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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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[
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464,
478
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[
[
675,
699
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[
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1739,
1772
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[
[
1860,
1862
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],
[
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6683,
6691
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[
10264,
10272
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[
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6950,
6961
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[
12396,
12407
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[
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6984,
6994
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[
[
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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
96,381
| 101,173
|
39335
|
Discharge summary
|
Report
|
Admission Date: [**2120-1-11**] Discharge Date: [**2120-1-14**]
Date of Birth: [**2054-4-29**] Sex: F
Service: NEUROSURGERY
Allergies:
Keflex / Azithromycin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
She experienced difficulty seeing her left side. She also had
vertigo, seeing colored lights in periphery of her visual field.
She experienced headaches at the left occipital region, and it
woke her at night. She had nausea, dry heaves, and decreased
dexerity with impaired ability to open pill bottle with her left
hand. She also had tinnitus in her right ear.
Major Surgical or Invasive Procedure:
[**2120-1-11**] Suboccipital craniotomy for tumor resection
History of Present Illness:
[**First Name9 (NamePattern2) 86978**] [**Known lastname 86979**] is a 65-year-old right-handed woman, with
history
of non-small cell lung cancer. Her neurological problem began in
the summer of [**2119**] when she experienced difficulty seeing her
left side. She also had
vertigo, seeing colored lights in periphery of her visual field.
She experienced headaches at the left occipital region, and it
woke her at night. She had nausea, dry heaves, and decreased
dexerity with impaired ability to open pill bottle with her left
hand. She also had tinnitus in her right ear. She initially
blamed the symptoms on her diabetes but an MRI of the brain
showed a left occipital brain mass with surrounding edema. She
was started on dexamethasone 4 mg 3 times daily and her headache
disappeared. She was referred to the BTC for evalaution and was
seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
Past Medical History:
Past Medical History: She has a history of type II diabetes
(diagnosed 2 years ago), hypertension, coronary artery disease,
and COPD. She does not have hypercholesterolemia.
Past Surgical History: She had CABG x 1 on [**2118-7-2**],
hysterectomy for fibroids, cholecystectomy, carpal tunnel
surgeries in both hands, and bladder distension surgery.
Social History:
She works in retail sales. She smoked 1.5 packs
of cigarettes per day for 30 years; she stopped smoking since
[**2102**]. She does not drink alcohol or use illicit drugs.
Family History:
She is adopted and she does not know the
biological or medical histories of her parents or siblings. She
has 1 daughter and 3 sons; they are all healthy.
Physical Exam:
PRE OP EXAM:
Temperature is 97.8 F. Her blood pressure
is 142/60. Heart rate is 60. Respiratory rate is 16. Her skin
has full turgor. HEENT examination is unremarkable. Neck is
supple and there is no bruit or lymphadenopathy. Cardiac
examination reveals regular rate and rhythms. Her lungs are
clear. Her abdomen is soft with good bowel sounds. Her
extremities do not show clubbing, cyanosis, or edema.
Neurological Examination: Her Karnofsky Performance Score is
90.
She is awake, alert, and oriented times 3. There is no
right-left confusion or finger agnosia. Calculation is intact.
Her language is fluent with good comprehension, naming, and
repetition. Her recent recall is good. Cranial Nerve
Examination: Her pupils are equal and reactive to light, 4 mm
to
2 mm bilaterally. Extraocular movements are full. Visual
fields
are full to confrontation. Funduscopic examination reveals
sharp
disks margins bilaterally. Her face is symmetric. Facial
sensation is intact bilaterally. Her hearing is intact
bilaterally. Her tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: She does not have a drift. Her muscle
strengths are [**6-7**] at all muscle groups. Her muscle tone is
normal. Her reflexes are 2- and symmetric bilaterally. Her
ankle jerks are 2-. Her toes are down going. Sensory
examination is intact to touch and proprioception. Coordination
examination does not reveal dysmetria. Her gait is normal. She
can do tandem gait. She does not have a Romberg.
Exam on the day of discharge: [**2120-1-14**] neurologically intact, no
field cut apprieciated on exam. patient is independently
ambulating in the halls, alert, oriented to person, place and
time. strength is full, sensation is full. no pronator drift
noted. occipital incision clean dry and intact sutures closing
the wound. perrl, pupils 5-3mm bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2120-1-11**] 08:38PM WBC-12.6* RBC-4.61 HGB-12.2 HCT-38.2 MCV-83
MCH-26.4* MCHC-31.9 RDW-18.5*
[**2120-1-11**] 08:38PM GLUCOSE-187* UREA N-33* CREAT-1.0 SODIUM-133
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-24 ANION GAP-19
[**2120-1-11**] 08:38PM CALCIUM-7.9* PHOSPHATE-5.1* MAGNESIUM-1.8
dISCHARGE LABS: na 140, GLUCOSE 120, wbc 12.5, PLATLETS 266, hgb
12.4, HCT 39.3, pt 10.1, ptt 19.7, inr .8
IMAGING:
CT Head [**1-11**]: Interval occipital mass resection with
pneumocephalus, but no hemorrhage or midline shift
MR HEAD W/ CONTRAST Study Date of [**2120-1-11**] 6:47 AM
[**Last Name (LF) **],[**First Name3 (LF) **] M. OPT [**2120-1-11**] 6:47 AM
MR HEAD W/ CONTRAST Clip # [**Clip Number (Radiology) 86980**]
Final Report
INDICATION: Left occipital mass.
