Coffee-ground blood in the stomach,Ulcer in the
pylorus (biopsy),Otherwise normal EGD to third part of the
duodenum."
5375,".
Of note, the patient had an extensive GI workup in HS that ruled
out celiac and lead to a presumptive diagnosis of IBS. In
college, she again had an extensive GI workup at [**Hospital **] was was finally found to have pleurisy. The
patient eats all foods except red meat.
.
She has two first cousins with [**Name (NI) 4522**] disease on opposite sides
of her family.
.
In the ED, Patient was initially 100.5 and then spiked a fever
to 102. She was given tylenol 1 g po x1, Unasyn 3 g IV x1,
Morphine a total of 8 mg IV, Zofran 8 mg IV x1, and a total of 3
L NS."
5376,"Ext: Marked edema in legs, feet and hands. Few splotchy red
macules on lower legs, with one raised 1 inchx1inch nodule on R
ankle.
Pertinent Results:
[**2186-7-30**] 05:05PM SED RATE-110*
[**2186-7-30**] 05:05PM PT-12.6 PTT-27.4 INR(PT)-1.1
[**2186-7-30**] 05:05PM PLT COUNT-578*
[**2186-7-30**] 05:05PM NEUTS-89.7* LYMPHS-6.8* MONOS-2.7 EOS-0.3
BASOS-0.5
[**2186-7-30**] 05:05PM WBC-24.5* RBC-3.96* HGB-11.5* HCT-33.7*
MCV-85 MCH-29.0 MCHC-34."
5377,"Her symptoms initially started with
diarrhea and developed into abdominal pain and polymyalgias.
.
#. Abdominal pain: In a patient who was completely healthy with
the exception of IBS, the differential of this pain was
extensive upon admission. A variety of tests were performed. She
had a normal HCG and normal pelvic exam. GC and Chlmydia labs
were negative. She had a normal abdomen CT with normal lipase
and amylase. Lactate was normal x2 and she was guaiac negative.
She was initially treated with Cipro/Flagyl, but this was
stopped when C.diff, O+P, and all other infectious stool studies
were negative and IBD became presumed diagnosis."
5378,"0
LEUK-TR
[**2186-7-30**] 05:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2186-7-30**] 05:40PM URINE UCG-NEGATIVE
[**2186-7-30**] 05:46PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2186-7-30**] 10:08PM LACTATE-0.9
[**2186-8-3**] 12:55PM BLOOD WBC-12.5* RBC-3.17* Hgb-9.3* Hct-27.5*
MCV-87 MCH-29.3 MCHC-33.9 RDW-12.7 Plt Ct-554*
[**2186-7-30**] 05:05PM BLOOD ESR-110*
[**2186-8-3**] 06:40AM BLOOD Glucose-128* UreaN-7 Creat-0."
5379,"Chief Complaint: Asthma With Acute Exacerbation
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
-Patient with continued negative fluid balance
-Asthma Rx optimized with decreased steroid dosing, optimized
beta-agonists
History obtained from [**Hospital 31**] Medical records
Allergies:
Codeine
Rash;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2196-10-10**] 11:00 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
5380,"She may
have significant imipact from relatively low lung volumers allowing
persistence of expiratory airflow limitation.
-Xoponex to continue
-Viral screen without enough cells and will continue with culture
across time
-Singulair
-Methylprednisolone
-Xoponex at max dosing
-Will move to central airway imaging given persistent of mono-phonic
more central wheezes on exam and with significant persisten complaints.
-Will move to ambulate today and consider response as at rest we have a
good tolerance of wean of O2 to 6 liters with persistence of good
saturations and with capacity to tolerate ambulation would have further
reassurance that we have continued improvement in bronchospasm.
RESPIRATORY FAILURE, CHRONIC
PNEUMONIA, OTHER
DYSPNEA (SHORTNESS OF BREATH)
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
ICU Care
Nutrition: PO diet
Glycemic Control:
Lines:
22 Gauge - [**2196-10-9**] 12:11 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 40 minutes"
5381,"Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower extremity
edema: Trace
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
12.3 g/dL
411 K/uL
113 mg/dL
0.8 mg/dL
35 mEq/L
3.8 mEq/L
9 mg/dL
99 mEq/L
141 mEq/L
37.1 %
19.0 K/uL
[image002.jpg]
[**2196-10-8**] 01:43 AM
[**2196-10-8**] 04:31 AM
[**2196-10-9**] 03:47 AM
[**2196-10-10**] 04:50 AM
WBC
16."
5382,"2
C (99
Tcurrent: 36.7
C (98
HR: 79 (65 - 110) bpm
BP: 116/90(96) {94/37(57) - 129/90(96)} mmHg
RR: 22 (10 - 26) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 130 kg (admission): 130 kg
Total In:
1,540 mL
1,080 mL
PO:
1,540 mL
1,080 mL
TF:
IVF:
Blood products:
Total out:
3,600 mL
1,800 mL
Urine:
3,600 mL
1,800 mL
NG:
Stool:
Drains:
Balance:
-2,060 mL
-720 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 95%
ABG: ///35/
Physical Examination
General Appearance: Overweight / Obese
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Distant)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),
(Breath Sounds: Wheezes : , Diminished: ), No significant improvement
from yesterday
she does have prominent central expiratory wheezes
it is
interesting that they are more monophonic than polyphonic and this does
raise the question of central airways involvement."
5383,"1
18.9
19.0
Hct
37.2
36.0
37.1
Plt
390
398
411
Cr
0.6
0.7
0.8
TropT
<0.01
TCO2
35
Glucose
133
124
113
Other labs: PT / PTT / INR:13.1/24.6/1.1, CK / CKMB /
Troponin-T:59/2/<0.01, ALT / AST:[**8-11**], Alk Phos / T Bili:104/0.1,
Differential-Neuts:90.8 %, Lymph:7.2 %, Mono:0.7 %, Eos:1.2 %, Lactic
Acid:1.9 mmol/L, Albumin:4.0 g/dL, LDH:148 IU/L, Ca++:9.5 mg/dL,
Mg++:2.2 mg/dL, PO4:3."
5384,"7 mg/dL
Fluid analysis / Other labs: TSH-0.14
Ft4-4.1
Imaging: CXR--no focal consolidation, no PTX, decreased lung volumes.
Assessment and Plan
27 yo female with history of Asthma now admitted with exacerbation of
Asthma which has been more severe than any experienced before. This is
in the setting of sick contacts, mold exposure and has had slow trend
to better in regards to bronchospasm.
1)Asthma-With acute exacerbation-This is persistent at this time with
continued bronchospasm noted thorugh to this morning with little
improvement. Do have a concern for possible impact from undiagnosed
upper airway compromise with paradoxical vocal cord motion."
5385,"# Tobacco abuse: pt currently still a smoker
- counsel pt to quit smoking
- Nicotine patch
.
# Fibromyalgia: currently complains of bilat leg pain
- continue home Percocet q4-6h PRN for pain
- continue home Lyrica
.
# Depression: stable
- continue home Cymbalta and Valium
.
# GERD/gasteoperesis:
- continue home pantoprazole, Ranitidine
- Ondesetron if needed
.
# Chest pain: can be due to PNA, PE, GERD, anxiety or ACS. EKG shows
no acute changes. Very low risk for CAD and sounds like chronic symptom
for her. CE flat x2.
-ekg prn
-pain management with outpatient percocet
.
# Central Hypothyroidism:
- need outpatient followup or can start workup on the floor to start
with a head CT
- previous cortstim from last year was wnl
- consider other HPA axis labs such as prolactin, growth hormone, FSH
.
# Vit D def:
- continue Ca, VitD suppl
.
# Thrush: on steroids
- nystatin swish and swallow
ICU Care
Nutrition: Full diet
Glycemic Control: ISS
Lines:
22 Gauge - [**2196-10-8**] 12:03 AM
Prophylaxis:
DVT: SC heparin
Stress ulcer: pantoprazole, ranitidine
VAP:
Comments:
Communication: Comments:
Code status: FULL
Disposition: ICU for now"
5386,"01
TCO2
35
Glucose
133
124
113
115
Micro:
Blood culture from [**10-7**]: pending
Urine culture from [**10-7**]: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.
Alpha hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
-Rapid respiratory viral culture ([**10-8**]): Pending
-Respiratory Viral Antigen Screen (Final [**2196-10-10**]):
Respiratory viral antigen test is uninterpretable due to the lack of
cells.
Imaging: CXR yesterday ([**10-10**])
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Borderline size of the cardiac silhouette. No evidence of focal
parenchymal opacity suggesting pneumonia. No pleural effusions."
5387,"6
C (99.7
Tcurrent: 36.5
C (97.7
HR: 82 (61 - 97) bpm
BP: 138/80(96) {116/60(73) - 139/90(111)} mmHg
RR: 21 (9 - 22) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 130 kg (admission): 130 kg
Total In:
1,680 mL
360 mL
PO:
1,680 mL
360 mL
TF:
IVF:
Blood products:
Total out:
4,200 mL
1,400 mL
Urine:
4,200 mL
1,400 mL
NG:
Stool:
Drains:
Balance:
-2,520 mL
-1,040 mL
Respiratory support
O2 Delivery Device: Aerosol-cool
SpO2: 96%
ABG: ///32/
Physical Examination
General: Alert, oriented, no acute distress
Lungs: diffuse expiratory wheezes, no crackles, significantly prolonged
expiratory phase
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-distended, TTP in RUQ, bowel sounds present,
no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Labs / Radiology
12."
5388,"No
hilar or
mediastinal adenopathies.
Assessment and Plan
Assessment and Plan: 27 yo female with MMP incl asthma, fibromyalgia
and tobacco abuse admitted to ICU for hypoxia/respiratory distress.
.
# Respiratory distress/hypoxia: Likely [**2-29**] asthma exacerbation, with
precipitating causes incl bacterial (atypical most likely) pneumonia,
viral pneumonia, influenza and long-term tobacco use. Eosinophilic PNA
less likely as no peripheral eosinophila, no other signs of vasculitis
at this time. Patient reports excessive mold in her building which
could be significant given ddx includes hypersensitivity
pneumonitis. PFTs frm [**7-5**] are normal. Given steroid use, PCP also
on diff. CRP, ESR mildly elev making vasculitis unlikely."
5389,"The leading
differential is asthma with exacerbating viral pneumonia.
- continue current regimen of singulair, MethylPREDNISolone Sodium Succ
80 mg IV Q8, Xopenex Neb *NF* 0.63 mg Other q4-6H, Ipratropium Bromide
Neb 1 NEB IH Q6H, Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **],
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
- continue on Levoquin for possible CAP vs atypical pna
- f/u on resp viral culture
- ABG if clinically declines
- wean oxygen as tolerated
- encourage ambulation
- consider broadening coverage if no clinical improvement, also can
consider bronchoscopy
- also consider pulm edema from 2L NS pt received in ED, can consider
Lasix
."
5390,"TITLE:
Chief Complaint:
HPI:
24 Hour Events:
[**10-10**]:
- advanced to regular diet
- lost access yesterday, so PICC was ordered
- OOB to commode with little assistance
- thyroid studies indicated essential hypothyroidism -> f/u outpt
- prolactin was added to AM labs -> nl
Allergies:
Codeine
Rash;
Last dose of Antibiotics:
Levofloxacin - [**2196-10-10**] 10:00 PM
Infusions:
Other ICU medications:
Ranitidine (Prophylaxis) - [**2196-10-10**] 08:00 PM
Omeprazole (Prilosec) - [**2196-10-10**] 08:00 PM
Heparin Sodium (Prophylaxis) - [**2196-10-10**] 10:00 PM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2196-10-11**] 06:28 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
5391,"5 g/dL
424 K/uL
115 mg/dL
0.8 mg/dL
32 mEq/L
3.7 mEq/L
8 mg/dL
98 mEq/L
140 mEq/L
37.9 %
20.2 K/uL
[image002.jpg]
[**2196-10-8**] 01:43 AM
[**2196-10-8**] 04:31 AM
[**2196-10-9**] 03:47 AM
[**2196-10-10**] 04:50 AM
[**2196-10-11**] 05:23 AM
WBC
16.1
18.9
19.0
20.2
Hct
37.2
36.0
37.1
37.9
Plt
390
398
411
424
Cr
0.6
0.7
0.8
0.8
TropT
<0."
5392,"Admission Date: [**2196-10-7**] Discharge Date: [**2196-10-13**]
Date of Birth: [**2168-11-16**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
difficulty breathing
Major Surgical or Invasive Procedure:
Placement of a midline IV
History of Present Illness:
Pt is a 27 yo female with MMP incl asthma, fibromyalgia and
tobacco abuse here with complaint of difficulty breathing and
wheezing for last 3 days. Has been having similar problems for
the last few months, but more acute now. Pt states that she had
fevers upto 101.4 and chills at home. Generalized weakness, and
myalgias as well."
5393,"Admits to cough, shortness of breath, chest pain.
Admits to some nausea and low PO intake, but denies vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Admits to chronic arthritis
and myalgias.
Past Medical History:
- Depression
- Fibromyalgia
- Asthma
- Tobacco abuse
- Obesity
- Anemia
- Internal hemorrhoids
- Gasteoperesis/GERD/hiatal hernia
- Vid D deficiency
Social History:
She is a CNA worker in surgery here at [**Hospital1 1444**], but currently is on medical
leave due to all of her chronic conditions. She currently is
smoking five cigarettes per day, started at age of 10, and
smoked
up to two packs per day in the past."
5394,"While on the
floor she remained stable, with improvement in her tachycardia.
# Chest pain: Differential included pneumonia, asthma
exacerbation and chest tightness, PE, GERD, anxiety or ACS. EKG
showed no acute changes. Patient had very low risk for CAD.
Cardiac enzymes were negative x 2. Outpatient percocet was
continued.
# Fibromyalgia: Patient complained of bilateral leg pain on
admission. Home Percocet q4-6h PRN was continued for pain. Home
dose Lyrica was continued as well.
# Depression: Stable. Home Cymbalta and Valium were continued.
# GERD/gasteoperesis: Home dose pantoprazole and ranitidine were
continued.
# Vit D def: Home dose calcium and vitD supplementation were
continued."
5395,"02 % Solution Sig: One (1) treatment
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
14. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*10 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Viral Pneumonia
Asthma Exacerbation
Discharge Condition:
Improved
Discharge Instructions:
Please return to the hospital if you develop fevers, chills,
nausea, vomiting, chest pain or shortness of breath. Please
follow-up with Dr.[**Last Name (STitle) 1007**] to have a complete blood count checked
and to plan a steroid taper.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] [**Last Name (LF) 766**], [**10-17**] at 1:45
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 558**] [**2196-12-5**] at 11:30"
5396,"Per patient's PCP
patient has long reported excessive mold in her building which
could be significant given ddx includes hypersensitivity
pneumonitis. Patient was put on Levoquin for possible CAP vs
atypical pna. CXR showed no consolidations or clear infiltrate;
together with her clinical exam of severe wheezing, this was
most consistent with viral pneumonia complicated by asthma
exacerbation despite her negative viral cultures. Patient was
put on Advair, Flovent, Xopenex. In addition, solumedrol and
singulair were started. Patient was initially put on high flow
aerosol mask, which was slowly weaned to nasal cannula. On the
day of transfer to floor, patient walked 3 laps on ICU floor on
room air with oxygen saturation of around 93%."
5397,"The current x-ray study, though limited as above,
demonstrates increased density in the left perihilar and lower
lung regions. It is unlikely that the process noted on the CT
has resolved; however, some of the opacity in the left lung that
is now visualized may be due to atelectasis. If clinically
feasible, consider PA and lateral view for more sensitive
evaluation. However, there is likely underlying evolving
infection as detailed in the chest CT report.
[**2196-10-9**] CXR: Cardiomediastinal silhouette remains stable. The
patient is in mild volume overload. There is still no focal
consolidation demonstrated with the focal areas of ground-glass
opacities seen on prior chest CT from [**2197-1-5**] can be
seen in the left upper lung and as previously mentioned might
represent infectious process."
5398,"FEN: regular diet
Prophylaxis: SC heparin, bowel regimen
Code: Full code
Communication: Patient
Medications on Admission:
Albuterol Sulfate 90 mcg 2 puffs q4-6h as needed
Butalbital-Acetaminophen-Caff 50 mg-325 mg-40 mg Tablet QID prn
Ciprofloxacin 500 mg Tablet [**Hospital1 **] [**2196-10-5**]
Diazepam 5 mg q6h
Duloxetine [Cymbalta] 20 mg [**Hospital1 **]
Esomeprazole Magnesium [Nexium] 40 mg [**Hospital1 **]
Fluticasone 50 mcg 2 sprays nasally daily
Advair Diskus 500 mcg-50 mcg/Dose 1 whiff(s) [**Hospital1 **]
Ondansetron 4 mg q6h PRN for nausea
Oxycodone-Acetaminophen 5 mg-325 mg q4-6 hours PRN for pain
Phenazopyridine 100 mg TID PRN [**2196-10-5**]
Pregabalin [Lyrica] 75 mg [**Hospital1 **]
Tretinoin [Retin-A] 0."
5399,"025 % Cream
wig use as directed daily For alopecia
Vitamin D 1000 units M-F, [**2187**] units SaSun
Ferrous Gluconate 325 mg daily
Loratadine 10 mg Tablet daily PRN for allergies
Multivitamins-Minerals-Lutein daily
Ranitidine 75 mg 1-2 times daily
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
2. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day)."
5400,"Pt was noted to have
lymphadenopathy in the past, and is being worked up for
sarcoidosis.
.
In the ED, initial vs were: T 98.8 P 111 BP 146/88 R 20 O2 sat
95% on RA. Patient's O2 sats went down to 88% on RA. She
received nebs, but was still hypoxic, eventually requiring NRB.
Pt also received 2L NS for IVF and Solumedrol 125mg IV,
Levofloxacin and Ceftriaxone.
.
She was then transferred to the ICU.
.
Review of sytems:
(+) Per HPI
(-) Admits to fever, chills, 20 lb recent weight loss in the
last 2-3wks. Admits to migraine headaches, denies rhinorrhea or
congestion."
5401,"Pt admits to a cough, but hasn't been able to
cough up anything. Denies any sick contacts. Denies nasal
congestion or sore throat. Was recently treated for a UTI with
7d course of Cipro. Pt also complains of chest pain in the
epigarstic area, no radiation, worse with deep inspiration and
certain movements. Took her inhalers/nebs and 40 mg of
Prednisone yesterday, with no improvement of symptoms.
.
Of note, pt went to see her PCP yesterday, and had a CT chest
that showed bilateral opacities. She was told to come to the ED
in the setting of increased SOB."
5402,"7 SODIUM-136
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-28 ANION GAP-15
[**2196-10-7**] 08:40PM estGFR-Using this
[**2196-10-7**] 08:40PM WBC-17.4*# RBC-4.18* HGB-12.9 HCT-40.9 MCV-98
MCH-30.9 MCHC-31.5 RDW-14.3
[**2196-10-7**] 08:40PM NEUTS-85.9* LYMPHS-10.5* MONOS-2.0 EOS-0.9
BASOS-0.7
[**2196-10-7**] 08:40PM PLT COUNT-420
[**2196-10-13**]
WBC-14.8* RBC-4.13* Hgb-12.9 Hct-40.4 MCV-98 Plt Ct-361
Glucose-85 UreaN-7 Creat-1."
5403,"4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
10. Ipratropium Bromide 0."
5404,"Brief Hospital Course:
27 yo female with MMP incl asthma, fibromyalgia and tobacco
abuse admitted to ICU for hypoxia/respiratory distress.
# Respiratory distress/hypoxia: On admission to the [**Hospital Unit Name 153**],
patient was satting at 97%-100% on NRB. Patient reports this
episode felt different from her usual asthma exacerbation as she
felt much worse this time. The differential diagnoses included
CAP pneumonia / atypical pneumonia, viral pneumonia, influenza
complicated by asthma exacerbation. PE, ACS, CHF on
differential but unlikely. Eosinophilic PNA less likely as no
peripheral eosinophila, no other signs of vasculitis at this
time (ESR and CRP only mildly elevated)."
5405,"1 Na-141 K-3.2* Cl-99 HCO3-33*
AnGap-12
Calcium-8.8 Phos-3.6 Mg-2.2
Imaging:
[**2196-10-6**] Chest CT: New widespread areas of ground-glass opacities
in both lungs involving all lobes with no central or peripheral
predisposition as well as with no apical basal gradient with
slightly more of the abnormality seen within the upper lungs.
The differential diagnosis might include infectious process such
as viral pneumonia or mycoplasma. Less likely , hypersensitivity
pneumonitis, eosinophilic pneumonia , vasculitis or COP may be
also suggested. Clinical correlation is recommended.
[**2196-10-7**] CXR: The CT scan of one day prior demonstrates scattered
areas of
ground-glass opacity throughout both lungs, predominantly in the
apices."
5406,"Denies any alcohol use.
Family History:
Maternal aunt with breast cancer in her mid 30s,
maternal great aunt with breast cancer and rectal cancer of
unknown age. Maternal grandfather diagnosed with pancreatic
cancer and died at the age of 70. Mother with sarcoidosis.
Physical Exam:
Vitals: T: 98 BP: 148/95 P: 101 R: 17 O2: 99% on NRB
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, dentures in place
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse wheezes, no crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-distended, TTP in RUQ, bowel sounds
present, no rebound tenderness or guarding
GU: no suprapubic tenderness
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: 4/5 strength in BLE, 5/5 strength in BUE, decr sensation
on R leg up to knee, CNII-XII intact, gait deferred"
5407,"Pertinent Results:
[**2196-10-7**] 10:31PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2196-10-7**] 10:31PM URINE BLOOD-SM NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2196-10-7**] 10:31PM URINE RBC-[**3-31**]* WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**3-31**]
[**2196-10-7**] 09:09PM URINE HOURS-RANDOM
[**2196-10-7**] 09:09PM URINE UCG-NEGATIVE
[**2196-10-7**] 09:09PM URINE UHOLD-HOLD
[**2196-10-7**] 08:52PM LACTATE-3.1*
[**2196-10-7**] 08:40PM GLUCOSE-167* UREA N-5* CREAT-0."
5408,"6
0.7
0.8
0.8
0.9
TropT
<0.01
TCO2
35
Glucose
133
124
113
115
119
Other labs: PT / PTT / INR:13.1/24.6/1.1, CK / CKMB /
Troponin-T:59/2/<0.01, ALT / AST:[**8-11**], Alk Phos / T Bili:104/0.1,
Differential-Neuts:90.8 %, Lymph:7.2 %, Mono:0.7 %, Eos:1.2 %, Lactic
Acid:1.9 mmol/L, Albumin:4.0 g/dL, LDH:148 IU/L, Ca++:9.3 mg/dL,
Mg++:2.4 mg/dL, PO4:3.7 mg/dL
Imaging: CXR-no chagne from previous
Assessment and Plan
27 yo female with admission with asthma with acute exacerbation--now
with substantial improvement.
Asthma with Acute exacerbation--improved, will continue with-->
-Advair
-Atrovent
-Singulair
-levoflox
-Xoponex q 4 hours
-Prednisone 50mg qd--and will taper over 7-10 days based on patient
symptoms.
RESPIRATORY FAILURE, CHRONIC
PNEUMONIA, OTHER
DYSPNEA (SHORTNESS OF BREATH)
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
ICU Care
Nutrition:
Glycemic Control:
Lines:
Midline - [**2196-10-11**] 09:16 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: H2 blocker
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :Transfer to floor
Total time spent: 33 minutes"
5409,"0 g/dL
357 K/uL
119 mg/dL
0.9 mg/dL
35 mEq/L
3.6 mEq/L
7 mg/dL
97 mEq/L
140 mEq/L
39.5 %
22.5 K/uL
[image002.jpg]
[**2196-10-8**] 01:43 AM
[**2196-10-8**] 04:31 AM
[**2196-10-9**] 03:47 AM
[**2196-10-10**] 04:50 AM
[**2196-10-11**] 05:23 AM
[**2196-10-12**] 04:39 AM
WBC
16.1
18.9
19.0
20.2
22.5
Hct
37.2
36.0
37.1
37.9
39.5
Plt
390
398
411
424
357
Cr
0."
5410,"6
C (99.7
Tcurrent: 36.7
C (98.1
HR: 61 (59 - 115) bpm
BP: 139/76(90) {114/62(75) - 149/115(118)} mmHg
RR: 15 (9 - 31) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 130 kg (admission): 130 kg
Total In:
1,320 mL
PO:
1,320 mL
TF:
IVF:
Blood products:
Total out:
3,530 mL
0 mL
Urine:
3,530 mL
NG:
Stool:
Drains:
Balance:
-2,210 mL
0 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 94%
ABG: ///35/
Physical Examination
Cardiovascular: (S1: Normal), (S2: Distant)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: Wheezes : Expiratory, central,
monophonic)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
13."
5411,"Chief Complaint: Asthma With Acute Exacerbation
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
MIDLINE - START [**2196-10-11**] 09:16 AM
CALLED OUT
History obtained from [**Hospital 31**] Medical records
Allergies:
Codeine
Rash;
Last dose of Antibiotics:
Levofloxacin - [**2196-10-10**] 10:00 PM
Infusions:
Other ICU medications:
Omeprazole (Prilosec) - [**2196-10-11**] 07:45 PM
Ranitidine (Prophylaxis) - [**2196-10-11**] 07:45 PM
Heparin Sodium (Prophylaxis) - [**2196-10-12**] 12:03 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: Fatigue
Flowsheet Data as of [**2196-10-12**] 09:20 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
5412,"[**2190-12-23**] 5:54 PM
BILAT LOWER EXT VEINS Clip # [**Clip Number (Radiology) 56209**]
Reason: eval for DVT. h/o b/l DVT on coumadin
Admitting Diagnosis: ACUTE RENAL FAILURE
______________________________________________________________________________
[**Hospital 4**] MEDICAL CONDITION:
72 year old man with h/o DVTs [**9-10**]
REASON FOR THIS EXAMINATION:
eval for DVT. h/o b/l DVT on coumadin
______________________________________________________________________________
PROVISIONAL FINDINGS IMPRESSION (PFI): KKgc FRI [**2190-12-24**] 1:51 AM
PFI: DVT involving bilateral lower extremity veins, not significantly changed
since the prior study.
______________________________________________________________________________
FINAL REPORT
INDICATION: 72-year-old man with history of bilateral lower extremity DVT,
the patient is currently on Coumadin.
COMPARISON: Bilateral lower extremity venous Doppler study, [**2190-10-11**].
FINDINGS: Grayscale and Doppler son[**Name (NI) 250**] of bilateral common femoral,
superficial femoral, popliteal, and calf veins are performed. Again seen is
deep venous thrombosis involving both common femoral, superficial femoral,
popliteal, and proximal calf veins, similar to the prior study.
IMPRESSION: DVT involving the bilateral lower extremity veins, not
significantly changed since the prior study."
5413,"Admission Date: [**2190-11-29**] Discharge Date: [**2190-12-28**]
Date of Birth: [**2118-7-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Poor appetite/PO intake, failure to thrive
Major Surgical or Invasive Procedure:
UGI endoscopy
hiatal hernia repair
PEG placement
PICC line placement
History of Present Illness:
72 year old male with a h/o AAA repair is/p EVAR in [**5-/2190**] at
OSH, complicated by multiple infections (psoas abscess,
vertebral osteomyelitis) who presents from rehab at request of
outpatient infectious disease physicians for evaluation of
failure to thrive."
5414,"He does
have family in the area, but [**Doctor Last Name 6165**] in [**State 108**] with his wife.
Currently, he is thirsty, but has no other complaints.
.
Of note, ESR continues to increase since last discharge,
although CRP is improving.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath, hemoptysis. Denied chest pain
or tightness, palpitations. Denied arthralgias or myalgias.
.
Past Medical History:
AAA s/p EVAR [**5-10**] with course complicated by emboli and L 1st &
5th toe gangrene s/p amputation
Polymicrobial vertebral osteomyelitis, discitis, and abscess,
continuing treatment
bilateral DVT s/p IVC filter
CAD s/p LAD [**Month/Year (2) **] placement [**2176**]
hyperlipidemia
Hypothyroidism
Prostate CA s/p placement of brachytherapy seeds
Hypercholesterolemia
HTN
Renal calculi sp surgery [**8-9**]
B/L cataract removal [**2182**]
Hital hernia repair 20yrs ago
Tonsilectomy
Appendectomy
gout"
5415,"Social History:
60 pack-year tobacco history (quit 15 years ago). Pt lives with
his wife, [**Name (NI) **] works for [**Name (NI) 39532**]. He spends his [**Doctor Last Name 6165**] in
[**State 108**]. No rcent travel outside the US. No Hx of +PPD or known
exposure to TB
Family History:
no family Hx of sudden cardiac death, no family h/o AAA or
cancer, including lymphoma
Physical Exam:
Vitals: T: 97.2 HR: 84 SR BP: 120/60 Sats: 98% RA
General: Alert, oriented, no acute distress. pleasant,
chronically ill-appearing. thin, with temporal wasting
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly."
5416,".
EGD [**2190-12-1**] IMPRESSION: Moderate sized 7 cm hiatal hernia
without other pathology noted. Gastritis noted. Continue PPI.
Please return to [**Hospital1 **] for further inpatient discussion.
Lower Extremity Ultrasound:
[**2190-12-23**]: DVT involving the bilateral lower extremity veins, not
significantly changed [**2190-9-23**] study.
[**2190-12-26**] WBC-5.7 RBC-2.90* Hgb-8.0* Hct-24.4 Plt Ct-317
[**2190-12-25**] WBC-6.8 RBC-2.83* Hgb-7.9* Hct-23.9 Plt Ct-293
[**2190-11-29**] WBC-8.2 RBC-3.16* Hgb-9.0* Hct-27.1 Plt Ct-462*"
5417,"He is not a surgical candidate
currently.
.
# Anemia of Chronic Disease: On recent labs, normocytic
normochromic with high RDW and with low iron, low TIBC, iron sat
27% all indicate anemia of chronic disease superimposed with
component of iron deficiency. He was transfused one unit of
blood and responded appropriately.
.
# Hypothyroidism: normal TSH, continued levothyroxine 125 mcg
daily
.
# PICC line: PICC line: 5 French right basilic venous approach.
Final internal length is 42 cm, with the tip positioned in SVC.
The line is ready to use.
ID: developed loose stools on [**2190-12-28**]. Sent for C.diff results
pending."
5418,".
# Code: DNR/DNI per patient, told pt to contact HCP to make sure
everyone is on the same page.
.
# Communication: Patient, [**Name (NI) **] [**Last Name (NamePattern1) 39533**]: [**Telephone/Fax (1) 39534**],
Daughter: [**Doctor First Name 233**]: [**Numeric Identifier 39535**]
Disposition: He continued to make steady progress and was
discharged to [**Hospital1 **] TLC on [**2190-12-28**]. He will follow-up with
Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
atorvastatin 80 mg daily
diltiazem HCl 120 mg daily
levothyroxine 125 mcg daily
mirtazapine 15 mg Tablet QHS
omeprazole 20 mg daily
docusate sodium 100 mg [**Hospital1 **]
senna 8."
5419,"He had Geriatric, GI and Psychiatry evaluation. Per Geriatric
recommendations, we have started him on Ritalin and titrate up
to 5mg QAm and 2.5 mg Qnoon.
.
He was to go for planned surgical repair of hiatal hernia on
[**12-15**], unfortunately, this was put on hold due to CONS infection
likely from the PICC. He was transferred to the MICU for closer
monitoring. He received broad spectrum coverage initially.
PICC line was removed and cultured. He was then narrowed to
vancomycin (completed 2 week course) and IV fluconazole. After
a two day stay, he was transferred to the floor with signs of
fluid overload due to IVF resuscitation."
5420,"19. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO four times
a day: hold HR < 60 SBP < 100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Hiatal Hernia
AAA s/p EVAR [**5-10**] with course complicated by emboli and L 1st &
5th toe gangrene s/p amputation
Polymicrobial vertebral osteomyelitis, discitis, and abscess,
continuing treatment
bilateral DVT s/p IVC filter [**9-/2190**]
CAD s/p LAD [**Year (4 digits) **] placement [**2176**]
hyperlipidemia
Hypothyroidism
Prostate CA s/p placement of brachytherapy seeds
Hypercholesterolemia
HTN
Tonsilectomy
Appendectomy
Gout
Discharge Condition:
Mental Status: Clear and coherent."
5421,"6 mg Tablet [**Hospital1 **] PRN
bisacodyl 5 mg Tablet [**Hospital1 **] PRN .
ondansetron HCl 4 mg PO TID PRN nausea
calcium carbonate 200 mg daily
aspirin 81 mg Tablet daily
morphine 15 mg Tablet Q6 PRN pain
cyclobenzaprine 10 mg Tablet Sig: One Tablet PO TID PRN back
pain
miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for breakthrough pain
fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H
warfarin 3 mg daily"
5422,".
On floor, he maintained largely stable. He underwent PEG
placement and hiatal hernia repair on [**2190-12-22**]. He did well.
.
# Vertebral osteomyelitis/discitis, h/o psoas abscesses- Per ID,
restart fluconazole given normal LFTs. There were improved fluid
collections on CT, with no evidence of para-spinal fluid
collection. ESR would suggest ongoing infection, although CRP is
improved. He was continued on fluconazole 400mg IV daily during
the hospitalization.
.
# [**Last Name (un) **]- Fe Na 1.3% though still suspect pre-renal physiology;
however, given recent antifungal and antibiotic, could be due to
ATN. There were no evidence of hydronephrosis on CT, with
decompressed bladder."
5423,"6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold for loose stools.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
9. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM.
10. 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.
11. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. methylphenidate 5 mg Tablet Sig: 0."
5424,"[**2190-12-28**] PT-25.0* INR(PT)-2.4*
[**2190-12-27**] PT-20.8* PTT-79.0* INR(PT)-1.9*
[**2190-12-26**] PT-17.3* PTT-74.0* INR(PT)-1.5*
[**2190-12-25**] PT-15.7* PTT-65.7* INR(PT)-1.4*
[**2190-12-22**] PT-16.3* PTT-50.5* INR(PT)-1.4*
[**2190-12-21**] PT-16.3* PTT-76.0* INR(PT)-1.4*
[**2190-12-27**] Glucose-114* UreaN-16 Creat-0.9 Na-142 K-4.4 Cl-107
HCO3-25
[**2190-12-27**] Glucose-135* UreaN-16 Creat-1."
5425,"There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
.
CT Head [**2190-11-30**] IMPRESSION: No evidence for an acute
intracranial process.
.
Barium swallow
[**2190-12-27**]: Paraesophageal hernia repair, without evidence of leak
or obstruction. Esophageal dysmotility, with frequent tertiary
contractions.
Small distal esophageal diverticulum.
[**2190-12-1**] IMPRESSION: Normal primary peristalsis with occasional
tertiary contractions. Moderately sized hiatal hernia with
notable delay in transit through diaphragmatic hiatus."
5426,"On [**2190-10-15**]
underwent L4/5 and L5/S1 disc debridement; then pt went for
posterior stabilization on [**2190-10-19**]. Right psoas abscess was
initially drained with JP in place on [**10-13**] (drain fell out
[**10-5**] and per IR, R psoas collection is much smaller so will not
replace drain for now). Culture grew [**Female First Name (un) **] parapsilosis. He
was seen by infectious disease who recommended 6 wk course of
vancomycin and zosyn (transitioned to cipro/flagyl prior to
discharge), as well as a year long course of PO fluconazole. He
was then discharged to rehab."
5427,".
ECHO [**2190-11-30**]: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened."
5428,"0 Na-137 K-3.4 Cl-104
HCO3-25
[**2190-11-29**] Glucose-84 UreaN-38* Creat-1.3* Na-138 K-3.8 Cl-104
HCO3-23
[**2190-11-30**] Glucose-84 UreaN-36* Creat-1.4* Na-140 K-3.7 Cl-107
HCO3-24
[**2190-12-2**] Glucose-112* UreaN-27* Creat-1.3* Na-139 K-3.1* Cl-107
HCO3-24
[**2190-12-1**] TSH-1.7
[**2190-12-22**] Hgb-7.7* calcHCT-23
[**2190-12-14**] Hgb-8.2* calcHCT-25
Brief Hospital Course:
72 year old male with a h/o AAA repair (EVAR) in [**5-/2190**] with
multiple complications (athero-emboli, psoas abscesses,
vertebral osteomyelitis s/p posterior fixation) with failure to
thrive
."
5429,"No evidence of UTI. His renal function
improved with aggressive IVF. He was not able to take in PO to
keep up with his output.
.
# h/o Deep Venous Thrombosis: Noted IVC clot on CT, with
non-occluded IVC filter. His Warfarin was restarted on [**2190-12-24**]
he was given 1 mg, 3 mg on [**12-25**] (INR 1.4), 26 (INR 1.5)& 27
(INR 1.9). INR on [**12-28**] 2.4 decreased dose to 1 mg daily.
.
# AAA s/p EVAR- stable. continued anti-hypertensive meds, ASA,
statin.
.
# h/o hiatal hernia- continued PPI, Barium swallow showed
questionable slowing of passage at the hernia, EGD was negative
for any obstructive symptoms."
5430,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Increased difficult or painful swallowing.
-Abdominal pain
Call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17029**] [**Telephone/Fax (1) 17030**]
-Fevers > 101 or chills
-Increased shortness of breath or chest pain
Warfarin for bilateral DVT INR Goal 2.0-3.0
Warfarin management after discharge from rehab with PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17029**]
Followup Instructions:
Provider: [**Name10 (NameIs) 2323**] [**Name11 (NameIs) 2324**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2191-2-4**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2191-2-1**] 11:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**].
Completed by:[**2190-12-29**]"
5431,"Discharge Medications:
1. levothyroxine 125 mcg 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 DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR Goal 2.0-3.0.
7. senna 8."
5432,"5 Tablet PO QNOON ().
13. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
14. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
16. oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO every [**4-6**]
hours as needed for pain.
17. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
18. metoclopramide 5 mg/5 mL Solution Sig: Ten (10) mL PO twice
a day."
5433,".
Patient has been followed by ID service, receiving OPAT. Regimen
has been simplified to cover for only infectious source,
non-candidal albicans. Initially treated with fluconazole, then
converted to ambisome given failure to thrive symptoms. He was
transferred to [**Hospital1 18**] ED for admission for evaluation of failure
to thrive.
.
In the ED, intitial vitals were 98.4 98 111/71 18 98%. He
received NS one liter and oxycodone x 1. Currently 98 F 99
107/69 16 95% RA
.
Tonight, the patient states that physical therapy has been going
well at [**Hospital3 **]. He is able to ambulate 60 feet."
5434,"He
describes anorexia and reflux of PO intake without associated
nausea or vomiting. He denies abdominal pain. No
odynophagia/dysphagia. Endorses 50 pound weight loss over many
weeks, also noted in previous OMR notes. No n/v/d/f/c, no night
sweats, low back pain improved following surgery. No change in
stool caliber. No evidence of GI hemorrhage. Last colonscopy
about 9 years ago, showed polyp per patient. He's also had and
EGD done in past that showed a hiatal hernia. No dysuria. No
enlarged glands noted by patient. Patient is depressed, denies
active SI/HI. He misses his wife (working in [**Name (NI) 108**])."
5435,".
Post-op complications include L 1st and 5th toe amputations [**2-2**]
athero-emboli, recent admission [**Date range (1) 39531**] for a subhepatic fluid
collection and left psoas abscess which was drained, fluid was
sterile, and he was treated with vanc/cipro/flagyl. He was
treated for antibiotics for gram positives and gram negatives
seen on gram stain (although no cx growth) and was treated with
fluconazole for growth of non-candidal albicans. He re-presented
on [**2190-9-22**] with worsening back pain and failure to thrive and
was found to have vertebral osteomyelitis/discitis, a
prevertebral abscess and bilateral psoas abscesses (including a
much larger right psoas abscess) which were drained."
5436,"# Failure to thrive/malnutrition: Significant weight loss most
likely due to his chronic infection, has history of TPN
peri-operatively. His weight loss and anorexia are complicated
by the history of hiatal hernia. Our recent CT evidence showed
paraesophageal hernia which patient underwent an UGI EGD. The
GI team did not observed a significant obstruction during this
test. Barium swallow, however, did show some signs of slow
passage at this juncture. He had a complete infectious workup
with echo and CT of head for possible other source of
disseminated fungal infection. ID was consulted and felt that
there were no infectious etiology to explain the course of FTT."
5437,"G-tube site
clean, no erythema
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no axillary LAD
Neuro: awake, alert oriented
Pertinent Results:
Imaging:
CT Torsal [**2190-11-29**]:
IMPRESSION: 1. Improvement in degree of inflammatory stranding
around the left psoas compared with prior, and decrease in
paraspinous fluid collection such that only inflammatory change
remains.
2. Emphysematous change of the lungs, without focal
consolidation or pleural effusion.
3. Atherosclerotic change of the aorta, with stable appearance
of
aortobiiliac [**Year (4 digits) **], right renal [**Last Name (LF) **], [**First Name3 (LF) **] IVC filter.
4. Again seen bilateral pelvic DVT with IVC filter in place."
5438,"He was
therefore referred for surgical revascualrization.
Past Medical History:
Hypertension
History of Paroxsymal Atrial Fibrillation
History of ETOH Abuse
Benign Prostatic Hypertrophy
Basal Cell Carcinoma s/p resection
Social History:
Lives with: sign. other
Occupation: semi retired chemical engineer
Tobacco: cigar per week
ETOH: Occasional
Family History:
No premature coronary artery disease
Physical Exam:
Preop Exam
Pulse: Resp: O2 sat:
B/P Right: 112/60 Left: 112/60
Height: Weight:
General:WDWN IN NAD
Skin: Dry [x] intact [x]Pale red lesions to LT midline upper
ant.
chest
HEENT: PERRLA x[] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
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:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2"
5439,"Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Hypertension
History of Paroxysmal Atrial Fibrillation
History of ETOH Abuse
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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"
5440,"[**2161-11-14**] WBC-5.8 RBC-3.02* Hgb-9.0* Hct-26.1* MCV-87 MCH-29.7
MCHC-34.3 RDW-13.0 Plt Ct-198
[**2161-11-10**] WBC-5.7 RBC-2.72*# Hgb-8.3*# Hct-23.9*# MCV-88 MCH-30.5
MCHC-34.8 RDW-12.9 Plt Ct-100*
[**2161-11-14**] Glucose-115* UreaN-19 Creat-0.7 Na-139 K-3.9 Cl-102
HCO3-30
[**2161-11-10**] UreaN-15 Creat-0.6 Na-142 K-3.7 Cl-111* HCO3-24
AnGap-11
[**2161-11-14**] Mg-2."
5441,"Disp:*5 Tablet(s)* Refills:*1*
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
11. sotalol 80 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
12. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO twice a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service"
5442,"Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal with normal free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
POSTBYPASS
The patient is A-paced. Biventricular systolic function remains
normal. Trace mitral regurgitation and mild aortic insufficiency
persist. The thoracic aorta is intact"
5443,"Particle/Crystal(s)* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)).
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day."
5444,"Carotid Bruit Right: no Left: no
Discharge Exam
VS: T: 98.2 HR: 93 Afib BP: 102/63 Sats: 99% RA Wt: 64.4 Kg
(59 kg)
General: 72 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: irregular
Resp:
GI: benign
Extr: warm no edema
Neuro: awake,alert oriented. Walking independently
Pertinent Results:
[**2161-11-10**] Intraop TEE:
PREBYPASS
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium. The coronary sinus is
dilated (diameter >15mm)."
5445,"1
CXR:
[**2161-11-14**]: PA & Lat preliminary read small left lower lobe
effusion
[**2161-11-11**]: There is no pneumothorax. Cardiac size is top normal.
Left lower lobe opacities have worsened, consistent with
worsening atelectasis. There are small bilateral pleural
effusions. Right IJ catheter remains in place. Sternal wires
are aligned. Right apical calcified granuloma is unchanged.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please
see operative note. Following the operation, he was brought to
the CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident."
5446,"Admission Date: [**2161-11-10**] Discharge Date: [**2161-11-14**]
Date of Birth: [**2089-7-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine / Tetracycline
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Positive stress test
Major Surgical or Invasive Procedure:
[**2161-11-10**] Two Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to left anterior descending artery with
vein graft to obtuse marginal)
History of Present Illness:
This is a 72 year old male who was recently noted to have subtle
ECG changes but complaints of angina, shortness of breath, etc.
Stress test was positive at high workload(completed). Subsequent
cardiac catheterization revealed 60% left main with a >95%
proximal LAD lesion not ammenable to PCI/stenting."
5447,"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
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2161-12-3**] 1:00
Cardiologist: Dr. [**Last Name (STitle) **] please call for a follow-up appointment
next week for atrial fibrillation.
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] in [**4-20**] 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**
Completed by:[**2161-11-14**]"
5448,"Pain: Pain well control on acetaminophen and occasional
narcotic.
Disposition: he was seen by physical therapy and was discharged
to home with VNA on [**2161-11-14**]. He will follow-up with Dr.
[**Last Name (STitle) **] and his cardiologist as an outpatient.
Medications on Admission:
Metoprolol XL 5omg daily, Plavix 75 mg daily - last dose
[**2161-11-6**], Hytrin 5mg daily, Avadart 0.5mg daily, ASA 325mg daily
Discharge Medications:
1. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day: take with
lasix.
Disp:*5 Tab Sust.Rel."
5449,"He
maintained stable hemodynamics and transferred to the SDU on
postoperative day one. Chest tubes and pacing wires were removed
without complication.
Respiratory: aggressive pulmonary toilet, nebs, incentive
spirometer he titrated off oxygen with saturations 96% on room
air.
Cardiac: Intermittent paroxysmal atrial fibrillation was started
on amiodarone, beta-blocker dose increased with rate control of
90-100. Blood pressure 100-110 hemodynamically stable.
GI: H2 blocker and bowel regime.
Nutrition: tolerated a cardiac healthy diet
Renal: renal function within normal range with good urine
output.
Incision: sternal incision clean, dry, intact, margins well
approximated no erythena
Heme: anticoagulation aspirin 325 mg & Plavix 75"
5450,"Admission Date: [**2191-12-23**] Discharge Date: [**2191-12-23**]
Date of Birth: [**2140-1-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Morphine / Hydrocodone / Oxycodone / Ativan
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
generalized weakness, diffuse abdominal pain, abnormal labs
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Patient is a 51 year old male with cirrhosis reportedly
secondary to alcohol and hemochromatosis complicated by
encephalopathy who presents to ED with concern for hyperkalemia
noted on labs with outside provider.
.
In the ED, his potassium was noted to be normal though he
appeared altered and reported generalized weakness and new
diffuse abdominal pain without fever, chills, dysuria and
headache."
5451,".
Of note, FAST in the ED showed trace free fluid without any
ascites though abomdinal ultrasound later confirmed moderate
ascites. Labs notable for elevated creatinine to 3.9, lactate
of 4.4, WBC of 3.8, elevated liver enzymes, INR of 2.09 and
T.bili of 4.7.
.
CXR showed no acute cardiopulmonary process with satisfactory
positioning of RIJ line. UA was WNL except for high specific
gravity. EKG showed diffusely low voltage. He also has
cellulitis.
.
Vitals prior to tranfer were 133/92 on levo gtt.
.
On arrival to the MICU, he was encephalopathic with somnolence
but did arouse to voice and sternal rub."
5452,"He answered questions
with simple yes and no. He denied bloody bowel movements and
vomiting blood although he had copious amounts of dried blood in
his mouth. He was not making urine in the foley.
Past Medical History:
1. Cirrhosis [**2-16**] alcohol, question of hemochromatosis given
elevated iron levels (ferritin ~1500, TIBC ~200). Saw
cardiology here in [**2191-4-15**], who performed an MRI and saw iron
deposits in liver concerning for hemochromatosis. Mild CHF on
last echo (LVEF 50-55%) may be due to EtOH vs. hemachromatosis.
2. Recurrent cellulitis of left leg
3. DVT following trauma to left leg (MVA) Was on warfarin for 1
year."
5453,"4. Chronic low back pain
5. Depression
6. Anxiety
Social History:
No current tobacco use, former tobacco ~ 10 pack years (quit 3
years ago). Former alcohol and Klonopin abuse. Patient lives
in [**Hospital 169**] Center, he does not work. He is separated from
his wife. The patient's weekly exercise regimen consists of
walking daily around the building. Patient usually tries to
adhere to a sensible diet and manages ADLs well with assistance.
He is separated from his wife. [**Name (NI) **] has 3 grown children ages 31,
27 and 23 who live in [**Location (un) 17927**]. He quit smoking 3 years ago."
5454,"7*
[**2191-12-23**] 10:43AM BLOOD Lactate-8.1*
[**2191-12-23**] 10:17AM BLOOD Lactate-7.9*
[**2191-12-23**] 09:43AM BLOOD Lactate-5.4*
[**2191-12-23**] 07:27AM BLOOD Lactate-4.1*
[**2191-12-23**] 03:17AM BLOOD Lactate-3.5*
[**2191-12-23**] 01:08AM BLOOD Lactate-3.7*
[**2191-12-22**] 11:07PM BLOOD Lactate-4.4*
Brief Hospital Course:
Mr. [**Known lastname **] is a 51 year old male with a history of alcoholic
cirrhosis and hepatic encephalopathy presented with new
abdominal pain, altered mental status, and hypotension.
.
# Septic shock: Admitted to MICU with MAP 58 after 2L IVF."
5455,".
# Altered mental status: Most likely a combination of his
baseline hepatic encephalopathy with infection and superimposed
delirium. There is also concern that his MAP is not high enough
to maintain cerebral perfusion pressure at this point since he
has had low MAP for >3 hours and is also not making urine. We
continued aggressive fluid resucication and pressors to maintain
MAP. He was also continued on lactulose and rifaximin, but
ultimately had to be intubated for declining mental status.
.
# Acute kidney injury: His creatinine is acutely elevated from
baseline < 1. The possible etiologies include HRS versus ATN.
We had planned to obtain renal consult in the morning."
5456,"Patient
had little to no urine output overnight, renal ultrasound in ED
negative for obstruction or hydronephrosis.
.
# Coagulopathy: Patient with baseline coagulopathy and
thrombocytopenia and presented with dried blood in his mouth.
Anesthesia also found blood in the oropharynx. He was not known
to have varicies. Given septic shock there was a concern for DIC
as his condition worsened.
.
# Cirrhosis: Known to be alcoholic and suspected also
hemochromatosis. His synthetic function is poor now with
increasing INR and decreasing albumin. His known
decompensations include hepatic encephalopathy and SBP.
.
# Cardiac arrest: Despite continued aggressive intervention with
pressors, antibiotics, and fluid resuscitation, the patient's
condition continued to decline with decreasing blood pressure,
increasing lactate, and no clinical improvement."
5457,"9*# Na-134
K-5.0 Cl-98 HCO3-22 AnGap-19
[**2191-12-23**] 09:59AM BLOOD CK(CPK)-76
[**2191-12-23**] 05:01AM BLOOD ALT-73* AST-112* LD(LDH)-277* CK(CPK)-65
AlkPhos-241* TotBili-5.3*
[**2191-12-22**] 09:40PM BLOOD ALT-83* AST-138* AlkPhos-282*
TotBili-4.7*
[**2191-12-23**] 09:59AM BLOOD Calcium-9.6 Phos-7.0* Mg-3.5*
[**2191-12-23**] 09:29AM BLOOD Calcium-8.3* Phos-6.9* Mg-2.4
[**2191-12-23**] 05:01AM BLOOD Calcium-9.0 Phos-7.0*# Mg-2."
5458,"Patient subsequently expired.
Medications on Admission:
- rifaximin 550 mg Tablet PO BID
- lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated topical
to back and hip
- tramadol 50 mg Tablet PO Q6H prn pain
- testosterone 5 mg/24 hr Patch 24 hr Q24H
- Calcium Citrate + D 315-200 mg-unit [**Hospital1 **]
- folic acid 1 mg Tablet daily
- thiamine HCl 100 mg Tablet daily
- multivitamin daily
- pyridoxine 25 mg Tablet daily
- heparin (porcine) 5,000 unit/mL Solution TID
- omeprazole 20 mg [**Hospital1 **]
- nystatin 100,000 unit/g twice a day as needed for rash
-lactulose 10 gram/15 mL 30 ML PO QID
-acetaminophen 325 mg Q6H prn pain: limit to 2g/24hrs
-polyethylene glycol 17 gram/dose PO DAILY
-insulin lispro 100 unit/mL sliding scale.
-midodrine 10 mg PO tid
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2191-12-24**]"
5459,"Bedside echo
showed poor cardiac systolic function. He subsequently went into
PEA cardiac arrest for which standard ACLS protocol was
initiated. He briefly return of spontaneous circulation, and
showed mildly improved systolic cardiac function on repeat
bedside echo. Within one hour of ROSC his blood pressure started
to trend downward, and family meeting was initiated at the
bedside. During this meeting the family decided not to continue
resuscitation of the patient given poor prognosis on maximal
support (he was on four pressors at that time). His family and
the medical team were all in agreement with this decision.
Chaplain was called to the bedside, and supportive care was
withdrawn."
5460,"8* RBC-2.52* Hgb-9.5* Hct-28.6*
MCV-114*# MCH-37.7* MCHC-33.2 RDW-17.0* Plt Ct-24*
[**2191-12-23**] 09:59AM BLOOD Plt Smr-VERY LOW Plt Ct-28*
[**2191-12-23**] 09:59AM BLOOD PT-24.1* PTT-88.5* INR(PT)-2.3*
[**2191-12-23**] 09:29AM BLOOD Plt Ct-46*
[**2191-12-23**] 09:29AM BLOOD PT-21.9* PTT-53.7* INR(PT)-2.1*
[**2191-12-23**] 05:01AM BLOOD Plt Ct-33*
[**2191-12-23**] 05:01AM BLOOD PT-22.0* PTT-65.2* INR(PT)-2."
5461,"Family History:
His father died of lung cancer and his mother has diabetes. He
has 3 sisters and 1 brother who are healthy. His 3 children who
are healthy.
Physical Exam:
Vitals: temperature 91.1, BP 80s/40s, HR 130s, RR 8-10, O2 sats
100% 5LNC
General: somnolent, arouses to voice and sternal rub, answers
""yes"" to some questions but not clearly appropriately
HEENT: Very mild scleral icterus, dried blood in the mouth
Neck: supple, difficult to assess JVP
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal rhythm, soft heart sounds
Abdomen: firm, obese, diffusely tender with guarding, worse in
the RUQ
Ext: cold, left radial pulse 2+, right trace pulse, b/l DP trace"
5462,"Etiology seemed to be SBP vs pneumonia, CXR was not c/w
pneumonia. Cardiac causes less likely given normal bedside echo
in ED w/ FAST negative for pericardial effusion. RUQ showed some
ascites but did not characertize hepatic vasculature well. He
was continued on pressors to maintain his MAP >65, and treated
per standard MUST protocol. He was also started on vancomycin
and zosyn in the ED. Despite aggressive goal-directed
resuscitation and prompt antibiotic treatment, his septic
physiology rapidly worsened and his lactate continued to rise
and his blood pressure progressively fell. He subsequently went
into PEA arrest as described below."
5463,"1*
[**2191-12-22**] 11:05PM BLOOD PT-22.0* PTT-150* INR(PT)-2.09*
[**2191-12-23**] 09:59AM BLOOD Glucose-513* UreaN-48* Creat-3.3* Na-135
K-4.1 Cl-101 HCO3-17* AnGap-21*
[**2191-12-23**] 09:29AM BLOOD Glucose-336* UreaN-48* Creat-3.3* Na-136
K-4.4 Cl-100 HCO3-17* AnGap-23*
[**2191-12-23**] 05:01AM BLOOD Glucose-304* UreaN-54* Creat-3.5* Na-134
K-4.3 Cl-97 HCO3-23 AnGap-18
[**2191-12-22**] 09:40PM BLOOD Glucose-340* UreaN-57* Creat-3."
5464,"Pertinent Results:
[**2191-12-23**] 09:59AM BLOOD WBC-4.2 RBC-1.71* Hgb-6.4* Hct-21.0*
MCV-123*# MCH-37.5* MCHC-30.5* RDW-16.9* Plt Ct-28*
[**2191-12-23**] 09:29AM BLOOD WBC-4.4 RBC-1.95* Hgb-7.2* Hct-22.5*
MCV-116* MCH-36.8* MCHC-31.8 RDW-17.1* Plt Ct-46*
[**2191-12-23**] 05:01AM BLOOD WBC-4.2 RBC-2.26* Hgb-8.4* Hct-25.5*
MCV-113* MCH-37.3* MCHC-33.1 RDW-17.0* Plt Ct-33*
[**2191-12-22**] 09:40PM BLOOD WBC-3."
5465,"His physical exam was notable for SIRS criteria with
heart rate of 110 and MAP of 50.
Bedside TTE showed normal ejection fraction though showed
collapsed IVC whose diameter improved with 2 liters of NS
resuscitation and 150 g of albumin resuscitation though no
response to his MAP with CVP 8 - 12 and SvCO2 of 97%. RIJ line
was placed and levophed was started with concern for septic
shock. He was given Vancomycin 1 gm IV x 1, ceftazidime 2 gm IV
x 1 and flagyl 500 mg IV x 1 as empiric coverage and admitted to
MICU for management of septic shock with likely nidus of
infection being SBP."
5466,"Admission Date: [**2163-11-27**] Discharge Date: [**2163-12-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Endoscopy
Colonoscopy
History of Present Illness:
Ms. [**Known lastname 81956**] is an 88 year old female with a history of breast
cancer, CAD s/p CABG, DM2, htn, and diverticulosis on recent
colonoscopy (otherwise normal by report) who is being
transferred from [**Hospital3 **] in the setting of GI bleeding.
She initially presented to [**Location (un) **] on [**11-24**] with dark maroon
stools. She was admitted to the ICU and GI was consulted."
5467,"She has 1 18G PIV and 1 20G PIV at time
of transfer. In the ambulance, BPs ranged 120s-170s systolic.
Her 2nd U PRBCs was hanging on transfer.
.
On arrival to the ICU, the patient was evaluated by the surgical
consult team. She complains of right shoulder pain. She denies
any abdominal pain, chest pain, difficulty breathing,
dizziness/lightheadedness, or dysuria. She recalls that she has
had dark stools but cannot give a timeline as to their
occurrence.
Past Medical History:
# breast cancer s/p radical mastectomy ~ 30 years ago
# DM2
# CAD s/p CABG (~[**2157**])
# chronic renal insufficiency (baseline Cr 1."
5468,"2-1.5)
# diverticulitis in [**6-/2163**]
# htn
# hyperlipidemia
# anxiety/depression
# glaucoma
# h/o pulmonary nodules
# s/p cholescystectomy/appendectomy
# h/o dysautonomia with postural hypotension
# s/p pacemaker (St. [**Male First Name (un) 923**])
# h/o TIA
Social History:
Lives at [**Location (un) 25576**] [**Hospital3 **]. Denies any current
alcohol, tobacco, drugs. Smoked many years ago.
Family History:
noncontributory
Physical Exam:
T: 98.3 BP: 165/69 HR: 68 RR: 24 O2 99% RA
Gen: Pleasant elderly female in no distress
HEENT: no scleral icterus, pupils small but reactive, eomi,
tongue midline and moist
NECK: thin, no JVP elevation, no lymphadenopathy
CV: rrr, no murmurs appreciated
LUNGS: clear bilaterally
ABD: + bowel sounds, nontender to palpation, nondistended, no
rebound
EXT: warm, well perfused, dp pulses 1+ bilaterally
SKIN: scattered ecchymoses
NEURO: alert, oriented X 3 but difficult to relate specifics of
admission to the hospital, face symmetric, moving all
extremities without difficulty"
5469,"Hypertension
Coronary artery disease
Diabetes Mellitus II
History of TIA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with blood in the stool. This may have been
due to bleeding from a diverticulosis, or outpouching of the
colon. However, no definitive source of bleeding was found.
Please continue to take a new medication called lansoprazole to
help prevent inflammation of the stomach. Please have your blood
count re-checked weekly while at the nursing facility to monitor
for signs of dropping blood counts. Please also have your
primary care doctor assist you in scheduling outpatient
follow-up with a gastroenterologist."
5470,"Polyp in the hepatic
flexure. No signs of active bleeding.
Brief Hospital Course:
The patient was transferred from an OSH where she had melanotic
stools and received 5U of PRBC's for unstable Hct of 24. EGD at
that hospital was described with findings of gastritis,
duodenitis and coffee grounds.The patient was started on twice
daily proton pump inhibitor. She was transferred to the [**Hospital1 18**]
MICU where she had serial Hct's that were stable. Bleeding scan
did not reveal a source of bleeding. GI consult team followed
the patient. Endoscopy was attempted and failed due to patient
being unable to tolerate the procedure."
5471,"3 MCHC-35.5* RDW-14.8
[**2163-11-27**] 02:33PM CALCIUM-9.1 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2163-11-27**] 02:33PM estGFR-Using this
[**2163-11-27**] 02:33PM GLUCOSE-90 UREA N-18 CREAT-1.0 SODIUM-144
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-26 ANION GAP-12
[**2163-11-27**] 10:58PM HCT-32.8*
[**2163-11-28**] 05:30AM BLOOD WBC-7.6 RBC-3.80* Hgb-11.9* Hct-34.6*
MCV-91 MCH-31.2 MCHC-34.2 RDW-14.7 Plt Ct-171
[**2163-11-28**] 05:30AM BLOOD Plt Ct-171
[**2163-12-2**] 06:20AM BLOOD WBC-7."
5472,"For recurrent bleeding, the
patient should undergo repeat bleeding scan. On admission, the
patient's home aggrenox, beta-blocker and diuretic were held.
These should not be restarted until the patient discusses
restarting these with her primary care doctor. Aggrenox should
be held for a minimum of 2 weeks.
The patient had poorly controlled hypertension on admission to
the OSH. She was restarted on her home medications including
ACEI with good effect. Her home beta-blocker and diuretic was
held in the setting of acute bleeding.
Renal insufficiency. Cr was at or below baseline throughout
admission.
Diabetes. The patient had hypoglycemia on a diabetic diet."
5473,"5 mg daily
zocor 40 mg daily
vitamin b12 1000 mcg daily
vitamin d 800 U daily
ocupres 1% opthalmic both eyes [**Hospital1 **]
.
Allergies:
NKDA
Discharge Medications:
1. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day as
needed for constipation.
2. Held Medications
Do NOT take furosemide 20mg daily, aggrenox 1 tab twice daily or
metoprolol tartrate 15mg twice daily until you are seen by your
primary care doctor and told to restart these.
3. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily)."
5474,"Her
home glucotrol should be held. She should have twice daily
fingerstick glucose and this can be restarted for any 2 or more
consecutive values >150.
CAD s/p CABG. The patient continued on ACEi and statin
throughout her hospitalization. Aggrenox and beta-blocker were
held in the setting of acute bleeding as described above.
History of TIA. As above, aggrenox was held.
Depression/anxiety/dementia. Continued home celexa and aricept.
CODE. While in the ICU, the medical team discussed goals of care
with the patient and her family. In accordance with her wishes,
she was DNR/DNI. The patient's daughter and HCP, [**Name (NI) **] [**Name (NI) 81957**]
[**Telephone/Fax (1) 81958**] was involved in the discussion."
5475,"5 RBC-3.49* Hgb-11.0* Hct-31.6*
MCV-91 MCH-31.6 MCHC-35.0 RDW-14.8 Plt Ct-190
.
GI Bleeding study ([**2163-11-27**]): Blood flow images show expected
distribution of tracer. Dynamic blood pool images show a brief
linear horizontal focus of activity superior to bladder at 9 -
11 minutes, but no continued abnormal activity, and no site of
bleed identified. IMPRESSION: No site of bleed identified.
.
EGD ([**2163-11-30**]): Patient unable to cooperate, procedure aborted
when the pharynx was reached.
.
Colonoscopy ([**2163-11-30**]): Diverticulosis of the sigmoid colon.
Diverticulosis of the ascending colon."
5476,"5. Vitamin B-12 1,000 mcg Tablet [**Hospital1 **]: One (1) Tablet PO once a
day.
6. Dulcolax 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
7. Milk of Magnesia 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30) ml
PO once a day as needed for constipation.
8. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
10. ocupres [**Hospital1 **]: One (1) Drop twice a day: Apply Ocupres 1%
opthalmologic solution to both eyes twice daily."
5477,"Medications on Admission:
Meds at nursing home:
colace 100 mg daily
lasix 20 mg daily
celexa 20 mg daily
glucotrol 2.5 mg daily
zocor 40 mg daily
vitamin b12 1000 mcg daily
dulcolax 10 mg prn constipation
milk of mag 30 mL prn constipation
tylenol 650 mg po q6h prn
vitamin d 800 U daily
aggrenox 1 tab po bid
ocupress 1% ophthalmologic solution to both eyes [**Hospital1 **]
ferrous sulfate 325 mg [**Hospital1 **]
lopressor 15 mg [**Hospital1 **]
vitamin c 500 mg po bid
aricept 10 mg qhs
lisinopril 10 mg qhs
.
Medications on transfer:
ferrous sulfate 325 mg po daily
lopressor 50 mg [**Hospital1 **]
vitamin c 500 mg [**Hospital1 **]
aricept 10 mg po qhs
lisinpril 10 mg qhs
protonix 40 mg daily
lasix 20 mg po daily
celexa 20 mg po daily
glucotrol 2."
5478,"Pertinent Results:
from OSH:
[**11-27**], 0500
WBC 6.3
Hgb 8.3 / hct 24.6
plt 169
Na 141, K 3.1, Cl 110, bicarb 25, BUN 24, cr 1.1, glucose 101
Ca 8.3
.
[**2163-11-27**] 02:33PM PT-13.2 PTT-26.6 INR(PT)-1.1
[**2163-11-27**] 02:33PM PLT COUNT-209
[**2163-11-27**] 02:33PM NEUTS-70.5* LYMPHS-17.9* MONOS-6.2 EOS-4.6*
BASOS-0.7
[**2163-11-27**] 02:33PM WBC-7.9 RBC-3.82* HGB-12.0 HCT-33.7* MCV-88
MCH-31."
5479,"Colonoscopy was
completed and revealed diverticulosis of the ascending and
sigmoid colon with a polyp in the region of the hepatic flexure
and no identifiable source of bleeding. It is possible that this
represented divertular bleeding though another explanation
cannot be excluded. Her stooling changed to brown. The patient
was discharged on once daily proton pump inhibitor (lansoprazole
as patient requires meds that can be crushed). She requires
repeat Hct check weekly and these results should be discussed
with a doctor if the value is less than 25. She was counselled
to be seen as an outpatient by gastroenterology for
consideration of capsule endoscopy."
5480,"You may benefit from
outpatient capsule endoscopy to try to find a source of your
bleeding.
Take all medications as prescribed. You should NOT take aggrenox
for at least 2 weeks, furosemide (also called lasix) or
metoprolol (also called lopressor). Please discuss restarting
these medications with your primary care doctor. Please also do
not restart glucotrol. Your blood sugars were low while in the
hospital. Only restart this medication if your blood sugars are
elevated above 150. You should have your blood sugar measured
twice daily to monitor for signs of rising blood sugars
requiring you to restart this medication.
Call your doctor or return to the hospital for any new or
worsening blood in the stool, dizziness, lightheadedness,
nausea, vomiting or any other concerning symptoms.
Followup Instructions:
Follow-up with your primary care doctor as soon as possible.
Please have your blood count re-checked weekly.
Please also have your primary care doctor assist you in
scheduling outpatient follow-up with a gastroenterologist. You
may benefit from outpatient capsule endoscopy to try to find a
source of your bleeding. If you would like to schedule this
appointment at [**Hospital1 69**], call
[**Telephone/Fax (1) **]."
5481,"An EGD
was performed which showed no evidence of active bleeding but
did show a hiatal hernia. Slightly irregular mucosa was also
noted at the SC juntion; coffee grounds were also noted in the
stomach with 1+ duodenitis. Initial Hb 8 -> 3 units PRBCs -> Hb
10. However, she has had recurrent episodes of rectal bleeding,
now with bright red blood. Hb 10 -> 8 after multiple episodes
of bloody stools. She has denied chest pain, SOB,
lightheadedness, nausea, or abdominal pain throughout her
admission. She has remained hemodynamically stable throughout.
Her most recent vitals prior to transfer, she was afebrile,
141/46, 62, 18 98% RA."
5482,"11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO twice a day.
12. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
13. Donepezil 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
14. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime.
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
GI bleed, likely diverticular but source unknown"
5483,"1. GI Bleed: Likely lower source, and diverticulosis high
suspicion in light of prior disease
but malignancy avm also in
differential. Limited role of c-scope but will plan for tagged RBC scan
and if positive proceed to Angio. Nuclear Med team has been called and
plans to come to [**Hospital Ward Name **] about 6PM.
She has 2 PIV, type and cross x 2.
EGD at OSH by report seems unlikely to be upper source though
odd report of coffee grounds and ? duodenitis so will
keep on PPI
2. HTN: will give a low dose short acting dose of home med ACEI
watch BP closely
goal is just to keep her less than SBP 150- we do
not want a long acting [**Doctor Last Name **] on board should she re bleed.
3. ARf: per report at OSH but cr here is 1.0 and making urine we
will trend
Remaining issues as per Housestaff notes.
ICU Care
Nutrition: NPO pending procedures, if neg
Glycemic Control:
Lines / Intubation:
18 Gauge - [**2163-11-27**] 01:15 PM
20 Gauge - [**2163-11-27**] 01:15 PM
Prophylaxis:
DVT: boots
Stress ulcer: PPI
Communication: with pt and dtr [**Name (NI) **]
[**Last Name (NamePattern1) 156**] status: DNR / DNI
Disposition: ICU
Total time spent: 45 minutes
Patient is critically ill"
5484,"7 %
12.0 g/dL
90 mg/dL
1.0 mg/dL
18 mg/dL
26 mEq/L
110 mEq/L
4.0 mEq/L
144 mEq/L
7.9 K/uL
[image002.jpg]
[**2163-11-27**] 02:33 PM
WBC
7.9
Hct
33.7
Plt
209
Cr
1.0
Glucose
90
Other labs: PT / PTT / INR:13.2/26.6/1.1, Differential-Neuts:70.5 %,
Lymph:17.9 %, Mono:6.2 %, Eos:4.6 %, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL,
PO4:2.8 mg/dL
Assessment and Plan
88 yr old woman with hx of diverticulosis, breast cancer, CAD, chronic
renal failure presents with melena."
5485,"Chief Complaint: GI bleed
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
88 year old female with a history of breast cancer, CAD s/p CABG, DM2,
htn, and diverticulosis on recent colonoscopy (otherwise normal by
report) who is being transferred from [**Hospital3 **] in the setting
of GI bleeding. Presented [**11-24**] with melena Hgb 8- tx to ICU EGD
without active bleeding but + coffee grounds and 1+ duodenitis. Today
she had BRBPR, Hgb which had been 10 dropped to 8 and requested tx for
nuc med or angio management of likely diverticular bleed."
5486,"5 mg daily
zocor 40 mg daily
vitamin b12 1000 mcg daily
vitamin d 800 U daily
ocupres 1% opthalmic both eyes [**Hospital1 **]
Occupation: retired
Drugs: neg
Tobacco: remote
Alcohol: neg
Other: lives at [**Location (un) 3397**] Asst Living
Review of systems:
Constitutional: Fatigue
Ear, Nose, Throat: Dry mouth
Cardiovascular: Tachycardia
Gastrointestinal: Diarrhea, melena
Genitourinary: Foley
Heme / Lymph: Anemia
Flowsheet Data as of [**2163-11-27**] 05:29 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37.3
C (99.1
Tcurrent: 37.3
C (99.1
HR: 71 (64 - 71) bpm
BP: 169/45(77) {165/45(77) - 198/69(95)} mmHg
RR: 23 (23 - 29) insp/min
SpO2: 97%
Height: 66 Inch
Total In:
26 mL
PO:
TF:
IVF:
26 mL
Blood products:
Total out:
0 mL
1,025 mL
Urine:
1,025 mL
NG:
Stool:
Drains:
Balance:
0 mL
-999 mL
Respiratory
SpO2: 97%
ABG: ///26/
Physical Examination
General Appearance: Well nourished, Thin, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
209 K/uL
33."
5487,"Patient admitted from: Transfer from other hospital
History obtained from Patient, Family / [**Hospital 216**] Medical records
Allergies:
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2163-11-27**] 04:30 PM
Other medications:
Past medical history:
Family history:
Social History:
# breast cancer s/p radical mastectomy ~ 30 years ago
# DM2
# CAD s/p CABG (~[**2157**])
# chronic renal insufficiency (baseline Cr 1.2-1.5)
# diverticulitis in [**6-/2163**]
# htn
# hyperlipidemia
# anxiety/depression
# glaucoma
# h/o pulmonary nodules
# s/p cholescystectomy/appendectomy
# h/o dysautonomia with postural hypotension
# s/p pacemaker (St. [**Male First Name (un) 1104**])
Meds on Transfer
ferrous sulfate 325 mg po daily
lopressor 50 mg [**Hospital1 **]
vitamin c 500 mg [**Hospital1 **]
aricept 10 mg po qhs
lisinpril 10 mg qhs
protonix 40 mg daily
lasix 20 mg po daily
celexa 20 mg po daily
glucotrol 2."
5488,"Chief Complaint: GI bleeding
HPI:
Ms. [**Known lastname 3398**] is an 88 year old female with a history of breast cancer, CAD
s/p CABG, DM2, htn, and diverticulosis on recent colonoscopy (otherwise
normal by report) who is being transferred from [**Hospital3 **] in the
setting of GI bleeding. She initially presented to [**Location (un) 196**] on [**11-24**]
with dark maroon stools. She was admitted to the ICU and GI was
consulted. An EGD was performed which showed no evidence of active
bleeding but did show a hiatal hernia. Slightly irregular mucosa was
also noted at the SC juntion; coffee grounds were also noted in the
stomach with 1+ duodenitis."
5489,"0 g/dL
90 mg/dL
1.0 mg/dL
18 mg/dL
26 mEq/L
110 mEq/L
4.0 mEq/L
144 mEq/L
33.7 %
7.9 K/uL
[image002.jpg]
[**2160-12-8**]
2:33 A12/21/[**2162**] 02:33 PM
[**2160-12-12**]
10:20 P
[**2160-12-13**]
1:20 P
[**2160-12-14**]
11:50 P
[**2160-12-15**]
1:20 A
[**2160-12-16**]
7:20 P
1//11/006
1:23 P
[**2161-1-8**]
1:20 P
[**2161-1-8**]
11:20 P
[**2161-1-8**]
4:20 P
WBC
7."
5490,"9
Hct
33.7
Plt
209
Cr
1.0
Glucose
90
Other labs: PT / PTT / INR:13.2/26.6/1.1, Differential-Neuts:70.5 %,
Lymph:17.9 %, Mono:6.2 %, Eos:4.6 %, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL,
PO4:2.8 mg/dL
Fluid analysis / Other labs: from OSH:
[**11-27**], 0500
WBC 6.3
Hgb 8.3 / hct 24.6
plt 169
Na 141, K 3.1, Cl 110, bicarb 25, BUN 24, cr 1.1, glucose 101
Ca 8.3
Assessment and Plan
88 y/o woman with PMH notable for CAD s/p CABG, prior pacemaker, and
hypertension admitted with anemia and melenotic stools."
5491,".
# GI bleeding: Dark stools at outside hospital with some bright stools
per report and now status post 5 U PRBCs in transfusion. Evaluated by
GI there and duodenitis and coffee grounds seen on EGD. Likely that
current presentation is related to diverticular bleed. Family is clear
that they would not want surgical intervention if bleeding persists or
is not controlled; will attempt to manage medically with transfusion
support and angiography if necessary.
- maintain 2 PIVs
- T&C on arrival
- check coags
- obtain bleeding scan with angiography if necessary
- continue [**Hospital1 **] ppi for now
- reinitiate ferrous sulfate once stabilized
.
# Hypertension: BPs elevated to nearly 200 systolic on arrival."
5492,"Initial Hb 8 -> 3 units PRBCs -> Hb 10.
However, she has had recurrent episodes of rectal bleeding, now with
bright red blood. Hb 10 -> 8 after multiple episodes of bloody stools.
She has denied chest pain, SOB, lightheadedness, nausea, or abdominal
pain throughout her admission. She has remained hemodynamically stable
throughout. Her most recent vitals prior to transfer, she was
afebrile, 141/46, 62, 18 98% RA. She has 1 18G PIV and 1 20G PIV at
time of transfer. In the ambulance, BPs ranged 120s-170s systolic. Her
2nd U PRBCs was hanging on transfer.
.
On arrival to the ICU, the patient was evaluated by the surgical
consult team."
5493,"5)
# diverticulitis in [**6-/2163**]
# htn
# hyperlipidemia
# anxiety/depression
# glaucoma
# h/o pulmonary nodules
# s/p cholescystectomy/appendectomy
# h/o dysautonomia with postural hypotension
# s/p pacemaker (St. [**Male First Name (un) 1104**])
# h/o TIA
noncontributory
Occupation:
Drugs: none
Tobacco: prior
Alcohol: none
Other: Currently living at [**Hospital3 22**] facility/nursing facility.
Review of systems:
Constitutional: Fatigue, No(t) Fever
Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis
Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Tachycardia
Respiratory: No(t) Cough, No(t) Dyspnea
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,
No(t) Diarrhea, No(t) Constipation, per hpi
Genitourinary: No(t) Dysuria
Musculoskeletal: Joint pain, right shoulder pain
Heme / Lymph: Anemia
Neurologic: No(t) Headache
Flowsheet Data as of [**2163-11-27**] 06:12 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 37."
5494,"Medications on transfer:
ferrous sulfate 325 mg po daily
lopressor 50 mg [**Hospital1 **]
vitamin c 500 mg [**Hospital1 **]
aricept 10 mg po qhs
lisinpril 10 mg qhs
protonix 40 mg daily
lasix 20 mg po daily
celexa 20 mg po daily
glucotrol 2.5 mg daily
zocor 40 mg daily
vitamin b12 1000 mcg daily
vitamin d 800 U daily
ocupres 1% opthalmic both eyes [**Hospital1 **]
Past medical history:
Family history:
Social History:
# breast cancer s/p radical mastectomy ~ 30 years ago
# DM2
# CAD s/p CABG (~[**2157**])
# chronic renal insufficiency (baseline Cr 1.2-1."
5495,"3
C (99.1
Tcurrent: 37.3
C (99.1
HR: 71 (64 - 71) bpm
BP: 169/45(77) {165/45(77) - 198/69(95)} mmHg
RR: 23 (23 - 29) insp/min
SpO2: 97%
Height: 66 Inch
Total In:
31 mL
PO:
TF:
IVF:
31 mL
Blood products:
Total out:
0 mL
1,165 mL
Urine:
1,165 mL
NG:
Stool:
Drains:
Balance:
0 mL
-1,134 mL
Respiratory
SpO2: 97%
ABG: ///26/
Physical Examination
T: 98.3 BP: 165/69 HR: 68 RR: 24 O2 99% RA
Gen: Pleasant elderly female in no distress
HEENT: no scleral icterus, pupils small but reactive, eomi, tongue
midline and moist
NECK: thin, no JVP elevation, no lymphadenopathy
CV: rrr, no murmurs appreciated
LUNGS: clear bilaterally
ABD: + bowel sounds, nontender to palpation, nondistended, no rebound
EXT: warm, well perfused, dp pulses 1+ bilaterally
SKIN: scattered ecchymoses
NEURO: alert, oriented X 3 but difficult to relate specifics of
admission to the hospital, face symmetric, moving all extremities
without difficulty
Labs / Radiology
209 K/uL
12."
5496,"She complains of right shoulder pain. She denies any
abdominal pain, chest pain, difficulty breathing,
dizziness/lightheadedness, or dysuria. She recalls that she has had
dark stools but cannot give a timeline as to their occurrence.
Patient admitted from: Transfer from other hospital
History obtained from Patient, Family / [**Hospital 216**] Medical records
Patient unable to provide history: Encephalopathy
Allergies:
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2163-11-27**] 04:30 PM
Other medications:
Meds at nursing home:
colace 100 mg daily
lasix 20 mg daily
celexa 20 mg daily
glucotrol 2.5 mg daily
zocor 40 mg daily
vitamin b12 1000 mcg daily
dulcolax 10 mg prn constipation
milk of mag 30 mL prn constipation
tylenol 650 mg po q6h prn
vitamin d 800 U daily
aggrenox 1 tab po bid
ocupress 1% ophthalmologic solution to both eyes [**Hospital1 **]
ferrous sulfate 325 mg [**Hospital1 **]
lopressor 15 mg [**Hospital1 **]
vitamin c 500 mg po bid
aricept 10 mg qhs
lisinopril 10 mg qhs
."
5497,"# PPx: pneumoboots, ppi, hold bowel meds for now
.
# ACCESS: 18 g piv, 20 g piv
.
# CODE: dnr/dni confirmed with patient's daughter, [**Name (NI) **] [**Last Name (NamePattern1) 3399**], who
is her HCP
.
# COMM: with patient and family. Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3399**] can be reached
at [**Telephone/Fax (1) 3400**]
.
# DISP: icu care for now
ICU Care
Nutrition:
Comments: npo for now
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2163-11-27**] 01:15 PM
20 Gauge - [**2163-11-27**] 01:15 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation
Comments:
Communication: ICU consent signed Comments:
Code status: DNR / DNI
Disposition: ICU"
5498,"It
appears that her BPs were always > 150 systolic at OSH despite PO meds.
- ACEi (captopril) at low dose tid
- hold beta blocker for now so as not to mask tachycardia
- continue to monitor
.
# Renal insufficiency: Patient's reported creatinine ~ 1.2 according to
OSh report. Cr down to 1. Continue to trend.
.
# CAD s/p CABG: Unclear anatomy but no current symptoms of heart
disease.
- continue statin
- no aspirin presently (on aggrenox as outpatient)
- hold beta blocker as above
.
# h/o TIA: Hold aggrenox.
.
# Glaucoma: continue usual eye gtt
.
# Depression/anxiety/dementia: Continue celexa/aricept.
.
# FEN: npo for now, replete lytes prn, continue calcium/vitamin
d/vitamin c
."
5499,"Admission Date: [**2124-11-27**] Discharge Date: [**2124-12-8**]
Date of Birth: [**2087-5-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
-R sided effusion tapped on [**11-25**]. Approx 2L removed. Labs
not consistent with empyema
-ERCP, [**2124-11-30**]
History of Present Illness:
Mr. [**Known lastname **] is a 37 year old man with hepatitis C cirrhosis c/b
portal HTN, varices, ascites, SBP, also with high-grade colonic
B-cell lymphoma (in remission since [**7-/2124**]), childhood ALL who
is admitted from [**Hospital 478**] clinic with increasing confusion and
lethargy as well as lower extremity fungal infection."
5500,"6*
[**2124-11-27**] 10:40AM NEUTS-84* BANDS-0 LYMPHS-5* MONOS-11 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2124-11-27**] 10:40AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-3+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL
SCHISTOCY-2+ TEARDROP-OCCASIONAL HOW-JOL-OCCASIONAL
BITE-OCCASIONAL ACANTHOCY-2+ FRAGMENT-1+
[**2124-11-27**] 10:40AM PLT SMR-VERY LOW PLT COUNT-57*
[**2124-11-27**] 10:40AM GRAN CT-4170
Brief Hospital Course:
37 year old man with HCV cirrhosis and high-grade B-cell
lymphoma (in remission) admitted with lethargy. Course
complicated by Portal Vein Thrombosis, Cholelithiasis with
likely choledocholithiasis, transudative pulmonary effusion s/p
tap, concern for DIC physiology (though thought unlikely given
lab derrangements in context of cirrhosis), as well as
hypercalcemia."
5501,"4, afebrile. LP on
previous admission for same presentation was negative and so do
not feel need to repeat at this time. There are case reports of
neoplastic syndromes secondary to CNS lymphoma (including in
this hospital), but these are diagnosed by brain biopsy and
exclusion. Hepatic encephalopathy worsened until patient's
ultimate demise.
.
.
#Hyperbilirubinemia: Unresolving circa 50. Of note, CT Abd
reveals 8MM stone noted in CBD and ductual dilitation, but no
improvement s/p ERCP with stent placement on [**11-30**]. In addition,
CT abd reveals no evidence of flow through portal vein in
contrast to [**7-31**] study at which time flow was still
visualized."
5502,"Lung exam
slowly resolving. Fluid analysis transudative, non-infectious
thus far. No apparent underlying organizing process on CT, but
moderate right pleural effusion with underlying
consolidation/collapse of the right lower lobe noted immediately
after tap. Repeat CXR with complete re-filling of right lung.
Patient's respiratory status appeared comfortable throughout the
hospitalization through until his death.
.
#Fungal infection: Histopath showed hyphal elements in the
inflammatory component and deeper skin structures. Cultures
positive for ""fungus"" from end of [**Month (only) 1096**]. ID was involved from
the onset and antibiotics were selected and titated according to
recommendations, but the patient passed away before clear
results could be identified.
.
# FEN: low sodium diet. replete lytes prn
.
# Prophylaxis: pneumoboots, bowel regimen
.
# Code: DNR DNI
Medications on Admission:
Albuterol 90 mcg, Cipro 250', Lactulose 60'''', MgOxide, Nadolol
20',
Nystatin, Pantoprazole 40',Rifaximin 400''', Spironolactone
200',
Testosterone 1 % (25 mg/2.5 g) Gel 2.5 grams Transdermal daily
Vitamin D3 400 units daily, Glargine 8 units qHS, Ursodiol
300'''
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver Failure [**12-25**] Hep C
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2125-3-9**]"
5503,"Non-focal
neuro exam.
.
Pertinent Results:
[**2124-11-27**] 10:40AM GLUCOSE-103 UREA N-50* CREAT-0.8 SODIUM-136
POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-34* ANION GAP-14
[**2124-11-27**] 10:40AM estGFR-Using this
[**2124-11-27**] 10:40AM ALT(SGPT)-47* AST(SGOT)-90* LD(LDH)-826* ALK
PHOS-151* TOT BILI-53.1*
[**2124-11-27**] 10:40AM ALBUMIN-3.9 PHOSPHATE-4.8* MAGNESIUM-3.0*
[**2124-11-27**] 10:40AM WBC-5.4 RBC-2.99* HGB-11.1* HCT-30.6*
MCV-102* MCH-37.3* MCHC-36.4* RDW-21."
5504,"Pt had ERCP on [**11-30**]. The stone as removed and a
filter was placed, but bilirubin remained high (50s). Sadly, the
patient expired on [**2124-12-9**]. A brief review of the hospital
course is presented belowd
.
.
.
#Altered mental status: Patient demonstrates marked rise in
TBili on presentation (38.5 -->53.1-->48.0), bumping hepatic
encephalopathy to top of differential. Other potential causes:
MS changes [**12-25**] fungemia given reported fungal derm infection,
bleed (but no recent trauma), mass effect or lyphomatous spread
to the meninges, drugs (denies drug use). Low suspicion for
meningitis or infection with white count at 5."
5505,"Finally, labs further described below concerning for
DIC (though subsequent factor assays--Factro VIII at 172 and ten
and 7 93 and 16, respectively, suggest otherwise). Hence, causes
may be multi-factorial. Lacutlose and Rifaximin given good
results with these medication on last admission with same
presentation.
.
.
Effusion: Patient's original R sided effusion tapped on [**11-25**]. Approx 2L removed. Labs not consistent with empyema. CT
Chest s/p tap on [**11-28**] shows moderate Right pulmoary effusion with
underlying consolidation/collapse of RLL (4mm nodule is unchaged
from before and requires follow-up as outpatient). Pt has
occasionally needed 02 to keep saturations above 92%."
5506,".
Of note, the patient was admitted to [**Hospital1 18**] from [**Date range (1) 62482**]
for hepatic encephalopathy which improved with lactulose and
rifaximin. Infectious work up, including LP, was negative during
that admission. Since discharge, he was noted to have some leg
wounds which were biopsied by Derm on [**11-20**] and found to be
fungal infections; no treatment has yet been started.
Past Medical History:
- acute lymphocytic T-cell leukemia at age 6; treated with
chemotherapy, thymectomy, and radiation therapy to whole brain
and testicles
- cirrhosis from hepatitis C, genotype 1 (presumed to have
contracted during childhood blood trnasfusions); s/p banding of
three grade II-III varices in [**5-/2124**]; prior admissions for
hepatic encephalopathy; prior acute renal failure likely from
hepatorenal syndrome
- high-grade B-cell lymphoma (EBV-negative) in transverse [**Year (4 digits) 499**]
diagnosed in [**6-/2124**] by colonoscopy for workup of anemia; has
completed 3 cycles of rituximab, nitrogen mustard, prednisone,
vincristine, and doxorubicin (last on [**2124-9-19**]) with
concurrent progression of his cirrhosis; PET-CT [**2124-10-18**] without
any FDG-uptake suggesting remission
- history of C perfringes peritonitis ([**7-/2124**]) treated with
ceftriaxone
- GNR bacteremia with Cupriavidus metallidurans in [**8-/2124**],
possibly due to contaminated heparin flushes"
5507,"Social History:
He lives independently in trailer 2 blocks from father and
denies current tobacco, alcohol, or drug use. His father is
closely involved in his care and lives near him. He is not
married and does not work.
Family History:
No family history of liver disease. Grandfather had [**Name2 (NI) 499**]
cancer.
Physical Exam:
T 96.9 BP 110/71 HR 101 (72-101) RR 20 Sat 91-100% on 2 L/min
General: mildly somnolent young man in no distress but very
still, laying in bed, father at bedside.
HEENT: (+) scleral icterus, EOMI, + thrush
Neck: supple, no lymphadenopathy
Chest: clear to auscultation bilaterally with no wheezes, rales,
or ronchi
CV: regular rate/rhythm, normal s1 and s2, II/VI systolic murmur
at RUSB
Abdomen: soft, distended with dullness to percussion at both
flanks; nontender; unable to palpate spleen tip or liver edge;
normal bowel sounds
Extremities: 2+ edema up to knees bilaterally;
Skin: markedly jaundiced; scattered subcentimeter eschars with
mild excoriations over both shins
Neuro: CN 2-12 intact; very mild asterixis; AOx4."
5508,"Admission Date: [**2110-12-31**] Discharge Date: [**2111-1-2**]
Date of Birth: [**2058-9-8**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Aspirin / Nsaids
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
RUQ pain and hypotension
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
52M w/ hx of PSC s/p open cholecystectomy, Roux-en-Y
hepaticojejunostomy ([**2103**]), Stage IB pancreatic neuroendocrine
tumor, recurrent RUQ pain presents w/ 4 to 5 days of worsening
RUQ pain. Today his pain increased and he developed nausea,
fever to 102.7F, decreased appetitite, and ""feeling septic"" in
the early afternoon."
5509,"Primary sclerosing cholangitis s/p open cholecystectomy,
common bile duct excision, liver biopsy, and Roux-en-Y
hepaticojejunostomy on [**4-/2103**], admitted every [**5-16**] wks for
flairs, usually responsive to abx.
2. s/p PTC placement times two.
3. Recurrant UTIs, with negative urology workup in past.
4. Depression.
5. Anxiety disorder.
6. Hx of Hep B, Hep A.
7. Hx of Lyme Disease
8. Papillary urothelial carcinoma in [**2105-6-11**].
Social History:
Patient in monogamous relationship, lives with male partner
[**Name (NI) **],
currently sexually active. Does not use condoms with
intercourse. No hx of STDs in himself or his partner."
5510,"Possibly related to transient bacteremia within biliary system.
He was continued on IV antibiotic treatment.
.
# Mild rales bilaterally. Patient has no history of heart
failure, but he was given 4L of total IVF in the ED prior to
admission. He was not diuresed while in the MICU.
.
# Depression/anxiety: The patient was continued on his home
Wellbutrin and citalopram.
.
TRANSITIONAL ISSUES:
Mr. [**Known lastname **] was sent home with VNA services for assistance with his
PICC line and IV antibiotic therapy. He has follow up
appointments with his PCP and the liver transplant center.
Medications on Admission:
- bupropion HCl 100 mg [**Hospital1 **]
- citalopram 20 mg daily
- gabapentin 100 mg [**Hospital1 **]
- metoclopramide 5 mg TID PRN nausea
- oxycodone 5 mg q6h PRN pain
- ursodiol [Actigall] 1500 mg daily
- acetaminophen 650 mg Tablet Extended Release, 2 tabs PRN
- famotidine [Pepcid] unknown dosage"
5511,"CBD is
Preliminary Reportof normal caliber measuring 5 mm. The portal
vein is patent demonstrating
Preliminary Reporthepatopetal flow. There is no ascites.
Gallbladder is surgically absent.
Preliminary ReportPancreas is obscured by overlying bowel gas.
Preliminary ReportIMPRESSION:
Preliminary ReportCoarse liver echotexture, which likely
represents underlying fibrosis, better
Preliminary Reportcharacterized on MRCP exam of [**2110-10-31**]. No
discrete hepatic lesion.
.
[**12-31**] CXR: COMPARISON: [**2109-4-9**].
PA AND LATERAL VIEWS OF THE CHEST: The cardiac, mediastinal and
hilar
contours are normal. The pulmonary vascularity is normal and the
lungs are
clear. No focal consolidation, pleural effusion or pneumothorax
is present."
5512,"There are mild degenerative changes of the thoracic spine with
anterior
osteophyte formation.
IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
Mr. [**Known lastname **] is a 52 year old male with a history of primary
sclerosing cholangitis (PSC) status post open cholecystectomy,
Roux-en-Y hepaticojejunostomy ([**2103**]), Stage IB pancreatic
neuroendocrine tumor, recurrent right upper quadrant (RUQ)
abdominal pain who presented with 4 to 5 days of worsening RUQ
pain.
.
# RUQ pain: Given fever, leukocytosis, RUQ pain, and liver
enzyme elevation suggestive of obstructive biliary pathology,
cholangitis was high on the differential, however ultrasound did
not show any evidence of common bile duct (CBD) dilation; pt
also with normal lactate."
5513,"[**Name (NI) **]
history of tobacco or alcohol. No IVDU.
Family History:
No history of UTIs, kidney stones, or other kidney pathology.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 99.0, 98/57, 85, 17 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no JVD
CV: Regular rate, no m/r/g
Lungs: No resp distress, very mild crackles at lung bases
bilaterally, otherwise CTAB
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Grossly intact"
5514,"Pertinent Results:
ADMISSION LABS:
[**2110-12-31**] 05:35PM BLOOD WBC-16.2*# RBC-4.30* Hgb-13.4* Hct-39.3*
MCV-91 MCH-31.0 MCHC-34.0 RDW-12.6 Plt Ct-387
[**2110-12-31**] 05:35PM BLOOD Neuts-85.5* Lymphs-8.4* Monos-5.4 Eos-0.5
Baso-0.2
[**2110-12-31**] 05:35PM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-135
K-3.9 Cl-99 HCO3-27 AnGap-13
[**2110-12-31**] 05:35PM BLOOD ALT-97* AST-82* AlkPhos-247* TotBili-1.2
[**2110-12-31**] 05:35PM BLOOD Lipase-33
[**2110-12-31**] 05:35PM BLOOD Albumin-4."
5515,"Hepatology saw patient in ED and it
was decided that ERCP was not indicated. The patient was
started on IV vancomycin/Unasyn for cholangitis treatment. He
was also continued on his home ursodiol and pain regimen. His
pain resolved in one day and he never developed any criteria of
sepsis. Vancomycin was discontinued and a PICC line was placed.
He was sent home with VNA to receive 6 more days of Unasyn and
then was to continue with 7 days of Augmentin.
.
# Hypotension: The patient had brief episode in ED responsive to
IVF bolus, but while in the MICU had no recurrent episodes."
5516,"metoclopramide 5 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for nausea.
8. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO QAM (once a
day (in the morning)).
9. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
10. famotidine 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days: START AFTER IV ANTIBIOTICS ARE COMPLETE.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]"
5517,"Discharge Medications:
1. ampicillin-sulbactam 3 gram Recon Soln Sig: Three (3) gram
Injection Q6H (every 6 hours) for 5 days.
Disp:*60 gram* Refills:*0*
2. PICC Line Dressing
Please change PICC line dressing weekly and prn
3. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7."
5518,"The following changes have been made to your medications:
START:
Ampicillin-Sulbactam 3grams via IV every 6 hours for five more
days
Augmentin 875-125mg take one tablet twice per day for 7 days
once IV antibiotics are complete
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
Appointment: Friday [**2111-1-9**] 10:20am
Department: LIVER CENTER
When: FRIDAY [**2111-1-23**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]"
5519,"He was
started on vancomycin and unasyn. Around 7pm he became
hypotensive to SBP upper 80's and felt light-headed. 18g and 16g
peripheral IVs were started and he was given 4L IVF w/ BP
incrasing to 96/54. Throughout his lactate remained unelevated
and he quickly felt better. He was admitted to the ICU given
concern for possible cholangitis w/ hypotension.
.
On arrival to the MICU, his pain had decreased and he was
otherwise feeling well. His blood pressure SBP was stable in the
low 100's.
.
Review of systems:
- Negative except as noted in HPI
Past Medical History:
1."
5520,"Discharge Diagnosis:
Acute Cholangitis
Primary Sclerosing Cholangitis
Depression/Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with abdominal
pain and fevers. You have been started on IV antibiotics to
treat an infection in your abdomen involving your liver. An IV
line was placed in your arm for home antibiotic administration.
You will need 5 more days of IV Ampicillin-Sulbactam every 6
hours. Once this is complete you should start taking Augmentin
875-125mg twice per day for 7 days."
5521,"0
[**2111-1-1**] 05:55AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1
[**2110-12-31**] 05:48PM BLOOD Lactate-1.3
[**2111-1-1**] 12:33AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.003
[**2111-1-1**] 12:33AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
MICRO:
[**12-31**] BLOOD AND URINE CULTURES NO GROWTH TO DATE
.
IMAGING:
[**12-31**] LIVER/GALLBLADDER U/S FINDINGS:
Preliminary ReportThe liver demonstrates coarse echotexture
without discrete lesions. There is
Preliminary Reportno evidence of intrahepatic or extrahepatic
biliary ductal dilatation."
5522,"After contacting his hepatologist (Dr.
[**Last Name (STitle) 497**] he presented to the ED for evaluation.
.
He was most recently evaluated by Dr. [**Last Name (STitle) 497**] in early [**Month (only) 1096**]
where he reported ongoing low-grade temps to 99F, RUQ
discomfort, pale stools, dark urine, occasional pruritis. He
does experience intermittent exacerbation of similar symptoms
for which he takes ciprofloxacin, but he was changed to
levofloxacin for better gram positive coverage and scheduled for
6 months follow up w/ MRCP at that time to evalute for disease
progression.
.
In the ED, initial VS were: 101.3 120 111/69 20 100%."
5523,"He
reported feeling tired, but was improved since his admission
Past Medical History:
- Pulmonary alveolar proteinosis, diagnosed [**5-10**] by open lung bx
-follow-up 11/08 per OSH report almost complete resolution of
infiltrates
- IBD s/p colon resection and colostomy
- Hashimoto's thyroiditis
- Hx of sinus surgery
Social History:
Occasional ETOH use, does not and has never smoked. Married, two
children. Works as a mechanical engineer in an office setting.
Has no known exposure to asbestos. Mother grew up on a farm in
[**State 23924**] and patient would visit often as a child. No known
exposure to any chemicals or solvents."
5524,"Brief Hospital Course:
51 yo man with IBD, pulmonary alveolar proteinosis who presented
from [**Hospital6 19155**] with pneumonia and respiratory
failure.
# Respiratory failure/Pneumococcal Pneumonia: In the setting of
an acute pulmonary process, this was initially attributed to
bacterial pneumonia, likely community acquired, supported by
intial GPC's on sputum at [**Hospital6 19155**]. However,
PCP and Nocardia were also considered given known diagnosis of
PAP and labs were sent accordingly. CXR demonstrated unilateral
disease, not c/w PAP flare and more concerning for an acute
process. Patient was intubated and intially started on an ARDS
type ventilation with low tidal volumes."
5525,"On transfer to the floor, his oxygen requirement was
initially 4L. Levaquin was continued. He had no acute events
on the floor, and O2 saturation was 94% on RA on day of
discharge. Physical Therapy evaluated him during his admission
and recommended [**1-4**] further visits. He still had dyspnea on
exertion so home oxygen was arranged for him.
FOLLOW-UP: PCP [**Last Name (NamePattern4) **] 1 week (their office will contact patient to
arrange appointment) and repeat chest imaging in [**4-8**] weeks.
# Acute Renal Failure - On transfer, patient had elevated
creatinine of 1.4, given 3L NS bolus in setting of hypotension
and pressors."
5526,"Responded appropriately. Discharged with
creatinine 0.8-0.9.
# Hypotension - Patient experienced hypotension prior to
transfer from OSH. He was transferred to [**Hospital1 18**] on a
neosynephrine (phenylephrine) drip. Chem-7 showed elevated
creatinine which likely indicated pre-renal state. Responded to
3L NS bolus and pressors were discontinued. Patient maintained
normal blood pressure for rest of admission.
# Pulmonary Alveolar Proteinosis - Not an acute issue during
admission, however, may have been contributing factor to his
illness. Instructed patient to follow-up with his pulmonologist
within 4 weeks of discharge.
# Hypothyroidism - TSH within normal limits. Continued home
dose of Levoxyl.
Medications on Admission:
- LEVOTHYROXINE - 200mcg po daily"
5527,"Patient was also
underwent bronchoscopy with aspiration of large, thick mucus
cast. Legionella Ag was sent and was negative. The patient was
initially started on vancomycin and aztreonam. He was
subsequently switched to levaquin after cultures (blood and
sputum) from [**Location (un) **] returned possitive for Streptococcus
Pneumoniae. On [**10-3**], patient grew agitated in the evening and
self-extubated. He was maintained with adequate saturations on
highflow facemask. Patient's mental status rapidly improved
over the next several days. His CXR also rapidly improved with
increased oxygenation of the RL fields. F/u of the nocardia
culture was negative to date and PCP smear was never done in the
lab."
5528,"2* Cl-112* HCO3-26 AnGap-11
[**2165-10-9**] 08:40AM BLOOD Glucose-80 UreaN-7 Creat-0.9 Na-137 K-4.8
Cl-106 HCO3-22 AnGap-14
[**2165-10-9**] 08:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2
LFTS
[**2165-10-1**] 09:45PM BLOOD ALT-14 AST-39 LD(LDH)-303* AlkPhos-60
TotBili-1.6*
CARDIAC ENZYMES
[**2165-10-2**] 03:16AM BLOOD CK(CPK)-53
[**2165-10-3**] 11:00AM BLOOD CK(CPK)-435*
[**2165-10-2**] 03:16AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2165-10-3**] 11:00AM BLOOD CK-MB-5 cTropnT-<0."
5529,"He presented to the hospital today and
was found to have a large LLL/lingular pneumonia on chest X-ray.
He was afebrile on admission there with RR 49, HR 143, BP
111/75. He was started on IV linezolid and levofloxacin and
admitted to the ICU. O2 sat on arrival to the ICU was 88% on
FiO2 70%. ABG was 7.48/33/51. His RR increased to 50, his HR
remained 130s and his temp increased to 100.4, and he was
intubated at that time. he was placed on ventilator support -
assist control, tidal volume 600, FiO2 100% and RR 12."
5530,"Discharge Medications:
1. Oxygen
O2 at 2 to 4 L continuous, Pulse dose for portability.
2. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis:
1. Pneumonia
2. Respiratory Failure
3. Hypotension
4. Acute Renal Failure
Secondary Diagnosis:
1. Pulmonary Alveolar Proteinosis
2. Hypothyroidism
Discharge Condition:
Hemodynamically Stable. Tolerating PO intake. Stable on oral
antibiotics.
Discharge Instructions:
You were transferred to [**Hospital1 18**] from [**Hospital6 19155**] for
further management of your pneumonia."
5531,"Married with two
children/
Family History:
Father deceased - kidney CA. Mother is alive and healthy
Physical Exam:
VS: T: 99.4 HR: 91 BP: 102/60 RR: 16 O2: 98% on FiO2 100%, PEEP
5
Gen: Intubated sedated
HEENT: PEERL, MM dry
Neck: Supple, no LAD, no JVD
Heart:RRR, nl S1/2, no murmurs
Lung: clear breath sounds b/l anteriorly
Abd: Colostomy with midline scar
Extrem: Warm, no edema, 2+ dp, radial pulses
Skin: no rashes
Neuro: No clonus, toes downgoing
Pertinent Results:
EKG: Sinus rhythm at 88 with PVC. nl intervals, nl axis, J point
elevation in lateral leads, changed from prior"
5532,"He was
placed on a propofol drip for sedation. He was suctioned for
thick yellow brownish-colored sputum, blood-tinged. Gram stain
showed <10 epis, 1+ gram positive cocci. BP dropped to 89/40 and
he received a NS bolus and started on neosynephrine. Repeat ABG
was 7.43/39/222. High A-a gradient of 442. He was transferred to
[**Hospital1 18**] for further management.
Upon arrival to the ICU, the patient was intubated, sedated, on
neo gtt. Central line and R radial A-line placed. Bronchoscopy
performed showing large mucus plug on the left.
On transfer to the floor, he felt that his shortness of breath
had improved, but was still requring supplemental oxygen."
5533,"difficile toxin A & B by EIA.
BLOOD AND URINE CULTURES AT [**Hospital1 18**] NEGATIVE TO DATE
CT CHEST [**2165-10-2**] - IMPRESSION: Confluent consolidation involving
nearly the entire left lung with either bronchocentric or
vascular dissemination to the right lung with assoicated
mediastinal and hilar lymphadenopathy most suggestive of
infection. Alternatively, consolidative forms of
bronchoaleveolar carcinoma or lymphoma could have a similar
appearance.
Review of the outside CT from [**2161**] and [**2164**] shows near
resolution of previous extensive ground glass opacity, diagnosed
as pulmonary alveloar proteinosis which may be idiopathic or
related to inhalational exposure. Extensive mediastinal soft
tissue and lymphadenopathy."
5534,"You were given both a flu and
pneumococcal vaccine prior to discharge to help prevent flu and
pneumonia.
Oxygen has been arranged for you to have at home. It is
intended to be used during exertion for the next 2-3 days or at
anytime that you are experiencing shortness of breath.
Changes in Medication
START Levofloxacin 750 mg by mouth daily for 5 days
CONTINUE Levothyroxine 200 mcg by mouth daily
If you experience fever > 101, worsening shortness of breath,
chest pain, pain when you breathe, coughing up blood, nausea or
vomitting, headaches, confusion or any other symptom that
concerns you, please contact your PCP or go to the nearest
emergency room for evaluation.
Followup Instructions:
Please follow-up with your PCP within one week of discharge.
Dr. [**Last Name (STitle) **] is no longer at the practice site your prevoiusly
went to and they stated your new PCP is [**Last Name (NamePattern4) **]. [**First Name (STitle) 1887**]. Dr. [**Name (NI) 77520**] nurse will contact you to arrange an appointment.
Additionally, you should follow-up with your pulmonologist
within 4-6 weeks for evaluation."
5535,"CULTURE DATA:
BAL: GRAM STAIN (Final [**2165-10-2**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2165-10-3**]):
SPARSE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary):
MOLD.
BAL: GRAM STAIN (Final [**2165-10-2**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2165-10-4**]):
RARE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Legionella Urinary Antigen (Final [**2165-10-2**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2165-10-7**]):
Feces negative for C."
5536,"01
[**2165-10-3**] 06:00PM BLOOD cTropnT-<0.01
ENDOCRINE/IRON
[**2165-10-6**] 05:11AM BLOOD calTIBC-133* Ferritn-749* TRF-102*
[**2165-10-4**] 03:04AM BLOOD TSH-1.4
[**2165-10-4**] 03:04AM BLOOD T4-2.1* T3-44* calcTBG-0.95 TUptake-1.05
T4Index-2.2* Free T4-0.44*
[**2165-10-3**] 11:00AM BLOOD Cortsol-11.9
[**2165-10-2**] 03:23AM BLOOD Lactate-1.6
URINE:
U/A: negative glucose, small bili, neg ketones, neg nitrates,
trace blood, negative leuk esterase, protein >=300, [**6-12**] WBC, 3+
bacteria, 1+ amorphous crystals
Influenza antigen screen - negative"
5537,"When you arrived, you
were sedated and had a tube down your throat to help you
breathe. You also needed medication to help your body maintain
your blood pressure. After recieving IV fluids, the medication
to help you maintain your blood pressure was discontinued. You
pulled the breathing tube out of your mouth while in the
Intensive Care Unit, however it was not inserted. Oxygen was
required for most of your hospitalization to help you breath.
Antibiotics were continued while you were in the hospital.
Please complete your course of antibiotics after discharge. It
is important that you follow-up with your PCP and your
Pulmonologist after discharge."
5538,"4 RBC-3.64* Hgb-10.8* Hct-33.8*
MCV-93 MCH-29.6 MCHC-31.9 RDW-14.6 Plt Ct-677*
[**2165-10-5**] 02:36AM BLOOD Neuts-92.1* Lymphs-4.7* Monos-2.5 Eos-0.5
Baso-0.2
COAGS
[**2165-10-4**] 03:04AM BLOOD PT-13.9* PTT-30.3 INR(PT)-1.2*
CHEMISTRY
[**2165-10-1**] 09:45PM BLOOD Glucose-114* UreaN-23* Creat-1.4* Na-141
K-3.7 Cl-107 HCO3-23 AnGap-15
[**2165-10-5**] 02:36AM BLOOD Glucose-100 UreaN-16 Creat-0.9 Na-146*
K-3."
5539,"Admission Date: [**2165-10-1**] Discharge Date: [**2165-10-9**]
Date of Birth: [**2114-6-3**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Transfer for respiratory failure
Major Surgical or Invasive Procedure:
bronchoscopy *2
History of Present Illness:
Mr. [**Known lastname 39602**] is a 51 yo man with a diagnosis of pulmonary
alveolar proteinosis who presents in transfer from [**Location 75548**] for treatment of pneumonia and respiratory
failure. Per H&P from OSH, the patient was in his usual state of
health until [**9-28**] when he developed URI symptoms, dyspnea,
cough, fever and chills."
5540,"HEMATOLOGY
[**2165-10-1**] 09:45PM BLOOD WBC-10.3 RBC-3.79* Hgb-11.7* Hct-35.6*
MCV-94 MCH-31.0 MCHC-33.0 RDW-13.9 Plt Ct-241
[**2165-10-4**] 03:04AM BLOOD WBC-13.0* RBC-3.16* Hgb-9.7* Hct-29.2*
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.5 Plt Ct-237
[**2165-10-7**] 04:08AM BLOOD WBC-11.2* RBC-3.13* Hgb-9.7* Hct-29.2*
MCV-93 MCH-31.0 MCHC-33.2 RDW-14.2 Plt Ct-381
[**2165-10-9**] 08:40AM BLOOD WBC-9."
5541,"[**2159-1-25**] 8:03 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 29699**]
Reason: Infiltrate?
Admitting Diagnosis: ALTERED MENTAL STATUS
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
66 year old woman with cough, history of COPD and recurrent pneumonias
REASON FOR THIS EXAMINATION:
Infiltrate?
______________________________________________________________________________
FINAL REPORT
INDICATION: 66-year-old female with history of COPD, now with new cough.
COMPARISON: Semi-upright portable AP chest radiograph [**2159-1-21**].
TECHNIQUE: Upright portable AP chest radiograph.
FINDINGS: Lungs are well inflated and clear bilaterally with stable upper
zone redistribution of vasculature. There is no pleural effusion or
pneumothorax. No areas of focal consolidation, masses or lesions are
identified. Aorta is mildly tortuous, and heart is top normal in size.
Pleural surfaces are unremarkable. An NG tube is seen properly placed
entering the stomach and then out of view. Stimulator is in place, unchanged
in position, projecting over the lower thoracic spine.
IMPRESSION: No evidence of infection or malignancy."
5542,"Admission Date: [**2159-1-17**] Discharge Date: [**2159-2-2**]
Date of Birth: [**2092-4-27**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
Lethargy, sleepiness, urinary incontinence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 26812**] is a 66yo W with a history of longstanding tobacco
abuse, EtOH Abuse (3 drinks/night per family), lower back pain
s/p placement of thecal morphine pump, recent history of
recurrent pneumonia/bronchitis, HTN, HLD, GERD, anemia who was
brought to the [**Hospital1 18**] ED for complaints of altered mental status
and urinary incontinence."
5543,"She
received CT imaging (which ""ruled out"" stroke), as well as
carotid US imaging which showed the presence of a right sided
70% stenosis
of the carotid artery. She was once again discharged to rehab.
Over the past two days prior to her ED presentation this time,
she was noted to be once again shaky, confused, lethargic and
displaying urinary incontinence. She was noted to be quite
perseverative and repeating herself, but was comprehending well
and the language that she used ultimately made sense. For these
complaints, the patient's family insisted that she brought to
the [**Hospital1 18**].
Past Medical History:
Chronic pain (has morphine pump) failed back syndrome
HTN
HLD
Failed back/ chronic pain on morphine pump
depression
GERD
Anemia
GI bleed
ETOH abuse (last drink 2 weeks ago)
Right hydronephrosis
R carotid stenosis 70%"
5544,"14. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
15. Keppra 500 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO twice a day.
16. lacosamide 150 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 26812**],
It was a pleasure taking care of you during this
hospitalization. You were admitted for altered mental status and
were found to have seizure activity on your EEG."
5545,"Her fosphenytoin was switched for Vimpat/lacosamide. She was
transferred out of the ICU in stable condition and gradually
improved with regards to her mental status. She was continued on
Keppra 1500mg [**Hospital1 **] and Vimpat 150mg [**Hospital1 **] with no further seizure
activity. She continued to improve clinically, and became more
awake and alert with fluent speech. She remained somewhat
inattentive and perseverative, and was oriented to place but not
date. She continued to have difficulty swallowing as well, and
failed several subsequent swallow evaluations. She was
maintained on tube feeds via an NG tube until a PEG tube could
be placed on [**2159-2-1**]."
5546,"She also displayed
bilateral asterixis with brisk reflexes and downgoing toes.
Formal strength testing was symmetric and full and there was no
drift.
Given her known morphine pump for lower back pain, an MRI could
not be performed. The pain service was consulted, and they
recommended that an MRI not be performed and that her morphine
pump not be changed in settings. To evaluate the cause for her
expressive aphasia, she received a NCHCT and CTA head/neck which
showed no evidence of an acute stroke, hemorrhage or mass, but
did reveal atherosclerotic disease in both carotid arteries
(R>L)."
5547,"Over the past two days prior to her ED presentation this time,
she was noted to be once again shaky, confused, lethargic and
displaying urinary incontinence. She was noted to be quite
perseverative and repeating herself, but was comprehending well
and the language that she used ultimately made sense. In the ED,
her examination was significant for inattention, inability to
follow commands, diffuse paratonia and a possible right lower
extremity drift. On her statnet EEG, she was noted to have
multifocal epileptiform discharges (L>R) and loaded with keppra.
She received 1mg of ativan she became more obtunded, bradycardic
to the 30's and hypotensive, SBP to the 90's."
5548,"Social History:
Patient has a long history of alcohol abuse ([**1-19**] drinks/night).
Current long standing smoker. Prior to her recent
hospitalizations, she was living at home.
Family History:
No history of seizures, strokes.
Physical Exam:
On Admission:
Vitals: T: 98.1 P: 88 R: 16 BP:140/98 SaO2:93% on 2l
General: Awake,NAD.
HEENT: NC/AT.
Neck: No nuchal rigidity
Pulmonary: + Wheezing, + rales
Cardiac: RRR.
Abdomen: soft, NT/ND.
Extremities: No edema .
Neurologic:
-Mental Status:
Not following commands. EYEs open, tracks my face. Says
""[**Known firstname **]""
-Cranial Nerves:
Pupils reactive b/l. + blink to threat from lateral sides."
5549,"During her
short rehab stint, she developed an episode of ""shakiness"", high
blood pressures to the 200s systolic, and visual disturbances
characterized as flashes of light in the peripheral visual
fields, odd shadows/contours around objects in her field as well
as patchy areas of blindness. During this episode, she was
confused. They improved her blood pressure and 12 hours after
the onset of symptoms her visual disturbance improved. She
received CT imaging (which ""ruled out"" stroke), as well as
carotid US imaging which showed the presence of a right sided
70% stenosis of the carotid artery. She was once again
discharged to rehab."
5550,"3. Right-sided thyroid nodule. Recommend thyroid ultrasound on a
non-emergent basis for further characterization.
4. Biapical pleural scarring, if clinically indicated, would be
better
evaluated with a dedicated chest CT.
Brief Hospital Course:
Ms [**Known lastname 26812**] is a 66yo W with a history of longstanding tobacco
abuse, EtOH Abuse (3 drinks/night per family), lower back pain
s/p placement of thecal morphine pump, recent history of
recurrent pneumonia/bronchitis, HTN, HLD, GERD, anemia who was
brought to the [**Hospital1 18**] ED for complaints of altered mental status
and urinary incontinence. Her history started two weeks ago
approximately when she developed her third pneumonia of the year
and she was hospitalized at [**Hospital **] Hospital for the same,
treated with IV antibiotics and discharged to rehab."
5551,"5 Leuks-NEG
[**2159-1-17**] 11:27AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2159-1-17**] 11:27AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Reports:
EEG [**2159-1-17**]: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of intermittent epileptic discharges
bilaterally in the posterior quadrants. These epileptic
discharges, at times, occur in a generalized distribution and
occasionally become briefly periodic. These findings are
indicative of independent areas of cortical irritability in the
posterior quadrants that are potentially epileptogenic as well
as
generalized cortical irritability."
5552,"baclofen 10 mg Tablet [**Date Range **]: Two (2) Tablet PO TID (3 times a
day).
rosuvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
amlodipine 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
lisinopril 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB, wheeze."
5553,"Speech fluent. Follows commands but with some
perserveration.
CN: PERRL, EOMI, face symmetric
Motor: No pronator drift, strength intact throughout
Sensation: Intact to light touch throughout
Reflexes: Equal and symmetric, plantars downgoing
Coordination: Intact FNF b/l
Pertinent Results:
Admission Labs
[**2159-1-17**] 11:15AM BLOOD WBC-8.8 RBC-4.02* Hgb-12.4 Hct-36.6
MCV-91 MCH-30.9 MCHC-33.9 RDW-14.0 Plt Ct-204
[**2159-1-17**] 11:15AM BLOOD Neuts-59.0 Lymphs-34.9 Monos-5.3 Eos-0.3
Baso-0.5
[**2159-1-17**] 11:15AM BLOOD PT-10."
5554,"Her history started two weeks ago
approximately when she developed her third pneumonia of the year
and she was hospitalized at [**Hospital **] Hospital for the same,
treated with IV antibiotics and discharged to rehab. During her
short rehab stint, she developed an episode of ""shakiness"", high
blood pressures to the 200s systolic, and visual disturbances
characterized as flashes of light in the peripheral visual
fields, odd shadows/contours around objects in her field as well
as patchy areas of blindness. During this episode, she was
confused. They improved her blood pressure and 12 hours after
the onset of symptoms her visual disturbance improved."
5555,"The following changes were made to your medications:
Started Keppra 1500mg twice a day
Started Vimpat 150mg twice a day
You should continue the rest of your medications as prescribed.
Please keep your follow-up appointments as listed below.
Please seek immediate medical attention should you experience
any of the below listed danger signs.
Followup Instructions:
You have the following appointment scheduled with Dr. [**First Name (STitle) 437**]:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) 68187**] [**Last Name (un) 68188**] Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2159-2-26**] 11:30
You should also make an appointment to see your primary care
doctor Dr. [**Last Name (STitle) 4454**] within 1-2 weeks."
5556,"Face
appreciated as symmetric, did not grin or smile for me.
-Motor: Paratonia + Tremor b/l hands/ fine tremor.
Strength (antigravity) Drift more prominent on the right lower
extremity which per family his her painfull leg.
-Sensory: + grin to pinch
-DTRs: [**Name2 (NI) **] 1 symmetric.
Plantar response was mute bilaterally.
On Discharge:
Vitals: 97.6 106/48 74 20 96% RA
General: Awake and alert, cooperative, NAD.
HEENT: NC/AT.
Neck: No nuchal rigidity
Pulmonary: CTAB
Cardiac: RRR.
Abdomen: soft, NT/ND
Extremities: No edema
Neurologic:
Mental status: Awake and alert, oriented to hospital and [**Location (un) 86**]
but not date."
5557,"8. amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. insulin regular human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED): Please give ACHS per insulin
sliding scale.
11. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily)."
5558,"In addition, the background
is
diffusely slow, indicative of a mild diffuse encephalopathy of
non-specific etiology. Note is made of sinus bradycardia through
most
of the recording.
CXR [**2159-1-17**]: Patchy left base opacity most likely represents
atelectasis,
although underlying aspiration not excluded.
NCHCT [**2159-1-17**]:
Severely limited evaluation due to streak artifact from EEG
cables, within
those limitations, no large, obvious acute intracranial process.
NCHCT, CTA Head/Neck [**2159-1-18**]:
1. No acute intracranial process.
2. Mixed hard and soft plaques at the carotid artery
bifurcations; moderate
narrowing of the right proximal internal carotid artery due to
the plaque."
5559,"She tolerated this well and was restarted
on tube feeds on [**2-2**].
She seen by PT and OT who recommended acute rehab placement upon
discharge. She was discharged to [**Hospital1 **] in good condition on
[**2159-2-2**].
TRANSITIONAL CARE ISSUES:
Patient will need to remain on Keppra 1500mg [**Hospital1 **] and Vimpat
150mg [**Hospital1 **] for seizure control. She has a follow-up appointment
in epilepsy clinic with Dr. [**First Name (STitle) 437**] on [**2159-2-26**]. She will need
continued PT/OT as well as speech therapy.
Medications on Admission:
hydrochlorothiazide 12.5 mg Capsule [**Date Range **]: One (1) Capsule PO
DAILY (Daily)."
5560,"We have treated
this with two medications called Keppra and Vimpat, which you
will need to continue as prescribed. Your other laboratory
studies and imaging studies were normal. You do have stenosis of
your right internal carotid artery which means you should
control your high blood pressure and cholesterol well and follow
closely with your primary care physician.
A feeding tube was placed in your stomach in order to give you
nutrition as you are still having difficulty swallowing. Your
swallowing function will continue to be followed by the speech
therapists at [**Hospital1 **], and hopefully at some point the tube
will be able to be removed if you are able to eat on your own."
5561,"8 PTT-26.8 INR(PT)-1.0
[**2159-1-17**] 11:15AM BLOOD Glucose-85 UreaN-35* Creat-1.0 Na-142
K-4.0 Cl-102 HCO3-37* AnGap-7*
[**2159-1-18**] 01:43AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.7 Cholest-141
[**2159-1-18**] 01:43AM BLOOD %HbA1c-6.1* eAG-128*
[**2159-1-18**] 01:43AM BLOOD Triglyc-128 HDL-53 CHOL/HD-2.7 LDLcalc-62
LDLmeas-68
[**2159-1-17**] 07:58PM BLOOD Ammonia-26
[**2159-1-17**] 07:58PM BLOOD TSH-3.5
[**2159-1-17**] 11:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2159-1-17**] 11:27AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5."
5562,"Given her continued hemodynamic stability, the patient
was transferred to the floor EMU service for continued EEG
monitoring.
On the floor, her exam slowly improved with increased
attentiveness but still some decreased fluency of speech. Her
EEG did not show any further seizures. To further evaluate the
cause of seizures, she received a contrast-enhanced Head CT on
[**2159-1-20**]
which did not reveal any abnormal enhancement. Her Levetiracetam
was decreased with the hopes of reducing her dose to a less
sedating standing dose; she was given 500mg on [**2159-1-20**] PM.
Overnight, she had a cluster of short seizures around 0215 with
motor manifestations which resolved with lorazepam 1 mg."
5563,"Around
0630 on [**2159-1-21**], she start to have clinical seizure activity
again with left head turn, left eye deviation, and left arm
myoclonic jerks which lessened but was followed by left foot
myoclonic jerks. She was given another LZP x 2mg without
resolution. Her
seizure started involving right hip/knee flexion, and right arm
raise to the nose. Levetiracetam 1500 mg was bolused, followed
by another LZP x 1mg and Fosphenytoin 1000 mg. She was
transferred back to the ICU for further monitoring and care for
status epilepticus.
The patient's seizures were able to be controlled on two agents."
5564,"2. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or T > 99.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. hydrochlorothiazide 12.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
6. baclofen 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day).
7. rosuvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily)."
5565,"Admitted to the
ICU for further care. EKG was reviewed, sinus with no block,
rapid repolarization but no significant ST changes and no TWI.
Overnight, there were no acute events. She remained
hemodynamically stable and her AM labs were all within normal
limits. On her second hospital morning, she had difficulty
producing words. On exam, she was afebrile and hemodynamically
stable with BPs overnight between 90-100 SBP, and satting 93-95%
on 2L/nC. There
were no remarkable abnormalities on her general physical
examination. Her neurologic examination was significant for a
transcortical motor aphasia with preserved repetition,
comprehension, [**Location (un) 1131**] but not writing."
5566,"Admission Date: [**2128-11-29**] Discharge Date: [**2128-12-1**]
Date of Birth: [**2054-10-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 74 year old male with a history of pulmonary
fibrosis with home O2 requirement of 2-3L, former smoker with
COPD, who presented on [**2128-11-28**] to [**Hospital6 33**] with
complaints of dyspnea.
The patinet has been followed for the last three years by Dr."
5567,"BCx were
no growth to date. He was treated with solumedrol and
levofloxacin with a pulmonology consultation. The patient was
transfered to [**Hospital1 18**] for further manegment.
Past Medical History:
Pulmonary Fibrosis with 2L Home O2
CAD, w/ stent in [**2125**] at [**Hospital1 336**] for UA
HTN
HLD
AAA s/p endograft repair in [**2124**]
Vasovagal syncope
COPD
Social History:
The patient is a widower. History of smoking, but quit in [**2108**]
after a bad pneumonia. He worked as both a professor as was
active in the US army Medicore. No history of significant
alcohol use. Live alone, but has invovled supportive family."
5568,"4. Mediastinal lymphadenopathy is consistent with reported
history of IPF.
Brief Hospital Course:
The patient is a 74 year old male with a history of IPF, COPD,
tobacco use who presents with hypoxia, tranfered for further.
mangement.
# Hypoxia: Most likely etiology of patient's hypoxia and dyspnea
is worsening of his underlying pulmonary fibrosis. He was
initially treated with antibiotics and steroids without any
improvement. He had a CT chest which showed worsening of his
underlying disease. His micro data did not show any new
microorganism. His viral respiratory panel was also negative.
He was maintained on a non-rebreather mask at 15L/min and nasal
cannula at 10L/min."
5569,"He was evaluated by palliative care, and
after much discussion with the patient and family, he was made
DNR/DNI and CMO with palliative care/hospice set up at home. He
will be discharged with morphine solution and oxygen for home
therapy. His other medications will be discontinued.
# CODE: DNR/DNI confirmed with patient- comfort measures only
# CONTACT: [**Known firstname **] [**Name (NI) 84017**] [**Name (NI) **] (Son and HCP)
Medications on Admission:
Advair 500/50 1 puff [**Hospital1 **]
Asprin 81mg daily
Atenolol 50mg daily
Boniva 150mg qmonth
Plavix 75mg daily
Spiriva 18mcg daily
Prednisone 5mg daily (has not been able to taper off steroids;
on for last 6 months)
Albuterol neb PRN
VB12
Fish Oil 300
Folic Acid
Glucosamine
MVI
Lovastatin 80mg qHS"
5570,"oxygen
high flow oxygen, 10-20L/min with non-rebreather mask
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA services
Discharge Diagnosis:
Primary Diagnosis: Idiopathic Pulmonary Fibrosis
Hypoxia
Discharge Condition:
hypoxia to 78-85% on high flow oxygen. unable to ambulate
without further hypoxia. Mental status normal and at baseline
Discharge Instructions:
You were admitted to [**Hospital1 18**] for worsening of your breathing and
low oxygen saturations. This is likely worsening of your
underlying pulmonary fibrosis. You were initially treated with
steroids and antibiotics, but there was no significant
improvement. A repeat CT scan showed evidence of worsening of
your disease. This is an end stage process. You were seen by
the palliative care team, and after further discussions with you
and your family, you decided to go home with hospice services.
You will be sent home with medications for your comfort.
Followup Instructions:
none"
5571,"He
had multiple dogs, but never had pet birds or other animals.
Family History:
No family history of malignancy, autoimmune idease, or lung
disease save for emphysema in his father.
Physical Exam:
General Appearance: Well nourished, No acute distress, On NRB
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Rhonchorous: diffuse dry rales
worse )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed"
5572,"His symptoms continued to worsen, and he began to notice audible
wheese and a marked decline in his dyspnea. On [**2128-11-28**] the
patients son found him to be hypoxic to the 70s on RA and
activated EMS. The patinet was treated intermittent BIPAP 10/5,
but was never able to maintain adequate oxygen saturations on
less than 50% venti-mask oxygen supplementation. CXR showed now
right middle and lower chest opacities which were felt to most
likely be consisent with airspace disease with possible
superimposed pneumonia. BNP was 517, urine leginlla was
negative, strep pneumoniae antigen were both negative."
5573,"Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1H as
needed for shortness of breath or wheezing.
Disp:*60 mL* Refills:*0*
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: [**11-27**] patches
Transdermal every seventy-two (72) hours.
Disp:*20 patch* Refills:*2*
3. Ativan 1 mg Tablet Sig: 0.5-2 Tablets PO every four (4) hours
as needed: sublingual.
Disp:*40 Tablet(s)* Refills:*0*
4. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*60 Tablet(s)* Refills:*2*
5."
5574,"2 Cl-104 HCO3-23 AnGap-16
[**2128-11-29**] 08:29PM BLOOD LD(LDH)-552*
[**2128-12-1**] 03:06AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
[**2128-11-30**] 04:54AM BLOOD Iron-22*
[**2128-11-30**] 04:54AM BLOOD calTIBC-255* Ferritn-821* TRF-196*
[**2128-11-30**] 11:40AM BLOOD Type-[**Last Name (un) **] pO2-62* pCO2-45 pH-7.35
calTCO2-26 Base XS-0
[**2128-11-30**] 11:40AM BLOOD Lactate-1.4
[**2128-11-30**] 11:40AM BLOOD freeCa-1.08*
[**2128-11-30**] 1:00 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab."
5575,"[**Last Name (NamePattern1) 84016**]at [**Hospital1 3278**], carying a diagnosis of IPF. He reports
to have been treated for many years for COPD, but describes a
change in his dyspnea in [**2125**]. Of note, in [**2124**] patient had an
oil spill in his basement with significant concrete dust in the
construction requiring hospitalization due to pulmonary
symptoms. He also describes a remote asbesstos exposure when in
the arm. He has been managed by Dr. [**First Name (STitle) **], but has never been on
any immunologic therapy. We have no recent CT scan or PFTs
available to us at this time. Over the last year, he has also
been on home O2, and has noted a progessive worsening of
symptoms over the last 6 months."
5576,"Pertinent Results:
[**2128-12-1**] 03:06AM BLOOD WBC-25.0* RBC-3.55* Hgb-10.2* Hct-30.5*
MCV-86 MCH-28.9 MCHC-33.6 RDW-14.5 Plt Ct-408
[**2128-11-29**] 08:29PM BLOOD Neuts-95.7* Lymphs-2.3* Monos-1.9* Eos-0
Baso-0.1
[**2128-12-1**] 03:06AM BLOOD Plt Ct-408
[**2128-12-1**] 03:06AM BLOOD Glucose-115* UreaN-22* Creat-1.1 Na-135
K-3.9 Cl-99 HCO3-25 AnGap-15
[**2128-11-29**] 08:29PM BLOOD Glucose-130* UreaN-25* Creat-1.1 Na-139
K-4."
5577,"Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final [**2128-11-30**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
IMPRESSION:
1. No pulmonary embolism.
2. Moderate progression of diffuse interstitial abnormality,
predominantly
subpleural reticulation and fibrosis. Honeycombing is new from
previous exam.
3. Diffuse ground-glass opacity superimposed on background
interstitial
changes. Findings are concerning for acute pulmonary edema, and
could be due to cardiogenic, or non-cardiogenic causes.
Differential includes acute drug reaction, and ARDS. Pneumonitis
secondary to infectious causes, such as PCP, [**Name10 (NameIs) **] also possible."
5578,"He has noted increasing dyspnea
and a slow escalation of O2 requirment. He was started on a
prednisone taper in [**4-3**], but has not been able to taper off
10mg daily. He is on a series of inhaler regimens given below,
but not currently anticoagulated. It does not seem the patient
has had a lung biopsy.
The patient had an admission to [**Hospital1 34**] in [**10-4**], for which he was
treated with a steroid burst and antibiotics for brochroncitis,
which improved but again gradualy worsended. It appears he was
on an extended course of azythromycin.
The patient noted that his respiratory symptoms worsened since
around the [**Holiday 944**] holiday, with incrasing dyspnea on
excersion, a productive cough with mildly blood tinged sputum."
5579,"Admission Date: [**2128-12-5**] Discharge Date: [**2128-12-16**]
Date of Birth: [**2071-11-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
Right hemiplegia
Headache with emesis
Major Surgical or Invasive Procedure:
[**2128-12-5**] Left craniotomy for microsurgical tumor resection and
hematoma evacuation.
Intubation/extubation
CT guided liver biopsy
Left PICC placement
History of Present Illness:
55 yo M with hx renal cell carcinoma s/p nephrectomy, HTN,
and HLD presented to [**Hospital1 18**] ER on [**12-4**] with R-sided hemipelgia.
On [**12-3**] patient noted some upper back discomfort and went to
bed but then woke up and vomitted."
5580,"He then went on to shower and
was found down by his wife and 911 was called and brought to
[**Hospital1 18**]. He arrived at [**Hospital1 18**] with a GCS of 15
and a code stroke was called. His NIHSS was 14. A CT head
revealed a large intraparenchymal hemorrhage and a neurosurgical
consult was called. While in the CT scanner the patient
deteriorated rapidly and was subsequently intubated and brought
to the OR.
