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Discharge summary
|
Report
|
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 101.3, 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. 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.
.
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. 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
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-1.3*
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. 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
.
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
.
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. 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. 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.
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. 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
.
==================
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
==================
[**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-0.08*
[**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 4.0
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. 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. 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. 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. 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. 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. 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
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. 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
().
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).
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". 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
|
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92,287
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18156
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Discharge summary
|
Report
|
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).
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. 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**].
- 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.
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-15.1* 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-0.9
[**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-0.3
[**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-2.0* 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-0.9
[**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-25.6*
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.
#. 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.
# 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. 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. 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. 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.
-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. 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. 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).
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.
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
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**]
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],
[
[
1739,
1772
]
],
[
[
1860,
1862
]
],
[
[
6683,
6691
],
[
10264,
10272
]
],
[
[
6950,
6961
],
[
12396,
12407
]
],
[
[
6984,
6994
]
],
[
[
7187,
7197
]
],
[
[
7203,
7213
]
],
[
[
7938,
7958
],
[
9952,
9968
]
],
[
[
9105,
9123
],
[
12442,
12460
]
],
[
[
9144,
9151
]
],
[
[
9697,
9716
],
[
12410,
12428
]
],
[
[
9970,
10008
]
],
[
[
12463,
12503
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12324, 12366
|
6523, 10707
|
295, 302
|
12528, 12528
|
3507, 6158
|
13677, 15026
|
2437, 2524
|
11590, 12301
|
12387, 12507
|
11142, 11567
|
12711, 13654
|
6174, 6500
|
2539, 3193
|
3209, 3488
|
10728, 11116
|
235, 257
|
330, 1554
|
12543, 12687
|
1576, 2105
|
2121, 2421
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
94,125
| 187,893
|
30125
|
Discharge summary
|
Report
|
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.
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.
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-9.2* 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-0.05*
[**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.} 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
.
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.
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.
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. 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.
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. 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.
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.
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. 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. 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.
.
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. 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.
[**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. 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. 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. 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
.
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. 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
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.
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).
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
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. 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**]
|
[
"553.21",
"401.9",
"V10.3",
"244.9",
"574.10",
"157.0",
"562.10",
"518.81",
"518.53",
"416.8",
"429.4",
"787.22",
"997.39",
"518.0"
] |
icd9cm
|
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[
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362,
378
]
],
[
[
1393,
1396
]
],
[
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1388,
1428
]
],
[
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1501
]
],
[
[
5953,
5983
]
],
[
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6253
]
],
[
[
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10094
]
],
[
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14315
]
],
[
[
21134,
21162
]
],
[
[
21222,
21243
]
],
[
[
21245,
21263
]
],
[
[
21290,
21317
]
],
[
[
21319,
21335
]
],
[
[
21345,
21355
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20989, 21068
|
13670, 19120
|
302, 480
|
21380, 21387
|
1966, 13647
|
22840, 22953
|
19348, 20966
|
21089, 21359
|
19146, 19325
|
21411, 22817
|
1703, 1947
|
242, 264
|
508, 1366
|
1388, 1643
|
1659, 1688
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,563
| 155,738
|
42184
|
Discharge summary
|
Report
|
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. 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).
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.
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.
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:
?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**]
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=97.6 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.
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.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
[**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-42.4* 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. 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. 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. 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
# 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. 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. 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
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. 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**]
|
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"427.32",
"410.51",
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"780.4",
"428.33",
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[
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[
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[] |
icd9pcs
|
[
[
[]
]
] |
10895, 11011
|
6895, 9780
|
240, 246
|
11242, 11242
|
5471, 6872
|
12238, 12683
|
4539, 4618
|
10277, 10872
|
11032, 11221
|
9806, 10254
|
11426, 12215
|
4633, 4633
|
3360, 3495
|
4655, 5452
|
375, 3230
|
274, 357
|
11257, 11402
|
3526, 4252
|
3274, 3340
|
4268, 4507
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,572
| 198,039
|
40520
|
Discharge summary
|
Report
|
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. 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. 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. 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
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.
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.
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-0.6
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.
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. 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.
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.
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. 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. 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
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
|
[
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"272.4",
"572.0",
"V15.82",
"038.49",
"428.31",
"584.9",
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icd9cm
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[
618,
620
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[
2452,
2454
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],
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625
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1470,
1478
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[
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5771
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],
[
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2624,
2652
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],
[
[
5666,
5676
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],
[
[
6961,
6981
]
],
[
[
7063,
7081
]
],
[
[
8615,
8627
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8493, 8588
|
5663, 7116
|
316, 535
|
8672, 8672
|
3093, 5640
|
9590, 10692
|
2672, 2747
|
7236, 8470
|
8609, 8651
|
7142, 7213
|
8822, 9567
|
2762, 2762
|
263, 278
|
563, 2423
|
2776, 3074
|
8687, 8798
|
2445, 2549
|
2565, 2656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,910
| 129,743
|
4998
|
Discharge summary
|
Report
|
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. 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
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
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. 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. 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.
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.