COMPARISON: [**2119-12-29**] MRI brain from [**Hospital3 3583**] and
scanned into our
PACS system for review.
FINDINGS: The right occipital lobe mass is similar in size to
the [**2119-11-28**] MRI, measuring today 24 x 27 x 26 mm (AP x ML x
SI). The mass has a thick rind of enhancement and a T1
hypointense center.
The adjacent edema has decreased slightly, with slight interval
expansion of the occipital [**Doctor Last Name 534**] and atrium of the left lateral
ventricle and better
definition of adjacent sulci. No new lesions are seen. Major
intracranial
vessels are patent.
IMPRESSION: Left occipital lobe mass, necrotic-appearing. This
can represent a metastasis from the patient's lung cancer or a
primary neoplasm. There has been slight interval decrease in the
adjacent vasogenic edema and slight interval decrease in mass
effect. Study for surgical planning.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2120-1-13**]
5:40 PM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2120-1-13**] 5:40 PM
MR HEAD W & W/O CONTRAST PRELIMINARY RADIOLOGY REPORT 1.
Post-surgical changes in the left occipital surgical resection
cavity, with small areas of linear nodular enhancement within,
which may relate to post-surgical changes/residual tumor or a
combination of both.
2. Areas of decreased diffusion in the periphery of the left
occipital lobe posteriorly and medially, may relate to acute
infarction. Consider followup to assess interval change.
Persistent surrounding vasogenic edema and partial effacement of
the atrium of the left lateral ventricle and the left occipital
[**Doctor Last Name 534**]. Other details as above.
Brief Hospital Course:
Patient presented electively for suboccipital craniotomy for
resection of tumor on [**2120-1-11**]. It was an uncomplicated
procedure, and she was admitted to the ICU for Q1 neurochecks
and Dexamethasone. She had no issues overnight and her pain was
well controlled.
On [**2120-1-12**], the morning of POD #1 she felt well and she had no
acute issues. SHe was transferred out of the ICU to the floor.
She experienced a severe headache and her pain medications were
changed with good post operative pain relief. On exam the
patient ws stable with right field cut noted. A decadron taper
was written.
On [**1-13**], the patient ws seen by physical therapy. She was
noted to ambulate independently but had higher level balance
issues requiring home physical therapy. The patient had her post
operative MRI of the brain which was reviwed by Dr [**Last Name (STitle) **] and
consistent with expected post operative change.
On [**2120-1-14**], the patient was tolerating a regular diet,
ambulating in the halls independently. The patient had not had a
post operative bowel movement but was passing flatus and has
baseline constipation. On exam, a visual field cut was no
apprieciated and the patients strength and sensation was full.
Pupils were equal and reactive bilaterally. The surgical
incision was clean dry and intact. The patient was instructed
to begin her Metformin on [**1-15**] hours after her last MRI of
the Brain. She was also instructed to resume her home dosing of
Humalog insulin. The patient will follow up in Brain [**Hospital 341**]
Clinic and with Opthomology. The patient's husband was at her
bedside and the patient was looking forward to her discharge
home.
Medications on Admission:
Metformin (held [**3-7**] contrast ). paroxetine, decadron, albuterol,
ativan, protonix, albuterol, asa 81mg
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
Disp:*60 Tablet(s)* Refills:*1*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
Wheezing, SOB.
5. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 1 days: start [**2120-1-14**].
Disp:*4 Tablet(s)* Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety: hold for lethargy.
Disp:*30 Tablet(s)* Refills:*0*
9. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*2*
10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every 4-6 hours as needed for pain: do not exceed
4 grams tylenol in 24 hours.
Disp:*50 Tablet(s)* Refills:*0*
11. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 12H
(Every 12 Hours): start this dose [**2120-1-15**].
Disp:*40 Tablet(s)* Refills:*1*
12. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for muscle spasm for 2 weeks: hold for lethargy-
do not drive while on this medication.
Disp:*20 Tablet(s)* Refills:*0*
13. humalog
please resume your home dose of humalog per your primary care
physician. [**Name10 (NameIs) 357**] continue to check finger sticks 4 times a day
and prior to bed as directed by your primary care physician.