Past Medical History:
Renal cell carcinoma, s/p nephrectomy approximately 5 years
prior
MRSA skin abscesses
HTN
infrarenal abdominal aneurysm
diverticulosis
hypercholesterolemia
MVP with moderate/severe MR"
5581,"Social History:
lives with wife, past history of alcohol abuse, current intake
unknown, has 3 children
Family History:
mother with pancreatic cancer
Physical Exam:
On Admission:
VS; BP 153/77 P 105 RR 20 100% on vent
Gen; intubated, sedated
Pulm; CTA b/l
CV; RRR, no murmurs
Abd; soft, NT, ND
Extr; no edema
Neuro; unable to perform neurological assessment as patient
received paralytic [**Doctor Last Name 360**] for urgent intubation and subsequent
craniotomy. As per neurology and ED teams, patient was alert
and
responsive at time of arrival. Exam was notable for left gaze
preference, RUQ visual field cut, plegic right arm and leg, and
mild-moderate aphasia."
5582,"3. Infrarenal abdominal aortic aneurysm and focal dissection of
the aorta
just above the bifurcation.
4. Moderate sigmoid diverticulosis, without evidence of acute
inflammation.
5. Small focal peripheral wedge-shaped hypodensity within the
spleen may
represent a small infarct.
6. New minimal pericardial fluid.
[**2128-12-11**] BLE ULTRASOUND:
IMPRESSION: No deep venous thrombosis within [**Month/Day/Year **] lower
extremity veins.
[**2128-12-14**] VIDEO SWALLOW:
IMPRESSION: Unremarkable swallow study.
[**2128-12-8**] TTE:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%)."
5583,"Repeat level should be drawn
and dose should be adjusted accordingly on [**2128-12-17**].
Bacitracin should be applied to surgical incision on scalp TID
for 7 days per NSGY recommendations. Any questions or concerns
regarding his incision after discharge
can be addressed by calling [**Telephone/Fax (1) 3231**] and asking for the NP
for Dr. [**Last Name (STitle) **] to be paged
2) MRSA bacteremia: During the patient's SICU course, the
patient developed a fever to 102 on [**12-6**]. He was also noted to
have thick secretions at that time as well. His blood cultures
were positive for MRSA."
5584,"He subsequently had a TEE which also showed no
vegetations, but there was posterior mitral leaflet flair with
severe MR. ID felt that this would warrant a full 6 week course
of antibiotic therapy as there may be some seeding or possible
endocarditis there. He will be maintained on vancomycin until
[**2129-1-18**]. He has a left sided PICC for access. ID will follow
as an outpatient.
3) Pneumonia: During the time the patient was in the SICU, there
was a CXR concerning for pneumonia. Most likely this represents
an aspiration pneumonia during the initial episode prior to
intubation."
5585,"14. Bacitracin 500 unit/g Ointment [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) for 7 days: apply to scalp incision.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left Intraparenchymal Hemorrhage s/p craniotomy
Mitral valve regurgiation with flail mitral valve
MRSA Bacteremia
Aspiration Pneumonia
Exophytic Liver Mass
Discharge Condition:
stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] and found to have a bleed in your
head. You had emergent surgery of your head on the neurosurgery
service, and had improvement of your neurological symptoms
during your hospitalization."
5586,"7 Calcium-9.0 Phos-3.7 Mg-1.4*
[**2128-12-14**] 05:22AM BLOOD Vanco-19.4
[**2128-12-5**] 09:57AM BLOOD Phenyto-12.9
[**2128-12-13**] 04:48AM BLOOD Phenyto-1.2*
Brief Hospital Course:
57M with PMH significant for renal cell carcinoma s/p
nephrectomy and MRSA skin abscesses who presented on [**12-4**] with
right hemipelgia.
1) Right hemiplegia: On [**12-5**], patient deteriorated and was
emergently intubated and brought to the OR for a left sided
craniotomy for evacuation. During surgery there was question of
an underlying lesion or cyst and the resected area was sent to
pathology for histology."
5587,"Pertinent Results:
Head CT [**12-5**]:
Note is made of a large intraparenchymal hemorrhage centered at
the
left frontal lobe, difficult to precisely marginate though
measuring
approximately 41 x 34 x 79 mm. Notably, this focus of hemorrhage
contains superolateral rim of frank parenchymal hemorrhage and
inferomedial to this is a 26 x 64 mm ovoid collection displaying
a blood-fluid level (2:23). The ventricles and sulci are normal
in size and in configuration. Extracranial soft tissue
structures are unremarkable. The included osseous structures
reveal no fracture or lesion. The visualized paranasal sinuses
are notable for mucus retention cysts at the maxillary sinuses
bilaterally, though most prominently on the left, as well as a
small amount of circumferential mucosal thickening at the
ethmoid air cells bilaterally."
5588,"In
this patient, status post right nephrectomy for renal cell
carcinoma, the findings are concerning for recurrent necrotic
tumor, perhaps in a retrocrural lymph node. Though abscess with
a thick rind of enhancement cannot be fully excluded, the lack
of reactive marrow change within the adjacent T12 vertebral
body, would be somewhat unusual.
Dedicated abdominal CT scan is recommended in further
evaluation.
2. Infrarenal aortic aneurysm, minimally changed from the prior
CT scan from [**2127**] with a maximal diameter measurement of
approximately 3.2 cm.
3. Edema versus artifactual signal overlying the left parotid
gland, which
should be correlated with clinical examination."
5589,"IMPRESSION: Large focus of intraparenchymal hemorrhage on the
left as described above. Diagnostic considerations include
metastatic disease in this patient with known history of
previous renal cell carcinoma, primary mass, and alternatively
vascular malformations. These findings may be further
characterized with an MRI.
C-spine CT [**12-5**]:
IMPRESSION:
No fracture. Multilevel DJD with Moderate canal stenosis and
moderate- severe left neural foraminal narrowing. Mild
effacement of the ventral thecal sac at C5/6. If concern exists
for ligamentous and intrathecal abnormalities recommend
further characterization with MR. [**First Name (Titles) **] [**Last Name (Titles) 60441**].
MRI Brain w/ & w/o [**12-6**]:
Status post left frontoparietal craniectomy with post-surgical
edema and
hematoma at the resection site."
5590,"The pathology returned as hemorrhage
and clot, there was no evidence of malignancy. Post-operatively
Mr. [**Known lastname **] was brought to the SICU. On [**12-6**] an MRI without
contrast was done which showed post-operative changes but no
lesion was seen. His neurologic symptoms progressively improved
during his hospitalization. At the time of discharge, he was
alert and oriented x 3, and was able to communicate with some
dysarthria, but mostly improved from admission. He continued to
have right sided weakness, but able to move slightly. He was
determined to be a candidate for rehab. Of note, initially, he
had difficulty swallowing and concern for aspiration pneumonia."
5591,"You will need to follow the
results of this with Dr. [**First Name (STitle) 1022**]. You will need to complete a 3
week course of vancomycin for the bacteria in your blood, and
complete an 8 day course of antibiotics for the pneumonia you
developed while you were in the hospital. You will be
discharged to a rehabilitation facility.
Please take all medications as prescribed.
The following medication changes were made during your
hospitalization:
1) Phenytoin 120 mg every 8 hours
2) Vancomycin 1250 mg IV Q12H for 6 week course (last day
[**2129-1-18**])
3) Furosemide 20 mg daily
4) Quetiapine 12."
5592,"An eccentric,
anteriorly directed jet of moderate to severe (3+) mitral
regurgitation is seen.
IMPRESSION: Mitral valve prolapse with moderate to severe MR. [**Name13 (STitle) **]
definite valvular vegetation seen. If indicated, a TEE would
better exclude a small valve vegetation.
[**2128-12-14**] TEE:
The left atrium is moderately dilated. No mass/thrombus is seen
in the left atrium or left atrial appendage. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve."
5593,"He was planned for PEG placement, but subsequent speech and
swallow consultation revealed that he had a good gag and
swallow, and after a video swallow, the patient was cleared for
solid foods with thin liquids, but medications to be crushed in
puree. He should have monitored eating at all time.
Patient will need to follow-up with Dr. [**Last Name (STitle) **] [**2129-1-11**] (appt in
the system) with a
Head CT. NSGY recommends no Aspirin, Coumadin, or Plavix until
follow-up appointment. He should continue Dilantin until seen by
Dr. [**Last Name (STitle) **]; Goal of [**11-30**]
(inpatient Dilantin levels have been corrected w/Albumin levels)
at current dose of 120 mg PO Q8H."
5594,"9. Quetiapine 25 mg Tablet [**Age over 90 **]: 0.5 Tablet PO DAILY (Daily):
please give dose at 1700 .
10. Furosemide 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day.
11. Vancomycin 500 mg Recon Soln [**Age over 90 **]: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 4 weeks: last day [**2129-1-18**].
12. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/insomnia.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily)."
5595,"No evidence of metastatic
disease.
No evidence of new hemorrhage or infarction.
Subdural thickening most consistent with post-surgical changes.
[**2128-12-12**] CXR:
Ill-defined opacities in the right upper and lower lobes
bilaterally have
improved consistent with improving pneumonia. There are no large
pleural
effusions. NG tube tip projects in the right upper quadrant as
before. Left PICC remains in place.
[**2128-12-9**] MRI C/T/L SPINE:
IMPRESSION:
1. 3-cm thoracic right paraspinal mass with a thick enhancing
rim and central fluid-intensity signal. There is no appreciable
bone marrow edema within the adjacent T12 vertebral body."
5596,"There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is moderate/severe mitral
valve prolapse. There is probable partial mitral leaflet flail
(posterior leaflet). No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Torn mitral chordae are present."
5597,"3. Lisinopril 40 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO once a day.
4. Senna 8.6 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**First Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Amlodipine 10 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO once a day.
7. Phenytoin 125 mg/5 mL Suspension [**First Name (STitle) **]: One [**Age over 90 **]y
(120) mg PO Q8H (every 8 hours).
8. Atenolol 100 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day."
5598,"Assigned Pathologist [**Last Name (LF) **],[**First Name3 (LF) **] H.
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**-1/4333**]
LIVER BIOPSY (1 JAR)
[**2128-12-15**] 05:49AM BLOOD WBC-9.1 RBC-3.50* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.8 MCHC-34.1 RDW-13.7 Plt Ct-393
[**2128-12-5**] 03:35AM BLOOD WBC-10.4 RBC-4.16* Hgb-13.5* Hct-37.4*
MCV-90 MCH-32.5* MCHC-36.1* RDW-13.6 Plt Ct-210
[**2128-12-15**] 05:49AM BLOOD Plt Ct-393
[**2128-12-13**] 04:48AM BLOOD PT-11."
5599,"[**2128-12-10**] CT ABDOMEN/PELVIS:
IMPRESSION:
1. Status post right nephrectomy. There is a right
paravertebral/retrocrural soft tissue lesion, likely
representing a necrotic lymph node. There is an exophytic mass
arising from segment VI of the liver, with extension into the
adjacent retroperitoneum. Findings are highly concerning for
metastatic renal cell carcinoma.
2. Right lower lobe consolidation with thin peripheral clearing.
Findings
could represent aspiration or organizing pneumonia. A nodular
opacity at the left lung base has some surrounding ground-glass
opacity and is likely
infectious or inflammatory. This does not have the typical
appearance for
metastatic renal cell carcinoma."
5600,"No aortic regurgitation is seen. There
is moderate/severe mitral valve prolapse. There is focal
posterior flail mitral leaflet. No mass or vegetation is seen on
the mitral valve. Severe (4+) mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
CONCLUSION: Severe MVP with a focal flail posterior mitral
leaflet. Severe mitral regurgitation. No evidence of
endocarditis.
[**2128-12-5**] PATHOLOGY
DIAGNOSIS: Parietal ""tumor"":
Blood clot, see note.
Note: No viable or necrotic epithelial tumor is detected.
Confirmed by cytokeratin cocktail.
[**2128-12-13**] TOUCH PREP CYTOLOGY
Touch prep of core, Liver: POSITIVE FOR MALIGNANT CELLS.
[**2128-12-13**] LIVER BIOPSY:
Report not finalized."
5601,"Dr.
[**First Name (STitle) 1022**] (PCP) will follow up on results and inform the patient and
his family accordingly. Follow up will be made with appropriate
providers based on the results of the pathology.
**Follow-up of liver mass pathology will be needed as it was
pending at the time of discharge
5) Nutrition: Cleared by video swallow study read as
unremarkable. Speech/swallow recommends normal solids and thin
liquid diet.
6) Agitation: Patient has been intermittently agitated during
stay, pulling foleys, NG tubes. At discharge, he'd been fairly
calm, including nights. He was maintained on uetiapine Fumarate
12."
5602,"Other possibilites include a MRSA pneumonia as
well. The patient completed an 8 day course of ceftazidime
while he was in the hospital, but will need to complete a course
of vancomycin as above. Of note, at the time of discharge he
was satting well on room air.
**Followup CXR should be performed in [**7-19**] weeks to ensure
resolution.
4) Exophytic mass on liver: During the hospital course, imaging
revealed a liver mass concerning for malignancy. The patient
had the mass biopsied under CT guidance. At the time of
discharge, the final path report is pending. Preliminary read
is that mass is neoplastic; otherwise not yet characterized."
5603,"Upon Discharge:
General: lying on back, 30 degree angle, A+Ox3
HEENT: head partially shaved/stitches from craniotomy visible,
no erythema or exudate. No scleral cterus. EOMI.
Cardiac: Regular rhythm, normal rate. Blowing systolic murmur,
III/VI, loudest in left axilla.
Lungs: mild bibasilar rhonchi, good air movement bilaterally
Abd: NABS, soft, NT, ND, no HSM
Extremities: right leg in contracture-prevention device. No
edema or calf pain bilaterally. Extremities warm and well
perfused.
Neuro: A&Ox3. Appropriate. Right hemiparesis. Light touch
sensation preserved throughout. 5/5 strength on left; 0/5 on
right.
Psych: Listens and responds to questions appropriately."
5604,"5 mg QPM
5) Bacitracin ointment to scalp TID
If you develop any of the following symptoms, please call your
PCP or go to the ED: fevers, chills, nausea, vomiting, weakness,
difficulty breathing, chest pain, or any other concerning
symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) **] (Neurosurgery):
CT scan [**2129-1-11**] 2:30pm Clinical Center [**Location (un) **]
Office with Dr. [**Last Name (STitle) **] [**2129-1-11**] 3:00pm LMOB [**Location (un) **] Ste 3B
Please call [**Location (un) 3230**] at [**Telephone/Fax (1) 3231**] to make any changes or with
questions. NO ASPIRIN OR COUMADIN UNTIL SEEN WITH DR. [**Last Name (STitle) **]
Dr. [**Last Name (STitle) **], cardiology, [**12-31**] at 3:20pm
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-1-11**] 2:30
Please follow up with Dr. [**First Name (STitle) 1022**] [**Telephone/Fax (1) 250**] within 1 month of
discharge.
Please make an appointment with Dr. [**Last Name (STitle) 914**] (Cardiac Surgery)
after the pt. is discharged from rehab. [**Telephone/Fax (1) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]"
5605,"7 PTT-23.6 INR(PT)-1.0
[**2128-12-5**] 03:35AM BLOOD Plt Ct-210
[**2128-12-5**] 03:35AM BLOOD PT-11.8 PTT-23.4 INR(PT)-1.0
[**2128-12-15**] 05:49AM BLOOD Glucose-121* UreaN-25* Creat-1.0 Na-139
K-4.1 Cl-103 HCO3-25 AnGap-15
[**2128-12-5**] 09:57AM BLOOD Glucose-207* UreaN-23* Creat-1.7* Na-134
K-4.6 Cl-102 HCO3-21* AnGap-16
[**2128-12-13**] 04:48AM BLOOD Albumin-3.1* Calcium-8.6 Phos-2.8 Mg-2.2
[**2128-12-5**] 09:57AM BLOOD Albumin-3."
5606,"5 mg PO DAILY in evening. Also, he will continue Lorazepam
0.5 mg IV Q4H:PRN agitation.
7) PPX: no anticoagulation given recent bleed, continue bowel
regimen
8) ACCESS: Left Picc
9) CODE: Full
Medications on Admission:
Aspirin 81 mg daily
Amlodipine 5 mg daily
Atenolol 100 mg daily
Lisinopril 40 mg daily
Ativan 0.5 mg q4h prn anxiety
Zocor 80 mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**First Name (STitle) **]: Ten (10) mL PO BID (2
times a day).
2. Simvastatin 80 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO once a day."
5607,"The patient was started on vancomycin
and ID was consulted at that time. He had complained of back
pain, and an MRI C/T/L spine showed a paraspinal lesion that was
concerning for a necrotic lymph node or mets, and CT Abd/pelvis
showed a large liver mass. Initially, there was concern for
abscess or other infectious source there, but radiology did not
feel this was likely infectious. The liver lesion was biopsied,
and prelim pathology read was likely malignancy, not infectious
though final read is pending at the time of discharge. Patient
had a TTE which showed severe mitral regurgitation, but no
vegetations."
5608,"Below is regarding your
neurosurgery follow up.
Neurosurgery Discharge Instructions:
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending. 10lb weight restriction x 4 weeks
??????If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, do not
restart until cleared by your neurosurgeon
??????If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]."
5609,"??????Please call the neurosurgeon's office if you experience: New
onset of tremors or seizures; Any confusion, lethargy 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; New onset of the loss of
function, or decrease of function on one whole side of your
body.
During your hospitalization, you were also found to have
bacteria in your blood. You had an extensive workup looking for
a source, but there was none evident at the time of discharge.
You also had a biopsy looking for infection, and this was
pending at the time of discharge."
5610,"History
Referral Date: [**2128-12-8**]
Reason for Referral: eval and treat
Medical Dx / ICD - 9: 432/ sdh
Activity Orders: oob with assist
HPI / Subjective Complaint: 57 year old male admit with right sided
weakness. found to have large left fronto- parietal hemorrhage and
tumor. taken to or for emergent left craniotomy and tumor/ hematoma
removal
Past Medical / Surgical History: htn, oa, gout, renal insufficiency
Labs
Hematocrit (serum): 31.1 ...
Hemoglobin: 10.6 ... g/dl
WBC: 9.9 ...
Platelet Count: 180 ...
Radiology
Radiology: Head CT: normal results s/p craniotomy
Occupational History
Occupational Profile: reports working as a realator
Baseline Occupational Performance: independent adl and iadl
Current Activities of Daily Living
Self Feeding: (Dependent)
Grooming: (Supervision)
UE Bathing: (Supervision)
LE Bathing: (max A)
UE Dressing: (mod A)
LE Dressing: (Supervision, max A)
Specify: cues for thoroughness with adl's."
5611,"Sensation: intact to light touch only on left ue
Integumentary: foley, aline left ue, piv right ue, nc, shovel mask
Team Communication: rn re patient status
Patient Education: role of ot, right ue elevation
Diagnosis
Diagnosis 1: decrease adl
Diagnosis 2: decrease mobility
Diagnosis 3: decrease cognition
Clinical Impression / Prognosis
Clinical Impression / Prognosis: 57 year old male s/p left fronto
parietal craniotomy now presenting with all abilities and limitations
above. pt is functioning below baseline and demonstrates the need to
d/c to rehab facility to maximize functional potential. recommend right
ue elevation for edema managent, daily rom of the extremeties, and
environmental setup to patients right side.
Goals: patient / family, objective, measurable
Goal 1: mod asssist le adl seated
Goal 2: mod assist commode tx
Goal 3: no cues for safety with seated grooming task
Time Frame (expected attainment): 1 week
Anticipated Discharge: Rehab
Treatment Plan: Interventions; patient / family education, community
resources
Treatment Plan: adl train, fxnl mobility, cog retraining, pt edu, d/c
plan
Frequency / Duration: 2x/wk
Therapist Information
Therapist's Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Date: [**2128-12-8**]
Time: 4:30 - 5:00
Pager #: [**Numeric Identifier 9450**]"
5612,"npo diet
Current Instrumental Activities of Daily Living
Home Management: Dependent
Money Management: Dependent
Performance Skills
Process Skills: alert, not oriented to year, follow 1 step commands,
fair insight, fair processing, left sided preference but can track to
right and turn head to right
Communication / Interactive Skills: pleasant and cooperative
Motor Skills - Functional Transfers
Rolling: (max A)
Supine / Side-lying to Sit: (max A)
Aerobic Capacity: Rest
Rest HR: 96
Rest BP: 146/70
Rest RR: 17
Rest O2 sat: 96 %
Supplemental O2: nc and shovel mask
Aerobic Capacity: Activity
Activity HR: 102
Activity BP: 180/62
Activity O2 sat: 96 %
Aerobic Capacity: Recovery
Recovery HR: 96
Recovery BP: 146/68
Recovery O2 sat: 96 %
Range of Motion
Range of Motion: bilateral ue intact
Muscle Performance: strength, power, endurance
Muscle Performance: flaccid right ue, left ue [**6-15**]
Additional Performance Skills
Motor Control: flaccid right ue
Coordination: used left ue only for adl
Limiting Symptoms: complains of right elbow pain with rom."
5613,"TITLE: BEDSIDE SWALLOWING EVALUATION:
HISTORY:
Thank you for consulting on this 55 y/o male with hx renal cell
carcinoma s/p nephrectomy, HTN, and HLD who was admitted to [**Hospital1 5**]
on [**2128-12-5**] with R-sided weakness, posterior neck pain, headache,
vomiting, and unsteady gait. Head CT upon arrival revealed a
large intraparenchymal hemorrhage suspicious for
possible underlying mass. While in the CT scanner the patient
deteriorated rapidly and was subsequently intubated. Patient was
taken to the OR for emergent tumor resection and hematoma
evacuation. Patient further c/b VAP. Patient was extubated on
[**2128-12-7**]."
5614,"Reduced labial seal and buccal
tone. Unable to assess palatal elevation [**3-15**] patient with minimal
mouth opening. No gag upon yankauer suctioning.
SWALLOWING ASSESSMENT:
PO trials included ice chips, thin liquids and nectar thick
liquids via small cup sips. Patient was unable to pull liquid up
through the straw. Oral phase was grossly wfl without oral
residue remaining. Laryngeal elevation felt reduced to palpation.
Throat clearing and coughing was noted on all PO trials. O2 sats
fluctuated between 92%-94%/95%.
SUMMARY / IMPRESSION:
Mr. [**Known lastname **] presents with baseline secretions he appears unable to
clear on his own. He was noted with s/sx of aspiration on all PO
trials."
5615,"We were consulted to evaluate patient's oral and
pharyngeal swallowing function and r/o aspiration while eating
and drinking.
PMHx;
Renal cell carcinoma, s/p nephrectomy approximately 5 years prior
EVALUATION:
The examination was performed while the patient was seated
upright in the chair on the SICU with shovel mask and nasal
cannula.
Cognition, language, speech, voice: Patient was awake, lethargic,
but stayed awake with cues. He was oriented to self and place and
followed a few commands with models. Patient with consistent
moaning/grunting and voice wfl. Speech was dysarthric and mostly
unintelligible.
Teeth: present dentition
Secretions: normal oral secretions from what I could see
ORAL MOTOR EXAM:
Tongue protruded weakly midline."
5616,"Recommend he remain NPO. We will return tomorrow to
repeat assessment to give more time to recover from extubation,
however if patient's status does not improve he may need
alternate means of nutrition.
This swallowing pattern correlates to a Functional Oral Intake
Scale (FOIS) rating of level 1, NPO.
RECOMMENDATIONS:
1. Continue NPO status.
2. Q4 oral care.
3. Meds IV as able.
4. We will return tomorrow to repeat the evaluation.
5. If patient's status does not improve he may need alternate
means of nutrition via tube feeds.
These recommendations were shared with the patient, nurse and
medical team.
____________________________________
[**First Name11 (Name Pattern1) 5241**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5628**], M.S., CCC-SLP
Pager #[**Numeric Identifier 5629**]
Face time: 0945-0955
Total time: 45 minutes"
5617,"Admission Date: [**2141-5-10**] Discharge Date: [**2141-5-18**]
Date of Birth: [**2070-4-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain and dyspnea
Major Surgical or Invasive Procedure:
[**2141-5-12**] 1. Urgent coronary artery bypass graft x3 -- left
internal mammary artery to the diagonal, vein graft to the
distal left anterior descending artery, and vein graft to the
right coronary artery. 2. Aortic valve replacement with a size
23 mm [**Doctor Last Name **] Magna Ease tissue valve.
History of Present Illness:
71 y/o Hispanic male with PMH significant for PVD, DM, and
hypertension who presented with fatigue after walking 2 to 3
blocks."
5618,"Presented with chest
discomfort in upper chest unrelated to activity. ECHO on [**2141-4-11**]
showed mild concentric LVH with EF of 60-65%, sever AS with mean
gradient of 53 mm HG and [**Location (un) 109**] of .63 cm2. Cardiac cath today
showed severe AS with mean gradient of 54 mm Hg and [**Location (un) 109**] of .77
cm2, 50% ostial lesion of RCA, 70% D1 and diffuse disease of
LCx. Transferred to [**Hospital1 18**] for further evaluation and treatment
Past Medical History:
Coronary artery disease
IDDM
hyperlipidemia
moderate aortic valve stenosis with a valve area of [**12-4**]."
5619,"2 cm2
psoriasis
Social History:
The patient lives with his wife in an apartment complex. He is
primarly Spanish speaking and denies tobacco, alcohol, or
illicit drug use.
Family History:
N/C
Physical Exam:
General: NAD, alert, cooperative
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 [x] grade _3-4/6 SEM across
precordium_____
Abdomen: Soft [x] non-distended [x] non-tender []x bowel sounds
+
[x]
Extremities: Warm [], well-perfused [] Edema [] _____
Varicosities: None [][**12-5**]+ left pretibial edema with stasis
dermatitis and amputation of rightsecond and third toes
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right:+1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +1 Left:+2"
5620,"Metoprolol Tartrate 50 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *Lopressor 50 mg twice a day Disp #*90 Tablet Refills:*2
11. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg daily Disp #*7 Tablet Refills:*0
12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
Hold for K >
RX *potassium chloride 20 mEq daily Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis
Coronary artery disease
Diabetes
Peripheral [**Location (un) 1106**] disease
Hypertension
post-op urinary retention"
5621,"CXR [**5-17**]:
Intact sternomy wires. Aortic valve prosthesis. Unchanged L
hemidiaphragm
elevation and atelectasis.
[**2141-5-17**] 06:02AM BLOOD WBC-6.4 RBC-3.37* Hgb-9.3* Hct-29.7*
MCV-88 MCH-27.7 MCHC-31.4 RDW-13.6 Plt Ct-113*
[**2141-5-17**] 06:02AM BLOOD Plt Ct-113*
[**2141-5-13**] 02:58AM BLOOD PT-15.4* PTT-36.7* INR(PT)-1.4*
[**2141-5-17**] 06:02AM BLOOD Glucose-148* UreaN-21* Creat-1.0 Na-138
K-3.9 Cl-104 HCO3-24 AnGap-14
[**2141-5-12**] 04:30AM BLOOD ALT-117* AST-133* LD(LDH)-310*
AlkPhos-130 TotBili-1."
5622,"All narcotics were discontinued and his
pain was managed with Tylenol only. Over the next day, his
mental status cleared. Aspirin, beta blocker, statin therapy and
diabetic management were continued. Mild confusion noted again
on POD#4 and Ultram was discontinued.. Confusion improved. POD#5
he went into rapid a-fib and remained in it for several hours,
was started on Amio and returned to SR for 24 hours prior to
discharge. He failed first and second voiding trial, urology was
consulted and it was determined that he would be discharged to
home with the foley in place and will follow up with urology as
an outpatient."
5623,"There
is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**First Name (STitle) **] was notified in person of the results before surgical
incision.
POST-BYPASS:
Preserved biventricular systolic functin.
LVEF 55%.
Intact thoracic aorta.
The bioprosthetic valve in the native aortic position is well
seated and moving well. The peak is 15 and mean is 5 mm of Hg.
Trivial MR>
.
[**2141-5-13**] Head CT
Arterial calcifications and signs of chronic sphenoid sinus
inflammation, otherwise normal study."
5624,"Carotid Bruit Right:murmur transmits to carotid
Left:murmur transmits to carotid
Pertinent Results:
[**2141-5-11**] Carotid ultrasound
Impression: Right ICA less than 40% stenosis. Left ICA less than
40% stenosis
.
[**2141-5-11**] CTA
1. No evidence of aortic aneurysm. No ascending aortic
calcifications with calcifications seen only at the level of the
aortic valve.
2. Extensive calcifications of the aortic valve itself
consistent with known aortic valve stenosis. Extensive coronary
calcifications.
3. Right lower lobe 6 mm spiculated nodule that should be
reassessed in three months for assessment of stability to
exclude the possibility of neoplastic growth."
5625,"Medications on Admission:
aspirin 81 mg QD, glipizide 5 mg QD, glucophage 1000 mg [**Hospital1 **],
lisinopril 5 mg QD, metoprolol extended release 50 mg QD
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
RX *acetaminophen 325 mg q 6 hours Disp #*60 Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg daily Disp #*30 Tablet
Refills:*2
3. MetFORMIN (Glucophage) 1000 mg PO BID
RX *Glucophage 1,000 mg twice daily Disp #*90 Tablet Refills:*0
4. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg daily Disp #*60 Tablet Refills:*2
5."
5626,"Additional
pulmonary nodules mentioned in the body of the report can be
reassessed at the same time.
[**2141-5-12**] ECHO
PRE-BYPASS:
The left atrium is dilated. 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 mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are severely thickened/deformed."
5627,"Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol only
Incisions:
Sternal - Healing well, no erythema, no tenderness - minimal
serosanginous drainage from mid sternal pole
Leg Left - healing well, no erythema or drainage.
Edema trace lower extremity edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided."
5628,"[**First Name (STitle) **]:[**2141-6-20**] at 2:15p
Cardiologist: [**Doctor Last Name 29070**] [**2141-6-9**] at 8:45a
Wound check: [**2141-5-23**] 10:45
[**Hospital 159**] Clinic for voiding trial: [**Last Name (LF) 5929**], [**5-25**] at 4:00 PM with
[**Name6 (MD) **] Crohn, NP - Shipiro Building [**Location (un) 470**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-9**] weeks
***Nodular opacity of CT scan seen on this admission - NEEDS
FOLLOW UP CT SCAN IN 6 MONTHS***
Scheduled appointments:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2141-6-2**]
9:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2141-6-2**] 10:30
**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:[**2141-5-18**]"
5629,"Labs showed that he had
elevated liver function studies. On [**2141-5-12**], Mr. [**Known lastname 13621**] was taken
to the operating room where he underwent coronary artery bypass
grafting to three vessels and replacement of his aortic valve
with a tissue valve. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next several hours he awoke and was
extubated. He was noted to have some confusion, hallucinations
and somnolence. A head CT scan was obtained which was negative.
The stroke service was consulted who suspected a metabolic or
possible infectious etiology to his confusion- no acute
infection was detected."
5630,"After second foley placement his urine was noted
to be cloudy. A UA C&S was sent and he was started on Cipro.
Cultures were negative and Cipro was discontinued. He was noted
to have some serosanguinous drainage from his mid sternal pole.
He was afebrile, CXR showed intact wires, and WBC was normal. He
was sent home on no antibiotics and will return for a wound
check on [**5-23**]. He was seen by the physical therapy department
and cleared for discharge. By time of discharge on POD #6 he was
deemed safe for discharge to home. Follow-up appointments were
advised."
5631,"4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Keep your urine catheter in place until you are advised by the
VNA or your primary care doctor to remove it.
**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:
The office will call you and schedule the following appointments
your Surgeon:
Dr."
5632,"0
Brief Hospital Course:
Mr. [**Known lastname 13621**] was transferred to the [**Hospital1 18**] on [**2141-5-10**] for surgical
management of his aortic valve and coronary artery disease. He
was worked-up in the usual preoperative manner. A carotid duplex
ultrasound was obtained which showed less then a 40% bilateral
internal carotid artery stenosis. A dental consult was obtained
which found no contraindication for surgery after obtaining a
Panorex x-ray of his teeth. A chest CT scan was performed which
showed no significant aortic calcifications but did note a right
lower lobe 6 mm spiculated nodule that should be reassessed in
three months for assessment of stability to exclude the
possibility of neoplastic growth."
5633,"Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg bedtime Disp #*30 Tablet Refills:*0
6. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days
Hold for K+ > 4.5
RX *K-Tab 10 mEq twice daily Disp #*28 Tablet Refills:*0
7. Glargine 24 Units Bedtime
8. Amiodarone 400 mg PO BID
for 6 more days starting [**5-18**] then 400mg daily for 1 week, then
200mg daily
RX *amiodarone 200 mg twice a day Disp #*90 Tablet Refills:*2
9. GlipiZIDE XL 10 mg PO DAILY
RX *glipizide 10 mg daily Disp #*60 Tablet Refills:*2
10."
5634,"Admission Date: [**2191-6-24**] Discharge Date: [**2191-7-1**]
Date of Birth: [**2114-4-1**] Sex: M
Service: SURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreatic mass
Major Surgical or Invasive Procedure:
[**2191-6-24**]:
1. Pylorus-Preserving Pancreaticoduodenectomy
2. Harvest of left internal jugular vein and portal vein
excision with reconstruction
History of Present Illness:
The patient is a very pleasant 77-year-old who had presented in
[**Month (only) 958**] with acute pancreatitis. On imaging studies, he was noted
to have a mass in the head of the pancreas. He subsequently
underwent endoscopic ultrasound with fine-needle aspiration."
5635,"Dr. [**First Name (STitle) **] evaluated the patient for
possible Whipple procedure secondary to highly suspicious
brushing results. During the evaluation all risks, goals and
benefits were discussed with the patient and his family, and
patient was scheduled for elective Whipple on [**2191-6-24**].
Past Medical History:
PMH: HTN, vertigo episodes x2, Giant cell arteritis [**2188**], CAD
PSH: lap CCY [**2191-5-19**]
Social History:
He has an 18-pack-year history of tobacco, but quit 13 years
ago. He drinks alcohol only occasionally. There are no
environmental exposures.
Family History:
Mr. [**Known lastname 92312**] reports a family history of pancreatic cancer."
5636,"On same day, the
patient underwent pylorus-preserving pancreaticoduodenectomy
(Whipple) and portal vein excision with reconstruction, which
went well without complication. The patient was transferred in
ICU after operation for observation. On POD # 1, patient was
extubated and was transferred on the floor NPO with an NG tube,
on IV fluids, with a foley catheter and a JP x 2 drain in place,
and epidural catheter for pain control. The patient was
hemodynamically stable.
Neuro: The patient received Fentanyl/Bupivacaine via epidural
catheter with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications."
5637,"No insulin
was needed upon discharge.
Hematology: The patient was transfused with 2 units of pRBC
intraoperatively secondary to blood loss. Post op patient's
complete blood count was examined routinely; no further
transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan."
5638,"lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Carenet
Discharge Diagnosis:
Locally advanced cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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 [**6-9**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions."
5639,"Electrolytes were routinely
followed, and repleted when necessary. The patient had two JP
drains placed intraoperatively. On POD # 4, one JP output
increased up to 1 L and patient underwent liver doppler to rule
out portal vein obstruction. The doppler revealed patent main
and right portal veins, but left portal vein was doppler was
limited. The patient's JP # 1 output still high, JP bilirubin
was sent and was elevated (7). On POD # 5, patient underwent
abdominal CT which demonstrated patent main, left and right
portal veins; however, some non-critical narrowing of the
presumed graft. The patient's JP output was started to slow
down."
5640,"Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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.
*If you have staples, they will be removed at your follow-up
appointment.
.
JP x 2 Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever)."
5641,"Cytology on these aspirates was nondiagnostic. He
subsequently developed obstructive jaundice and on [**Month (only) **], he was
noted to have a biliary stricture. A biliary stent was placed.
He underwent a laparoscopic cholecystectomy with a presumed
diagnosis of gallstone pancreatitis. The subsequent CT scan
images showed complete resolution of pancreas mass. However,
repeat [**Month (only) **] showed persistence of biliary stricture. Brushings
of the biliary stricture are suspicious for adenocarcinoma. The
patient is well known for Dr. [**First Name (STitle) **] and she was followed the
patient along. The patient also had cholecystectomy done with
Dr. [**First Name (STitle) **] in the past."
5642,"CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Metoprolol was
restarted on POD # 1. On POD # 2, patient was started on Aspirin
325 mg daily per Vascular Surgery, he was discharge home on this
medication as well.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: Post-operatively, the patient was made NPO with IV fluids.
Diet was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary."
5643,"His
sister died of it at age [**Age over 90 **]. There is no other history of
pancreatic disease or GI malignancy.
Physical Exam:
On Discharge:
VS: 98.6, 70, 138/69, 12, 95% RA
GEN: Pleasan with NAD
NECK: Left longitudinal incision open to air with steri strips
and c/d/i
CV: RRR
RESP: CTAB
ABD: Bilateral subcostal incision open to air with staples,
minimal erythema on middle portion of incision. RLQ JP drains x
2 to bulb suction, site c/d/i and covered with drain dressing.
EXTR: Warm, no c/c/e
Pertinent Results:
[**2191-6-29**] 06:20AM BLOOD WBC-6."
5644,"Medications on Admission:
Diazepam 5mg PRN; Lisinopril 5mg'; Metoprolol tartrate 12.5mg'';
Percocet PRN; ASA 81mg'; Calcium carbonate; Vitamin D3; Centrum
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours)."
5645,"On POD # 6 JP amylase was sent from both drains and was
normal. The patient was discharged home with both JP to continue
monitor their output.
GU: The foley catheter discontinued at midnight of POD#4. The
patient subsequently voided without problem.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound was evaluated
daily and small area of erythema was noticed on the middle part
of the incision on POD # 3. The erythema subsided prior
discharge, and though to be cause by staples.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly."
5646,"5 RBC-3.38* Hgb-10.7* Hct-33.0*
MCV-98 MCH-31.5 MCHC-32.3 RDW-14.1 Plt Ct-205#
[**2191-6-29**] 06:20AM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-139
K-4.0 Cl-105 HCO3-29 AnGap-9
[**2191-6-29**] 06:20AM BLOOD ALT-81* AST-82* AlkPhos-91 TotBili-2.7*
[**2191-6-29**] 06:20AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.9
[**2191-6-30**] 09:55AM ASCITES Amylase-10
[**2191-6-30**] 09:55AM ASCITES Amylase-12
[**2191-6-29**] 10:16AM ASCITES TotBili-7."
5647,"*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You 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 yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2191-7-11**] at 2:15 PM
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
.
Please follow up with Dr. [**Last Name (STitle) **] (PCP) in [**3-4**] weeks after
discharge
Completed by:[**2191-7-1**]"
5648,"7 Albumin-LESS THAN
[**2191-6-28**] LIVER DOPPLER:
IMPRESSION:
1. Patent main and right portal veins. Flow within the left
portal vein could not be detected. This could be due to
technical factors or slow flow, however a thrombosed LPV cannot
be excluded.
2. Pneumobilia
3. Right pleural effusion.
[**2191-6-29**] ABD CT:
IMPRESSION:
1. Patent main, left and right portal veins; however, some
non-critical
narrowing of the presumed graft.
2. Small non-hemorrhagic pleural effusions with adjacent
compressive
atelectasis.
3. Generalized anasarca.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2191-6-24**] for elective Whipple procedure."
5649,"5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*5*
8. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
9. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
10."
5650,"Admission Date: [**2110-2-28**] Discharge Date: [**2110-3-6**]
Date of Birth: [**2092-3-18**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
wound infection, intra-abdominal abscess
Major Surgical or Invasive Procedure:
CT guided drainage of abscess with pigtail drain placement
History of Present Illness:
17 M s/p appendectomy at [**Hospital3 2737**] on [**2-17**] for
perforated appendicitis. The patient recovered well and had an
initial improvement in his symptoms and leukocytosis. On POD2
the
patient started experiencing worsening abdominal pain, nausea
and
vomiting and was transferred to the OSH ICU where a CT was
obtained showing postoperative changes and continued
inflammation
but no clear abscess."
5651,"Past Medical History:
PMH: Hypogammaglobulinemia
PSH: Appendectomy [**2110-2-17**], ex-lap LOA, end ileostomy [**2110-2-21**]
Social History:
senior in high school, no ETOH, tobacco or drugs, active
football player
Family History:
no immunodeficiencies, 2 siblings - one with ? diagnosis of SLE,
other healthy
Physical Exam:
On Discharge:
AVSS
GEN: resting comfortably, NAD
CV: RRR
Lungs: CTAB
ABD: Open midline abdominal wound with wet/dry dressing in
place. Appropriately tender around the wound. Ostomy
pink/viable.
EXT: warm, well perfused
Pertinent Results:
[**2110-2-28**] 04:05AM BLOOD WBC-18.0* RBC-3.82* Hgb-11.3* Hct-34."
5652,"1. Two discrete collections are again visualized throughout the
abdomen and pelvis. The previously aspirated, but not drained
collection along the right paracolic gutter appears relatively
unchanged with a focus of air consistent with prior
instrumentation. The right lower quadrant collection with
extension to pelvis which was aspirated and had a drain placed
appears smaller with resolution of the lateral and superficial
portion of the collection anterior to the right psoas muscle.
2. Moderate left pleural effusion, which is increased in size in
comparison to prior study with adjacent atelectasis. Small right
pleural effusion with adjacent atelectasis.
Brief Hospital Course:
Mr."
5653,"Neuro: His pain was initially well controlled on intermittent IV
dilaudid. When tolerating po intake, the patient was switched to
vicodin, which was well tolerated.
CV: He arrived tachycardic with stable blood pressure. This
improved quickly during his hospital stay, and he had no other
issues.
Resp: He had significant oxygen demand upon arrival and CXR
showed bilateral effusions and atelectasis. Sputum cultures were
drawn that were insufficient. Patient was concurrently being
treated with vancomycin and meropenem for his intra-abdominal
abscesses, which was determined to be sufficient for presumed
pneumonia as well. The patient was also given intermittent lasix
to improve his respiratory status as his lungs looked fluid
overloaded."
5654,"Disp:*30 Capsule(s)* Refills:*0*
10. Outpatient Lab Work
LAB TESTS: CBC, Bun, Crea, LFTs, ESR, CRP
FREQUENCY: Qweekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
Discharge Disposition:
Home With Service
Facility:
[**Telephone/Fax (1) 269**] of Southeastern Mass.
Discharge Diagnosis:
wound infection, intra-abdominal abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*New chest pain, pressure, squeezing or tightness.
*New or worsening cough, shortness of breath, or wheeze."
5655,"Disp:*22 Tablet(s)* Refills:*0*
6. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 syringes* Refills:*0*
7. Normal Saline Flush 0.9 % Syringe Sig: One (1) syringe
Injection PRN as needed for drain or PICC line flush.
Disp:*100 * Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
9. loperamide 2 mg Capsule Sig: [**12-22**] Capsules PO With meals and
at bedtime as needed for ostomy output greater than 1200cc/day."
5656,"His open abdominal wound was treated with wet/dry
dressing changes TID, and showed continued healing and
improvement during his stay.
ID: He was seen by our ID team upon arrival who recommended
switching imipenem to meropenem. He was also started on
vancomycin at arrival for presumed PNA. His abdominal wound was
packed with wet to dry dressings. Abdominal fluid collections
showed vanc sensitive enterococcus and [**Female First Name (un) **], so fluconazole
was added as well. The patient was kept on this antibiotic
regimen during his hospital stay. PICC line was placed on [**3-3**]
to continue atbx as an outpatient."
5657,"[**Known lastname 89930**] was transferred to our trauma surgical intensive
care unit from [**Hospital3 **] early in the AM of [**2110-2-28**]. He
was seen by Dr [**Last Name (STitle) **] and his team, and based on the fluid
collections seen on OSH CT scan, he was sent to IR for
percutaneous drainage. The IR team aspirated the right paracolic
gutter collection and left a drain in the pelvic collection.
This fluid was sent for culture. The patient was initially
tachycardic upon admission to the ICU, but was otherwise
hemodynamically stable. He was transferred to the floor on HD4
in good condition."
5658,"3*
MCV-90 MCH-29.7 MCHC-33.0 RDW-13.9 Plt Ct-543*
[**2110-3-4**] 06:35AM BLOOD WBC-8.6 RBC-3.59* Hgb-10.6* Hct-32.2*
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.9 Plt Ct-642*
[**2110-2-28**] 04:05AM BLOOD Glucose-106 UreaN-11 Creat-0.9 Na-137
K-5.1 Cl-101 HCO3-27 AnGap-14
[**2110-3-4**] 06:35AM BLOOD Glucose-86 UreaN-9 Creat-0.7 Na-139 K-4.8
Cl-102 HCO3-28 AnGap-14
CT abd/pel ([**3-5**]):
IMPRESSION:"
5659,"These effusions were followed with serial CXRs and
improved throughout his stay. He was weaned off of oxygen on the
floor and his breathing remained comfortable.
GI/GU/FEN: The patient was initially NPO/IVF upon admission. His
diet was advanced to regular by HD3 and this was well tolerated.
Ostomy output was nearly 2 liters the first 24 hours of
admission. The output remained high the first few days of his
hospital stay, but then decreased on its own to an appropriate
level without medical intervention. His electrolytes and fluid
status were closely monitored and patient was repleted as
needed."
5660,"*Please do not engage in any strenous activity until instructed
to do so by your surgeon.
.
Wound Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the wound
site.
*No showering, tub baths, or swimming until cleared by Dr.
[**Last Name (STitle) **] at your follow-up appointment. You may sponge bath
until then.
*Please perform wet-to-dry dressing changes three times daily.
You will have a visiting nurse come to help assist you with
dressing changes, and they will teach you how to perform these
dressing changes yourself.
.
Drain Care:"
5661,"*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 is 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."
5662,"*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or [**Last Name (STitle) 269**] nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output
daily.
*Keep the insertion site clean and dry otherwise.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Monitoring ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily."
5663,"Medications on Admission:
zyrtec
Discharge Medications:
1. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. vancomycin 500 mg Recon Soln Sig: 1.5g Recon Solns
Intravenous Q 8H (Every 8 Hours): Through [**3-8**].
Disp:*12 Grams* Refills:*0*
4. meropenem 500 mg Recon Soln Sig: 500mg Recon Solns
Intravenous Q6H (every 6 hours): Through [**3-17**].
Disp:*23 grams* Refills:*0*
5. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Through [**3-17**]."
5664,"Required laboratory monitoring while on IV antibiotics:
LAB TESTS: CBC, Bun, Crea, LFTs, ESR, CRP
FREQUENCY: Weekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**]
MD in when clinic is closed.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-3-20**].
Please come to Dr.[**Name (NI) 1482**] clinic at 8:15am to receive the
contrast for your scan. You will then have the CAT scan at
9:30am.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2110-3-20**] 10:45am. You will see Dr. [**Last Name (STitle) **] after
your CAT scan to go over the results.
3. Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2110-3-25**] 9:30am
Completed by:[**2110-3-7**]"
5665,"He was taken to the operating room for a
exploratory laporotomy on [**2-21**] where, per report, an enterotomy
or
perforation was identified in the terminal ileum. An ileal
resection was performed and an end ileostomy was placed, and the
patient was taken to the ICU for further recovery. Following the
procedure the patient continued to have abdominal pain and
increasing leukocytosis up to [**Numeric Identifier 3301**]. His midline laparotomy
wound
was opened [**1-22**] wound infection. The patient had been receiving
Zosyn and Flagyl and was then switched to Imipenem per ID
recommendation. A repeat CT was obtained on [**2-27**] and
demonstrated
multiple fluid collections and the patient was transferred to
[**Hospital1 18**] for further management."
5666,"DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.
*Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse
if the dressing comes undone or is significantly soiled for
further instructions.
.
Antibiotic Instructions:
*You will be receiving IV antibiotic therapy through your PICC
line. Per Infectious Disease recommendations, you will be on the
following regimen:
Vancomycin 1.5g IV every 8 hrs
Start date: [**2110-2-28**]
Stop date: [**2110-3-8**]
Meropenem 500mg IV every 6 hrs
Start date: [**2110-2-27**]
Stop date: [**2110-3-17**]
Fluconazole 400mg PO daily
Start date: [**2110-2-27**]
Stop date: [**2110-3-17**]"
5667,"*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*If ostomy output is greater than 1200mL in one day, please use
Immodium to slow down the output: 2-4mg with meals and at
bedtime, as needed. Do not exceed 16mg/24 hours.
.
PICC Line Care:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely."
5668,"*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.
.
General Discharge Instructions:
*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 [**4-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
*Avoid driving or operating heavy machinery while taking pain
medications."
5669,"Repeat CT scan was performed
on [**3-5**] that showed persistent abscesses in the pelvis and R
pericolic gutter. However, after patient's drain was adequately
flushed, the drain began to put out purulent material. Radiology
felt the drain was in good position and did not need to be
re-adjusted. The patient was sent home on meropenem, vancomycin,
and fluconazole per ID's recommendations.
Prophylaxis: Patient was started on SQH and encouraged to
ambulate often.
Dispo: Patient received ostomy teaching, Picc line teaching, and
wound care teaching. He understood all of this and agreed with
the plan. He was given discharge instructions and told to keep
all follow up appointments as scheduled."
5670,"o. F s/p total colectomy and end ileostomy for severe c diff
colitis and subsequent perforation. Pt remains intubated and sedated
on propofol, and CVVHD was started for ARF. Note that propofol gtt is
providing ~600kcals/day at current rate. If TF will be started, a
lower goal rate will be needed temporarily due to propofol gtt to avoid
overfeeding pt.
Medical Nutrition Therapy Plan - Recommend the Following
1) If medically stable, rec try trophic TF, Fibersource @
10cc/hr. If tolerated, advance slowly by 10cc q6-8hrs to goal of
45cc/hr. This is pt
s TF goal if propofol gtt is still running."
5671,"Pertinent medications: Propofol, Citrate gtt, Abx, others noted
Labs:
Value
Date
Glucose
137 mg/dL
[**2193-2-26**] 09:27 AM
Glucose Finger Stick
173
[**2193-2-26**] 10:00 AM
BUN
44 mg/dL
[**2193-2-26**] 02:54 AM
Creatinine
2.9 mg/dL
[**2193-2-26**] 02:54 AM
Sodium
133 mEq/L
[**2193-2-26**] 09:27 AM
Potassium
3.7 mEq/L
[**2193-2-26**] 09:27 AM
Chloride
99 mEq/L
[**2193-2-26**] 02:54 AM
TCO2
25 mEq/L
[**2193-2-26**] 02:54 AM
PO2 (arterial)
112 mm Hg
[**2193-2-25**] 12:50 AM
PO2 (venous)
48 mm Hg
[**2193-2-24**] 07:46 AM
PCO2 (arterial)
44 mm Hg
[**2193-2-25**] 12:50 AM
PCO2 (venous)
40 mm Hg
[**2193-2-24**] 07:46 AM
pH (arterial)
7."
5672,"2) If pt off propofol gtt, TF goal will be Fibersource @ 65cc/hr
(1872kcals, 83g protein).
Following
please page with ?
s #[**Numeric Identifier 977**]
------ Protected Section ------
Noted that team ordered for pt to start Day 1 std TPN today. Note that
pt should not receive lipid in TPN if she continues on propofol gtt.
Please check TG
s, if <400, lipid can be added to TPN after propofol
gtt is off. If pt tolerates, rec adv to Day 2 std TPN [**2-27**]. Goal TPN
if pt continues on propofol gtt is 1400mL (245g dextrose, 95g amino
acid). If propofol gtt is d/c
d, rec TPN goal of 1700mL (300g
dextrose/ 95g amino acid/ 45g lipid) = 1850kcals.
Page with ?
s #[**Numeric Identifier 977**]
------ Protected Section Addendum Entered By:[**Name (NI) 544**] [**Last Name (NamePattern1) 3030**], RD, [**Name (NI) 399**]
on:[**2193-2-26**] 12:13 ------"
5673,"23 units
[**2193-2-25**] 12:50 AM
pH (venous)
7.29 units
[**2193-2-26**] 03:12 AM
pH (urine)
5.0 units
[**2193-2-21**] 07:29 PM
CO2 (Calc) arterial
19 mEq/L
[**2193-2-25**] 12:50 AM
CO2 (Calc) venous
21 mEq/L
[**2193-2-24**] 07:46 AM
Albumin
2.0 g/dL
[**2193-2-26**] 02:54 AM
Calcium non-ionized
7.9 mg/dL
[**2193-2-26**] 02:54 AM
Phosphorus
4.3 mg/dL
[**2193-2-26**] 02:54 AM
Ionized Calcium
1.06 mmol/L
[**2193-2-26**] 09:40 AM
Magnesium
2."
5674,"0 mg/dL
[**2193-2-26**] 02:54 AM
ALT
96 IU/L
[**2193-2-26**] 02:54 AM
Alkaline Phosphate
114 IU/L
[**2193-2-26**] 02:54 AM
AST
227 IU/L
[**2193-2-26**] 02:54 AM
Amylase
66 IU/L
[**2193-2-24**] 05:00 AM
Total Bilirubin
0.4 mg/dL
[**2193-2-26**] 02:54 AM
WBC
14.9 K/uL
[**2193-2-26**] 02:54 AM
Hgb
8.5 g/dL
[**2193-2-26**] 02:54 AM
Hematocrit
30.0 %
[**2193-2-26**] 02:54 AM
Current diet order / nutrition support: TF: off
Diet: NPO
GI: Abd remains open, absent BS
Assessment of Nutritional Status
61 y."
5675,"Attending Physician: [**Name10 (NameIs) 4155**]
Referral date: [**2193-2-23**]
Medical Diagnosis / ICD 9: / Fever
Reason of referral: Eval and tx
History of Present Illness / Subjective Complaint: 61yo f c a
complicated medical history with recent hospital admit for respiratory
failure, cardiac failure requiring a trach andPEG on the [**7-12**]. She subsequently was discharged to Rehab. She returned to
[**First Name5 (NamePattern1) 289**] [**Last Name (NamePattern1) 4152**] with line sepsis, urinary tract infection, and
C.DIF colitis on [**2-21**]. Pt developed increase abdominal pain [**2-24**], along
with worsening acute on chronic renal failure and was anuric for
48hours, follow-up imaging showing free air."
5676,"Pt is high risk for skin breakdown given obesity
and sedation, therefore equipment to aid in turning and repositioning
was ordered to optimize patients mobility and limit risks for nursing
and other caregivers. Pt tolerated using the Viking lift and transfer
sheet for bed mobility, at this time that is the only means of activity
patient can participate in. The no-lift sheet can be left under
patient, with either [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3863**] or sheet as a barrier. PT will continue to
follow patient from a far at this time as she is not stable to engage
in PT treatment, nursing can contact us for assistance with equipment
or can contact vendor who
s information is listed above, and is also on
patients white board.
Goals
Time frame:
1.
Nursing will demonstrate proper technique while using no-lift equipment
2.
Mobility and activity goals to follow
3.
Pt will require max A x 2 to roll
4.
5.
6.
Anticipated Discharge: Rehab
Treatment Plan:
f/u for mobility assessment as appropriate.
Frequency / Duration:
Patient agrees with the above goals and is willing to participate in
the rehabilitation program."
5677,"400-.500s.
Integumentary / Vascular: Trach, R dialysis cath, L subclavian, CVVHD,
colostomy bag, abdominal dressing with moderate amounts of serosangeous
drainage. foley. B UE and LE with areas of flaky dry skin. B UE and LE
edema
Sensory Integrity: Pt withdraws to pain x 4
Pain / Limiting Symptoms: Pt grimacing in pain with turning
Posture: obese
Range of Motion
Muscle Performance
N/A
N/A
Motor Function: N/A
Functional Status:
Activity
Clarification
I
S
CG
Min
Mod
Max
Gait, Locomotion: Bed mobility; Pt required total A x 4 for rolling.
Rolling:
Supine /
Sidelying to Sit:
Transfer:
Sit to Stand:"
5678,"0
8.5
224
14.9
[image002.jpg]
Other labs:
Activity Orders: bedrest
Social / Occupational History: unable to obtain from patient, per chart
pt is married
Living Environment: unable to obtain information at this time
Prior Functional Status / Activity Level: PTA pt was in rehab
Objective Test
Arousal / Attention / Cognition / Communication: Pt intubated and
sedated, was arousable with turning, grimacing, and attempting to mouth
words.
Hemodynamic Response
Aerobic Capacity
HR
BP
RR
O[2 ]sat
HR
BP
RR
O[2] sat
RPE
Supine
/
Rest
/
Sit
/
Activity
/
Stand
/
Recovery
/
Total distance walked:
Minutes:
Pulmonary Status: Trach: CPAP PEEP 15, Psup 10 FiO240% TV ."
5679,"She was taken originally
to the operating [****] for exploratory laparotomy, however
underwent total abdominal colectomy [**2-11**] perforation. Pt remains in the
ICU, intubated, on propofol, and undergoing CVVHD
Past Medical / Surgical History: Hypertension
Diabetes
Obesity
COPD on home O2 2-3L at all times
Currently Tobacco use
Obstructive Sleep Apnea on home CPAP
Obesity hypoventilation syndrome
diastolic CHF
Medications: Propofol, FLagyl, Phenylephrine, Vancomycin, Ciprofloxacin
Radiology: cxr: [**2-24**] There is increased hazy opacity over the
visualized portion of the right lung suggesting that there may be an
element of fluid overload but given technique, this is difficult to
assess
Labs:
30."
5680,"Ambulation:
Stairs:
Balance: N/A
Education / Communication: RN educated on use of LIKO (no lift)
equipment to assist patient with turning.
Intervention: A no-lift transfer sheet was placed under patient. The
""viking"" transfer assist equipment was used to perform bed mobility
including boosting and turning. RN was educated on use of equipment and
was able to demonstrate proper technique. If there are any problems
with the equipment the vendor can be called at this number: [**Doctor First Name 4153**]
[**Telephone/Fax (1) **]
Other:
Diagnosis:
1.
Arousal, Attention, and Cognition, Impaired
2.
Integumentary Integrity, Impaired
Clinical impression / Prognosis: 61 yo f with mmp readmitted from rehab
with c-diff, line sepsis, required total abdominal colectomy remains
intubated, sedated, and requiring CVVHD presents with above impairments
c/w decondidtioning."
5681,"Admission Date: [**2193-2-21**] Discharge Date: [**2193-3-5**]
Date of Birth: [**2131-11-17**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Pentothal / Codeine / Wellbutrin / Zosyn
/ Meropenem
Attending:[**Doctor First Name 5188**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Total Abdominal Colectomy and end ileostomy [**2193-2-24**]
History of Present Illness:
61 morbidly obese female with multiple medical problems
including DM, HTN, dCHF, COPD. Was recently discharged on [**2-17**]
after admission for hypoxic and hypercarbic respiratory failure
after being found unresponsive at home by her husband, treated
for [**Name (NI) 16630**] with Vanco/Levo/Zosyn, s/p trach after prolonged wean,
course c/b ARF and drug fever, transferred to [**Hospital1 **] on [**2193-2-17**]."
5682,"C. Diff cultures came back positive today and Medical tem
was concerend that abdominla exam had changed overnight to
include rebound tenderness. The patient has remianed
hemodynamically stable throughout this admission thus far.
Past Medical History:
Past Medical History:
relative immobility, spends a lot of time in bed
Hypertension
Diabetes
Obesity
COPD on home O2 2-3L at all times
Currently Tobacco use
Obstructive Sleep Apnea on home CPAP
Obesity hypoventilation syndrome
diastolic CHF (by c.cath [**1-/2192**])
Social History:
Social history is significant for the current tobacco use (40-50
pk yr). There is no history of alcohol abuse, only occasional
wine She lives at home with her husband."
5683,"Facility:
[**Location (un) 32674**] - [**Location (un) **]
Discharge Diagnosis:
Clostridium Difficile Colitis
Sepsis
Acute renal failure
Respiratory Failure
Discharge Condition:
Hemodynamics stable, still requiring some vent support but
tolerating periods of trach collar. Acute renal failure appears
to be resolving. Tolerating tube feeds. Wound healing well
with wound VAC dressing.
Discharge Instructions:
DIET: patient should continue on tube feeds for now. [**Month (only) 116**] try
POs if passes swallow evaluation, off ventilator, and tolerating
PMV
ACTIVITY: OOB as much as possible, aggressive PT
WOUND: abdominal wound with large wound vac. Wound appears
healthy, should be changed every 3-4 days.
OSTOMY: stoma healthy, putting out adequate stool, continue
current management.
ANTIBIOTICS: flagyl should continue for a total of 14 days from
day of surgery (end on [**3-10**])
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5182**] in 2 weeks
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]"
5684,"9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Insulin Regular Human 100 unit/mL Solution Sig: insulin
sliding scale Injection ASDIR (AS DIRECTED).
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
12. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
One (1) dose Intravenous Q24H (every 24 hours).
13. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
Discharge Disposition:
Extended Care"
5685,"Family History:
There is family history of premature coronary artery disease-
her father died in his 40s of an MI.
Physical Exam:
PE:
103.7 104 136/55 25 95% AC 500x14 PEEP 5 Fluids NaCL 200/hr UOP
>100/hr
AbX IV vanc/levo/flagyl started last night
Obese female
Mod distress
NCAT trach in place
mottled skin with drug rash
diffuse bilateral ronchi
tachycardia
gastrostomy tube in place Abd obese TTP diffusely R>L with no
tap
tenderness but with gaurding and rebound
stool guiac neg
Pertinent Results:
12.7>-----<294
28.4
149 112 57
---I---I---<153
4."
5686,"2 25 3.4
CT [**2-21**]:
Interval worsening of colitis extending from the
ascending colon to the splenic flexure, with new area of
involvement within the sigmoid colon.
Stool Cx C.Diff pos
Brief Hospital Course:
The patient was initially admitted to the MICU service. General
Surgery consulted for C.Diff colitis. She was treated
conservatively. However, over the next 48 hours her abdominal
become worrisome and she developed ARF and essentially became
anuric. A KUB at this time demonstrated free air. The patient
was then taken to the operating room where she underwent a total
abdominal colectomy with end ileostomy."
5687,"1 % Cream Sig: One (1) Appl Topical
TID (3 times a day).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q4H (every 4 hours).
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed."
5688,"Readmitted yesterday after she was complaining of diffuse
abdominal pain and had low grade fevers to 100.9. At [**Hospital1 **] on
the morning of [**2-20**], she had altered mental status, and was more
difficult to arouse. On exam she seemed to have significant
right
sided abdominal/flank pain. She was started on levoflox 250mg
Q48h when she began to spike fevers to 103 with a dirty U/A no
culture was sent. Blood Cx post for staph and vanco Iv was
started yesterday. Flagyl IV Started yesterday after CT
abd/pelvis which showed diffuse colitis (unchanged from previous
exam."
5689,".
ID: she was initially treated with Cipro/Flagyl/Vanco. The IV
vanco was for a coag neg blood Cx. The flagyl was for the
C.Diff, and the cipro was continued for 7 days for coverage due
to gross abdominal contamination.
.
Endo: blood sugars controlled with sliding scale insulin.
Medications on Admission:
Benadryl 50mg IV q6,Triamcinolone cream TID,Sarna,Insulin SS
Bisacodyl,Colace,Levofloxacin 250mg q48,Vancomycin x 1,Albuterol
Ipratropium,Fluticasone,TF's
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
2. Triamcinolone Acetonide 0."
5690,"She was noted to have
2.5 Liters of purulent material in the abdomen in the OR.
POST-OP:
The patient was transferred to the SICU for further
resuscitation.
Neuro: pain was controlled and sedation minimized
.
CV: At this point her hemodynamics had begun to improve. She
was quickly weaned off of pressors and required minimal fluid
resuscitation.
.
Pulm: She was eventually able to wean to minimal vent settings,
but only tolerated trach collar for a few hours at a time. This
is likely due to her pre-existing condition as well as severe
illness she was recovering from.
.
GI/FEN: She was placed on trophic tube feeds and advanced to
goal which she tolerated."
5691,"Her stoma was functioning well at the
time of discharge.
.
Renal: Renal was consulted for her ARF. She began CVVHD after a
HD line was placed. This was continued for about a week until
enought volume had been taken off to adequately wean her vent
settings. The CVVHD was stopped and she began making more
urine, about 50-100cc per hour. Her electrolytes and Creatinine
remained stable. Renal recommended holding off on further
dialysis for now. She did receive a few doses of lasix and seems
to respond well to this.
.
Heme: her Hct was stable but slowly drifted down to 22 by
discharge, she received one unit of PRBC for this."
5692,"[**2193-2-23**] 3:51 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 39956**]
Reason: eval for interval change
Admitting Diagnosis: FEVER
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
61 year old woman with recent admission for PNA, +tracheostomy, now returns
with fevers
REASON FOR THIS EXAMINATION:
eval for interval change
______________________________________________________________________________
FINAL REPORT
STUDY: AP CHEST [**2193-2-23**].
HISTORY: 61-year-old woman with recent admission for pneumonia. Now returns
with fever, evaluate for interval change.
IMPRESSION: Comparison is made to prior study from [**2193-2-22**].
Study is somewhat limited due to rotation of the patient. There is likely
cardiomegaly. The left sided central venouscatheter tip terminates within the
proximal brachiocephalic vein. The right lung is clear. The left lung is
partly obscured due to the cardiac silhouette. A tracheostomy is also
visualized."
5693,"Admission Date: [**2142-6-21**] Discharge Date: [**2142-6-26**]
Date of Birth: [**2072-11-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Nut Sup, Glucose Intolerant #1 / Spironolactone / Bactrim DS /
Fluarix [**2135**]-[**2136**] (PF)
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Residual Pituitary Adenoma
Major Surgical or Invasive Procedure:
[**2142-6-21**] Right Craniotomy for resection of pituitary ademona
History of Present Illness:
69yo woman with pituitary lesion who underwent a subtotal
transphenoidal resection in 2/[**2140**]. Pathology was
c/w ACTH secreting pituitary adenoma. MRI [**12-11**] showed residual
adenoma centered in the supracellar cistern with radiologic
compression on the optic apparatus."
5694,"On her last visit it was recommended that she have an open
resection to decompress the optic apparatus. The patient wanted
to wait and have an reconsultation with Radiation oncology.
Patient denies visual problems, heat intolerance, breast
leakage, wt loss or gain.
Past Medical History:
Diabetes, hypertension , GERD, glaucoma, cataract, hypokalemia,
(+)PPD s/p INH, AV reentrant and nodal tachycardia, left knee
OA,
ectopic pregnancy surgery, tubal ligation, appendectomy,
parathyroidectomy, knee surgery
Social History:
No tob/etoh. Lives independently with husband. [**Name (NI) 1403**] FT in
environmental services here at [**Hospital1 **].
Family History:
Mother died in childbirth, Father 98 and only hard of hearing; 4
children, daughter with MS."
5695,"Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Potassium Chloride 30 mEq PO DAILY Duration: 24 Hours
Hold for K >4.0
7. Valsartan 320 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN Constipation
9. Calcium Carbonate 600 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Fish Oil (Omega 3) Dose is Unknown PO DAILY
Discharge Medications:
1. Outpatient Lab Work
seurm and urine NA, serum osm and urine osm
2. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*90
Capsule Refills:*0
3."
5696,"OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-1**] Capsule(s) by mouth every four (4) hours
Disp #*60 Capsule Refills:*0
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Valsartan 320 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Vitamin D 1000 UNIT PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
10. Calcium Carbonate 600 mg PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN Constipation
12. Amlodipine 10 mg PO DAILY"
5697,"She may drink to thirst. D5W was discontinued
and q6h labs were continued. She was albe to be OOB and dangle
her feet at the edge of the bed. On [**6-24**], a-line was removed and
foley d/c'ed. Hydorcortisone was decreased to 20mg in am and no
dose in pm.
On [**6-25**], cortisol level was drawn and was 12.9. She remains in
stable condition, ambulating independently and reports no
drainage. She was transferred to the floor and PT/OT consulted.
She recieved on dose of 20mg hydrocortisone in the am. Her
cortisol level was normal, so hydrocotisone was discontinued."
5698,"She was monitered with
frequent labs and UAs and her urine output was monitered closely
for signs of DI. She had increasign sodiums overnight on [**6-21**]
into [**6-22**], endocrinology did not feel that she required DDAVP or
vasopressin. She was started on IV fluids and her urine output
and lab valuyes continued to be closely monitoried. On [**6-22**] she
underwent an MRi scan of teh brain to assess for post-operative
change which showed no evidence of residual enhancement within
the resection bed. Endocrine recommended hydrocortisone 40mg in
am and 20mg in pm, then on [**6-23**] she should recieve 20mg in am
and 10mg in pm."
5699,"?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring."
5700,"IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: . Strength full power [**5-5**] throughout. No pronator drift
Sensation: Intact to light touch; no paresthesias
Symmetric brisk reflexes
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger bilaterally
No extrapyramidal signs
On Discharge:
Pertinent Results:
MRI Brain [**6-21**]:
Surgical planning study with surface markers demonstrates a
sellar and suprasellar mass suggestive of residual pituitary
neoplasm. No
other abnormalities are seen. No hydrocephalus or enhancing
brain lesions are identified.
CT Head [**6-21**] post-op
1. Expected post-surgical changes with bilateral prefrontal
pneumocephalus and a small amount of blood products layering
along the right frontal dural surface."
5701,"She was cleared by PT and nursing was working with her and
stairs. Patient felt unsteady on her feet and requested that she
have more time in the hospital.
On [**6-26**], patient was doing well. She was ambulating
independently and felt more comfortable being discharged home
today. She was discharged home and should follow up with
endocrine in one week and neurosurgery in 4 weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amlodipine 10 mg PO DAILY
2. Aprepitant 40 mg PO ONCE Duration: 1 Doses
3 hours prior to preop
3."
5702,"Physical Exam:
On Admission:
Gen: AF VSS;
WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: no adventicious sounds
Cardiac: RRR to auscultation
Abd: Soft, NT
warm peripherals
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.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally."
5703,"?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F."
5704,"Discharge Disposition:
Home
Discharge Diagnosis:
pituitary adenoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head."
5705,"2. No evidence of intraparenchymal hemorrhage.
MRI Brain Post-op [**6-22**]:
1. No evidence of residual enhancement within the resection
bed. Recommend continued followup after the immediate
postoperative changes have resolved.
2. Normal postoperative appearance after right craniotomy
without evidence of large postoperative hemorrhage
Brief Hospital Course:
[**Known firstname 99759**] [**Known lastname 174**] was admitted to the Neurosurgery service after
right craniotomy for resection of residual pituitary adenoma.
Postoperatively she was admited to the Neuro-ICU for frequent
neuro checks and blood pressure control less than 140.
Endocrinology service was consulted. Postoperative head CT
showed expected post-operative changes."
5706,"Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-10**] days(from your date of
surgery) a wound check. This appointment can be made with the
Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need an MRI of the brain with or without gadolinium
contrast.
?????? Please follow up with Endocrine in 1 week. You can
schedule this appointment by calling [**Telephone/Fax (1) 1803**].
Completed by:[**2142-6-26**]"
5707,"Following
intravenous administration of Magnevist, sagittal MP-RAGE and axial
T1-weighted images were obtained. Axial and coronal reformats were generated
and reviewed.
FINDINGS: Again seen are multiple hemorrhagic contusions with surrounding
edema in the right frontal, left basal ganglia, and left temporal regions.
Multiple foci of abnormal susceptibility are seen at the [**Doctor Last Name 34**]-white matter
junction in bilateral frontal lobes which are seen to bloom on the gradient
echo sequences suggestive of microhemorrhages. There is no hydrocephalus or
midline shift. There is no intraventricular extension of hemorrhage.
Diffusion-weighted images reveal areas of slow diffusion within the left
caudate head, distinct from the regions of hemorrhage, representing areas of
ischemia."
5708,"[**2142-10-8**] 7:58 PM
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 43163**]
Reason: please evaluate for intracranial process, diffuse axonal inj
Admitting Diagnosis: BLUNT TRAUMA
Contrast: MAGNEVIST Amt: 17
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
32 year old man with TBI and suspected [**Doctor First Name **]
REASON FOR THIS EXAMINATION:
please evaluate for intracranial process, diffuse axonal injury
No contraindications for IV contrast
______________________________________________________________________________
FINAL REPORT
INDICATION: A 32-year-old man with traumatic brain injury and suspected [**Doctor First Name **].
COMPARISON: CT head of [**2142-10-7**].
TECHNIQUE: Sagittal T1, axial T1, T2, FLAIR, diffusion-weighted, and
susceptibility sequences were obtained without contrast."
5709,"The ischemic changes are likely secondary to injury to the left
lenticulostriate arteries. The visualized globes and mastoid air cells are
unremarkable. Major intracranial flow voids appear normal. Abnormal signal
intensity is seen within the right maxillary sinus, ethmoid and bilateral
sphenoid sinuses. Correlating with the CT, multiple facial fractures are
present with hemosinus.
IMPRESSION:
1. Multiple hemorrhagic contusions in bilateral cerebral hemispheres as
demonstrated on the previous CT. In addition, there are multiple tiny foci of
microhemorrhages, predominantly at the [**Doctor Last Name 34**]-white matter junction in the
frontal lobes consistent with diagnosis of diffuse axonal injury.
2."
5710,"Areas of ischemia in the left caudate head likely from injury to the
lenticulostriate branches. The A1 and M1 segments of the anterior and middle
cerebral arteries respectively appear grossly normal. Please note that
lenticulostriate arteries are much below the resolution of noninvasive imaging
and cannot be reliably evaluated on CTA/MRA.
Findings discussed by Dr. [**First Name (STitle) 685**] [**Name (STitle) 686**] with [**Last Name (NamePattern1) 33402**] on [**2142-10-9**]
at 1:00 p.m.
(Over)
[**2142-10-8**] 7:58 PM
MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 43163**]
Reason: please evaluate for intracranial process, diffuse axonal inj
Admitting Diagnosis: BLUNT TRAUMA
Contrast: MAGNEVIST Amt: 17
______________________________________________________________________________
FINAL REPORT
(Cont)"
5711,"Admission Date: [**2142-10-4**] Discharge Date: [**2142-10-17**]
Date of Birth: [**2110-3-5**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
TBI s/p MCC
Major Surgical or Invasive Procedure:
[**10-4**] R ICP bolt placement
[**10-11**] perc trach / PEG
History of Present Illness:
32M s/p MCC. Found unconscious but breathing at scene with blood
tinged sputum. Brought to [**Hospital1 18**] and was moving extremities x4,
non-verbal but not protecting airway. Intubated in the field. CT
revealed bilateral IPH.
Past Medical History:
PMH: none
PSH: adenoidectomy, tonsillectomy, knee arthroscopy"
5712,"IMPRESSION:
1. Multiple intraparenchymal hemorrhages compatible with diffuse
axonal injury.
2. Tiny extra-axial hemorrhage noted adjacent to the right
frontal intraparenchymal hemorrhage, likely subarachnoid blood.
Small subdural hemorrhage layering over the left tentorium.
3. Facial fractures as described above. A dedicated
maxillofacial CT would be recommended when possible for further
evaluation.
CThead [**10-5**]:
FINDINGS: Right frontal parenchymal hemorrhage with a
fluid-fluid level seen dependently is redemonstrated, unchanged
in size. Foci of left frontal and temporal parenchymal
hemorrhage are also redemonstrated, also appearing unchanged.
There is no new intracranial hemorrhage, edema, mass effect, or
vascular territorial infarction. Ventricles and sulci are
unchanged in size
and in configuration."
5713,"Multiple rib fractures as described above.
Brief Hospital Course:
The patient was admitted to the Trauma Surgical Intensive Care
Unit for evaluation and treatment of polytrauma following MCC.
Attending of record was Dr. [**Last Name (STitle) **] of the Acute Care Surgical
Service.
Injuries at time of admission:
- RUL pulm contusion
- multifocal areas of probable aspiration
- b/l rib fxs(2nd, 3rd L, 5th on R)
- intraparenchymal hem L frontal lobe
- focus of SAH at R frontovertex
- R inf+sup orbit floor [**Last Name (LF) **], [**First Name3 (LF) **] sinus fx
- R non-displaced rad/uln fx
On [**10-4**] the patient underwent placement of R bolt for ICP
monitoring which went well without complication (reader referred
to the Operative Notes for details)."
5714,"14. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever/pain.
15. ChlorproMAZINE 25 mg IV Q4H:PRN hiccups
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
30M s/p MCC p/w TBI/[**Doctor First Name **], facial fxs, R rad/ulna fx, mult rib fxs
req intubation in ED s/p trach/peg
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness."
5715,"Pulmonary: The patient arrived to the ICU intubated and was
subsequently extubated without complication and comfortable on
trach mask with blow-by throughout the remainder of his
admission. Concern for RUL, RML, RLL, LUL aspiration PNA with
negative sputum cultures. VAP protocol initiated with serial CXR
and completion of antibiotic course.
GI/GU/FEN: The patient was made NPO with IV fluids. Due to
impaired mental status and concern for inability to protect
airway with PO intake and subsequently underwent PEG placement
for definitive enteral access through which he received tube
feeds at goal. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary."
5716,"*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.
.
General Discharge Instructions:
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 [**5-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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.
Followup Instructions:
Please follow-up in [**Hospital 2536**] clinic within 1 week of discharge. Call
([**Telephone/Fax (1) 2537**] with any questions and to schedule an appointment
Completed by:[**2142-10-17**]"
5717,"5* RBC-4.43* Hgb-13.5* Hct-40.0
MCV-90 MCH-30.5 MCHC-33.8 RDW-12.7 Plt Ct-269
[**2142-10-16**] 01:58AM BLOOD Glucose-121* UreaN-21* Creat-0.6 Na-137
K-4.5 Cl-102 HCO3-26 AnGap-14
[**2142-10-5**] 01:55AM BLOOD Glucose-129* UreaN-8 Creat-0.9 Na-136
K-4.0 Cl-105 HCO3-20* AnGap-15
[**2142-10-4**] 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT head [**10-4**]:
FINDINGS: This study is technically limited due to motion
artifact."
5718,"There is mild interval increase in the
edema surrounding these hemorrhagic contusions, especially
surrounding the large hematoma in the right frontal vertex. The
large right frontal vertex hematoma now measures 2.8 x 2.3 cm,
which allowing for differences in technique is unchanged since
the prior study 3.0 x 2.2 cm. Mild effacement of the right
frontal hemispheric sulci, is more prominent since the prior
study. No significant shift of midline structures is seen.
Multiple parenchymal hematomas in the left frontal lobe, left
caudate nucleus, basal ganglia, temporal lobe, are again
redemonstrated. No new intracranial hematoma is seen."
5719,"*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 is 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."
5720,"The nasal septum is intact, and notable for a
moderate-sized rightward nasal septal spur. There is a minimally
displaced right nasal bone fracture. Note is made of partial
opacification of ethmoidal air cells bilaterally, greater on the
right than left as well as moderate mucosal thickening in the
left maxillary sinus, sphenoid sinus and frontal sinuses. The
sphenoid sinus contains a single dominant septum which
terminates near the midline.
IMPRESSION:
1. Bilateral parenchymal hemorrhage as described above, similar
to the most recent comparison study.
2. Right facial fractures as characterized above.
CThead [**10-8**]
FINDINGS: Again seen are multiple evolving intraparenchymal
hematomas, without significant interval change in size since the
prior study of [**2139-10-6**]."
5721,"The
ventricles and sulci are unchanged in appearance. There is no
intraventricular extension of hemorrhage. The basal cisterns are
normal. Multiple facial fractures including right superolateral
orbital fracture, right orbital floor fracture are again
redemonstrated. There is diffuse opacification of the right
maxillary, right ethmoid sinuses, with air-fluid levels in both
sphenoid sinuses.
IMPRESSION:
1. Evolving intraparenchymal hematomas, without significant
interval change in size. Mildly increased surrounding edema and
mass effect.
2. No evidence of transtentorial herniation. No new parenchymal
hematomas.
LUE duplex [**10-7**]
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of left internal
jugular, subclavian, axillary, brachial veins were performed."
5722,"There are multiple foci of intraparenchymal hemorrhage
seen within the grey-white matter junction of the left frontal
lobe and right frontal lobe towards the vertex, as well as the
left basal ganglia and left internal capsule. A tiny focus of
extra-axial hemorrhage adjacent to the right frontal
intraparenchymal
hemorrhage also is likely present suggestive of subarachnoid
blood. Thin hyperdensity layering along the left tentorium may
represent a tiny subdural hemorrhage. There is no evidence of
edema, mass effect or shift of normally midline structures. The
[**Doctor Last Name 352**]-white matter interface is well preserved with no evidence
of acute major vascular territorial infarct."
5723,"There
is no evidence of extraluminal contrast or free air. There is no
perihepatic or perisplenic fluid. The kidneys enhance with and
excrete contrast symmetrically. The visualized portion of large
and small bowel show significant colonic fecal load. The aorta
shows no evidence of injury.
BONES: Again are seen fractures of the anterior portions of the
left second and third ribs as well as the anterior portions of
the right second, third, fourth, fifth, and sixth ribs.
IMPRESSION:
1. Worsening bibasilar consolidations as described above.
2. Status post PEG tube placement without evidence of free air
or extraluminal contrast.
3."
5724,"An intracranial bolt is visualized, placed
via a right frontal approach.
Osseous structures are notable for a comminuted fracture
involving the superolateral corner of the right orbit anteriorly
with adjacent extraconal hematoma slightly impinging on the
globe. Additionally, there is a comminuted right orbital floor
fracture with a fallen osseous fragment, though no evidence of
entrapment of the inferior rectus extraocular muscle. A
minimally displaced fracture is also visualized in the right
anterior maxillary sinus wall. There is expected near total
opacification of the right maxillary sinus. The pterygoid
plates, and zygomatic arches are intact. The lamina papyracea
are intact."
5725,"There is no evidence of ligamentous injuries.
IMPRESSION: Unremarkable MRI of the cervical spine.
LENI [**10-12**]
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of bilateral common
femoral, superficial femoral, popliteal, posterior tibial and
peroneal veins were performed. There is normal compressibility,
flow and augmentation.
IMPRESSION: No evidence of DVT.
CT torso [**10-14**]
FINDINGS:
CHEST: The visualized portion of the thyroid is unremarkable.
There is no axillary, hilar, or mediastinal lymphadenopathy. A
tracheostomy tube is in place. The aorta is of a normal caliber
along its course without evidence of injury. The pulmonary
artery shows no large central filling defect."
5726,"Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Wound care: Incisional wounds were regularly monitored for
signs of infection of which there were none.
Antibiotics: The patient received vancomycin/cefepime/cipro for
VAP protocol and completed antibiotic course during this
admission with >24 hours aefbrile at time of discharge.
Endocrine: The patient's blood sugar was monitored throughout
this admission. Insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots during this admission and was encouraged to get
up and ambulate as early as possible."
5727,"The ventricles and
sulci are normal in size and configuration.
The extracalvarial soft tissues show right frontal scalp and
periorbital hematoma. Multiple facial fractures are identified
of the right superior lateral orbital wall and inferolateral
orbital wall. There is a fracture of the floor of the right
orbit with a displaced fragment displaced in the right maxillary
sinus without herniation of extraocular musculature.
Opacification in the right maxillary sinus and right ethmoid air
cells suggests hemorrhage from the multiple facial fractures.
The skull base is intact without fracture. The bilateral globes
are intact with lenses in place bilaterally.
No retrobulbar hematoma present."
5728,"Disposition: Discharge to rehabilitation facility.
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours)."
5729,"Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
VS: T 100, HR 96, BP 123/61, RR 27, SaO2 96% TM40%
Gen: A/Ox2
HEENT: trach in place, midline, no surrounding erythema
CV: RRR, no M/R/G
P: coarse breath sounds throughout
GI: PEG in place, soft, no rebound, no guarding, nondistended
GU: foley in place
Ext: WWP, No edema, abrasions to RLE
Pertinent Results:
[**2142-10-16**] 01:58AM BLOOD WBC-13.1* RBC-3.17* Hgb-9.4* Hct-27.5*
MCV-87 MCH-29.7 MCHC-34.2 RDW-13.9 Plt Ct-854*
[**2142-10-4**] 01:40PM BLOOD WBC-13."
5730,"There is normal compressibility, flow and augmentation
throughout. The left cephalic and basilic veins are normal.
IMPRESSION: No evidence of DVT in the left upper extremity.
MR [**Last Name (Titles) **] [**10-8**]:
FINDINGS: Cervical vertebrae reveal normal height, signal
intensity and alignment. Craniocervical junction appears normal.
Cervical spinal cord reveals normal morphology and signal
intensity. Pre- and paravertebral and posterior paraspinal soft
tissues appear unremarkable. Fluid signal is seen within the
oropharynx and around the endotracheal tube, likely secondary to
intubation.
There is no spinal canal or neural foraminal narrowing seen.
Intervertebral discs are normal in height and signal
intensities."
5731,"Patient arrived to the
Trauma Surgical Intensive Care Unit NPO, on IV fluids, with a
foley catheter, and fentanyl for pain control. The patient was
hemodynamically stable.
Neuro: TBI with subsequent MRI concerning for [**Doctor First Name **]. The patient
received intermittent mannitol with good effect and fentanyl
with adequate pain control. ICPs remained stable and bolt was
subsequently dc'd. Subsequent head CT demonstrated stable ICH.
Pt completed course of seizure prophylaxis. Pt's baseline mental
status gradually improved throughout hospitalization with
patient interactive and following some commands with family
members.
CV: The patient arrived to the ICU hemodynamically stable in
sinus rhythm without pressor requirement."
5732,"There is no
pericardial effusion.
Assessment of fine detail of the lungs is slightly limited by
mild motion artifact. Bibasilar consolidations have worsened
compared to prior study. Additionally, the previously described
right lower lobe anterior basal segment contusion demonstrates a
more confluent well-rounded appearance, possibly representing
rounded atelectasis or a focal area of diaphragmatic eventration
(2:45), measuring 26 x 17 mm. There is no large pleural effusion
or pneumothorax.
ABDOMEN: A gastrostomy tube is in place. Extensive streak
artifact is seen from the oral contrast administered as well as
from excreted IV contrast in the renal collecting systems."
5733,"7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
8. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for agitation.
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1)
Tablet PO DAILY (Daily)."
5734,"She states she was last admitted 3 weeks
ago with similar symptoms and was diagnosed with a CHF
exacerbation. She has been taking her diuretics faithfully
since that time. Referred for cardiac catheterization which
showed 3V CAD. Subsequently referred for surgery.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-diastolic CHF
3. OTHER PAST MEDICAL HISTORY:
-Hypothyroidism
-Squamous cell carcinoma of left forearm.
- h/o varicella zoster
- vitreous hemorrhage- R and L eye.
- L hemispheric stroke [**4-20**]
Social History:
Married, lives at home with husband, denies tobacco, alcohol,
illicits.
Family History:
No early CAD, DM, or HTN."
5735,"LEVEMIR to be restarted at rehab provider [**Name Initial (PRE) 8469**]
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 388**]
Discharge Diagnosis:
CAD/mitral regurgitation s/p cabg x4/MV repair
Dyslipidemia
Hypertension
diastolic Congestive heart failure
Diabetes Mellitus type 2
Hypothyroidism
Squamous cell carcinoma- left forearm and chest
h/o varicella zoster
vitreous hemorrhage- Right and Left eye (post Heparin)
Left hemispheric stroke [**4-20**]
Anemia- baseline Hct=27 (per patient)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage."
5736,"Brief Hospital Course:
Admitted [**1-16**] and underwent surgery with Dr. [**First Name (STitle) **]. Transferred
to the CVICU in stable condition on titrated phenylephrine and
propofol drips. Extubated early on POD #1. Sleep medicine was
consulted for possible sleep apnea risks. Transferred to the
floor on POD #2 to begin increasing her activity level. Chest
tubes and pacing wires removed per protocol. PICC placed for
access and subsequently removed. Gently diuresed toward pre-op
weight. Made good progress and was cleared for discharge to
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] rehab on POD #5. All f/u appts were
advised."
5737,"Pertinent Results:
[**2165-1-21**] 06:00AM BLOOD WBC-7.4 RBC-3.87* Hgb-11.5* Hct-34.9*
MCV-90 MCH-29.8 MCHC-33.0 RDW-14.9 Plt Ct-247
[**2165-1-21**] 06:00AM BLOOD Glucose-222* UreaN-44* Creat-1.6* Na-137
K-4.9 Cl-98 HCO3-29 AnGap-15
[**2165-1-21**] 06:00AM BLOOD Mg-2.2
Conclusions
PRE BYPASS The left atrium is moderately dilated. 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."
5738,"Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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:
Surgeon:Dr. [**First Name (STitle) **] [**2-11**] @ 1:45 pm
PCP/Cardiologist:Dr. [**Last Name (STitle) **] [**2-27**] at 2:45 pm ([**Location (un) 4628**] office)
**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:[**2165-1-21**]"
5739,"10. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED): humalog per sliding scale .
14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
15. METFORMIN to be restarted at discretion of Dr. [**Last Name (STitle) **] when
creatinine normalized
16."
5740,"Insulin Sliding Scale
Humalog Insulin Sliding Scale
As directed by your primary care physician
14. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. insulin detemir 100 unit/mL Insulin Pen Sig: Fourteen (14)
units Subcutaneous at bedtime.
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day: hold for
K+ >4.5.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months."
5741,"Admission Date: [**2165-1-16**] Discharge Date: [**2165-1-21**]
Date of Birth: [**2094-11-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing / adhesive tape
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB and left arm burning
Major Surgical or Invasive Procedure:
[**2165-1-16**] CABG x4 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to
PDA)/MV repair (28 mm [**Company 1543**] CG Future ring)
History of Present Illness:
70 year old female who complains of
SOB. She awoke from sleep with burning chest pain. She reported
stuttering chest pain all day today as with some associated
shortness of breath."
5742,"Metformin to be restarted at discretion of Dr. [**Last Name (STitle) **]
when creatinine normalizes.
Levemir to be restarted at discretion of rehab provider.
Medications on Admission:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at
bedtime.
2. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAYS
(MO,TU,WE,TH,FR).
3. levothyroxine 150 mcg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],SA) .
4. lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Avalide 300-25 mg Tablet Sig: One (1) Tablet PO once a day."
5743,"4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): on lovastatin 40 mg daily at home.
7. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO MON TUES
WED [**Last Name (un) **] FRI ().
8. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO SAT SUN
().
9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
5744,"Physical Exam:
Pulse:89 Resp:16 O2 sat: 98/RA
B/P Right:175/73 Left:160/52
Height:63"" Weight:195 lbs
General:
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
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
[x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:- Left:-"
5745,"7. hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. isosorbide mononitrate 30 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:*0*
12. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13."
5746,"Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study.
POST BYPASS The patient is AV paced. There is normal
biventricular systolic function with a left ventricular ejection
fraction of 55-60%. A mitral valve annuloplasty ring is in situ.
It appears well seated. There is trace mitral regurgitation.
There is no mitral stenosis. The remainder of valvular function
remains unchanged. The thoracic aorta appears intact after
decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2165-1-16**] 16:12"
5747,"No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thicknesses are
normal. Overall left ventricular systolic function is mildly
depressed globally(LVEF= 45 %). The right ventricle displays
borderline normal free wall function. 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. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
regurgitation is mostly central but has a slight posterior lean."
5748,"C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4339**]
Discharge Diagnosis:
cervical cord contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Do not smoke
?????? You are required to wear cervical collar at all times.
?????? You may shower briefly daily without the collar.
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2161-11-16**]"
5749,") PO Q24H (every 24 hours).
6. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours)
as needed for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for no BM>24hr.
11. bisacodyl 5 mg Tablet, Delayed Release (E."
5750,"Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): may dc when activity increases.
2. acetaminophen 650 mg/20.3 mL Solution Sig: [**12-27**] PO Q6H (every
6 hours) as needed for pain or fever.
3. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for muscle spasm.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C."
5751,"+ ETOH
Past Medical History:
Unknown
Social History:
Unknown. + ETOH now
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM:
O: T: BP: 95/74 HR: 81 R 21 O2Sats 97% ETT
Gen: Intubated, on profolol
HEENT: multiple small lacs
Neck: Hard cervical collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awakes to noxious stim
Motor Initially:
RUE: Delt 3, Bic 2, Tri 0, Grasp 0, WE/WF 0
LUE: Delt 2, Bic 0, Tri 0, Grasp 0, WE/WF 0
RLE: triple flexion to stim
LLE: no mvmt to noxious
On repeat exam:
RUE: antigravity, appears stronger than LUE
LUE: localizes, but weaker than RUE
RLE: withdraws
LLE: withdraws L>R"
5752,"Brief Hospital Course:
Pt was admitted to the TSICU and monitored closely. His
thoracic/lumbar spine was cleared in order to attempt
extubation. He was febrile on admission and blood, urine and
sputum cultures were obtained. Urine cultures were negative and
sputum gram stain showed 1+ GPC's and he was started on
levofloxacin and completed 5 day course.
He was safely extubated on [**11-10**] without difficulty and was
kept in the ICU overnight for continued observation and neuro
checks. He did complain of burning sensation in his RUE and was
started on neurontin 300mg three times daily which was then
further increased to 600mg TID."
5753,"Admission Date: [**2161-11-8**] Discharge Date: [**2161-11-16**]
Date of Birth: [**2107-5-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
54M who was found down by friends outside. Pt was brought to an
OSH where a Cspine xray showed concern for C3,C4,C5 fx along
with LUE/LLE weakness and was intubated and transferred to [**Hospital1 18**]
for further management. Upon arrival, a CT Cspine was performed
which did not show any cervical fracture."
5754,"Sensation: Pt grimaces to noxious stim throughout, Nods yes to
sensation to light touch and noxious. Proprioception intact.
Reflexes: B T Br Pa Ac
Right 0 0 0 2 2
Left 0 0 0 2 2
Toes: Mute on left, upgoing on right
Rectal exam normal sphincter control
Exam upon discharge:
motor exam slowly improving daily - weak distally in UEs right
weaker than left; and weaker distally LEs but full proximally
Pertinent Results:
CT Cspine:
No fracture noted, C5-6 osteophytes impinging on the thecal sac.
CT Head:
no acute bleed, incidental finding of a right frontal sinus
osteoma
MRI Cspine:
Cord impingement at C4-5 with hyperintensity on T2 imaging."
5755,"His physical exam at this time
was full strength in LLE, RLE weakness 2/5 proximally and [**4-29**]
gastroc, RUE 3 biceps and 2 in deltoid and triceps with no
finger movements. His LUE had 2 in grips with no other motor
function. He was transferred to the floor in stable condition on
[**11-11**]. His exam continued to slowly improve. He was kept in
cervical collar. He was evaluated by PT/OT and suitable
candidate for rehab. He was on neurontin for neurogenic pain and
this can be titrated slowly to off as it resolves.
Medications on Admission:
Unknown"
5756,"Admission Date: [**2142-9-7**] Discharge Date: [**2142-9-10**]
Date of Birth: [**2122-3-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
tylenol PM and naproxen overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
20 yo F, with hx of depression w/ SI on Effexor, no previously
established care here at [**Hospital1 18**], p/w tynenol / NASIADS overdose
in setting of a suidical attempt.
.
Of note, night prior to admission pt heard from her boyfriend
that his friends do not like her and don't want her around
anymore."
5757,"The low tylenol level and
lack of elevation in LFT does not support overdose of such
extent. However, the benadryl in Tylenol PM could potentially
delay the absorption and administration of alcohol in the same
time could be hepatic protective by competing with tylenol for
cytochrome C. An N-acetylcysteine protocol was initiated at ED
and continued initially in the MICU. Her Tylenol level was
trended till non-detectable.
.
# ASA intoxication: The elevated ASA level is likely a result
from Excedrin overdose. Pt was treated conservative with fluid
hydration, and monitored closely on the rising ASA level. There
was an anion gap initially, which was closed shortly after
treatment."
5758,"Her ASA level was trended till non-detectable.
.
# SI: Pt had a history of depression and suicidal ideation. She
was evaluated by on-call psychiatrist in the ED. The
psychiatrist at her college was notified. We restarted her
effexor after her nausea resolved. Medically cleared for
transfer to psychiatric facility.
.
CHRONIC ISSUES
# Anemia: Pt has known anemia from thalassemia. No transfusion
given. No evidence of iron deficiency.
.
Transitions of care:
Outpatient management of anemia.
Medications on Admission:
Venlafaxine XR 225 mg PO
altavera
Discharge Medications:
1. venlafaxine 225 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day."
5759,"2. Altavera (28) 0.15-30 mg-mcg Tablet Sig: as directed
previously Tablet PO Daily ().
Discharge Disposition:
Extended Care
Facility:
Four Winds Saratoga
Discharge Diagnosis:
Primary:
tylenol / aspirin overdose
Secondary:
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital for taking too much tylenol and
aspirin. You were treated for this and improved and were deemed
medically clear for transfer to a facility that specializes in
psychiatric care.
REGARDING YOUR MEDICATIONS...
no changes were made to your medications
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Followup Instructions:
Otherwise, please followup with your primary care physician
[**Name Initial (PRE) 176**] 7-10 days regarding the course of this hospitalization.
Completed by:[**2142-9-10**]"
5760,"Depression
Social History:
[**University/College 5130**] 3rd year student, digital arts major. History of SI
attempt at age 15 per her mother, pt denies. Drinks alcohol [**11-26**]
times per week, 3 drinks per time. Denies tobacco or drug use.
Family History:
Mother and aunts have depression
Physical Exam:
ADMISSION EXAM
General: Lying in bed, breathing comfortably, interactive,
stable.
HEENT: PERRL, anicteric sclera, OP clear.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA bilaterally w/o crackles or wheezing. Good air
movement.
Ab: Positive BS??????s, mild diffuse tenderness with deep palpation,
non-distended, no HSM.
Ext: No c/c/e."
5761,"3
Cl-104 HCO3-27 AnGap-10
[**2142-9-9**] 07:05AM BLOOD ALT-14 AST-17 AlkPhos-43 TotBili-0.5
[**2142-9-9**] 07:05AM BLOOD Calcium-9.7 Phos-4.5# Mg-2.0
[**2142-9-7**] 09:50AM BLOOD calTIBC-321 Ferritn-58 TRF-247
[**2142-9-8**] 12:52AM BLOOD ASA-NEG Acetmnp-NEG
Brief Hospital Course:
20 yo F with hx of depression and suicidal ideation, currently
on Effexor, no previously established care here at [**Hospital1 18**], p/w
tynenol / ASA overdose in setting of a suidical attempt.
.
ACTIVE ISSUES
# Tylenol intoxication: Pt self-reported an overdose of large
quantity of acetominophen (>25 gram)."
5762,"0
PERTINENT LABS
[**2142-9-7**] 01:53AM BLOOD ASA-7.3 Ethanol-158* Acetmnp-14
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-9-7**] 04:24AM BLOOD ASA-22.4 Acetmnp-76*
[**2142-9-7**] 07:05AM BLOOD ASA-22.4 Acetmnp-55*
[**2142-9-7**] 09:50AM BLOOD ASA-18.4 Acetmnp-26
[**2142-9-7**] 12:20PM BLOOD ASA-16.0 Acetmnp-15
[**2142-9-7**] 03:01PM BLOOD ASA-11.9 Acetmnp-7*
[**2142-9-8**] 12:52AM BLOOD ASA-NEG Acetmnp-NEG
PERTINENT STUDIES
CXR ([**9-7**])
Cardiomediastinal contours are normal. The lungs are clear."
5763,"7 RDW-14.8 Plt Ct-308
[**2142-9-7**] 01:53AM BLOOD Neuts-55.7 Lymphs-38.9 Monos-4.6 Eos-0.4
Baso-0.4
[**2142-9-7**] 01:53AM BLOOD PT-11.5 PTT-25.1 INR(PT)-1.0
[**2142-9-7**] 01:53AM BLOOD Glucose-113* UreaN-10 Creat-0.7 Na-139
K-3.1* Cl-105 HCO3-19* AnGap-18
[**2142-9-7**] 01:53AM BLOOD ALT-11 AST-19 AlkPhos-53 TotBili-0.2
[**2142-9-7**] 01:53AM BLOOD Albumin-5.0 Calcium-9.6 Phos-2.0* Mg-2."
5764,"Neuro: Awake, alert, appropriately oriented, no focal motor
deficits noted. No asterixis.
DISCHARGE EXAM:
VS: 97.3 103 110/80 20 99% RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no lymphadenopathy. neck supple.
Cards: RRR, no murmurs/gallops/rubs.
Pulm: CTAB, no crackles or wheezes
Abd: soft, NT ND
Extremities: wwp, no edema.
Skin: warm and dry
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities
with sensation intact.
Pertinent Results:
ADMISSION LABS
[**2142-9-7**] 01:53AM BLOOD WBC-8.1 RBC-5.45* Hgb-11.7* Hct-34.6*
MCV-63* MCH-21.4* MCHC-33."
5765,"There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.
[**2142-9-9**] 07:05AM BLOOD WBC-8.4 RBC-4.95 Hgb-10.6* Hct-31.4*
MCV-63* MCH-21.4* MCHC-33.8 RDW-15.0 Plt Ct-244
[**2142-9-9**] 07:05AM BLOOD PT-11.7 PTT-24.2 INR(PT)-1.0
[**2142-9-7**] 01:53AM BLOOD Neuts-55.7 Lymphs-38.9 Monos-4.6 Eos-0.4
Baso-0.4
[**2142-9-9**] 07:05AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-137 K-4."
5766,"At 10pm, pt took 50 tylenol PM, 30 naproxen and an
unknown amount of excedrin and a bottle of wine. Pt called the
suicidal hotline and was sent to [**Hospital1 18**] by ambulance.
.
In the ED, initial VS were: Initial ASA 7.3 and tylenol 14 and
EtOH 158. Two hours later, her ASA increased to 22.4, tylenol
increased to 76. Toxicology was consulted and decided to admit
to MICU for NAC protocol.
.
On arrival to the MICU, 98.6, 109, 109/48, 18, 98% on RA
Past Medical History:
History of SI attempt at age 15 per her mother, pt denies."
5767,"She has some right lower extremity
weakness from prior surgery. Her bowel and bladder function is
normal.
Past Medical History:
* DM1 - complicated by neuropathy, retinopathy autonomic
dysfunction, gastropathy
* HTN
* Asthma
* S/P Renal/Pancreas Transplant ([**2139**])
* Numular Eczema
* H/O Rectal Bleeding ([**2152**])
* Psuedoaneurysm of left External Iliac Artery s/p stent ([**2154**])
* H/O Deep Venous Thrombophlebitis ([**2155**])
* Chronic Lower Back Pain
* Left First Toe Osteomyelitis
* Retinopathy of Right Eye
Social History:
Patient denies tobacco or illicit drug use. She infrequently
consumes alcohol.
She was living with her daughter but recently moved out. She
currently lives alone. She has a very close relationship with
her daughter."
5768,"Pertinent Results:
An MRI of the lumbosacral spine obtained on [**2160-3-3**],demonstrates prior surgery both L4-L5 and L5-S1. There is
a grade 1 spondylolisthesis at L4-L5. There is lateral recess
stenosis bilaterally at L4-L5. There is a recurrent residual
disc herniation at L5-S1 on the right side. Flexion and
extension x-rays were obtained which demonstrate a grade 1
spondylolisthesis at L4-L5 and no abnormal movement when flexion
and extension views were compared.
[**2160-5-15**] 02:10PM BLOOD WBC-4.3 RBC-3.45* Hgb-10.2* Hct-30.8*
MCV-90 MCH-29."
5769,"Ferritin is elevated in setting of
illness. No signs of hemolysis. Patient continued on iron
supplementation with Hct remaining stable through remainder of
hospital stay. Hct on discharge was 27.6
5. s/p renal tranplant: during course of hospitalization,
creatinine trended up to 1.6 from recent baseline of 1.1- 1.3.
Etiology of renal damage unclear, may be indicative of brief
period post op hypotension. Continued cyclosporine/ prednisone/
azathiodine at current dose. Continued bactrim SS for PCP [**Name Initial (PRE) **]
6. type 1 DM: hx of brittle diabetes with multiple medical cxs.
Continued on home dose of lantus and humalog per sliding scale."
5770,"[**Last Name (un) **] followed patient while in house, uring patient to
consider insulin pump for tighter glycemic control
7. CAD s/p multiple PCI (baloon angioplasty): stable with no
signs of ischemia
Medications on Admission:
Albuterol
ASA
Azathioprine
Bactrim
Captopril
Clobetasol
Cyanocobalamin
Cyclosporine
Cymbalta
Flovent
Folate
Insulin
Lyrica
Metoprolol
Midodrine
Nitroglycerine
Pravachol
Prednisone
Serevent
Singulair
Vicodin
Vitamin D
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Unit
Injection ac+hs: Dose as per PCP.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing."
5771,"16. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Pregabalin 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
18. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
19. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Discharge Disposition:
Home With Service
Facility:
Greater [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Lumbar stenosis
labile blood pressure
post op anemia of blood loss
Discharge Condition:
Stable
Discharge Instructions:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up / take daily showers including incision
?"
5772,"1 Phos-3.6 Mg-1.7
[**2160-5-20**] 07:25AM BLOOD calTIBC-147* Hapto-214* Ferritn-186*
TRF-113*
[**2160-5-17**] 07:05AM BLOOD Cyclspr-58*
[**2160-5-22**] 08:00AM BLOOD Cyclspr-60*
[**2160-5-23**] 07:40AM BLOOD Cyclspr-204
[**2160-5-24**] 07:35AM BLOOD Cyclspr-PND
[**2160-5-20**] 01:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2160-5-20**] 01:15AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-300 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2160-5-16**] 01:12AM URINE Hours-RANDOM Creat-136 Na-LESS THAN
[**2160-5-17**] 05:51AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1."
5773,"2. Fevers: Post-operative fevers as high as 101.2 without focal
symptoms of infection. Blood and urine cultures were drawn and
patient had CXR on [**5-19**]. Started empirically on ciprofloxacin
for presumed cystitis with positive U/A. When urine culture
returned negative on [**2160-6-2**], ciprofloxacin was discontinued.
Patient defervesced with no evidence of infectious etiology.
3. labile BP: patient has history of autonomic instability from
underlying diabetes mellitus compounded by hypovolemia in
setting of low grade fevers and anemia. Low salt diet was
discontinued and midodrine was titrated up to 5mg TID in an
effort to decrease orthostatic hypotension."
5774,"10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day)."
5775,"3. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1)
Inhalation Q12H (every 12 hours).
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual PRN (as needed) as needed for chest pain."
5776,"Family History:
nc
Physical Exam:
On examination, her strength was [**5-28**] in hip flexion,
extension,quadriceps, hamstrings, and plantarflexion
bilaterally. Dorsiflexion was graded at 4/5 on the left and was
normal on the right. Extensor hallucis longus could not be
assessed on the left due to previous toe surgery and was normal
on the right.
Her sensory examination revealed a decreased appreciation of
light touch in both the medial and lateral aspect of her left
foot.
ON DISCHARGE:
Bialteral IP's [**4-28**], quad, ham, gastroc, AT, and Right [**Last Name (un) 938**] 5-/5,
left [**Last Name (un) 938**] [**4-28**](secondary to toe surgery), incision clean dry
intact with steri strips, sensation decreased to light touch on
right lateral thigh and left lateral foot, ambulates with
walker."
5777,"She
had JP that was removed late in the POD#1. She was out of bed
with PT. She was managed on PO pain medications. On [**5-17**] her
foley was removed and a UA was negative. She had a chest X-ray
which showed small bilateral pleural effusions. On [**5-18**] her
hematocrit was 26 and was being followed for potential need for
transfusion. On [**5-19**] her hematocrit was 25.4 and did not require
trasnfusion. She was screened for rehab, however due to
postoperative complications of labile blood pressure, difficult
to control blood glucose, anemia and low grade fevers, discharge
was delayed (see below for discussion of postoperative
complications)."
5778,"Admission Date: [**2160-5-15**] Discharge Date: [**2160-5-24**]
Date of Birth: [**2106-10-2**] Sex: F
Service: MEDICINE
Allergies:
Actonel
Attending:[**First Name3 (LF) 7281**]
Chief Complaint:
LBP/BLE pain
Major Surgical or Invasive Procedure:
[**2160-5-15**]: L4-S1 posterior decompression and fusion w/ bone marrow
aspirate
History of Present Illness:
She is s/p a left-sided L4-L5 and L5-S1 microlumbar discectomy
on [**12-26**]. She initially did well with her left lower
extremity radiculopathy. Unfortunately,she has gone on to
develop progressive symptoms. For that reason, she underwent
followup MRI. She describes pain that radiates down the left
leg and into the little toe."
5779,"for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Please arrange follow up with Dr. [**Last Name (STitle) 14591**] at [**Telephone/Fax (1) 2384**] from
[**Last Name (un) **].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 7284**]"
5780,"????? You have steri-strips in place. Do not pull them off.
They will fall off on their own or be taken off in the office
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc."
5781,"7 MCHC-33.2 RDW-14.9 Plt Ct-216
[**2160-5-24**] 07:35AM BLOOD WBC-4.6 RBC-3.10* Hgb-9.1* Hct-27.6*
MCV-89 MCH-29.3 MCHC-33.0 RDW-15.0 Plt Ct-429
[**2160-5-20**] 07:25AM BLOOD PT-11.1 PTT-23.6 INR(PT)-0.9
[**2160-5-20**] 07:25AM BLOOD Ret Aut-1.3
[**2160-5-15**] 02:10PM BLOOD Glucose-213* UreaN-23* Creat-1.2* Na-143
K-4.8 Cl-114* HCO3-24 AnGap-10
[**2160-5-24**] 07:35AM BLOOD Glucose-113* UreaN-25* Creat-1."
5782,"Medications with
anticholinergic side effects were also discontinued/ decreased
to alleviate orthostatic symptoms. Although B-blocker was
likely contributing to orthostatic hypotension by blocking
compensatory response in heart rate, carvedilol was continued
given marked supine hypertension. Patient continued to have
labile blood pressure, but her symptoms had improved
significantly and she was able to perform ADLs without
significant difficulty.
4. acute on chronic anemia: Hct on admission 30.8, drifted down
to 25 following spinal surgery. Likely etiology from multiple
chronic medical problems i.e. renal insufficiency and blood loss
from surgery. Iron studies are indicative of some mild iron
-deficiency with serum iron of 21 and a borderline low
transferrin saturation (14%)."
5783,"The PLIF is in situ.
Unremarkable
appearance.
Radiology Report CHEST (PA & LAT) Study Date of [**2160-5-19**] 6:04 PM
There are no findings to suggest pneumonia. Heart size is
normal. There is
no pleural abnormality. Pulmonary vasculature is unremarkable.
No free
subdiaphragmatic gas.
Brief Hospital Course:
1. Lumbar fusion: Pt was admitted on [**2160-5-15**] and underwent above
procedure. Postoperativley she was continued on her home meds.
She remained overnight in PACU and required multiple fluid
boluses for low urine output. She was seen in consult by renal
and [**Last Name (un) **] who followed her throughout her hospital course."
5784,"5* Na-142
K-3.8 Cl-103 HCO3-31 AnGap-12
[**2160-5-16**] 01:13AM BLOOD CK(CPK)-235*
[**2160-5-16**] 11:00AM BLOOD CK(CPK)-222*
[**2160-5-16**] 07:30PM BLOOD CK(CPK)-236*
[**2160-5-20**] 07:25AM BLOOD LD(LDH)-180
[**2160-5-16**] 01:13AM BLOOD cTropnT-<0.01
[**2160-5-16**] 11:00AM BLOOD CK-MB-8 cTropnT-<0.01
[**2160-5-16**] 07:30PM BLOOD CK-MB-6 cTropnT-<0.01
[**2160-5-15**] 02:10PM BLOOD Calcium-7.9* Phos-2.7 Mg-1.5*
[**2160-5-24**] 07:35AM BLOOD Calcium-9."
5785,"007
[**2160-5-17**] 05:51AM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2160-5-17**] 05:51AM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2160-5-20**] URINE URINE CULTURE-FINAL INPATIENT
[**2160-5-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2160-5-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2160-5-17**] URINE URINE CULTURE-FINAL INPATIENT
Radiology Report L-SPINE (AP & LAT) Study Date of [**2160-5-17**] 2:27
PM
FINDINGS: A frontal view is provided."
5786,"[**2131-2-10**] 3:37 PM
CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # [**Clip Number (Radiology) 68072**]
Reason: ? acute process; ct abdomen/pelvis w/ and w/o PO and IV cont
Admitting Diagnosis: DIABETIC KETOACIDOSIS
Contrast: OPTIRAY Amt: 100
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
40 year old woman with chronic pancreatitis s/p whipple p/w abd pain
REASON FOR THIS EXAMINATION:
? acute process; ct abdomen/pelvis w/ and w/o PO and IV contrast.
No contraindications for IV contrast
______________________________________________________________________________
FINAL REPORT
HISTORY: 40-year-old female presenting with a history of chronic pancreatitis
status post a Whipple procedure, now presenting with abdominal pain."
5787,"Please
evaluate for an acute process.
COMPARISON: CT scan from [**2130-8-30**].
TECHNIQUE: Contiguous axial images were obtained through the abdomen and
pelvis before and after the injection of IV contrast. In addition, enteric
contrast was administered. Coronal and sagittal reformatted images were also
available for review. Total exam DLP is 606.27.
FINDINGS: The visualized lower lungs reveal mild bibasilar atelectasis.
Since the prior examination, the gallbladder, distal pancreas, and spleen have
been removed. The liver enhances homogeneously without focal mass. The
common bile duct measures up to 7.5 mm, presumably related to the recent
surgery. As on the prior examination, there are at least three walled off
collections in the pancreas that probably represent hematomas and are slightly
smaller from prior exam."
5788,"The largest measures up to 3.4 x 2.8 cm.
These likely are related to the patient's ovaries representing ovarian cysts.
There is some free fluid in the pelvis.
Oral contrast is seen extending to the hepatic flexure. There is a
jejunostomy tube extending into a small bowel loop through the left anterior
abdominal wall. There is a 4 x 1.2 cm well circumscribed indurated fat
structure along the left lateral aspect of the omentum consistent with an
omental infarct.
(Over)
[**2131-2-10**] 3:37 PM
CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # [**Clip Number (Radiology) 68072**]
Reason: ?"
5789,"The pancreatic duct is normal. The remaining
pancreas is atrophic without calcifications.
Multiple hypodensities are seen in both kidneys that are too small to
adequately characterize but likely represent cysts. The largest is in the
upper pole of the left kidney and measures up to 1 cm. The kidneys otherwise
enhance symmetrically with symmetric excretion of contrast. No adrenal nodule
is identified.
There is a Foley catheter in a mildly distended bladder. Air within the
bladder lumen is presumably iatrogenic from Foley catheter placement.
Multiple fluid-filled structures posterior to the uterine body are more
apparent on the current examination."
5790,"acute process; ct abdomen/pelvis w/ and w/o PO and IV cont
Admitting Diagnosis: DIABETIC KETOACIDOSIS
Contrast: OPTIRAY Amt: 100
______________________________________________________________________________
FINAL REPORT
(Cont)
The portal vein and SMV are patent. The splenic vein is no longer visualized,
presumably secondary to the recent surgery. The celiac axis, SMA, and renal
arteries are patent. There is a venous catheter with its tip in the left
external iliac vein.
No osseous abnormalities are identified.
IMPRESSION:
1. Omental infarct along the left lateral aspect of the abdomen. Clinically
correlate with the patient's pain.
2. The patient is status post distal pancreatectomy, splenectomy, and
cholecystectomy.
3. At least three walled off collections are again seen in the pancreas which
probably represent chronic hematomas and are slightly smaller. No evidence
for chronic pancreatitis.
4. Mild dilation of the common bile duct. MRCP may be performed to further
evaluate.
These findings were discussed with Dr. [**Last Name (STitle) 9217**] via telephone by Dr. [**Last Name (STitle) 874**] on
[**2131-2-10**]."
5791,"Admission Date: [**2131-2-8**] Discharge Date: [**2131-2-16**]
Date of Birth: [**2091-2-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / picc dressing
/ lisinopril
Attending:[**Doctor First Name 3298**]
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
left femoral central line placement
History of Present Illness:
40yo F with history of distal pancreatectomy on [**2130-12-8**], on
chronic tube feeds,type 2 DM, who presents with 3 days of
nausea, bilious vomiting and abdominal pain. Her abdominal pain
is minimal, located diffusely, present for 3 days, constant
[**11-7**], worsened with food intake."
5792,"Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections, plans to try botox if approved
-first headaches [**2124-10-20**]
2. Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age 15
3. Type 2 Diabetes Mellitus
4. Hypertension
5. Obesity
6. Complex Regional Pain Syndrome of the right face and right
upper extremity on methadone
7. Right eye blindness
8. Left pupil dysfunction - ADIE
9. PUD
10. Rheumatoid Arthritis
11. Vitamin D deficiency
12. abnormal LFT's - no response to Hep B vaccines x3
[**32**]. Pancreatitis: complicated by necrotizing pancratitis [**5-/2130**]
w/ multiple admissions for abdominal pain"
5793,"4 Cl-103 HCO3-26 AnGap-14
[**2131-2-13**] 09:06AM BLOOD Calcium-9.2 Phos-5.1* Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] is a 40yo F with history of distal pancreatectomy on
[**2130-12-8**], on chronic tube feeds, who presented with 1 day of
nausea, blilious vomiting and abdominal pain. Patient was found
to have pancreatitis and diabetic ketoacidosis.
ACTIVE ISSUES:
1. Diabetic ketoacidosis: In the ED, she was found to have
elevated blood glucose to 900s and to be in DKA. Her anion gap
was 31. She was started on an Insulin drip and IV fluids."
5794,"2. Pancreatitis: Patient was found to have elevated lipase to
913 on admission and diffuse abdominal tenderness. Surgery was
consulted and recommended CT scan, which did not any changes
except for omental infarct in the left upper abdomen (nothing to
do for this as per surgery). No surgical intervention was
recommended. Surgery followed patient throughout
hospitalization. She was able to tolerate a regular diet in
addition to her tube feeds.
Patient was controlled with IV morphine in the ICU. When
patient tolerated PO, her pain medication was changed to
oxycodone. Patient was discharged with several days of
oxycodone as she continued to have some abdominal pain at
discharge."
5795,"3. Hyperglycemia: When tube feeds were restarted, hyperglycemia
was a problem for patient. [**Last Name (un) **] consulted. Glargine insulin
was increased from 12 [**Hospital1 **] to 34 [**Hospital1 **] at discharge. Given tube
feeding, patient was changed from humalog insulin sliding scale
to regular insulin sliding scale.
4. Leukocytosis: Likely secondary to pancreatitis. No other
localizing symptoms of infection. Improved throughout admission
and was 13 at last check prior to discharge. Patient should
have her CBC checked next week at visit with her PCP.
CHRONIC INACTIVE ISSUES:
1. Hypertension: Normotensive. Continued clonidine.
2. Chronic pain: Worse than typical pain in setting of acute
pancreatitis."
5796,"Social History:
Denies tobacco, previously drank socially (3 drinks per night
per some reports but per her report she drank no more than one
drink per day for many years, no alcohol for months.) Denies
drug use. Lives with boyfriend, unemployed since [**2129-9-28**].
Family History:
Father and sister with HTN. Family history of CAD. No family
history of CVA or headache.
Physical Exam:
Admission exam:
Vitals:pulse 122, 99% RA, BP-120/95.
General: Alert, oriented, no acute distress, sleepy at times but
wakes up to verbal stimuli
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, diffusley tender, no rebound, no guarding, BS +,
non-distended, bowel sounds present, no organomegaly
GU: foley placed
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact."
5797,"fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
4. naratriptan 2.5 mg Tablet Sig: One (1) Tablet PO As needed as
needed for migraine headache.
5. gabapentin 400 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
6. Lantus 100 unit/mL Solution Sig: Thirty Four (34) units
Subcutaneous twice a day.
Disp:*20 mL* Refills:*2*
7."
5798,"Please check your fingerstick four times per day. Please record
this information and bring it to your next appointment with your
[**Last Name (un) **] doctor.
Please make the following changes to your medications:
1. INCREASE lantus insulin to 34 units twice a day
2. STOP humalog insulin
3. START oxycodone 10 mg every 6 hours as needed for pain. This
medication may make you drowsy. Do not drive while taking this
medication.
4. START regular insulin as per sliding scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Breakfast Lunch Dinner Bedtime
71-80 mg/dL 2 Units 2 Units 2 Units 2 Units
81-120 mg/dL 14 Units 14 Units 14 Units 14 Units
121-160 mg/dL 18 Units 18 Units 18 Units 18 Units
161-200 mg/dL 20 Units 20 Units 20 Units 20 Units
201-240 mg/dL 22 Units 22 Units 22 Units 22 Units
241-350 mg/dL 26 Units 26 Units 26 Units 26 Units
Followup Instructions:
Department: [**State **]When: WEDNESDAY [**2131-2-21**] at 10:45 AM
With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Name: [**Last Name (LF) **], [**First Name3 (LF) 16244**] K. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appointment: TUESDAY [**3-6**] AT 9AM"
5799,"Pertinent Results:
[**2131-2-8**] URINE CULTURE:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
[**2131-2-9**] Urine Culture: No growth.
CT Abdomen/Pelvis:
IMPRESSION:
1. Omental infarct along the left lateral aspect of the abdomen.
Clinically correlate with the patient's pain.
2. The patient is status post distal pancreatectomy,
splenectomy, and
cholecystectomy.
3. At least three walled off collections are again seen in the
pancreas which probably represent chronic hematomas and are
slightly smaller. No evidence for chronic pancreatitis.
4. Mild dilation of the common bile duct."
5800,".
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Diabetic ketoacidosis, pancreatitis, hyperglycemai
SECONDARY: Chronic abdominal pain, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Ms. [**Known lastname **]. You
were admitted to the hospital with pancreatitis and diabetic
ketoacidosis. You were initially in the ICU and received an
insulin drip. The diabetic ketoacidosis improved. You were
seen by the surgeons. The pancreatitis improved. You were
transferred to the medical floor and restarted tube feeds. Your
blood surgar was high so we increased your insulin."
5801,"MRCP may be performed
to further evaluate.
Admission [**Month/Day/Year **]:
[**2131-2-8**] 01:30PM BLOOD WBC-34.0*# RBC-5.05 Hgb-11.0* Hct-40.9#
MCV-81*# MCH-21.8* MCHC-27.0* RDW-17.5* Plt Ct-634*
[**2131-2-8**] 01:30PM BLOOD Glucose-965* UreaN-34* Creat-1.5* Na-140
K-5.6* Cl-101 HCO3-8* AnGap-37*
[**2131-2-8**] 01:30PM BLOOD ALT-26 AST-33 AlkPhos-216*
[**2131-2-8**] 01:30PM BLOOD Lipase-913*
[**2131-2-8**] 01:30PM BLOOD Albumin-4.9 Calcium-9.6 Phos-5."
5802,"Oriented X 3, with poor
attention not able to say days of week backward.
Discharge exam:
T 97.5, 98/50, 78, 18, 98% on RA
General: Alert, oriented, covering her eyes with her arm, but in
no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: very soft, diffuse mild tenderness, no rebound, no
guarding, BS +, non-distended, bowel sounds present, no
organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: left pupil dysfunction (at baseline), CNIII-XII intact,
5/5 strength upper/lower extremities"
5803,"13. tizanidine 4 mg Tablet Sig: Two (2) Tablet PO at bedtime:
Please take as directed by your PCP. .
14. multivitamin Oral
15. Tube Feeds
NUTRITIONAL SUPPLEMENT - FIBER [REPLETE/FIBER] - Liquid - 90
cc via tube feed per hour x 16 hours Please give 90cc/hr via
j-tube with a pump for 16 hours daily.
16. insulin regular human 100 unit/mL Solution Sig: As directed
units Injection QACHS: Please take subcutaneously as directed by
sliding scale. Pt will use 14 - 26 units four times per day.
Disp:*30 mL* Refills:*2*
17. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: Do not drive while taking this
medication."
5804,"She recieved 4 Liters of NS and one liter of 1/2NS.
She was given calcium gluconate for questionable T waves.
On arrival to the MICU, her vitals are pulse 122, 99% RA,
BP-120/95. The above hx was obtained and she was oriented X 3.
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 dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
1."
5805,"Her vomitus is green with few
specks of red in her last vomiting episode earlier today , she
denies any frank hematemesis, melena, hematochezia,
diarrhea.Last BM was normal yesterday, brown and formed. She at
times feels sleepy, but denies confusion.
In the ED, initial VS were: 96.1 128 136/92 16 . She was found
to have elevated blood glucose and in DKA. Started on Insulin
drip and IV fluids.She also recieved 4 mg IV dilaudid, 8 mg IV
Morphine for abdominal pain and IV/p.o Zofran, compazine, for
nausea.For her leukocytosis she was given Vancomycin and
Meropenem."
5806,"lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. doxepin 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
9. gabapentin 800 mg Tablet Sig: As directed Tablet PO three
times a day: Take 1100 mg in AM and afternoon, 1600 mg at
bedtime.
10. naratriptan 2.5 mg Tablet Sig: One (1) Tablet PO As needed
as needed for headache.
11. ondansetron 4 mg Film Sig: One (1) PO every eight (8) hours
as needed for nausea.
12. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea."
5807,"In
the ICU she was continued on the insulin drip and her anion gap
closed within 12 hours. She was ruled out for MI. No infectious
etiology of hyperglycemia was found (had urine culture with
10,000-100,000 colonies of gram positive alpha hemolytic
colonies consistent with alpha streptococcus or Lactobacillus
sp). Pt was not treated for UTI as it was felt that this was a
contaminant. She denied insulin noncompliance or recent drug
abuse. Mental status was stable and not obtunded Anion gap
closed with insulin drip and IV fluids (8-10 liters). On
hospital Day # 2 tolerated orals and was transitioned to SC
Insulin."
5808,"5* Mg-2.6
[**2131-2-8**] 04:25PM BLOOD Triglyc-189*
[**2131-2-8**] 04:25PM BLOOD Osmolal-359*
[**2131-2-8**] 09:04PM BLOOD Type-[**Last Name (un) **] pO2-68* pCO2-47* pH-7.30*
calTCO2-24 Base XS--3
[**2131-2-8**] 01:54PM BLOOD Lactate-1.9
Discharge [**Year/Month/Day **]:
[**2131-2-13**] 09:06AM BLOOD WBC-13.7* RBC-4.03* Hgb-8.7* Hct-30.0*
MCV-75* MCH-21.6* MCHC-29.0* RDW-17.6* Plt Ct-385
[**2131-2-13**] 09:06AM BLOOD Glucose-351* UreaN-13 Creat-0.5 Na-139
K-4."
5809,"Continued fentanyl patch, gabpentin, tizanidine.
Patient received Oxycodone PRN for breakthrough pain.
TRANSITIONAL ISSUES:
1. Repeat CBC in one week as patient had elevated WBC count
throughout hospitalization.
2. Patient instructed to track finger stick glucose and insulin
requirement. She will bring this information to next [**Last Name (un) **]
appointment.
Medications on Admission:
Fentanyl patch 75 mcg q72 hours
Tizanidine 4 mg qhs
Naratriptan 2.5 mg prn migraine
lantus/humalog,
clonidine 0.4 [**Hospital1 **]
lorazepam 0.5 mg qhs,
promethazine 12.5 q6h prn nausea,
doxepim 50 mg qhs
gabapentin 800 [**Hospital1 **], 1600 qhs,
zofran 4 mg daily
Discharge Medications:
1."
5810,"Admission Date: [**2137-3-29**] Discharge Date: [**2137-4-1**]
Date of Birth: [**2061-2-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline Analogues / Atrovent / Chlorhexidine
/ Cephalosporins
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Palpitations/tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 yo M with history of AML, MDS, and prostate cancer who
presents to [**Hospital1 18**] ED with palpitations after he had been sent
home from [**Hospital1 3242**] outpatient clinic after assessment for dyspnea and
fevers. According to patient's wife, the patient had been
cleared to go home from [**Hospital1 3242**] outpatient clinic after a CXR was
unrevealing, though the patient was only home for a coupld of
hours prior to feeling acutely unwell and EMS was called."
5811,"[**Last Name (STitle) **]; he's experienced a PSA only relapse
.
Other Past Medical History:
#2V CAD s/p BMS to ramus [**2-28**]
#HTN
#Hyperlipidemia
#AAA s/p endovascular repair in [**9-1**]
#s/p appendectomy
#emphysema
#s/p basal cell ca excision
Social History:
Lives in [**Location **] with wife. 3 kids. Former VP Gillete for 32
yrs, retired in [**2128**]. Smoked 68 yrs 2ppd. Quit smoking
[**Holiday 1451**] in [**2135**]. Drinks 1 [**Doctor Last Name 6654**] a day.
Family History:
Father died of lung cancer at age 44. Mother died of an MI.
Physical Exam:
ADMISSION EXAM:
.
GEN: Somnolent, appears comfortable, though high respiratory
rate
[**Doctor Last Name 4459**]: Corrective lenses, PERRL, oral mucosa dry
NECK: Supple, no [**Doctor First Name **], no JVP elevation
PULM: Anteriorly coarse breath sounds with inspiratory squeaks
and mild exp wheezing
CARD: Tachycardic, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND
EXT: 1+ BLE pitting edema
SKIN: no rashes
NEURO: somnolent, though easy to awake and is oriented x 3 when
awake
."
5812,"Small
pleural effusions are present bilaterally.
IMPRESSION:
1. Near resolution of bibasilar opacities which were likely due
to
atelectasis.
2. Right apical opacity, likely due to slowly resolving
infection. Continued radiographic followup of this region may be
helpful to document complete resolution.
Brief Hospital Course:
#. Atrial fibrillation with RVR:
Patient presented to ED primarily because of new palpitations at
home which was proven to be atrial fibrillation with RVR as well
as one documented episode of atrial flutter. Patient converted
to sinus rhythm soon after admission to MICU overnight. The
patient was switched to oral amiodarone after having converted
to sinus."
5813,"He tolerated the PO well and was called out to the
floor and was transfered to the [**Hospital Ward Name **] under the care of
the oncology/[**Hospital Ward Name 3242**] service. Pt was not not discharged on amio
given that he converted prior to receiving his 1st dose and we
thought the benefits did not outweight the drawbacks given his
baseline pulmonary disease and overall decreased life
expectancy.
.
#. Anemia:
Pt has long term anemia with frequent outpatient transfusions
related to MDS. The patient was ordered for HCT daily with
transfusion threshold of HCT < 21. The patient had a stable
hematocrit and did not require any transfusions while in the
ICU, but did receive 2U of PRBC for a Hct of 23."
5814,"5 on the day of
discharge.
.
#. Febrile neutropenia with pneumonia:
Patient with ANC of 60 at presentation and spiked a fever to
100.8 in the ED and pneumonia on CXR. Patient with reported
end-stage MDS and AML and will be difficult for him to mount a
response to any infection. He was given neupogen recently as a
trial to attempt to affect change in his refractory neutropenia.
The patient was covered with broad antibiotics with Vancomycin,
Meropenem. This was continued as the patient was called out to
the oncology floor. Upon discharge he was sent home on
linezolid and levofloxacin with the course to be determined by
his outpatient oncologist."
5815,"11. zolpidem 12.5 mg Tablet,Ext Release Multiphase Sig: One (1)
Tablet,Ext Release Multiphase PO at bedtime.
12. dexamethasone 2 mg Tablet Sig: 1-2 Tablets PO twice a day:
[**11-25**] Tablet(s) by mouth As directed Take 2 tablets in the
morning, and 1 tablet at 12pm .
13. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO twice
daily at 8am, 12pm: [**Month (only) 116**] skip second dose if desired.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Atrial flutter
Pneumonia
Secondary Diagnosis:
Acute Myelogenous Leukemia
Discharge Condition:
Mental Status: Clear and coherent."
5816,"5
LEUK-NEG
[**2137-3-29**] 10:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2137-3-29**] 01:05PM PLT COUNT-22*#
[**2137-3-29**] 03:30PM PLT COUNT-35*#
[**2137-3-29**] 09:55PM PT-13.4 PTT-29.8 INR(PT)-1.1
[**2137-3-29**] 09:55PM PLT SMR-VERY LOW PLT COUNT-30*
[**2137-3-29**] 09:55PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
BURR-1+ BITE-OCCASIONAL
[**2137-3-29**] 09:55PM NEUTS-1* BANDS-0 LYMPHS-4* MONOS-66* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-29* NUC RBCS-2*
[**2137-3-29**] 09:55PM WBC-7."
5817,"5 mg QHS
10) Multivitamin
Discharge Medications:
1. voriconazole 200 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
2. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): Please follow up with your oncologist to determine when
to stop this medication.
Disp:*60 Tablet(s)* Refills:*0*
3. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day:
Please follow up with your oncologist to determine when to stop
this medication.
Disp:*30 Tablet(s)* Refills:*0*
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every four (4) hours as needed for shortness
of breath or wheezing."
5818,".
#. MDS, AML:
Patient and family aware of overall poor prognosis and have
expressed their wish for patient to be DNR/DNI. Counts were
trended, and he remained anemic, neutropenic, and
thrombocytopenic as above. He received a total of 2U PRBC and
3U of platelets.
Medications on Admission:
1) Albuterol sulfate 90 mcg HFA Inhaler Q4H:PRN dyspnea/wheezing
2) Dexamethasone 4 mg in the morning and 2 mg at noon
3) Fluticasone-salmeterol 250 mcg-50 mcg [**Hospital1 **]
4) Lorazepam 0.5-1 mg PO QHS:PRN insomnia
5) Morphine 15-30 mg Q4H:PRNs hortness of breath or wheezing
6) Omeprazole 40 mg DAILY
7) Tiotropium bromide 18 mcg
8) Voriconazole 400 mg [**Hospital1 **]
9) Zolpidem 12."
5819,"0# RBC-3.02* HGB-9.0* HCT-26.4* MCV-88
MCH-29.9 MCHC-34.1 RDW-14.4
[**2137-3-29**] 09:25AM ALBUMIN-3.5 CALCIUM-8.4 PHOSPHATE-3.6
MAGNESIUM-2.0
[**2137-3-29**] 09:25AM ALT(SGPT)-12 AST(SGOT)-42* LD(LDH)-1287* ALK
PHOS-96 TOT BILI-0.6
[**2137-3-29**] 09:25AM UREA N-26* CREAT-0.8 SODIUM-138 POTASSIUM-4.1
CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2137-3-29**] 10:50AM URINE RBC-3* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2137-3-29**] 10:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6."
5820,"5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Inhalation twice a day.
6. multivitamin Capsule Sig: One (1) Capsule PO once a day.
7. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
8. morphine 15 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for shortness of breath or wheezing.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day."
