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allergies: no known allergies / adverse drug reactions attending: chief complaint: abnormal labs; weakness, altered mental status major surgical or invasive procedure: intubation central venous line placement arterial line placement trach/peg history of present illness: mr. is a 66 year old man with ckd (baseline cr 1.7-2), cad, chronic back pain and recent hospitalization after a fall with altered mental status and acute on chronic renal failure who presents from home with weakness. patient was discharged from rehab two weeks ago. was initially doing well at home, but started having difficulty getting up and being active for a week. per report, increased confusion, waxing and in nature, over the last couple of days. vna came to his home yesterday and drew labs which were notable for a elevated creatinine of 3.59 and hyperkalemia. he was brought to the ed for further evaluation and management. . in the ed, initial vs were: t 97.3 hr78 bp113/55 rr16 o2 sat95% ra. initial ed labs were otherwise notable for k of 7.4, creatinine of 6.4 and bun of 106. ekg with peaked t waves. patient received kayexelate, calcium gluconate, bicarb, 10 units of insulin and 1 amp d50 with minimal improvement of k to 4.9 (after an interval increase to 8.8). renal was consulted and recommended renal u/s, more d50 with bicarb, and placement of an hd line for emergent dialysis. three hours into his ed visit an ekg was done, which was remarkable for st elevations in the inferior leads, ii, iii, avf. initial cardiac markers were notable for troponin 3.70, ck 3965 and mb 82. repeat troponin 3 hours later was 4.03. he was given aspirin 81, but given guaic positive stool heparin and plavix was held. cardiology was notified and deferred catheterization secondary to time elapsed and his multiple other co-morbidities. other notable labs from the ed included an initial wbc was 15 with 93% neutrophils. ua was notably dirty with >50 wbcs and a lactate of 2.2. patient had a ph of 7.23 with an anion gap of 18. patient's blood pressures dropped to 80s/50s, he received 3 liters of fluid in boluses and he was started on dopamine and neo. pressures improved to 110s. patient's sat's started to drop and he was showing signs of increased wob. he was subsequently intubated with rocuronium and etomidate. lij hd catheter was placed. he was given a dose of vancomycin and ctx for presumed urosepsis. . vs prior to transfer were afebrile, hr129 bp113/74 o2 sat 100% on vent. in the micu, patient was intubated. patient underwent beside echo with akinesis of inferior wall, ef of about 40%. . review of systems: unable to obtain given to patient's altered mental status. past medical history: coronary artery disease macular degeneration chronic back/leg pain secondary to djd tremor peripheral neuropathy abdominal bruit chronic renal failure believed secondary to vascular disease (, cr: 2.6 and bun 49, k: 5.9) gerd anemia (: hct: 33.5) bilateral cea depression hyperlipidemia colonic polyps??? copd???, in record, however patient denies left and right total hip replacements pvd: mild-moderate aorto--ilac disease as noted in social history: denies current tobacco use (h/o 20+ pack year, quit 15-20 years ago) admits to approximately 2+ beers most nights of the week. denies h/o illicit drug use. lives with wife. family history: non-contributory physical exam: on admission: vitals: t 97.5 bp: 124/107 p: 118 r: 22 o2: 100% (on ac fio2 100%, peep 10, tv .500) general: alert, intubated; follows simple commands heent: endotracheal tube in place; mmm, r eye with ptosis; perrl neck: supple, no jvd, lij hd catheter in place lungs: clear to auscultation in r field anteriorly; coarse bs in left anterior lung field;, no wheezes, rales cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: cool to touch, diminished dp and pt pulses, intact radial pulses; non-blanching violaceous ischemic appearing macules on toes b/l; heel ulceration with deep necrosis r>l; no exudates or purulence visible; 1+ pedal edema back: unstageable sacral decubitus ulcer with necrotic appearance . on discharge: general appearance: awake, alert, following commands, nad heent: eomi, sclera anicteric, mucus membranes moist neck: trach collar in place, site clean and dry cardiovascular: regular but slightly tachycardic, no r/m/g appreciated respiratory / chest: coarse bs bilaterally with decreased bs at bases, no wheezes or rales abdomen: soft, nt/nd, bowel sounds present extremities: right foot cooler than the left, warmer on exam today compared to yesterday neurologic: alert, cns grossly intact, sensation intact, still somewhat delirious, oriented to person, year, season pertinent results: admission labs: wbc rbc hgb hct mcv mch mchc rdw plt ct 15.0* 3.40* 10.6* 32.2* 95 31.3 33.0 13.9 352 glucose urean creat na k cl hco3 angap 131*1 106* 6.4* 7.4*11 99 13*12 30* . pertinent labs: 07:42 ck-mb mb indx ctropnt 157* 3.0 5.37*1 20:44 79* 2.3 4.95*1 caltibc vitb12 folate ferritn trf 233* 724 7.8 342 179* 15:45 fio2 o2 flow po2 pco2 ph caltco2 base xs aado2 req o2 intubat vent 12/ 409* 44 7.46* 32* 7 assist/con1 intubated . discharge labs: wbc rbc hgb hct mcv mch mchc rdw plt ct 8.2 2.46* 8.0* 23.1* 94 32.6* 34.8 17.7* 62* glucose urean creat na k cl hco3 angap 143*1 56* 1.7* 145 4.0 105 28 16 alt ast alkphos totbili 44*2 229*3 65 0.2 ................................................................ micro: , , urine cx: enterococcus ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- <=1 s vancomycin------------ 2 s . blood cx: enterococcus ampicillin------------ =>32 r daptomycin------------ s linezolid------------- 2 s penicillin g---------- =>64 r vancomycin------------ =>32 r ................................................................ studies: ekg: sinus rhythm. inferior st elevation myocardial infarction. compared to the previous tracing of myocardial infarction pattern is new. . cxr: mild cardiomegaly, but no acute intrathoracic process. . tte (bedside): left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. lv systolic function appears depressed (ejection fraction 30%) secondary to severe hypokinesis/akinesis of the inferior and posterior walls. the right ventricular cavity is dilated with depressed free wall contractility. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is no pericardial effusion. impression: inferior posterior infarction; right ventricular infarction . ekg: sinus tachycardia. inferior st segment elevations with rare reciprocal precordial depressions are suggestive of inferoposterior myocardial infarction. compared to the previous tracing st-t wave changes are more extensive. . renal u/s: atrophy of the right kidney is unchanged. the left kidney is normal. no hydronephrosis or mass noted. . tte: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is moderate regional left ventricular systolic dysfunction with inferior/inferolateral akinesis and hypokinesis of the inferior septum. doppler parameters are indeterminate for left ventricular diastolic function. the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: inferior/inferolateral akinesis and septal hypokinesis consistent with inferior infarction/ischemia. dilated and hypokinetic right ventricle likely due to ischemia/infarction. . cxr: compared to most recent prior, there is increased pulmonary vascular prominence, consistent with vascular congestion. cardiomegaly is stable compared to prior. persistent retrocardiac density likely represents a combination of atelectasis and left pleural effusion. there is increased opacity at the right base, consistent with atelectasis. an endotracheal tube is seen with the tip approximately 6.5 cm above the carina. a left internal jugular line is seen with tip projecting over the mid svc. an intestinal tube is seen traversing the diaphragm with tip coiled in the stomach. impression: increased right basilar atelectasis with stable pulmonary edema. . ct abd/pelvis: 1. atrophic right kidney with extensive vascular calcifications. no renal calculi identified. 2. bilateral small pleural effusions and atelectasis. 3. gallbladder wall edema likely due to third spacing and possible hepatitis; this is unlikely to be cholecystitis, but correlation with physical exam is recommended. . ruq u/s: 1. no son signs of cholecystitis. no gallstones and no sludge identified. 2. atrophic right kidney again noted. 3. mild splenomegally. . rue u/s: 1. occlusive clot in the right cephalic vein. of note, the cephalic vein is a superficial vein. 2. otherwise, no deep vein thrombosis in the right upper extremity. . cxr: et tube is in standard placement. left internal jugular line ends at the origin of the left brachiocephalic vein. nasogastric tube passes below the diaphragm and out of view. mild pulmonary edema has not changed appreciably since . heart size is normal. small left pleural effusion is likely. lateral aspect left lower chest is excluded from the examination. there is no evidence of pneumothorax along the imaged pleural surfaces. . cxr: left ij catheter tip is in the proximal svc. there is no pneumothorax. cardiac size is top normal. et tube is in standard position. ng tube tip is in the stomach. if any, there is a small right pleural effusion. bibasilar opacities are improved, consistent with improving atelectasis. persistent opacities in the right perihilar region, and right lower lobe that have improved from , stable from earlier in the morning, are a combination of atelectasis and pleural effusion. superimposed infection cannot be totally excluded. . cxr: ap chest compared to through 4: over the past 24 hours, pulmonary edema has worsened, moderate cardiomegaly and mediastinal vascular engorgement have increased and small bilateral pleural effusion, left greater than right, has increased as well. findings are more consistent with cardiogenic edema than non-cardiogenic. left internal jugular line ends in the svc. . ct chest: 1. moderate bilateral pleural effusions, right greater than left, without evidence of loculation. bilateral adjacent dependent atelectasis, with slightly heterogeneous in shape on the right. possible right lower lobe pneumonia. no cavitary lesion. 2. severe centrilobular emphysema. 3. two sub-5-mm perifissural nodules. given the underlying emphysema and increased risk for lung cancer, recommend followup in 6 to 12 months for stability. 5. moderate-to-severe 3-vessel coronary artery disease. moderate systemic atherosclerotic disease. 6. ett tip 7cm above carina, and nasogastric tube ends in the proximal stomach with most proximal sideport in the distal esophagus. consider advancing both for better positioning. . cxr: as compared to the previous radiograph, there is no relevant change. widespread parenchymal opacities are constant. enlarged pulmonary vessels suggest that these opacities are predominantly caused by edema. in addition, particularly at the right lung bases, a second opacity is seen that shows subtle air bronchograms and could reflect pneumonia. moderate retrocardiac atelectasis. the presence of small pleural effusions cannot be excluded. . 3/12/1 kub: portable ap radiograph of the abdomen was reviewed with no relevant prior studies available for comparison. the limited view obtained in portable technique of supine ap abdomen demonstrates known percutaneous gastrostomy. there is diffuse pattern of bowel gas that might be consistent with ileus, although the pattern is nonspecific and no dilatation of the bowel is present. there is left lower lobe atelectasis and small amount of pleural effusion seen. . ct head: no evidence of an acute intracranial process. . ct torso: 1. moderate-sized bilateral pleural effusions, with associated opactities of both lower lobes. superimposed infection cannot be excluded, but the appearance could be explained by atelectasis. effusions are similar, but parenchymal opacity has improved somewhat at the right lung base. 2. no evidence of bowel obstruction or ileus. 3. tracheostomy tube, left upper extremity picc, and a percutaneous gstrostomy tube are in optimal position. 4. extensive atherosclerotic calcification of the aorta and the coronary arteries. . cxr: as compared to the previous radiograph, there is no relevant change. the tracheostomy tube is in unchanged position. unchanged mild bilateral pleural effusions. unchanged evidence of mild pulmonary edema. retrocardiac atelectasis. normal size of the cardiac silhouette. no newly occurred focal parenchymal opacities. brief hospital course: 66 year old man with ckd (baseline cr 1.7-2.3), cad, chronic back pain and recent hospitalization for altered mental status and acute on chronic renal failure, who presents from home with weakness and altered mental status in the setting of stemi and shock. . # goals of care: patient has a progressive deterioration over the course of his hospital stay, with many complications. on patient developed recurrent episodes of vt (see below), and family decided to make patient dnr/i with goals of care being lack of escalation, but with plan to continue current therapeutic measures. . # shock/urosepsis: patient was admitted to the micu on dopamine and neo for blood pressure support. an arterial line was placed for hemodynamic monitoring. he was transitioned to levophed and vasopressin and was gradually weaned off of pressors as his blood pressures improved. patient's shock was attributed to sepsis rather than a cardiogenic presentation given his high mixed venous oxygen saturation and hyperdynamic cardiac function. the source of his sepsis was attributed to a uti given his dirty ua and eventual multiple enteroccocal urine cultures. he was treated empirically with vancomycin and cefepime, and cipro was added when fevers persisted. blood cultures were initially negative, but eventually grew enterococcus (vre). antibiotics were switched to daptomycin and patient's lines were removed and replaced. patient was transitioned to linezolid and meropenem, and subsequent cultures were negative. . # respiratory failure: patient was intubated increased work of breathing and was put on assist control ventilation. initial cxr was without focal consolidation, but with signs of pulmonary congestion after resuscitation with 3 l ivf. attempted to wean patient off vent but ran into difficulty as diuresis was limited by patient's compromised cardiac function and pre-load dependence after his inferior mi. in addition, patient developed a mrsa pneumonia for which he was treated with 8 days of vancomycin. patient was extubated on , but reintubated on for increased work of breathing. on trach and peg were placed at bedside. patient intermittently required lasix and he has responded to lasix 80 mg iv. we would advise using lasix intermittently to maintain euvolemia. . # stemi: patient suffered an ste inferior mi with depressed rv function (dilated and hypokinetic on serial echos). cardiology was consulted in the ed and patient was medically managed with heparin, plavix, asa, statin. cardiac catheterization was not pursued as it was felt there was little therapeutic benefit to intervention. the heparin drip was stopped after 48 hours. attention was paid to his blood pressure given his preload dependence and small boluses of ivf were given as needed. eventually his blood pressures stabilized and it was possible to gently diurese with lasix drip to attempt to wean patient off vent. patient was tachycardic and was started on metoprolol which was gradually uptitrated. . # acute on chronic renal insufficiency: patient with baseline creatinine of 2.3, presenting here with initial creatinine of 6.4 and hyperkalemia to 7.4. acute renal failure was attributed primarily to obstruction as urine output picked up quickly and creatinine trended down rapidly after foley was placed. however, renal u/s did not show signs of hydronephrosis. atn was felt less likely given the speed of recovery and the relatively acute onset of hypotension in the ed which was quickly addressed with pressors. regardless of etiology, patient's renal function rapidly improved and his creatinine trended down as low as 1.0. his new baseline appears to be 1.2 to 1.8. . # ventricular tachycardia: on patient developed in the setting of desaturating from presumed mucous plugging. patient had 6 episodes, 2 that self terminated, and 4 that required synchronized shock because of loss of pulse. patient was bolused with iv amiodarone and then transitioned to oral amiodarone. his betablocker was stopped. plan to continue amiodarone 400 mg tid for 1 week, then switch to 400 mg for 2 weeks, and then transition to amiodarone 400 mg daily therafter. . # thrombocytopenia: patient developed thromobcytopenia to the 70s, and heparin was discontinued. hit antibody was pending at the time of discharge, and as such we have held heparin products. platelet count nadir was in the 50s, and improved to 62 on the day of discharge. we would ask that his facility please call in order to check on the status of his antibody on . we will also try to reach out to the facility in order to facilitate this process. for now, please hold heparin products. . # guaiac positive stool/anemia: patient with guaiac positive stool in ed. has known severe (grade 3) erosive esophagitis and gastritis on egd in . hct similar to prior hospitalization, baseline may be in mid 30s. he was continued on his home ppi and did drop his hct slightly while on the heparin drip. he was transfused 2 units on and , and one unit on , and . . # wounds: patient with deep necrotic heel ulcers and advanced sacral decubitus ulcer. per wife these are relatively new and likely developed during stay in rehab. wound care was consulted and provided recommendations for dressing changes. patient was seen by vascular surgery when there was concern that the heel ulcers may have been infected and contributing to his fevers, however it was felt the ulcers were not infected and no further intervention was pursued. general surgery was consulted regarding the sacral decub and perforemed bedside debridement on . wound care consult on made the following recs # discontinue dakins to bilateral feet cleanse all wounds with wound cleanser then pat dry # aloe vesta to b/l le's and feet # for left foot ulcers: xeroform dressing daily - cover with dry gauze/abd and secure with kerlix change daily # for right foot: duoderm gel to ulcers ( none on achilles ulcer) then cover with moist ns gauze cover with dry abd then wrap with kerlix change daily # for sacrum : no sting barrier to periwound tissue then antifungal powder continue with santyl - rub into /yellow tissue cover wound with moist ns gauze cover with abd or softsorb dressing secure with pink hy tape to protect from stooling change daily . # depression: on clonazepam and olanzapine at home, which were held given acute illness and restarted prior to discharge. medications on admission: clonazepam 2mg qam olanzapine 20 qam metoprolol tartrate 50mg diltiazem 300mg sr qd asa 81mg qd gabapentin 100mg tid protonix 40mg colace ferrous sulfate carafate slurry qid senna tylenol prn dilaudid 2 mg po prn dressing changes discharge medications: 1. atorvastatin 80 mg tablet : one (1) tablet po daily (daily). 2. polyethylene glycol 3350 17 gram/dose powder : one (1) pack po daily (daily) as needed for constipation. 3. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for pain/fever. 4. sodium hypochlorite 0.5 % solution : one (1) appl miscellaneous asdir (as directed). 5. docusate sodium 50 mg/5 ml liquid : one hundred (100) mg po bid (2 times a day) as needed for constipation. 6. insulin lispro 100 unit/ml solution : one (1) unit subcutaneous asdir (as directed): per sliding scale. 7. ascorbic acid 500 mg tablet : one (1) tablet po daily (daily). 8. collagenase clostridium hist. 250 unit/g ointment : one (1) appl topical daily (daily). 9. aspirin 325 mg tablet : one (1) tablet po daily (daily). 10. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 11. chlorhexidine gluconate 0.12 % mouthwash : fifteen (15) ml mucous membrane (2 times a day). 12. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 13. quetiapine 25 mg tablet : 0.5 tablet po hs (at bedtime) as needed for anixety or insomnia. 14. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : six (6) puff inhalation q6h (every 6 hours) as needed for wheezing. 15. amiodarone 200 mg tablet : two (2) tablet po tid (3 times a day): for 1 more week, then 400 mg for 2 weeks, then 400 mg daily. 16. clonazepam 1 mg tablet : one (1) tablet po bid (2 times a day). 17. acetaminophen 650 mg/20.3 ml solution : six y (650) mg po q6h (every 6 hours) as needed for fever, pain. 18. fentanyl citrate 25-100 mcg iv q2h:prn pain 19. midazolam 0.5-2 mg iv q2h:prn anxiety discharge disposition: extended care facility: - discharge diagnosis: septic shock stemi ventricular tachycardia urinary tract infection discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: you presented to the hospital with weakness and confusion. you were found to have a severe heart attack and a blood infection. you developed problems with your lungs related to fluid overload and pneumonia. you were extubated, but need to have a breath tube placed again. you also had several irregular heart rhythms that required electric shocks. eventually a tracheostomy and peg feeding tube were placed. given your overall medical condition, the decision was made to make your goals of care do not resuscitate. you are being discharged to a rehab facility in order to continue your care. followup instructions: please follow up with your primary care doctor as you see necessary md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Other bronchoscopy Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Nonexcisional debridement of wound, infection or burn Nonexcisional debridement of wound, infection or burn Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acidosis Hyperpotassemia Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Severe sepsis Chronic airway obstruction, not elsewhere classified Atherosclerosis of aorta Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Pulmonary collapse Paroxysmal ventricular tachycardia Dysthymic disorder Acute respiratory failure Cardiogenic shock Septic shock Infection with microorganisms without mention of resistance to multiple drugs Acute myocardial infarction of other inferior wall, initial episode of care Paralytic ileus Pressure ulcer, lower back Do not resuscitate status Pressure ulcer, heel Hyperosmolality and/or hypernatremia Other and unspecified infection due to central venous catheter Ventilator associated pneumonia Streptococcal septicemia Delirium due to conditions classified elsewhere Rhabdomyolysis Other esophagitis Acute on chronic combined systolic and diastolic heart failure Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Methicillin resistant pneumonia due to Staphylococcus aureus Atherosclerosis of other specified arteries Pressure ulcer, unstageable Atrophic gastritis, with hemorrhage |
allergies: no known allergies / adverse drug reactions attending: chief complaint: gastrointestinal bleed major surgical or invasive procedure: right internal jugular central line placement and removal history of present illness: mr. is a 66 year old man with dm, cad, s/p recent stemi, ischemic cardiomyopathy levf 25%, errosive gastritis, and colon polyps who is admitted from rehabilitation for 1 week of black stool, and a slow hct drop. according to the report hct trend: 30 () -> 27 ()->22 today and he was transferred to the emergency department. . in the ed, initial vs were: t: not recorded, p:92 bp:120/69 rr:28 sa02:100% fio2: 40%. he subsequently spiked to t:102.6. labs were remarkable for hct 20.9, wbc 6.7 83.2% lactate 2.4, cr 1.5, ua positive. patient was given vanc/zosyn, pantoprazole drip and 80mg bolus, and a rij was placed, gi was consulted who recommended non-urgent scope, and to continue pantoprazole 40mg iv bid vs drip. not transfused in the ed. vs prior to transfer: t99.8 hr 84 122/67 22 on vent 100% ac 450x12 peep 5 fi02 50% . on arrival to the icu, t:99.9 bp: p:84 r: 18 o2:100% ac 450x12 50% fio2. he reported that his breathing is comfortable, denies chest pain. he complained of pain at the site of his saccral decubitis. . review of sytems: (+) per hpi (-) denies fever, chills. denied shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting. . of note patient was hospitalized recently in the micu . he was admitted for stemi, urosepsis and hypotension. stemi was medically managed with heparin, plavix, asa, statin, echo showed newly depressed ef to 25% with wide lv hypokinesis. he grew vre from blood and urine and was treated with daptomycin, meropenem and linezolid. he was intubated for increased work of breathing and treated for heart failure and vap however the micu team was unable wean him off of the vent, he is s/p trach and peg. hospital course was also complicated by pulseless vt x4 managed with synchronized cardioversion and amiodarone. goals of care at end of hospital course were dnr, do not escalate care past medical history: ventilator dependent last vent settings psv 12/5 atc 40% fio2 coronary artery disease c/b stemi medically managed ventricular tachycardia s/p cardioversion ischemic cardiomyopathy lvef 25% erosive esophagitis c/b recurrent gi bleeds bilateral cea diabetes mellitus sacral decubitis bl heel pressure ulcers chronic kidney disease baseline creatinine 1.4-1.6 pvd: mild-moderate aorto--ilac disease as noted in gerd colonic polyps vre uti mrsa pneuomonia hyperlipidemia macular degeneration chronic back/leg pain secondary to djd essential tremor peripheral neuropathy s/p left and right total hip replacements copd depression social history: denies current tobacco use (h/o 20+ pack year, quit 15-20 years ago) admits to approximately 2+ beers most nights of the week. denies h/o illicit drug use. resident at health. family history: non-contributory physical exam: admission examination vitals: t:99.9 bp: p:84 r: 18 o2:100% ac 450x12 50% fio2 cvp:16 general: alert; follows simple commands heent: tracheostomy in place on ventilator tube in place; mmm, perrl neck: supple, jvp elevated at 10cm, right ij catheter in place lungs: left basilar rales, otherwise clear to auscultation in posterior lung fields. cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly back: deep sacral decubitis ulcer with packing in place gu: foley in place ext: right lower ext cool to touch, left warm to the touch. radial pulses 1+ bl. bilateral r>l heel ulceration with granular base and eschar; no exudates/purulence visible; 1+ pedal edema pulses: right pt palpated, dp not dopplerable left pt and dp dopplerable discharge exam: t96.2, hr66 bp135/69, rr21, 100% on pressure support 8cm/5cm, rr20,fi02 40% general: alert; follows simple commands heent: tracheostomy in place on ventilator tube in place; mmm, perrl neck: supple, right ij catheter in place lungs: bibasilar rales on anterior/lateral auscultation cv: rrr, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: cool, 1+ radial pulses, bandages over heels b/l, trace pedal edema pertinent results: admission labs: 06:45pm blood wbc-6.7 rbc-2.17* hgb-6.9* hct-20.9* mcv-96 mch-31.7 mchc-33.0 rdw-17.9* plt ct-157# 06:45pm blood neuts-83.2* lymphs-11.4* monos-4.3 eos-0.7 baso-0.5 06:45pm blood pt-14.3* ptt-37.1* inr(pt)-1.2* 06:45pm blood glucose-155* urean-82* creat-1.5* na-147* k-3.8 cl-99 hco3-36* angap-16 06:45pm blood alt-96* ast-73* ld(ldh)-249 ck(cpk)-22* alkphos-125 totbili-0.4 06:45pm blood calcium-8.3* phos-5.3*# mg-2.7* 06:45pm blood hapto-380* 07:08pm blood lactate-2.4* cardiac enzymes 06:45pm blood ck-mb-1 ctropnt-0.49* . discharge labs: 03:17am blood wbc-8.5 rbc-3.36* hgb-11.2* hct-32.3* mcv-96 mch-33.2*# mchc-34.6# rdw-17.8* plt ct-175 03:17am blood plt ct-175 03:17am blood pt-14.3* ptt-38.7* inr(pt)-1.2* 03:17am blood glucose-74 urean-66* creat-1.6* na-148* k-3.3 cl-104 hco3-31 angap-16 03:17am blood calcium-8.0* phos-4.3 mg-2.3 04:29am blood lactate-1.1 . imaging: cxr 1. interval placement of right internal jugular central venous catheter terminating in the proximal to mid svc, without evidence of pneumothorax. 2. bilateral layering pleural effusions, increased, with overlying atelectasis, underlying consolidation not excluded. additional peripheral right upper lobe patchy opacity may be due to additional site of infection and/or aspiration. pulmonary edema. cardiomegaly. . tte the left atrium is mildly dilated. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed (lvef= 25-30 %) secondary to akinesis of the inferior and posterior walls, and hypokinesis of the interventricular septum. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated with depressed free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. severe (4+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. compared with the findings of the prior study (images reviewed) of , there has been marked progression of mitral and tricuspid regurgitation (both of the functional ischemic classification) consistent with the natural history of this patient's recently documented untreated extensive inferior posterior and right ventricular myocardial infarction. brief hospital course: hospital course 66yo chronically-ventilated m pmh recent stemi, ischemic cardiomyopathy levf 25%, errosive gastritis, a/w slow upper gastrointestinal bleed and pna, bleeding stabilized without surgical/endoscopic intervention, started on high-dose cefepime for mdr psuedomonal pna, clinical status improving with patient discharged to ecf. . active # gi bleed: patient w h/o errosive gastritis on egd , who presented w downtrending hct (30 to 20.9), guaiac + stool. patient received 3 units prbcs w stabilization of hct in low 30s. patient was continued on iv ppi and started on carafate. hct stabilized (>48 hours) without invasive intervention and gi service opted not to scope. . # respiratory failure pna and chronic systolic chf: ventilator dependent patient mrsa pneumonia and heart failure, with pulmonary infiltrates on admission. sputum grew out psuedomonas with sensitivities demonstrating carbapenem resistance. per id recommendations, patient was started on high dose extended infusion cefepime. id fellow agreed to follow up further micro data on patient. he was continued on home lasix, nebulizers. . # coronary artery disease c/b ischemic cardiomyopathy: patient with recent stemi that was medically managed (given his prior bleeds) with asa, plavix, and a statin, who was w/o signs ischemia on admission, but w signs c/w worsening failure. given some hypotension on admission, metoprolol dosing was decreased. tte demonstrated lvef 25%, 4+mr. cardiology was consulted, who recommended started ace-i. if he remained stable, they also recommended starting spironolactone (not started at discharge, recommended to start at ecf). . inactive # h/o vt: patient was continued on amiodarone. . # dm: patient was continued on standing glargine and sliding scale insulin . # thrombocytopenia: patient continued to have thrombocytopenia on this admission. heparin antibody was negative in prior admission. on discharge platelets 175. . # sacral decubitis: patient with deep sacral decubitis, bilateral heel ulcers. followed by wound care during inpatient stay. should be followed at rehab center. . transitional 1. code status: patient remained dnr for duration of hospital stay 2. pending: at time of discharge, additional sensitivities for psuedomonas (doripenem and colistin) were pending. id fellow would follow-up. 3. transition of care: patient discharged to , with follow-up planned with heart failure clinic. 4. barriers to care: recurrent gi bleeds have had major effect on patient management (rehospitalizations, inability to manage stemi w cath), and may necessitate recurrent transfusions or future readmissions medications on admission: acetaminophen 650 mg/20.3 ml oral soln q6h prn albuterol sulfate hfa 90 mcg 6 puffs q6-8 hrs prn amiodarone 400 mg daily ascorbic acid 500 mg daily atorvastatin 80 mg daily chlorhexedine 0.12% 12ml q12h diphenhydramine 25mg q4h prn itching diphenhydramine cream 1appl q8h prn docusate 100mg glucerna 1.2 tube feed 75ml/h furosemide 80 mg iv bid collnaagese clostridium histolyticum 250 unit/g ointment topical insulin glargine 14 qhs insulin regular sliding scale ipratropium/albuterol 3ml q2h prn lorazepam 1mg q8h prn metoprolol tartrate 75 mg q8h pantoprazole 40 mg iv bid sucralfate 1 gram 4x daily polyethylene glycol 17g daily free water 200cc q6h discharge medications: 1. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily). 2. acetaminophen 650 mg/20.3 ml solution sig: six y (650) mg po q6h (every 6 hours) as needed for pain. 3. ascorbic acid 500 mg tablet sig: one (1) tablet po once a day. 4. atorvastatin 80 mg tablet sig: one (1) tablet po once a day. 5. pantoprazole 40 mg iv q12h 6. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane tid (3 times a day). 7. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 8. cefepime 2 gram recon soln sig: two (2) grams injection q12h (every 12 hours): to be infused over 3 hours. 9. furosemide 80 mg iv bid hold for sbp<90; please contact md if going to hold. 10. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 ml solution for nebulization sig: one (1) inhalation q2h as needed for shortness of breath or wheezing. 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. 12. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 13. captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day). tablet(s) 14. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 15. sucralfate 1 gram tablet sig: one (1) tablet po qid (4 times a day). 16. insulin glargine 100 unit/ml solution sig: fourteen (14) units subcutaneous at bedtime. 17. sliding scale regular insulin sliding scale discharge disposition: extended care facility: - discharge diagnosis: primary hospital acquired pneumonia secondary gi bleed discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: mr. , it was a pleasure taking care of you at . you were admitted with decreasing blood levels, likely due to bleeding from your gastrointestinal tract. you were transfused with red blood cells. your blood levels returned to levels, and remained stable for 3 days. we discussed your care with gastroenterologists who felt that you did not need to have an endoscopy as long as your blood levels remained stable. given your recent history of a heart attack and heart failure, we discussed your case with cardiologists, who felt that certain medications should be started to help your heart function. you were found to have a pneumonia with a very resistant bacteria called psuedomonas. you were seen by infectious disease doctors, who started you on a strong antibiotic called cefepime that you will need to continue for 2 weeks. during the course of this hospitalization, the following changes were made to your medications: -decreased metoprolol to 50mg -started cefepime (to be continued for 13 days) -started captopril -started aspirin -started sucralfate followup instructions: name: , np location: division of cardiology address: , e/rw-453, , phone: we are working on a follow up appointment with np within 1-2 weeks. you will be called with the appointment. if you have not heard from the office within 2 days or have any questions, please call the number above. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Atherosclerosis of aorta Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Depressive disorder, not elsewhere classified Hypopotassemia Chronic kidney disease, unspecified Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Acute and chronic respiratory failure Long-term (current) use of insulin Macular degeneration (senile), unspecified Pressure ulcer, lower back Do not resuscitate status Pressure ulcer, heel Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Unspecified hereditary and idiopathic peripheral neuropathy Acute on chronic systolic heart failure Pressure ulcer, ankle Gastrostomy status Pressure ulcer, stage IV Pseudomonas infection in conditions classified elsewhere and of unspecified site Tracheostomy status Other esophagitis Mixed acid-base balance disorder Dependence on respirator, status Acute myocardial infarction of other inferior wall, subsequent episode of care Spondylosis of unspecified site, without mention of myelopathy Personal history of Methicillin resistant Staphylococcus aureus Atherosclerosis of other specified arteries Essential and other specified forms of tremor |