Discharge Disposition:
Home With Service
Facility:
VNA [**Hospital3 **] inc
Discharge Diagnosis:
occipital mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
You may resume Aspirin one week following your surgery
Please restart your home dose of Metformin on [**2120-1-15**]
(48 hours after your MRI that was performedin the hospital)
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**8-12**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**1-29**] at 9:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain
You may resume Aspirin one week following your surgery
Please restart your home dose of Metformin on [**2120-1-15**] (48 hours
after your MRI that was performed in the hospital which was
performed at 6pm [**1-13**])
You will need formal visual field testing performed
with Opthomology before you will be able to drive. This should
be performed in the next 6 weeks. The office number to call for
an appointment is Office Phone:([**Telephone/Fax (1) 5120**],Office Fax:([**Telephone/Fax (1) 22009**]
Office Location:E/TCC-5, [**Location (un) 86**], [**Numeric Identifier 718**]
You may resume your home dose of humalog insulin as
prescribed by your primary care physician.
Completed by:[**2120-1-14**]
|
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"401.9",
"414.01",
"496",
"V45.81",
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"V58.67"
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icd9cm
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[
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[
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[
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[
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8335,
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] |
[] |
icd9pcs
|
[
[
[]
]
] |
10652, 10707
|
6864, 8553
|
652, 714
|
10766, 10766
|
4382, 4382
|
12807, 14335
|
2253, 2410
|
8713, 10629
|
10728, 10745
|
8579, 8690
|
10917, 12784
|
4708, 6841
|
1893, 2046
|
2425, 4363
|
247, 614
|
742, 1670
|
4399, 4692
|
10781, 10893
|
1715, 1869
|
2062, 2237
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,427
| 141,751
|
22980
|
Discharge summary
|
Report
|
Admission Date: [**2130-1-21**] Discharge Date: [**2130-1-25**]
Date of Birth: [**2083-8-19**] Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Petechial rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 59319**] is a 46F with a history of mild asthma, obesity,
hypertension and chronic lower back pain who presents with a
petechial rash to body (starting on right hand, also noticed
spread to forehead) and tongue since yesterday. She also had
some bloody mucous with blowing her nose, but no gross
epistaxis. She went to her PCP's office this morning, where she
was seen in urgent care by [**Name8 (MD) **] NP; bloodwork there was notable
for platelets of zero and ESR of 36. She was therefore referred
into [**Hospital1 18**] for further evaluation.
She reports use of hydrocodone x 1 dose for musculoskeletal pain
about a week prior to presentation. Otherwise, she denies any
recent medication changes or over-the-counter/herbal
medications, including no other pain medications or antibiotics.
(There is a prescription for ophthalmic erythromycin ointment in
[**Hospital1 **] records from the end of [**Month (only) 404**], but patient
states she never filled this prescription as it was not needed.)
In the ED, initial VS were: T 99.3, HR 63, BP 143/90, RR 16, O2
sat 100% on RA. Hematology was contact[**Name (NI) **] and recommended 100 mg
PO prednisone and 1 unit platelets. While in the ED, patient
developed a headache and was sent for head CT to rule out bleed
(negative preliminarily for bleed). Hematology recommended
frequent neuro checks overnight given the hemorrhagic bullae in
the mouth (sometimes associated with intracranial bleed), which
is the reason for ICU admission. Vitals on transfer were T98.7,
HR 62, RR 16, BP 123/76, 98% on RA.
.
On arrival to the MICU, she reports that her headache has
resolved. She feels dehydrated due to nothing to drink since
11AM, and also hungry. Otherwise, no complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Has felt fatigue recently, but she has attributed this to
stress over her divorce. Denies sinus tenderness, rhinorrhea or
congestion though endorses sore throat for about 2 weeks which
she has attributed to "allergies." Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
- Morbid obesity
- Asthma (not on medication)
- Essential hypertension
- Chronic lower back pain following fall in [**2117**] (fell from a
fire escape that gave way; had two herniated disks, sacral
fracture, abdominal hematoma which required "panniculectomy" to
treat; chronic bursitis in hip and chronic pain are
consequences, though not on pain medication)
- History of abnormal LFTs (currently WNL)
- Impaired fasting glucose
- Rapid weight loss followed by weight re-gain a few years ago
- Domestic abuse by ex-husband
- [**Name (NI) **] apnea requiring CPAP
- "Arrhythmia" for which she takes atenolol (? PVCs per Atrius
records, unable to locate Holter study from [**2126**])
- "Water weight" problems (no known heart problems)
- Peripheral neuropathy in feet/hands of unclear etiology (has
been told related to swelling, B12 deficiency, carpal tunnel in
hands)
- PTSD related to her fall as well as to history of abuse by her
husband and other instances of high stress (son sick as a child)
Surgical history:
- Panniculectomy x 2
- Lipectomy (complicated by infection requiring two subsequent
procedures)
- C-sections x 2
Social History:
Currently lives with 7-year old daughter and periodically hosts
[**Name (NI) **] exchange students. 20-year old son lives with her part-time.
She has been engaged in an expensive and drawn out custody
battle with her ex-husband for the past two and a half years,
whom she says has been physically abusive toward her and has
also threatened to kill her. Currently, she is in a
"quasi-relationship" with a male partner, with whom she is
sexually active by oral/anal sex (no vagnial sex). Significant
social stress related to interactions with her ex-husband.