5821,"However, due to your frequent
neutropenia and pneumonia infections, it was felt best to
re-start you on antibiotics until follow-up with your primary
outpatient oncologist.
You were also given a transfusion of platelets and red blood
cells while in the hospital to increase your blood counts.
The following changes were made to your home medications:
- Linezolid was re-STARTED.
- Levofloxacin was re-STARTED.
Please follow up with your oncologist about when to stop taking
these medications.
Followup Instructions:
Department: [**Hospital 3242**] CHAIRS & ROOMS
When: WEDNESDAY [**2137-4-3**] at 12:30 PM
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2137-4-3**] at 12:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2137-4-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]"
5822,"3 RBC-2.93* HGB-9.2* HCT-24.5* MCV-84
MCH-31.3 MCHC-37.5* RDW-14.6
[**2137-3-29**] 09:55PM LACTATE-1.5
[**2137-3-29**] 09:55PM TSH-1.5
[**2137-3-29**] 09:55PM cTropnT-0.01
[**2137-3-29**] 09:55PM GLUCOSE-106* UREA N-23* CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
.
DISCHARGE LABS:
.
[**2137-4-1**] 06:20AM BLOOD WBC-7.3 RBC-2.67* Hgb-7.9* Hct-23.5*
MCV-88 MCH-29.5 MCHC-33.6 RDW-14."
5823,"EMS
noted HR of 190 and pushed diltiazem with little change in HR.
.
At presentation to the ED, patient was noted to have HR of 150
and EKG consistent with atrial flutter and was started on an
amiodarone bolus and infusion. Patient was given morphine for
dyspnea per home regimen. Vitals prior to transfer to the MICU
were: T 100.8, HR 134, BP 98/56, RR 36, O2Sat 97% 3L NC.
.
Upon arrival to the floor the patient's wife and daughter
indicated that patient would want to be DNR/DNI and would be
discerning about performing any invasive procedures."
5824,"DISCHARGE EXAM:
.
VS: T: 96.98.9 BP: 144/74 (100s-140s/50s-70s) HR: 87
(80s-100s) RR: 18 O2: 94% 2L
GEN: AOx3, interactive, NAD
[**Doctor First Name 4459**]: MMM. Neck supple.
Cards: RRR, S1/S2 normal, no murmurs/gallops/rubs.
Pulm: Scattered crackles
Abd: Soft, NT/ND, no rebound/guarding
Extremities: WWP, 1+ pitting LE edema bilaterally.
Pertinent Results:
ADMISSION LABS:
.
[**2137-3-29**] 09:25AM GRAN CT-60*
[**2137-3-29**] 09:25AM PLT SMR-RARE PLT COUNT-10*#
[**2137-3-29**] 09:25AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
[**2137-3-29**] 09:25AM NEUTS-1* BANDS-0 LYMPHS-24 MONOS-48* EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0 BLASTS-24* NUC RBCS-1*
[**2137-3-29**] 09:25AM WBC-6."
5825,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for palpitations, and were
found to be in a rapid heart rhythm called atrial flutter. You
received medications for the rapid heart rhyrhm and your heart
rate converted back to normal. You had no further symptoms
other than shortness of breath, and you received a dose of
medication called Lasix to remove fluid from your lungs.
Your chest xray from admission showed a possible pneumonia, and
a repeat chest xray in the hospital was more consistent with
residual findings from a resolving pneumonia you had previously
rather than a new pneumonia."
5826,"3 Plt Ct-28*#
[**2137-4-1**] 06:20AM BLOOD Neuts-0 Bands-0 Lymphs-9* Monos-34* Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Promyel-1* Blasts-56* NRBC-1*
Other-0
.
STUDIES:
.
CXR [**2137-3-29**]:
In comparison to study performed earlier the same day, lung
volumes are
decreased. This may account for increased bibasilar opacitites,
though new
consolidation should also be considered. Right apical opacity is
likely
unchanged, though is now partially obscured by overlying soft
tissue artifact. Left peripherally inserted central catheter
reaches the mid SVC. Hilar and cardiomediastinal contours are
unchanged. There is no large effusion or pneumothorax."
5827,"There is
no free air in the upper abdomen.
IMPRESSION: Persistent right apical opacity with apparent new
bibasilar
opacities, which may in part reflect atelectasis in conjunction
with low lung volumes. Repeat PA and lateral radiographs with
better inspiration would be helpful for further evaluation.
.
CXR [**2137-3-31**]:
Heart size remains normal. Pulmonary vascularity is also within
normal limits. Lung volumes are increased compared to the recent
radiograph, and recently described new bibasilar opacities have
nearly resolved with only minimal linear atelectasis remaining.
Poorly defined right apical opacity has slightly decreased in
size since prior studies and is likely due to slowly resolving
infection based on appearance on [**2137-3-2**] chest CT."
5828,"Within 30
minutes of arriving to the MICU, patient spontaneously converted
to sinus rhythm and HR dropped from 150s to 80s.
Past Medical History:
Past Oncologic History:
# AML status post induction with 7 and 3 on [**2134-12-5**].
Consolidation treatment initiated on ALFA low dose 7+3
chemotherapy regimen on [**2135-4-4**], s/p 3 cycles. Currently
off azecitadine.
#MDS diagnosed in [**9-1**] s/p 2x decitabine then treated with
Neulasta and Nplate, started on azacytidine in [**2136-11-24**]
#Prostate Cancer - diagnosed in [**2121**] ([**Doctor Last Name **] 2+5) at which
time he received bracytherapy and was subsequently followed
expectantly by Dr."
5829,"Admission Date: [**2177-7-30**] Discharge Date: [**2177-8-12**]
Date of Birth: [**2124-7-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Horrible headache
Major Surgical or Invasive Procedure:
Angiogram
L ICA aneurysm coiling
History of Present Illness:
53 y/o female with a hx of migranes, had a sudden onset
headache yesterday which caused pain in the back of her head
down
her neck, she said it self resolved on it's own after 20 minutes
and 2 advil. Early this morning she developed a sudden severe
posterior headache with a ""popping"" feeling in her head with
neck
pain while drinking her morning coffee."
5830,"She went to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
hospital where she was found to have an intraventricular
hemorrhage and questionable SAH, her BP was 204/115 at [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] hospital
Past Medical History:
Migraines, Hyperlipidemia, Back pain and anxiety
Social History:
37 pack year history of smoking; Currently a smoker;
Denies IV drug use or ETOH. She is not married, has 2 grown
children and is sole caregiver of her 4 year old grandchild. She
works as a nursing assistant
Family History:
2 aunts with brain aneursyms
Physical Exam:
PHYSICAL EXAM:
O: T: BP:159/68 HR: 80 R 18 O2Sats
Gen: WD/WN, comfortable, NAD."
5831,"6 SODIUM-135
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
[**2177-7-30**] 10:20AM WBC-15.8* RBC-4.47 HGB-14.0 HCT-40.5 MCV-91
MCH-31.3 MCHC-34.5 RDW-12.8
[**2177-7-30**] 10:20AM NEUTS-86.9* LYMPHS-8.7* MONOS-3.3 EOS-0.7
BASOS-0.5
[**2177-7-30**] 10:20AM PT-12.3 PTT-24.1 INR(PT)-1.0
DISCHARGE LABS:
IMAGING:
CTA Head [**7-30**]
IMPRESSION:
1. Intraventricular hemorrhage and diffuse subarachnoid
hemorrhage.
2. Mild temporal [**Doctor Last Name 534**] dilatation indicating early obstructive
hydrocephalus."
5832,"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 [**4-2**] throughout. No pronator drift
Sensation: Intact to light touch, can discern warm and cold.
vibration bilaterally.
Toes downgoing bilaterally
CT/MRI:Intraventricular hemorrhage and diffuse subarachnoid
hemorrhage. Mild temporal [**Doctor Last Name 534**] diliation; CTA read pending
initial no aneurysm or AVM noted
Labs:Crit 40.5 plt 397, INR 1.0
EXAM ON DISCHARGE:
Intact
Pertinent Results:
ADMISSION LABS:
[**2177-7-30**] 10:20AM GLUCOSE-135* UREA N-13 CREAT-0."
5833,"3. No aneurysm or AVM is seen. Followup conventional angiogram
or CT
angiogram may be helpful.
4. Mild prominence of nasopharyngeal soft tissues. Suggest
correlation with direct visualization and immune status.
CT Head [**7-30**]:
No significant change in intraventricular and subarachnoid
hemorrhage, with mildly prominent temporal horns of lateral
ventricles
CTA [**2177-8-7**]: IMPRESSION: Mild to moderate vasospasm, most
prominent in the distal (A2 and A3) ACA segments.
CT Head [**8-10**]: IMPRESSION:
1. No new intracranial hemorrhage or evidence of infarction.
2. Unchanged appearance of right AICA aneurysm coil in the right
inferior
portion posterior fossa; associated artifact limits evaluation
for acute
hemorrhage in the region."
5834,"Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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."
5835,"HEENT: Pupils: EOMs
Neck: + Meningismus
Neuro: Patient received Fentanyl and Ativan for transport
Mental status: Prefers eyes closed, opens eyes to voice.
Orientation: Oriented to person, place, and date.
Recall: [**1-29**] objects at 5 minutes.
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, 2.5 min reactive
(recently received narcotic). Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice."
5836,"Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 12 days.
Disp:*144 Capsule(s)* Refills:*0*
3. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-30**]
Tablets PO Q4H (every 4 hours) as needed for h/a: Do not exceed
4gms of Tylenol per day.
Disp:*60 Tablet(s)* Refills:*0*
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: Three (3) Patch 24 hr
Transdermal DAILY (Daily): Please have PCP follow you and write
for further refils."
5837,"CTA [**8-11**]
1. unchanged R AICA aneurysm coil w/ surrounding streak artifact
limiting
assessment of that area; otherwise, no acute ICH.
2. patent anterior & posterior circulations
Brief Hospital Course:
The patient was admitted to the ICU for Q1 hour neuro checks.
She was placed on keppra for seizure prophylaxis, and nimodipine
for vasospasm prevention. She went for a diagnostic angiogram,
however, due to her pain and agitation, the procedure was unable
to be completed. She returned to the ICU. Her post op check was
negative. She continued to have a very severe HA, but her exam
was non focal."
5838,"blood cultures
that were obtained on [**8-8**] for fever work up revealed VIRIDANS
STREPTOCOCCI from sample that was obtained from PICC line
therefore the PICC was discontinued. Repeat blood cultures were
ordered.
[**8-11**]: CTA showed no vasospasm and pt was cleared for discharge
from neurosurgical standpoint. She was cleared for home without
services from PT/OT. She will be discharged home in stable
condition on [**8-12**] with plan to follow up in clinic in 4 weeks.
She will also have a repeat cerebral angiogram in 4 weeks as
well.
Medications on Admission:
Lipitor 20mg QD, Percocet/Valium
prn"
5839,"Current pain regimen appears to
alleviate the headaches, at least to a tolerable level. PT
consult was requested.
on [**8-7**] we discontinued her IV fluids and changed her pain
medications to dilaudid P.O prn and obtained a CTA to evaluate
the amount of bld and underlying vasospasm. This was significant
for mild to moderate vasospasm therefore her IV fluids were
restarted on [**8-8**].
On [**8-9**] and [**8-10**] she remained neurologically stable but had
persistant headaches. She was started on Topamax in addition to
her existing pain regimen to attempt to help with this. She also
described some chest discomfort that she had x1 therefore an EKG
was obtained which was negative for changes, NSR."
5840,"Disp:*3 Patch 24 hr(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
8. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Aneurysmal Subarachnoid hemorrhage
R ICA Aneurysm coiling
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive."
5841,"On [**7-31**], the patient underwent another angio, but this time had a
general anesthesia in order to complete the procedure. This
revealed a right AICA aneurysm that was successfully coiled.
Post angiogram patient was transferred to the ICU for
observation and monitoring for Vasospasm. She was maintained on
IV fluids with a goal to keep her euvolemic. Her severe
headaches were treated with a steroid taper and narcotic pain
meds which seemed to be effective.
Throughout her ICU course her exam remained non-focal.
On [**8-6**] she was cleared for transfer to the floor. Her IV fluids
were decreased to 50ml/hr."
5842,"?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] , to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. You will also need to schedule cerebral
angiogram for 4 weeks as well. This can both be scheduled when
you call to make your office visit appointment.
?????? You stated that you have been having headaches everyday
for many years. We are recommending that you follow up with Dr.
[**Last Name (STitle) **] in the [**Hospital **] Clinic. Please call ([**Telephone/Fax (1) 87190**] to
set up an appointment with him regarding pain control for your
headaches.
Completed by:[**2177-8-19**]"
5843,"[**2177-7-31**] 10:45 AM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 15817**]
Reason: eval for aneurysm
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE
Contrast: OPTIRAY Amt: 204
********************************* CPT Codes ********************************
* [**Numeric Identifier 284**] EMBO TRANSCRANIAL [**Numeric Identifier 287**] SEL CATH 2ND ORDER *
* -51 MULTI-PROCEDURE SAME DAY [**Numeric Identifier 289**] VERT/CAROTID A-GRAM *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 43**] TRANSCATH EMBO THERAPY *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
53 year old woman with sah
REASON FOR THIS EXAMINATION:
eval for aneurysm
______________________________________________________________________________
FINAL REPORT
PREPROCEDURE DIAGNOSIS: Subarachnoid hemorrhage with intraventricular
extension. Right ICA aneurysm.
INDICATION: Embolization of right ICA aneurysm.
ANESTHESIA: General anesthesia."
5844,"PROCEDURE PERFORMED: Left vertebral artery arteriogram, embolization of right
ICA aneurysm and Angio-Seal closure of right common femoral artery puncture
site.
ATTENDING:[**Last Name (NamePattern4) 15818**]
NEURORADIOLOGY FELLOW: [**Name6 (MD) 2331**] [**Name8 (MD) 2332**], M.D., MRCP, FRCR.
DETAILS OF THE PROCEDURE: Informed consent was obtained prior to the
procedure explaining the risks, benefits and alternatives. Prior to the
procedure, a timeout was performed using name, date of birth, and medical
record number as identifiers. Both groins were prepped and draped in the
typical sterile fashion. Using a micropuncture set, the right femoral artery
was accessed and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 52**] wire was advanced under fluoroscopic observation."
5845,"There were no immediate post-procedure complications, and the patient was
transferred from the angio suite to the intensive care unit in stable
condition.
FINDINGS: Diagnostic angiogram of the left vertebral artery confirmed a
(Over)
[**2177-7-31**] 10:45 AM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 15817**]
Reason: eval for aneurysm
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE
Contrast: OPTIRAY Amt: 204
______________________________________________________________________________
FINAL REPORT
(Cont)
conclusive aneurysm measuring 5.2 x 4.2 mm with a 1.5 mm neck arising from the
distal left AICA. Successful embolization of the aneurysm was achieved using
detachable GDC coils. Post-procedure angiogram demonstrates no distal
occlusion.
IMPRESSION:
1. Right distal ICA aneurysm identified as a possible source of the recent
subarachnoid hemorrhage with intraventricular extension.
2. Successful embolization of the distal right AICA aneurysm was achieved
using GDC embolization coils."
5846,"Using Seldinger technique, the needle was removed and replaced with a 4 French
arterial sheath. Thereafter, a 4 French Berenstein 2 catheter was advanced
over the [**Last Name (un) 52**] wire and the [**Last Name (un) 52**] wire was thereafter removed and replaced
with a 035 Glidewire. With fluoroscopic assistance, the catheter was
positioned in the left vertebral artery from which position angiograms were
performed in the oblique and lateral projections. A microcatheter guidewire
and catheter was used to access the distal right eye ICA aneurysm. The
aneurysm was successfully embolized using GDC Detachable Coils. Following
angiogram and embolization, the catheter and sheath were removed and Angio-
Seal device was used to secure hemostasis in the right common femoral artery."
5847,"INDICATION: Assess for aneurysm or AVM.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
fentanyl and Versed throughout the total intraservice time of 80 minutes
during which the patient's hemodynamic parameters were continuously monitored.
PROCEDURE PERFORMED: Left vertebral artery arteriogram, left common carotid
artery arteriogram, right common carotid artery arteriogram and Angio-Seal
closure of left deep femoral artery puncture site.
ATTENDING:[**Name8 (MD) 15606**]
NEURORADIOLOGY FELLOW: [**Last Name (un) 2331**] Ramachandran, MB, MRCP, FRCR.
DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite.
IV sedation was given. Following this, both groins were prepped and draped in
a sterile fashion."
5848,"There is a right AICA- PICA configuration. There is a 5.2 x 4.2 mm
aneurysm with a neck of 1.5 mm arising from the distal right AICA. No early
draining veins were seen on this injection.
(Over)
[**2177-7-30**] 6:06 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 15605**]
Reason: R/O underlying aneursym versus avm
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE
Contrast: OPTIRAY Amt: 220
______________________________________________________________________________
FINAL REPORT
(Cont)
Left common carotid artery shows normal filling of the left external carotid
artery and its branches. The left internal carotid artery fills well along
with the cervical, petrous, cavernous and supraclinoid portion."
5849,"Access was gained into the left deep femoral artery using
a Seldinger technique, and a 5-French vascular sheath was placed in the left
deep femoral artery. Now using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 586**] 2 catheter, the abovementioned
arteries were catheterized. AP and lateral filming was done. Following this,
the left deep femoral artery puncture site was closed with a 6-French Angio-
Seal device. There were no complications.
FINDINGS: Left vertebral artery arteriogram shows normal filling of the left
vertebral artery, the basilar artery and the posterior cerebral arteries.
There is reflux into the right vertebral artery. The left PICA and left ICA
are seen."
5850,"The left ACA
and MCA are visualized well showing normal filling of the contrast.
Common carotid artery arteriogram shows normal filling of the right external
carotid artery and its branches. There is focal short segmental narrowing of
the right ICA origin which shows the luminal diameter of 4.5 mm compared to
maximal luminal diameter of 9 mm, demonstrating a 50% stenosis at the origin.
The remaining cervical ICA shows normal contrast opacification and caliber.
The right internal carotid fills well along the petrous, cavernous and
supraclinoid portions. The anterior and middle cerebral arteries are seen
normally.
The left common femoral artery arteriogram shows normal caliber and left
common femoral artery. There is no stenosis.
IMPRESSION:
1. [**Known firstname 6103**] [**Known lastname **] underwent cerebral angiography which showed a 5.2 mm x 4.2 mm
aneurysm with a neck of 1.5 mm at the distal right AICA. The patient will
return to the interventional suite the following day for coiling under general
anesthesia.
2. 50% stenosis of the origin of right ICA."
5851,"[**2177-7-30**] 6:06 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 15605**]
Reason: R/O underlying aneursym versus avm
Admitting Diagnosis: INTRACRANIAL HEMORRHAGE
Contrast: OPTIRAY Amt: 220
********************************* CPT Codes ********************************
* [**Numeric Identifier 287**] SEL CATH 2ND ORDER [**Numeric Identifier 287**] SEL CATH 2ND ORDER *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 819**] SEL CATH 1ST ORDER *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 288**] CAROTID/CEREBRAL BILAT *
* [**Numeric Identifier 821**] CAROTID/CERVICAL BILAT [**Numeric Identifier 289**] VERT/CAROTID A-GRAM *
* [**Numeric Identifier 44**] MOD SEDATION, FIRST 30 MIN. [**Numeric Identifier 45**] MOD SEDATION, EACH ADDL 15 MIN *
* [**Numeric Identifier 45**] MOD SEDATION, EACH ADDL 15 MIN [**Numeric Identifier 45**] MOD SEDATION, EACH ADDL 15 MIN *
* [**Numeric Identifier 45**] MOD SEDATION, EACH ADDL 15 MIN *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
53 year old woman with SAH with intraventricular hemorrhage
REASON FOR THIS EXAMINATION:
R/O underlying aneursym versus avm
______________________________________________________________________________
FINAL REPORT
PREPROCEDURE DIAGNOSIS: Subarachnoid hemorrhage with intraventricular
extension."
5852,"Admission Date: [**2141-4-10**] Discharge Date: [**2141-4-17**]
Date of Birth: [**2067-3-5**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Feldene / epinephrine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T11-L2 fusion on [**4-10**] and T3-L5 fusion [**4-11**] for kyphosis,
spondylosis and compression fracture
History of Present Illness:
Ms. [**Known lastname **] has a long history of a kyphoscoliosis. She is
electing to proceed with surgical intervention.
Past Medical History:
HTN, HLD, depression, L footdrop, chronic LBP, left frozen
shoulder, left foot drop, bilateral lower extremity neuropathy,
reflux, constipation, depression"
5853,"15. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Kyphoscoliosis
Acute post-op blood loss anemia
Post-op delerium
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks."
5854,"You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office."
5855,"You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking."
5856,"Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T3-L5 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the SICU in
stable condition. Postoperative HCT was low and she was
transfused PRBCs. A bupivicaine epidural pain catheter placed at
the time of the posterior surgery remained in place until postop
day one.
POD#2 the chest tube was removed and an x-ray showed no signs of
a pneumothorax."
5857,"3* Hct-28.2*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.3 Plt Ct-174
[**2141-4-14**] 05:14AM BLOOD Glucose-103* UreaN-9 Creat-0.5 Na-134
K-3.9 Cl-102 HCO3-24 AnGap-12
[**2141-4-12**] 03:19PM BLOOD Glucose-113* UreaN-12 Creat-0.5 Na-132*
K-4.0 Cl-103 HCO3-22 AnGap-11
[**2141-4-11**] 02:36PM BLOOD Glucose-171* UreaN-14 Creat-0.6 Na-128*
K-4.4 Cl-98 HCO3-23 AnGap-11
[**2141-4-14**] 05:14AM BLOOD Calcium-8.0* Phos-2."
5858,"-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2141-4-17**]"
5859,"She was kept NPO until bowel function returned
then diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#2 from the second procedure. She was
fitted with a TLSO brace for ambulation. Physical therapy was
consulted for mobilization OOB to ambulate. Hospital course was
otherwise unremarkable. On the day of discharge the patient was
afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
vicodin PRN, atacand 32', HCTZ 25', arthrotec 75-200 1-2 tabs
daily, cymbalta 60', nexium 40', gabapentin 1000''', vitamin D
[**2128**] units', vitamin B, MVI, lovasa 2 tabs QHS, crestor 5 QHS,
oxybutynin SR 20 QHS, tylenol PRN, claritin 5', fortical nasal
spray, miralax, senna"
5860,"Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
6. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E."
5861,"Social History:
Denies tobacco
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
RLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
diminished at quads and Achilles
LLE- foot drop; reflexes diminished at quads and Achilles
Pertinent Results:
[**2141-4-14**] 05:14AM BLOOD WBC-13."
5862,"C.) PO DAILY (Daily).
7. gabapentin Oral
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
10. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
12. loratadine 10 mg Tablet Sig: 0.5 Tablet PO daily () for 4
days.
13. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) Nasal daily () for 4 days.
14. insulin regular human 100 unit/mL Solution Sig: One (1)
syringe Injection ASDIR (AS DIRECTED)."
5863,"2* Mg-1.9
[**2141-4-12**] 12:42AM BLOOD Calcium-7.3* Phos-2.5* Mg-2.5
[**2141-4-10**] 03:56PM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2141-4-10**] and taken to the Operating Room for T11-L2 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis."
5864,"2* RBC-3.03* Hgb-9.0* Hct-27.8*
MCV-92 MCH-29.6 MCHC-32.3 RDW-14.3 Plt Ct-181
[**2141-4-13**] 03:30PM BLOOD WBC-13.9* RBC-2.58* Hgb-7.9* Hct-24.0*
MCV-93 MCH-30.5 MCHC-32.8 RDW-13.5 Plt Ct-183
[**2141-4-13**] 04:20AM BLOOD WBC-18.4* RBC-3.10* Hgb-9.4* Hct-30.4*
MCV-98 MCH-30.3 MCHC-30.9* RDW-13.7 Plt Ct-169
[**2141-4-12**] 12:42AM BLOOD WBC-14.6* RBC-2.99* Hgb-9."
5865,"Case Management Initial Assessment and Discharge Planning
The patient is a 28 year-old man with a h/o EtOH abuse, necrotizing
pancreatitis, anoxic brain injury, and seizures, who presents from the
LTACH with anemia, fevers, and hypotension, concerning for an acute
bleed. The patient was then found to have bilateral thigh hematomas
that are likely the cause of his drop in hematocrit.
This nurse case manager was contact[**Name (NI) **] by the MICU resident and informed
that the patient would likely be ready to return to [**Hospital1 25**] today so a
call was placed to the facility to have their liaison nurse complete a
screen and seek payer authorization for the patient
s return."
5866,"This NCM also met with the patient
s mother in the [**Name (NI) 8319**], and she
indicated that the family may not want the patient to return to
[**Hospital1 25**], but she will defer to the judgment of her son [**Name (NI) **]. [**Name2 (NI) **]
should be in to visit the patient later today and this NCM will speak
to him at that time. In anticipation of the possibility that the
family does not want the patient to return to [**Hospital1 25**], a referral has
been made to [**Hospital6 6804**] as the family had previously
considered the facility and ended up choosing [**Hospital1 25**] instead.
This NCM will continue to follow closely with the MICU team to
facilitate the patient
s transfer to LTACH when indicated.
Please page for any questions, concerns or change in the discharge
plan.
[**First Name11 (Name Pattern1) 596**] [**Last Name (NamePattern4) 5890**], RN, BSN
MICU Service Case Manager
Phone: 2-7925/7-0306
Pager: [**Numeric Identifier **]"
5867,"He was
found to have an SVC thrombus and was started on Lovenox 100 mg
[**Hospital1 **]. He was discharged to [**Hospital6 **] on [**2131-7-5**].
.
At [**Hospital1 **], the patient was found to have frequent seizure
activity and was thus transferred back to [**Hospital1 18**] on [**2131-7-9**].
During this hospital stay, the patient's anti-epileptic regimen
was fine-tuned, and he continued to spike cyclic fevers. He
grew multiple different colonies of Pseudomonas and was started
on Ceftaz and Tobramycin, which was continued until [**2131-8-14**]. He
was also found to have hypercalcemia, hyponatremia, and
hypothyroidism during this admission, which were treated with
Vitamin D, fluid restriction, and levothyroxine, respectively."
5868,"Denied chest pain or tightness,
palpitations. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Depression
Alcoholism
Pancreatitis
s/p Cardiac Arrest
Tracheostomy
Anoxic brain injury
Social History:
Patient originally from Western Mass. Works for a IT computing
company. Not married and without children, lives with a roomate
in [**Last Name (un) 813**]. Significant alcohol use for 5-6 years, drinking 6
mixed drinks daily with withdrawl symptoms. 1.5 ppd of
cigarrettes, denies drug use.
Family History:
Mother with DM2.
Physical Exam:
Vitals: T 100.9, P 134, BP 92/69, R 40
General: Young man, tracking with eyes and responding to simple
commands, in NAD."
5869,"GRAM NEGATIVE ROD #2. MODERATE GROWTH.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- 1 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
The patient is a 28 yo man with h/o EtOH abuse, necrotizing
pancreatitis, anoxic brain injury, and seizures, who presents
from rehab facility with anemia, fevers, and hypotension,
concerning for an acute bleed.
# Anemia: The patient had an acute Hct drop from 26.9 on [**8-11**] to
16 on [**8-16**]. He was given a total of 4 U PRBCs, and his Hct
remained stable in the mid 20s range."
5870,"He had been on lovenox for
treatment of superior mesenteric vein thrombosis. The source of
the bleed was indentified to be a thigh hematoma. His thigh
circumference remained stable at 20'' right and 18'' left. CT of
thighs/pelvic did not show evidence of retroperitoneal
expansion. Lovenox was stopped, and he was placed back on
Heparin SQ for DVT prophylaxis.
# Hypotension: The patient was hypotensive upon arrival the the
ICU. This was also attributed to blood loss. His blood
pressure was controlled with IVF and pRBC transfusion.
# Fevers, leukocytosis: He has had a history of intermittent
fevers which have been attributed to central sources."
5871,"# Hyperglycemia: Sugars on prsentation were 307 and he was
continued on a Humalog ISS.
# Hypothyroidism: Continued Levoxyl 50 mcg daily. He will need
to have TSH and FT4 levels checked in two weeks.
# Seizures: He had no seizure activity. His total and free
dilantin levels were 7 and 2.1, respectively. His dilantin dose
was decreased to 200 mg tid and a daily additional dose of 500
mg if his total dilantin level is less than 7. He should
continue to have dilantin levels/free dilantin levels checked
daily and his dose should be adjusted accordingly.
Medications on Admission:
Multivitamins One (1) ML PO DAILY
Ipratropium-Albuterol Aerosol 4-6 puffs Q6H
Albuterol Sulfate (0."
5872,"17. Fentanyl Citrate 25-100 mcg IV Q3H:PRN agitation, pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Posterior thigh hematoma (acute)
Hypovolemic hypotension
Urinary tract yeast infection
Secondary:
Chronic respiratory failure
Seizure disorder
Discharge Condition:
Good
Discharge Instructions:
You were admitted for low blood pressure and a low blood count.
We determined that you were bleeding into your thigh, likely
because of the lovenox you were taking. We stopped the lovenox
and transfused you with blood. We also gave you fluids. Both
of these helped improve your blood pressure.
While you were here, we also cultured bacteria from your lungs."
5873,"HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, trach in place
Lungs: Clear to auscultation anteriorly. Frequent use of
accessory muscles.
CV: Soft S1 and S2. Tachycardic. No murmurs, rubs, gallops
appreciated
Abdomen: Soft, non-distended, bowel sounds present. Likely
pain on palpation given patient's facial response. No guarding
or rebound tenderness
Ext: Multiple hypopigmented lesions on legs bilaterally. 2+
pulses, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
[**2131-8-17**] 09:50PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017
[**2131-8-17**] 09:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5."
5874,"5* PTT-28.5 INR(PT)-1.2*
[**2131-8-17**] 08:50PM RET AUT-2.7
PERTINENT LABS/STUDIES:
CXR [**2131-8-19**]: AP chest compared to [**8-9**] through 14:
Consolidation at the left lung base is substantially increased
since [**8-19**] and 14. This could represent either atelectasis
or pneumonia. Lung volumes are generally low, but otherwise
clear. Heart size top normal. No pleural effusion. Upper
mediastinal widening is probably due to vascular congestion.
Tracheostomy tube in standard placement. The study and the
report were reviewed by the staff radiologist.
CT ABDOMEN [**2131-8-18**]: No evidence of retroperitoneal hematoma."
5875,"0
LEUK-MOD
[**2131-8-17**] 09:50PM URINE RBC-0-2 WBC-[**6-13**]* BACTERIA-MOD
YEAST-MANY EPI-0-2
[**2131-8-17**] 09:03PM LACTATE-2.4*
[**2131-8-17**] 08:50PM GLUCOSE-307* UREA N-31* CREAT-0.9 SODIUM-135
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-17* ANION GAP-17
[**2131-8-17**] 08:50PM estGFR-Using this
[**2131-8-17**] 08:50PM NEUTS-68 BANDS-4 LYMPHS-15* MONOS-10 EOS-1
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2131-8-17**] 08:50PM PLT COUNT-668*
[**2131-8-17**] 08:50PM PT-13."
5876,"We think this is related to colonization rather than active
infection. We also cultured a bacteria from your PICC line, so
we discontinued your PICC on [**8-21**].
While you were here, we made the following changes to your
medications:
1. We decreased you Dilantin dose to 200 TID. The 500 mg
morning dose should only be given as needed if the Dilantin
level is low.
Please return to the hospital if you have worsening fevers,
chills, shortness of breath, or any other serious concerns.
Followup Instructions:
Contact your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up
appointment in two to four weeks. You will need to have your
thryoid studies checked in about two weeks.
Completed by:[**2131-8-24**]"
5877,"He was then discharged on [**8-12**] back to [**Hospital1 **].
.
At [**Hospital1 **], the patient again developed recurrent fevers over
the past three days with a rising leukocytosis and he was placed
back on Tobramycin on [**8-16**]. He had multiple blood cultures this
week at rehab which were negative for infection. He was also
found to have a Hct drop from 27 to 16 without an obvious source
for bleed. He was given 2 U PRBCs and his Hct only increased to
19.4. Hemolysis labs were negative. He developed transient
hypotension while at [**Hospital1 **] to SBP of 80s this morning, which
responded to IVFs."
5878,"Admission Date: [**2131-8-17**] Discharge Date: [**2131-8-22**]
Date of Birth: [**2103-3-21**] Sex: M
Service: MEDICINE
Allergies:
Meropenem
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Hypotension and anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 28 yo man with h/o EtOH abuse who presented in
[**5-12**] with hematemesis, necrotizing pancreatitis, and acute
hepatitis. His hospital course was complicated by sepsis,
respiratory failure s/p trach, recurrent fevers, [**Last Name (un) **] secondary
to ATN requiring CVVH, seizures, a/p trach and PEG, and PEA
arrest. He had cyclic fevers and tachycardia throughout the
admission, necessitating multiple antibiotic regimens,eventually
thought to be secondary to a central neurologic process."
5879,"[**Last Name (STitle) **] [**2131-8-21**] 10:25AM.
Aerobic Bottle Gram Stain (Final [**2131-8-21**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Sputum Culture ([**8-18**]): [**2131-8-18**] 9:58 am SPUTUM Site:
EXPECTORATED
Source: Expectorated.
GRAM STAIN (Final [**2131-8-18**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2131-8-21**]):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES."
5880,"5 mg TID
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-5**] nebs Inhalation Q2H (every 2 hours) as
needed for sob, dyspnea.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4H (every 4 hours) as needed for pain: PEG.
3. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED
Subcutaneous ASDIR (AS DIRECTED).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-5**] NEBS Inhalation Q6H (every 6 hours) as
needed for sob, dyspnea.
5. Ipratropium Bromide 0."
5881,"Per [**Hospital1 **], the patient also endorsed RUQ
pain on physical exam. Given the concern for potential
retroperitoneal bleed, he was transferred to [**Hospital1 18**] for further
evaluation.
.
On arrival to the ICU, the patient's VS were T 100.9, P 134, BP
92/69, R 40. He was given 2 [**Location **] and 500 cc fluid bolus
and was ordered for a stat abdominal CT. The patient's history
was obtained from his father who was present on admission.
.
Review of sytems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath."
5882,"083 %) Nebulization Q2H prn for
sob/wheezing.
Acetaminophen 160 mg/5 mL Solution. 20 mL PO Q6H prn
RISS
Enoxaparin 100 mg/mL [**Hospital1 **]
Folic Acid 1 mg daily
Ergocalciferol 50,000 unit twice weekly (Mon/Th)
Dextromethorphan Poly Complex SR 10 ML PO BID prn cough
Levothyroxine 50 mcg daily
Phenytoin 300mg PO TID (3 times a day) (12, 6, 10 PM)
Phenytoin 500 mg at 0600.
Famotidine 20 mg PO BID
Keppra 2,000 mg [**Hospital1 **]
Lorazepam 1 mg q6h
Percocet 5-325 mg Tablet PO q4h prn for pain
Hydrocortisone Sod Succinate 100 mg 1345
Metoprolol 12."
5883,"Bilateral intramuscular hematomas involving the adductor
musculature of the proximal lower extremities. 2. Mild residual
peripancreatic fatty stranding, but likely improved. correlation
with pancreatic enzymes is recommended.
Multiple pancreatic pseudocysts not as well visualized on the
current
study with no definite overall change. Cholelithiasis without
cholecystitis. Small left pleural effusion and atelectasis.
CXR ([**8-21**]): Bilateral basilar opacities, consistent with
pneumonia or
atelectasis.
Blood Cultures ([**8-20**]) from PICC line
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2131-8-21**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO DR."
5884,"11. Levetiracetam 100 mg/mL Solution Sig: [**2122**] ([**2122**]) MG PO BID
(2 times a day): PEG.
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): PEG.
13. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as
needed for cough: PEG.
14. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: [**Numeric Identifier 1871**]
([**Numeric Identifier 1871**]) Capsules PO 2X/WEEK (MO,TH): PEG .
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
PEG.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNITS Injection TID (3 times a day): SC."
5885,"02 % Solution Sig: [**1-5**] nebs
nebs Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q4H (every 4 hours) as needed for fever, pain: PEG.
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): PEG.
8. Phenytoin 125 mg/5 mL Suspension Sig: Two Hundred (200) mg PO
Q8H (every 8 hours): PEG.
9. Phenytoin 125 mg/5 mL Suspension Sig: Five Hundred (500) mg
PO DAILY (Daily): Please give at 0600 through PEG.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): PEG."
5886,"He again
presented with fever. His presenting WBCs were elevated, as they
have been in the past, but trended down during admission. With
regards to sources of infection, there was concern for a
respiratory process, given increase in secretions. The CXR
however remained without findings suggestive of pneumonia. Also
cultures obtained from his PICC line on [**8-20**] grew GPC in [**2-7**]
bottles (from one PICC draw) Peripheral cultures from this day
were negative. The PICC line was discontinued on [**8-21**] and he was
not started on antibiotics as this did not appear to be an
active infection given decreasing WBC and improved mental
status."
5887,"Chief Complaint: leg hematoma
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
28M with necrotizing pancreatitis, c/b anoxic brain injury, prolonged
hospitalization, recent re-admission to MICU after dramatic Hct drop
due to large thigh hematomas in the setting of systemic
anticoagulation.
24 Hour Events:
BLOOD CULTURED - At [**2131-8-20**] 02:56 PM
Blood c/s from pic line
BLOOD CULTURED - At [**2131-8-20**] 04:54 PM
FEVER - 101.6
F - [**2131-8-20**] 11:00 AM
-stable overnight
History obtained from Medical records
Patient unable to provide history: Encephalopathy
Allergies:
Meropenem
skin blisters a
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Fentanyl - [**2131-8-21**] 04:15 AM
Other medications:
ativan, keppra, famotidine, vitd, fa, riss, dilantin, fentanyl 50
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: No(t) Fatigue, Fever
Ear, Nose, Throat: No(t) OG / NG tube, peg
Cardiovascular: No(t) Chest pain
Nutritional Support: Tube feeds
Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea
Gastrointestinal: No(t) Abdominal pain
Genitourinary: Foley
Endocrine: No(t) Hyperglycemia
Psychiatric / Sleep: No(t) Agitated
Signs or concerns for abuse : No
Pain: No pain / appears comfortable
Flowsheet Data as of [**2131-8-21**] 10:04 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 38."
5888,"1
12.7
Hct
24.3
23.8
24.2
24.4
23.9
25.2
25.6
24.9
25.5
Plt
[**Telephone/Fax (3) 8330**]
Cr
0.8
0.8
0.8
TCO2
17
Glucose
[**Telephone/Fax (3) 8331**]
Other labs: PT / PTT / INR:15.8/26.7/1.4, CK / CKMB / Troponin-T:63//,
ALT / AST:18/35, Alk Phos / T Bili:132/0.6, Amylase / Lipase:/35,
Differential-Neuts:70.6 %, Band:0.0 %, Lymph:19.8 %, Mono:3.7 %,
Eos:5.3 %, Lactic Acid:1.1 mmol/L, Albumin:2.5 g/dL, LDH:243 IU/L,
Ca++:9."
5889,"2 g/dL
785 K/uL
197 mg/dL
0.8 mg/dL
18 mEq/L
4.1 mEq/L
16 mg/dL
116 mEq/L
142 mEq/L
25.5 %
12.7 K/uL
[image002.jpg]
[**2131-8-18**] 12:48 PM
[**2131-8-18**] 05:14 PM
[**2131-8-18**] 11:05 PM
[**2131-8-19**] 03:24 AM
[**2131-8-19**] 11:23 AM
[**2131-8-19**] 08:31 PM
[**2131-8-19**] 08:44 PM
[**2131-8-20**] 03:04 AM
[**2131-8-20**] 07:31 PM
[**2131-8-21**] 03:21 AM
WBC
14.2
12."
5890,"3 mg/dL, Mg++:1.6 mg/dL, PO4:3.6 mg/dL
Imaging: cxr: no new opacities though lower lung volumes
Microbiology: sputum cx: pseudomonas, sensies pending
Assessment and Plan
.H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**])
ANEMIA, OTHER
FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)
.H/O SEIZURE, WITH STATUS EPILEPTICUS
28M with necrotizing pancreatitis, c/b anoxic brain injury, prolonged
hospitalization, recent re-admission to MICU after dramatic Hct drop
due to large thigh hematomas in the setting of systemic
anticoagulation, now improved off anticoagulation with stable hct. Pt
has persistent fevers without a clear source, though likely from
resolving hematomas."
5891,"7
C (101.6
Tcurrent: 37.7
C (99.8
HR: 122 (117 - 131) bpm
BP: 133/88(96) {116/67(83) - 145/111(120)} mmHg
RR: 25 (22 - 45) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Height: 71 Inch
Total In:
1,804 mL
874 mL
PO:
TF:
964 mL
384 mL
IVF:
240 mL
79 mL
Blood products:
Total out:
2,290 mL
1,220 mL
Urine:
2,250 mL
1,220 mL
NG:
40 mL
Stool:
Drains:
Balance:
-486 mL
-346 mL
Respiratory support
O2 Delivery Device: Aerosol-cool
SpO2: 100%
ABG: ///18/
Physical Examination
General Appearance: No acute distress, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, trach
Cardiovascular: (S1: Normal), (S2: Normal), tachy
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : )
Extremities: Right lower extremity edema: 2+, Left lower extremity
edema: 2+
Musculoskeletal: No(t) Muscle wasting
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
8."
5892,"Other potential sources of fever include picc
line, pneumonia, though blood cultures have been negative and cxr has
not revealed a new infiltrate. Will continue to hold off antibioitics
and will follow-up cultures. His improving mental status is
encouraging.
Will contact rehab for more complete sing-off and transfer of care.
Rest of the plan per resident notes.
ICU Care
Nutrition:
NovaSource Renal (Full) - [**2131-8-21**] 03:49 AM 40 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2131-8-17**] 11:54 PM
20 Gauge - [**2131-8-18**] 02:11 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care
Comments:
Communication: Family meeting held , ICU consent signed Comments:
Code status: Full code
Disposition : Transfer to rehab
Total time spent: 35 minutes"
5893,"Chief Complaint: leg hematoma
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
28M with necrotizing pancreatitis, complicated by several PEA arrests,
anoxic brain injury, returned to MICU with acute hct drop from thigh
hematomas while on full anticoagulation, now stable off full
anticoagulation, slowly-improving mental status:
24 Hour Events:
PICC LINE - STOP [**2131-8-21**] 06:53 PM
-bcx resent, PICC pulled
Allergies:
Meropenem
skin blisters a
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2131-8-21**] 08:00 PM
Fentanyl - [**2131-8-22**] 04:45 AM
Other medications:
ativan 1q6, keppra, pepcid, fa, riss, dilantin, synthroid, sqh
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Constitutional: Fever
Cardiovascular: No(t) Chest pain
Nutritional Support: Tube feeds
Respiratory: Cough, No(t) Dyspnea, No(t) Tachypnea
Gastrointestinal: No(t) Abdominal pain
Genitourinary: Foley
Integumentary (skin): No(t) Jaundice, No(t) Rash
Signs or concerns for abuse : No
Pain: No pain / appears comfortable
Flowsheet Data as of [**2131-8-22**] 09:19 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
5894,"5 g/dL, LDH:243 IU/L,
Ca++:9.8 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL
Imaging: cxr: improved LLL opacity
Microbiology: sputum: pseudomonas
bcx: coag-neg staph from picc line only
Assessment and Plan
.H/O RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**])
ANEMIA, OTHER
FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)
.H/O SEIZURE, WITH STATUS EPILEPTICUS
28M with necrotizing pancreatitis, complicated by several PEA arrests,
anoxic brain injury, returned to MICU with acute hct drop from thigh
hematomas while on full anticoagulation, now stable off full
anticoagulation, slowly-improving mental status."
5895,"1 g/dL
867 K/uL
183 mg/dL
0.7 mg/dL
17 mEq/L
3.3 mEq/L
15 mg/dL
114 mEq/L
140 mEq/L
25.6 %
12.8 K/uL
[image002.jpg]
[**2131-8-18**] 05:14 PM
[**2131-8-18**] 11:05 PM
[**2131-8-19**] 03:24 AM
[**2131-8-19**] 11:23 AM
[**2131-8-19**] 08:31 PM
[**2131-8-19**] 08:44 PM
[**2131-8-20**] 03:04 AM
[**2131-8-20**] 07:31 PM
[**2131-8-21**] 03:21 AM
[**2131-8-22**] 04:22 AM
WBC
14.2
12."
5896,"9
C (100.3
Tcurrent: 37.9
C (100.3
HR: 133 (112 - 134) bpm
BP: 116/105(108) {113/55(73) - 143/105(108)} mmHg
RR: 25 (19 - 33) insp/min
SpO2: 96%
Heart rhythm: ST (Sinus Tachycardia)
Height: 71 Inch
Total In:
2,063 mL
523 mL
PO:
TF:
963 mL
353 mL
IVF:
200 mL
Blood products:
Total out:
2,370 mL
470 mL
Urine:
2,370 mL
470 mL
NG:
Stool:
Drains:
Balance:
-307 mL
53 mL
Respiratory support
O2 Delivery Device: Aerosol-cool, Trach mask
SpO2: 96%
ABG: ///17/
Physical Examination
General Appearance: No(t) Well nourished
Head, Ears, Nose, Throat: Normocephalic, trach
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Distended
Extremities: Right lower extremity edema: 2+, Left lower extremity
edema: 1+
Musculoskeletal: Muscle wasting
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
8."
5897,"1
12.7
12.8
Hct
23.8
24.2
24.4
23.9
25.2
25.6
24.9
25.5
25.6
Plt
[**Telephone/Fax (3) 8340**]67
Cr
0.8
0.8
0.8
0.7
TCO2
17
Glucose
[**Telephone/Fax (3) 8341**]83
Other labs: PT / PTT / INR:15.8/26.7/1.4, CK / CKMB / Troponin-T:63//,
ALT / AST:18/35, Alk Phos / T Bili:132/0.6, Amylase / Lipase:/35,
Differential-Neuts:56.0 %, Band:8.0 %, Lymph:22.0 %, Mono:3.0 %,
Eos:7.0 %, Lactic Acid:1.1 mmol/L, Albumin:2."
5898,"Mr [**Known lastname 6420**] remains
tachycardic and febrile. His sputum culture is growing previously known
resistant pseudomonas, and peripheral blood cultures from have been
negative. We are holding off on antibiotics given stable clinical
status and no signs of active pulmonary or blood stream infection. Will
proceed with transfer back to [**Hospital1 25**] with close communication with
staff at [**Hospital1 25**] for aggressive monitoring for signs of worsening
infection:
positive blood cultures
-follow-up cultures over the last several day; will communicate with
new providers
-hold off on new picc line unless necessary
-hold off on empiric abx; if necessary prefer linezolid
-monitor thigh hematomas for signs of infection
positive sputum cultures; secretions
-holding off on antibiotics
-would need meropenem if shows signs of active pulmonary infection
-MIE, though cough if excellent
sinus tachycardia: pain vs infection vs centrally driven
-will consider bb to prevent tachy-induced cm once other causes are
explired
seizure
-will clarify with neuro appropriate doses and
ICU Care
Nutrition:
NovaSource Renal (Full) - [**2131-8-22**] 04:43 AM 40 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2131-8-18**] 02:11 AM
22 Gauge - [**2131-8-21**] 07:01 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP: HOB elevation
Comments:
Communication: Family meeting held , ICU consent signed Comments:
Code status: Full code
Disposition :Transfer to rehab / long term care facility
Total time spent: 35 minutes"
5899,"SICU
HPI:
30 year old man who presents w/ headaches, neck pain, known chiari I
malformation,
Chief complaint:
headache
PMHx:
OSA (uses home CPAP)
Current medications:
Acetaminophen
Bisacodyl
Docusate Sodium
Gentamicin
Glucagon
HYDROmorphone (Dilaudid)
Heparin
HydrALAzine
Insulin
Ondansetron
Pantoprazole
Senna
Vancomycin
24 Hour Events:
sub-occipital crani for decompression of chiari
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2119-2-22**] 04:15 PM
Gentamicin - [**2119-2-23**] 12:19 AM
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2119-2-23**] 02:40 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**21**] a."
5900,"m.
Tmax: 36.5
C (97.7
T current: 36.1
C (97
HR: 68 (61 - 112) bpm
BP: 123/66(83) {121/58(80) - 140/80(97)} mmHg
RR: 11 (11 - 23) insp/min
SPO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Total In:
3,011 mL
294 mL
PO:
Tube feeding:
IV Fluid:
3,011 mL
294 mL
Blood products:
Total out:
3,260 mL
80 mL
Urine:
1,080 mL
80 mL
NG:
300 mL
Stool:
Drains:
Balance:
-249 mL
214 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 96%
ABG: ////
Physical Examination
General Appearance: No acute distress
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
[image002."
5901,"jpg]
Assessment and Plan
[**Last Name **] PROBLEM - ENTER DESCRIPTION IN COMMENTS
Assessment and Plan: ASSESSMENT: 30y M s/p sub-occipital craniotomy
Neurologic: Alert, oriented, moves extremities x4, Dilaudid PCA for
pain, MRI in am
Cardiovascular: <140 POD#0, <160 POD#1, Hemodynamically stable
Pulmonary: OSA, home CPAP, sats 90's on NC
Gastrointestinal / Abdomen: sips-> ADAT
Nutrition: sips-> ADAT
Renal: good UOP, voiding, no foley
Hematology: hct 38.4
Endocrine: RISS
ID: Vanc/Gent 24hours post-op
Lines / Tubes / Drains: PIV, a-line
Wounds:
Imaging: MRI [**2-23**]
Fluids: NS w/20K @75 - Heplock
Consults: Neurosurg
Billing Diagnosis:
Prophylaxis:
DVT: boots
Stress ulcer: PPI
VAP bundle:
Comments:
Communication:Comments: Patient
Code status:FULL
Disposition: floor
Time spent: 35
ICU Care
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2119-2-22**] 02:37 PM
16 Gauge - [**2119-2-22**] 02:38 PM
20 Gauge - [**2119-2-22**] 02:38 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: Transfer to floor
Total time spent:"
5902,"6 Phos-4.3 Mg-2.1
Brief Hospital Course:
Patient is a 30M electively admitted for suboccipital craniotomy
for Chiari Type I malformation. Operative course was uneventful,
and he was taken to the ICU post-operatively for close
neuromonitoring overnight. Post-op head CT showed no hemorrhage.
There were no adverse events overnight. He was transfered to the
floor on [**2119-2-23**], his PCA was discontinued and given PO
medications. He continued with normal expected headaches
throughout his hospitalization. His incision was clean and dry.
On discharge he was voiding, tolerating a regular [**Date Range **] and had a
normal neurological exam."
5903,"-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again."
5904,"?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101."
5905,"07* Hgb-12.4* Hct-35.7*
MCV-88 MCH-30.4 MCHC-34.6 RDW-12.4 Plt Ct-284
[**2119-2-25**] 06:05AM BLOOD Plt Ct-284
[**2119-2-25**] 06:05AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-136
K-4.1 Cl-98 HCO3-26 AnGap-16
[**2119-2-25**] 06:05AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.1
[**2119-2-25**] 06:05AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-136
K-4.1 Cl-98 HCO3-26 AnGap-16
[**2119-2-25**] 06:05AM BLOOD Calcium-9."
5906,"Medications on Admission:
Ambien prn, Motrin prn, FLUOCINONIDE prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)."
5907,"Admission Date: [**2119-2-22**] Discharge Date: [**2119-2-25**]
Date of Birth: [**2088-12-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2119-2-22**]: Suboccipital craniotomy for Chiari decompression
History of Present Illness:
Patient is a 30M electively admitted for Chiari Type I
decompression.
Past Medical History:
OSA
Chiari Malformation(Type I)
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
Exam on Discharge:
Neurologically intact
Pertinent Results:
[**2119-2-25**] 06:05AM BLOOD WBC-8.2 RBC-4."
5908,"5. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
Discharge Disposition:
Home
Discharge Diagnosis:
Chiari Type I Malformation
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment."
5909,"5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed."
5910,"In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool."
5911,"Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**11-9**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 2 weeks.
??????You will not need a CT scan of the brain.
Completed by:[**2119-10-4**]"
5912,"?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Name10 (NameIs) **]
Usually no special [**Name10 (NameIs) **] is prescribed after a craniotomy. A
normal well balanced [**Name10 (NameIs) **] is recommended for recovery, and you
should resume any specially prescribed [**Name10 (NameIs) **] you were eating
before your surgery.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone)."
5913,"[**2147-3-20**] 4:42 PM
PARACENTESIS DIAG/THERAP W IMAGING GUID Clip # [**Clip Number (Radiology) 33009**]
Reason: therapeutic and diagnostic paracentesis, please remove up to
Admitting Diagnosis: ABDOMINAL PAIN
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
54 year old woman with ascites, with adhesions, now with partial sbo, and
concern for infection
REASON FOR THIS EXAMINATION:
therapeutic and diagnostic paracentesis, please remove up to 4L if possible
______________________________________________________________________________
FINAL REPORT
EXAMINATION: Bedside ultrasound-guided therapeutic and diagnostic
paracentesis via a right flank approach.
INDICATION: 54-year-old woman with ascites and small-bowel obstruction with
adhesions. Request is to perform therapeutic and diagnostic paracentesis to
exclude SBP and to reduce intra-abdominal pressure."
5914,"ANALGESIA: The patient was on a propofol infusion in the ICU. The patient
received 8 cc of 1% buffered lidocaine to the skin and subcutaneous tissues
via the right flank approach.
PHYSICIANS: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1057**] and Dr. [**First Name4 (NamePattern1) 23571**] [**Last Name (NamePattern1) **] performed the procedure. Dr.
[**Last Name (STitle) **], the attending radiologist, was present throughout the procedure.
PROCEDURE NOTE IN DETAIL: Informed consent was obtained from the healthcare
proxy outlining the risks and benefits of the proposed procedure. Limited
ultrasound demonstrates moderate volume ascites and a suitable site for
percutaneous access was identified in the right flank and the area marked on
the patient's skin."
5915,"The area was prepped and draped in the usual sterile
fashion. A preprocedure timeout was performed as per [**Hospital1 51**] protocol.
Following administration of 8 cc of 1% buffered lidocaine to the skin and
subcutaneous tissues, a 5 French [**Last Name (un) 1275**] catheter was carefully advanced and
positioned within the peritoneal space. A sample was obtained and sent for
cell count and microbiological assessment. Following this, the catheter was
attached to a vacuum drainage bottle and 3 liters of translucent yellow fluid
were removed. The [**Last Name (un) 1275**] catheter was then removed and a sterile dressing was
applied. The patient tolerated the procedure well with no early
complications.
IMPRESSION: Uncomplicated bedside therapeutic and diagnostic paracentesis via
a right flank approach.
Overall, the patient tolerated the procedure well with no early complications."
5916,"Admission Date: [**2147-3-9**] Discharge Date: [**2147-3-24**]
Date of Birth: [**2092-6-30**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Ultrasound-guided paracentesis [**2147-3-9**], [**2147-3-17**] and [**2147-3-23**]
IR-guided Nasogastric Tube Advancement [**2147-3-10**]
History of Present Illness:
Ms. [**Name14 (STitle) 79180**] is a 54F with PMH of HCV and EtoH cirrhosis (MELD =
16) decompensated with esophageal varices and ascites requiring
weekly paracentesis, multiple prior SBOs, mesenteric ischemia
s/p Ex-Lap/LOA [**10/2146**] p/w abdominal distension and severe pain."
5917,"9 85 102/78 14 99%RA.
.
On arrival to the floor, vital signs were 97.8 102/74 80 20
100%RA. Patient reported abdominal pain, improved from prior,
similar to prior admissions.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, cough, shortness
of breath, chest pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- HCV/EtOH cirrhosis (dx ~[**2124**]; c/b ascites, esophageal varices
s/p clipping x2, encephalopathy)
- CKD
- s/p ex-lap LOA [**2146-10-20**]
- s/p ex-lap/SBR x2 for perforation from blunt trauma [**2120**]
- s/p Laparoscopic tubal ligation [**2125**]"
5918,"Social History:
- tobacco: 30 pack/year history quit 5 years ago
- etoh: 12 beer/day x 30 years quit 5 years ago
- IVDU > 30 years ago
- On disability, former surgical tech [**Hospital1 2177**]
Family History:
Not contributory to current hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.8 102/74 80 20 100%RA
GENERAL - cachectic, appearing older than stated age, no acute
distress
HEENT - dry mucous membranes, sclera anicteric,
NECK - Supple, no JVD, no LAD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh
ABDOMEN - normoactive BS, distended with large hernia protruding
above umbilicus, tympanic to percussion, mildly tender around
the umbilicus, no rebound/guarding
EXTREMITIES - WWP, no edema, 2+ DP/radial pulses
NEURO - A&Ox3, no asterixis
."
5919,"Pulmonary and mediastinal
calcifications are partially imaged.
IMPRESSION: Worsening small bowel distention.
.
[**2147-3-23**] IR-guided paracentesis: Ultrasound-guided therapeutic
and diagnostic paracentesis with removal of 7 L of clear,
straw-colored fluid.
Brief Hospital Course:
54yo F PMHx HCV and EtoH cirrhosis decompensated with esophageal
varices and ascites requiring weekly paracentesis, multiple
SBOs, mesenteric ischemia s/p Ex-Lap/LOA [**10/2146**] p/w abdominal
distention and pain, found to have chronic partial small bowel
obstruction, which was managed conservatively. Hospital course
was complicated by encephalopathy requiring intubation and MICU
admission, as well as Klebsiella UTI and [**Last Name (un) **]."
5920,"She ultimately
left against medical advice.
.
.
ACTIVE ISSUES:
#CHRONIC ABDOMINAL PAIN/SBO: Patient had multiple prior
admissions for chronic adbominal pain, thought to multifactorial
due to chronic ascites, transient obstruction from
adhesions/ileus, now presents with worsening of chronic pain.
Narcotic bowel syndrome was initially thought to be most likely
diagnosis, given patient's hx of narcotic abuse and dependence,
now trying to taper off narcotics to be listed for transplant.
Patient's SBO is likely contributing to acute nature of pain.
Patient then developed partial SBO, thus contributing to pain.
Patient was made NPO and NGT was put to suction."
5921,".
# Encephalopathy: Patient was appropriate late afternoon on
[**3-17**], but found to be aggressive and encepahlopathic that night,
pulled out NGT and PIV. On morning of [**3-18**], was unresponsive,
but vitals were stable. Lactulose had been held for 7 days in
the setting of SBO. At that time, there was no evidence of
infection, as no SBP on paracentesis, no pneumonia on CXR, UA
negative, and afebrile, no white count. CT head on AM of [**3-19**]
showed no acute intracranial process. Patient was transferred to
the MICU for concern of airway production as patient was
becoming increasingly more confused in the context of being
unable to take her lactulose and rifaxamin due to abdominal
pain."
5922,".
# Klebsiella UTI: As noted above, in the context of
encephalopathy, patient was noted to have Klebsiella UTI. She
was treated with one day of ceftazidime (to which the bacteria
was sensitive) before she left AMA. She was given a prescription
for cefpodoxime to continue at home. It is unknown whether her
Klebsiella is sensitive to cefpodoxime, but the patient was
willing to risk worsening of infection and possible sepsis/death
by leaving the hospital.
.
# Acute kidney injury: Creatinine 1.7 on admission (baseline
ranges from 0.8-1.1), which trended down to her baseline
throughout admission. Most likely, this was secondary to
pre-renal azotemia from volume distribution with ascites, along
with poor PO intake from SBO/abdominal pain."
5923,"Several albumin
challenges over the course of admission resulted in improved
kidney function.
.
.
CHRONIC ISSUES:
#Unspecified Protein/Calorie Malnutrition: Pt w chronically poor
nutrition [**1-5**] abdominal pain, albumin 3.1, many month period of
poor PO intake/weight gain. She appears cachectic, was planned
for admission for Dobhoff and tube feedings on a separate
occasion. Patient was given dobhoff (could not be advanced
post-pyloric at IR), and TF were initiated based on nutrition
consult, but stopped when patient developed SBO. Patient cut
dobhoff in half one night, hence it was pulled. Current plan is
to reinitiate tube feeds on another admission."
5924,".
#Gastritis: Patient was continued on home omeprazole.
.
# Cirrhosis: The patient has cirrhosis with multiple
complications. She is on cipro at home for SBP prophylaxis. MELD
10 today. She is not a transplant candidate at [**Hospital1 18**] due to
continued narcotic-seeking behavior. She was recommended to
pursue transplant at another institution.
.
.
TRANSITIONAL ISSUES:
# Patient is not a liver transplant candidate at [**Hospital1 18**] due to
continued narcotic-seeking behavior. She was recommended to
pursue transplant at another institution.
# Given prescription for cefpodoxime for Klebsiella UTI,
although bacteria may not be sensitive to this medication.
Patient understood risks of leaving the hospital without full
treatment of UTI."
5925,"# Patient left AMA.
# CODE: Full (confirmed)
# CONTACT: [**Name (NI) **], daughter - [**Name (NI) **] [**Name (NI) 7933**] [**Telephone/Fax (1) 90768**]
Medications on Admission:
- Rifaximin 550 mg t.i.d.
- thiamine 100mg daily
- albuterol 90 HFA prn (patient states she does not take)
- Lasix 20 mg b.i.d.
- omeprazole 40 mg b.i.d.
- spironolactone 100 mg daily
- Cipro 500 mg daily
- lactulose 30 mL t.i.d.
- gabapentin 300 mg qHS
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
5926,"10. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Partial Small Bowel Obstruction
HCV/Alcoholic Cirrhosis
Type 2 Hepatorenal Syndrome
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted with abdominal pain and found to have a
partial small bowel obstruction."
5927,".
IMAGING:
[**2147-3-19**] CHEST (PORTABLE AP):
FINDINGS: The tip of the endotracheal tube measures
approximately 3.1 cm
above the carina. Patient has taken a slightly better
inspiration. Cardiac
silhouette is within normal limits and there is no definite
vascular
congestion. There are areas of increased opacification at both
bases.
Although this most likely reflects atelectasis, in the
appropriate clinical
setting, the possibility of supervening pneumonia would have to
be considered.
.
[**2147-3-20**] PORTABLE ABDOMEN:
There has been interval improved number of small bowel loops
that are
distended consistent with improved partial small bowel
obstruction. NG tube
tip is in the stomach."
5928,"You had a urinary tract infection, with a bacteria (Klebsiella)
that was resistant to multiple antibiotics. It required
treatment with intravenous ceftazidime, but you did not want to
stay for this treatment. You understood that risks of stopping
treatment included worsening of urinary tract infection, sepsis
and death. We discharged you on an antibiotic that might work
for the infection.
Please note that the following changes have been made to your
medications:
- START cefpodoxime 200 mg by mouth twice per day for seven days
- START simethicone four times per day for abdominal pain
You left against medical advice, but understood the risks of
leaving the hospital.
Followup Instructions:
Department: LIVER CENTER
When: WEDNESDAY [**2147-4-12**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage"
5929,"Chronic pain
was consulted and recommended bupronorphine, which was not
initially started out of concern for outpatient management of
this drug. Patient's tramadol and gabapentin were increased,
lidoderm patch to back, and baclofen. SBO was followed by daily
KUB, abdominal exam, and lactate. While in the MICU, Transplant
Surgery was consulted, and recommended conservative management
of partial SBO with NGT, along with PO and PR lactulose.
Additionally, she had several therapeutic paracenteses for
reflief of abdominal pressure from accumulating ascites.
Thereafter, she continued to have bowel movements and pass
flatus. Her diet was eventually advanced to regular. She had
discontinued her NGT in the MICU, and it was not replaced."
5930,".
[**2147-3-21**] PORTABLE ABDOMEN: Frontal abdominal chest radiograph
demonstrates the NG tube terminates in the stomach. The small
bowel is persistently dilated. There is little change from [**3-20**], [**2146**].
.
[**2147-3-21**] PORTABLE ABDOMEN: Portable supine abdominal radiograph
is little changed from 3:59 a.m. The abdomen is not completely
imaged. The NG tube is no longer visualized. The small bowel is
persistently dilated.
.
[**2147-3-22**] ABDOMEN (SUPINE/ERECT): Supine and erect abdominal
radiographs again demonstrate mild small bowel distention,
worsened [**3-21**] at 4:41 p.m. Hernial orifices are not imaged.
There is no pneumoperitoneum."
5931,"She was readmitted again several days later in [**Month (only) 958**]
w/ similar symptoms and again NPO. A CT of the abdomen and
pelvis during this hospitalization demonstrated again a small
bowel obstruction with a transition point approximately in
distal ileum presumed from adhesions. The SBO appeared worse
than similar CT scan several weeks prior. As discharge summaries
from two most recent hospital stays have not been completed, it
appears her symptoms improved with w/ bowel rest and she was
subsequently discharged.
.
Per patient report, since discharge from [**Hospital1 18**], has had a 5d
hospitalization at LGH for pain control of abdominal pain."
5932,"Thus, malnutrition is most likely secondary to decreased GI
absorption, possibly secondary to bowel edema.
.
In the ED, patient triggered for hypotension with initial VS
HR100 SBP 87/69, which resolved without intervention. Exam
demonstrated moderately tender abd w/o rebound/guarding. Labs
were significant for creatinine 1.7 (baseline 1.0), mild
transaminitis, Tbili at baseline, lactate 2.0. She received 4mg
of IV morphine for pain control. A diagnostic paracentesis was
attempted by no ultrasound windows were visualized. Liver was
consulted who recommended admission to [**Doctor Last Name 3271**] [**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**].
Vitals on transfer were: 97."
5933,"She was transferred to the MICU on [**2147-3-19**], and intubated
for airway protection rather than respiratory failure. She was
extubated on [**2147-3-20**] prior to transfer for the floor. Mental
status improved with decompression of SBO, rifaxmin and
lactulose. In the MICU, she was noted to have a UTI that was
likely contributing to encephalopathy, ans she was started on
ceftriaxone, while cultures were pending. Cultures eventually
returned with Klebsiella resistant to ceftriaxone. Patient was
treated with one day of ceftazidime (to which the bacteria was
sensitive) before she left AMA. She was given a prescription for
cefpodoxime to continue at home."
5934,"[**2147-3-17**] Peritoneal fluid gram stain and culture: no growth
[**2147-3-18**] Blood cultures x2: no growth
[**2147-3-18**] Urine culture: no growth
[**2147-3-19**] MRSA screen: no growth
[**2147-3-20**] URINE CULTURE:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2147-3-20**] Blood cultures x2: no growth
[**2147-3-21**] Sputum gram stain and culture: [**9-28**] PMNs, no growth on
culture
[**2147-3-21**] Blood culture: no growth to date
[**2147-3-21**] Urine culture: KLEBSIELLA PNEUMONIAE 10,000-100,000
ORGANISMS/ML
SENSITIVITIES AS ABOVE
[**2147-3-23**] Peritoneal fluid gram stain and culture: no growth
."
5935,"2*
[**2147-3-9**] 03:21AM BLOOD Glucose-119* UreaN-38* Creat-1.7* Na-134
K-4.1 Cl-101 HCO3-24 AnGap-13
[**2147-3-9**] 03:21AM BLOOD ALT-47* AST-99* AlkPhos-296* TotBili-1.7*
[**2147-3-9**] 06:45AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.6
.
RELEVANT LABS:
[**2147-3-19**] 06:28PM BLOOD Type-ART pO2-182* pCO2-22* pH-7.58*
calTCO2-21 Base XS-1 Intubat-NOT INTUBA
[**2147-3-20**] 12:37PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-76* pCO2-30*
pH-7.45 calTCO2-21 Base XS--1
[**2147-3-19**] 06:28PM BLOOD Lactate-2."
5936,"DISCHARGE PHYSICAL EXAM:
VS 98.3 (98.9) 125/72 (113-136/60-75) 98 (84-102) 20 100RA
(96-100RA(
Weight 54.9 kg
I/O PO 2840 + IV 300 / BRP, BMx4
GENERAL: Very thin and cachetic female, looks older than stated
age, comfortable. NAD.
HEENT: Sclera icteric. PERRL, EOMI. Clear oropharynx.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air
symmetrically."
5937,"8* Plt Ct-84*
[**2147-3-24**] 06:30AM BLOOD PT-17.1* PTT-48.4* INR(PT)-1.6*
[**2147-3-24**] 06:30AM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-139
K-4.1 Cl-106 HCO3-21* AnGap-16
[**2147-3-24**] 06:30AM BLOOD ALT-22 AST-40 AlkPhos-79 TotBili-3.3*
[**2147-3-24**] 06:30AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.9
.
MICROBIOLOGY:
[**2147-3-9**] Blood cultures x2: no growth
[**2147-3-9**] Peritoneal fluid gram stain and culture: no growth
[**2147-3-17**] HCV VL: 577,629 IU/mL."
5938,"While you were here, we
performed two paracenteses on your ascites, and found that you
did not have an infection of your peritoneal fluid either time.
We treated your obstruction with NGT to suction and keeping you
with out food. Eventually, we allowed you to slowly eat clear
and then full liquids. We tried to initiate tube feeding during
this admission, but this was complicated by your small bowel
obstruction, so we were unable to initiate tube feeding at this
time. We controlled your pain with tylenol, tramadol,
gabapentin and flexeril, but you were not satisfied with this
pain regimen."
5939,"She also reports associated nausea, but denies
diarrhea/vomitting. She has been passing gas and having having
regular bowel movements 3-4 times a day. The stools are soft,
light brown, and no blood. She does note that during her recent
stay at LGH, she had one black-colored stool that was not
guaiaced. She denies fevers, chills, shortness of breath, chest
pain.
.
Of note she is scheduled for an elective admission to [**Hospital Ward Name 121**] 10 on
[**2147-3-15**] for inpatient nutrition c/s and dobhoff placement.
Patient states she has been eating high calorie foods per
nutrition recommendations, but has been unable to gain weight."
5940,".
Of note, patient has had several recent admissions to [**Hospital1 18**]
([**Date range (1) 2953**], [**Date range (1) 58857**], [**Date range (1) 90767**], [**Date range (1) 17387**]). In early [**Month (only) 956**] she
was treated medically for an ileus which improved w/ time and
NPO. In early [**Month (only) 958**] she was readmitted for abdominal pain and
BRBPR. After transient hypotension, she was admitted to the ICU
where her pressures improved after volume resussitation and
transfusion of 2 units of pRBC. Flex sig demonstrated rectal
varices without stigmata of recent bleeding, and grade 1 interal
hemorrhoids were noted. Her abdominal pain ultimately improved
w/ time again and she was advanced to a solid diet prior to
discharge."
5941,"During that time she underwent 2 paracentesis of 3L each, most
recent being day prior to admission. She states she normally
gets a paracentesis once/week at [**Hospital 3597**] [**Hospital **] Hospital, and then
once/2 weeks at LGH, but lately, has been hospitalized so
frequently she has not needed those outpatient appointments.
Patient reports that after discharge from LGH, abdominal pain
worsened almost immediately. She describes pain as diffuse
throughout her entire abdomen, worse around right flank and
mid-abdomen. It's sharp, stabbing and constant. Only relief is
through pain meds; eating and bowel movements do not affect [**Last Name (un) **]
pain."
5942,"Minimal expiratory wheezes diffusely, slightly
shallow breathing.
ABDOMEN: Normoactive bowel sounds. Less distended, soft,
non-tender. Dullness to percussion over dependent areas but
tympanic anteriorly. No HSM or tenderness. +Foley.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No
edema, 2+ distal pulses.
NEURO: Awake, alert and oriented x3. No asterixis.
Pertinent Results:
ADMISSION LABS:
[**2147-3-9**] 03:21AM BLOOD WBC-8.0 RBC-4.47 Hgb-11.9* Hct-38.3
MCV-86 MCH-26.6* MCHC-31.1 RDW-19.1* Plt Ct-125*#
[**2147-3-9**] 03:21AM BLOOD PT-13.4* PTT-35.3 INR(PT)-1."
5943,"0 Leuks-LG
[**2147-3-21**] 09:36AM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
[**2147-3-20**] 12:32PM URINE Mucous-MANY
[**2147-3-21**] 09:36AM URINE WBC Clm-FEW Mucous-FEW
[**2147-3-20**] 04:35PM ASCITES WBC-145* RBC-1480* Polys-2* Lymphs-51*
Monos-0 Mesothe-2* Macroph-45*
[**2147-3-20**] 04:35PM ASCITES TotPro-1.4 Glucose-89 LD(LDH)-115
.
DISCHARGE LABS:
[**2147-3-24**] 06:30AM BLOOD WBC-3.4* RBC-3.38* Hgb-9.4* Hct-30.4*
MCV-90 MCH-27.8 MCHC-30.9* RDW-18."
5944,"1*
[**2147-3-20**] 12:37PM BLOOD Lactate-2.1*
[**2147-3-19**] 06:28PM BLOOD freeCa-1.17
[**2147-3-20**] 12:37PM BLOOD freeCa-1.20
[**2147-3-20**] 12:32PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.039*
[**2147-3-21**] 09:36AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.028
[**2147-3-20**] 12:32PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-2* pH-6.0 Leuks-NEG
[**2147-3-21**] 09:36AM URINE Blood-LG Nitrite-POS Protein-100
Glucose-NEG Ketone-10 Bilirub-SM Urobiln-NEG pH-6."
5945,"3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. acetaminophen 500 mg Capsule Sig: One (1) Capsule PO every
four (4) hours as needed for pain.
6. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
8. lactulose 10 gram/15 mL (15 mL) Solution Sig: Thirty (30) mL
PO three times a day.
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day."
5946,"There is evidence of ascites
.
[**2147-3-20**] CHEST (PORTABLE AP):
There are low lung volumes. Cardiac size is top normal. There
are unchanged multiple bilateral right greater than left
calcified granulomas. Left lowerlobe opacity is likely
atelectasis. There is no pneumothorax or pleural effusion. ET
tube is in standard position. NG tube tip is in the stomach.
.
[**2147-3-20**] PARACENTESIS DIAG/THERAP W IMAGING GUIDE:
IMPRESSION: Uncomplicated bedside therapeutic and diagnostic
paracentesis via a right flank approach.
Overall, the patient tolerated the procedure well with no early
complications.
.
[**2147-3-20**] PELVIS (AP ONLY):
IMPRESSION:
Radiopaque pessary device is in place projecting over the pubic
symphysis on single oblique frontal view."
5947,"SICU
HPI:
HPI: 79 yo male s/p ant/post L3-S1 decompression/fusion for failed back
surgery sydrome with 2.5L EBL, 5 PRBCs and 2 FFP intraop.
Chief complaint:
Chr anemia, thrombocytosis,back surgery
PMHx:
PMH: Dyslipidemia, Asthma (CONTROLLED SOB w/activity), DM 2, Anemia
PSH: anterior L3-S1 decopression fusion on [**9-6**], partial thyroid [**2129**],
back surgery x 2 [**2130**], [**2135**], L TKR [**2133**], appy [**2125**], shoulder [**2124**],
lipoma neck [**2135**]
[**Last Name (un) **]: celebrex, doxazocin 4', avandia, synthroid, ativan, paroxetene
20', fentanyl patch 75, simvastatin 40', gemfibrozol 600"", naproxen,
fent patch 75 mcg, ativan 1mg [**Hospital1 7**]
Current medications:
Active Medications [**Known lastname **],[**Known firstname 2562**]
1."
5948,"PLAN:
Neuro: d/c PCA not used appropriatly in favor of Q2H dilaudid IV,
Fentanyl patch 75mcg/hr on.Ativan, Valium
CVS: HD stable, on no pressors r/o for MI. PAC
s O/N.
Pulm: ext 93% 4 L
GI: CT abdomen now. Famotidine,sips started and advance to tolerate
after CT.
FEN: HLIVF D5 1/2 NS @75 IF TOLERATES PER ORAL.
Renal: Foley, good UOP
Heme: Monitor Hct, 26.5 after 2 U of PRBC 25.1, coags 1.2
Endo: RISS, to restart synthroid once taking po
ID: Cefazolin prophylaxis
TLD: L IJ TLC, L radial Aline, PIV x2, Hemovac
Wounds: Back
Imaging:
Prophylaxis: H2B, SCDs
Consults: Ortho spine, APS
Code: full
Disposition: SICU
Billing Diagnosis:
Lines:
Multi Lumen - [**2140-9-9**] 06:05 PM rewired [**9-10**]
Total time spent:"
5949,"m.
Tmax: 37.6
C (99.6
T current: 37.1
C (98.8
HR: 81 (71 - 103) bpm
BP: 99/45(59) {98/38(56) - 179/81(100)} mmHg
RR: 21 (14 - 26) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 110.8 kg (admission): 109 kg
Height: 67 Inch
Total In:
3,376 mL
618 mL
PO:
30 mL
Tube feeding:
IV Fluid:
2,621 mL
618 mL
Blood products:
725 mL
Total out:
1,470 mL
450 mL
Urine:
1,090 mL
370 mL
NG:
Stool:
Drains:
380 mL
80 mL
Balance:
1,906 mL
168 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 478 (478 - 478) mL
PS : 5 cmH2O
RR (Spontaneous): 18
PEEP: 5 cmH2O
FiO2: 40%
PIP: 11 cmH2O
SPO2: 100%
ABG: 7."
5950,"46/37/137/30/3
Ve: 9 L/min
PaO2 / FiO2: 343
Physical Examination
General Appearance: No acute distress
HEENT: EOMI
Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :
, Crackles : )
Abdominal: Non-distended, Bowel sounds present
Left Extremities: (Edema: Absent, Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Diminished)
Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Diminished)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
167 K/uL
8.2 g/dL
185 mg/dL
0.9 mg/dL
30 mEq/L
4."
5951,"2. 3. 4. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 5.
Acetaminophen 6. Albuterol Inhaler
7. Bisacodyl 8. Calcium Gluconate 9. CefazoLIN 10. Diazepam 11.
Diazepam 12. Docusate Sodium 13. Doxazosin
14. Famotidine 15. Fentanyl Patch 16. Furosemide 17. Gabapentin 18.
Gemfibrozil 19. HYDROmorphone (Dilaudid)
20. HYDROmorphone (Dilaudid) 21. Insulin 22. Levothyroxine Sodium 23.
Lorazepam 24. Magnesium Sulfate
25. Multivitamins 26. Paroxetine 27. Pneumococcal Vac Polyvalent 28.
Potassium Chloride 29. Simvastatin
30. Sodium Chloride 0.9% Flush 31. Sodium Chloride 0.9% Flush
24 Hour Events:
EXTUBATION - At [**2140-9-10**] 08:40 AM
pt weaned and extubated pt had audible cuff leak and no post extuabtion
stridor currently on 50% face tent with sats >98%
INVASIVE VENTILATION - STOP [**2140-9-10**] 08:41 AM
EKG - At [**2140-9-10**] 09:00 AM
ARTERIAL LINE - STOP [**2140-9-10**] 11:02 AM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2140-9-11**] 12:10 AM
Infusions:
Other ICU medications:
Diazepam (Valium) - [**2140-9-10**] 05:00 PM
Famotidine (Pepcid) - [**2140-9-10**] 08:00 PM
Other medications:
Flowsheet Data as of [**2140-9-11**] 05:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**43**] a."
5952,"9
0.8
0.9
Troponin T
<0.01
<0.01
TCO2
33
32
27
Glucose
174
203
205
185
Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin
T:1370/18/<0.01, Lactic Acid:1.3 mmol/L, Ca:7.7 mg/dL, Mg:2.1 mg/dL,
PO4:2.5 mg/dL
Assessment and Plan
VENTRICULAR PREMATURE BEATS (VPB, VPC, PVC), AIRWAY, INABILITY TO
PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH),
BACK PAIN
Assessment and Plan: Assessment: 79 yo male s/p ant/post L3-S1
decompression/fusion
H/O CAD recent preop cath for clearance."
5953,"0 mEq/L
20 mg/dL
101 mEq/L
139 mEq/L
25.1 %
8.9 K/uL
[image002.jpg]
[**2140-9-9**] 05:24 PM
[**2140-9-9**] 10:08 PM
[**2140-9-10**] 03:47 AM
[**2140-9-10**] 04:16 AM
[**2140-9-10**] 07:26 AM
[**2140-9-10**] 08:25 AM
[**2140-9-10**] 04:27 PM
[**2140-9-10**] 04:30 PM
[**2140-9-10**] 06:40 PM
[**2140-9-11**] 12:43 AM
WBC
9.7
8.8
8.9
Hct
28.2
26.5
25.3
24.9
25.1
Plt
162
160
167
Creatinine
0."
5954,"Admission Date: [**2140-9-6**] Discharge Date: [**2140-9-16**]
Date of Birth: [**2060-10-4**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation
History of Present Illness:
Mr. [**Known lastname **] has a long history of back and leg pain. He has
attempted conservative therapy including physical therapy and
has failed. He now presents for surgical intervention.
Past Medical History:
Dyslipidemia, Asthma (CONTROLLED SOB w/activity), DM 2, Anemia'
partial thyroid [**2129**], back surgery x 2 [**2130**], [**2135**], L TKR [**2133**],
appy [**2125**], shoulder [**2124**], lipoma neck [**2135**]"
5955,"Postoperative HCT was 25. He was transfused
PRBCs and transfered to the SICU for observation.
In the SICU he was confused and this was thought to be due to
anaesthesia. He subsequently became more awake and alert over
the following three days. A bupivicaine epidural pain catheter
placed at the time of the posterior surgery remained in [**Known lastname **]
until postop day#1 from the second procedure when it was
removed. He was kept NPO until bowel function returned then diet
was advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating PO diet. Foley was removed on
POD#3 from the second procedure."
5956,"16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal
Q72H (every 72 hours).
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 83060**] Nursing Facility
Discharge Diagnosis:
Lumbar spondylosis and disc degeneration
Acute post-op anemia
Post-op confusion
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks."
5957,"C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily)."
5958,"10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
syringe Injection ASDIR (AS DIRECTED).
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day)."
5959,"You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking."
5960,"-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity as tolerated
LSO for ambulation; may be out of bed to chair without.
Treatment Frequency:
Please continue to inspect the incisions daily and look for
signs of infection.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 363**] in his clinic. Call
[**Telephone/Fax (1) **] for an appointment.
Completed by:[**2140-9-15**]"
5961,"1 MCHC-34.5 RDW-14.7 Plt Ct-164
[**2140-9-11**] 12:43AM BLOOD WBC-8.9 RBC-2.91* Hgb-8.2* Hct-25.1*
MCV-86 MCH-28.0 MCHC-32.6 RDW-14.8 Plt Ct-167
[**2140-9-10**] 03:47AM BLOOD WBC-8.8 RBC-3.10* Hgb-9.1* Hct-26.5*
MCV-86 MCH-29.4 MCHC-34.4 RDW-14.1 Plt Ct-160
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2140-9-6**] and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach."
5962,"He was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
celebrex, doxazocin 4', avandia, synthroid, ativan, paroxetene
20', fentanyl patch 75, simvastatin 40', gemfibrozol 600"",
naproxen, fent patch 75 mcg,
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E."
5963,"Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#4 ([**2140-9-9**]) he returned to the operating
room for a scheduled L3-S1 decompression with PSIF as part of a
staged 2-part procedure. Please refer to the dictated operative
note for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition."
5964,"1* Hct-28.7*
MCV-88 MCH-28.0 MCHC-31.8 RDW-14.9 Plt Ct-369
[**2140-9-14**] 02:35AM BLOOD WBC-6.8 RBC-3.33* Hgb-9.7* Hct-29.4*
MCV-88 MCH-29.0 MCHC-32.9 RDW-14.4 Plt Ct-276
[**2140-9-13**] 01:16AM BLOOD WBC-7.9 RBC-3.17* Hgb-9.0* Hct-27.7*
MCV-88 MCH-28.3 MCHC-32.4 RDW-15.1 Plt Ct-212
[**2140-9-12**] 02:27AM BLOOD WBC-7.7 RBC-2.80* Hgb-8.4* Hct-24.5*
MCV-87 MCH-30."
5965,"You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office."
5966,"Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation diminished L4-5 dermatomes; - clonus,
reflexes symmetric at quads and Achilles
Pertinent Results:
[**2140-9-15**] 07:00AM BLOOD WBC-7.9 RBC-3.25* Hgb-9."
5967,"SICU
HPI:
79 yo male s/p ant/post L3-S1 decompression/fusion for failed back
surgery sydrome with 2.5L EBL, 5 PRBCs and 2 FFP intraop.
Chief complaint:
PMHx:
Dyslipidemia, Asthma (CONTROLLED SOB w/activity), DM 2, Anemia
Current medications:
1000 mL NS 5. Acetaminophen 6. Albuterol Inhaler 7. Bisacodyl 8.
Calcium Gluconate
9. CefazoLIN 10. Diazepam 11. Docusate Sodium 12. Doxazosin 13.
Famotidine 14. Fentanyl Patch 15. Furosemide
16. Gabapentin 17. Gemfibrozil 20. HYDROmorphone (Dilaudid) 21. Insulin
22. Levothyroxine Sodium 23. Lorazepam 24. Magnesium Sulfate 25.
Metoprolol Tartrate 26. Multivitamins 27. Paroxetine 28. Pneumococcal
Vac Polyvalent 29."
5968,"5L.
PLAN:
Neuro: 1) Pain - Dil prn, Cont fentanyl patch 75mcg/hr on. 2) Anxiety -
cont Ativan. 3) Spasm- cont Valium 4) q4h neuro checks - no changes
CVS: HD stable, MI r/o
Pulm: No active issues. On NC.
GI: Reg diet
FEN: KVO
Renal: Foley, good UOP
Heme: Low hct post-op. CT scan of abd did not show retroperitoneal
bleed. Given 1u pRBC with appropriate rise in hct to 26. Now down to
24.5, likely [**2-29**] post-op oozing. Cont to monitor q8h, if stable, can
monitor daily.
Endo: RISS, synthroid
ID: Cefazolin prophylaxis
TLD: PIV x1, Hemovac
Wounds: Back c/d/i, hemovac draining serosanguinous fluid
Prophylaxis: H2B, SCDs
Consults: Ortho spine
Code: full
Disposition: SICU
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2140-9-11**] 09:30 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent:"
5969,"4 g/dL
147 mg/dL
0.8 mg/dL
33 mEq/L
3.6 mEq/L
13 mg/dL
100 mEq/L
138 mEq/L
24.5 %
7.7 K/uL
[image002.jpg]
[**2140-9-10**] 07:26 AM
[**2140-9-10**] 08:25 AM
[**2140-9-10**] 04:27 PM
[**2140-9-10**] 04:30 PM
[**2140-9-10**] 06:40 PM
[**2140-9-11**] 12:43 AM
[**2140-9-11**] 06:23 AM
[**2140-9-11**] 11:46 AM
[**2140-9-11**] 06:13 PM
[**2140-9-12**] 02:27 AM
WBC
8.9
7.7
Hct
25."
5970,"Potassium Chloride 30. Simvastatin
24 Hour Events:
MULTI LUMEN - STOP [**2140-9-11**] 08:27 PM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Cefazolin - [**2140-9-12**] 12:00 AM
Infusions:
Other ICU medications:
Diazepam (Valium) - [**2140-9-11**] 06:30 PM
Famotidine (Pepcid) - [**2140-9-11**] 10:17 PM
Metoprolol - [**2140-9-12**] 12:00 AM
Hydromorphone (Dilaudid) - [**2140-9-12**] 01:00 AM
Other medications:
Flowsheet Data as of [**2140-9-12**] 04:31 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**43**] a.m.
Tmax: 37.7
C (99.9
T current: 37."
5971,"7
C (99.9
HR: 86 (70 - 89) bpm
BP: 108/53(67) {88/38(46) - 143/77(91)} mmHg
RR: 19 (12 - 22) insp/min
SPO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 110.3 kg (admission): 109 kg
Height: 67 Inch
Total In:
2,880 mL
131 mL
PO:
360 mL
Tube feeding:
IV Fluid:
2,145 mL
131 mL
Blood products:
375 mL
Total out:
2,540 mL
275 mL
Urine:
2,460 mL
275 mL
NG:
Stool:
Drains:
80 mL
Balance:
340 mL
-144 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 97%
ABG: ///33/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
164 K/uL
8."
5972,"3
24.9
25.1
23.6
26.0
25.6
24.5
Plt
167
164
Creatinine
0.9
0.8
Troponin T
<0.01
<0.01
TCO2
27
Glucose
185
147
Other labs: PT / PTT / INR:13.9/26.9/1.2, CK / CK-MB / Troponin
T:1370/18/<0.01, Lactic Acid:1.3 mmol/L, Ca:7.9 mg/dL, Mg:1.8 mg/dL,
PO4:2.1 mg/dL
Assessment and Plan
HEMORRHAGE/HEMATOMA, PROCEDURE-RELATED (E.G., CATH, PACEMAKER, ICD
BLEED) , VENTRICULAR PREMATURE BEATS (VPB, VPC, PVC), AIRWAY, INABILITY
TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH),
BACK PAIN
Assessment and Plan: 79 yo male s/p ant/post L3-S1 decompression/fusion
with EBL of 2."
5973,"PCA p extubation. Moving all extremities
CVS: HD stable, on no pressors resolved hypovolemic shock. 2. new
onset PVC
s O/N will rule out for ischemia. Start statin, metporolol
Pulm: CPAP, ABG, extubate today
GI: Famotidine, NPO
FEN: IVF D5 1/2 NS @75
Renal: Foley, good UOP
Heme: Monitor Hct, coags. Stable anemia
Endo: RISS, to restart synthroid once taking po
ID: Cefazolin prophylaxis
TLD: L IJ TLC, L radial Aline, PIVx2, Hemovac
Wounds: Back
Imaging:
Prophylaxis: H2B, SCDs
Consults: Ortho spine, APS
Code: full
Disposition: SICUBilling Diagnosis:
ICU Care
Nutrition: NPO
Glycemic Control:
Lines:
14 Gauge - [**2140-9-9**] 05:35 PM
Multi Lumen - [**2140-9-9**] 06:05 PM
Arterial Line - [**2140-9-9**] 08:00 PM
Prophylaxis:
DVT: SCDs
Stress ulcer: H2B
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition: SICU
Total time spent: 31 min."
5974,"SICU
HPI:
79 yo male s/p ant/post L3-S1 decompression/fusion for failed back
surgery sydrome with 2.5L EBL, 5 PRBCs and 2 FFP intraop. Admitted for
volume resusitation and pt left intubated due to prone positioning
intraop and extensive EBL.
Chief complaint:
Back pain
PMHx:
Dyslipidemia, Asthma (CONTROLLED SOB w/activity), DM 2, Anemia,
anterior L3-S1 decopression fusion on [**9-6**], partial thyroid [**2129**], back
surgery x 2 [**2130**], [**2135**], L TKR [**2133**], appy [**2125**], shoulder [**2124**], lipoma
neck [**2135**]
Current medications:
1. Albuterol Inhaler 2. Calcium Gluconate 3. CefazoLIN 4.
Famotidine 5. Fentanyl Citrate gtt 6."
5975,"9
9.7
Hct
29
27.1
28.2
Plt
148
162
Creatinine
0.9
0.9
TCO2
33
33
Glucose
179
178
174
203
Other labs: PT / PTT / INR:14.1/26.1/1.2, Lactic Acid:1.3 mmol/L,
Ca:8.7 mg/dL, Mg:1.7 mg/dL, PO4:2.9 mg/dL
Assessment and Plan
BACK PAIN
Assessment and Plan: Assessment: 79 yo male s/p ant/post L3-S1
decompression/fusion. PVC
s O/N
PLAN:
Neuro: (1) Sedation: wean Propofol (2) Pain: Fentanyl gtt, d/c
epidural, off until extubated will need to be tested if used, Fentanyl
patch 75mcg/hr from home."
5976,"43/48/327/28/7
Ve: 7.2 L/min
PaO2 / FiO2: 654
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Trace)
Right Extremities: (Edema: Trace)
Neurologic: Sedated
Labs / Radiology
162 K/uL
9.4 g/dL
203 mg/dL
0.9 mg/dL
28 mEq/L
4.1 mEq/L
19 mg/dL
101 mEq/L
137 mEq/L
28.2 %
9.7 K/uL
[image002.jpg]
[**2140-9-9**] 04:00 PM
[**2140-9-9**] 05:14 PM
[**2140-9-9**] 05:24 PM
[**2140-9-9**] 10:08 PM
WBC
7."
5977,"Fentanyl Patch 7. Insulin
SS 8. Magnesium Sulfate 9. Potassium Chloride 10. Propofol gtt
24 Hour Events:
OR [**9-6**] and [**9-9**]: 2.5 L EBL on [**9-9**] with 5 PRBCs, 2 FFP
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Fentanyl - 25 mcg/hour
Other ICU medications:
Famotidine (Pepcid) - [**2140-9-9**] 08:00 PM
Other medications:
Flowsheet Data as of [**2140-9-10**] 03:30 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**43**] a.m.
Tmax: 37.1
C (98.7
T current: 37.1
C (98.7
HR: 75 (73 - 89) bpm
BP: 130/68(87) {118/60(78) - 169/87(113)} mmHg
RR: 13 (7 - 17) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 67 Inch
Total In:
6,431 mL
325 mL
PO:
Tube feeding:
IV Fluid:
3,718 mL
325 mL
Blood products:
2,713 mL
Total out:
3,435 mL
150 mL
Urine:
385 mL
150 mL
NG:
Stool:
Drains:
Balance:
2,996 mL
175 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 596 (596 - 596) mL
PS : 12 cmH2O
RR (Set): 16
RR (Spontaneous): 13
PEEP: 5 cmH2O
FiO2: 50%
PIP: 17 cmH2O
Plateau: 13 cmH2O
SPO2: 100%
ABG: 7."
5978,"SICU
HPI:
37 yo male right hand dominant construction worker who
lacerated his left hand, amputating left 2 and 3rd digits with
severe lacerations to the 4th and 5th digits. s/p Replantation of left
index and long fingers at the level of the PIP joint, xploration of
left ring finger and small finger complex open wounds, open
reduction and percutaneous pin fixation of left ring finger
and small finger middle phalangeal fractures, and complex
wound closure of left index finger, middle finger, ring
finger and small finger greater than 25 cm.
Chief complaint:
venous congestion
PMHx:
PMH:R Hip pain, Vasectomy, Umbilical and inguinal hernias, Psoriasis
PSHx: Umbilical and Inguinal herniorapphy
Current medications:
1."
5979,"s/p Replantation of left
index and long fingers at the level of the PIP joint, xploration of
left ring finger and small finger complex open wounds, open
reduction and percutaneous pin fixation of left ring finger
and small finger middle phalangeal fractures, and complex
wound closure of left index finger, middle finger, ring
finger and small finger greater than 25 cm.
Neurologic: Neuro checks Q: 4 hr, Pain controlled, infraclav off to
assess sensation. Will restart after asssessment
Cardiovascular: Aspirin, hirudin therapy still continues
Pulmonary: IS, room air
Gastrointestinal / Abdomen: tolerating regular diet
Nutrition: npo for possible OR today
Renal: Adequate UO
Hematology: hcts stable
Endocrine: RISS
Infectious Disease: unasyun and levaquin
Lines / Tubes / Drains: brachial plexus catheter
Wounds: Dry dressings, hirudin therapy to continue
Imaging:
Fluids: D5 1/2 NS while NPO
Consults: Plastics
Billing Diagnosis: Other: hirudin therapy; flap reconstruction
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2163-12-13**] 12:50 PM
Prophylaxis:
DVT: Boots
Stress ulcer::
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 32 minutes"
5980,"2. 3. 1000 mL D5 1/2NS 4. Acetaminophen 5. Ampicillin-Sulbactam 6.
Aspirin 7. Bupivacaine 0.1%
8. DiphenhydrAMINE 9. Docusate Sodium 10. Gabapentin 11. Heparin 12.
Ibuprofen 13. Insulin 14. Levofloxacin
15. Ondansetron 16. Promethazine 17. Sodium Chloride 0.9% Flush 18.
Sodium Chloride 0.9% Flush
19. Sodium Chloride 0.9% Flush
24 Hour Events:
[**12-11**] admitted for hirudotherapy of the left middle finger, vascular
checks of the left middle finger q 30 min
[**12-12**] started leeches
[**12-13**] continuing leeches
[**12-14**] continuing leeches
.
Post operative day:
[**12-11**] admitted for hirudotherapy of the left middle finger, vascular
checks of the left middle finger q 30 min
[**12-12**] started leeches
[**12-13**] continuing leeches
[**12-14**] continuing leeches
."
5981,"Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ampicillin/Sulbactam (Unasyn) - [**2163-12-15**] 12:00 AM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2163-12-14**] 02:31 PM
Other medications:
Flowsheet Data as of [**2163-12-15**] 05:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**67**] a.m.
Tmax: 37.4
C (99.4
T current: 35.6
C (96.1
HR: 57 (57 - 97) bpm
BP: 110/63(73) {99/50(62) - 129/78(87)} mmHg
RR: 22 (14 - 30) insp/min
SPO2: 98%
Heart rhythm: SB (Sinus Bradycardia)
Total In:
1,545 mL
485 mL
PO:
880 mL
Tube feeding:
IV Fluid:
665 mL
485 mL
Blood products:
Total out:
2,200 mL
0 mL
Urine:
2,200 mL
NG:
Stool:
Drains:
Balance:
-655 mL
485 mL
Respiratory support
SPO2: 98%
ABG: ////
Physical Examination
General Appearance: No acute distress
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:
Present), (Pulse - Posterior tibial: Present)
Skin: venous congestion still persists
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves
all extremities
Labs / Radiology
318 K/uL
11."
5982,"2 g/dL
94 mg/dL
0.7 mg/dL
25 mEq/L
4.0 mEq/L
15 mg/dL
105 mEq/L
139 mEq/L
24.8 %
6.5 K/uL
[image002.jpg]
[**2163-12-8**] 11:25 AM
[**2163-12-9**] 01:37 AM
[**2163-12-11**] 10:46 PM
[**2163-12-12**] 01:34 PM
[**2163-12-13**] 03:30 AM
[**2163-12-14**] 05:17 AM
[**2163-12-15**] 03:37 AM
WBC
10.9
9.8
8.0
6.5
6.5
Hct
33.4
29.6
28.6
30.0
30.8
26.8
24."
5983,"8
Plt
[**Telephone/Fax (3) 2989**]10
318
Creatinine
0.7
0.6
0.7
Glucose
117
114
94
Other labs: PT / PTT / INR:15.0/31.1/1.3, Differential-Neuts:78.4 %,
Lymph:13.0 %, Mono:7.6 %, Eos:0.9 %, Ca:8.1 mg/dL, Mg:2.0 mg/dL,
PO4:2.8 mg/dL
Assessment and Plan
ALTERATION IN TISSUE PERFUSION, [**Last Name 9**] PROBLEM - ENTER DESCRIPTION IN
COMMENTS, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
Assessment and Plan: 37 yo male right hand dominant construction worker
who
lacerated his left hand, amputating left 2 and 3rd digits with
severe lacerations to the 4th and 5th digits."
5984,"TITLE:
SICU
HPI:
37 yo male right hand dominant construction worker who
lacerated his left hand, amputating left 2 and 3rd digits with
severe lacerations to the 4th and 5th digits. s/p Replantation of left
index and long fingers at the level of the PIP joint, xploration of
left ring finger and small finger complex open wounds, open
reduction and percutaneous pin fixation of left ring finger
and small finger middle phalangeal fractures, and complex
wound closure of left index finger, middle finger, ring
finger and small finger greater than 25 cm, now s/p amputation of 2nd
finger."
5985,"6
6.8
Hct
33.4
29.6
28.6
30.0
30.8
26.8
24.8
24.1
23.6
Plt
[**Telephone/Fax (3) 3052**]
422
Creatinine
0.7
0.6
0.7
0.7
0.7
Glucose
117
114
94
107
101
Other labs: PT / PTT / INR:13.8/33.5/1.2, Differential-Neuts:78.4 %,
Lymph:13.0 %, Mono:7.6 %, Eos:0.9 %, Ca:8.8 mg/dL, Mg:2.0 mg/dL,
PO4:3.9 mg/dL
Assessment and Plan
ALTERATION IN TISSUE PERFUSION, [**Last Name 9**] PROBLEM - ENTER DESCRIPTION IN
COMMENTS, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
Assessment and Plan: 37M s/p traumatic injury to L hand, s/p
replantation of 2nd/3rd fingers, s/p amputation of 2nd digit."
5986,"5 g/dL
101 mg/dL
0.7 mg/dL
26 mEq/L
4.3 mEq/L
14 mg/dL
104 mEq/L
138 mEq/L
23.6 %
6.8 K/uL
[image002.jpg]
[**2163-12-8**] 11:25 AM
[**2163-12-9**] 01:37 AM
[**2163-12-11**] 10:46 PM
[**2163-12-12**] 01:34 PM
[**2163-12-13**] 03:30 AM
[**2163-12-14**] 05:17 AM
[**2163-12-15**] 03:37 AM
[**2163-12-16**] 02:00 AM
[**2163-12-17**] 01:39 AM
WBC
10.9
9.8
8.0
6.5
6.5
9."
5987,"Chief complaint:
no complaints
PMHx:
R Hip pain, Vasectomy, Umbilical and inguinal hernias, Psoriasis
PSHx: Umbilical and Inguinal [**First Name9 (NamePattern2) 3089**]
[**Last Name (un) **]: none
Current medications:
Acetaminophen 3. Ampicillin-Sulbactam 4. Aspirin 5. Docusate Sodium 6.
Gabapentin 7. HYDROmorphone (Dilaudid)
8. HYDROmorphone (Dilaudid) 9. Heparin 10. Ibuprofen 11. Levofloxacin
12. Ondansetron 13. Oxycodone-Acetaminophen
14. Promethazine 15. Sodium Chloride 0.9% Flush
24 Hour Events:
continued leech therapy, infraclavicular cath DC'd, minimal use of
PCA. Backed off on vascular checks
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ampicillin/Sulbactam (Unasyn) - [**2163-12-17**] 02:00 AM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2163-12-17**] 12:00 AM
Other medications:
Flowsheet Data as of [**2163-12-17**] 05:11 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**67**] a."
5988,"Neurologic: gabapentin, d/c PCA as pt does not use it, add percocet,
pain well controlled.
Cardiovascular: hemodynamically stable, q 2 hr vasc checks with
leeches, punctures PRN to keep active bleeding if no leeches
Pulmonary: no issues
Gastrointestinal / Abdomen: regular diet, no issues
Nutrition: regular diet
Renal: Adequate UO
Hematology: Stable anemia, no need for transfusion yet
Endocrine: no issues
Infectious Disease: no evidence of infection, afebrile, normal white
count. Levaquin/unasyn, ? duration.
Lines / Tubes / Drains: peripheral IV
Wounds: continue leech therapy, vascular checks, dressing changes per
plastics
Imaging: none
Fluids: KVO
Consults: Plastics, acute pain service
Billing Diagnosis: Other: traumatic hand injury
ICU Care
Nutrition:
Glycemic Control: Comments: none needed.
Lines:
20 Gauge - [**2163-12-17**] 02:00 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: Not indicated
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: [**Hospital 704**] Transfer to floor
Total time spent: 15 minutes"
5989,"m.
Tmax: 36.9
C (98.4
T current: 36.2
C (97.2
HR: 70 (63 - 94) bpm
BP: 110/51(66) {93/50(60) - 127/69(79)} mmHg
RR: 32 (15 - 40) insp/min
SPO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Height: 66 Inch
Total In:
2,320 mL
271 mL
PO:
1,880 mL
120 mL
Tube feeding:
IV Fluid:
440 mL
151 mL
Blood products:
Total out:
4,095 mL
0 mL
Urine:
3,875 mL
NG:
220 mL
Stool:
Drains:
Balance:
-1,775 mL
271 mL
Respiratory support
O2 Delivery Device: None
SPO2: 96%
ABG: ///26/
Physical Examination
General Appearance: No acute distress, Well nourished
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Skin: No(t) Rash: , R 3rd finger swollen, bullae, vascular exams
unchanged
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
422 K/uL
8."
5990,"2. Revision amputation of index finger
History of Present Illness:
This is a 37-year-old gentleman who at approximately 11:30 a.m.
on [**2163-12-6**], sustained a severe table saw injury to his
left hand while at work.
Past Medical History:
Umbilical and Inguinal herniorapphy
Social History:
Right handed construction worker. Smokes cigars (4/day), no
ETOH, no IVDU
Family History:
Diabetes on mothers side. o/w non-contributory
Physical Exam:
PE: Somewhat limited to pain and severity of injury.
GEN: Lying in moderate to severe pain.
HEENT: NC/AT, EOMI, PERRL
CV: RRR, nl S1 and S2, no MRG
PULM: CTA-B
ABD: Soft, NT/ND, no HSM, BS+
Skin: mild psoriatic plaques over both elbows and knees."
5991,"Disp:*30 Tablet(s)* Refills:*2*
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*1*
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed."
5992,"Medications on Admission:
None
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day)."
5993,"The patient
tolerated the procedure well.
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. Leeching therapy was
instituted to maintain perfusion to the severed digits. The
patient was weaned off leeching therapy prior to discharge.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well."
5994,"8* PTT-33.5 INR(PT)-1.2*
[**2163-12-17**] 01:39AM BLOOD Glucose-101 UreaN-14 Creat-0.7 Na-138
K-4.3 Cl-104 HCO3-26 AnGap-12
[**2163-12-16**] 02:00AM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-138
K-3.9 Cl-104 HCO3-27 AnGap-11
[**2163-12-7**] 01:00PM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-141
K-3.9 Cl-104 HCO3-28 AnGap-13
[**2163-12-17**] 01:39AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0
[**2163-12-16**] 02:00AM BLOOD Calcium-8."
5995,"9 Phos-3.6 Mg-1.8
[**2163-12-7**] 01:00PM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9
Brief Hospital Course:
On [**2163-12-7**], the patient was taken to the operating room
directly from the Emergency department for operative
repair/reimplantation of his severed digits. The patient
tolerated the procedure well. He was subsequently admitted to
the plastic surgery service. Over the ensuing week his fingers
remained perfused. However, on [**12-13**] the tone on the index finger
waxed and waned eventually losing digital pulse and no bleeding
with pin prick. On [**2163-12-15**], the patient was taken back to the
OR for revision amputation of the index finger."
5996,"Disp:*90 Capsule(s)* Refills:*2*
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
Disp:*60 Tablet(s)* Refills:*0*
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*1*
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
5997,"* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2163-12-27**] 8:40
Provider: [**Name10 (NameIs) **] CLINIC Phone:[**Telephone/Fax (1) 3009**] Date/Time:[**2163-12-27**] 9:00"
5998,"0 RBC-2.77* Hgb-8.9* Hct-24.5*
MCV-88 MCH-32.2* MCHC-36.5* RDW-14.6 Plt Ct-458*
[**2163-12-17**] 01:39AM BLOOD WBC-6.8 RBC-2.67* Hgb-8.5* Hct-23.6*
MCV-88 MCH-32.0 MCHC-36.3* RDW-14.1 Plt Ct-422
[**2163-12-7**] 01:00PM BLOOD WBC-16.4* RBC-4.64 Hgb-14.7 Hct-40.3
MCV-87 MCH-31.7 MCHC-36.5* RDW-13.4 Plt Ct-274
[**2163-12-17**] 01:39AM BLOOD Plt Ct-422
[**2163-12-17**] 01:39AM BLOOD PT-13."
5999,"Admission Date: [**2163-12-7**] Discharge Date: [**2163-12-21**]
Date of Birth: [**2126-10-8**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
Table saw accident leading to amputation
Major Surgical or Invasive Procedure:
1. Replantation of left index and long fingers at the level of
the PIP joint, exploration of left ring finger and small finger
complex open wounds, open reduction and percutaneous pin
fixation of left ring finger and small finger middle phalangeal
fractures, and complex wound closure of left index finger,
middle finger, ring finger and small finger greater than 25 cm."
6000,"Left Upper EXT:
- Amputations to the 2nd and 3rd digits are severed just past
the
proximal phalanx, through the PIP joints. The lacerations are
fairly clean and linear.
- Lacerations to the 4th and 5th digits are complex, with
portions along the length of the digit through PIP joint with
the
4th nearly amputated. These lacerations include severe tendon
injury.
Pertinent Results:
[**2163-12-20**] 06:00PM BLOOD Hct-24.6*
[**2163-12-19**] 06:51AM BLOOD WBC-7.4 RBC-2.74* Hgb-8.8* Hct-24.7*
MCV-90 MCH-32.2* MCHC-35.7* RDW-14.3 Plt Ct-475*
[**2163-12-18**] 02:07AM BLOOD WBC-8."
6001,"SICU
HPI:
37 yo male right hand dominant construction worker who lacerated his
left hand, amputating left 2 and 3rd digits with severe lacerations to
the 4th and 5th digits. s/p Replantation of left index and long fingers
at the level of the PIP joint, exploration of left ring finger and
small finger complex open wounds, open reduction and percutaneous pin
fixation of left ring finger and small finger middle phalangeal
fractures, and complex wound closure of left index finger, middle
finger, ring finger and small finger greater than 25 cm.
Chief complaint:
left finger amp/lac s/p reimplantation/ORIF
PMHx:
R Hip pain, Vasectomy, Umbilical and inguinal hernias, Psoriasis
Current medications:
24 Hour Events:
Post operative day:
POD#4 - left index/long finger reimplantation, ORIF left ring
finger/small finger
24 hour events - admitted to ICU for hirudotheraphy of left middle
finger and q30min vascular checks for flap - leeches en route
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ampicillin/Sulbactam (Unasyn) - [**2163-12-12**] 06:00 AM
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2163-12-12**] 09:38 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**67**] a."
6002,"6 g/dL
114 mg/dL
0.6 mg/dL
26 mEq/L
3.9 mEq/L
5 mg/dL
105 mEq/L
136 mEq/L
28.6 %
8.0 K/uL
[image002.jpg]
[**2163-12-8**] 11:25 AM
[**2163-12-9**] 01:37 AM
[**2163-12-11**] 10:46 PM
WBC
10.9
9.8
8.0
Hct
33.4
29.6
28.6
Plt
[**Telephone/Fax (3) 2970**]
Creatinine
0.7
0.6
Glucose
117
114
Other labs: PT / PTT / INR:15.0/31.1/1.3, Differential-Neuts:78.4 %,
Lymph:13.0 %, Mono:7.6 %, Eos:0."
6003,"m.
Tmax: 37.7
C (99.8
T current: 37.1
C (98.8
HR: 79 (62 - 85) bpm
BP: 126/72(85) {105/55(66) - 137/89(90)} mmHg
RR: 30 (13 - 33) insp/min
SPO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Total In:
200 mL
PO:
Tube feeding:
IV Fluid:
200 mL
Blood products:
Total out:
0 mL
2,120 mL
Urine:
2,120 mL
NG:
Stool:
Drains:
Balance:
0 mL
-1,920 mL
Respiratory support
O2 Delivery Device: None
SPO2: 97%
ABG: ////
Physical Examination
General Appearance: No acute distress
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), moves L thumb, + sensation L hand
Labs / Radiology
276 K/uL
10."
6004,"9 %, Ca:8.1 mg/dL, Mg:2.0 mg/dL,
PO4:2.8 mg/dL
Assessment and Plan
ALTERATION IN TISSUE PERFUSION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
Assessment and Plan: 37 yo male h/o psoriasis sustained left hand
lacerations and 2nd/3rd digit amputations POD#4 s/p reimplantation of
2nd/3rd digits and ORIF of 4th and 5th digit fractures, now here for
hirudotherapy of venous congestion middle finger.
Neurologic: Neuro checks Q: 4 hr, Pain controlled, Pain free with
infraclavicular catheter. D/c dilaudid. Q 30 minutes vascular check
Cardiovascular: Stable hemodynamically
Pulmonary: Stable
Gastrointestinal / Abdomen:
Nutrition: Regular diet
Renal: Adequate UO, No issues
Hematology: Serial Hct, Stable hemodynamically
Endocrine: RISS, BG well controlled. Keep < 150
Infectious Disease: No evidence of infection. On Augmentin/Levofloxacin
prophylaxis
Lines / Tubes / Drains:
Wounds: Dry dressings
Imaging:
Fluids: KVO
Consults: Plastics
Billing Diagnosis: Post-op complication
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2163-12-11**] 10:34 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer:
VAP bundle: HOB elevation
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status:
Disposition: ICU
Total time spent: 20 minutes"
6005,"HTN
2. GI Bleeds
3. Kidney Stones
4. PE - has IVC Filter
5. Known AAA
6. Prostate CA s/p TURP
7. alzheimers dementia.
PSH:inguinal hernia repair, IVC filter placement, TURP
Soc: lives at home with wife
Flowsheet Data as of [**2135-12-11**] 11:10 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36
C (96.8
Tcurrent: 35.6
C (96
HR: 54 (54 - 63) bpm
BP: 119/72(79) {86/50(58) - 149/72(90)} mmHg
RR: 18 (18 - 27) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
18,960 mL
PO:
TF:
IVF:
5,260 mL
Blood products:
3,600 mL
Total out:
0 mL
1,275 mL
Urine:
235 mL
NG:
Stool:
Drains:
Balance:
0 mL
17,685 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 50%
PIP: 39 cmH2O
Plateau: 32 cmH2O
SpO2: 100%
ABG: ///21/
Ve: 12."
6006,"bilat small pntx w indwelling chest tubes (R posterior but kinked, L
in major fissure), ant LUL contusion, R lower lobe opacity likely combo
of contusion, atx, possibly aspiration
5. ~8cm pre-exiusting AAA - no acute injury
6. R adductor muscle hematoma with active extravasation (apparent
iatrogenic with indwelling L CFV cath)
7. UNSTABLE extension-distraction injury of T9-T10, fxs of T9, T10 sp
processes
8. ALL R ribs fx'd including R5-7 fx'd x3 places, R8-10 fx'd 2 places
-> flail chest, L 1st rib fx'd ant at SC junction
9. IVC mildly flattened with air at infrarenal filter, small spleen
(hypovolemia)
[**2135-12-11**] CT head: Acute right posterior parietal 1."
6007,"urology to follow.
Hematology: Hct 30 -> 21 -> 17. s/p 4U PRBC. Platelets 170 -> 66 -> 42.
INR climbing. likely component of DIC. will trend Hct post second
transfusion of 4U PRBC.
Infectious Disease: afebrile, no antibiotics at this point.
Endocrine: RISS
Fluids: LR boluses PRN, LR at 100cc/hr
Electrolytes: significant metabolic acidosis
Nutrition:
General:
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
16 Gauge - [**2135-12-11**] 09:06 PM
20 Gauge - [**2135-12-11**] 09:07 PM
Cordis/Introducer - [**2135-12-11**] 09:08 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: DNR (do not resuscitate)
Disposition: ICU
Total time spent:"
6008,"TITLE:
Chief Complaint: s/p fall
HPI:
This is a [**Age over 90 **] year old male transferred via med flight from
OSH s/p fall down 5 steps this afternoon. Was carrying a table
down the steps, and fell backwards. He hit his head on the
ground, and the table landed on his abdomen. At OSH, he was
originally A&Ox3 and followed commands, but began to develop
increasing abdominal pain and respiratory distress. His head CT
demonstrated a reported IPH, however, the patient came without a
CT report or a disk. He was intubated for transport. Upon
arrival to the ED, he was hypoxic and hypotensive."
6009,"3 g/dL
134 mg/dL
1.3 mg/dL
21 mEq/L
4.8 mEq/L
20 mg/dL
122 mEq/L
145 mEq/L
24.6 %
6.9 K/uL
[image002.jpg]
[**2135-12-11**] 07:15 PM
[**2135-12-11**] 08:54 PM
[**2135-12-11**] 09:10 PM
[**2135-12-11**] 09:52 PM
WBC
8.5
10.7
6.9
Hct
17.6
28.0
24.6
Plt
72
66
42
Cr
1.4
1.3
Glucose
148
138
134
Other labs: PT / PTT / INR:17.7/44.3/1.6, CK / CKMB / Troponin-T:344//,
ALT / AST:15/37, Alk Phos / T Bili:20/0."
6010,"He had b/l chest
tubes placed for b/l pneumothoraces which initially put out 600cc of
blood on the R and 100cc on the L. His fast exam was postitive for
blood in the spleno-renal space and [**Location (un) **] pouch. He was given 4U
PRBC, 2U FFP, and 8L NS in the ED for hypotension with systolic blood
pressures between 60 and 80. His blood pressure initially improved but
he then became hypotensive and his repeat HCt was down to 17 (from
initial Hct 30 at OSH). He was noted to have brown guiac positive stool
on rectal exam."
6011,"He was found to have a small R IPH, multiple
intra-abdominal injuries as well as multiple rib fractures on the R
with flail chest and the plan was made to bring him to the OR, however
the family elected instead for conservative management. He was made
DNR/DNI and brought to the TSICU for further resuscitation. Patient
arrived on vent with stable vital signs.
Post operative day:
Allergies:
Last dose of Antibiotics:
Infusions:
Midazolam (Versed) - 2 mg/hour
Other ICU medications:
Dilantin - [**2135-12-11**] 09:25 PM
Sodium Bicarbonate 8.4% (Amp) - [**2135-12-11**] 09:38 PM
Fentanyl - [**2135-12-11**] 09:46 PM
Other medications:
Past medical history:
Family / Social history:
PMH:
1."
6012,"2cm IPH with edema.
Tiny second focus just posterior. Hypodensity in the left frontal lobe.
No intraventricular extension. No significant shift of midline
structures.
[**2135-12-11**]: Min displ fx R TP of C7, no body or post element Cspine fx,
normal lordosis w/o malalignment; post osteophytes at C3-4 - cannot
assess cord for injury, if indicated consider MR; min coiling NGT in
hypopharynx, ETT ok; R1st and 2nd ribs fx'd at costovert junctions
Assessment and Plan
Assessment And Plan: 89 YO M with multiple intraabdominal and
intrathoracic injuries as well as an IPH after falling today. He was
coagulopathic on arrival with multiple sites of hemorrhage and his labs
continue to show multi-organ system failure, despite aggressive
resuscitative measures
Neurologic: intubated, sedated."
6013,"5, Amylase / Lipase:96/44,
Differential-Neuts:85.6 %, Lymph:3.5 %, Mono:10.5 %, Eos:0.3 %, Lactic
Acid:3.1 mmol/L, Ca++:5.2 mg/dL, Mg++:1.3 mg/dL, PO4:3.7 mg/dL
Imaging: [**2135-12-11**] CT torso:
1.active bleeding mesenteric hematoma with thickening of supplied prox
jejunum (presumed early ischemic) just distal to Lig of Treitz
2.active bleeding of L RP hemorrhage medial and separate to L adrenal
gland - ?transected L diaphragmatic crus vessel vs L suprarenal art
3. cannot exclude panc body laceration though > or = 50% panc
transection NOT suspected
4."
6014,"3 L/min
Physical Examination
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube, OG tube, large scalp
laceration
Lymphatic: c-collar in place
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: Diminished: b/l), + subcutaneous
emphysema present L>R
Abdominal: No(t) Soft, Distended
Extremities: Right lower extremity edema: 1+, Left lower extremity
edema: 1+
Musculoskeletal: No(t) Muscle wasting
Skin: Cool
Neurologic: Responds to: Unresponsive, Movement: Non -purposeful,
Sedated, Tone: Not assessed
Labs / Radiology
42 K/uL
8."
6015,"PERRL. Not responsive to vigorous
painful stimuli. Patient with 2 small R frontal IPH. Exam reportedly
declining prior to intubation.
Neuro checks Q: 1h
Cardiovascular: hypotensive, treated with PRBC, FFP, and crystalloid.
Patient is DNR which was verified by the family.
Pulmonary: intubated, ventillated on AC at 500 x16 PEEP: 5 FIO2: 50 %
Patient with b/l chest tubes for pneumothorax putting out significant
amounts of blood. Continue chest tubes to low suction while patient on
vent. Monitor VBGs.
Gastrointestinal: npo. guiac positive stools and blood from NGT.
Renal: hematuria. s/p false lumen [**2-14**] traumatic foley placment at OSH."
6016,"Admission Date: [**2135-12-11**] Discharge Date: [**2135-12-12**]
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p fall with multiple injuries
Major Surgical or Invasive Procedure:
2 chest tube placements
History of Present Illness:
This is an 89 year old man transferred via med flight from
OSH s/p fall down 5 steps [**2135-12-11**]. Was carrying a table
down the steps and fell backwards. He hit his head on the
ground, and the table landed on his abdomen. At OSH, he was
originally A&Ox3 and followed commands, but began to develop
increasing abdominal pain and respiratory distress."
6017,"His head CT
demonstrated a reported IPH, and he also had a known R
hemothorax. He was intubated for transport.
Past Medical History:
1. HTN
2. GI Bleeds
3. Kidney Stones
4. PE - has IVC Filter
5. Known 7.5cm AAA
Social History:
Married, lives with wife, does not smoke, drink EtOH, or take
drugs. Retired.
Family History:
Non-contributory
Physical Exam:
Not applicable
Brief Hospital Course:
The patient was admitted to the emergency department, where
bilateral chest tubes were placed. These immediately returned a
large volume of blood and continued returning blood. The
patient's hct was quickly falling, ultimately to 17."
6018,"His
pressure was also falling. He was transfused 4 units blood and 2
FFP in the ED. He was also given 11L crystalloid. On imaging,
the patient was found to have extensive serious traumatic
injuries. There was active mesenteric bleeding with hematoma and
evidence of early small bowel ischemia, retroperitoneal active
bleeding, likely low grade pancreatic injury, blateral
pneumathoraces with indwelling chest tubes and likely right
lower lobe contusion and/or aspiration (#5), iatrogenic injury
resulting inactive bleeding in the R adductor musculature (#7),
unstable extension distracton injury at T9-T10 and numerous
other spinal fractures, right
flail chest, and evidence of hypovlemia."
6019,"He was en route to the
operating room when the family decided to forego surgery. He
was then transferred to the trauma ICU, where he was given 4
more units of PRBCs, 2 units of FFP, and 5L crystalloid before
being made CMO. He was out on a fentanyl/dilaudid drip and
taken off the vent. His oxygen saturation and blood pressure
fell quickly over the next hours, and he expired at 1:42am,
Medications on Admission:
1. Lisinopril 60mg Daily
2. Lopressor 50mg Twice Daily
3. Citalopram 20mg Daily
4. Aricept 20mg Daily
5. Iron Daily
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
fall with extensive internal injuries
Discharge Condition:
expired
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]"
6020,"Admission Date: [**2168-1-16**] Discharge Date: [**2168-1-19**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 23009**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2168-1-16**]
History of Present Illness:
89yo female with diabetes, hypertension, hyperlipidemia,
rheumatoid arthritis on methotrexate, history of anemia, and
history of low back pain who presents with arm and throat pain.
.
The patient was in her usual state of health until 6pm yesterday
when she developed sudden onset of arm pain associated with a
sore throat. This was not associated with diaphoresis, chest
pain, palpitations or shortness of breath."
6021,"She only
reports arm and throat pain.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: N/A
- PERCUTANEOUS CORONARY INTERVENTIONS: N/A
- PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
- Anemia
- Pancreatic cyst
- Bursitis of right shoulder
- Left and right total hip replacement ([**2161**], [**2149**])
- Rheumatoid arthritis
- Ovarian cyst
- Monoclonal gammopathy
- Osteoporosis
- Lacunar stroke [**2159**]
- Rosacea
- Type II DM
- Hypertension
- Hyperlipidemia
- Migraines
Social History:
Lives with son and daughter-in-law in [**Name (NI) 4628**]. No tobacco
history.
Family History:
Sister- breast cancer, brother- CABG at age 45, mother- CAD/PVD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T- 96."
6022,"The LMCA was
angiographically-free of any flow-limiting stenoses. The LAD
had a mid
30-40% lesion involving D1. D1 itself was noted to have a
50-60%
stenosis. The LCx had an occluded branch before a moderate OM1;
no AV
groove Cx identified. The RCA was a large vessel that had a
40-50%
lesion at the ostium, as well as a 50% lesion distally.
2. Limited resting hemodynamics revealed normal systemic
systolic
arterial pressures, with a central aortic pressure of 135/59,
mean 66
mmHg.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease - lateral STEMI likely due
to
occluded small OM branch of LCx."
6023,"There is no
mitral valve prolapse. Mild to moderate ([**12-7**]+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction c/w CAD (LCX or Diagonal
distribution). Mild-moderate mitral regurgitation.
Brief Hospital Course:
89yo female with multiple cardiac risk factors admitted with
ST-elevation MI.
.
#.CAD: Patient with ST-elevation MI, found to have occlusion of
small OM branch during cath. No intervention was indicated at
the time of the procedure. She was plavix loaded and started on
75 daily in AM, also started ASA 325mg PO daily, bivalirudin and
SL nitro."
6024,"However, CXR WNL. Blood
cx and urine cx NGTD. Most likely etiology is post-STEMI
inflammation causing cytokine release resulting in fever, as can
occur in the natural history of myocardial infarction when no
intervention occurs.
.
#.Hypertension: Patient's blood pressures ranging from SBP
130s-160s on admission; on amlodipine and losartan at home.
Amlodipine was discontinued, losartan was continued and
metoprolol also added in the post-MI setting.
.
#. Hyperlipidemia- Lipid panel from [**12/2167**] demonstrated TC 210,
HDL 44, LDL 148, TG 90. Pt treated with atorvastatin 80mg PO
daily while in hospital, but switched back to pravastatin 80mg
PO daily on discharge due to lower risk of statin myopathy."
6025,".
#.DM- On metformin 500mg daily at home. Last A1c- 6.6%.
Patient's home metformin was held in the setting of recent
cardiac cath and she was treated with ISS. Restarted metformin
on discharge.
.
#.Rheumatoid arthritis- continued home dose of methotrexate +
acetaminophen PRN.
.
#.Asthma- continued home fluticasone but held albuterol in the
setting of recent MI.
.
#.Osteoporosis- continued home calcium and vitamin D.
.
# Pulmonary nodule: CXR showed incidental right upper lung
opacity approximately 11 x 7 mm in diameter, slightly increased
in size since previous study. Recommend outpatient CT chest to
further evaluate.
- outpatient chest CT for further evaluation
.
================================================
TRANSITION OF CARE:
-CXR showed incidental RUL opacity, ~11x7cm diameter, slightly
increased in size since previous study."
6026,"Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
ST elevation Myocardial Infarction
Hypertension
Diabetes mellitus
Dyslipidemia
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**].
You experienced several hours of left arm pain and sore throat
at home and your family brought you to the Emergency Department
(ED) at [**Hospital1 18**]. In the [**Last Name (LF) **], [**First Name3 (LF) **] EKG was completed and it indicated
that you had a Myocardial Infacrtion (MI), also known as a heart
attack. You were then taken to the cardiac catherization lab and
a blockage of a small OM branch of the left circumflex artery
was seen."
6027,"Today,
you are ready to go home with your children and VNA (visiting
nurses) will come to help with your care as you recover at home.
We made the following changes to your medicines:
1. INCREASE the pravastatin to 80 mg daily to lower your
cholesterol
2. INCREASE the Aspirin to 325 mg daily to protect your heart
and decrease your risk of blood clots.
3. ADD a new blood pressure medication, Metoprolol Succinante
25mg daily, and stop an old one, Amlopidine, because Metoprolol
better protects your heart after a heart attack.
Followup Instructions:
Name: [**Last Name (LF) 67691**],[**First Name3 (LF) **]
Location: [**Location (un) 2274**] [**Location (un) **], Primary Care
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appt: Appt: Friday, [**1-22**] at 11:40am
Name: [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 29819**], NP
Location: [**Location (un) 2274**] [**Location (un) **], Cardiology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] [**Location (un) 551**]
Phone: [**Telephone/Fax (1) 2258**]
Appt: Monday, [**2-1**] at 10:40am"
6028,"Retention 24 hr Sig: One (1)
Tablet,ER [**Last Name (un) **].Retention 24 hr PO once a day.
9. metoprolol succinate 25 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*
10. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check Chem-7 on Friday [**1-22**] with results to [**First Name8 (NamePattern2) 2563**]
[**Last Name (NamePattern1) 2564**] at [**Telephone/Fax (1) 2258**]
Discharge Disposition:
Home With Service"
6029,"3* cTropnT-0.37*
[**2168-1-16**] 11:27AM BLOOD CK(CPK)-584*
[**2168-1-16**] 11:27AM BLOOD CK-MB-77* MB Indx-13.2* cTropnT-0.82*
[**2168-1-16**] 05:02PM BLOOD CK(CPK)-614*
[**2168-1-16**] 05:02PM BLOOD CK-MB-73* MB Indx-11.9* cTropnT-1.00*
[**2168-1-17**] 03:56AM BLOOD CK(CPK)-321*
[**2168-1-17**] 03:56AM BLOOD CK-MB-27* MB Indx-8.4* cTropnT-0.80*
Cadiac Catherization [**2168-1-16**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated one vessel coronary artery disease."
6030,"1 MCHC-33.6 RDW-15.0 Plt Ct-184
[**2168-1-15**] 11:55PM BLOOD WBC-8.2 RBC-3.53* Hgb-11.0* Hct-32.6*
MCV-92 MCH-31.1 MCHC-33.6 RDW-15.0 Plt Ct-184
[**2168-1-15**] 11:55PM BLOOD PT-10.9 PTT-27.2 INR(PT)-1.0
[**2168-1-15**] 11:55PM BLOOD Glucose-227* UreaN-27* Creat-1.0 Na-138
K-3.8 Cl-103 HCO3-25 AnGap-14
[**2168-1-16**] 05:24AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.9
Cardiac Enzymes:
[**2168-1-16**] 05:24AM BLOOD CK(CPK)-390*
[**2168-1-16**] 05:24AM BLOOD CK-MB-52* MB Indx-13."
6031,"2. Systemic systolic arterial normotension.
TTE ([**2168-1-16**]):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
hypokinesis of the basal half of the anterolateral wall. The
remaining segments contract normally (LVEF = 55 %). The
estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal."
6032,"3. fluticasone 110 mcg/actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for angina.
Disp:*25 tablet* Refills:*0*
6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. metformin 500 mg Tablet,ER [**Last Name (un) **]."
6033,"Her symptoms
persisted so, around 1130pm, she was brought to the ED by her
family.
.
On arrival to the ED, EKG demonstrated ST-elevations in I, aVL.
She received aspirin, heparin gtt and SL nitro with some relief
of her symptoms and was taken to the cath lab. While in the
cath lab, she received plavix 300mg and bivalirudin. Cath
demonstrated an occlusion of a small OM branch of LCx so no
intervention was performed. The patient remained
hemodynamically stable after the procedure. She is being
admitted to the CCU for further monitoring.
.
On arrival to the CCU, vital signs were T- 96."
6034,"After procedure she was chest pain free but initially
reported mild left arm/shoulder pain which resolved. Post-cath
echo showed normal left ventricular cavity size with mild
regional systolic dysfunction (LVEF 55%) c/w CAD (LCX or
Diagonal distribution) amd mild-moderate mitral regurgitation.
Patient
initially on high-dose atorvastatin; discharged on pravastatin
80mg daily given lower risk of myalgias. Also started ASA 325
daily, losartan 25mg daily, metoprolol 25mg daily and plavix 75
daily.
.
#.Fever: patient had fever to 100.8 in the 24hrs following cath.
Initial concern was aspiration PNA given that she was seen
possibly aspirating food while in CCU."
6035,"1, HR 69, BP
172/66, RR 21, SaO2- 100% on 2L NC. The patient remains chest
pain free but has persistent arm and throat pain that is much
improved from prior to arrival to [**Hospital1 18**].
.
On review of systems, she denies any deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, cough,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She 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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope."
6036,"Pt will need outpt chest
CT to further evaluate.
-Pt needs Chem 10 on Friday [**1-22**]
Medications on Admission:
1. Amlodipine 5mg daily
2. Methotrexate 2.5mg tablet, 6 tablets PO q week
3. Albuterol inh prn
4. Fluticasone 1 puff [**Hospital1 **]
5. Gabapentin 300mg qHS
6. Metformin ER 500mg qAM
7. Losartan 25mg daily
8. Pravastatin 10mg daily
9. Aspirin 81mg daily
Discharge Medications:
1. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. methotrexate sodium 2.5 mg Tablet Sig: Six (6) Tablet PO once
a week."
6037,"DISCHARGE PHYSICAL EXAM:
GENERAL: 78yo F in NAD, AAOx3, pleasant and conversant
HEENT: mucous membs moist, no lymphadenopathy, JVD 10 cm lying
down.
CHEST: crackles BB, [**Month (only) **] BS overall. No wheezes. Crackles clear w
deep breath.
CV: RRR no murmurs rubs or gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 1+. R groin with mild ecchymoses.
NEURO: 4/5 strength in U/L extremities. gait WNL.
SKIN: no rash
Pertinent Results:
Labs on Admission:
[**2168-1-15**] 11:55PM BLOOD WBC-8.2 RBC-3.53* Hgb-11.0* Hct-32.6*
MCV-92 MCH-31."
6038,"However, this artery was very small and no
interventions were indicated at that time. Your heart rate and
blood pressure were stable, but you were taken to the Cardiac
Intensive Unit (CCU) for further monitoring. An echocardiogram
was also completed, which showed that your heart function is
essentially normal following the heart attack. You had a
low-grade fever, but urine and blood cultures were all negative
and your chest xray did not indicate a pneumonia, your fever
resolved, and you did not need any antibiotics. You were
transferred to the cardiac step down unit, where you continued
to progress, even doing some work with Physical Therapy."
6039,"1, HR 69, BP 172/66, RR 21, SaO2- 100% on 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
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+
."
6040,"Admission Date: [**2187-12-13**] Discharge Date: [**2187-12-16**]
Date of Birth: [**2140-9-8**] Sex: F
Service: NEUROLOGY
Allergies:
Aspirin / Norvasc
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 47 year-old left-handed woman with PMH
significant for myasthenia [**Last Name (un) 2902**], HTN, and DM who presents for
evaluation of increasing shortness of breath over the past month
and difficulty clearing secretions over the past 1-2 weeks. She
says she has noticed increased difficulty breathing over the
past
month, but this has been noticeably worse over the past week."
6041,"With regards to her myasthenia, she was diagnosed in [**2161**]
after
presenting with diplopia and is s/p thymectomy. She has been
treated with Cytoxan, Prednisone and Azathioprine in the past.