allergies: bee venom (honey bee) attending: chief complaint: gi bleed major surgical or invasive procedure: egd history of present illness: 47 m with history of cirrhosis secondary to hepatitis c, ascites, known esophageal varices (planned to have banding done on ) who presents with gi bleed. according to the patient, two and a half weeks ago, he vomited about a half-cup of blood and was worked up for gi bleed at an outside hospital (endoscopy performed at ). last night at 10:30pm, the patient began to feel nauseated. by 11pm, he had some dry heaves that brought up a few tablespoons of blood. at whcih point he called an ambulance, which took him to hospital. the patient also said that he had experienced some episodes of bright red blood in the toilet and on the toilet paper, but he has known hemorrhoids and thinks that the source of his brbpr. at the outside hospital, the patient was found to be guaiac positive and started on a protonix gtt before transfer here. he also received morphine there for mild abdominal pain. . in the ed, initial vs were: 98.6 81 110/75 16 96% ra. pt was given pantoprazole 40mg iv once, zofran 2mg iv once, morphine 5mg iv. pt was typed and crossmatched. access: 2 large bore ivs, 16 gauge, already placed. given known varices, pt is admitted to micu for endoscopy and close observation, plan to give protonix and octreotide drip, and hepatology will follow. . on arrival to the micu, the patient would have moments of somnolence from which he was readily awakened. he was generally oriented and not complaining of any pain. he was originally complaining of suprapubic discomfort, but had foley placed and drained one liter of urine, with relief. past medical history: cirrhosis hepatitis c esophageal varices ascites htn myocardial infarction hip replacement social history: - tobacco: cigarettes per day along with snuff - alcohol: patient has been sober for 103 days; previously drank 25-30 beers plus schnapps. - worked in construction. family history: hypertension physical exam: admission: vitals: bp: 123/74 p: 55 r: 18 o2: 100% general: alert, oriented, no acute distress heent: sclera anicteric, oropharynx clear, eomi, perrl neck: supple, no cervical lymphadenopathy cv: s1, s2, no murmurs auscultated lungs: clear to auscultation bilaterally, no wheezes abdomen: umbilical hernia, caput medusae, fluid wave, some tenderness at ruq and hernia to deep palpation gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, no asterixis. discharge: vs: 98.3, 92-104/45-66, 65-69, 20, 98-100% ra. general: mildly jaundiced, aaox3 heent: sclera mildly icteric. mmm. cardiac: rrr, nl s1/s2, no m/r/g lungs: cta b/l with no wheezing, rales, or rhonchi. abdomen: distended but soft, tender to epigastrium on palpation with voluntary guarding, over an area of a fascial defect with a ventral hernia on valsalva. no hsm or tenderness appreciated. extremities: no edema. warm and well perfused with varicosities, with 2+ dp pulses, no clubbing or cyanosis. pertinent results: admission; 10:24pm sodium-121* potassium-4.0 chloride-92* 10:24pm hct-33.4* 05:00pm urine hours-random urea n-432 creat-56 sodium-251 potassium-42 chloride-249 05:00pm urine osmolal-749 12:35pm glucose-101* urea n-9 creat-0.6 sodium-122* potassium-4.7 chloride-93* total co2-21* anion gap-13 12:35pm estgfr-using this 12:35pm alt(sgpt)-119* ast(sgot)-235* alk phos-150* tot bili-1.6* 12:35pm lipase-57 12:35pm albumin-2.9* calcium-8.3* phosphate-3.9 magnesium-1.5* 12:35pm wbc-7.5 rbc-3.76* hgb-12.0* hct-34.2* mcv-91 mch-32.0 mchc-35.3* rdw-16.8* 12:35pm neuts-64.0 lymphs-21.2 monos-8.4 eos-5.8* basos-0.5 12:35pm pt-18.6* inr(pt)-1.8* 12:35pm plt count-81* discharge: 05:58am blood wbc-5.3 rbc-3.65* hgb-11.6* hct-33.1* mcv-91 mch-31.8 mchc-35.1* rdw-17.2* plt ct-69* 05:58am blood glucose-108* urean-9 creat-0.7 na-125* k-4.9 cl-95* hco3-23 angap-12 05:58am blood alt-114* ast-245* ld(ldh)-237 alkphos-101 totbili-1.6* 05:58am blood albumin-3.2* calcium-8.5 phos-3.4 mg-1.6 pertinent: helicobacter pylori antibody test (final ): negative by eia. brief hospital course: 47 year old male with history of hcv and etoh cirrhosis, complicated by ascites and grade ii esophageal varices s/p banding, now admitted with upper gi bleed likely secondary to portal gastropathy and antral erosions. . # upper gi bleed - most likely secondary to portal gastropathy with erosions and/or grade ii esophageal varices, which were visualized and banded on repeat egd. he remained hemodynamically stable and has not had any more hematemesis during this hospitalization. he was monitored for 48 hours without any further bleeding episodes. ppi and carafate qid were continued. h pylori serologic testing was negative. . # hyponatremia - given high urine sodium and osmolality with otherwise normal electrolytes and lack of renal failure, likely a large component of siadh, which seemed to improve while he was npo for egd. loop diuretics may help to decrease the action of adh by washing out the osmolar gradient, so there were restarted slowly in light of borderline hypotension (sbp 90-100). free water restriction to 1.5l per day was begun. consider outpatient workup for siadh. # epigastric abdominal pain - his pain was located over site of ventral hernia and has been intermittent for several months while outside of the hospital. no symptoms concerning for strangulation, as the hernia is reducible and no changes in bowel habits. would recommend outpatient follow-up by general surgeon . # hcv and etoh cirrhosis: known treatment-naive hcv with last viral load in of 8.36 million iu/ml. no liver biopsy in our records to help assess the grade of inflammation or fibrosis. likely component of etoh as well, given heavy alcohol abuse history. known complications of varices and ascites, though no extensive ascites on exam. nadolol and spironolactone were continued. consider transplantation workup as an outpatient. . # chronic itching: hydroxine was continued. . # chronic pain: home dose oxycodone was continued. medications on admission: cyclobenzaprine 10 mg tablet 1 tablet(s) by mouth per day as needed for muscle spasm furosemide 40 mg tablet 1 tablet(s) by mouth once a day hydroxyzine hcl 50 mg tablet 1 tablet(s) by mouth per night lisinopril 10 mg tablet 1 tablet(s) by mouth once nadolol 20 mg tablet 1 tablet(s) by mouth once a day omeprazole 40 mg capsule, delayed release(e.c.) 1 capsule(s) by mouth twice a day ondansetron 4 mg tablet, rapid dissolve 1 tablet(s) by mouth every 8 hours as needed as needed for nausea nr oxycodone 5 mg tablet 1 tablet(s) by mouth three times per day as needed for hip and back pain spironolactone 100 mg tablet 1 tablet(s) by mouth once a day zinc dosage uncertain discharge medications: 1. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itching. 2. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). 4. sucralfate 1 gram tablet sig: one (1) tablet po qid (4 times a day). disp:*100 tablet(s)* refills:*2* 5. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 6. spironolactone 25 mg tablet sig: two (2) tablet po daily (daily). 7. hydroxyzine hcl 25 mg tablet sig: four (4) tablet po qhs (once a day (at bedtime)). 8. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po tid (3 times a day). 9. zinc sulfate 220 mg capsule sig: one (1) capsule po bid (2 times a day). 10. oxycodone 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain: do not drive while taking this medication. 11. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 12. docusate sodium 100 mg capsule sig: one (1) capsule po once (once) for 1 doses. 13. cyclobenzaprine 10 mg tablet sig: one (1) tablet po once a day as needed for pain. 14. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. discharge disposition: home discharge diagnosis: primary: upper gi bleed cirrhosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , it was a pleasure caring for you at . you were admitted with bleeding from your gastrointestinal tract. a study was done where a camera was placed down your esophagus and we saw evidence of erosions that were likely causing your bleeding. we also noted varices that we banded. you will need to follow-up in weeks with the gi doctors they repeat the study. we have made the following changes in your medications: start sucralfate 1 gram four time a day for your stomach erosions change furosemide (lasix) to 20mg daily ( original dose) because your blood pressure is a little low change spironolactone t0 50mg daily ( original dose) because your blood pressure is a little low stop lisinopril for now, until your blood pressure increases. you do not need this right now. please take the rest of your medications as prescribed. followup instructions: department: liver center when: friday at 11:40 am with: , md building: lm campus: west best parking: garage department: endo suites when: tuesday at 2:00 pm department: digestive disease center when: tuesday at 2:00 pm with: , md building: building (/ complex) campus: east best parking: main garage Procedure: Other endoscopy of small intestine Other endoscopy of small intestine Diagnoses: Tobacco use disorder Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Hyposmolality and/or hyponatremia Other and unspecified alcohol dependence, in remission Portal hypertension Old myocardial infarction Other ascites Duodenitis, without mention of hemorrhage Esophageal varices in diseases classified elsewhere, without mention of bleeding Other specified disorders of stomach and duodenum Hip joint replacement Unspecified pruritic disorder Other specified gastritis, with hemorrhage |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: patient admitted for weight reduction surgery. major surgical or invasive procedure: status post laparoscopic gastric bypass history of present illness: has class iii morbid obesity with weight of 290.1 lbs as of (her initial screen weight on was 286.9 lbs), height of 64.5 inches and bmi of 49. her previous weight loss efforts have included 2 months of the diet in and losing 20 lbs, 4 months of prescription weight loss medication phentermine in - losing 47 lbs that she regained after stopping medication in one year and 3 months of pondimin (fenfluramine) in losing 20 lbs. past medical history: dyslipidemia, urinary stressincontinence, migraine headaches, gerd, gallbladder disease and b/l knee and low back pain social history: she denied tobacco and recreational drug usage, has one bottle of wine cooler twice a month and drinks 5-7 cups of coffee a day. she works as a manager for insurance company. she is married living with her husband age 43 and they have 3 children ages 12, 17 and 20 years old. family history: her family history is noted for both parents living father age 74 with obesity; mother in her 70s with cancer; aunt living in her 70s with diabetes and grandmother deceased with diabetes. physical exam: her blood pressure was 134/90, pulse 98 and o2 saturation 98% room air. on physical examination was casually dressed, slightly anxious but in no distress. skin was warm, moist, no rashes. sclerae were anicteric, conjunctiva clear, pupils were equal round and reactive to light, fundi were normal, mucous membranes were moist, tongue pink and the oropharynx was without exudates or hyperemia. trachea was in the midline and the neck was supple without adenopathy, thyromegaly or carotid bruits. chest was symmetric and the lungs were clear to auscultation bilaterally with good air movement. cardiac exam was regular rate and rhythm, normal s1 and s2, no murmurs, rubs or gallops. the abdomen was obese but soft and non-tender, non-distended with normal bowel sounds, no masses, healed trocar scars, no hernias. there was no spinal tenderness or flank pain. lower extremities were without edema, venous insufficiency or clubbing. there was no joint swelling or joint inflammation. there were no focal neurological deficits. pertinent results: 10:21pm blood ptt-38.4* 04:10am blood wbc-13.8*# rbc-3.83* hgb-11.8* hct-32.8* mcv-86 mch-30.7 mchc-35.8* rdw-13.9 plt ct-224 04:10am blood glucose-108* urean-7 creat-0.6 na-136 k-3.5 cl-101 hco3-25 angap-14 01:42am blood type-art po2-45* pco2-34* ph-7.47* caltco2-25 base xs-1 intubat-not intuba comment-collection 01:42am blood freeca-1.10* cta of chest massive pe, including a saddle embolus, occluding right main pulmonary artery and multiple lobar, segmental and subsegmental right sided emboli. evidence of right ventricular strain; right main pulmonary artery is progressively dilated on delayed scan. lower extremity ultrasound compressible but echogenic left greater saphenous and common femoral veins with possible slight decrease of variability in the common femoral veins (compared with the right) is compatible with a more proximal partially-occlusive thrombus. brief hospital course: patient admitted and underwent a laparoscopic gastric bypass on . postoperatively patient developed tachycardia and intermittent drops in oxygen saturation. on postoperative day one she underwent an upper gi study that confirmed no leak or obstruction. a chest x-ray showed lung volumes relatively low, a heart that is moderately enlarged, but no signs of overhydration was seen and moderate retrocardiac atelectasis, but no evidence of pneumonia, no pneumothorax. patient was then given ct scan of chest. this confirmed a massive pe, including a saddle embolus, occluding right main pulmonary artery and multiple lobar, segmental and subsegmental right sided emboli. patient was immediately started on a heparin gtt and transfered to the intensive care unit for close monitoring. on postoperative day 3 patient had an ultrasound of her lower extremities to rule out clot. this exam showed compressible but echogenic left greater saphenous and common femoral veins with possible slight decrease of variability in the common femoral veins (compared with the right) is compatible with a more proximal partially-occlusive thrombus. vascular service consulted. recommends that inr be maintained between 2.5 - 3. coumadin to be continued for 6 months. on postoperative day 7 her heparin gtt was discontinued as her inr was 3.5. on postoperative day 9 her inr was 3.6. we will discharge her home on coumadin 2.5mg daily with follow up management by her primary care provider. . at . i have spoken with dr. regarding hospital course and follow up needs. dr. has agreed to see on friday and manage her coumadin regimen. has been given information regarding coumadin and it's side effects. she will follow up with dr. in 2 weeks. medications on admission: midol prn cramps; tylenol es, aleve and advil for knee and back pain prn; daily mv with minerals and vitamin d 1000 u qd discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). disp:*500 ml* refills:*0* 2. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4h (every 4 hours) as needed for pain. disp:*500 ml* refills:*0* 3. zantac 15 mg/ml syrup sig: ten (10) ml po twice a day. disp:*600 ml* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: obesity discharge condition: stable discharge instructions: discharge instructions: please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. diet: stay on stage iii diet until your follow up appointment. do not self advance diet, do not drink out of a straw or chew gum. medication instructions: resume your home medications, crush all pills. you will be starting some new medications: 1. you are being discharged on medications to treat the pain from your operation. these medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. you must refrain from such activities while taking these medications. 2. you should begin taking a chewable complete multivitamin with minerals. no gummy vitamins. 3. you will be taking zantac liquid 150 mg twice daily for one month. this medicine prevents gastric reflux. 4. you should take a stool softener, colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 5. you must not use nsaids (non-steroidal anti-inflammatory drugs) examples are ibuprofen, motrin, aleve, nuprin and naproxen. these agents will cause bleeding and ulcers in your digestive system. activity: no heavy lifting of items pounds for 6 weeks. you may resume moderate exercise at your discretion, no abdominal exercises. wound care: you may shower, no tub baths or swimming. if there is clear drainage from your incisions, cover with clean, dry gauze. your steri-strips will fall off on their own. please remove any remaining strips 7-10 days after surgery. please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. followup instructions: provider: , rd phone: date/time: 3:30 provider: , md phone: date/time: 4:00 provider: , rd phone: date/time: 9:00 Procedure: Laparoscopic gastroenterostomy Laparoscopic repair of diaphragmatic hernia, abdominal approach Diagnoses: Esophageal reflux Cardiac complications, not elsewhere classified Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Pain in joint, lower leg Morbid obesity Iatrogenic pulmonary embolism and infarction Lumbago Tachycardia, unspecified Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever major surgical or invasive procedure: 8 fr double j stent from renal pelvis to bladder. 6 fr pigtail in renal pelvis and capped. transferred to floor l perc neph tube placed (to bag drainage); l ureter stent placed (tube capped) history of present illness: 73f discharged yesterday pod 5 s/p sigmoid colectomy for bleeding colonic mass, as well as s/p craniotomy on for bilateral cva associated with nstemi, returns with fevers and general malaise from rehab. on her recent hospitalization, she prestented with acute vertigo and she was found to have bilateral cerebellar cvas. she was taken to the or by neurosurgery on for posterior fossa decompression and evd. her hospitalization was complicated by afib with rvr. she also had an nstemi with a peak trop of 0.22 most likely in the setting of demand ischemia. she also developed brbpr during this hospitalization, and was taken to colonoscopy on which showed a colonic mass which was sent for biopsy. she had a sigmoid colectomy and her operative course was uncomplicated. she returns from rebab with fevers/chills and altered mental status. she denies having any nausea, vomiting, abdominal pain. past medical history: hypertension gerd sigmoid colectomy for bleeding mass , craniotomy with posterior fossa decompression and evd placement social history: she lives with her husband, has 3 children, quit smoking in , she denies of alcohol family history: no hx of stroke in the family. her parents died in their 70's of unknown cause physical exam: a and o x 2 person, place, easy to reorient, sundowns at night. v.s.s lscta bilat rrr no m/r/g abd soft, nt, nd. llq nephrostomy tube capped. no c/c/e pertinent results: 06:55am blood wbc-10.1 rbc-3.76* hgb-11.4* hct-35.9* mcv-96 mch-30.3 mchc-31.7 rdw-14.7 plt ct-540* 10:45pm blood wbc-17.8*# rbc-2.89* hgb-9.4* hct-29.1* mcv-101* mch-32.6* mchc-32.4 rdw-14.6 plt ct-636* 10:45pm blood neuts-91.4* lymphs-5.8* monos-2.3 eos-0.3 baso-0.3 10:45pm blood neuts-91.4* lymphs-5.8* monos-2.3 eos-0.3 baso-0.3 06:55am blood plt ct-540* 06:55am blood pt-12.3 ptt-32.3 inr(pt)-1.0 10:45pm blood plt ct-636* 12:18am blood pt-26.9* ptt-35.9* inr(pt)-2.6* 06:55am blood glucose-84 urean-5* creat-0.6 na-141 k-3.5 cl-103 hco3-29 angap-13 10:45pm blood glucose-107* urean-14 creat-1.1 na-139 k-5.6* cl-104 hco3-25 angap-16 04:35am blood ck(cpk)-69 10:45pm blood ck(cpk)-98 06:55am blood calcium-8.8 phos-3.4 mg-1.8 06:32am blood mg-1.3* 02:08pm urine color- appear-hazy sp -1.010 11:03pm urine color-yellow appear-hazy sp -1.010 02:08pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-tr bilirub-neg urobiln-neg ph-8.0 leuks-lg 11:03pm urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-0.2 ph-6.0 leuks-lg 02:08pm urine rbc-621* wbc-56* bacteri-none yeast-none epi-0 11:03pm urine rbc-0-2 wbc-21-50* bacteri-few yeast-none epi-0-2 transe-0-2 . blood culture, routine (final ): no growth. x 2 . mrsa screen (final ): no mrsa isolated. . 9:45 am fluid,other site: pelvis lt pelvic fl gram stain (final ): +(5-10 per 1000x field): polymorphonuclear leukocytes. fluid culture (final ): no growth. anaerobic culture (final ): no growth. . urine culture (final ): no growth. . head ct head w/o contrast: minimal change with no intracranial hemorrhage and redemonstration of post-operative findings. . ct pelvis w/contrast 1. extraluminal collection of fluid and oral contrast in the deep pelvis, concerning for anastomotic leak. 2. bibasilar pulmonary consolidations, increased from the previous study. 3. extensive atherosclerotic disease with an infrarenal abdominal aortic aneurysm, unchanged from the comparison studies.11 . cxr: new endotracheal tube and nasogastric tube, with the endotracheal tube at the carina and this tube should be retracted. new mild pulmonary edema. . punc asp abs hem bul cyst study date of impression: successful ct-guided drain placement in a left pelvic fluid collection. . percutaneous nephrostomy and antegrade stent placement impression: 1. partial transection of the distal left ureter at the l4 level with associated large urinoma in the left flank. nondilated pelvicalyceal system secondary to free leakage of urine into the retroperitoneum. 2. technically successful placement of an unformed 8 french nephrostomy tube. 3. failed attempts at advancing a nephroureteral stent across the area of ureteral injury to the bladder. a decision was made to bridge the partial ureteral transection with a 5 french catheter terminating within the bladder and to reattempt ureteral stent placement in two to three days to allow decreased inflammation. 4. right ureter seen in total and normal from kidney to bladder. 5. normal cystogram . change perc tube or cath w/contrast study date of 1.antegrade nephrostogram demonstrating a persistent leak involving the proximal third of the left ureter in the region of ureteral injury. 2. successful placement of an 8 french double-j stent traversing the ureteral partial transection. the 6 french nephrostomy catheter was left in place to maintain access to the left collecting system for a trial of internal drainage. . no destructive or sclerotic bone lesions. a hemangioma in the vertebral body of t6 is unchanged and loss of vertebral body height of l1 is stable. . ct chest w/contrast study date of impression: 1)new bilateral pleural effusions, moderate on the right and small on the left causing overlying compressive atelectasis, no consolidation. 2)multiple calcified granulomas suggest prior granulomatous exposure. 3)stable right thyroid nodule. 4)mild enlargement of the pulmonary artery suggests pulmonary arterial hypertension. 5)focal ectasia of the thoracic aortic arch with diffuse ulcerated plaque, unchanged. . head ct minimal change since most recent prior on with no intracranial hemorrhage or new infarction. post-operative changes are once again noted improved since . an mri is more sensitive than ct for the detection of ischemic changes and is recommended if clinically indicated and if there are no contraindications to the use of mri in this patient. brief hospital course: mrs. returned to from rehab secondary to fevers and general malaise. she was intubated in the ed for hypoxia, ? flash pulmonary edema. . she was given vanc, ceftriaxone, flagyl, 2l ivf, and started on levophed for persistent hypotension. seen by surgery who did not feel that the abdomen was the concerning source but recommended ct a/p to eval. seen by neurosurgery to eval new head ct in setting of altered ms initially. ct head done as well. . fever, elevated wbc and +u/a lead to concern for urosepsis, although other source cannot be ruled out. no abdominal symtoms to lead to concern for anastomitic leak, although remains on differential. she was intubated and started on iv abx. . hypotension: septic like picture with fever, elevated wbc, and positive u/a are concerning for urosepsis. other sources are adbominal leak (less likely given benign exam) vs. intracranial infection given recent craniotomy. she was given ivf, levophed as needed, abx. . hypoxic respiratory failure: no clear infiltrate or pulmonary edema seen on cxr. history of recent pe but inr therapeutic so less likely worsening or new embolism. possible flash pulmonary edema that is not visible on cxr. diuresis was held secondary to hypotenstion and serial abg's were obtained. . ct showed concern for anastamotic leak with extraluminal po contrast. the patient's anticoagulation was reversed with 4u ffp and 10 iv vitamin k, she was given broad spectrum antibiotic coverage and 7l of crystalloid and was prepped for the or. the decision was made to hold-off on surgery because on review, the ct finding was c/w abscess from ? a prior leak and not an active leak. instead, the patient underwent a ct guided drainage procedure. drainage fluid was serosanginous and not purulent. analysis of fluid showed elevated level of creatinine, concerning for urine. a nephrostomy tube was placed and it was noted that the pt had hematuria. her coumadin had been held secondary to this. the patient will need to be restarted on coumadin when hematuria resolvse to prevent further clotting. . mrs. appeared confused at times, a urine sample was sent and it was positive for a uti. a repeat head ct was obtained, showing no changes and neurology was called and belived that the cause of confusion was secondary to her uti. she was started on cipro for this. it is also noted that at night she sundowns and needs to be reoriented. her nephrostomy tube is capped and secured to her body. she will f/u with ir in 3 months to have drain reimaged. medications on admission: metoprolol 25", sliding scale insulin, colace 100", senna prn, simvastatin 40', famotidine 20" discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po q 8h (every 8 hours). 2. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. acetaminophen 500 mg tablet sig: two (2) tablet po q 8h (every 8 hours) as needed for pain. 6. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for sob/wheeze. 8. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 3 days. 9. coumadin 2.5 mg tablet sig: as directed tablet po once a day: please start once hematuria is resolved. titrate to theraputic range. . discharge disposition: extended care facility: - discharge diagnosis: primary: urinoma from possible left ureteral injury uti . secondary: 1. embolic cerebellar infarcts (bilateral) 2. status post posterior fossa decompression 3. non-st elevation myocardial infarction (nstemi) 4. hematochezia 5. colonic mass 6. status post colonic mass resection 7. atrial fibrillation with rapid ventricular response 8. deep vein thrombosis, right 9. status post ivc filter placement 10. hypertension 11. hyperlipidemia discharge condition: activity status:ambulatory - requires assistance or aid (walker or cane) level of consciousness:alert and interactive mental status:confused - sometimes discharge instructions: should you develop any further difficulty with balance, vertigo, headache, weakness, changes in vision, difficulty with speech, chest pain, shortness of breath, fever, chills or any other symptom concering to you, please call your doctor or go to the emergency room. please call your doctor or return to the er for any of the following: * 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 pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *avoid driving or operating heavy machinery while taking pain medications. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * continue to ambulate several times per day. . incision care: -keep open to air. dermabond will slough off. dissolvable sutures. -you may shower, and wash surgical incisions. -avoid swimming and baths until your follow-up appointment. -please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . nephrostomy tube capped and secured to body. followup instructions: 1. please follow-up with dr. in weeks. call for an appointment. 2. provider (neurologist), md phone: date/time: 1:30 3. follow-up with your pcp, . for continued management of your hypertension and anticoagulation once you are discharged from rehab. 4. ir will call you in call you to make a follow up appointment. the drain will stay in for 3 months and than you will be reimaged. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Percutaneous nephrostomy without fragmentation Percutaneous abdominal drainage Ureteral catheterization Ureteral catheterization Percutaneous pyelogram Replacement of nephrostomy tube Diagnoses: Esophageal reflux Other postoperative infection Unspecified pleural effusion Urinary tract infection, site not specified Unspecified essential hypertension Unspecified septicemia Severe sepsis Atrial fibrillation Accidental puncture or laceration during a procedure, not elsewhere classified Acute respiratory failure Gross hematuria Anticoagulants causing adverse effects in therapeutic use Abdominal aneurysm without mention of rupture Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Subendocardial infarction, subsequent episode of care Acute edema of lung, unspecified Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity Malignant neoplasm of sigmoid colon |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: vertigo and imbalance major surgical or invasive procedure: suboccipital decompression/craniotomy colonic mass resection diagnostic cardiac catheterization ivc filter placement history of present illness: per admitting resident: 73 year old r handed woman with pmh of htn who p/w acute onset vertigo and nausea. she had no weakness, no visual cuts. she thought she may have had mild incoordination bl; some trouble with fine movements. however, she could hold objects and walk normally. she denied ha. . she went to osh where bp 127/75 hr 84 and she was neurologically intact. a cta head/neck was performed and showed occlusion of r vertebral, mild stenosis of mid basilar artery and short segment stenosis p2 segment of l pca. a brain mri revealed bilateral cerebellar stroke and small punctate cortical infarcts r and l occipital lobes. patient was then transferred to for further care. . per accepting resident, 73 yo female with h/o htn admitted with acute vertigo found to have bilateral cerebellar cvas. she was taken to the or by neurosurgery on for posterior fossa decompression and evd. her hospitalization has been complicated by afib with rvr requiring iv metoprolol and po metoprolol for rate control. she also had an nstemi with a peak trop of 0.22 most likely in the setting of demand ischemia. she also developed brbpr during this hospitalization, and was taken to colonoscopy on which showed a colonic mass which was sent for biopsy. general surgery was consulted for possible surgical resection. also, today, patient was noted to have a leukocytosis, though she has not had a fever. 2 days ago, she had a mild fever to 100.0. . currently, the patient denies any cp, dyspnea, abdominal pain, palpitations, nausea, vomiting, diarrhea, or constipation. she states from a neurological standpoint she is doing better. she has been up in the chair as well. she is tolerating a regular diet. she has a basic understanding of all of her acute illnesses, and she is aware that she has a colonic "polyp/mass". she is currently prepping for a colonoscopy. . of note, patient reports she had not been taking any medications prior to admission. she actually wasn't following with a pcp at all fairly recently. no colonoscopy recently either. she denies any cp at home. . ros: the patient denied visual difficulty, hearing changes, difficulty speaking, language problems, memory difficulty, difficulty swallowing, paresthesias, sensory loss, weakness, or falls. . the patient denied fever, wt loss, appetite changes, cp, palpitations, doe, sob, cough, wheeze, nausea, vomiting, diarrhea, constipation, abd pain, fecal incont, dysuria, nocturia, urinary incontinence, muscle or joint pain, hot/cold intolerance, polyuria, polydipsia, easy bruising, depression, anxiety, stress, or psychotic sx. past medical history: hypertension gerd social history: she lives with her husband, has 3 children, quit smoking in , she denies of alcohol family history: no hx of stroke in the family. her parents died in their 70's of unknown cause physical exam: exam on admission: t-98.4 bp-146/80 hr-86 rr-18 97o2sat gen: lying in bed, nad heent: nc/at, moist oral mucosa neck: no tenderness to palpation, normal rom, supple, no carotid or vertebral bruit back: no point tenderness or erythema cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: clear to auscultation bilaterally abd: +bs soft, nontender ext: no edema . neurologic examination: mental status: awake and alert, cooperative with exam, normal affect. oriented to person, place, and date. attentive, says backwards. speech is fluent with normal comprehension and repetition; naming intact. no dysarthria. and writing intact. registers , recalls in 5 minutes. no right left confusion. no evidence of apraxia or neglect. . cranial nerves: pupils equally round and reactive to light, 4 to 2 mm bilaterally. visual fields are full to confrontation. extraocular movements intact bilaterally, l sided nystagmus. sensation intact v1-v3. facial movement symmetric. hearing intact to finger rub bilaterally. palate elevation symmetrical. sternocleidomastoid and trapezius normal bilaterally. tongue midline, movements intact . motor: normal bulk bilaterally. tone normal. no observed myoclonus or tremor. no pronator drift tri wf we fe ff ip h q df pf te tf r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 . sensation: intact to light touch, pinprick, vibration and proprioception throughout. no extinction to dss . reflexes: b t br pa pl right 2 2 2 3 2 left 2 2 2 3 2 toes were downgoing bilaterally. . coordination: finger-nose-finger with mild dysmetria bl, heel to shin mildly abnormally bl, rams normal. . gait: not tested . at discharge: vitals: 99, 82, 146/72, 18, 95% on ra gen: nad, a/ox2-3. easily re-oriented to place. neuro: short-term memory deficits. otherwise refer to above "neuro" exam. cv: rrr, no m/r/g resp: ctab, no w/r/r abd: soft, nd, appropriately ttp, +bs, +flatus incision: multiple small laparoscopic incisions ota with dermabond, cdi. old jp site intact with suture. no drainage. extrem: no c/c/e pertinent results: labs on admission: 06:18pm blood wbc-16.3* rbc-4.57 hgb-14.9 hct-44.0 mcv-96 mch-32.7* mchc-33.9 rdw-14.0 plt ct-363 06:18pm blood neuts-94.1* lymphs-4.0* monos-1.5* eos-0.2 baso-0.1 06:18pm blood pt-12.0 ptt-27.8 inr(pt)-1.0 08:05pm blood glucose-134* urean-16 creat-0.8 na-138 k-4.6 cl-103 hco3-23 angap-17 12:20am blood ck(cpk)-158* 05:00am blood ck-mb-13* ctropnt-0.21* 12:20am blood ctropnt-0.22* 08:05pm blood ck-mb-13* ctropnt-0.22* 12:20am blood phos-3.7 mg-1.8 08:05pm blood cholest-302* 08:05pm blood triglyc-185* hdl-59 chol/hd-5.1 ldlcalc-206* 08:39pm blood %hba1c-5.6 . labs on discharge: . imaging: . from osh: cta head/neck was performed and showed occlusion of r vertebral, mild stenosis of mid basilar artery and short segment stenosis p2 segment of l pca. . a brain mri revealed bilateral cerebellar stroke and small punctate cortical infarcts r and l occipital lobes . ct head : impression: areas of hypodensity within the cerebellar hemispheres bilaterally corresponding to area of acute infarct seen on the outside hospital mri with mass effect on the 4th ventricle. no significant change in size of the lateral ventricles and 3rd ventricle since the prior study. no acute intracranial hemorrhage. . echo: the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior septum, and the distal anterior wall, apex, and distal inferior wall. the remaining segments contract normally (lvef = 45 %). no masses or thrombi are seen in the left ventricle. the remaining left ventricular segments contract normally. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. . impression: no apparent intracardiac source of embolism. regional left ventricular systolic dysfunction consistent with mid lad disease. mild mitral regurgitation. moderate pulmonary hypertension. . ct head : impression: 1. status post suboccipital craniectomy and decompression, with right transfrontal placement of evd with tip at the third ventricular floor, and short-interval improvement in hydrocephalus. 2. evolving cerebellar infarcts, as well as more evident left occipital lobar and smaller parieto-occipital infarcts, superiorly. 3. no hemorrhage. . diagnostic cath: 1. selective coronary angiography of this right dominant system demonstrated one vessel coronary artery disease. the lmca was without flow-limiting stenosis. the lad had a 30% stenosis in the mid vessel just prior to the second diagonal branch which was a very small vessel that had an 80% ostial stenosis. the lcx had no angiographically apparent stenosis. the rca had minimal plaquing. 2. limited resting hemodynamics revealed mild systemic arterial systolic hypertension sbp=152 mmhg. . final diagnosis: 1. one small branch vessel coronary artery disease. . echo with bubble study: focused study. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. no masses or thrombi are seen in the left ventricle. . brief hospital course: 73 year old woman with htn presented with vertigo, difficulty with balance without other associated symptoms who initially presented to osh where she was found to have bilateral cerebellar infarcts in pica distribution, as well as small infarcts in occipital lobes bilaterally. cta at osh revealed occlusion of r vertebral, mild stenosis of mid basilar artery and short segment stenosis p2 segment of l pca. she was transferred to for further management on . . when she arrived at , her examination was notable for loss of color vision in right peripheral field, nystagmus in bilateral gaze, mild dysmetria bilaterally in ues and l > r impaired coordination in les with a mild r nlf flattening. . neuro. she was admitted to neuro icu and treated per stroke protocol. she was started on heparin gtt for likely artery to artery embolism, however, she was noted to deteriorate with r vf loss, inability bisect the line and dysmetria. she was noted to have progression of edema and infarcts on repeat ct and thus heparin was discontinued. she was started on asa, and statin given ldl of 201 and nstemi (see below). hob was maintained at 30 degrees, iss and tylenol were used for euglycemia and normothermia. bp was maintained at goal with iv hydralazine to 120-140 mm hg sbp. echo did not show a source of a thrombus, but did show extensive hypokinesis in the mid to distal anterior septum, the distal anterior wall, apex, and distal inferior wall without an overt evidence of an embolism. a bubble study did not show a pfo. . by hd2 she became more confused and agitated. repeat ct scans showed increased edema and mild tonsilar hernation. she was taked to or for suboccipital decompression on and evd placement. mental status improved significantly after decompression. she was restarted on asa. by hd#4, she was noted to have several episodes of afib w/ rvr. given this, she started heparin on , however, as noted below heparin was eventually stopped secondary to bleeding complications. . cv. pt. reported having left sided chest pain in the setting of her vertigo. she did not recall whether this occured prior or after the onset of vertigo. pain was typical for unstable angina (sob, diaphoresis, pressure like) and resolved upon receiving morphine at osh. initial ekg showed mild tw flattening, however it progressed to twi in ii, avf, and v1-6 by time of admission to neuro icu. due to progressing cerebellar infracts, heparin gtt was stopped. she was started on asa 81mg, statin and bb with goal of hr to 60-70s. echo showed findings as above including ef of 45%. this was felt to be due to either central/cva induced demand or an nstemi in setting of prior stenosis. bb was started, acei held due to low bps. . as noted above, patient developed afib with rvr. she was treated on bb with good effect (amiodarone was intermittently used which resulted in hypotension). her hr at time of transfer to the surgery service was ranging in the mid-70s. . for risk stratification after her troponin leak, she underwent cardiac catheterization which showed 20% mid-lad stenosis and 80% d2 stenosis. she had no interventions and was deemed at average risk to undergo colonic surgery. . pulm. patient was hypoxemic requiring 1l nc. she had an episode of flash pulmonary edema which resolved w/ lasix/bb/hydralazine treatment. she then had a staging ct for the colonic mass noted below, which showed subsegmental pes bilaterally. subsequent lenis showed right posterior tibial dvt. because of hematochezia (see below) she was not anticoagulated and instead an ivc filter was placed on . her o2 sats were stable at 95-99% on 2l nc prior to transfer to the surgery service on . . gi. she was noted to have a large, loose, bloody bowel movement on hd4 with stable hct. gi consultants felt that the likely cause was c.diff (given abx exposure); she was started on po vancomycin. however, she then developed hematochezia with a hematocrit drop from 37 to 31. gi was consulted and performed a colonoscopy showing a fungating colonic mass. she had a staging ct as above which showed the pes but no metastases. a cea was 1.9. she was transferred to the surgery service on for resection of her colonic surgery course: operative course uncomplicated. admitted to stone 5 for post-op care. pain controlled with iv pain medication. multiple lap abdominal incisions ota with dermabond, cdi. diet advanced gradually from sips to regular food as bowel function and abdominal distention improved. reported flatus, and eventual bm. iv fluid discontinued. foley removed. voided without issue. medications switched to oral, including antihypertensive regimen (conversion to po medication discussed with cardiology, dr. ). blood pressure and heart rate well controlled. pain well controlled with oral oxycodone and tylenol. coumadin dose titrated according to inr. bridged from lovenox. lovenox discontinued. activity returned to baseline. ambulated in halls with assistance. tremulous. physical and occupational therapy consulted. recommended rehab. . out-patient follow up: the ct done for staging purposes showed a heterogeneous thyroid for which she will need an ultrasound as an outpatient. it also showed an infrarenal 3.5 cm aaa for which she will need an ultrasound every 3 years. in addition, she will follow-up with neurology and dr. (colorectal surgeon) once she is discharged from rehab, or as indicated in follow-up section. . mrs. should eventually have her hytertension and antocoagulation managed per her pcp. medications on admission: prilosec 20mg daily discharge medications: 1. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for pain: do not exceed 4000mg in 24hrs. 2. metoprolol succinate 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily): decrease to 81mg daily once inr therapeutic. 4. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain for 2 weeks. 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 7. coumadin 1 mg tablet sig: titrate dose per inr tablet po once a day: goal inr . discharge disposition: extended care facility: - discharge diagnosis: primary: 1. embolic cerebellar infarcts (bilateral) 2. status post posterior fossa decompression 3. non-st elevation myocardial infarction (nstemi) 4. hematochezia 5. colonic mass 6. status post colonic mass resection 7. atrial fibrillation with rapid ventricular response 8. deep vein thrombosis, right 9. status post ivc filter placement . secondary: 1. hypertension 2. hyperlipidemia discharge condition: ambulating with assist-tremulous, alert & oriented x . tolerating a regular diet pain well controlled. discharge instructions: you were admitted to with vertigo and imbalance. you were found to have a stroke of your cerebellum (a part of the brain). for this, you required a surgical decompression. you tolerated the surgery well. . you were also noted to have bleeding from your colon, and were found to have a colonic mass which was resected via the surgery team (dr.). prior to this, you underwent cardiac evaluation with coronary angiogram, which showed no significant coronary disease. . during this admission, you were diagnosed with atrial fibrillation (irregular heart rate), for which you will require anticoagulation. you were started on coumadin (a blood thinner), which you will need to continue for at least three months. your primary care doctor will manage your coumadin dosing and inr level (a measure of how thin your blood is). . new medications/medication changes: -aspirin (decrease to 81mg daily once inr therapeutic) -coumadin (titrate dose according to daily inr, goal= ) -toprol xl (extended release metoprolol) -simvastatin . should you develop any further difficulty with balance, vertigo, headache, weakness, changes in vision, difficulty with speech, chest pain, shortness of breath, fever, chills or any other symptom concering to you, please call your doctor or go to the emergency room. please call your doctor or return to the er for any of the following: * 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 pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *avoid driving or operating heavy machinery while taking pain medications. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * continue to ambulate several times per day. . incision care: -keep open to air. dermabond will slough off. dissolvable sutures. -you may shower, and wash surgical incisions. -avoid swimming and baths until your follow-up appointment. -please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. followup instructions: please attend the following appointments listed below: . 1. please follow-up with dr. in weeks. call for an appointment. 2. provider (neurologist), md phone: date/time: 1:30 3. follow-up with your pcp, . for continued management of your hypertension and anticoagulation once you are discharged from rehab. Procedure: Left heart cardiac catheterization Coronary arteriography using a single catheter Interruption of the vena cava Intravascular imaging of intrathoracic vessels Angiocardiography of right heart structures Esophagogastroduodenoscopy [EGD] with closed biopsy Closed [endoscopic] biopsy of large intestine Other craniotomy Laparoscopic sigmoidectomy Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Obstructive hydrocephalus Congestive heart failure, unspecified Atrial fibrillation Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction Other chronic pulmonary heart diseases Compression of brain Cerebral edema Acute systolic heart failure Hemorrhage of gastrointestinal tract, unspecified Other pulmonary embolism and infarction Unspecified intestinal obstruction Other esophagitis Acute venous embolism and thrombosis of deep vessels of distal lower extremity Benign essential hypertension Malignant neoplasm of sigmoid colon |
allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: complete heart block major surgical or invasive procedure: placement of dual chamber pacemaker history of present illness: mr. is a 74 year old obese male with pmh of htn, transferred from osh with symptomatic heart block. patient complains of worsening dyspnea on exertion with nonradiating chest pressure x 1 -2 weeks. + dizziness, no syncope, nausea/ vomiting, diaphoresis or other associated symptoms. symptoms of dyspnea have progressed so that patient can not walk > 1 block without needing to rest. no preceding fevers, sore throat or recent tick bites. of note, the patient has complained of intermittent doe for approx 10 yrs with comprehensive evaluation by both cardiology and pulmonary, including pft, stable persantine stress test (last in ), coronary ct scan and pfts. today, presented to his pcp office where hr was in the 40s so sent for further evaluation to ed. at , vs: t98.4 p44 rr18 bp181/74 and sao2 97%. initial labs were remarkable for negative cardiac enzymes; ekg showed 2:1 heart block with pr prolongation and intraventicular conduction delay and then complete heart block. given asa 325mg and fentanyl x 1. after consultation with cardiology, the patient was transferred to for evaluation and management by ep. on arrival to the ccu, patient had hr in the 30s, but was asymptomatic- denying any chest pain, shortness of breath, confusionor other complaint. on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: - diabetes, + dyslipidemia, + hypertension 2. other past medical history: - s/p r hip replacement - s/p l hip replacement - hydrocele - s/p r knee arthroscopy social history: lives with wife, used to work as a courrier of a local newspaper but now works as a house inspector for the bank - tobacco history: quit 40yrs ago, previously smoked 3ppd - etoh: quit 6 yrs ago, moderate previous use - illicit drugs: none family history: - mother: cad requiring cabg in 60s - father: active tuberculosis in 40s physical exam: on admission: vs: t= 97.2 bp= 146/84 hr= 40 rr= 12 o2 sat= 95% ra general: nad. oriented x3. heent: ncat. sclera anicteric. perrl, eomi. mmm neck: supple with jvp of 7 cm, no hepatojugular reflex cardiac: bradycardia, regular rhythm. s1 s2. no m/r/g lungs: ctab, no crackles, wheezes or rhonchi. abdomen: soft, obese, ntnd. no hsm or tenderness. extremities: no c/c/e. 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+ discharge exam: tc: 96.8, p: 62, bp: 152/99, rr: 13, 99% on ra general: nad. oriented x3. heent: ncat. mmm neck: supple with jvp of 7 cm cardiac: distant heart sounds, regular rate rhythm. normal s1, s2. no m/r/g lungs: mild crackles at bilateral bases, otherwise ctab abdomen: soft, obese, ntnd. no hsm or tenderness. extremities: no edema skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: + dp 2+ pt 2+ pertinent results: admission labs (): wbc-6.4 rbc-4.53* hgb-13.3* hct-39.0* mcv-86 mch-29.4 mchc-34.1 rdw-15.0 plt ct-249 neuts-55.2 lymphs-33.5 monos-6.3 eos-3.5 baso-1.5 pt-13.6* ptt-23.4 inr(pt)-1.2* esr-5 tsh-2.0 crp-2.9 glucose-100 urean-21* creat-1.3* na-142 k-4.8 cl-108 hco3-25 alt-38 ast-31 ck(cpk)-63 alkphos-64 calcium-9.5 phos-4.2 mg-2.0. ck-mb-4 ctropnt-<0.01 . imaging: cxr pa/lat (): pacer lead in place over right atrium and right ventricle. final read pending. . discharge labs: 05:05am blood wbc-5.9 rbc-4.39* hgb-13.3* hct-37.5* mcv-86 mch-30.4 mchc-35.6* rdw-14.9 plt ct-199 05:05am blood glucose-89 urean-17 creat-1.1 na-138 k-4.1 cl-105 hco3-25 angap-12 05:05am blood calcium-9.1 phos-4.6* mg-2.0 other: 08:29pm blood tsh-2.0 08:29pm blood crp-2.9 08:29pm blood esr-5 brief hospital course: 74 y/o obese male with pmh of htn, transferred from osh with symptomatic complete heart block. # heart block: ekgs showed significant conduction disease with underlying rhythm complete heart block. qt interval was prolonged placing patient at risk of torsades. patient was asymptomatic at rest with no indications for emergent transcutaneous/transvenous pacing. etiology remained unclear although given risk factors, most likely cause would be ischemic heart disease vs idiopathic fibrotic reaction. sarcoidosis, lymes disease, tuberculosis are much less likely, although still on differential. endocarditis affecting conduction system extremely unlikely with lack of systemic symptoms. pt was monitored on tele overnight with no changes. esr/crp and tsh were normal. made npo after midnight for pacemaker placement and pacer successfully placed on afternoon of . rate had been mid 30s before pacing and was paced around 60 after placement. pt did well post-proceedure and was discharged home the next day. acei level still pending at time of discharge and pt will be considered for outpt mri to further eval possible etiology of complete heart block. # htn: hypertensive with sbp in the 140- 180s in the setting of bradycardia. although patient has known htn, may be high catecholamine response to maintain organ perfusion. as patient asymptomatic, so initial treatment deferred until pacer placed. despite hx of htn, pt not on any home medications. after pacer was placed, systolic bps up to 200s. there was thought that in setting of high catecholamines and new increased cardiac output with pacer placed that bp had been further elevated. pt was started on captopril 12.5mg tid to titrate to dose with bp falling into 150s systolic over next 12 hrs. will plan to discharge on lisinopril 20 mg po daily and follow-up bp for further titration as outpatient. # hld: per prior records, ldl elevated to 153 with 10 yr cardiovascular risk of 44% indicating that patient would likely benefit from statin therapy. pt not on any home medications, though previously on red rice yeast until 4-5 months ago. he was started on simvastatin 10 mg po daily. # coronaries: no know history of cad but multiple risk factors including age, htn, hl, prior smoking. c/o symptoms consistent with stable angina for years although evaluation with stress test has shown stable reversible defect alone. as above, heart block is mostly likely related to ischemia. he was started on aspirin 81 mg po daily. #code: full code (confirmed with patient) #transition of care: -ace level pending -consider cardiac mri as outpatient to further evaluate etiology of heart block -follow electrolytes as patient has been started on an ace inhibitor. medications on admission: none discharge medications: 1. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 4 doses. disp:*4 capsule(s)* refills:*0* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. simvastatin 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 4. lisinopril 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 5. percocet 5-325 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain for 3 days. disp:*10 tablet(s)* refills:*0* 6. outpatient lab work please check electrolytes on : na, k, cl, hco3, bun, creatinine. please fax results to dr. at fax # discharge disposition: home discharge diagnosis: primary: complete heart block secondary: hypertension hyperlipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , you were admitted to the hospital due to a slow heart rate and ekg findings showing complete heart block. you were monitored in the cardiac intensive care unit overnight and had a pacemaker successfully placed the next day. after pacemaker placement, your blood pressure was running high so you were started on a medication for blood pressure control. you may need to have a cardiac mri to further evaluate the cause of your low heart rate. you should discuss the need for further testing with dr. . new medications started this admission: - cephalexin 500 mg by mouth every 6 hours for 4 more doses. this is an antibiotic to prevent an infection at the pacemaker site. - lisinopril 20 mg by mouth once a day for high blood pressure - aspirin 81 mg by mouth once a day for heart protection - simvastatin 10 mg by mouth once a day to lower cholesterol - percocet 1 tab every 4 hours as need for pain control you should follow-up with your cardiologist, dr. on at 1:30 pm. followup instructions: you have an appointment with dr. at 1:30 pm brothers , , , ma ph: if you need to change this appointment please call at at . Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Diagnoses: Unspecified essential hypertension Other and unspecified hyperlipidemia Atrioventricular block, complete Obesity, unspecified Hip joint replacement |
allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: chest pain and dyspnea on exertion major surgical or invasive procedure: cardiac cath coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, obtuse marginal artery and first diagonal artery. history of present illness: 75 year old male reports a history of intermittent chest discomfort, often in the setting of a meal and light exertion. this has been present for the past seven to eight years but fairly infrequent. prior stress tests have revealed mild inferolateral ischemia and he has been treated with medical management through the years. he reports that over the past year his symptoms have been more noticeable and frequent, occurring at least daily. he describes substernal chest pain/pressure accompanied by shortness of breath with very little exertion. he was now referred for left heart catheterization for further evaluation. upon catheterization he was found to have left main and three vessel diseae and is now being referred to cardiac surgery for revascularization. past medical history: coronary artery disease s/p coronary artery bypass graft x 4 past medical history: hyperlipidemia hypertension complete heart block s/p dual chamber pacemaker paroxysmal atrial fibrillation, newly diagnosed bph s/p prostate surgery gerd/hiatal hernia arthritis left finger amputation from a traumatic accident right detached retina, s/p surgery social history: lives with:wife contact: (wife) phone # occupation:works one day a week as an inspector for construction projects. cigarettes: smoked no yes hx:quit 40 years ago, smoked ppd x20 years other tobacco use:denies etoh: previously drank several six packs of beer on a weekend. he quit 7-8 years ago illicit drug use:denies family history: premature coronary artery disease- mother had a valve replacement in her late 40's. brother with a coronary stent in his mid 60's. physical exam: pulse:64 resp:13 o2 sat:97/ra b/p right:150/78 left:142/76 height:5'9" weight:245 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally l upper chest pacer, well healed heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema _____ varicosities: none neuro: grossly intact pulses: femoral right: p left: p dp right: p left: p pt : p left: p radial right: p left: p carotid bruit right: no left: no pertinent results: cardiac cath: 1. selective coronary angiography in this right dominant system demonstrated severe 3vd and left main disease. the lmca had an 80% distal lesion. the lad had a long 70% lesion in the mid-vessel and a 60% origin lesion in the major first diagonal. the lcx had a 100% proximal lesion with good filling of the major om via right to left collaterals. the rca had a 60% proximal lesion, 60% mid-lesion, serial 60% distal lesionsx2, and a 60% pda lesion. 2. limited resting hemodynamics revealed a normal systemic arterial blood pressure with a central aortic pressure of 104/56 mmhg. . carotid u/s: mild plaque in the proximal internal carotid arteries, but no hemodynamically significant stenoses on either side. flow in the vertebral arteries is prograde on both sides. . echo: pre-bypass: the left atrium is dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results on mr. before bypass. post-bypass: normal biventricular function. intact thoracic aorta. no valvular findings. mild mr. other valvular findings. . 05:56am blood wbc-7.3 rbc-3.36* hgb-10.4* hct-30.8* mcv-92 mch-31.1 mchc-33.9 rdw-13.6 plt ct-188 05:34am blood wbc-8.2 rbc-3.20* hgb-9.9* hct-29.4* mcv-92 mch-30.9 mchc-33.6 rdw-13.7 plt ct-132* 05:56am blood glucose-96 urean-20 creat-0.9 na-141 k-3.9 cl-102 hco3-28 angap-15 05:34am blood glucose-107* urean-16 creat-0.9 na-137 k-4.0 cl-102 hco3-30 angap-9 brief hospital course: mr. a cardiac cath on which revealed severe left main and three vessel disease. he was referred for surgery and usual surgical work-up. on he was brought to the operating room where he a coronary artery bypass graft x 4. please see operative note for surgical details. following surgery he was transferred to the cvicu for invasive monitoring in stable condition. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. pacer was interrogated by ep. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to the rehab in good condition with appropriate follow up instructions. medications on admission: metoprolol succinate 50 mg daily nitroglycerin 0.4 mg prn omeprazole 20 mg daily aspirin 81 mg daily vitamin b-12 250 mcg daily magnesium oxide 250 mg daily puffs inhalation q6h (every 6 hours) as needed for dyspnea. 10. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 11. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 10 days. 12. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po twice a day for 10 days. discharge disposition: extended care facility: nursing and rehab center discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 4 past medical history: hyperlipidemia hypertension complete heart block s/p dual chamber pacemaker paroxysmal atrial fibrillation, newly diagnosed bph s/p prostate surgery gerd/hiatal hernia arthritis left finger amputation from a traumatic accident right detached retina, s/p surgery discharge condition: alert and oriented x3 nonfocal ambulating, deconditioned incisional pain managed with ultram incisions: sternal - healing well, no erythema or drainage leg -left - healing well, no erythema or drainage. edema, 1+ left, none on right discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. date/time: 1:30 please call to schedule appointments with your cardiologist: dr. 2-3 weeks primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Artificial pacemaker rate check Diagnoses: Other iatrogenic hypotension Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Unspecified essential hypertension Atrial fibrillation Personal history of tobacco use Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Obesity, unspecified Fitting and adjustment of cardiac pacemaker Hip joint replacement Arthropathy, unspecified, site unspecified Body Mass Index 36.0-36.9, adult |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: respiratory distress major surgical or invasive procedure: none history of present illness: patient is 77 yo female with pmhx sig. for recent massive stemi at osh 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring iabp x 3 days and pneumonia treated with flagyl and levaquin. she was sent to rehab on and presents from rehab with increasing sob. . pt reports that at rehab, every night she had chest tightness, rating , associated with heavy breathing and nausea. no diaphoresis. the discomfort would last all night, preventing her from sleeping. she states it's a different pain than her mi. she denied any f/c. she reports that she has a chronic cough, but is blood-tinged. notablely, she has a cough with lisinopril, which she is currently on. at 3pm, she c/o sob wtih wheezing. vs were 90/54, 72, 18, 97% on 2l o2, t 98. she was taken to the ed. . in the ed, initial vs: 85/47, on exam, pt was using accessory muscles. a bedside ultrasound showed minimal pericardial effusion, no evidence of tamponade. cxr showed r-sided pneumonia. pt received vanc/zosyn and 1 l ns. rij placed. initially she was on dopamine without much response and was switched to levophed, currently at 0.18. 