- Tobacco: Never-smoker
- Alcohol: None
- Illicits: None
Family History:
Father with diabetes and hypertension; mother with hypertension
and reduced EF, paternal grandfather and great uncles with CAD.
Brother has [**Name (NI) 13808**] (carrier for hemochromatosis) and has had
bleeding/coagulopathy. No known FH of autoimmune disease or ITP.
Physical Exam:
On admission:
General: Alert, oriented, no acute distress. Periodically
tearful during interview.
Skin: Scattered petechiae over face, arms, legs, upper torso.
Ecchymoses on right arm at site of forearm BP cuff.
HEENT: Sclera anicteric, no conjunctival hemorrhage, MMM, EOMI,
PERRL. Hemorrhagic bullae on top center of tongue, under tongue,
left buccal mucosa.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, distant S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft/obese, non-tender, non-distended, bowel sounds
present, no clear organomegaly but difficult to palpate given
body habitus
GU: no foley
Ext: warm, well perfused, minimal LE edema but significant
adipose tissue on lower extremities
Neuro: No focal deficits appreciated; patient upset due to
stress/PTSD and unable to cooperate with full exam at this time
Pertinent Results:
Labs at [**Hospital1 **] [**2130-1-21**]:
- Antistreptolysin O titer (pending at time of admission)
- Smear from [**Hospital1 **] notable for zero platelets seen
- Chem-7, liver panel all WNL (except for glucose 111)
- Coags WNL
- CBC 6.5/13.8/41/0, normal differential
- ESR 36
Labs on admission to [**Hospital1 18**]:
[**2130-1-21**] 01:20PM GLUCOSE-89 UREA N-13 CREAT-0.8 SODIUM-142
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-24 ANION GAP-20
[**2130-1-21**] 01:20PM ALT(SGPT)-29 AST(SGOT)-28 LD(LDH)-255* ALK
PHOS-56 TOT BILI-0.4
[**2130-1-21**] 01:20PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.6
MAGNESIUM-1.8
[**2130-1-21**] 01:20PM WBC-7.3 RBC-4.57 HGB-14.4 HCT-40.1 MCV-88
MCH-31.4 MCHC-35.9* RDW-13.0
[**2130-1-21**] 01:20PM NEUTS-58.4 LYMPHS-33.3 MONOS-4.8 EOS-2.1
BASOS-1.4
[**2130-1-21**] 01:20PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2130-1-21**] 01:20PM PLT COUNT-5*
[**2130-1-21**] 01:20PM PT-11.6 PTT-31.6 INR(PT)-1.1
Microbiology:
- EBV IgM
- EBV IgG
- HIV 1&2 antibody:
Imaging:
CT HEAD W/O CONTRAST [**2130-1-21**]: No evidence of acute intracranial
process. No definite evidence of intracranial hemorrhage.
Brief Hospital Course:
46 yo F with morbid obesity and hypertension who presented with
petechial rash, found to have platelets of 0. Assumed to be ITP
and started on steroids.
ACTIVE ISSUES:
# THROMBOCYTOPENIA: Platelet count on admission was markedly
abnormal at 5, which explains the patient's petechial rash. She
is not known to have any chronic condition associated with low
platelets and has no history of similar symptoms. Differential
is broad and includes ITP, TTP, and pregnancy-related,
drug-induced, and viral causes (no history to support
genetic/congenital conditions). Serum hCG is negative which
rules out gestational cause. She had not used medications
(heparin, sulfonamides) commonly known to cause drug-induced
thrombocytopenia. Smear was negative for schistocytes, making
TTP unlikely. HCV, H pylori, EBV and HIV serologies were sent
and returned negative for acute infection. Given the absence of
other suggestive cause, the most likely etiology for the
patient's presentation was felt to be ITP. She was evaluated by
the hematology service, who recommended treatment with high-dose
prednisone (initial dose of 100 mg PO daily was increased to 150
mg PO daily given patient's body weight of ~375lbs and desire to
avoid use of IVIg, which could be dangerous in this patient if
used according to weight-based dosing guidelines). Given oral
lesions which are associated with intracranial hemorrhage, she
was admitted to the MICU for close monitoring overnight. A head
CT was done and read as negative for acute bleed. She received a
partial platelet transfusion on admission (stopped due to
development of hives as below). Further platelet transfusions
were not required. Platelet count trended up to 68 on
discharge. She was discharged on prednisone 150mg daily with
followup with heme.
# ALLERGIC REACTION: Patient began receiving a platelet
transfusion on arrival to ICU. About 10 minutes into the
transfusion, she developed hives on face, a "heavy" sensation in
her chest and subjective SOB (had normal RR, no wheezing, no
desaturation, no evidence of angioedema or stridor). The
transfusion was discontinued, and she received 50 mg of IV
diphenhydramine and 20 mg of IV famotidine. She became very
emotional (crying) and stated that this response reminded her of
a scary experience with her son's breathing when he was young
and that it had triggered her PTSD. After approximately 20-30
minutes hives began to resolve, and resolution was cmoplete by
one hour. She never developed objective evidence of respiratory
compromise. Emotional response was aided by one dose of IV
lorazepam, supportive listening by staff, and speaking with her
family on the phone.