Her Neurologist is Dr. [**Last Name (STitle) **] at [**Hospital1 47763**]. She is
currently taking Cellcept [**Pager number **] mg daily and Prednisone 15 mg
daily. The Cellcept was started in [**2178**] for erythema nodosum.
There have been no recent changes to her medications. In the
past, her myasthenic exacerbations have usually been
characterized by either diplopia or severe weakness, but has had
respirartory exacerbations many years ago. Of note, last year,
she was admitted with dyspnea and was diagnosed with
bronchospasm
that was relieved with Albuterol."
6042,"No headache, loss of
vision, blurred vision, diplopia, dysarthria, lightheadedness,
vertigo, tinnitus or hearing difficulty. No difficulties
producing or comprehending speech. No focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention. No
difficulty with gait.
General ROS: Positive for the dyspnea, mucus production and
difficulty with coughing/clearing secretion. No fever or chills.
No chest pain or tightness, palpitations, nausea, vomiting,
diarrhea, constipation or abdominal pain. No dysuria. No rash.
Past Medical History:
Myasthenia [**Last Name (un) 2902**] (diagnosed [**2161**])
- s/p thymectomy
- associated erythema nodosum
Hypertension
History of migraines
Obstructive sleep apnea not on therapy as cannot tolerate mask
GERD
Allergic rhinitis
Evaluated in [**Hospital1 18**] ED with an exercise stress test [**2186-7-7**]; she
achieved [**4-26**] mets and had atypical chest pain with no ECG
changes"
6043,"EKG: Sinus rhythm. Possible left ventricular hypertrophy.
CXR [**12-13**]:
IMPRESSION: Subsegmental atelectasis in the left lung base.
CXR [**12-16**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Status post sternotomy. Mediastinal clips. Borderline
size of the
cardiac silhouette without overt pulmonary edema. Mild
atelectasis at the
left lung bases. No pleural effusions. No parenchymal opacity
suggesting
pneumonia.
Brief Hospital Course:
47 year-old left-handed woman with PMH significant for
myasthenia [**Last Name (un) 2902**], HTN, and DM who presents with increasing
shortness of breath over the past month and difficulty clearing
secretions over the past 1-2 weeks."
6044,"12. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
Myasthenia [**Last Name (un) **] Flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
CN, motor, sensory exam intact
last NIF was -70, last VC was 1 liter
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted because of concern of increasing shortness of
breath and inability to clear sputum, which appeared to be
slowly progressing over the last few months, but worsened over
the last few days before you came to [**Hospital3 **] Hospital."
6045,"Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Mild left postural tremor. No asterixis noted. She has mild
weakness of neck flexors greater than neck extensors, though
there seemed to be giveway component to this (with
encouragement,
strength seemed to improve but still mild weakness noted)
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 5 5 5 5 5 5- 5 5 5 5
R 5 5 5 5 5 5 5- 5 5 5 5
Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout. No extinction to DSS.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
Plantar response was flexor bilaterally."
6046,"5* RBC-4.19* HGB-12.9 HCT-40.7 MCV-97
MCH-30.9 MCHC-31.8 RDW-12.7
[**2187-12-13**] 05:30PM NEUTS-84.9* LYMPHS-11.5* MONOS-2.3 EOS-1.1
BASOS-0.2
[**2187-12-13**] 05:30PM PLT COUNT-360
[**2187-12-13**] 05:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2187-12-13**] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0
LEUK-NEG
[**2187-12-13**] 05:30PM URINE RBC-0 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-3
[**2187-12-13**] 05:30PM URINE MUCOUS-RARE"
6047,"Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. Attentive, able to
name [**Doctor Last Name 1841**] backward without difficulty. Able to follow both
midline
and appendicular commands. No right-left confusion. Able to
register 3 objects and recall [**2-22**] at 5 minutes. No evidence of
apraxia or neglect
Language: Voice is hoarse and sounds as if there is a lot of
mucus in throat when she is trying to speak. Otherwise, speech
is
clear, fluent, nondysarthric with intact naming, repetition and
comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk."
6048,"Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout. No extinction to DSS.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF or HKS bilaterally.
Pertinent Results:
[**2187-12-13**] 05:30PM GLUCOSE-165* UREA N-12 CREAT-0.8 SODIUM-145
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-31 ANION GAP-14
[**2187-12-13**] 05:30PM estGFR-Using this
[**2187-12-13**] 05:30PM IgA-325
[**2187-12-13**] 05:30PM URINE HOURS-RANDOM
[**2187-12-13**] 05:30PM URINE UCG-NEGATIVE
[**2187-12-13**] 05:30PM WBC-12."
6049,"We
discussed these changes with your outpatient neurologsit Dr.
[**Last Name (STitle) **]. Your pulmonary tests improved over the next day and you
were discharged from the intensive care unit. We had another
chest x-ray done and you were discharged home.
Your medications we changed as follows:
Prednisone increased to 40mg daily
Cell - Cept (mycophenolate mofetil) increased to 1000mg [**Hospital1 **]
Mestinon: can take more frequently as needed
You should take all medications as prescribed. Please make all
follow up appointments, particularly with Dr. [**Last Name (STitle) **]. If you
have any concerns about problems breathing, problems swallowing,
problems speaking or weakness, you should call your doctor and
return to the nearest emergency room, as this may represent a
flare.
Followup Instructions:
Please follow up with your outpatient neurologist Dr. [**Last Name (STitle) **],
you have an appointment in [**Month (only) **]. As it is the holiday
weekend the office is currently closed and we cannot confirm
this but it is important that you follow up with him
Please also see your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 8031**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2261**] after
discharge"
6050,"At that time, difficulty with
clearing secretions was not an issue as it is now. She did try
an
Albuterol inhaler earlier this week with little relief, but did
note some improvement with Albuterol nebs at her PCP office
earlier in the week. She tried an Albuterol inhaler today at
home, which did not provide any relief. For her exacerbations,
she takes Mestinon prn along with Atropine. She tried taking 30
mg Mestinon this past weekend, with little effect. She has never
been treated with IVIG or Plasmapheresis in the past.
Neuro ROS: Dysphagia associated with mucus, but cannot rule out
contribution of underlying myasthenia."
6051,"Coordination: No intention tremor or dysmetria on finger-nose,
FNF or HKS bilaterally.
Gait: deferred given dyspnea
Specialized testing: She was able to count up to 5 without
needing to take breath. She was only able to sustain upgaze for
about 15 seconds before needing to look down; no diplopia in the
15 seconds of upgaze. No fatigueability of deltoid strength
after
arm flapping for 30 seconds.
Physical Exam on Discharge:
Vitals: T 97.6 BP 132/60 HR 74 RR 20 O2 100% RA
NIF -70, VC 1L
General: Awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: CTAB
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Skin: no rashes or lesions noted."
6052,"4 mg with mestinon dose
Discharge Medications:
1. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO DAILY (Daily).
2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath.
4. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6."
6053,"Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. Attentive, able to
name [**Doctor Last Name 1841**] backward without difficulty. Able to follow both
midline
and appendicular commands. No right-left confusion. No evidence
of
apraxia or neglect
Language: Voice is somewhat nasal but speech is otherwise speech
is
clear, fluent, nondysarthric with intact naming, repetition and
comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: She is not fully able to bury sclera on abduction
of
either eye, but otherwise EOMI without nystagmus."
6054,"Her Mestinon was
increased to 30mg Q8 and her prednisone was increased to 40mg
daily. She was continued on Cellcept 1g daily. She improved on
this regimen and was transferred to the floor on [**12-15**]. Her
neurologic exam remained stable with mild weakness of eye
closing b/l but full neck flexors/extensors and full strength
throughout.
Respiratory:
Her respiratory status was monitored closely with Q4hr NIF and
VC as well as continuous O2 sat monitoring. Her NIF and VC
steadily improved during her admission and she remained stable
on room air. CXR x 2 were negative for pneumonia."
6055,"As
you have myasthenia [**Last Name (un) 2902**] we were concerned that this
represented a myasthenic crisis. You have had flares of your
myasthenia before but this was the first time you had any
respiratory involvement. Your initial pulmonary funciton tests
were concerning, however after review of you records it seems
that they are not far off your baseline. You were admitted to
the ICU for close monitoring. As you had decreased your
prednisone over time, and were on a once a day dosing of
Cell-cept, we increased the dose of prednisone to 40mg daily,
and increased the dosing of cell-cept to 1000mg [**Hospital1 **]."
6056,"Social History:
She lives with her daughter She does not work. No
smoking, drinking, or illicit drug use.
Family History:
Mother with history of diabetes, migraines and brain
aneurysm. Father deceased with lung cancer. No family history of
myasthenia.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98.2 P: 100 R: 18 BP: 182/108 SaO2: 100% RA
General: Awake, cooperative, continuously trying to clear
secretions
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Skin: no rashes or lesions noted."
6057,"On exam, she appears to be
breathing comfortably, though her voice is somewhat nasal and
seems to be affected by increased mucus and she is notably
having difficulty clearing her secretions. She has mild right
ptosis (though lid not covering pupil) and is unable to close
either eye tightly, which are old findings. There are otherwise
no focal deficits on her exam. Her dyspnea, worse with lying
down and her difficulty clearing secretions are concerning for a
myasthenic crisis.
Neuro:
Her NIF and VC were low on admission (-22 and 850 respectively)
and she was thus admitted to the ICU for close monitoring due to
possible impending respiratory decompensation."
6058,"This is exacerbated by laying flat. Over the past week, she has
noticed it more difficult to either walk or talk. She says over
this time, she also has a lot of phlegm production and is having
difficulty clearing the mucus from her throat; she says ""it
feels
like there is a big glob of mucus in my throat"". She notes
difficulty swallowing because of the mucus that she feels liks
is
stuck in her throat. She does not think she would have
difficulty
swallowing if there was no mucus there. She was able to eat
breakfast and drink liquid today without choking."
6059,"pyridostigmine bromide 60 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours): can decrease frquency of dose if no symptoms
noted.
Disp:*45 Tablet(s)* Refills:*2*
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. atropine 0.4 mg Tablet Sig: One (1) Tablet PO as directed:
can take with mestinon dose.
10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
11. Miralax 17 gram Powder in Packet Sig: One (1) PO twice a
day as needed for constipation."
6060,"VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: She is not fully able to bury sclera on abduction
of
either eye, but otherwise EOMI without nystagmus. Saccadic
intrusions on tracking. There is mild right ptosis, but it does
not cover the pupil. She is unable to fully close her eyes, with
sclera still present bilaterally.
V: Facial sensation intact to light touch.
VII: No facial droop
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."
6061,"-continuous O2 sat monitoring
CV:
She was maintained on tele monitoring throuhgout her admission.
She was continued on her home Losartan for BP control.
GI
She was cleared by speech/swallow for a regular diet with thin
liquids. She was continued on her home Ranitidine given daily
Prednisone use.
Endo
She was continued on her home Glipizide and maintained on
fingersticks ACHS with SSI.
ID
She remained afebrile with no signs of infection during her
admission. CXR was negative for pneumonia.
DVT proph:
She was maintained on hep SQ for DVT prophylaxis.
By [**2187-12-16**] Ms. [**Known lastname **] had improved symptomatically and her
respiratory status had also improved with NIF -70 and VC 1L."
6062,"CXR
was again negative for pneumonia. She was discharged home in
good condition on increased doses of Mestinon 30mg TID and
Prednisone 40mg daily, in addition to Cellcept 1g daily. She has
a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Medications on Admission:
-Glipizide XL 5 mg daily
-Fiorocet prn headache
-Albuterol prn shortness of breath
-Depo-Provera 150 mg IM q12 wk x 4 doses
-Trazodone 50 mg qhs prn insomnia
-Losartan 25 mg daily
-Miralax 17 gm [**Hospital1 **]
-Cellcept [**Pager number **] mg daily
-Prednisone 15 mg daily
-Sucralafate 1 gram 4 times daily
-Ranitidine 150 mg daily
-Fluticasone 110 mcg 2 inh [**Hospital1 **]
-Pyridostigmine 30 mg [**Hospital1 **] (she takes prn for crisis)
-Atropine 0."
6063,"Saccadic
intrusions on tracking. There is mild right ptosis, but it does
not cover the pupil. She is unable to fully close her eyes, with
sclera still present bilaterally.
V: Facial sensation intact to light touch.
VII: No facial droop
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 asterixis noted.
Full strength of neck flexors and extensors.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5"
6064,"2
Hct
32.0
Plt
364
Cr
0.7
TCO2
49
49
47
47
Glucose
193
Other labs: PT / PTT / INR:13.8/25.3/1.2, Ca++:10.0 mg/dL, Mg++:2.1
mg/dL, PO4:4.1 mg/dL
Assessment and Plan
Assessment and Plan: This is a 80 yo female with severe COPD, diastolic
HF, DM II who presented with hypoxia and hypercarbia.
.
# Hypoxia/Hypercarbia: likely in the setting of COPD. Other
possibilities for hypoxia include HF, but clinically does not appear to
be in over HF. PE also possible, but unlikely based on clinical exam."
6065,"Possible causes of worsening COPD include PNA, URI.
- treat CAP with CTX, Azithro ([**5-17**] day 1)
- solumedrol 125 mg Q8H for now; consider transitioning to PO
prednisone in AM
- atrovent nebs q6H and albuterol nebs q2hours PRN
- repeat ABG to assess oxygenation and ventilation off BiPAP
- Continue O2 NC, using BIPAP at 8/8 only as needed and based on ABG
resultes
- f/u sputum cx, f/u blood culture
- goal PaO2 in 70-80s range; attempt to maintain PCO2 <80
- no intubation- discussed with patient and son, both are in agreement
with patient's wishes
.
# Diastolic HF: doesn't seem to be in overt heart failure at this time
- holding home lasix, consider starting 1 day after taking good PO
intake
."
6066,"Chief Complaint:
24 Hour Events:
Maintained on BiPAP with intermittent breaks
Ativan 0.5, then 0.25 for anxiety
NON-INVASIVE VENTILATION - START [**2167-5-17**] 02:00 PM
Allergies:
Sulfa (Sulfonamides)
Unknown;
Levaquin (Oral) (Levofloxacin)
Abdominal pain;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2167-5-17**] 05:20 PM
Lorazepam (Ativan) - [**2167-5-18**] 04:17 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2167-5-18**] 06:00 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
6067,"7
C (98.1
Tcurrent: 36.4
C (97.5
HR: 95 (68 - 107) bpm
BP: 151/65(83) {94/38(56) - 163/79(91)} mmHg
RR: 33 (14 - 35) insp/min
SpO2: 88%
Heart rhythm: SR (Sinus Rhythm)
Height: 62 Inch
Total In:
583 mL
417 mL
PO:
TF:
IVF:
583 mL
417 mL
Blood products:
Total out:
300 mL
150 mL
Urine:
300 mL
150 mL
NG:
Stool:
Drains:
Balance:
283 mL
267 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: Standby
Vt (Spontaneous): 222 (222 - 310) mL
PS : 10 cmH2O
RR (Spontaneous): 22
PEEP: 8 cmH2O
FiO2: 35%
PIP: 19 cmH2O
SpO2: 88%
ABG: 7."
6068,"# DM2: not on home medications; fingersticks here markedly elevated in
the setting of steroids
- insulin SS and QID FS
.
# Depression/Anxiety: cont home antidepressant, hold trazadone and
zolpidem
.
# FEN:
- hold IVF
- replete electrolytes prn
- nutrition c/s to maximize nutrition status
.
# Prophylaxis: Subcutaneous heparin
.
# Access: peripheral IV
.
# Code: DNR/DNI confirmed with patient and son [**Name (NI) **]
.
# Communication: Patient. Son [**Name (NI) **] [**Name (NI) 1362**] [**Telephone/Fax (1) 6008**]
.
# Disposition: case management to screen today for rehab
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2167-5-17**] 02:00 PM
Prophylaxis:
DVT: pneumoboots, SQH
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: DNR/DNI confirmed with son and patient
Disposition:"
6069,"35/81.[**Numeric Identifier **]/77.[**Numeric Identifier **]/40/14
Ve: 4.7 L/min
PaO2 / FiO2: 223
Physical Examination
Gen: Alert, interactive
HEENT: Mucous membranes markedly dry
Chest: distant breath sounds, low volumes, scattered wheezing
Abd: soft, NT, ND
Ext: trace peripheral edema bl LE
Labs / Radiology:
364 K/uL
9.6 g/dL
193 mg/dL
0.7 mg/dL
40 mEq/L
4.5 mEq/L
24 mg/dL
93 mEq/L
141 mEq/L
32.0 %
5.2 K/uL
[image002.jpg]
[**2167-5-17**] 03:15 PM
[**2167-5-17**] 07:15 PM
[**2167-5-17**] 08:15 PM
[**2167-5-17**] 10:50 PM
[**2167-5-18**] 04:10 AM
WBC
5."
6070,"Admission Date: [**2167-5-17**] Discharge Date: [**2167-5-18**]
Date of Birth: [**2087-3-31**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Levaquin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
na
History of Present Illness:
80 yo female with h/o severe COPD (on home O2), diastolic CHF
who presented to ED this AM with severe dyspnea and hypoxia.
She is currently on BiPap therefore history is somewhat limited.
She reports having cough, maybe a fever but didn't check her
temp at home. She states her breathing has gotten worse over
the last few days to about a week or so."
6071,"After about 25 mins of BiPAP, her ABG was 7.27/102/72.
Her FiO2 was decreased to 35% because she was having apneic
episodes, and with that, her repeat ABG was 7.34/79/57. She was
also given steroids and nebs in the ER, then admitted to the
MICU for further management.
.
On the floor, she reports feeling dyspneic, but slightly better.
Past Medical History:
severe COPD - on 2L home O2 FEV1: 0.56 (36%) FEV1/FVC: 48
(71%), refuses steroids
DM-no meds
Recurrent choledocholithiasis, s/p cholecystectomy, s/p ERCP X8
for stone retrieval/stent placement (Dr."
6072,"[**Last Name (STitle) **]
Depression/Anxiety
Severe Right hip arthritis
Aneurysm with cranial clips x2
PVD: [**1-7**] doppler right significant superficial femoral and
tibial artery occlusive disease. On the left, there
is moderate popliteal/tibial arterial occlusive disease.
Diastolic heart failure with acute CHF during previous admission
Rhinitis
Social History:
The patient currently lives at [**Location 10138**] [**Hospital3 **]
facilily. At baseline she is able to walk with a walker, feed
her self, bath and dress herself but has meals prepared for her.
She has two sons involved in her life and care, [**Doctor First Name **] and [**Doctor Last Name **]
but is unable to recall if 1 has been designated HCP, she would
prefer both help with decisions for now."
6073,"Brief Hospital Course:
This is a 80 yo female with severe COPD, diastolic HF, who
presents with hypoxia and hypercarbia
# Hypoxia/Hypercarbia: COPD exacurbation. Possible causes of
worsening COPD include PNA, URI. Also anxiety plays a big role
in her exacurbations. We treated her with nebs, CTX and
Azithromycin. Also she was given stress dose solumedrol and
transition to prednisone po with 15 day [**Doctor Last Name 2949**]. Ativan was given
every 8 hrs as needed. Initially she was placed on BiPAP but
was able to be weaned from this device. She is a baseline CO2
retainer and her oxygenation goal should be Sat 88-92%."
6074,"35
calTCO2-47* Base XS-14
[**2167-5-17**] 08:15PM BLOOD Type-ART pO2-69* pCO2-84* pH-7.34*
calTCO2-47* Base XS-15
[**2167-5-17**] 07:15PM BLOOD Type-ART Temp-37.7 O2 Flow-3 pO2-62*
pCO2-93* pH-7.31* calTCO2-49* Base XS-15 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2167-5-17**] 03:15PM BLOOD Type-ART Temp-37.8 FiO2-35 pO2-60*
pCO2-88* pH-7.33* calTCO2-49* Base XS-15 Intubat-NOT INTUBA
Comment-BIPAP 5/5
[**2167-5-17**] 12:18PM BLOOD Rates-/35 Tidal V-400 PEEP-5 FiO2-35
pO2-57* pCO2-79* pH-7."
6075,"34* calTCO2-44* Base XS-12 Intubat-NOT
INTUBA
[**2167-5-17**] 11:34AM BLOOD Type-ART Rates-/39 Tidal V-350 FiO2-35
pO2-72* pCO2-102* pH-7.27* calTCO2-49* Base XS-15 Intubat-NOT
INTUBA
[**2167-5-17**] 11:15AM BLOOD Lactate-1.6
[**2167-5-18**] 11:52AM BLOOD Lactate-0.7
CXR
[**2167-5-18**]
In comparison with the study of [**5-17**], there is some increasing
opacification at the left base consistent with atelectasis or
supervening
pneumonia. Hyperexpansion of the lungs is again suggestive of
chronic
pulmonary disease. Small bilateral pleural effusions are again
seen."
6076,"Sputum
and blood cultures were sent and were ngtd on discharge. The
patient is DNR/DNI.
# Diastolic HF: No evidence of CHF exacurbation on this
admissin. We continued home dose lasix.
# DM2: not on home medications; fingersticks here markedly
elevated in the setting of steroid use. We placed her on insulin
sliding scale which should be continued until steroid [**Last Name (un) 10128**] is
completed.
# Depression/Anxiety: continued home meds
Medications on Admission:
Avair diskus 2 pufs daily
COlace 100 mg daily
Combivent 2 puffs QID
Cymbalta 60 mg daily
Duoneb PRN
Fluticasone [**1-2**] sprays 50 mcg
Lasix 20 mg daily
MVI"
6077,"Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7."
6078,"Tobacco: 2 PPD x 40 years, quit many years ago
ETOH: None
Illicits: None
Family History:
Sons are healthy. No pulmonary disease, no h/o recurrent GB
stones per pt.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
[**2167-5-18**] 04:10AM BLOOD WBC-5."
6079,"Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-2**] Inhalation Q3H (every 3 hours).
12. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 6 days."
6080,"18. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
COPD exacurbation
Discharge Condition:
Good, Sa O2 92% 2 lt, comfortable
goal SaO2 88-92%
Discharge Instructions:
You were admited with worsening of your COPD. We treated you
with antibiotics, nebulizer treatments and steroids.
Please call your regular doctor or return to the ED if you have
shortness of breath, chest pain, palpitations, wheezing worsened
edema or any other concerns
Followup Instructions:
Please follow up with your regular doctor within 10 days.
[**Last Name (LF) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 2205**]
Completed by:[**2167-5-18**]"
6081,"She also reports
having some mild lower extremity edema. She has been having
some chest tightness as well. She denies any other symptoms.
She has been taking her nebs, but otherwise feels she was
getting worse.
.
In the ED, initial vs were: T 98.4 P 113 BP 138/46 R O2 sat.
Patient was given CTX and azithromycin in the ER for ? PNA on
CXR. Her initial O2 sat was unable to be read in triage, then
in the room, was in the low 80s, and improved to 92% on NRB.
Given that she had barely any air movement, she was started on
BiPAP."
6082,"[**2167-5-17**]
Within that limitation, there is suggestion of a left basilar
opacity. Small
bilateral pleural effusions are new compared to [**2167-4-15**].
Calcified granulomas
in bilateral lungs are unchanged. The lungs are hyperinflated,
as before. The
cardiomediastinal silhouette, hilar contours, and pulmonary
vasculature are
not significantly changed. Osseous structures are grossly
unchanged including
the old right clavicular fracture and loss of height in mid
thoracic vertebral
body.
IMPRESSION: Limited study as above. Left basilar opacity
suggested
which may represent atelectasis versus pneumonia. There are
small bilateral
pleural effusions, new since [**2167-4-15**]. If feasible, consider PA
and lateral
views in the radiology suite for more sensitive evaluation."
6083,"3 INR(PT)-1.2*
[**2167-5-17**] 11:00AM BLOOD Plt Smr-NORMAL Plt Ct-336
[**2167-5-18**] 04:10AM BLOOD Glucose-193* UreaN-24* Creat-0.7 Na-141
K-4.5 Cl-93* HCO3-40* AnGap-13
[**2167-5-17**] 11:00AM BLOOD Glucose-302* UreaN-21* Creat-0.8 Na-136
K-4.4 Cl-88* HCO3-39* AnGap-13
[**2167-5-18**] 11:52AM BLOOD Type-ART pO2-83* pCO2-91* pH-7.30*
calTCO2-47* Base XS-14 Intubat-NOT INTUBA
[**2167-5-17**] 10:50PM BLOOD Type-ART pO2-78* pCO2-81* pH-7."
6084,"13. Prednisone 10 mg Tablet Sig: ASDIR Tablet PO once a day for
15 days: 60 mg for 3 days, 40 mg for 3 days, 20 mg for 3 days,
10 mg for 3 days,
5 mg for 3 days, then off.
14. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO three times a day
as needed for anxiety.
15. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
16. Fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
Inhalation twice a day.
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day."
6085,"2 RBC-3.82* Hgb-9.6* Hct-32.0*
MCV-84 MCH-25.1* MCHC-29.9* RDW-15.0 Plt Ct-364
[**2167-5-17**] 11:00AM BLOOD WBC-7.3 RBC-3.91* Hgb-9.9* Hct-31.7*
MCV-81* MCH-25.3* MCHC-31.1 RDW-15.7* Plt Ct-336
[**2167-5-17**] 11:00AM BLOOD Neuts-73* Bands-16* Lymphs-7* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2167-5-18**] 04:10AM BLOOD Plt Ct-364
[**2167-5-18**] 04:10AM BLOOD PT-13.8* PTT-25."
6086,"Admission Date: [**2186-1-15**] Discharge Date: [**2186-1-17**]
Date of Birth: [**2141-2-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
2 episodes of syncope in the setting of BRBPR s/p colonoscopy
with 2 hot snare polypectomies 5 days ago
Major Surgical or Invasive Procedure:
Colonoscopy [**2185-1-16**]
History of Present Illness:
This is a 44 year old otherwise healthy male who is presenting
for evaluation of 2 episodes of syncope in the setting of BRBPR
5 days after having a colonoscopy with 2 hot snare
polypectomies."
6087,"The patient does not recall his syncopal
episodes, but his wife was present to witness them. She said
that he had multiple, brief syncopal episodes that occurred
around 12:30 AM in the setting of a large bloody bowel movement.
He remembers feeling lightheaded and dizzy, but does not
acutally remember passing out. His wife says that he fell into
her arms but did not injure himself.
The indication for the patient's colonoscopy on [**1-10**] was that
he was intermittently having blood coating his stools. He was
found to have a 6mm sessile polyp in his cecum and an 8mm
pedunculated polyp in his sigmoid which were both completely
removed with hot snare polypectomy."
6088,"2. It is likely
that the patient has thalassemia. Iron studies were sent and
showed ferritin 299 (normal), iron level 49 (normal), TIBC 243
(low), and transferrin 187 (low).
Medications on Admission:
Vitamin D 3000 units daily
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 7.5 Tablets
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleeding
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, Hct 31, without pain or active bleeding,
tolerating po diet and medications.
Discharge Instructions:
You were transferred to our hospital after experiencing large
amounts of blood in your stools. A colonoscopy was performed to
evaluate the source of the bleeding."
6089,"The patient did have 1
episode of nausea and vomiting immediately after his
colonoscopy, but otherwise did well until 5:30 PM on [**2186-1-14**] when
he began to have BRBPR. He had a total of [**7-21**] episodes of
watery, BRBPR before reporting to an OSH where his Hct was
measured to be 37. He was transferred to [**Hospital1 18**] because his
original GI procedure took place here and his Hct upon arrival
had fallen to 31.7. He has not had any further BRBPR since
arriving at [**Hospital1 18**].
.
In the ED, initial vs were: T=98."
6090,"On the floor, the patient appeared well and has not yet had any
bowel movements since arriving to [**Hospital1 18**]. He denies any fevers,
chills, or abdominal pain.
.
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, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
-atopic eczema
-s/p colonoscopy [**2186-1-10**] with removal of 2 adenomatous polyps
(6mm sessile polyp at the cecum and 8mm pedunculated polyp at
sigmoid)"
6091,"Pertinent Results:
[**2186-1-15**] 02:45AM BLOOD WBC-9.7# RBC-4.67# Hgb-9.8*# Hct-31.7*#
MCV-68* MCH-21.0* MCHC-31.0 RDW-14.2 Plt Ct-214
[**2186-1-15**] 02:45AM BLOOD Neuts-83.5* Lymphs-11.6* Monos-3.4
Eos-1.2 Baso-0.2
[**2186-1-15**] 02:45AM BLOOD Glucose-119* UreaN-22* Creat-1.2 Na-141
K-4.7 Cl-109* HCO3-26 AnGap-11
[**2186-1-15**] 02:45AM BLOOD calTIBC-243* Ferritn-299 TRF-187*
HCT trend:
[**2186-1-17**] 07:25AM BLOOD WBC-6."
6092,"You were found to be
bleeding from the sites of your recent biopsies. Clips were
placed over the bleeding vessels and you had no further episodes
of bleeding. You were monitored closely overnight. Your vital
signs and blood counts remained stable and you were discharged
home.
.
No changes were made to your home medications. Please continue
all home medications as previously prescribed.
Followup Instructions:
Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] at the [**Hospital1 **] [**Last Name (Titles) 516**] at [**Telephone/Fax (1) 7703**] to schedule follow
up in the next few weeks.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2186-1-18**]"
6093,"No active
bleeding noted. (endoclip)Cecal polypectomy site clean based
with red spot suggestive of visible vessel. No active bleeding.
(endoclip)
Otherwise normal colonoscopy to cecum
Recommendations: Likely post polypectomy bleed from cecal and
sigmoid colon polypectomy site. S/p endoclip to each ulcerative
area x 2. Please remain in ICU, clear fluids, trend hct. No MRI
x 1 month.
Brief Hospital Course:
This is a 44 year old otherwise healthy male who is presenting
for evaluation of 2 episodes of syncope in the setting of BRBPR
5 days after having a colonoscopy with 2 hot snare polypectomies
admitted to the ICU for concern of post-polypectomy bleeding."
6094,"9 RBC-4.61 Hgb-9.8* Hct-31.0*
MCV-67* MCH-21.3* MCHC-31.7 RDW-14.2 Plt Ct-212
[**2186-1-16**] 09:25PM BLOOD Hct-32.3*
[**2186-1-16**] 04:00AM BLOOD WBC-6.3 RBC-4.89 Hgb-10.2* Hct-32.0*
MCV-65* MCH-20.8* MCHC-31.9 RDW-14.4 Plt Ct-230
[**2186-1-15**] 08:15PM BLOOD Hct-31.0*
[**2186-1-15**] 01:26PM BLOOD Hct-33.6*
[**2186-1-15**] 05:20AM BLOOD Hct-30.6*
Colonoscopy [**2186-1-15**]:
Impression: Sigmoid colon polypectomy site visualized with clean
base but with red spot suggestive of visible vessel."
6095,"2, P=76, BP=106/65, RR=16, O2
sat=100%. In general the patient appeared well and his exam was
benign. He did not report any abdominal pain, fevers, or chills.
His Hct fell to 31.7 from 37 at the OSH but he did not have any
further episodes of BRBPR. His coags were normal. Two 18 gauge
peripheral IVs were placed for access and he was cross matched
for 2 units of blood but not transfused. He was given 2L of NS
boluses and GI and surgery were contact[**Name (NI) **] regarding his
admission. Upon transfer to the floor, his VS were P=78,
BP=107/66, RR=19, and POx=100% 2L
."
6096,".
#. Post-polypectomy GI bleed. The patient is presenting with
BRBPR 5 days following colonoscopy with removal of 2 adenomatous
polyps. GI performed colonoscopy to evaluate for
post-polypectomy bleed which showed sigmoid colon polypectomy
sites visualized with clean base but with red spot suggestive of
visible vessels which were endoclipped. Hct was trended closely
after the procedure, and remained stable around 32 for 48 hours
prior to floor transfer on [**1-16**] and for the remainder of his
hospitalization. He was tolerating a normal diet prior to
discharge.
.
#. Microcytic anemia. The patient's MCV has consistently been 68
even dating back to [**2183**] when his Hct was 45."
6097,"Social History:
The patient lives at home with his wife and 4 kids. He is a
non-smoker and does not drink any EtOH. He works as a software
engineer at [**Company **] Systems.
Family History:
The patient has a maternal uncle with liver cancer and both of
his parents have HTN. No family history of thalassemia that he
is aware of.
Physical Exam:
Vitals: T: 98.9, BP: 126/73, P: 79, R: 13, O2: 100% 3L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox3, CN II-XII intact, motor strength and sensory
grossly equal and intact bilaterally"
6098,"Admission Date: [**2179-7-26**] Discharge Date: [**2179-7-27**]
Date of Birth: [**2134-12-1**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for R paraclinoid aneurysm
Major Surgical or Invasive Procedure:
[**2179-7-26**]: Cerebral angiogram with a stent assisted coiling
History of Present Illness:
44M who had a surveillance MRI/MRA after his sister was treated
for a aneurysm. The MRA showed a R paraclinoid aneurysm. He
underwent a angiogram in [**Month (only) 116**] which confirmed the R paraclinoid
aneurysm measuring about 4x3mm. He was given the option to watch
with serial imaging vs."
6099,"oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. therapeutic multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Right paraclinoid aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?"
6100,"Physical Exam:
Pre-operatively:
Nonfocal exam. MAE [**5-20**].
Upon discharge:
xxxxxxxxxxx
Pertinent Results:
[**2179-7-26**] 12:35PM GLUCOSE-95 UREA N-15 CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14
[**2179-7-26**] 12:35PM estGFR-Using this
[**2179-7-26**] 12:35PM WBC-6.5 RBC-4.66 HGB-15.3 HCT-40.8 MCV-88
MCH-32.9* MCHC-37.5* RDW-13.3
[**2179-7-26**] 12:35PM PLT COUNT-253
Brief Hospital Course:
44M elective admission for a stent assisted coiling of a R
paraclinoid aneurysm."
6101,"????? Take Aspirin 325mg (enteric coated) once daily. *****
?????? Take Plavix (Clopidogrel) 75mg once daily for 30 days. ******
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?"
6102,"????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?"
6103,"Post-angio, he was admitted to the ICU for
observation, he was placed on Heparin drip overnight. He had no
complications overnight, his Heparin drip was discontinued.
Neurologically he was intact on day of discharge. He tolerated a
regular diet and was voiding without difficulty.
Medications on Admission:
Claritin
MVI
Plavix for 5 days as prescribed
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain/fever.
2. docusate sodium 100 mg Capsule Sig: [**1-17**] Capsules PO BID (2
times a day): use while taking oxycodone.
Disp:*30 Capsule(s)* Refills:*0*
3."
6104,"????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a MRI/MRA Brain
+/- ([**Doctor Last Name **] Protocol). Please call Takeisha at [**Telephone/Fax (1) 4296**] to
make this appointment.
Completed by:[**2179-7-27**]"
6105,"a stent assisted coiling. Given his
young age and his profession as a pilot in the military and
commercial airline it was decided to treat now.
Past Medical History:
No significant PMH noted. Hx of wisdom teeth extraction.
Social History:
He does not use tobacco or alcohol. He works in the US Air
Force as a reserve and also has a regular job as a pilot in USA
with American Airlines. He is married and has a young son.
Family History:
Sister was diagnosed and treated for a unruptured aneurysm.
There is also a history of another family memeber with an
aneurysm."
6106,"PREOPERATIVE DIAGNOSIS: Right paraclinoid aneurysm of the internal carotid
artery.
PROCEDURE PERFORMED: Coil embolization of right paraclinoid aneurysm with
target coils assisted by Neuroform stent 4.5 x 20 mm EZ stent. Right common
femoral artery arteriogram and Angio-Seal closure of right common femoral
artery puncture site.
DETAILS OF PROCEDURE:
The patient was brought to the angiography suite. IV sedation was given.
Following this, both groins were prepped and draped in a sterile fashion.
Access was gained to the right common femoral artery using a Seldinger
technique and a 6 French vascular sheath was placed in the right common
femoral artery."
6107,"We now catheterized the right internal carotid artery with a
[**Doctor Last Name 586**] 2 catheter and the [**Doctor Last Name 586**] 2 catheter was exchanged over an exchange
length glidewire for a Neuron 6 French catheter. Following this, the patient
was fully anticoagulated to maintain an ACT close to 250. We now passed a
Marksman catheter over a Synchro wire into the right middle cerebral artery.
Through this, a Neuroform EZ 4.5 x 20 mm stent was deployed across the neck of
the paraclinoid aneurysm. The Marksman catheter was removed and the aneurysm
was recatheterized through the cells of the Neuroform stent using an SL-10
microcatheter and a Synchro wire."
6108,"[**2179-7-26**] 3:04 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 41713**]
Reason: Stent assisted coiling via cerebral angiogram Anesthesia has
Contrast: OPTIRAY Amt: 128
********************************* CPT Codes ********************************
* [**Numeric Identifier 284**] EMBO TRANSCRANIAL [**Numeric Identifier 285**] SEL CATH 3RD ORDER [**Last Name (un) 286**] *
* -51 MULTI-PROCEDURE SAME DAY [**Numeric Identifier 304**] CAROTID/CEREBRAL UNILAT *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 43**] TRANSCATH EMBO THERAPY *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
44 year old man with known aneurysm
REASON FOR THIS EXAMINATION:
Stent assisted coiling via cerebral angiogram Anesthesia has been booked for
[**7-26**] on waitlist
______________________________________________________________________________
FINAL REPORT
DATE OF SERVICE: [**2179-7-26**]."
6109,"The aneurysm was coiled starting with a
3-mm 360 UltraSoft Target coil, followed by 2 mm coil. Followed this, the
aneurysm was completely obliterated. The ophthalmic artery was seen to be
patent. Right common femoral artery arteriogram was done and a 6 French
Angio-Seal was used for closure of the right common femoral artery puncture
site. The patient tolerated the procedure well and was neurologically intact
at the end of the procedure.
FINDINGS:
Right internal carotid artery arteriogram demonstrates a 4-mm aneurysm
projecting laterally from the paraclinoid segment at the level of the
(Over)
[**2179-7-26**] 3:04 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 41713**]
Reason: Stent assisted coiling via cerebral angiogram Anesthesia has
Contrast: OPTIRAY Amt: 128
______________________________________________________________________________
FINAL REPORT
(Cont)
ophthalmic artery.
Right internal carotid artery arteriogram status post stenting and coiling
demonstrates that the internal carotid artery is patent in the cavernous and
supraclinoid portion. There is no stenosis secondary to stent placement, the
aneurysm is completely obliterated by a coil mass. The ophthalmic artery is
patent.
Right common femoral artery arteriogram shows widely patent right common
femoral artery.
IMPRESSION:
[**Known firstname **] [**First Name8 (NamePattern2) 1247**] [**Known lastname 1560**] underwent cerebral angiography, which revealed a right
paraclinoid aneurysm measuring 4 mm which was coiled with the assistance of a
Neuroform stent. The procedure was uneventful."
6110,"Admission Date: [**2171-7-10**] Discharge Date: [**2171-7-18**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 86897**]
Chief Complaint:
lower extremity erythema, hypotension, fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. [**Known lastname **] is an 88yoM with a history of AML (s/p 10 cycles
azacitadine), bladder cancer s/p transurethral resection, atrial
fibrillation, chronic left lower extremity osteomyelitis from a
shrapnel injury in WWII, and possible venous thromboembolism who
was referred to the ED by his rehab center for increasing
erythema of the left lower extremity.
.
He has a very longstanding history of left lower extremity osteo
with a chronic wound draining purulent discharge ever since he
sustained a shrapnel injury in [**Country 6171**] in a WWII explosion."
6111,"LLE tib-fib
films showed chronic osteomyelitis without subcutaneous gas, and
a CXR showed stable bilateral effusions from earlier this month.
He received 2g cefepime and 1g vancomycin. He had an elevated
lactate to 3.5 that corrected with fluids to 2.0. Blood cultures
drawn prior to antibiotics. Given his hypotension, he was
admitted to the [**Hospital Unit Name 153**] for possible sepsis.
.
Upon transfer to the ICU, his initial vitals were T98.1 BP94/54
P58 RR17 Sat94/4LNC. He is comfortable and in no acute
distress. He denies any increased pain or fevers recently. He
has intermittent shortness of breath, and notes that he
sometimes is on oxygen at the nursing home."
6112,"[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 63724**] with [**Hospital1 **] in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**]).
-AML diagnosed (care by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] at [**Location (un) **]) [**8-/2170**],
[**9-/2170**] started azacytidine, now s/p 10 cycles, most recent dose
[**2171-6-3**].
-atrial fibrillation, rate controlled on fundaparinux
-HTN
-Chronic left lower ext ulcer with osteomyelitis and cellulitis
s/p shrapnel injury in WWII
- Barrett's esophagus
- Low back pain
- Venous thromboembolism?
Social History:
Lives with wife. Professor emeritus in neuroscience at [**University/College **]
Med and [**Hospital 1191**] hospital. Denies smoking. Seven drinks per week."
6113,"# LEFT LOWER EXTREMITY CELLULITIS: Likely port of entry was
non-healing chronic ulcer in left lower extremity. He was
treated with intravenous vancomycin and cefepime starting [**2171-7-10**]
and will continue until follow up appointment with infectious
disease on [**2171-8-1**]. At that point it will be determined if IV
antibiotics can be stopped and whether oral suppressive
antibiotics need to be started. His erythema and edema improved
over the course of his stay. PICC line was placed [**2171-7-17**] and
can be removed once IV antibiotics are finished. Once IV
antibiotics are finished, he will start on oral suppressive
antibiotics for chronic osteomyelitis."
6114,"# HYPOTENSION: Initial systolic blood pressure 80-90's prompted
ICU admission, he received intravenous fluids and improved. His
furosemide was restarted on [**2171-7-10**], however his
antihypertensives were held. Note recent blood pressures prior
to admission have been low, so there is a question of whether
SBP 90-100 is his baseline.
# HYPOXIA: Resolved spontaneously, suspected atelectasis and
mild pulmonary edema. No pneumonia was seen on CXR. Lasix was
resumed [**2171-7-13**] once blood pressure was deemed stable.
# ACUTE RENAL FAILURE: Pre-renal secondary to infection and
hypotension, resolved with intravenous fluids.
# AML: Azacytidine was held during admission, but may be
resumed as an outpatient by Dr."
6115,"19. Outpatient Lab Work
Please check daily CBC with differential for 3 days to monitor
his hematocrit, white blood cell count, and absolute neutrophil
count. Please fax results to [**Last Name (un) **] [**Doctor Last Name 2405**] [**Telephone/Fax (1) 6808**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]
Discharge Diagnosis:
Left lower extremity cellulitis
Septic shock
Acute renal failure
Chronic left lower extremity osteomyelitis
Acute myelogenous leukemia
Anemia
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because of swelling and redness in your
left lower leg which was diagnosed as cellulitis (infection of
the soft tissues)."
6116,"C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
8. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
BID (2 times a day).
9. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day."
6117,"It was a pleasure caring for you. We wish you a speedy
recovery.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) 2405**]
[**7-29**] at 2:00pm
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
Fax: [**Telephone/Fax (1) 6808**]
Department: INFECTIOUS DISEASE
When: THURSDAY [**2171-8-1**] at 2:50 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 86898**]
Completed by:[**2171-7-18**]"
6118,"9. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Four
Hundred (400) mg PO BID (2 times a day).
10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
11. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day) as needed for constipation.
12. Ocuvite Oral
13. Multivitamin
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E."
6119,"You had low blood pressure which responded
to intravenous fluids. You were placed on intravenous
antibiotics and improved. You will continue to take intravenous
antibiotics until your follow up infectious disease appointment
on [**2171-8-1**] at which time it will be determined whether you will
need more antibiotics. Please elevate your leg daily to
decrease the swelling.
We made the following changes to your medications:
- START vancomycin 1 gram every 24 hours until ID appointment on
[**2171-8-1**]
- START cefepime 2grams every 24 hours until ID appointment on
[**2171-8-1**]
- START oxycontin 10mg twice daily for pain
- START sarna lotion as needed for itching"
6120,"2. fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily)."
6121,"No ilicits.
Family History:
Denies history of malignancy.
Non-contributory
Physical Exam:
Vitals: T98.1 BP94/54 P58 RR17 Sat94/4LNC
General: alert and oriented x3, NAD
HEENT: Sclera anicteric, very dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at the bases, R>L, otherwise clear to
auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM at the
second RICS without radiation, second SEM at the apex with
radiation to the axilla.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: The left lower extremity has a 3cmx1cm open wound with
purulent necrotic discharge at the level of the tibial
tuberosity."
6122,"Note 1/2 blood cultures
grew Staph coag negative (sensitive to oxacillin and
tetracycline), presumed to be a contaminant rather than actual
bacteremia. Echocardiogram was deferred due to lack of
suspicion for endocarditis and MRI leg was not pursued due to
clinical improvement on antibiotics and patient resistance to
surgical debridement. His chronic non-healing ulcer/chronic
osteomyelitis of his left lower extremity is stable in size and
without exudate. Note weekly labs should be checked including
CBC with diff, chem 7, vanco trough and LFTs and faxed to
infectious disease. Additionally, vanco trough will need to be
checked on [**2171-7-20**], goal trough is 15-20."
6123,"4* Na-142
K-4.5 Cl-106 HCO3-25 AnGap-16
[**2171-7-10**] 11:49AM BLOOD Lactate-3.5*
[**2171-7-10**] 02:30PM BLOOD Lactate-2.0
[**2171-7-10**] 11:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2171-7-10**] 11:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Labs upon discharge:
***********
Microbiology
[**2171-7-10**]: 1/2 bottles of blood culture: Staph coag negative,
sensitivities pending
[**2171-7-11**]: blood culture: no growth to date (preliminary)
[**2171-7-12**]: Feces negative for C."
6124,"10. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
three times a day as needed for constipation.
11. Ocuvite Tablet Sig: One (1) Tablet PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Outpatient Lab Work
Please check vancomycin trough on Saturday [**2171-7-20**] Please fax
results to [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **] Infectious Disease at [**Telephone/Fax (1) 1419**].
Please check labs weekly CBC with differential, chem 7, LFTS and
vancomycin trough, while on intravenous antibiotics. Please fax
results to [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **] Infectious disease at FAX [**Telephone/Fax (1) 1419**]"
6125,"The entire distal extremity is warm, erythematous
with 2+ pitting edema that is tender to touch. No other portals
of entry noted. Pulses 2+. Unaffected extremity is warm and
well purfused.
NEURO: CNII-XII intact bilaterally, strength 5/5 throughout, no
sensory limitations to soft touch.
Labs: see below
Pertinent Results:
Labs upon admission:
[**2171-7-10**] 11:40AM BLOOD WBC-3.2* RBC-2.97* Hgb-10.0* Hct-29.5*
MCV-100*# MCH-33.6* MCHC-33.8 RDW-26.3* Plt Ct-174#
[**2171-7-10**] 11:40AM BLOOD Neuts-46* Bands-2 Lymphs-27 Monos-12*
Eos-2 Baso-0 Atyps-2* Metas-6* Myelos-3*
[**2171-7-10**] 11:40AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
[**2171-7-10**] 11:40AM BLOOD Glucose-127* UreaN-31* Creat-1."
6126,"He has been a
resident there for about 2 weeks, and is rehabbing from a recent
pneumonia. He has no coughing or sputum production, however. Of
note, he is in the midst of a azacitidine cycle for his AML,
which was diagnosed in [**2170**]. He saw his oncologist yesterday,
who's note details a pressure of 94/64.
.
On review of systems, he denies confusion, weakness, fevers,
chills, sore throat, coughing, chest pain, abdominal pain,
nausea, vomiting, diarrhea, bloody stools, black stools,
dysuria, hematuria, myalgias, arthralgias.
Past Medical History:
-Bladder Ca dxed [**2170-8-9**] s/p transurethral surgery (care by
Dr."
6127,"[**First Name (STitle) 2405**]. His hematocrit was 24
for several days of admission. We gave 1 unit PRBC on [**2171-7-17**]
and another 1 unit PRBC on [**2171-7-18**]. He was mildly neutropenic on
the day of discharge (ANC 961), but he was afebrile. His CBC
and ANC should be monitored daily for 3 days upon discharge.
His other medical problems were managed with his home
medications without complications. He was FULL CODE for this
admission.
Medications on Admission:
from recent d/c summary and rehab list
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
6128,"14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): please continue until
appointment with ID on [**2171-8-1**].
15. cefepime 2 gram Recon Soln Sig: One (1) Intravenous q24H:
please continue until appointment with ID on [**2171-8-1**].
16. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis."
6129,"He
denies any significant change in this condition recently, but
his wife notes increasing swelling and erythema of the extremity
over the past few days. He had been rehabbing from an early-[**Month (only) 116**]
hospitalization for multifocal pneumonia for which he received a
course of CTX/Azithro, and was referred to the ED this morning
when he became febrile to 104.
.
In the ED, initial vs were: 99.2 83 115/59 18 92% RA. He was
noted to be hypotensive to the 80s-90s, and received 2 L of NS
with stabilization of pressures to the low 90s."
6130,"difficile toxin A & B by EIA.
Imaging:
Tib/fib X-ray [**2171-7-10**]: FINDINGS: In comparison with the study of
[**9-13**], there is little overall change. Areas of sclerosis and
lucency with periosteal reaction is consistent with chronic
osteomyelitis. Deformity of the adjacent fibula is seen with
substantial resorption at its proximal aspect. No definite
evidence of gas within soft tissues.
CXR [**2171-7-10**]: IMPRESSION: Little change except possibly for some
small increase in left effusion.
Brief Hospital Course:
Dr. [**Known lastname **] is an 88yoM with AML, h/o bladder cancer, chronic LLE
osteomyelitis, HTN, Afib who presented with lower extremity
cellulitis and septic hypotension."
6131,"TITLE: Physician Resident Admission Note
Chief Complaint: s/p fall
HPI:
85 yo F with HTN, polymyalgia rheumatica, transferred from [**Hospital1 1**]
[**Location (un) 78**] for cardiac catheterization. The patient was in her usual state
of health until Wednesday [**2-11**], when she developed black diarrhea,
occuring 5 times daily. The patient attributes the black color to her
iron supplements. Along with diarrhea, the patient also experienced 2
episodes of vomiting (clear, no blood or coffee grounds). The patient
also had fever to as high as 100.6 on Friday [**2-13**] and Saturday [**2-14**].
.
On Sunday [**2-15**], the patient became lightheaded when getting up from the
toilet and fell, hitting her head and right elbow."
6132,"# Acute on chronic diastolic congestive heart failure/worsened mitral
regurgitation: Echo shows new focal wall motion abnormalities and
worsened MR, likely of ischemic etiology. Currently hypervolemic.
-BP control/afterload reduction with beta blocker, amlodipine
-evaluation for CABG/MVR
-supplemental O2
-diurese with Lasix IV
-TEE in a.m. for better look at mitral valve
.
# Afib: Chronic, not on anticoagulation.
-telemetry
-K>4, Mg>2
-metoprolol for rate control
.
# Chronic kidney disease: Creatinine at baseline 1.5.
-renally dose meds
-avoid nephrotoxins
-trend creatinine
.
# Diarrhea: Concerning for infectious etiology in setting of recent
fever/chills. Ddx includes gut ischemia or gut edema from CHF.
-stool cultures; C. diff
-monitor fluid status
.
# Polymyalgia rheumatica:
-continue prednisone at home dose
.
# Anxiety/Depression:
-continue nortriptaline and Zyprexa at home dose
ICU Care
Nutrition: Low-Na diet. NPO after midnight for TEE.
Glycemic Control:
Lines: PIV's
Prophylaxis:
DVT: heparin SC
Stress ulcer:
VAP:
Comments:
Communication: Comments: healthcare proxy is son [**Name (NI) 821**] [**Name (NI) 1080**]
([**Telephone/Fax (1) 11577**]
Code status: DNR/DNI, confirmed with patient
Disposition: CCU for now"
6133,"No syncope. The patient reports a
recent decrease in exercise toelrance from 100 feet on a flat surface
to 50 feet on a flat surface.
Allergies:
Demerol (Oral) (Meperidine Hcl)
Nausea/Vomiting
Morphine
Nausea/Vomiting
Hydrocodone
Nausea/Vomiting
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2161-2-16**] 10:15 PM
Furosemide (Lasix) - [**2161-2-16**] 10:15 PM
Meds on admission:
Ativan 0.5 mg daily PRN
Tylenol 650 mg Q4H PRN
Prochlorperidzine 10 mg Q6H PRN
Lidoderm 5% patch apply to left hip for 12 hours on 12 hours off
Norvasc 5 mg daily
Prilosec 20 mg daily
Nortriptyline 10 mg daily
Metoprolol ER 100 mg daily
Vitamin D 50,000 units weekly for 4 weeks, then monthy
prednisone 10 mg daily
Drisdol once a month
ferrous sulfate 325 mg [**Hospital1 **]
Tylenol 1000 mg PO BID
Calcium carbonate 500 mg TID
acidophilus 1 capsule [**Hospital1 **]
Zyprexa 5 mg daily
Trazodone 12."
6134,"At rest,
the left ventricular ejection fraction is 62%. At pharmacologic
stress, the left ventricular ejection fraction is 63%, which is within
normal limits. No significant regional wall motion abnormality is
seen.
1. No evidence of focal jeopardized myocardium as described above.
2. Normal left ventricular ejection fraction of 63% without significant
regional wall motion abnormality at stress.
.
CARDIAC CATH: [**2161-2-16**]
Right dominant
LM: distal calcified 30%
LAD: diffuse disease throughout to serial 60% lesions just before
major D4 with distal 85%; apical 80%; septal collaterals to RPDA
LCx: tortuous prox with slow flow, OM prox 50% with tortuous upper
pole of OM with mild diffuse disease in AV groove Cx and lower pole of
OM with distal AV groove Cx supplying collaterals to the distal
RCA system
RCA:ostial 40% withous pressure dampening; prox diffuse disease
to 75%; distal diffuse dz before RPDA to 45%; moderate diffuse dz
throughout RPDA with severe diffuse dz in the distal AV groove
RCA supplying the RPLs with slow flow
."
6135,"She was transferred to the CCU
on a non-rebreather for further management. In the CCU, the patient was
weaned to a non-rebreather. She reported that her breathing was
improved and had no other complaints.
.
On review of systems, she denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, cough, hemoptysis, or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. She denies sore throat, sinus
congestion, dysuria. She denies weakness, tingling, or numbness. All of
the other review of systems were negative.
.
Cardiac review of systems is notable for chest pain and lightheadedness
as above and two pillow orthopnea."
6136,"5 BP=129/54 HR=69 RR=18 O2 sat=96%/6L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were
unlabored, no accessory muscle use. CTA anteriorly (could not sit up
due to recent cath).
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
Labs / Radiology
300 K/uL
9."
6137,"The prevertebral soft tissue thickness
ismaintained. There is osteopenia. IMPRESSION: NO FRACTURE. OTHER
CHANGES AS ABOVE.
Assessment and Plan
85 yo F with HTN, Afib, dCHF, CKD, h/o guaiac-positive stools,
transferred from [**Hospital1 **] [**Location (un) 78**] for cardiac catheterization in the setting
of elevated cardiac enzymes, new focal wall motion abnormalities, and
worsened MR. [**Name13 (STitle) **] to have extensive 3-vessel disease.
.
# Troponin leak: Troponin peaked at 0.26. Cath shows 3-vessel disease.
Poor candidate for PCI given 3VD and history of GI bleeding.
-CT surgery evaluation for possible CABG/MVR
-ASA
-no Plavix given surgical evaluation
-no heparin as low suspicion for acute thrombosis as mechanism of
ischemia
-statin
-beta blocker
-holding ACE for now in setting of renal failure
."
6138,"6 g/dL
174 mg/dL
1.5 mg/dL
31 mg/dL
22 mEq/L
105 mEq/L
3.3 mEq/L
141 mEq/L
29.4 %
15.0 K/uL
[image002.jpg]
[**2156-11-29**]
2:33 A3/22/[**2160**] 11:01 PM
[**2156-12-3**]
10:20 P
[**2156-12-4**]
1:20 P
[**2156-12-5**]
11:50 P
[**2156-12-6**]
1:20 A
[**2156-12-7**]
7:20 P
1//11/006
1:23 P
[**2156-12-30**]
1:20 P
[**2156-12-30**]
11:20 P
[**2156-12-30**]
4:20 P
WBC
15."
6139,"She has Q-waves in leads 1,
V4-6 and an axis of 90 degrees. There is no prior tracing to compare
to, but she does reportedly have a history of right bundle branch block
in the past. No ischemic changes are seen.
.
TTE [**2161-2-16**] ([**Hospital1 **] [**Location (un) 78**]): The left atrium is normal in size. The left
atrial volume is normal. There is mild regional left ventricular
systolic dysfunction with akinesis of the posterobasal septum and
dyskinesis of the adjacent posterior wall. The aortic valve leaflets
are mildly thickened (?#). Mild to moderate ([**11-29**]+) aortic regurgitation
is seen."
6140,"She presented to
[**Hospital1 1**] [**Location (un) 78**], where head and c-spine CT were negative. She developed
chest pain after admission, relieved with metoprolol and nitroglycerin.
She received 1 unit of RBCs for Hct 27, and became short of breath. She
was given 40mg IV lasix and diuresed 500cc. She ruled in for MI with
third set of troponins peaking at 0.26. She was transferred to [**Hospital1 1**]
for cardiac catheterization on 100% non-rebreather and a heparin gtt.
Of note, pt was guaiac positive on admission.
.
On arrival to [**Hospital1 1**], the patient was taken to the cardiac catherization
lab, where she was found to have severe 3-vessel disease and an
elevated LVEDP (see below for details)."
6141,"HEMODYNAMICS:
.
CT head w/o contrast [**2161-2-15**]: Mild brain atrophy and mild changes of
small vessel disease seen. No hemorrhage, mass effect, midline shift or
hydrocephalus. Vascular calcifications. IMPRESSION: NO ACUTE
INTRACRANIAL ABNORMALITIES.
.
CT C-spine [**2161-2-15**]: There is no fracture or subluxation seen. A small
calcific density identified between the lamina of C4 and C5 appears to
be due to calcification in the ligamentum flavum. Degenerative changes
of facet joints are identified. Minimal anterolisthesis of C4 over C5
and C5 over C6 as well as C7 over T1. There is no evidence of high
grade spinal stenosis seen."
6142,"The mitral valve leaflets are mildly thickened. Severe (4+)
mitral regurgitation is seen.
.
TTE [**2160-11-13**]: Mild left atrial enlargement, other chamber sizes are
within normal limits. Mild concentric left ventricular hypertrophy.
Left ventricular systolic function estimated 55-60%. There are no wall
motion abnormalities seen. The aortic valve is mildly calcified with
mild aortic insufficiency. The mitral valve is mildly thickened with
moderate mitral regurgitation. Trace tricuspid regurgitation is seen.
There is no evidence of pericardial effusion or intracardiac mass.
.
ETT: P-MIBI [**2160-11-13**]: No significant focal reversible perfusion defect
is seen. There is decreased perfusion to the inferior wall during
stress, which does not improve with rest and is consistent with
diaphragmatic attenuation artifact or a small fixed defect."
6143,"5 mg PO QHS
Senna 1 tab [**Hospital1 **]
Past medical history:
Family history:
Social History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypertension
diastolic CHF
Chronic Kidney Disease (Baseline 1.5-1.7)
Right BBB
MRSA in nares
Atrial Fibrillation
Gout
Cellulitus
Polymyalgia Rheumatica
Diverticulosis
Depression and anxiety
s/p cholecystecomty/appendectomy
s/p tonsillectomy
s/p surgery for anal fissure
Father with stroke at 68. Mother with MI at 65. Two brothers with HTN.
Two sisters. Had 4 children (one died)."
6144,"Retired. Worked as secretary. Lives alone at [**Location (un) 1265**].
-Tobacco history: quit 40 yrs ago, 1 ppd x 30 years
-ETOH: denies
-Illicit drugs: denies
Review of systems:
Flowsheet Data as of [**2161-2-17**] 01:17 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**62**] AM
Tmax: 36.4
C (97.5
Tcurrent: 36.3
C (97.3
HR: 70 (69 - 81) bpm
BP: 119/57(70) {119/46(65) - 142/77(90)} mmHg
RR: 24 (18 - 24) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
810 mL
150 mL
PO:
480 mL
150 mL
TF:
IVF:
Blood products:
Total out:
960 mL
160 mL
Urine:
310 mL
160 mL
NG:
Stool:
Drains:
Balance:
-150 mL
-10 mL
Respiratory
O2 Delivery Device: Non-rebreather
SpO2: 98%
ABG: ///22/
Physical Examination
VS: T=97."
6145,"0
Hct
29.4
Plt
300
Cr
1.5
TropT
0.14
Glucose
174
Other labs: PT / PTT / INR:12.0/26.0/1.0, CK / CKMB /
Troponin-T:110/3/0.14, Differential-Neuts:93.5 %, Lymph:4.0 %, Mono:2.3
%, Eos:0.1 %, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:4.3 mg/dL
EKG [**2161-2-16**]: Sinus rhythm with PACs at 82 bpm. RBBB. RAD. TWI in III,
V1. TWF in aVF.
.
EKG [**2160-11-12**] (per OMR note): normal sinus rhythm at a rate of 70 with
right bundle branch block and upright T-wave, and T-waves in V2-3 which
may be considered primary T-wave changes."
6146,"TITLE: CCU Fellow Admit Note
85F with PMR, dCHF admitted to [**Location (un) **] with diarrhea. Was orthostatic
and anemic. Transfused 1u prbc then developed CHF and dyspnea for which
she was treated with lasix. Then developed CP last night and was
started on IV ntg and heparin. Echo with new posterior wall HK and
posterior papillary muscle dysfunction with severe MR. Had slowly
increasing Troponin levels to 0.26 and was transferred to [**Hospital1 1**] for
cath. Cath today revealed diffuse 3vd and LVEDP of 29. Transferred to
CCU for further management.
97.6 129/54 69 18 96%NC
Comfortable, NAD
S1/s2 rrr
Crackles bilaterally on anterior auscultation
Abd soft nt/nd
2+dp no [**First Name7 (NamePattern1) **]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2172**] c/d/i
Labs: reviewed in OMR. Notable for wbc 13.7, Hct 29.4,
ECG: RBBB w/ inf T wave inversions
A/P: 85F with CAD, CHF, PMR admitted with diarrhea and with hospital
course complicated by CHF exacerbation and NSTEMI. Found to have 3vd.
CAD:
-[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] evaluation for ? of CABG and MVR
-no plavix pending csurg eval and c/f gi bleed
CHF:
-elevated LVEDP -> cont diuresis with IV lasix
Leukocytosis: infection > steroid related
-TEE to eval MR and r/o endocarditis
-f/u cx at OSH
-w/u of etiologies of diarrhea"
6147,"Admission Date: [**2161-2-16**] Discharge Date: [**2161-2-21**]
Service: MEDICINE
Allergies:
Demerol / Morphine / Hydrocodone / Codeine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
S/p Fall
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
85 yo F with HTN, polymyalgia rheumatica, transferred from [**Hospital1 18**]
[**Location (un) 620**] for cardiac catheterization. The patient was in her
usual state of health until Wednesday [**2-11**], when she developed
black diarrhea, occuring 5 times daily. The patient attributes
the black color to her iron supplements. Along with diarrhea,
the patient also experienced 2 episodes of vomiting (clear, no
blood or coffee grounds)."
6148,"She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. She denies
sore throat, sinus congestion, dysuria. She denies weakness,
tingling, or numbness. All of the other review of systems were
negative.
Cardiac review of systems is notable for chest pain and
lightheadedness as above and two pillow orthopnea. No syncope.
The patient reports a recent decrease in exercise tolerance from
100 feet on a flat surface to 50 feet on a flat surface.
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Diastolic CHF
Chronic Kidney Disease (Baseline 1."
6149,"5-1.7)
Right BBB
MRSA in nares
Atrial Fibrillation
Gout
Cellulitus
Polymyalgia Rheumatica
Diverticulosis
Depression and Anxiety
S/p cholecystecomty/appendectomy
S/p tonsillectomy
S/p surgery for anal fissure
Social History:
Retired. Worked as secretary. Lives alone at [**Location (un) 582**].
-Tobacco history: quit 40 yrs ago; smoked 1 ppd x 30 years
-ETOH: denies
-Illicit drugs: denies
Family History:
Father with stroke at 68. Mother with MI at 65. Two brothers
with HTN. Had 4 children (one died).
Physical Exam:
(Per Admitting Resident)
VS: T=97.5 BP=129/54 HR=69 RR=18 O2 sat=96%/6L
GENERAL: WDWN in NAD."
6150,"There was
moderate systemic arterial systolic hypertension with an SBP of
160 mmHg. No cardiac index could be calculated as unable to
float PWP catheter beyond RA.
3. Modest hypoxemia (O2 sat 93% on 15L NRB mask) improved to 96%
with the addition of 2L via nasal cannula arguing against
significant shunt physiology.
FINAL DIAGNOSIS:
1. Severe three vessel CAD.
2. Severe left ventricular diastolic dysfunction.
Brief Hospital Course:
85 yo F with HTN, Afib, dCHF, CKD, h/o guaiac-positive stools,
transferred from [**Hospital1 **] [**Location (un) 620**] for cardiac catheterization in the
setting of elevated cardiac enzymes, new focal wall motion
abnormalities, and worsened MR."
6151,"[**Name13 (STitle) **] to have extensive 3-vessel
disease.
# Coronary Artery Disease: Pt noted to have a troponin leak at
an OSH, with peak of 0.26. Was transferred to [**Hospital1 18**] for cardiac
catheterization, which revealed three-vessel disease. Given
this, pt is a poor candidate for PCI. After much discussion, pt
decided that she would not want cardiac surgery. [**Hospital 49578**]
medical management was pursued. During her hospitalization, she
experienced episodes of chest discomfort, particularly at night.
She did not exhibit any ECG changes during these episodes. Her
metoprolol was uptitrated, and she was started on a long-acting
nitrate for further antianginal activity."
6152,"By the time of
discharge, she had been free of chest pain for several days.
# Acute on Chronic Diastolic HF / Worsened Ritral Regurgitation:
Echo at OSH showing new focal wall motion abnormalities and
worsened MR, likely of ischemic etiology. On presentation, she
was thought to be hypervolemic. Metoprolol and amlodipine were
tirated for optimum BP control / afterload reduction. The option
of mitral valvular surgery was addressed, but the patient was
not interested in cardiac surgery. She was diuresed with bolus
IV lasix, which was converted to PO lasix prior to discharge.
# Pneumonia: CXR performed on [**2161-2-18**] was suspicious for
multifocal pneumonia."
6153,"Pt was initially started on broad-spectrum
coverage with vancomycin, cefepime, levofloxacin. She was noted
to spike a fever on the night of [**2161-2-18**]; however, she remained
afebrile after that. She did also have a leukocytosis throughout
her hospitalization, which was improving at the time of
discharge. On [**2161-2-20**], her antibiotics were narrowed to
levofloxacin, as she had no positive cultures and appeared
improved clinically. Of note, at the time of discharge, she did
continue to have an oxygen requirement, which was likely
multifactorial in etiology (see below).
# GI Bleeding: The patient was noted to have guaiac positive
stools during her hospitalization."
6154,"She did have one episode of a
hematocrit drop, for which she received a unit of PRBCs. Her
hematocrit remained stable after that. She also complained of
some episodes of dysphagia, with food getting ""stuck"" in her
throat. She states that this has been occuring for some time.
She was seen by GI for both of these issues. Further evaluation
with a barium swallow was recommended as an outpatient. Further
work-up of her GI bleeding should also be pursued as an
outpatient. Of note, in the setting of this GI bleeding, her
aspirin dose was decreased and her PPI dose was increased."
6155,"Her
iron was also discontinued.
# Oxygen Requirment: Likely multifactorial in the setting of the
patient's pneumonia and severe MR. Treatment as above.
# Positive Blood Cx: One blood cx positive for GPR's. Likely a
contaminant. Speciation pending and not further cultures
positive at the time of d/c.
# Pre-Diabets: Pt was noted to have elevated blood sugars in the
CCU. A1C was 6.1, consistent with pre-diabetic state. This
should be further followed as an outpatient.
# Chronic Kidney Disease: Baseline creatinine 1.5 to 1.7. The
patient remained at her baseline throughout the hospitalization.
ACE inhibitors was held in the setting of her kidney disease."
6156,"# Diarrhea: Pt presented with some recent diarrhea in the
setting of recent fever and chills. Stool cultures were sent,
including C.diff, and were negative. Her diarrhea improved.
# Vitamin D Repletion: Pt's previous vitamin D regimen was not
entirely clear. She is being discharged on 1000 units of Vitamin
D3 daily. This may be adjusted as an outpatient if more
significant vitamin supplementation is desired.
# Polymyalgia Rheumatica: Continued on home prednisone dose.
# Anxiety/Depression: Continued on nortriptyline and zyprexa at
home dose.
Medications on Admission:
Ativan 0.5 mg daily PRN
Tylenol 650 mg Q4H PRN
Prochlorperidzine 10 mg Q6H PRN
Lidoderm 5% patch apply to left hip for 12 hours on 12 hours off
Norvasc 5 mg daily
Prilosec 20 mg daily
Nortriptyline 10 mg daily
Metoprolol ER 100 mg daily
Vitamin D 50,000 units weekly for 4 weeks, then monthy
prednisone 10 mg daily
Drisdol once a month
ferrous sulfate 325 mg [**Hospital1 **]
Tylenol 1000 mg PO BID
Calcium carbonate 500 mg TID
acidophilus 1 capsule [**Hospital1 **]
Zyprexa 5 mg daily
Trazodone 12."
6157,"Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary:
Acute on chronic diastolic heart failure
Pneumonia
Coronary artery disease
Secondary:
Chronic kidney disease
Guaiac positive stool
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance
Discharge Instructions:
You were admitted to [**Hospital1 18**] for a heart catheterization to
evaluate for coronary disease. We found disease in all 3 blood
vessels as well as a leaky mitral valve. You declined to have
heart surgery to repair these problems. We removed extra fluid
with medications called diuretics and treated you for a
pneumonia."
6158,"If not resolved after three, call physician.
19. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days: Start [**2-22**] am.
20. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for reflux.
21. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
22. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
23. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
6159,"12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
14. Acidophilus Capsule Sig: One (1) Capsule PO twice a day.
15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime)
as needed for insomnia.
17. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual x3 as needed for CP : Up to three doses
separated by 5 min."
6160,"The
LMCA had distal calcification with a hazy 30% stenosis. The LAD
was heavily calcified with diffuse disease throughout with
serial 60% stenoses just before a major D4 with a distal 85%
stenosis and an 80% apical stenosis. There was a high D1,
functionally a large septal branch which was patent. A large D2
and D4 were also patent. The LCx was tortuous proximally with
slow flow and mild diffuse disease in the AV groove LCx. OM
branch had a proximal 50% stenosis with a tortuous upper pole
and mild diffuse disease in the lower pole. The distal AV groove
LCx supplied collaterals to the distal RCA system."
6161,"5 mg PO QHS
Senna 1 tab [**Hospital1 **]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea .
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day: to right hip, 12 hrs on, 12 hrs
off."
6162,"26. She was transferred to [**Hospital1 18**] for
cardiac catheterization on 100% non-rebreather and a heparin
gtt. Of note, pt was guaiac positive on admission.
On arrival to [**Hospital1 18**], the patient was taken to the cardiac
catherization lab, where she was found to have severe 3-vessel
disease and an elevated LVEDP (see below for details). She was
transferred to the CCU on a non-rebreather for further
management. In the CCU, the patient was weaned to a
non-rebreather. She reported that her breathing was improved and
had no other complaints.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, cough,
hemoptysis, or red stools."
6163,"Overall,
the morphology and distribution of the changes suggests
multifocal pneumonia rather than pulmonary edema. No evidence of
right basal changes, no evidence of right-sided pleural
effusion.
CXR ([**2161-2-20**]) - In comparison with study of [**2-18**], there has been
placement of left subclavian PICC line extends to the mid
portion of the SVC. There has been some decrease in the
bilateral patchy areas of opacification, most likely consistent
with improving pneumonia.
Cardiac Cath ([**2161-2-16**]) -
1. Coronary angiography in this right dominant system
demonstrated severe three vessel CAD. The LCx was the least
stenosed and there was no obvious single culprit stenosis."
6164,"7* RBC-3.60* Hgb-9.7* Hct-29.4*
MCV-82 MCH-27.0 MCHC-33.0 RDW-14.9 Plt Ct-311
[**2161-2-16**] 05:30PM BLOOD Neuts-92.2* Lymphs-5.4* Monos-2.1 Eos-0.3
Baso-0
[**2161-2-16**] 11:01PM BLOOD PT-12.0 PTT-26.0 INR(PT)-1.0
[**2161-2-16**] 11:01PM BLOOD Glucose-174* UreaN-31* Creat-1.5* Na-141
K-3.3 Cl-105 HCO3-22 AnGap-17
[**2161-2-16**] 11:01PM BLOOD CK(CPK)-110
[**2161-2-16**] 11:01PM BLOOD CK-MB-3 cTropnT-0."
6165,"The RCA was
heavily calcified with a 40% ostial stenosis without pressure
dampening. There was proximal diffuse disease up to 75% and
distal diffuse disease before the RPDA up to 45%. There was
moderate diffuse disease throughout the RPDA with severe diffuse
disease in the distal AV groove RCA supplying the RPLs with slow
flow (? severe disease vs. competitive flow from collaterals).
Septal collaterals from the LAD fill the RPDA.
2. Limited resting hemodynamics revealed mildly elevated RA
pressure
with a mean RAP of 9 mmHg. There was severely elevated left
sided filling pressures with an LVEDP of 29 mmHg."
6166,"4* Na-139
K-4.2 Cl-98 HCO3-32 AnGap-13
[**2161-2-21**] 05:42AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.1
[**2161-2-18**] 04:05AM BLOOD %HbA1c-6.1* eAG-128*
CXR ([**2161-2-18**]) - The size of the cardiac silhouette is at the
upper range of normal, there is no evidence for overt pulmonary
edema. In the right upper lobe as well as in the entire left
lung, the interstitial markings are increased, there are patchy
areas of opacities, that are ill-defined and distributed in a
mainly peribronchial pattern. In addition, a small left basilar
atelectasis and a small left pleural effusion is seen."
6167,"Please take all medications as prescribed. We have made the
following medication changes:
STOPPED:
Lorazepam (Ativan)
Ferrous sulfate (iron)
CHANGED:
Increased metoprolol succinate to 225mg daily
Vitamin D to 1000 units daily
STARTED:
Atorvastatin for cholesterol
Levofloxacin for 4 days (antibiotic for pneumonia)
Isosorbide mononitrate for chest pain
Aspirin for blood thinning
Furosemide to prevent fluid buildup
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with the physician at your nursing facility.
Please call [**Telephone/Fax (1) 62**] on Monday to set up a follow up
appointment for 2-3 weeks with one of our cardiologists."
6168,"The patient also had fever to as high
as 100.6 on Friday [**2-13**] and Saturday [**2-14**].
On Sunday [**2-15**], the patient became lightheaded when getting up
from the toilet and fell, hitting her head and right elbow. She
presented to [**Hospital1 18**] [**Location (un) 620**], where head and c-spine CT were
negative. She developed chest pain after admission, relieved
with metoprolol and nitroglycerin. She received 1 unit of RBCs
for Hct 27, and became short of breath. She was given 40mg IV
lasix and diuresed 500cc. She ruled in for MI with third set of
troponins peaking at 0."
6169,"14*
[**2161-2-16**] 11:01PM BLOOD Calcium-8.6 Phos-4.3 Mg-1.9
[**2161-2-16**] 05:33PM BLOOD Type-ART O2 Flow-15 pO2-75* pCO2-34*
pH-7.46* calTCO2-25 Base XS-0 Intubat-NOT INTUBA
Discharge Labs
[**2161-2-21**] 05:42AM BLOOD WBC-14.9* RBC-3.43* Hgb-9.8* Hct-29.3*
MCV-86 MCH-28.4 MCHC-33.2 RDW-15.2 Plt Ct-360
[**2161-2-21**] 05:42AM BLOOD PT-12.1 PTT-25.7 INR(PT)-1.0
[**2161-2-21**] 05:42AM BLOOD Glucose-103* UreaN-36* Creat-1."
6170,"6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: total
dose = 225mg/day.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: total
dose = 225mg/day.
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
6171,"Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTA anteriorly (could
not sit up due to recent cath).
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs
[**2161-2-16**] 05:30PM BLOOD WBC-13."
6172,"[**Name13 (STitle) **] to have 3-vessel disease.
.
# Chest pain: Patient has recurrent chest pain that is not completely
responsive to NTG. Etiology unclear: cardiac vs. related to pt
s PNA
vs. related to dysphagia. Of note, pt was started on long-acting
nitrate yesterday in an effort to better control her pain. Also,
increased metprolol overnight.
- continue metoprolol
- increase imdur to 90 mg daily; consider giving dose at bedtime
because pt seems to develop her chest discomfort at night
- continue PRN ntg
- consider further GI evaluation for potential dysphagia (see below)
.
# Hypoxemia: Pt will on NC and intermittently requiring NRB."
6173,"# Acute on chronic mitral regurgitation/heart failure: Echo shows new
focal wall motion abnormalities and worsened MR, likely of ischemic
etiology. Endocarditis less likely given blood cultures negative to
date. Patient does not want valve surgery. Currently euvolemic to
hypervolemic.
-BP control with beta blocker, amlodipine, and Imdur
-supplemental O2
-diurese with IV Lasix (goal negative 2 liters today, already negative
1 liter)
-f/u pending blood cultures
.
# Rhythm: In sinus rhythm with frequent PACs. Unclear history of Afib.
Not on anticoagulation.
-telemetry
-K>4, Mg>2
.
# Chronic kidney disease: Creatinine at baseline.
-renally dose meds
-avoid nephrotoxins
-trend creatinine
.
# Diarrhea: Possible infectious etiology in setting of recent
fever/chills. Ddx includes gut ischemia or gut edema from CHF. C. diff
negative.
-f/u pending stool cultures
.
# Polymyalgia rheumatica:
-continue prednisone at home dose
.
# Anxiety/Depression:
-continue nortriptaline and Zyprexa at home dose
ICU Care
Nutrition:
Glycemic Control: Comments: ISS
Lines:
20 Gauge - [**2161-2-18**] 02:30 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: DNR / DNI
Disposition:ICU"
6174,"NAD.
HEENT: Periorbital echymosis of right eye.
CV: RRR. Normal S1 and S2. No m/r/g appreciated over respiratory
sounds.
Lungs: Dependent crackles noted.
Abd: Soft. NT/ND.
Ext: WWP. DP pulses 2+ bilaterally. No edema.
Labs / Radiology
276 K/uL
8.4 g/dL
121 mg/dL
1.6 mg/dL
28 mEq/L
4.2 mEq/L
34 mg/dL
100 mEq/L
137 mEq/L
25.8 %
21.0 K/uL
[image002.jpg]
[**2161-2-16**] 11:01 PM
[**2161-2-17**] 06:37 AM
[**2161-2-17**] 10:00 AM
[**2161-2-18**] 04:05 AM
[**2161-2-18**] 02:50 PM
[**2161-2-19**] 04:30 AM
[**2161-2-19**] 05:07 AM
WBC
15."
6175,"Her
hypoxemia likely multifactorial, related to mitral regurgitation (4+ on
recent echo) and pneumonia (CXR shows multifocal pneumonia).
- f/u pending blood cultures and send second set prior to antibiotics
- continue antibiotics for HAP: vancomycin, cefepime, levofloxacin (day
1 = [**2161-2-18**])
- treat heart failure/mitral regurgitation with diruesis and BP control
- wean O2 as tolerated
.
.
# NSTEMI: Troponin peaked at 0.26. Cath shows 3-vessel disease. Poor
candidate for PCI given 3VD and history of GI bleeding. Patient does
not want CABG.
-ASA
-no Plavix given guaiac positive stools
-statin
-metoprolol
-Imdur
-holding ACE for now; will consider adding if BP not control
."
6176,"0
13.7
19.2
13.8
18.9
21.0
Hct
29.4
28.4
28.3
30.1
24.9
25.8
Plt
300
198
327
329
272
276
Cr
1.5
1.5
1.6
1.7
1.6
TropT
0.14
Glucose
174
102
119
186
121
Other labs: PT / PTT / INR:12.7/32.8/1.1, CK / CKMB /
Troponin-T:110/3/0.14, Differential-Neuts:92.8 %, Lymph:4.0 %, Mono:2.9
%, Eos:0.2 %, Ca++:8.3 mg/dL, Mg++:2.5 mg/dL, PO4:2.1 mg/dL
Assessment and Plan
85 yo F with HTN, dCHF, CKD, h/o guaiac-positive stools, transferred
from [**Hospital1 **] [**Location (un) 78**] for cardiac catheterization in the setting of elevated
cardiac enzymes, new focal wall motion abnormalities, and worsened MR."
6177,"4
C (102.9
Tcurrent: 36.9
C (98.5
HR: 69 (66 - 111) bpm
BP: 118/47(64) {101/34(51) - 155/91(99)} mmHg
RR: 26 (14 - 38) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 70 kg (admission): 70.3 kg
Height: 67 Inch
Total In:
1,270 mL
60 mL
PO:
1,020 mL
60 mL
TF:
IVF:
250 mL
Blood products:
Total out:
2,215 mL
791 mL
Urine:
2,215 mL
791 mL
NG:
Stool:
Drains:
Balance:
-945 mL
-731 mL
Respiratory support
O2 Delivery Device: Non-rebreather
SpO2: 98%
ABG: ///28/
Physical Examination
General: Alert."
6178,"Chief Complaint:
24 Hour Events:
EKG - At [**2161-2-18**] 09:15 PM
BLOOD CULTURED - At [**2161-2-18**] 11:50 PM
Temp spike 102.9PO
FEVER - 102.9
F - [**2161-2-18**] 11:00 PM
Overnight Events:
- started on long-acting nitrate
- passed by speech and swallow
- had an episode of food ""getting stuck"" in esophagus while eating
dinner with regurgitation of partially digested food
- started on broad specturm abx (vanc/cef/levo) for ?multifocal PNA
- A1C showed borderline DM, started ISS
- had a large, black, guaiac positive stool
- had more chest pain overnight - did not respond to NTGx3; increased
metoprolol and gave zyprexa - pain returned about 1 hour later; gave 1
NTG - pain became ""tolerable"" at that point
- ordered PICC b/c pt will need abx and is a very difficult stick
- spiked a temp to 102."
6179,"9
- 5 point hematocrit drop - wrote for 1 unit of PRBCs and 20 mg IV
lasix
Allergies:
Demerol (Oral) (Meperidine Hcl)
Nausea/Vomiting
Morphine
Nausea/Vomiting
Hydrocodone
Nausea/Vomiting
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Levofloxacin - [**2161-2-18**] 12:30 PM
Vancomycin - [**2161-2-18**] 03:58 PM
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2161-2-18**] 08:00 AM
Heparin Sodium (Prophylaxis) - [**2161-2-18**] 10:00 PM
Furosemide (Lasix) - [**2161-2-19**] 06:20 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2161-2-19**] 07:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**62**] AM
Tmax: 39."
6180,"7/24.6/1.0, CK / CKMB /
Troponin-T:110/3/0.14, Differential-Neuts:92.8 %, Lymph:4.0 %, Mono:2.9
%, Eos:0.2 %, Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL
Assessment and Plan
85 yo F with HTN, dCHF, CKD, h/o guaiac-positive stools, transferred
from [**Hospital1 **] [**Location (un) 78**] for cardiac catheterization in the setting of elevated
cardiac enzymes, new focal wall motion abnormalities, and worsened MR.
[**Name13 (STitle) **] to have 3-vessel disease.
.
# Hypoxemia: Patient satting 90% on 6L NC, mid 90s on non-rebreather.
Her hypoxemia is multifactorial, related to mitral regurgitation (4+ on
recent echo) and pneumonia (CXR shows multifocal pneumonia)."
6181,"3 kg
Height: 67 Inch
Total In:
986 mL
180 mL
PO:
930 mL
180 mL
TF:
IVF:
56 mL
Blood products:
Total out:
1,462 mL
1,075 mL
Urine:
1,462 mL
1,075 mL
NG:
Stool:
Drains:
Balance:
-476 mL
-895 mL
Respiratory support
O2 Delivery Device: Non-rebreather
SpO2: 97%
ABG: ///27/
Physical Examination
General: NAD.
HEENT: Periorbital echymosis of right eye. PERRL. EOMI.
CV: RRR. Normal s1 and s2. I/VI HSM at apex.
Lungs: Basilar rales.
Abd: Soft. NT/ND.
Ext: WWP. No femoral bruits. DP and PT pulses 2+ bilaterally. No
edema. Right groin site with clean dressing in place and no hematoma."
6182,"- PT consult in.
Allergies:
Demerol (Oral) (Meperidine Hcl)
Nausea/Vomiting
Morphine
Nausea/Vomiting
Hydrocodone
Nausea/Vomiting
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2161-2-17**] 10:00 PM
Furosemide (Lasix) - [**2161-2-18**] 02:30 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2161-2-18**] 06:47 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**62**] AM
Tmax: 37.2
C (98.9
Tcurrent: 37
C (98.6
HR: 126 (63 - 126) bpm
BP: 164/114(127) {109/43(63) - 178/114(127)} mmHg
RR: 25 (16 - 31) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 70 kg (admission): 70."
6183,"Neuro: A+Ox3.
Labs / Radiology
329 K/uL
10.0 g/dL
119 mg/dL
1.6 mg/dL
27 mEq/L
4.0 mEq/L
36 mg/dL
104 mEq/L
142 mEq/L
30.1 %
13.8 K/uL
[image002.jpg]
[**2161-2-16**] 11:01 PM
[**2161-2-17**] 06:37 AM
[**2161-2-17**] 10:00 AM
[**2161-2-18**] 04:05 AM
WBC
15.0
13.7
19.2
13.8
Hct
29.4
28.4
28.3
30.1
Plt
300
198
327
329
Cr
1.5
1.5
1.6
TropT
0.14
Glucose
174
102
119
Other labs: PT / PTT / INR:11."
6184,"# Rhythm: In sinus rhythm with frequent PACs. Unclear history of Afib.
Not on anticoagulation.
-telemetry
-K>4, Mg>2
.
# Chronic kidney disease: Creatinine at baseline.
-renally dose meds
-avoid nephrotoxins
-trend creatinine
.
# Diarrhea: Possible infectious etiology in setting of recent
fever/chills. Ddx includes gut ischemia or gut edema from CHF. C. diff
negative.
-f/u pending stool cultures
.
# Polymyalgia rheumatica:
-continue prednisone at home dose
.
# Anxiety/Depression:
-continue nortriptaline and Zyprexa at home dose
ICU Care
Nutrition: Low-Na diet
Glycemic Control:
Lines:
22 Gauge - [**2161-2-17**] 05:00 PM
Prophylaxis:
DVT: heparin SC
Stress ulcer:
VAP:
Comments:
Communication: Comments: healthcare proxy is son [**Name (NI) 821**] [**Name (NI) 1080**]
([**Telephone/Fax (1) 11577**]
Code status: DNR / DNI
Disposition: CCU for now"
6185,"-f/u pending blood cultures and send second set prior to antibiotics
-antibiotics for HAP: vancomycin, cefepime, levofloxacin (day 1 =
[**2161-2-18**])
-treat heart failure/mitral regurgitation with diruesis and BP control,
as below
.
# Chest pain: Patient has recurrent chest pain responsive to NTG. Will
need to manage medically as the patient does not want CABG and her
coronary anatomy is not amenable to PCI.
-Increase metoprolol to 50 mg TID
-Imdur 60 mg daily
-nitro PRN
-identify and treat non-cardiac causes of chest pain (i.e. GERD)
.
# NSTEMI: Troponin peaked at 0.26. Cath shows 3-vessel disease."
6186,"Poor
candidate for PCI given 3VD and history of GI bleeding. Patient does
not want CABG.
-ASA
-no Plavix given guaiac positive stools
-statin
-metoprolol
-Imdur
-holding ACE for now; will consider adding if BP not control
.
# Acute on chronic mitral regurgitation/heart failure: Echo shows new
focal wall motion abnormalities and worsened MR, likely of ischemic
etiology. Endocarditis less likely given blood cultures negative to
date. Patient does not want valve surgery. Currently euvolemic to
hypervolemic.
-BP control with beta blocker, amlodipine, and Imdur
-supplemental O2
-diurese with IV Lasix (goal negative 2 liters today, already negative
1 liter)
-f/u pending blood cultures
."
6187,"TITLE: Physician Resident Progress Note
Chief Complaint:
24 Hour Events:
- Had CPx2. No EKG changes. Maalox no help. Resolved with SL NTG X2
overnight. then x2 + 10mg isosorbide mononitrate only dropped pain from
10 to 7 so increased imdur to 20mg. Developed 02 requirement after
midnight, on 6L non rebreather. CXR done.- Uptitrated metoprolol for
better BP control. Added back home amlodipine.Got am antihypertensives
early as HTN and tachy.
- Does not want C-surgery
- F/U OSH blood cx -no growth
- f/u stool Cx, c.diff- pending.
- f/u fluid status/if having diarrhea
- got lasix 20 IV x 2, goal -ve 1
- Written for 20 mg Lasix daily for severe MR
- Called out but no bed available."
6188,"Admission Date: [**2144-1-24**] Discharge Date: [**2144-1-27**]
Date of Birth: [**2079-12-25**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vicodin
Attending:[**First Name3 (LF) 65686**]
Chief Complaint:
s/p seizure
Major Surgical or Invasive Procedure:
Extubation [**2144-1-25**]
History of Present Illness:
64M h/o brain mass undergoing cyber knife last Tx last teusday,
followed by [**First Name5 (NamePattern1) 1151**] [**Last Name (NamePattern1) 6570**] (neuro-onc), no h/o sz but on keppra
after first cyberknife and stopped 2-3d ago, was also tapering
decadron, pt found by wife this morning with jerking movements
of arms, unresponsive."
6189,"He was not given
empiric Abx because he was afebrile, no leukocytosis and had a
good reason for sz other than meningitis.
.
VS prior to transfer: 87, 102/63, 100% 550 18, PEEP 50% FiO2.
.
Past Medical History:
# Mestatastic clear cell renal CA s/p R nephrectomy 3 yrs ago
# Prostate CA s/p prostatectomy
# HTN
# DM
# HL
# Anxiety
# GERD
# Gout
Social History:
Married. Lives with his wife. [**Name (NI) **] is a retired insurance [**Doctor Last Name 360**].
He never smoked. No alcohol since [**2140**]. No drugs.
Family History:
He has two daughtres and one son, all healthy. His father died
at age 49 after returning from WWII, cause unclear."
6190,"All these issues would be resolved
with routine chest CT.
Heart is top normal size, there is no pulmonary edema or pleural
effusion.
Brief Hospital Course:
64 yo M w/ renal cell CA to the brain p/w new onset seizure.
.
#. S/p seizure: Pt presented with new onset seizure at home. Pt
had mass lesion in brain and had been recently taken off seizure
prophylaxis. He had been on a dexamethasone taper and had had
his last dose of keppra on [**2144-1-21**]. He initially presented to an
OSH where he was intubated for airway protection. Head CT at
OSH was largely unchanged per neurology team."
6191,"Lumbar puncture
was not performed as he was afebrile with no leukocytosis and
because he had thrombocytopenia (plts 60s). Clinical suspicion
for infectious etiology for seizure was quite low. He was
placed back on keppra and dexamethasone and extubated on [**2144-1-25**]
with no complications. He did not have further seizures in the
hospital. He was discharged with follow-up with his primary
neuro-oncologist.
.
#. Renal cell carcinoma: Pt with renal cell carcinoma metastatic
to brain. He was diagnosed with renal cell carcinoma in [**6-/2141**]
and was s/p right nephrectomy [**8-/2141**] with recently diagnosed
left frontal brain mass."
6192,"Clinical suspicion for PNA was quite low and he was not
started on antibiotics. Repeat cxr showed an opacity that was
read as possible composite shadow of osteophytes and lung
vessels; two other regions of fullness were interpreted as
adenopathy or fat. Pt also reportedly had difficulty swallowing
at ICU and was put on thickened liquid diet. He underwent a
speech and swallow assessment and was deemed safe for thin
liquids and regular consistency solids.
#. Normocytic Anemia: Pt with normocytic anemia, Hct 30-35
during hospital admission. Given anemia in conjunction with
thrombocytopenia, SPEP and UPEP were sent to rule out multiple
myeloma."
6193,"SPEP showed low levels of IgG but was otherwise
unremarkable. Hct remained stable and pt had no evidence of
bleeding.
.
#. CKD: Cr baseline was 1.7. Cr was 1.3-1.5 during admission.
.
#. Thrombocytopenia: Pt presented with thrombocytopenia, plt
count in 60s. He was given 1 unit platelets upon admission to
ICU. Platelet count had slowly been downtrending since
[**2143-11-21**]. Peripheral smear was examined per ICU and did not
show schistocytes to suggest TTP. Thrombocytopenia may have
been [**12-25**] dexamethasone. He was started on folic acid and plt
count rose to 108 by time of discharge."
6194,".
#. DMII: Pt had been on glyburide at home and was maintained on
HISS while in the hospital. He had rare hyperglycemia to 400s
while on dexamethasone which improved by time of discharge. He
was discharged back on home dose of glyburide.
Medications on Admission:
ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet -
1
Tablet(s) by mouth DAILY (Daily)
DEXAMETHASONE - (Prescribed by Other Provider; Dose adjustment
-
no new Rx) - 2 mg Tablet - 2 Tablet(s) by mouth once a day
GLYBURIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth twice a day
LEVETIRACETAM [KEPPRA] - 500 mg Tablet - One Tablet(s) by mouth
twice a day starting [**2144-1-12**] stopped [**2144-1-21**]
LISINOPRIL - (Prescribed by Other Provider) - Dosage uncertain
LORAZEPAM - 0."
6195,"dexamethasone 2 mg Tablet Sig: One (1) Tablet PO at bedtime
for 3 days: Take in addition to dexamethasone 4mg in the morning
through [**2144-1-29**].
Disp:*3 Tablet(s)* Refills:*0*
6. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain: [**Street Address(1) 87025**], DRINK ALCOHOL, OR OPERATE HEAVY
MACHINERY WITH THIS MEDICATION.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Seizure
Secondary:
Renal cell carcinoma with metastases to brain
Diabetes mellitus"
6196,"He was s/p first cyberknife treatment
[**2144-1-14**]. Pt had chronic mild right hemiparesis, anomia, and
dysphasia but no new neurologic deficits. He had recently
completed keppra course and had been on dexamethasone taper
prior to presenting with new onset seizure. He had intermittent
headaches controlled with oxycodone. He will follow up with his
primary oncologist as outpatient.
.
#. ?Aspiration: CXR on admission showed retrocardiac opacity,
likely atelectasis vs. aspiration but could not rule out PNA. Pt
had low grade temp 100.2 upon arrival to [**Hospital1 18**] ED but was
afebrile with no leukocytosis throughout remainder of hospital
course."
6197,"4* Hct-31.1*
MCV-91 MCH-33.3* MCHC-36.7* RDW-15.7* Plt Ct-65*
[**2144-1-24**] 01:00PM BLOOD PT-12.9 PTT-21.7* INR(PT)-1.1
[**2144-1-24**] 01:00PM BLOOD Fibrino-481*
[**2144-1-24**] 01:00PM BLOOD Ret Aut-4.0*
[**2144-1-24**] 11:48PM BLOOD Glucose-260* UreaN-31* Creat-1.5* Na-138
K-4.2 Cl-104 HCO3-22 AnGap-16
[**2144-1-24**] 01:00PM BLOOD ALT-37 AST-23 LD(LDH)-377* AlkPhos-72
TotBili-0.9
[**2144-1-24**] 11:48PM BLOOD Calcium-7."
6198,"His mother
died at age 85. He has no siblings.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
PHYSICAL EXAM ON DISCHARGE:
Vital signs: Tc 98.2 Tmax 99.1 BP 118/74 (118-146/70-82) HR 63
(63-70) O2 sat 100% RA FS 208-279
GEN: AOx3, NAD
HEENT: PERRL."
6199,"6 RDW-15.1 Plt Ct-108*
[**2144-1-27**] 07:20AM BLOOD Glucose-203* UreaN-34* Creat-1.3* Na-137
K-4.5 Cl-100 HCO3-28 AnGap-14
[**2144-1-27**] 07:20AM BLOOD TotProt-5.9* Calcium-9.3 Phos-3.7 Mg-1.5*
[**2144-1-27**] 07:20AM BLOOD PEP-HYPOGAMMAG IgG-356* IgA-93 IgM-63
IFE-TRACE MONO
[**2144-1-26**] 01:58PM URINE U-PEP-NO PROTEIN
[**2144-1-26**] 01:58PM URINE Hours-RANDOM TotProt-12
Portable CXR [**2144-1-24**]:
1. ET tube terminates 5 cm from the carina without evidence of
pneumothorax."
6200,"If you have further difficulties with
swallowing, please contact the speech and swallow clinic.
The following changes were made to your medications:
1) Keppra 1000mg twice a day to prevent seizures
2) Dexamethasone 4mg in the morning and 2mg at night for three
days until [**2144-1-29**], then take dexamethasone 4mg daily ONLY
starting on [**2144-1-30**]
Followup Instructions:
You have the following appointments scheduled for you:
Department: RADIOLOGY
When: MONDAY [**2144-2-10**] at 12:35 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2144-2-10**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2144-2-2**]"
6201,"8* Phos-4.2 Mg-1.3*
[**2144-1-24**] 01:00PM BLOOD Hapto-234*
[**2144-1-24**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-1-24**] 01:19PM BLOOD Type-MIX pO2-209* pCO2-36 pH-7.46*
calTCO2-26 Base XS-2 Comment-GREEN TOP
[**2144-1-24**] 01:19PM BLOOD Glucose-179* Lactate-1.0 Na-138 K-4.4
Cl-102
LABS ON DISCHARGE:
[**2144-1-27**] 07:20AM BLOOD WBC-7.6 RBC-3.86* Hgb-12.1* Hct-35.0*
MCV-91 MCH-31.4 MCHC-34."
6202,"MMM. No LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB, no wheezes/crackles
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+. Contracture of right
hand (chronic for 10 years)
Skin: no rashes or bruising
Neuro: A & O x 3, slow to speak, CNs II-XII intact. 5/5 strength
in U/L extremities.
Pertinent Results:
LABS ON ADMISSION:
[**2144-1-24**] 01:00PM BLOOD WBC-6.4 RBC-3.43* Hgb-11."
6203,"He was transferred to [**Hospital1 **] ED for continuity
of care.
.
Seen by Neuro in ED, reviewed CT head from OSH. Has not been
getting chemo but anemic and thrombocytopenic. His primary
neuro-oncologist was paged and suggested that LP may be
necessary if he appears to be infected clinically. Dr. [**Last Name (STitle) 6570**]
will follow in house instead of neuro consult team. He
recommended: Keppra 1g IV BID 1:1 w/ PO as well as decadron 4mg
Q6hrs. ED was not comfortable w/ doing LP given mass effect
(though recommended by his neuro-oncologist) and
thrombocytopenia to 64 (guideline is 80)."
6204,"5 mg Tablet - [**11-24**] Tablet(s) by mouth 30 minutes
prior to your CyberKnife treatment
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours as needed for pain
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO qam.
Disp:*90 Tablet(s)* Refills:*0*
5."
6205,"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 in the hospital. You were
admitted with a new seizure. This was likely caused by your
brain mass. You were re-started on a medication to prevent
seizures and steroids to reduce swelling in the brain. You
should follow-up with your primary oncologist to discuss further
management of your renal cancer.
You were also evaluated with a speech and swallow assessment
given your difficulties swallowing. You were assessed to be
safe when swallowing."
6206,"Prior to this he had been having coughing
fit and wife found him slumped on the couch with rhythmic
jerking of hands but did not respond to voice but could squeeze
his hands. He had not been having any fevers. Spontaneously
resolved after several minutes, when EMS arrived pt was
post-ictal with GCS 3. Intubated for airway protection at
Southern [**Hospital **] medical center because he was still unresponsive but
had stopped convulsing, got tylenol suppository there. got
decadron, keppra, ativan, propofol for sedation. Head CT was
obtained at OSH which was unchanged from scan [**10-31**] when mass
initially discovered."
6207,"2. There is prominence of hilar and mediastinal silhouette and
pulmonary
vasculature, which may be reflective of increased pulmonary
vascular pressure.
3. Retrocardiac opacity, likely atelectasis or aspiration;
however,
superimposed infection cannot be entirely excluded.
CXR (PA & LAT) [**2144-1-26**]:
IMPRESSION: PA and lateral chest reviewed in the absence of
prior chest
radiographs:
The lateral view shows a wedge-shaped area of opacity in one of
the lower
lungs, could be a composite shadow of anterior spinal
osteophytes and large lower lung vessels. Two other regions of
abnormality are the suggestion of 11-mm wide right upper lobe
nodule at the level of the first anterior interspace and
fullness in the right lower paratracheal mediastinum, which
could be adenopathy or fat."
6208,"Admission Date: [**2166-2-6**] Discharge Date: [**2166-2-17**]
Date of Birth: [**2091-10-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2166-2-7**] Cardiac cath
[**2166-2-12**] Coronary artery bypass graft x3: Left internal mammary
artery to left anterior descending artery; and saphenous vein
grafts to obtuse marginal-1 and posterior descending artery
History of Present Illness:
74-year-old male with history of hypertension, accelerated
junctional rhythm causing symptoms during exertion much improved
following aggressive blood pressure control,and Crohns disease
that presents after nuclear stress test today showed 3 mm ST
segment depression inferolaterally."
6209,"He was admitted for cardiac
cath which revealed severe coronary artery disease and is now
referred for surgery.
Past Medical History:
Benign prostatic hypertrophy
Crohn's disease
Hypertension
Macular degeneration
Osteoporosis
Osteoarthritis (back)
Back surgery with rod (as teenager)
Bilateral rotator cuffs
Bilateral carpal tunnel release
Skin cancer excised from lower lip
Social History:
He quit smoking in [**2132**]. He retired as a vice-president of a
construction company. He has been married for 29 years. He has
not drunk any alcohol for the past 15 years or so. Lives with
wife and daughter. [**Name (NI) **] Dental Exam: [**4-8**] mos."
6210,"Chest tubes and epicardial pacing wires were
removed per protocol. On post-op day two he had an episode of
atrial fibrillation which was treated with Amiodarone and
Lopressor with conversion back to sinus rhythm. He otherwise
made good recovery while working with physical therapy for
strength and mobility. On post-op day five he was discharged
home with the appropriate medications and follow-up
appointments.
Medications on Admission:
Alendronate 70 mg Tablet 1 Tablet(s) by mouth weekly (Sat)
Chlorthalidone 12.5 mg Tablet daily
Folic acid 1 mg Tablet by mouth daily
Hydrocortisone 100 mg/60 mL enema rectally every third night
(Patient takes about every ten days, last time on [**2166-2-5**])
Lisinopril 40 mg Tablet 1 Tablet(s) by mouth daily
Terazosin 5 mg Capsule 1 Capsule(s) by mouth at bedtime
Aspirin 81 mg Tablet 1 (One) Tablet(s) by mouth once a day
Bifidobacterium infantis [Align]
Calcium citrate-vitamin D3 [Citracal + D]
Multivitamin
Study medication for macular degeneration at [**Hospital1 2025**] (unknown
formulation)"
6211,"metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Benign prostatic hypertrophy
Crohn's disease
Hypertension
Macular degeneration
Osteoporosis
Osteoarthritis (back)
Back surgery with rod (as teenager)
Bilateral rotator cuffs
Bilateral carpal tunnel release
Skin cancer excised from lower lip"
6212,"Patient
underwent usual pre-operative work-up for bypass surgery while
receiving appropriate medical management prior to surgery. On
[**2-12**] he was brought to the operating room where he underwent a
coronary artery bypass graft x 3. Please see operative for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Later that
day he was weaned from sedation, awoke neurologically intact and
extubated. On post-op day one beta-blockers and diuretics were
started and he was gently diuresed towards his pre-op weight.
Later on this day he was transferred to the step-down unit for
further care."
6213,"MR remains trace. No aortic
dissection seen, though incidental note is made of shadowing in
the proximal aortic root near the right coronary cusp- can not
exclude mass or throumbus, no luminal irregularities- discussed
with and shown to Dr. [**Last Name (STitle) **]. Remaining exam is
unchanged, all findings discussed with surgeons at the time of
the exam.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 11165**] is a 74-year-old male with
history of hypertension, accelerated junctional rhythm and
Crohns disease that presents after abnormal nuclear stress test
with cardiac cath showing left main and RCA CAD."
6214,"ago
Family History:
Mother had some type of cervical or perhaps bladder cancer.
There is no family history of colon cancer. Father and one
sister had a history of alcoholism. His other sister is
otherwise well. He has three healthy children ages 51, 45, and
43 along with four grandchildren, all in good health.
Physical Exam:
Pulse: 56 Resp: 16 O2 sat: 100%RA
B/P Right: Left: 129/57
Height: Weight: 73.6kg
General: NAD, WGWN, appears stated age
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
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema- none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ **Mynx closure device** Left: 2+
DP Right: 1+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+"
6215,"Flow in the vertebral arteries is prograde on both
sides.
[**2166-2-12**] Echo: Pre Bypass: The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. Trivial
mitral regurgitation is seen. Post Bypass: Preserved
biventricular function, LVEF>55%."
6216,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**3-3**] at 1:30PM
Cardiologist: Dr. [**Last Name (STitle) 1911**] [**2-27**] at 3:30PM
[**Hospital Ward Name 121**] 6 wound check on Tuesday [**2166-2-25**] at 11am with Midlevel #
[**Telephone/Fax (1) 3071**]
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**4-8**] 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:[**2166-2-17**]"
6217,"C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
Disp:*8 Tablet(s)* Refills:*2*
9. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
10."
6218,"Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]."
6219,"Discharge Medications:
1. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO Q12H (every 12 hours).
Disp:*10 Tablet, ER Particles/Crystals(s)* Refills:*0*
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. aspirin 81 mg Tablet, Delayed Release (E."
6220,"Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2166-2-6**] Nuclear perfusion: 1. Normal myocardial perfusion at the
level of exercise achieved and in the setting of ischemic ECG
changes. EF of 63% at stress and 66% at rest.
[**2166-2-7**] Cardiac cath: 1. Selective coronary angiography of this
right dominant system revealed three vessel coronary artery
disease. The LMCA had a hazy distal 60-70% stenosis. The LAD and
LCx were free of angiographically significant disease. The RCA
had serial 70% stenoses from its mid-portion to distal vesel.
[**2166-2-10**] Carotid U/S: Plaque at the ostia of the internal carotid
arteries but no evidence of a hemodynamically significant
stenosis."
6221,"Admission Date: [**2138-8-28**] Discharge Date: [**2138-8-29**]
Date of Birth: [**2112-6-21**] Sex: F
Service: MEDICINE
Allergies:
Tylenol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Nausea and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 26 year old woman with a history of IDDM,
depression, anxiety, and a recent admission for DKA in [**7-/2138**],
who presents with nausea and abdominal pain in the setting of
insulin noncompliance at home. Since her recent discharge, she
has not been taking her insulin regularly. She cannot say why
she finds it difficult to maintain her insulin regimen, however."
6222,"3, bicarb 14, Glu 549, AG 21, venous pH
7.25, urine glucose 1000, urine ketones 150. She was given
insulin 10U IV bolus followed by insulin gtt at 10U/hr. She
received 1L NS bolus. After 2 hours, her labs were notable for
Na 133, K 3.7, bicarb 17, glu 134, AGap 13.
On arrival to the MICU, patient's VS were HR 100 BP 103/62.
Past Medical History:
Type 1 Diabetes Mellitus, ~20 years
Bipolar 1
PTSD
Borderline personality disorder
Asthma
Hashimoto's Thyroiditis, untreated (according to patient)
Non-alcoholic fatty liver disease
Social History:
The patient smokes 1 pack per day."
6223,"Normal tracing. Compared to the previous
tracing of [**2135-10-6**] no diagnostic interim change.
Brief Hospital Course:
Ms. [**Known lastname **] is a 26 year old woman with a history of IDDM,
depression, anxiety, and a recent admission for DKA in [**7-/2138**],
who presents with nausea and abdominal pain in the setting of
insulin noncompliance at home.
ACTIVE ISSUES
#) Diabetic ketoacidosis: On arrival to the ICU, the patient's
blood sugar was 134 (down from 549) and her anion gap was 13
(down from 21). She was given an insulin gtt at 3U/hr and D5
1/2NS at 150/hr."
6224,"GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, strength and sensation grossly normal.
Pertinent Results:
ADMITTING LABS
[**2138-8-28**] 01:00PM WBC-5.9 RBC-4.85 HGB-15.4 HCT-44.2 MCV-91
MCH-31.7 MCHC-34.7 RDW-12.3
[**2138-8-28**] 01:00PM CALCIUM-9.0 PHOSPHATE-3.8# MAGNESIUM-2.1
[**2138-8-28**] 01:00PM GLUCOSE-549* UREA N-16 CREAT-0.9 SODIUM-130*
POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-14* ANION GAP-26*
[**2138-8-28**] 01:15PM TYPE-[**Last Name (un) **] TEMP-36."
6225,"Her gap closed by the evening of her admission
and her glucose remained between 100-150. She ate dinner and was
given 12U NPH overnight, overlapped with the insulin gtt. Her
gap remained closed through the night and she was given her home
lantus dose of 34U the morning after admission. She was seen by
the [**Last Name (un) **] diabetes fellow who recommended continuation of her
usual home regimen. She has a follow-up appointment with Dr.
[**Last Name (STitle) **] of [**Hospital 18**] [**Hospital3 **] on Tuesday, [**9-2**]
to follow up with her diabetes management and general health
needs. He will be able to arrange a referral to [**Last Name (un) **] for
further diabetes care if necessary."
6226,"#)Depression/Anxiety: stable, patient was continued on home
medication regimen. Further management as per new PCP.
TRANSITIONAL ISSUES
Patient has been established with new PCP at [**Hospital1 18**] who can
arrange for referral to [**Hospital **] clinic for diabetes management if
necessary. Social work remains available at [**Hospital1 18**] should she
have further access issues in the future.
Medications on Admission:
Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing/sob
Diazepam 5 mg PO BID:PRN anxiety, insomnia
LaMOTrigine 75 mg PO DAILY
Quetiapine Fumarate 50 mg PO HS
Glargine 34 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1."
6227,"She denies alcohol.
Marijuana 4-5 times per week
Previously has tried acid, mushrooms, ectasy, not heroin or
cocaine or meth. not done drugs for greater than 2 years
She completed 3 years of college
She has worked many jobs, like HR, managers, now is a bank
teller.
Lives with her mother and her mother's boyfriend in [**Name (NI) **].
Family History:
Father - Alcohol abuse
Mother - ""Anxiety""
Brothers - Bipolar disorder
Grandma - Rheumatoid arthritis
Maternal uncle and aunt, paternal [**Name2 (NI) 53305**] with DM2
Maternal cousin with type 1 diabetes
Physical Exam:
ADMITTING EXAM
Vitals: 98.7 89 102/61 17 98/RA
General: Alert, oriented, occasionally tearful
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, no LAD
CV: tacxhycardic, normal S1 + S2, no murmurs."
6228,"Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] over sees this doctor and both will be
involved in your care. You will need to call your insurance
company and name Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as your Primary Care Physician.
[**Name10 (NameIs) **] MUST BE DONE BEFORE YOUR APPT.
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Location (un) **] [**Location (un) **]-ENDOCRINOLOGY
Address: [**2138**], [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 84918**]
****Please call dr [**Last Name (STitle) 84919**] office to make a follow up appt once
you are home from the hospital.
Completed by:[**2138-8-31**]"
6229,"You
were treated in the ICU with iv insulin and fluids. Your
condition improved significantly after the treatment. You were
also seen by [**Last Name (un) **] specialist, who recommended to continue the
following home medication regimen. We also scheduled several
followup appointments for you.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2138-9-2**] at 3:00 PM
With: [**First Name8 (NamePattern2) 8694**] [**Last Name (NamePattern1) 25284**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: Dr [**Last Name (STitle) **] is a resident and your new physician in
[**Name9 (PRE) 191**]."
6230,"Quetiapine Fumarate 50 mg PO HS
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
4. LaMOTrigine 200 mg PO DAILY
5. Diazepam 5 mg PO Q12H:PRN anxiety
please hold for sedation or RR < 10
6. Glargine 34 Units Breakfast
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Diabetic ketoacidosis
Secondary diagnosis:
- healthcare access
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted here at [**Hospital1 18**] for diabetic ketoacidosis."
6231,"JVP 6cm
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, strength and sensation grossly normal.
DISCHARGE EXAM
General: Alert, oriented, in NAD
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, no LAD
CV: tacxhycardic, normal S1 + S2, no murmurs. JVP 6cm
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding"
6232,"6 PO2-63* PCO2-26* PH-7.25*
TOTAL CO2-12* BASE XS--14 COMMENTS-GREEN TOP
[**2138-8-28**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2138-8-28**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2138-8-28**] 02:00PM URINE UCG-NEGATIVE
[**2138-8-28**] 03:50PM GLUCOSE-134* UREA N-12 CREAT-0.7 SODIUM-133
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-17* ANION GAP-16
[**2138-8-28**] 09:55PM CALCIUM-8."
6233,"#)Healthcare access: Reason for patient's presentation stems
from her recent job loss and a change in her health insurance.
Her previous endocrinologist and PCP apparently do not accept
her new insurance now that she is unemployed. Social work was
consulted who discussed patient's options under her new health
insurance. She was advised that [**Hospital1 18**] PCP's would accept her
new insurance, and likely that [**Last Name (un) **] would as well. Patient
was established with a PCP at [**Hospital1 18**] [**Name9 (PRE) 191**] and told to contact the
[**Name (NI) **] clinic for further diabetes care upon discharge.
CHRONIC ISSUES"
6234,"She is in a day program that is helping slightly, but she
recently lost her job and her health insurance, so she does not
know if she can continue with this program.
At home, she checks her sugars frequently and they are normally
in the 300s due to her poor compliance. On the morning of [**8-28**],
her fingerstick was over 500 and her home ketone monitor
reported a high [**Location (un) 1131**]. She felt nauseated and presented to the
ED.
In the ED, initial VS were: 97.5 109 129/71 22 99%. Labs were
notable for Na 130, K 5."
6235,"9 PHOSPHATE-3.1 MAGNESIUM-1.9
[**2138-8-28**] 09:55PM GLUCOSE-197* UREA N-11 CREAT-0.6 SODIUM-134
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-12
DISCHARGE LABS
[**2138-8-29**] 05:52AM BLOOD Glucose-191* UreaN-11 Creat-0.6 Na-135
K-4.1 Cl-104 HCO3-24 AnGap-11
[**2138-8-29**] 05:52AM BLOOD WBC-6.8 RBC-4.43 Hgb-13.7 Hct-38.8 MCV-88
MCH-30.9 MCHC-35.3* RDW-12.4 Plt Ct-305
IMAGING
[**8-28**]: CXR - no acute process
EKG: Sinus rhythm."
6236,"He has chronic
diastolic congestive heart failure secondary to aortic stenosis.
He has a known bicuspid aortic valve and stable ascending aortic
aneurysm. He is followed closely by Dr. [**First Name (STitle) 437**] from the heart
failure service who referred him for aortic valve replacement
surgery.
He reports worsening shortness of breath, increasing fatigue
and lower extremity edema. He denied chest pain, orthopnea and
syncope. He reports symptoms of SOB and chest burning has
increased over the past month.
Past Medical History:
Chronic Diastolic Congestive Heart Failure
Bicuspid Aortic Valve, Severe Aortic Stenosis
Ascending Aortic Aneurysm
Hypertension
Hypercholesterolemia
alcoholiccirrhosis
History of variceal bleeding
end stage renal failure, s/p [**First Name (STitle) **]
Depression
s/p simultaneous liver/kidney [**First Name (STitle) **] on [**2187-10-11**]
s/p L4-5 spinal fusion
s/p Hernia Repair, left
s/p Knee Meniscal Repair"
6237,"This did not reveal significant coronary
disease. The liver /renal tranplant team clearance was obtained
for surgery. He underwent surgery with Dr. [**Last Name (STitle) **] on [**5-13**]. He
was transferred to the CVICU in stable condition on titrated
phenylephrine and Propofol drips. He remained stable, weaned
from pressors and the ventilator easily, was extubated and
transferred to the floor. He developed rate controlled atrial
fibrillation and Coumadin was added to the medications.
His pacing wires and CTs were removed per protocols and wound
were clean and healing well. Arrangements were made for
Coumadin management by Dr. [**First Name (STitle) **] and dosing and results were
given to his office."
6238,"Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Chronic Diastolic Congestive Heart Failure
Bicuspid Aortic Valve with Severe Aortic Stenosis
dilated ascending aorta
Hypertension
Hypercholesterolemia
alcoholic cirrhosis
History of variceal bleeding paracenteses
end stage Renal failure
s/p renal [**Hospital1 **]
s/p liver [**Hospital1 **]
Depression
Discharge Condition:
Alert and oriented x3. nonfocal
Ambulating independently steady gait
Incisional pain managed with oral analgesics
Incisions:
sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon."
6239,"Mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2189-5-13**] 13:43
[**2189-5-18**] 05:15AM BLOOD WBC-9.4 RBC-3.17* Hgb-9.5* Hct-29.2*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.7* Plt Ct-216
[**2189-5-17**] 05:20AM BLOOD WBC-10.4 RBC-3.08* Hgb-9.4* Hct-28.7*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16."
6240,"Admission Date: [**2189-5-10**] Discharge Date: [**2189-5-19**]
Date of Birth: [**2127-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vicodin / Cidofovir / Lisinopril / Ace Inhibitors / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dypnea
Major Surgical or Invasive Procedure:
[**2189-5-13**] AVR ([**Street Address(2) 6158**]. [**Male First Name (un) 923**] porcine)/ eplacement Ascending aorta
(30 mm Gelweave
left heart catheterization, coronary angiogram [**2189-5-11**]
History of Present Illness:
This 61 year old male is status post orthotopic liver and kidney
transplantation with a well functioning [**Month/Day/Year **] liver and a
marginally functioning [**Month/Day/Year **] kidney."
6241,"0* Plt Ct-197
[**2189-5-18**] 05:15AM BLOOD Glucose-122* UreaN-60* Creat-3.3* Na-134
K-4.5 Cl-101 HCO3-24 AnGap-14
[**2189-5-10**] 04:00PM BLOOD Glucose-133* UreaN-44* Creat-3.2* Na-139
K-5.1 Cl-106 HCO3-23 AnGap-15
[**2189-5-19**] 04:40AM BLOOD PT-12.6 INR(PT)-1.1
[**2189-5-19**] 04:40AM BLOOD Glucose-104* UreaN-56* Creat-3.2* Na-136
K-4.5 Cl-101 HCO3-26 AnGap-14
Brief Hospital Course:
He was admitted on [**5-10**] for pre-op work up and cardiac
catheterization."
6242,"Look at
your incisions daily for redness or drainage
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**]
**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:"
6243,"Surgeon: Dr. [**Last Name (STitle) **] on Thursday, [**2189-6-18**] @ 1:15 pm
([**Telephone/Fax (1) 170**])
Please call to schedule appointments with:
Primary Care: Dr. [**First Name11 (Name Pattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 45859**]) in [**12-27**] weeks
Cardiologist: Dr. [**First Name (STitle) 437**] in [**12-27**] weeks
[**Date Range 1326**] and renal as requested by them
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Coumadin follow up: Indication-atrial fibrillation. Goal 2-2.5.
Next blood draw on Thursday, [**5-21**]. Fax results to Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 45868**].
Completed by:[**2189-5-19**]"
6244,"transmitted murmur
Pertinent Results:
PRE-BYPASS:
The left atrium is dilated. 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.
A patent foramen ovale is present with left to right flow under
anesthesia
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. There are simple
atheroma in the descending thoracic aorta."
6245,"General: WDWN male in NAD
Skin: Dry [x] intact [x] - well healed abd scars, right forearm
scar
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] - no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur IV/VI systolic ejection
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema - trace bilaterally
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 1 Left: 1
DP Right: decreased Left: decreased
PT [**Name (NI) 167**]: decreased Left: decreased
Radial Right: 1 Left: 1
Carotid Bruit Right: ? transmitted murmur Left: ?"
6246,"Social History:
Born in [**State **], lived in [**Male First Name (un) 1056**], then Mass for last 30
yrs, worked as school counselor and high school basketball
coach, retired [**6-1**]. Lives with wife, has dog at home. Drank [**1-28**]
drinks/day (martinis, beer) on social basis, last drink [**2187-1-21**]
for wife's birthday. Denies smoking or illicit drug use.
Family History:
Father had CABG in 40's, father and paternal grandmother with
leukemia, uncle with unknown liver problem. [**Name (NI) **] hx pulmonary
disease, diabetes, stroke.
Physical Exam:
admission:
T 98
Pulse:74 Resp:18 O2 sat:98% RA
B/P Right:118/80 Left:
Height: 72inches Weight:213#"
6247,"The aortic valve is
bicuspid. There is severe aortic valve stenosis (valve area
0.8-1.0cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known firstname **]
[**Known lastname **] before surgical incision.
POST-BYPASS:
Preserved biventricualr systolic function.
Intact thoracic aorta and the tube graft in the ascening aorta
is visualized well with a good contour and no leaks
Aortic bioprosthetic valve is well seated and functioning well
with a residual peak gradient of 28mm of Hg peak and 15mm of Hg
mean."
6248,"Discharge restrictions, medications and
follow up were explained to him. He remained edematous with
10kilograms of extra fluid aborad. he was discharge to home on
lasix 40mg daily, indefinitely after discussion with his
nephrologist Dr. [**Last Name (STitle) **].
Tacrolimus levels remained therapeutic on the current dose. His
BUN, creatinine and potassium will be checked on [**5-21**] along with
his INR.
Medications on Admission:
Carvedilol 25 mg po BID
Fenofibrate 160 mg daily
Lovaza 1 gram capsulte (2) capsules po BID
Prednisone 5 mg daily
Ranitidine 300 mg daily
Sertraline 50 mg po daily
Bactrim 400-80 mg po daily
Tacrolimus 1 mg capsules (2) capsules [**Hospital1 **]
Calclium Carb-Vit D3 supplement 600-400 1 tab [**Hospital1 **]"
6249,"Admission Date: [**2115-12-16**] Discharge Date: [**2116-1-3**]
Date of Birth: [**2066-7-18**] Sex: M
Service: MEDICINE
Allergies:
Epzicom / Sustiva / Norvir
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Thoracentesis
Mechanical Intubation
History of Present Illness:
Found today by the maintence staff at his rehab with SOB,
tachypnea and found to have a O2 sat of 60%. He was brought in
by EMS and was 88% on a non-rebreather.
.
In the emergency department initial VS were T: 100. HR 115, BP
140/91, RR:34, 88% on on-rebreather."
6250,"He has a DNR/DNI order, but
after discussion with the ED staff he reversed his code status
to full and was intubated. He was given etomidate/ succinate.
He was sedated with versed and fentanyl. Vent settings were
Tv:550, PEEP:5, RR:16, FiO2:100% with sats in 92%.
Past Medical History:
-- HIV diagnosed [**2106**], (CD4 count 198 [**7-/2115**])
-- History of Hepatitis C, diagnosed [**2099**] and treated
unsucessfully with interferon at that time
-- Right sided retinal detachment and subsequent R-sided
blindness
-- h/o Temporal lobe epilepsy
-- h/o PCP [**Name Initial (PRE) 11091**] [**2113**]
Social History:
Tobacco - Smokes [**2-2**] pack/day x33 years
EtOH - Denies
Drugs - IVDU (Heroin) 20 years ago, cocaine until 2 years ago,
occasional marijuana use."
6251,"He was transferred to the
medicine floor on [**2115-12-26**].
MEDICINE FLOOR COURSE:
# Respiratory: Patient had persistent fevers since admission
without an identified infectious etiology. He was treated with
10 days of zosyn for presumed pneumonia. He was very difficult
to wean off the ventilator. This was thought to be secondary to
rapidily accumulating pleural effusions secondary hepatic
hydrothorax. Patient is not a good candidate for TIPS procedure
given his significant comorbidities. He was given oxygen
supplementation and treated with albuterol nebulization.
# HCV Cirrhosis: Patient has ascites and hepatic
hydropneumothorax. Diminished functional capacity of liver was
further evidenced by coagulopathy (INR 1."
6252,"9-2.0). TIPS and
pleurodesis were not recommended per hepatology in the setting
of this other comorbidities. For the same reason, patient would
be a poor liver transplant surgery. He was treated with
spironolactone and lasix for diuresis. He was given lactulose
for hepatic encephalopathy.
#Altered Mental Status: hepatic encephalopathy is most likely
etiology though AIDS dementia, delirum may have also
contributed. His mental status waxed and waned. He was often not
oriented to place or time. His hepatic encephalopathy was
treated with lactulose. He was oriented to person, hospital,
year and city on discharge.
# Liver Nodule: very suspicious for HCC though AFP not elevated."
6253,"21. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
Harbour Lights
Discharge Diagnosis:
Primary: Pneumonia, hepatic hydrothrorax
Secondary: HCV Cirrhosis, HIV/AIDS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. You
were intubated with a breathing tube to help you breath and you
were in the intensive care unit for 10 days. You were treated
with antibiotics for pneumonia. You also have a large amount of
fluid around your lungs."
6254,"2* Phos-3.7 Mg-2.0
[**2115-12-16**] 08:14PM BLOOD Calcium-8.7 Phos-2.4* Mg-2.2
[**2116-1-1**] 05:37AM BLOOD AFP-9.0*
IMAGING:
CXR: [**2115-12-31**]:
IMPRESSION: An AP chest compared to [**12-25**]:
Large right pleural effusion has decreased and mediastinum has
returned to the midline. Right lower lobe is presumably
collapsed. Left lung grossly clear. No left pleural effusion.
No pneumothorax. No free subdiaphragmatic gas.
CXR: [**2115-12-25**]:
SINGLE AP VIEW OF THE CHEST: An endotracheal tube tip terminates
5 cm from
the carina. A left PICC terminates within the cavoatrial
junction."
6255,"0 Baso-0.5
[**2115-12-16**] 10:00AM BLOOD Neuts-84.6* Lymphs-9.4* Monos-4.4 Eos-0.7
Baso-0.8
[**2116-1-2**] 05:43AM BLOOD PT-20.4* INR(PT)-1.9*
[**2115-12-16**] 10:42AM BLOOD PT-21.9* PTT-34.4 INR(PT)-2.1*
[**2115-12-16**] 10:42AM BLOOD WBC-18.0* Lymph-10* Abs [**Last Name (un) **]-1800 CD3%-57
Abs CD3-1032 CD4%-15 Abs CD4-262* CD8%-40 Abs CD8-720*
CD4/CD8-0.4*
Chemistries:
[**2116-1-2**] 05:43AM BLOOD Glucose-85 UreaN-29* Creat-1."
6256,"Mini-BAL was negative for pneumocystis, AFB.
Bactrim was changed to prophylatic dose for PCP. [**Name10 (NameIs) **] had
persistent right sided effusion which was thought [**3-5**] hepatic
pneumothorax. Thoracentesis was done and pleural fluid was
negative for culture, malignancy. Patient had question of
pneumonia and was treated with zosyn for 10 days. Patient was
difficult to wean from the ventilator as his effusions rapidly
accumulate. He was extubated on [**12-25**]. His course was also
complicated by encephalopathic picture. MRI brain showed
question of encephalitis. He was treated with acyclovir until
the LP viral cultures came back negative. He was also followed
by hepatology as he had increasingly elevated LFTs and MR
abdomen is concerning for HCC."
6257,"This was treated with drainage and with
diuretics. Your shortness improved by the time of discharge.
The following changes were made to your medications:
-INCREASED Lactulose from 30 ml twice a day to 30 ml three times
a day
-INCREASED Etravirine (Intelence) 100 mg twice a day to 200 mg
twice a day
-STOPPED: Dilaudid, Neurontin, MS Contin, Tylenol
Followup Instructions:
Name: PA [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10564**] (works with [**Last Name (LF) **],[**First Name3 (LF) **] C.)
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appt: [**1-8**] at 1pm
Department: LIVER CENTER
When: FRIDAY [**2116-1-10**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]"
6258,"2 Na-136
K-4.6 Cl-103 HCO3-27 AnGap-11
[**2115-12-17**] 02:44AM BLOOD Glucose-137* UreaN-28* Creat-0.9 Na-131*
K-4.8 Cl-98 HCO3-28 AnGap-10
[**2115-12-16**] 08:14PM BLOOD Glucose-123* UreaN-24* Creat-0.9 Na-131*
K-4.6 Cl-98 HCO3-30 AnGap-8
[**2115-12-16**] 10:42AM BLOOD Glucose-96 UreaN-21* Creat-0.8 Na-135
K-5.4* Cl-99 HCO3-25 AnGap-16
[**2115-12-16**] 10:00AM BLOOD Glucose-85 UreaN-22* Creat-0.9 Na-132*
K-7."
6259,"5mg TID prn
Discharge Medications:
1. maraviroc 300 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
5. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
7. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime."
6260,"He was transitioned to
BiPAP 16/6 and sats improved to 95-98%. CXR showed b/l pleural
effusions and likely consolidation on the left. He was covered
with Vancomycin/Zosyn/Bactrim. He was also given 40mg IV lasix.
His labs were significant for 17.2 (84.6%poly, no bands) with
repeat 18.0, plts 105 (baseline 20-60's), lactate 3.1. Potassium
5.4. LFT showed ALT 62, AST 143 (in [**10-11**] ALT40/AST66), TBili
3.6, INR 2.1. He had a negative UA. ABG was performed and was
7.40/47/93/30 on BiPAP, however he was becoming more agitated
and not tolerating the BiPAP mask."
6261,"He is single with no children. He is currently living [**Hospital1 **]
Lights. Estranged from all family and does not want any of them
contact[**Name (NI) **]. His life partner is apparently incarcerated for a
long-term sentence.
Family History:
His mother with [**Name (NI) 933**] disease, Rheumatoid Arthritis.
Grandmother with ovarian cancer.
Physical Exam:
ADMISSION:
Vent setting: Tv:550, PEEP:5, RR:16, FiO2:100% with sats in 92%.
GEN: intubated and sedated
HEENT: left pupil 3mm and right pupil 2, reactive to light,
sclera anicteric
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: coarse breath sounds L>R, belly breathing
ABD: Soft, distended, slight fluid wave, +BS
EXT: No C/C/E
NEURO: cranial nerves grossly intact except for pupils, Plantar
reflex downgoing."
6262,"8. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
9. multivitamin Capsule Sig: One (1) Capsule PO once a day.
10. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Marinol 10 mg Capsule Sig: One (1) Capsule PO QACHS.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for wheeze.
13. simethicone 80 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for gas pain.
14. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea."
6263,"Consider MR [**Name13 (STitle) 430**] if clinically indicated
to assess the extent and anture (infarct vs encephalitis).
Prominent ventricles and sulci related to volume loss.
[**2115-12-27**]: RUQ US:
FINDINGS: The liver echotexture is slightly coarsened. In
segment V of the
liver, there is a heterogeneous and overall hypoechoic lesion
measuring 1.9 x 1.8 cm. This lesion was seen on the prior CT
from [**2115-12-24**] and is
concerning for hepatocellular carcinoma. Additional hypoechoic
areas are seen at the dome of the liver in a subdiaphragmatic
distribution and are likely artifact. The portal vein is patent
and shows normal hepatopetal flow."
6264,"Correlation with CSF for Herpes, etc and continued follow up can
be
considered.
2. Symmetric prominence of the ventricles, cisterns and sulci
for age,
compatible with volume loss
Brief Hospital Course:
A/P: This is a 49 yo male with PMH of HCV cirrhosis, HIV/AIDS
(CD4 count 262 [**2115-12-16**]) who presented with hypoxic respiratory
failure was admitted to the MICU with a course that was
complicated by persistent fevers, difficulty extubating and
rapidly re-accumulating pleural effusion.
MICU COURSE:
He was inbuted in the ED and transferred to the MICU. He was
placed on vancomycin, zosyn, cipro and continued on bactrim for
PCP [**Name Initial (PRE) 31304**]."
6265,"There is symmetric prominence of the ventricles, cisterns and
sulci. There is no other evidence of mass, infarct or
hemorrhage. There is no pathologic intracranial enhancement.
Major intracranial flow voids are preserved.
The examination is otherwise significant for small amount of
fluid/mucosal
thickening in the mastoid tips, fluid layering in the pharynx,
minimal
maxillary sinus mucosal thickening and abnormal shape of the
right globe
likely status post scleral banding.
IMPRESSION:
1. Area of increased FLAIR/T2 signal within the left temporal
white matter
and adjacent cortex could represent an area of evolving
encephalitis,
inflammatory, infectious or demyelinating process or related to
seizure."
6266,"SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
DISCHARGE:
VS: 97.2, BP: 100/70, P: 82, RR: 18, 97% on RA
GEN: Chronically ill appearing, cachextic AAOx person, year,
hospital, city
CV: enlarged, laterally displaced PM; reg rate rhythm, no m/r/g
PULM: decreased BS over right side to mid lung, dull to
percussion over right lower lung, no wheezes, rales, rhonchi
over left lung
ABD: BS+, soft, ND, NT, palpable HSM, minimal ascites
EXT: thin, no edema, 2+ DP/ PT pulses., +asterixis
Pertinent Results:
Hematology:
[**2116-1-2**] 05:43AM BLOOD WBC-9.7 RBC-3."
6267,"97* Hgb-12.4* Hct-37.7*
MCV-95 MCH-31.3 MCHC-32.9 RDW-20.3* Plt Ct-61*
[**2115-12-16**] 10:42AM BLOOD WBC-18.0* RBC-4.32* Hgb-12.8* Hct-38.4*
MCV-89 MCH-29.7 MCHC-33.4 RDW-19.0* Plt Ct-90*
[**2115-12-16**] 10:00AM BLOOD WBC-17.2*# RBC-4.78 Hgb-14.4 Hct-43.5
MCV-91 MCH-30.2 MCHC-33.1 RDW-19.1* Plt Ct-105*#
[**2115-12-26**] 03:09AM BLOOD Neuts-79.9* Lymphs-14.4* Monos-4.3
Eos-1."
6268,"15. Artificial Tears Drops Sig: One (1) drop Ophthalmic
twice a day as needed for dry eyes.
16. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
17. Maalox RS 600 mg (1.5 gram) Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day as needed for heartburn.
18. nystatin 100,000 unit/mL Suspension Sig: One (1) cap PO
twice a day as needed for thrush.
19. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
20. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
every eight (8) hours as needed for itching."
6269,"2. Additional hypoechoic foci in a subdiaphragmatic distribution
along the
dome of the liver felt likely artifactual, but suggest attention
to these
regions on next contrast-enhanced scan.
3. Large right pleural effusion.
4. Small amount of perihepatic ascites.
[**2115-12-23**] MR HEAD:
FINDINGS:
There is an area of increased FLAIR/T2 signal within the left
temporal white matter and also involving the adjacent cortex (
se 4, im [**9-11**], 13), with no associated enhancement or mass
effect or decreased diffusion. Thsi may relate to encephalitis,
inflammatory, infectious etiology/demeylinating
disease/associated with seizure. Small scattered FLAIR
hyperintense foci int hecerebral white matter are liekly
non-specific."
6270,"Suprasellar and basilar cisterns appear
patent. Paranasal sinuses and mastoid air cells are well
aerated, within limitation of motion. Vascular calcification is
present in the cavernous carotid arteries. A scleral band is
seen around the right globe. Soft tissues are within normal
limits.
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
NOTE ON ATTENDING REVIEW:
on the prior MR [**Name13 (STitle) 430**] dated [**2115-12-23**], there were FLAIR
hyperintense foci in the left temporal lobe invovling the cortex
and adjacent white amtter . These are possibly seen on the
present CT study as hypodense areas and are
inadequately assessed."
6271,"3* Cl-99 HCO3-19* AnGap-21*
[**2116-1-2**] 05:43AM BLOOD ALT-129* AST-107* LD(LDH)-320*
AlkPhos-144* TotBili-3.6*
[**2116-1-1**] 05:37AM BLOOD ALT-140* AST-106* LD(LDH)-332*
AlkPhos-136* TotBili-3.7*
[**2115-12-31**] 02:59PM BLOOD ALT-155* AST-120* LD(LDH)-321*
AlkPhos-143* TotBili-3.3*
[**2115-12-26**] 03:09AM BLOOD ALT-220* AST-342* LD(LDH)-355*
AlkPhos-121 TotBili-3.6*
[**2115-12-16**] 10:42AM BLOOD ALT-62* AST-143* LD(LDH)-531*
AlkPhos-172* TotBili-3.6*
[**2116-1-2**] 05:43AM BLOOD Calcium-8."
6272,"There is no evidence of
intra- or extra-hepatic biliary duct dilatation. The common bile
duct is normal in caliber, measuring 2 mm. The gallbladder wall
is diffusely thickened, likely secondary to the patient's
underlying liver disease. The remainder of the gallbladder is
normal in appearance and no gallstones are identified.
The pancreatic tail is not well visualized secondary to
overlying bowel gas. The visualized portions of the pancreas
are unremarkable. A small amount of perihepatic ascites is
present. A large right pleural effusion is seen.
IMPRESSION:
1. Segment V liver lesion as previously seen on the CT from
[**2115-12-24**] that is concerning for HCC."
6273,"An NG
tube is partially imaged. Diffuse hazy opacification of the
right hemithorax is compatible with a large layering right
pleural effusion, which is slightly denser compared to prior
study, suggestive of an interval increase in size compared to
the prior study. Aside from left retrocardiac atelectasis, the
left lung is clear.
IMPRESSION: Large right layering pleural effusion, slightly
larger compared to the prior study.
CT HEAD [**2115-12-28**]:
FINDINGS: There is no intracranial hemorrhage, mass effect,
edema, or shift of normally midline structures. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. Ventricles and sulci are
prominent for age."
6274,"Patient has follow-up with hepatology.
# HIV/AIDS: On HAART. Last CD4 was 262 on [**2115-12-16**]. VL
undetectable. Patient meets AIDS criteria with prior CD4<200
(114 [**8-/2114**]) and previous infection with pneumocystis. HIV was
likely contributing to altered mental status and HCV cirrhosis
progression. He was treated with Raltegravir 400 mg PO BID,
Maraviroc 600 mg PO BID, Etravirine 200 mg PO BID (doubled per
ID recs). He was continued on bactrim for PCP [**Name Initial (PRE) 1102**].
Medications on Admission:
ETRAVIRINE [INTELENCE] - 100mg [**Hospital1 **]
RALTEGRAVIR [ISENTRESS] 400mg [**Hospital1 **]
MARAVIROC [SELZENTRY] - 600mg [**Hospital1 **]
Bactrim SS 1 tab daily
Lasix 40mg [**Hospital1 **]
Spironolactone 100mg daily
Lactulose 30ml [**Hospital1 **]
amitryptyline 50mg qhs
ranitidine 150mg daily
Multivitamin
Dilaudid 2mg [**Hospital1 **] prn
Celexa 40mg daily
Neurontin 300mg TID
Nystatin 10,000U swish and swallow
Tylenol prn
Marinol 10mg qachs
MS Contin 30mg TID
Tums
Diphenydramine 25mg prn
Alubterol
simetheicone 80mg prn
artificial tears
compazine 10mg prn
maalox
dulcolax
Klonopin 0."
6275,"CVICU
HPI:
HD13 POD 3-Redo sternotomy/AVR(#21 St. [**Male First Name (un) 1104**] tissue)
Ejection Fraction:>65%
Hemoglobin A1c:5.3
Pre-Op Weight:267.86 lbs 121.5 kgs
Baseline Creatinine:1.0
PMHX: Hypertension,Hyperlipidemia,Aortic Stenosis,H/o Endocarditis from
PPM wire infection s/p MV repair [**2151**],Atrial Fibrillation s/p sucessful
DCCV [**2156-11-9**],SSS s/p DDD pacemaker [**9-5**],Moderate Pulmonary
Hypertension,Barrett's esophagus,Cervical CA,CVA per patient [**10-7**]
without residual,Pacemaker wire infection [**10-7**],Chronic Back pain,
Arthritis, s/p Mitral valve repair [**11/2152**],s/p DDD
Pacemaker([**Company 346**] Enpulse) [**11-6**],s/p Left CEA,s/p Bilateral knee
replacements 10 years ago,s/p Tonsillectomy,s/p Appendectomy,s/p
Hysterectomy
[**Last Name (un) **]:Diltiazem HCL 240',Hydrochlorothiazide 25',Irbesartan
300',Metoprolol Tartrate 50"",Omeprazole 20',Propafenone
225"",Simvastatin 20',Warfarin 2."
6276,"Cont beta blocker
Pulmonary: IS, Enc DB/IS/amb/ negs/ Needs aggressive pulm toilet.
Nutrition: Regular diet, Able to tolerate po today with improved mental
status
Renal: Foley, Cont to diurese with lasix 40 IV TID - monitor BUN
(slightly increased) creat stable
Hematology: hct 25.7 - stable. ASA. ? restart coumdain (home med) for
Afib
Endocrine: RISS
Infectious Disease: UA, UA neg - cx pending with mental status
changes. WBC decreasing
Lines / Tubes / Drains: Foley, Pacing wires
Wounds: Dry dressings
Imaging: CXR today, Bilateral atlectasis with small- moderate pleural
effusions
Fluids: KVO
Consults: P.T.
ICU Care
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2156-12-8**] 03:37 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU"
6277,"0 g/dL
104 mg/dL
1.3 mg/dL
29 mEq/L
4.3 mEq/L
32 mg/dL
101 mEq/L
137 mEq/L
25.7 %
16.5 K/uL
[image002.jpg]
[**2156-12-8**] 08:47 PM
[**2156-12-8**] 10:04 PM
[**2156-12-9**] 12:02 AM
[**2156-12-9**] 01:50 AM
[**2156-12-9**] 06:39 AM
[**2156-12-9**] 10:52 AM
[**2156-12-9**] 06:05 PM
[**2156-12-10**] 02:30 AM
[**2156-12-10**] 08:11 AM
[**2156-12-11**] 03:24 AM
WBC
18.1
18.8
16."
6278,"5
Hct
29.6
27.1
25.8
25.7
Plt
271
253
273
Creatinine
0.9
1.3
1.3
TCO2
23
25
24
22
26
30
Glucose
122
112
142
119
96
107
104
Other labs: PT / PTT / INR:16.1/40.0/1.4, Lactic Acid:1.7 mmol/L,
Ca:9.0 mg/dL, Mg:1.9 mg/dL, PO4:6.1 mg/dL
Assessment and Plan
80F s/p Redo sternotomy/AVR(#21 St. [**Male First Name (un) 1104**] tissue) [**2156-12-8**]
Neurologic: Pain controlled, No narcotics - Ultram only for pain
secondary to confusion
Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue epicardial
wires, D/C amio with chronic afib."
6279,"5mg po daily Mon, Tues, Wed, Fri,
Sat,Warfarin 5mg po q Sun and Thurs,Aspririn 81',Multivitamin'
Current medications:
Acetaminophen, Albuterol-Ipratropium, Albuterol 0.083% Neb Soln,
Amiodarone, Aspirin EC, Docusate Sodium, Furosemide, Heparin,
HydrALAzine, Insulin, Magnesium Sulfate, Metoclopramide, Metoprolol
Tartrate, Milk of Magnesia, Omeprazole, Potassium Chloride,
Simvastatin, TraMADOL (Ultram)
24 Hour Events:
Mental status slowly improving - rate controlled afib - started on amio
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Ciprofloxacin - [**2156-12-9**] 09:06 PM
Vancomycin - [**2156-12-10**] 08:00 AM
Infusions:
Amiodarone - 0.5 mg/min
Other ICU medications:
Amiodarone - [**2156-12-10**] 08:01 PM
Heparin Sodium (Prophylaxis) - [**2156-12-11**] 04:01 AM
Furosemide (Lasix) - [**2156-12-11**] 04:01 AM
Other medications:
Flowsheet Data as of [**2156-12-11**] 12:30 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**58**] a."
6280,"m.
Tmax: 36.8
C (98.3
T current: 36.2
C (97.1
HR: 73 (70 - 110) bpm
BP: 123/50(67) {96/36(53) - 147/70(89)} mmHg
RR: 21 (17 - 28) insp/min
SPO2: 96%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 130.8 kg (admission): 122 kg
Height: 66 Inch
Total In:
281 mL
236 mL
PO:
Tube feeding:
IV Fluid:
281 mL
236 mL
Blood products:
Total out:
2,332 mL
1,593 mL
Urine:
2,232 mL
1,593 mL
NG:
Stool:
Drains:
Balance:
-2,051 mL
-1,357 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 96%
ABG: ///29/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Irregular)
Respiratory / Chest: (Breath Sounds: Crackles : at bases, Diminished:
at bases), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,
Hypoactive BS
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 2), Moves all extremities
Labs / Radiology
273 K/uL
8."
6281,"CVICU
HPI:
HD12 POD 2-Redo sternotomy/AVR(#21 St. [**Male First Name (un) 1104**] tissue)
Ejection Fraction:>65%
Hemoglobin A1c:5.3
Pre-Op Weight:267.86 lbs 121.5 kgs
Baseline Creatinine:1.0
PMHX: Hypertension,Hyperlipidemia,Aortic Stenosis,H/o Endocarditis from
PPM wire infection s/p MV repair [**2151**],Atrial Fibrillation s/p sucessful
DCCV [**2156-11-9**],SSS s/p DDD pacemaker [**9-5**],Moderate Pulmonary
Hypertension,Barrett's esophagus,Cervical CA,CVA per patient [**10-7**]
without residual,Pacemaker wire infection [**10-7**],Chronic Back pain,
Arthritis
----------------------------------------------------------------
PSHx:
s/p Mitral valve repair [**11/2152**],s/p DDD Pacemaker([**Company 346**]
Enpulse) [**11-6**],s/p Left CEA,s/p Bilateral knee replacements 10 years
ago,s/p Tonsillectomy,s/p Appendectomy,s/p Hysterectomy
----------------------------------------------------------------
[**Last Name (un) **]:
Diltiazem HCL 240',Hydrochlorothiazide 25',Irbesartan 300',Metoprolol
Tartrate 50"",Omeprazole 20',Propafenone 225"",Simvastatin 20',Warfarin
2."
6282,"8 %
18.8 K/uL
[image002.jpg]
[**2156-12-8**] 03:21 PM
[**2156-12-8**] 07:34 PM
[**2156-12-8**] 08:47 PM
[**2156-12-8**] 10:04 PM
[**2156-12-9**] 12:02 AM
[**2156-12-9**] 01:50 AM
[**2156-12-9**] 06:39 AM
[**2156-12-9**] 10:52 AM
[**2156-12-9**] 06:05 PM
[**2156-12-10**] 02:30 AM
WBC
18.1
18.8
Hct
29.6
27.1
25.8
Plt
271
253
Creatinine
0.9
1.3
TCO2
28
24
23
25
24
22
26
Glucose
107
134
122
112
142
119
96
107
Other labs: PT / PTT / INR:16."
6283,"1/40.0/1.4, Lactic Acid:1.7 mmol/L,
Ca:9.0 mg/dL, Mg:2.2 mg/dL, PO4:6.1 mg/dL
Assessment and Plan
VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR)
Assessment and Plan: 80F s/p Redo sternotomy/AVR(#21 St. [**Male First Name (un) 1104**] tissue)
[**2156-12-8**]
Neurologic: Pain controlled, Change morphine to Vicodin PRN. Minimize
opioids.
Cardiovascular: Aspirin, Beta-blocker, Statins
Pulmonary: IS, OOB / Chest PT and wean FiO2. PT consult. Sleep
consult for OSA.
Gastrointestinal / Abdomen: standard bowel regimen.
Nutrition: Regular diet, Advance diet as tolerated
Renal: Foley, Adequate UO, Cont lasix for diuresis for goal 1 liter
negative today.
Hematology: Mod anemia --> cont to follow with diuresis.
Endocrine: RISS
Infectious Disease: Periop antibx.
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: CT surgery
Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2156-12-8**] 03:37 PM
Prophylaxis:
DVT:
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: Transfer to floor
Total time spent: 31 minutes
Patient is critically ill"
6284,"m.
Tmax: 38.3
C (100.9
T current: 35.7
C (96.3
HR: 70 (70 - 97) bpm
BP: 114/35(56) {114/34(55) - 124/41(61)} mmHg
RR: 16 (16 - 34) insp/min
SPO2: 98%
Heart rhythm: A Paced
Wgt (current): 131 kg (admission): 122 kg
Height: 66 Inch
CVP: 7 (4 - 23) mmHg
PAP: (50 mmHg) / (11 mmHg)
CO/CI (Thermodilution): (5.92 L/min) / (2.6 L/min/m2)
SVR: 730 dynes*sec/cm5
SV: 85 mL
SVI: 37 mL/m2
Total In:
2,346 mL
PO:
360 mL
Tube feeding:
IV Fluid:
1,986 mL
Blood products:
Total out:
2,752 mL
905 mL
Urine:
2,152 mL
805 mL
NG:
250 mL
Stool:
Drains:
Balance:
-406 mL
-905 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 304 (304 - 423) mL
PS : 5 cmH2O
RR (Spontaneous): 33
PEEP: 0 cmH2O
FiO2: 60%
RSBI: 86
PIP: 6 cmH2O
SPO2: 98%
ABG: 7."
6285,"5mg po daily Mon, Tues, Wed, Fri, Sat,Warfarin 5mg po q Sun and
Thurs,Aspririn 81',Multivitamin'
Chief complaint:
PMHx:
Current medications:
Acetaminophen 5. Albuterol-Ipratropium 6. Albuterol 0.083% Neb Soln 7.
Aspirin EC
8. Calcium Gluconate 9. Ciprofloxacin HCl 10. Dextrose 50% 11.
Dexmedetomidine 12. Docusate Sodium
13. Furosemide 14. HydrALAzine 15. Insulin 16. Ketorolac 17. Magnesium
Sulfate 18. Metoclopramide
19. Metoprolol Tartrate 20. Milk of Magnesia 21. Morphine Sulfate 22.
Nitroglycerin 23. Nitroprusside Sodium
24. Omeprazole 25. Oxycodone-Acetaminophen 26. Phenylephrine 27.
Potassium Chloride 28. Simvastatin
31. Vancomycin
24 Hour Events:
EXTUBATION - At [**2156-12-9**] 11:00 AM
INVASIVE VENTILATION - STOP [**2156-12-9**] 11:00 AM
ARTERIAL LINE - STOP [**2156-12-10**] 01:27 AM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2156-12-9**] 07:03 PM
Ciprofloxacin - [**2156-12-9**] 09:06 PM
Infusions:
Other ICU medications:
Omeprazole (Prilosec) - [**2156-12-9**] 02:44 PM
Morphine Sulfate - [**2156-12-9**] 11:44 PM
Furosemide (Lasix) - [**2156-12-10**] 03:00 AM
Other medications:
Flowsheet Data as of [**2156-12-10**] 06:12 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**58**] a."
6286,"37/43/81.[**Numeric Identifier **]/27/0
Ve: 11.9 L/min
PaO2 / FiO2: 137
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
253 K/uL
8.1 g/dL
107 mg/dL
1.3 mg/dL
27 mEq/L
4.6 mEq/L
25 mg/dL
104 mEq/L
138 mEq/L
25."
6287,"Admission Date: [**2156-11-29**] Discharge Date: [**2156-12-14**]
Date of Birth: [**2076-5-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
s/p Redo sternotomy/aortic valve replacement(21mm tissue valve)
[**2156-12-8**]
History of Present Illness:
80F with critical AS ([**Location (un) 109**] 0.7 cm2 by TTE [**2156-11-24**]), AFib s/p
successful DCCV [**2156-11-9**], SSS s/p PPM, endocarditis s/p MV
repair, and moderate pulmonary hypertension who presents with 10
day history of worsening dyspnea. The patient has been having
shortness of breath for months, but over this span her symptoms
have gotten much worse."
6288,"She does have possibly a 5 lb weight gain over past
10 days, but patient is not entirely clear on this.
ROS: positive as above, otherwise negative.
Past Medical History:
-Critical AS ([**Location (un) 109**] 0.7 cm2, peak grad 85 mmHg, mean grad 49 mmHg
by TTE [**2156-11-24**])
-AFib s/p DCCV [**2156-11-9**]
-sick sinus syndrome s/p DDI [**Company 1543**] Enpulse pacemaker
[**2152-11-13**]
-Severe pulm HTN (PASP 69 mmHg by cath [**12-1**])
-endocarditis s/p MV annular repair
-hypertension
- past surgical history - hysterectomy, left carotid
endarterectomy, mitral valve annular repair.
Social History:
-Tobacco history: 47 pack years, quit 12-14 years ago
-ETOH: 1 drink a month
-Illicit drugs: none
Previously worked as a nurse, married, 4 children - 3 sons and 1
daughter"
6289,"Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2156-12-8**] 15:06
Brief Hospital Course:
The patient was admitted on [**2156-11-29**] and underwent cardiac
catheterization on [**2156-12-1**] which revealed: severe aortic
stenosis and minor irregularities of the coronary arteries. Dr.
[**Last Name (STitle) **] was consulted and the patient had a preop workup which
consisted of a dental consult and carotid studies which showed
<40% stenosis on the right and 60-69% stenosis on the left. She
also had a chest CT to evaluate her aorta and was treated for a
UTI."
6290,"On [**2156-12-8**] she underwent redo sternotomy/aortic valve replacement
with a 21mm tissue valve. Her cross clamp time was 70 minutes
and her total bypass time was 98 minutes. She tolerated the
procedure well and was transferred to the CVICU in stable
condition on Neosynepherine and Propofol. She was extubated on
POD#1 and she did well until POD#2 when she developed severe
post operative pain and received pain medicine which sedated her
and she became confused. She required aggressive respiratory
therapy. Her chest tubes were discontinued on POD#2 and she was
started on coumadin. Her epicardial pacing wires were
discontinued on POD#2 as well."
6291,"C.) - 1 Capsule(s) by mouth once a day
PROPAFENONE - (Prescribed by Other Provider) - 225 mg Tablet -
1
Tablet(s) by mouth twice a day - only for when she feels she is
in afib.
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
LORAZEPAM 1 mg DAILY (started [**2156-11-24**])
WARFARIN - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth once a day 5 mg on Sun and Thurs.
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain"
6292,"Disp:*30 Tablet(s)* Refills:*2*
11. Propafenone 225 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
aortic stenosis
chronic atrial fibrillation
sick sinus syndrome, s/p pacemaker placement
pulmonary hypertension
endocarditis-s/p mitral valve annular repair
hypertension
s/p hysterectomy
s/p left carotid endarterectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs."
6293,"No
pneumothorax. Left
internal jugular line ends at the junction of the
brachiocephalic vein, should
be withdrawn 2 cm from the wall of the superior vena cava.
Transvenous right
atrial and right ventricular pacer leads are in standard
placements. No
pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80566**]
(Complete) Done [**2156-12-8**] at 11:19:47 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2076-5-16**]
Age (years): 80 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for redo sternotomy, AVR
ICD-9 Codes: 427."
6294,"There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area = 0.6cm2). No aortic regurgitation is seen.
A mitral valve annuloplasty ring is present. The gradient across
the mitral valve is increased (mean = 9 mmHg). There is moderate
valvular mitral stenosis (area 1.5cm2). Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is initially being AV paced and then A
paced."
6295,"9* Plt Ct-400
[**2156-12-13**] 02:58AM BLOOD PT-16.1* PTT-40.3* INR(PT)-1.4*
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2156-12-13**] 8:09 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80565**]
Reason: eval for effusion
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman s/p cabg
REASON FOR THIS EXAMINATION:
eval for effusion
Final Report
AP CHEST, 8:29 A.M. [**12-13**]
HISTORY: Status post CABG. Check for effusions.
IMPRESSION: AP chest compared to [**12-11**].
Moderate cardiomegaly has increased but mild pulmonary edema has
decreased and
small right pleural effusion is new or newly apparent."
6296,"Family History:
Father passed away from MI at 68, also both brothers passed away
in 60's and early 70s, unclear reasons although patient believes
them to be cardiac.
Physical Exam:
VS: T= 98.0 BP=158/68 HR=70 RR=24 O2 sat=91% on RA
GENERAL: WDWN woman 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 at sternal angle. No hepatojugular reflex.
CARDIAC: RRR, normal S1, S2. [**2-5**] high pitched holosystolic
murmur heard best at RUSB."
6297,"1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.1 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *52 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 39 mm Hg
Aortic Valve - LVOT diam: 1.7 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 9 mm Hg
Mitral Valve - MVA (P [**12-4**] T): 1."
6298,"She continued to slowly progress
and her mental status completely cleared and she was transferred
to the floor on POD#5. She was discharged to rehab in stable
condition on POD# six by Dr. [**Last Name (STitle) **]. All follow-up
appointments were advised.
Medications on Admission:
SPIRONOLACTONE 25 mg [**Hospital1 **] (started [**2156-11-24**])
DILTIAZEM HCL [CARDIZEM CD] - (Prescribed by Other Provider) -
240 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once
a day
FUROSEMIDE 20 mg daily (started [**2156-11-9**])
IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - 300 mg
Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth twice a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E."
6299,"31, 424.1, 394.0, 424.2
Test Information
Date/Time: [**2156-12-8**] at 11:19 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2010AW2-: Machine: AW2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.1 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1."
6300,"She was seen by Dr. [**Last Name (STitle) **] on [**2156-11-24**]
with continued c/o SOB and being unable to sleep lying flat. The
symptoms have not gotten any worse but have also not improved.
She was found to have mild heart failure but was in NSR at 75
beats per minute. She was started on Spironolactone 25 mg twice
a day and was given Ativan 1 mg. She spoke to Dr. [**Last Name (STitle) **] today
who has decided to admit her to [**Hospital Ward Name **] 3 for evaluation and to
have a cardiac catheterization with Dr. [**Last Name (STitle) **] on [**2156-11-30**]."
6301,"5 cm2
Findings
LEFT ATRIUM: Marked LA enlargement. Elongated LA. Mild
spontaneous echo contrast in the body of the LA. No
mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Mild spontaneous echo contrast
in the LAA. Good (>20 cm/s) LAA ejection velocity. All four
pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. 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, cavity size,
and global systolic function (LVEF>55%)."
6302,"The patient is receiving epinephrine by infusion. There
is normal biventricular systolic function. There is a
bioprosthesis in the aortic position. It is only very poorly
seen. It does appear well seated but the leaflets cannot be
visualized. No aortic regurgitation is seen. The maximum
gradient across the valve was 60 mmHg with a mean gradient of 40
mmHg at a cardiac output of 6.5 liters/minute. These gradients
are higher than expected. The effective orifice area of the
aortic valve was 1.2 cm2. The mitral valvular function is
essentially unchanged. The thoracic aorta appears intact.
I certify that I was present for this procedure in compliance
with HCFA regulations."
6303,"No mass/thrombus is seen in the left atrium
or left atrial appendage. Mild spontaneous echo contrast is
present in the left atrial appendage. The right atrium is
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The basal and mid right ventricular free wall
displays normal contractility. There are simple atheroma in the
aortic arch. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta."
6304,"Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E."
6305,"... in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr..... in [**12-4**] weeks
Cardiologist Dr ...... in [**12-4**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Major Surgical or Invasive procedures: xx
Discharge Diet: heart healthy
Danger Signs:
When to Call 911
You should call 911 or your local emergency number to be taken
to the nearest emergency room for any emergency situation, such
as:
* Chest pain not related to your incision or angina pain,
similar to the pain you had prior to surgery
* Extreme shortness or breath or difficulty breathing
* Severe bleeding, especially if you are on warfarin (Coumadin)
* Fainting, severe lightheadedness or changes in mental status"
6306,"TRICUSPID VALVE: Tricuspid valve not well visualized. Mild to
moderate [[**12-4**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
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. No TEE related complications. Suboptimal image
quality. The rhythm appears to be A-V paced. Results were
Conclusions
PRE BYPASS The left atrium is markedly dilated. The left atrium
is elongated. Mild spontaneous echo contrast is seen in the body
of the left atrium."
6307,".
Today, she reports continued symptoms that have been stable
since seeing Dr. [**Last Name (STitle) **] on the 23rd. She reports orthopnea
where she needs to sleep in her recliner at night. She is able
to sleep with 2 pillows in bed until about 4am, when she
develops PND and moves to the recliner. She denies any dietary
indiscretions or alcohol use. She reports that she has had
swelling of her legs that generally resolves by the morning
which is not worse than previously. No unilateral leg pain or
swelling, no chest pain or pleuritis. She does report some
wheezing when she feels short of breath, but has no history of
emphysema."
6308,"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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Recommended Follow-up: Please call to schedule appointments
Surgeon Dr ."
6309,"Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Mildly dilated
descending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). No AR.
MITRAL VALVE: Mitral valve annuloplasty ring. Increased
transmitral gradient. Moderate mitral annular calcification.
Moderate valvular MS (MVA 1.0-1.5cm2) Mild (1+) MR."
6310,"No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles.
Slight end expiratory wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. 1+ lower extremity mildly pitting edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
DP and radial pulses 2+ bilaterally.
Pertinent Results:
[**2156-12-13**] 02:58AM BLOOD WBC-10.1 RBC-3.00* Hgb-7.6* Hct-24.4*
MCV-81* MCH-25.5* MCHC-31.3 RDW-15."
6311,"C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days: titrate as clinically indicated.
Disp:*20 Tablet(s)* Refills:*2*
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
2.5mg MTWFS, 5mg on Sunday and Thursday for atrial fibrillation,
INR goal of [**1-5**]."
6312,"When to Call Your Surgeon
Call your surgeon ([**Telephone/Fax (1) 1504**] (24 hours a day, seven days a
week) if any of the following occur:
* Your incision is warm, red or swollen or there is increased
tenderness or pain
* Any of your incisions have ANY fluid or drainage coming out
* You have a fever of 100.5 degrees Fahrenheit or higher
* Your weight has gone up more than two pounds in one day or
five pounds in a week
* You have severe pain or increased swelling in either leg
* You have palpitations
* You feel dizzy or weak (if severe, call 911)
* You notice any of the following, especially if you are on
warfarin (Coumadin)
o A lot of dark, large bruises
o Black or dark bowel movements
o Pain, discomfort or swelling in any area, especially after an
injury
o Severe or unusual headache (if symptoms are severe, please
call 911)
Discharge Condition: Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Medications/Orders:
No Saved Discharge Medications/Orders
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 46763**] in [**12-4**] weeks [**Telephone/Fax (1) 68971**]
Cardiologist Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 80567**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2156-12-14**]"
6313,"1/40.0/1.4, Lactic Acid:1.7 mmol/L,
Ca:9.0 mg/dL, Mg:2.2 mg/dL, PO4:6.1 mg/dL
Assessment and Plan
VALVE REPLACEMENT, AORTIC BIOPROSTHETIC (AVR)
Assessment and Plan: 80F s/p Redo sternotomy/AVR(#21 St. [**Male First Name (un) 1104**] tissue)
[**2156-12-8**]
Neurologic: Pain controlled, Change morphine to Vicodin PRN. Minimize
opioids.
Cardiovascular: Aspirin, Beta-blocker, Statins
Pulmonary: IS, OOB / Chest PT and wean FiO2. PT consult. Sleep
consult for OSA.
Gastrointestinal / Abdomen: standard bowel regimen.
Nutrition: Regular diet, Advance diet as tolerated
Renal: Foley, Adequate UO, Cont lasix for diuresis for goal 1 liter
negative today.
Hematology: Mod anemia --> cont to follow with diuresis.
Endocrine: RISS
Infectious Disease: Periop antibx.
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: CT surgery
Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2156-12-8**] 03:37 PM
Prophylaxis:
DVT:
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: Transfer to floor
Total time spent: 31 minutes
Patient is critically ill"
6314,"CVICU
HPI:
HD12 POD 2-Redo sternotomy/AVR(#21 St. [**Male First Name (un) 1104**] tissue)
Ejection Fraction:>65%
Hemoglobin A1c:5.3
Pre-Op Weight:267.86 lbs 121.5 kgs
Baseline Creatinine:1.0
PMHX: Hypertension,Hyperlipidemia,Aortic Stenosis,H/o Endocarditis from
PPM wire infection s/p MV repair [**2151**],Atrial Fibrillation s/p sucessful
DCCV [**2156-11-9**],SSS s/p DDD pacemaker [**9-5**],Moderate Pulmonary
Hypertension,Barrett's esophagus,Cervical CA,CVA per patient [**10-7**]
without residual,Pacemaker wire infection [**10-7**],Chronic Back pain,
Arthritis
----------------------------------------------------------------
PSHx:
s/p Mitral valve repair [**11/2152**],s/p DDD Pacemaker([**Company 346**]
Enpulse) [**11-6**],s/p Left CEA,s/p Bilateral knee replacements 10 years
ago,s/p Tonsillectomy,s/p Appendectomy,s/p Hysterectomy
----------------------------------------------------------------
[**Last Name (un) **]:
Diltiazem HCL 240',Hydrochlorothiazide 25',Irbesartan 300',Metoprolol
Tartrate 50"",Omeprazole 20',Propafenone 225"",Simvastatin 20',Warfarin
2."
6315,"m.
Tmax: 38.3
C (100.9
T current: 35.7
C (96.3
HR: 70 (70 - 97) bpm
BP: 114/35(56) {114/34(55) - 124/41(61)} mmHg
RR: 16 (16 - 34) insp/min
SPO2: 98%
Heart rhythm: A Paced
Wgt (current): 131 kg (admission): 122 kg
Height: 66 Inch
CVP: 7 (4 - 23) mmHg
PAP: (50 mmHg) / (11 mmHg)
CO/CI (Thermodilution): (5.92 L/min) / (2.6 L/min/m2)
SVR: 730 dynes*sec/cm5
SV: 85 mL
SVI: 37 mL/m2
Total In:
2,346 mL
PO:
360 mL
Tube feeding:
IV Fluid:
1,986 mL
Blood products:
Total out:
2,752 mL
905 mL
Urine:
2,152 mL
805 mL
NG:
250 mL
Stool:
Drains:
Balance:
-406 mL
-905 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 304 (304 - 423) mL
PS : 5 cmH2O
RR (Spontaneous): 33
PEEP: 0 cmH2O
FiO2: 60%
RSBI: 86
PIP: 6 cmH2O
SPO2: 98%
ABG: 7."
6316,"37/43/81.[**Numeric Identifier **]/27/0
Ve: 11.9 L/min
PaO2 / FiO2: 137
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
253 K/uL
8.1 g/dL
107 mg/dL
1.3 mg/dL
27 mEq/L
4.6 mEq/L
25 mg/dL
104 mEq/L
138 mEq/L
25."
6317,"8 %
18.8 K/uL
[image002.jpg]
[**2156-12-8**] 03:21 PM
[**2156-12-8**] 07:34 PM
[**2156-12-8**] 08:47 PM
[**2156-12-8**] 10:04 PM
[**2156-12-9**] 12:02 AM
[**2156-12-9**] 01:50 AM
[**2156-12-9**] 06:39 AM
[**2156-12-9**] 10:52 AM
[**2156-12-9**] 06:05 PM
[**2156-12-10**] 02:30 AM
WBC
18.1
18.8
Hct
29.6
27.1
25.8
Plt
271
253
Creatinine
0.9
1.3
TCO2
28
24
23
25
24
22
26
Glucose
107
134
122
112
142
119
96
107
Other labs: PT / PTT / INR:16."
6318,"5mg po daily Mon, Tues, Wed, Fri, Sat,Warfarin 5mg po q Sun and
Thurs,Aspririn 81',Multivitamin'
Current medications:
Acetaminophen 5. Albuterol-Ipratropium 6. Albuterol 0.083% Neb Soln 7.
Aspirin EC
8. Calcium Gluconate 9. Ciprofloxacin HCl 10. Dextrose 50% 11.
Dexmedetomidine 12. Docusate Sodium
13. Furosemide 14. HydrALAzine 15. Insulin 16. Ketorolac 17. Magnesium
Sulfate 18. Metoclopramide
19. Metoprolol Tartrate 20. Milk of Magnesia 21. Morphine Sulfate 22.
Nitroglycerin 23. Nitroprusside Sodium
24. Omeprazole 25. Oxycodone-Acetaminophen 26. Phenylephrine 27.
Potassium Chloride 28. Simvastatin
31. Vancomycin
24 Hour Events:
EXTUBATION - At [**2156-12-9**] 11:00 AM
INVASIVE VENTILATION - STOP [**2156-12-9**] 11:00 AM
ARTERIAL LINE - STOP [**2156-12-10**] 01:27 AM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2156-12-9**] 07:03 PM
Ciprofloxacin - [**2156-12-9**] 09:06 PM
Infusions:
Other ICU medications:
Omeprazole (Prilosec) - [**2156-12-9**] 02:44 PM
Morphine Sulfate - [**2156-12-9**] 11:44 PM
Furosemide (Lasix) - [**2156-12-10**] 03:00 AM
Other medications:
Flowsheet Data as of [**2156-12-10**] 06:12 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**58**] a."
6319,"CVICU
HPI:
HD15 POD 5-Redo sternotomy/AVR(#21 St. [**Male First Name (un) 1104**] tissue)
Ejection Fraction:>65%
Hemoglobin A1c:5.3
Pre-Op Weight:267.86 lbs 121.5 kgs
Baseline Creatinine:1.0
PMHX: Hypertension,Hyperlipidemia,Aortic Stenosis,H/o Endocarditis from
PPM wire infection s/p MV repair [**2151**],Atrial Fibrillation s/p sucessful
DCCV [**2156-11-9**],SSS s/p DDD pacemaker [**9-5**],Moderate Pulmonary
Hypertension,Barrett's esophagus,Cervical CA,CVA per patient [**10-7**]
without residual,Pacemaker wire infection [**10-7**],Chronic Back pain,
Arthritis, s/p Mitral valve repair [**11/2152**],s/p DDD
Pacemaker([**Company 346**] Enpulse) [**11-6**],s/p Left CEA,s/p Bilateral knee
replacements 10 years ago,s/p Tonsillectomy,s/p Appendectomy,s/p
Hysterectomy
[**Last Name (un) **]:Diltiazem HCL 240',Hydrochlorothiazide 25',Irbesartan
300',Metoprolol Tartrate 50"",Omeprazole 20',Propafenone
225"",Simvastatin 20',Warfarin 2."
6320,"m.
Tmax: 36.9
C (98.5
T current: 36.7
C (98
HR: 80 (70 - 86) bpm
BP: 130/56(75) {93/34(45) - 153/94(127)} mmHg
RR: 22 (13 - 26) insp/min
SPO2: 96%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 125.3 kg (admission): 122 kg
Height: 66 Inch
Total In:
990 mL
250 mL
PO:
940 mL
150 mL
Tube feeding:
IV Fluid:
50 mL
100 mL
Blood products:
Total out:
2,290 mL
555 mL
Urine:
2,290 mL
555 mL
NG:
Stool:
Drains:
Balance:
-1,300 mL
-305 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 96%
ABG:
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Irregular)
Respiratory / Chest: (Breath Sounds: Crackles : at bases, Diminished:
at bases)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3)
Labs / Radiology
400 K/uL
7."
6321,"Chronic Afib
Pulmonary: IS, OOB/IS/DB
Gastrointestinal / Abdomen:
Nutrition: Regular diet, Good po intake
Renal: Foley, D/C foley at midnight tonight. Cont lasix 40 IV BID x 1
more day. Crea improved, BUN stable
Hematology: Hct slowly decreasing. Start FeSo4 and recheck in am.
Cont Coumadin for chronic Afib
Endocrine: RISS
Infectious Disease: Afebrile, WBC decreasing
Lines / Tubes / Drains: Foley
Wounds: Dry dressings
Imaging: CXR today, pending
Fluids: KVO
Consults: P.T.
ICU Care
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2156-12-8**] 03:37 PM
Prophylaxis:
Stress ulcer: PPI
Communication: Patient discussed on interdisciplinary rounds , ICU
Disposition: Transfer to floor"
6322,"6 g/dL
79 mg/dL
1.0 mg/dL
36 mEq/L
3.6 mEq/L
35 mg/dL
99 mEq/L
142 mEq/L
24.4 %
10.1 K/uL
[image002.jpg]
[**2156-12-9**] 12:02 AM
[**2156-12-9**] 01:50 AM
[**2156-12-9**] 06:39 AM
[**2156-12-9**] 10:52 AM
[**2156-12-9**] 06:05 PM
[**2156-12-10**] 02:30 AM
[**2156-12-10**] 08:11 AM
[**2156-12-11**] 03:24 AM
[**2156-12-12**] 03:56 AM
[**2156-12-13**] 02:58 AM
WBC
18.1
18.8
16."
6323,"5
13.2
10.1
Hct
27.1
25.8
25.7
25.6
24.4
Plt
271
253
273
327
400
Creatinine
0.9
1.3
1.3
1.3
1.0
TCO2
25
24
22
26
30
Glucose
112
142
119
96
107
104
92
79
Other labs: PT / PTT / INR:16.1/40.3/1.4, Lactic Acid:1.7 mmol/L,
Ca:8.5 mg/dL, Mg:1.8 mg/dL, PO4:3.9 mg/dL
Assessment and Plan
80F s/p Redo sternotomy/AVR(#21 St. [**Male First Name (un) 1104**] tissue) [**2156-12-8**]
Neurologic: Pain controlled, Ultram only for pain
Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,
Titrate lopressor as tolerated."
6324,"5mg po daily Mon, Tues, Wed, Fri,
Sat,Warfarin 5mg po q Sun and Thurs,Aspririn 81',Multivitamin'
Current medications:
Acetaminophen Albuterol-Ipratropium Albuterol 0.083% Neb Soln Aspirin
EC Docusate Sodium Furosemide Heparin HydrALAzine Magnesium Sulfate
Metoclopramide Metoprolol Tartrate Milk of Magnesia Omeprazole
Potassium Chloride Simvastatin TraMADOL (Ultram) Warfarin
24 Hour Events:
Mental status conts to improve
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2156-12-13**] 04:06 AM
Furosemide (Lasix) - [**2156-12-13**] 08:06 AM
Other medications:
Flowsheet Data as of [**2156-12-13**] 09:10 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**58**] a."
6325,"Admission Date: [**2134-1-17**] Discharge Date: [**2134-1-24**]
Date of Birth: [**2070-10-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Voltaren
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
AORTIC STENOSIS, DILATED ASCENDING AORTA
Major Surgical or Invasive Procedure:
aortic valve replacement (23MM St. [**Male First Name (un) 923**] Mechanical) [**2134-1-18**]
Graft replacement of ascending aorta [**2134-1-18**]
History of Present Illness:
63 year old male who was undergoing pre-operative cardiac
evaluation for elective total hip arthroplasty. Patient has been
limited due to hip pain. He states he can climb two flights of
stairs slowly. Patient's exercise is not limited by chest pain
or dyspnea but by hip pain."
6326,"During evaluation an echocardiogram
revealed severe aortic stenosis with dilated asc. aorta.
Subsequent cardiac cath revealed similar findings with no
coronary artery disease. In view of these findings he is now
referred for surgical evaluation.
Past Medical History:
Aortic stenosis
h/o Atrial fibrillation
Hyperlipidemia
Venous insufficiency
h/o phlebitis
Asthma
Gastroesophageal reflux disease
Nephrolithiasis
Benign prostatic hypertrophy
Obesity
Osteoarthritis
Mycosis Fungoides->followed by Dr.[**Last Name (STitle) 89680**]
s/p Left total hip [**2129**]
s/p Bilateral vein leg stripping
Social History:
Race: Caucasian
Last Dental Exam: every 6 months
Lives with: wife
Occupation: [**Name (NI) 75297**] cibtroller and works for a realty co."
6327,"Tobacco: Quit 40 years ago
ETOH: 10 glasses of wine/week
Family History:
Family History: non-contributory
Physical Exam:
vs pnd
Pulse: Resp: O2 sat:
B/P Right: Left:
Height: 5'9"" Weight:251.7lbs, 114.2kgs
General: Well-developed man in no acute distress using cane for
walking assistance
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 sSEM III/VI
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: 2+
(B)Varicosities: None [] Severe venous insufficiency changes
bilat
extremities R>L , post."
6328,"28 m2
Indication: Aortic valve disease. Ascending aorta aneurysm.
Intraoperative TEE for AVR + ascending aorta replacement.
ICD-9 Codes: 402.90, 427.31, 441.2, 424.1
Test Information
Date/Time: [**2134-1-18**] at 12:28 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW000-0:00 Machine: siemens 1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.6 cm 0."
6329,"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. CTs and wires were removed on POD 1 and
2 respectively without complication and Coumadin begun on POD 1
for mechanical aortic valve and atrial fibrillation. The patient
was transferred to the telemetry floor for further recovery."
6330,"Discharge Diagnosis:
Aortic stenosis
h/o Atrial fibrillation
Hyperlipidemia
Venous insufficiency
dialated ascending aorta
Asthma
Gastroesophageal reflux disease
Nephrolithiasis
Benign prostatic hypertrophy
Obesity
Osteoarthritis
Mycosis Fungoides->followed by Dr.[**Last Name (STitle) 89680**]
s/p Left total hip [**2129**]
s/p Bilateral vein stripping of LE
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema:2+pitting edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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"
6331,"Peak gradient
across the valve is 10 mm Hg and the mean gradient is 3 mm Hg.
Dr [**Last Name (STitle) **] aware of post bypass findings.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2134-1-18**] 16:38
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2134-1-17**] for Heparin bridge
preoperatively. The patient was brought to the operating room on
[**2134-1-18**] where the patient underwent aortic valve replacement and
ascending graft were performed with 14 minutes of circulatory
arrest."
6332,"6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 5.0 cm
Left Ventricle - Fractional Shortening: *0.19 >= 0.29
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Left Ventricle - Stroke Volume: 79 ml/beat
Left Ventricle - Cardiac Output: 6.13 L/min
Left Ventricle - Cardiac Index: 2.69 >= 2.0 L/min/M2
Aorta - Sinus Level: *4.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm
Aorta - Ascending: *5.1 cm <= 3.4 cm
Aorta - Arch: 2."
6333,"The patient was evaluated by the physical therapy service for
assistance with strength and mobility. On POD 4, the patient
went into rapid atrial fibrillation. This was treated with
amiodarone and he converted to sinus rhythm. It was noted that
the sternal incision had some serosanguinous drainage but no
erythema which resolved on its own by the following day without
intervention. By the time of discharge on POD 6 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. His INR was therapeutic at 2.0 on day of
discharge. The patient was discharged [**2134-1-24**] in good condition
with appropriate follow up instructions."
6334,"[**Last Name (STitle) 2912**] on [**2-18**] at 2pm ([**Telephone/Fax (1) 89685**]
Please call to schedule appointments with:
Primary Care: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP in [**2-23**] 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**
Labs: PT/INR for Coumadin - mechanical aortic valve
Goal INR 2-2.5
First draw [**2134-1-25**]
Results to the office of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(3) **]:([**Telephone/Fax (1) 89684**].
Plan confirmed with Ms. [**Last Name (Titles) **]
Completed by:[**2134-1-24**]"
6335,"Wean
off as able. .
Disp:*50 Tablet(s)* Refills:*0*
6. Pravachol 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: Take 400mg(2 tablets) twice a day for 1
week.
Then take 400mg(2 tablets) once a day for 1 week.
Then take 200mg(1 tablet)once a day for 1 week. Follow up with
Cardiologist to discuss continuing or discontinuing amiodarone.
.
Disp:*60 Tablet(s)* Refills:*0*
8. warfarin 5 mg Tablet Sig: MD to order daily dose Tablet PO
once a day: Please take 7."
6336,"2 Cl-99 HCO3-29 AnGap-13
[**2134-1-17**] 07:33PM BLOOD ALT-17 AST-22 LD(LDH)-236 AlkPhos-61
Amylase-78 TotBili-1.2
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 89681**]
Reason: eval aorta/retrosternal space
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with severe AS/dilated aorta
REASON FOR THIS EXAMINATION:
eval aorta/retrosternal space
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Evaluate aorta and retrosternal space.
TECHNIQUE: Axial non-contrast imaging was performed from the
lung apices to
upper abdomen.
FINDINGS: The ascending aorta is dilated, maximally measuring
5.2 cm;
however, no contrast was given to further evaluate."
6337,"INRs to be drawn Monday, Wednesday, Friday for the first 2
weeks, then at the discretion of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP.
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks: Please do
not drive or operate heavy machinery while taking this
medication. Take stool softeners to prevent constipation."
6338,"0
[**2134-1-17**] 07:33PM BLOOD Plt Ct-180
[**2134-1-18**] 06:20AM BLOOD PTT-31.7
[**2134-1-18**] 03:10PM BLOOD PT-14.6* PTT-30.8 INR(PT)-1.3*
[**2134-1-18**] 03:10PM BLOOD Plt Ct-103*
[**2134-1-18**] 06:00PM BLOOD PT-14.4* PTT-31.1 INR(PT)-1.3*
[**2134-1-18**] 06:00PM BLOOD Plt Ct-212#
[**2134-1-19**] 04:03AM BLOOD Plt Ct-155
[**2134-1-20**] 03:23AM BLOOD PT-12.3 INR(PT)-1.0
[**2134-1-20**] 03:23AM BLOOD Plt Ct-96*
[**2134-1-21**] 03:13AM BLOOD PT-12."
6339,"Critical AS (area
<0.8cm2). Mild to moderate ([**11-22**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: No TS. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient.
Conclusions
Prebypass
Prebypass study performed by Dr [**Last Name (STitle) 168**]."
6340,"9 Na-136
K-4.4 Cl-104 HCO3-22 AnGap-14
[**2134-1-20**] 03:23AM BLOOD Glucose-137* UreaN-22* Creat-1.2 Na-137
K-4.5 Cl-104 HCO3-28 AnGap-10
[**2134-1-21**] 03:13AM BLOOD Glucose-131* UreaN-28* Creat-1.3* Na-139
K-4.8 Cl-104 HCO3-27 AnGap-13
[**2134-1-22**] 03:45AM BLOOD Glucose-108* UreaN-31* Creat-1.2 Na-138
K-4.1 Cl-102 HCO3-30 AnGap-10
[**2134-1-23**] 04:54AM BLOOD Glucose-108* UreaN-28* Creat-1.1 Na-137
K-4."
6341,"There is critical
aortic valve stenosis (valve area <0.8cm2). Mild to moderate
([**11-22**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**2134-1-18**] at 1130am.
Post bypass
Post bypass study performed by Dr [**First Name (STitle) 1510**]
[**Name (STitle) **] is AV paced and receiving an infusion of phenylephrine.
LVEF=40%. Mechanical valve seen in the aortic position. The
valve appears well seated and the leaflets move well. Washing
jets typical for this type of valve is seen."
6342,"Medications on Admission:
***Coumadin 5 mg MWFSat and 7.5mg TuesThurSun***
Pravachol 20mg daily
Acetaminophen 975mg prn
Vitamin D 1000 untis daily
Zantac 150mg qhs
Flucocinonide cream
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
2. Outpatient [**Name (NI) **] Work
PT/INR for Coumadin - mechanical aortic valve
To be drawn on [**2134-1-25**]
Goal INR 2-2.5
Results to the office of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(3) **]:([**Telephone/Fax (1) 89684**].
Plan confirmed with Ms. [**Last Name (Titles) **]"
6343,"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 on [**Hospital Ward Name 121**] 6 with a midlevel provider on Tuesday [**2-2**]
@ 10:30am
-Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2134-2-11**] At 1pm
-Cardiologist:Dr."
6344,"IMPRESSION: The ascending aorta is dilated measuring 5.2 cm.
Aortic valve
calcification.
The study and the report were reviewed by the staff radiologist.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 89682**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 89683**] (Complete)
Done [**2134-1-18**] at 12:28:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2070-10-6**]
Age (years): 63 M Hgt (in): 69
BP (mm Hg): 134/67 Wgt (lb): 253
HR (bpm): 78 BSA (m2): 2."
6345,"Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Moderately dilated LV
cavity. Moderately depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV
systolic function.
AORTA: Mildy dilated aortic root. Moderately dilated ascending
aorta Normal aortic arch diameter. Normal descending aorta
diameter.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets."
6346,"2 INR(PT)-1.0
[**2134-1-22**] 03:45AM BLOOD PT-14.7* PTT-29.2 INR(PT)-1.3*
[**2134-1-23**] 04:54AM BLOOD PT-18.4* PTT-70.2* INR(PT)-1.7*
[**2134-1-24**] 09:48AM BLOOD PT-21.3* PTT-57.6* INR(PT)-2.0*
[**2134-1-17**] 07:33PM BLOOD Glucose-106* UreaN-23* Creat-1.2 Na-139
K-4.2 Cl-102 HCO3-25 AnGap-16
[**2134-1-18**] 06:00PM BLOOD UreaN-20 Creat-0.8 Na-138 K-4.3 Cl-110*
HCO3-22 AnGap-10
[**2134-1-19**] 04:03AM BLOOD Glucose-114* UreaN-16 Creat-0."
6347,"Significant
aortic valve
calcification is present. Calcification of the left anterior
descending
artery is present. Minor pericardial thickening is noted. The
mediastinal
structures are otherwise normal with normal retrosternal space.
No enlarged
mesenteric lymph nodes.
Minor pleural thickening is noted along the right lateral margin
adjacent to
the right lower lobe with associated pleural bands, likely
related to a
previous effusion. The lung parenchyma is otherwise normal.
In the upper abdomen, nonobstructive calculi are noted in both
kidneys.
Pancreatic atrophy is also present. Bone review demonstrates
significant
degenerative changes. There is loss of height of T11, likely an
old wedge
compression fracture."
6348,"8 RBC-3.02* Hgb-10.2* Hct-29.6*
MCV-98 MCH-33.8* MCHC-34.5 RDW-13.7 Plt Ct-117*
[**2134-1-22**] 03:45AM BLOOD WBC-7.2 RBC-2.64* Hgb-9.0* Hct-25.6*
MCV-97 MCH-34.1* MCHC-35.0 RDW-13.5 Plt Ct-148*
[**2134-1-23**] 04:54AM BLOOD WBC-6.6 RBC-2.80* Hgb-9.2* Hct-27.2*
MCV-97 MCH-32.9* MCHC-33.8 RDW-13.7 Plt Ct-195
[**2134-1-17**] 07:33PM BLOOD PT-12.3 PTT-21.1* INR(PT)-1."
6349,"4 RBC-3.71* Hgb-12.1* Hct-35.9*
MCV-97 MCH-32.6* MCHC-33.7 RDW-13.5 Plt Ct-212#
[**2134-1-18**] 09:36PM BLOOD Hct-31.4*
[**2134-1-19**] 04:03AM BLOOD WBC-8.6 RBC-3.35* Hgb-10.8* Hct-32.6*
MCV-97 MCH-32.2* MCHC-33.1 RDW-13.9 Plt Ct-155
[**2134-1-20**] 03:23AM BLOOD WBC-7.8 RBC-3.07* Hgb-10.0* Hct-29.8*
MCV-97 MCH-32.6* MCHC-33.6 RDW-13.9 Plt Ct-96*
[**2134-1-21**] 03:13AM BLOOD WBC-8."
6350,"5mg today [**1-24**] and have your INR drawn
tomorrow [**1-25**] with results called to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP--she will
determine tomorrow's dose. .
Disp:*60 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA and Hospice of Northern [**Hospital1 **],Inc."
6351,"No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. Overall left ventricular systolic
function is moderately depressed (LVEF= 35-40% %). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The aortic root is mildly dilated at the sinus
level. The ascending aorta is moderately dilated. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are severely thickened/deformed."
6352,"6 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *75 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 58 mm Hg
Aortic Valve - LVOT VTI: 16
Aortic Valve - LVOT diam: 2.5 cm
Mitral Valve - Pressure Half Time: 65 ms
Mitral Valve - MVA (P [**11-22**] T): 3.4 cm2
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A ratio: 1.50
Mitral Valve - E Wave deceleration time: 223 ms 140-250 ms"
6353,"varicosities noted
Neuro: Grossly intact [X]
Pulses:
Femoral Right: Left:
DP Right: NP Left: NP
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ Left: 2+
Carotid Bruit-none , pulses= Right: 2+ Left: 2+
Pertinent Results:
[**2134-1-17**] 07:33PM BLOOD WBC-6.0 RBC-4.73 Hgb-15.3 Hct-46.2 MCV-98
MCH-32.4* MCHC-33.2 RDW-13.8 Plt Ct-180
[**2134-1-18**] 03:10PM BLOOD WBC-7.2 RBC-3.42*# Hgb-11.2*# Hct-33.3*#
MCV-98 MCH-32.7* MCHC-33.5 RDW-13.5 Plt Ct-103*
[**2134-1-18**] 06:00PM BLOOD WBC-9."
6354,"Admission Date: [**2143-4-4**] Discharge Date: [**2143-4-8**]
Service: CARDIOTHORACIC
Allergies:
Ibuprofen / Oxycodone Hcl/Acetaminophen / Aspirin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional chest pain and dyspnea on exertion.
Major Surgical or Invasive Procedure:
Aortic valve replacement(27-mm [**Company 1543**] mosaic ultra aortic
valve bioprosthesis) and Coronary artery bypass grafting
x3(LIMA-LAD,SVG-diag 1,SVG-diag 2),Patch bovine pericardial
aortoplasty.
History of Present Illness:
This is a 87 year old male with known severe aortic stenosis and
multivessel
coronary artery disease orginally seen 3 years ago. She states
over the last 5 months he has developed chest pain and dyspnea
on exertion."
6355,"He was referred for surgical evaluation and was
admitted now for this.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
h/o bleeding gastric ulcer
h/o bleeding cecal arteriovenous malformation
Hypertension
Dyslipidemia
Diverticulosis
Rheumatic fever
Pulmonary Hypertension
Axillary Adenopathy
Cholelithiasis
Social History:
Lives alone. Two daughters. Denies tobacco and EtOH.
Family History:
non contributory
Physical Exam:
Admission:
Pulse: 54 Resp: 16 O2 sat: 99%
B/P Right: 146/51 Left: 137/79
Height: 5'8"" Weight: 179
General: well-developed obese elderly male 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 [**2-2**]
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 [X]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+"
6356,"8* PTT-36.9* INR(PT)-1.2*
[**2143-4-8**] 04:45AM BLOOD UreaN-20 Creat-1.0 K-3.9
[**2143-4-7**] 03:40AM BLOOD Glucose-104* UreaN-22* Creat-1.1 Na-135
K-3.7 Cl-101 HCO3-27 AnGap-11
[**2143-4-4**] 02:35PM BLOOD UreaN-14 Creat-0.8 Cl-112* HCO3-23
[**2143-4-8**] 04:45AM BLOOD Mg-2.1
Brief Hospital Course:
Following admission he was taken to the Operating Room where
revascularization was accomplished. See operative note for
details. He weaned from bypass on Epinephrine
and Propofol. He remained stable, weaned from pressors and the
ventilator easily and was begun on beta blockers and diuretics
as usual."
6357,"Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]"
6358,"12. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 6930**] Skilled Nursing and Rehabilitation Center - [**Hospital1 6930**]
Discharge Diagnosis:
Aortic Stenosis
Coronary Artery Disease
h/o Bleeding gastric ulcer
h/o bleeding cecal arteriovenous malformation
Hypertension
Dyslipidemia
Diverticulosis
Rheumatic fever
Pulmonary Hypertension
Axillary Adenopathy-benign
Cholelithiasis
Discharge Condition:
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions: clean and dry"
6359,"**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:
Surgeon: Dr.[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on Tuesday, [**5-7**] at 1:30pm
Please call to schedule appointments with:
Primary Care: Dr.[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 19980**]in [**12-1**] weeks
Cardiologist: Dr. [**Last Name (STitle) **] in [**12-1**] 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**
Completed by:[**2143-4-8**]"
6360,"He did have brief rapid atrial fibrillation which
converted to sinus with Amiodarone.
Ph6ysical therapy worked eith him for mobility and strength. He
was felt to be an appropriate candidate for rehabilitation and
arrangemnents were made for this. he was transferred to
[**Hospital 71164**] Rehab on POD 4. Wounds were clean and healing well.
Discharge instructions, medications and follow up were sent with
the patient.
Medications on Admission:
Lipitor 40mg qd
Hydrocodone-Acetaminophen 5-500mg q6 prn
Omeprazole 40mg qd
Diovan 80mg qd
Colace 100mg [**Hospital1 **]
Fish oil
Vitamin D
Nystatin cream
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day)."
6361,"Disp:*50 Tablet(s)* Refills:*0*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Amiodarone 200 mg Tablet Sig: see below Tablet PO see below
for 4 weeks: two tablets twice daily for two weeks, then one
tablet twice daily for two weeks, then stop."
6362,"2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks."
6363,"Carotid Bruit Right/Left: -
Pertinent Results:
[**2143-4-8**] 04:45AM BLOOD WBC-12.1* RBC-3.35* Hgb-9.0* Hct-27.9*
MCV-83 MCH-26.9* MCHC-32.3 RDW-16.2* Plt Ct-314
[**2143-4-7**] 03:40AM BLOOD WBC-14.6* RBC-3.23* Hgb-9.4* Hct-26.6*
MCV-82 MCH-29.0 MCHC-35.2* RDW-16.6* Plt Ct-243
[**2143-4-4**] 12:45PM BLOOD WBC-25.5*# RBC-2.50*# Hgb-6.7*#
Hct-21.0*# MCV-84 MCH-26.7* MCHC-31.8 RDW-16.2* Plt Ct-311
[**2143-4-4**] 02:35PM BLOOD PT-13."
6364,"The hypodense area
appears to be a jejunal loop; however, hematoma or postop collection
cannot be excluded. Multiple hypodense liver lesions in both lobes of
iver, one in segment II appears to be new. 3. Sml bilateral pleural
effusions w/ incr dependent atelectasis vs. infiltrate in RLL. Min
atelectasis in Lt base. Lg bladder calculus. diverticulosis w/o evid of
diverticulitis.
[**8-1**] CTA PE Protocol: No PE or acute aortic abnormality. Bilateral
pleural effusions, right greater than left, with fluid tracking into
the fissures, which could be loculated. Associated atelectasis is also
present.
Chief complaint:
respiratory failure
PMHx:
PMH:HTN, hlipid, tics&polyps, breast ca [**2158**] s/p L mast, osteopenia,
panc cyst, esophagitis, hypothyroidism, colitis s/p partial colectomy,
arthritis, urin incont
Current medications:
1."
6365,"8 g/dL, LDH:181 IU/L,
Ca:8.5 mg/dL, Mg:2.2 mg/dL, PO4:4.6 mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**]), SEPSIS WITHOUT ORGAN
DYSFUNCTION
secondary to anastamotic leak, [**Last Name 9**] PROBLEM - ENTER DESCRIPTION IN
COMMENTS
pancreatic mass
Assessment and Plan:
Neurologic: pain controlled
Cardiovascular: will increase BP parameters for hydralizine, no
evidence of ischemia on EKG orECHO or labs
Pulmonary: CTA shows negative for PE, positive for RLL atelectasis and
small effusion, risk of thoracentesis not waranted. Will try
aggressive PT, bronchodilators, mucomyst, and will bronch as necessary
Gastrointestinal / Abdomen: cont goal feeds through Jtube
Nutrition: tube feeds at goal
Renal: cont lasix gtt to keep overall I/O negative.
Hematology: stable
Endocrine: RISS, Regular insulin
Infectious Disease: fluc for oral and cutaneous fungal
Lines / Tubes / Drains: Foley, J-Tube, Trach, Surgical drains (hemovac,
JP), a-line
Wounds: clean dry intact
Imaging: CXR today
Fluids: KVO
Consults: General surgery
Billing Diagnosis: Other: resp failure
ICU Care
Nutrition:
Impact (Full) - [**2188-8-2**] 12:17 AM 50 mL/hour
Glycemic Control:
Lines:
PICC Line - [**2188-7-31**] 12:30 PM
20 Gauge - [**2188-8-2**] 12:35 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
Total time spent: 30 min"
6366,"m.
Tmax: 37.1
C (98.7
T current: 36.4
C (97.5
HR: 83 (56 - 85) bpm
BP: 182/63(102) {104/40(57) - 197/74(115)} mmHg
RR: 27 (16 - 34) insp/min
SPO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 100.7 kg (admission): 86.3 kg
Height: 67 Inch
Total In:
3,438 mL
613 mL
PO:
Tube feeding:
993 mL
380 mL
IV Fluid:
1,567 mL
123 mL
Blood products:
100 mL
50 mL
Total out:
1,870 mL
920 mL
Urine:
1,860 mL
920 mL
NG:
Stool:
Drains:
10 mL
Balance:
1,568 mL
-307 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 290 (290 - 497) mL
PS : 10 cmH2O
RR (Spontaneous): 25
PEEP: 5 cmH2O
FiO2: 60%
RSBI Deferred: FiO2 > 60%
PIP: 15 cmH2O
SPO2: 95%
ABG: 7."
6367,"; acute hypotensive
episode x 1 with spontaneous return, CTA PE - negative, BL atelectasis
with R>L effusions, secretions reduced from previous but present; Echo
- nl ef, no gross abnormalities; Cards consulted - no changes;
increased Fi02 to 60% for improved oxygenation; acetazolamide started
.
IMAGING:[**7-18**] CT chest: 1. Negative examination for PE.
2. Bibasilar consolidations, probably 2' atelectasis, but
infection/aspiration cannot be excluded. Minimal pleural effusion. 3.
ETT end impinges lat ant wall of the trachea. Suggest reposition. 4.
Coronary calcifications. 5. Enlarged heart size, esp LV
6. Unchanged appearance of the liver hypodense lesion, likely cyst.
[**7-22**] CT abd: hypodense area adjacent to the pancreaticojejunostomy that
cannot be evaluated well without oral contrast."
6368,"2. 500 mL NS 3. Acetylcysteine 20% 4. AcetaZOLamide 5. Acetaminophen
6. Albuterol 0.083% Neb Soln
7. Albumin 25% (12.5g / 50mL) 8. Bisacodyl 9. Calcium Gluconate 10.
Chlorhexidine Gluconate 0.12% Oral Rinse
11. Fluconazole 12. Furosemide 13. Furosemide 14. HYDROmorphone
(Dilaudid) 15. Heparin 16. Heparin Flush (10 units/ml)
17. HydrALAzine 18. 19. Insulin 20. Levothyroxine Sodium 21.
Metoclopramide 22. Metoprolol Tartrate
23. Miconazole Powder 2% 24. Midazolam 25. Midazolam 26. Octreotide
Acetate 27. Pantoprazole 28. Phenaseptic Throat Spray
29. Potassium Chloride 30. Sodium Chloride 0.9% Flush
24 Hour Events:
[**8-1**] CTA PE Protocol: No PE or acute aortic abnormality."
6369,"SICU
HPI:
HPI:73F with panc mass by imaging, now s/p classical Whipple [**7-16**].
admitted to SICU with hypoxic resp distress, likely secondary to
anastomatic leak with ?sepsis
[**7-18**]: CTA neg for PE , increased PEEP, EKG cardiac enzymes
[**7-19**]: weaning vent [**7-20**]: aline, lasix qtt, TPN, hydralazine prn,
febrile - cx sent [**7-21**]: vanc and zosyn lasix d/ced and then restarted
then d/ced JP Amylase [**Numeric Identifier 495**]; TTE EF 60% RV dilated fever inc insulin in
TPN
[**7-22**]: ct abd - small fluid collection (not drainable), wean fio2
[**7-23**]: decr lopressor, JP cx, wean vent, tighten SSI, cont TPN, incr
insulin to 50, vulvar lesion clean (recent partial vulvectomy [**2188-7-8**])
[**7-24**]: Decrease PEEP, Insulin 65 with TPN [**7-25**]: wound care consult,
added NPH 40/40 [**7-26**]: consult gyn for vulvar lesion
[**7-27**]:wean propofol
[**7-28**]: head ct negative, continue tpn,
[**7-29**]: trach,
[**7-30**]-nasoenteric feeding tube placed by radiology
[**7-31**]: picc placed, CVL removed; increased secretions from trach (02 sat
stable)
[**8-1**]:d/c vanco/cirpo; increased secretions from trach (O2 sat stable),
increased level of agitation--versed gtt inc to 1."
6370,"43/43/90.[**Numeric Identifier 299**]/26/3
Ve: 10.4 L/min
PaO2 / FiO2: 150
Physical Examination
Labs / Radiology
356 K/uL
7.4 g/dL
92 mg/dL
0.8 mg/dL
26 mEq/L
4.4 mEq/L
42 mg/dL
107 mEq/L
140 mEq/L
21.7 %
9.8 K/uL
[image002.jpg]
[**2188-7-31**] 04:00 AM
[**2188-8-1**] 03:30 AM
[**2188-8-1**] 05:05 AM
[**2188-8-1**] 11:59 AM
[**2188-8-1**] 03:48 PM
[**2188-8-1**] 04:08 PM
[**2188-8-1**] 07:35 PM
[**2188-8-1**] 09:09 PM
[**2188-8-2**] 12:38 AM
[**2188-8-2**] 12:49 AM
WBC
12."
6371,"0
10.5
9.8
Hct
24.9
22.0
21.7
Plt
372
370
356
Creatinine
0.7
0.8
0.8
0.8
Troponin T
0.04
0.06
TCO2
29
30
27
28
29
Glucose
87
116
166
177
64
92
Other labs: PT / PTT / INR:19.5/51.7/1.8, CK / CK-MB / Troponin
T:28/6/0.06, ALT / AST:38/34, Alk-Phos / T bili:163/0.4, Amylase /
Lipase:19/25, Differential-Neuts:85.6 %, Lymph:7.3 %, Mono:4.9 %,
Eos:2.0 %, Lactic Acid:1.2 mmol/L, Albumin:2."
6372,"Bilateral
pleural effusions, right greater than left, with fluid tracking into
the fissures, which could be loculated. Associated atelectasis is also
present.
Allergies:
Pravachol (Oral) (Pravastatin Sodium)
Rash;
Lisinopril
Rash;
Last dose of Antibiotics:
Vancomycin - [**2188-7-30**] 08:59 PM
Ciprofloxacin - [**2188-7-30**] 10:31 PM
Infusions:
Furosemide (Lasix) - 2 mg/hour
Midazolam (Versed) - 0.5 mg/hour
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2188-8-1**] 09:00 AM
Furosemide (Lasix) - [**2188-8-1**] 10:25 AM
Hydralazine - [**2188-8-1**] 12:07 PM
Other medications:
Flowsheet Data as of [**2188-8-2**] 08:17 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**91**] a."
6373,"3 g/dL, LDH:181 IU/L,
Ca:9.7 mg/dL, Mg:2.2 mg/dL, PO4:3.3 mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**])
Assessment and Plan:
Neurologic: Neuro checks Q: 4 hr, Pain controlled, Avoid sedation. D/c
dilaudid order as pt receives no medication for pain
Cardiovascular: Stable hemodynamically. Off beta-blockers, no episodes
of asystole in > 48h. Self limiting bradycardia. Per cards, no
intervention needed
Pulmonary: Trach, Tolerating trach collar > 48 hrs, speaking valve,
walking
Gastrointestinal / Abdomen:
Nutrition: Tube feeding
Renal: Adequate UO
Hematology: Serial Hct, Stable anemia
Endocrine: RISS, Glucose well controlled."
6374,"SICU
HPI:
73F with panc mass by imaging, now s/p classical Whipple [**7-16**]. admitted
to SICU with hypoxic resp distress, likely secondary to anastomatic
leak with ?sepsis
Chief complaint:
respiratory failure
PMHx:
HTN, hlipid, tics&polyps, breast ca [**2158**] s/p L mast, osteopenia, panc
cyst, esophagitis, hypothyroidism, colitis s/p partial colectomy,
arthritis, urin incont
Current medications:
IV access: PICC, heparin dependent Location: Right Antecubital Order
date: [**8-12**] @ 0952 16. Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose Order date: [**8-15**] @ 1346
2. Acetaminophen 650 mg PO Q4-6H:PRN Order date: [**7-18**] @ [**2115**] 17."
6375,"5
13.6
Hct
25.0
26.4
26.7
25.8
Plt
354
419
350
322
Creatinine
0.9
0.9
0.9
0.9
0.9
0.8
TCO2
29
Glucose
126
80
155
132
[**Telephone/Fax (2) 921**]1
108
104
Other labs: PT / PTT / INR:14.5/30.3/1.3, CK / CK-MB / Troponin
T:23/6/0.05, ALT / AST:38/34, Alk-Phos / T bili:163/0.4, Amylase /
Lipase:19/25, Differential-Neuts:84.4 %, Lymph:7.8 %, Mono:3.8 %,
Eos:4.0 %, Lactic Acid:1.2 mmol/L, Albumin:3."
6376,"Order date: [**8-12**] @ 0952 28.
Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN. Order date: [**7-18**] @ [**2115**]
14. Heparin 5000 UNIT SC Q12H Order date: [**7-18**] @ [**2115**] 29. Tobramycin
Inhalation Soln 300 mg IH [**Hospital1 **] Order date: [**8-8**] @ 0803
15. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed
by Heparin as above daily and PRN. Order date: [**7-18**] @ [**2115**]
24 Hour Events:
CALLED OUT
none, pt stable
Allergies:
Pravachol (Oral) (Pravastatin Sodium)
Rash;
Lisinopril
Rash;
Last dose of Antibiotics:
Piperacillin - [**2188-8-14**] 02:12 PM
Piperacillin/Tazobactam (Zosyn) - [**2188-8-17**] 04:00 AM
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2188-8-16**] 08:08 PM
Famotidine (Pepcid) - [**2188-8-16**] 08:09 PM
Other medications:
Flowsheet Data as of [**2188-8-17**] 06:18 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**91**] a."
6377,"Levothyroxine Sodium 150 mcg PO DAILY Order date: [**8-11**] @ 0801
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
TO GIVE WITH MUCOMYST Order date: [**7-31**] @ 0819 18. Loperamide 2 mg PO
QID:PRN Order date: [**8-16**] @ 1836
4. Albuterol MDI 8 PUFF IH Q4H:PRN Order date: [**8-3**] @ 0132 19.
Metolazone 5 mg PO DAILY Order date: [**8-11**] @ 0759
5. Bisacodyl 10 mg PR HS:PRN Order date: [**7-24**] @ 1330 20.
Metoclopramide 20 mg IV Q6H Order date: [**8-14**] @ 1224
6. Bisacodyl 10 mg PR DAILY:PRN Order date: [**8-6**] @ 0948 21."
6378,"Keep < 150
Infectious Disease: Check cultures, Inhaled Tobra, Zosyn, Fluconazole
for a total 14/10 days course. ? culturing drain output.
Lines / Tubes / Drains: Dobhoff, Trach, Surgical drains (hemovac, JP)
Wounds: Dry dressings
Imaging:
Fluids: KVO
Consults: General surgery
Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /
Post-op), Post-op complication
ICU Care
Nutrition:
Impact (Full) - [**2188-8-17**] 03:20 AM 50 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2188-7-31**] 12:30 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: Transfer to floor
Total time spent: 10 minutes"
6379,"Famotidine 20 mg PO Q12H Order date: [**8-16**] @ 1017 25. Phenaseptic
Throat Spray 1 SPRY PO Q6H:PRN Order date: [**7-18**] @ [**2115**]
11. Fluconazole 400 mg PO Q24H
stop [**8-21**] Order date: [**8-16**] @ 1017 26. Piperacillin-Tazobactam Na 4.5
g IV Q8H Order date: [**8-8**] @ 0803
12. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN Order date: [**7-20**] @
0924 27. Potassium Chloride IV Sliding Scale Order date: [**8-12**] @ 0753
13. 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."
6380,"9 g/dL
104 mg/dL
0.8 mg/dL
30 mEq/L
3.3 mEq/L
22 mg/dL
99 mEq/L
137 mEq/L
25.8 %
13.6 K/uL
[image002.jpg]
[**2188-8-13**] 05:32 AM
[**2188-8-14**] 03:31 AM
[**2188-8-14**] 10:00 AM
[**2188-8-14**] 04:00 PM
[**2188-8-14**] 10:00 PM
[**2188-8-15**] 03:50 AM
[**2188-8-15**] 10:07 AM
[**2188-8-15**] 06:13 PM
[**2188-8-16**] 03:12 AM
[**2188-8-17**] 03:08 AM
WBC
11.1
16.0
13."
6381,"Miconazole Powder 2% 1 Appl TP QID:PRN Order date: [**7-31**] @ 0310
7. Calcium Gluconate IV Sliding Scale Order date: [**7-21**] @ 0044 22.
Midazolam 0.5 mg IV Q2H:PRN agitation Order date: [**7-31**] @ 0817
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**7-18**] @
2227 23. Midazolam 0.5-2 mg IV ONCE MR2 Order date: [**8-7**] @ 2338
9. Docusate Sodium (Liquid) 100 mg PO BID Order date: [**8-6**] @ 0948 24.
Ondansetron 4 mg IV Q 8H Order date: [**8-13**] @ 1310
10."
6382,"m.
Tmax: 37.1
C (98.7
T current: 36.8
C (98.2
HR: 49 (49 - 83) bpm
BP: 112/52(64) {96/42(58) - 152/72(91)} mmHg
RR: 24 (17 - 26) insp/min
SPO2: 100%
Heart rhythm: SB (Sinus Bradycardia)
Wgt (current): 96.4 kg (admission): 86.3 kg
Height: 67 Inch
Total In:
1,796 mL
408 mL
PO:
Tube feeding:
1,201 mL
308 mL
IV Fluid:
535 mL
100 mL
Blood products:
Total out:
25 mL
0 mL
Urine:
NG:
Stool:
Drains:
25 mL
Balance:
1,771 mL
408 mL
Respiratory support
O2 Delivery Device: Aerosol-cool
SPO2: 100%
ABG: ///30/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),
(Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands
Labs / Radiology
322 K/uL
8."
6383,"SICU
HPI:
73F with panc mass by imaging, now s/p classical Whipple [**7-16**]. admitted
to SICU with hypoxic resp distress, likely secondary to anastomatic
leak with ?sepsis
Chief complaint:
respiratory failure
PMHx:
HTN, hlipid, tics&polyps, breast ca [**2158**] s/p L mast, osteopenia, panc
cyst, esophagitis, hypothyroidism, colitis s/p partial colectomy,
arthritis, urin incont
Current medications:
1. 2. Acetaminophen 3. Bisacodyl 4. Calcium Gluconate 5. Chlorhexidine
Gluconate 0.12% Oral Rinse
6. Ciprofloxacin 7. HYDROmorphone (Dilaudid) 8. Heparin 9. Heparin
Flush (10 units/ml) 10. HydrALAzine
11. 12. Insulin 13. Levothyroxine Sodium 14. Metoprolol Tartrate 15."
6384,"m.
Tmax: 37.2
C (98.9
T current: 36.8
C (98.3
HR: 73 (54 - 100) bpm
BP: 156/58(81) {105/33(49) - 187/82(104)} mmHg
RR: 18 (14 - 29) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 100.7 kg (admission): 86.3 kg
Height: 67 Inch
Total In:
3,407 mL
374 mL
PO:
Tube feeding:
24 mL
93 mL
IV Fluid:
919 mL
37 mL
Blood products:
50 mL
50 mL
Total out:
5,677 mL
235 mL
Urine:
4,187 mL
235 mL
NG:
1,475 mL
Stool:
Drains:
15 mL
Balance:
-2,270 mL
139 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 804 (804 - 804) mL
PS : 15 cmH2O
RR (Spontaneous): 12
PEEP: 5 cmH2O
FiO2: 50%
PIP: 21 cmH2O
SPO2: 98%
ABG: ///29/
Ve: 7."
6385,"8 mg/dL, Mg:2.0
mg/dL, PO4:4.2 mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**]), SEPSIS WITHOUT ORGAN
DYSFUNCTION
secondary to anastamotic leak, [**Last Name 9**] PROBLEM - ENTER DESCRIPTION IN
COMMENTS
pancreatic mass
Assessment and Plan: 73 year old female with sepsis likely secondary to
anastomatic leak.
Neurologic: Midaz gtt
Cardiovascular: Beta-blocker, Metoprolol, change to po today
Pulmonary: Trach, (Ventilator mode: CPAP + PS), Continue CPAP,PS
alternate with TC as tolerated.
Gastrointestinal / Abdomen: Nasoenteric feeding tube started overnight
Nutrition: Tube feeding, Impact 60kg x20 kcal/kg= 1200kcal/day =50kcal
per hour
Impact with Goal of 50
Renal: Foley
Hematology: Stable
Endocrine: RISS, FS 60-80, NPH decreased from 40 to 30 [**Hospital1 **]
Infectious Disease: Vancomycin day 11, Cipro Day7
Lines / Tubes / Drains: Foley, Dobhoff
Wounds:
Imaging: CXR today
Fluids: KVO
Consults:
Billing Diagnosis: Sepsis
ICU Care
Nutrition:
TPN without Lipids - [**2188-7-30**] 06:00 PM 62.5 mL/hour
Impact (Full) - [**2188-7-30**] 11:13 PM 30 mL/hour
Glycemic Control: Regular insulin sliding scale, NPH
Lines:
Multi Lumen - [**2188-7-30**] 12:00 PM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent:"
6386,"8 L/min
Physical Examination
General Appearance: Anxious
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
, Rhonchorous : )
Abdominal: Soft, Non-tender, Bowel sounds present
Left Extremities: (Pulse - Dorsalis pedis: Present)
Right Extremities: (Pulse - Dorsalis pedis: Present)
Neurologic: Follows simple commands, Sedated
Labs / Radiology
372 K/uL
8.2 g/dL
71 mg/dL
0.8 mg/dL
29 mEq/L
3.5 mEq/L
31 mg/dL
108 mEq/L
143 mEq/L
24.3 %
10.2 K/uL
[image002.jpg]
[**2188-7-26**] 05:54 AM
[**2188-7-26**] 04:21 PM
[**2188-7-27**] 03:24 AM
[**2188-7-27**] 03:35 AM
[**2188-7-28**] 02:41 AM
[**2188-7-29**] 04:00 AM
[**2188-7-29**] 04:04 AM
[**2188-7-29**] 04:30 PM
[**2188-7-29**] 04:43 PM
[**2188-7-30**] 03:51 AM
WBC
12."
6387,"4
10.5
9.9
10.2
Hct
26.5
25.3
24.7
24.3
Plt
374
354
359
372
Creatinine
0.5
0.6
0.9
0.8
0.8
TCO2
25
26
30
31
29
Glucose
109
148
112
83
85
71
Other labs: PT / PTT / INR:13.9/26.0/1.2, CK / CK-MB / Troponin
T:863/6/<0.01, ALT / AST:42/19, Alk-Phos / T bili:95/0.4,
Differential-Neuts:85.6 %, Lymph:7.3 %, Mono:4.9 %, Eos:2.0 %, Lactic
Acid:1.2 mmol/L, Albumin:2.3 g/dL, LDH:187 IU/L, Ca:8."
6388,"Metoclopramide 16. Midazolam
17. Midazolam 18. Miconazole Powder 2% 19. Octreotide Acetate 20.
Pantoprazole 21. Phenaseptic Throat Spray
22. Potassium Chloride 23. Sodium Chloride 0.9% Flush 24. Vancomycin
24 Hour Events:
Patient with episode of destaturation overnight, due to mucus plugging.
Responded to suction down trach and lavage. Patient maintained on
increased pressure support (5-->15) after episode of desat to maintain
O2 Sat
Allergies:
Pravachol (Oral) (Pravastatin Sodium)
Rash;
Lisinopril
Rash;
Last dose of Antibiotics:
Vancomycin - [**2188-7-30**] 08:59 PM
Ciprofloxacin - [**2188-7-30**] 10:31 PM
Infusions:
Midazolam (Versed) - 2 mg/hour
Other ICU medications:
Hydralazine - [**2188-7-30**] 06:30 PM
Hydromorphone (Dilaudid) - [**2188-7-30**] 07:01 PM
Pantoprazole (Protonix) - [**2188-7-30**] 08:59 PM
Metoprolol - [**2188-7-31**] 12:31 AM
Other medications:
Flowsheet Data as of [**2188-7-31**] 03:34 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**91**] a."
6389,"Admission Date: [**2188-7-16**] Discharge Date: [**2188-8-21**]
Date of Birth: [**2114-9-29**] Sex: F
Service: SURGERY
Allergies:
Pravachol / Lisinopril
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic Head Mass
Major Surgical or Invasive Procedure:
1. Classical Whipple resection.
2. Open cholecystectomy.
3. Incisional hernia repair (separate procedure).
.
4. Percutaneous tracheostomy placement
.
PICC
Dobhoff Feeding tube
History of Present Illness:
This is a 73 year old female with pancreatic head mass, which is
newly identified incidentally. She came alone to the clinic
today after having seen Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from our oncology
group just yesterday."
6390,"Basically, she was getting a workup for dysphasia. She was
asymptomatic otherwise. The workup led ultimately to
identification of a mass in the head of the pancreas. She has
had no weight loss and no steatorrhea. She has no evidence of
diabetes. She had an ultrasound-guided biopsy performed by
endoscopic ultrasound technique and this has shown cells
suspicious for adenocarcinoma.
Her only GI procedures of late has been the endoscopic
ultrasound performed on the [**2188-7-4**] and this showed biopsy
proven adenocarcinoma. She has not been jaundiced and she has
not required stenting.
Past Medical History:
PMH: HTN, hlipid, tics&polyps, breast ca [**2158**] s/p L mast,
osteopenia, panc cyst, esophagitis, hypothyroidism, colitis s/p
partial colectomy, arthritis, urin incont
PSH: L mast, hysterect, herniorrhaphy w mesh infxn and removal,
partial colectomy."
6391,"SPECIMEN SUBMITTED: fs pancreatic neck margin, gall bladder,
Jejunum, whipple specimen.
Procedure date Tissue received Report Date Diagnosed
by
[**2188-7-16**] [**2188-7-16**] [**2188-7-21**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl
DIAGNOSIS:
I. Gallbladder (A-B):
1. Chronic cholecystitis, mild.
2. Cholelithiasis, cholesterol-type.
II. Jejunum (C-D):
Within normal limits.
III. Pancreatic neck margin (E):
1. Tiny focus of pancreatic intraepithelial neoplasm, low grade
(PanIN I).
2. No invasive carcinoma.
IV. Whipple (F-AR):
1. Adenocarcinoma of the pancreas, see synoptic report.
2. Multiple foci of pancreatic intraepithelial neoplasm, low
grade (PanIN I-II), including the uncinate area."
6392,"6. Diverticulosis without evidence of diverticulitis.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-7-27**] 4:27
AM
Provisional Findings Impression: DJRX SUN [**2188-7-27**] 11:49 AM
Bilateral perihilar densities suspicious for pneumonia.
IMPRESSION: Focal areas of increased density bilaterally
suspicious for
pneumonia. A little interval change
.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2188-7-28**]
12:16 PM
IMPRESSION:
1. No acute intracranial pathology identified.
2. Sinus disease as described above, likely related to chronic
inflammatory
process and/or patient's intubated status; however, correlation
should be made
for any findings to suggest acute sinusitis/mastoiditis."
6393,"Classical Whipple resection.
2. Open cholecystectomy.
3. Incisional hernia repair (separate procedure).
During the case there was some concern about her oxygenation
particularly in the early portion of the operation where she
required 100% oxygen saturation in order
to maintain a appropriate saturation rate level. There is no
evidence of any pneumothorax, and she had a bronchoscopy in the
case which was nonrevealing.
On POD 2, she desaturated on floor and was transferred to the
ICU and reintubated for acute respiratory distress/failure. She
remained in the ICU for 3 weeks. The following summarizes
significant events:
[**7-18**]: CTA neg for PE , increased PEEP, EKG, cardiac enzymes were
negative."
6394,"15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) Subcutaneous twice a day.
16. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection four times a day.
17. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 2 weeks: 2
weeks.
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Adenocarcinoma of the pancreas
Post-op Acute Respiratory Failure / Hypoxia
Post-op Blood Loss Anemia
Post-op Fluid Volume Overload / Pulmonary Hypertension
Post-op Bradycardia / Cardiac Pauses
Post-op Mild oropharyngeal dysphagia
Post-op Pneumonia
Post-op Atelectasis"
6395,"Suggest followup.
Minimal pleural
effusion.
3. Endotracheal tube end impinges lateral anterior wall of the
trachea.
Suggest reposition.
4. Coronary calcifications.
5. Enlarged heart size, especially left ventricle.
6. Unchanged appearance of the liver hypodense lesion, likely
cyst.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-7-20**] 4:46
AM
Final Report
REASON FOR EXAM: Intubated patient, post-Whipple.
Comparison is made with prior study performed the day earlier.
There have
been no interval changes. ET tube is in standard position. Right
IJ catheter
tip is in the SVC. Small bilateral pleural effusions, greater in
the left
side with associated atelectasis and atelectasis in the right
upper lobe are
unchanged as does cardiomegaly and prominent pulmonary arteries."
6396,"Lasix gtt decreased
[**8-11**]: cont diuresis, stopped diamox, started metalozone, fluc
started
[**8-13**]: Tube feeds restarted p MN, NGt was placed for
decompression/evacuation, no asystolic events
[**8-14**]: Pt had FS 57, NPH decreased to 25, 25. Pt self d/c aline
[**8-15**]: passed S/S eval, [**Hospital 71806**] rehab screening, diamox
[**8-20**] CT: resolving stranding, soft tissue atten in
pancreaticojej bed not well-evaluated, but no signif. change,
likely represents loops of jejunum. 3 hypodense LVR lesions not
fully characterized. Peribronchovascular ground glass opacities
may represent infection, inflammation and less likely edema.
.
CARDIOVASCULAR: Due to Bradycardia and pauses, her nodal
blocking agents were held."
6397,"Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 1.7 cm. Specified
margin: Pancreatic neck.
Venous/Lymphatic vessel invasion: Absent.
Perineural invasion: Present.
Additional Pathologic Findings: Pancreatic intraepithelial
neoplasia -- highest grade: PanIN: 2.
Comments: The tumor extends focally into the peripancreatic
adipose tissue. One of the lymph nodes involved with tumor is
due to contiguous spread.
Clinical: Pancreatic cancer.
.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2188-7-18**] 1:38 PM
IMPRESSION:
1. Negative examination for pulmonary embolism.
2. Bibasilar consolidations, probably corresponding to
atelectasis, but
infection/aspiration cannot be excluded."
6398,"Social History:
Retired Teacher
Lives alone
Physical Exam:
98.7/98.7 57 96/47 19 93% on trach mask 50%
f.s. 117-181
Gen: NAD, comfortable
HEENT: PERRL, NCAT
Heart: sinus, no murmur
Chest: crackles bilat, symmetric bs
Abd: soft, NTND, JP in place
ext: min. edema, 2+ pulses throughout
Pertinent Results:
[**2188-7-16**] 07:06PM BLOOD WBC-9.9 RBC-3.67* Hgb-10.6* Hct-30.5*
MCV-83 MCH-29.0 MCHC-34.9 RDW-14.5 Plt Ct-234
[**2188-7-27**] 03:24AM BLOOD WBC-12.4* RBC-3.22* Hgb-9."
6399,"Patient is status post classic Whipple procedure. There is a
hypodense
area adjacent to the pancreaticojejunostomy that cannot be
evaluated well
without oral contrast. The hypodense area appears to be a
jejunal loop;
however, hematoma or postoperative collection cannot be
excluded.
2. Multiple hypodense liver lesions in both lobes of the liver,
one in
segment II appears to be new. Attention will be paid to these
areas on future
studies.
3. Small bilateral pleural effusions with increased dependent
atelectasis
versus infiltrate in the right lower lobe. Minimal atelectasis
in the left
base.
4. Status post abdominal hernia repair.
5. Large bladder calculus."
6400,"2* Hct-26.5*
MCV-82 MCH-28.5 MCHC-34.6 RDW-14.0 Plt Ct-374
[**2188-8-21**] 04:25AM BLOOD WBC-12.7* RBC-3.14* Hgb-8.7* Hct-26.6*
MCV-85 MCH-27.5 MCHC-32.6 RDW-15.7* Plt Ct-376
[**2188-8-19**] 06:42AM BLOOD Glucose-125* UreaN-25* Creat-0.8 Na-139
K-3.8 Cl-98 HCO3-31 AnGap-14
[**2188-8-1**] 03:48PM BLOOD ALT-38 AST-34 LD(LDH)-181 CK(CPK)-29
AlkPhos-163* Amylase-19 TotBili-0.4
[**2188-8-1**] 03:48PM BLOOD Lipase-25
[**2188-8-13**] 05:29AM BLOOD CK-MB-NotDone cTropnT-0."
6401,"Esophageal tube or probe ends in the
upper
stomach, as before.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-8-14**] 4:47
AM
Of note, the patient is markedly rotated. Tracheostomy tube and
right PICC
are in standard positions. NG tube tip is out of view below the
diaphragm.
Bibasilar consolidations consistent with aspiration or pneumonia
are stable.
Opacity in the right upper lobe is more conspicuous in this
examination
could be due to aspiration.
.
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2188-8-19**] 9:47 AM
IMPRESSION: Mild oropharyngeal dysphagia characterized by mildly
reduced
bolus control with thin liquids, and mildly reduced laryngeal
elevation and laryngeal valve closure, resulting in episodes of
penetration during swallow of thin liquids."
6402,"There is no
CHF or new lung abnormalities. NG tube tip is out of view below
the
diaphragm.
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
IMPRESSION: Suboptimal image quality. LVH with preserved
regional and global function. The RV is not well seen but may be
dilated with depressed systolic function. Mild pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of [**2187-7-6**],
the right ventricle appears to be dilated with depressed
function on the current study. Mild pulmonary artery systolic
hypertension is now seen. The other findings are similar.
.
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2188-7-22**]
11:50 AM
IMPRESSION:
1."
6403,"Once transferred
to the floor, she was no longer having pauses and meds were
restarted.
.
Video Swallow:
1. PO intake of thin liquids and regular solids.
2. Pills may be given whole with puree.
3. Aspiration Precautions:
A. Use straws while drinking thin liquids.
B. If drinking by cup, use a chin tuck.
C. Use intermittent cough to help clear any penetration.
D. No mixed consistencies (i.e. cereal, hearty soups).
4. PMV must be in place for all POs.
5. Continue supervision to assist with feeding and monitor
swallow safety.
Medications on Admission:
Alendronate 35 Qwk, atenolol 25', fenofibrate 200', fexofenadine
180', levothyroxine 150mcg', nifedipine 90', valsartan 320', ASA
81', percs, tylenol, B12, Ca +D, naproxen, VitE"
6404,"No pulmonary embolus or acute aortic abnormality.
2. Bilateral pleural effusions, right greater than left, with
fluid tracking
into the fissures, which could be loculated. Associated
compressive
atelectasis demonstrates enhancement, and is not likely to
represent pneumonic
consolidation.
3. Support lines in place.
4. Extensive vascular calcification.
5. Cardiomegaly.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-8-6**] 4:36
AM
IMPRESSION: AP chest compared to [**7-31**]:
Mild pulmonary edema has worsened since [**8-5**]. Large heart
and
generally large and tortuous thoracic aorta are chronic. No
pneumothorax or
pleural effusion. Right subclavian line barely central should be
re-evaluated
by film it is not rotated."
6405,"Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q12H (every 12 hours).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: One (1)
Inhalation [**Hospital1 **] (2 times a day).
4. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed."
6406,"3. Segments of stomach, duodenum, and bile duct; No tumor.
Pancreas (Exocrine): Resection Synopsis
MACROSCOPIC
Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy.
Tumor Site: Pancreatic head.
Tumor Size
Greatest dimension: 2.0 cm. Additional dimensions: 2.0
cm.
Other organs/Tissues Received: Gallbladder, Jejunum.
MICROSCOPIC
Histologic Type: Ductal adenocarcinoma.
Histologic Grade: G2: Moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric artery.
Regional Lymph Nodes: pN1a: Metastasis in single regional
lymph node (see comment).
Lymph Nodes
Number examined: 31.
Number involved: 2.
Distant metastasis: pMX: Cannot be assessed."
6407,"Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* Monitor your incision for signs of infection (redness,
drainage).
* Continue with drain care
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2188-9-12**] at
8:30am.
Completed by:[**2188-8-21**]"
6408,"Lasix gtt increased for
fluid volume overload and pulmonary hypertension
[**8-4**]: up in chair, good sat, lasix 2/hr
[**8-5**]: up in chair, secretions still tend to be substantial, lasix
gtt increased to make the patient negative
[**8-6**]: replaced dobhoff, clonidine patch and PO, versed prn,
increased lasix gtt
[**8-7**]: Recurrent episodes of desaturation, likely secondary to
mucous plugging. Increased Fi02, Aggressive suctioning. Pt also
with episode of vomiting when given large volume KCL down
dobhoff. Feeds held, then restarted. Pt with vagal episode with
vomiting.
[**8-9**]: Dobhoff removed and patient fighting placement, IVF
started while tube feeds off, copious secretions, lasix gtt
increased, diamox frequency increased, albumin level f/u in AM
[**8-10**]: Dobhoff placed."
6409,"Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours."
6410,"05*
[**2188-8-19**] 06:42AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.1
.
Micro:
Date 6 Specimen Tests Ordered By
All [**2188-7-20**] [**2188-7-21**] [**2188-7-23**] [**2188-7-28**] [**2188-7-31**]
[**2188-8-3**] [**2188-8-6**] [**2188-8-8**] [**2188-8-11**] [**2188-8-12**]
[**2188-8-19**] [**2188-8-20**] All BLOOD CULTURE BRONCHOALVEOLAR LAVAGE
CATHETER TIP-IV MRSA SCREEN PERITONEAL FLUID SPUTUM STOOL SWAB
URINE All INPATIENT
[**2188-8-20**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2188-8-19**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY {PSEUDOMONAS AERUGINOSA}; ANAEROBIC
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY INPATIENT
[**2188-8-12**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2188-8-11**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {GRAM NEGATIVE ROD(S)}; FUNGAL CULTURE-PRELIMINARY
INPATIENT
[**2188-8-11**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2188-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-8**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}; FUNGAL
CULTURE-PRELIMINARY INPATIENT
[**2188-8-8**] URINE URINE CULTURE-FINAL INPATIENT
[**2188-8-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA} INPATIENT
[**2188-8-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-3**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}
INPATIENT
[**2188-8-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-7-31**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2188-7-31**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2188-7-28**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
{ENTEROCOCCUS SP."
6411,"} INPATIENT
[**2188-7-23**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {ESCHERICHIA COLI, STAPH AUREUS COAG +}; ANAEROBIC
CULTURE-FINAL INPATIENT
[**2188-7-21**] URINE URINE CULTURE-FINAL INPATIENT
[**2188-7-21**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2188-7-21**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2188-7-21**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2188-7-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +} INPATIENT
[**2188-7-20**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
.
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos
[**2188-8-19**] 03:14AM [**Numeric Identifier 71804**]* 13* 92* 8* 0 Import Result
ASCITES CHEMISTRY Glucose Amylase
[**2188-8-19**] 12:16PM [**Numeric Identifier 71805**] Import Result
[**2188-8-19**] 03:14AM 207 Import Result
[**2188-7-21**] 11:00AM [**Numeric Identifier **] Import Result
OTHER BODY FLUID CHEMISTRY Amylase
[**2188-8-1**] 10:46AM 1652 Import Result
."
6412,".
Pathology:
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric
artery. 2/31 nodes positive. Margins uninvolved by invasive
carcinoma:
No PVI, +perineural invasion.
.
Micro:
[**8-20**] C dif: Negative x2
[**8-19**] Peritoneal: Pseudomonas - Resistant to Cipro
[**8-12**] C dif: negative
[**8-11**] BAL: GNRs
[**8-8**] Spcx: pseudomonas - R cipro
[**8-8**] Ucx: neg
[**8-6**] Spcx: pseudomonas - R cipro
[**8-3**] Ucx: pseudomonas - R cipro
[**7-23**] JPcx: E.coli - R gent; MRSA
.
Consults:
[**8-15**] Cards: AF, WBC downtrending. d/c nodal blocking agents;
atropine at bedside, pacer pads; if continues to have pauses > 5
secs, would consider placing temp pacing wire."
6413,"3. S/P left occipital craniotomy- please provide reason for this
procedure.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-7-30**] 2:59
AM
FINDINGS: The tracheostomy tube remains in place, but appears to
contact the right lateral tracheal wall. Nasogastric tube is
still in place. The right internal jugular line ends in the SVC.
Allowing for difference in positions, there is no significant
change in the degree of cardiomegaly, bilateral pleural
effusions, or pulmonary vascular congestion.
.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2188-8-1**] 10:21 PM
IMPRESSION:
1."
6414,"These were restarted without incident
once back on the floor.
PULMONARY: trach and passe muir valve in place.
GI / ABD: abdomen soft, and nontender. JP drain on the right
side has sequentially been backed out. There is now an ostomy
appliance in place. The last JP Amylase was [**Numeric Identifier 71805**].
NUTRITION: TF at goal 50cc/hr. Tolerating some PO's. See recs
below.
RENAL: lasix gtt, diamox stopped. Fluid status now stable.
HEMATOLOGY:stable
ENDOCRINE: RISS
ID:inhaled tobramycin, and fluc have been completed. Zosyn to
continue for 2 weeks due to PSEUDOMONAS AERUGINOSA from the JP
drain.
LINES/TUBES/DRAINS: Trach, picc line rt antecub,
WOUNDS:none"
6415,"8. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
12. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
13. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily)."
6416,".
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2188-8-20**]
10:13 AM
IMPRESSION:
1. Resolving postoperative stranding status post Whipple
procedure. Soft
tissue attenuation conglomeration in the pancreaticojejunostomy
bed is
not as well evaluated on the current study but is not
significantly
changed and likely represents loops of jejunum.
2. Three hypodense liver lesions no fully characterized.
Attention should be
paid to these areas on followup studies.
3. Peribronchovascular ground glass opacities may represent
infection,
inflammation and less likely edema.
4. Enlarged pulmonary artery suggesting underlying pulmonary
arterial
hypertension.
5. Dense coronary artery calcificiations.
Brief Hospital Course:
This is a 73 year old female with a pancreatic head mass who
went to the OR on [**2188-7-16**] for:
1."
6417,"[**7-19**]: continue vent
[**7-21**]: vanc and zosyn lasix d/ced and then restarted TTE EF 60%
RV dilated, fever, inc insulin in TPN
[**7-22**]: ct abd - small fluid collection (not drainable), wean fio2
[**7-23**]: decr lopressor, JP cx, wean vent, tighten SSI, cont TPN,
incr insulin to 50, vulvar lesion clean (recent partial
vulvectomy [**2188-7-8**])
[**7-24**]: Decrease PEEP, Insulin 65 with TPN [**7-25**]: wound care
consult, added NPH 40/40 [**7-26**]: consult gyn for vulvar lesion
[**7-27**]:wean propofol
[**7-28**]: head ct negative, continue tpn,
[**7-29**]: trach,
[**7-30**]-nasoenteric feeding tube placed by radiology
[**7-31**]: picc placed, CVL removed; increased secretions from trach
(02 sat stable)
[**8-1**]:d/c vanco/cirpo;acute hypotensive episode x 1 with
spontaneous return, CTA PE - negative, BL atelectasis with R>L
effusions, secretions reduced from previous but present; Echo -
nl ef, no gross abnormalities; Cards consulted - no changes;
increased Fi02 to 60% for improved oxygenation; acetazolamide
started
[**8-2**]: 2 units PRBC, desat after 1 unit, improved after lasix
[**8-3**]: destat episode, mucous plugging."
6418,"8 mg/dL, Mg:2.2
mg/dL, PO4:3.2 mg/dL
Fluid Analysis / Other Labs: none
Imaging: PICC line placement read Pending; CXR read pending
Microbiology: CATHETER TIP-IV
WOUND CULTURE-PENDING
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**]), SEPSIS WITHOUT ORGAN
DYSFUNCTION
secondary to anastamotic leak, [**Last Name 9**] PROBLEM - ENTER DESCRIPTION IN
COMMENTS
pancreatic mass
Assessment and Plan:
Neurologic: Versed gtt up to 1 (increased agitation), lower as
tolerated, especially as WOB decreases; pt following commands
Cardiovascular: Beta-blocker, acute htn...controlled w/hydralazine prn,
metoprolol prn--inc to 25mg PO; add on IV lopressor 10
Pulmonary: Trach, (Ventilator mode: CPAP + PS), Continue pressure
support at current level until patient has significant diuresis
Gastrointestinal / Abdomen:
Nutrition: Tube feeding, Impact 60kg x20 kcal/kg= 1200kcal/day =50kcal
per hour
Impact with Goal of 50."
6419,"IV access request: PICC Place Indication: TPN Urgency: Routine
Order date: [**7-29**] @ 1208
24 Hour Events:
PICC LINE - START [**2188-7-31**] 12:30 PM
MULTI LUMEN - STOP [**2188-7-31**] 05:00 PM
FEVER - 101.2
F - [**2188-7-31**] 08:00 AM
d/c vanco/cirpo; increased secretions from trach (O2 sat stable),
increased level of agitation--versed gtt inc to 1, hypertensive--IV
lopressor
Allergies:
Pravachol (Oral) (Pravastatin Sodium)
Rash;
Lisinopril
Rash;
Last dose of Antibiotics:
Vancomycin - [**2188-7-30**] 08:59 PM
Ciprofloxacin - [**2188-7-30**] 10:31 PM
Infusions:
Midazolam (Versed) - 1 mg/hour
Other ICU medications:
Other medications:
Flowsheet Data as of [**2188-8-1**] 06:21 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**91**] a."
6420,"7 mg/dL
23 mEq/L
4.4 mEq/L
34 mg/dL
106 mEq/L
138 mEq/L
24.9 %
12.0 K/uL
[image002.jpg]
[**2188-7-28**] 02:41 AM
[**2188-7-29**] 04:00 AM
[**2188-7-29**] 04:04 AM
[**2188-7-29**] 04:30 PM
[**2188-7-29**] 04:43 PM
[**2188-7-30**] 03:51 AM
[**2188-7-31**] 02:50 AM
[**2188-7-31**] 04:00 AM
[**2188-8-1**] 03:30 AM
[**2188-8-1**] 05:05 AM
WBC
10.5
9.9
10.2
12.1
12.0
Hct
25."
6421,"D/C TPN
Renal: Will restart lasix gtt, albumin with intent of making patient
negative.
Hematology:
Endocrine: Maintain RISS, FS in 100's, NPH 30 [**Hospital1 **]. Check amylase
Infectious Disease:
Lines / Tubes / Drains: J-drain, right PICC, Check amylase on drain
Wounds:
Imaging: CXR today
Fluids: dextrose 5% KVO
Consults:
Billing Diagnosis:
ICU Care
Nutrition:
TPN without Lipids - [**2188-7-31**] 06:06 PM 62.5 mL/hour
Impact (Full) - [**2188-7-31**] 06:22 PM 50 mL/hour
Glycemic Control: Insulin infusion
Lines:
PICC Line - [**2188-7-31**] 12:30 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Comments:
Code status: Full code
Disposition:
Total time spent:"
6422,"Phenaseptic
Throat Spray 1 SPRY PO Q6H:PRN Order date: [**7-18**] @ [**2115**]
11. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed
by Heparin as above daily and PRN. Order date: [**7-18**] @ [**2115**] 24.
Potassium Chloride IV Sliding Scale Order date: [**7-21**] @ 0037
12. HydrALAzine 10 mg IV Q4H:PRN
Hold for SBP < 130 Order date: [**7-20**] @ 1346 25. Sodium Chloride 0.9%
Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN. Order date: [**7-18**] @ [**2115**]
13."
6423,"Order date: [**7-31**] @ 0817
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**7-18**] @
2227 20. Midazolam 0.5 mg IV Q2H:PRN agitation Order date: [**7-31**] @
0817
8. Fluconazole 400 mg PO Q24H Order date: [**7-31**] @ 0931 21. Octreotide
Acetate 150 mcg SC Q8H Order date: [**7-21**] @ 1413
9. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN Order date: [**7-20**] @
0924 22. Pantoprazole 40 mg IV Q24H Order date: [**7-18**] @ [**2115**]
10. Heparin 5000 UNIT SC Q12H Order date: [**7-18**] @ [**2115**] 23."
6424,"Acetaminophen 650 mg PO Q4-6H:PRN Order date: [**7-18**] @ [**2115**] 16.
Metoclopramide 10 mg IV Q6H Order date: [**7-28**] @ 0918
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
TO GIVE WITH MUCOMYST Order date: [**7-31**] @ 0819 17. Metoprolol Tartrate
12.5 mg PO BID Order date: [**7-31**] @ 0816
5. Bisacodyl 10 mg PR HS:PRN Order date: [**7-24**] @ 1330 18. Miconazole
Powder 2% 1 Appl TP QID:PRN Order date: [**7-31**] @ 0310
6. Calcium Gluconate IV Sliding Scale Order date: [**7-21**] @ 0044 19.
Midazolam 1 mg/hr IV DRIP TITRATE TO up to 2mg/hr
Patient must have adequate airway support prior to administration of
dose."
6425,"SICU
HPI:
73F with panc mass by imaging, now s/p classical Whipple [**7-16**]. admitted
to SICU with hypoxic resp distress, likely secondary to anastomatic
leak with ?sepsis
Chief complaint:
respiratory failure
PMHx:
hlipid, tics&polyps, breast ca [**2158**] s/p L mast, osteopenia, panc cyst,
esophagitis, hypothyroidism, colitis s/p partial colectomy, arthritis,
urin incont
Current medications:
Sliding Scale & Fixed Dose Order date: [**7-30**] @ 2153 2. Acetylcysteine
20% 1-10 mL NEB Q6H:PRN secretions
to be given with albuterol Order date: [**7-31**] @ 0819 15. Levothyroxine
Sodium 75 mcg IV DAILY Order date: [**7-18**] @ [**2115**]
3."
6426,"3
24.7
24.3
26.0
24.9
Plt
354
359
372
397
372
Creatinine
0.6
0.9
0.8
0.8
0.8
0.7
TCO2
31
29
29
Glucose
112
83
85
71
99
87
116
Other labs: PT / PTT / INR:14.1/29.5/1.2, CK / CK-MB / Troponin
T:863/6/<0.01, ALT / AST:42/19, Alk-Phos / T bili:95/0.4,
Differential-Neuts:85.6 %, Lymph:7.3 %, Mono:4.9 %, Eos:2.0 %, Lactic
Acid:1.2 mmol/L, Albumin:2.3 g/dL, LDH:187 IU/L, Ca:8."
6427,"46/40/90.[**Numeric Identifier 299**]/23/4
Ve: 11.9 L/min
PaO2 / FiO2: 180
Physical Examination
General Appearance: Anxious
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),
(Breath Sounds: Crackles : R>L), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: Absent, No(t) 2+), (Pulse - Dorsalis pedis:
Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent, No(t) 2+), (Temperature: Warm),
(Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious
stimuli), non verbal
Labs / Radiology
372 K/uL
8.4 g/dL
116 mg/dL
0."
6428,"m.
Tmax: 38.4
C (101.2
T current: 37.2
C (99
HR: 100 (65 - 100) bpm
BP: 180/65(91) {137/51(76) - 239/99(109)} mmHg
RR: 32 (0 - 32) insp/min
SPO2: 95%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 100.7 kg (admission): 86.3 kg
Height: 67 Inch
Total In:
2,885 mL
709 mL
PO:
Tube feeding:
978 mL
300 mL
IV Fluid:
316 mL
4 mL
Blood products:
100 mL
Total out:
1,904 mL
360 mL
Urine:
1,888 mL
360 mL
NG:
Stool:
Drains:
16 mL
Balance:
981 mL
351 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 332 (332 - 553) mL
PS : 10 cmH2O
RR (Spontaneous): 31
PEEP: 5 cmH2O
FiO2: 50%
RSBI: 100
PIP: 16 cmH2O
SPO2: 95%
ABG: 7."
6429,"Admission Date: [**2146-7-22**] Discharge Date: [**2146-7-23**]
Date of Birth: [**2106-4-10**] Sex: M
Service: MEDICINE
Allergies:
Nsaids / Percocet / Morphine Sulfate / Ativan / adhesive tape
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Tongue and mouth swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
40 year old male with history of recurrent bone lymphoma (DLBCL
on path) s/p 6 cycles of R-[**Hospital1 **], chronic HBV on lamivudine,
Crohn's disease who underwent excision of left submandibular
duct stones yesterday by ENT, now with significant submandibular
swelling L>R and difficulty speaking starting last night."
6430,"He relapsed in [**2143**], did have
radiation
to some bony sites, does have multiple FDG avid lesions on his
most recent PET scan from [**Month (only) 1096**]. Initial right femur biopsy
was negative. Removal of the right rib did not demonstrate any
lymphoma. He did have a CT-guided bone biopsy of his right
femur
which demonstrated recurrent disease with diffuse large B-cell
lymphoma.
Other medical history:
# Crohn's disease - s/p 6MP and small bowel resections x3, no
clear flares in 10 years though chemotherapy associated bouts of
enteritis only on mesalamine.
# Chronic hepatitis B - likely due to transfusion, dx [**2-/2146**],
currently on lamivudine."
6431,"# Chronic LBP/sciatica
# NSVT
RECENT TREATMENT HISTORY:
Cycle 1 of [**Hospital1 **]-[**3-7**], first dose of Rituxan was on [**3-4**]
Cycle 2 R-[**Hospital1 **] [**3-28**]
Cycle 3 R-[**Hospital1 **] [**2146-4-18**] Rituximab [**4-15**], complicated by
tachycardia
Cycle 4 R-[**Hospital1 **] [**2146-5-13**]
Cycle 5 R-[**Hospital1 **] [**2146-6-3**]
Cycle 6 R-[**Hospital1 **] [**2146-6-27**]
Social History:
He denies alcohol, tobacco, or illicit drugs. He is quite
physically active at baseline with biking. Works in IT.
Married, he lives with his wife and a dog.
Family History:
Aunt with ovarian Ca. Sister has asthma."
6432,"# Tongue/submandibular swelling: He was POD #1 from his ENT
procedure, with resulting submandibular swelling. Per ENT, they
were concerned about his airway and recommended monitoring in
the ICU to ensure airway management if necessary. He has been
handling his own secretions and ENT evaluation confirmed that
there was no vocal cord edema. There was some concern for
Ludwig's angina, with his concomitant neck pain and location of
his inflammation (submandibular), but his presentation was most
consistent with post-operative swelling. We continued
antibiotic coverage with Unasyn 3g IV q6hrs and dexamethasone
10mg IV q8hrs x2 to control the swelling."
6433,"Discharge Medications:
1. budesonide 3 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
3. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
6. simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for pain."
6434,"Otherwise family
history unremarkable and markedly negative for inflammatory
bowel disease.
Physical Exam:
On admission:
Vitals: T 97.1, HR: 66, BP: 115/74(83), RR: 13, SpO2: 95%
General: Alert, oriented, no acute distress, soft voice
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear; increased
erythema and swelling underneath tongue, especially over left
side with no obvious exudate
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
6435,"ENT
was consulted and did not appreciate any swelling in the vocal
cords, recommended administration of Unasyn and dexamethasone,
and to admit to the ICU overnight for airway monitoring. The ED
physicians were concerned about Ludwig's angina, based on the
appearance of the tongue and mucosa in the submandibular area.
Vitals on transfer: 114/72, 72, 14, 95% RA
In the ICU, he is feeling a bit better, swallowing easier, and
breathing without extra effort.
Past Medical History:
ONCOLOGIC HISTORY: Initial diagnosis of primary bone lymphoma
back in [**2136**]. Pathology was consistent with diffuse large
B-cell
lymphoma with some small lymphoid aggregates, initially treated
with two cycles of R-CHOP with severe GI toxicity but changed a
complete response, had relapsed disease approximately five years
treated with a cycle of RCVP with severe GI toxicity with the
small bowel obstruction requiring resection, did obtain another
remission for two years."
6436,"On discharge:
HEENT: improved swelling beneath tongue with improved speech and
pain, easier swallowing
Otherwise, unchanged
Pertinent Results:
LABS:
[**2146-7-22**] 10:58AM BLOOD WBC-13.5* RBC-4.16* Hgb-12.4* Hct-36.2*
MCV-87 MCH-29.9 MCHC-34.4 RDW-18.1* Plt Ct-357
[**2146-7-22**] 11:50AM BLOOD WBC-11.6* RBC-3.71* Hgb-11.2* Hct-32.7*
MCV-88 MCH-30.2 MCHC-34.2 RDW-19.2* Plt Ct-311
[**2146-7-22**] 11:50AM BLOOD Neuts-80* Bands-2 Lymphs-8* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-1*"
6437,"A nasal trumpet was
kept by the bedside in the event of respiratory distress. He
will be discharged on 10 days of augmentin. His exam improved
and the patient felt noticeably better on the day of discharge.
# Pain control: We tried to control his pain with fentanyl
boluses, as he felt this was most helpful for him. We would
advise to continue at home with his as-needed regimen of
oxycodone, and to contact ENT for further pain options if this
is not adequately controlling his pain.
Medications on Admission:
-budesonide 3 mg Capsule, Three (3) Capsule daily
-sulfamethoxazole-trimethoprim 800-160 mg MWF
-lamivudine 100 mg daily
-mesalamine DR 800 mg Tablet, 6 tablets daily
-cholestyramine-sucrose 4 gram [**Hospital1 **]
-simethicone 40-80 mg QID PRN
-ondansetron HCl 4-8 mg q8h PRN
-prochlorperazine maleate 10 mg q6h PRN"
6438,"He
has been handling his secretions without difficulty and
complains of some mild tongue swelling as well. Some difficulty
with swallowing as well, but no fevers, chills, or
nausea/vomiting. He called his ENT surgeon (Dr. [**First Name (STitle) **] and was
instructed to report to the ED for further management.
He was admitted to the Onco-Hospitalist service earlier this
month with presumed SBO, started on Cefepime and Flagyl,
discharged on moxifloxacin through his WBC nadir.
In the ED, initial vs were: 99 100 120/76 18 97% RA. Patient was
given one dose of zosyn 4.5 gm IV and solumedrol 125mg IV."
6439,"Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted to the ICU for tongue and
mouth swelling shortly after your ENT procedure. We monitored
you closely to make sure that your breathing was not compromised
and felt that you were safe to return home since your symptoms
have improved and you have not had any respiratory distress.
Followup Instructions:
Please follow-up with your ENT physician as previously
scheduled.
You have the following appointments scheduled at [**Hospital1 18**] already:
Department: BMT/ONCOLOGY UNIT
When: FRIDAY [**2146-7-29**] at 1:30 PM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: RADIOLOGY
When: FRIDAY [**2146-7-29**] at 3:40 PM
With: XMR [**Telephone/Fax (1) 327**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: FRIDAY [**2146-7-29**] at 4:20 PM
With: XMR [**Telephone/Fax (1) 327**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]"
6440,"7. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for nausea.
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Post-operative submandibular duct swelling
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive."
6441,"[**2146-7-22**] 11:50AM BLOOD Glucose-89 UreaN-8 Creat-0.9 Na-141 K-3.9
Cl-101 HCO3-29 AnGap-15
[**2146-7-22**] 11:50AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.8
[**2146-7-22**] 10:58AM BLOOD ALT-20 AST-28 LD(LDH)-274* AlkPhos-72
TotBili-0.4
[**2146-7-22**] 11:59AM BLOOD Lactate-1.2
MICRO: Blood cultures x2 - pending
IMAGING: none
Brief Hospital Course:
40 year old male with history of NHL/DLBCL s/p [**Hospital1 **] and on
neupogen, presenting on POD #1 for submandibular duct stone
removal with tongue swelling and difficulty speaking, admitted
to the ICU for airway monitoring."
6442,"[**2170**])
-Paroxysmal a.fib in setting of knee surgery: post-op course
complicated by abif and dyspnea, with negative PE-CT; CHADS
score 4, anticoag with lovenox and ASA
-Hyperglycemia: HbA1c 6.1%
-Hyperlipidemia
-Coronary artery disease s/p PCI in [**2168**]
-Diastolic heart dysfunction: echo from [**2179-7-22**] shows LVEF 75%,
increased left ventricular pressure, moderate calcific aortic
stenosis
-Osteoarthritis causing chronic knee pain: R-knee replacemetn on
[**8-/2179**], ambulating with walker
-Lumbar disc disease and spinal stenosis cervical spine
degeneration of C3 through C7 with neck pain
-Sleep apnea on home oxygen
-Benign essential tremor
-Restless leg syndrome
-h/o bladder cancer status post resection, followed by Dr."
6443,"[**Last Name (STitle) 365**],
his last resection was in [**5-/2174**] for recurrence
-h/o stroke with residual right 7th nerve palsy
-h/o hiatal hernia: dx in setting of dysphagia in [**12/2176**] via
double contrast barium esophogram
Social History:
Retired artist(painter). 75-pack-year smoking history (Quit
smoking in [**2152**]). He lives with his wife in an apartment. He
immigrated from [**Location (un) 49506**] in 30 years ago. He denies alcohol or
drug use.
Family History:
non-contributory
Physical Exam:
Vitals: T:97.3 BP:135/79 P:106 R:32 O2:91%
General: Alert, aao to day, ""[**Hospital **] hospital"", no acute distress"
6444,"However, assessment for endoluminal
lesions or abnormalities is limited due to intubation. Follwoup
as clinically indicated.
3. Endotracheal tube in standard position, 3.3 cm above the
carina.
4. Mild paraseptal emphysema in the lung apices.
5. Stable degenerative changes of the cervical spine.
Brief Hospital Course:
78 yo gentleman with hx of MICU admission for stridor with no
evidence of obstruction, now presenting with recurrent stridor.
.
#. Stridor: Initially unclear cause of his stridor given normal
laryngoscope on last visit. Pt intubated on admission and
stabilized on vent. CT scan of the neck did not show any
extraluminal masses compressing."
6445,"[**10-27**] an attempt was made to
extubate him, but he afterwards developed stridor and had to be
re-intubated. During the brief extubation, a laryngoscopy was
done that was concerning for at least partial paralysis of the
vocal cords. He was treated with 24 hours of IV solumedrol in
case there was a contribution of airway swelling. [**10-29**] he had a
tracheostomy placed by the ENT service with some difficulty
because of his severe scoliosis and altered anatomy. Afterwards
he was quickly weaned to a trach collar. With the concomitant
dysphagia, there was concern for neuromuscular weakness, so
neurology was consulted."
6446,"Patient declined video swallow study.
#. Hyponatremia: Most likely hypovolemic as this improved with
IV fluids. Likely from poor PO intake [**1-6**] dysphagia. This
resolved with tube feeds.
#. Anemia: at baseline, no evidence of active bleeding, with low
iron [**9-14**], nl ferritin, iron/TIBC<18 concerning for iron
deficiency. Likely from poor PO intake.
#. Tachycardia: sinus, likely due to resp distress.
Transitional Issues:
There are several tests requested by Neurology that were sent
off by pathology to outside facility that are pending prior to
discharge. Patient should follow up with outpatient Neurology
regarding these tests.
Medications on Admission:
1."
6447,"12. fluticasone-salmeterol 100-50 mcg/dose Disk with Device [**Last Name (STitle) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
1)Vocal Chord dysfunction
2)Dysphagia
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:
Dear Mr. [**Known lastname 105647**],
You were admitted to our hospital with shortness of breath. We
have determined that you needed a tracheostomy. We have placed a
tube in your neck to help you with breathing."
6448,"3 PTT-30.4 INR(PT)-0.9
[**2179-10-25**] 10:54AM LACTATE-0.7
Discharge Labs:
[**2179-11-9**] 03:55AM BLOOD WBC-4.1 RBC-3.93* Hgb-10.4* Hct-31.4*
MCV-80* MCH-26.4* MCHC-33.0 RDW-13.9 Plt Ct-214
[**2179-10-28**] 04:52AM BLOOD Neuts-67.2 Lymphs-25.3 Monos-7.3 Eos-0.1
Baso-0.1
[**2179-11-9**] 03:55AM BLOOD PT-10.6 PTT-34.2 INR(PT)-1.0
[**2179-11-10**] 04:48AM BLOOD Glucose-147* UreaN-15 Creat-0.6 Na-133
K-4."
6449,"7. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H
(every 6 hours) as needed for pain.
8. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
9. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q2H (every 2 hours) as needed for SOB.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q2H (every 2 hours) as
needed for SOB.
11. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day)."
6450,"Admission Date: [**2179-10-25**] Discharge Date: [**2179-11-10**]
Date of Birth: [**2101-3-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / [**Doctor First Name **] / Tylenol #3
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Stridor
Major Surgical or Invasive Procedure:
Bronchoscopy and laryngoscopy [**10-27**]
Tracheostomy placement by ENT [**10-29**]
Tracheostomy replacement by ENT [**11-8**]
Laryngeal Electromyogram by ENT and Neurology [**11-9**]
History of Present Illness:
Mr [**Known lastname 105647**] is a 78M h/o with COPD on continuous O2 at 2L who
presented to the ED with c/o 2 days of not feeling and trouble
breathing."
6451,"Hours) as needed for [**Month/Year (2) **] or pain.
7. nitroglycerin 0.3 mg Tablet, Sublingual [**Month/Year (2) **]: One (1) tablet
Sublingual as needed as needed for chest pain: Take one tablet
under tonque every 5 inutes up to 3 pills, if pain persists call
doctor.
8. aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Year (2) **]: [**12-6**]
puffs Inhalation every four (4) hours as needed for wheeze.
10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
[**Month/Day (2) **]: One (1) puff Inhalation twice a day."
6452,"To help you with
eating, we placed a feeding tube into your stomach through your
nose.
Your were also evaluated by our neurologists and our ear, nose
and throat doctors. The cause of your trouble swallowing and
vocal cord dysfunction is not clear. You will follow-up with the
neurologists regarding these issues.
The following changes were made to your medications:
- STOPPED Spiriva, pantoprazole
- STARTED ipratroprium, advair, lansoprazole
- STARTED colace, biscodyl and senna as needed for constipation
- INCREASED Citalopram from 10 mg to 20 mg po daily
Followup Instructions:
Please keep the following appointments:
Department: NEUROLOGY/NEUROMUSCULAR DIVISION
When: FRIDAY [**2179-11-19**] at 9:30 AM
With: DRS. [**Name5 (PTitle) 3524**]/[**Doctor Last Name 37664**] [**Telephone/Fax (1) 558**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ENT
With: Dr. [**Last Name (STitle) **] S. Mallur
DATE: [**2179-11-22**] at 3:30 pm
[**Hospital Unit Name 105648**], [**Location (un) 86**], [**Numeric Identifier 718**]
([**Telephone/Fax (1) 6213**]"
6453,"Discharge Medications:
1. atorvastatin 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
2. citalopram 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. trazodone 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
5. aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily)."
6454,"Of note, pt was here recently for same presentation
and had ENT scope that was unrevealing. On that occasion, he
was admitted to the ICU and required intubation, was evaluated
by ENT who visulaized a small amount of tissue overlying the
vocal cords with no evidence of obstruction to level of
epiglottis, however not able to view larynx.
.
In the ED, initial vs were not recorded, however pt was reported
to be hypoxic. Patient was given heliox, albuterol, ipratroprium
and 125 mg methylprednisolone. Initially he was anxious and
very stridorous but subesequently relaxed and was breathing more
comfortably, although still with insp stridor."
6455,"Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
-COPD: evaluated in pulmonary clinic (Dr. [**First Name4 (NamePattern1) 1370**] [**Last Name (NamePattern1) **]) prior
to surgery in [**2179-8-5**], spirometry at the time revealed FEV1
of 1.41L (59% predicted) and FVC of 2.25L (60% predicted), with
ration 0.63 suggesting moderate mixed obstructive and
restrictive deficit (little change since [**2172**]); previously
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from [**2169**] to [**2172**]; intermittent
adherance to therapy; emphysema with right lower lobe
atelectasis seen on CT from [**2179-8-31**]
-Pulmonary HTN: mean pulmonary artery pressure of 27 (on cath in"
6456,"Their work-up consisted of MRI, which
failed to demonstrate a lesion that would explain the pathology
found. The next test Neurology recommended was an EMG, this
demonstrated a pattern consistent with a myopathy. The
neuromuscular service was consulted to evaluate the LEMG and
guide further diagnostic studies. LEMG was EMG suggestive of
neuromuscular junction disorder. He was discharged with
follow-up with the neuromuscular clinic and ENT.
#. Dysphagia: patient had been having several weeks of worsening
dysphagia prior to admission, including weight loss. He had an
EGD [**2179-10-2**] for similar symptoms that did not show a cause for
dysphagia."
6457,"Pertinent Results:
Admission labs:
[**2179-10-25**] 10:45AM GLUCOSE-134* UREA N-14 CREAT-0.6 SODIUM-120*
POTASSIUM-4.5 CHLORIDE-82* TOTAL CO2-31 ANION GAP-12
[**2179-10-25**] 10:45AM estGFR-Using this
[**2179-10-25**] 10:45AM TSH-0.44
[**2179-10-25**] 10:45AM WBC-4.7 RBC-4.13* HGB-10.8* HCT-32.5*
MCV-79*# MCH-26.0* MCHC-33.1 RDW-13.1
[**2179-10-25**] 10:45AM NEUTS-59.5 LYMPHS-32.9 MONOS-5.4 EOS-1.4
BASOS-0.7
[**2179-10-25**] 10:45AM PLT COUNT-278
[**2179-10-25**] 10:45AM PT-11."
6458,"Labs were
notable for hyponatremia to the 120s, mild anemia. CT neck was
attempted but was unable to be completed because the patient was
unable to lie down. Chest xray showed no acute CP process. EKG
showed NSR with occ PACs. Vitals on transfer were 108/70 94 24
100% on non-rebreather.
.
On the floor, pt continues to be stridorous and is difficulty to
understand due to mask/heliox. Stridor improved throughout the
H&P.
.
Review of sytems:
(+) Per HPI, also endorses wt loss, last BM last night
(-) Denies [**Known lastname **], chills, night sweats, recent weight loss or
gain."
6459,"0 Cl-91* HCO3-36* AnGap-10
[**2179-11-10**] 04:48AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.2
OTHER:
[**2179-11-1**] 03:52AM BLOOD %HbA1c-5.8 eAG-120
[**2179-10-25**] 10:45AM BLOOD TSH-0.44
[**2179-10-29**] 04:29AM BLOOD Cortsol-9.9
[**2179-11-3**] 06:42AM BLOOD Vanco-13.9
EKG: NSR, no acute ST tw changes
CT Neck [**2179-10-25**]:
IMPRESSION:
1. Simple fluid lining the posterior [**Last Name (un) **]-, oro-, and
laryngopharynx, and
anterior laryngopharynx, findings likely secondary to recent
intubation. No compressive extrinsic enhancing mass lesion to
explain patient's stridor."
6460,"HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: R-sided rhonchi, stridorous, no wheezes, rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild ttp throughout, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Discharge:
T: 98, P: 74, BP: 91/ 64, RR: 25, 97% on TM
General: Awake, alert and oriented xt3, NAD
HEENT: continues to have minimal trach secretions, trach in
place, strong voice, minimal stridor on capping
Neck: supple, minimal secretions around trach, no LAD
Lungs: loud upper airway sounds, minimal scattered rhonchi
ant/lat
CV: Regular rate and rhythm, normal S1 + S2 shifted to the
right, 3/6 SEM radiating to carotids
Abdomen: soft, non-tender, slightly distended in upper portion,
no peritoneal signs
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
6461,"salmeterol 50 mcg/dose Disk with Device [**Month/Year (2) **]: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
2. Lipitor 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
3. Protonix 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. citalopram 20 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO DAILY (Daily).
5. Clotrimazole Foot 1 % Cream [**Month/Year (2) **]: One (1) application Topical
twice a day: apply to feet.
6. acetaminophen 500 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q 8H (Every 8"
6462,"Admission Date: [**2190-6-15**] Discharge Date: [**2190-6-20**]
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
The patient is a [**Age over 90 **] year old female with a history of
Aflutter/AF (on coumadin) s/p AV node ablation and pacemaker,
hypertension, systolic HF, and dementia who presents with
complaints of [**2-23**] days of BRBPR. The patient has a known history
of diverticulosis and internal hemmeroids. While their is no
documentation in our OMR, she may have a history of LGIB She is
maintained on coumadin for reduction of thromboembolic risk in
the setting of AF."
6463,"She denies any chest pain, shortness of
breath, or lightheadedness. Shes is a poor historian at
baseline, but reports feeling well.
.
In the ED, initial vs were: T 97.5 P 71 BP 161/59 O2 sat 100% on
RA. The patient was noted to have rectal bleeding, and had a BM
w/ a reported 10-15cc of BRB. She was given 10mg of vit K and
protonix, and was admitted to the ICU for further manegment.
Past Medical History:
1. Atrial fibrillation/flutter - on anticoagulation and s/p AVJ
ablation w/ PPM
2. Diastolic / Systolic heart failure - EF of 35% in [**2188**]
Moderate global LV hypokinesis."
6464,"Brief Hospital Course:
[**Age over 90 **] year old female with a history of AF on coumadin, systolic
HF, diverticulosis, and internal hemorrhoids who presents with
complaints of LGIB.
.
# BRBPR: In the ER patient received 10 mg of vitamin K for an
INR of 2.6. Due to concern of acute bleed patient was admitted
to ICU, but transferred to the general medicine floor when found
to be hemodynamically stable. Sigmoidoscopy demonstrated a
significant amount of old blood, but no acute bleed. Source felt
to be extensive diverticular disease. On admission patient's HCT
dropped 5 points (from 34.7 -> 29."
6465,"- Check HCT twice a week
.
# Atrial fibrillation: status post AVJ ablation w/ PPM. On
coumadin as an outpatient. INR was reversed on admission due to
concern of acute bleed (see above).
- Continue to hold coumadin 1 week following discharge. Re-start
following 1 week, but patient needs to follow-up with pcp, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17143**], regarding continuation of all three anti-coagulents.
.
# Chronic Systolic CHF: Patient currently euvolemic on exam.
B-blocker and diuretics held briefly in setting of acute bleed.
Metoprolol 100 mg TID and diuretics re-started prior to
discharge.
.
# Hx of CVA: Dipyradiole and ASA as outpatient suggest history
of TIA or small vessel disease."
6466,"4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
6. Outpatient Lab Work
Check Hematocrit twice weekly
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Lower gastrointesintal bleeding
.
Atrial fibrillation/flutter s/p AV ablation
Congestive heart failure
Hypertension
Discharge Condition:
Fair. Patient is alert and interactive. She has poor short
term memory and cannot remember why she is in the hospital.
Discharge Instructions:
You were admitted for gastrointestinal bleeding. You underwent a
sigmoidoscopy which demonstrated old blood in the
gastrointestinal tract, but there was no active bleeding."
6467,"Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-22**] PO BID (2 times a
day) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Furosemide 20 mg Daily
7. Spironolactone 12.5 mg daily
8. Coumadin
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation."
6468,"Relatively preserved apical LV
contraction.
3. Hypertension
Social History:
Lives at [**Hospital3 **] at Scandinavian Center. Was living
alone and caring for sister in hospice until she passed away. No
Smoking or ETOH.
Family History:
Family History: Patient unaware.
Physical Exam:
Vitals: T 97.3 BP 135/56 P 72 R 22 18 SaO2 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal (previously documented): No no visible external
hemorrhoids, fissues, or cracks on exam, BRB
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, oriented x 2"
6469,"You
were monitored in the hospital to ensure stable blood counts and
blood pressure. You are being discharged to a short term rehab
for physical therapy.
.
Please continue taking all medications as you were previously
taking with the following exceptions:
HOLD Coumadin, aspirin, dypridamole for 1 week following
discharge. Re-start and discuss longterm coagulation plan with
primary care doctor.
.
Attend the following appointments:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**]
Specialty: PCP
Date and time: [**2190-7-1**] 1:00pm
Location: [**Apartment Address(1) 21247**] F
Phone number: [**Telephone/Fax (1) 19196**]
.
Please return to the hospital or call your primary care
physician if you have lightheadedness, shortness of breath,
chest pain, or any other concerning symptoms.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**]
Specialty: PCP
Date and time: [**2190-7-1**] 1:00pm
Location: [**Apartment Address(1) 21247**] F
Phone number: [**Telephone/Fax (1) 19196**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2190-6-20**]"
6470,"- Continue to hold ASA, dipyridamole for 1 week following
discharge. Re-start following 1 week, but patient needs to
follow-up with pcp, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17143**], regarding continuation of all
three anti-coagulatents.
.
# FEN: Tolerating regular diet prior to discharge.
# Code: DNR/DNI - confirmed with patient.
# Communication: Patient. Only relative (nephew in law) [**Name (NI) **]
[**Name (NI) 21244**] [**Telephone/Fax (1) 21245**], [**Telephone/Fax (1) 21246**].