70, 97/78, 18, 99% on 2 l. cvp 11-16. cardiology to perform formal echo when patient hits the floor. past medical history: asthma hyperlipidemia hypertension coronary artery disease diabetes mellitus type 2 gerd social history: pt is divorced, has 2 children. worked as a housewife. she smoked from -. no etoh or recreational drug use. family history: father died with dm. mother died with kidney disease physical exam: vitals - t: 97.5 bp: 119/71 hr: 83 rr: 17 02 sat: 98% on 2l nc general: anxious. no apparent distress. heent: no lad. jvp is slightly elevated. supple cardiac: regular rate and rhythm, no m/r/g lung: bilateral inspiratory crackles and expiratory wheezes. good respiratory effort- no signs of accessory muscle use. abdomen: +bs, soft, non-tender, non-distended ext: trace edema in b/l le. no c/c. neuro: aao x 3. grossly intact derm: no rashes or lesions noted. pertinent results: 05:16pm blood wbc-20.1* rbc-3.38* hgb-9.6* hct-29.4* mcv-87 mch-28.4 mchc-32.7 rdw-15.0 plt ct-383 03:53am blood wbc-30.8*# rbc-3.35* hgb-9.7* hct-29.0* mcv-87 mch-28.9 mchc-33.3 rdw-15.0 plt ct-510* 04:54am blood wbc-26.2* rbc-3.33* hgb-9.4* hct-29.1* mcv-88 mch-28.3 mchc-32.4 rdw-14.9 plt ct-522* 04:16am blood wbc-20.5* rbc-3.19* hgb-9.2* hct-28.1* mcv-88 mch-28.8 mchc-32.7 rdw-15.0 plt ct-556* 04:13am blood wbc-16.5* rbc-3.24* hgb-9.3* hct-28.3* mcv-87 mch-28.7 mchc-32.8 rdw-15.1 plt ct-457* 09:37pm blood wbc-11.7* rbc-2.94* hgb-8.4* hct-25.5* mcv-87 mch-28.4 mchc-32.8 rdw-15.2 plt ct-320 03:06am blood wbc-13.1* rbc-3.02* hgb-8.7* hct-26.2* mcv-87 mch-28.8 mchc-33.2 rdw-15.3 plt ct-355 03:40am blood wbc-16.5* rbc-3.19* hgb-9.1* hct-27.6* mcv-87 mch-28.7 mchc-33.1 rdw-15.4 plt ct-410 04:10am blood wbc-21.3* rbc-3.25* hgb-9.4* hct-28.0* mcv-86 mch-29.0 mchc-33.7 rdw-15.2 plt ct-421 05:21am blood wbc-23.9* rbc-3.35* hgb-9.5* hct-28.7* mcv-86 mch-28.2 mchc-32.9 rdw-15.2 plt ct-368 05:10am blood wbc-21.3* rbc-3.29* hgb-9.6* hct-28.1* mcv-86 mch-29.2 mchc-34.1 rdw-15.2 plt ct-334 05:16pm blood neuts-88* bands-2 lymphs-4* monos-4 eos-0 baso-0 atyps-0 metas-1* myelos-1* 05:16pm blood pt-53.0* ptt-45.4* inr(pt)-5.9* 11:00pm blood pt-57.8* ptt-46.4* inr(pt)-6.5* 03:53am blood pt-45.1* ptt-44.5* inr(pt)-4.8* 02:20pm blood pt-27.6* ptt-36.4* inr(pt)-2.7* 04:54am blood pt-23.8* ptt-34.5 inr(pt)-2.3* 04:16am blood pt-24.2* ptt-31.4 inr(pt)-2.3* 04:13am blood pt-25.7* ptt-31.5 inr(pt)-2.5* 03:06am blood pt-36.0* ptt-32.9 inr(pt)-3.7* 03:40am blood pt-44.1* ptt-34.5 inr(pt)-4.7* 04:10am blood pt-42.0* ptt-34.8 inr(pt)-4.4* 05:21am blood pt-33.7* ptt-34.2 inr(pt)-3.4* 05:10am blood pt-29.5* ptt-31.9 inr(pt)-2.9* 05:10am blood pt-28.2* ptt-30.0 inr(pt)-2.8* 05:10am blood plt ct-317 03:53am blood fibrino-799* 02:20pm blood fibrino-817* 02:20pm blood fdp-10-40* 05:16pm blood glucose-153* urean-35* creat-1.6* na-133 k-5.7* cl-96 hco3-26 angap-17 11:00pm blood glucose-230* urean-37* creat-1.6* na-133 k-4.6 cl-99 hco3-22 angap-17 03:53am blood glucose-206* urean-35* creat-1.4* na-134 k-4.5 cl-101 hco3-24 angap-14 04:54am blood glucose-251* urean-36* creat-1.3* na-138 k-4.8 cl-106 hco3-23 angap-14 04:16am blood glucose-191* urean-42* creat-1.3* na-141 k-5.0 cl-110* hco3-25 angap-11 04:13am blood glucose-182* urean-46* creat-1.2* na-141 k-5.0 cl-109* hco3-26 angap-11 09:37pm blood glucose-243* urean-48* creat-1.2* na-139 k-4.6 cl-107 hco3-25 angap-12 03:06am blood glucose-180* urean-50* creat-1.2* na-141 k-4.8 cl-107 hco3-25 angap-14 05:57pm blood glucose-281* urean-47* creat-1.1 na-139 k-4.6 cl-104 hco3-26 angap-14 03:40am blood glucose-199* urean-45* creat-1.1 na-138 k-4.4 cl-103 hco3-29 angap-10 03:54pm blood glucose-308* urean-42* creat-1.2* na-135 k-4.3 cl-97 hco3-31 angap-11 04:10am blood glucose-176* urean-41* creat-1.2* na-139 k-4.0 cl-97 hco3-34* angap-12 05:21am blood glucose-161* urean-39* creat-1.0 na-138 k-3.4 cl-96 hco3-35* angap-10 05:10am blood glucose-121* urean-37* creat-1.1 na-139 k-3.9 cl-97 hco3-32 angap-14 05:10am blood glucose-183* urean-32* creat-0.8 na-139 k-4.0 cl-101 hco3-29 angap-13 05:16pm blood ck(cpk)-110 11:00pm blood ck(cpk)-94 03:53am blood ld(ldh)-446* ck(cpk)-79 totbili-0.6 02:20pm blood ck(cpk)-80 04:54am blood ck(cpk)-77 08:12pm blood ck(cpk)-84 03:06am blood ck(cpk)-73 05:16pm blood ck-mb-3 05:16pm blood ctropnt-2.08* 11:00pm blood ck-mb-notdone ctropnt-1.93* 03:53am blood ck-mb-notdone ctropnt-1.48* 02:20pm blood ck-mb-notdone ctropnt-1.30* 04:54am blood ck-mb-notdone ctropnt-1.06* 03:06am blood ck-mb-notdone ctropnt-0.60* 05:57pm blood probnp-* 03:40am blood probnp-* 11:00pm blood calcium-7.7* phos-4.5 mg-1.9 05:10am blood calcium-7.9* phos-2.9 mg-2.1 03:53am blood hapto-285* 06:09am blood vanco-12.6 05:43am blood vanco-13.0 09:54am blood type-art temp-35.4 po2-74* pco2-41 ph-7.34* caltco2-23 base xs--3 intubat-not intuba comment-left radia 01:58pm blood type-art po2-99 pco2-44 ph-7.32* caltco2-24 base xs--3 05:07am blood type-central ve temp-36.7 rates-/12 peep-5 fio2-50 po2-79* pco2-53* ph-7.27* caltco2-25 base xs--2 intubat-intubated vent-spontaneou 06:19pm blood type-art po2-40* pco2-47* ph-7.33* caltco2-26 base xs--1 10:35pm blood type-art temp-36.5 rates-18/ tidal v-500 peep-5 fio2-40 po2-137* pco2-28* ph-7.54* caltco2-25 base xs-3 -assist/con intubat-intubated 11:48pm blood type-art temp-36.1 rates-12/ tidal v-500 peep-5 fio2-40 po2-128* pco2-36 ph-7.45 caltco2-26 base xs-2 -assist/con intubat-intubated 01:12am blood type-art temp-36.1 rates- tidal v-450 peep-5 fio2-40 po2-123* pco2-48* ph-7.36 caltco2-28 base xs-1 -assist/con intubat-intubated 02:12am blood type-art temp-36.1 peep-5 fio2-35 po2-120* pco2-43 ph-7.40 caltco2-28 base xs-1 intubat-intubated 06:21am blood type-art temp-35.8 fio2-35 po2-125* pco2-46* ph-7.45 caltco2-33* base xs-7 intubat-intubated 06:00pm blood lactate-3.1* 11:13pm blood lactate-2.1* 09:54am blood lactate-2.5* 01:58pm blood lactate-1.5 05:07am blood lactate-1.7 10:35pm blood lactate-1.7 10:35pm blood freeca-1.13 echo ()- the left atrium is mildly dilated. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thicknesses and cavity size are normal. there is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the septum and anterior walls, apex, and distal lateral wall. the apex is mildly aneurysmal. the remaining segments contract normally (lvef = 25-30 %). no intraventricular thrombus is seen. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a small pericardial effusion. no right ventricular diastolic collapse is seen. impression: extensive regional left ventricular systolic dysfunction c/w cad. moderate mitral regurgitation. mild pulmonary artery systolic hypertension. cxr ()- impression: right middle lobe opacity concerning for pneumonia. cxr ()- comparison is made with a prior study performed a day earlier. mild pulmonary edema has improved. cardiac size is top normal. there is mild bilateral pleural effusions, greater on the right side. left lower lobe atelectasis has increased. opacity in the right lower lobe is most likely atelectasis. right ij catheter, et tube and ng tube remain in place. cxr ()- comparison: ; . portable upright chest radiograph: again seen is a right internal jugular catheter with tip projecting over the mid svc. heart size and mediastinal contours are unchanged. the aorta is mildly calcified and unfolded. there is persisting bu t improved retrocardiac and right basilar opacity. there are no large pleural effusion. no pneumothorax. lenis ()- conclusion: 1. there is no ultrasound evidence of deep venous thrombosis of the lower extremities. 2. there is evidence of edema of the soft tissues of both lower limbs. brief hospital course: # sepsis: patient presented from rehab for increasing sob. patient was recently discharged from and osh for stemi and was being treated for a pneumonia with levaquin and flagyl. on arrival here, she was noted to have hypotension with cxr consistent with rml pneumonia. she was started on pressors for blood pressure control. she was intubated to respiratory distress. she was started on vanco/zosyn initially for her pneumonia and was switched to vanco/cefepime/ciprofloxacin on the morning of for treatmed of health care associated pneumonia. she was weaned off of pressors. on , she was extubated and then reintubated the following day respiratory distress. cardiology was consulted given recent history of stemi with ef of 20% as chf was thought to be contributing to her respiratory distress and difficulty with extubation. she was diuresed with lasix gtt and re-extubated successfully on which was successful. she was transferred to the medical floor on . upon transfer, she was continued on po vanc. patient remained afebrile but continued to have an elevated wbc. she was ruled out for c.diff x 3 and cxr improved daily. shortness of breath also improved. her bp's returned to limits and she remained hemodynamically stable. upon discharge, patient was doing well. she was started on amiodarone at osh but it was held while here given her hemodynamic status- we continued to hold it on discharge and will ask that her outpatient cardiologist re-evaluate giving her amiodarone. she was restarted on her home dose of lisinopril 5mg daily. her beta-blocker was also restarted but, instead of toprol xl 50mg daily, she was given metoprolol tartrate 12.5mg po bid. her aldactone was also held on discharge. patient will have her cardiac medications re-evaluated once she see her outpatient cardiologist in weeks. # health care associated pneumonia: patient presented with a right middle lobe pneumonia s/p recent discharge from hospital for her stemi. she was treated with vanco/zosyn/cipr as above. she was transitioned to po vancomycin and did well. cxr improved daily. she also remained afebrile. she is to continue po vanc for a 14 day course (day 1 was ). # acute systolic heart failure: mr. had a recent stemi complicated by new ef of 20%. she was treated with lasix as above with improvement in her respiratory status. she diuresed well she was discharged on lasix 40mg by mouth daily. # diarrhea: patient initially complained of diarrhea and was started on flagyl empirically for c.difficile infection. during her hospitalization, wbc became elevated on treatment for her hap and diarrhea became more significant so she was staretd on vanco po for presumed for c.diff. c.diff was then sent and was negative x 3. patient's diarrhea had resolved by discharge. # cad, s/p recent stemi, now with ef 20%: cardiology was consulted as above. beta blocker was held intitially hypotension. she was continued on her asa, plavix, statin. beta-blocker (metoprolol tartrate 12.5mg po bid), ace-i (lisinopril 5mg daily) were restarted. her home dose of aldactone was held on discharge. she was chest-pain free on discharge. she will continue aspirin 325mg daily and plavis # afib: patient was in sinus rhythm. amiodarone and beta-blocker were held intially as patient was hypotensiv. her blood pressures returned to levels so she was restarted on lisinopril and metoprolol. amiodarone was discontinued (per above). her inr was supratherapeutic on admission so her coumadin was initially held. it returned to a therapeutic level (2.9) on so her coumadin was resumed at 1mg po daily. # htn: per above. lisinopril 5mg daily and beta-blocker (metoprolol 12.5mg po bid) resumted. aldactone and amiodarone were held on discharge. patient hemodynamically stable on discharge. # hyperlipidemia: continued atorvastatin 80mg po daily # asthma: started on methylprednisolone on and was treated for a 5 day course, she was also treated with albuterol inhalers and placed on her home advair. she was also given ipratropium bromide. patient counseled not to over-use her asthma medications # diabetes mellitus type 2: metformin held as an inpatient, treated with insulin sliding scale while in-house, with good control of her sugars. she was restarted on home dose of metformin 500mg daily upon discharge. # gerd: continued patient on home dose of ranitidine 150mg daily medications on admission: atenolol 25 mg daily asa 325 mg daily plavix 75 mg daily atorvastatin 80 mg daily lasix 40 mg qod flagyl 500 mg po tid levofloxacin 750 mg qod lisinopril 5 mg po daily amiodarone 200 mg x 3 weeks then d/c aldactone 2.5 mg daily advair 250/50 i puff glucophage 500 mg daily zantac 150 mg daily atrovent nebulizers xanax 0.5 mg tid toprol xl 50 mg daily discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed for wheezing. 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 9. lorazepam 0.5 mg tablet sig: 0.5-1 tablet po q4h (every 4 hours) as needed for anxiety. 10. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 11. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 12. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. 13. glucophage 500 mg tablet sig: one (1) tablet po once a day. 14. vancomycin 125 mg capsule sig: one (1) capsule po every six (6) hours for 9 days: 14 total days (day 1- ). last day is . discharge disposition: extended care facility: of discharge diagnosis: primary: anterior st-elevation myocardial infarction secondary: asthma, gerd, hypertension, hyperlipidemia discharge condition: good. vital signs stable. ambulated with physical therapy- cleared for rehab. discharge instructions: you were admitted to the hospital after suffering a heart attack. afterward, you developed some difficulty breathing that required a intubation. you were kept in the icu and did well. we diuresed you using lasix with good results. your chest x-rays improved daily and your shortness of breath continued to resolve. you denied any chest pain. upon discharge, you were stable and asymptomatic. the following changes were made to your medications: 1. please stop taking amiodarone 200mg by mouth twice daily 2. please stop taking toprol xl 50mg by mouth daily 3. please start taking metoprolol tartrate 12.5mg by mouth twice daily 4. please stop taking your aldactone 5. please start taking vancomycin 125mg by mouth every 6 hours for a total of 14 days (day 1- , last day is ) 6. please start taking ipratropium bromide inhaler- 2 puffs four times/day weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please set-up an appointment with a primary care physician of your choice (you mentioned someone in ) in weeks. , md (cardiology) phone: date/time: at 9:40am Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Severe sepsis Atrial fibrillation Asthma, unspecified type, unspecified Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Acute respiratory failure Septic shock Intestinal infection due to Clostridium difficile Acute systolic heart failure Subendocardial infarction, subsequent episode of care |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain, sob major surgical or invasive procedure: avr(#21mm ce magna)/mvr(#29mm st. epic)/tv repair (#28mm ce mc3ring)/coronary artery bypass grafting x 4(left internal mammary artery grafted to left anterior descending/saphenous vein grafted to diag/om2/pda)- history of present illness: mr. is an italian-speaking 65 yo male with htn and 50+ pack-year smoking history who has not been seen by a physician 1.5 years, presented to the ed with 1 day of sob, diaphoresis and cp. he began to feel diaphoretic and short of breath while at work as . when the symptoms did not resolve with rest, he left work early and went home. there, he describes feeling cp that he describes as "squeezing," , non-radiating and not relieved with rest, which led him to take an ambulance to the ed. he reports frequent sob and occasional cp on exertion at baseline for at least the past year, which he says normally resolves with rest, although he does endorse occasional sob at rest. he attributes these symptoms to his age and smoking. he also notes a chronic cough over the past year, which he attributes to his smoking, and denies any recent worsening of the cough. ekg showed inferior q waves, twi and st depressions. cxr showed pulmonary edema anmd and ces were elevated with troponin 3.13. he was loaded with plavix 600mg, received one full dose asa and started on heparin gtt. he was sent to the cath lab for angiography which showed severe lm/3vd. a swan-ganz catheter was placed and showed low cardiac index (1.4). a tte was performed in the cath lab which revealed inferior and inferoseptal hypokinesis, normal rv function, significant as, 4+ mr, 3+tr, lvef 35% and moderate pulmonary htn. an iabp was placed. dr. was consulted for coronary revascularization and valvular replacement. past medical history: 1. cardiac risk factors: hypertension, dyslipidemia, +tobacco 2. cardiac history: none 3. other past medical history: -patient denies any other pmh but per omr, h/o pud. htn erectile dysfunction no medical care for many years social history: he is in and lives with his wife in . -tobacco history: 1-1.5ppd for 30+ years, still smoking -etoh: social family history: -mother with a "large heart" from a young age, died of heart disease at 66 -father diagnosed with dm2 in his 50s, died at 74 -brother with cva, liver disease diagnosed in his 50s physical exam: vs: t= 99.8 bp= 114/63 hr= 87 rr= 23 o2 sat= 96% 2l nc general: wdwn male in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with 5cm jvp, but with bed flat due to iabp. cardiac: rr, with mechanical sounds. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab anteriorly, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. +bs. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ pt 2+ dp by doppler left: carotid 2+ pt 2+ dp by doppler pertinent results: cxr : single ap chest radiograph without comparison shows moderate interstitial pulmonary edema. the heart size is probably top normal. there is no pneumothorax or large pleural effusions. impression: moderate interstitial pulmonary edema. . ekg , 10:48:24: sinus tachycardia at 110 bpm with some lad, normal intervals, notable for q waves in ii, iii, avf; deep twi in ii, iii, avf; 1mm std in i, avl. . 2d-echocardiogram: the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with near akinesis of the inferior and inferoseptal walls. the remaining segments contract normally (lvef = 35 %). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. significant aortic stenosis is present (not quantified - ? mild-moderate)). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. severe (4+) mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal left ventricular cavity size with regional systolic dysfunction c/w cad. severe mitral regurgitation. moderate pulmonary artery systolic hypertension. moderate to severe tricuspid regurgitation. if clinically indicated, a tee would be able to better identify a potential mechanical problem with the mitral valve (i.e., flail leaflet or partial papillary muscle rupture as the cause of the mitral regurgitation). carotid u/s (): impression: right ica stenosis <40%. left ica stenosis <40%. 05:30am blood wbc-11.1* rbc-3.68* hgb-10.2* hct-31.2* mcv-85 mch-27.8 mchc-32.8 rdw-15.4 plt ct-320 10:28am blood wbc-13.8* rbc-4.80 hgb-12.5* hct-38.2* mcv-80* mch-26.1* mchc-32.7 rdw-14.0 plt ct-266 05:30am blood pt-19.1* inr(pt)-1.7* 10:28am blood pt-15.2* ptt-25.6 inr(pt)-1.3* 05:25am blood glucose-100 urean-27* creat-0.9 na-138 k-4.3 cl-100 hco3-30 angap-12 10:28am blood glucose-134* urean-22* creat-1.1 na-134 k-4.6 cl-98 hco3-22 angap-19 brief hospital course: 65yo italian-speaking male was taken to the operating room and underwent avr(#21mm ce magna)/mvr(#29mm st. epic)/tv repair (#28mm ce mc3ring)/coronary artery bypass grafting x 4(left internal mammary artery grafted to left anterior descending/saphenous vein grafted to diag/om2/pda)-. cross clamp time= 192 minutes. cardiopulmonary bypass time=230 minutes. please refer to dr operative report for further details. he tolerated the procedure well and was transferred to the cvicu in critical but stable condition requiring multiple pressors and milrinone to optimize cardiac output.the intra-aortic balloon pump, placed preop, was discontinued on pod#1.he awoke neurologically intact and was extubated on pod#2. drips were weaned off. lines and tubes were discontinued in a timely fashion.beta-blocker and diuresis was initiated. he continued to progress and was transferred to the step down unit for further monitoring on pod#5. dental was consulted regarding mr. ill-maintained lower teeth. amoxicillin was empirically initiated and recommended to continue until dental extraction is completed as an outpatient. coumadin was started for low dose anticoagulation secondary to the double tissue valves and tricupsid ring. on day of discharge, coumadin was held and the patient's daughter was instructed that mr. should hold off taking coumadin until the dental procedure is complete. once coumadin is restarted, it is to be continued for 2 months. dr., cardiology, will follow the inr/coumadin dosing. the remainder of his postoperative course was essentially uneventful. on pod# 8, mr. was cleared by dr. for discharge to home with vna. all follow up appointments were advised. medications on admission: medications at home: enalapril 10 mg daily viagra 50mg prn discharge medications: 1. aspirin 81 mg , delayed release (e.c.) sig: one (1) , delayed release (e.c.) po daily (daily). disp:*60 , delayed release (e.c.)(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. atorvastatin 80 mg sig: one (1) po daily (daily). disp:*60 (s)* refills:*2* 4. potassium chloride 20 meq packet sig: one (1) packet po q12h (every 12 hours). disp:*60 packet(s)* refills:*2* 5. warfarin 1 mg sig: md once daily at 4 pm: **do not resume until dental procedure completed. than x 2months. disp:*90 (s)* refills:*2* 6. ranitidine hcl 150 mg sig: one (1) po bid (2 times a day): x 2 months (while on coumadin). disp:*60 (s)* refills:*2* 7. oxycodone-acetaminophen 5-325 mg sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*45 (s)* refills:*0* 8. furosemide 80 mg sig: one (1) po daily (daily). disp:*60 (s)* refills:*2* 9. carvedilol 12.5 mg sig: one (1) po bid (2 times a day). disp:*60 (s)* refills:*2* 10. amoxicillin 250 mg capsule sig: two (2) capsule po q8h (every 8 hours): continue until dental procedure completed. disp:*90 capsule(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: cad mr s/p cabg/avr/mvr/tvr htn erectile dysfunction discharge condition: good discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet please shower daily including washing incisions, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: ***your chest ct scan showed some small nodules. this should be followed up with a repeat scan in 6 weeks to ensure that the nodules have improved. you can arrange this through your primary care doctor or when you follow-up with your cardiologist.*** dr in 4 weeks () please call for appointment dr , please call for appointment (in 1 week dr in weeks () please call for appointment **please have dental extractions done as soon as can be arranged **dr. to follow inr/coumadin dosing (once resumed after dental extractions)x 2months, than coumadin to be discontinued wound check appointment 6 as instructed by nurse () Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart Open and other replacement of mitral valve Open and other replacement of aortic valve with tissue graft Implant of pulsation balloon Annuloplasty Nonoperative removal of heart assist system Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Tobacco use disorder Congestive heart failure, unspecified Acute and subacute necrosis of liver Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other chronic pulmonary heart diseases Chronic kidney disease, unspecified Cardiogenic shock Acute myocardial infarction of other inferior wall, initial episode of care Old myocardial infarction Long-term (current) use of anticoagulants Mitral valve insufficiency and aortic valve stenosis Acute on chronic systolic heart failure Diseases of tricuspid valve Chronic total occlusion of coronary artery Personal history of peptic ulcer disease Impotence of organic origin Mitral valve stenosis and aortic valve insufficiency |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: intubation, placement of arterial line, central line history of present illness: ms. is a 59f with a pmh s/f chronic pain with narcotic abuse (tramadol), remote history of etoh abuse, and depression. this history is taken from the patient's husband, and from the medical record as the patient is not able to give a history secondary to altered mental status. per the patient's husband, the patient has been having altered mental status for several months now. he notes that things progressed when she was laid off from her job as a social worker (in a dual diagnosis center). he observed that her behavior was more disorganized- she would put items away in the wrong place, was sleeping more, taking longer to do things that she would normally do quickly. eventually she became more agitated, and more disheveled. mr. brought his wife to see a neurologist this past to have this worked up, where she admitted to abusing tramadol for the first time. she reported obtaining it illegally from the internet and taking 50mg pills at a time. an mri at that time did not show any acute cva or other process. on monday () the patient's husband woke up to the sound of his wife sounding agitated. he found her on the floor, disheveled. he helped her back into bed, and returned to sleep. the next day, after coming home from work, he found her in her bed covered in feces. she was arousable to voice, and could follow simple commands, but had slurred speech, and was confused. an ambulance was called, and the patient was taken to . at the patient was noted to have the following: 1. thrombocytopenia: on admission, her platelet count was 11,000, and fell to 7,000 on the day of transfer. her cbc was otherwise normal with a wbc count of 10.7 and a hct of 36.7. coagulation studies were wnl, fibrinogen 986, fdp negative. total bilirubin was 1.0 a smear was evaluated by the hematologist at , and per report, no schistocytes were seen. 2. leukocytosis: elevated to 10.7 with 76% neutrophils and 15% bands. found to have a uti on urinalysis, started on levofloxacin. 3. acute renal failure: creatinine was initially elevated to 2.2. urine sediment showed granular casts. this improved to 1.8 with fluid challenges. a ck was 138. fena was 0.15%, urine eosinophils were negative. 4. ams: the patient had a serum alcohol and tylenol level wnl, as well as a negative urine toxicology. a head ct non-contrast showed no acute abnormalities. she did admit to last using tramadol 4 days ago, and also using her husbands ativan. 5. uti: urinaylysis with too many to count wbc, 4+ bacteria and positive les. she was started on levofloxacin 250mg iv daily review of systems is notable for a uri two months ago, easy bruising, and one episode of epistaxis in the last month. her husband denies fevers, melena, hematochezia, hematuria. he does note that she has had the chills. past medical history: #. altered mental status: time course over the past several months. evaluated by neurology here. had an mri of the brain on with chronic white matter ischemic changes, but nothing acute. #. history of etoh abuse -sober x 28 years #. chronic lower back pain- secondary to lumbar spondylosis -reports buying tramadol illegaly over the internet and taking 15-50 50mg tablets twice weekly (in ), now reports she is no longer using. #. urinary incontinence -over the last 5 years -consistent with urge incontinence -has had a work up with urology #. depression -has been hospitalized twice for depressive episodes #. nephrolithiasis #. hyperlipidemia #. s/p cholecystectomy #. osa social history: lives at home with her husband. she worked as a program director treating dual diagnoses of addiction/psychiatric illness, currently laid off. smokes ppd x 40 years. h/o etoh abuse, sober x 28 years. tramadol use as above. family history: sister with a cva, mother with alzheimer's dementia and breast ca, father with brain ca. physical exam: t=101.1... bp=127/65... hr=95... rr=22... o2=95% 6l physical exam general: somnolent, arousable to voice. follows simple commands, but nods off during exam. no apparent distress. heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. no buccal petechia, or evidence of gum bleeding. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: ctab anteriorly abdomen: nabs. soft, diffusely tender to deep palpation extremities: no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: no petichiae, eccymoses, purpura neuro: oriented to person and "hospital". opens eyes to voice. glascow coma scale 13. cn 2-12 in tact. moves extremities spontaneously. cannot cooperate with a full neuro exam. pertinent results: 07:30pm ret aut-1.0* 07:30pm fibrinoge-990* 07:30pm fdp-10-40* 07:30pm pt-10.8 ptt-21.4* inr(pt)-0.9 07:30pm plt smr-rare plt count-10*# 07:30pm neuts-93.6* lymphs-4.9* monos-0.9* eos-0.2 basos-0.4 07:30pm wbc-7.4 rbc-4.20 hgb-12.4 hct-36.9 mcv-88 mch-29.5 mchc-33.6 rdw-15.6* 07:30pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 07:30pm haptoglob-375* 07:30pm albumin-3.2* calcium-8.8 phosphate-2.1* magnesium-2.2 07:30pm alt(sgpt)-54* ast(sgot)-41* ld(ldh)-423* ck(cpk)-83 alk phos-217* tot bili-1.3 dir bili-0.6* indir bil-0.7 07:30pm glucose-224* urea n-50* creat-1.7* sodium-137 potassium-3.2* chloride-104 total co2-19* anion gap-17 07:31pm urine blood-mod nitrite-neg protein- glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg tsh 25 t4 <1.0* t3<20* calc tbg 1.21 tuptake-0.83 free t4 0.10 tsh 38 t4-2.6* t3-40* calc tbg-1.21 tuptake-0.83 t4 index-2.2* free t4-0.31* anti-tpo 124 echo: the left atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis (lvef = %). the right ventricular cavity is mildly dilated with focal hypokinesis of the apical free wall. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small to moderate sized circumferential pericardial effusion. there are no echocardiographic signs of tamponade. impression: severely globally depressed left ventricular systolic function. small to moderate circumferential pericardial effusion with no evidence of tamponade. ct head w/o contrast: there is no intracranial hemorrhage, edema, mass effect or vascular territorial infarction. the ventricles and sulci are normal in size and in configuration. extracranial soft tissue structures are unremarkable. the included osseous structures reveal no fracture. the visualized mastoid air cells are clear. the visualized paranasal sinuses reveal a small amount of mucosal thickening in the maxillary sinuses bilaterally. impression: no acute intracranial process. ct chest/ abdoman/ pelvis: endotracheal tube terminates approximately 4.5 cm above the carina. the lungs contain dense bilateral consolidations, worst at the lower lobe on the left and involving all lobes on the right. note is made of small bilateral pleural effusions. note is also made of a moderate pericardial effusion. otherwise, the heart and great vessels are notable for atherosclerotic calcification at the aorta. numerous mediastinal lymph nodes are visualized, none of which appear enlarged by ct size criteria. ct abdomen without contrast: nasogastric tube has been repositioned and now terminates in the stomach. otherwise, the stomach and duodenum are unremarkable. the spleen is 13 cm. the pancreas is unremarkable. the liver is diffusely hypodense, consistent with the findings described on the ultrasound. the patient is status post cholecystectomy. the kidneys are notable for a right parapelvic cyst and left hydronephrosis. there is no free gas or fluid in the abdomen and note is made of a fat-containing umbilical hernia. scattered retroperitoneal and mesenteric lymph nodes are visualized, none of which meet ct size criteria for pathologic enlargement. ct pelvis without contrast: the rectum, decompressed colon, uterus, and adnexa appear unremarkable. the urinary bladder contains a foley catheter and is collapsed. left hydroureter extends to an obstructive 6x5mm ureteral stone (2:103). there is no free gas or fluid in the pelvis and there is no pelvic or inguinal lymphadenopathy. echo: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. regional left ventricular wall motion is normal. there is mild global left ventricular hypokinesis (lvef = 40-45%). there is no ventricular septal defect. right ventricular chamber size is normal. with borderline normal free wall function. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is a moderate sized pericardial effusion. there are no echocardiographic signs of tamponade. impression: mild global left ventricular systolic dysfunction. moderate pericardial effusion without signs of tamponade. compared with the prior study (images reviewed) of , left ventricular cavity is smaller and systolic function has substantially improved. there is less mitral regurgitation. the other findings are similar. mr head: there is no acute infarction, edema, mass effect, or blood products in the brain. there are no pathologic extra-axial collections. the ventricles and sulci are normal in size and configuration for age. there are scattered small t2 hyperintensities in the subcortical, deep, and periventricular white matter of the cerebral hemispheres, which are nonspecific but could be related to minimal chronic small vessel ischemic disease in a patient of this age. the major arterial flow voids appear unremarkable. the mastoid air cells are opacified bilaterally. there is mild mucosal thickening in the paranasal sinuses without evidence of fluid levels. impression: 1. no acute infarction and no evidence of other acute abnormalities in the brain. 2. bilateral mastoid air cell opacification, which could be related to the presence of the endotracheal tube. however, clinical correlation is recommended to exclude the possibility of superimposed infection. brief hospital course: 59 year old female admitted for ams after several months of declining functional and mental status, partially secondary to tramadol overdose. upon hospitalization, the patient was intubated for hypoxia, and was found to have an obstructing left ureteral stone with hydronephrosis and purulent discharge after placement of perc nephrostomy tube. the patient was also found to be hypothyroid, with high titers of anti-tpo antibodies and to have severe cardiomyopathy with ef of % and a moderately sized pericardial effusion. 1. altered mental status: patient presented with progressive behavioral changes, daytime somnolence, and agitation. she admitted to tramadol and ativan ingestion although initial tox screen from urine and blood were negative. presenting symptoms were most likely attributable to a combination of tramadol/ other drug abuse, depression, and hypothyroidism, much less likely an evolving early dementia or degenerative process. extensive evaluation for other organic process was unrevealing: head ct on negative for acute process, lp on with minimal wbcs in csf (pertinent negatives: gram stain, enterovirus, west , eastern equine encephalitis, hsv 1 and 2 negative, crypto ag, hiv negative), mri head on negative. following intubation for hypoxia (see below), the patient required a significant amount of sedation due to agitation. through her course was maintained on versed, propofol, precedex. also started on iv haldol, despite prolonged qtc as an iv anti-psychotic was felt to be necessary, which was then switched to po seroquel following extubation. initially following extubation, the patient was quite delirious on exam and was unable to recognize even her family members. mental status quickly improved although patient showed some persistent psychomotor retardation. as patient no longer exhibited agitated behavior, seroquel was stopped and patient was discharged on no psychiatric medications. of note, the patient will need to be followed by a for evaluation of depression once her acute medical issues have resolved. 2. hypothyroidism: on admission, patient had markedly elevated tsh and low t3, t4, and ft4. anti-tpo antibodies were also markedly elevated. endocrine was consulted over concern of hashimoto's encephalopathy. patient was initially started on a low dose of iv thyroxine which was titrated up slowly. upon extubation, patient was started on oral thryroxine which was increased to full replacement based on body weight on at 175 mcg. last thyroid function tests on were t4 2.6, t3 40, free t4 0.31. the patient will need repeat t3 and free t4 on to ensure that hormone levels are increased following dose adjustment of levothyroxine. of note patient will need repeat tft in 2 weeks following discharge. close follow up with endocrinology has been arranged, especially as patient has history of cardiomyopathy that would be exacerbated by any hyperthyroidism. 3. systolic congestive heart failure: patient observed to have ef of % on echo, thought mainly to be due to hypothyroidism. virus negative and b1 normal. anca negative, negative. improved to 50-55% with thyroxine therapy. also with pericardial effusion initially seen on ct. initially, in the setting of persistent low grade temps, there was concern for a purulent effusion, however cardiology did not feel this likely and a pericardiocentesis was not performed. patient will need follow up arranged with cardiology with repeat echocardiogram 4. fevers/ sepsis secondary to obstructive nephrolithiasis and multifocal pneumonia: admitted with fever, tachycardia, 2% bandemia in the setting of a positive urinalysis and altered mental status. progressed to respiratory failure requiring intubation on and hypotension requiring pressor support (dobutamine, neo, levo). the patient was initially covered with acyclovir, vanc, ceftriaxone secondary to concern for meningoencephalitis, then broadened with meropenem, oseltamavir. ct scan on showed 1. multiple bilateral pulmonary consolidations concerning for multifocal pna and 2. obstructing stone causing l hydroureter and l hydronephrosis. - for the multifocal pneumonia: the patient was treated with broad spectrum abx until . patient remained intubated for almost 2 weeks, but following extubation, her oxygen requirement resolved rapidly. by the time of transfer out of icu, she was saturating well on room air. - for obstructive nephrolithiasis with left hydronephrosis and urosepsis: on got percutaneous nephrostomy tube which drained pinkish purulent fluid, cx'd and grew out pansensitive klebsiella. the patient was started on a three week course of fluoroquinolones (initially levofloxacin then ciprofloxacin) ending on . follow up was arranged with urology for definitive management of nephrolithiasis. pertinent negatives: 12 bcx's through micu course negative. ucx's other than that described above all negative. lyme serology negative, influenza negative, sputum negative, hiv negative, legionella in urine negative, blood myco/lytic negative, mini-bal for pcp negative, negative. also negative: , lcm, babesia, leptospira, ehrlichia, adenovirus, parvo b19 (positive igg, negative igm). lp was performed with results as above in ams section. 5. thrombocytopenia/ thrombosytosis: patient presented with thrombocytopenia likely caused by bone marrow suppression. smear without shistos, labs not showing hemolysis, dic ruled out (not coagulopathic and with elevated fibrinogen). mild splenomegaly on abdominal u/s. infectious causes of thrombocyopenia were also negative (hiv, , hepb, hepc all negative; cmv and ebv serologies showing past infection). platelet counts recovered spontaneously and patient developed a subsequent thrombocytosis which was thought to be rebound. by the time of discharge, platelets were 972. of note, the patient will require follow up monitoring of platelet count and possibly further evaluation for essential thrombocytosis. 6. ileus: while patient was intubated and unresponsive, seen to have increased tf residuals with constipation. ct scan showed ruq focal colonic ileus, treated with decompression and aggressive bm regimen. finally started to have some stool output. following extubation, ileus resolved. 7. acute renal failure: patient was found to be in acute on chronic renal failure on admission with a creatinine of 1.7 (from presumed baseline of 1.4). etiology of acute injury multifactorial with component prerenal ischemia (fena 0.13%), atn (muddy brown casts), and postrenal l ureter obstruction. creatinine peaked at 3.8 but returned to baseline of 1.4 -1.5 by the time of discharge. 8. pancreatitis: was noticed by labs, with elevated lipases but no ct evidence of pancreatitis. it was thought to be due to the propofol that the pt was on and so this was stopped. following extubation, patient had no abdominal discomfort and tolerated po intake. 9. transaminitis: u/s with evidence of fatty liver. lft's were trended and returned to by time of discharge. 10. anemia: admitted with hct 36 which has slowly trended down over icu course to nadir of 21 (normocytic), requiring transfusion with 1u prbc's on . no evidence of hemolysis or active bleed. serum b12 and folate levels were normal. iron studies showing anemia of chronic disease with a reticulocyte count of 4.1. because ferritin/tibc ratio was low, patient was started on supplementation with ferrous sulfate. 11. spinal stenosis: folling extubation, the patient complained of chronic low back pain due to spinal stenosis. there was no indication of progression of symptoms and neurologic exam was not focal (lower extremity strength 5/5, dtr bilaterally, urinary incontinence at baseline but intact recatal tone). she had previously been seen by neurosurgery who recommended conservative treatment. maintained on pain regimen of acetaminophen and lidocaine patches. opiod analgesics were avoided in setting of prior abuse. medications on admission: ibuprophen prn fluoxetine 20 mg daily omeprazole 20mg daily discharge medications: 1. white petrolatum-mineral oil 42.5-56.8 % ointment sig: one (1) appl ophthalmic prn (as needed) as needed for dry eyes. 2. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 1 days: end date (3 week course from ). 3. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 4. levothyroxine 175 mcg tablet sig: one (1) tablet po once a day. 5. outpatient lab work please check cbc, serum electrolytes, urinalysis and urine culture on 6. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical q24 prn () as needed for pain. 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. discharge disposition: extended care facility: hospital @ discharge diagnosis: primary diagnosis: altered mental status hypothyroidism cardiomyopathy obstructive nephrolithiasis with sepsis; resolved secondary diagnosis: depression prescription drug abuse spinal stenosis discharge condition: stable, mental status: alert and oriented to person/place/time; mild psychomotor slowing discharge instructions: you were admitted with lethargy and decreased consciousness. you were found to have a very hypoactive thyroid gland, a poorly functioning heart and a kidney stone obstructing the outflow of your urine and causing a urinary tract infection. we treated you with iv antibiotics, thyroid replacement medications, and placed a tube in your ureter to drain the urine obstructed by the stone. your hospital course was complicated by respiratory failure due to a bad pneumonia, briefly requiring a breathing tube. you also suffered acute damage to your kidneys which returned to later in your hospital course. with hormonal replacement, your thyroid level is returning to normal and your heart is also recovering. although you are still very weak from your prolonged hospitalization, you are making excellent progress. at time of discharge, your mental status is improving significantly every day. it will be important for you to follow up closely with the endocrinologist, urologist and for further management of your medical problems (see below for details). please make the following changes to your medication regimen: 1. take levothyroxine 175 mcg daily 2. take ciprofloxacin 500 mg every 12 hourse until for a total 3 week course following percutaneous nephrostomy tube placement on . you will need to take one final dose ofthis antibiotic following discharge 3. take ferrous sulfate 325mg for iron deficiency 4. use lidocaine patch 5% once daily for lower back pain 5. stop prozac: ask your primary care doctor whether you should start an antidepressant 6. please avoid tramadol and any other opiod- derivative pain medications such as percocet, lortab, dilaudid, morphine please return to the emergency room or call your physician if you develop worsening confusion, fevers, your nephrostomy tube no longer drains urine, abdominal pain, nausea/ vomiting, or any other concerning symptom. followup instructions: please make sure to arrange a visit with a within 1- 2 months. provider: , md phone: date/time: 2:10 provider: , md phone: date/time: 1:00 provider: , md phone: date/time: 10:00 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous nephrostomy without fragmentation Percutaneous nephrostomy without fragmentation Arterial catheterization Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Acidosis Thrombocytopenia, unspecified Obstructive sleep apnea (adult)(pediatric) Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Toxic encephalopathy Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Unspecified septicemia Severe sepsis Depressive disorder, not elsewhere classified Poisoning by opium (alkaloids), unspecified Accidental poisoning by other opiates and related narcotics Other and unspecified hyperlipidemia Unspecified disease of pericardium Acute respiratory failure Septic shock Morbid obesity Paralytic ileus Acute systolic heart failure Hydronephrosis Calculus of kidney Opioid abuse, continuous Acute pancreatitis Acute pyelonephritis with lesion of renal medullary necrosis |
allergies: levofloxacin / quinolones attending: chief complaint: respiratory distress - most likely due to anaphylactic reaction major surgical or invasive procedure: intubation history of present illness: 64 yo f with pmh significant for bronchiectasis presents with respiratory distress. she states that on she went to a storage facility where she keeps her belongings and her possessions had been stolen. she related being in much distress for the rest of the day and not feeling herself. she also states that she had been feeling more sob with cough lately. around midnight, she had increased coughing and sob and asked her daughter for a pill that her outside pcp in ny prescribed for her. she says that it was not levoquin, she thinks that it may have been . ~15 minutes after taking the , she began to feel faint and her daughter noticed that her lips and the area around her lips was beginning to turn blue. her neck and face became blue quickly after and she collapsed to the floor. her daughter called 911 and she began compressions per their instructions. when ems arrived, pt had a pulse but was not breathing so they intubated her on the field and she was brought to ed. . in the , pt was given nebs, solumedrol, fent/midzolam. an epipen was placed in her left thigh. she was also given h2 blocker and benedryl. for brief episodes of hypotension she was given 5l ns and then placed on levophed and neo very shortly but is currently not on pressors and has only pivs. per ed resident she really turned around after epinephrine. extubated in micu without incident. . on medicine service, pt reports feeling very weak. she still relates a persistent cough with some sputum without blood. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies chest pain or tightness, palpitations. denies nausea, vomiting, diarrhea, constipation or abdominal pain. denies recent change in bowel or bladder habits. denies dysuria. denies arthralgias or myalgias. past medical history: bronchiectasis reactive airway disease mucocele social history: social history: lives in - visiting daughter here in - tobacco: never - alcohol: never - iv drug use: never family history: family history: - daughter - asthma physical exam: physical exam: vitals: t:95.2 bp: 136/75 p:75 r: 18 o2:100 on 450x20 peep 5 fio2 40% general: intubated/sedated heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: right sided expiratory wheeze and slight crackles in left upper lobe cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley ext: warm, well perfused, trace edema skin: faint erythematous, macular blanching rash on upper extremities, not on chest or back. pertinent results: cardiology cardiology ecg: sinus rhythm. normal tracing. compared to the previous tracing of no diagnostic interim change. cardiology ecg: sinus tachycardia. slight non-specific st-t wave changes. compared to the previous tracing of sinus tachycardia is new. radiology radiology chest (portable ap): plate-like right lower lobe atelectasis, otherwise, improving basilar aeration without new consolidations. radiology rib bilat, w/ap chest: 1. no rib fracture or malalignment identified. 2. mildly improved atelectasis at both lung bases compared to the prior study. radiology chest (pa & lat): comparison is made with prior study . new left upper and bibasilar opacities are most likely atelectasis, superimposed infection cannot be totally excluded. followup is recommended. there are low lung volumes. there is no pneumothorax or large pleural effusion. there is mild cardiomegaly. mild degenerative changes are in the thoracic spine. radiology chest (portable ap): ap chest compared to at 2:21 a.m.: endotracheal tube is in standard placement, at least 3 cm from the carina. lungs are clear, heart size normal. no pleural effusion or evidence of central adenopathy. nasogastric tube passes into the stomach and out of view. no pneumothorax. radiology cta chest w&w/o c&recon: 1. no acute pulmonary embolism or aortic syndrome. 2. mild bronchial wall thickening with progressive intrathoracic lymphadenopathy since , likely due to infection/inflammation. 3. 5-mm pulmonary nodules should be followed by dedicated chest ct in one year. 4. thyroid nodules could be further evaluated by non-emergent ultrasound if indicated. radiology chest (portable ap): 1. ett too low, please retract 1-2 cm. 2. stable hilar lymphadenopathy. cardiac enzymes 11:00 ck mb:1 trop:<0.011 11:00 alt:46* ast:36 ck:28*1 alk phos:57 tbili:0.3 microbiology sputum gram stain-final; respiratory culture-final: gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. mrsa screen mrsa screen-final: no mrsa isolated. urine urine culture-final: no growth. blood culture blood culture, routine: no growth. urine 02:45am urine color-straw appear-hazy sp -1.022 02:45am urine blood-neg nitrite-neg protein-75 glucose-neg ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg 02:45am urine rbc-0-2 wbc-0-2 bacteri-mod yeast-none epi-0 02:45am urine castgr-0-2 casthy-* 02:45am urine ucg-negative 02:45am urine bnzodzp-pos barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg hematology 05:15am blood wbc-9.1 rbc-4.30 hgb-12.9 hct-35.9* mcv-84 mch-30.0 mchc-35.9* rdw-13.3 plt ct-196 05:15am blood plt ct-196 04:45am blood wbc-11.5* rbc-4.23 hgb-12.3 hct-36.1 mcv-85 mch-29.1 mchc-34.1 rdw-13.3 plt ct-200 06:30am blood wbc-13.0* rbc-4.00* hgb-11.5* hct-34.0* mcv-85 mch-28.8 mchc-33.9 rdw-13.4 plt ct-180 04:13am blood wbc-8.8 rbc-3.97* hgb-11.7* hct-33.5* mcv-84 mch-29.4 mchc-34.8 rdw-13.1 plt ct-194 02:35am blood wbc-12.1* rbc-4.35 hgb-13.0 hct-37.3 mcv-86 mch-29.8 mchc-34.8 rdw-13.1 plt ct-234 04:45am blood plt ct-200 04:13am blood pt-13.8* ptt-22.6 inr(pt)-1.2* 10:12am blood pt-13.4 ptt-22.5 inr(pt)-1.1 02:35am blood pt-13.4 ptt-22.8 inr(pt)-1.1 chemistry 05:15 glucose:88 urean:15 creat:0.6 na:139 k:3.8 cl:105 hco3:26 angap:12 04:45am blood glucose-89 urean-21* creat-0.7 na-140 k-4.3 cl-105 hco3-25 angap-14 04:13am blood glucose-154* urean-13 creat-0.5 na-143 k-3.3 cl-108 hco3-24 angap-14 10:12am blood glucose-142* urean-13 creat-0.6 na-141 k-3.7 cl-109* hco3-25 angap-11 10:12am blood alt-24 ast-30 alkphos-60 totbili-0.3 04:13am blood calcium-8.8 phos-2.7 mg-1.9 10:12am blood albumin-3.9 calcium-7.6* phos-2.2*# mg-1.6 blood gas 04:51am blood type- temp-37.2 ph-7.41 comment-axillary=9 01:11pm blood type-art po2-104 pco2-37 ph-7.40 caltco2-24 base xs-0 02:53am blood type-art temp-36.1 rates-18/ tidal v-500 fio2-50 po2-127* pco2-54* ph-7.24* caltco2-24 base xs--4 -assist/con intubat-intubated 04:51am blood lactate-2.7* calhco3-25 02:36am blood glucose-204* lactate-3.1* na-142 k-3.7 cl-104 10:38am blood hgb-12.8 calchct-38 o2 sat-98 04:51am blood freeca-1.13 02:36am blood freeca-1.14 labs on discharge 11:00 wbc:9.5 rbc:4.42 hgb:13.1 hct:37.6 mcv:85 mch:29.7 mchc:34.9 rdw:13.9 platelets:204 11:00 glucose:911 urean:20 creat:0.9 na:141 k:3.9 cl:106 hco3:25 angap:14 brief hospital course: 64 yo f s/p respiratory distress questionable as to quinolone ingestion or mucous plug with hx of bronchiectasis and reactive airway process. . # respiratory distress - pt was initially seen in the micu prior to transfer. she states that she began to experience shortness of breath and coughing spells later in the evening after discovering her storage facility had been robbed that morning. her daughter asked if she wanted to try using her nebs. she deferred and instead told her daughter to bring her either an or levofoxacin. after ingestion, her daughter noticed pt's mouth beginning to turn blue. her entire face and neck quickly became blue. the daughter called 911 and started chest compressions per their instructions. ems arrived on the scene and saw that she had a pulse but was not breathing. she was intubated on the field and brought to the ed. in the ed, she was treated for a likely anaphylactic reaction, the patient was administered an epipen, h2 blocker, and benadryl. she was intubated with fentanyl and midazolam. she also received solumedrol, nebs, 5l of ns, and briefly required pressors. a cxr was negative for foreign body. per follow up and ed resident, she really turned around with epinephrine. in the micu, she was seen by orl who cleared her for airway edema prior to extubation. she was successfully extubated and continued on steroids for a 3 day burst to prevent delayed anaphylactic reaction and nebs. she briefly developed stridor which responded well to racemic epinephrine. at the time of transfer, she was breathing comfortably with good oxygen saturations on 2l of oxygen by nasal cannula. on the floor, pt finished her 3 day steroid course while on the medicine service. she did not show any residual complications from the initial respiratory distress. her oxygen requirements were titrated down while she in-house and on discharge she did not have any requirements. a repeat cxr was clear but patient was adamant that she required antibiotics. pulmonary was consulted while pt was in-house as she has a history of bronchiectasis. due to her changing story of the actual incident, it was mentioned that an anaphylactic reaction might be questionable since pt later denied ever taking any medication just prior to the incident. pt is to see an allergist as an outpt to confirm a fluoroquinolone allergy as this cannot be done for 4-6 weeks after the incident. a tryptase level was never sent. . # chronic cough - pt continued to have coughing spells with nonbloody sputum production. nebulizers, guaifenesin, and tessalon perles were utilized to minimize coughing. pulm recommended nasonex . cxrs were negative for any infiltrates or pneumonia. pt started on azithromycin for possiblity of any infectious process. pt was encouraged to ambulate as much as tolerated, use incentive spirometer bedside, and sit up in bed with positional changes to increase oxygen flow. pt to followup with pulmonology as an outpatient to readdress her bronchiectasis. . # msk chest pain - pt complained of chest pain following admission to the floors. a cxr and dedicated rib film showed no fractures. cardiac enzymes and ekgs demonstrated no acute cardiac processes. the chest pain was likely secondary to chest compressions that the daughter performed at home before ems arrived. pt later denied her daughter giving her chest compressions though she was not conscious at the time. percocet prn, lidocaine patch, and hot packs were used to alleviate her pain. it was explained to her that it would take time for pain associated with rib bruising to dissipate. pt was able to ambulate and breathe without oxygen requirement on discharge. . # anxiety - pt related mental distress due to the robbery preceding her respiratory distress. a social consult was called in and met with pt and her daughter. pt denies talking to the social worker although this meeting was documented in her chart. she was given lorazepam for anxiety. she was also given a small prescription for ativan as an outpatient until she sees her pcp. medications on admission: nasonex (mom nasal inhalation) advair diskus ventilin hfa levofloxacin duoneb (ipratropium bromide and albuterol sulfate) discharge medications: 1. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for sob, wheezing . 2. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day) as needed for asthma, sob. 3. nasonex 50 mcg/actuation spray, non-aerosol sig: two (2) sprays nasal once a day as needed for shortness of breath or wheezing: 2 sprays in each nostril. 4. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for apply to chest: use for 12 hours on and 12 hours off. disp:*10 adhesive patch, medicated(s)* refills:*0* 5. ventolin hfa 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*0* 6. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*20 tablet(s)* refills:*0* 7. azithromycin 250 mg tablet sig: one (1) tablet po once a day for 3 days: start morning of . disp:*3 tablet(s)* refills:*0* 8. mucinex 600 mg tablet sustained release sig: one (1) tablet sustained release po every six (6) hours as needed for cough. disp:*30 tablet sustained release(s)* refills:*0* 9. ativan 0.5 mg tablet sig: one (1) tablet po once a day as needed for anxiety. disp:*15 tablet(s)* refills:*0* 10. epipen 0.3 mg/0.3 ml pen injector sig: one (1) intramuscular once as needed for respiratory arrest, anaphylactic shock: use only in emergency. we highly recommend you avoid fluorquinolones. disp:*1 pen* refills:*0* discharge disposition: home discharge diagnosis: primary: respiratory distress musculoskeletal chest pain secondary: lung dysfunction discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital for respiratory distress requiring intubation. you were given medications and ivf to improve your breathing and low blood pressures which appeared to be due to anaphylaxis. you responded well to steroids and epinephrine. you also had residual sternal pain likely from chest compressions as xrays of your ribs showed no fractures. your labs and ekg were not significant for any cardiac issues. you also related some anxiety you had from the robbery that preceded your respiratory arrest so a social consult was called. changes in medication: 1. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for apply to chest: use for 12 hours on and 12 hours off. 2. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. 3. azithromycin 250mg by mouth daily for 3 more days to complete a 5 day course. 4. epinephrine pen as need for anaphylaxis.***we strongly recommend avoiding quinolone antibiotics. 5. you can take mucinex as needed for cough. 6. you can continue to take tylenol and ibuprofen as needed for pain as well. 6. ativan 0.5 mg tablet sig: one (1) tablet po once a day as needed for anxiety. if you develop any of the symptoms listed below or anything else that concerns you, please see your pcp or go to your nearest emergency room. please see your primary pulmonologist to readdress treatment for your chronic cough. please keep all followup appointments. followup instructions: department: when: wednesday at 4:45 pm with: , md building: (, ma) campus: off campus best parking: none department: pulmonary function lab when: tuesday at 7:40 am with: pulmonary function lab building: campus: east best parking: garage **please arrive at 7:30am department: medical specialties when: tuesday at 8:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage department: div of allergy and inflam when: wednesday at 9:00 am with: , md building: one place (, ma) campus: off campus best parking: parking on site md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Asthma, unspecified type, unspecified Constipation, unspecified Acute respiratory failure Other diseases of lung, not elsewhere classified Other chest pain Nausea alone Enlargement of lymph nodes Other specified antibiotics causing adverse effects in therapeutic use Bronchiectasis without acute exacerbation Other abnormal glucose Unspecified sinusitis (chronic) Other anaphylactic reaction Nontoxic uninodular goiter Predominant disturbance of emotions |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: severe hematuria secondary to radiation cystitis major surgical or invasive procedure: removal of suprapubic tube, ileal conduit. history of present illness: mr. is a 65 year-old gentleman, with a history of prostatectomy and adjuvant radiation for prostate cancer in , who recently has had severe hematuria secondary to radiation cystitis. this hematuria was unable to be resolved with hand irrigation, continuous bladder irrigation with normal saline and alum and oral amicar, as well as bladder fulguration, urine diversion with suprapubic tube and recent cystoscopy with clot evacuation. he presents for urinary diversion by ileal conduit and removal of suprapubic tube. past medical history: past medical history: 1. hypertension 2. hyperlipidemia 3. bicuspid aortic valve without as - followed by dr. 4. dm ii 5. prostate cancer 6. radiation cystitis resulting in recurrent hematuria psh: 1. radical prostatectomy by dr. in , adjuvant xrt 6 months later 2. s/p penile prosthesis 3. spt placement on social history: the patient currently lives alone, he is divorced. he has three daughters. the patient works for an mri production company tobacco: none etoh: none illicits: none family history: nc brief hospital course: patient was admitted to dr. urology service after undergoing spt removal and ileal conduit. no concerning intraoperative events occurred; please see dictated operative note for details. patient received perioperative antibiotic prophylaxis with cefazolin and metronidazole. while in the pacu on pod 0, the patient became febrile to 104 with associated tachycardia and relative hypotension. his antibiotics were switched to zosyn and vancomycin and he was admitted to the icu for further monitoring. by the am of pod 1, his fever resolved, and he was transferred to the floor. he continued on vancomycin and zosyn for three days, was changed to cefazolin and flagyl for an additional two days, and then was placed on ciprofloxacin to complete a total of seven days of empiric abx therapy. the patient had an ngt in place post-operatively, which was removed on pod 2. with the passage of flatus, patient's diet was advanced as tolerated. the patient was ambulating and pain was controlled on oral medications by this time. the ostomy nurse saw the patient for ostomy teaching. at the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. the ostomy was perfused and patent. the patient will receive in home ostomy care through the visiting nurses association. the patient was asked to call dr. office for a follow-up appointment. medications on admission: atenolol 25 mg po daily metformin 1000 mg po bid glipizide 15 mg po daily moexipril 15 mg po daily discharge medications: 1. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 2. ibuprofen 600 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain: take as firstline pain medication. take vicodin for backup pain. disp:*120 tablet(s)* refills:*2* 3. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 4. colace 100 mg capsule sig: one (1) capsule po twice a day: take this medication if you are taking vicodin - it helps prevent constipation. disp:*60 capsule(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: radiation cystitis discharge condition: stable discharge instructions: please resume all home meds -do not drive while taking oxycodone. please take tylenol in addition to oxycodone, and transition to tylenol as pain improves. -you may shower, but do not immerse incision, no tub baths/swimming. -small white steri-strips bandages will fall off in days, you may remove at that time if irritating. -call if incision becomes markedly more red, swollen, or begins to drain purulent fluid, or for fever more than 101.5. -please refer to visiting nurses (vna) for management of the ileal conduct. followup instructions: please contact dr. office in one week to schedule follow up appointment Procedure: Formation of cutaneous uretero-ileostomy Diagnoses: Other iatrogenic hypotension Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Personal history of malignant neoplasm of prostate Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Gross hematuria Congenital insufficiency of aortic valve Tachycardia, unspecified Irradiation cystitis Late effect of radiation Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Postprocedural fever |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: gi bleed major surgical or invasive procedure: egd colonoscopy tagged rbc scan cvl placement transfusion of 10 units of prbc history of present illness: for full details please see prior admission note and micu transfer notes x 2. briefly the patient is a 65 year old male with history of prostate cancer s/p resection and bicuspid av who initially presented to hospital with gi bleeding and syncope x 2. he was prepped for colonoscopy but this was deferred given ct imaging revealed large bladder and mild hydro for which patient was transferred to , foley placed by urology without difficulty. since that time patient has had recurrent bleeding and syncope x 2 requiring transfer to icu. the patient underwent colonoscopy which revealed blood throughout the colon and significant diverticulosis but no obvious bleeding lesion. the patient was transferred to the medical floor and subsequently transferred back to icu given recurrent bleeding of approximately 1l maroon blood with anginal jaw pain and lateral st depressions. evaluation by angio was expedited but no active bleeding seen at time of procedure. the patient was transferred back to the icu for supportive care early this a.m. the patient is now called out to the medical floor for ongoing management given relative stability and need to free an icu bed. the patient has in total received 7u prbc, 5 at , 2 at osh. the patient's hct today has trended from 32 -> 27 with passing small amounts of very dark/black stool around noon. the patient received 1u prbc prior to transfer for hct of 27 as above. on arrival to the floor the patient reports he currently feels well. he denies any chest or jaw pain, difficulty breathing, abdominal pain, nausea/vomiting or any other localizing symptoms. he is fatigued. remainder of ros negative as below. ros: -constitutional: wnl weight loss fatigue/malaise fever chills/rigors nightweats anorexia -eyes: wnl blurry vision diplopia loss of vision photophobia -ent: wnl dry mouth oral ulcers bleeding gums/nose tinnitus sinus pain sore throat -cardiac: wnl chest pain palpitations le edema orthopnea/pnd doe -respiratory: wnl sob pleuritic pain hemoptysis cough -gastrointestinal: wnl nausea vomiting abdominal pain abdominal swelling diarrhea constipation hematemesis hematochezia melena -heme/lymph: wnl bleeding bruising lymphadenopathy -gu: wnl incontinence/retention dysuria hematuria discharge menorrhagia -skin: wnl rash pruritus -endocrine: wnl change in skin/hair loss of energy heat/cold intolerance -musculoskeletal: wnl myalgias arthralgias back pain -neurological: wnl numbness of extremities weakness of extremities parasthesias dizziness/lightheaded vertigo confusion headache -psychiatric: wnl depression suicidal ideation -allergy/immunological: wnl seasonal allergies . past medical history: #. hypertension #. hyperlipidemia #. bicuspid aortic valve without as - followed by dr. #. dm ii #. prostate cancer s/p prostate resection #. s/p penile prosthesis social history: the patient currently lives alone, he is divorced. he has three daughters. the patient works for an mri production company tobacco: none etoh: none illicits: none family history: nc physical exam: vitals: 98.6, 116/69, 76, 18, 98% ra general: patient is a middle aged male, tired appearing, but in no distress heent: ncat, eomi, sclera anicteric, conjunctiva pale. mild facial flushing neck: jvp not elevated chest: generally cta anterior and posteriorly cor: rrr, normal s1/s2. ii/vi systolic murmur at llsb abd: soft, non-tender, non-distended ext: no c/c/e gu: + triple lumen in right groin, dressing c/d/i . brief hospital course: the patient is a 65 year old male with history of hypertension, diabetes, prostate cancer s/p resection now admitted with recurrent gi bleed . #. gi bleed: .the patient was admitted to the service as a transfer from an outside hospital with a gi bleed. he was brought to the when had syncope while having a bloody bowel movement on the floor. gi performed an upper and lower endoscopy, but despite the investigation of multiple diverticuli, none were identified as sources of bleeding. his upper egd was normal. he was in fact called out to the floor, but again started bleeding. he was brought back to the . the evening of and morning of he had an angiographic study looking for bleeding which was negative. a femoral cvl was placed. of note, he had jaw pain and ischemic ekg changes with a hct of 26. he was transfused to keep his hct ~30 as a result. he remained stable, but did have several dark stools. he was transfered to the floor for continued monitoring. for the remainder of the hospitalization his hematocrit remained stable and he displayed no further signs of active bleeding. he will follow-up for a outpatient capsule endoscopy study. #. urinary obstruction, acute on chronic: s/p foley placement on arrival by urology. he intermittently required foley catheterization this hospitalization. however, at discharge he was voiding large volumes without post-void residuals. . #. hypertension: - antihypertensives were held at admission and throughout most of the hospitalization. his ace-i was restarted prior to discharge #. hyperlipidemia: continued on statin . #. diabetes ii controlled without complication: blood sugar improved on transfer to floor treat with insulin sliding scale during acute illness. he did not require insulin prior to discharge and was discharge on his home medications. . medications on admission: atenolol 25mg daily metformin 1000mg qam, 500mg qpm glipizide xl 5mg daily zocor 20mg daily moexipril 15mg daily discharge medications: 1. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 2. metformin 1,000 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 3. metformin 500 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 4. glipizide 5 mg tab,sust rel osmotic push 24hr sig: one (1) tab,sust rel osmotic push 24hr po once a day. 5. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 6. moexipril 15 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: home discharge diagnosis: 1. gi bleed discharge condition: good discharge instructions: you were admitted to the hospital with gi bleed and fainting episodes from the bleed. we did egd, colonoscopy and a tagged nuclear scan to but could not find the exact source of your bleeding. you have multiple coloni diverticuli and you may have bled from there. the recommended treatment would be colectomy but you stopped bleeding and did not want to pursue surgery. you need to call the number given below to set up a capsule endoscopy. you also should follow up with your primary care doctor next week for a check on your blood count please return to ed for another gi bleeding episode, fainting episode, dizziness, chest pain, shortness of breath, or any other concerning symptoms. followup instructions: 1. pcp, . , ph: , please call and make appt to be seen next week with a cbc check 2. gi, ph: , please call to set up outpt capsule endoscopy Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Colonoscopy Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of malignant neoplasm of prostate Congenital insufficiency of aortic valve Hydronephrosis Diverticulosis of colon with hemorrhage Orthostatic hypotension Other ureteric obstruction |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: expressive aphasia major surgical or invasive procedure: transesophageal echocardiogram cardiac catheterization surgical extraction of infected teeth number 13 and 32. mitral valve repair(30mm cefuture ring) pfo closure, laa ligation history of present illness: 39 yo male with a history of mitral valve vegetations who presented with aphasia likely from mca embolic stroke. transferred to after presenting to hospital. one week prior to his initial presentation he felt fatigued and stayed in bed for 3 days. for the two days prior to presenting he spent most hours of the day sleeping, did not eat or drink or get out of bed. 1 day prior to inital presentation he found that he could not speak, although he knew what he wanted to say and could understand what others said to him. pt reports he had less energy for the past 1 yrs and feels this may be related to his endocarditis. he describes having night sweats for the past year and a half, and a l parieto-temporal headache for the past year. he had no documented fevers. he had no focal weakness, numbness, or paresthesia. no blurry vision or diplopia. no lightheadeness or dizziness. he initially presented to cape code hospital were he had a ct of the head that showed a low attenuation zone in the posterior corona radiata extending along the left external capsule of uncertain etiology. mri scan showed multiple acute/subacute infarcts with paramagnetic effect in the left temporal lobe and right parietal hemisphere suggestive of hemosiderin from hemorrhage. he was transferred to this hospital for further management. past medical history: 1. endocarditis - strep viridans bacteremia with mitral valve endocarditis in , endocarditis with strep intermedius , and endocarditis with strep oralis . 2. mitral valve prolapse 3. kidney stones 4. hepatitis b 5. hepatitis c 6. mild mi in setting of cocaine use 7. pulmonary fibrosis? (in osh records) social history: smokes pack per day for the past 25 years. he has used every illicit drug in the past but none in the past 5 years. he denies current alcohol use and has not drank for many years, although admits to abuse in past. lives with his girlfriend and 2 cats in . has a teenage daughter. in hvac heating industry, but was laid off 2 months ago. does not have health insurance. was in jail for two years for robbing a bank, released in . family history: father had a stroke at age 35. mother is alive and healthy, but a heavy smoker. physical exam: exam upon arrival to micu: vitals: t: 99.2 bp: 99/59 p: 88 r: 13 o2: 97% on ra general: alert, oriented, no acute distress heent: sclera anicteric, mm dry, poor dentition neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, ii/vi hsm at apex, no rubs or gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neurologic: cn ii-xii tested and intact, strength 5/5 in upper and lower extremities bilterally, sensation intact to light touch and cold bilaterally, is able to name simple objects, is able to repeat, finger to nose intact, gait intact. toes downgoing. skin: no splinter hemorrhages, no rashes pertinent results: osh labs and cultures: troponin of 0.01, bnp of 12.5, tbili of 0.6, na 133, k 4.0, cl 97, co2 27, bun 10, cr 0.98, glu 100, inr 1.1, wbc 12.1, hct 25, plts 406. blood culture : positive for strept mitis preop 11:10pm sed rate-67* 11:10pm plt count-406 11:10pm neuts-74.5* lymphs-17.7* monos-5.3 eos-2.1 basos-0.5 11:10pm wbc-9.8 rbc-3.67* hgb-11.7* hct-32.7* mcv-89 mch-31.8 mchc-35.7* rdw-13.9 11:17pm glucose-115* lactate-1.3 na+-135 k+-3.8 cl--97* tco2-25 11:29pm pt-13.1 ptt-27.9 inr(pt)-1.1 11:29pm hcv ab-positive* 11:29pm crp-62.3* 11:29pm hbsag-negative hbs ab-positive hbc ab-positive 11:29pm caltibc-241* ferritin-264 trf-185* 11:29pm iron-117 11:29pm ck-mb-1 ctropnt-<0.01 11:42pm lactate-1.3 02:38am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-1 ph-6.5 leuk-neg discharge 05:25am blood wbc-4.2 rbc-2.36* hgb-7.6* hct-22.6* mcv-96 mch-32.1* mchc-33.6 rdw-16.6* plt ct-210 05:25am blood plt ct-210 11:54am blood pt-12.7 ptt-33.6 inr(pt)-1.1 05:02am blood glucose-88 urean-14 creat-1.1 k-4.3 02:16pm blood alt-21 ast-23 alkphos-51 totbili-0.2 id testing: 06:24am blood hiv ab-negative toxicology: blood: asa-neg ethanol-neg acetmnp-6.0 bnzodzp-neg barbitr-neg tricycl-neg urine bnzodzp-neg barbitr-pos opiates-neg cocaine-pos amphetm-neg mthdone-neg micro: blood cultures : positive for strept viridans blood cultures : no growth to date at time of discharge urine culture : negative images: mri/mra head w/o contrast (done at osh): multiple acute/subacute infracts with paramagnetic effect left temporal lobe and right parietal hemisphere suggestive of hemosiderin from hemorrhage. suggestion of petecheal hemorrhage was also noted on recent head ct. the multiplicity of infarcts is suggestive of embolic source. there is gradual narrowing of the m2 segment of the left middle cerebral artery with paucity of signal involving cistal branch vessels. findings are consistent with hemodynamically significant stenosis and probable distal occlusion there is no evidence of aneurysm or high flow avm. mra brain w/o contrast : occlusion of an m2 branch of the left middle cerebral artery with attenuation of distal mca branches and acute ischemia in the left posterior mca territory consistent with acute infarction. additional foci of restricted diffusion as described above along with several punctate foci of enhancement and susceptibility artifact are suggestive of an embolic process. enhancement may be secondary to septic emboli or subacute infarction. bas/ugi air/sbft : normal upper gi esophagram and normal hypopharynx without evidence of zenker's diverticulum, dysmotility, ulcers, or strictures. additional studies: tte : compared to the findings of the prior study of , left ventricular cavity size has increased and systolic function has deteriorated. the previously seen large posterior mitral leaflet vegetation has probably decreased in size while the anterior vegetation has probably increased in size. however, direct comparison of vegetation size can be inaccurated with tte. moderate to severe mitral regurgitation persists. egd : negative for any obstruction or ring/web of esophagus log-in date/time: 11:46 am tissue site: valve-bicuspid (mitral) leaflets. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (final ): no growth. anaerobic culture (preliminary): no growth. fungal culture (preliminary): acid fast smear (final ): no acid fast bacilli seen on direct smear. log-in date/time: 9:44 am tissue mitral valve vegetation tissue. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (final ): no growth. anaerobic culture (preliminary): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. fungal culture (preliminary): acid fast culture (preliminary): echocardiography report-intraop date/time: at 11:48 interpret md: , md, md echocardiographic measurements results measurements normal range left atrium - long axis dimension: *5.8 cm <= 4.0 cm left ventricle - diastolic dimension: *6.4 cm <= 5.6 cm left ventricle - systolic dimension: 5.4 cm left ventricle - fractional shortening: *0.16 >= 0.29 left ventricle - ejection fraction: 50% >= 55% findings left atrium: moderate la enlargement. right atrium/interatrial septum: pfo is present. left-to-right shunt across the interatrial septum at rest. left ventricle: normal lv wall thickness. moderately dilated lv cavity. normal regional lv systolic function. low normal lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. normal aortic arch diameter. normal descending aorta diameter. aortic valve: three aortic valve leaflets. no as. no ar. mitral valve: mildly thickened mitral valve leaflets. mild mvp. severe (4+) mr. tricuspid valve: no tr. pulmonic valve/pulmonary artery: no pr. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. no tee related complications. the patient appears to be in sinus rhythm. results were personally reviewed with the md caring for the patient. see conclusions for post-bypass data the post-bypass study was performed while the patient was receiving vasoactive infusions (see conclusions for listing of medications). conclusions pre-bypass: the left atrium is moderately dilated. a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen at rest. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50%). right ventricular chamber size and free wall motion are normal. there are three aortic valve leaflets. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is mild mitral valve prolapse of the p3 scallop. annulus is enlarged to 4.5 cm. an echo dense mass ( vegetation vs. torn chordae) seen attached to the p3 scallop. severe (4+) mitral regurgitation is seen. post-bypass: for the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in sinus rhythm. 1. an annuloplasty is seen well seated in the mitral position. leaflets open well. no mr is seen. mean gradient of 3 mm of hg across the valve. 2. ventricular function is unchanged. 3. no flow is detected across the ias by color flow doppler. 4. aortic contours appear intact post decannulation dr. was notified in person of the results. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, md, interpreting physician 12:03 radiology report chest (portable ap) study date of 11:40 am medical condition: 39 year old man cad/post pull final report history: chest tube removal, to evaluate for pneumothorax. findings: in comparison with the earlier study of this date, there is little overall change. no evidence of pneumothorax. left picc line remains in place and the paramediastinal drain has been removed. bilateral small pleural effusions and basilar atelectasis is again seen. dr. brief hospital course: mr. is a 39 year old male with a history of mitral valve endocarditis and iv drug use presenting with word finding difficulties and new infarctions on brain mri. the patient presented with expressive aphasia and was found to have multiple t2 hyperintense lesions in the l temporal and r parietal lobes on mri suggestive of an embolic process. he has a history of infectious endocarditis, for which has has been treated on three occassions in the past, and had a holosystolic mitral murmur at apex on exam. blood culture from came back positive for streptococcus viridans. tee and tte showed evidence of mitral valve vegetations and moderate to severe mitral regurgitation. he was started on vancomycin and gentamicin, later changed to penicillin g (1st day was ) and gentamicin once blood cultures came back positive for strep viridans. the patient tested positive for hepatitis c, so serum hepatitis a antibody and hepatitis b surface antibody were both assessed and found to be positive. he was counseled about getting long-term treatment for hepatitis c as an outpatient. additionally, because of difficulty passing the tee probe during his work-up, mr. had a ugi/sbft and egd, both of which were unremarkable. dental saw mr. during his hospital stay and recommended that dental prophylaxis, completion of a previously started root canal at the left anterior maxilla, and extraction of #32. oral surgery performed extraction of #13 & #32 on without complication. repeat tte showed increased lv size and deterioration of systolic function compared to tte done , and ct recommended mitral valve replacment. ct abdomen/pelvis demonstrating a non-specific splenic edge hypodensity which was non-specific, and a clean cardiac catheterization on . he completed his antibiotic regimen as an inpatient and was sent to surgery on . please see operative report for details, in summary the patient had a mitral valve repair with a p3 posterior leaflet triangular resection and 30-mm profile 3-d ring annuloplasty. resection of left atrial appendage, and closure of patent foramen ovale. his bypass time was 86 minutes with a crossclamp of 67 minutes. he tolerated the operation well and was transferred to the cardiac surgery icu in stable condition. in the immediate post operative period he was hemodynamically stable, his anesthesia was reversed he was weaned from the ventilator and extubated. the following day he was transferred from the icu to the stepdown floor for continued care and recovery. all tubes lines and drains were removed per cardiac surgery protocols. he was started on bblockers and diuretics and activity was gradually advanced. the patient remained on penicillin coverage until the cultures from the operating room were finalized as negative. on pod 4 he was cleared for discharge home with visiting nurses. medications on admission: none discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. multivitamins tablet, chewable sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*45 tablet(s)* refills:*0* 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*30 capsule(s)* refills:*2* discharge disposition: home with service discharge diagnosis: 1. endocarditis 2. bacteremia 3. mitral regurgitation s/p mitral valve repair(30mm cefuture ring) pfo closure, laa ligation 4. stroke of l mca discharge condition: activity status:ambulatory - independent mental status:clear and coherent level of consciousness:alert and interactive hemodynamically: stable wound: healing well, no erythema or drainage discharge instructions: you were admitted to the hospital because you had an infected heart valve, bacteria in your blood, and septic emboli to your brain. an mri showed that you had a stroke and several small areas of bleeding in your brain. these findings explain your difficulty speaking upon presentation to the hospital. a blood culture grew a bacteria called streptococcus viridans. you had an echocardiogram that showed bacteria growing on your mitral valve, and dysfunction of the mitral valve called mitral regurgitation. cardiothoracic surgery repaired your mitral valve. it is also important that you follow-up with your dentist regarding dental procedures as you will require antibiotics each time you need dental work. please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon no lifting more than 10 pounds for 10 weeks please call with any questions or concerns danger signs: when to call 911 you should call 911 or your local emergency number to be taken to the nearest emergency room for any emergency situation, such as: * chest pain not related to your incision or angina pain, similar to the pain you had prior to surgery * extreme shortness or breath or difficulty breathing * severe bleeding, especially if you are on warfarin (coumadin) * fainting, severe lightheadedness or changes in mental status when to call your surgeon call your surgeon ( (24 hours a day, seven days a week) if any of the following occur: * your incision is warm, red or swollen or there is increased tenderness or pain * any of your incisions have any fluid or drainage coming out * you have a fever of 100.5 degrees fahrenheit or higher * your weight has gone up more than two pounds in one day or five pounds in a week * you have severe pain or increased swelling in either leg * you have palpitations * you feel dizzy or weak (if severe, call 911) followup instructions: clinic in 2 weeks. appointment to be scheduled before discharge dr on (tues)@1pm dr , r in 2 weeks. please call for appointment Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Other and unspecified repair of atrial septal defect Extraction of other tooth Open heart valvuloplasty of mitral valve without replacement Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Anemia of other chronic disease Tobacco use disorder Mitral valve disorders Unspecified viral hepatitis C without hepatic coma Cocaine abuse, unspecified Anxiety state, unspecified Bacteremia Ostium secundum type atrial septal defect Old myocardial infarction Acute and subacute bacterial endocarditis Personal history of urinary calculi Cerebral embolism with cerebral infarction Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus Aphasia Opioid abuse, unspecified Other specified hypotension Cardiomegaly Septic arterial embolism Acute apical periodontitis of pulpal origin Other ill-defined heart diseases Disease of spleen, unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: left main coronary artery disease major surgical or invasive procedure: coronary artery bypass grafts 3 (lima-lad, svg-om, svg-pda) preoperative intra-aortic balloon pump history of present illness: this 84 year old white male sought medical care in late for several weeks of nocturnal shoulder discomfort at rest. he has had no care in 30 years. he was referred for stress testing which was positive today. urgent catheterization revealed 80% left main disease and 95% proximal lad and circumflex disease. lv function was depressed at 35%. he was pain free, but an intraaortic balloon was placed and heparin begun. he was transferred by air here for surgery. past medical history: appendectomy in cholecystectomy in social history: non smoker, glasses of wine a month family history: father died of heart disease in his late 60s physical exam: admission: pulse: resp:14 o2 sat: 100% (2l) b/p right:157/79 left: 155/80 height: 79" weight:79.4 kg admission: general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right:2 left:2 dp right:2 left:2 pt :2 left:2 radial right:2 left:2 carotid bruit right:n left:n pertinent results: echo pre-bypass: no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. there is mild regional left ventricular systolic dysfunction with antero-apical hypokinesis. overall left ventricular systolic function is low normal (lvef 45%). right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated at the sinus level. there are simple atheroma in the ascending aorta. there are simple atheroma in the descending thoracic aorta. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. moderate (2+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. post-bypass: for the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. some decrease in mitral regurgition post-bypass is seen. overall ventricular function is same as pre-bypass. all other findings on post-bypass exam are consistent with pre-bypass findings. the aorta is intact post-decannulation. all findings communicated with the surgeon. cxr there is interval extubation of the patient with removal of the ng tube, mediastinal drains, and left chest tube and swan-ganz catheter. the chest radiograph was obtained in a lordotic projection, thus it is difficult to compare the cardiac silhouette and mediastinal contours, although they appear to be stable. there is left basal opacity containing air bronchogram most likely consistent with area of gradually improving atelectasis. lungs are otherwise essentially clear with no evidence of failure. there is minimal pleural effusion, bilateral. no evidence of pneumothorax is present within the limitations of the study. 09:06am blood wbc-9.9 rbc-3.46* hgb-10.6* hct-30.4* mcv-88 mch-30.5 mchc-34.7 rdw-14.3 plt ct-263 05:46am blood wbc-9.7 rbc-3.41* hgb-10.4* hct-29.4* mcv-86 mch-30.5 mchc-35.4* rdw-14.2 plt ct-260 05:00am blood pt-26.9* inr(pt)-2.6* 05:46am blood pt-21.9* inr(pt)-2.0* 05:35am blood pt-14.8* inr(pt)-1.3* 02:16am blood pt-12.8 ptt-31.2 inr(pt)-1.1 05:00am blood urean-38* creat-1.4* k-4.6 09:06am blood glucose-203* urean-39* creat-1.5* na-134 k-4.8 cl-101 hco3-24 angap-14 09:06am blood calcium-8.4 phos-2.5* mg-2.2 07:42pm blood %hba1c-6.1* brief hospital course: mr. was admitted to the via for surgical management of his coronary artery disease. following admission he had vague shoulder discomfort which resolved with intravenous nitroglycerin. routine preoperative evaluation was begun. he was in af when admitted but converted to normal sinus rhythm with amiodarone. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. within the next 24 hours, mr. neurologically intact and was extubated. his inta-aortic balloon pump was removed without issue. on postoperative day two, he was transferred to the step down unit for further recovery. he was gently diuresed towards his preoperative weight. the physical therapy service was consulted for assistance with his preoperative strength and mobility. he developed atrial fibrillation which was treated with amiodarone. this persisted and he was anti-coagulated with coumadin. he did return to sinus rhythm prior to discharge, and was maintained on amiodarone, beta-blocker and coumadin. he developed an upper extremity phlebitis and was treated with keflex. postoperative course was otherewise uneventful and the patient was discharged on pod 5 to home with vna services. medications on admission: at osh: plavix 75mg asa 325mg/d metoprolol 25mg ntp 1"/6hr pepcid 20mg/d kefzol discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week, then 200mg/day until further instructed. disp:*120 tablet(s)* refills:*2* 6. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*270 tablet(s)* refills:*2* 7. furosemide 40 mg tablet sig: one (1) tablet po daily (daily) for 1 weeks. disp:*7 tablet(s)* refills:*0* 8. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po daily (daily) for 1 weeks. disp:*7 tab sust.rel. particle/crystal(s)* refills:*0* 9. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for left arm phlebitis for 6 days. disp:*24 capsule(s)* refills:*0* 10. warfarin 1 mg tablet sig: one (1) tablet po once a day: dose will change daily for goal inr , dr. to manage. disp:*30 tablet(s)* refills:*2* 11. outpatient lab work serial pt/inr dx: atrial fibrillation goal inr results to dr. fax: 12. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: unstable angina coronary artery disease paroxysmal atrial fibrillation s/p appendectomy s/p cholecystectomy discharge condition: good discharge instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed followup instructions: dr. in 4 weeks () 6 wound clinic in 2 weeks dr. in weeks dr. in 2 weeks please call for appointments dr. to manage coumadin dosing/inr, fax: Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Atrial fibrillation Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other vascular complications of medical care, not elsewhere classified Phlebitis and thrombophlebitis of upper extremities, unspecified Other abnormal glucose |