# PTSD/ANXIETY/SOCIAL STRESS: Patient was very tearful when she
developed hives. She reported flashbacks to when her son was ill
at [**Hospital3 1810**] years ago. She also was very concerned
about her on-going custody battle with her ex-husband and his
potential to use her hospitalization to claim custody of their
7-year old daughter. She received one dose of IV lorazepam
overnight on the night of admission, and was seen by social work
consult the following day. Required PO ativan as needed.
INACTIVE ISSUES:
# HYPERTENSION: The patient was generally normotensive with SBPs
ranging ~115-140 off of medication. Her home antihypertensives
were held on admission at the recommendation of hematology
(though chlorthalidone, lisinopril and atenolol have not been
commonly associated with thrombocytopenia, there have been case
reports of low platelets with chlorthalidone and captopril),
with a plan to restart one medication at a time once platelets
become stable.
# "ARRHYTHMIA": Patient reported a history of "arrhythmia" on
admission which she states is the reason she uses the atenolol.
The "arrhythmia" seems most likely due to palpitations from PVCs
based on limited documentation in [**Hospital1 **] primary care
and cardiology notes. She was monitored on telemetry in the ICU
and other than sinus bradycardia to the 50s with sleep, no
arrhythmias were noted. She remained asymptomatic.
# OSA: Patient reported using CPAP at home but did not know her
settings. She was seen by the respiratory therapist who selected
settings that resulted in good-quality sleep in-house per
patient report. She required continuous O2 monitoring per
hospital protocol, although she eventually requestd it be
removed.
Medications on Admission:
- Atenolol 25 mg PO daily
- Chlorthalidone 25 mg PO daily
- Lisinopril 20 mg PO daily
- Cholecalciferol, Vitamin D3 2,000 unit PO daily (when
remembers)
- Vitamin B12 PO daily (when remembers)
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. calcium carbonate 400 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*0*
6. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
7. prednisone 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Immune Thrombocytopenic Purpura
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 59319**],
You were admitted to [**Hospital1 18**] with low platelets that were thought
to be due to a condition called Immune Thrombocytopenic Purpura.
You were given steroids which have increased your platelet
numbers. You will need to continue these steroids until the
hematologist asks you to taper them.
Medication Changes
Please START prednisone 150mg daily (until tapered by your
doctor)
Please START bactrim 1 DS tab daily for pneumonia prophylaxis
Please START famotidine 20mg daily for ulcer prophylaxis
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Location (un) 2274**] [**Location 1268**], Internal Medicine
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1701**]
Appt: [**2-3**] at 10:40am
Name: [**Last Name (LF) 349**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: [**Location (un) 2274**] [**Location (un) **], Oncology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
Appt: [**1-30**] at 3:30pm
|
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"401.9",
"309.81",
"300.00",
"427.9",
"327.23",
"287.31"
] |
icd9cm
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[] |
icd9pcs
|
[
[
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] |
12404, 12410
|
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|
285, 291
|
12485, 12485
|
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|
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|
231, 247
|
7106, 10102
|
319, 2070
|
10120, 11317
|
4767, 5662
|
12500, 12611
|
2687, 3819
|
3835, 4451
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
|
[
[
[
362,
378
]
],
[
[
1393,
1396
]
],
[
[
1388,
1428
]
],
[
[
1488,
1501
]
],
[
[
5953,
5983
]
],
[
[
6224,
6253
]
],
[
[
10081,
10094
]
],
[
[
14282,
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**]
|
[
"585.9",
"404.91",
"272.4",
"244.9",
"274.9",
"427.89",
"285.9",
"530.81",
"426.0",
"427.32",
"410.51",
"923.03",
"780.4",
"428.33",
"584.9",
"427.31"
] |
icd9cm
|
[
[
[
515,
517
]
],
[
[
520,
522
]
],
[
[
525,
526
],
[
9232,
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[
[
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[
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[
[
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[
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[
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[
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[
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[
[
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],
[
[
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8004
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],
[
[
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]
],
[
[
11048,
11084
]
],
[
[
11100,
11104
]
],
[
[
11133,
11151
]
]
] |
[] |
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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,103
| 107,082
|
25511
|
Discharge summary
|
Report
|
Admission Date: [**2120-11-26**] Discharge Date: [**2120-12-3**]
Date of Birth: [**2090-10-22**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreatitis, ETOH overdose, severe acidosis, ETOH hepatitis,
substance abuse, UGIB
Major Surgical or Invasive Procedure:
[**2120-11-26**]: Intubation, CVL and axillary [**Last Name (un) **] monitor placment
[**2120-12-2**]: UGI:
History of Present Illness:
30F w active EtOH abuse and alcoholic hepatitis p/w altered
mental status and report of hematemesis. Of note, HPI is per
report/documentation as pt intubated/sedated at time of
consultation. Pt has hx EtOH abuse/binge drinking w multiple
EtOH related admits/ED visits for withdraw, escalating in
frequency in recent months. Presents today in setting of
reported 2.5 day EtOH abstention with altered mental status,
nausea and vomiting. Intubated on arrival for
confusion/hematemesis and inability to protect airway. Reported
episodes of hematemesis at this time though quality/quantity of
blood in emesis unclear. Started on pressors w massive
resuscitation for hypotension/ tachycardia. Laboratories
reflected dehydration, known EtOH hepatitis and lipase 100
suggestive of acute pancreatitis. CT scan showed severe
pancreatitis and GB with edematous wall filled w sludge vs
blood.