Discharge to short term rehab for physical therapy needs.
Medications on Admission:
per OMR
1. Dipyridamole 25 mg Tablet TID
2. Metoprolol Tartrate 100 mg TID
3. Aspirin 81 mg Daily
4."
6471,"6 RBC-3.03* Hgb-9.3* Hct-28.7*
MCV-95 MCH-30.6 MCHC-32.3 RDW-16.0* Plt Ct-229
[**2190-6-18**] 06:25AM BLOOD WBC-7.2 RBC-3.09* Hgb-9.4* Hct-28.8*
MCV-93 MCH-30.5 MCHC-32.8 RDW-15.7* Plt Ct-228
[**2190-6-18**] 12:50PM BLOOD Hct-31.6*
[**2190-6-20**] 06:50AM BLOOD WBC-7.9 RBC-3.20* Hgb-9.9* Hct-30.1*
MCV-94 MCH-30.8 MCHC-32.8 RDW-16.1* Plt Ct-225
.
Labs on Discharge:
[**2190-6-20**] 06:50AM BLOOD WBC-7."
6472,"8), however remained stable at
28-30 throughout the remainder of admission and upon discharge.
Patient required no blood transfusions and was hemodynamically
stable throughout her hospital course. On discharge she
continued to have dark, loose, guaiac positive stool which was
felt to be old blood (HCT and hemodynamics stable). Patient is
on coumadin for A Fib and ASA + dipyridamole for TIA - all three
were held throughout admission.
- Continue to hold coumadin, ASA, dipyridamole for 1 week
following discharge. Re-start following 1 week, but patient
needs to follow-up with pcp, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17143**], regarding continuation
of all three anti-coagulents."
6473,"3 RBC-3.73* Hgb-11.4* Hct-34.7*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.5* Plt Ct-272
[**2190-6-15**] 11:01PM BLOOD Hct-29.8*
[**2190-6-16**] 03:01AM BLOOD WBC-6.1 RBC-3.05* Hgb-9.4* Hct-28.7*
MCV-94 MCH-30.9 MCHC-32.9 RDW-15.9* Plt Ct-220
[**2190-6-16**] 09:15AM BLOOD Hct-29.7*
[**2190-6-16**] 05:16PM BLOOD Hct-29.7*
[**2190-6-17**] 12:45AM BLOOD Hct-28.0*
[**2190-6-17**] 06:35AM BLOOD WBC-6."
6474,"9 RBC-3.20* Hgb-9.9* Hct-30.1*
MCV-94 MCH-30.8 MCHC-32.8 RDW-16.1* Plt Ct-225
[**2190-6-20**] 06:50AM BLOOD Plt Ct-225
[**2190-6-20**] 06:50AM BLOOD Glucose-102 UreaN-21* Creat-1.1 Na-142
K-4.1 Cl-108 HCO3-27 AnGap-11
.
Imaging:
Permanent pacer in place, moderate cardiomegaly.
Mild-to-moderate chronic failure with interstitial edema, but no
acute pulmonary edema or acute infiltrates.
.
Procedures:
Sigmoidoscopy: Significant amount of old blood. No acute bleed
or active source. Extensive diverticular disease throughout
colon.
.
Prior studies:
Colonoscopy [**2180**]:
Diverticulosis of the distal descending colon and proximal
sigmoid colon
Internal hemorrhoids
Polyp in the sigmoid colon (biopsy)"
6475,"Pertinent Results:
Labs on Admission:
[**2190-6-15**] 03:30PM BLOOD WBC-7.3 RBC-3.73* Hgb-11.4* Hct-34.7*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.5* Plt Ct-272
[**2190-6-15**] 03:30PM BLOOD Neuts-75.7* Lymphs-14.7* Monos-5.5
Eos-3.8 Baso-0.3
[**2190-6-15**] 03:30PM BLOOD PT-26.4* PTT-30.1 INR(PT)-2.6*
[**2190-6-15**] 03:30PM BLOOD Glucose-109* UreaN-31* Creat-1.3* Na-136
K-4.7 Cl-100 HCO3-24 AnGap-17
.
HCT trend:
[**2190-6-15**] 03:30PM BLOOD WBC-7."
6476,"TITLE:
Chief Complaint: [**Age over 90 **] year old female with a history of AF on coumadin,
systolic HF, diverticulosis, and internal hemmeroids who presents with
complaints of LGIB.
24 Hour Events:
Received one unit of FFP
Allergies:
Amiodarone
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems: No chest pain, shortness of breath, fevers, chills
Flowsheet Data as of [**2190-6-16**] 07:45 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
6477,"# BRBPR: Multiple possible etiologies for this patient with history of
LGIB. Has a known internal hemorrhoids and diverticulosis, and either
would be consistent with her presentation. No complaints of
fever/chills or abdominal pain to suggest more malignant abdominal
pathology. Has no visible external hemorrhoids, fissures, or cracks on
exam. No evidence of hemodynamic instability and hct is down four
points from baseline but repeat check is stable. Last colonoscopy in
[**2180**].
- check q12h hct unless evidence of bleeding
- holding warfarin
- GI reccs, though unlikely to undergo colonoscopy
# Atrial fibrillation: Prior history of poor rate control, now status
post AVJ ablation w/ PPM."
6478,"On coumadin as an outpatient.
- hold coumadin in setting of potential bleed
- given high-dose vitamin K in [**Last Name (LF) 73**], [**First Name3 (LF) **] be resistant to anticoagulation
for some time.
# Systolic CHF: Patient currently euvolemic on exam.
- hold metoprolol in setting of bleed
- will hold diuretics until acute bleed is stabilized.
# HTN: hypertension at presentation. Will still hold BP meds in
setting of bleed. [**Month (only) 51**] need to optimize prior to d/c
# Hx of CVA: no residual deficits. Hold dipyradiole, and clarify need
while on coumadin prior to d/c.
# FEN: No IVF, replete electrolytes, NPO for now, will clarify w/ GI
need for prep.
# Prophylaxis: SCDs
# Access: peripherals
# Code: FULL CODE
# Communication: Patient
# Disposition: Call out to floor
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2190-6-15**] 08:23 PM
Prophylaxis:
DVT: pneumoboots
Stress ulcer: None
VAP:
Comments:
Communication: Comments:
Code status: Full
Disposition:"
6479,"4 g/dL
93 mg/dL
1.1 mg/dL
29 mEq/L
4.4 mEq/L
28 mg/dL
106 mEq/L
142 mEq/L
28.7 %
6.1 K/uL
[image002.jpg]
[**2190-6-15**] 11:01 PM
[**2190-6-16**] 03:01 AM
WBC
6.1
Hct
29.8
28.7
Plt
220
Cr
1.1
Glucose
93
Other labs: PT / PTT / INR:15.9/27.2/1.4, Ca++:8.0 mg/dL, Mg++:2.6
mg/dL, PO4:3.3 mg/dL
Assessment and Plan
[**Age over 90 **] year old female with a history of AF on coumadin, systolic HF,
diverticulosis, and internal hemmeroids who presents with complaints of
LGIB."
6480,"4
C (97.6
Tcurrent: 36.4
C (97.6
HR: 70 (70 - 71) bpm
BP: 128/58(75) {114/48(65) - 150/64(84)} mmHg
RR: 17 (15 - 21) insp/min
SpO2: 96%
Heart rhythm: A Flut (Atrial Flutter)
Wgt (current): 61.4 kg (admission): 61.4 kg
Total In:
305 mL
PO:
TF:
IVF:
Blood products:
305 mL
Total out:
0 mL
200 mL
Urine:
200 mL
NG:
Stool:
Drains:
Balance:
0 mL
105 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 96%
ABG: ///29/
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, No(t) Cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
220 K/uL
9."
6481,"Admission Date: [**2108-2-23**] Discharge Date: [**2108-2-25**]
Date of Birth: [**2048-8-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest pain secondary to jailed diagonal artery during elective
cardiac catheterization with DES to LAD.
Major Surgical or Invasive Procedure:
Cardiac Catheterization with drug eluting stent placement.
History of Present Illness:
This 59 year old man with hypertension, hyperlipidemia and an
extensive cardiac history s/p several MI's and multiple coronary
stents to the LAD and RCA, presents following elective cardiac
catheterisation here today , when a diagonal branch off the LAD
was jailed during stenting."
6482,") - 1 Tablet(s) by mouth every morning
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
6483,"COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary disease. The LMCA was
patent. The
LAD had a 70% stenosis proximal to the prior stent. There were
also
stenoses to 20-30% in the mid and distal LAD. The LCX had mild
luminal
irregularities. The RCA had widely patent stents with less than
20-30%
narrowings in the mid-distal vessel.
2. Limited resting hemodynamics revealed normotension.
3. There was extreme tortuosity in the right subclavian artery
that
required placement of a 5 French [**Last Name (un) 12297**] sheath into the ascending
aorta.
The diagnostic procedure was then performed via the right radial
artery."
6484,"A
2.5x15mm
Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was deployed in the mid LAD at 14 atms.
Interval
angiography showed occlusion of a small caliber, medium sized
diagonal
branch. The patient did experience chest pain at this point. The
stent
was postdilated with a 2.5x12mm NC Quantum apex balloon at 12
and 22
atms. Despite nitroglycerin, the diagonal remained occluded.
Mulitple
attempts were made to cross into the occluded diagonal (BMW,
prowater,
PT [**Last Name (Prefixes) **] intermediate, and Run-through wires), however, we
were unable
to wire the diagonal. Final angiography showed no residual
stenosis in
the LAD and occluded diagonal branch that had been jailed by the
stent."
6485,"He did not seek treatment for
this and his symptoms eventually went away. Again last week, the
patient had similar ""heartburn symptoms"" with radiation to the
jaw and throat. These symptoms occurred at night and were
associated with nausea but no vomiting. He was evaluated at
[**Hospital3 7571**]Hospital and transferred to [**Hospital1 18**] where he ruled
out for an MI. It was felt that his symptoms were more likely GI
in origin and he was discharged to home on Pantoprazole and his
normal cardiac medications.
.
His most recent events include an MI in [**2105**] while in
[**State 4565**], requiring RCA stenting x [**Street Address(2) 28710**] elevation
IMI in [**2107-3-1**] while on Plavix therapy."
6486,"Anticoagulation:
Heparin 8000 units IV
Other medication:
Atropine 0.5mg
Eptifibatide 32mg bolus and 28.4ml/hr drip
TNG 400mcg bolus IA
TNG 30mcg/hr drip
Verapamil 5mg IA
Cardiac Cath Supplies Used:
- [**Company **], MAGIC TORQUE 180CM
- [**Doctor Last Name **], BMW UNIVERSAL 190CM
- [**Doctor Last Name **], PROWATER 190CM
- [**Company **], CHOICE PT [**Name (NI) **] INTERMEDIATE
300CM
2.5MM [**Company **], SPRINTER 06MM
2.5MM [**Company **], APEX 12
5FR CORDIS, XB 3.5
6FR CORDIS, XB 3.5
6FR [**Doctor Last Name **], PERCLOSE PROGLIDE
5FR COOK, [**Last Name (un) 28712**] 70CM
5FR COOK, [**Last Name (un) 28712**] 90CM
2.5MM [**Company **], PROMUS RX 15MM
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
5FR TERUMO, JACKY RADIAL CATHETER
5FR ARROW, TRANSRADIAL ARTERY ACCESS KIT
- TERUMO, ANGLED 260CM GLIDEWIRE
- [**Doctor Last Name **], PRIORITY PACK 20/30
- TERUMO, TR BAND LARGE"
6487,"He is being admitted to the CCU for
monitoring.
.
Cardiac catheterisation revealed tight stenosis with
calcification near the prior LAD lesion. Drug-eluting stent was
placed, jailing the diagonal, which remained occluded. He
experienced some chest pain peri-procedurally, which improved
with 20 mcg nitroglycerin. Radial access for cath was
attempted, but failed due to vessel tortuosity. TR band was
placed on right wrist. Femoral access was obtained instead and
was successful. He has been hemodynamically stable since the
procedure. . He is receiving peri-procedural integrillin and
is on a nitro drip for chest pain.
.
The patient reports that approximately three weeks ago he had
severe heartburn and nausea which was very similar to what he
experienced with his MI in [**2105**]."
6488,"There were faint collaterals to the diagonal territory. There
was no
angiographically apparent dissection and tIMI 3 flow in the LAD.
The
patient was started on IV nitroglycerin with improving chest
pain. The
patient was transferred to CCU for monitoring in stable
condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 49 minutes.
Arterial time = 1 hour 45 minutes.
Fluoro time = 48.8 minutes.
Effective Equivalent Dose Index = 2850 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 155 ml
Premedications:
Midazolam 1 mg IV
Fentanyl 100 mcg IV
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq."
6489,"Right groin bandage
in place, no hematoma, no bruits, distal pulses readily
palpable. TR band on right wrist, no hematoma, some dried blood
around site.
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+
Pertinent Results:
[**2108-2-25**] 07:19AM BLOOD WBC-8.2 RBC-4.45* Hgb-13.0* Hct-38.3*
MCV-86 MCH-29.2 MCHC-33.9 RDW-13.5 Plt Ct-181
[**2108-2-24**] 12:40PM BLOOD WBC-8.2 RBC-4."
6490,"At this time he
was treated at [**Hospital 1727**] Medical Center where a drug eluting stent
was placed in the posterolateral branch of the RCA at a site of
ISR. LVEF by ventriculogram was preserved at 57%. A residual LAD
stenosis of 50% was mentioned. Prasugrel was added to his
medical regimen.
.
Continuing to have 5/10 chest pain, dyspnea, palpitations, LE
edema, orthopnea, PND, lightheadedness, claudication
.
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."
6491,"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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: CAD with large IMI ([**2094**] and [**2097**]), stenting
of RCA/LAD. Also had MI in [**State 4565**] in [**2104**], treated at [**First Name8 (NamePattern2) **]
[**Doctor First Name **], unknown territory but [**3-2**] stents placed. MI in [**State 1727**] in
[**3-/2107**], with 2 more stents."
6492,"Name: [**Known lastname 11597**],[**Known firstname **] Unit No: [**Numeric Identifier 11598**]
Admission Date: [**2152-1-23**] Discharge Date: [**2152-1-29**]
Date of Birth: [**2083-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 741**]
Addendum:
The patient has a history of CHRONIC systolic heart failure with
EF 40% as documented on echo [**2152-1-24**]. Discharge diagnosis
section has been addended to reflect this.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary artery disease s/p CABG
Atrial fibrillation/flutter
Sick Sinus syndrome
Chronic systolic heart failure
Dyslipidemia
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2152-2-29**]"
6493,"Repeat cath in [**Month (only) **]
revealed CAD of a large diagonal vessel as well as the
circumflex. He presents for surgical evaluation.
Past Medical History:
coronary artery disease s/p DES to PDA [**2151-5-6**]
sick sinus syndrome
atrial flutter
chronic systolic heart failure
dyslipidemia
diverticulosis
Social History:
Lives with:wife
Occupation: driver of charter busses, plays guitar for fun
Tobacco: quit 6 years ago-prior [**4-8**] cigarettes/day
ETOH: [**2-6**] glasses of wine/day
Family History:
noncontributory
Physical Exam:
VS; T 97.8 HR BP 148/92 RR 18 O2sat 99%-RA
Wt 180 lbs
Gen NAD, lying in bed
Neuro: Alert and oriented x3, MAE-nonfocal exam
HEENT: PERRL/EOMI, anicteric-noninjected."
6494,"He was doing well and was
transferred to the floor for the remainder of his care.
Physical therapy worked with him on strength and mobility. On
post operative day three he went into atrial flutter in
controlled rate and was treated with beta-blockers and
amiodarone. Coumadin was resumed. He was discharged home on
POD 5 with appropriate follow up instructions.
Medications on Admission:
pravastatin 40mg daily
warfarin 6mg daily
lisinopril 40mg daily
toprol 50mg daily
asa 81mg daily
cymbalta 30mg daily
bupropion XL 300mg daily
omeprazole 20mg daily
Discharge Medications:
1. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day."
6495,"Disp:*120 Tablet(s)* Refills:*2*
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dr.
[**Last Name (STitle) **] to dose for goal INR 2-2.5, dx: a-fib.
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication Atrial Flutter
Goal INR 2.0-2.5
First draw [**2152-2-1**]
Results to Dr [**Last Name (STitle) **] phone [**Telephone/Fax (1) 30837**] fax [**Telephone/Fax (1) 30838**]
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary artery disease s/p CABG
Atrial fibrillation/flutter
Sick Sinus syndrome
Acute systolic heart failure
Dyslipidemia"
6496,"C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week,then 400mg daily x 1 week,then 200mg
daily until further instructed."
6497,"MMM,
oropharynx-benighn
Neck: supple, full ROM. no JVD or lymphadenopathy
CV: irreg irreg no M/R/G
Pulm: CTA bilat
Abdm: soft, NT/ND/NABS
Ext: warm, well perfused, no CCE. no varicosities
Pertinent Results:
[**2152-1-29**] 05:45AM BLOOD WBC-8.4 RBC-3.87* Hgb-11.6* Hct-34.6*
MCV-90 MCH-29.9 MCHC-33.4 RDW-15.6* Plt Ct-288#
[**2152-1-29**] 05:45AM BLOOD PT-26.5* INR(PT)-2.6*
[**2152-1-28**] 04:25AM BLOOD PT-22.5* INR(PT)-2.1*
[**2152-1-27**] 04:25AM BLOOD PT-18."
6498,"**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
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2-17**] at 2:30 pm
Cardiologist: Dr [**Last Name (STitle) 14522**] [**Telephone/Fax (1) 14525**] [**3-3**] at 4:00 pm
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 30837**] in [**5-10**] 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**
Labs: PT/INR for Coumadin ?????? indication Atrial Flutter
Goal INR 2.0-2.5
First draw [**2152-2-1**]
Results to Dr [**Last Name (STitle) **] phone [**Telephone/Fax (1) 30837**] fax [**Telephone/Fax (1) 30838**]
Completed by:[**2152-1-29**]"
6499,"9
[**2152-1-24**] Intra-op TEE
Conclusions
Pre Bypass: Patient is in A flutter. No left atrial appendage
thrombus, velocities in LAA > 20 cm/s. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation.
Post Bypass: Pateint is AV paced on Phenylepherine infusion.
Preserved biventricular function and wall motion."
6500,"Admission Date: [**2152-1-23**] Discharge Date: [**2152-1-29**]
Date of Birth: [**2083-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2152-1-24**] Coronary artery bypass graft x3 (left internal
mammary artery > left anterior descending, saphenous vein graft
> diagonal, Saphenous vein graft > posterior descending)
History of Present Illness:
68 year old male who developed atrial flutter and was found to
have evidence of
inferior ischemia on stress test. He does c/o chest discomfort
on exertion, which resolves with rest."
6501,"0* INR(PT)-1.6*
[**2152-1-26**] 04:50AM BLOOD PT-14.8* PTT-29.1 INR(PT)-1.3*
[**2152-1-24**] 03:29PM BLOOD PT-14.8* PTT-28.7 INR(PT)-1.3*
[**2152-1-24**] 02:02PM BLOOD PT-16.8* PTT-27.1 INR(PT)-1.5*
[**2152-1-23**] 03:43PM BLOOD PT-15.0* PTT-27.2 INR(PT)-1.3*
[**2152-1-29**] 05:45AM BLOOD Glucose-100 UreaN-20 Creat-0.8 Na-140
K-4.1 Cl-103 HCO3-30 AnGap-11
[**2152-1-29**] 05:45AM BLOOD Mg-1."
6502,"Disp:*30 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
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:*0*
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E."
6503,"LVEF 55%. No
change in valvular function. Aortic contours intact. Reamaining
exam is unchanged. All findings discussed with surgeons at the
time of the exam.
Brief Hospital Course:
Admitted [**2152-1-23**] for heparin bridge and surgical evaluation.
On [**1-24**] he was brought to the operating room and underwent
coronary artery bypass graft surgery, see operative report for
further details. He received cefazolin for perioperative
antibiotics and was transferred to the intensive care unit for
post operative management. In the first twenty four hours he
was weaned from sedation, awoke, and was extubated without
complications. On postoperative day one he was started on
diuresis and beta blockers."
6504,"Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema -none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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**]"
6505,"Admission Date: [**2150-5-31**] Discharge Date: [**2150-6-10**]
Date of Birth: [**2123-6-3**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
S/P MVC
Right leg and chest pain
Major Surgical or Invasive Procedure:
[**2150-5-31**]
1. Irrigation debridement skin to bone right femur.
2. Open reduction internal fixation with intramedullary
nail right open femur fracture.
History of Present Illness:
26 year old female who unrestrained
driver in a high-speed MVC with intrusion to the dashboard
noted to have open R femur fx and R rib fx's"
6506,"Past Medical History:
PMH
none
PSH
none
Social History:
Smokes [**11-30**] ppd. Social alcohol drinker. Denies other
illicits.
Family History:
non contributory
Physical Exam:
Constitutional: uncomfortable
HEENT: Normocephalic, atraumatic
Trachea midline
Chest: Clear to auscultation equal breath sound tender
along right chest
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: Open wound with swelling to right thigh
Skin: No rash pulses intact distally
Neuro: Speech fluent
Psych: Normal mood, Normal mentation Cranial nerves II
through XII grossly intact, Motor [**4-2**] in all extremities,
sensory without focal deficits
Pertinent Results:
[**2150-5-31**] 05:00AM WBC-21."
6507,"2* RBC-4.83 HGB-14.2 HCT-40.9 MCV-85
MCH-29.5 MCHC-34.8 RDW-13.7
[**2150-5-31**] 05:00AM PLT COUNT-337
[**2150-5-31**] 05:00AM PT-12.9 PTT-21.3* INR(PT)-1.1
[**2150-5-31**] 05:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-5-31**] 05:07AM GLUCOSE-247* LACTATE-3.3* NA+-140 K+-3.6
CL--102 TCO2-24
[**2150-5-31**] 05:00AM UREA N-15 CREAT-0.9
[**2150-5-31**] CXR :
Minimally displaced rib fractures, left first through third
ribs."
6508,"[**2150-6-3**] CTA Chest :
1. Traumatic focal dissection in the proximal descending aorta
with expanding contained thrombus since [**2150-5-31**].
2. No central pulmonary embolism.
3. Mild pulmonary edema.
4. Small bilateral pleural effusions and adjacent atelectasis.
5. Stable anterior proximal left rib fractures.
6. Fatty liver.
[**2150-6-4**] MRI Left knee :
1. No evidence of injury to the menisci, ligaments, or tendons.
2. Medial femoral condyle osseous contusion.
3. Full thickness chondral fissure in the lateral tibial
plateau.
4. Diffuse subcutaneous soft tissue and vastus muscle edema.
[**2150-6-8**] CTA Chest :
1. Focal contained, post-traumatic aortic dissection in the
proximal
descending aorta is unchanged since previous CT dated [**2150-6-3**]."
6509,"* Dr. [**Last Name (STitle) 89092**] will regulate your Coumadin dose.
* Your blood sugars have been on the high side since your
admission and you should talk to your PCP about further testing
for diabetes.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ), chest pain, or increased leg
pain.
Followup Instructions:
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 4 weeks.
Call the Vascular Surgery Clinic at [**Telephone/Fax (1) 2625**] for a follow up
appointment in 4 weeks.
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-1**] weeks.
Dr. [**Last Name (STitle) 89092**] ([**Telephone/Fax (1) 89093**]) Wednesday [**2150-6-17**] at 11:45AM.
Completed by:[**2150-6-10**]"
6510,"In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible."
6511,"She
will be discharged on Labetolol alone at 100 mg [**Hospital1 **] and the VNA
will follow up with blood pressure checks for the first few
days.
Her blood sugars have been elevated since admission in the high
100-240 range. She was encouraged to follow up with Dr. [**Last Name (STitle) 89092**]
for further management.
From an Orthopedic standpoint she has done well post op. Her
incision is healing well and after many Physical Therapy visits
she is able to crutch walk safely. Her weight bearing status is
partial (50%) on the right leg and full weight bearing on the
left."
6512,"Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 189**]
Discharge Diagnosis:
S/P MVC
1. Open right femur fracture
2. Proximal descending thoracic aortic dissection with contained
thrombus
3. Left rib fractures [**12-1**]
4. Right first rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital after your car accident with
multiple injuries including a broken right leg, rib fractures
and a small tear in your aorta which sealed over."
6513,"On [**6-3**], the patient underwent CTA to rule out PE, which
showed dissection of the descending aorta. Cardiac surgery was
consulted and recommended no surgery, but instead strict blood
pressure control. On [**6-4**], patient was started on labetalol gtt
for better HR and BP control, and this was transitioned to po
Lopressor and labetalol gtt was discontinued. Otherwise, patient
was doing well, tolerating regular diet. Ortho recommended 50%
weight bearing on right leg and full wt bearing on the left leg.
The patient was transferred to the floor on [**6-5**].
Following transfer to the Trauma floor she continued to make
good progress."
6514,"Vascular surgery was consulted regarding her
descending thoracic aortic dissection and they recommended
Coumadin, aspirin and keeping SBP < 140 mmHg. Her Coumadin was
started on [**2150-6-7**] at 5mg followed by 7.5 mg on [**6-8**] and [**6-9**].
Her INR on [**6-10**] is 1.7 and she will take 5mg daily with an INR
check on [**2150-6-12**]. Dr. [**Last Name (STitle) 89092**], her PCP will dose her Coumadin
starting on Friday [**2150-6-12**]. Her last CTA chest was on [**2150-6-8**]
which showed no progression of her dissection.
Blood pressure control was successful with Lopressor and
hydralazine with SBP 95-120/70 and heart rates in the 70's."
6515,"Her staples will be removed by the VNA on [**2150-6-15**].
After a long recovery she was discharged home on [**2150-6-10**] with
VNA services for BP checks and Coumadin teaching and monitoring.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. senna 8."
6516,"* Your orthopedic surgery went well and your weight bearing
status on the right leg is partial weight bearing with crutches.
The VNA will take your staples out.
* Your injury caused left rib fractures [**12-1**] and the right first
rib which can cause severe pain and subsequently cause you to
take shallow breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures."
6517,"2. Stable fractures involving the anterior ends of first and
second ribs on left side.
Brief Hospital Course:
On [**5-31**], the patient went to the OR for femur fx repair, she had
low O2 sats postoperatively, requiring a non rebreather. On [**6-1**],
the patient's C-spine was cleared and her diet was slowly
advanced. Logroll precautions were d/c'd and patient was started
on dilaudid PCA. ON [**6-2**], the patient had an acute drop in her
HCT down to 23.7, she received a unit of blood and responded
appropriately. She continued to have some desaturation with
turning/sleeping, but she was able to be transitioned from NRB
to NC."
6518,"6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): thru [**2150-6-12**].
Disp:*4 Tablet(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
[**2150-6-12**] to determine future."
6519,"* Do NOT smoke
* The aortic dissection was noted on your initial CT scan. You
need to have good blood pressure control and also must stay on a
blood thinner called Coumadin. You will need to have your blood
tested frequently in the beginning of therapy but after you are
regulated it should be once a month. Maintain safety
precautions while on Coumadin so that you don't bleed. Be
careful with sharp objects. Shave your legs with an electric
razor to prevent cuts that will bleed excessively. Do not use
ibuprofen or any product with Ibuprofen in it as it can increase
your bleeding tendency."
6520,"Admission Date: [**2175-4-12**] Discharge Date: [**2175-4-13**]
Date of Birth: [**2105-6-23**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
incidental finding
Major Surgical or Invasive Procedure:
[**2175-4-12**]: Cerebral Angiogram with stent assisted coiling
History of Present Illness:
She was recently admitted at [**Hospital3 **] in [**2175-2-2**] for a
transient episode of left-sided blindness that started acutely.
No cause was found for this and her aspirin was upgraded to
Plavix with a presumptive diagnosis of TIA. However, during the
admission, we also found a 5-mm aneurysm involving the
right supraclinoid area measuring 3."
6521,"7 x 6.2 mm. This is in the
superior hypophyseal area. I had offered her the option of
conservative management given her age of 69 years, but she is
being distraught with the fear that this could rupture despite
the fact that I had discussed with her that the risk of rupture
is only approximately 2% per year. However, she wants this to
be
treated and electively presents today to undergo embolization.
Past Medical History:
Hypothyroidism
Gastritis
Hyperlipidemia
Social History:
quit tobacco over 25 yrs ago. alcohol [**12-5**]/week; married, retired
Family History:
Father had stroke in his 80s, 3 brothers all past away, 2 from
prostate CA (One recently in fall [**2173**]) and 3rd brother passed
away this winter from a stroke that occurred after his 1st chemo
session for pancreatic CA."
6522,"????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 6 months with a MRI/A. This
appointment can be scheduled by calling [**Telephone/Fax (1) 1669**].
Completed by:[**2175-4-13**]"
6523,"Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
right supraclinoid aneurysm."
6524,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?"
6525,"Physical Exam:
On Discharge:
Nonfocal
Groin- no hematoma, soft
dorsalis pedis pulses 2+ bilaterally
Pertinent Results:
Angiogram: successful stent asssited coiling of brain aneurysm
Brief Hospital Course:
Pt electively presented and underwent cerebral angiogram, and
stent assisted coiling. Procedure was without complication. She
extubated and transferred to the SICU. She was continued on
aspirin and plavix with an SBP goal <160. Overnight, her HOB and
diet were advanced. She was nonfocal on AM exam, pulses intact
and groin soft and no hematoma. She was discharged home in
stable condition on aspirin and plavix.
Medications on Admission:
PLAVIX, LEVOTHROID, ZANTAC,SIMVASTATIN, ambien, VitB12"
6526,"PREOPERATIVE DIAGNOSIS: Right superior hypophyseal artery aneurysm.
INDICATION: For treatment of cerebral aneurysm.
PROCEDURE PERFORMED: Right internal carotid artery arteriogram, right common
femoral artery arteriogram.
INTERVENTIONAL PROCEDURE PERFORMED: Neuroform 4.5 x 20 mm stent-assisted coil
embolization of a right superior hypophyseal artery aneurysm.
ATTENDING PHYSICIAN: [**First Name8 (NamePattern2) 2152**] [**Name11 (NameIs) 118**], [**Name Initial (NameIs) **].D.
ASSISTANT: [**First Name4 (NamePattern1) 2161**] [**Last Name (NamePattern1) 2162**], nurse practitioner.
ANESTHESIA: General.
DETAILS OF PROCEDURE: The patient was brought to the angiography suite. IV
sedation was given. Anesthesia was induced in the supine position. Both
groins were prepped and draped in a sterile fashion."
6527,"We now deployed a 4 x 4.5 x 20 mm Neuroform stent across the
neck of the aneurysm. Following this, the aneurysm was coiled with a 3-mm
Target UltraSoft coil and with 2-mm Target UltraSoft coil. Following this,
the aneurysm was seen to be fairly obliterated except for a small residual at
the base. The catheters were now removed and right common femoral artery
arteriogram was done and a 6 French Angio-Seal was used for closure of the
right common femoral artery puncture site.
(Over)
[**2175-4-12**] 4:05 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 24720**]
Reason: coiling of anuerysmAnesthesia has been booked for [**4-12**] at 1pm
Contrast: OPTIRAY Amt: 100ML OPTI240; 66MM OPTI320
______________________________________________________________________________
FINAL REPORT
(Cont)
FINDINGS: Right internal carotid artery arteriogram shows 5 x 3 mm aneurysm
of the right superior hypophyseal artery with a broad neck.
Right internal carotid artery arteriogram status post coil embolization shows
no evidence of stenosis at the placement of the stent and the aneurysm itself
is obliterated except for a small residual at the base.
Right common femoral artery arteriogram shows widely patent right common
femoral artery.
IMPRESSION: [**Known firstname 1100**] [**Known lastname **] underwent cerebral angiography and stent-assisted
coil embolization of a brain aneurysm in the right paraclinoid area without
any complications. The patient was extubated and found to be neurologically
unchanged."
6528,"[**2175-4-12**] 4:05 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 24720**]
Reason: coiling of anuerysmAnesthesia has been booked for [**4-12**] at 1pm
Contrast: OPTIRAY Amt: 100ML OPTI240; 66MM OPTI320
********************************* CPT Codes ********************************
* [**Numeric Identifier 2151**] EMBO TRANSCRANIAL [**Numeric Identifier 146**] SEL CATH 3RD ORDER [**Last Name (un) **] *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 2159**] CAROTID/CEREBRAL UNILAT *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 1238**] TRANSCATH EMBO THERAPY *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
69 year old woman with aneurysm
REASON FOR THIS EXAMINATION:
coiling of anuerysmAnesthesia has been booked for [**4-12**] at 1pm
______________________________________________________________________________
FINAL REPORT
ANGIO REPORT"
6529,"Access was gained to the
right common femoral artery using a Seldinger technique and a 6 French
vascular sheath was placed in the right common femoral artery. I now
catheterized the right internal carotid artery with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2155**] 2 catheter and
this was exchanged out and a Neuron 6 French catheter was placed in the right
internal carotid artery. 5000 units of heparin was given to anticoagulate the
patient. Following this, we proceeded to catheterize the right middle
cerebral artery with XT-27 microcatheter along with a Synchro wire. Following
this, through a second port, the aneurysm was catheterized with an SL-10
microcatheter."
6530,"Admission Date: [**2121-6-8**] Discharge Date: [**2121-6-10**]
Date of Birth: [**2090-10-22**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12722**]
Chief Complaint:
abdominal pain, vomiting - admitted to MICU for severe
dehydration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30 year old woman with history of alcohol abuse, pancreatitis,
depression/anxiety who presents in with two days of LLQ
abdominal pain, vomiting and inability to tolerate PO's. She
reports that symptoms are similar to episodes of pancreatitis.
Patient states she has been sober for 2 months and then relapsed
one week ago."
6531,"9
[**2121-6-10**] 07:30AM BLOOD Glucose-86 UreaN-2* Creat-0.6 Na-139
K-4.1 Cl-102 HCO3-28 AnGap-13
[**2121-6-10**] 07:30AM BLOOD ALT-20 AST-37 AlkPhos-61 TotBili-0.4
[**2121-6-10**] 07:30AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.2 Mg-1.7
.
CXR
No acute cardiopulmonary process.
.
EKG: SR at 99, normal axis, possible [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6192**], incomplete
RBBB, ST depression V3-V4, lead 2, 3, aVF new compared to prior
EKG.
Brief Hospital Course:
30 year old female with alcohol dependence admitted with alcohol
intoxication and abdominal pain, requiring brief MICU course for
hypotension."
6532,".
# Hypotension: Patient presented with hypotension in the setting
of decreased PO intake, vomiting and significant ETOH use. She
received 6L of IV fluids in the ED prior to arrival to MICU with
resolution of hypotension, supporting a diagnosis of
hypovolemia. No source of infection was identified and the
patient maintained good urine output. Blood pressure remained at
home SBP of 90-110 for the remainder of admission, as the
patient had improved PO intake.
.
# Acidemia: On admission, patient had combined AG acidosis, NAG
acidosis and respiratory acidosis. AG acidosis likely lactate
(admission lactate of 6.3)/ETOH ketosis (trace ketones on u/a),
hyperchloremic NAG from NS volume resuscitation."
6533,"Respiratory
depression likely related to hypoventilation in setting of
benzodiazepine administration while intoxicated with PCO2 of 44
on ABG. Patient's lactate and pH improved in MICU.
.
# Elevated Lactate: Likely in setting of significant
hypovolemia and EtOH consumption. Evidence of acidemia on ABG.
Improved with volume resuscitation.
.
# EKG changes: Pt presented with ST depressions in anterolateral
chest leads and inferolateral limb leads. Could represent
changes due to hypokalemia or hypoglycemia. Repeat EKG on HD #2
showed resolution of all ST depressions s/p correction of
electrolyte abnormalities.
.
# Hypoglycemia: Likely due to poor intake while drinking.
Patient initially given D5 in ED and quickly normalized."
6534,"She will attend [**Hospital1 **] starting Wednesday,
[**6-18**]. The patient was also resumed on home naltrexone
prior to discharge. She will follow up with her PCP on
discharge regarding her alcohol abuse. Her behavioral health
group coordinator was also notified of her admission and
discharge date to further plan support groups for the patient.
.
# Abdominal pain: Likely secondary to gastritis related to ETOH
abuse. LFTs mildly elevated, but consistent with her baseline
as she has alcoholic hepatitis. Lipase returned normal and
abdominal exam remained clinically benign. No evidence of bleed
throughout admission. The patient was continued on omeprazole.
.
# Hypothermia: Pt hypothermic to 93 on admission, likely
secondary to wearing inadequate clothing in cold weather, poor
nutritional state and receiving unwarmed IVF in ED."
6535,"TSH was
found to be low (0.17), free T4 elevated. The patient should
follow up with her PCP for repeat thyroid function studies. She
may require thyroid suppression therapy.
.
# Depression/Anxiety: Followed as outpatient at [**Hospital1 778**] for dual
diagnosis, EtOH abuse and depression. The patient's behavioral
health coordinator was [**Hospital1 653**] regarding admission with
planned close follow-up.
.
# Bulimia/malnutrition: Patient reported it was not a current
issue, but demonstrated binging and purging behavior with
ordering multiple meals and witnessed emesis in the MICU. The
patient also has a poor nutritional status due to ETOH use.
Patient was felt to be potentially at risk for refeeding."
6536,"Her
electrolytes were monitored closely and repleted aggressively.
=======================================
Transitional Issues:
- Patient scheduled an appointment with [**Hospital1 **] Outpatient
Services in [**Location (un) 86**] on Wednesday, [**6-18**] at 10:30 AM. We have
strongly encouraged her to keep this appointment and call her
PCP with any concerns.
- The patient should undergo repeat check TSH/Free T4 on
discharge from the hospital, as she likely requires thyroid
suppression therapy
Medications on Admission:
Per recent d/c summary (not reconciled)
1. FoLIC Acid 1 mg PO DAILY
2. Thiamine 100 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 40 mg PO DAILY"
6537,"3* Na-148* K-3.4
Cl-104
[**2121-6-8**] 04:48AM BLOOD Lactate-4.8*
[**2121-6-8**] 06:49AM BLOOD Lactate-5.5*
[**2121-6-8**] 06:49AM BLOOD freeCa-0.86*
[**2121-6-8**] 04:51AM BLOOD TSH-0.17*
[**2121-6-8**] 12:43PM BLOOD Free T4-0.49*
.
DISCHARGE
[**2121-6-10**] 07:30AM BLOOD WBC-4.9 RBC-4.26 Hgb-13.4 Hct-42.8
MCV-101* MCH-31.4 MCHC-31.3 RDW-13.0 Plt Ct-229
[**2121-6-10**] 07:30AM BLOOD PT-9.5 PTT-35.7 INR(PT)-0."
6538,"[**Known lastname 1887**],
.
You were admitted to the hospital with alcohol relapse leading
to low blood pressure and low blood sugar. You were given IV
fluids and your blood pressure improved. You were able to
tolerate foods without difficulty, and your blood sugar remained
stable. You did not show any signs of withdrawal.
.
For prevention of further alcohol relapse, you were resumed on
your home naltrexone. You should follow up with your primary
care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 63733**] injection as previously planned.
You should also follow up for your psychiatry intake as
previously scheduled. You should follow up with [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 15131**]
for coordination of your substance abuse care. You were seen by
social work and recommended for a partial day program. You were
given this information and were strongly advised to call and
have this set up.
.
MEDICATIONS CHANGED THIS ADMISSION:
START naltrexone 50 mg daily
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Thursday [**2121-6-12**] at 4:00 PM
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BWD"
6539,"Subsequent FS WNL.
.
# Alcohol Abuse: Patient with significant history of ETOH abuse
with evidence of end-organ damage, including pancreatitis and
hepatitis. At the time of presentation, the patient was
intoxicated with ETOH level of 366. Patient has had multiple
hospitalizations related to ETOH abuse. The patient was started
on folate, thiamine, and a multivitamin on admission. She was
monitored on CIWA with PO diazepam, did not score on CIWA
(likely because had only been drinking for max 6 days after 30
days of abstinence in rehab). She was evaluated by social work
and was recommended for an alcohol abuse partial day program to
prevent relapse."
6540,"Pt denies
she has ever tried any illicit drugs. She currently lives alone.
.
Pt is from CA. Her mother is a major support and continues to
live in CA. Pt is not close with father. Pt states that she
stays in MA because it is one of the few states she is able to
practice as a dental hygenist.
Family History:
Family History per OMR
Maternal grandfather with alcoholism
Maternal uncle with drug problem
Paternal aunt with alcoholism
Physical Exam:
ADMISSION:
Vitals: T:96 BP: 95/76 P: 86 R: 18 O2: 100RA
General: Somnolent, arousable to voice, following commands, no
acute distress
HEENT: Sclera anicteric, dry MM, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley with clear light yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: following commands, moving all extremities
."
6541,"Social History:
Social History Per OMR:
Pt reports that she has hx of bulemia. States that her mo was
bulemic and that is something she has dealt with since
childhood. States she did not start drinking until she was 21.
She successfully completed undergraduate degree in biochemistry
in [**Location (un) 11177**] State and was accepted to [**Hospital1 3278**] dental school.
Drinking gradually became a problem and she identifies etoh
becoming a more significant problem during a difficult
relationship with a boyfiend after she moved to [**Location (un) 86**]. She
describes bulemia as being less of a problem currently, although
something she continues to deal with."
6542,"Pt moved to [**Location (un) 86**] to go
to dental school at [**Hospital1 3278**]. She actually walked in graduation in
[**2116**] but has not finished her degree. She does not have plans to
return to dental school. Pt cont to stay in Ma because she is
certified as a dental hygenist in the state. She feels that her
etoh abuse was related to her inability to complete dental
school.
.
Pt has been to several detox facilities and 2 rehab programs in
CA. Pt did feel that programs were helpful. She has a hx of
being sober through AA and with support of her church."
6543,"7 Cl-96 HCO3-25 AnGap-30*
[**2121-6-8**] 04:51AM BLOOD Glucose-186* UreaN-6 Creat-0.5 Na-144
K-2.4* Cl-112* HCO3-16* AnGap-18
[**2121-6-8**] 03:37AM BLOOD WBC-7.7# RBC-4.70 Hgb-15.3 Hct-45.8
MCV-98 MCH-32.6* MCHC-33.4 RDW-13.3 Plt Ct-391
.
PERTINENT
[**2121-6-8**] 03:37AM BLOOD Albumin-4.5 Calcium-8.9 Phos-4.4 Mg-1.9
[**2121-6-8**] 03:37AM BLOOD ALT-30 AST-73* AlkPhos-70 TotBili-0.3
[**2121-6-8**] 03:37AM BLOOD Lipase-26
[**2121-6-8**] 03:37AM BLOOD ASA-NEG Ethanol-366* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2121-6-8**] 04:14AM BLOOD Glucose-19* Lactate-6."
6544,"Documented initial vitals in ED were: T 98.1 HR 108 BP
94/52 RR 12 O2 sat 98% RA. Labs were sigificant for EtOH of 366
with otherwise negative serum tox. AST 73, ALT 30, lipse 26.
Bedside ultrasound of abdomen and heart showed no abnormalities.
The patient was given 1 amp of D50 for hypoglycemia, 5 L NS for
volume repletion. She received zofran, Thiamine 100mg, folate,
Reglan, ativan 2mg Pantoprazole 40.
.
On arrival to the MICU, patient is somnolent and unable to
provide meaningful history.
Past Medical History:
- EtOH dependence
- EtOH pancreatitis
- EtOH hepatitis
- EtOH gastritis
- Anxiety
- Depression
- Bulemia"
6545,"Discharge Medications:
1. Fluoxetine 40 mg PO DAILY
2. naltrexone *NF* 50 mg Oral daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
RX *naltrexone 50 mg daily Disp #*30 Tablet Refills:*0
3. Omeprazole 40 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol abuse, hypoglycemia, hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms."
6546,"States her last drink was 24 hours ago. Denies
fevers, diarrhea, HA, CP, SOB, vaginal bleeding, vaginal
discharge. Lives alone.
.
Of note patient was recently hospitalized for ETOH withdrawal.
During this admission, there was concern that she was not safe
to go home given multiple admissions to the hospital related to
ETOH use. A section 35 as filed and patient was ultimately
escorted by police to court, where she was determined to require
involuntary admission for treatment of ETOH abuse. Her 30 days
of treatment ended 2 weeks ago.
.
At the time of presentation to ED patient was hypotensive to BP
83/69."
6547,"DISCHARGE:
Vitals: 97.5 100/84 80 18 100%RA
General: Alert, oriented, laying comfortably in bed
HEENT: Sclera anicteric, PERRL, MMM, OP without lesions; cheeks
prominent
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: following commands, moving all extremities
Pertinent Results:
ADMISSION
[**2121-6-8**] 03:37AM BLOOD Glucose-31* UreaN-7 Creat-0.9 Na-147*
K-3."
6548,"Admission Date: [**2127-11-7**] Discharge Date: [**2127-11-11**]
Date of Birth: [**2049-7-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic stenosis, DOE
Major Surgical or Invasive Procedure:
[**2127-11-7**] Aortic Valve replacement (21 StJude epic/porcine)
History of Present Illness:
78 year old male with a life long history of heart murmur. He
claims this was never really followed. He recently underwent a
urologic procedure and developed urosepsis with MRSA bactermia.
An echocardiogram was performed while an inpatient due to the
presence of his systolic murmr and he was noted to have severe
aortic stenosis."
6549,"He currently complains of very mild dyspnea on
exertion. He has now been referred for surgical evaluation.
Past Medical History:
aortic stenosis, s/p AVR [**2127-11-7**]
PMH:
Recent urosepsis with MRSA bactermia
Glaucoma
Prostate and bladder cancer diagnosed 14 years ago
s/p TURP, prostate biopsies, recent dilation and ureter stenting
Social History:
Race: Caucasian
Last Dental Exam: Years ago
Lives with: Wife in [**Name2 (NI) 38**]
Occupation: Insurance Broker
Cigarettes: Smoked no [] yes [X] last cigarette 30 years ago Hx:
4-5 packs per day for 20 years
Other Tobacco use:
ETOH: < 1 drink/week [X] [**2-3**] drinks/week [] >8 drinks/week []
Illicit drug use"
6550,"There
is critical aortic valve stenosis (valve area <0.8cm2). Mild
(1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results before
surgical incision.
POST-BYPASS: Preserved biventricular systolic function. LVEF 50%
The aortic bioprosthesis is stable and functioning well with a
mean residual gradient of 15mm of Hg.
Intact thoracic aorta. No new valvular findings.
[**2127-11-10**] 05:50AM BLOOD WBC-10.4 RBC-3.06* Hgb-9.5* Hct-28.7*
MCV-94 MCH-31."
6551,"1 MCHC-33.0 RDW-14.4 Plt Ct-195
[**2127-11-11**] 05:30AM BLOOD UreaN-35* Creat-1.6* Na-138 K-4.3 Cl-101
[**2127-11-10**] 05:50AM BLOOD Glucose-124* UreaN-31* Creat-1.4* Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
The patient was brought to the operating room on [**11-7**] where the
patient underwent [**2127-11-7**] AVR(21 StJude epic/porcine). Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring."
6552,"Disp:*20 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**] [**Location (un) **]
Discharge Diagnosis:
aortic stenosis, s/p AVR [**2127-11-7**]
PMH:
Recent urosepsis with MRSA bactermia
Glaucoma
Prostate and bladder cancer diagnosed 14 years ago
s/p TURP, prostate biopsies, recent dilation and ureter stenting
Discharge Condition:
DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
[**Last Name (un) **] trace
Discharge Instructions:
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**]."
6553,"The patient was discharged home with VNA in good
condition with appropriate follow up instructions.
Medications on Admission:
DORZOLAMIDE-TIMOLOL 2 %-0.5 % Drops - 1 gtt in each eye [**Hospital1 **],
SULFAMETHOXAZOLE-TRIMETHOPRIM 800 mg-160 mg [**Hospital1 **], TRAVOPROST
0.004 % Drops - 1 gtt ou daily
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
6554,"DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: MON [**2127-11-10**] 2:29
TEE [**2127-11-7**]
Conclusions
PRE-BYPASS:
The left atrium is dilated. 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 mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are severely thickened/deformed."
6555,"Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check: [**Telephone/Fax (1) 170**] Date/Time:[**2127-11-19**] 10:00
Surgeon Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 170**], [**2127-12-17**] 1:00
Please call to schedule the following:
Cardiologist Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] [**Doctor First Name **]
Primary Care Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17503**] in [**4-1**] 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**
Completed by:[**2127-11-11**]"
6556,"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 Tranmsitted vs. Bruit
Pertinent Results:
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 91265**]
Reason: eval for effusion
Final Report
HISTORY: AVR.
FINDINGS: In comparison with study of [**11-9**], there is less
opacification at
the right base. However, this most likely reflects primarily the
change in
patient position, as there is continued large effusion with
compressive
atelectasis. The right IJ sheath has been removed. Lower lung
volumes and
some atelectatic changes are also seen at the left base."
6557,"Disp:*30 Tablet(s)* Refills:*0*
4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
5. travoprost 0.004 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 10 days."
6558,"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. He
developed junctional rhythm, beta blocker was decreased and
sinus rhythm returned.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility.
By the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics."
6559,"Family History:
Family History: Mother with valve issues and died at 80, father
with CAD and died at 83. Brother with CAD and died at 56.
Physical Exam:
Physical Exam
Pulse: 67 SR Resp: 16 O2 sat: 100%
B/P Right: 112/64 Left: 108/67
Height: 66"" Weight: 163
General: WDWN in NAD
Skin: Warm, Dry and intact. No C/C/E
HEENT: NCAT [X] PERRLA [X] EOMI [X] Sclera anicteric, OP benign.
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, IV/VI SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Anterior venous dilation below knee, GSV appears
suitable bilaterally."
6560,"Admission Date: [**2186-6-17**] Discharge Date: [**2186-6-28**]
Date of Birth: [**2140-2-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Jaundice and malaise
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
The patient is a 46 year old female with a history of
hypertension, OSA, and depression who was transferred from [**Hospital1 **] after presenting to the ED there with 4 days of
nausea, vomiting, diarrhea, and worsening jaundice. She was
hypotensive to the 70s in triage and received IV fluids. She
was noted to have creatinine 8, TBili 10, and Lipase 3400."
6561,"She was mentating well and in no acute distress.
Initial labs showed multiple electrolyte abnormalities including
Na 126, Ca 6.7, and bicarb 12 with anion gap 16 and lactate 2.3.
Her creatinine had decreased to 4.6 from 8 at OSH after IV
fluids. Her LFTs were still abnormal but generally improved
from OSH labs. She had a leukocytosis with WBC 13.9 and anemia
with Hct 23.6. Her INR was elevated to 1.6. Her stool was
guaiac negative. ERCP and Surgery were consulted in the ED, and
she is planned for ERCP this morning. She was admitted to the
ICU for further monitoring and management."
6562,"Denies shortness of
breath or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies abdominal pain. Denies
dysuria, frequency, urgency, or change in urine. Denies
arthralgias or myalgias. Denies rashes or skin changes besides
jaundice.
Past Medical History:
# Hypertension
# Obstructive Sleep Apnea
-- uses CPAP at home
# Depression
Social History:
Social History:
# Tobacco: Smoked 1 PPD for five years in the distant past.
# Alcohol: Prior alcohol abuse, none in two years, now on
Campral.
# Illicits: None
# Lives at home with husband, [**Name (NI) **] [**Telephone/Fax (1) 90543**]
Family History:
Family History:
# Father: died from lymphoma at age 57
# Mother: CAD with CABG, rapidly progressive dementia recently
# Oldest Sister: died from alcohol abuse
# Sister: cholecystectomy
# Brother: GERD and hypertension"
6563,"Sludge is visualized within
the
gallbladder. Additionally, there are echogenic foci with dirty
posterior
shadowing in nondependent portions of the gallbladder is
consistent with air
within the gallbladder lumen, likely from recent ERCP and
sphincterotomy.
The spleen is mildly enlarged measuring 13 cm. There is no
ascites.
Bilateral kidneys are without evidence of hydronephrosis. The
pancreas is not
well visualized due to overlying bowel gas.
IMPRESSION:
1. Gallbladder sludge without acute cholecystitis. There is also
evidence of
air within the gallbladder lumen, likely from recent ERCP and
sphincterotomy.
2. Echogenic liver consistent with fatty infiltration of the
liver. More
significant liver disease including significant hepatic
fibrosis/cirrhosis
cannot be excluded based on this study."
6564,"The pancreatic duct appears
normal. There
is small amount of peripancreatic fluid/edema consistent with
patient's
diagnosis of acute pancreatitis. The splenic vein and superior
mesenteric
veins remain patent. There are no fluid collections.
There is a trace amount of perihepatic and perisplenic ascites.
The spleen,
adrenal glands, kidneys, and stomach are within normal limits.
There is no
retroperitoneal or mesenteric lymphadenopathy.
IMPRESSION:
1. No evidence of pancreatic mass. Small amount of
peripancreatic fluid/edema
is consistent with uncomplicated acute pancreatitis. Trace
perihepatic and
perisplenic ascites.
2. Marked diffuse fatty deposition in the liver. However,
heterogeneous
enhancement of the liver suggests diffuse liver disease beyond
fatty liver,
possibly reflecting hepatitis oor fibrosis, though there is not
overt
cirrhosis."
6565,"Mild to moderate pulmonary hypertension.
Brief Hospital Course:
46 year old female with a medical history of hypertension &
depression transferred from [**Hospital6 2561**] after
presenting with 4 days of nausea, vomiting, diarrhea, and
worsening jaundice. Admitted to the ICU, found to have acute
alcoholic pancreatitis and hepatitis.
.
# Acute Alcoholic Pancreatitis:
Pt presented to OSH with symptoms consistent with acute
pancreatitis. The patient has a history of alcohol abuse, but
initial denied alcohol use within the past 2 years, so gallstone
pancreatitis was suspected. RUQ ultrasound at OSH reportedly
showed sludge without visible stone. She underwent ERCP with CBD
stent placement."
6566,"Lipase was initially quite elevated and trended
down moderately after aggressive IVF. Other possible causes for
her pancreatitis were explored, including the possibility of
abdominal trauma suffered in a single-car accident the patient
suffered two weeks before this admission. However, MRCP was
negative. When TTG was elevated and patient was confronted with
the lack of other explanations for her acute
pancreatitis/hepatitis, she admitted to drinking 1.5 bottles of
wine/day prior to admission (see below, alcohol abuse).
.
# Acute Alcoholic Hepatitis:
Pt also presented with elevated LFTs and jaundice. Alcoholic
hepatitis was diagnosed when biliary obstruction and viral
hepatitis were ruled out."
6567,"Vitals prior to
transfer were BP 114/57, HR 102, and CVP 8.
.
Once in the ICU, she denied any pain or other specific
complaints besides the Foley catheter being uncomfortable. She
was in no acute distress and mentating well. She denied any
current nausea or abdominal pain.
.
Review of systems:
(+) Per HPI. She noted some chills at home prior to admission
but no fevers. She reports losing about 25 lbs over the last
few weeks due to lack of appetite. She has an occasional cough
which has not changed recently.
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea, or congestion."
6568,"7 HR 98 BP 120/66 RR 21 O2 97/RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, slightly dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Mild tachycardia with regular rhythm. Normal S1, S2.
Blowing holosystolic murmur at LLSB with radiation to axilla.
Abdomen: normoactive bowel sounds present. Soft, non-tender,
mildly distended, no rebound tenderness or guarding.
GU: no foley
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema
DISCHARGE EXAM:
Vitals: 97.9 98/62 94 20 95/RA 1000+300/BRP
General: AAOx3 NAD
HEENT: Scleral icterus, MMM, oropharynx clear
Neck: supple, no LAD JVP 3+sternal angle
Lungs: CTAB no r/r/w
CV: RRR."
6569,"Recent alcohol use likely
contributed to her current presentation, and should be
readdressed prior to and after discharge as she will continue to
need support for this ongoing issue.
.
# Alcohol Abuse:
Patient has longstanding history of alcohol abuse; she sees a
therapist [**Hospital1 **]-weekly and a psychopharmacologist for Campral
prescription. Denies alcohol use within the past 2 years until
confronted with laboratory data (GGT) confirming her providers'
suspicion of ongoing alcohol use. Family meeting was held prior
to discharge, to discuss prognosis for alcoholic hepatitis,
request that husband remove all alcohol from the home, agree
upon a plan for post-discharge detox program, and to re-inforce
the absolute importance of abstinence for her survival."
6570,"6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lexapro 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Campral 333 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO three times a day.
10. pentoxifylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO TID (3 times a day).
Disp:*90 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Alcoholic Pancreatitis
Alcoholic Hepatitis
."
6571,".
[**6-17**] ERCP
Impression: Successful biliary cannulation was achieved.
Partial opacification of the biliary tree was performed because
of clinical suspicion of cholangitis- no evidence of stones or
filling defects was seen.
Successful placement of a 7cm x 10Fr stent for biliary drainage-
with drainage of clear bile.
Otherwise normal ERCP to 3rd portion of duodenum.
Recommendations: Juices when awake and alert, then advance diet
as tolerated.
Continue antibiotics.
No definitive explanation for jaundice found on ERCP, although
contrast opacification limited. It is possible that the patient
passed a stone. Consider evaluation for other causes of jaundice
including viral hepatitis."
6572,"Please call Dr.[**Name (NI) 90544**] office if you need to reschedule this
appointment.
Please also call your Psychopharmacologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 90545**] at [**Telephone/Fax (1) 90546**] to book a follow up appointment within
1 week.
.
You should also see your therapist next week. The [**Hospital1 18**] social
worker will be in contact with your therapist to ensure a smooth
transition so you can receive the support you need.
.
You will also need to follow-up with the ERCP service, to have
the stent removed. Dr[**Name (NI) 90547**] administrator, [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 15954**],
will call you to arrange this appointment. If you don't hear
from her by next Monday, please call her at [**Telephone/Fax (1) 21143**]."
6573,"4*
[**2186-6-17**] 01:00AM BLOOD ALT-53* AST-149* AlkPhos-463*
TotBili-8.8*
[**2186-6-18**] 05:17AM BLOOD Lipase-514*
[**2186-6-17**] 01:00AM BLOOD Lipase-760*
[**2186-6-17**] 05:58AM BLOOD TotProt-5.3* Calcium-6.7* Phos-3.6 Mg-1.6
Iron-50
[**2186-6-17**] 05:58AM BLOOD calTIBC-163* VitB12-1777* Folate-6.0
Hapto-142 Ferritn-921* TRF-125*
[**2186-6-17**] 12:34AM BLOOD Lactate-2.3* K-4.5
.
DSICHARGE LABS:
[**2186-6-28**] 06:13AM BLOOD WBC-19.2* RBC-2.39* Hgb-8.4* Hct-25."
6574,"3. Gallbladder wall edema, likely due to underlying liver
disease.
Gallbladder sludge.
4. Biliary stent in place without intra or extraphepatic biliary
dilation.
Mild enhancement of the common bile duct is likely from stent
placement.
There is no evidence of abnormal biliary ductal enhancement
above the level of
the stent to suggest cholangitis.
.
[**6-28**] ECHO
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Estimated cardiac
index is normal (>=2.5L/min/m2). TDI E/e' < 8, suggesting normal
PCWP (<12mmHg)."
6575,"The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mitral regurgitation is seen. There is mild
to moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function."
6576,"No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild thickening of mitral valve chordae. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%)."
6577,"Normal S1, S2. holosystolic mumur LLSB radiates to
axilla.
Abdomen: Soft, non-tender, distended no rebound tenderness or
guarding, liver palpable, +BS
Ext: Warm, well perfused, 2+ pulses. No c/c/e
Pertinent Results:
ADMISSION LABS:
[**2186-6-17**] 01:00AM BLOOD WBC-13.9* RBC-2.28* Hgb-8.1* Hct-23.6*
MCV-104* MCH-35.6* MCHC-34.3 RDW-15.0 Plt Ct-200
[**2186-6-18**] 05:17AM BLOOD WBC-16.4* RBC-2.47* Hgb-8.7* Hct-25.3*
MCV-102* MCH-35.3* MCHC-34.5 RDW-15.1 Plt Ct-202
[**2186-6-17**] 01:00AM BLOOD Neuts-86."
6578,"These were very elevated when you first arrived, but
they trended down with IV fluids and time. However, they were
still elevated at the time of discharge and you were still
jaundiced. You were not having any abdominal pain. We looked for
infection but did not see any signs. The inflammation in your
pancreas and liver appeared to be from another non-infectious
cause.
.
We thought your liver and pancreas inflammation was due to
alcohol consumption. Lab tests showed that this was true. You do
have several reasons for increased stress in your life recently.
You met with a social worker during this hospitalization who
will help coordinate your care after you leave the hospital."
6579,"Laboratory tests showed
that you were not infected at the time you left the hospital.
.
We made the following changes to your medications:
1. We DECREASED your metoprolol dose to 25 mg per day.
2. We STARTED you on Pentoxifylline 400 mg PO three times daily
3. We STARTED you on multivitamins and thiamine which you should
take daily
.
Please continue to take all other medications as prescribed, or
as instructed by your doctor.
.
Followup Instructions:
We arranged a follow-up appointment with your primary care
doctor:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **]
Location: [**Hospital **] MEDICAL ASSOCIATION
Address: [**Apartment Address(1) 83440**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
Appointment: Friday [**6-30**] 2:15 PM
."
6580,"Follow-up ERCP will allow for
complete evaluation of intrahepatics given possibility of PSC.
Repeat ERCP in 4 weeks for stent removal and complete evaluation
of biliary tree.
.
[**6-18**] RUQ US
FINDINGS: The liver is diffusely increased in echogenicity,
consistent with
fatty infiltration of the liver. No focal hepatic mass is
definitely noted.
There is no intrahepatic or extrahepatic ductal dilatation with
the common
bile duct measuring 4mm. However, the known common bile duct
stent is not
visualized. The main portal vein is patent with hepatopetal
flow.
The gallbladder is mildly distended, without wall thickening,
pericholecystic
fluid, or son[**Name (NI) 493**] [**Name2 (NI) 515**] sign."
6581,"We
felt it was very important that you get adequate support after
you leave the hospital so that you can stay sober. Drinking
alcohol will further injury your pancreas and liver, which are
already fragile. You will see your own therapist, [**Female First Name (un) **], twice a
week from now on. She will help you follow-through with your
intention to enroll in a full-time alcohol detox program within
a week after leaving the hospital.
.
When you first arrived, we treated you with intravenous
antibiotics to fight a possible bacterial infection in your
gallbladder. Later we gave you antibiotics again when we
suspected an infection in your blood."
6582,"3. No biliary dilatation, although the common bile duct stent is
not
visualized.
.
[**6-21**] MRCP
MR ABDOMEN WITH IV CONTRAST: There is marked diffuse fatty
deposition of the
liver in addition to more focal areas of almost mass-like fatty
deposition
surrounding the gallbladder fossa (3A:9, 12). There is also
deposits of
increased fat within the periphery of the liver. There is a
heterogeneous
enhancement pattern to the liver suggesting diffuse liver
disease beyond fatty
deposition. This appearance could be seen with chronic fibrosis,
although
there are no other findings on this study to suggest cirrhosis.
The hepatic
and portal veins are patent."
6583,"Physical Exam:
Admission Physical Exam:
Vitals: T 97.1, BP , HR 107, RR 23, SpO2 100% on RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, slightly dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Mildtachycardia with regular rhythm. Normal S1, S2. Blowing
holosystolic murmur at LLSB with radiation to axilla.
Abdomen: Bowel sounds present. Soft, non-tender, mildly
distended, no rebound tenderness or guarding.
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema
ICU Discharge Physical Exam:
VS Tc 36."
6584,"She was restarted on a decreased dose of
home metoprolol (25 mg QD) but home lisinopril was held given
acute renal injury (below). Lisinopril was restarted at
discharge.
.
# Hyponatremia:
Related to pancreatitis/hepatitis. Resolved with current Na 137
in the ICU, up from 126 on admission and 123 at OSH. This
likely represented hypovolemic hyponatremia from her
pancreatitis and volume depletion from GI losses and poor PO
intake.
.
# [**Last Name (un) **]:
Creatinine 8.0 on admission to OSH, fell gradually during this
admission, to 1.2 at discharge. Baseline creatinine was unknown.
The most likely etiology was prerenal from hypotension and fluid
shifts in the context of pancreatitis."
6585,"Her RBCs are macrocytic with MCV 104. Iron panel was
difficult to interpret in the setting of her current acute
illness. Hct was trended, iron panel, B12, and folate were
checked. She received B12, folate, and iron supplementation
during this admission.
.
# Leukocytosis:
Patient presented with a leukocytosis, WBC 13.9; this rose
during admission. Attributed to alcoholic hepatitis. Cultures
all negative apart from a single spuriously-positive GPC blood
culture. WBC remained >15 after treatment with vancomycin.
.
# Depression:
Reports 25-lb weight loss in past 3 weeks secondary to stress.
She is on Lexapro for depression and . These should be held for
now pending improvement in her renal and hepatic function, both
of which are currently impaired."
6586,"There is no intra- or extra-hepatic
biliary
dilation.
A stent is noted in place within the common bile duct. While
there is mild
enhancement of the bile duct wall at the level of the stent,
above the level
of the stent, the bile ducts do not demonstrate any abnormal
enhancement to
suggest cholangitis.
There is diffuse gallbladder wall edema which is likely related
to the
underlying liver process. There is no hyperenhancement of the
gallbladder
wall or surrounding liver to suggest acute cholecystitis. The
gallbladder
contains sludge.
No pancreatic mass is identified. The pancreas demonstrates
normal
homogeneous enhancement throughout."
6587,"RUQ
ultrasound showed biliary sludge with no visible stone. CT
abdomen showed colitis. She was treated with Levofloxacin 500
mg IV and Metronidazole 500 mg IV, and transferred to [**Hospital1 18**] for
ERCP due to concern for biliary obstruction, cholangitis, and
gallstone pancreatitis.
.
In the ED, initial vital signs were T 97.1, BP 103/60, HR 100,
RR 20, SpO2 98% on RA. She arrived on her seventh liter of NS,
but was still hypotensive in the 90s systolic. Central access
was obtained with a right IJ line. She also has access with two
18g PIVs. Foley catheter was placed for urine output
monitoring."
6588,"She had initially been started on
antibiotics in the ED, but these were stopped given lack of
concern for infection. Patient provided additional history of
recent MVA with 6 g/day tylenol use for 3 days thereafter
([**Date range (1) 24996**]) + intermittent alcohol use. Hepatology was consulted
in the ICU with concern for PSC or other liver parenchymal
process, in addition to alcohol and possible tylenol overdose;
the patient was transferred to the hepatology service after
discharge from the ICU. Her leukocytosis persisted, LFTs
remained elevated and she continued to spike fevers. These were
thought to be [**12-21**] underlying alcoholic hepatitis rather than
infection, especially since only 1 bottle of many many blood
culture samples was ever positive for bacterial growth, and thus
was thought to be a lab contaminant."
6589,"GRAM POSITIVE COCCI IN CLUSTERS.
-------
-------
IMAGING
.
[**6-17**] CXR:
INDICATION: Central line placement.
COMPARISON: None available.
FRONTAL RADIOGRAPH OF THE CHEST: A right internal jugular
central venous line terminates with the tip at the upper
cavoatrial junction. There is no
pneumothorax. Lung volumes are low with resultant vascular
crowding. Cardiac silhouette is top normal. Mediastinal and
hilar contours are normal. There is no pleural effusion or
pneumothorax.
.
[**6-20**] CXR
IMPRESSION No evidence of pneumonia.
.
[**6-25**] CXR
FINDINGS: In comparison with the study of [**6-20**], there is no
interval change or
evidence of acute cardiopulmonary disease. Specifically, no
pneumonia,
vascular congestion, or pleural effusion."
6590,"2*
MCV-106* MCH-35.2* MCHC-33.3 RDW-17.1* Plt Ct-252
[**2186-6-28**] 06:13AM BLOOD Glucose-93 UreaN-13 Creat-1.2* Na-134
K-4.0 Cl-100 HCO3-24 AnGap-14
[**2186-6-28**] 06:13AM BLOOD ALT-29 AST-113* LD(LDH)-202 AlkPhos-324*
TotBili-11.1*
[**2186-6-28**] 06:13AM BLOOD Albumin-2.9* Calcium-9.0 Phos-4.7* Mg-2.2
.
OTHER PERTINENT LABS:
[**2186-6-17**] 05:58AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2186-6-17**] 05:58AM BLOOD HCV Ab-NEGATIVE
[**2186-6-19**] 04:55AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2186-6-19**] 04:55AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2186-6-17**] 05:58AM BLOOD PEP-NO SPECIFI IgG-1232 IgA-424* IgM-138
IFE-NO MONOCLO
[**2186-6-19**] 04:55AM BLOOD tTG-IgA-61*
[**2186-6-17**] 05:58AM BLOOD calTIBC-163* VitB12-1777* Folate-6."
6591,"Denied alcohol use prior to this
accident. Took 6 g/day tylenol in the 3 days following, which
may have contributed to her liver failure.
TRANSITIONAL ISSUES
1. ***Alcohol abuse follow-up.*** Patient has agreed to
inpatient detox but wanted to go home first to see her
8-year-old son. Inpatient social worker [**Name (NI) 636**] [**Name (NI) 12471**] and
outpatient therapist will follow-up to ensure this happens.
Medications on Admission:
Lexapro 30 mg PO daily
Lisinopril 10 mg PO daily
Metoprolol 50 mg PO BID
Campral (Acamprosate) 333 mg 2 tabs TID
Omeprazole OTC PO daily
Discharge Medications:
1."
6592,"Secondary Diagnoses:
Depression
Alcohol Abuse
Sleep Apnea
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for allowing us to participate in your care.
.
You were admitted to the hospital for abdominal pain and
jaundice.
.
You underwent an endoscopic procedure called ERCP, to visualize
your gallbladder and biliary tree. No gallstones or obstruction
was seen. A stent was placed in the bile duct, to allow free
drainage of bile into your intestines, in case there was some
mild obstruction not seen on the test.
.
Your liver and pancreas enzyme levels were followed during this
admission."
6593,"0
Hapto-142 Ferritn-921* TRF-125*
[**2186-6-19**] 04:55AM BLOOD TSH-13*
[**2186-6-19**] 04:55AM BLOOD T4-7.2 T3-56*
.
--------
--------
MICRO
[**6-17**], [**6-20**], [**6-21**], [**6-22**], 8/5 Blood Cultures NEGATIVE except [**11-20**]
bottles on [**6-20**] which grew:
Blood Culture, Routine (Final [**2186-6-26**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2186-6-22**]):
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2186-6-22**] 8:45AM
9-0958."
6594,"Maintained urine output
in the context of aggressive IVF hydration as above.
.
# Metabolic Acidosis:
Patient had an anion gap acidosis at the OSH. Lactate was 1.2 at
OSH and 2.3 here. Acidosis thought to be related to
pancreatitis, [**Last Name (un) **], and ketones from alcohol intake/poor
nutrition prior to admission. Resolved by time of discharge,
with bicarb 24 and anion gap 10.
.
# Anemia:
Hct was 28.2 at OSH. Baseline Hct unknown. She reports recent
diarrhea that was sometimes black, but her stool was guaiac
negative in the ED. She has not had a menstrual period since
[**Month (only) 404**]."
6595,"She received a 7-day course
of vancomycin, then was started on pentoxyfilline.
.
# Coagulopathy:
Related to hepatitis. The patient??????s INR was elevated to 1.6 on
arrival at the [**Hospital1 18**] ED. She does not have a reported history of
liver disease and is not on anticoagulation at home. Best
explained by new diagnosis of acute alcoholic hepatitis.
.
# Hypotension:
Related to pancreatitis. Patient was hypotensive on admission
with SBP 90s despite receiving significant IV fluids at OSH.
Her hypotension was likely related to fluid shifts from acute
alcoholic pancreatitis rather than sepsis. SBP improved to the
110s with IV fluids."
6596,"Inpatient social work has arranged for outpatient detox, to
begin the Monday after discharge ([**7-3**]); patient was unwilling
to be discharged directly to a detox facility. Outpatient
therapist aware and will follow-up; psychopharmacologist alerted
by telephone.
.
# Recent motor vehicle accident:
Large bruise noted on pt's lower back during physical
examination in the ICU. Pt reported history of a single-vehicle
car accident on [**6-5**]: she drove over two curbs in trying to
avoid other drivers, resulting in two blown tires. She denies
steering wheel impact and did not seek police or medical
attention after the accident."
6597,"8* Lymphs-8.5* Monos-2.5 Eos-1.7
Baso-0.4
[**2186-6-18**] 05:17AM BLOOD Plt Ct-202
[**2186-6-18**] 05:17AM BLOOD PT-18.8* PTT-37.1* INR(PT)-1.7*
[**2186-6-18**] 05:17AM BLOOD Glucose-100 UreaN-32* Creat-1.7*# Na-137
K-4.0 Cl-105 HCO3-18* AnGap-18
[**2186-6-17**] 05:58AM BLOOD Glucose-91 UreaN-53* Creat-3.7* Na-131*
K-4.0 Cl-102 HCO3-14* AnGap-19
[**2186-6-18**] 05:17AM BLOOD ALT-50* AST-170* LD(LDH)-429*
AlkPhos-497* TotBili-8."
6598,"multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain: Please limit to 2gm."
6599,"Admission Date: [**2101-8-11**] Discharge Date: [**2101-8-17**]
Date of Birth: [**2022-11-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Fosamax / Bactrim / hydrochlorothiazide
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue, decreasing stamina, and occasional palpitations
Major Surgical or Invasive Procedure:
[**2101-8-11**] Mitral valve replacement with 31mm St. [**Male First Name (un) 923**] epic valve
History of Present Illness:
78 year old female was found to have a murmur at age 38 and was
diagnosed with presumed Rheumatic Mitral Stenosis and
Regurgitation. She was followed annually with an echocardiogram.
Over the past 6 months she has noted some exertional fatigue and
palpitations."
6600,"On recent echo she was found to a new decreasing
EF and evidence of pulmonary hypertension. She reports overall
she just does not have the energy or stamina to do her usual
activities. She notes occasional dizziness with position changes
lasting only moments and resolves spontaneously. She feels
palpitations at times lasting on a few moments and are self
limiting. She was referred for a cardiac catheterization for
further evaluation. Upon cardiac catheterization she was found
to have severe mitral stenosis and is now being referred to
cardiac surgery for a mitral valve replacement.
Past Medical History:
Rheumatic Mitral valve stenosis/regurgitation
Brief Atrial Fibrillation in [**2095**]
Hypertension
Hyperlipidemia
Hypothyroidism
Polymyalgia Rhuematica - chronic steroids, now on only 1 mg
daily."
6601,"Dr. [**First Name (STitle) **] has prescribed a 10mg stress dose x 1 on the day
of the catheterization.
Left Breast Cancer s/p left partial mastectomy, XRT & oral chemo
[**2096**]
Osteopenia/Osteoporosis
Anxiety
Squamous Cell Cancer excision right Knee
H. Pylori
s/p Cholecystectomy
s/p left partial mastectomy
Social History:
Race:Caucasisan
Last Dental Exam:1-2 months ago, will call dentist to have
clearance faxed to office
Lives with:Husband
Contact: [**Name (NI) 449**] (husband) Phone #[**Telephone/Fax (1) 111938**]
Occupation:retired receptionist
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: 2 glasses of wine/week
Illicit drug use:denies"
6602,"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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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:
The following appointments have been arranged:
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2101-9-14**] 1:00pm in
the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Wound check with cardiac surgery [**Telephone/Fax (1) 170**] Date/Time:[**2101-8-23**]
10:00am in the [**Hospital **] medical office building, [**Doctor First Name **],
[**Hospital Unit Name **]
Please call to schedule appointments with your
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to be seen in 2 weeks
Primary Care Dr. [**First Name8 (NamePattern2) 7346**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8506**] in [**5-12**] 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**
Completed by:[**2101-8-17**]"
6603,"7 Na-139
K-4.0 Cl-103 HCO3-29 AnGap-11
[**2101-8-17**] 05:57AM BLOOD Mg-2.2
Brief Hospital Course:
Mrs. [**Known lastname 1024**] was a same day admit and brought directly to the
operating room where she underwent a mitral valve replacement.
Please see operative report for surgical details. Following
surgery she was transferred to the CVICU for invasive monitoring
in stable condition. Later this day she was weaned from
sedation, awoke neurologically intact and extubated.
Beta-blockers and diuretics were started on post-op day one and
she was gently diuresed towards her pre-op weight."
6604,"Warfarin MD to order daily dose PO DAILY
10. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
11. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 3 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
12. Warfarin 1 mg PO DAILY16
Dr. [**First Name (STitle) **] to manage, dose will change daily for goal INR [**3-11**]
RX *Coumadin 1 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
13."
6605,"Carotid Bruit Right: NO Left: NO
Pertinent Results:
[**2101-8-15**] 06:10AM BLOOD WBC-12.9* RBC-3.04* Hgb-9.4* Hct-29.1*
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.3 Plt Ct-185#
[**2101-8-14**] 03:57AM BLOOD WBC-12.5* RBC-2.64* Hgb-8.2* Hct-25.1*
MCV-95 MCH-31.3 MCHC-32.8 RDW-13.5 Plt Ct-121*
[**2101-8-13**] 01:33AM BLOOD WBC-12.9* RBC-2.80* Hgb-8.9* Hct-26.9*
MCV-96 MCH-31.8 MCHC-33.2 RDW-13."
6606,"Later she was
transferred to the step-down floor for further care. Chest tubes
and epicardial pacing wires were removed per protocol. She
developed Atrial Fibrillation. Amiodarone was started and
lopressor titrated. Coumadin was started for anti-coagulation.
Physical therapy worked with her for strength and mobility. She
was discharged home on POD 6 with follow-up instructions.
Medications on Admission:
AMOXICILLIN [**2089**] mg one hour prior to dental visits
ANASTROZOLE [ARIMIDEX] 1 mg daily only has 1 week left in 5 year
treatment
ATENOLOL 25 mg daily
LEVOTHYROXINE 25 mcg daily
ATIVAN 0.5 mg PRN TID
PREDNISONE 1 mg daily (10mg x 1 on morning of cardiac)
QUINAPRIL [ACCUPRIL] 10 mg Daily
SIMVASTATIN 20 mg daily
ASPIRIN 81 mg daily
CALCIUM 600 + D3 600 mg calcium (1,500 mg)-400 unit Tablet - 1
Tablet [**Hospital1 **]
MULTIVITAMIN 1 Tablet daily
POLYCARBOPHIL [REPLENS] Gel - apply as needed PRN"
6607,"Discharge Medications:
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Acetaminophen 650 mg PO Q4H:PRN pain, fever
5. Amiodarone 400 mg PO BID
400mg twice a day for 5 days then decrease to 400mg daily for
7days then 200mg daily ongoing
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*75
Tablet Refills:*0
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. PredniSONE 1 mg PO DAILY
8. Ranitidine 150 mg PO BID
RX *Heartburn 150 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9."
6608,"Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
RX *Klor-Con M20 20 mEq 1 tablet by mouth daily Disp #*7 Tablet
Refills:*0
14. Calcium Carbonate 1500 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Replens *NF* (polycarbophil) 0 unit VAGINAL PRN prn
17. Vitamin D 400 UNIT PO BID
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Mitral valve stenosis/regurgitation s/p Mitral valve Replacement
Past medical history:
Brief Atrial Fibrillation in [**2095**]
Hypertension
Hyperlipidemia
Hypothyroidism
Polymyalgia Rhuematica - chronic steroids, now on only 1 mg
daily. Dr."
6609,"4 Plt Ct-107*
[**2101-8-17**] 05:57AM BLOOD PT-31.7* INR(PT)-3.1*
[**2101-8-16**] 03:50PM BLOOD PT-34.6* INR(PT)-3.4*
[**2101-8-16**] 05:47AM BLOOD PT-24.2* INR(PT)-2.3*
[**2101-8-14**] 03:57AM BLOOD PT-11.7 PTT-21.5* INR(PT)-1.1
[**2101-8-17**] 05:57AM BLOOD UreaN-26* Creat-0.9 Na-135 K-4.9 Cl-99
[**2101-8-15**] 06:10AM BLOOD Glucose-125* UreaN-23* Creat-0.6 Na-138
K-4.4 Cl-102 HCO3-27 AnGap-13
[**2101-8-14**] 03:57AM BLOOD Glucose-106* UreaN-22* Creat-0."
6610,"Family History:
Premature coronary artery disease- non contributory
Physical Exam:
Pulse:54 Resp:18 O2 sat: 100/RA
B/P Right:no BP Left: 132/65
Height:5'3"" Weight:126 lbs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [] Irregular [X] Murmur [] grade _NO___
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema [] __NO___
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: P Left: P
DP Right: P Left: P
PT [**Name (NI) 167**]: P Left: P
Radial Right: P Left: P"
6611,"[**First Name (STitle) **] has prescribed a 10mg stress dose x 1 on the day
of the catheterization.
Left Breast Cancer s/p left partial mastectomy, XRT & oral chemo
[**2096**]
Osteopenia/Osteoporosis
Anxiety
Squamous Cell Cancer excision right Knee
H. Pylori
s/p Cholecystectomy
s/p left partial mastectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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"
6612,"Admission Date: [**2167-7-7**] Discharge Date: [**2167-7-16**]
Date of Birth: [**2096-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
70 yo M with [**Hospital 7235**] medical problems including ESRD on HD
M/W/F iwth HD line that was changed [**6-11**], diabetes (? not on
insulin per discharge meds from earlier this month), sCHF FE
40%, HTN, HLP, boderline PD who was found to be unresponsive at
HD yesterday with BP 70/40 and fingerstick to fs 41."
6613,"CT torsos (one without contrast and one with contrast) were
obtained to look for source of hypoglycemia and found a
large-moderate intussception and L3/L4 discitis. Surgery was
consulted for intussception and felt comfortable with medical
admission, no emergent surgery given lactate 0.6 this morning at
3am. Radiology read partial obstruction with small amount of
contrast passing through but very edematous bowel and
recommended that surgery address. Additionally, renal masses
concerning for RCC were noted which are old. Per prior
transplant note, nephrology/urology aware, last urology visit
[**2-/2167**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**]."
6614,"This morning, blood cultures were drawn and CTX/vanco were
ordered (unclear if given) in the [**Name (NI) **].
Vitals prior to transfer to the ICU: 4L nc, sating 99%. BP
114/64. HR 60 paced. Per ED resident. abd exam totally benign.
Past Medical History:
- Diabetes mellitus c/b neuropathy - not on insulin
- End-stage renal disease on hemodialysis on M,W,F
- Hyperlipidemia
- CHF (EF 40%)
- HTN
- CAD s/p cath and AICD
- s/p gastric bypass
- h/o aspiration pneumonia
- hypothyroid
- peripheral vascular disease
- benign prostatic hypertrophy
- h/o bacteremia (Klebs/Serratia/pseudomonas)
- recurrent C. diff
- Zoster
- h/o delirium
- spinal stenosis
- adjustment disorder
- personality disorder
- mitral regurgitation
- h/o hypocalcemia
- h/o bilateral renal mass"
6615,"5. Similar destructive appearance of L3-L4 compared to the prior
L-spine CT study eight days ago. Findings again may represent
renal spondyloarthropathy but clinical correlation is necessary
to exclude osteomyelitis/discitis.
6. Similar cholelithiasis and choledocholithiasis, without
evidence of acute cholecystitis.
Brief Hospital Course:
70 yo M with [**Hospital 7235**] medical problems including ESRD on HD
M/W/F, diabetes, sCHF EF 40%, HTN, HLP, borderline PD who was
found to be unresponsive at HD with BP 70/40 and fingerstick to
fs 41 thought to be secondary to UTI.
# Hypoglycemia: Etiology unclear. In the MICU, patient initially
required D10 gtt which was then weaned off."
6616,"diff. In house C.diff negx2. However, given
patient's history of severe c.diff infection and current use of
meropenem, ID consult service recommended treating empirically
for c.diff with flagyl for 14day (end date [**7-25**]).
.
# Hypoxia: Occurred in MICU in setting of IVF for hypotension
and known sCHF 40% EF. CXR with mild volume o/l. Resolved with
HD and fluid removal. On the floor patient saturated well on RA.
# Hypotension: Occurred at HD and in ED on presentation.
Persisted in the MICU and gradually resolved with IVF and
antibiotics likely in setting of infection. Patient
asymptomatically hypotensive on floor with SBP ranging between
80s-110s."
6617,"[**Last Name (STitle) **] for this as above.
# Diabetes: On insulin at nursing home per NH paperwork, however
insulin held secondary to hypoglycemia. [**Last Name (un) **] followed in house
and will follow him as an outpatient as above.
# Systolic Heart Failure: EF 40%, mild edema on CXR.
# HTN: Anti-HTN meds held due to persistent asymptomatic
hypotension.
# Hyperlipidemia: Statin continued.
# BPH: Home medication regimen continued
# Renal Masses: High concern for RCC per out pt notes, patient
aware with plan to follow-up as outpatient with Dr. [**Last Name (STitle) 3748**] of
urology.
# Hypothyroidism: Thyroid medications initially held in MICU as
patient was not taking in adequate PO."
6618,"MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY
Urosepsis, Klebseilla PNA
Hypoglycemia
Intussussception
SECONDARY:
ESRD on HD
Discitis
CHF
Hypoglycemia
Intussception
Discharge Condition:
Mental Status: oriented to person and place
Hemodynically stable
Unable to ambulate without assistance.
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
after becoming unresponsive at dialysis. At that time were
sugars and blood pressure was found to be low. We felt your low
pressures resulted from an infection in your urine. We treated
your low pressures with IV fluids and antibiotics. A PICC line
was placed to faciliate antibiotic administration after you
leave the hospital."
6619,"However, several
hours after the D10 gtt was stopped, the patient's blood sugars
dropped back down to the 60's, ultimately requiring the D10 gtt
to be restarted. [**Last Name (un) **] stim was unrevealing and TSH was WNL.
Patient transferred to the floor. There remained off D10gtt
however blood sugars remained labile with pre-prandial fs
runnning in the 70s during which patient asymptomatic. [**Last Name (un) **]
following the patient and also unclear on etiology of persistent
hypoglycemia. Per their rec's sent C-peptide and insulin level
which is still pending. He will follow up with [**Hospital 387**] clinic for
further workup of this."
6620,"2. Destructive change of L3-4 endplates with appearance of
widening of
intervertebral space, unchanged from CT of lumbar spine of
[**2167-6-29**], may
again represent noninfective spondyloarthropathy although
superimposed
infection (discitis/osteomyelitis) cannot be entirely excluded
and clinical correlation is necessary.
3. Cholelithiasis in a moderately distended gallbladder. Cannot
assess
gallbladder wall without IV contrast. If concern for acute
cholecystitis,
recommend ultrasound or HIDA. Unchanged probable stone or sludge
in the CBD.
4. Bilateral pleural effusions, moderate to large on the left
and small on
the right. Ascites and anasarca.
5. Marked coronary artery calcifications. Marked vascular
calcifications
throughout the abdomen."
6621,"Department: [**Last Name (un) **] Diabetes Center
When: Monday [**2167-7-27**] 2:00pm
With: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**]
Location: [**Last Name (un) 3911**] [**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2384**]
Department: GASTROENTEROLOGY
When: TUESDAY [**2167-7-28**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Dr. [**Last Name (STitle) 3748**] (your urologist) will also be in touch with you re:
an appointment in follow up of the mass in your kidney and
whether you need to undergo surgery for this mass.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2167-7-17**]"
6622,"5 mg q4 hours PRN
- Morphine Oral Conc 8 mg q 1 hr PRN pain
- Oxycodone 5 mg q4hrs PRN pain
- Psyllium Seed 1 tsp [**Hospital1 **] PRN
- Senna 17.2 mg daily PRN
- Trazodone 50 mg qHS PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday)."
6623,"As diet/nutrition
improved levothyroxine 200mcg QD was restarted on the floor.
# CAD: On initial presentation troponins elevated 0.4 (baseline
0.3). No changes on EKG and per cardiology low liklihood for
ACS. Bblocker held secondary to hypotension.
# Code: Full (discussed with patient)
.
# Dispo. Patient received PT/OT consult prior to discharge to
rehab facility.
Medications on Admission:
- Calcium Acetate 1334 mg three times daily with meals
- Calcium Carbonate 1300 mg three times a day
- Cholecalciferol 1000 units daily
- Ferrous sulfate 325 mg every Mon, Wed, Fri
- Finasteride 5 mg daily
- Gabapentin 200 mg three times a day
- Heparin SC 5000 units q8hrs
- Humalog SS
- Levothyroxine 200 mcg daily
- Lidocaine Patch
- Loperamide 2 mg daily
- Omeprazole 20 mg daily
- Oxycontin 30 mg [**Hospital1 **]
- Oxycodone 5 mg four times a day
- Pentoxifylline CR 400 mg once daily
- Sevelamer 800 mg three times a day with meals
- Anusol Suppositories 1 [**Hospital1 **]
PRNS:
- Acetaminophen 650 mg q4 hours PRN
- Bisacodyl 10 mg daily PRN
- Loperadime 2 mg q6hrs PRN
- Lorazepam 0."
6624,"Recent
admission for pseudomonal urosepsis in [**Month (only) 547**] and c. diff in [**Month (only) 116**].
Also has ? discitis/osteomyelitis but negative bone biopsy in
[**Month (only) **].
At HD, he received an amp of D50 and MS improved to - A/O x3 and
he was brought to [**Location (un) 620**] ED. There, EKG showed with AV pacing
and trop found to be elevated to 0.4 (baseline per ED there is
0.3). Got PR ASA and was sent here for ROMI/NSTEMI.
On arrival to the [**Hospital1 18**] ED last night, pressures remained low,
hypoxic on 3L (unclear baseline O2 requirement)."
6625,"The source of your recurrent urine
infections is felt to be due to stasis of urine in the bladder
and it is recommended to perform straight catherization daily to
ensure the the bladder is empty.
You continued to experience back pain while hospitalized. Pain
resulted both from inflammation of an area of your spine as well
as irritation of the skin on your backside. We worked with the
pain team to create a treatment regimen and with the wound care
nurses to care for your ulcers, skin sores.
The kidney doctors followed [**Name5 (PTitle) **] [**Name5 (PTitle) 1028**] you were hospitalized and
you continued dialysis on your M,W,F schedule."
6626,"Patient will continue to need QD/[**Hospital1 **] straight caths in future -
and education will be needed for both patient and wife in order
to be able to do this at home. There are also plans for him to
follow up with Dr. [**Last Name (STitle) 3748**] (urology) for evaluation and possible
nephrectomy as he has a renal mass seen on multiple CT scans
(this admission and prior) and this may keep him from making
urine which he retains causing the frequent UTIs. Dr. [**Last Name (STitle) 3748**]
will set him up with an appointment in the next few weeks.
.
#History of C."
6627,"3
[**2167-7-7**] 03:43AM BLOOD Glucose-70 Lactate-0.6
[**2167-7-9**] 12:05PM BLOOD Lactate-1.5 K-4.2
[**Last Name (un) **] Stim-
[**2167-7-10**] 08:19PM BLOOD Cortsol-23.8*
[**2167-7-10**] 09:47PM BLOOD Cortsol-43.5*
CXR ([**2167-7-7**]) - IMPRESSION: No pneumonia. Mild pulmonary
congestion.
CT A/P ([**2167-7-7**]) - IMPRESSION:
1. Prior gastric bypass surgery with enteroenteric
intussusception in the
left upper quadrant at the distal anastomosis. No evidence of
proximal
dilation of bowel to suggest obstruction at the time of the
examination but correlation with physical examination is
recommended."
6628,"Pertinent Results:
Admission Labs
[**2167-7-6**] 09:50PM BLOOD WBC-10.4 RBC-3.39* Hgb-10.7* Hct-33.0*
MCV-97 MCH-31.7 MCHC-32.5 RDW-16.2* Plt Ct-314
[**2167-7-6**] 09:50PM BLOOD PT-13.6* PTT->150* INR(PT)-1.2*
[**2167-7-6**] 09:50PM BLOOD ESR-10
[**2167-7-6**] 09:50PM BLOOD Fibrino-349
[**2167-7-6**] 09:50PM BLOOD Glucose-97 UreaN-35* Creat-2.8* Na-136
K-4.4 Cl-104 HCO3-24 AnGap-12
[**2167-7-6**] 09:50PM BLOOD ALT-9 AST-18 CK(CPK)-34* AlkPhos-55
TotBili-0."
6629,"CT A/P ([**2167-7-7**]) - IMPRESSION:
1. Persistent jejunojejunal intussusception at the distal
anastomosis with
marked bowel wall edema in the intussuscepted bowel and partial
small bowel obstruction.
2. Oral contrast in the excluded stomach and afferent limb,
consistent with either represent reflux secondary to obstruction
from the intussusception or a fistula between the gastric
remnant and the excluded stomach or components of both
processes.
3. Bilateral enhancing renal masses. The largest one in the left
upper pole demonstrates interval increase in size. Findings are
again concerning for renal cell carcinoma.
4. Unchanged cystic pancreatic lesions. Could be further
assessed by MR [**First Name (Titles) **] [**Last Name (Titles) 40806**]y indicated."
6630,"11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO TID (3 times a day).
16. Meropenem 500 mg IV Q24H
Administer dose after HD on HD days
17."
6631,"2
[**2167-7-6**] 09:50PM BLOOD Albumin-2.1* Calcium-7.0* Phos-3.7 Mg-2.0
[**2167-7-6**] 09:50PM BLOOD CRP-5.8*
Cardiac Enzymes:
[**2167-7-6**] 09:50PM BLOOD CK(CPK)-34* CK-MB-5 cTropnT-0.36*
[**2167-7-7**] 06:15AM BLOOD cTropnT-0.34*
[**2167-7-7**] 02:03PM BLOOD CK(CPK)-46* cTropnT-0.31*
Other Labs:
[**2167-7-10**] 02:33PM BLOOD TSH-2.8
[**2167-7-7**] 06:15AM BLOOD Cortsol-17.0
[**2167-7-6**] 09:50PM BLOOD CRP-5.8*
[**2167-7-8**] 05:29AM BLOOD Vanco-10."
6632,"Social History:
Retired. Denies alcohol use. Non smoker. Discharged to Newbridge
on the [**Doctor Last Name **] on [**6-16**]. Prior to that lived with wife.
Family History:
Brother with DM.
Physical Exam:
VS:
- General Appearance: Chronically ill appearing
- Eyes / Conjunctiva: PERRL,
- Head, Ears, Nose, Throat: Poor dentition
- Cardiovascular: distant heart sounds, S1, S2, ii/vi systolic
murmur, 1+pitting peripheral edema of upper and lower extremity
- Peripheral Vascular: (Right radial pulse: Present), (Left
radial pulse: Present), (Right DP pulse: Present), (Left DP
pulse: Present)
- Respiratory / Chest: symmetic, unlabored respirations, Breath
Sounds: Crackles : bilaterally at bases
- Abdominal: Soft, Non-tender, non-distended Bowel sounds
present,
- Extremities: pale, ulcer on toe
- Skin: Warm, bangages on forearms with scattered traumatic
skin tears
- Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): person, place."
6633,"5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS)."
6634,"Difficult to obtain accurate [**Location (un) 1131**] in HD patient.
Anti-hypetensives were held. Occasional 250mL Boluses were given
if SBP<80.
# Intussception: See on CT, moderate-to-large. Surgery
recommended admission to medicine service for initial
management. However, surgicaly repair remained an option.
Ultimately, the decision was made to monitor patient with serial
abdominal exam and lactate levels. Surgery was reassured with
lactate level of 0.6. On the floor patient without pain and
tolerating a regular diet without nausea, vomiting or pain. Plan
to follow-up with GI as outpatient as there is concern regarding
the nidus for intussception ?"
6635,"cancer ?polyp.
# Discitis: Appears old - seen on prior imaging. Ortho spine
and ID consulted and per imaging was not felt to be a likely
source of infection. In addition, nl WBC and lack of fever not
suggestive of active infection. Pain was managed with plan to
follow-up L3-L4 endplate degeneration as outpatient. Current
pain regimen has been adequately controlling his back pain for
the last 2 days while hospitalized.
# ESRD: On HD through HD line which was changed on [**2167-6-11**].
Continued on HD on MWF schedule. Not transplant candidate [**2-10**]
likely RCC. Per renal notes, question possible nephrectomy in
the future and will follow up with Dr."
6636,"He has had stable blood sugars for
several days on the general medical floor on no anti-glycemic
medications.
.
# UTI: UA on admission grossly positive. As had history of
pseudomonal urosepsis, decision was made initially to treat with
cefepime. However, urine cultures ultimately grew Klebsiella
resistant to cefepime, so the patient was switched to meropenem,
to complete a 7 day course (end date [**7-18**]). Midline placed to
facilitate antibiotic administration as outpatient. PICC line
unable to be placed as subclavian thrombosed per IR. Etiology of
recurrent UTIs felt secondary to stasis therefore foley was
d/c'ed with decision for QD/[**Hospital1 **] bladder scans and straight cath."
6637,"You experienced abdominal pain while in the ICU and a picture of
belly showed an intussception. Surgery was consulted and did not
feel that you needed surgical intervention but it is important
that you follow-up with GI doctors [**First Name (Titles) **] [**Last Name (Titles) 4656**] this.
You were discharged to a rehab facility for continued care and
assistance.
Followup Instructions:
Department: HEMODIALYSIS
When: WEDNESDAY [**2167-7-15**] at 7:30 AM
Department: INFECTIOUS DISEASE
When: MONDAY [**2167-7-27**] at 11:30 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage"
6638,"BP's were
90/palp and pt was bradycardic to 38 (though unclear how it's
possible given that pt is paced). Given slightly higher trop,
there was initial concern for NSTEMI. He receive 2L IVF for his
hypotension and cardiology was consulted. They were not
concerned given trop around baseline. Unclear if EKG's were
faxed for them to look at. Overnight, pressures improved with
IVF, no antibiotics or blood cultures were drawn. Fingersticks
continued to be low 40-80 and he was started on D5 gtt at 100
cc/hr. BP's overnight continued to be low and this morning D5
increased to 150cc/hr."
6639,"[**2167-7-14**] 2:32 PM
PICC LINE PLACMENT SCH Clip # [**Clip Number (Radiology) 50278**]
Reason: Has HD line on right and Central IJ on left. PICC placement
Admitting Diagnosis: HYPOTENSION
Contrast: OPTIRAY Amt: 25
********************************* CPT Codes ********************************
* [**Numeric Identifier 447**] PICC W/O [**Numeric Identifier 448**] FLUORO GUID PLCT/REPLCT/REMOVE *
****************************************************************************
______________________________________________________________________________
[**Hospital 4**] MEDICAL CONDITION:
70 year old man with ESRD on HD, diabetes, sCHF, HTN, discitis, admitted for
complicatiosn of urosepsis.
REASON FOR THIS EXAMINATION:
Has HD line on right and Central IJ on left. PICC placement too difficult at
bedside.
______________________________________________________________________________
FINAL REPORT
INDICATION: 70-year-old man with end-stage renal disease on hemodialysis,
diabetes, CHF, hypertension and discitis, admitted for complication of
urosepsis."
6640,"Pre-existing hemodialysis line on the right and central IJ on
left. For PICC placement, too difficult at bedside.
RADIOLOGISTS: Dr. [**First Name (STitle) 596**] performed the procedure. Dr. [**Last Name (STitle) 192**], the
attending radiologist, was present and supervised throughout.
TECHNIQUE: Using sterile technique and 1% lidocaine for local anesthesia, the
left brachial vein was punctured under direct ultrasound guidance using a
micropuncture set. Hard copies of ultrasound images were obtained before and
immediately after establishing intravenous access. A 0.018 guidewire was
advanced into the left subclavian vein, but stopped more proximally. A 0.018
nitinol and angled Glidewire were used in an attempt to pass this obstructed
area into the SVC."
6641,"These attempts failed. Next, a 5 French 40-cm Kumpe
catheter was advanced and a 0.016 Headliner used attempt to pass this
apparently occluded area. This was unsuccessful. Injection of contrast
indicated occlusion of the more proximal SVC with contrast seen in the azygos
system. The fluoro team was consulted and representative for Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2622**]
indicated that a midline would be sufficient for the medical needs of the
patient. Therefore, a peel-away sheath was placed over a guidewire and a PICC
line measuring 26 cm in length placed through the peel-away sheath with its
tip positioned in the mid subclavian vein under fluoroscopic guidance."
6642,"Position of the catheter was confirmed by fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The catheter was
secured to the skin, flushed, and a sterile dressing applied. The patient
tolerated the procedure well. There were no immediate complications.
IMPRESSION: Complicated ultrasound and fluoroscopically left double-lumen
PICC line placement via the left brachial venous approach. There is apparent
occlusion of the proximal subclavian vein at its confluence with the SVC.
Final internal PICC length is 26 cm with the tip positioned in the subclavian
vein. The line is ready to use.
(Over)
[**2167-7-14**] 2:32 PM
PICC LINE PLACMENT SCH Clip # [**Clip Number (Radiology) 50278**]
Reason: Has HD line on right and Central IJ on left. PICC placement
Admitting Diagnosis: HYPOTENSION
Contrast: OPTIRAY Amt: 25
______________________________________________________________________________
FINAL REPORT
(Cont)"
6643,"Admission Date: [**2119-12-17**] Discharge Date: [**2119-12-27**]
Date of Birth: [**2050-1-3**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin / Erythromycin Base
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
internal jugular line placement
History of Present Illness:
Ms. [**Known lastname 1007**] is a 69 year-old woman with a history of asthma, CAD,
CHF (EF 10%), IDDM, CKD, discharged 1 week ago after an
admission for cellulitis and hypercarbic respiratory failure,
who now presents hypotension and acute on chronic kidney injury.
.
She was recently admitted [**12-1**] - [**12-11**]. She had acute on chronic
cellulitis and completed a 10 day course of vancomycin."
6644,"Atrial fibrillation on coumadin
5. DM - insulin dependent, c/b DM retinopathy
6. Morbid obesity
7. stage III chronic kidney disease
8. Vitamin D deficiency
9. chronic peripheral edema
10. h/o blood in stool
11. hypercholesterolemia
12. lower extremity cellulitis
Social History:
Lives independently with husband. Denies alcohol, drugs and
smoking.
Family History:
Cancer, hypertension, substance abuse, heart disorder, adult
onset diabetes.
Physical Exam:
Vitals: BP 125/38 (on norepi .04), HR 86, RR 20, O2 95% on 4L NC
General: obese female, lying in bed with eyes closed, no
apparent distress.
HEENT: no apparent lesions in OP
Neck: obese, difficult to assess JVD
Lungs: distant breath sounds, faint crackles at bases barely
audible
Heart: regular, no murmurs appreciated, sternal defect with
palpable heart tones
Abdomen: Obese, soft, nondistended, positive bowel sounds
Ext: 2+ bilateral partially pitting edema."
6645,"However, the following morning her
WBC was elevated so vancomycin and zosyn were started.
Norepinephrine was weaned to low doses and continued to maintain
MAP >60. Patient was transferred to the floor off pressors and
was normotensive for the remainder of her stay. Her home
hypertension medications were held except for
hydrochlorothiazide which was restarted prior to discharge.
.
# Shortness of breath: Patient with increased work of breathing
on the second hospital day. This was attributed in part CHF
exacerbation. She intermittently became drowsy. ABGs showed
hypoxia and hypercarbia. Bipap was used, but patient was poorly
tolerant of this and consistently took it off when she woke up."
6646,"5 on this admission. Given
concominant mild hyponatremia, hypotension, this may be simply
due to volume depletion. Creatinine fell with IVF in the ED.
Urine electrolytes showed a prerenal etiology. Labs were
discontinued on the floor per patient request. She continued to
have good urine output throughout the rest of her hospital stay.
.
# Elevated troponin: Troponin .45. Recently, .08 in the setting
of not quite so bad renal function. It does seem likely that she
has had some cardiac ischemia, probably in the setting of poor
coronary perfusion secondary to systemic hypotension. This was
trended and fell appropriately.
.
# Hyponatremia: likely secondary to volume depletion."
6647,"Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
hypotension, responsive to fluids
acute renal failure, likely pre-renal
UTI
diabetes
CHF
Afib
chronic pain
respiratory failure, resolved,
CAD s/p CABG
Chronic lower extremity venous stasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mrs. [**Known lastname 1007**],
It was a pleasure participating in your health care. You were
admitted to [**Hospital1 **] for hypotension
and acute renal failure for which you were admitted to the
intensive care unit where you were given fluids. In the
intensive care unit, you were treated with pressors and diuresis
as well as antibiotics. The decision was made to transition to
hospice care and to stop anticoagulation with warfarin.
Please make the following changes to your medications:
STOP WARFARIN
DECREASE Torsemide to 30 mg daily
INCREASE Lisinopril to 5 mg daily
DECREASE Metoprolol to 25 mg twice a day
DECREASE Glargine to 5 units daily
START Oxycodone 2.5 mg every 3 hours as needed for pain
Followup Instructions:
Please follow-up with a physician as desired
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]"
6648,"13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO at bedtime.
14. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
15. torsemide 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
16. needle (disp) Needle Sig: One (1) Miscellaneous once a
day.
Disp:*30 needles* Refills:*2*
17. lancets Misc Sig: One (1) Miscellaneous once a day.
Disp:*30 lancets* Refills:*2*
18. One Touch Basic System Kit Sig: One (1) Miscellaneous
once a day.
Disp:*1 kit* Refills:*0*"
6649,"8 EOS-2.4
BASOS-0.6
Brief Hospital Course:
Assessment and Plan: Ms. [**Known lastname 1007**] is a 69 year-old woman with
ischemic cardiomyopathy and EF 10-15% who presents with
hypotension.
.
# Hypotension: Given [**Last Name (un) **], hyponatremia, hypotension, and good
response to 4 L IVF in the ED, this may have been simply related
to volume depletion and an aggressive heart failure regimen.
However, diuretics have recently been held and it is notable
that her bicarb and her Hct are actually both lower than
discharge on admission labs. CVP on admission was 18. Sepsis
was also on the differential, but patient afebrile, WBC not
elevated, CXR clear, UA not impressive, so she was not initially
covered with antibiotics."
6650,"She also
had hypercarbic respiratory failure requiring intubation. She
was treated for a COPD exacerbation as well as volume overload
and was extubated after two days. She was called out of the ICU.
On the medical floor, she was agressively diuresed. Her heart
failure regimen was also optimized in consultation with
cardiology. In particular, metoprolol was increased from Toprol
XL 100 mg qday to metoprolol tartrate 150 mg [**Hospital1 **]. Lisinopril 2.5
mg was started. She remained mildly hypoxic and was discharged
to home on [**1-29**] L O2, having refused rehab. Her previous dose of
torsemide 100 mg daily was resumed on discharge."
6651,".
Upon arrival to ED, initial VS: 96.6 58 103/42 18 99% 6L NC. FS
WNL. She was very confused. Blood pressure then fell into the
70s systolic. She was given vancomycin 1 g,
piperacillin-tazobactam 4.5 g, and 4 L NS. IJ was placed and
levophed started (initially at .03, titrated up to .12 prior to
transfer). She was not more hypoxic than baseline (99% on 2L).
EKG was similar to prior. Labs were notable for a troponin
elevated to .45 and creatinine 2.4. CXR did not demonstrate
volume overload or infiltrate. Her mental status improved after
the initiation of pressors."
6652,"Glargine was decreased
to 5 units daily on the floor. Blood sugars were well
controlled on this regimen.
.
Medications on Admission:
-insulin glargine 15 units qhs
-humalog sliding scale
-warfarin 1.5 mg daily (but held on [**12-15**] and decreased to .5 mg
[**12-16**], not given [**12-17**])
-metoprolol tartrate 150 mg [**Hospital1 **]
-torsemide 100 mg daily
-simvastatin 40 mg qhs
-cholecalciferol 1000 IU daily
-ipratropium-albuterol nebs prn
-calcium carbonate 500 mg daily
-ASA 81 mg daily
-docusate 100 mg [**Hospital1 **]
-senna 8.6 mg [**Hospital1 **]
-acetaminophen 650 mg tid prn
-oxycodone 1.25 - 2.5 mg prn dressing changes
-lisinopril 2."
6653,"Risks and benefits of
anticoagulation were discussed with patient and she decided that
she did not want to continue anticoagulation. Warfarin was thus
stopped and will not be continued at discharge. No evidence of
bleeding or clots on exam. Will continue metoprolol for rate
control as described above.
.
#End of life: Palliative care consult was obtained per PCP
[**Name Initial (PRE) **]. Patient was confirmed DNR/DNI and also did not wish to
be transferred to the MICU or undergo NIPPV should she
decompensate. She will be discharged to hospice
.
# DM: Home dose of glargine 15 units qam was initially
continued, with humalog sliding scale."
6654,"5 mg daily
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ipratropium bromide 0.02 % Solution Sig: One (1) spray
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing."
6655,"7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) spray Inhalation Q6H (every 6 hours)
as needed for shortness of breath or wheezing.
8. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Five (5)
units Subcutaneous once a day.
Disp:*30 ml* Refills:*2*
9. Humalog Subcutaneous
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day."
6656,"Cardiology was consulted with regard
to the elevated troponin. They thought an ischemic event was
unlikely and will follow. She was sent for CT head and torso
prior to transfer to the ICU. However, she refused the torso
portion of this exam. She was transferred to the ICU.
.
Upon arrival to the MICU, the patient complains of low back pain
that is chronic for her. She also has leg pain when moved. She
denies chest pain, cough, palpitations, abdominal pain, nausea,
diarrhea, dysuria.
Past Medical History:
1. Asthma
2. CAD s/p CABG [**2112**]
3. Congestive heart failure with EF 10-15% on TTE [**11/2119**]
4."
6657,"Creatinine was
1.5 on the day of discharge.
.
After arrival at home, Ms. [**Known lastname 1007**] was living with her husband who
noted her to be mostly immobile, unwilling to eat, and taking
her medications unreliably. A visiting nurse noted that she was
unable to care for herself and so was admitted to rehab from
home on [**12-14**]. At the time her initial BP was low 70s but
quicklky rose into the 80s and then 90s. Diuretics were held.
Despite holding torsemide for two days, the patient remained
hypotensive. Today, sge was noted to be more lethargic and BP
70s so she was referred to [**Hospital1 18**]."
6658,"Bilateral lower legs
with woody changes, areas of denuded skin, minimal serous
drainage, appear much improved compared to prior admission
Neuro: oriented to self and year, not place. Moving all
extremities
Pertinent Results:
Admission labs:
[**2119-12-17**] 01:00PM GLUCOSE-114* UREA N-111* CREAT-2.4*
SODIUM-129* POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-30 ANION GAP-13
[**2119-12-17**] 01:00PM WBC-7.5 RBC-3.79* HGB-10.7* HCT-34.0* MCV-90
MCH-28.3 MCHC-31.6 RDW-16.7*
[**2119-12-17**] 01:00PM NEUTS-76.1* LYMPHS-15.1* MONOS-5."
6659,"Improved
after IVF resuscitation. Labs discontinued on floor after
discussion with patient.
.
# CHF: EF 10%: Metoprolol, ACEI, torsemide held in the setting
of hypotension but were restarted at lower-than-home-doses. She
will be discharged on lower doses of these medications as she
has been stable during hospital stay.
.
# Atrial fibrillation: Rate controlled and anticoagulated on
admission. Was subtherapeutic INR after having warfarin held at
rehab for several days (for INR 5 on [**12-15**]). Warfarin was
restarted at a lower dose and she was started on a heparin drip
while warfarin subtherapeutic. INR was then found to be
supratherapeutic and warfarin was held."
6660,"She was also diuresed, with improvement in shortness of breath.
She was initially maintained on torsemide 20 mg daily with IV
lasix 40 mg prn volume overload. After necessitating IV lasix
due to tachypnea, torsemide was increased to 30 mg daily.
Oxygen and IV morphine prn were continued as needed for comfort
although patient did not require IV morphine. She remained
stable on 1-3L NC with no respiratory distress during her
hospital stay.
.
# Acute on chronic kidney injury: Baseline creatinine per
records obtained at last hospitalization ~1.5, which was what it
was on discharge a week ago. 2."
6661,"Admission Date: [**2105-9-7**] Discharge Date: [**2105-9-10**]
Date of Birth: [**2041-12-18**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5084**]
Chief Complaint:
right cerebellar lesion.
Major Surgical or Invasive Procedure:
[**2105-9-7**]: posterior fossa craniotomy and tumor resection.
History of Present Illness:
Ms. [**Known lastname 57655**] is a 63 y/o female with metastatic melanoma on study
drug PD1 antibody was recently seen with worst headache of life.
She reports she was cleaning when she experienced sudden onset
diffuse headache which was associated eventually with nausea and
vomiting. When symptoms did not remit she took herself to [**Hospital **]
Hospital near her home where she underwent a CT scan that
demonstrated an area of acute right cerebellar hemorrhage."
6662,"She
was transferred to [**Hospital1 18**] for further care. After stabilization
and further work up she was cleared for discharge home. She
returns [**9-7**] for posterior fossa craniotomy and resection.
Past Medical History:
Past Medical History:
- Melanoma with metastatic disease to lung, bone, and liver
- Hypertension
- Hypercholesterolemia
- Depression
- Hypothyroidism
- S/p hip stabilization [**2105-1-7**]
- S/p TAH with BSO for fibroids
Social History:
Lives alone in [**State 1727**]. Widowed but has two adult sons ages 23 and
28. Continues to work as a teacher (teaches early childhood
development) and also has a part-time job working at [**First Name8 (NamePattern2) 9102**]
[**Last Name (NamePattern1) 3060**]."
6663,"OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
RX *oxycodone 5 mg [**12-15**] tablet(s) by mouth Q6 PRN Disp #*30
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
Northeast rehabilation
Discharge Diagnosis:
Right cerebellar hemorrhagic lesion.
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:
Craniotomy for Tumor Excision
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending."
6664,"Polyethylene Glycol 17 g PO daily until bowel movement.
Pantoprazole 40mg PO Q24H.
Heparin 5000 Units SC TID.
Discharge Medications:
1. Dexamethasone 2 mg PO PER TAPER
Take 3mg PO x1 tonight ([**9-10**]) at 18:00. Then take 2mg PO Q8 x24
hours (start [**9-11**]). Then take 2mg PO BID x24 hours (start [**9-12**]).
Then stop.
2. Acetaminophen-Caff-Butalbital [**12-15**] TAB PO Q8H:PRN Headache
max apap 4g/24 hrs
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Duloxetine 60 mg PO DAILY
6."
6665,"8
MCV-81* MCH-26.7* MCHC-33.0 RDW-15.2 Plt Ct-237
Brief Hospital Course:
This is a 63 year-old-female that electively presented and
underwent a posterior fossa craniotomy and resection of mass
with Dr [**Last Name (STitle) **]. The patient tolerated the surgery was without
complication. She was extubated and transferred to the ICU for
close neurological observation. The post operative Head CT
revealed expected post operative changes. She remained stable
overnight. On [**9-8**], the patient was neurologically intact and
the surgical dressing is clean dry and intact. The patient
exhibited full strength there was no pronator drift."
6666,"8, HR 83, BP 133/77, RR 20, O2 98% RA.
Gen: NAD; alert and oriented x3. Eyes open spontaneously.
HEENT: PEERLA; pupil size 6mm-4mm bilaterally. EOMs intact
bilaterally.
Follows complex commands. Face symmetric; tongue midline.
Comprehension intact. CN II-XII grossly intact.
Motor: Upper and lower extremity strength 5/5 bilaterally. No
pronator drift.
Incision: Clean, dry and intact without edema, erythema or
discharge. Sutures in place.
Mild dysmetria bilaterally.
Pertinent Results:
[**9-7**] CT Head:
Suboccipital craniectomy and postoperative changes in the right
cerebellum. Partially improved mass effect on the fourth
ventricle and partially improved leftward shift of the
cerebellar vermis."
6667,"[**9-8**] MRI Brain:
Blood products in the right cerebellar surgical bed and thin
linear
enhancement along the surgical cavity margins, without clear
evidence for a residual mass. Recommend follow up after blood
products resolve.
[**2105-9-10**] 05:30AM BLOOD Plt Ct-237
[**2105-9-10**] 05:30AM BLOOD PT-10.2 PTT-28.6 INR(PT)-0.9
[**2105-9-10**] 05:30AM BLOOD Glucose-101* UreaN-19 Creat-0.5 Na-134
K-4.3 Cl-100 HCO3-26 AnGap-12
[**2105-9-10**] 05:30AM BLOOD WBC-10.5 RBC-4.55 Hgb-12.1 Hct-36."
6668,"She was being screened for rehab. On
[**9-10**] she was neurologically intact on examination with the
exception of mild dysmetrial bilaterally. The incision was
clean, dry and intact with non-dissolvable sutures in place. It
was determined she would be discharged to rehabilitation today.
Medications on Admission:
Duloxetine 60mg PO daily.
Hydrochlorothiazide 25mg PO daily.
Levothyroxine Sodium 150mcg PO daily.
Lisinopril 20mg PO daily.
Loperamide 2mg PO QID prn diarrhea.
Metoprolol Succinate XL 25mg PO daily.
Dexamethasone 4mg PO Q6H.
Diazepam 5 mg PO Q8H prn anxiety/vertigo.
Docusate Sodium 100mg PO BID.
Prochlorperazine 25mg PR Q12H prn nausea."
6669,"Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
??????Your sutures need to be removed 10-14 days from surgery. This
can be done at your follow-up appointment in the Brain [**Hospital 341**]
Clinic. If there are any problems they can contact the Physician
Assistant or [**Name9 (PRE) **] Practitioner. Please make this appointment
by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic for follow-up
on [**2105-9-28**] at 2:30 PM. The Brain [**Hospital 341**] Clinic is
located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building,
[**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if
you need to change your appointment, or require additional
directions.
Completed by:[**2105-9-10**]"
6670,"?????? Your wound was closed with non-dissolvable sutures. You must
wait until after they are removed to wash your hair. You may
shower before this time using a shower cap to cover your head
and the incision.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation."
6671,"Plans to retire from teaching at the end of this academic
year. Has a sister who lives in MA and will serve as emergency
contact.
- Tobacco: None
- Alcohol: Very rare
- Illicits: None
Family History:
Father died of melanoma.
Physical Exam:
Physical Examination on Admission:
98.4 107 140/74 16 98%RA
Gen NAD, alert and oriented
HEENT PERRLA, MMM
CV RRR
Chest CTAB
Abd soft
Ext WWP
CN 2-12 intact
Strength/sensation and reflexes equal and intact in UEs and [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]/l
Cerebellar intact to finger-nose-finger; gate grossly normal
Physical Examination on Discharge:
T 98."
6672,"Heparin 5000 UNIT SC TID
7. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP <100.
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Lisinopril 20 mg PO DAILY
Hold for SBP <100.
10. Metoprolol Succinate XL 25 mg PO DAILY
Hold for SBP <100 and/or HR <60.
11. Pantoprazole 40 mg PO Q24H
Take this medication while taking Dexamethasone. Once finished
with Dexamethasone taper, stop this medication.
12. Senna 1 TAB PO BID:PRN constipation
13. Tizanidine 2 mg PO TID:PRN muscle spasm
14. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
15."
6673,"face was
symetric. Toungue was midline. Pupils were equal and reactive.
The foley catheter was discontinued and the patients diet was
advanced. The intravenous fluid was discontinued and the patient
was initiated on subcutaneous heparin dor deep vein thrombosis
prophylaxis. A physical therapy consult was placed and the
patient was transferred to the floor when a bed was available.
The patient continued her decadron taper. She had complainted
of headache and neck pain and was started on tizdanadine for
muscle spasm PRN. She was feeling well on [**9-9**] and was working
with PT. She continued on her steroid taper and was covered by
an insulin sliding scale."
6674,"WET READ VERSION #1
WET READ VERSION #2 SJBj SAT [**2179-5-8**] 6:46 AM
Extensive type A aortic dissection extending from the aortic root to the
distal abdominal aorta. Dissection extends up both carotids.
WET READ VERSION #3 SJBj SAT [**2179-5-8**] 7:40 AM
Extensive type A aortic dissection extending from the aortic root to the
distal abdominal aorta. Dissection extends up left bracheocephalic and left
common carotid. RCC extension cannot be assessed.
______________________________________________________________________________
FINAL REPORT
INDICATION: 73-year-old man with collapse, decreased right hand pulse,
question dissection.
COMPARISON: None.
TECHNIQUE: MDCT data were acquired through the chest, abdomen and pelvis
after the administration of 80 cc of IV contrast."
6675,"The appendix is
normal.
BONE WINDOWS: There are moderate multilevel degenerative changes throughout
the thoracolumbar spine. No concerning lytic or sclerotic lesions.
IMPRESSION:
1. Extensive type-A dissection extending from the aortic root to the
infrarenal abdominal aorta. The dissection extends into the proximal left
subclavian and right brachiocephalic arteries. There is a small thrombosed
pseudoaneurysm in the proximal right brachiocephalic artery. Evaluation for
extension into the common carotid arteries is markedly limited by poor
contrast bolus timing. Should further evaluation of the carotid arteries be
necessary, neck CTA could be performed.
2. Right inguinal hernia containing a loop of fecalized ileum without
inflammation or wall thickening."
6676,"The remainder of the lungs are clear. The airways are patent to the
subsegmental level. An endotracheal tube ends in the upper trachea.
ABDOMEN: The liver parenchyma is homogeneous. The gallbladder is thin-walled
and not distended. The pancreas, spleen, and adrenal glands are unremarkable.
The kidneys enhance symmetrically. The stomach, small and large bowel are of
normal caliber and appearance.
PELVIS: Diffuse diverticulosis is seen throughout the colon. There is a
right inguinal hernia (2:35) containing loops of small bowel with mild
fecalization, but no wall thickening or adjacent stranding. There is no free
pelvic fluid. There is no inguinal or pelvic adenopathy."
6677,"3. Dependent atelectasis versus possible aspiration.
4. Haziness of the mediastinal fat may be inflammatory although hematoma is
not excluded.
Findings were urgently conveyed to the ER physicians by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9366**]
immediately after the completion of the scan by telephone on the morning of
[**2179-5-8**] and discussed with [**First Name8 (NamePattern2) 4730**] [**Last Name (NamePattern1) **] on the morning of [**2179-5-6**] @
9:55 am by Dr. [**Last Name (STitle) 210**].
(Over)
[**2179-5-8**] 6:17 AM
CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # [**Clip Number (Radiology) 23394**]
Reason: aortic dissection?
Contrast: OMNIPAQUE Amt: 80
______________________________________________________________________________
FINAL REPORT
(Cont)"
6678,"[**2179-5-8**] 6:17 AM
CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # [**Clip Number (Radiology) 23394**]
Reason: aortic dissection?
Contrast: OMNIPAQUE Amt: 80
______________________________________________________________________________
[**Hospital 4**] MEDICAL CONDITION:
73M with decreased pulse R hand, diaphoretic, fall, altered
REASON FOR THIS EXAMINATION:
aortic dissection?
No contraindications for IV contrast
______________________________________________________________________________
WET READ: SJBj SAT [**2179-5-8**] 7:41 AM
Extensive type A aortic dissection extending from the aortic root to the
distal abdominal aorta. Dissection extends up left bracheocephalic and left
common carotid. RCC extension cannot be assessed. Diffuse large bowel wall
thickening raises the possibility of ischemic bowel even though the [**Female First Name (un) **]
appears patent from the true lumen."
6679,"Images were displayed in
multiple planes.
FINDINGS: The exam is limited by suboptimal contrast bolus timing.
There is an extensive type-A aortic dissection extending from the aortic root,
to the descending and abdominal aorta, to the level of the infrarenal
abdominal aorta. Evaluation for carotid extension is severely limited by poor
contrast bolus timing and streak artifact through the neck. The dissection at
least extends into the proximal left subclavian and into the proximal right
brachiocephalic artery. Approximately 1.2 cm distal to the right
brachiocephalic origin, there is a 1.3 x 0.6 cm outpouching (300b:18) which
may represent a pseudoaneurysm."
6680,"Extension into the right common carotid
cannot be assessed. The celiac, SMA and right and left renal arteries
originate from the true lumen. The [**Female First Name (un) **] originates from the true lumen.
There is no hemopericardium. There is fat stranding within the mediastinum
(Over)
[**2179-5-8**] 6:17 AM
CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # [**Clip Number (Radiology) 23394**]
Reason: aortic dissection?
Contrast: OMNIPAQUE Amt: 80
______________________________________________________________________________
FINAL REPORT
(Cont)
without frank extravasation. Numerous chest wall collateral vessels are
noted.
CHEST: There is dependent atelectasis plus aspiration at both lung bases."
6681,"Admission Date: [**2179-5-8**] Discharge Date: [**2179-5-8**]
Date of Birth: [**2106-6-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Type A aortic dissection involving b/l carotids and severe
neurologic deficits,
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73M found down at home approximately 2 hours prior to
presentation, EMS called immediately by wife. EMS noted unequal
pulses in his upper extremities during transport. Upon arrival,
he was found to be minimally responsive with a GCS of 5, with a
fixed and dilated right pupil and posturing movements of his
left
arm."
6682,"He was intubated and underwent a CT of the head, which was
negative, and then a CTA of the torso with dissection protocol.
This demonstrated an aortic dissection from the root into the
abdomen with involvement of the brachiocephalic artery as well
as
the left carotid.Cardiac surgery was consulted for possible
dissection repair.
Past Medical History:
CAD, HTN, lipids, BPH
Social History:
unknown
Family History:
unknown
Physical Exam:
PE in ED:
Pulse: Resp:intubated O2 sat:100%
B/P 140/59 HR 44 (SR)
Pertinent Results:
[**2179-5-8**] 06:01AM BLOOD WBC-10.7 RBC-4.89 Hgb-14."
6683,"DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
Approved: SAT [**2179-5-8**] 9:55 AM
Imaging Lab
There is no report history available for viewing.
Brief Hospital Course:
The patient presents with abdominal pain secondary to back pain
and rapidly deteriorating mental status with left hemi-neglect.
He was intubated for airway protection. CT of the head was
negative, CTA of the chest showing diffuse type A dissection.
Stat consult to cardiac surgery and vascular surgery was done.
The family discussed with Dr.[**Last Name (STitle) **] the risks of surgery."
6684,"Contrast: OMNIPAQUE Amt: 80
[**Hospital 93**] MEDICAL CONDITION:
73M with decreased pulse R hand, diaphoretic, fall, altered
REASON FOR THIS EXAMINATION:
aortic dissection?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SJBj SAT [**2179-5-8**] 7:41 AM
Extensive type A aortic dissection extending from the aortic
root to the
distal abdominal aorta. Dissection extends up left
bracheocephalic and left
common carotid. RCC extension cannot be assessed. Diffuse large
bowel wall
thickening raises the possibility of ischemic bowel even though
the [**Female First Name (un) 899**]
appears patent from the true lumen.
Wet Read Audit # 1
Wet Read Audit # 2 SJBj SAT [**2179-5-8**] 6:46 AM
Extensive type A aortic dissection extending from the aortic
root to the
distal abdominal aorta."
6685,"Evaluation for carotid extension is severely
limited by poor
contrast bolus timing and streak artifact through the neck. The
dissection at
least extends into the proximal left subclavian and into the
proximal right
brachiocephalic artery. Approximately 1.2 cm distal to the right
brachiocephalic origin, there is a 1.3 x 0.6 cm outpouching
(300b:18) which
may represent a pseudoaneurysm. Extension into the right common
carotid
cannot be assessed. The celiac, SMA and right and left renal
arteries
originate from the true lumen. The [**Female First Name (un) 899**] originates from the true
lumen.
There is no hemopericardium."
6686,"There is fat stranding within the
mediastinum
without frank extravasation. Numerous chest wall collateral
vessels are
noted.
CHEST: There is dependent atelectasis plus aspiration at both
lung bases.
The remainder of the lungs are clear. The airways are patent to
the
subsegmental level. An endotracheal tube ends in the upper
trachea.
ABDOMEN: The liver parenchyma is homogeneous. The gallbladder is
thin-walled
and not distended. The pancreas, spleen, and adrenal glands are
unremarkable.
The kidneys enhance symmetrically. The stomach, small and large
bowel are of
normal caliber and appearance.
PELVIS: Diffuse diverticulosis is seen throughout the colon.
There is a
right inguinal hernia (2:35) containing loops of small bowel
with mild
fecalization, but no wall thickening or adjacent stranding."
6687,"Dissection extends up both carotids.
Wet Read Audit # 3 SJBj SAT [**2179-5-8**] 7:40 AM
Extensive type A aortic dissection extending from the aortic
root to the
distal abdominal aorta. Dissection extends up left
bracheocephalic and left
common carotid. RCC extension cannot be assessed.
Final Report
INDICATION: 73-year-old man with collapse, decreased right hand
pulse,
question dissection.
COMPARISON: None.
TECHNIQUE: MDCT data were acquired through the chest, abdomen
and pelvis
after the administration of 80 cc of IV contrast. Images were
displayed in
multiple planes.
FINDINGS: The exam is limited by suboptimal contrast bolus
timing.
There is an extensive type-A aortic dissection extending from
the aortic root,
to the descending and abdominal aorta, to the level of the
infrarenal
abdominal aorta."
6688,"5 Hct-43.8
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.7 Plt Ct-233
[**2179-5-8**] 06:01AM BLOOD PT-10.5 PTT-24.7* INR(PT)-1.0
[**2179-5-8**] 06:01AM BLOOD Glucose-178* UreaN-18 Creat-1.0 Na-143
K-4.1 Cl-108 HCO3-21* AnGap-18
[**Known lastname **],[**Known firstname **] F [**Medical Record Number 33869**] M 72 [**2106-6-13**]
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2179-5-8**] 6:17 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 488**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2179-5-8**] 6:17 AM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD & PELVIS Clip #
[**Clip Number (Radiology) 33870**]
Reason: aortic dissection?"
6689,"There is no free
pelvic fluid. There is no inguinal or pelvic adenopathy. The
appendix is
normal.
BONE WINDOWS: There are moderate multilevel degenerative changes
throughout
the thoracolumbar spine. No concerning lytic or sclerotic
lesions.
IMPRESSION:
1. Extensive type-A dissection extending from the aortic root to
the
infrarenal abdominal aorta. The dissection extends into the
proximal left
subclavian and right brachiocephalic arteries. There is a small
thrombosed
pseudoaneurysm in the proximal right brachiocephalic artery.
Evaluation for
extension into the common carotid arteries is markedly limited
by poor
contrast bolus timing. Should further evaluation of the carotid
arteries be
necessary, neck CTA could be performed."
6690,"The
family were in agreement at having the pt extubated and allowing
him to die, knowing that it is what Mr. [**Known lastname 23**] would want; they
did not want to wait until his children, who live out of state,
arrive. Ms. [**Known lastname 23**] does not want an organ donation or
an autopsy. Mr.[**Known lastname 23**] was taken off the ventilator and shortly
thereafter pronounced dead. The appropriate post mortem agencies
were contact[**Name (NI) **] per hospital policy.
Medications on Admission:
Amlodipine 10'
Isosorbinde mononitrate 100'
Metoprolol 50''
Nitroglycerin PRN
Pravastatin 40'
Tamsulosin 0.8'
ASA 325'
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Type A dissection
Discharge Condition:
expired
Completed by:[**2179-5-8**]"
6691,"2. Right inguinal hernia containing a loop of fecalized ileum
without
inflammation or wall thickening.
3. Dependent atelectasis versus possible aspiration.
4. Haziness of the mediastinal fat may be inflammatory although
hematoma is
not excluded.
Findings were urgently conveyed to the ER physicians by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
immediately after the completion of the scan by telephone on the
morning of
[**2179-5-8**] and discussed with [**First Name8 (NamePattern2) 7279**] [**Last Name (NamePattern1) 18647**] on the morning of
[**2179-5-6**] @
9:55 am by Dr. [**Last Name (STitle) 18936**].
The study and the report were reviewed by the staff radiologist."
6692,"Sats 92% on 5 L, desats to 88% when
talking. PTT has been very labile, became therapeutic, but then
increased to >100.
- Continue heparin gtt on weight based protocol.
- Continue to follow PTTs TID
- Bridging with Coumadin 5mg PO Qhs
- Albuterol and Ipratropium PRN nebs
- Continue to wean oxygen (currently on 5L NC with 35% FM).
# S/p laminectomy: Midline incision healing well, pt still having pain
in abdomen, low back.
- Transition to PO pain meds today
home regimen.
- Ortho following, appreciate recommendations about anticoagulation
given risk of bleeding into dural sac with IV heparin
- Written for morphine IV prn if not tolerating PO pain meds."
6693,"6*
[8][**2172-4-24**] 04:21PM
14.6*
53.2*
1.3*
[9][**2172-4-24**] 11:32AM
54.5*
[10][**2172-4-24**] 03:24AM
398
[11][**2172-4-24**] 03:24AM
14.7*
52.1*
1.3*
Assessment and Plan
55 y/o F with hx of gastric bypass and recent spinal fusion on [**2172-4-7**]
who presents with acute pulmonary embolism.
# Pulmonary embolism/hypoxia:, Pt has diffuse PE's bilaterally, with
very little lung perfusion. Due to HD stability, no TPA/thrombectomy
was pursued. Pt is currently stable on NC, at times requires face
mask, with stable BP and pulse."
6694,"5 g/dL
102 mg/dL
0.6 mg/dL
26 mEq/L
3.3 mEq/L
10 mg/dL
103 mEq/L
140 mEq/L
26.9 %
8.1 K/uL
[image002.jpg]
[**2172-4-23**] 02:37 PM
[**2172-4-23**] 05:48 PM
[**2172-4-24**] 03:24 AM
[**2172-4-25**] 02:53 AM
[**2172-4-26**] 01:47 AM
WBC
8.8
10.0
8.1
Hct
27.8
26.7
26.9
Plt
398
392
372
Cr
0.7
0.6
0.6
0.6
TCO2
24
Glucose
109
99
103
102
Other labs: PT / PTT / INR:16."