allergies: codeine attending: chief complaint: left sided weakness major surgical or invasive procedure: none history of present illness: neurology at bedside for evaluation after code stroke activation within: 4 minutes time (and date) the patient was last known well: 20:10 nih stroke scale score: 7 t-: no reason t-pa was not given or considered: high risk of gi bleed i was present during the ct scanning and reviewed the images within 20 minutes of their completion. nih stroke scale score was 7: 1a. level of consciousness: 0 1b. loc question: 0 1c. loc commands: 0 2. best gaze: 0 3. visual fields: 0 4. facial palsy: 2 5a. motor arm, left: 1 5b. motor arm, right: 0 6a. motor leg, left: 1 6b. motor leg, right: 0 7. limb ataxia: 0 8. sensory: 1 9. language: 0 10. dysarthria: 1 11. extinction and neglect: 1 hpi: the pt is a 66 year-old r-handed woman with a history of htn, hl, hypertrophic cardiomyopathy s/p pm/icd on coumadin, chf, copd, and a small bowel mass s/p recent biopsy as well as colonoscopy with polypectomy who presents as a code stroke with acute onset l sided weakness. her daughter reports that she was in her usual state of health throughout the day today and when she dropped her off at her house shortly before 8pm. the patient's sister was at home with her when suddenly around 8:10pm she noticed a "change" in her face and slurred speech. she called ems and the patient was brought to hospital. upon arrival she was found to have a left facial droop and weakness of her left arm and leg. ct head was unremarkable. neurology was consulted and felt uncomfortable giving iv tpa due to her recent colonoscopy with subsequent black stools. she was therefore transferred to for further evaluation and possible interventional procedure. upon arrival to our ed a code stroke was called. initial nihss was 7 with exam significant for left facial droop, mild dysarthria, 3-4/5 weakness in l arm and leg, decreased sensation to pinprick over l hemibody, and extinction on dss on l. ct head was negative for acute process or signs of ischemia. cta showed acute occlusive thrombus of r distal m1. ctp showed increased mtt, decreased cbf/cbv in r mca distribution. upon further history the patient reports that she began having bloody stool immediately after the colonoscopy on during which polyps were removed. by the next day her stools were black and this continued until yesterday, when she went back to the hospital and had some blood drawn (her daughter thinks to check her inr and blood count). she was told that these results were normal. today her stool appeared more brown but was hemoccult positive in the ed. of note she stopped taking coumadin on prior to the procedure and has not yet restarted it. she otherwise reports feeling well. denies any prior strokes or tia's. denies any recent headaches, changes in vision, lightheadedness, numbness/tingling, difficulty walking. on general review of systems, the pt denies recent fever or chills. +chronic cough and sob related to copd. no chest pain. denies nausea, vomiting, +recent loose black stools since colonoscopy on . given the risk of gi bleed and the overall relatively mild severity of her deficits, tpa was not given. she was also not an appropriate candidate for neurointervention given the overall risks vs. benefits in the setting of her multiple comorbidities and mild and improving deficits. during her ed course her left sided weakness transiently worsened with a drop in her bp to 110-120 systolic. she was started on phenylephrine with increase in bp to 130's with improvement in her exam. given this the decision was made to manage her medically with close observation in the icu with a goal sbp of 140-150. she was given aspirin 300mg pr in the ed. past medical history: htn hl hypertrophic cardiomyopathy - on coumadin and s/p pm/icd mi x 3, no intervention chf copd small bowel mass - recently biopsied, told was benign arthritis social history: lives at home with sister. daughter and live in the area. previously worked in a mill doing stitching. prior smoking history, quit in . no etoh or illicit drug use. family history: mother had a stroke in her 70's, died of complications of father died at age of chf, renal failure sister healthy physical exam: physical exam on admission: vitals: t 97.8 hr 72 bp 125/46 rr 12 o2 99% 3l general: awake, cooperative, nad. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple pulmonary: +wheezes and rhonchi b/l cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd extremities: trace le edema b/l skin: no rashes or lesions noted neurologic: -mental status: alert, oriented to self, says at hospital, knows month and year. able to relate history without difficulty. speech is mildly dysarthric. language is fluent with intact repetition and comprehension. there were no paraphasic errors. pt was able to name both high and low frequency objects. able to follow both midline and appendicular commands. there was some evidence of mild left-sided neglect. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. vff to confrontation. iii, iv, vi: r gaze preference but able to cross midline easily. eomi without nystagmus. v: facial sensation intact to light touch. vii: l lower facial droop viii: hearing intact to voice bilaterally. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: normal bulk, tone throughout. no adventitious movements, such as tremor, noted. delt bic tri wre ffl fe ip quad ham ta l 3 4+ 4+ 4 4+ 3 4+ 5 4+ 5- 5 5- r 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: reports decreased sensation to pinprick over r face, arm, and leg. +extinction to dss on l. -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was flexor on r, extensor on l. -coordination: fnf intact on r without dysmetria. some difficulty performing on l weakness but no obvious dysmetria. -gait: deferred ============================================ pertinent results: 11:50pm pt-10.7 ptt-24.6* inr(pt)-1.0 11:50pm plt count-200 11:50pm neuts-70.7* lymphs-22.2 monos-5.7 eos-1.0 basos-0.4 11:50pm wbc-7.5 rbc-3.63* hgb-10.1* hct-30.8* mcv-85 mch-27.7 mchc-32.7 rdw-14.1 11:50pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 11:50pm urine hours-random 11:50pm estgfr-using this 11:50pm glucose-144* urea n-30* creat-0.6 sodium-141 potassium-4.0 chloride-104 total co2-24 anion gap-17 03:42am pt-10.8 ptt-25.5 inr(pt)-1.0 03:42am plt count-264 03:42am wbc-11.7*# rbc-3.73* hgb-10.3* hct-31.6* mcv-85 mch-27.5 mchc-32.5 rdw-14.1 03:42am triglycer-149 hdl chol-40 chol/hdl-4.5 ldl(calc)-108 03:42am %hba1c-5.9 eag-123 03:42am albumin-4.2 calcium-9.2 phosphate-3.0 magnesium-1.9 cholest-178 03:42am ck-mb-4 ctropnt-<0.01 03:42am alt(sgpt)-27 ast(sgot)-24 ld(ldh)-239 alk phos-76 tot bili-0.4 03:42am glucose-181* urea n-25* creat-0.6 sodium-143 potassium-4.1 chloride-109* total co2-23 anion gap-15 01:07pm hct-30.1* 04:47pm hct-29.7* 07:59pm ptt-26.0 07:59pm hct-29.2* ct/cta/ctp : plain ct: no intracranial hemorrhage 1. apparent embolus with severe narrowing of the distal right m1 segment, just at the mca bifurcation with associated decreased blood flow, blood volume and increased mean transit time. note is made that the periphery of this region demonstrates decreased blood flow but normal blood volume which may represent a mismatch. findings likely represent right mca territory ischemia/infarction with no hemorrhagic transformation. followup is recommended to assess evolution. 2. prominent pulmonary artery measuring up to 3.6 cm suggesting pulmonary hypertension. 3. cta of the neck demonstrates mild right ica atheromatous disease with no evidence of stenosis or occlusion. echo : impression: suboptimal image quality. moderate left ventricular regional dysfunction c/w cad. apical aneurysm. non-diagnostic study for evaluation of interatrial shunt with bubble study (poor image quality). ct head : impression: acute right mca infarction. no hemorrhage. ct abd/pelvis : 1. no evidence of retroperitoneal bleed. 2. small right and trace left pleural effusion. 3. lipoma along the left flank. brief hospital course: ms. is a 66 year-old r-handed woman with a history of hypertension, hyperlipidemia, hypertrophic cardiomyopathy s/p pm/icd on coumadin, chf, copd. she had been off of coumadin due to a small bowel mass requiring recent biopsy as well as colonoscopy with polypectomy . she presented on to with acute onset l sided weakness (face/arm/leg) and was subsequently transferred to . hospital course # neuro: on arrival, nihss was 7 with exam notable for left facial droop, mild dysarthria, 3-4/5 weakness in l arm and leg, decreased sensation to pinprick over l hemibody, and extinction on dss on l. ct head was negative for acute process or signs of ischemia. cta showed acute occlusive thrombus of r distal m1. ctp showed increased mtt, decreased cbf/cbv in r mca distribution. tpa was not given due to high risk of gi bleed and she was not felt to be a candidate for neurointervention. exam fluctuated somewhat with bp in ed so she was started on a phenylephrine drip with goal sbp 140-150. she was started on aspirin 300mg pr daily. she will be admitted to the neuro icu for close monitoring of her exam and bp. given the initial improvement in her exam, she was kept in a state of augmented blood pressures with neosynephrine with goal bp 140-180. despite the risks posed by anticoagulation (from a gi blood loss ) she was also started on heparin gtt with a goal ptt of 40-60. despite these measures, her initial improvements were not sustained and her strength deteriorated to a dense left sided hemiplegia. a repeat nchct did not show hemorrhagic conversion. over the course of the next 24hrs, her exam did not improve and. she was assumed to have completed her infarct and her pressors were stopped. her heparin was continued given the concern for apical akinesis and the possibility of local thrombus. on she was noted to have a drop in her hct which did not bump appropriately to prbc tx and her heparin gtt was switched to asa 325mg. she subsequently remained hemodynamically stable (see gi below). neurologically, she has had little improvement in her symptoms. at the time of discharge, she had a dense left hemiparesis. # gi: the patient initially had epigastric and ruq pain for about 1 year, especially some hours after eating. no black or bloody stools at that time. for work-up, an endoscopy and colonoscopy was performed on at . a mass in the small intestine as well as polyps in the course of the colonoscopy. she stopped taking coumadin on prior to the gi procedures and didn't take it after them because she developed having black and tarry stool after the procedures. she went back to the hospital to have this checked, lab results "were told to be normal", but an appointment with dr. for reevaluation of the small intestine mass with eus at the was scheduled for . gi service was consulted from the start and they recommended to go ahead with anticoagulation. she was initially started on a heparin drip but this was stopped due to hemorrhage. her hematocrit dropped from 30 to a low of 22. heparin was discontinued and she was switched to asa as her hematocrit improved. gi recommended that the patient undergo the previously planned eus as well as egd to further evaluate possible sources of bleeding, but the patient did not want to undergo any additional gi proceedures in the current setting and preferred to wait until her stroke issues were stable. she was maintained on a bowel regimen but will need to work on promoting bowel regularity, as she has not had a bowel movement in several days. # cv: on pressors as above. tte revealed depressed ef with lv apical akinesis without clear evidence of thrombus. per her outpatient cardiologist ( ), she also has a history of paroxysmal atrial fibrillation. given the mutiple cardiac risk factors for stroke, it was recommended that anticoagulation be restarted. given that her hct had been stable for several days, we planned on initating coumadin on . # heme: initially, her downtrending hct this admission was thought to be secondary to recent endoscopy/colonoscopy, + dilution, + blood loss from hospitalization/picc line placement. however when she failed to respond to blood tx, a gi blood loss source was suspected and heparin was stopped. she will need close monitoring of her stools and hct for evidence of bleeding. # copd: on admission had significant wheezing and sob, was given high dose steroids in the ed and respiratory status improved markedly as she remained on 2l nc for the next several days. however, she also received several liters of fluid during the first days of her admission and had evidence of pulmonary edema on cxr. she recieved one dose of furosemide 20mg iv and was also treated with albuterol and ipratropium nebs. respiratory status improved with these measures and she continued to remain stable in this regards throughout the rest of her hospitalization. # fen: she was cleared for a ground dysphagia diet with thin liquids. she requires 1:1 assistance while eating. aha/asa core measures for ischemic stroke and tia 1. dysphagia screening before any po intake? (x) yes () no 2. dvt prophylaxis administered? (x) yes - () no 3. antithrombotic therapy administered by end of hospital day 2? (x) yes - () no 4. ldl documented? (x) yes (ldl = 108 ) () no 5. intensive statin therapy administered? (for ldl > 100) (x) yes - () no (if ldl >100, reason not given: ) 6. smoking cessation counseling given? () yes - () no (reason (x) non-smoker - () unable to participate) 7. stroke education given? (x) yes - () no 8. assessment for rehabilitation? (x) yes - () no 9. discharged on statin therapy? (x) yes - () no (if ldl >100, reason not given: ) 10. discharged on antithrombotic therapy? (x) yes (type: () antiplatelet - (x) anticoagulation) - () no 11. discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) yes - () no - () n/a transitional care issues: - initiating coumadin and inr monitoring - monitoring for hemorrhage/gi bleed - follow-up with both gi and neurology on . medications on admission: amitriptyline 10mg qhs atorvastatin 40mg daily beclomethasone 2 puffs diltiazem 180mg xl daily lasix 40mg daily metoprolol 50mg q6hrs salmeterol 50mg warfarin 5.5-7.5mg daily depending on inr --> held since discharge medications: 1. furosemide 40 mg po daily 2. warfarin 5 mg po days (,mo,tu,we,th,fr,sa) please follow up inr and hematocrit closely. aim for inr . 3. acetaminophen 650 mg po q6h:prn pain/fever do not exceed 4gm qd 4. amitriptyline 10 mg po hs 5. atorvastatin 40 mg po daily 6. diltiazem extended-release 180 mg po daily htn hold for sbp < 100, hr < 55 7. docusate sodium 100 mg po bid hold if loose stools 8. metoprolol tartrate 12.5 mg po tid hold for sbp < 95, hr < 55 9. pantoprazole 40 mg po q24h 10. polyethylene glycol 17 g po daily hold if loose stools 11. qvar *nf* (beclomethasone dipropionate) 2 puffs inhalation reason for ordering: wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 12. salmeterol xinafoate diskus (50 mcg) 1 inh ih q12h 13. senna 1 tab po bid hold if loose stools discharge disposition: extended care facility: in discharge diagnosis: primary diagnosis: acute ischemic stroke secondary diagnosis: gi bleed discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. neurologic exam: dense left hemiparesis. discharge instructions: dear ms , you were hospitalized due to symptoms of left sided weakness resulting from an acute ischemic stroke, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. the brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. in order to prevent future strokes, we plan to modify those risk factors. while in the icu, you began bleeding from your gastrointestinal system. given your recent colonoscopy with polypectomy, it is likely that you were bleeding from these sites. you required some blood; however, your bleeding stopped and your blood level went back to your normal level. given your heart history, it is very important that you restart coumadin. however, there is a risk of bleeding while on this medication. the gastroenterologists offered an endoscopy with ultrasound to evaluate for bleeding; however, you did not want this study done. it is very important that you look for signs of bleeding from your gastrointestinal system. these include blood in your stools, dark tarry or black stools, bleeding through your mouth, or vomiting of blood. please make your doctor aware if you experience any of these symptoms. we are changing your medications as follows: 1.please take metoprolol 12.5mg three times a day instead of 25mg every 6 hours. 2. please take pantoprazole 40mg daily please take your other medications as prescribed. please followup with neurology and your primary care physician as listed below. if you experience any of the symptoms below, please seek medical attention. in particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake it was a pleasure providing you with care during this hospitalization. followup instructions: department: gastroenterology when: tuesday at 2:20 pm with: , md building: ra (/ complex) campus: east best parking: main garage department: neurology when: tuesday at 4:30 pm with: , md, phd building: sc clinical ctr campus: east best parking: garage md, Procedure: Arterial catheterization Central venous catheter placement with guidance Diagnoses: Other chronic pain Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Hypotension, unspecified Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Old myocardial infarction Long-term (current) use of anticoagulants Automatic implantable cardiac defibrillator in situ Dysarthria Backache, unspecified Arthropathy, unspecified, site unspecified Cerebral thrombosis with cerebral infarction Facial weakness Other specified hemiplegia and hemiparesis affecting nondominant side Other hypertrophic cardiomyopathy |
allergies: no known allergies / adverse drug reactions attending: chief complaint: ascending aortic aneurysm, bicuspid aortic valve major surgical or invasive procedure: bental(27mm /28mm gelweave graft) history of present illness: this 59 year old male with a known ascending aneruysm for at least 7 years, followed by serial echocardiograms. his last echo revealed a 5cm dilated root with a probable bicuspid valve and moderate aortic insufficiency. he had a negative stress echo and catheterization revealed no significant coronary disease. he was admitted for elective surgery. past medical history: thoracic ascending aneurysm depression vertigo paroxysmal atrial fibrillation social history: self employed/actor 20pk year history, stopped bottle of wine /week demntal exam <6 months family history: father had aneurysm sx in his 80s(? type) physical exam: hr 54 bp 122/75 rr 18 sat 99% physical exam- general: wdwn in nad cardiac: rrr with quiet diastolic murmur chest: lungs clear bilateral abdomen: soft nontender nondistended extremities: warm well perfused edema: none pertinent results: day of surgery: 05:19pm blood wbc-12.3*# rbc-2.86*# hgb-9.1*# hct-25.5*# mcv-89 mch-31.8 mchc-35.6* rdw-12.9 plt ct-132* 05:19pm blood pt-15.3* ptt-33.8 inr(pt)-1.3* 05:19pm blood fibrino-167 10:16pm blood urean-13 creat-1.1 na-145 k-4.0 cl-106 hco3-28 angap-15 day of discharge: 04:45am blood wbc-9.5 rbc-4.15* hgb-12.4* hct-36.5* mcv-88 mch-29.8 mchc-33.9 rdw-13.8 plt ct-199 04:45am blood plt ct-199 04:45am blood glucose-117* urean-47* creat-1.2 na-137 k-4.1 cl-102 hco3-23 angap-16 radiology report chest (pa & lat) study date of 2:25 pm chest two views on findings: the right ij line has been removed. there is dense retrocardiac opacification consistent with volume loss/infiltrate. there is also small left effusion, small right effusion. the upper lungs are clear. compared to the study from three days ago the lung aeration is improved. dr. echocardiography report echocardiographic measurements results measurements normal range left ventricle - ejection fraction: 55% to 65% >= 55% aorta - ascending: *4.9 cm <= 3.4 cm aortic valve - lvot diam: 2.2 cm findings left atrium: normal la size. good (>20 cm/s) laa ejection velocity. no thrombus in the laa. right atrium/interatrial septum: normal ra size. left ventricle: normal lv wall thickness. normal lv cavity size. right ventricle: normal rv chamber size and free wall motion. aorta: mildy dilated aortic root. moderately dilated ascending aorta mildly dilated aortic arch. normal descending aorta diameter. aortic valve: bicuspid aortic valve. no as. moderate to severe (3+) ar. mitral valve: normal mitral valve leaflets with trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. the patient received antibiotic prophylaxis. the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope. no tee related complications. patient. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions pre-cpb: 1. the left atrium is normal in size. no thrombus is seen in the left atrial appendage. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. 3. right ventricular chamber size and free wall motion are normal. 4. the aortic root is mildly dilated at the sinus level. the ascending aorta is moderately dilated. the aortic arch is mildly dilated. 5. the aortic valve is bicuspid. there is no aortic valve stenosis. moderate to severe (3+) aortic regurgitation is seen. 6. the mitral valve appears structurally normal with trivial mitral regurgitation. 7. there is no pericardial effusion. dr. was notified in person of the results. post-cpb: on infusion of nitroglycerine, av pacing for slow sr with 1 degree av block. pt placed on cpb x 3 for bleeding, dehiscence of aortic valve. well-seated bioprosthetic valve in the aortic position. trace ai. trivial systolic gradient with co= 5 l/min. small pericardial efusion. aortic contour in the descending arch is normal post decannulation. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 21:38 brief hospital course: this patient is a same day admission, he was taken to the operating room where a bental procedure was performed. the valve was indeed bicuspid. at the end of the case he had significant bleeding from the right coronary button which required reopening of the chest, the bleeding was then controlled surgically. he required multiple blood products to correct a coagulopathy but stabilized and was brought to the cardiac surgery icu in stable condition. he was relatively hypoxic post-operatively likely from the volume of blood products he received. he was kept sedated and aggressively diuresed over the next several days. he awoke neurologically intact but cognitively slowed, he was weaned from the ventilator and extubated on pod 3. he continued to be diuresed, beta blockade was begun and he was seen by physical therapy to assist with mobility and endurance. he remained in the icu to monitor his pulmonary status. all tubes, lines and drains were removed per cardiac surgery protocols. on pod5 he transferred to the step down floor. over the next several days he worked with physical therapy and nursing to improve his conditioning and allow his cognitive status to improve. by pod8 he was ready for discharge home with a visiting nurse. followup in 1 week for wound check and 4 weeks with dr medications on admission: medications - prescription bupropion hcl - (prescribed by other provider) - 150 mg tablet sustained release - 1 tablet(s) by mouth once a day escitalopram - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth once a day discharge medications: 1. escitalopram 20 mg tablet sig: one (1) tablet po once a day. 2. bupropion hcl 150 mg tablet extended release sig: one (1) tablet extended release po qam (once a day (in the morning)). 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for temperature >38.0. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 5. tramadol 50 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*40 tablet(s)* refills:*0* 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 7. ibuprofen 600 mg tablet sig: one (1) tablet po every eight (8) hours as needed for pain. disp:*60 tablet(s)* refills:*1* 8. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 10. furosemide 40 mg tablet sig: one (1) tablet po daily (daily) for 2 weeks. disp:*14 tablet(s)* refills:*0* 11. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po daily (daily) for 2 weeks. disp:*28 tablet extended release(s)* refills:*0* 12. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: homehealth visiting nurses discharge diagnosis: ascending thoracic aortic aneurysm paroxysmal atrial fibrillation depression vertigo s/p bental procedure s/p bilateral knee arthroscopies discharge condition: alert and oriented x3, nonfocal ambulating with steady gait incisional pain managed with ultram/ibuprophen incisions: sternal - healing well, no erythema or drainage edema -trace pedal edema bilaterally discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for one month or while taking narcotics. driving will be discussed at follow up appointment with surgeon. no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. () on at 1:45pm cardiologist: dr. on at 2:40pm wound check @10am phone please call to schedule appointments with your primary care dr. . (in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Resection of vessel with replacement, thoracic vessels Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Thoracic aneurysm without mention of rupture Atrial fibrillation Aortic valve disorders Depressive disorder, not elsewhere classified Hemorrhage complicating a procedure Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Congenital insufficiency of aortic valve Other and unspecified coagulation defects Other fluid overload Other vitreous opacities |
allergies: patient recorded as having no known allergies to drugs attending: addendum: exam upon discharge: slight weakness right deltoid but limited due to neck/incisional pain, staples clean, dry, intact, motor otherwise full discharge disposition: home md Procedure: Imageless computer assisted surgery Excision or destruction of lesion of spinal cord or spinal meninges Diagnoses: Unspecified acquired hypothyroidism Depressive disorder, not elsewhere classified Myalgia and myositis, unspecified Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Myelopathy in other diseases classified elsewhere Other musculoskeletal symptoms referable to limbs Benign neoplasm of spinal meninges |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: right arm pain major surgical or invasive procedure: laminectomy with excision t1 mass with intra-operative monitoring history of present illness: hpi: patient is a 53 year old rhw with hx of fibromyalgia,hypothyroidism and depression here with several months r arm numbness found to have large spinal mass near t1 at an outside imaging facility.patient reports that she developed tightness sensation that radiated down from her neck to r arm more medially since . she describes that it felt like a bp cuff tightening her arm which loosened within seconds followed by some tingling sensation. this was intermittent and possibly more intense 3 months ago when it started than now. she then felt that she has been getting weaker on her r arm. although she can't describe any specific things that she is no longer able to do, she feels that she has been using her l hand more because she is weaker on her r arm than l.she denies any trauma or injury. upon more probing, she feels that her husband noticed that she occasionally wobbled while walking. possibly more to the r but no falls or brushing against the wall. she denies any numbness or weakness in her legs. she does have hx of headaches/migraines and is on imitrex as needed.she feels that she may have been getting more frequent headaches than before but no nausea/vomiting or visual problems. she was diagnosed with fibromyalgia 3~4 years ago after complaining of severe hand pain especially in her thumbs. she also had some leg throbbing that improved with starting cymbalta for her "fibromyalgia." she was on 60 mg until several months ago but then she developed some trouble going to the bathroom. she felt that she had trouble initiating urination and her pcp decreased the dose to 30 mg without too much relief. she denies any accidents or abnormal perivaginal sensation but she still feels that she has hesitancy before urination. no problems with bowel including constipation. ros otherwise negative including fever, night sweats or significant weight loss. she reports possible 15 lb weight gain over the past year or so. of note, she does report mild numbness of the tongue as if she receive novocaine for the past few days. past medical history: pmhx: 1. fibromyalgia 2. depression 3. hypothyroidism 4. migraine 5. hx of diverticulitis social history: social hx: lives at home with daughter and husband. for stop and shop - real estate. denies any smoking or drugs. occasional wine. full code and no hcp. family history: family hx: father died of lung cancer at age 81 and was a smoker.mother died of stomach disease (?) at age 76 and was also a smoker. son died of melanoma at age 21. physical exam: physical exam: o: t: 98.2 bp: 108/71 hr: 79 r: 20 o2sats: 100% ra gen: wd/wn, comfortable, nad. neck: supple. lungs: clear cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. attentive and no apraxia. motor: no pronator drift but does have curling in of r fingers. d b t we fe ip q h at g r 4 4 4 5 4 4 5 5 5 5 5 l 5 5 5 5 5 5 5 5 5 5 5 sensation: intact to light touch, cold, proprioception, pinprick bilaterally. sensory level found posteriorly right below the scapula around t6 to pp but less clear anteriorly. reflexes: b t br pa ac right 2 2 2 2 1 left 2 2 2 2 0 no clonus. toe down on r but mute on l. gait: steady and good initiation. able to tandem but positive romberg. exam upon discharge: xxxxxxx pertinent results: mri from shields was uploaded and reveals a large extra-axial,enhancing mass effacing the cord around t1. it has broad dural base and seems most likely meningioma. brief hospital course: patient was admitted to neurosurgery and started on decadron. she had work up including brain mri which was negative. her motor exam improved on steroids. she was readied for the or. on she underwent a t1 excsion intrdural mass, without complications. the frozen pathology showed meningioma she had a post operative mri which showied complete resection of the meningioma. she was monitored overnight in the pacu and was transferred to the floor on . her steroids were weaned, pt and ot consults were obtained and recommended discharge to home with outpatient pt. diet and activity were advanced. she required titration of pain medication and soft collar was added for comfort. post op mri showed no residual mass. wound was clean and dry with staples. medications on admission: 1. synthroid 50mcg daily 2. cymbalta 30 mg daily 3. wellbutrin 150mg 4. imitrex prn discharge medications: 1. bupropion hcl 75 mg tablet sig: two (2) tablet po bid (2 times a day). 2. duloxetine 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): take while on narcotic. disp:*60 capsule(s)* refills:*0* 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for t>100.4 or pain. 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for no bm>48hr. 7. hydromorphone 2 mg tablet sig: 1-3 tablets po q3h (every 3 hours) as needed for pain. disp:*90 tablet(s)* refills:*0* 8. gabapentin 300 mg capsule sig: two (2) capsule po bid (2 times a day) for 10 days: then dc. disp:*40 capsule(s)* refills:*0* 9. diazepam 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for neck spasm. disp:*40 tablet(s)* refills:*0* 10. outpatient physical therapy s/p laminectomy t1 with excision mass for right arm weakness/pain discharge disposition: home discharge diagnosis: t1 mass discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ?????? do not smoke ?????? keep wound clean / no tub baths or pools until seen in follow up/ take daily showers ?????? no pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? limit your use of stairs to 2-3 times per day ?????? have a family member check your incision daily for signs of infection ?????? take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation followup instructions: please return to the office on friday for removal of your staples. call to schedule time . please call to schedule an appointment with dr. to be seen in 6 weeks. you will not need xrays prior to your appointment Procedure: Imageless computer assisted surgery Excision or destruction of lesion of spinal cord or spinal meninges Diagnoses: Unspecified acquired hypothyroidism Depressive disorder, not elsewhere classified Myalgia and myositis, unspecified Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Myelopathy in other diseases classified elsewhere Other musculoskeletal symptoms referable to limbs Benign neoplasm of spinal meninges |