Surgery consult obtained for pancreatitis, UGIB.
Past Medical History:
EtOH abuse with several inpatient detox stays
Social History:
The patient is originally from [**Location (un) 11177**], [**State 4565**]. She is
currently on dental student on a leave of absence. She reports a
history of binge drinking, typically [**3-26**] "strong" drinks at a
time. She reports a history of multiple inpateint detox stays
without success. She denies tobacco or IVDU
Family History:
Maternal grandfather with alcoholism
Maternal uncle with drug problem
Paternal aunt with alcoholism
Physical Exam:
At time of admission:
P/E:
Levo: 0.12, Protonix: 8; Versed: 18
VS: T: 97.0 P: 134 BP: 110/57 RR: 20 O2sat: 100
CMV 0.5; 20x500; 5
GEN: WD, WN F intubated/sedated
HEENT: NCAT, PERRLA, anicteric
CV: RRR; tachy
PULM: CTA B/L w no W/R/R, intubated
ABD: firmly distended, unable to assess tenderness [**1-24**] sedation
EXT: WWP, no CCE, 2+ B/L radial/DP/PT
NEURO: moves all 4 extremities; sedated
On Discharge:
VS:
GEN; Pleasant with NAD
CV: RRR
Lungs: Diminished breath sounds bilateraly on bases
Abd: NT/ND, soft
Extr: Warm, no c/c/e
Neuro: AAO x 3, Cranial nerves II-XII grossly intact
Pertinent Results:
Labs at time of admission:
15.7>-14.8/48.1-<393
N:86.4 L:11.2 M:1.2 E:0.7 Bas:0.5
PT: 11.0 PTT: 31.8 INR: 1.0
150 91 13
-------------< 93 AGap=58
4.7 6 2.8 ∆
ALT: 230 AP: 180 Tbili: 1.2
AST: 485 Lip: 100
Serum EtOH 255
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
8AM:
pH 6.93 pCO2 33 pO2 124 HCO3 8 BaseXS -26
Type:Art; Intubated; FiO2%:50; Rate:/16; TV:500;
Mode:Assist/Control
Lactate:12.0
[**12-2**]:
7.4>----<125
36.1
142 101 5 aGap=11
-------------<118
3.3 33 1.0
Ca: 9.2 Mg: 1.3 P: 2.0
ALT: 51 AP: 78 Tbili: 0.8
AST: 62 LDH: 430
[**Doctor First Name **]: 146 Lip: 206
IMAGING:
CT A/P [**11-26**]: Noncontrast CT due to elevated creatinine, limiting
assessment. Peripancreatic inflammation, c/w pancreatitis.
Cannot assess parenchymal enhancement or vascular complications.
But no obvious large pseudocyst or abscess. Diffusely fatty
liver. Gallbladder with diffuse mural thickening and distended
with hyperdense material. No free air. Free fluid in pelvis.
[**12-3**] CXR:
As compared to the previous radiograph, all monitoring and
support
devices have been removed. There are persistent opacities at
both lung bases, right more than left, that are exaggerated by
relatively [**Name2 (NI) 15410**] breast tissue.
The changes could reflect minimal fluid overload or layering
pleural
effusions. No circumscribed focal parenchymal opacity suggesting
pneumonia.
No cardiomegaly. No lung nodules or masses.
[**12-3**] EGD:
Impression:
1. Erythema in the stomach body compatible with gastritis
(biopsy)
2. Mucosa suggestive of Barrett's esophagus (biopsy)
Brief Hospital Course:
[**11-26**]- Admitted to the TSICU after a reported 2.5 day EtOH
abstention ( ETOH level 255) with altered mental status, nausea
and vomiting. Intubated on arrival for confusion/hematemesis and
inability to protect airway. Reported episodes of hematemesis
prior to arrival prompted Protonix and Octreotide drips. IN the
Ed patient was started on Levophed w 12L resuscitation for
hypotension/ tachycardia in the ED. She was admitted to the ICU
with suspected EtOH hepatitis, acute pancreatitis with lipase
100, severe acidosis with lactate 22, ph 6.9. Sh was
hypernatremic to 150 qith acute renal failure Cr 2.3. Liver
function tests significant for ALT: 230 AP: 180 Tbili: 1.2 Alb:
AST: 485 Serum ASA, Acetaminophen, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
CT scan showed severe pancreatitis and GB with edematous wall
filled w sludge vs blood. In the ICU an Axillary line and [**Last Name (un) 18821**]
monitor were placed, as well as a central line in the R IJ. A
Bicarb drip for PH 6.9 that was later stopped in the pm.