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.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. 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. 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**]
|
[
"V45.82",
"355.8",
"V15.82",
"427.31",
"427.81",
"162.5"
] |
icd9cm
|
[
[
[
1259,
1274
]
],
[
[
1381,
1390
]
],
[
[
1432,
1459
]
],
[
[
2894,
2912
]
],
[
[
2919,
2937
]
],
[
[
6133,
6159
]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[
4989,
4993
]
]
] |
6054, 6112
|
2498, 5230
|
305, 535
|
6184, 6184
|
2137, 2475
|
7007, 7651
|
1522, 1665
|
5324, 6031
|
6133, 6163
|
5256, 5301
|
6335, 6984
|
1680, 2118
|
245, 267
|
563, 1235
|
6199, 6311
|
1257, 1416
|
1432, 1506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
96,443
| 103,219
|
15250
|
Discharge summary
|
Report
|
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
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?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. 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
[**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. 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.
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. 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. 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. 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. 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. 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**]
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. 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. 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. 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. 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. 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.
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**]
|
[
"V45.81",
"244.9",
"530.81",
"V15.82",
"441.2",
"747.69",
"997.39",
"995.91",
"518.82",
"429.4",
"285.1"
] |
icd9cm
|
[
[
[
1824,
1855
]
],
[
[
1990,
2003
]
],
[
[
2006,
2037
]
],
[
[
2222,
2233
]
],
[
[
14115,
14149
]
],
[
[
14156,
14186
]
],
[
[
14446,
14454
]
],
[
[
14456,
14469
]
],
[
[
14471,
14513
]
],
[
[
14515,
14541
]
],
[
[
14551,
14556
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14085, 14094
|
11153, 13827
|
293, 894
|
15100, 15109
|
2439, 3853
|
15165, 15203
|
2339, 2382
|
14045, 14062
|
9712, 9768
|
14115, 15079
|
13853, 14022
|
15133, 15142
|
2397, 2397
|
2410, 2420
|
234, 255
|
9800, 11130
|
922, 1531
|
1553, 2159
|
2175, 2323
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
97,765
| 118,349
|
39728
|
Discharge summary
|
Report
| "Admission Date: [**2173-10-4**] Discharge Date: [**2173-10-16**]\n\nDate of Birth: (...TRUNCATED)
|
[
"456.21",
"511.89",
"V15.82",
"572.3",
"584.5",
"799.4",
"458.9",
"V46.3",
"285.9",
"571.2"
] |
icd9cm
| [[[1061,1067]],[[1872,1888],[27994,28016]],[[2880,2910]],[[19610,19629]],[[20926,20928]],[[23665,236(...TRUNCATED)
|
[] |
icd9pcs
|
[
[
[]
]
] |
27838, 27921
|
19547, 26255
|
330, 359
|
28100, 28100
|
3886, 3891
|
29131, 30097
|
3010, 3028
|
26813, 27815
|
27942, 28079
|
26281, 26281
|
28279, 29108
|
3043, 3867
|
26299, 26476
|
6076, 19524
|
278, 292
|
387, 2631
|
3905, 6040
|
28116, 28255
|
2653, 2784
|
2800, 2994
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,233
| 130,846
|
14318
|
Discharge summary
|
Report
| "Admission Date: [**2122-6-13**] Discharge Date: [**2122-6-23**]\n\n\nService: SURGE(...TRUNCATED)
| ["414.01","V45.01","427.31","402.91","244.9","428.0","V12.04","427.5","799.02","486","599.0","041.7"(...TRUNCATED)
|
icd9cm
| [[[761,763]],[[769,787],[1101,1113]],[[790,808],[1115,1133]],[[1082,1084]],[[1086,1099]],[[1135,1137(...TRUNCATED)
|
[
"39.71",
"99.60",
"89.45"
] |
icd9pcs
|
[
[
[
291,
362
]
],
[
[
6867,
6891
]
],
[
[
7080,
7102
]
]
] |
11971, 12073
|
5692, 10593
|
274, 664
|
12142, 12142
|
1908, 5669
|
15118, 15610
|
1289, 1293
|
10780, 11948
|
12094, 12121
|
10619, 10757
|
12325, 14539
|
14565, 15095
|
1308, 1308
|
1623, 1889
|
222, 236
|
692, 1055
|
1322, 1609
|
12157, 12301
|
1077, 1222
|
1238, 1273
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,123
| 151,973
|
49512
|
Discharge summary
|
Report
| "Admission Date: [**2125-11-26**] Discharge Date: [**2125-12-7**]\n\nDate of Birth: (...TRUNCATED)
|
[
"402.91",
"491.22",
"303.90",
"305.1",
"571.2",
"486",
"518.81",
"291.81",
"348.30",
"491.21",
"428.33"
] |
icd9cm
| [[[375,377],[2280,2291]],[[380,383],[2275,2278]],[[390,399]],[[2313,2402]],[[6790,6817],[8001,8009]](...TRUNCATED)
|
[
"93.90",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[
1449,
1453
]
],
[
[
7217,
7226
]
],
[
[
7300,
7308
]
]
] |
9636, 9642
|
6670, 8609
|
312, 319
|
9785, 9785
|
3658, 3658
|
12700, 13313
|
2496, 2567
|
8937, 9613
|
9663, 9764
|
8774, 8914
|
9936, 12677
|
6338, 6627
|
3287, 3639
|
3272, 3272
|
6641, 6647
|
2025, 2171
|
265, 274
|
347, 2006
|
3674, 6322
|
9800, 9912
|
8632, 8748
|
2193, 2295
|
2311, 2480
|
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