6695,"8
C (98.2
Tcurrent: 36.4
C (97.6
HR: 80 (76 - 96) bpm
BP: 115/67(78) {98/26(40) - 135/77(85)} mmHg
RR: 18 (13 - 28) insp/min
SpO2: 94% on 5L NC
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 92.5 kg (admission): 91.6 kg
Height: 64 Inch
Total In:
1,702 mL
188 mL
PO:
1,080 mL
TF:
IVF:
622 mL
188 mL
Blood products:
Total out:
865 mL
385 mL
Urine:
865 mL
385 mL
NG:
Stool:
Drains:
Balance:
837 mL
-197 mL
Respiratory support
O2 Delivery Device: Aerosol-cool
SpO2: 94%
ABG: ///26/
Physical Examination
Gen: NAD, sleeping prior to exam
Pulm: CTA anteriorly, no wheezes/crackles
CV: RRR, no murmur appreciated
Abd: soft, NT/ND
Peripheral Vascular: pulses intact, no edema
Skin: warm, dry, intact
Neurologic: alert, oriented, no focal deficits
Labs / Radiology
372 K/uL
8."
6696,"6/101.7/1.5, Ca++:8.1 mg/dL, Mg++:2.1
mg/dL, PO4:3.4 mg/dL
BASIC COAGULATION (PT, PTT, PLT, INR)
PT
PTT
Plt Ct
INR(PT)
[1][**2172-4-26**] 01:47AM
372
[2][**2172-4-26**] 01:47AM
16.6*
101.7*[1]
1.5*
[3][**2172-4-25**] 03:30PM
15.2*
57.5*
1.3*
[4][**2172-4-25**] 03:30PM
15.1*
55.3*
1.3*
[5][**2172-4-25**] 02:53AM
392
[6][**2172-4-25**] 02:53AM
16.1*
93.4*
1.4*
[7][**2172-4-24**] 09:50PM
94."
6697,"Chief Complaint:
24 Hour Events:
- arterial line D/c
-weaned O2 to 5L NC
-following PTTs, latest 81
-changed to PO meds today
Allergies:
Ambien (Oral) (Zolpidem Tartrate)
Headache;
Last dose of Antibiotics:
Infusions:
Heparin Sodium - 2,950 units/hour
Other ICU medications:
Heparin Sodium - [**2172-4-25**] 11:15 PM
Morphine Sulfate - [**2172-4-26**] 04:45 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2172-4-26**] 06:41 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**74**] AM
Tmax: 36."
6698,"- Consider pain consult if medication regimen ineffective
# Constipation
not stooling, feels bloated, written for colace and
senna PRN
- Write for standing colace and senna
- Dulcolax today
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: IV heparin
# Access: peripherals
# Communication: Patient, family
# Code: Full (discussed with patient); HCP husband [**Name (NI) 938**] [**Name (NI) 3033**]
# Disposition: ICU pending weaning off face mask to nasal canula.
References
1. JavaScript:parent.POPUP(self,%22_WEBTAG=_5%22);
2. JavaScript:parent.POPUP(self,%22_WEBTAG=_6%22);
3. JavaScript:parent.POPUP(self,%22_WEBTAG=_7%22);
4. JavaScript:parent.POPUP(self,%22_WEBTAG=_8%22);
5. JavaScript:parent.POPUP(self,%22_WEBTAG=_9%22);
6. JavaScript:parent.POPUP(self,%22_WEBTAG=_10%22);
7. JavaScript:parent.POPUP(self,%22_WEBTAG=_11%22);
8. JavaScript:parent.POPUP(self,%22_WEBTAG=_12%22);
9. JavaScript:parent.POPUP(self,%22_WEBTAG=_13%22);
10. JavaScript:parent.POPUP(self,%22_WEBTAG=_14%22);
11. JavaScript:parent.POPUP(self,%22_WEBTAG=_15%22);"
6699,"Chief Complaint: Shortness of Breath
24 Hour Events:
Pt. did well hemodynamically, but we have had a lot of difficulty
getting her PTT to desired level.
LENI yesterday showed non-occlusive DVT within the right distal femoral
vein, inferior to the bifurcation.
ECHO showed dilated and mildly hypokinetic right ventricle. Normal
global and regional left ventricular systolic dysfunction. Moderate
functional tricuspid regurgitation. Moderate pulmonary hypertension.
Allergies:
Ambien (Oral) (Zolpidem Tartrate)
Headache;
Last dose of Antibiotics:
Infusions:
Heparin Sodium - 2,150 units/hour
Other ICU medications:
Morphine Sulfate - [**2172-4-24**] 03:00 AM
Heparin Sodium - [**2172-4-24**] 05:31 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2172-4-24**] 06:44 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**74**] AM
Tmax: 36."
6700,"9
C (98.4
Tcurrent: 36.9
C (98.4
HR: 81 (80 - 89) bpm
BP: 130/66(85) {120/62(0) - 158/76(98)} mmHg
RR: 18 (18 - 27) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 91.6 kg (admission): 91.6 kg
Total In:
881 mL
133 mL
PO:
TF:
IVF:
881 mL
133 mL
Blood products:
Total out:
745 mL
245 mL
Urine:
745 mL
245 mL
NG:
Stool:
Drains:
Balance:
136 mL
-112 mL
Respiratory support
O2 Delivery Device: Non-rebreather
SpO2: 94%
ABG: 7.43/35/70/24/0
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
398 K/uL
8."
6701,".
# Pulmonary embolism: Per reports from OSH, and per discussion with
radiologists at [**Hospital1 5**] and review of the images, pt has diffuse PE's
bilaterally, with very little lung perfusion. Pt is currently stable on
NRB with NC, with stable BP and pulse.
- Discussed case with IR/angio; the angio team will review records,
but are reluctant to persue thrombectomy while pt HD stable
- Obtain ECHO to evaluate for right heart strain
- Continue heparin gtt
- Continue supplemental O2 with NRB
.
# S/p laminectomy: Midline incision healing well, pt still having pain
in abdomen, low back.
- Pain control with IV morphine for now, anticipate change to PO meds
if pt does not require procedure or intubation today
- Ortho following, appreciate recommendations about anticoagulation
given risk of bleeding into dural sac with IV heparin
.
# FEN: No IVF, replete electrolytes, NPO for now given uncertainty of
intubation/procedure
.
# Prophylaxis: IV heparin
.
# Access: peripherals
.
# Communication: Patient, family
.
# Code: Full (discussed with patient); HCP husband [**Name (NI) 938**] [**Name (NI) 3033**]
.
# Disposition: ICU pending clinical improvement
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2172-4-23**] 08:31 AM
22 Gauge - [**2172-4-23**] 08:38 AM
20 Gauge - [**2172-4-23**] 10:37 AM
Arterial Line - [**2172-4-23**] 04:00 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
6702,"9 g/dL
99 mg/dL
0.6 mg/dL
24 mEq/L
3.5 mEq/L
9 mg/dL
105 mEq/L
137 mEq/L
27.8 %
8.8 K/uL
[image002.jpg]
[**2172-4-23**] 02:37 PM
[**2172-4-23**] 05:48 PM
[**2172-4-24**] 03:24 AM
WBC
8.8
Hct
27.8
Plt
398
Cr
0.7
0.6
TCO2
24
Glucose
109
99
Other labs: PT / PTT / INR:14.7/52.1/1.3, Ca++:7.8 mg/dL, Mg++:1.9
mg/dL, PO4:2.8 mg/dL
Assessment and Plan
55 y/o F with hx of gastric bypass and recent spinal fusion on [**2172-4-7**]
who presents with acute pulmonary embolism."
6703,"Chief Complaint: Shortness of Breath
24 Hour Events:
Pt. did well hemodynamically, but we have had a lot of difficulty
getting her PTT to desired level.
LENI yesterday showed non-occlusive DVT within the right distal femoral
vein, inferior to the bifurcation.
ECHO showed dilated and mildly hypokinetic right ventricle. Normal
global and regional left ventricular systolic dysfunction. Moderate
functional tricuspid regurgitation. Moderate pulmonary hypertension.
Allergies:
Ambien (Oral) (Zolpidem Tartrate)
Headache;
Last dose of Antibiotics:
Infusions:
Heparin Sodium - 2,150 units/hour
Other ICU medications:
Morphine Sulfate - [**2172-4-24**] 03:00 AM
Heparin Sodium - [**2172-4-24**] 05:31 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2172-4-24**] 06:44 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**74**] AM
Tmax: 36."
6704,"9
C (98.4
Tcurrent: 36.9
C (98.4
HR: 81 (80 - 89) bpm
BP: 130/66(85) {120/62(0) - 158/76(98)} mmHg
RR: 18 (18 - 27) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 91.6 kg (admission): 91.6 kg
Total In:
881 mL
133 mL
PO:
TF:
IVF:
881 mL
133 mL
Blood products:
Total out:
745 mL
245 mL
Urine:
745 mL
245 mL
NG:
Stool:
Drains:
Balance:
136 mL
-112 mL
Respiratory support
O2 Delivery Device: Non-rebreather
SpO2: 94%
ABG: 7.43/35/70/24/0
Physical Examination
Gen: NAD, on NC/NRB
Pulm: Expiratory wheezes, L>R, equal air entry
CV: RRR, no m/c/r
Abd: soft, NT/ND
Peripheral Vascular: pulses 2+
Skin: warm, dry
Neurologic: alert and oriented x 3
Labs / Radiology
398 K/uL
8."
6705,".
# Pulmonary embolism: Per reports from OSH, and per discussion with
radiologists at [**Hospital1 5**] and review of the images, pt has diffuse PE's
bilaterally, with very little lung perfusion. Pt is currently stable on
NRB with NC, with stable BP and pulse.
- Discussed case with IR/angio; the angio team will review records,
but are reluctant to persue thrombectomy while pt HD stable
- Obtain ECHO to evaluate for right heart strain
- Continue heparin gtt
- Continue supplemental O2 with NRB
.
# S/p laminectomy: Midline incision healing well, pt still having pain
in abdomen, low back.
- Pain control with IV morphine for now, anticipate change to PO meds
if pt does not require procedure or intubation today
- Ortho following, appreciate recommendations about anticoagulation
given risk of bleeding into dural sac with IV heparin
.
# FEN: No IVF, replete electrolytes, NPO for now given uncertainty of
intubation/procedure
.
# Prophylaxis: IV heparin
.
# Access: peripherals
.
# Communication: Patient, family
.
# Code: Full (discussed with patient); HCP husband [**Name (NI) 938**] [**Name (NI) 3033**]
.
# Disposition: ICU pending clinical improvement
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2172-4-23**] 08:31 AM
22 Gauge - [**2172-4-23**] 08:38 AM
20 Gauge - [**2172-4-23**] 10:37 AM
Arterial Line - [**2172-4-23**] 04:00 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
6706,"9 g/dL
99 mg/dL
0.6 mg/dL
24 mEq/L
3.5 mEq/L
9 mg/dL
105 mEq/L
137 mEq/L
27.8 %
8.8 K/uL
[image002.jpg]
[**2172-4-23**] 02:37 PM
[**2172-4-23**] 05:48 PM
[**2172-4-24**] 03:24 AM
WBC
8.8
Hct
27.8
Plt
398
Cr
0.7
0.6
TCO2
24
Glucose
109
99
Other labs: PT / PTT / INR:14.7/52.1/1.3, Ca++:7.8 mg/dL, Mg++:1.9
mg/dL, PO4:2.8 mg/dL
Assessment and Plan
55 y/o F with hx of gastric bypass and recent spinal fusion on [**2172-4-7**]
who presents with acute pulmonary embolism."
6707,"Was called out of MICU
yesterday and returning for continued hypoxia and worsening pain.
.
# Pulmonary emboli: were diffuse, never hemodynamically unstable. On
CT today, she continues to have extensive clot burden. Is requiring
fask mask oxygen and has been slow to wean. Desats on the floor,
likely from exertion and movement. Will be transferred back to unit
for continued respiratory monitoring.
- continue coumadin; can continue to hold heparin
- wean O2 as tolerated
- nebs PRN wheezing, SOB
.
# LUL infiltrate: concerning for pneumonia. [**Month (only) 8**] have contributed to
her desaturations on the floor. Is not febrile and no leukocytosis,
but may be early."
6708,"- vanco/cefepime for HAP coverage
- repeat CXR tomorrow
.
# Back pain: unclear etiology, no bleeding seen on CT scan today.
Likely is post-operative pain and/or pain from lying in bed all day.
Could also have pleuretic pain from PEs and new pneumonia.
- pain control with home PO meds
- can use morphine IV PRN if needed
.
# S/p laminectomy: Midline incision healing well, pt still having pain
in abdomen, low back. Ortho is following along.
- will continue home pain control regimen of oxycontin, oxycodone and
tizanidine; morphine PRN as above
- ortho requesting AP & lateral L-spine x-rays prior to d/c
- follow up ortho recs if any
."
6709,"8
10.0
8.1
7.7
6.6
6.5
Hct
27.8
26.7
26.9
26.3
26.7
28.7
Plt
398
392
372
[**Telephone/Fax (3) 12186**]
Cr
0.7
0.6
0.6
0.6
0.7
0.6
0.6
TC02
24
Glucose
109
99
103
102
137
100
99
87
Other labs: PT / PTT / INR:23.3/111.3/2.2, Ca++:8.2 mg/dL, Mg++:1.9
mg/dL, PO4:4.2 mg/dL
Imaging: [**4-23**] CTA (OSH, uploaded):
Large left main pulmonary artery PE extending to segmental arteries
involving all lobes of the left lung, as well as a right upper lobe
apical segmental artery PE, and an occlusive embolus in the right lower
lobe pulmonary artery."
6710,"Chief Complaint: hypoxia, back pain
HPI:
55 y/o F with hx of recent L5/S1 laminectomy who presented on [**4-23**] with
worsening SOB and found to have multiple PEs. Was in the MICU from
[**4-23**] until the night of [**4-29**]. See the initial admission note and last
night's transfer note for details of her presentation and hospital
stay.
.
In short, she was admitted and started on a heparin gtt which was
difficult to titrate to a therapeutic range. She remained hypoxic with
O2 sats in the high 80s to low 90s while on high flow mask and nasal
canula."
6711,"She had a CT torso to evaluate lung
parenchyema and for RP bleed. Her hct was stable today at 29 and had a
therapeutic INR. Her herparin was stopped.
.
She was transferred to the MICU for nursing concern about her hypoxia.
Patient admitted from: [**Hospital1 5**] [**Hospital1 **]
History obtained from [**Hospital 19**] Medical records
Allergies:
Ambien (Oral) (Zolpidem Tartrate)
Headache;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
(Per prior admission note)
Past Medical History:
Obesity
Gastric Bypass
s/p anterior L4-S1 fusion
.
Medications:
Oxycodone 5 mg [**2-8**] Tablet(s) every 4 hours, as needed
Docusate Sodium 100 mg Tab Twice Daily
Tizanidine 4 mg Tab Daily, at bedtime
Quetiapine 50 mg Tab Daily, at bedtime
Cyanocobalamin 50 mcg Tab Daily
Multivitamin Tab Daily
Clonazepam 0."
6712,"5 mg Tab Daily, at bedtime
Venlafaxine ER 225 mg 24 hr Tab Daily
Doxidan (bisacodyl) 5 mg Tab Oral 2 Tablet Once Daily, as needed
OxyContin 20 mg 12 hr Tab every 12 hours
.
Transfer MEDS:
see OMR
.
Allergies:
Ambien
no hx of blood clots; otherwise non-contributory
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Lives with husband, runs food service supplying mixes for
breads/brownies/etc to chain stores. Denies tobacco, etoh or illicits.
Having a difficult time with coping about her diagnosis. Also has a
son who was recently incarcerated.
Review of systems:
Constitutional: Fatigue
Ear, Nose, Throat: Dry mouth
Cardiovascular: Chest pain, Palpitations
Respiratory: Dyspnea, Tachypnea, Wheeze
Gastrointestinal: Abdominal pain, Constipation
Genitourinary: Foley
Musculoskeletal: Myalgias
Heme / Lymph: Anemia
Neurologic: Headache
Psychiatric / Sleep: Agitated, depressed
Pain: [**8-13**] Severe
Pain location: upper and lower back
Flowsheet Data as of [**2172-4-30**] 03:21 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**74**] AM
Tmax: 37."
6713,"Over the course of her stay, she became therapeutic on the
heparin and was started on coumadin on [**4-26**] after being therapeutic for
24 hours. She was weaned from the high flow face mask to a venti mask
and then nasal canula overnight. She was otherwise normotensive with
mild tachycardia to high 100s throughout her hospitalization. She had
pain control with IV morphine and then PO oxycodone/oxycontin for her
post-surgical pain.
.
On transfer to the floor last night, she triggered for a SBP in the
80s. She had just received all her pain medications, and her BP
quickly normalized after a fluid bolus."
6714,".
[**4-30**] CXR:
.
[**4-30**] CT Torso: (per dictation)
Large central pulmonary emboli extending into all segments which has
slightly increased in extent, more on the Right. No evidence of pulm
artery enlargement or R heart strain. Small L and trace R pleural
effusion. LUL infiltrate consistent with a pneumonia. Bowel is
without free air or obstruction. No evidence of bleed. No
abnormalities of other organs. Has post operative seroma. Spinal
hardware appears intact.
Microbiology: mrsa screen negative
ECG: NSR, no signs of ischemia
Assessment and Plan
DEPRESSION
ACTIVITY INTOLERANCE
PULMONARY EMBOLISM (PE), ACUTE
ASSESSMENT AND PLAN:
55 y/o F with hx of obesity, s/p gastric bypass, s/p L5/S1 laminectomy
who presented with large bilateral PEs."
6715,"She was called out yesterday to the
floor but returns to us with ongoing hypoxemia and new pleuritic chest
pain on L. Pt has been therapeutic on her Coumading CTA today shoes
ongoing extensive bilateral PEs as well as scattered groung glass
infiltrates, which are most prominent in the LUL. There is also a
component best viewed on chest/abdomen windows that appears to be
pleural-based in the LUL and a new L-sided effusion. I suspect that
her pleuritic CP is due to distal inflammation/pleuritis as a late
consequence of her PEs but we will also treat her for hospital-acquired
PNA. Her oxygenation is stable at the moment.
[**Name2 (NI) **] is critically ill. Time spent 35 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 1776**] [**Name8 (MD) **], MD
on:[**2172-4-30**] 18:18 ------"
6716,"1 g/dL
87 mg/dL
0.6 mg/dL
6 mg/dL
28 mEq/L
103 mEq/L
3.3 mEq/L
141 mEq/L
28.7 %
6.5 K/uL
[image002.jpg]
[**2168-2-8**]
2:33 A3/18/[**2172**] 02:37 PM
[**2168-2-12**]
10:20 P3/18/[**2172**] 05:48 PM
[**2168-2-13**]
1:20 P3/19/[**2172**] 03:24 AM
[**2168-2-14**]
11:50 P3/20/[**2172**] 02:53 AM
[**2168-2-15**]
1:20 A3/21/[**2172**] 01:47 AM
[**2168-2-16**]
7:20 P3/22/[**2172**] 04:12 AM
1//11/006
1:23 P3/23/[**2172**] 05:27 AM
[**2168-3-10**]
1:20 P3/23/[**2172**] 12:11 PM
[**2168-3-10**]
11:20 P3/24/[**2172**] 02:17 AM
[**2168-3-10**]
4:20 P
WBC
8."
6717,"Moderate pulmonary hypertension.
.
[**4-23**] LENIs: Subacute, non-occlusive DVT within the right distal femoral
vein, inferior to the bifurcation.
.
[**4-23**] CXR:
ABDOMEN, SUPINE PORTABLE FRONTAL VIEW: The lateral aspect of the left
lung is not included on this study. Lung volumes are low. Linear
opacity of the right lung base corresponds to atelectasis on CT. The
imaged portion of the left lung is clear. The heart is accentuated by
low lung volumes. There is no evidence of pulmonary edema. Medial right
apical density corresponds to an azygos fissure on CT.
IMPRESSION: No acute cardiopulmonary abnormality.
Please refer to CT for imaging of bilateral pulmonary emboli."
6718,".
[**4-23**] TTE:
The left atrium is mildly dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal (LVEF
>55%). The right ventricular cavity is dilated with mild global free
wall hypokinesis. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated and mildly hypokinetic right ventricle. Normal
global and regional left ventricular systolic dysfunction. Moderate
functional tricuspid regurgitation."
6719,".
[**First Name8 (NamePattern2) 4452**] [**Last Name (NamePattern1) 4399**], MD
PGY 2
pager [**Numeric Identifier 11908**]
ICU Care
Nutrition:
Glycemic Control:
Lines:
Prophylaxis:
DVT: Boots(Systemic anticoagulation: Coumadin)
Stress ulcer:
VAP:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
------ Protected Section ------
I saw and examined the patient, and was physically present with the ICU
resident for the key portions of the services provided. I agree with
the note above, including the assessment and plan. To that I would add
the following:
Mrs. [**Known lastname 3033**] is well-known to the MICU service, having presented last
week with extensive bilateral PEs."
6720,"# Anemia: hct is within her recent baseline after surgery. Will
continue cyanocobalamin and multivitamin. No active evidence of
bleeding. No bleed seen on CT
- monitor hct daily
.
# Anxiety: Will continue venlafaxine, clonazepam, quetiapine. Social
work has seen patient. Continues to be anxious and crying. Supportive
care as needed.
.
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: on coumadin, bowel regimen, pain control as above
# Access: peripherals; consider PICC for abx and blood draws
# Communication: Patient, family
# Code: Full (discussed with patient); HCP husband [**Name (NI) 938**] [**Name (NI) 3033**]
# Disposition: ICU for now, consider calling out when stable on nasal
canula
."
6721,"Then she triggered again this
morning for marked nursing concern with increased upper and lower back
and ""lung"" pain. She had desatted to the high 80s on her nasal canula
and was placed back on a venti mask. Her oxygenation saturations
improved to mid 90s after being placed back on the mask.
.
During evaluation, she was tachypneic and uncomfortable, complaining of
middle upper back pain and pain with deep breaths. She was afebrile,
her BP was 110/80, P 98. She was 92% on venti-face mask. She had
already received her morning pain meds and was not comfortable. She
was given IV morphine and ativan."
6722,"2
C (99
Tcurrent: 36.7
C (98
HR: 93 (69 - 97) bpm
BP: 144/71(89) {119/59(73) - 154/88(102)} mmHg
RR: 29 (14 - 29) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 89.3 kg (admission): 91.6 kg
Height: 64 Inch
Total In:
1,175 mL
PO:
500 mL
TF:
IVF:
675 mL
Blood products:
Total out:
1,340 mL
0 mL
Urine:
1,340 mL
NG:
Stool:
Drains:
Balance:
-165 mL
0 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 95%
Physical Examination
General Appearance: Well nourished, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,
No(t) Crackles : , Bronchial: at bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Labs / Radiology
433 K/uL
9."
6723,".
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Obesity
Gastric Bypass
s/p anterior L4-S1 fusion
Depression/Anxiety
Social History:
Lives with husband, runs food service.
- Tobacco: Denies.
- Alcohol: Denies.
- Illicits: Denies.
Family History:
Noncontributory.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R single lumen EJ in
place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, + ttp, non-distended, midline incision C/D/I
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema"
6724,"There
is no pericardial effusion.
CTA Chest [**4-30**]: IMPRESSION:
1. Minimally increase in large pulmonary artery clot burden on
the right
since 1 week prior. The pulmonary artery remains almost the same
diameter as the aorta suggesting mild pulmonary hypertension.
There are no other signs to suggest right ventricular strain.
2. Left upper lung ground glass opacities may represent
infectious etiology, asymmetric ventilation from pulmonary
embolus or foci of hemorrhage.
3. New small, left greater than right pleural effusions.
4. No RP bleed.
5. Small splenic infarct.
Brief Hospital Course:
55 y/o F with hx of gastric bypass and recent spinal fusion on
[**2172-4-7**] who presents with acute pulmonary embolism."
6725,"Pain service consulted. Tizanidine
continued. Started gabapentin and lidocaine patch.
# Depression/Anxiety: Pt. was very tearful during admission as
she was not expecting this and has had tremendous stress at home
(her son is in prison). Social work was consulted for support.
Home anxiety regimen continued. Seroquel increased to 50 qhs. Pt
able to discuss her anxiety and depression at length with this
provider. [**Name10 (NameIs) **] also states that she has never considered hurting
herself and that she believes she is here for a reason.
# splenic infact: unclear etiology
-recommend outpt heme eval
# anemia: iron studies c/w iron deficiency plus anemia of
chronic inflammation."
6726,"Would recommend starting iron when pt on
less opiates (pt had issues c constipation during
hospitalization, did not want to start iron at this time).
- recommend start iron as outpt
Medications on Admission:
Oxycodone 5 mg [**2-8**] Tablet(s) every 4 hours, as needed
Docusate Sodium 100 mg Tab Twice Daily
Tizanidine 4 mg Tab Daily, at bedtime
Quetiapine 50 mg Tab Daily, at bedtime
Cyanocobalamin 50 mcg Tab Daily
Multivitamin Tab Daily
Clonazepam 0.5 mg Tab Daily, at bedtime
Venlafaxine ER 225 mg 24 hr Tab Daily
Doxidan (bisacodyl) 5 mg Tab Oral 2 Tablet Once Daily, as needed"
6727,"# Pulmonary embolism (provoked): Per reports from OSH, and per
discussion with radiologists at [**Hospital1 18**] and review of the images,
pt has diffuse PE's bilaterally, with very little lung
perfusion. Pt was started on oxygen and a heparin drip (with
which there was initially some difficulty in obtaining
therapeutic PTT) as well as coumadin. Upon admission she was on
a nonrebreather, but was weaned to facemask and then to nasal
cannula and, on discharge, was on room air during the day with
desaturations overnight requiring her to get home oxygen for
overnight only.
-could consider outpt sleep study
-pt discharged c therapeutic INR, will need close f/u"
6728,"Disp:*30 Tablet(s)* Refills:*0*
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take
on Tue, Wed, Fri, Sat, Sun (take the other dose on Mon and
Thurs).
Disp:*30 Tablet(s)* Refills:*0*
15. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours.
Disp:*90 Capsule(s)* Refills:*0*
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain: do NOT take at the same time as oxycontin as
it may make you sleepy. Do NOT drive or operate machinery or
drink alcohol while taking this medicine."
6729,"OxyContin 20 mg 12 hr Tab every 12 hours
Discharge Medications:
1. oxygen
oxygen 2L per minute continuous for portability pulse dose
system
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clonazepam 1 mg Tablet Sig: [**2-8**] Tablet PO QHS (once a day (at
bedtime))."
6730,"The
pt was started on a heparin gtt and transfered to [**Hospital1 18**] ED for
further management. ABG at OSH showed: 7.46/30/53/21.
.
In the [**Hospital1 18**] ED, initial vs were: T 98.6 P 88 BP 135/88 R 28 O2
sat 91% NRB. Patient was given morphine and ondansetron and
heparin was continued. Patient was admitted to ICU for further
management.
.
On the floor, patient appears comfortable but tachypnic on NRB.
Reports that she is thirsty.
.
Review of systems:
(+) Per HPI
Also, patient endorses non-productive, non-bloody cough for
three days, constipation (no BM since she was discharged from
the hospital [**2172-4-12**]), and abdominal pain at the site of the
surgical incision."
6731,"Flow was seen around this
clot. The remaining vessels demonstrate normal compressibility,
flow and augmentation.
Outside Hospital CTA Scan: massive b/l PE
TTE [**4-23**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular cavity is
dilated with mild global free wall hypokinesis. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension."
6732,"You required intravenous heparin and coumadin was
started - when this drug reached a good level, the heparin was
discontinued. You will need to take coumadin for a year. You
will need to have your coumadin levels checked carefully so you
will see Dr [**Last Name (STitle) 10023**] on Wednesday. Please use your oxygen at
night while sleeping.
Please continue your medications with the following changes:
1. STOP percocet
2. STOP flexoril
3. START colace and senna and bisacodyl for constipation as pain
meds can be constipating
4. START oxycontin twice daily for pain
5. START oxycodone as needed for pain
6."
6733,"Disp:*20 Tablet(s)* Refills:*0*
17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every six (6) hours as needed for shortness
of breath or wheezing for 2 weeks.
Disp:*1 inhaler* Refills:*0*
18. Mirapex Oral
Discharge Disposition:
Home With Service
Facility:
Homemakers of [**Location (un) 33810**]
Discharge Diagnosis:
Primary
Pulmonary Embolus
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You came to the hospital after having a blood clots in your
lungs (pulmonary embolus) in the context of recovering from back
surgery."
6734,"START gabapentin
7. START lidocaine patch (12 hours on, 12 hours off)
8. START albuterol inhaler
9. START coumadin
Followup Instructions:
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: [**Last Name (LF) 2974**], [**2173-5-22**]:30 am
Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER
Address: [**Last Name (LF) **], [**First Name3 (LF) **] BLDG. [**Location (un) **]
Phone: [**Telephone/Fax (1) 3573**]
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
When: This Wednesday [**5-6**] 11:30a
Location: [**Location (un) **] INTERNAL MEDICINE
Address: [**Apartment Address(1) 83581**], [**Location (un) **],[**Numeric Identifier 62963**]
Phone: [**Telephone/Fax (1) 10026**]
Completed by:[**2172-5-6**]"
6735,"Pertinent Results:
[**2172-4-23**] 09:28PM PTT-54.2*
[**2172-4-23**] 02:37PM GLUCOSE-109* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11
[**2172-4-23**] 02:37PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.1
[**2172-4-23**] 06:17AM GLUCOSE-96 LACTATE-1.3 NA+-141 K+-3.2*
CL--102 TCO2-24
Iron: 20
calTIBC: 274
Ferritn: 64
TRF: 211
LE Ultrasound:
Grayscale and Doppler son[**Name (NI) **] of the bilateral common femoral,
superficial femoral, and popliteal veins were performed. Within
the right distal femoral vein, inferior to the bifurcation
(SFV), an echogenic clot is seen."
6736,"Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Put on
for 12 hours then MUST be removed for 12 hours (cannot wear 24
hours per day).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
12. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: take on Monday and Thursday only."
6737,"Admission Date: [**2172-4-23**] Discharge Date: [**2172-5-4**]
Date of Birth: [**2117-2-7**] Sex: F
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year old woman s/p L4-L5 laminectomy and fusion on [**2172-4-7**],
discharged [**2172-4-12**], who presented to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Hospital **] hospital with 3
days of SOB on [**2172-4-23**]. Pt states that she developed SOB three
days prior to admission. She denies CP, palpitations, but does
endorse DOE with recent difficulty reaching the top of her
stairs."
6738,"7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): do NOT
take at the same time as oxycontin as it may make you sleepy. Do
NOT drive or operate machinery or drink alcohol while taking
this medicine."
6739,"Following dinner on [**4-22**] the pt developed worsening SOB
at rest and the pt called EMS. En route to hospital pt was
initally bradycardic, hypotensive and with low sats, BP improved
with non-rebreather and the pt became tachycardic in the low
100's. At OSH pt was given 3L NS and 1u pRBCs for tachycardia
and anemia (OSH hct 26), and pt had a CTA PE protocol that
revealed a large left main pulmonary artery PE extending to
segmental arteries involving all lobes of the left lung, as well
as a right upper lobe apical segmental artery PE, and an
occlusive embolus in the right lower lobe pulmonary artery."
6740,"# s/p laminectomy (Dr. [**Last Name (STitle) 363**]: Midline incision healing well,
pt still having pain in abdomen, low back. She was initially
controlled with IV pain medication, but transitioned back to her
home regimen of PO oxycontin and oxycodone. Ortho recommended
A/P and lateral L-spine films during her admission. These were
obtained and showed no change in alignment.
-pt to f/u with Dr [**Last Name (STitle) 363**] as outpt
# Pain Management s/p laminectomy: Midline incision healing
well, pt still having pain in abdomen, low back. Ortho is
following along. Left back pain perhaps due to small splenic
infarct seen on chest CT."
6741,"Diet: Regular
Meds: Senna, Warfarin, vitamin B12, multivitamin, colace, others noted
55 y.o. Female with hx of gastric bypass and recent spinal fusion on
[**2172-4-7**] who presents with acute pulmonary embolism. Patient is
tolerating a regular diet, just starting to eat small meals. Patient
ate oatmeal for breakfast and is eating macaroni and cheese and
carrots/celery for lunch. Will follow up with po intake and tolerance.
#[**Numeric Identifier 1312**]
01:00 PM"
6742,"[**Last Name (LF) 7088**],[**First Name3 (LF) 7089**] MED SICU-B [**2172-4-23**] 11:55 AM
BILAT LOWER EXT VEINS PORT Clip # [**Clip Number (Radiology) 95139**]
Reason: MASSIVE PE, R/O DVT
Admitting Diagnosis: PULMONARY EMBOLUS
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
55 year old woman with massive PE
REASON FOR THIS EXAMINATION:
r/o DVT
______________________________________________________________________________
PFI REPORT
Subacute DVT within the right distal femoral vein inferior to the bifurcation."
6743,"Admission Date: [**2151-11-27**] Discharge Date: [**2151-12-3**]
Date of Birth: [**2066-9-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname **] is an 85 year old female with a PMH significant for
CAD s/p PCI, HTN, and HLD admitted for hyponatremia. The patient
and her daughters report that she has had decreased PO intake
over the past week, and yesterday developed nausea and vomiting.
Her daughters further state that she was admitted to NEBH one
month prior for ""dehydration,"" but she did not have a low
sodiuum level at that time."
6744,"A CTAP demonstrated a 7 mm celiac aneurysm, for
which vascular surgery was consulted in the ED with
recommendation for no acute intervention at this time. The
patient was then admitted to the MICU for further management.
.
Currently, the patient is resting comfortably without
complaints.
Past Medical History:
Bradycardia
Labile hypertension
Hyperlipidemia
Cholecystectomy
Bilateral cataract surgery
Acid reflux
Coronary artery disease, s/p PCI to LAD, LCX and RCA
COPD/asthma (not an active problem)
Glaucoma
Appendectomy
Tonsillectomy
Eczema on legs bilaterally
Social History:
Married, lives at home with her husband, independent prior to
admission
Family History:
Non-contributory
Physical Exam:
VS: 97."
6745,"Pertinent Results:
CTAP:
1. No AAA or acute aortic process.
2. Ectatic celiac axis origin without discrete aneurysm.
3. No acute intra-abdominal process seen.
CXR: No acute intrathoracic process.
CT head: 1. No evidence of intracranial mass to suggest a source
of SIADH.
2. No acute intracranial process.
CT chest: Minimal subsegmental atelectasis. No evidence of
malignancy or
infection.
Admission labs:
[**2151-11-27**] 11:20AM GLUCOSE-140* UREA N-11 CREAT-0.5 SODIUM-113*
POTASSIUM-4.2 CHLORIDE-77* TOTAL CO2-26 ANION GAP-14
[**2151-11-27**] 11:20AM LIPASE-91*
[**2151-11-27**] 11:20AM ALT(SGPT)-21 AST(SGOT)-30 ALK PHOS-92 TOT
BILI-0."
6746,"# Hyponatremia: The patient was admitted with a serum sodium of
113, but without seizure activity or evidence of coma,
suggesting that patient's sodium decreased slowly over time.
However her mental status was not at baseline, very likely [**12-29**]
delirium in the setting of hyponatremia. Her thiazide diuretic
was held, as this was likely contributing to hyponatremia. On
admission, she was noted to be hypovolemic and her sodium
improved some with normal saline. However, her sodium started
to decrease with continued normal saline infusion. Urine and
serum lytes were rechecked and in the setting of euvolemia, her
hyponatremia was thought most likely to be due to SIADH (urine
osm >400, serum Na <120 and serum osms low, and urine Na
inappropriately high)."
6747,"She was also continued on isosorbide mononitrate. SBP was still
elevated to 140s-160s, so amlodipine 5 mg daliy was started for
improved BP control.
# ?Celiac aneurysm: Initially CT Abd/pelvis showed concern for
celiac artery aneursym, however final CTA read ectatic celiac
artery without aneurysm.
# Elevated lipase: Unclear significance with no radiographic
evidence of pancreatic and benign abdominal exam. Also had CTA
abd/pelvis without evidence of pancreatitis.
# CAD s/p PCI: She was continued on ASA, valsartan, and
clopidogrel.
# DM 2: HISS with accuchecks, continued home metformin on
discharge.
# HLD: Vytorin continued on discharge.
Code: DNR/DNI (confirmed with daughters/[**Name2 (NI) **]-HCPs during admission"
6748,"Disp:*90 Tablet(s)* Refills:*2*
10. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
11. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
12. Fosamax 35 mg Tablet Sig: One (1) Tablet PO once a week.
13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Trusopt 2 % Drops Sig: One (1) Ophthalmic twice a day: 1
drop both eyes [**Hospital1 **].
15. Vytorin [**9-14**] 10-20 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service"
6749,"7 87 173/78 21 100%RA
Gen: Elderly frail woman in NAD
HEENT: Dry MM, PERRL, eomi, sclerae anicteric. No LAD
CV: Nl S1+S2, JVP flat
Pulm: CTAB
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
On discharge:
VS: 97.8 156/90 92 16 97% RA
Gen: Elderly frail woman in NAD, AOx3
HEENT: mmm, PERRL, eomi, sclerae anicteric. No LAD
CV: Nl S1+S2, JVP flat
Pulm: CTAB
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, unable to do days of the week backwards"
6750,"3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3
times a day)."
6751,"Contact: [**Name (NI) 107386**],[**First Name3 (LF) **] [**Telephone/Fax (1) 107387**]
Medications on Admission:
Clonidine 0.15 mg po bid
ASA 325 mg daily
MVI
xalatan eye drops
Valsartan 320 mg daily
Clopidogrel 75 mg daily
Vytorin daily
Ca/Vit D
Omeprazole
Aricept 10 mg daily
MOM
Fosamax 35 mg weekly
Metformin 850 mg po bid
HCTZ 25 mg daily
Imdur 60 mg daily
SL NTG PRN
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime)."
6752,"This means limiting the intake
of plain water, juice, tea, and other fluids like this to one
liter per day. Liquids such as gatorade, soup, supplement
shakes, and others that have a higher content of salt and
electrolytes are not limited. Please continue limiting free
water to 1 liter per day unless directed otherwise by your PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
We also stopped your hydrochlorothiazide, which may have been
contributing to the low sodium level in your blood. To control
your blood pressure, we started a new medication, amlodipine,
for blood pressure control.
Changes to your medications:
STOP taking hydrochlorothiazide
STOP taking clonidine
START taking amlodipine daily
START taking salt tablets (sodium chloride) three times a day
with meals
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 7960**]
Appt: [**12-8**] at 3pm
Completed by:[**2151-12-3**]"
6753,"They further state that since her
discharge, she has had an acute decline in her memory and
ability to function independently, and is currently living at
home with her husband under 24 hour nursing care. She denies
any f/c/s, diarrhea, chest pain, shortness of breath, HA,
palpitations, orthopnea, LE edema, or PND. The patient does
report a periumbilicar abomdinal pain, which her daughters state
has been going on for years. Her daughters also state that she
has had no recent medication changes.
.
In the [**Hospital1 18**] ED, initial VS 77 115/55 20 100%RA. A CXR and UA
was negative."
6754,"Has 24 hr nursing care at home.
During admission initially, was frequently not oriented to
place or location, or why she was in the hospital and often saw
people and things that were not actually present, with both
auditory and visual hallucinations. Waxing and [**Doctor Last Name 688**] course
suggested delirium in the setting of her hyponatremia vs
worsening dementia. On discharge, mental status at baseline per
family, unable to do months of the year backwards but AOx3 and
no hallucinations. continued home aricept.
# HTN: Her hydrochlorothiazide was held as above. She was
continued on valsartan at 160 mg [**Hospital1 **], which is her home dose."
6755,"Facility:
Bayada VNA
Discharge Diagnosis:
Hyponatremia
Syndrome of inappropriate secretion of antidiuretic hormone
(SIADH)
Hypertension
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were seen in the hospital for hyponatremia, which is a low
level of sodium in your blood. This may have been caused by
decreased eating and drinking at home, and also by a hormone in
your body that was holding on to too much water in the blood
stream and diluting the sodium in your blood.
Please continue taking salt tablets three times a day and
restricting free water intake."
6756,"CT head and chest were done to eval for
malignancy for etiology of SIADH, no masses were noted. She was
treated with free water restriction and TID salt tabs, as
recommended by the nephrology service. On discharge she will
continue to take salt tabs and have her Na monitored as an
outpatient. Na on discharge 132. She will f/u with PCP for
another [**Name9 (PRE) **] check on [**12-7**]. She should probably not restart a
thiazide diuretic in the future.
#Altered mental status: likely has baseline dementia that
initially was slowly progressing but acutely worsened after
being hospitalized in [**Month (only) **]."
6757,"5
[**2151-11-27**] 03:51PM URINE HOURS-RANDOM CREAT-53 SODIUM-70
POTASSIUM-46 CHLORIDE-73
Discharge labs:
[**2151-12-3**] 09:50AM BLOOD WBC-8.6 RBC-3.86* Hgb-10.7* Hct-32.4*
MCV-84 MCH-27.8 MCHC-33.0 RDW-16.4* Plt Ct-329
[**2151-12-3**] 09:50AM BLOOD Glucose-173* UreaN-11 Creat-0.5 Na-132*
K-3.9 Cl-97 HCO3-28 AnGap-11
Brief Hospital Course:
Mrs. [**Known lastname **] is an 85 year old female with a PMH significant for
CAD s/p PCI, HTN, and HLD admitted for hyponatremia."
6758,"In ED, he remains intubated, in NSR and on
norepi for blood pressure. Found to have Acute type 2 dens fracture.
Admitted to TICU for further management.
Chief complaint:
unresponsive
PMHx:
idiopathic generalized neuropathy, distant h/o seizure, BPH, leukopenia
(presumed [**3-13**] lamictal, no h/o serious infection), sleep apnea, spinal
stenosis, retinal detachment, [**Hospital Ward Name 5060**] cyst, rt 3rd fx
Current medications:
1. IV access: Temporary central access (ICU) Location: Left Subclavian,
Date inserted: [**2147-12-18**] Order date: [**12-18**] @ 1325
10. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**12-18**] @ 1132
2. IV access: Temporary central access (ICU) Location: Left Subclavian,
Date inserted: [**2147-12-18**] Order date: [**12-18**] @ 1557
11."
6759,"Anoxic brain injury and C2 cord injury. Neurology consulted
regarding questionable status epilepticus - given 1 time dose of
keppra. EEG monitoring cancelled as pts family wishes to make pt [**Name (NI) 303**] in
am.
Neuro checks Q:4h
Pain: fentanyl prn
CVS: currently on levophed gtt with goal to titrate SBP>90.
PULM: intubated, AC 500/22/5/100%. F/U repeat CXR to eval for pulm
hematoma s/p CVL placement.
GI: NPO, unable to place NGT, famotidine prophy
RENAL: foley. Monitor UOP. Cr 1.0
HEME: Hct 36.9 -> 38.5, cont to monitor
ENDO: RISS
ID: afebrile, no signs of infection
TLD: right radial artery line, left subclavian CVL, ETT, foley
IVF: NS@100cc/hr
CONSULTS: Red (west 3) surgery
BILLING DIAGNOSIS:
ICU CARE:
GLYCEMIC CONTROL: RISS
PROPHYLAXIS:
DVT - boots
STRESS ULCER - famotidine
VAP BUNDLE - yes
COMMUNICATIONS: wife
ICU Consent: Yes
CODE STATUS: Full Code
DISPOSITION: TICU"
6760,"4 K/uL
[image002.jpg]
[**2147-12-18**] 12:14 PM
[**2147-12-18**] 02:17 PM
[**2147-12-18**] 02:34 PM
[**2147-12-18**] 06:50 PM
[**2147-12-18**] 07:00 PM
[**2147-12-19**] 01:00 AM
[**2147-12-19**] 01:01 AM
[**2147-12-19**] 01:11 AM
WBC
3.7
7.4
Hct
38.5
37.3
Plt
225
208
Creatinine
0.8
0.7
TCO2
22
24
22
23
Glucose
195
153
127
153
159
Other labs: PT / PTT / INR:13.5/23.6/1.2, ALT / AST:280/333, Alk-Phos /
T bili:177/0."
6761,"TITLE:
TSICU
HPI:
This is a 71 year old male who presents to ED in cardiac arrest s/p
fall from bicycle. Per witnesses report, the patient was riding his
bike with a helmet at a low speed and hit a pot hole; he did not lose
consciousness, but stood up and then suddenly collapsed. Per witnesses,
patient was initially unresponsive but with a pulse. Upon EMS arrival,
he arrested; CPR was started, and a pulse was regained. However the
patient went into cardiac arrest again. He was pulseless and
non-breathing for approximately 5-10 minutes. ACLS protocol was started
and a pulse was found."
6762,"3, Amylase / Lipase:56/41, Differential-Neuts:82.2 %,
Lymph:13.5 %, Mono:1.9 %, Eos:1.8 %, Fibrinogen:210 mg/dL, Lactic
Acid:1.2 mmol/L, Albumin:3.7 g/dL, Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:5.0
mg/dL
Assessment and Plan
CERVICAL FRACTURE (WITH SPINAL CORD INJURY)
ASSESSMENT AND PLAN: 71y M s/p fall from bike with subsequent
unresponsiveness and cardiac arrest for approximately 10 minutes.
Found to have a Type II Dens fracture with C2 cord injury, and anoxic
brain injury.
NEURO: unresponsive, reactive pupils, no gag reflex, no oculocephalic
reflex."
6763,"Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**12-18**] @ 1455
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**12-18**] @
1132
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN. Order date: [**12-18**] @ 1325
8. Famotidine 20 mg IV Q12H Order date: [**12-18**] @ 1454
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN."
6764,"Order date: [**12-18**] @ 1557
9. Fentanyl Citrate 25-100 mcg IV Q1H:PRN discomfort Order date: [**12-18**]
@ [**2160**]
24 Hour Events:
Pan-scanned and found to have Acute type 2 dens fracture. Admitted to
TICU. Left subclavian CVL and right radial artery line placed. MRI
brain/c-spine c/w anoxic brain injury and C2 cord transection. Family
meeting - pt will be made [**Year (4 digits) 303**] this AM. DNR overnight. No acute issues
overnight.
Allergies:
Last dose of Antibiotics:
Infusions:
Norepinephrine - 0.06 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2147-12-18**] 08:20 PM
Fentanyl - [**2147-12-19**] 02:03 AM
Other medications:
Flowsheet Data as of [**2147-12-19**] 04:55 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**50**] a."
6765,"37/38/162/21/-2
Ve: 10.4 L/min
PaO2 / FiO2: 270
Physical Examination
General Appearance: No acute distress
HEENT: pupils sluggish to react b/l
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Neurologic: (Responds to: Unresponsive)
Labs / Radiology
208 K/uL
12.2 g/dL
159 mg/dL
0.7 mg/dL
21 mEq/L
4.3 mEq/L
27 mg/dL
108 mEq/L
139 mEq/L
37.3 %
7."
6766,"LeVETiracetam 1000 mg IV 1X Duration: 1 Doses Order date: [**12-18**] @
1609
3. OK to use line Order date: [**12-18**] @ 1557
12. Magnesium Sulfate IV Sliding Scale Order date: [**12-18**] @ 1455
4. 1000 mL NS
Continuous at 100 ml/hr Order date: [**12-18**] @ 1525
13. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO sbp > 90
Order date: [**12-18**] @ 1132
5. 500 ml NS Bolus 500 ml Over 15 mins Order date: [**12-18**] @ 1132
14. Potassium Chloride IV Sliding Scale Order date: [**12-18**] @ 1455
6. Calcium Gluconate IV Sliding Scale Order date: [**12-18**] @ 1455
15."
6767,"m.
Tmax: 36.7
C (98.1
T current: 36.3
C (97.4
HR: 54 (53 - 67) bpm
BP: 110/62(81) {93/57(71) - 155/96(117)} mmHg
RR: 22 (17 - 22) insp/min
SPO2: 98%
Heart rhythm: SB (Sinus Bradycardia)
Wgt (current): 92 kg (admission): 92 kg
Total In:
5,424 mL
539 mL
PO:
Tube feeding:
IV Fluid:
1,424 mL
539 mL
Blood products:
Total out:
1,995 mL
407 mL
Urine:
1,995 mL
157 mL
NG:
250 mL
Stool:
Drains:
Balance:
3,429 mL
132 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 10 cmH2O
FiO2: 60%
RSBI Deferred: PEEP > 10, FiO2 > 60%
PIP: 24 cmH2O
Plateau: 20 cmH2O
SPO2: 98%
ABG: 7."
6768,"Consult requested by: ED Team / Trauma Team
Chief Complaint: s/p arrest
HPI:
71M BIBEMS after fall of bicycle, by report stood up, then collapsed,
found to be pulseless. Received CPR, meds, with ROSC. Re-arrested with
EMS, and again in Trauma bay. Found to have C2 fx on imaging, rib fx,
no other acute injuries. MRI of spine ordered and pending. Estimated
downtime 10 mins.
Currently on Levophed for hypoTN. Rhythm strips currently unavailable
for review.
Allergies:
Last dose of Antibiotics:
Infusions:
Norepinephrine - 0.1 mcg/Kg/min
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social history:
idiopathic generalized neuropathy, distant h/o seizure, BPH, leukopenia
(presumed [**3-13**] lamictal, no h/o serious infection), sleep apnea, spinal
stenosis, retinal detachment, [**Hospital Ward Name 5060**] cyst,
Occupation:
Drugs:
Tobacco:
Alcohol:
Other:
Review of systems:
Flowsheet Data as of [**2147-12-18**] 03:59 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36."
6769,"8 %, Fibrinogen:210 mg/dL, Lactic
Acid:4.5 mmol/L, Albumin:3.7 g/dL, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL,
PO4:5.7 mg/dL
Assessment and Plan
71M s/p fall with subsequent cardiac arrest, ? cord injury [**3-13**] dens
fracture.
Recommendations for neuroprotection:
1. Therapeutic Hypothermia: Pt had a cardiac arrest of unclear
etiology, although may be related to a high cervical spine injury since
pt has evidence of a dens fracture on CT scan. Induction of hypothermia
carries a theoretical risk of coagulopathy and while this pat sustained
trauma, there is currently no evidence of active hemorrhage."
6770,"29/48/81.[**Numeric Identifier **]/21/-3
Ve: 10.7 L/min
PaO2 / FiO2: 81
Physical Examination
General Appearance: Intubated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube
Lymphatic: c-collar
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Not assessed
Neurologic: Responds to: Unresponsive, Movement: No spontaneous
movement, Tone: Not assessed
Labs / Radiology
225 K/uL
12.4 g/dL
153 mg/dL
0."
6771,"4
C (97.6
Tcurrent: 35.5
C (95.9
HR: 59 (59 - 67) bpm
BP: 113/67(87) {93/59(74) - 114/67(87)} mmHg
RR: 21 (17 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 92 kg (admission): 92 kg
Total In:
4,552 mL
PO:
TF:
IVF:
552 mL
Blood products:
Total out:
0 mL
1,380 mL
Urine:
1,380 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,172 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 10 cmH2O
FiO2: 100%
PIP: 24 cmH2O
SpO2: 96%
ABG: 7."
6772,"However,
in discussion with the attending trauma surgeon, there is a concern for
the possibility of delayed bleeding around site of cord injury if the
pt becomes coagulopathic; therefore, will defer cooling for now,
pending MRI of spine. If MRI is negative for cord edema, this issue
could be revisited, although pt is now at least 5 hours out from
initial arrest.
2. Avoid elevated ICP:
- HOB > 30 degrees
- Maintain normocarbia goal pCO2 35-40
3. Monitor for seizure activity:
- Continuous EEG x 48 hrs
- If sz activity on EEG, treat with benzos/AEDs as
per Neurology recs
- Neurology ICU/Epilepsy consult for EEG
interpretation, prognosis
We will continue to follow with primary team, please call/page with
questions.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 963**], MD
EM/CCM Fellow
Pager [**Numeric Identifier 8744**]"
6773,"8 mg/dL
21 mEq/L
5.0 mEq/L
29 mg/dL
107 mEq/L
139 mEq/L
38.5 %
3.7 K/uL
[image002.jpg]
[**2147-12-18**] 12:14 PM
[**2147-12-18**] 02:17 PM
[**2147-12-18**] 02:34 PM
WBC
3.7
Hct
38.5
Plt
225
Cr
0.8
TCO2
22
24
Glucose
195
153
Other labs: PT / PTT / INR:14.7/23.8/1.3, ALT / AST:333/517, Alk Phos /
T Bili:199/0.3, Amylase / Lipase:56/41, Differential-Neuts:82.2 %,
Lymph:13.5 %, Mono:1.9 %, Eos:1."
6774,"In ED, he remains intubated, in NSR and on
norepi for blood pressure. Found to have Acute type 2 dens fracture.
Admitted to TICU for further management.
Chief complaint:
unresponsive
PMHx:
idiopathic generalized neuropathy, distant h/o seizure, BPH, leukopenia
(presumed [**3-13**] lamictal, no h/o serious infection), sleep apnea, spinal
stenosis, retinal detachment, [**Hospital Ward Name 5060**] cyst, rt 3rd fx
Current medications:
1. IV access: Temporary central access (ICU) Location: Left Subclavian,
Date inserted: [**2147-12-18**] Order date: [**12-18**] @ 1325
10. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**12-18**] @ 1132
2. IV access: Temporary central access (ICU) Location: Left Subclavian,
Date inserted: [**2147-12-18**] Order date: [**12-18**] @ 1557
11."
6775,"Order date: [**12-18**] @ 1557
9. Fentanyl Citrate 25-100 mcg IV Q1H:PRN discomfort Order date: [**12-18**]
@ [**2160**]
24 Hour Events:
Pan-scanned and found to have Acute type 2 dens fracture. Admitted to
TICU. Left subclavian CVL and right radial artery line placed. MRI
brain/c-spine c/w anoxic brain injury and C2 cord transection. Family
meeting - pt will be made [**Year (4 digits) 303**] this AM. DNR overnight. No acute issues
overnight.
Allergies:
Last dose of Antibiotics:
Infusions:
Norepinephrine - 0.06 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2147-12-18**] 08:20 PM
Fentanyl - [**2147-12-19**] 02:03 AM
Other medications:
Flowsheet Data as of [**2147-12-19**] 04:55 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**50**] a."
6776,"m.
Tmax: 36.7
C (98.1
T current: 36.3
C (97.4
HR: 54 (53 - 67) bpm
BP: 110/62(81) {93/57(71) - 155/96(117)} mmHg
RR: 22 (17 - 22) insp/min
SPO2: 98%
Heart rhythm: SB (Sinus Bradycardia)
Wgt (current): 92 kg (admission): 92 kg
Total In:
5,424 mL
539 mL
PO:
Tube feeding:
IV Fluid:
1,424 mL
539 mL
Blood products:
Total out:
1,995 mL
407 mL
Urine:
1,995 mL
157 mL
NG:
250 mL
Stool:
Drains:
Balance:
3,429 mL
132 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 10 cmH2O
FiO2: 60%
RSBI Deferred: PEEP > 10, FiO2 > 60%
PIP: 24 cmH2O
Plateau: 20 cmH2O
SPO2: 98%
ABG: 7."
6777,"3, Amylase / Lipase:56/41, Differential-Neuts:82.2 %,
Lymph:13.5 %, Mono:1.9 %, Eos:1.8 %, Fibrinogen:210 mg/dL, Lactic
Acid:1.2 mmol/L, Albumin:3.7 g/dL, Ca:7.9 mg/dL, Mg:2.0 mg/dL, PO4:5.0
mg/dL
Assessment and Plan
CERVICAL FRACTURE (WITH SPINAL CORD INJURY)
ASSESSMENT AND PLAN: 71y M s/p fall from bike with subsequent
unresponsiveness and cardiac arrest for approximately 10 minutes.
Found to have a Type II Dens fracture with C2 cord injury, and anoxic
brain injury.
NEURO: unresponsive, reactive pupils, no gag reflex, no oculocephalic
reflex."
6778,"4 K/uL
[image002.jpg]
[**2147-12-18**] 12:14 PM
[**2147-12-18**] 02:17 PM
[**2147-12-18**] 02:34 PM
[**2147-12-18**] 06:50 PM
[**2147-12-18**] 07:00 PM
[**2147-12-19**] 01:00 AM
[**2147-12-19**] 01:01 AM
[**2147-12-19**] 01:11 AM
WBC
3.7
7.4
Hct
38.5
37.3
Plt
225
208
Creatinine
0.8
0.7
TCO2
22
24
22
23
Glucose
195
153
127
153
159
Other labs: PT / PTT / INR:13.5/23.6/1.2, ALT / AST:280/333, Alk-Phos /
T bili:177/0."
6779,"37/38/162/21/-2
Ve: 10.4 L/min
PaO2 / FiO2: 270
Physical Examination
General Appearance: No acute distress
HEENT: pupils sluggish to react b/l
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present)
Neurologic: (Responds to: Unresponsive)
Labs / Radiology
208 K/uL
12.2 g/dL
159 mg/dL
0.7 mg/dL
21 mEq/L
4.3 mEq/L
27 mg/dL
108 mEq/L
139 mEq/L
37.3 %
7."
6780,"Anoxic brain injury and C2 cord injury. Neurology consulted
regarding questionable status epilepticus - given 1 time dose of
keppra. EEG monitoring cancelled as pts family wishes to make pt [**Name (NI) 303**] in
am.
Neuro checks Q:4h
Pain: fentanyl prn
CVS: currently on levophed gtt with goal to titrate SBP>90.
PULM: intubated, AC 500/22/5/100%. F/U repeat CXR to eval for pulm
hematoma s/p CVL placement.
GI: NPO, unable to place NGT, famotidine prophy
RENAL: foley. Monitor UOP. Cr 1.0
HEME: Hct 36.9 -> 38.5, cont to monitor
ENDO: RISS
ID: afebrile, no signs of infection
TLD: right radial artery line, left subclavian CVL, ETT, foley
IVF: NS@100cc/hr
CONSULTS: Red (west 3) surgery
BILLING DIAGNOSIS:
ICU CARE:
GLYCEMIC CONTROL: RISS
PROPHYLAXIS:
DVT - boots
STRESS ULCER - famotidine
VAP BUNDLE - yes
COMMUNICATIONS: wife
ICU Consent: Yes
CODE STATUS: Full Code
DISPOSITION: TICU
Total time spent: 32 minutes"
6781,"TITLE:
TSICU
HPI:
This is a 71 year old male who presents to ED in cardiac arrest s/p
fall from bicycle. Per witnesses report, the patient was riding his
bike with a helmet at a low speed and hit a pot hole; he did not lose
consciousness, but stood up and then suddenly collapsed. Per witnesses,
patient was initially unresponsive but with a pulse. Upon EMS arrival,
he arrested; CPR was started, and a pulse was regained. However the
patient went into cardiac arrest again. He was pulseless and
non-breathing for approximately 5-10 minutes. ACLS protocol was started
and a pulse was found."
6782,"Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**12-18**] @ 1455
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**12-18**] @
1132
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN. Order date: [**12-18**] @ 1325
8. Famotidine 20 mg IV Q12H Order date: [**12-18**] @ 1454
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN."
6783,"LeVETiracetam 1000 mg IV 1X Duration: 1 Doses Order date: [**12-18**] @
1609
3. OK to use line Order date: [**12-18**] @ 1557
12. Magnesium Sulfate IV Sliding Scale Order date: [**12-18**] @ 1455
4. 1000 mL NS
Continuous at 100 ml/hr Order date: [**12-18**] @ 1525
13. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO sbp > 90
Order date: [**12-18**] @ 1132
5. 500 ml NS Bolus 500 ml Over 15 mins Order date: [**12-18**] @ 1132
14. Potassium Chloride IV Sliding Scale Order date: [**12-18**] @ 1455
6. Calcium Gluconate IV Sliding Scale Order date: [**12-18**] @ 1455
15."
6784,"[**2147-12-18**] 11:05 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 27042**]
Reason: trauma?
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
60 year old man with asystole, s/p bike trauma
REASON FOR THIS EXAMINATION:
trauma?
______________________________________________________________________________
FINAL REPORT
INDICATION: 60-year-old male status post asystole and bike trauma.
No comparison studies available.
Supine AP view of the chest: There is a trauma board underneath the patient.
There is increased density along the right upper lobe, which may represent
pulmonary contusion or aspiration pneumonitis. The remaining lungs are clear.
Cardiomediastinal contours are otherwise within normal limits. There is no
pneumothorax or pleural effusion seen. The endotracheal tube tip is noted
within the proximal right bronchus.
IMPRESSION:
1. Right upper lobe opacity could be secondary to contusion or aspiration in
the setting of this patient's history of trauma and cardiac arrest.
2. The endotracheal tube is positioned within the right bronchus. Please
note, ETT repositioned on subsequent CT.
Please refer to CT torso performed subsequently for additional findings."
6785,"Order date: [**12-18**] @ 1325
Post operative day:
Allergies:
DI VALPROATE
Last dose of Antibiotics:
Infusions:
Norepinephrine - 0.1 mcg/Kg/min
Other ICU medications:
Past medical history:
Family / Social history:
idiopathic generalized neuropathy, distant h/o seizure, BPH, leukopenia
(presumed [**3-13**] lamictal, no h/o serious infection), sleep apnea, spinal
stenosis, retinal detachment, [**Hospital Ward Name 5060**] cyst, rt 3rd fx
Married to wife [**Name (NI) 2379**], works for [**Company 4535**]
Flowsheet Data as of [**2147-12-18**] 03:25 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.4
C (97.6
Tcurrent: 35."
6786,"Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO sbp > 90
Order date: [**12-18**] @ 1132
4. Calcium Gluconate IV Sliding Scale Order date: [**12-18**] @ 1455
10. Potassium Chloride IV Sliding Scale Order date: [**12-18**] @ 1455
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**12-18**] @
1132
11. Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**12-18**] @ 1455
6. Famotidine 20 mg IV Q12H Order date: [**12-18**] @ 1454
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN."
6787,"In ED, he remains intubated, in NSR and on norepi for blood
pressure. Found to have Acute type 2 dens fracture. Admitted to TICU
for further management.
Other medications:
1. IV access: Temporary central access (ICU) Location: Left Subclavian,
Date inserted: [**2147-12-18**] Order date: [**12-18**] @ 1325
7. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**12-18**] @ 1132
2. 1000 mL NS
Continuous at 100 ml/hr Order date: [**12-18**] @ 1525
8. Magnesium Sulfate IV Sliding Scale Order date: [**12-18**] @ 1455
3. 500 ml NS Bolus 500 ml Over 15 mins Order date: [**12-18**] @ 1132
9."
6788,"5
C (95.9
HR: 59 (59 - 67) bpm
BP: 113/67(87) {93/59(74) - 114/67(87)} mmHg
RR: 21 (17 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 92 kg (admission): 92 kg
Total In:
4,539 mL
PO:
TF:
IVF:
539 mL
Blood products:
Total out:
0 mL
1,380 mL
Urine:
1,380 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,159 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 10 cmH2O
FiO2: 100%
PIP: 24 cmH2O
SpO2: 96%
ABG: 7."
6789,"[**12-18**] CT Head - no acute intracranial pathology.
[**12-18**] - CT C-Spine - Acute type 2 dens fracture with neighboring soft
tissue swelling and no significant displacement.
Assessment and Plan
Assessment And Plan: 71y M s/p fall from bike with subsequent
unresponsiveness and cardiac arrest for approximately 10 minutes. Found
to have a Type II Dens fracture, and signs of anoxic brain injury.
Neurologic: unresponsive, unreactive pupils, no gag reflex, showing no
signs of brain activity. F/u MRI brain to eval for anoxic brain injury.
F/U MRI C-spine to assess for spinal cord involvement. Pt to remain in
C-collar
Cardiovascular: currently on levophed gtt with goal to titrate SBP>90."
6790,"29/48/81.[**Numeric Identifier **]//-3
Ve: 10.7 L/min
PaO2 / FiO2: 81
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: Pupils dilated, nonreactive pupils
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (No(t) PMI), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Musculoskeletal: No withdrawal of extremities to noxious stimuli
Skin: Warm
Neurologic: Responds to: Unresponsive, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
225 K/uL
12."
6791,"Bedside echo with no signs of wallmotion abnormality. F/[**Location 9212**]
echocardiogram.
Pulmonary: intubated, AC 500/22/5/100%. F/U repeat CXR to eval for pulm
hematoma s/p CVL placement.
Gastrointestinal: NPO, unable to place NGT, famotidine prophy
Renal: foley. Monitor UOP. Cr 1.0
Hematology: Hct 36.9, cont to monitor
Infectious Disease: afebrile. WBC wnl.
Endocrine: RISS
Fluids: NS@100cc/hr
Electrolytes: replace as needed
Nutrition: NPO
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2147-12-18**] 01:25 PM
Arterial Line - [**2147-12-18**] 02:50 PM
18 Gauge - [**2147-12-18**] 02:50 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care
Need for restraints reviewed
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: ICU
Total time spent:
Patient is critically ill"
6792,"TITLE:
Chief Complaint: Unresponsive
HPI:
This is a 71 year old male who presents to ED in cardiac arrest s/p
fall from bicycle. Per witnesses report, the patient was riding his
bike with a helmet at a low speed and hit a pot hole; he did not lose
consciousness, but stood up and then suddenly collapsed. Per witnesses,
patient was initially
unresponsive but with a pulse. Upon EMS arrival, he arrested; CPR was
started, and a pulse was regained. However the patient went into
cardiac arrest again. He was pulseless and non-breathing for
approximately 5-10 minutes. ACLS protocol was started and a pulse was
found."
6793,"4 g/dL
195 mg/dL
4.2 mEq/L
105 mEq/L
137 mEq/L
38.5 %
3.7 K/uL
[image002.jpg]
[**2147-12-18**] 12:14 PM
[**2147-12-18**] 02:17 PM
[**2147-12-18**] 02:34 PM
WBC
3.7
Hct
38.5
Plt
225
TCO2
22
24
Glucose
195
Other labs: Lactic Acid:4.5 mmol/L
Imaging: [**12-18**] CT Chest/Abd/Pelv - Small hematoma along the left renal
pelvis/UPJ without evidence of urinary tract disruption; Bilateral
posterior lung consolidations likely reflect the sequelae of
aspiration; Extensive atherosclerotic calcification along the coronary
arteries; Multiple left-sided rib fractures; Heterogeneous perfusion
along the dome of the liver likely reflects abnormal perfusion and may
be related to volume resuscitation and asystolic arrest."
6794,"8 mg/dL
21 mEq/L
5.0 mEq/L
29 mg/dL
107 mEq/L
139 mEq/L
38.5 %
3.7 K/uL
[image002.jpg]
[**2147-12-18**] 12:14 PM
[**2147-12-18**] 02:17 PM
[**2147-12-18**] 02:34 PM
WBC
3.7
Hct
38.5
Plt
225
Cr
0.8
TCO2
22
24
Glucose
195
153
Other labs: PT / PTT / INR:14.7/23.8/1.3, ALT / AST:333/517, Alk Phos /
T Bili:199/0.3, Amylase / Lipase:56/41, Differential-Neuts:82.2 %,
Lymph:13.5 %, Mono:1.9 %, Eos:1.8 %, Fibrinogen:210 mg/dL, Lactic
Acid:4.5 mmol/L, Albumin:3.7 g/dL, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL,
PO4:5.7 mg/dL
Assessment and Plan
71M s/p fall with subsequent cardiac arrest, ? cord injury [**3-13**] dens
fracture."
6795,"29/48/81.[**Numeric Identifier **]/21/-3
Ve: 10.7 L/min
PaO2 / FiO2: 81
Physical Examination
General Appearance: Intubated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube
Lymphatic: c-collar
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Not assessed
Neurologic: Responds to: Unresponsive, Movement: No spontaneous
movement, Tone: Not assessed
Labs / Radiology
225 K/uL
12.4 g/dL
153 mg/dL
0."
6796,"Consult requested by: ED Team / Trauma Team
Chief Complaint: s/p arrest
HPI:
71M
Allergies:
Last dose of Antibiotics:
Infusions:
Norepinephrine - 0.1 mcg/Kg/min
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social history:
Occupation:
Drugs:
Tobacco:
Alcohol:
Other:
Review of systems:
Flowsheet Data as of [**2147-12-18**] 03:59 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.4
C (97.6
Tcurrent: 35.5
C (95.9
HR: 59 (59 - 67) bpm
BP: 113/67(87) {93/59(74) - 114/67(87)} mmHg
RR: 21 (17 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 92 kg (admission): 92 kg
Total In:
4,552 mL
PO:
TF:
IVF:
552 mL
Blood products:
Total out:
0 mL
1,380 mL
Urine:
1,380 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,172 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 10 cmH2O
FiO2: 100%
PIP: 24 cmH2O
SpO2: 96%
ABG: 7."
6797,"Sinus bradycardia. Non-specific slight anterolateral ST segment elevation.
Clinical correlation is suggested. Compared to tracing #1 of earlier the same
day sinus bradycardia is new, ST segment elevation is new and the lateral
T wave flattening has resolved.
TRACING #2"
6798,"Admission Date: [**2147-12-18**] Discharge Date: [**2147-12-19**]
Date of Birth: [**2076-7-26**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
fall from bike
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
71M who was brought to the [**Hospital1 18**] ED after a fall from his bike.
Past Medical History:
seizure disorder, BPH, spinal stenosis, sleep apnea
Social History:
N/A
Family History:
N/A
Physical Exam:
No brainstem reflexes
Pertinent Results:
N/A
Brief Hospital Course:
Mr. [**Known lastname 58085**] was admitted after a fall from his bicycle."
6799,"He was
seen getting up from the accident and then collapsed shortly
thereafter. He then was noted to be in asystole when EMS
arrived. The total amount of time the patient was in asystole
is not known. Upon arrival to the ED he had regained a pulse.
A neuro exam was performed and he had no brainstem reflexes. An
MRI confirmed a C2 level spinal cord injury and changes
consistent with an anoxic brain injury. The NEOB was contact[**Name (NI) **]
but due to unknown circumstances surrounding his cardiac arrest
he did not meet donation criteria. The family elected to
withdraw care. He was extubated and expired shortly thereafter.
Medications on Admission:
N/A
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Odontoid fracture
spinal cord injury
respiratory failure
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A"
6800,"Order date: [**12-18**] @ 1325
Post operative day:
Allergies:
DI VALPROATE
Last dose of Antibiotics:
Infusions:
Norepinephrine - 0.1 mcg/Kg/min
Other ICU medications:
Past medical history:
Family / Social history:
idiopathic generalized neuropathy, distant h/o seizure, BPH, leukopenia
(presumed [**3-13**] lamictal, no h/o serious infection), sleep apnea, spinal
stenosis, retinal detachment, [**Hospital Ward Name 5060**] cyst, rt 3rd fx
Married to wife [**Name (NI) 2379**], works for [**Company 4535**]
Flowsheet Data as of [**2147-12-18**] 03:25 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.4
C (97.6
Tcurrent: 35."
6801,"Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO sbp > 90
Order date: [**12-18**] @ 1132
4. Calcium Gluconate IV Sliding Scale Order date: [**12-18**] @ 1455
10. Potassium Chloride IV Sliding Scale Order date: [**12-18**] @ 1455
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**12-18**] @
1132
11. Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**12-18**] @ 1455
6. Famotidine 20 mg IV Q12H Order date: [**12-18**] @ 1454
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN."
6802,"Bedside echo with no signs of wallmotion abnormality. F/[**Location 9212**]
echocardiogram.
Pulmonary: intubated, AC 500/22/5/100%. F/U repeat CXR to eval for pulm
hematoma s/p CVL placement.
Gastrointestinal: NPO, unable to place NGT, famotidine prophy
Renal: foley. Monitor UOP. Cr 1.0
Hematology: Hct 36.9, cont to monitor
Infectious Disease: afebrile. WBC wnl.
Endocrine: RISS
Fluids: NS@100cc/hr
Electrolytes: replace as needed
Nutrition: NPO
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2147-12-18**] 01:25 PM
Arterial Line - [**2147-12-18**] 02:50 PM
18 Gauge - [**2147-12-18**] 02:50 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care
Need for restraints reviewed
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: ICU
Total time spent:
Patient seen by Dr. [**Last Name (STitle) 293**] at 1pm:
Patient seen by Dr. [**Last Name (STitle) **] at 7pm, plus family discussion regarding
prognosis and withdrawal of care - 25 minutes.
Patient is critically ill"
6803,"29/48/81.[**Numeric Identifier **]//-3
Ve: 10.7 L/min
PaO2 / FiO2: 81
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: Pupils dilated, nonreactive pupils
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (No(t) PMI), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Musculoskeletal: No withdrawal of extremities to noxious stimuli
Skin: Warm
Neurologic: Responds to: Unresponsive, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
225 K/uL
12."
6804,"[**12-18**] CT Head - no acute intracranial pathology.
[**12-18**] - CT C-Spine - Acute type 2 dens fracture with neighboring soft
tissue swelling and no significant displacement.
Assessment and Plan
Assessment And Plan: 71y M s/p fall from bike with subsequent
unresponsiveness and cardiac arrest for approximately 10 minutes. Found
to have a Type II Dens fracture, and signs of anoxic brain injury.
Neurologic: unresponsive, unreactive pupils, no gag reflex, showing no
signs of brain activity. F/u MRI brain to eval for anoxic brain injury.
F/U MRI C-spine to assess for spinal cord involvement. Pt to remain in
C-collar
Cardiovascular: currently on levophed gtt with goal to titrate SBP>90."
6805,"In ED, he remains intubated, in NSR and on norepi for blood
pressure. Found to have Acute type 2 dens fracture. Admitted to TICU
for further management.
Other medications:
1. IV access: Temporary central access (ICU) Location: Left Subclavian,
Date inserted: [**2147-12-18**] Order date: [**12-18**] @ 1325
7. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**12-18**] @ 1132
2. 1000 mL NS
Continuous at 100 ml/hr Order date: [**12-18**] @ 1525
8. Magnesium Sulfate IV Sliding Scale Order date: [**12-18**] @ 1455
3. 500 ml NS Bolus 500 ml Over 15 mins Order date: [**12-18**] @ 1132
9."
6806,"4 g/dL
195 mg/dL
4.2 mEq/L
105 mEq/L
137 mEq/L
38.5 %
3.7 K/uL
[image002.jpg]
[**2147-12-18**] 12:14 PM
[**2147-12-18**] 02:17 PM
[**2147-12-18**] 02:34 PM
WBC
3.7
Hct
38.5
Plt
225
TCO2
22
24
Glucose
195
Other labs: Lactic Acid:4.5 mmol/L
Imaging: [**12-18**] CT Chest/Abd/Pelv - Small hematoma along the left renal
pelvis/UPJ without evidence of urinary tract disruption; Bilateral
posterior lung consolidations likely reflect the sequelae of
aspiration; Extensive atherosclerotic calcification along the coronary
arteries; Multiple left-sided rib fractures; Heterogeneous perfusion
along the dome of the liver likely reflects abnormal perfusion and may
be related to volume resuscitation and asystolic arrest."
6807,"5
C (95.9
HR: 59 (59 - 67) bpm
BP: 113/67(87) {93/59(74) - 114/67(87)} mmHg
RR: 21 (17 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 92 kg (admission): 92 kg
Total In:
4,539 mL
PO:
TF:
IVF:
539 mL
Blood products:
Total out:
0 mL
1,380 mL
Urine:
1,380 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,159 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 10 cmH2O
FiO2: 100%
PIP: 24 cmH2O
SpO2: 96%
ABG: 7."
6808,"TITLE:
Chief Complaint: Unresponsive
HPI:
This is a 71 year old male who presents to ED in cardiac arrest s/p
fall from bicycle. Per witnesses report, the patient was riding his
bike with a helmet at a low speed and hit a pot hole; he did not lose
consciousness, but stood up and then suddenly collapsed. Per witnesses,
patient was initially
unresponsive but with a pulse. Upon EMS arrival, he arrested; CPR was
started, and a pulse was regained. However the patient went into
cardiac arrest again. He was pulseless and non-breathing for
approximately 5-10 minutes. ACLS protocol was started and a pulse was
found."
6809,"In ED, he remains intubated, in NSR and on norepi for blood
pressure. Found to have Acute type 2 dens fracture. Admitted to TICU
for further management.
Other medications:
1. IV access: Temporary central access (ICU) Location: Left Subclavian,
Date inserted: [**2147-12-18**] Order date: [**12-18**] @ 1325
7. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**12-18**] @ 1132
2. 1000 mL NS
Continuous at 100 ml/hr Order date: [**12-18**] @ 1525
8. Magnesium Sulfate IV Sliding Scale Order date: [**12-18**] @ 1455
3. 500 ml NS Bolus 500 ml Over 15 mins Order date: [**12-18**] @ 1132
9."
6810,"Order date: [**12-18**] @ 1325
Post operative day:
Allergies:
DI VALPROATE
Last dose of Antibiotics:
Infusions:
Norepinephrine - 0.1 mcg/Kg/min
Other ICU medications:
Past medical history:
Family / Social history:
idiopathic generalized neuropathy, distant h/o seizure, BPH, leukopenia
(presumed [**3-13**] lamictal, no h/o serious infection), sleep apnea, spinal
stenosis, retinal detachment, [**Hospital Ward Name 5060**] cyst, rt 3rd fx
Married to wife [**Name (NI) 2379**], works for [**Company 4535**]
Flowsheet Data as of [**2147-12-18**] 03:25 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.4
C (97.6
Tcurrent: 35."
6811,"5
C (95.9
HR: 59 (59 - 67) bpm
BP: 113/67(87) {93/59(74) - 114/67(87)} mmHg
RR: 21 (17 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 92 kg (admission): 92 kg
Total In:
4,539 mL
PO:
TF:
IVF:
539 mL
Blood products:
Total out:
0 mL
1,380 mL
Urine:
1,380 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,159 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 10 cmH2O
FiO2: 100%
PIP: 24 cmH2O
SpO2: 96%
ABG: 7."
6812,"Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO sbp > 90
Order date: [**12-18**] @ 1132
4. Calcium Gluconate IV Sliding Scale Order date: [**12-18**] @ 1455
10. Potassium Chloride IV Sliding Scale Order date: [**12-18**] @ 1455
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**12-18**] @
1132
11. Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**12-18**] @ 1455
6. Famotidine 20 mg IV Q12H Order date: [**12-18**] @ 1454
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN."
6813,"Bedside echo with no signs of wallmotion abnormality. F/[**Location 9212**]
echocardiogram.
Pulmonary: intubated, AC 500/22/5/100%. F/U repeat CXR to eval for pulm
hematoma s/p CVL placement.
Gastrointestinal: NPO, unable to place NGT, famotidine prophy
Renal: foley. Monitor UOP. Cr 1.0
Hematology: Hct 36.9, cont to monitor
Infectious Disease: afebrile. WBC wnl.
Endocrine: RISS
Fluids: NS@100cc/hr
Electrolytes: replace as needed
Nutrition: NPO
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2147-12-18**] 01:25 PM
Arterial Line - [**2147-12-18**] 02:50 PM
18 Gauge - [**2147-12-18**] 02:50 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care
Need for restraints reviewed
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: ICU
Total time spent:
Patient seen by Dr. [**Last Name (STitle) 293**] at 1pm:
Patient seen by Dr. [**Last Name (STitle) **] at 7pm, plus family discussion regarding
prognosis and withdrawal of care - 35 minutes.
Patient is critically ill"
6814,"TITLE:
Chief Complaint: Unresponsive
HPI:
This is a 71 year old male who presents to ED in cardiac arrest s/p
fall from bicycle. Per witnesses report, the patient was riding his
bike with a helmet at a low speed and hit a pot hole; he did not lose
consciousness, but stood up and then suddenly collapsed. Per witnesses,
patient was initially
unresponsive but with a pulse. Upon EMS arrival, he arrested; CPR was
started, and a pulse was regained. However the patient went into
cardiac arrest again. He was pulseless and non-breathing for
approximately 5-10 minutes. ACLS protocol was started and a pulse was
found."
6815,"[**12-18**] CT Head - no acute intracranial pathology.
[**12-18**] - CT C-Spine - Acute type 2 dens fracture with neighboring soft
tissue swelling and no significant displacement.
Assessment and Plan
Assessment And Plan: 71y M s/p fall from bike with subsequent
unresponsiveness and cardiac arrest for approximately 10 minutes. Found
to have a Type II Dens fracture, and signs of anoxic brain injury.
Neurologic: unresponsive, unreactive pupils, no gag reflex, showing no
signs of brain activity. F/u MRI brain to eval for anoxic brain injury.
F/U MRI C-spine to assess for spinal cord involvement. Pt to remain in
C-collar
Cardiovascular: currently on levophed gtt with goal to titrate SBP>90."
6816,"4 g/dL
195 mg/dL
4.2 mEq/L
105 mEq/L
137 mEq/L
38.5 %
3.7 K/uL
[image002.jpg]
[**2147-12-18**] 12:14 PM
[**2147-12-18**] 02:17 PM
[**2147-12-18**] 02:34 PM
WBC
3.7
Hct
38.5
Plt
225
TCO2
22
24
Glucose
195
Other labs: Lactic Acid:4.5 mmol/L
Imaging: [**12-18**] CT Chest/Abd/Pelv - Small hematoma along the left renal
pelvis/UPJ without evidence of urinary tract disruption; Bilateral
posterior lung consolidations likely reflect the sequelae of
aspiration; Extensive atherosclerotic calcification along the coronary
arteries; Multiple left-sided rib fractures; Heterogeneous perfusion
along the dome of the liver likely reflects abnormal perfusion and may
be related to volume resuscitation and asystolic arrest."
6817,"29/48/81.[**Numeric Identifier **]//-3
Ve: 10.7 L/min
PaO2 / FiO2: 81
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: Pupils dilated, nonreactive pupils
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (No(t) PMI), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Musculoskeletal: No withdrawal of extremities to noxious stimuli
Skin: Warm
Neurologic: Responds to: Unresponsive, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
225 K/uL
12."
6818,"TITLE:
Chief Complaint: Unresponsive
HPI:
This is a 71 year old male who presents to ED in cardiac arrest s/p
fall from bicycle. Per witnesses report, the patient was riding his
bike with a helmet at a low speed and hit a pot hole; he did not lose
consciousness, but stood up and then suddenly collapsed. Per witnesses,
patient was initially
unresponsive but with a pulse. Upon EMS arrival, he arrested; CPR was
started, and a pulse was regained. However the patient went into
cardiac arrest again. He was pulseless and non-breathing for
approximately 5-10 minutes. ACLS protocol was started and a pulse was
found."
6819,"Order date: [**12-18**] @ 1325
Post operative day:
Allergies:
DI VALPROATE
Last dose of Antibiotics:
Infusions:
Norepinephrine - 0.1 mcg/Kg/min
Other ICU medications:
Past medical history:
Family / Social history:
idiopathic generalized neuropathy, distant h/o seizure, BPH, leukopenia
(presumed [**3-13**] lamictal, no h/o serious infection), sleep apnea, spinal
stenosis, retinal detachment, [**Hospital Ward Name 5060**] cyst, rt 3rd fx
Married to wife [**Name (NI) 2379**], works for [**Company 4535**]
Flowsheet Data as of [**2147-12-18**] 03:25 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.4
C (97.6
Tcurrent: 35."
6820,"Bedside echo with no signs of wallmotion abnormality. F/[**Location 9212**]
echocardiogram.
Pulmonary: intubated, AC 500/22/5/100%. F/U repeat CXR to eval for pulm
hematoma s/p CVL placement.
Gastrointestinal: NPO, unable to place NGT, famotidine prophy
Renal: foley. Monitor UOP. Cr 1.0
Hematology: Hct 36.9, cont to monitor
Infectious Disease: afebrile. WBC wnl.
Endocrine: RISS
Fluids: NS@100cc/hr
Electrolytes: replace as needed
Nutrition: NPO
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Multi Lumen - [**2147-12-18**] 01:25 PM
Arterial Line - [**2147-12-18**] 02:50 PM
18 Gauge - [**2147-12-18**] 02:50 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP: HOB elevation, Mouth care
Need for restraints reviewed
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status: Full code
Disposition: ICU
Total time spent:
Patient seen by Dr. [**Last Name (STitle) 293**] at 1pm:
Patient seen by Dr. [**Last Name (STitle) **] at 7pm, plus family discussion regarding
prognosis, DNR, and potential withdrawal of care - 35 minutes.
Patient is critically ill"
6821,"[**12-18**] CT Head - no acute intracranial pathology.
[**12-18**] - CT C-Spine - Acute type 2 dens fracture with neighboring soft
tissue swelling and no significant displacement.
Assessment and Plan
Assessment And Plan: 71y M s/p fall from bike with subsequent
unresponsiveness and cardiac arrest for approximately 10 minutes. Found
to have a Type II Dens fracture, and signs of anoxic brain injury.
Neurologic: unresponsive, unreactive pupils, no gag reflex, showing no
signs of brain activity. F/u MRI brain to eval for anoxic brain injury.
F/U MRI C-spine to assess for spinal cord involvement. Pt to remain in
C-collar
Cardiovascular: currently on levophed gtt with goal to titrate SBP>90."
6822,"5
C (95.9
HR: 59 (59 - 67) bpm
BP: 113/67(87) {93/59(74) - 114/67(87)} mmHg
RR: 21 (17 - 21) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 92 kg (admission): 92 kg
Total In:
4,539 mL
PO:
TF:
IVF:
539 mL
Blood products:
Total out:
0 mL
1,380 mL
Urine:
1,380 mL
NG:
Stool:
Drains:
Balance:
0 mL
3,159 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 10 cmH2O
FiO2: 100%
PIP: 24 cmH2O
SpO2: 96%
ABG: 7."
6823,"4 g/dL
195 mg/dL
4.2 mEq/L
105 mEq/L
137 mEq/L
38.5 %
3.7 K/uL
[image002.jpg]
[**2147-12-18**] 12:14 PM
[**2147-12-18**] 02:17 PM
[**2147-12-18**] 02:34 PM
WBC
3.7
Hct
38.5
Plt
225
TCO2
22
24
Glucose
195
Other labs: Lactic Acid:4.5 mmol/L
Imaging: [**12-18**] CT Chest/Abd/Pelv - Small hematoma along the left renal
pelvis/UPJ without evidence of urinary tract disruption; Bilateral
posterior lung consolidations likely reflect the sequelae of
aspiration; Extensive atherosclerotic calcification along the coronary
arteries; Multiple left-sided rib fractures; Heterogeneous perfusion
along the dome of the liver likely reflects abnormal perfusion and may
be related to volume resuscitation and asystolic arrest."
6824,"Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO sbp > 90
Order date: [**12-18**] @ 1132
4. Calcium Gluconate IV Sliding Scale Order date: [**12-18**] @ 1455
10. Potassium Chloride IV Sliding Scale Order date: [**12-18**] @ 1455
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation. Order date: [**12-18**] @
1132
11. Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**12-18**] @ 1455
6. Famotidine 20 mg IV Q12H Order date: [**12-18**] @ 1454
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and
PRN."
6825,"29/48/81.[**Numeric Identifier **]//-3
Ve: 10.7 L/min
PaO2 / FiO2: 81
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: Pupils dilated, nonreactive pupils
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (No(t) PMI), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Musculoskeletal: No withdrawal of extremities to noxious stimuli
Skin: Warm
Neurologic: Responds to: Unresponsive, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
225 K/uL
12."
6826,"In ED, he remains intubated, in NSR and on norepi for blood
pressure. Found to have Acute type 2 dens fracture. Admitted to TICU
for further management.
Other medications:
1. IV access: Temporary central access (ICU) Location: Left Subclavian,
Date inserted: [**2147-12-18**] Order date: [**12-18**] @ 1325
7. Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**12-18**] @ 1132
2. 1000 mL NS
Continuous at 100 ml/hr Order date: [**12-18**] @ 1525
8. Magnesium Sulfate IV Sliding Scale Order date: [**12-18**] @ 1455
3. 500 ml NS Bolus 500 ml Over 15 mins Order date: [**12-18**] @ 1132
9."
6827,"After intubation, OG
tube placement yielded 500mL of dark bloody fluid that clear
with 250mL of NS lavage. He had guaiac positive brown stool. He
received Protonix 80mg IV x1, 40mEq of potassium and had 2
peripheral IVs placed through which he received 1L NS. Transfer
VS: 52 180/82 14 100% on vent settings below.
.
On the floor, the patient arrives intubated and sedated,
responding only to sternal rub.
.
Review of systems: Unable to obtain
Past Medical History:
CHF
Atrial Fibrillation
COPD
Hypertension
Schizophrenia
DJD
Osteoporosis
Back pain
s/p Discectomy
BPH
Social History:
Lives in nursing home since [**2095**], unable to obtain further
history"
6828,"2. On discharge:
- WBC-10.0 RBC-3.88* Hgb-12.0* Hct-36.5* MCV-94 MCH-30.8
MCHC-32.8 RDW-15.0 Plt Ct-386
- Glucose-101* UreaN-15 Creat-0.8 Na-140 K-3.6 Cl-107 HCO3-24
AnGap-13
- Albumin-3.1* Calcium-8.3* Phos-3.2 Mg-2.0
- Digoxin-0.4*
Brief Hospital Course:
70 year man, resident at [**Doctor Last Name **] house, admitted for altered mental
status, found to have an upper GI bleed, RLL pneumonia now
resolved who has been hemodynamically stable andambulating.
.
1) Altered mental status: On admission, patient had altered
mental status."
6829,"There was concern for poor airway protection, so
he was intubated. EEG and CT head were obtained to rule out
intracranial bleed and seizure, which were negative. Metobolic
workup was all negative. Blood cultures were negative. He was
extubated and transferred to the floor.
.
2) Pneumonia: On arrival, patient was found to have clinical
signs of penumonia including fever, sputum production, and
cough. CXR showed RLL pneumonia, so patient was started
empirically on vancomycin + aztreonem + levofloxacin + flagyl
for ventilator-associated pneumonia. Sputum culture showed H.
influenza and beta Streptococci, thus he was narrowed to
levofloxain, and completed a 7day course prior to discharge."
6830,".
3) Aspiration: Initial video speech and swallow exam on the
floor showed aspiration of liquids. An dobhoff tube was placed
temporarily for feeding. Repeat video swallow showed no more
aspiration and patient was placed on thin liquid with crushed
solid diet.
.
3) Upper GI Bleed: On admission, NG lavage was positive for
blood. Aspirin was held and patient placed on [**Hospital1 **] PPI. On the
floor, patient remained HD stable. He refused an EGD and after
discussion with his legal guardian [**Name (NI) **] [**Name (NI) 108882**], the decision was
made to perform the EGD as an outpatient. Resuming aspirin
should be reconsidered as outpt after Hct has been stable for
several weeks."
6831,".
4) Skin blisters on left back: There was concern for shinles at
first, thus DFA, viral cultures, and HSZ/VZV serologies were
sent, which came negative. Would care was provided and the rash
improved without further treatment.
.
4) CHF/Afib/Hypertension: No evidence of heart failure. He was
kept on his home medications ACE-I, metoprolol, and digoxin upon
transfer to the floor.
.
5) Schizophrenia: Continue Zyprexa 7.5mg PO QHS
.
6) Depression/Anxiety: Continue Paroxetine
.
7) Osteoporosis: Continue alendronate upon arrival on the floor
Medications on Admission:
ASA 325mg PO Daily
Ibuprofen 600mg PO QAM
Metoprolol 50mg PO Daily
Digoxin 0."
6832,"Gabapentin 300 mg by mouth twice a day
4. Budesonide 1 puff by mouth daily
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2101-9-7**] at 2:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], 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
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2101-9-14**] at 8:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2101-8-24**]"
6833,"We
found out that you had an infection in your stomach by a
bacteria called Helicobacter pylori, which can lead to stomach
ulcers and cause bleeding. We started you on antibiotics to
treat that. We also asked the speech and swallow doctors to [**Name5 (PTitle) 788**]
[**Name5 (PTitle) **] who saw that you were aspirating food into your lungs. So we
put a small tube through your nose into your stomach and gave
you nutrition that way. After two days, you gained your strength
and the speech and swallow doctors decided that [**Name5 (PTitle) **] were no
longer aspirating food. You also worked with physical therapists
to gain your strength."
6834,"Normal swallowing
mechanics are demonstrated. For further details please refer to
full report on OMR by the speech pathology team.
Relevant laboratory results:
1. On admission:
- WBC-9.4 RBC-4.26* Hgb-13.6* Hct-40.0 MCV-94 MCH-31.9 MCHC-33.9
RDW-15.3 Plt Ct-237
- Glucose-140* UreaN-15 Creat-0.7 Na-146* K-3.2* Cl-108 HCO3-28
AnGap-13
- PT-13.4 PTT-26.5 INR(PT)-1.1
- 2 sets of cardiac enzymes were negative
- Albumin-3.8 Calcium-8.8 Phos-2.0* Mg-1.9 Cholest-131
- ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG"
6835,"Family History:
unable to obtain
Physical Exam:
ADMISSION PHYSICAL
Vitals: T: 96.2 BP: 183/74 P: 55 R: 500x14 50% FiO2 PEEP 6, Sat
100%
General: Intubated, sedated, responds to vigorous sternal rub
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils
constricted, minimally responsive but equal/bilateral
Neck: supple, JVP not elevated, no LAD
Lungs: Anterior/lateral clear to auscultation, no rhonchi or
crackles
CV: Slow, regular rate, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, obese, bowel sounds present
GU: foley in place
Rectal: No blood in rectal vault
Ext: RLE trace edema, 2+ pulses
DISCHARGE PHYSICAL
Vitals: T: 97."
6836,"Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebs Inhalation Q4H (every 4 hours) as
needed for sob/wheeze.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Olanzapine 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday)."
6837,"125mcg PO daily
Lisinopril 30mg PO daily
Albuterol INH PRN
Ipratropium/Albuterol Nebs PRN
Budesonide 1 Puff PO Daily
Zyprexa 7.5mg PO QHS
Gabapentin 300mg PO BID
Paroxetine 20mg PO daily
Tylenol 1g PO BID
Alendronate 70mg PO QSaturday
Oxybutynin 5mg PO daily (to end [**9-/2101**])
Vitamin D 400 IU PO BID
Calcium 500mg PO TID
Thiamine 100mg PO Daily
Folic 1mg PO Daily
Multivitamin 1 tab PO Daily
Colace 100mg PO QAM
Senna PRN
Milk of Mag PRN
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2."
6838,"He apparently then
did arouse with slurred speech, although this may have been due
to missing dentures. He was found to be confused, weak and
unable to stand, with a blood sugar of 100. The ambulance was
called and he developed worsening confusion/mental status while
en route to the ED and was on a face mask on arrival.
.
In the ED, initial vs were: Tmax 99.2 P 68 BP 210/99 R 21 O2 sat
99% NRB. Patient was altered but following commands during code
stroke (neuro consulted, tPA not given). He was intubated for
airway protection, propofol for sedation."
6839,"Admission Date: [**2101-8-14**] Discharge Date: [**2101-8-24**]
Date of Birth: [**2024-12-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. EU Critical [**Last Name (un) **], believed to be [**Known firstname **] [**Known lastname 7356**] born
[**2024-12-28**], but not yet identified, is a 70 year old gentleman
currently residing at [**Doctor Last Name **] House. He was last known to be well
at 6pm this evening. At 6:30 pm, the patient's roommate was
unable to arouse him from couch initially."
6840,"This tracing is etiologically non-specific but indicative of
diffuse
encephalopathy such as metabolic disturbance, infection, or
medication
effect. There are no focal abnormalities or epileptiform
features
noted. Compared to prior EEG recordings, this EEG is unchanged.
3. CXR: Right middle lobe collapse. Adjacent right lower lobe
opacity could also be due to atelectasis, but appearance and
clinical symptoms raise concern for pneumonia. The terminal tip
of the left PICC line is positioned at the cavoatrial junction.
4. Video swallow test ([**2101-8-19**]): Aspiration with all liquid
consistencies with oropharyngeal residue after swallow.
5. Video swallow test ([**2101-8-23**]): No aspiration or penetration is
seen with multiple consistencies of barium."
6841,"The neurologists also did an EEG exam to make sure you were not
having a seizure. You were not. Because your mental status was
altered, we were worried you would not be able to breath
properly on your own so we put a breathing tube down to help you
breath. We also realized that you had blood in your stomach, and
we were concerned you might be bleeding because of an ulcer. We
wanted to put a scope down your throat to examine your stomach
but you refused. We talked to your legal guardian who agreed
that the scoping can happen after you leave the hospital as long
as you were not actively bleeding."
6842,"At the time of discharge, you were able
to move around with your walker on your own.
We ADDED the following medications:
1. Clarithromycin 500 mg by mouth every 12 hours UNTIL [**2101-9-4**]
2. Metronidazole 500 mg by mouth, three times a day UNTIL
[**2101-9-4**]
3. Omeprazole 40 mg PO by mouth every 12 hours
We STOPPED the following medications:
1. Aspirin 325 mg by mouth per day --> given your recent GI
bleed, please discuss with your primary care doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 11370**]g.
2. Ibuprofen 600 mg by mouth in the morning
3."
6843,"You developed a rash on your
back which we at first thought might be due to shingles, but
after doing some tests decided it was not. We protected your
skin and performed regular wound care. After a few days we were
able to take the breathing tube out and you began to breath well
on your own with a little bit of supplemental oxygen. You were
transferred from the intensive care unit to the regular medical
floor. There, we found that you had a pneumonia, most likely
because you were aspirating fluids into your lung. We gave you
antibiotics to treat the pneumonia and you got much better."
6844,"1 BP: 112/64 P: 89 R: 18 Sat 100% RA
General: alert, awake, interactive
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, minimal bronchiole sounds in RLL
CV: Slow, regular rate, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: + bs, soft, non-tender, non-distended
Ext: wwp, 2+ DP
Neuro: Alert and oriented x 3, CN 2- 12 intact, able to ambulate
with walker
Pertinent Results:
Imaging/diagnostics:
1. CT head w/o contrast: No evidence of acute intracranial
abnormalities.
2. EEG: This is an abnormal VEEG telemetry due to the presence
of a
generalized slow background rhythm of [**3-10**] Hz, with frequent
periods of
[**5-12**] theta activity, indicative of severe diffuse cerebral
dysfunction."
6845,"13. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
14. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
15. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. Colace 100 mg Capsule Sig: One (1) Capsule PO qAM.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
20. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) 5 ml PO
once a day as needed for constipation."
6846,"9. Oxybutynin Chloride 5 mg Tablet Sig: Five (5) Tablet PO once
a day for 1 months: Please stop in 9/[**2101**].
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days: Please continue until [**2101-9-4**] for a
14-day course. .
11. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 14 days: Please continue until [**2101-9-4**] for
a 14-day course.
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day."
6847,"Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Acute mental status change
.
Secondary:
Upper GI bleed
Pneumonia
Schizophrenia
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:
Mr. [**Known lastname 7356**], you were admitted to the [**Hospital1 **]
Hospital because you were noted to have mental status changes,
slurring of speech, and difficulty walking. We were worried that
you were having a stroke so when you got the hospital, we got a
CT scan of your head which did no show any signs of bleeding."
6848,"Admission Date: [**2102-5-23**] Discharge Date: [**2102-5-26**]
Date of Birth: [**2047-1-28**] Sex: M
Service: MEDICINE
Allergies:
Bethanechol / Levofloxacin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Muscle spasms
Major Surgical or Invasive Procedure:
Placement of a PICC
History of Present Illness:
Patient is a 55 y.o. male s/p C6 injury ([**2069**]) c/b autonomic
dysreflexia, spasticity, neurogenic bladder with chronic foley
who presented from OSH with increased episodes of autonomic
dysreflexia that included muscle spasms, tachycardia,
hypertension/hypotension in setting of UTI. Patient was
initially admitted to unit for labile BP, including hypotension.
Patient reports recently being treated for UTI at an OSH with
levofloxacin and macrobid."
6849,"Past Medical History:
(1) Traumatic C6 quadroplegia from car accident in [**2069**]
(2) Neurogenic bladder, has had indwelling foley catheter for
last 10 years.
(3) Dysreflexia - autonomic and somatic
(4) Spasticity
(5) Multiple UTIs (including ESBL E. coli)
Social History:
Lives alone, not married, no children. Smoked, quit 6 mos ago,
2-3 beers/night. Denies illicits. Works at VA in [**Hospital1 1474**].
Family History:
Non-contributory.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema."
6850,"UreaN Creat Na K Cl HCO3 AnGap
7 0.6 139 4.0 102 28 13
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
6.8 4.38* 12.9* 37.5* 86 29.5 34.4 14.1 184
Brief Hospital Course:
55 y.o. male s/p C6 injury ([**2069**]) c/b autonomic dysreflexia,
spasticity, neurogenic bladder with chronic foley who presents
from OSH with increased spasms, tachycardia, hypertension with a
likely UTI found in our ED to be hypotensive.
# Urinary Tract Infection/Neurogenic bladder. Patient likely has
chronic urinary tract infection or incompletely eradicated
urinary tract infection."
6851,"# Depression/Anxiety. The patient was continued on home doses of
imipramine, and sertraline.
# Osteopenia. Likely due to non-weight bearing status, muscular
atrophy, and possible autonomic nervous system changes. The
patient was continued on his home calcium/vitamin D.
# GERD. Patient was continued on his home omeprazole.
# FEN: No IVF, replete electrolytes, heart healthy diet
# Prophylaxis: Subcutaneous heparin, bowel regimen
# Access: peripherals
# Communication: Patient
# Code: Full (discussed with patient)
Medications on Admission:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)."
6852,"unchanged exam
Pertinent Results:
Labs on admission:
[**2102-5-23**] 06:20PM URINE RBC-21-50* WBC-[**4-7**] BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2102-5-23**] 06:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2102-5-23**] 06:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.035
[**2102-5-23**] 06:20PM PLT COUNT-231
[**2102-5-23**] 06:20PM NEUTS-71.0* LYMPHS-22.8 MONOS-4.8 EOS-1.0
BASOS-0.4
[**2102-5-23**] 06:20PM WBC-10."
6853,"He does have a recent history of ESBL
E. Coli in the urine. He was initially started on Zosyn as prior
ESBL E. coli was listed as sensitive, but given this is also a
beta-lactam, he was converted to meropenem on the morning
following admission. Urine culture grew pan-sensitive
Pseudomonas. Meropenem was continued, as patient had recent
history of quinolone-resistent Enterococcus UTI and ESBL E. coli
in past few months. He was continued on home medications of
Detrol and imipramine. He was discharged on [**2102-5-26**] to rehab to
complete a 10 day course of meropenem, a PICC was placed prior
to discharge."
6854,"contractures of bilateral hands; external rotation of
bilateral feet.
Exam at discharge: afebrile, 120/80s, HR 90s, 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. contractures of bilateral hands; external rotation of
bilateral feet."
6855,"We
think that the UTI probably exacerbated your autonomic
dysreflexia. We treated your infection with an antibiotic called
meropenem and you got better. We made plans for you to continue
your treatment in a rehab center and to follow-up with a
urologist as an outpatient.
Please note that the following medications have changed:
-Meropenem
-No other changes were made to your medications.
Please see below for your follow up appointments.
Followup Instructions:
Please follow-up with the following:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2102-6-5**] at 1 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage"
6856,"He was discharged home with
macrobid. He endorses increasing episodes of autonomic
dysreflexia over the past few days despite being treated for
ESBL UTI. He presented to OSH yesterday with these symptoms,
and was transferred to [**Hospital1 18**] for further management. The
patient had endorsed chest pain that was not [**3-7**] ACS, and had
CTA chest that was negative for PE.
.
Approximately 8 months ago he began experiencing episodes of
autonomic dysreflexia. The muscle spasms associated with these
episodes are extensor only and begin in his legs and move
proximally to involve his hips, middle and upper back. Each
extensor spasm lasts only a few seconds, is recurrent every few
minutes, and is painful, culminating in discomfort in the left
chest region."
6857,"6# RBC-4.52* HGB-13.5* HCT-38.3*
MCV-85 MCH-29.8 MCHC-35.3* RDW-14.1
[**2102-5-23**] 06:20PM estGFR-Using this
[**2102-5-23**] 06:20PM GLUCOSE-98 UREA N-9 CREAT-0.7 SODIUM-137
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-25 ANION GAP-20
[**2102-5-23**] 06:25PM LACTATE-3.9*
IMAGES / STUDIES:
[**2102-5-23**] CXR: UPRIGHT AP VIEW OF THE CHEST: The left PICC has
been removed. The heart size remains top normal. The mediastinal
and hilar contours are unremarkable. The lungs are grossly
clear. No large pleural effusion or pneumothorax is seen."
6858,"Wipe off for BP <150.
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): please continue while at rehab.
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: for PICC
management.
20. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous every
six (6) hours for 10 days: course to complete on [**2102-6-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
Primary Diagnoses:
Pseudomonas UTI
Autonomic dysreflexia
Secondary Diagnoses:
Depression and anxiety
Osteopenia
GERD"
6859,"C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day)."
6860,"Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It has been a pleasure to be involved in your care Mr. [**Known lastname 86093**]
while you have been a patient at [**Hospital1 1170**]. You were transferred here from [**Hospital3 **] because
you were having muscle spasms, fast heart rate, and high blood
pressure consistent with previous episodes of autonomic
dysreflexia. In our emergency department you had low blood
pressure and were admitted first to the ICU and then to the
general medicine [**Hospital1 **]. You were found to have a urinary tract
infection with a bacteria called pseudomonas aeruginosa."
6861,"9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Nitroglycerin 2 % Ointment Sig: [**2-4**] inch Transdermal prn
dysreflexia as needed for SBP >190: Recheck 1 hour after placing
(or earlier if pt lightheaded). Wipe off for BP <150.
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for spacticity: hold for sedation, rr<12
15."
6862,"There
are no acute osseous abnormalities. Partially imaged is a
cerclage wire within the cervical spine. IMPRESSION: No acute
cardiopulmonary abnormality.
MICRO:
- [**2102-5-23**] Urine culture - P. aeruginosa see below
- [**2102-5-23**] Blood culture - NGTD
- [**2102-5-23**] MRSA screen - pending
**FINAL REPORT [**2102-5-25**]**
URINE CULTURE (Final [**2102-5-25**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
MRSA screen (-)
[**5-23**], [**5-25**], and [**5-26**] blood cultures pending"
6863,"12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
13. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for spasticity.
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain/headache.
15. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
17. Nitroglycerin 2 % Ointment Sig: One (1) [**2-4**] inch Transdermal
PRN as needed for SBP>190: Recheck 1 hour after placing
(or earlier if pt lightheaded)."
6864,"3. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
5. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constip.
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily)."
6865,"Associated with the spasms are: acute onset severe
headaches, blurred vision, mild sweating/hot feeling, and a
feeling of disorientation. Systolic blood pressure (taken at
work and at home) during these episodes is elevated to the
170-200 range. Sitting upright helps reduce the spasms and
symptoms of autonomic dysreflexia.
.
In the ED, initial vs were: 98.7 81 122/64 18 100, though he
also had an episode of hypotension in the 60s. Patient was given
vancomycin for concern for sepsis. Dropped pressures to the
60's. The patient received IVF and had a clonidine patch was
removed. Admitted to MICU for hypotension with ?"
6866,"Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for headache.
16. Clonazepam 1mg Tablet Sig 1.5 tablets PO every eight (8)
hours.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E."
6867,"The patient will see Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] Urology at [**Hospital1 18**]
on [**2102-6-5**] to establish care and for evaluation of his recurrent
UTIs and possible uro-dynamic studies, as he does not have
access to urologic care at home.
# Autonomic Dysreflexia/Spasticity - Symptoms were likely
exacerbated by urinary tract infections causing worsening of
spasticity. Previous exacerbations of autonomic dysreflexia have
improved with treatment of underlying UTI. BPs were monitored
closely and improved to baseline levels on teh morning following
admission. The patient was continued on home doses of
baclofen/diazepam/clonazepam. The patient required nitro paste
twice in the setting of elevated BP, with good effect."
6868,"sepsis.
.
In the MICU, patient continued to complain of spasms. He denied
any dysuria, fevers, or chills. Patient reports foley catheter
was last changed about a week ago. His UTI was positive for P.
Aeruginosa. His antibiotics were changed from zosyn to
meropenem. His foley catheter was changed.
.
On the medicine floor, the patient endorses spasms. He denies
chest pain/SOB. He also denies f/c. He has no abdominal pain.
He is concerned about his urologic care. He had been followed
by a urologist until recently. He had a scheduled urodynamic
eval that he was not able to keep [**3-7**] his recent
hospitalization."
6869,"Admission Date: [**2158-9-13**] Discharge Date: [**2158-9-15**]
Date of Birth: [**2106-7-25**] Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
52 year old male with h/o CAD, depression with [**Last Name (LF) **], [**First Name3 (LF) **] allergy,
admitted with substernal cp, MIBI showed mod PDA and mild LAD
reversible ischemia. Admitted to CCU for [**First Name3 (LF) **] desensitization
protocol.
.
Pt reports new onset of CP yesterday morning described as
substernal pressure that traveled up to his left shoulder."
6870,"Past Medical History:
Bipolar disorder
- self reported MI [**58**] years ago
- HTN
- Hypercholesterolemia (diet controlled)
- siezure disorder
- osteoarthritis
- Degenerative Disc Disease
MEDICATIONS:
- Norvasc 20 mg daily
- Flexeril 10 mg TID
- Motrin daily
- Trileptil dose uncertain.
Social History:
SOCIAL HISTORY Positive for tobacco, ethanol, and
intravenous drug use including heroine and cocaine.
.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
.
Physical Exam:
VS: T=96.6 BP=144/84 HR=71 RR=15 O2 sat= 98
GENERAL:. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa."
6871,"He was told to f/u with his
PCP after he leaves [**Hospital1 **].
Medications on Admission:
- Norvasc 10 mg daily
- Flexeril 10 mg [**Hospital1 **]
- Ibuprofen 800 mg TID
- Trileptil 150 mg [**Hospital1 **]
- cortisone cream
- trazadone 50 mg at hs
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Flexeril 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a
day) as needed for rash."
6872,"5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
7. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
10. aluminum-magnesium hydroxide 300-150 mg Tablet, Chewable
Sig: One (1) ML PO QID (4 times a day) as needed for
indigestion."
6873,"Pain
has been fairly constant, though now less than at onset.
Associated with nausea and diapheresis. Patient does not know if
it is worse with exhursion or not. EMS was called with a
negative EKG in the field and mild improvement with NTG x3.
Denies and dyspnea, fevers, chills. Has a history of cocaine
use, but denies recent use.
.
In the ED, initial vitals were 98.7; HR68; BP125/80; RR18;
100%RA
Labs and imaging significant for negative troponins, positive
utox for opiates. CXR unremarkable. Pt given 4mg IV morphine and
pain improved. Given plavix 600mg.
.
Of note the patient reports having a baby [**Name (NI) 17408**] at age 19 and
being rushed to the hospital with difficulty breathing,
wheezing, throat swelling and rash."
6874,"The lungs are clear. There is no pleural effusion or
pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
.
Stress MIBI [**9-13**]:
IMPRESSION:
1. Reversible, medium sized, mild perfusion defect involving the
PDA territory.
2. Reversible, small, mild perfusion defect involving the LAD
territory.
.
Cardiac cath [**9-14**] preliminary:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated no angiographically apparent flow-limiting disease.
The
LMCA, LAD, LCx and RCA all had no significant stenoses.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures.
FINAL DIAGNOSIS:
1. No angiographically apparent flow-limiting disease.
2. Normal systemic arterial pressures.
Brief Hospital Course:
52 year old male with history of CAD admitted with chest pain
found to have reversible defect on MIBI."
6875,"This went well
with no signs on an allergic response. You are now being
transferred back to [**Hospital3 8063**] for continued
psychiatric care.
No baths or pools for one week, no lifting more than 10 pounds
for one week.
.
We made the following changes to your medicines:
1. Continue Ibuprofen with mylanta and pantoprazole to porotect
your stomach
2. START taking aspirin daily, do not stop taking this medicine
or you may become allergic again.
3. Take tylenol 650 mg up to 4 times per day to treat your pain
Followup Instructions:
It is recommended you follow up with an Orthopedic doctor in the
next 2 weeks. Please call our department at [**Telephone/Fax (1) 1228**] to book
an appointment. If you have any questions or concerns please
also call the office.
.
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center: [**Telephone/Fax (1) 1652**]
Dr. [**Last Name (STitle) 724**]
[**10-20**] at 8:50am
[**Location (un) 8170**]
[**Location (un) **] [**Apartment Address(1) 9492**]
Please bring any medical information including films if possible
to this appt. You have been put on a cancellation list for an
earlier appt if possible.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]"
6876,"Has h/o [**Month/Year (2) **] allergy so
admitted to CCU for [**Month/Year (2) **] desensitization protocol.
.
# Chest pain: Unclear history of MI in past. P MIBI showed PDA
and mild LAD reversible ischemia. Had intermittant chest pain
treated with IV morphine. ECG's unchanged. Caridac
catheterization performed with no significant CAD found. Right
groin angioseal done. Pt states his chest pain is now gone and
he feels that it is from the ibuprofen. LIkely pt has some
gastritis from the ibuprofen although the severity and radiation
of the pain does not suggest mild gastritis. Pantoprazole and
oral antacids were started to be taken with the ibuprofen."
6877,"Pertinent Results:
[**2158-9-15**] 06:25AM BLOOD WBC-6.2 RBC-4.44* Hgb-13.6* Hct-37.2*
MCV-84 MCH-30.5 MCHC-36.4* RDW-12.4 Plt Ct-220
[**2158-9-12**] 11:02PM BLOOD WBC-5.5 RBC-4.26* Hgb-13.3* Hct-36.1*
MCV-85# MCH-31.2 MCHC-36.8* RDW-13.0 Plt Ct-221
[**2158-9-15**] 06:25AM BLOOD Glucose-120* UreaN-12 Creat-0.8 Na-139
K-3.8 Cl-100 HCO3-35* AnGap-8
[**2158-9-12**] 11:02PM BLOOD Glucose-127* UreaN-9 Creat-0."
6878,"No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4. PMI located in 5th intercostal space, midclavicular line.
LUNGS: CTAB, no crackles, wheezes or rhonchi. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
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+"
6879,"Aspirin desensitization was done without incident. Pt should
continue aspirin 81 mg which may allow more choice with NSAID
pain medications.
.
# Bipolar depression: Continued on medications prescribed at
[**Hospital1 **]. Pt admitted to [**Hospital1 **] on [**9-9**] for suicidal
ideation, was admitted to them under section 21. Had 1:1 sitter
during stay.
.
# HTN: well controlled on norvasc.
.
# Back pain: Exibited extreme drug seeking behavior during
hospitalization. After multiple conversations, pt agreed to
continue ibuprofen with pantoprazole and mylanta along with
tylenol. Appt made with pain clinic here in 1 month. Pt
demonstrated anger towards staff regarding lack of narcotics but
seems to have legitimate pain needs."
6880,"Has not taken aspirin since.
.
Of note, pt has had suicidal ideation, requiring a one to one
sitter.
.
On arrival to the floor, patient stable.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope."
6881,"9 Na-141
K-4.0 Cl-102 HCO3-31 AnGap-12
[**2158-9-14**] 01:37AM BLOOD CK(CPK)-45*
[**2158-9-14**] 01:37AM BLOOD CK-MB-2 cTropnT-<0.01
[**2158-9-13**] 05:12AM BLOOD cTropnT-<0.01
[**2158-9-12**] 11:02PM BLOOD cTropnT-<0.01
[**2158-9-14**] 01:37AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.1
[**2158-9-12**] 11:02PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
CXR [**9-13**]:
FINDINGS: The heart size is normal. The mediastinal and hilar
contours are
normal."
6882,"Discharge Disposition:
Extended Care
Discharge Diagnosis:
Chest pain
Bipolar Disorder
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had chest pain and a stress test showed that there may have
been a part of your heart that wasn't getting enough blood flow.
You did not have a heart attack. A cardiac catheterization was
performed that showed you did not have any significant blockages
in your arteries. We think the chest pain is from an old injury
and is not your heart. You underwent an aspirin desensitization
so that you could get aspirin for the procedure."
6883,"0
42.1
Plt
223
220
Cr
0.8
0.8
TropT
0.02
<0.01
TCO2
39
39
39
37
37
36
43
Glucose
147
141
Other labs: PT / PTT / INR:14.8/34.6/1.3, CK / CKMB /
Troponin-T:91//<0.01, ALT / AST:20/19, Alk Phos / T Bili:78/0.4,
Differential-Neuts:88.5 %, Lymph:8.2 %, Mono:2.8 %, Eos:0.2 %, Lactic
Acid:0.8 mmol/L, Albumin:3.5 g/dL, LDH:190 IU/L, Ca++:8.4 mg/dL,
Mg++:2.2 mg/dL, PO4:4.4 mg/dL
Assessment and Plan
RESPIRATORY FAILURE, CHRONIC
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2192-1-11**] 02:16 PM
20 Gauge - [**2192-1-11**] 02:20 PM
Arterial Line - [**2192-1-11**] 04:30 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status:
Disposition:"
6884,"1
C (98.8
Tcurrent: 36.6
C (97.9
HR: 93 (87 - 104) bpm
BP: 134/58(90) {111/45(73) - 148/66(97)} mmHg
RR: 14 (11 - 20) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Total In:
170 mL
32 mL
PO:
TF:
IVF:
170 mL
32 mL
Blood products:
Total out:
990 mL
290 mL
Urine:
990 mL
290 mL
NG:
Stool:
Drains:
Balance:
-820 mL
-258 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 96%
ABG: 7.26/91.[**Numeric Identifier 143**]/137/39/10
PaO2 / FiO2: 343
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
220 K/uL
14."
6885,"Chief Complaint:
24 Hour Events:
Transitioned from facemask to nasal canula.
Allergies:
[**Last Name (un) 4586**] Dayquil Cough (Oral) (Dextromethorphan Hbr)
pt. is allergic
Last dose of Antibiotics:
Levofloxacin - [**2192-1-11**] 04:30 PM
Ceftazidime - [**2192-1-12**] 09:00 AM
Infusions:
Other ICU medications:
Metoprolol - [**2192-1-12**] 08:18 AM
Heparin Sodium (Prophylaxis) - [**2192-1-12**] 08:19 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2192-1-13**] 06:27 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37."
6886,"1 g/dL
141 mg/dL
0.8 mg/dL
39 mEq/L
5.1 mEq/L
32 mg/dL
100 mEq/L
141 mEq/L
42.1 %
4.8 K/uL
[image002.jpg]
[**2192-1-11**] 04:52 PM
[**2192-1-11**] 08:44 PM
[**2192-1-11**] 08:54 PM
[**2192-1-12**] 01:57 AM
[**2192-1-12**] 02:35 AM
[**2192-1-12**] 08:17 AM
[**2192-1-12**] 12:35 PM
[**2192-1-12**] 06:07 PM
[**2192-1-13**] 02:24 AM
[**2192-1-13**] 02:57 AM
WBC
3.4
4.8
Hct
45."
6887,"Admission Date: [**2192-1-11**] Discharge Date: [**2192-1-17**]
Date of Birth: [**2116-11-1**] Sex: M
Service: MEDICINE
Allergies:
[**Last Name (un) 18774**] Dayquil Cough
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
History of present illness: Mr. [**Known lastname 13260**] is a 75 year old male
with COPD, h/o spontaneous pneumothorax, pleurodesis, and LUL
lobectomy, Prostate ca, PAF, who presented to [**Hospital3 13347**] with SOB. He was initially found to be 84% on RA. At
home, he is supposed to be on 2LNC as needed, though he reports
he wasn't using it recently."
6888,"30*
TOTAL CO2-39* BASE XS-7 INTUBATED-NOT INTUBA
Brief Hospital Course:
Mr. [**Known lastname 13260**] is a 75 year old male with severe COPD, prostate ca
s/p lupron and brachytherapy, PAF, urinary retention who
presents with respiratory distress, likely secondary to COPD
exacerbation.
# COPD - AE, Patient is known to have severe COPD. His blood
gasses showed significant hypercarbia and he was initially
wheezing on exam, making COPD exacerbation the most likely
diagnosis. Patient had significant improvement with nebs,
steroids, antibiotics, lasix. Got ceftaz/levaquin to cover
severe CAP, however ceftaz stopped given lack of cough, fever,
wbc or clinical suggestion of pneumonia."
6889,"He initially diuresed
1L with lasix, but appeared euvolemic so did not have
significant further lasix. Patient will be discharged on slow
Prednisone 40mg PO taper and placed on Spiriva/Combivent/Duoneb.
Patient was observed in the MICU on non-rebreather until
determined to be stable for the floor. Patient completed a seven
day course of Levoquin. Cultures were negative through the
course of the admission. At the time of discharge patient was
sating 94% on baseline oxygen of 2L and 87% 2L on ambulation.
# HTN. Patient has HTN. Home cardiac meds appear to be
diltiazem 240mg [**Hospital1 **] and no BB as well as cozar."
6890,"Disp:*30 Capsule,Degradable Cnt Release(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Chronic Obstructive Pulmonary Disease, Acute Exacerbation
Community Acquired Pneumonia
Secondary:
Paroxymal Atrial Fibrillation
Urinary Retention
Hypertension
Discharge Condition:
stable, on home O2 requirement
Discharge Instructions:
You presented to an outside hospital for shortness of breath and
were found to have low oxygen satuaration secondary to your
known COPD. You were diagnosed to be in acute exacerbation and
were given nebulizers, antibiotics, and IV steroids."
6891,"18* TOTAL
CO2-36* BASE XS-2 INTUBATED-NOT INTUBA
[**2192-1-11**] 04:42PM VoidSpec-[**First Name9 (NamePattern2) 21799**] [**Male First Name (un) **]
[**2192-1-11**] 04:52PM freeCa-1.17
[**2192-1-11**] 04:52PM LACTATE-1.0
[**2192-1-11**] 04:52PM TYPE-ART O2-50 PO2-82* PCO2-83* PH-7.26*
TOTAL CO2-39* BASE XS-7 INTUBATED-NOT INTUBA
[**2192-1-11**] 08:44PM CK-MB-NotDone cTropnT-0.02*
[**2192-1-11**] 08:44PM CK(CPK)-92
[**2192-1-11**] 08:54PM freeCa-1.14
[**2192-1-11**] 08:54PM LACTATE-1.0
[**2192-1-11**] 08:54PM TYPE-ART O2-50 PO2-66* PCO2-76* PH-7."
6892,"5 RBC-5.46 HGB-17.2 HCT-51.5 MCV-94#
MCH-31.5 MCHC-33.5 RDW-14.5
[**2192-1-11**] 12:45PM proBNP-507
[**2192-1-11**] 12:45PM estGFR-Using this
[**2192-1-11**] 12:45PM GLUCOSE-146* UREA N-25* CREAT-0.8 SODIUM-142
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-34* ANION GAP-11
[**2192-1-11**] 01:10PM LACTATE-1.0
[**2192-1-11**] 01:39PM TYPE-ART RATES-/17 O2-50 PO2-84* PCO2-88*
PH-7.20* TOTAL CO2-36* BASE XS-3 INTUBATED-NOT INTUBA
COMMENTS-VENTIMASK
[**2192-1-11**] 01:45PM TYPE-ART O2-50 PO2-89 PCO2-91* PH-7."
6893,"Meds doses
taken from PCP by phone (from memory) which agreed with
paperwork from [**Hospital3 5365**]. Patient's pressures were too low
and the regimen was changed to Diltiazem ER 240 daily.
# PAF/MAT?. In house patient had one episode of irregular
heart rate on telemetry. It remains unclear if this was PAF vs
MAT. Given the setting of severe COPD exacerbation it is more
likely to be MAT. Rhythm rapidly converted spontaneously and
he remained in NSR over the next 48 hours. The patient does
have a history of PAF (athough details unknown). Given this
history and unclear event in hospital, the patient was started
on Aspirin 325mg PO daily and instructed to further discuss with
his PCP with regards to coumadin anticoagulation for stroke
prevention."
6894,"He was given 125 mg IV of
methylprednisolone, albuterol neb, and moxifloxacin at OSH. He
was then transferred to [**Hospital1 **] per family request. Over the last
two weeks, he reports increasing SOB. He denies fevers, chills,
productive cough. Per patient's wife, he always has some
non-productive coughing. He has has intermittent chest pain
versus SOB for 2 years. He is unable to characterize the pain.
He denies associated nausea, vomiting, diaphoresis. CP is not
exertional.
In the ED, vitals were T 97.9, HR 108, BP 216/81, RR 16, 87% on
3LNC. He was given a 50% ventimask, albuterol neb, and
ceftriaxone."
6895,"Disp:*93 Tablet(s)* Refills:*0*
3. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation twice a day.
4. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day as needed.
5. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1)
Inhalation four times a day.
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO once a day
for 28 days.
Disp:*19 Tablet(s)* Refills:*0*
7. DILT-XR 240 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO qam."
6896,"Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Wheezes : diffuse wheezes,
Diminished: b/l), poor air entry
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Follows simple commands, Responds to: Not assessed,
Oriented (to): x3, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2192-1-11**] 12:45PM PLT COUNT-246
[**2192-1-11**] 12:45PM NEUTS-91.7* LYMPHS-6.5* MONOS-0.9* EOS-0.4
BASOS-0.4
[**2192-1-11**] 12:45PM WBC-6."
6897,"You
completed a seven day course of antibiotics. Steriods were
switched to PO and you are being discharged on a slow taper. You
are to resume your home Spiriva/Combivent/Duoneb. You have
returned to your baseline oxygen requirement.
Please take all medications as prescribed. Please go to all
scheduled follow up appointments. You are being discharged on a
prednisone taper. Your blood pressure medications were reduced
and changed as your blood pressure was too low. You are to
resume your home oxygen of 2L and wear it continuously.
Please contact your physician if you have resumed shortness of
breath, change in cough, chest pain, or decreased exercise
tolerance.
Followup Instructions:
Please schedule an appointment with your primary care physician
in two weeks. Please discuss with your primary with regards to
seeing a pulmonogist for further management of your COPD. You
should discuss with your primary with regards to starting
anticoagulation for your Paroxymal Atrial Fibrillation.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 10348**] [**Telephone/Fax (1) 10349**]
Completed by:[**2192-1-17**]"
6898,"#. Urinary retention. Has history of prostate cancer s/p
brachytherapy with history of subsequent urinary retention.
Patient was started on flomax, and to continue at home
Medications on Admission:
Flomax 0.4 mg qhs
Carvedilol 6.25mg [**Hospital1 **]
Diltiazem XT 240mg [**Hospital1 **]
Duo nebs (last [**Month (only) 462**])
Spiriva (has not filled since [**Month (only) 462**])
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
2. Prednisone 10 mg Tablet Sig: Taper PO once a day for 28 days:
Please take 6 tablets per day for the next 3 days, the 5 tablets
per day for the following 5 days, then 4 tablets per day for the
following 5 days, then 3 tablets per day for the following 5
days, 2 tablets per day for 5 days, and finally 1 tablet per day
for a final 5 days."
6899,".
Upon arrival to the MICU, patient is tachypneic with increased
work of breathing. He denies chest pain at present. Review of
systems is otherwise negative.
Past Medical History:
Prostate Cancer
Empysema
Nephrolitiasis
Dysrhythmia
s/p LUL lobectomy for ruptured emphysematous bleb in [**2179**] (in
[**Country 2560**])
s/p spontaneous pneumothorax x2
s/p Rt pleurodesis and wedge resection in [**2183**]
Social History:
History of heavy tobacco use, quit over 1 year ago. Denies
recreational drug use or alcohol use.
Family History:
NC
Physical Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL, anicteric sclear
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)"
6900,"There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
Compared with the findings of the prior report (images unavailable for
review) of [**2184-11-15**], the right ventricle is now dilated and
hypocontractile. At least moderate pulmonary hypertension is now
present.
.
IMPRESSION: early cor pulmonale
Microbiology: Micro:
[**2192-1-11**] - Blood cultures x 2 - NGTD
ECG: EKG. sinus tachycardia at 108 bpm. RAD. Normal qrs, pr, qtc
intervals. TWI in V1. No ST changes. Q wave in II, III, avf."
6901,"02, Lactic Acid:1.0 mmol/L
Fluid analysis / Other labs:
142 | 101 | 25 /
--------------- 146
4.4 | 34 | 0.8 \
(Baseline Cr 0.7 - 1.0)
.
.. \ 17.2 /
6.5 ------ 246
.. / 51.5 \
(Baseline Hct 40-45)
.
Diff: 91.7%N, 6.5%L, 0.9%M, 0.4%E, 0.4%B
.
ABG: 7.20/88/84, bicarb 36
ABG: 7.18/91/89, bicarb 36
.
Lactate 1.0
Imaging: CXR.
Diffuse increased reticular infiltrates consistent with pneumonia.
Follow-up to resolution.
.
Echo [**2191-10-10**].
The left atrium is normal in size. No atrial septal defect is seen by
2D or color Doppler."
6902,"Unchanged from prior EKG dated [**2190-11-18**].
Assessment and Plan
Mr. [**Known lastname 4584**] is a 75 year old male with severe COPD, prostate ca s/p
lupron and brachytherapy, PAF, urinary retention who presents today
with respiratory distress, likely secondary to COPD exacerbation +/-
CHF and pneumonia.
.
1. Respiratory failure. Patient is known to have COPD, s/p
pneumothorax x 2 treated with pleuradesis. No prior PFTs in our
records. His blood gasses show significant hypercarbia and there is
wheezing on exam, making COPD exacerbation the most likely diagnosis.
However, will cover for pneumonia with ceftaz/levaquin given patients
cough and CXR."
6903,"jpg]
[**2189-1-19**]
2:33 A12/24/[**2191**] 01:39 PM
[**2189-1-23**]
10:20 P12/24/[**2191**] 01:45 PM
[**2189-1-24**]
1:20 P12/24/[**2191**] 04:52 PM
[**2189-1-25**]
11:50 P12/24/[**2191**] 08:44 PM
[**2189-1-26**]
1:20 A12/24/[**2191**] 08:54 PM
[**2189-1-27**]
7:20 P
1//11/006
1:23 P
[**2189-2-19**]
1:20 P
[**2189-2-19**]
11:20 P
[**2189-2-19**]
4:20 P
TropT
0.02
TC02
36
36
39
39
Other labs: CK / CKMB / Troponin-T:92//0."
6904,"Chief Complaint: shortness of breath
HPI:
Mr. [**Known lastname 4584**] is a 75 year old male with COPD, h/o spontaneous
pneumothorax, pleurodesis, and LUL lobectomy, Prostate ca, PAF, who
presented to [**Hospital6 4585**] with SOB. He was initially found to
be 84% on RA. At home, he is supposed to be on 2LNC as needed, though
he reports he wasn't using it recently. He was given 125 mg IV of
methylprednisolone, albuterol neb, and moxifloxacin at OSH. He was
then transferred to [**Hospital1 **] per family request. Over the last two weeks,
he reports increasing SOB. He denies fevers, chills, productive
cough."
6905,"is allergic
Last dose of Antibiotics:
Levofloxacin - [**2192-1-11**] 04:30 PM
Ceftazidime - [**2192-1-11**] 10:10 PM
Infusions:
Other ICU medications:
Metoprolol - [**2192-1-12**] 12:09 AM
Heparin Sodium (Prophylaxis) - [**2192-1-12**] 12:10 AM
Other medications:
Medications: Patient does not know, unable to contact pharmacy. The
following meds are from the medical record.
Flomax 0.4 mg qhs
Carvedilol
Diltiazem
Losartan
.
Past medical history:
Family history:
Social History:
Prostate cancer, s/p brachytherapy [**2190-11-25**] and two lupron injections
COPD
HTN
PAF
h/o nephrolithiasis
S/p LUL lobectomy for ruptured bleb in [**2179**]
s/p spontaneous pneumothorax x 2
s/p right pleurodesis and wedge resection in [**2183**]
urinary retenion
Noncontributory
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Patient is a former smoker, quit 2 years ago."
6906,"However, patient unclear as to what medications he
currently takes and his pharmacy (CVS in [**Location (un) 1714**] (zip code [**Numeric Identifier 4587**]) is
currently closed.
- metoprolol IV 5 q 4 hours and titrate as needed for HR and BP
control; will transition to orals when diet is advanced
.
3. PAF. Patient has a history of PAF. Currently in NSR. Not
currently antocoagulated.
- continue BB
- continue monitor on tele
- aspirin
.
4. Urinary retention. Has history of prostate cancer s/p brachytherapy
with history of subsequent urinary retention.
- continue flomax
.
Prophylaxis: HSQ
FEN: NPO for now pending improvement of respiratory status
CODE: Full code
Communication: wife (understands some english) and daughter (english
speaking)
.
ICU Care
Nutrition:
Comments: NPO
Glycemic Control:
Lines:
18 Gauge - [**2192-1-11**] 02:16 PM
20 Gauge - [**2192-1-11**] 02:20 PM
Arterial Line - [**2192-1-11**] 04:30 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer:
VAP: HOB elevation
Comments:
Communication: Family meeting held , ICU consent signed Comments:
Code status: Full code
Disposition: ICU"
6907,"Per patient's wife, he always has some non-productive
coughing. He has has intermittent chest pain versus SOB for 2 years.
He is unable to characterize the pain. He denies associated nausea,
vomiting, diaphoresis. CP is not exertional.
In the ED, vitals were T 97.9, HR 108, BP 216/81, RR 16, 87% on 3LNC.
He was given a 50% ventimask, albuterol neb, and ceftriaxone.
.
Upon arrival to the MICU, patient is tachypneic with increased work of
breathing. He denies chest pain at present. Review of systems is
otherwise negative.
Patient admitted from: Transfer from other hospital
History obtained from Patient, Family / Friend, [**Hospital 1330**] Medical
records
Patient unable to provide history: Language barrier
Allergies:
[**Last Name (un) 4586**] Dayquil Cough (Oral) (Dextromethorphan Hbr)
pt."
6908,"30/76.[**Numeric Identifier 126**]/66//7
Ve: 2.8 L/min
PaO2 / FiO2: 165
Physical Examination
General Appearance: Thin
Eyes / Conjunctiva: PERRL, anicteric sclear
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: Wheezes : diffuse wheezes,
Diminished: b/l), poor air entry
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Follows simple commands, Responds to: Not assessed,
Oriented (to): x3, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
[image002."
6909,"Will diurese gently in case there is an element of CHF
though this seems less likely given normal BNP. Prior echo shows
pulmonary hypertension with RV hypertrophy and dilitation.
- albuterol, atrovent nebs
- solumedrol 125 IV q 8 hours
- levaquin/ceftaz
- BIPAP as needed for pH < 7.20 or pCO2> 90 or respiratory distress
- titrate supplemental oxygen to keep sats 88-92%
- lasix IV 20 x 1 with goal negative 500 - 1 L negative tonight
- repeat CXR in AM post diuresis
- ROMI
- f/u blood and sputum cultures
- follow fever curve and WBC
.