Thiamine and folate where repleted. Toxicology , general
surgery and Gi were consulted. Bladder pressure were checked for
evidence of compartment syndrome. With aggressive management she
improved overnight. Cardiac ECHO showed no evidence of
infarction.
[**11-27**]: By the am her ventilator was weaned to [**4-25**]. Fentanyl dc'd
and she was started on 3mg IV Ativan for intermittent agitation
and question of withdrawal. She had Elevated BPs 150-160's
overnight. Also started clonidine patch.
[**11-28**]: She was changed to Precedex gtt. IR attempt to make
Dobbhoff post pyloric unsuccessful so tube remained as NG.
[**11-29**] Extubated. A&Ox3. She was advanced to a regular diet.
Overnight pt with hallucinations (Visual/auditory) and she was
agitated requiring Valium. CIWA protocol was initiated. She was
also noted to have a drop in her platelets to the 69s, Her HSQ
was discontinued and HITT panel sent.
[**11-30**]: Patient was transferred to floor; psych and social work
c/s ordered to help facilitate substance abuse counseling.
Patient's abdominal pain slowly resolving.
[**12-1**]: After psychiatry and SW recommended 30 day substance
abuse rehab upon dc. GI consult recomended inpatient endoscopy
to evaluate the source of patient's reported UGIB. Recheck of
platelets showed recovery to 125 without intervention.
[**12-2**]: Upper Endoscopy. HITT pending. In the am pt complained of
mild SOB prompting a CXR.
[**12-3**]: CXR was negative for PNA. EGD demonstrated erythema in
the stomach body compatible with gastritis and mucosa suggestive
of Barrett's esophagus, biopsy were taken. Patient's diet was
advanced to regular and she was discharge home in stable
condition. Her PCP was [**Name (NI) 653**] prior discharge, and message
was left explaining patient's needs for prompt follow up with
PCP.
Medications on Admission:
[**Last Name (un) 1724**]: folic acid 1', thiamine 100', fluoxetine 10', MVI,
naltrexone 50'
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. naltrexone 50 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks: Please do not drink alcohol while taking this
medication.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. EtOH induced pancreatitis
2. Alcohol abuse
3. Alcohol withdrawal
4. Metabolic acidosis
5. Upper gastrointestinal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Please call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2998**] if you have any
questions.
.
Please follow up with [**Doctor Last Name 634**], PA (PCP) in 1 week after
discharge
.
Call [**Telephone/Fax (1) 13545**] in one week for the biopsy (EGD) results
Completed by:[**2120-12-3**]
|
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"458.9",
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icd9cm
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309
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[
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7812
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[
[
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326
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[
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[
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[
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[
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[
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],
[
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],
[
[
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7768
]
],
[
[
7817,
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[
"96.71",
"45.16"
] |
icd9pcs
|
[
[
[
5976,
5984
]
],
[
[
6917,
6944
]
]
] |
7697, 7703
|
4284, 7166
|
389, 498
|
7872, 7872
|
2621, 4261
|
9027, 9325
|
1891, 1993
|
7310, 7674
|
7724, 7851
|
7192, 7287
|
8023, 9004
|
2008, 2408
|
2422, 2602
|
266, 351
|
526, 1466
|
7887, 7999
|
1488, 1535
|
1551, 1875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,170
| 105,063
|
457465
|
Physician
|
Physician Resident Progress Note
|
TITLE:
Chief Complaint: hyponatremia, altered MS
24 Hour Events:
-Family mtg: D/c home with hospice, full code.