2. HTN. Patient has HTN. Was previously on metoprolol and diltiazem
at unclear doses."
6910,"Denies alcohol or
drug use.
Review of systems:
Flowsheet Data as of [**2192-1-12**] 02:25 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.2
Tcurrent: 36.7
C (98
HR: 82 (82 - 114) bpm
BP: 160/75(106) {124/54(79) - 160/89(117)} mmHg
RR: 22 (10 - 22) insp/min
SpO2: 89%
Heart rhythm: SR (Sinus Rhythm)
Total In:
238 mL
11 mL
PO:
TF:
IVF:
238 mL
11 mL
Blood products:
Total out:
1,270 mL
40 mL
Urine:
1,270 mL
40 mL
NG:
Stool:
Drains:
Balance:
-1,033 mL
-30 mL
Respiratory
O2 Delivery Device: Venti mask
Ventilator mode: Standby
Vt (Spontaneous): 618 (618 - 848) mL
PS : 12 cmH2O
RR (Spontaneous): 0
PEEP: 6 cmH2O
FiO2: 40%
PIP: 0 cmH2O
SpO2: 89%
ABG: 7."
6911,"CCA peak systolic
velocity is 56 cm/sec. ECA peak systolic velocity is 66 cm/sec. The ICA/CCA
ratio is 1.23. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 46/10, 59/22, 88/29 cm/sec. CCA peak systolic velocity
is 63 cm/sec. ECA peak systolic velocity is 69 cm/sec. The ICA/CCA ratio is
1.4. These findings are consistent with <40% stenosis.
Right vertebral antegrade artery flow.
Left vertebral antegrade artery flow.
Impression: Right ICA stenosis <40%.
Left ICA stenosis <40%."
6912,"[**2199-12-24**] 9:08 AM
CAROTID SERIES COMPLETE Clip # [**Clip Number (Radiology) 81545**]
Reason: CAD, ?STENOSIS
Admitting Diagnosis: CORONARY ARTERY DISEASE;CHRONIC OBSTRUCTIVE PULMONARY DISEASE;DIABETES
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
70 year old woman with cad
REASON FOR THIS EXAMINATION:
? stenosis
______________________________________________________________________________
FINAL REPORT
Standard Report Carotid US
Study: Carotid Series Complete
Reason: CAD, r/o stenosis
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is moderate heterogeneous plaque in the ICA and CCA. On the
left there is mild heterogeneous plaque seen in the ICA and CCA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 54/18, 56/25, 69/29 cm/sec."
6913,"CVICU
HPI:
HD6
Ejection Fraction:50%
Hemoglobin A1c:9.9
Pre-Op Weight:299 lbs 135.63 kgs
Baseline Creatinine:1.1-1.4
PMH: morbid obesity,IDDM,COPD(noc 3Lnc),s/p LT THR, s/p hysterectomy,
hypercholesterolemia,HTN
[**Last Name (un) **]:Verapamil 360mg daily,HCTZ 25mg daily,ASA 81mg daily,Lipitor 80mg
daily,Amitryptilline 50mg daily, Mirtazapine 15mg daily, Lantus 14u
HS,Humalog 4u at dinner,Ipratropium 0.5ml neb QID,Lisinopril 40mg
daily,Ranitidine 150mg [**Hospital1 **]
Current medications:
Acetaminophen Albuterol-Ipratropium Albuterol Atorvastatin Docusate
Sodium Insulin Ipratropium Bromide Neb
Magnesium Sulfate Metoprolol Tartrate Metoclopramide Milk of Magnesia
Morphine Sulfate Potassium Chloride Ranitidine TraMADOL (Ultram)
Vancomycin
24 Hour Events:
[**2199-12-27**] seen by EP for O/N pauses/junctional, no PPM planned
Allergies:
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
Nausea/Vomiting
Codeine
Nausea/Vomiting
Aspirin
Nausea/Vomiting
Last dose of Antibiotics:
Vancomycin - [**2199-12-28**] 08:30 AM
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2199-12-28**] 01:25 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**01**] a."
6914,"3
26.9
Plt
147
136
Creatinine
1.1
1.2
TCO2
26
24
26
Glucose
151
94
130
150
140
138
124
Other labs: PT / PTT / INR:13.2/26.0/1.1, Fibrinogen:231 mg/dL, Lactic
Acid:2.8 mmol/L
Assessment and Plan
71 F s/p CABG x 3 (LIMA to LAD, SVG to OM, SVG to PDA)[**12-26**]
Neurologic: Ultram for pain.
Cardiovascular: Aspirin, Statins, EP consulted for complete heart
block/pauses. OK to start low dose lopressor today per EP. Keep V
demand at 50. Keep PW in for the weekend per EP
Pulmonary: Discontinue chest tube(s), Pull drainage if drainage low.
IS/OOB
Nutrition: Regular diet
Renal: Foley, Good UOP with lasix to run neg. Crea improving
Hematology: Hct stable. ASA, teds, venodynes
Endocrine: RISS
Infectious Disease: afebrile, periop abx complete
Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Fluids: KVO
Consults: P.T.
ICU Care
Glycemic Control: Regular insulin sliding scale
Lines:
[**First Name4 (NamePattern1) 549**] [**Last Name (NamePattern1) **] - [**2199-12-26**] 02:05 PM
Prophylaxis:
DVT: Boots, teds
Stress ulcer: H2 blocker
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU"
6915,"8 g/dL
124
1.2 mg/dL
28 mEq/L
5.0 mEq/L
14 mg/dL
105 mEq/L
137 mEq/L
26.9 %
13.2 K/uL
[image002.jpg]
[**2199-12-26**] 09:52 PM
[**2199-12-26**] 10:22 PM
[**2199-12-27**] 01:54 AM
[**2199-12-27**] 02:03 AM
[**2199-12-27**] 06:15 AM
[**2199-12-27**] 08:00 AM
[**2199-12-28**] 01:08 AM
[**2199-12-28**] 03:00 AM
[**2199-12-28**] 05:00 AM
[**2199-12-28**] 07:00 AM
WBC
9.5
13.2
Hct
29.4
27."
6916,"m.
Tmax: 37.2
C (99
T current: 37.2
C (99
HR: 106 (81 - 110) bpm
BP: 118/58(72) {90/43(54) - 123/74(81)} mmHg
RR: 19 (11 - 22) insp/min
SPO2: 99%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 136 kg (admission): 133.7 kg
Height: 66 Inch
Total In:
628 mL
393 mL
PO:
60 mL
Tube feeding:
IV Fluid:
628 mL
333 mL
Blood products:
Total out:
2,625 mL
1,705 mL
Urine:
2,165 mL
1,485 mL
NG:
Stool:
Drains:
Balance:
-1,997 mL
-1,312 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 99%
ABG: ///28/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), Sinus tach
Respiratory / Chest: (Breath Sounds: Diminished: at bases)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,
Hypoactive BS
Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3)
Labs / Radiology
136 K/uL
8."
6917,"CVICU
HPI:
h/o CAD s/p CABGx3
Chief complaint:
PMHx:
CAD, morbid obesity,IDDM,COPD(noc 3Lnc),s/p LT THR, s/p hysterectomy,
hypercholesterolemia,HTN
Current medications:
Acetaminophen 6. Aspirin EC 11. Docusate Sodium 15. Insulin 16.
Magnesium Sulfate 17. Metoclopramide 19. Morphine Sulfate 22.
Phenylephrine 25. Propofol 26. Ranitidine 29. Vasopressin 30.
Vancomycin
24 Hour Events:
OR RECEIVED - At [**2199-12-26**] 01:00 PM
INVASIVE VENTILATION - START [**2199-12-26**] 01:00 PM
NASAL SWAB - At [**2199-12-26**] 01:51 PM
ARTERIAL LINE - START [**2199-12-26**] 02:04 PM
CCO PAC - START [**2199-12-26**] 02:04 PM
[**Location (un) 549**] LINE - START [**2199-12-26**] 02:05 PM
EKG - At [**2199-12-26**] 03:06 PM
Allergies:
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
Nausea/Vomiting
Codeine
Nausea/Vomiting
Aspirin
Nausea/Vomiting
Last dose of Antibiotics:
Vancomycin - [**2199-12-26**] 08:52 PM
Infusions:
Phenylephrine - 0."
6918,"9 cmH2O/mL
SPO2: 100%
ABG: 7.31/49/122/24/-2
Ve: 8.6 L/min
PaO2 / FiO2: 305
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft, Non-distended, Non-tender
Left Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)
Right Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: Follows simple commands, Moves all extremities, Sedated,
minimal sedation
Labs / Radiology
147 K/uL
9.2 g/dL
130 mg/dL
1.1 mg/dL
24 mEq/L
4.9 mEq/L
15 mg/dL
110 mEq/L
137 mEq/L
27."
6919,"2/26.0/1.1, Fibrinogen:231 mg/dL, Lactic
Acid:2.8 mmol/L
Assessment and Plan
CORONARY ARTERY BYPASS GRAFT (CABG)
Assessment and Plan: 71 F POD#1 s/p CABG x 3 (LIMA to LAD, SVG to OM,
SVG to PDA)
Neurologic: Pain controlled, minimal sedation on propofol, wean for
extubation
Cardiovascular: Aspirin, No longer requiring pressors. A-V pacer
dependent at this point. Restart Ca-channel blocker, ACE-I, and statin
as BP tolerates.
Pulmonary: Extubate today, (Ventilator mode: CPAP + PS), Requiring
minimal ventilatory support.
Gastrointestinal / Abdomen: Bowel regimen. Start stress ulcer
prophylaxis
Nutrition: NPO, Advance diet after extubation
Renal: Foley, Adequate UO
Hematology: Stable anemia
Endocrine: RISS, Restart home insulin therapy once diet started
Infectious Disease: Peri-op ABx without evidence of infection
Lines / Tubes / Drains: Foley, OGT, ETT, Chest tube - pleural , Chest
tube - mediastinal, Pacing wires
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: CT surgery
Billing Diagnosis: Arrhythmia, (Respiratory distress: Insufficiency /
Post-op), Post-op hypotension
ICU Care
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2199-12-26**] 02:04 PM
CCO PAC - [**2199-12-26**] 02:04 PM
[**First Name4 (NamePattern1) 549**] [**Last Name (NamePattern1) **] - [**2199-12-26**] 02:05 PM
20 Gauge - [**2199-12-26**] 02:06 PM
Communication: ICU consent signed Comments:
Code status: Full code
Disposition: ICU
Total time spent: 33 minutes"
6920,"8 mcg/Kg/min
Insulin - Regular - 2 units/hour
Other ICU medications:
Ranitidine (Prophylaxis) - [**2199-12-26**] 06:19 PM
Morphine Sulfate - [**2199-12-27**] 05:10 AM
Insulin - Regular - [**2199-12-27**] 05:56 AM
Other medications:
Flowsheet Data as of [**2199-12-27**] 08:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**01**] a.m.
HR: 88 (67 - 91) bpm
BP: 112/60(75) {93/54(65) - 138/77(95)} mmHg
RR: 24 (10 - 27) insp/min
SPO2: 100%
Heart rhythm: AV Paced
Height: 66 Inch
CVP: 8 (8 - 24) mmHg
PAP: (31 mmHg) / (18 mmHg)
CO/CI (Fick): (8 L/min) / (3."
6921,"3 %
9.5 K/uL
[image002.jpg]
[**2199-12-26**] 03:15 PM
[**2199-12-26**] 04:33 PM
[**2199-12-26**] 05:06 PM
[**2199-12-26**] 05:14 PM
[**2199-12-26**] 09:52 PM
[**2199-12-26**] 10:22 PM
[**2199-12-27**] 01:54 AM
[**2199-12-27**] 02:03 AM
[**2199-12-27**] 06:15 AM
[**2199-12-27**] 08:00 AM
WBC
9.5
Hct
25.1
29.4
27.3
Plt
147
Creatinine
1.1
TCO2
24
23
26
24
26
Glucose
127
100
95
151
94
130
Other labs: PT / PTT / INR:13."
6922,"4 L/min/m2)
CO/CI (CCO): (5 L/min) / (1.7 L/min/m2)
SvO2: 68%
Mixed Venous O2% sat: 66 - 76
Total In:
6,371 mL
280 mL
PO:
Tube feeding:
IV Fluid:
6,021 mL
280 mL
Blood products:
350 mL
Total out:
1,685 mL
795 mL
Urine:
1,505 mL
575 mL
NG:
Stool:
Drains:
Balance:
4,686 mL
-515 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 550 (550 - 550) mL
Vt (Spontaneous): 371 (371 - 551) mL
PS : 5 cmH2O
RR (Set): 18
RR (Spontaneous): 22
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 75
PIP: 14 cmH2O
Plateau: 21 cmH2O
Compliance: 35."
6923,"Cardiovascular: Aspirin, Pacer dependent, Beta-blockade held. 3rd
degree AV block under pacer.EP consult requested. Statin started.
Pulmonary: IS, Nebs.
Gastrointestinal / Abdomen: Bowel regimen
Nutrition: Regular diet
Renal: Adequate UO
Hematology: Hct stable
Endocrine: insulin infusion
Infectious Disease: No current issues
Lines / Tubes / Drains: Chest tube - pleural , Chest tube -
mediastinal, Pacing wires
Wounds: Dry dressings
Consults: P.T., EP dept
ICU Care
Nutrition: Heart healthy
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2199-12-26**] 02:04 PM
CCO PAC - [**2199-12-26**] 02:04 PM
[**First Name4 (NamePattern1) 549**] [**Last Name (NamePattern1) **] - [**2199-12-26**] 02:05 PM
20 Gauge - [**2199-12-26**] 02:06 PM
Prophylaxis:
DVT: Boots
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU"
6924,"CVICU
HPI:
71 F s/p CABG x 3 (LIMA to LAD, SVG to OM, SVG to PDA)[**12-26**]
PMHx:
morbid obesity,IDDM,COPD(noc 3Lnc),s/p LT THR, s/p hysterectomy,
hypercholesterolemia,HTN
Current medications:
Aspirin 81 mg NG DAILY, Phenylephrine 0.2-2.0 mcg/kg/min IV DRIP,
Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **], Ranitidine 150 mg NG DAILY,
HYDROmorphone (Dilaudid) 2-4 mg PO/NG Q4H:PRN pain, Vancomycin 1000 mg
IV Q12H
24 Hour Events:
OR RECEIVED - At [**2199-12-26**] 01:00 PM
INVASIVE VENTILATION - START [**2199-12-26**] 01:00 PM
NASAL SWAB - At [**2199-12-26**] 01:51 PM
ARTERIAL LINE - START [**2199-12-26**] 02:04 PM
CCO PAC - START [**2199-12-26**] 02:04 PM
[**Location (un) 549**] LINE - START [**2199-12-26**] 02:05 PM
EKG - At [**2199-12-26**] 03:06 PM
Allergies:
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
Nausea/Vomiting
Codeine
Nausea/Vomiting
Aspirin
Nausea/Vomiting
Last dose of Antibiotics:
Vancomycin - [**2199-12-26**] 08:52 PM
Infusions:
Phenylephrine - 0."
6925,"9 cmH2O/mL
SPO2: 99%
ABG: 7.31/49/122/24/-2
Ve: 8.6 L/min
PaO2 / FiO2: 305
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
scattered), (Sternum: Stable )
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis
pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,
Moves all extremities, difficult to assess orientation as patient does
not answer questions appropriately, non-focal exam
Labs / Radiology
147 K/uL
9."
6926,"4
27.3
Plt
147
Creatinine
1.1
TCO2
24
23
26
24
26
Glucose
127
100
95
151
94
130
Other labs: PT / PTT / INR:13.2/26.0/1.1, Fibrinogen:231 mg/dL, Lactic
Acid:2.8 mmol/L
Imaging: CXR no acute process
Microbiology: NGTD
ECG: AV paced
Assessment and Plan
CORONARY ARTERY BYPASS GRAFT (CABG)
Assessment and Plan: 71 F s/p CABG x 3 (LIMA to LAD, SVG to OM, SVG to
PDA)[**12-26**] now extubated but pacer dependent
Neurologic: Neuro checks Q: 6 hr, Pain poorly controlled, started on
dilaudid. Orientation difficult to assess because patient does not
directly answer questions."
6927,"8 mcg/Kg/min
Insulin - Regular - 3 units/hour
Other ICU medications:
Ranitidine (Prophylaxis) - [**2199-12-26**] 06:19 PM
Morphine Sulfate - [**2199-12-27**] 05:10 AM
Insulin - Regular - [**2199-12-27**] 05:56 AM
Flowsheet Data as of [**2199-12-27**] 10:05 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**01**] a.m.
HR: 88 (67 - 91) bpm
BP: 92/59(71) {92/54(65) - 138/77(95)} mmHg
RR: 15 (10 - 27) insp/min
SPO2: 99%
Heart rhythm: AV Paced
Height: 66 Inch
CVP: 13 (8 - 24) mmHg
PAP: (34 mmHg) / (23 mmHg)
CO/CI (Fick): (6 L/min) / (2."
6928,"5 L/min/m2)
CO/CI (CCO): (4.5 L/min) / (2 L/min/m2)
SvO2: 59%
Mixed Venous O2% sat: 66 - 76
Total In:
6,371 mL
334 mL
PO:
Tube feeding:
IV Fluid:
6,021 mL
334 mL
Blood products:
350 mL
Total out:
1,685 mL
975 mL
Urine:
1,505 mL
695 mL
NG:
Stool:
Drains:
Balance:
4,686 mL
-641 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 550 (550 - 550) mL
Vt (Spontaneous): 371 (371 - 551) mL
PS : 5 cmH2O
RR (Set): 18
RR (Spontaneous): 22
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 75
PIP: 14 cmH2O
Plateau: 21 cmH2O
Compliance: 35."
6929,"2 g/dL
130 mg/dL
1.1 mg/dL
24 mEq/L
4.9 mEq/L
15 mg/dL
110 mEq/L
137 mEq/L
27.3 %
9.5 K/uL
[image002.jpg]
[**2199-12-26**] 03:15 PM
[**2199-12-26**] 04:33 PM
[**2199-12-26**] 05:06 PM
[**2199-12-26**] 05:14 PM
[**2199-12-26**] 09:52 PM
[**2199-12-26**] 10:22 PM
[**2199-12-27**] 01:54 AM
[**2199-12-27**] 02:03 AM
[**2199-12-27**] 06:15 AM
[**2199-12-27**] 08:00 AM
WBC
9.5
Hct
25.1
29."
6930,"The pain was relieved with
rest. She called her pulmonologist and sent to ED, and was ruled
out for myocardial infarction. She was started on Heparin, no
plavix given, underwent cardiac work up and was transferred for
surgical evaluation.
Past Medical History:
morbid obesity
IDDM
COPD(noc 3Lnc
s/p LT THR
s/p hysterectomy
hypercholesterolemia
hypertension
Social History:
Lives: alone
Occupation: retired
Tobacco: 1ppd for 60yrs stopped 2yrs ago
ETOH: rare
Family History:
noncontributory
Physical Exam:
Pulse: Resp:14 O2 sat: 97% on RA
B/P Right:138/70 Left: 136/70
Height:67"" Weight:136kg
General:morbidly obese female, walking w/ cane."
6931,"On [**2199-12-26**] she was
taken to the operating room and underwent coronary artery bypass
graft surgery. See operative report for further details. In
summary she had coronary artery bypass grafting x3 with LIMA-LAD
saphenous vein graft to OM and saphenous vein graft to PDA. Her
bypass time was 78 minutes with a crossclamp of 67 minues. She
received vancomycin for perioperative antibioticcs. She was
transferred to the intensive care unit for hemodynamic
management in stable condition. In the first twenty four hours
she was weaned from sedation, awoke neurologically intact, and
was extubated without complications. Post operativly she had
complete heart block and was 100% paced via epicardial wires."
6932,"EP was consulted, her rhythm was monitored and recovered without
intervention. On post operative day two she was started on beta
blockers, tolerating well, and epicardial wires were removed on
post operative day four. She was transferred from the ICU to
stepdown floor on POD4 Physical therapy worked with her on
strength and mobility. She continued to progress and was ready
for discharge to rehab on post operative day 5.
Medications on Admission:
verapamil 360mg daily,HCTZ 25mg daily,ASA
81mg daily,Lipitor 80mg daily,Amitryptilline 50mg daily,
Mirtazapine 15mg daily, Lantus 14u HS,Humalog 4u at
dinner,Ipratropium 0."
6933,"14. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
15. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous QAM.
16. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC&HS.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**]
Discharge Diagnosis:
Coronary Artery Disease s/p cabg x3
Diabetes mellitus type 2
Chronic obtructive pulmonary disease
Hypercholesterolemia
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, with assist
Sternal pain managed with ultram prn
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"
6934,"7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)."
6935,"2 PTT-26.0 INR(PT)-1.1
[**2199-12-31**] 06:09AM BLOOD Glucose-105* UreaN-18 Creat-1.3* Na-140
K-4.3 Cl-102 HCO3-32 AnGap-10
[**2199-12-31**] 06:09AM BLOOD Mg-2.5
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 83870**]
Reason: Please do oblique view as well 60 cm Picc placed in left
bas
Final Report
FINDINGS: Comparison is made to the prior study from [**2199-12-28**].
New left
PICC terminates in the vicinity of the left subclavian vein.
Subclavian
versus brachiocephalic. It should be advanced. Right IJ Cordis
continues to be kinked."
6936,"Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**12-7**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
PRE-BYPASS:
The left atrium is dilated. 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.
The left ventricular cavity is mildly dilated. There is moderate
regional left ventricular systolic dysfunction with apical
hypokinesis and mid basal hyokinesis in the RCA territory."
6937,"Patient is status post median
sternotomy. Appearance of the chest is relatively unchanged.
Opacity along prior left chest tube tract remains at the left
periphery mid lung zone. There is a small left pleural effusion
with left lower lobe atelectasis.
IMPRESSION:
Mild atelectasis at right base persists. Heart and mediastinum
within normal limits.
DR. [**First Name11 (Name Pattern1) 3993**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3994**]
Approved: MON [**2199-12-30**] 4:06 PM
Brief Hospital Course:
Transferred from outside hospital and underwent preoperative
workup including pulmonary function test, and [**Last Name (un) 387**] consult for
elevated hgba1c 9.9 on insulin at home."
6938,"5ml neb QID,Lisinopril 40mg
daily,Ranitidine
150mg [**Hospital1 **]
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain."
6939,"8 CALCIUM-9.4 PHOSPHATE-3.5
MAGNESIUM-1.9 IRON-99
[**2199-12-23**] 09:15PM LIPASE-24
[**2199-12-23**] 09:15PM ALT(SGPT)-29 AST(SGOT)-29 LD(LDH)-256* ALK
PHOS-87 AMYLASE-115* TOT BILI-0.2
[**2199-12-23**] 09:15PM GLUCOSE-297* UREA N-24* CREAT-1.6* SODIUM-140
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13
[**2199-12-31**] 06:09AM BLOOD WBC-8.9 RBC-3.20* Hgb-10.2* Hct-29.2*
MCV-91 MCH-32.0 MCHC-35.0 RDW-14.7 Plt Ct-234
[**2199-12-31**] 06:09AM BLOOD Plt Ct-234
[**2199-12-26**] 01:31PM BLOOD PT-13."
6940,"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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Dr [**Last Name (STitle) **] (for Dr [**Last Name (STitle) **] [**Hospital1 **] heart center - Thrusday [**1-16**]
at 9am
[**Telephone/Fax (1) 6256**]
Dr [**Last Name (STitle) 20222**] (cardiologist) - [**Hospital1 **] heart center - Thrusday
[**1-16**] at 330pm
Please call to schedule appointments
Primary Care Dr [**Last Name (STitle) **] in [**12-7**] weeks [**Telephone/Fax (1) 20261**]
Completed by:[**2199-12-31**]"
6941,"No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mildly dilated LV cavity. Moderate regional LV
systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Moderately dilated RV cavity.
AORTA: Normal aortic diameter at the sinus level. Complex
(mobile) atheroma in aortic root. Normal ascending aorta
diameter. Focal calcifications in ascending aorta. Normal aortic
arch diameter. Complex (mobile) atheroma in the descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP."
6942,"Admission Date: [**2199-12-23**] Discharge Date: [**2199-12-31**]
Date of Birth: [**2128-12-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet / Codeine / Aspirin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2199-12-26**]
Coronary artery bypass grafting x3 with left internal mammary
artery to the left anterior descending artery and reverse
saphenous vein graft to the left posterior descending artery and
the obtuse marginal artery
History of Present Illness:
70 year old female with 2 weeks of intermittent right chest pain
with and without exertion. No radiation of pain or associated
nausea, vomiting or diaphoresis."
6943,"NAD
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 N
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:no Left:no
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**2199-12-26**] at 12:46:01 PM
LEFT ATRIUM: Dilated LA."
6944,"Due
to suboptimal imaging, other WMA might have been missed..
Overall left ventricular systolic function is mildly depressed
(LVEF=40 %).
The right ventricular cavity is moderately dilated with mild
global RV hypokinesis.
There are complex (mobile) atheroma in the aortic root There are
complex (mobile) atheroma in the descending aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion."
6945,"Dr.[**Last Name (STitle) **] was notified in person of the results on Mrs.[**Known lastname 10936**] before
surgical incision.
Post_Bypass:
Mild global RV hypokinesis.
Overall LVEF 40% with similar wall motional abnormalities.
Intact thoracic aorta.
Mild MR. Mild to moderate TR.
[**2199-12-23**] 09:15PM PT-11.9 PTT-22.1 INR(PT)-1.0
[**2199-12-23**] 09:15PM PLT COUNT-280
[**2199-12-23**] 09:15PM WBC-5.7 RBC-3.55* HGB-10.6* HCT-33.8* MCV-95
MCH-29.8 MCHC-31.3 RDW-13.8
[**2199-12-23**] 09:15PM %HbA1c-9.9*
[**2199-12-23**] 09:15PM ALBUMIN-3."
6946,"He is unclear on the specifics of why he had the procedure,
but does not believe that he underwent PCI.Over the past six
months he has been bothered by chest discomfort, dyspnea and
fatigue. This can occur with walking about one block. In
addition, he notices right calf
pain with similar amounts of walking.Denies edema, orthopnea,
PND, lightheadedness. Cardiac workup with his PCP showed an
abnormal ETT and he was referred for an elective cardiac
catheterization [**2150-3-26**], which revealed three vessel coronary
disease. Cardiac surgery was consulted for evaluation of
coronary revascularization.
Past Medical History:
hypertension
hyperlipidemia
Diabetes
[**2150-2-4**] ETT: 5 minutes 30 seconds [**Doctor First Name **] protocol, 89% max
PHR."
6947,"Insulin Glargine 100 unit/mL Solution Sig: Thirty Four (34)
units Subcutaneous once a day.
Disp:*qs qs* Refills:*0*
10. Humalog 100 unit/mL Solution Sig: per scale Subcutaneous
before each meal : 14 units before breakfast, 8 units before
lunch, 14 units before dinner.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Diabetes mellitus type 2
Hyperlipidemia
Chronic renal insufficiency baseline cr 1.9
Discharge Condition:
Alert and oriented x2 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol
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**]
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2150-5-6**] 1:00
Please call to schedule appointments
Primary Care Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 1057**] in [**2-14**] weeks [**Telephone/Fax (1) 14331**]
Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-14**] weeks [**Telephone/Fax (1) 8725**]
Completed by:[**2150-4-7**]"
6948,"Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): 1 drop in each eye twice a day .
Disp:*qs qs* Refills:*0*
5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
7. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
9."
6949,"0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec
Aortic Valve - LVOT pk vel: 0.80 m/sec
Aortic Valve - LVOT VTI: 15
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *2.2 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 84 ms
Mitral Valve - MVA (P [**2-14**] T): 2.6 cm2
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 0.86"
6950,"2* PTT-30.5 INR(PT)-1.2*
[**2150-4-3**] 11:40AM BLOOD Fibrino-173
[**2150-4-7**] 05:10AM BLOOD Glucose-99 UreaN-22* Creat-1.5* Na-141
K-4.9 Cl-103 HCO3-31 AnGap-12
[**2150-4-3**] 12:45PM BLOOD UreaN-18 Creat-1.3* Cl-114* HCO3-25
[**2150-4-7**] 05:10AM BLOOD Mg-2.2
[**2150-4-3**] 05:59PM BLOOD Mg-2.3
Radiology Report CHEST (PA & LAT) Study Date of [**2150-4-6**] 1:48 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2150-4-6**] 1:48 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 86421**]
Reason: please do in afternoon [**4-6**] - eval for effusion"
6951,"Carotid Bruit Right: none Left:none
Pertinent Results:
[**2150-4-7**] 05:10AM BLOOD WBC-7.3 RBC-3.67* Hgb-10.3* Hct-32.6*
MCV-89 MCH-28.1 MCHC-31.7 RDW-14.4 Plt Ct-310
[**2150-4-3**] 11:40AM BLOOD WBC-7.4 RBC-2.85*# Hgb-8.4*# Hct-24.8*#
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.6 Plt Ct-199#
[**2150-4-3**] 11:40AM BLOOD Neuts-75.3* Lymphs-20.1 Monos-2.7 Eos-1.5
Baso-0.3
[**2150-4-7**] 05:10AM BLOOD Plt Ct-310
[**2150-4-3**] 11:40AM BLOOD Plt Ct-199#
[**2150-4-3**] 11:40AM BLOOD PT-14."
6952,"Admission Date: [**2150-4-3**] Discharge Date: [**2150-4-7**]
Date of Birth: [**2081-6-4**] Sex: M
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:
[**2150-4-3**] Coronary artery bypass grafting x3 with left internal
mammary artery to the left anterior descending artery, and
reverse saphenous vein graft to the distal right coronary artery
and the obtuse marginal artery.
History of Present Illness:
68 year old male with progressive, exertional chest discomfort
over the past 6 months. He reports that he underwent a cardiac
catheterization at [**Hospital 1474**] hospital approximately 8-9 years
ago."
6953,"TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
Post Bypass: Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch."
6954,"80 m2
Indication: Intraop CABG Evaluate wall motion, aortic contours,
valves
ICD-9 Codes: 424.0
Test Information
Date/Time: [**2150-4-3**] at 10:08 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: aw2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1."
6955,"There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
Post Bypass: Patient is A paced, on phenylepherine infusion.
Preserved biventricular function. LVEF 55%. MR is now trace.
Aortic contours intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician"
6956,"Findings
LEFT ATRIUM: Normal LA size. Elongated LA. No thrombus in the
LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR."
6957,"C.) - 1 Tablet(s) by mouth every morning
OLMESARTAN-HYDROCHLOROTHIAZIDE [BENICAR HCT] - (Prescribed by
Other Provider; OTC) - 20 mg-12.5 mg Tablet - 1 Tablet(s) by
mouth daily every morning
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4."
6958,"+ Anginal discomfort with exercise. EKG with anterolateral
ST depression. Imaging: moderate in size, severe in intensity
territory of inferior reversibility. LVEF 55%.
Chronic renal insufficiency, creatinine 2.4
Left eye laser surgery approximately one month ago
Social History:
Lives with spouse
[**Name (NI) 1139**]: None
ETOH: None in 30 years
Family History:
No family history of premature CAD. Father died when patient was
5 years old-unknown cause.
Physical Exam:
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []few scattered rhonchi
Heart: RRR [x] Irregular [] NO Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +1 Left:+1"
6959,"In the first twenty four
hours he was weaned from sedation, awoke, and was extubated
without complications. He continued to do well and was
transferred to the floor. His percocet was stopped due to
confusion which resolved. Physical therapy worked with him on
strength and mobility. He was ready for discharge home with
services on post operative day four.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth every morning
DILTIAZEM HCL - (Prescribed by Other Provider) - 300 mg
Capsule,
Sustained Release - 1 Capsule(s) by mouth every morning
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 34 units at bedtime
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - 14 units before breakfast, 8 units before
lunch, 14 units before dinner
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth every
morning
METFORMIN - (Prescribed by Other Provider) - 850 mg Tablet - 1
Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth qam
QUINAPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth every morning
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Delayed Release (E."
6960,"0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: *0.14 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 57 ml/beat
Left Ventricle - Cardiac Output: 3.71 L/min
Left Ventricle - Cardiac Index: 2.06 >= 2.0 L/min/M2
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3."
6961,"Cardiology Report ECG Study Date of [**2150-4-3**] 2:08:28 PM
Sinus rhythm. Low QRS voltage. Non-diagnostic repolarization
abnormalities.
Compared to the previous tracing of [**2150-3-31**] QRS voltage is
diffusely reduced.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 162 104 372/387 84 0 -14
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. See operative report
for further details. He received cefazolin for perioperative
antibiotics. Post operatively he was transferred to the
intensive care unit for management."
6962,"Improving multifocal atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2150-4-6**] 3:36 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 5259**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86422**] (Complete)
Done [**2150-4-3**] at 10:08:02 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2081-6-4**]
Age (years): 68 M Hgt (in): 65
BP (mm Hg): / Wgt (lb): 160
HR (bpm): 65 BSA (m2): 1."
6963,"[**Hospital 93**] MEDICAL CONDITION:
68 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
please do in afternoon [**4-6**] - eval for effusion
Final Report
TWO VIEW CHEST, [**2150-4-6**]
COMPARISON: [**2150-4-5**].
INDICATION: Status post coronary artery bypass surgery. Pleural
effusion
assessment.
FINDINGS: Status post median sternotomy and coronary bypass
surgery with
similar postoperative appearance of cardiomediastinal contours.
Improving
multifocal atelectasis with residual linear atelectasis in the
mid and lower
lungs. Persistent small lateral left pneumothorax as well as
bilateral small
pleural effusions. Retrosternal gas, probably postoperative
considering
recent surgery.
IMPRESSION: Persistent small lateral left pneumothorax and small
bilateral
pleural effusions."
6964,"Admission Date: [**2195-2-13**] Discharge Date: [**2195-2-19**]
Date of Birth: [**2160-1-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
dyspnea, hypertensive emergency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
35yo M with h/o HTN, renal artery stenosis, and asthma, off all
medications x4 months as unable to afford them, who is
transferred to [**Hospital1 18**] for management of hypertensive emergency
after presenting to OSH ED earlier in day with weight gain,
dyspnea, orthopnea, PND, worsening bilateral lower extremity
edema, and general malaise, and was found to be hypertensive to
270/170."
6965,"Had not occurred before, no recurrence.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies 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:
-hypertension
-left renal artery stenosis (diagnosed on renal ultrasound
[**6-/2194**])
-asthma
-? childhood seizures, reports loss of consciousness events
occuring from early childhood until age [**10-3**], mother said that
they were seizures. Pt is not in contact with mother, unable to
get further information from her."
6966,"-history of childhood epistaxis
Social History:
- Tobacco: [**11-26**] cigarettes per day x20 years
- Alcohol: use varies between 6 pack per day to no EtOH for >1
month at time
- Illicits: occasional marijuana use, remote cocaine use, no
history of IVDU
- works for carnival, and lives/travels with carnival
Family History:
Unknown, patient adopted
Physical Exam:
ADMISSION EXAM:
Vitals: T: 99.4 BP: 179/119 P: 91 R: 26 O2: 95% 1L NC
General: awake, alert, oriented, resting comfortably, NAD
HEENT: PERRL, EOMI, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 10 cm, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, S4, loud P2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ DP/PT pulses, 2+ lower extremity
edema bilaterally
Neuro: CN 2-12 grossly intact
At discharge: same as above except: JVP less elevated to just
above clavicle, lower extremity edema slightly reduced
."
6967,"Mild pulmonary hypertension. These findings are
most consistent with hypertensive heart disease.
[**2-15**] MRI abdomen: There are bilateral solitary renal arteries
without stenosis with conventional branching. The kidneys
demonstrate normal size, morphology and signal intensity. There
is an 8-mm cyst in the interpolar region of the left kidney.
There is a 1.6-cm hemorrhagic lesion in the upper pole of the
right kidney. Due to absence of contrast, presence of enhancing
or nodular components in this hemorrhagic lesion cannot be
[**Month/Year (2) 6349**]. The ultrasound did not demonstrate any suspicious
septation in this lesion. Adrenals are unremarkable without
lesion."
6968,".
ACTIVE ISSUES:
.
#. Hypertensive Emergency: Hypertensive emergency occurred in
the setting of an apparent history of renal artery stenosis and
patient being off all blood pressure medications x4 months.
Given elevated troponin, cardiac enzymes were cycled and
remained flat. EKG not concerning for ischemia, and patient did
not have any chest pain. TTE was suggestive of hypertensive
heart disease. Patient continued on nitro gtt and esmolol gtt,
and initially admitted to ICU overnight for close monitoring.
Patient's BP improved on nitro and esmolol gtts, and he was
transitioned to oral antihypertensive regimen of nifedipine and
Imdur, then adjusted to find an outpatient regimen that would
facilitate compliance by being as cheap and infrequently dosed
as possible."
6969,"Renal was consulted. They recommended MRI/MRA kidney
to evaluate L renal artery which was negative for renal artery
stenosis (though it was without contrast). It was felt that
renal artery stenosis was unlikely and this was not further
pursued. **Renin, Angiotensin, and catecholamines were all
pending at the time of discharge.**
.
#. CHF: Patient presented with evidence of volume overload given
elevated JVP, bilateral lower extremity edema. CXR not
suggestive of florid pulmonary edema, though patient does have
elevated BNP in addition to history of dyspnea, orthopnea, and
PND. [**Month (only) 116**] be acute on chronic process, in setting of
hypertensive emergency, though also concern for CHF given more
long-standing symptoms."
6970,"CXR also suggests more chornic process
given cardiomegaly, and EKG shows evidence of LVH and atrial
enlargement. Patient had TTE [**2-14**] which showed moderate
symmetric left ventricular hypertrophy with mild global systolic
dysfunction. Mild pulmonary hypertension. These findings are
most consistent with hypertensive heart disease. Was diuresed
with IV lasix and then transitioned to lasix 40mg PO BID with no
electrolyte repletion requirement for discharge. He was
discharged as detailed above in clinically euvolemic to mildly
hypervolemic status breathing comfortably on RA with mild trace
to 1+ LE edema. **Titration of diuretic and electrolyte
repletion will need to be revisited on follow-up."
6971,"**
.
#. Renal Failure: Cr elevated to 2.9, baseline unclear. [**Name2 (NI) 116**] be
chronic given history of untreated hypertension, but had concern
for malignant nephrosclerosis, which can occur in hypertensive
emergencies and lead to acute renal failure, hematuria, and
proteinuria. UA demonstrated trace protein, but only 1 RBC.
Renal ultrasound showed normal flow and resistive indices in the
right main, upper and interpolar renal arteries. The left main
and intrarenal arteries could not be adequately interrogated.
Renal consulted, and recommended renal MRI and multiple urine
studies which showed bland urine sediment only notable for
microhematuria. Creatinine improved to 2.3 at the time of
discharge."
6972,".
# Incidental Renal Cyst: Renal MRI showed an 8-mm cyst in the
interpolar region of the left kidney and a 1.6-cm hemorrhagic
lesion in the upper pole of the right kidney. This lesion could
not be definitvely evalutated without a contrast study.
**Further studies may be helpful in further evaluating the cyst
and hemorrhagic lesion in the future.**
.
INACTIVE ISSUES:
.
#. Anemia: Patient noted to be anemic, no baseline HCT for
comparison. Iron studies demonstrated low iron at 21 (normal 45
- 160 ug/dL). Normal TIBC, ferritin, transferrin. Iron started
with plan to continue as outpatient.
.
#. Asthma: No SOB or wheezing at present, and lung exam
unremarkable."
6973,"7. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*8*
8. Imdur 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet
Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*8*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hypertensive emergency
2. Acute kidney injury
Secondary:
1. Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with dangerously high blood
pressures. We gave you IV medications to reduce your blood
pressure at first, and then switched to oral medications."
6974,"CXR
showed cardiomegaly, and patient was also felt to have evidence
of pulmonary edema based on imaging. EKG without evidence of
ishcemia. Patient also had renal ultrasound which showed normal
appearing right renal artery, though left renal artery not well
visualized. Admitted to ICU for further management, and just
prior to transfer VS: 86 174/119 24 96% 2L.
.
On the floor, patient states he is comfortable. Denies any CP
or SOB at present, though reports intermittent SOB over past
week.
.
Review of systems:
(+) Per HPI. Episode of substernal chest pain about 1 week ago,
which he reports resolved on its own after he drank glass of
water."
6975,"Also reports
bilateral ear discomfort and sensation that his equilibrium was
off. Patient initially presented to [**Hospital1 2436**] ED, where he was
found to be hypertensive with pressure 270/170 per report.
Started on nitro gtt and later transitioned to esmolol gtt. Also
given 80mg lasix. Transferred to [**Hospital1 18**], with pressure improved
to 170s/130s prior to transfer. On arrival to [**Hospital1 18**] ED,
triggered for HTN with VS 97 180/138 87 18 99% 2L. Patient
continued on esmolol gtt, nitro gtt. Exam unremarkable. Labs
notable for WBC of 12.9, Cr 2.9, Trop 0.09, proBNP 6684."
6976,"Albuterol inhaler prn SOB/wheezing.
.
TRANSITIONAL ISSUES:
-As above in **.
-Because the patient's insurance application for MassHealth is
not yet approved, we were unable to schedule a PCP [**Name Initial (PRE) 648**].
We gave him a phone number for [**Company 191**] to set up a PCP appointment,
plus [**Name Initial (PRE) **] letter and his inpatient records in case he chose a PCP
outside of the [**Hospital1 18**] system. The results of his pending labs
will be sent to his temporary residence in [**Location (un) 4444**], also to
bring to his new PCP.
Medications on Admission:
None. Previously on:
-ASA 81mg daily
-ergocalciferol 50,000 units PO weekly
-ferrous sulfate 325mg PO daily
-albuterol inhaler 2 puffs INH Q6H prn SOB or wheezing
-amlodipine 10mg daily
-lisinopril 15mg daily
-metoprolol succinate 150mg daily
-isosorbide monontriate (Imdur ER) 30mg daily"
6977,".
Some of your medications were changed during this admission:
#START:
lisinopril 40mg, take once a day at bedtime
carvedilol 50mg, take twice a day
Isosorbide Mononitrate (Imdur) ER 60 mg take once a day
Furosemide 80mg, take once a day
Ferrous Sulfate (Iron) 325 mg once a day
.
#STOP:
Metoprolol
Amlodipine
.
You should continue to take all of your other medications as
prescribed. You should stop smoking.
Followup Instructions:
As soon as you receive [**State 350**] Health insurance coverage,
it is VERY important that you schedule an appointment with a new
primary care physician here at [**Hospital1 **] for further management of your high blood pressure and
for follow-up of your pending tests."
6978,"After titration, this regimen was lisinopril 40mg
daily, carvedilol 50 [**Hospital1 **], and imdur 60mg, lasix 80 daily. On
this regimen his blood pressures were in the 160s-170s/100s.
**Titration of blood regimen will need to be addressed on
follow-up. The etiology of the patient's hypertension will also
need to be revisited as detailed below under Renal Artery
Stensosis.**
.
#. Question of Renal Artery Stenosis: Patient with an apparent
history of left renal artery stenosis diagnosed on ultrasound at
[**Hospital1 2025**] 8/[**2193**]. Renal ultrasound here did not visualize left renal
artery well, but does not reveal e/o right renal artery
stenosis."
6979,"Non-contrast evaluation of the liver, spleen and
pancreas are unremarkable.
.
DISCHARGE LABS:
.
[**2195-2-18**] 07:35AM BLOOD WBC-10.3 RBC-4.05* Hgb-9.4* Hct-30.4*
MCV-75* MCH-23.1* MCHC-30.8* RDW-17.8* Plt Ct-401
[**2195-2-18**] 07:35AM BLOOD Plt Ct-401
[**2195-2-19**] 07:15AM BLOOD Glucose-93 UreaN-24* Creat-2.3* Na-137
K-4.6 Cl-100 HCO3-31 AnGap-11
[**2195-2-19**] 07:15AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.2
Brief Hospital Course:
35yo male with history of HTN and renal artery stenosis, who
presents now with hypertensive emergency in setting of being off
anti-hypertensives for past 6 months."
6980,"The right
atrium is moderately dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
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 mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. Moderate symmetric
left ventricular hypertrophy with mild global systolic
dysfunction."
6981,"We
also made sure that you did not have a heart attack. Your kidney
function was abnormal and the kidney doctors [**Name5 (PTitle) 6349**] [**Name5 (PTitle) **]. It
not clear what is causing your high blood pressure, or
hypertension. Imaging of your kidneys showed that there was no
significant narrowing the blood vessels supplying those organs.
You will need to follow-up with a physician for the results of a
few chemistry tests that are still pending at the time of
discharge.
.
It will be extremely important that you take your medications
and follow up with doctors [**Name5 (PTitle) **] it is possible your high blood
pressure could cause a stroke or heart attack."
6982,".
Department: [**Hospital3 **]
Specialty: Internal Medicine
Location: [**Hospital1 69**]
Address: [**Location (un) **], [**Hospital Ward Name 23**] Building, [**Location (un) 86**] [**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 250**]
.
Also schedule an appointment with the kidney doctors [**First Name (Titles) **] [**Hospital1 1535**]. THE KIDNEY DOCTORS HAVE AGREED
TO SEE YOU FREE OF CHARGE.
.
Name: [**Last Name (LF) 4090**], [**Name8 (MD) 4102**] MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) 4090**] within
2-4 weeks. You will be called at home with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above."
6983,"Patient has previously been admitted to [**Hospital1 2025**] in [**6-/2194**]
for similar episode of hypertension, though per his report BP
was not this elevated. Was discharged on regimen of amlodipine,
lisinopril, metoprolol succinate, and isosorbide monontriate,
but has not taken these medications for the past 4 months as he
does not have insurance and has been unable to afford them.
Work-up during that admission notable for renal ultrasound
demonstrating left renal artery stenosis.
.
Over past 6 months patient notes weight gain of unclear amount.
Has also had dyspnea, dry cough, orthopnea, PND. Worsening
bilateral lower extremity edema over past week."
6984,"Discharge Medications:
1. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*8*
2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*8*
3. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*8*
4. 2 liter oral fluid restriction
Try to restrict your oral fluid intake to less than 2 liters of
fluid daily.
5. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing."
6985,"6* Lymphs-9.1* Monos-1.4*
Eos-0.7 Baso-0.2
[**2195-2-13**] 09:20PM BLOOD Glucose-107* UreaN-34* Creat-2.9* Na-139
K-3.4 Cl-99 HCO3-30 AnGap-13
[**2195-2-13**] 09:20PM BLOOD proBNP-6684*
[**2195-2-13**] 09:20PM BLOOD Calcium-8.5 Phos-5.6* Mg-2.0
[**2195-2-13**] 09:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2195-2-13**] 09:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2195-2-13**] 09:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1."
6986,"004
[**2195-2-13**] 09:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2195-2-13**] 09:45PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
IMAGING:
[**2-13**] CXR: Severe cardiomegaly.
[**2-13**] Renal Ultrasound:Technically limited study showing normal
flow and resistive indices in the right main, upper and
interpolar renal arteries. The left main and intrarenal arteries
could not be adequately interrogated. An MRI may be obtained for
further evaluation if clinically necessary.
[**2-14**] TTE: The left atrium is moderately dilated."
6987,"DISCHARGE EXAM:
Vitals: BP 150/100
Gen: AO x 3, NAD
HEENT: JVP @ 30* not elevated
Lungs: slightly decreased breath sound over RLL improved from
the day prior, otherwise no wheezes, rales, rhonci
CV: RRR nml s1/2 no [**1-23**]/m/r/g
Ab: +BS NTND
Ext: 1+ edema bilaterally, improved from the day prior
Neuro: Grossly non-focal
Pertinent Results:
ADMISSION LABS:
[**2195-2-13**] 09:20PM BLOOD WBC-12.9* RBC-4.23* Hgb-9.6* Hct-31.2*
MCV-74* MCH-22.7* MCHC-30.7* RDW-18.0* Plt Ct-418
[**2195-2-13**] 09:20PM BLOOD Neuts-88."
6988,"Admission Date: [**2160-3-3**] Discharge Date: [**2160-3-4**]
Date of Birth: [**2107-1-29**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
L PICA aneurysm
Major Surgical or Invasive Procedure:
[**2160-3-3**]: Cerebral angiogram with coiling of the L PICA aneurysm
History of Present Illness:
53F elective admission for coiling of the L PICA aneurysm
Past Medical History:
carpal tunnel syndrome, COPD, tonsillectomy, and adenoidectomy,
right thumb pulley,
bunionectomy of the right foot.
Physical Exam:
Pre-procedure:
Nonfocal exam
Post-procedure:
Nonfocal exam
Brief Hospital Course:
53F elective admission for PICA aneurysm coiling."
6989,"What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate."
6990,"6. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) as needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
L PICA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with coiling
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort."
6991,"Post-angio she
was monitored in the ICU and extubated. Overnight she remained
stable. On [**3-4**] her foley was removed and she ambulated
independently. She was discharged home on [**3-4**].
Medications on Admission:
-albuterol sulfate 90 mcg 1-2 Puffs Inhalation UP TO 7 TIMES A
DAY
-fluticasone-salmeterol 500-50 mcg/dose Disk One (1) Disk with
Device Inhalation [**Hospital1 **] (2 times a day).
-sertraline 100mg PO DAILY (Daily).
-tiotropium bromide 18 mcg Capsule, w/Inhalation Device One (1)
Cap Inhalation DAILY (Daily).
-alprazolam 0.50 mg PO TID (3 times a day) as needed for
anxiety."
6992,"?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 4 weeks, you do not need
imaging at that time. Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
Completed by:[**2160-3-4**]"
6993,"Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain .
Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation UP TO 7 TIMES A DAY ().
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day)."
6994,"REASON FOR EXAMINATION: Coiling of aneurysm left PICA to prevent rupture.
ATTENDING PHYSICIAN: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD
ASSISTANT: [**First Name4 (NamePattern1) 823**] [**Last Name (NamePattern1) 824**], NP
PROCEDURE PERFORMED: Left vertebral artery arteriogram and coil embolization
of left PICA aneurysm with GDC Target coils. Right common femoral artery
arteriogram and Angio-Seal closure of right common femoral artery.
ANESTHESIA: General.
DETAILS OF PROCEDURE: The patient was brought to the angiography suite.
Anesthesia was induced. Following this, both groins were prepped and draped
in a sterile fashion. Access was gained to the right common femoral artery
using a Seldinger technique and a 6 French vascular sheath was placed in the
right common femoral artery leading up into the distal aorta."
6995,"We now performed a right common femoral artery arteriogram . Since the artery
was small, the sheath was left in place to be taken out later rather than
using an Angioseal device.
The ACT was maintained around 230 for the procedure.
FINDINGS: Left vertebral artery arteriogram reveals a 4.8 x 7.8 mm aneurysm
(Over)
[**2160-3-3**] 1:46 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 20240**]
Reason: Coiling of aneurysmAnesthesia has been book for [**3-3**] on wait
Contrast: OPTIRAY Amt: 100ML OPTI240; 70ML OPTI320
______________________________________________________________________________
FINAL REPORT
(Cont)
arising at the PICA origin, incorporating the origin of the PICA vessel.
Left vertebral artery arteriogram status post coiling shows complete
obliteration of the aneurysm with a very small residual neck.
Right common femoral arteriogram shows a small right common femoral artery.
IMPRESSION: [**Known firstname **] [**Known lastname 20241**] underwent cerebral arteriography and coil embolization
of a PICA aneurysm which was uneventful."
6996,"This was
connected to a continuous saline flush. The left vertebral artery was
catheterized with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 586**] 2 catheter, under roadmapping guidance. The
[**Doctor Last Name 586**] 2 catheter was exchanged out over an exchange length 0.038 Glidewire
and a 6 French Neuron catheter was placed in the left vertebral artery.
Following this, the aneurysm was catheterized with an SL-10 microcatheter and
microwire. Coiling was commenced with a 4 mm 360 UltraSoft Target coil
followed by 3 mm 360 UltraSoft Target coil followed by 2 mm 360 UltraSoft
Target coil. Following this, the aneurysm was obliterated except for a very
small residual at the neck, which had to be maintained to keep the patency of
the PICA artery."
6997,"[**2160-3-3**] 1:46 PM
CAROT/CEREB [**Hospital1 **] Clip # [**Clip Number (Radiology) 20240**]
Reason: Coiling of aneurysmAnesthesia has been book for [**3-3**] on wait
Contrast: OPTIRAY Amt: 100ML OPTI240; 70ML OPTI320
********************************* CPT Codes ********************************
* [**Numeric Identifier 284**] EMBO TRANSCRANIAL [**Numeric Identifier 287**] SEL CATH 2ND ORDER *
* -51 MULTI-PROCEDURE SAME DAY [**Numeric Identifier 289**] VERT/CAROTID A-GRAM *
* -59 DISTINCT PROCEDURAL SERVICE [**Numeric Identifier 43**] TRANSCATH EMBO THERAPY *
* [**Numeric Identifier 822**] F/U TRANS CATH THERAPY *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
53 year old woman with known aneurysm
REASON FOR THIS EXAMINATION:
Coiling of aneurysmAnesthesia has been book for [**3-3**] on waitlist
______________________________________________________________________________
FINAL REPORT
DATE OF SERVICE: [**2160-3-3**]."
6998,"Admission Date: [**2171-6-4**] Discharge Date: [**2171-6-18**]
Date of Birth: [**2091-8-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Abdomnal pain
Major Surgical or Invasive Procedure:
ERCP with placement of a plastic stent ([**2171-6-4**])
PICC line placement ([**2171-6-6**])
Percutaenous cholecystostomy drain ([**2171-6-7**])
Drainage of liver abscess by interventional radiology ([**2171-6-13**])
History of Present Illness:
Mr. [**Known lastname **] is a 79yoM with a history of HTN, HLD, and previous
bladder neoplasm who developed acute RUQ pain two days ago."
6999,"A CT
showed pneumobilia with scattered hepatic densities concerning
for abscesses.
He was transferred to [**Hospital1 18**], initial VS were T99.4 BP83/42 HR80
RR18 Sat97RA. His lactate was elevated to 4.4, he received 2L
NC. His initial labs showed transaminitis of AST/ALT 198/167,
Tbili 4.9 Dbili 4.0, AP 34, Lipase 86. Surgery was consulted for
suspicion of cholangitis. He received zosyn, and was admitted to
[**Hospital Unit Name 153**] briefly before undergoing ERCP, which revealed only sludge
in the gallbladder without note of stone. A stent was placed,
and he received tetracycline/clindamycin for suspected
claustridium given his pneumobilia."
7000,"He was transferred back to
the [**Hospital Unit Name 153**] in stable condition.
On arrival back to the [**Hospital Unit Name 153**], his initial VS were T95.6 P82
BP118/39 RR14 Sat94%RA. He has mild RUQ pain but he is
comfortable and has no acute complain. On ROS, denies chest
pain, shortness of breath, N/V/D, no palps, myalgias,
arthralgieas, dysuria, hematuria.
Past Medical History:
PMH:
- HTN
- hyperlipidemia
- ? bladder neoplasm
PSH:
- TURP
- ? resection of tumor from the bladder
Social History:
Lives with wife, retired, smoked a pack a day for about 40
years, quit several years ago"
7001,"Brief Hospital Course:
1. SIRS/sepsis with:
- cholangitis
- septicemia (GNR and anaerobic bacteremia)
- liver abscess
Initially presented to an OSH with signs and symptoms suggestive
of cholangitis (RUQ pain, fever and hypotension; labs and
ultrasound indicative of biliary obstruction). He was taken for
ERCP on [**6-4**] which revealed gallbaldder sludge and a filling
defect in the middle third of CBD without stone presence or
extrinsic compression; a stent was placed.
Surgery recommended PTC drain to decompress the gallbladder
which was done on [**6-7**]. Blood cultures returned with klebsiella
and clostridium species. After initially treating broadly,
antibiotics were narrowed."
7002,"Unfortunately, the patient worsened
with RUQ ultrasound and MRCP showed worsening perihepatic
abscesses; repeat blood culture returned positive for bacillus.
After drainage of the largest liver abscess by interventional
radiology and use of vancomycin (for empiric enterococcus),
pip-tazo, and fluconazole (for empiric fungal coverage) he once
again improved.
At the time of discharge, plan included;
- antibiotics (vancomycin and ertepenem) until
cholecystectomy
- cholecystectomy in [**4-3**] weeks
- once cholecystectomy performed, both the gallbladder
drain and plastic stent can be removed
2. CHF, acute diastolic, resolved. After volume repletion was
grossly overloaded requiring diuresis.
3. Acute renal failure. Improved with supportive care."
7003,"oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Location (un) 5871**]/[**Location (un) 6159**]
Discharge Diagnosis:
acute cholecystitis, choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fevers, confusion and cholangitis.
An ERCP on [**6-4**] revealed gallbaldder sludge and a filling defect
in the middle third of CBD without stone. To help reduce the
pressure in the gallbladder, a stent was placed followed by a
drain."
7004,"Family History:
No family history of biliary or hepatic disease, gallstones,
pancreatitis
Physical Exam:
on admission:
gen: NAD, pleasant, jaundiced sclera, flushed in the face,
uncomfortable in pain
VS: 99.4 80 83/42 16 97% Nasal Cannula
CV: RRR
pulm: CTA b/l
abdomen: mildly softly distended, + BS, tender in the RUQ
tolight palpation, also tender in RLQ to deeper palpation
extremities: no LE edema, no cyanosis
Pertinent Results:
ERCP ([**2171-6-4**])
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized. The course and caliber of the
structures are normal with no evidence of extrinsic compression."
7005,"There was a filling defect in the middle third of the common
bile duct. This could represent stone fragment or debris. The
intrahepatics appeared normal, but the cholangiogram was limited
due to a small amount of contrast injection due to the patient's
sepsis from cholangitis. Successful placement of a plastic
biliary stent for decompression. Otherwise normal ercp to third
part of the duodenum
CT ABDOMEN ([**2171-6-4**])
1. Air within a mildly distended gallbladder with associated
pericholecystic stranding is compatible with acute
cholecystitis, with likely involvement of a gas-forming
organism.
2. Pneumobilia and ill-defined hypodensities in the left lobe of
the liver are concerning for infection with developing hepatic
abscesses, likely secondary to ascending cholangitis."
7006,"6
BLOOD CULTURE ([**2171-6-4**]): pansensitive
BLOOD CULTURE ([**2171-6-10**])
GRAM POSITIVE ROD(S).
CONSISTENT WITH CLOSTRIDIUM OR
BACILLUS SPECIES.
BILE CULTURE ([**2171-6-7**])
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN/SULBACTAM-- <=2 S 8 S
CEFAZOLIN------------- <=4 S 16 I
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2171-6-11**]):
CLOSTRIDIUM PERFRINGENS. SPARSE GROWTH."
7007,"3. Calcifications in the region of the distal common bile duct
could be within the lumen of the duct, although could also be
within the pancreatic head. Further evaluation could be
performed with MRCP, if clinically indicated.
4. Right adrenal nodule, not fully characterized.
5. Well-defined hypodense liver lesions are likely simple cysts,
as described above.
DISCHARGE LABS ([**2171-6-17**])
WBC-7.0 RBC-3.55* Hgb-11.1* Hct-33.4* MCV-94 MCH-31.2 MCHC-33.2
RDW-13.4 Plt Ct-362
Glucose-107* UreaN-8 Creat-1.0 Na-141 K-3.7 Cl-104 HCO3-26
AnGap-15
BLOOD ALT-63* AST-51* LD(LDH)-248 AlkPhos-52 TotBili-0."
7008,"Medications on Admission:
- HCTZ 25 mg PO qd
- cetirizine 10 mg PO qd
- citalopram 20 mg PO qd
Discharge Medications:
1. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. ertapenem 1 gram Recon Soln Sig: One (1) gram Injection once
a day for 4 weeks.
Disp:*qs mg* Refills:*0*
5. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 4 weeks."
7009,"You also required drainage of a liver abscess by
interventional radiology.
As a result of these multiple infections, you will require:
1. Treatment with antibiotics (ertapenem and vancomycin) with
coordination and duration directed by the infectious diseases
team
2. Removal of your gallbladder (cholecystectomy). Dr. [**Last Name (STitle) 853**] will
coordinate timing of this with you.
Once the gallbladder has been removed, the current gallbladder
drain and stent can be removed.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2171-6-25**] at 4:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage"
7010,"It
occurred suddenly, has been constant, dull, and nonradiating in
nature. He has been anorexic but denies nausea or vomiting. He
notes subjective fevers. He had confusion per his wife. His
urine has been cola-colored, but denies changes in his stool.
Has not noticed yellowing of skin. No previous history of
biliary or hepatic disease. Denies previous gall stones. He saw
his PCP, [**Name10 (NameIs) 1023**] referred him to the [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **]. There he was
febrile to 103.8F with systolic blood pressures in the upper 80s
which responded well to fluid resuscitations. He had a RUQ US
showing acute cholecystitis with a CBD diameter of 5mm."
7011,"Disp:*[**Numeric Identifier **] mg* Refills:*0*
6. Outpatient Lab Work
[**2171-6-24**] - result to Dr. [**Last Name (STitle) 9461**] (fax [**Telephone/Fax (1) 17715**])
Vancomycin trough
LFTs
CBC with diff
Chem 7
7. Outpatient Lab Work
[**2171-7-2**] - result to Dr. [**Last Name (STitle) 9461**] (fax [**Telephone/Fax (1) 17715**])
Vancomycin trough
LFTs
CBC with diff
Chem 7
8. Outpatient Lab Work
[**2171-7-8**] - result to Dr. [**Last Name (STitle) 9461**] (fax [**Telephone/Fax (1) 17715**])
Vancomycin trough
LFTs
CBC with diff
Chem 7
9. Outpatient Lab Work
[**2171-7-15**] - result to Dr. [**Last Name (STitle) 9461**] (fax [**Telephone/Fax (1) 17715**])
Vancomycin trough
LFTs
CBC with diff
Chem 7
10."
7012,"Department: INFECTIOUS DISEASE
When: THURSDAY [**2171-6-27**] at 3:10 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ENDO SUITES
When: TUESDAY [**2171-7-2**] at 12:00 PM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2171-7-2**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage"
7013,"The patient was deemed to be not a surgical
candidate currently and request for percutaneous cholecystostomy was made for
treatment of acute cholecystitis.
COMPARISON: Outside ultrasound [**2171-6-4**] and outside CT [**2171-6-4**].
ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY:
Limited preprocedural ultrasound demonstrated persistently mildly distended
gallbladder at approximately 4 cm with some small echogenic stones within the
lumen and unchanged wall thickening and mild edema. These findings are again
most consistent with underlying acute cholecystitis in concordance with the
prior imaging.
Informed consent was obtained from the patient after explaining the risks and
benefits of the procedure. A preprocedure timeout was performed documenting
the nature of procedure and the patient identity using two independent
verifiers."
7014,"Appropriate spot for catheter placement was chosen using a lower
right intercostal space and the overlying skin was prepped and draped in
normal sterile fashion. Subsequently, under continuous ultrasound guidance,
approximately 10 mL of sodium bicarbonate buffered 1% lidocaine was instilled
for local anesthesia, extending down towards the liver capsule. Using trocar
technique, an 8 French [**Last Name (un) 1372**] catheter was then advanced into the gallbladder
lumen under continuous son[**Name (NI) 211**] observation with tip placement confirmed to
be within the lumen under ultrasound. The catheter was deployed after return
of bilious material. The pigtail was formed and the catheter was secured
using a StatLock device and a total of 100 mL of slightly hemorrhagic bile
with mild purulence was aspirated."
7015,"[**2171-6-7**] 2:02 PM
GB DRAINAGE,INTRO PERC TRANHEP BIL US; Clip # [**Clip Number (Radiology) 42360**]
Reason: please place perc chole
Admitting Diagnosis: CHOLANGITIS
********************************* CPT Codes ********************************
* GB DRAINAGE,INTRO PERC TRANHEP BIL U *
****************************************************************************
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
79 year old man here with cholangitis, sepsis, s/p ERCP and stent
REASON FOR THIS EXAMINATION:
please place perc chole
______________________________________________________________________________
PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe FRI [**2171-6-7**] 4:47 PM
PFI:
Uncomplicated 8 French percutaneous cholecystostomy tube. Small sample was
sent for Gram stain and culture.
______________________________________________________________________________
FINAL REPORT
HISTORY: Cholangitis, sepsis and acute cholecystitis status post ERCP, CBD
stent with probable stone."
7016,"A small sample was sent for Gram stain and
culture. A sterile dressing was applied. The patient tolerated the procedure
well with no immediate post-procedural complications. The procedure was
performed by Dr. [**Last Name (STitle) 1455**] and Dr. [**Last Name (STitle) 1722**], the attending radiologist, who was
participating throughout.
(Over)
[**2171-6-7**] 2:02 PM
GB DRAINAGE,INTRO PERC TRANHEP BIL US; Clip # [**Clip Number (Radiology) 42360**]
Reason: please place perc chole
Admitting Diagnosis: CHOLANGITIS
______________________________________________________________________________
FINAL REPORT
(Cont)
Moderate sedation was provided by administering divided doses of 50 mcg of
fentanyl and 1 mg of Versed throughout the total intraservice time of 20
minutes during which time the patient's hemodynamic parameters were
continuously monitored.
IMPRESSION:
Uncomplicated 8 French percutaneous cholecystostomy tube. Small sample was
sent for Gram stain and culture."
7017,"He has no history of similar pain.
He was taken by EMS where he was found to have ST elevations in
the inferior leads, which resolved with nitroglycerine. He was
taken to the cath lab were he was found to have severe, difuse 3
vessel disease not amenable to percutaneous intervention. He is
transfered for surgical intervention.
Past Medical History:
PMHx: Multiple broken bones, s/p spinal fusion ""L region"" 25
years ago
s/p surgical repair/pinning of R clavicle s/p repair of torn R
rotator cuff
Social History:
Lives with:wife and 3 children
Occupation:IT analyist
Tobacco:denies
ETOH:2 beers/week
runs 5 miles/day"
7018,"Discharge Disposition:
Home With Service
Facility:
Care Centrix
Discharge Diagnosis:
CAD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
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**]"
7019,"13 m2
Indication: Intraop CABG acute STEMI
ICD-9 Codes: 410.91, 424.0
Test Information
Date/Time: [**2127-4-25**] at 09:34 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine: us 4
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm"
7020,"Carotid Bruit Right: none Left:none
Pertinent Results:
[**2127-4-29**] 06:50AM BLOOD WBC-5.8 RBC-3.11* Hgb-10.3* Hct-28.9*
MCV-93 MCH-33.3* MCHC-35.8* RDW-14.6 Plt Ct-187#
[**2127-4-25**] 04:14AM BLOOD WBC-4.8 RBC-4.03* Hgb-13.4* Hct-37.7*
MCV-94 MCH-33.2* MCHC-35.5* RDW-12.6 Plt Ct-237
[**2127-4-25**] 01:43PM BLOOD PT-14.2* PTT-26.3 INR(PT)-1.2*
[**2127-4-25**] 04:14AM BLOOD PT-12.6 PTT-46.5* INR(PT)-1."
7021,"1
[**2127-4-29**] 06:50AM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-139
K-4.2 Cl-103 HCO3-27 AnGap-13
[**2127-4-25**] 04:14AM BLOOD Glucose-107* UreaN-15 Creat-0.7 Na-139
K-3.7 Cl-105 HCO3-27 AnGap-11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 89931**] (Complete)
Done [**2127-4-25**] at 9:34:01 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2074-8-24**]
Age (years): 52 M Hgt (in): 72
BP (mm Hg): 101/56 Wgt (lb): 200
HR (bpm): 40 BSA (m2): 2."
7022,"Admission Date: [**2127-4-25**] Discharge Date: [**2127-4-29**]
Date of Birth: [**2074-8-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
OPERATION:
1. Emergency coronary artery bypass graft x6, left internal
mammary artery to left anterior descending artery,
saphenous vein sequential grafting to obtuse marginal 1
and 2, saphenous vein sequential grafting to posterior
left ventricular branch and posterior descending artery,
saphenous vein graft to diagonal.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
Mr. [**Known lastname **] is a 52 yo who woke this pm with left sided chest
discomfort radiating to jaw."
7023,"Family History:
n/c
Physical Exam:
Physical Exam
Pulse:47 Resp: 14 O2 sat: 100%
B/P Right: 115/67 Left:
Height: Weight:
General:
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-none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
[x]Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: angioseal-no hematoma Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right: 2+ Left:2+"
7024,"All appropriate follow up instructions were advised.
Medications on Admission:
None
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5."
7025,"2 cm
Aortic Valve - Valve Area: 3.3 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.2 m/sec
Mitral Valve - E/A ratio: 2.50
Mitral Valve - E Wave deceleration time: 197 ms 140-250 ms
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. No atheroma in ascending aorta. Normal
aortic arch diameter."
7026,"He 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. Mr.[**Known lastname **] was
transferred to the step down unit further recovery. Chest tubes
and pacing wires were discontinued without complication.
Physical therapy was consulted for evaluation of assistance with
strength and mobility. He continued to progress and by the time
of discharge on POD #4 he was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. Dr.[**First Name (STitle) **]
cleared him for discharge to home with VNA services on POD#4."
7027,"Focal calcifications in aortic arch.
Normal descending aorta diameter. Focal calcifications in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
Pre bypass: The left atrium is normal in size. There is mild
symmetric LVH with mild LV chamber enlargement."
7028,"Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Post bypass: Patient is a paced on phenylepherine infusion.
Preserved biventricular function, LVEF >55%. MR remains trace.
Aortic contours intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2127-4-25**] 13:51"
7029,"?????? [**2119**] CareGroup IS. All rights reserved.
Brief Hospital Course:
The patient was brought to the operating room on [**4-25**] where he
underwent CABGX6 ( left internal mammary artery to left anterior
descending artery, saphenous vein sequential grafting to obtuse
marginal 1 and 2, saphenous vein sequential grafting to
posterior left ventricular branch and posterior descending
artery, saphenous vein graft to diagonal) with Dr.[**First Name (STitle) **]. Please
refer to operative report for further surgical details. He was
transferred to CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably."
7030,"docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*"
7031,"Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: 0.43 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Left Ventricle - Stroke Volume: 76 ml/beat
Left Ventricle - Cardiac Output: 3.04 L/min
Left Ventricle - Cardiac Index: *1.43 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 2 mm Hg
Aortic Valve - LVOT VTI: 20
Aortic Valve - LVOT diam: 2."
7032,"**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr.[**Last Name (STitle) 7772**] #[**Telephone/Fax (1) 170**] Date/Time:[**2127-5-26**] at 1:00
Cardiologist Dr.[**Last Name (STitle) 31888**] on [**5-29**] at 1pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] in [**5-20**] weeks
Address: [**2127**], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 42001**]
Phone: [**Telephone/Fax (1) 76493**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2127-4-29**]"
7033,"# Hypotension: resolved in ED after IVFs and normotensive in MICU;
elevated lactate
- monitor BPs
- f/u all culture data
- IVF boluses prn
- repeat lactate in AM
.
# Leukocytosis: Likely [**2-24**] UTI and pancreatitis with ? ascending
cholangitis
- continue IV antibiotics as above
- monitor fever curve
- trend WBC
.
# Hypernatremia: Appears volume contracted.
- gentle IVFs overnight
- recheck Na in AM
.
# UTI: UA + in ED; got ceftriaxone in ED
- send urine culture
- continue IV antibiotics (zosyn) and narrow accordingly
.
# Atrial fibrillation: irregularly irregular
- continue digoxin
.
# GI bleed: noted to have guiaic positive emesis. Pt hemodynamically
stable now. Hct 37.6. Likely UGI Bleed, possibly [**First Name4 (NamePattern1) 331**] [**Last Name (NamePattern1) **], in
setting of vomiting."
7034,"[**First Name (STitle) 335**]
s note
above and would add/emphasize:
88F with Alzheimer's dementia, afib, and [**Hospital 337**] transferred from [**Hospital 327**]
Hospital for emergent ERCP for presumed gallstone pancreatitis. Pt was
in USOH at NH until episode of emesis large amount of undigested food
at 2 AM on [**2187-9-21**]. Then episode emesis lg quantity of brown liquid
that was reportedly guiaic positive. There found to have presumed
gallstone pancreatitis. Transferred to [**Hospital1 1**] ED for admission for
possible ERCP. In [**Name (NI) **] pt hypotensive & tachycardic. Admitted to ICU
for close hemodynamic monitoring, stabilization prior to possible ERCP
in am."
7035,"Thought to have gallstone pancreatitis and would need
ERCP, so pt was transferred to [**Hospital1 **].
.
In [**Hospital1 1**] ED, T 98.9 BP 99/62 HR 101 RR 19 O2 sat 93% 2L NC
2 L NS given. Flagyl 500 mg IV x 1, Vancomycin 1 gram IV x 1, and
Ceftriaxone 1 g IV x 1 given. RUQ U/S, CXR, and CT abdomen with
contrast performed. UA +. ERCP fellow aware and want to continue IV
fluids and IV antibiotics. Fellow plans to see pt in AM for possible
ERCP. Of note, report from ED that pt was transiently hypotensive in
90s but cannot find documentation of this in ED notes."
7036,".
ROS: Unable to obtain.
.
PAST MEDICAL HISTORY:
Dementia
Edema
Atrial Fibrillation
Failure to thrive
Cellulitis
GI bleed
.
MEDICATIONS:
Milk of Magnesia prn
Acetaminophen prn
Compazine 25 mg PR q 12 hour prn
ASA 81 mg daily
Digoxin 250 mcg daily
Colace 100 mg daily
.
ALLERGIES: Penicllins
.
SOCIAL HISTORY: Lives in [**Hospital3 59**] facility, [**Hospital 328**] Nursing Home.
.
FAMILY HISTORY: Unable to obtain
.
PHYSICAL EXAM:
VITALS: T: 98.5 BP: 132/76 HR: 86 RR: 22 O2Sat: 92% on 2 L NC
GEN: NAD, only responsive to noxious stimuli (i.e. opening eyes),
sleeping in bed
HEENT: pinpoint pupils, sluggish reaction to light, unable to assess
EOMI, no LAD, unable to assess OP
CHEST: CTAB anteriorly, no w/r/r
CV: irreg irreg, II/VI SEM heard at LUSB, no r/g
ABD: slightly distended, TTP over RUQ, decreased BS
EXT: no c/c/e
NEURO: only responsive to noxious stimuli
SKIN: no rashes noted
."
7037,"98.5 132/76 86 22 92% 2LNC
Somnolent (4:30am) but arouses to nox stim.
Lungs clear anteriorly
Cv
II 2/6SEM
Abd
sl distended. Tender RUQ. No rebound or guarding.
Ext
no c/c/e
Data: na 146. creat 0.8 ast 55 lipase 2645
WBC 13.2 no bands, lactate 3.1
+UTI
EKG
ST dep v3-v6 no basis for comparison.
U/S no acute cholecystitis, 10mm cbd
CT c/w pancreatitis
A/P
88F transferred w/ presumed GS pancreatitis for ? ERCP
GS pancreatitis
- ERCP fellow aware
likely to ERCP in am
Sepsis
febrile (OSH), inc WBC, lactate, Hypotension, tachy.
- several potential etiol
asc cholangitis vs.
UTI/pyelo
- fluid resuscitation, pressors if needed.
- cx sent
- broad spectrum abx empirically pendnig cx data
guidance.
Hypernatremia
fluid resusc
Emesis
anitemetics as needed. Likely element gastritis
Code - full
Pt is hemodyn unstable requiring critical care. Time spent 40 min.
------ Protected Section Addendum Entered By:[**Name (NI) 322**] [**Last Name (NamePattern1) 323**], MD
on:[**2187-9-22**] 04:59 ------"
7038,"Also consider gastritis.
- monitor Hcts q12 hours
.
# Alzheimer's Dementia:
- frequent reorientation
- strict sleep-wake cycle
.
# Access: PIVs
.
# PPx: PPI / heparin SQ / bowel regimen
.
# FEN: IVFs / replete lytes prn / NPO for possible ERCP in AM
.
# Code: FULL
.
# COMM: [**First Name8 (NamePattern2) 332**] [**Known lastname 326**]-[**Doctor Last Name **] cell [**Telephone/Fax (1) 333**]
.
# Dispo: ICU until ERCP
.
.
.
.
[**First Name8 (NamePattern2) 334**] [**Last Name (NamePattern1) 335**], MD, MPH
[**Numeric Identifier 336**]
PGY-2
------ Protected Section ------
Chart reviewed & pt examined, case discussed in detail w/ Dr. [**First Name (STitle) 335**]. I
was present for all key aspects of care. I agree with Dr."
7039,"LABORATORIES: See below.
.
STUDIES:
EKG: NSR at 90 bpm, nl axis, II, V3-V5 with ST depressions. No
comparison.
.
CXR [**2187-9-21**]: moderate rotation on CXR, no evidence of PTX or focal
consolidation. no pulmonary edema or large effusions. calcifications
over R heart likely severe annular calcification. Air filled upper
esophagus, may be dysmotility.
.
LIVER U/S [**2187-9-21**]: Please note this examination was extensively limited
due to patient inability to cooperate during image acquisition. The
liver parenchyma is homogenous with no focal lesions identified. No
intrahepatic ductal dilatation is identified with the CHD measuring
approximately 3 mm."
7040,"[**Hospital Unit Name 10**] Resident Admission Note
.
Reason for MICU Admission: Pancreatitis and hypotension.
.
Primary Care Physician: [**Name Initial (NameIs) 324**].
.
CC:[**CC Contact Info 325**] .
HPI: Ms. [**Known lastname 326**] is an 88 y.o. F with Alzheimer's dementia, afib, and
failure to thrive, transferred from [**Hospital 327**] Hospital for emergent ERCP
for presumed gallstone pancreatitis. The patient was at her nursing
home when she was noted to have an episode of vomiting of large amount
of undigested food at 2 AM on [**2187-9-21**]. She then vomited a large amount
of brown liquid that was reportedly guiaic positive."
7041,"MD [**First Name (Titles) **] [**Last Name (Titles) 122**] made
aware and referred to ED. O2 sats were noted to be 85-88% on RA and 2
L NC brought O2 sat to 92%.
.
At [**Hospital 327**] Hospital ED, VS: BP 129/68 P 83 R 18 Temp 100.3 O2 sat
93% on RA. EKG reported to have sinus rhythm with ST depressions in
V3-V6 consistent with digoxin without comparison. the patient was
given Flagyl 500 mg IV x 1 and Levaquin 500 mg IV x 1. U/S reportedly
showed few GB stones, slightly enlarged CBD, pancreas with
inflammation."
7042,"stranding around pancreas consistent with known
pancreatitis with no regions of necrosis. RLL infectious bronchiolitis
with complete mucoid impaction of lower lobe bronchi b/l.
.
ASSESSMENT & PLAN: 88 y.o. F with Alzheimer's dementia, afib, and
failure to thrive, transferred from [**Hospital 327**] Hospital for emergent ERCP
for presumed gallstone pancreatitis.
.
# Pancreatitis: Likely gallstone with stones and sludge in
gallbladder. Elevated lipase on labs and CT abd/pelvis demonstrated
pancreas stranding as well as 10 cm CBD.
- NPO
- IVFs overnight
- trend LFTs, amylase, lipase
- f/u ERCP recs: likely to go to ERCP tomorrow; continue IV fluids and
IV antibiotics
- continue IV antibiotics (zosyn) and narrow accordingly
."
7043,"The gallbladder displays a mild amount of layering
biliary [**Doctor Last Name 329**] (combination of sludge/stones) but no evidence of wall
edema or pericholecystic fluid collections. The right kidney measures 9
cm and displays mild caliectasis, but no pelviectasis or
hydronephrosis. Limited evaluation of the pancreatic
body and tail was normal with additional region of the pancreas unable
to be identified due to bowel gas obscuration. Portal vein is patent
with normal hepatopetal flow.
IMPRESSION:
1. Cholelithiasis/biliary sludge. No son[**Name (NI) 330**] findings to suggest
acute cholecystitis.
2. Mild right-sided calyectasis without hydronephrosis.
.
CT ABD/PELVIS [**2187-9-21**]: (wet read)10mm cbd, no intrahepatic ductal
dilatation."
7044,"[**Hospital Unit Name 10**] Resident Admission Note
.
Reason for MICU Admission: Pancreatitis and hypotension.
.
Primary Care Physician: [**Name Initial (NameIs) 324**].
.
CC:[**CC Contact Info 325**] .
HPI: Ms. [**Known lastname 326**] is an 88 y.o. F with Alzheimer's dementia, afib, and
failure to thrive, transferred from [**Hospital 327**] Hospital for emergent ERCP
for presumed gallstone pancreatitis. The patient was at her nursing
home when she was noted to have an episode of vomiting of large amount
of undigested food at 2 AM on [**2187-9-21**]. She then vomited a large amount
of brown liquid that was reportedly guiaic positive."
7045,"stranding around pancreas consistent with known
pancreatitis with no regions of necrosis. RLL infectious bronchiolitis
with complete mucoid impaction of lower lobe bronchi b/l.
.
ASSESSMENT & PLAN: 88 y.o. F with Alzheimer's dementia, afib, and
failure to thrive, transferred from [**Hospital 327**] Hospital for emergent ERCP
for presumed gallstone pancreatitis.
.
# Pancreatitis: Likely gallstone with stones and sludge in
gallbladder. Elevated lipase on labs and CT abd/pelvis demonstrated
pancreas stranding as well as 10 cm CBD.
- NPO
- IVFs overnight
- trend LFTs, amylase, lipase
- f/u ERCP recs: likely to go to ERCP tomorrow; continue IV fluids and
IV antibiotics
- continue IV antibiotics (zosyn) and narrow accordingly
."
7046,"Thought to have gallstone pancreatitis and would need
ERCP, so pt was transferred to [**Hospital1 **].
.
In [**Hospital1 1**] ED, T 98.9 BP 99/62 HR 101 RR 19 O2 sat 93% 2L NC
2 L NS given. Flagyl 500 mg IV x 1, Vancomycin 1 gram IV x 1, and
Ceftriaxone 1 g IV x 1 given. RUQ U/S, CXR, and CT abdomen with
contrast performed. UA +. ERCP fellow aware and want to continue IV
fluids and IV antibiotics. Fellow plans to see pt in AM for possible
ERCP. Of note, report from ED that pt was transiently hypotensive in
90s but cannot find documentation of this in ED notes."
7047,".
ROS: Unable to obtain.
.
PAST MEDICAL HISTORY:
Dementia
Edema
Atrial Fibrillation
Failure to thrive
Cellulitis
GI bleed
.
MEDICATIONS:
Milk of Magnesia prn
Acetaminophen prn
Compazine 25 mg PR q 12 hour prn
ASA 81 mg daily
Digoxin 250 mcg daily
Colace 100 mg daily
.
ALLERGIES: Penicllins
.
SOCIAL HISTORY: Lives in [**Hospital3 59**] facility, [**Hospital 328**] Nursing Home.
.
FAMILY HISTORY: Unable to obtain
.
PHYSICAL EXAM:
VITALS: T: 98.5 BP: 132/76 HR: 86 RR: 22 O2Sat: 92% on 2 L NC
GEN: NAD, only responsive to noxious stimuli (i.e. opening eyes),
sleeping in bed
HEENT: pinpoint pupils, sluggish reaction to light, unable to assess
EOMI, no LAD, unable to assess OP
CHEST: CTAB anteriorly, no w/r/r
CV: irreg irreg, II/VI SEM heard at LUSB, no r/g
ABD: slightly distended, TTP over RUQ, decreased BS
EXT: no c/c/e
NEURO: only responsive to noxious stimuli
SKIN: no rashes noted
."
7048,"MD [**First Name (Titles) **] [**Last Name (Titles) 122**] made
aware and referred to ED. O2 sats were noted to be 85-88% on RA and 2
L NC brought O2 sat to 92%.
.
At [**Hospital 327**] Hospital ED, VS: BP 129/68 P 83 R 18 Temp 100.3 O2 sat
93% on RA. EKG reported to have sinus rhythm with ST depressions in
V3-V6 consistent with digoxin without comparison. the patient was
given Flagyl 500 mg IV x 1 and Levaquin 500 mg IV x 1. U/S reportedly
showed few GB stones, slightly enlarged CBD, pancreas with
inflammation."
7049,"LABORATORIES: See below.
.
STUDIES:
EKG: NSR at 90 bpm, nl axis, II, V3-V5 with ST depressions. No
comparison.
.
CXR [**2187-9-21**]: moderate rotation on CXR, no evidence of PTX or focal
consolidation. no pulmonary edema or large effusions. calcifications
over R heart likely severe annular calcification. Air filled upper
esophagus, may be dysmotility.
.
LIVER U/S [**2187-9-21**]: Please note this examination was extensively limited
due to patient inability to cooperate during image acquisition. The
liver parenchyma is homogenous with no focal lesions identified. No
intrahepatic ductal dilatation is identified with the CHD measuring
approximately 3 mm."
7050,"# Hypotension: resolved in ED after IVFs and normotensive in MICU;
elevated lactate
- monitor BPs
- f/u all culture data
- IVF boluses prn
- repeat lactate in AM
.
# Leukocytosis: Likely [**2-24**] UTI and pancreatitis with ? ascending
cholangitis
- continue IV antibiotics as above
- monitor fever curve
- trend WBC
.
# Hypernatremia: Appears volume contracted.
- gentle IVFs overnight
- recheck Na in AM
.
# UTI: UA + in ED; got ceftriaxone in ED
- send urine culture
- continue IV antibiotics (zosyn) and narrow accordingly
.
# Atrial fibrillation: irregularly irregular
- continue digoxin
.
# GI bleed: noted to have guiaic positive emesis. Pt hemodynamically
stable now. Hct 37.6. Likely UGI Bleed, possibly [**First Name4 (NamePattern1) 331**] [**Last Name (NamePattern1) **], in
setting of vomiting. Also consider gastritis.
- monitor Hcts q12 hours
.
# Alzheimer's Dementia:
- frequent reorientation
- strict sleep-wake cycle
.
# Access: PIVs
.
# PPx: PPI / heparin SQ / bowel regimen
.
# FEN: IVFs / replete lytes prn / NPO for possible ERCP in AM
.
# Code: FULL
.
# COMM: [**First Name8 (NamePattern2) 332**] [**Known lastname 326**]-[**Doctor Last Name **] cell [**Telephone/Fax (1) 333**]
.
# Dispo: ICU until ERCP
.
.
.
.
[**First Name8 (NamePattern2) 334**] [**Last Name (NamePattern1) 335**], MD, MPH
[**Numeric Identifier 336**]
PGY-2"
7051,"The gallbladder displays a mild amount of layering
biliary [**Doctor Last Name 329**] (combination of sludge/stones) but no evidence of wall
edema or pericholecystic fluid collections. The right kidney measures 9
cm and displays mild caliectasis, but no pelviectasis or
hydronephrosis. Limited evaluation of the pancreatic
body and tail was normal with additional region of the pancreas unable
to be identified due to bowel gas obscuration. Portal vein is patent
with normal hepatopetal flow.
IMPRESSION:
1. Cholelithiasis/biliary sludge. No son[**Name (NI) 330**] findings to suggest
acute cholecystitis.
2. Mild right-sided calyectasis without hydronephrosis.
.
CT ABD/PELVIS [**2187-9-21**]: (wet read)10mm cbd, no intrahepatic ductal
dilatation."
7052,"Admission Date: [**2187-9-22**] Discharge Date: [**2187-9-27**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 year old Female with Alzheimer's dementia, Atrial
Fibrillation, moderate malnutrition, transferred from [**Hospital 1562**]
Hospital for emergent ERCP for presumed gallstone pancreatitis
and septic shock. The patient was at her nursing home when she
was noted to have an episode of vomiting of large amount of
undigested food at 2 AM on [**2187-9-21**]. She then vomited a large
amount of brown liquid that was reportedly hemocult positive."
7053,"CHEST (PORTABLE AP) Study Date of [**2187-9-23**] 4:50 AM
IMPRESSION: Increasing density in the left lung and right lung
base
concerning for pneumonia. Clinical correlation is recommended.
CHEST (PORTABLE AP) Study Date of [**2187-9-25**] 11:16 AM
FINDINGS: Bilateral pleural effusions and moderate interstitial
edema have
increased, compared with the prior study. The left upper lobe
opacity has
improved. Opacity in the right lower lung has increased in the
interval. Left retrocardiac opacity remains present. There is no
pneumothorax.
Brief Hospital Course:
1. Acute Pancreatitis, Choledocolithiasis with Obstruction,
Septicemia
- Patient was kept NPO, and given agressive IV rehydration
- Amylase trended down from 1107 to 305, lipase from 1175 down
to 92 on discharge from ICU."
7054,"- ERCP team was consulted, who believed that she had passed the
stone, given her improving labs.
- Levaquin and Flagyl were initiated
- Patient was on Vancomycin in hospital for MRSA empiric
coverage, discontinued prior to discharge
- Feeds were reintroduced on the floor and tolerated well
2. Bacterial UTI with Indwelling Catheter:
- Levaquin/Flagyl
- Foley changed
3. Acute Blood Loss Anemia due to Hematemesis
- Resolved on admission
- Likely [**Doctor First Name 329**] [**Doctor Last Name **] tear vs. mild gastritis
4. Bacterial Pneumonia
- Levaquin/Flagyl given possibility of aspiration
- Afebrile x48 hours at time of discharge
- Some element of fluid overload, so intermittant lasix given"
7055,"No focal filling defects were identified;
however, CT is insensitive for detection of choledocholithiasis.
2. Peri-inflammatory changes and free fluid within the abdomen
consistent
with acute pancreatitis. No regions of pancreatic necrosis
identified.
3. Scattered tree-in-[**Male First Name (un) 239**] opacities reflecting an infectious
bronchiolitis
within the right lower lobe in this patient with a complete
mucoid impaction of the lower lobe bronchi bilaterally.
4. Incompletely characterized small hypoattenuating right
hepatic and right renal lesions, likely benign cysts, but too
small to definitively
characterize.
5. Extensive mitral annular calcification and atherosclerotic
disease within the coronary vessel and aorta."
7056,"6
[**2187-9-23**] 05:15AM BLOOD ALT-30 AST-22 LD(LDH)-205 AlkPhos-62
Amylase-305* TotBili-0.6
[**2187-9-22**] 04:01AM BLOOD ALT-50* AST-41* LD(LDH)-279* AlkPhos-69
Amylase-1107* TotBili-0.5
[**2187-9-21**] 08:20PM BLOOD ALT-70* AST-55* AlkPhos-75 TotBili-0.6
[**2187-9-25**] 05:35AM BLOOD Lipase-35
[**2187-9-24**] 05:10AM BLOOD Lipase-32
[**2187-9-23**] 05:15AM BLOOD Lipase-92*
[**2187-9-22**] 04:01AM BLOOD Lipase-1175*
[**2187-9-26**] 05:30AM BLOOD Calcium-7.6* Phos-2.0* Mg-1."
7057,"5. Atrial fibrillation
- continue digoxin
6. Alzheimer's Dementia:
- at baseline, per family.
- Geriatrics consult was obtained, concur with current
management
- There is a suggestion by the geriatrics team, for her primary
team at the [**Hospital1 1501**] to consider hospice discussions with the family
Medications on Admission:
Milk of Magnesia prn
Acetaminophen prn
Compazine 25 mg PR q 12 hour prn
ASA 81 mg daily
Digoxin 250 mcg daily
Colace 100 mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily)."
7058,"No previous tracing available for
comparison.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2187-9-21**]
8:51 PM
IMPRESSION:
1. Cholelithiasis/biliary sludge. No son[**Name (NI) 493**] findings to
suggest acute
cholecystitis.
2. Mild right-sided calyectasis without hydronephrosis.
CHEST (SINGLE VIEW) Study Date of [**2187-9-21**] 9:27 PM
1. No evidence of pneumonia, slightly limited film due to
patient
incooperation and rotation.
2. Extensive mitral annular calcification.
CT ABDOMEN W/CONTRAST Study Date of [**2187-9-21**] 11:14 PM
IMPRESSION:
1. Moderately distended gallbladder without any intrahepatic
ductal
dilatation and mild prominence of the extrahepatic CBD which
measures 10 mm."
7059,"The nursing home physician was made aware and referred to ED.
The patient's oxygen saturation was noted to be 85-88% on room
air and 2L of oxygen via NC brought her saturation to 92%.
At [**Hospital 1562**] Hospital ED, VS: BP 129/68 P 83 R 18 Temp 100.3
O2 sat 93% on RA. EKG reported to have sinus rhythm with ST
depressions in V3-V6 consistent with digoxin artifact without
comparison. The patient was given Flagyl 500 mg IV x 1 and
Levaquin 500 mg IV x 1. An ultrasound of the abdomen there
reportedly showed cholelithiasis, a slightly enlarged CBD, and
pancreatic inflammation."
7060,"Thought to have gallstone pancreatitis
and would need an ERCP, so she was transferred to [**Hospital1 **].
In [**Hospital1 18**] ED, her vitals were T 98.9 BP 99/62 HR 101 RR 19 O2
sat 93% 2L NC
2 L NS given. Flagyl 500 mg IV x 1, Vancomycin 1 gram IV x 1,
and Ceftriaxone 1 g IV x 1 were given. RUQ ultrasound, CXR, and
CT abdomen with contrast were performed. her urinalysis was
noted positive for infection. Urgent ERCP consult was obtained
with a plan to continue IV fluids and IV antibiotics. She was
noted hypotensive in the ED, and was admitted to the [**Hospital Unit Name 153**] for
further management."
7061,"9* PTT-30.5 INR(PT)-1.2*
[**2187-9-26**] 05:30AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-144
K-3.0* Cl-110* HCO3-25 AnGap-12
[**2187-9-24**] 05:10AM BLOOD Glucose-82 UreaN-18 Creat-0.7 Na-144
K-3.3 Cl-111* HCO3-24 AnGap-12
[**2187-9-21**] 08:20PM BLOOD Glucose-133* UreaN-25* Creat-0.8 Na-146*
K-4.3 Cl-109* HCO3-27 AnGap-14
[**2187-9-25**] 05:35AM BLOOD ALT-14 AST-14 AlkPhos-67 Amylase-73
TotBili-0.5
[**2187-9-24**] 05:10AM BLOOD ALT-19 AST-14 LD(LDH)-236 AlkPhos-68
Amylase-101* TotBili-0."
7062,"[**2187-9-21**] 11:17 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2187-9-23**]**
URINE CULTURE (Final [**2187-9-23**]): NO GROWTH.
[**2187-9-23**] 6:03 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2187-9-23**]**
GRAM STAIN (Final [**2187-9-23**]):
>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 [**2187-9-23**]):
TEST CANCELLED, PATIENT CREDITED.
ECG Study Date of [**2187-9-21**] 8:57:54 PM
Sinus rhythm. Non-specific ST-T wave abnormalities. Clinical
correlation is suggested."
7063,"3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal every six (6) hours as needed for fever or pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]
Discharge Diagnosis:
Acute Pancreatitis
Choledocolithiasis with Obstruction
Septicemia
Bacterial Pneumonia
Bacterial UTI with Indwelling Catheter
Moderate Malnutrition
Atrial Fibrillation
Acute Blood Loss Anemia
Hematemesis
Alzheimer's Dementia
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with fever, chills, nausea/vomitting,
hypotension, agitation.
Followup Instructions:
Follow up as needed with the medical staff at the facility"
7064,"PHYSICAL EXAM:
GEN: NAD
Pain: 0/0
HEENT: Dry, - OP Lesions
PUL: CTA B/L
COR: Irregular, S1/S2, 2/6 SEM
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: non-verbal, minimally responsive
Pertinent Results:
[**2187-9-26**] 05:30AM BLOOD WBC-12.0* RBC-3.03* Hgb-9.5* Hct-28.7*
MCV-95 MCH-31.4 MCHC-33.2 RDW-12.8 Plt Ct-251
[**2187-9-23**] 11:07AM BLOOD WBC-13.6*# RBC-3.28* Hgb-10.3* Hct-31.2*
MCV-95 MCH-31.5 MCHC-33.2 RDW-13.0 Plt Ct-230
[**2187-9-22**] 04:01AM BLOOD Neuts-84* Bands-7* Lymphs-5* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2187-9-22**] 04:01AM BLOOD PT-13."
7065,"9
[**2187-9-25**] 05:35AM BLOOD Albumin-2.5* Calcium-7.5* Phos-2.3*
Mg-2.0
[**2187-9-23**] 05:15AM BLOOD Hapto-229*
[**2187-9-27**] 06:05AM BLOOD Vanco-12.9
[**2187-9-21**] 08:20PM BLOOD Digoxin-0.9
[**2187-9-22**] 03:45PM BLOOD Lactate-1.3
[**2187-9-22**] 09:59AM BLOOD Lactate-2.2*
[**2187-9-21**] 08:41PM BLOOD Lactate-3.1*
[**2187-9-22**] 09:59AM BLOOD freeCa-1.06*
[**2187-9-22**] 08:59PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2187-9-21**] 10:40PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1."
7066,"A conservative approach to the cholangitis was followed given
her comorbitidities and her response to fluids and antibiotics.
She was also noted with a pneumonia. She was continued on
Vancomycin, along with levaquin and flagyl. After stabilizing,
she was transferred to the medical floor.
She subsequently defervesced, and slowly improved to baseline.
After being afebrile for 48 hours, she was stable to return to
her [**Hospital1 1501**].
Past Medical History:
Dementia
Atrial Fibrillation
Moderate Malnutrition
Social History:
Lives in [**Hospital3 **] facility, [**Hospital 4542**] Nursing Home.
Family History:
non-contributory
Physical Exam:
ROS:
GEN: - fevers
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain"
7067,"024
[**2187-9-22**] 08:59PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2187-9-21**] 10:40PM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2187-9-22**] 08:59PM URINE RBC-65* WBC-12* Bacteri-FEW Yeast-NONE
Epi-0
[**2187-9-21**] 10:40PM URINE RBC-[**12-13**]* WBC-[**12-13**]* Bacteri-FEW
Yeast-NONE Epi-0-2
[**2187-9-21**] 8:20 pm BLOOD CULTURE
**FINAL REPORT [**2187-9-27**]**
Blood Culture, Routine (Final [**2187-9-27**]): NO GROWTH."
7068,"Admission Date: [**2110-8-27**] Discharge Date: [**2110-9-6**]
Date of Birth: [**2059-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Esophageal cancer.
Major Surgical or Invasive Procedure:
[**2110-8-27**]: Minimally-invasive esophagectomy, EGD and laparoscopic
jejunostomy tube placement.
.
[**2110-9-5**]: Esophagogastroduodenoscopy. Dilation of pylorus with 20
mm radial balloon. Injection of pylorus with 200 units of Botox
History of Present Illness:
The patient is 51-year-old gentleman who had a local regionally
advanced esophageal cancer which was T3n2. He underwent
chemotherapy and radiation and had an excellent response by
repeat PET imaging."
7069,"He presented to the OR on [**2110-8-27**] for
Minimally-invasive esophagectomy, EGD and laparoscopic
jejunostomy tube placement.
Past Medical History:
Past Oncologic History:
- [**12-13**] developed symptoms of difficulty swallowing and
dysphagia which progressed over several months, saw GI who
performed an EGD and biopsy which demonstrated adenocarcinoma
- [**2110-5-2**] EUS done at [**Hospital1 18**] showed circumferential mass of
malignant appearance at 36-38 cm in the distal esophagus,
causing partial obstruction, staged as T3 due to
pseudopodia-like tumor extension noted beyond the outer
muscularis margin. [**3-7**] paraesophageal lymph nodes were noted,
with most suspicious being 0."
7070,"8cm at 38cm in the esophagus.
Repeat biopsies of the mass demonstrated moderately
differentiated adenocarcinoma, invasive into at least the
mucosa, arising in a background of focal intestinal metaplasia
consistent with Barrett's esophagus
- [**2110-5-26**] started neoadjuvant treatment with 5-FU via continuous
infusion over 4 days, Cisplatin (given [**2110-5-27**]) and XRT;
infusion discontinued on day 3 [**2-5**] to chest pain. Recent cycle
given end of [**6-14**] - similiar symptoms but tolerated
.
Other Past Medical History:
Insulin-dependent diabetes mellitus
Cholecystectomy
Appendectomy
Rotator cuff surgery
Hernia repair
Asthma
Social History:
The patient is married and has four children."
7071,"His pathology returned T1bN0Mx- 33 mm
margin,perinueral,lmphatic and venous invasion absent. He was
followed by the [**Hospital **] clinic while inpatient given elevated
FSGs while on TF, and should follow up with [**Last Name (un) **] as an
outpatient. He will follow up with Dr. [**First Name (STitle) **] on discharge. VNA
was arranged on discharge to assist him with his tube feeding at
home.
Medications on Admission:
Albuterol inh, insulin (levemir), omeprazole 40''
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q3H (every 3 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*2*
2."
7072,"8 Phos-3.4 Mg-1.5*
[**2110-9-5**] 05:17AM BLOOD Calcium-9.0 Phos-4.9*# Mg-1.9
.
[**2110-9-2**] UGI:
IMPRESSION:
1. No evidence of leak. Free passage of contrast from the upper
esophagus to the neoesophagus.
2. Dilution of contrast within a fluid-filled neoesophagus,
somewhat limiting evaluation of this structure.
.
[**2110-8-27**] Esophagectomy Pathology:
MACROSCOPIC
Specimen Type: Esophagogastrectomy.
Specimen Size: Greatest Dimension: 15 cm. Additional
dimensions: 10.5 cm x 2.5 cm.
Tumor Site: Distal esophagus (lower thoracic esophagus).
Relationship of Tumor to Esophagogastric Junction: Tumor
midpoint lies in The distal esophagus and tumor involves the
esophagogastric junction."
7073,"6. insulin detemir 100 unit/mL Insulin Pen Sig: Thirty (30)
Units Subcutaneous 1 hour before tube feed.
Disp:*1 Cartridge* Refills:*2*
7. One Touch Basic System Kit Sig: One (1) Kit Miscellaneous
once.
Disp:*1 Kit* Refills:*0*
8. One Touch Delica Lanc Device Kit Sig: One (1) Lancet
Miscellaneous once a day.
Disp:*30 * Refills:*2*
9. Glucometer Test Strips Sig: One (1) Strip once a day.
Disp:*30 Strips* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Esophageal Cancer (T1bN0Mx)
Discharge Condition:
Mental Status: Clear and coherent."
7074,"docusate sodium 50 mg/5 mL Liquid Sig: [**1-5**] PO BID (2 times a
day) as needed for constipation.
Disp:*250 ml* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*1*
4. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-5**] Inhalation Q6H (every 6 hours)."
7075,"J-tube site: If your j-tube falls out call Dr.[**Name (NI) 5067**] office
immediately. You may keep this covered changing dressing daily
to protect site while wearing pants. If there is no drainage
around j-tube you may keep site open to air.
Diet: Soft mechanical diet
Tube feeds: Boost Glu Control/Glucerna 1.0 Cal Full strength;
Additives: Beneprotein, 21 gm/day
Flush J-tube with water every 8 hours with 1 cup of water,
before and after starting tube feeds and giving medications
through tube
Continue a full liquid diet and then advance as tolerated to a
soft solid diet after 3-4 days as tolerated.
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for 30-45 minutes after meals
Daily weights: keep a log bring with you to your appointment
NO CARBONATED DRINKS
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2110-9-16**] 10:00
[**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
Chest XRay [**Location (un) **] radiology 30 minutes before your
appointment
Please continue to follow up with the [**Last Name (un) **] Diabetes Center
([**Telephone/Fax (1) 4847**] to monitor your blood sugars."
7076,"He underwent chemotherapy and
radiation and had an excellent response by
repeat PET imaging. He presented to the OR on [**2110-8-27**] for
Minimally-invasive esophagectomy, EGD and laparoscopic
jejunostomy tube placement. His operation was without
complication, and he was extubated without difficulty. He
remained in the surgical ICU POD0 and was transferred to the
floor on POD1. His pain was initially well controlled with an
epidural, and once removed on POD1 was well controlled on a
dilaudid PCA, IV toradol, and transitioned to oral pain
medications when he was tolerating clears. He began J-tube feeds
on POD1, with the nutrition service providing relevant
recommendations."
7077,"Specified margin: Proximal esophageal margin.
Treatment Effect (applicable to carcinomas treated with
neoadjuvant therapy): No definite response identified (grade
3, poor or no response).
Lymphatic (Small Vessel) Invasion: Absent.
Venous (Large vessel) invasion: Absent.
Perineural invasion: Absent.
TNM Descriptors:
y (post-treatment).
Additional Pathologic Findings: Columnar epithelium-lined
esophagus.
Comments: One nodule in the periesophageal adipose tissue that
was grossly identified as a lymph node shows fibrous tissue with
tumor infiltration. This could represent treatment effect on a
lymph node totally replaced by tumor.
Brief Hospital Course:
Mr [**Known lastname 31**] is a 51M who had a local regionally advanced
esophageal cancer which was T3n2."
7078,"He tolerated his feeds well. His NGT was
discontinued on POD4. An UGI study on [**2110-9-2**] did not show
evidence of any anastamotic leak, and therefore his mediastinal
chest tube and [**Doctor Last Name **] were removed on this date (POD6). On POD7
he did complain of increased heartburn with clears, and CXR
showed a slightly enlarged conduit. Given his symptoms, he was
taken back to the OR on [**2110-9-5**] for EGD, dilation of pylorus with
20 mm radial balloon, and inkection of pylorus with 200u Botox.
He tolerated the procedure well, and post-operatively no longer
had heart burn symptoms."
7079,"He works as a
heating and an air conditioning technician. He is a lifetime
nonsmoker and does not drink alcohol.
Family History:
Mother died of complications of diabetes. Father died of
complications of diabetes. Brothers and sisters have diabetes.
His children are healthy. There is no cancer in the family.
Physical Exam:
Physical Exam on Discharge:
Vitals: T97.9 HR 96 BP 147/84 RR 20 O297 RA
Gen: NAD, Comfortable
CV: rrr
Resp: cta b/l
Abd: soft, non-tender. j-tube. no erythema
Ext: MAE, no calf tenderness
Pertinent Results:
[**2110-8-26**] 11:34AM BLOOD WBC-6."
7080,"Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting (take anti-nausea medication)
-Increased abdominal pain
-Incision develops drainage
Pain
-Roxicet via J-tube as needed for pain
-Take stool softners with narcotics
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
-Remove j-tube site gauze bandages as needed"
7081,"Tumor Size: Greatest Dimension: 3.5 cm. Additional dimensions:
2.0 cm x 0.5 cm.
Distance of tumor center from esophagogastric junction: 10 mm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: G2: Moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT1b: Tumor invades submucosa.
Regional Lymph Nodes: pN0: No regional lymph node metastasis;
see comments.
Lymph Nodes
Number examined: 12.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
MARGINS
Proximal margin:
Uninvolved by invasive carcinoma.
Uninvolved by dysplasia.
Distal margin:
Uninvolved by invasive carcinoma.
Uninvolved by dysplasia.
Circumferential (adventitial) margin: Uninvolved by
invasive carcinoma.
Distance of invasive carcinoma from closest margin: 33 mm."
7082,"8 RBC-3.67* Hgb-11.5* Hct-33.9*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.8 Plt Ct-193
[**2110-8-31**] 04:12AM BLOOD WBC-7.3 RBC-3.03* Hgb-9.5* Hct-26.7*
MCV-88 MCH-31.3 MCHC-35.5* RDW-14.1 Plt Ct-167
[**2110-8-26**] 11:34AM BLOOD UreaN-16 Creat-1.1 Na-136 K-4.6 Cl-98
HCO3-29 AnGap-14
[**2110-9-5**] 05:17AM BLOOD Glucose-80 UreaN-10 Creat-0.8 Na-139
K-4.1 Cl-101 HCO3-29 AnGap-13
[**2110-8-27**] 10:26PM BLOOD Calcium-8."
7083,"Admission Date: [**2146-11-28**] Discharge Date: [**2146-12-26**]
Date of Birth: [**2100-1-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Leg pain, fever
Major Surgical or Invasive Procedure:
Transesophageal echo
Urgent aortic valve replacement with size 23 St.
[**Male First Name (un) 923**] Epic tissue valve [**2146-12-21**]
History of Present Illness:
is 46 yo F with hx of IVDU, HCV, granulomatous disease of GI
tract, liver, spleen, and bone, hx of cellulitis, osteomyelitis
of spine, and chronic leg ulcers, and anxiety who p/w 2 days of
leg pain, right worse than left, bilateral leg swelling that
feel hot to touch."
7084,"Last night, she used a pin to put a hole in her R leg
in hopes of relieving pressure, noticed minimal clear drainage
from the area. Of note, pt has chronic venous stasis changes
with erythema on R leg. Also has large ulcers in inguinal areas
L>R (6cm ulcer with pus and drainage in L inguinal area, 1cm
ulcer in R), she does dressing changes for these daily at home
using Silvedene. Inguinal ulcers are [**3-1**] heroin injection, pt
reports she has not injected in about 6 months and ulcers have
improved since then. She never injected in her toes, has not
injected in arms in many years due to scarring."
7085,"The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. Severe (4+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is a very small pericardial effusion. There are
no echocardiographic signs of tamponade.
POSR CPB:
1. Improved [**Hospital1 **]-ventricular systolci function with inotropic
support
2. Bioprosthetic valve in aortic p[osition. Well seated and good
leaflet excursion (PG =30 mm Hg
3. RV mass in the subvalvular apparatus is still visible
4. No other change
Brief Hospital Course:
Pt is 46 yo F with hx of IVDU, HCV, hx of cellulitis and
osteomyelitis who p/w chronic non-healing ulcers [**3-1**] heroin use
b/l and fever, found to have MSSA bacteremia and aortic valve
endocarditis."
7086,".
# MSSA Bacteremia - blood cultures ([**3-3**]) bottles from admission
positive for MSSA. The most likely source is the bilateral
chronic non-healing ulcers [**3-1**] heroin use. Though pt reports not
having used heroin in the past 6 months, ulcers have not healed
despite dressing changes at home. On admission, ulcers appeared
infected and pt was febrile. Pt was started on IV nafcillin for
MSSA, to complete a total 6-week course. Of note, pt has history
of MSSA infections in the past (abscesses, bacteremia, and R
sided endocarditis) for which she completed nafcillin courses.
Pt also had history of thoracic osteomyelitis in [**2144**] treated at
[**Hospital1 2025**], though this was considered as possible source of bacteremia
on this admission, it seems less likely given no clinical
symptoms of back pain and more likely source of ulcers."
7087,"Daily ECGs did
not show any abnormalities, pt had hypotension to SBP 100
throughout most of hospital stay and one episode of fever to
100.5 a week into therapy; given this, a TEE was done to
evaluate for cardiac abscess and was negative for this.
-Patient was transferred into MICU after code was called on
floors for hypoxic respiratory failure. This respiratory
failure was quickly reversed with diuresis and NIMV, and was
thought to be [**3-1**] severe aortic valve insufficiency in the
setting of patient anxiety. Similar episodes occurred
intermittently in the ICU with any mild increase in SVR, so
patient was kept with sedative/opiate regimen to stave off
anxiety."
7088,"Pt had bilateral venous stasis changes and 1+
edema below knees, in addition to leg elevation and
betamethasone cream, she was diuresed with lasix and had
decrease in edema and pain in legs.
.
# Acute renal insufficiency - likely pre-renal given poor PO
intake recently and infection. Cr improved to 1.3 today, FeNa
2.5% and FeUrea 52% both of which suggest resolution of
pre-renal state
- encourage PO intake
- continue to trend Cr
.
# Hypotension - now improved, SBP 110s-120s. Given aortic valve
vegetation, will maintain high suspicion for valve dysfunction
contributing to hypotension.
- encourage PO intake
- monitor on tele, daily ECGs
- continue abx as above
."
7089,"# Anemia - chronic, HCT baseline 26-27, [**Month/Day (2) **] studies in [**2145**]
revealed likely etiology as anemia of chronic inflammation. [**Year (4 digits) **]
panel indicates likely ACI, no evidence for hemolysis. HCT
bumped appropriately to 1U RBC. HCT stable today.
- T+S, PIV
- peripheral smear - no schistocytes
- B12 / folate - normal
.
# Anxiety - continue home 1mg TID ativan
.
# HCV - ""inactive"", never treated for this. Pt had liver biopsy
in [**6-6**] which showed fibrosis with no clear etiology for
hepatomegaly. She follows in [**Hospital **] clinic here. Recent poor
appetite and weight loss is concerning for malignancy, though
AFP not elevated.
- outpt work-up for ?"
7090,"malignancy
- LFTs stable
# IVDU - pt reports being clean for 6 months
- social work consult
MICU Course
The patient is a 46 yo F with hx of IVDU complicated by MSSA
verebral osteo [**2143**], and prior history of endocarditis [**2145**] at
[**Hospital1 2025**], h/o MRSA/pseudomonal hip wound infection, HCV,
granulomatous disease of GI tract, chronic inguinal ulcers, and
anxiety with MSSA endocarditis who was transferred to the MICU
for hypercarpic respiratory failure and code blue after being
briefly unresponsive.
.
#. Hypercarpic Respiratory Failure: Pt initial ABG showed ph
6.84 and PCO2 of 112. The differential for her respiratory
failure was medication related especially opioid use causing
respiratory depression."
7091,"Required briefly phenylephrine but
was later weaned off and tolerated well without. TTE repeated
yesterday showed EF 40%, worsening AR. Was transfused 2 units
of PRBC's.
.
#. ECG Changes: Pt with inverted t-waves in the setting of her
severe acidosis and tachycardia. Troponin peaked at 0.27 and
trended down at 0.22. Per cardiology, will not pursue
anticoagulation for concern of ACS , according to ECHO report
patient most likely experienced coronary artery embolization
from her endocarditis
.
#. S/p Fall: Pt found down for undetermined time. She is
currently complaining of neck pain. MRI of the cervial and
thoracic spine was unremarkable and trauma surgery cleared the
patient."
7092,".
# Inguinal ulcers - [**3-1**] long-standing heroin use. No evidence
of infection and was being followed by plastics.
- wound care with wet to dry dressings TID
.
# HCV - Never underwent treatment. Pt had liver biopsy in [**6-6**]
which showed fibrosis with no clear etiology for hepatomegaly.
Trended LFTs Q daily
.
# IVDU - pt reports being clean for 6-8 months per prior notes
.Social work following
.
#[**Last Name (un) **]??????Cr elevated to 1.6 from low of 1.1 a few days ago. [**Month (only) 116**] be
hypoperfusion [**3-1**] cardiogenic shock. UA also positive; may have
thrown septic emboli to kidneys."
7093,"Urine lytes showed a boderline
prerenal etiology with Fe urea 28%. Eosinophil smear showed.....
.
# Chronic Pain??????on opioids for pain. However, given respiratory
failure after receiving dilaudid and ativan, will be
conservative in dosing, ordered Lorazepam 1 mg PO/NG Q6H:PRN
anxiety , HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN
pain/agitation
.
#Anemia: Hct drop from 27 to 22 this morning, 20 on repeat.
Transfused 2 units PRBCs,did not increase appropiately to first
unit and DIC labs were sent which were unremarkable, Guiac
stools...
Cardiac Surgery Course:
The patient was brought to the operating room on [**2146-12-21**] where
the patient underwent aortic valve replacement with 23mm Porcine
tissue valve."
7094,"Non-caseating granulomas ([**6-3**]): liver biopsy, bone marrow,
gastric antrum thought to be the etiology of her elevated alk
phos (likely a result of injecting heroin with cocaine
containing talc)
Social History:
Lives with parents given need for assistance but has her own
home. Parents are incredibly supportive and caring. Patient also
has a sister, brother and step-brother who are involved in her
life. She no longer works. Hx of IVDU, cocaine, heroin but clean
for 6 months. >60 pack year history now 6 cigs/day, Hx of EtOH
abuse now quit 10 years ago. Had daughter who died 2 years ago
at age 24 from overdose."
7095,"No spontaneous echo contrast or
thrombus is seen in the body of the right atrium or the right
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-35 %). The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. There
is a mass in the right ventricle. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to XX cm from the incisors. The diameters
of aorta at the sinus, ascending and arch levels are normal."
7096,"4
[**2146-11-29**] 07:30AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
[**2146-12-1**] 07:15AM BLOOD calTIBC-147* Hapto-189 Ferritn-761*
TRF-113*
[**2146-12-2**] 07:00AM BLOOD VitB12-419 Folate-12.2
[**2146-11-29**] 07:30AM BLOOD AFP-1.2
.
[**2146-12-26**] 05:54AM BLOOD WBC-4.9 RBC-2.67* Hgb-8.4* Hct-24.7*
MCV-93 MCH-31.5 MCHC-34.1 RDW-17.3* Plt Ct-215
[**2146-12-25**] 03:38AM BLOOD WBC-5.1 RBC-2.67* Hgb-8.5* Hct-24.7*
MCV-93 MCH-31."
7097,"Cardiac surgery was consulted, and it was agreed that
surgical correction of valve was only viable therapeutic option.
.
# Inguinal ulcers - [**3-1**] long-standing heroin use though pt
reports no use for past 6 months. She had been doing daily
dressing changes at home though these ulcers were likely
infected on admission (6x6cm in L anterior thigh area, 2x2cm in
R). Wound care and plastic surgery were consulted, plastic
surgery did not recommend surgical debriding, pt had wet-to-dry
dressing changes three times a day which required 1mg IV
dilaudid for pain control beforehand. Once pt completes
antibiotic course for bacteremia and endocarditis, she will
follow up with plastic surgery to consider flap placement to
ensure healing."
7098,"Recommendations were made for dilaudid. ID continued to follow
and the patient is to be maintained on Nafcillin for a 6 week
course through [**2147-1-9**]. PICC was placed to facilitate therapy.
Fluconazole was initiated for yeast in the urine. 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."
7099,"083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
13. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. Nafcillin 2 g IV Q4H
15. nafcillin 2 gram Recon Soln Sig: One (1) Intravenous every
four (4) hours for 2 weeks: Last day of treatment [**2147-1-9**]."
7100,"Pt was extubated after being intubated
for 2 days and sating well on 2L NC/RA.
.
#. MSSA Endocarditis: Pt previously on Nafcillin for MSSA
endocarditis seen on TEE. Pt had stat ECHO performed at bedside
by cardiology ID consulted and recommended changing to
vancomycin and meropenem given concern for sepsis upon initial
presentation to ICU, which was later switched back to Nafcillin
given stable BP's and clinical status, as this provides better
coverage of her MSSA bacteremia.Follow-up blood, urine and
sputum cultures
.
# Hypotension: Likely [**3-1**] cardiogenic shock given markedly
decreased EF. Sepsis was initially also a concern in this pt
with MSSA endocarditis but given mixed venous of < 70,
cardiogenic is more likely."
7101,"no motor deficits, gait not
assessed
Pertinent Results:
Admission labs:
.
[**2146-11-28**] 12:35PM BLOOD WBC-6.4# RBC-2.94* Hgb-9.2* Hct-27.4*
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.7 Plt Ct-217
[**2146-11-28**] 12:35PM BLOOD Neuts-81.4* Lymphs-13.3* Monos-3.0
Eos-2.1 Baso-0.3
[**2146-11-28**] 12:35PM BLOOD Glucose-94 UreaN-33* Creat-1.9* Na-134
K-5.5* Cl-101 HCO3-22 AnGap-17
[**2146-11-29**] 07:30AM BLOOD ALT-24 AST-25 AlkPhos-276* TotBili-0."
7102,"Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
The following appointments have already been scheduled for you:
.
Department: DIV OF PLASTIC SURGERY
When: FRIDAY [**2147-1-6**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD [**Telephone/Fax (1) 6742**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: [**Hospital3 249**]
When: MONDAY [**2147-1-23**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2147-2-2**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Cardiac Surgery
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2147-1-16**] 1:30
Cardiology:
Dr [**First Name (STitle) **] on [**2-2**] at 11:40am
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2146-12-26**]"
7103,"Pt
refused MRI imaging, but should consider outpatient open MRI if
does not continue to have improvement. All surveillance cultures
since admission have had no growth to date. As described below,
pt was found to have aortic valve vegetation and infective
endocarditis with no abscess seen on TEE.
.
# Endocarditis - in setting of MSSA bacteremia, pt was found to
have 1.4cm vegetation on aortic valve, new since echo in [**3-9**],
with moderate aortic insufficiency. Started on 6-week course of
IV nafcillin as above. Cardiology and CT surgery were consulted
and did not recommend acute surgical intervention given
bacteremia and no decompensated heart function."
7104,"We gave you
some water pills to take the fluid out of your legs. You should
continue your antibiotic course for a total of 6 weeks
.
We have made the following changes to your medications:
Continue nafcillin for 6 weeks total (last day = [**2147-1-9**])
CARDIAC SURGERY:
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**]."
7105,"Although pt with high tolerance and has
been stable on dilaudid dosing and no recent increase. The
patient does have a history of drug abuse and could have had an
alternate source of drugs or been hording her medications. Pt
also could have fallen because of a seizure with head injury
leading to bleed or embolic/hemorrhagic stroke given
endocarditis, but pt awake and interactive making major CNS
process unlikely. Pt does not have a history of COPD or other
history of bronchospasm. CXR did not show clear evidence of
acute pathology. LENIs performed yesterday negative for DVT,
making PE less likely."
7106,"4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. hydromorphone 2 mg Tablet Sig: 3-5 Tablets PO Q3H (every 3
hours) as needed for pain.
8. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
9. albuterol sulfate 2.5 mg /3 mL (0."
7107,"16. HYDROmorphone (Dilaudid) 1 mg IV BID:PRN dressing changes
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
18. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
MSSA bacteremia
Infective endocarditis, s/p AVR
PMH:
IVDA -heroin(says clean 6months).
Ulcers/cellulitis B thighs. HepC, ascites,T9 osteo w/paraspinal
abscess [**2143**],hepatosplenomegaly
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+ LEs"
7108,"Family History:
Denies famiy history of CA, HTN, heart disease, liver disease.
Physical Exam:
GA: AOx3, NAD
HEENT: PERRLA, moist oral mucosa, anicteric sclera
Cards: RRR, S1/S2, holosystolic murmur [**4-2**] in LUSB
Pulm: coarse breath sounds B/L, no wheezes or rales
Abd: soft, distended, + hepatosplenomegaly, no appreciable fluid
wave, non-tender, no rebound/guarding
6x6cm draining ulcer in L inguinal area; 1x1cm ulcer in R
inguinal area
Extremities: R>L edema and erythema, no distinct border, warm to
touch b/l, erythematous, small draining tract on R dorsal shin,
scaling b/l, 2+ distal pulses
Neuro/Psych: CNs II-XII intact."
7109,"Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. The patient
remained intubated on POD 1 as she had no cuff leak and had been
intubated multiple times during this admission, and it was
decided to manage her conservatively. She remained on
epinephrine and propofol drips. Decadron was initiated for lack
of cuff leak on POD 2.
POD 3 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Acute pain service was consulted, as she
has a h/o IVDA and refused MS Contin or Oxycontin."
7110,"Discharge Instructions:
Medical Service:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
with fevers and leg pain. We found a bacteria growing in your
blood called MSSA (which you have had in the past) and we
started you on appropriate antibiotics for this. We did an
echocardiogram of your heart which showed that the bacteria had
spread to a valve in your heart. Your heart function was
monitored and was stable throughout your hospital stay. The most
likely source for your infection are the ulcers on your legs.
Our plastic surgery team recommended that you get these debrided
during dressing changes by using wet-to-dry dressings, which we
have been doing three times a day in the hospital."
7111,"The patient was discharged
to [**Hospital1 **], [**Location (un) 701**] in good condition with
appropriate follow up instructions.
Medications on Admission:
Currently taking only 1 mg lorazepam three times a
day for anxiety. Does not take any other medications at
present.
Medications were reviewed and reconciled with the patient.
Discharge Medications:
1. betamethasone valerate 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): apply to both legs twice a day.
2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)."
7112,"Pt says she was
tested for HIV since stopping drugs and has been negative, HCV
infection is ""inactive"" per her, she was never treated for this.
.
In ED vitals were 99.2, 96/49, 78, 16, 97% RA, she received 1g
vancomycin.
.
Review of systems:
+ Weight loss of 15 lbs in past month, decreased appetite;
chronic headaches; + non-productive cough of few days
No N/V, no diarrhea, no changes in urine or bowel, abdominal
distension at baseline per pt
Past Medical History:
Hepatitis C antibody positive, negative VL [**4-/2143**], neg VL [**4-5**]
HIV negative as of [**4-5**]
IVDU with unclear timeline of use
[**Name (NI) **] Deficiency Anemia
Septic R shoulder s/p drainage and debridement of rotator cuff
Osteo of spine
Thigh ulcers (left upper thigh ulcer for >7 years)
MSSA bacteremia with endocarditis resulting in 8 week [**Hospital1 2025**]
admission in [**4-4**]
MSSA osteo [**2143**] resulting in 7 week [**Hospital1 18**] admission in [**2143**]"
7113,"She was in her usual state of health until 2
days ago when she noticed that her R leg was painful and
swollen, she took 6 Advil for pain relief which did not help.
Measured her fever at home to be 103. Yesterday, she began to
notice swelling and pain in her L leg. No recent trauma in the
area, no open cuts or wounds preceding swelling. She was seen
yesterday at OSH where she was advised to be admitted for
antibiotics, she left AMA because she had a negative experience
during an admission last year. Did not get any antibiotics PO on
discharge."
7114,"6 MCHC-34.2 RDW-17.4* Plt Ct-217
[**2146-12-26**] 05:54AM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-139
K-3.2* Cl-101 HCO3-31 AnGap-10
[**2146-12-25**] 03:38AM BLOOD Glucose-93 UreaN-21* Creat-1.3* Na-137
K-3.0* Cl-98 HCO3-31 AnGap-11
[**2146-12-24**] 03:17AM BLOOD Glucose-114* UreaN-17 Creat-1.3* Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14
[**2146-12-21**] TEE
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage."
7115,"Past Medical History:
- Hypertension
- Dyslipidemia
- OCD
- s/p pilonidal cyst removal ~ 20 years ago
- s/p left testical removal ~ 25 years ago, [**3-18**] trauma
- s/p bilateral knee surgery
Social History:
- Married with 2 children (1 son & 1 daughter)
- [**Name (NI) 6160**]
- Denies EtOH.
- Ex smoker, quit 35 yrs ago, 1.5 ppd x 15 yrs
- remote history of marijuana and cocaine use
- denies IVDU
Family History:
- brother had CABG at 70
- another brother had MI in the 60s
Physical Exam:
Admission PE:
Pulse: 56 Resp: 16 O2 sat: 98% RA
B/P Right: 154/61 Left: 138/55
Height: 5'5"" Weight: 83."
7116,"The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. On [**10-8**] he had rapid
atrial fibrillation. He was treated with increased beta-blocker
and Amiodarone, he ultimately converted to nsr. On [**10-11**] he had
atrial flutter and was treated with IV Beta-blocker/Amio bolus
x2/gtt/IV Diltiazem and once again converted to normal sinus
rhythm. He continued to require oxygen. CXR revealed a left
pleural effusion. He was transferred back to CVICU for more
intensive monitoring while a left therapeutic thoracentesis was
performed. It drained 450 cc. The oxygen requirement decreased
and Mr."
7117,"Disp:*40 Tablet(s)* Refills:*1*
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
13. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 10 days.
Disp:*20 Tablet Sustained Release(s)* Refills:*0*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary diagnosis:
- Coronary artery disease, s/p coronary artery bypass grafting
x2, left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft the marginal branch."
7118,"Secondary diagnoses:
- Iron deficiency anemia
- Carotid artery stenosis, Left
- Dyslipidemia
- Obsessive compulsive disorder
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions: Sternal - healing well, no erythema or drainage
Leg Right- healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
1. Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2. Please NO lotions, cream, powder, or ointments to incisions
3. Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4."
7119,"No driving for approximately one month until follow up with
surgeon
5. No lifting more than 10 pounds for 10 weeks
6. 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
Surgeon: Dr. [**Last Name (STitle) **] [**2110-10-30**] 2:00PM
Cardiologist: Dr [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 8579**] on [**11-4**] @ 10AM.
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**5-19**] 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**
Completed by:[**2110-10-15**]"
7120,"Brief Hospital Course:
62 year old male was admitted on [**2110-10-3**] for cardiac
catheterization. He was found to have 2-vessel-disease and
critical left main disease on cardiac catheterization.
Subsequently, he underwent pre-op evaluation for CABG while
waiting for Plavix wash-out. It was noted that he has ~60-69%
stenosis on left carotid artery based on ultrasound. On [**2110-10-7**],
Mr. [**Known lastname **] was taken to the operating room where he underwent
coronary artery bypass grafting to two vessels. Please see
operative note for details. In summary he had: Coronary artery
bypass grafting x2, left internal mammary artery graft to left
anterior descending, reverse saphenous vein graft the marginal
branch."
7121,"Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
mild global left ventricular hypokinesis (LVEF = 45-50 %). The
right ventricle displays normal free wall contractility. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study."
7122,"There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
pathology or pathologic flow identified.
- Carotid U/S:
1. No significant right ICA stenosis.
2. 60-69% left ICA stenosis
- ECHO [**2110-10-7**]
PRE BYPASS The left atrium is moderately dilated. 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."
7123,"9 RBC-3.44* Hgb-9.8* Hct-27.6*
MCV-80* MCH-28.6 MCHC-35.6* RDW-14.0 Plt Ct-123*
[**2110-10-10**] 04:50AM BLOOD UreaN-30* Creat-1.2 Na-135 K-4.0 Cl-97
[**2110-10-3**]
- CBC: WBC-6.5 RBC-4.08* HGB-11.6* HCT-33.1* MCV-81* MCH-28.3
MCHC-34.9 RDW-13.3 NEUTS-73.9* LYMPHS-18.1 MONOS-5.2 EOS-2.1
BASOS-0.8 PLT COUNT-217
- BMP: GLUCOSE-99 UREA N-27* CREAT-0.9 SODIUM-138 POTASSIUM-4."
7124,"2
CHLORIDE-107 TOTAL CO2-26
- LFT: ALT(SGPT)-18 AST(SGOT)-23 ALK PHOS-53 TOT BILI-0.3
- Coag: PT-13.1 PTT-23.5 INR(PT)-1.1
- Iron studies: IRON-44* calTIBC-285 VIT B12-473 FOLATE-16.3
FERRITIN-81 TRF-219
- %HbA1c-5.5
Lipid profile: cholesterol 182, TGA 126, HDL 40, LDL 117
Discahrge Labs:
[**2110-10-13**] 05:10AM BLOOD Hct-28.6*
[**2110-10-12**] 07:25AM BLOOD WBC-9.5 RBC-3.38* Hgb-9.5* Hct-28.0*
MCV-83 MCH-28.2 MCHC-34.0 RDW-14.0 Plt Ct-261
[**2110-10-12**] 07:25AM BLOOD Plt Ct-261
[**2110-10-15**] 05:20AM BLOOD UreaN-36* Creat-1."
7125,"Admission Date: [**2110-10-3**] Discharge Date: [**2110-10-15**]
Date of Birth: [**2048-5-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
- [**2110-10-3**] - Cardiac catheterization without intervention on
- [**2110-10-7**] - Coronary artery bypass grafting x2, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft the marginal branch.
History of Present Illness:
This 62 year old gentleman has been experiencing new onset,
exertional chest pressure for the last few months. He describes
chest pressure and jaw discomfort occurring about 20 minutes
into his walk."
7126,"7* Na-139 K-5.3* Cl-100
[**2110-10-13**] 05:10AM BLOOD UreaN-28* Creat-1.4* Na-137 K-4.4 Cl-97
Images & Procedures:
[**2110-10-6**]
- Transthoracic Echo: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation."
7127,"His bypass time was 38 minutes with a crossclamp time 29
minutes. He tolerated the operation well and postoperatively he
was taken to the intensive care unit for monitoring. He woke
neurologically intact and was extubated on the day of surgery.
POD 1 found the patient alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or 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 on POD2 Chest tubes
and pacing wires were discontinued without complication."
7128,"POST BYPASS The patient is a-paced. There is normal
biventricular systolic function (LVEF = 55%). No significant
change in valvular function. The thoracic aorta is intact s/p
decannulation.
CHEST (PA & LAT) Study Date of [**2110-10-14**] 3:27 PM
[**Hospital 93**] MEDICAL CONDITION: 62 year old man s/p CABG
Final Report
PA AND LATERAL VIEWS, CHEST: Small bilateral pleural effusions
and bibasilar atelectasis are unchanged since yesterday,
however, improved since multiple prior radiographs. There is no
pulmonary edema. Mild cardiomegaly is stable.
Post-CABG appearance of the mediastinum is also unchanged. No
pneumothorax is present.
IMPRESSION: No significant changes with mild basilar atelectasis
and trace
pleural effusions."
7129,"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*
7. Aripiprazole 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg QD x7 days the 200mg QD."
7130,"9 kg
General:
Skin: Dry [x] intact [x] scar on nose healed, multiple tattoos
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no lymphadenopathy
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left: angioseal
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: + bruit
Pertinent Results:
Admission Labs:
[**2110-10-9**] 07:00PM BLOOD WBC-10."
7131,"This is also associated with nausea. His
symptoms resolve with rest. He does not have non-exertional
chest discomfort. He has also noticed occasional dizziness, not
associated with the chest discomfort. He denies any edema,
orthopnea, or PND.
Per report, he was referred for a stress test which was done on
[**2110-9-24**]. It was negative for chest pain or EKG changes, but
did show inferior ischemia and EF of 52%. (The record is not
available at this time).Patient came in for a cardiac
catheterization, which found critical L main and 2VD. Cardiac
surgery was consulted for surgical revascularization."
7132,"[**Known lastname **] was transferred back down to the stepdown floor.
The remainder of his hospital stay was uneventful.
By the time of discharge on POD8 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with visiting nurse services. He is to follow up with Dr [**Last Name (STitle) **]
in 3 weeks.
Medications on Admission:
- amlodipine 10 mg, once daily
- aripiprazole 2 mg, once daily
- fluoxetine 40 mg, once daily
- omeprazole 20 mg EC, once daily
- simvastatin 40 mg, once daily
- trazodone 50 mg, once at bed time (takes regularly)
- ASA 325 mg, once daily
- metoprolol ER 25 mg, once at bedtime"
7133,"Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Zocor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
5. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
6."