-Renal: Cont fluid restrict
-Abx changed to cefpodoxime for dispo as MRSA screen negative and
pseudomonas unlikely
[**Hospital 7395**] hospice bed
Allergies:
Coumadin (Oral) (Warfarin Sodium)
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin - [**2189-3-30**] 11:12 PM
Piperacillin/Tazobactam (Zosyn) - [**2189-4-1**] 08:00 AM
Vancomycin - [**2189-4-1**] 08:32 AM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-4-2**] 06:51 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.1
C (98.8
Tcurrent: 37.1
C (98.8
HR: 119 (93 - 119) bpm
BP: 91/44(55) {74/40(51) - 97/57(63)} mmHg
RR: 35 (15 - 35) insp/min
SpO2: 94%
Heart rhythm: AF (Atrial Fibrillation)
Total In:
1,291 mL
64 mL
PO:
150 mL
TF:
IVF:
1,141 mL
64 mL
Blood products:
Total out:
712 mL
115 mL
Urine:
712 mL
115 mL
NG:
Stool:
Drains:
Balance:
579 mL
-51 mL
Respiratory support
O2 Delivery Device: None
SpO2: 94%
ABG: ////
Physical Examination
Gen:
Neck:
CV:
Lungs:
[**Last Name (un) 61**]:
Extre:
Neuro:
Labs / Radiology
458 K/uL
9.3 g/dL
50 mg/dL
0.8 mg/dL
16 mEq/L
4.3 mEq/L
21 mg/dL
98 mEq/L
127 mEq/L
28.2 %
25.5 K/uL
[image002.jpg]
[**2189-3-30**] 12:31 AM
[**2189-3-30**] 05:30 AM
[**2189-3-31**] 04:47 AM
[**2189-3-31**] 08:14 AM
[**2189-4-1**] 05:31 AM
WBC
22.3
21.2
25.5
Hct
28.3
27.3
28.2
Plt
446
490
458
Cr
0.7
0.7
0.7
0.8
Glucose
60
69
44
49
50
Other labs: PT / PTT / INR:15.3/33.4/1.4, ALT / AST:35/96, Alk Phos / T
Bili:496/1.5, Lactic Acid:4.0 mmol/L, Albumin:2.1 g/dL, LDH:765 IU/L,
Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL
Assessment and Plan
71 yo man with history of metastatic pancreatic cancer was admitted
with dyspnea, new ascites, and profound hyponatremia.
# Hyponatremia: Likely etiology of altered mental status. Has improved
with hypertonic saline and restriction of free water intake. Underlying
mild SIADH and hyponatremia was likely exacerbated by excessive free
water intake at home given recent admission for
dehydration.
-fluid restrict to 1L
-would avoid add
l IV fluids per Renal, could consider lasix
-appreciate renal recommendations
# Hypotension: DDx intravascular hypovolemia (given tachycardia) versus
new baseline w/ chronic disease
-holding IV fluids for now due to concern of worsening hyponatremia
# Dyspnea, ?pneumonia on CT: Infiltrate on CXR being treated as HAP.
Also with small bilateral effusions, ddx parapneumonic v. malignancy.
[**Month (only) 51**] also have hypoventilation related to increased ascites.
-vanco and Zosyn stopped yesterday; will continue cefpodoxime for 8-day
course (today is d4/8)
# Bandemia: Likely [**12-29**] pneumonia, stable to mildly improved. No other
localizing sx. Blood cultures negative. Respiratory viral screen, MRSA
swab both negative. Urine legionella and urine culture negative. Still
awaiting stool sample for c. diff
-continue cefpodoxime for pna, 8-day course
-f/u cultures
-awaiting stool for C. diff
# Guaiac positive stools: Patient was found to have guiac positive
stools, likely related to metastatic pancreatic cancer. In light of
guiac positive stools, will hold off on any anticoagulation at this
time.
-hematocrit stable, will continue to follow
# Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis. Unclear if this
represents a spontaneous thrombosis or is related to tumor invasion.
Patient is certainly a poor candidate for anticoagulation given his
poor PO intake, multiple comorbidities, and reported allergy to
coumadin.
-continue to monitor
# Fluid overload: [**Month (only) 51**] be [**12-29**] increased metastatic disease, low albumin.
[**Month (only) 51**] have some diastolic dysfunction not assessed on prior echo. [**Month (only) 51**]
also have third-spacing [**12-29**] hyponatremia. Nephrotic syndrome unlikely
given U/A. ? of new ascites which is likely related to metastatic
disease.
-high protein diet, could consider lasix per renal recs
# Metastatic pancreatic cancer: Evidence of progression on CT
abdomen/pelvis. He declined palliative chemo and/or radiation therapy.
Goals of care meeting [**4-1**] addressed home hospice, which patient would
like to try.
ICU Care
Nutrition: High protein, pureed/nectar-thick
Glycemic Control:
Lines:
18 Gauge - [**2189-3-30**] 12:54 AM
20 Gauge - [**2189-4-1**] 12:00 AM
Prophylaxis:
DVT: pneumoboots
Stress ulcer: eating
VAP:
Comments:
Communication:
Code status: FULL code (per patient and family mtg on [**4-1**]
Disposition: Home w/ hospice
|
[
"288.66",
"157.8"
] |
icd9cm
|
[
[
[
4215,
4222
]
],
[
[
5621,
5648
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
630, 701
|
723, 2946
|
27, 611
|
2958, 6216
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,572
| 198,039
|
40520
|
Discharge summary
|
Report
| "Admission Date: [**2171-6-4**] Discharge Date: [**2171-6-18**]\n\nDate of Birth: [(...TRUNCATED)
|
[
"402.91",
"272.4",
"572.0",
"V15.82",
"038.49",
"428.31",
"584.9",
"574.31"
] |
icd9cm
| [[[618,620],[2452,2454]],[[623,625]],[[1470,1478],[5759,5771]],[[2624,2652]],[[5666,5676]],[[6961,69(...TRUNCATED)
|
[] |
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**]\n\nDate of Birth: [*(...TRUNCATED)
|
[
"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
|
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