allergies: patient recorded as having no known allergies to drugs attending: addendum: the patient's discharge was held until due to a drop in hematocrit. this was repeatewd and rose to 25.6. the creatinine fell to 1.3 the day of discharge. discharge disposition: extended care facility: - md Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Diagnostic ultrasound of heart Diagnoses: Sciatica Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Acute kidney failure, unspecified Cardiac complications, not elsewhere classified Atrial fibrillation Depressive disorder, not elsewhere classified Atrial flutter Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Long-term (current) use of insulin Unspecified hearing loss Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Other psoriasis Chronic total occlusion of coronary artery Urinary obstruction, unspecified Urge incontinence |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: - cardiac catheterization - urgent coronary artery bypass graft x4, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal obtuse marginal and posterior descending arteries. history of present illness: pleasant 66 yo gentleman with history of hypertension, reflux, hyperlipidemia who presents from stress lab after having st depressions and evidence of myocardial stunning on imaging. patient states that he consistently has substernal, left sided non-radiating chest pain with exertion, which is predicable, relieved with rest, not associated with nausea, vomiting or diaphoresis and at worst is . he would occasionally have episodes of heavy breathing when this occurred. he states this has been going on for several months, however last weekend he was awakened by the pain at night. at that time, it took several hours for the pain to go away, however pt thought it may just be indigestion and waited for it to resolve. he later presented to his pcp who referred him for stress testing. cardiac surgery was consulted for revascularization. past medical history: hypertension hyperlipidemia diabetes mellitus gastroesophageal reflux disease tenosynovitis obstructive uropathy, urge incontinence gi bleed d/t gastric ulcer colonic adenoma s/p polypectomy adhd psoriasis hearing loss depression with h/o lithium toxicity-- misses work weekly chronic low back pain/sciatica muscle cramps social history: denies etoh, tobacco, illicits. lives alone in , has a friend that lives upstairs from him. he works as a health inspector. family history: mother with hx of stroke, died of "old age". father died in his 40s of unknown causes. physical exam: on admission: vs - 140/75 97.4 63 14 97% ra gen: wdwn middle aged male in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 5 cm. cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. small errythematous plaques on forehead, scalp . pulses: right: dp 2+ pt 2+ left: 2+ dp 2+ pt 2+ pertinent results: cardiac cath : lm:30% prox lad:70% tubular prox 99%, mod sized d1 with total occlusion of lower pole branch lcx:50% prox, 60% mid, and 50% diffuse om1 rca:100% mid, distal vessel fills via l-r collaterals . carotid us : right ica stenosis 60-69% left ica stenosis <40%. . echo : prebypass: no atrial septal defect is seen by 2d or color doppler. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. dr. was notified in person of the results on at 1330pm. post bypass: patient is av paced and receiving an infusion of phenylephrine. biventricular systolic function is unchanged. aorta is intact post decannulation. mild mitral regurgitation present. 09:40am blood wbc-5.4 rbc-2.71* hgb-8.6* hct-24.4* mcv-90 mch-31.6 mchc-35.0 rdw-13.7 plt ct-143* 07:10pm blood wbc-5.7 rbc-4.47* hgb-14.1 hct-41.5 mcv-93 mch-31.5 mchc-33.9 rdw-14.1 plt ct-178 04:50am blood pt-13.8* ptt-31.0 inr(pt)-1.2* 11:30am blood pt-13.3 ptt-30.1 inr(pt)-1.1 09:40am blood glucose-234* urean-31* creat-1.5* na-132* k-4.2 cl-97 hco3-30 angap-9 07:10pm blood glucose-140* urean-35* creat-1.4* na-139 k-4.8 cl-102 hco3-29 angap-13 brief hospital course: mr. was admitted to the on for further management of his chest pain. he underwent a cardiac catheterization which revealed severe three vessel disease. given the severity of his disease, the cardiac surgery service was consulted. mr. was worked-up in the usual preoperative manner including a carotid ultrasound which showed moderate right internal carotid artery stenosis. as he had a mild elevation in his creatinine following the cardiac catheterization, his renal function was allowed to normalize prior to surgery. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. over the next 24 hours, mr. neurologically intact and was extubated. beta blockade, statin and aspirin were resumed. later on postoperative day one, he was transferred to the step down unit for further recovery. he was gently diuresed towards his preoperative weight. chest tubes and epicardial pacing wires were removed per protocol. mr. had a brief bout of afib lasting less than 24hrs and was placed on amiodarone. the physical therapy service was consulted for assistance with his postoperative strength and mobility. mr. continued to make steady progress and was discharged to on postoperative day #6. he will follow-up with dr. and his primary care physician as an outpatient. his primary care physician will refer him to a local cardiologist for continued care. his anticipated length of stay at rehab will be less than 30days. medications on admission: flomax 0.4 er q day metoprolol sr 100 q 24 ketoconazole topical metformin 1000 vesicare 5 mg lantus 50 u q day lisinopril 40 mg q day omeprazole 20 mg amlodipine 5 mg q day lorazepam 2 mg crestor 5 mg q hs aspirin 81 mg concerta 10 mg daily discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po daily (daily) as needed for constipation. 5. rosuvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 8. lorazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 9. concerta 54 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po daily (). 10. vesicare 5 mg tablet sig: one (1) tablet po daily (). 11. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days. 12. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po tid (3 times a day). 13. lantus 100 unit/ml solution sig: thirty (30) units subcutaneous qam. 14. humalog sliding scale humalog based on fingertsick qid 15. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day). 16. lantus 100 unit/ml cartridge sig: 50 units subcutaneous qpm. discharge disposition: extended care facility: - discharge diagnosis: coronary artery disease s/p cabgx4 past medical history: hypertension hyperlipidemia diabetes mellitus gastroesophageal reflux disease tenosynovitis obstructive uropathy, urge incontinence gi bleed d/t gastric ulcer colonic adenoma s/p polypectomy adhd psoriasis hearing loss depression with h/o lithium toxicity-- misses work weekly chronic low back pain/sciatica muscle cramps discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesic incisions: sternal - healing well, no erythema or drainage leg left - healing well, no erythema or drainage. edema -trace pedal edema discharge instructions: 1) please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage 2) please no lotions, cream, powder, or ointments to incisions 3) each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) no driving for approximately one month until follow up with surgeon 5) no lifting more than 10 pounds for 10 weeks 6) please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. wednesday 1:45pm ( please call to schedule appointments with your primary care dr. in weeks cardiologist in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Diagnostic ultrasound of heart Diagnoses: Sciatica Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Acute kidney failure, unspecified Cardiac complications, not elsewhere classified Atrial fibrillation Depressive disorder, not elsewhere classified Atrial flutter Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Long-term (current) use of insulin Unspecified hearing loss Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Other psoriasis Chronic total occlusion of coronary artery Urinary obstruction, unspecified Urge incontinence |
allergies: no known allergies / adverse drug reactions attending: chief complaint: gi bleed major surgical or invasive procedure: egd- ulcers endoclipped and injected with epinephrine/cauterized. history of present illness: patient is a 57yo female with past medical history of duodenal ulcer who presents with three days of dark stools. . she was in her usual state of health until about 1 week ago, when she experienced some lower back pain. she saw her pcp and was prescribed a pain medication but is unable to recall which one. she took two tablets of the pain meds 1 week ago and her pain resolved. she was doing well until wednesday, when she noticed dark-colored stool. she denies any hematochezia, pain on wipping bottom, nausea, vomiting or changes in bowel movement or appetite. last night, she developed a dull, non-radiating abdominal pain in her midepigastric region that she rated at a 5 out of 10. she reports taking 100mg cefixime. her pain resolved today. she denies fevers, chest pain or sob but reports chills and generalized weakness. she was seen by her pcp this morning and was sent to the ed with increasing complaints of fatigue. . on arrival to the ed, vital signs were t- 98.1, rr- 89, bp- 129/46, rr- 16, sao2- 100% on ra. labs pertinent for an hct of 22, normal coag panel and potassium of 3.2. she underwent an ng lavage which did not clear after 500cc flush. she continued to have dark red blood with some coffee grounds in the ng tube. gi was consulted and plan on egd tonight. patient is being admitted to the micu for further monitoring. . on arrival to the micu, vital signs were t- 98.3, hr- 82, bp- 114/62, rr- 19, sao2- 97% on ra. the patient was comfortable and denied any acute complaints. past medical history: 1. duodenal ulcer- 20yrs ago 2. osteopenia social history: denies tobacco, drug use. family history: denies gi cancers or ulcers physical exam: vitals: t- 98.3, hr- 82, bp- 114/62, rr- 19, sao2- 97% on ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear 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: foley in place rectal: (per ed)- rectal exam had dark stools no hemorrhoids or masses noted ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: 02:35pm blood wbc-5.4 rbc-2.60* hgb-7.8* hct-22.0* mcv-85 mch-30.0 mchc-35.5* rdw-13.3 plt ct-256 07:44pm blood wbc-5.5 rbc-2.45* hgb-7.4* hct-20.8* mcv-85 mch-30.2 mchc-35.5* rdw-13.5 plt ct-258 02:34am blood hct-25.2* 07:03am blood wbc-9.2# rbc-3.27*# hgb-10.0*# hct-28.2* mcv-86 mch-30.4 mchc-35.3* rdw-13.9 plt ct-187 02:35pm blood pt-13.5* ptt-22.4 inr(pt)-1.2* 02:35pm blood glucose-111* urean-16 creat-0.6 na-139 k-3.2* cl-105 hco3-24 angap-13 07:44pm blood glucose-105* urean-14 creat-0.5 na-143 k-3.5 cl-112* hco3-20* angap-15 07:03am blood glucose-80 urean-8 creat-0.5 na-142 k-5.0 cl-113* hco3-24 angap-10 07:44pm blood calcium-7.8* phos-1.8* mg-2.2 07:03am blood calcium-7.4* phos-2.0* mg-2.2 brief hospital course: 1. gi bleed- the patient has history of duodenal ulcer, which was thought to be likely etiology of the bleed. she was found to have a positive ng lavage that did not clear in the ed after 500cc. gi recommended micu admission with plans to scope on arrival to the icu given active bleed and history of ulcer. she was started on ppi (bolus and 8mg/hr gtt). she underwent egd on , which demonstrated blood in the lower of the esophagus. coffee ground material with some blood noted in stomach body and fundus with a few ulcers ranging from 4mm to 8mm in size in the antrum. two 6-8mm ulcers were seen in the angularis; an endoclip was placed in one and the other was injected with 6cc epinephrine with success. it was then cauterized. patient did well overnight, had no acute complaints, and remained hemodynamically stable. post transfusion hct 25.4 (from 20.8) and am hct up to 28.2, but then down trending the day after egd (). her hct dropped to 23.5, she was given 1 additional unit of blood. the patient was taken back for repeat egd where oozing was found around the endoclip. there was no evidence of active bleeding. she was transitioned to ppi gtt on and kept npo overnight. gi recommended the patient remain on a ppi gtt for 72 hours. she was monitored overnight and her diet was regular. she was discharged on ppi and will follow-up with gi on. 2. osteopenia- continue home calcium, asked pt to hold fosamax until gi clears her to restart. 3. back pain- consistent with pain prior to admission. no neurologic signs. she responded well to prn acetaminophen. transitional issues: pt needs follow up h pylori eradication test in 3 months, which could be stool or breath test medications on admission: 1. fosamax 2. calcium discharge medications: calcium 500 mg tablet sig: one (1) tablet po once a day. clarithromycin 500 mg tablet sig: one (1) tablet po twice a day for 11 days. disp:*22 tablet(s)* refills:*0* amoxicillin 500 mg tablet sig: two (2) tablet po twice a day for 11 days. disp:*44 tablet(s)* refills:*0* pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: peptic ulcer disease acute blood loss anemia from upper gi bleed discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with a bleeding from an ulcer in your small intestine. you underwent a procedure called an egd, which demonstrated ulcers in your stomach and small intestine. these was treated and the bleeding stopped. you remained stable and did not have any further bloody bowel movements while here. we found that you have an infection in your stomach that can cause these ulcers. we are treating this infection with antibiotics. the following changes were made to your medications: 1. start taking pantoprazole 40mg by mouth twice daily 2. please do not take ibuprofen 3. start amoxicillin 1000 mg twice a day for 11 more days 4. start clarithromycin 500 mg twice a day for 11 more days if you develop another gi bleed or any other symptoms that concern you, please call your doctor or come to the emergency department immediately. followup instructions: name: , location: address: , , phone: appt: at 1pm department: digestive disease center when: friday at 1:30 pm building: building (/ complex) campus: east best parking: main garage department: endo suites when: friday at 1:30 pm Procedure: Endoscopic control of gastric or duodenal bleeding Endoscopic control of gastric or duodenal bleeding Diagnoses: Acidosis Acute posthemorrhagic anemia Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Backache, unspecified Helicobacter pylori [H. pylori] Disorder of bone and cartilage, unspecified Hypoglycemia, unspecified |
allergies: erythromycin base attending: chief complaint: mitral regurgitation major surgical or invasive procedure: mitral valve replacement (25mm st. mechanical) via right thoracotomy closed right thoracostomy history of present illness: this is a 76 year old female with history of rheumatic heart disease. she is s/p aortic valve replacement in . recent echocardiogram revealed moderate to severe mitral regurgitation. recent cardiac catheterization showed normal coronaries. she presented for redo-operation with mitral valve replacement on she was brought to the operating room. after intubation, she had an og tube placed which suctioned out approximately 30cc of coffee-ground fluid. there was concern for gi bleed and since surgery was elective, it was cancelled. gi was immediately consulted for an upper endoscopy. the patient was transferred to the cvicu, remained intubated and underwent an esophagogastroendoscopy by the gi service shortly thereafter. this showed gastritis with barrett's esophagus. this was treated with proton pump inhibitors and she was discharged.she now presents as a same day admit for surgery. past medical history: rheumatic valvular disease barrett's esophagus hypertension hyperlipidemia chronic atrial fibrillation neuropathy of lower extremities hemorrhoids arthritis s/p aortic valve replacement(bioprosthetic) by dr. at hysterectomy bilateral cataracts social history: last dental exam: several weeks ago, cleaning performed lives with: husband : tobacco: denies etoh: rare family history: father died of heart failure at age 61 physical exam: admission: pulse: 79 resp: 16 o2 sat: b/p right: 168/87 left: 127/85 general: elderly female in no acute distress skin: dry intact - well healed sternotomy and abd incision heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur - mixed systolic and diastolic murmurs, soft abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema trace bilaterally varicosities: none neuro: grossly intact pulses: femoral right: 2 left: 2 dp right: 1 left: 1 pt : 1 left: 1 radial right: 1 left: 1 carotid bruit right: none left: none pertinent results: 07:30am hgb-11.8* hct-34.1* 12:50pm glucose-102 lactate-1.2 na+-141 k+-3.6 cl--103 06:41pm fibrinoge-235 06:41pm pt-15.9* ptt-29.8 inr(pt)-1.4* 06:41pm plt count-164 06:44pm glucose-187* lactate-3.1* na+-139 k+-3.1* cl--105 08:13pm estgfr-using this 08:13pm urea n-14 creat-0.5 chloride-114* total co2-21* 06:05am blood wbc-13.7* rbc-3.01* hgb-8.9* hct-27.8* mcv-92 mch-29.6 mchc-32.0 rdw-17.5* plt ct-372 06:01am blood wbc-19.1* rbc-2.84* hgb-8.5* hct-26.1* mcv-92 mch-30.0 mchc-32.7 rdw-18.0* plt ct-383 06:05am blood plt ct-372 06:05am blood pt-31.5* inr(pt)-3.2* 06:01am blood pt-28.7* inr(pt)-2.8* 06:01am blood urean-20 creat-0.7 k-3.9 04:19am blood glucose-118* urean-21* creat-0.6 na-139 k-3.6 cl-100 hco3-31 angap-12 radiology report chest (pa & lat) study date of 10:14 am final report reason for examination: followup of the patient after mitral valve replacement with elevated white blood cells. pa and lateral upright chest radiographs were compared to . the right picc line tip is at the level of mid svc. the replaced aortic and mitral valves are in unchanged position. the right pleural effusion which is partially loculated with adjacent area of atelectasis did not change in the interim. there are no areas of consolidation worrisome for newly developed infectious process. no pneumothorax is demonstrated. dr. echocardiography report tee (complete) echocardiographic measurements results measurements normal range left ventricle - inferolateral thickness: *1.4 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 5.3 cm <= 5.6 cm left ventricle - ejection fraction: 55% to 60% >= 55% left ventricle - stroke volume: 62 ml/beat left ventricle - cardiac output: 3.80 l/min left ventricle - cardiac index: *1.98 >= 2.0 l/min/m2 left ventricle - peak resting lvot gradient: 3 mm hg <= 10 mm hg aorta - sinus level: 3.6 cm <= 3.6 cm aorta - ascending: *3.9 cm <= 3.4 cm aorta - arch: 3.0 cm <= 3.0 cm aortic valve - peak velocity: *2.4 m/sec <= 2.0 m/sec aortic valve - peak gradient: *23 mm hg < 20 mm hg aortic valve - mean gradient: 11 mm hg aortic valve - lvot vti: 18 aortic valve - lvot diam: 2.1 cm aortic valve - valve area: *1.3 cm2 >= 3.0 cm2 mitral valve - mva (p t): 2.0 cm2 tr gradient (+ ra = pasp): *46 to 50 mm hg <= 25 mm hg findings left ventricle: mild symmetric lvh. normal lv cavity size. overall normal lvef (>55%). aortic valve: avr leaflets move normally. thickened avr leaflets. cannot exclude as. no ar. mitral valve: moderately thickened mitral valve leaflets. partial mitral leaflet flail. mild valvular ms (mva 1.5-2.0cm2). moderate to severe (3+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. severely thickened/deformed tricuspid valve leaflets. no ts. moderate to severe tr. severe pa systolic hypertension. pulmonic valve/pulmonary artery: pulmonic valve not well seen. no pr. pericardium: no pericardial effusion. conclusions pre bypass: there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). the aortic valve prosthesis leaflets appear to move normally. the prosthetic aortic valve leaflets are thickened. the study is inadequate to exclude significant aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is partial mitral leaflet flail. there is mild valvular mitral stenosis (area 1.5-2.0cm2). moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the tricuspid valve leaflets are severely thickened/deformed. moderate to severe tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. rv function mildly depressed at baseline, improved on milrinone infusion. post bypass: patient is in atrial fibrillation (baseline rhythm) on milrinone and phenylepherine infusions. preseved biventricular function. lvef >55%. a mechanical mitral valve prosthesis is in situ with peak gradient 8, mean 4 mm hg normal washing jets and a small, stable, perivalvular leak. aortic prosthesis is unchanged from baseline. aortic contours intact. remaining exam is unchanged. all findings discussed with surgeons at the time of the exam. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, brief hospital course: was a same day admit and underwent a mitral valve replacement via right thoracotomy on . please see operative note for surgical details. following surgery she was transferred to the cvicu for invasive monitoring on milrinone, epinephrine and neosynephrine she was tacchycardic to the 140s with good cardiac function. despite weaning off the epinephrine and small doses of beta blockers, her heart rate remained rapid and her bp was lower with the fast rate. the milrinone was then weaned and stopped with the heart rate falling into the 110-120 range. amiodarone and beta blockers did not slow her ventricular response adequtely and eventually digoxin was given with a drop in the rate to below 100. she remained stable. she was extubated during this time without incident. she became hypertensive postoperatively and required a nitroglycerin drip. she had pauses after digoxin loading and a heart rate in the 50's. digoxin was stopped, ep was consulted and lopressor was held until her heart rate improved. lopressor was added back and eventually converted to atenolol with reasonable heart rate control in the 80-90s. chest tubes were removed per cardiac surgery protocol. ms. was started on anticoagulation for chronic atrial fibrillation and the mechanical mitral valve. she was started on coumadin and then a heparin drip on postoperative day 3 at midnight. she was therapeutic on heparin and coumadin. on postoperative day 6 she developed guaiac positive stools. a chest xay was done which showed a right hemothorax. a chest tube was placed which drained 1.9 l dark red fluid. she was hemodynamically stable throughout this. she was transfused with 2 units of packed red blood cells and serial hematocrits were done. hematocrit remained stable at 26. cxr showed improvement of the effusion with a moderate lateral residual component on . coumadin was restarted with inr 2.2. she was transferred to the floor in stable condition. once on the floor her activity level was advanced. a picc line was placed on and the triple lumen catheter was removed from the jugular vein. a cxr demonstarted some improvement in the aeration of the right lung but a persisitent loculated effusion. the ct was removed per dr. . she continued to make slow improvement while awaiting her inr to become therapeudic. during this period she was noted to have an elevated white blood cell count, she was pan cultured and all cultures returned negative. her right groin cannulation site had slight erythema and she was begun on keflex with a resultant downward trend of her white cell count. on pod 15 she was discharged home with visiting nurses. inr levels and coumadin dose adjustments to be followed by dr medications on admission: atorvastatin 10 mg daily furosemide 80 mg daily gabapentin 300 mg am,600mg 1600,600my 2200 isosorbide dinitrate 30 mg daily colchicine 0.6 mg daily losartan 25 mg daily pantoprazole 40 mg metoprolol tartrate 50 mg ciprofloxacin 500 mg discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 3. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. losartan 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 9. furosemide 80 mg tablet sig: one (1) tablet po twice a day: take 80mg x10 days then 80mg qd. disp:*60 tablet(s)* refills:*1* 10. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po daily (daily). disp:*30 tab sust.rel. particle/crystal(s)* refills:*2* 11. keflex 500 mg capsule sig: one (1) capsule po twice a day for 2 weeks. disp:*28 capsule(s)* refills:*0* 12. atenolol 25 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 13. warfarin 2 mg tablet sig: as directed tablet po once a day: take 6mg on and then as directed by dr . disp:*100 tablet(s)* refills:*0* discharge disposition: home with service facility: area vna discharge diagnosis: mitral regurgitation s/p mitral valve replacement rheumatic valvular disease hypertension hyperlipidemia chronic atrial fibrillation neuropathy of lower extremities hemorrhoids arthritis s/p 21mm avr (bioprosthetic) by dr. at s/p hysterectomy bilateral cataracts discharge condition: good discharge instructions: monitor wounds for signs of infection. these include redness, drainage or increased pain. report any fever of greater then 100.5 report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. shower daily. wash wound with soap and water. no lotions, creams or pwoders to incision until it has healed. no lifting greater then 10 pounds for 10 weeks from date of surgery. no driving for 1 month from date of surgery and taking narcotics. please call with any questions or concerns. take all medications as directed followup instructions: 6 wound clinic in 2 weeks-nurses to schedule prior to discharge dr. in 4 weeks () dr. in weeks () dr. in weeks please call providers for all appointments Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of mitral valve Removal of thoracotomy tube or pleural cavity drain Diagnoses: Acidosis Other iatrogenic hypotension Thrombocytopenia, unspecified Unspecified essential hypertension Atrial fibrillation Mononeuritis of lower limb, unspecified Rheumatic heart failure (congestive) Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Long-term (current) use of anticoagulants Nonspecific abnormal findings in stool contents Heart valve replaced by transplant Aphasia Barrett's esophagus Hemopericardium Oliguria and anuria Rheumatic mitral insufficiency Arthropathy, unspecified, site unspecified Adhesive pericarditis Other specified forms of effusion, except tuberculous |
allergies: erythromycin base attending: addendum: lopressor dosage increased prior to discharge to optimize heart rate control. -metoprolol tartrate 50 mg tabs: 2 tabs po tid discharge disposition: home md Procedure: Other endoscopy of small intestine Diagnoses: Unspecified essential hypertension Atrial fibrillation Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Unspecified gastritis and gastroduodenitis, with hemorrhage Heart valve replaced by transplant Surgical or other procedure not carried out because of contraindication Barrett's esophagus Arthropathy, unspecified, site unspecified Encounter for therapeutic drug monitoring Mitral stenosis with insufficiency |
allergies: erythromycin base attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: - upper endoscopy history of present illness: this is a 76 year old female with questionable history of rheumatic heart disease. she is s/p aortic valve replacement in . recent echocardiogram revealed moderate to severe mitral regurgitation. recent cardiac catheterization showed normal coronaries. she presents for evaluation for redo-operation with mitral valve replacement. past medical history: possible rheumatic valvular disease hypertension hyperlipidemia chronic afib, history of dccv neuropathy of lower extremities hemorrhoids arthritis past surgical history: - s/p 21mm avr (bioprosthetic) by dr. at - hysterectomy - bilateral cataracts social history: last dental exam: several weeks ago, cleaning performed lives with: husband : tobacco: denies etoh: rare family history: father died of heart failure at age 61 physical exam: pulse: 79 resp: 16 o2 sat: b/p right: 168/87 left: 127/85 general: elderly female in no acute distress skin: dry intact - well healed sternotomy and abd incision heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur - mixed systolic and diastolic murmurs, soft abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema trace bilaterally varicosities: none neuro: grossly intact pulses: femoral right: 2 left: 2 dp right: 1 left: 1 pt : 1 left: 1 radial right: 1 left: 1 carotid bruit right: none left: none pertinent results: cxr: the patient is now intubated, with the endotracheal tube terminating 3.5 cm above the carina. the nasogastric tube is in the standard placement with the side ports below the expected location of the gastroesophageal junction. the degree of mediastinal widening is expected for immediate post- operative appearance. mild bibasal atelectasis is new. there is no pulmonary edema or large pleural effusion. right costophrenic angle is not included inthe field of view. 05:30pm blood wbc-14.4* rbc-4.10* hgb-13.1 hct-37.2 mcv-91 mch-31.9 mchc-35.2* rdw-16.3* plt ct-231 03:18am blood wbc-12.5* rbc-3.71* hgb-11.4* hct-33.7* mcv-91 mch-30.6 mchc-33.8 rdw-16.5* plt ct-181 05:30pm blood pt-13.4 ptt-23.1 inr(pt)-1.1 05:30pm blood glucose-113* urean-22* creat-0.9 na-141 k-4.2 cl-100 hco3-30 angap-15 03:18am blood glucose-122* urean-11 creat-0.7 na-140 k-3.4 cl-104 hco3-25 angap-14 05:30pm blood alt-21 ast-28 ld(ldh)-258* alkphos-106 amylase-64 totbili-0.5 03:18am blood calcium-8.1* mg-2.0 monday, endoscopist(s): , md , md patient: ref.phys.: birth date: (76 years) instrument: gif 180 id#: indications: coffee ground aspirates from ng tube procedure: the procedure, indications, preparation and potential complications were explained to the patient's husband, who indicated his understanding and consented telephonically. a physical exam was performed. the patient was administered intravenous propofol for sedation. a physical exam was performed prior to administering anesthesia. supplemental oxygen was used. the patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. careful visualization of the upper gi tract was performed. the procedure was not difficult. the patient tolerated the procedure well. there were no complications. findings: esophagus: mucosa: localized erythema of the mucosa was noted at the lower third of the esophagus compatible with mild esophagitis. also short segment of barretts esophagus noted at the ge junction. stomach: contents: coffee ground heme was seen in the fundus, stomach body, antrum and pylorus. mucosa: localized discontinuous erythema and granularity of the mucosa with no bleeding were noted in the antrum. these findings are compatible with gastritis. duodenum: normal duodenum. impression: erythema in the lower third of the esophagus and short segment barrett's gastritis coffee gounds in the stomach. no active bleeding site found. otherwise normal egd to second part of the duodenum recommendations: gastritis could have been the source of bleeding in this patient. recommend ppi drip. _________________________________ , md _________________________________ , md case documentation started on 12:39:41 pm patient: () brief hospital course: was admitted one day before surgery for pre-admission work-up and heparin bridge as she has a history of atrial fibrillation and takes coumadin at home. coumadin was discontinued 5 days before surgery. on she was brought to the operating room. after intubation, patient had an og tube placed which suctioned out approximately 30cc of coffee-ground fluid. there was concern for gi bleed and since surgery was elective, it was cancelled. gi was immediately consulted for an upper endoscopy. patient was transferred to the cvicu, intubated and underwent an egd by the gi service shortly thereafter. egd showed gastritis with barrett's esophagus. she awoke neurologically intact and was extubated without difficulty. ms. was transitioned to protonix by mouth, diet advanced, and transferred to the floor. dr. discussed with ms. and her family, coumadin is not to be resumed upon discharge due to the egd findings of gastritis as probable source of bleeding. her surgery was rescheduled for tues, . ms. was discharged to home with preoperative instructions reviewed. she and her family had all questions and concerns resolved at the time of her discharge. she was advised to call dr. if any further concerns ahould arise. medications on admission: asa 81mg po daily atacand 32 mg po daily calcium 500mg 2 tabs po bid colchicine 0.6mg po daily ******coumadin 5 mg m-w-f and 7.5mg t-th-s-sun fe 320mg po daily gabapentin 300mg five times a day isosorbide 30 mg po daily kcl 20 meq daily lasix 80mg po daily lipitor 10 qd metoprolol tartrate 50 mg po qid mvi daily nitro prn ranitidine 150mg po daily discharge medications: 1. atorvastatin 10 mg tablet sig: one (1) tablet po hs (at bedtime). 2. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). 3. gabapentin 300 mg capsule sig: one (1) capsule po four times daily (). 4. isosorbide dinitrate 30 mg tablet sig: one (1) tablet po daily (daily). 5. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily). 6. losartan 25 mg tablet sig: one (1) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 8. metoprolol tartrate 50 mg tablet sig: one (1) tablet po qid (4 times a day). 9. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 2 days. disp:*4 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: medical history: -gastritis -barrett's esophagus -possible rheumatic valvular disease -hypertension -hyperlipidemia -chronic afib, history of dccv -neuropathy of lower extremities -hemorrhoids -arthritis past surgical history: - s/p 21mm avr (bioprosthetic) by dr. at - hysterectomy - bilateral cataracts discharge condition: good discharge instructions: 1) take all medications as prescribed. 2) maintain all follow-up appointments as instructed. 3) nothing by mouth on ,after midnight, as previously instructed. 4) scrub preoperative as directed. followup instructions: mitral valve repair/replacement/ redo-sternotomy rescheduled with dr. for tues,.call if any questions#( follow-up with dr. as instructed Procedure: Other endoscopy of small intestine Diagnoses: Unspecified essential hypertension Atrial fibrillation Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Unspecified gastritis and gastroduodenitis, with hemorrhage Heart valve replaced by transplant Surgical or other procedure not carried out because of contraindication Barrett's esophagus Arthropathy, unspecified, site unspecified Encounter for therapeutic drug monitoring Mitral stenosis with insufficiency |
allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: shortness of breath major surgical or invasive procedure: 1. cardiac catherization 2. valvuloplasty history of present illness: this is an 85-year-old woman with a history of cad s/p multiple interventions (total of 10 stents), recent cath for doe in , severe aortic valve stenosis and mitral regurgitation who presents to for dyspnea at rest and precordial chest pressure. patient states that dyspnea has been increasing for the last 5 weeks and came to a crescendo night prior to admission; patient was was unable to lie down and was tripoding against the wall in order to get in enough air. also relates history of pressure in middle of her chest, which was constant. oxygen requirement at home is 3lpm. . ms. is followed by dr. as an outpatient and was going to be evaluated by dr. of ct surgery for double valve repair. recent echo shows aortic pullback, as gradient 25, area 0.74, significant mitral regurgitation, and bad pulmonary hypertention. . in the ed, patient was put on a non-rebreater and titrated down to 4lpm. her initial vitals were bp: 120/70, hr: 75, sp02: 97% on 4lpm. she was slightly uncomfortable and could not lie flat. a cxr was consistent with heart failure and a possible consolidation in the left lower lobe. patient took her asa and plavix morning of admission. past medical history: --cad s/p numerous cardiac catherizations, most recent in --htn --hyperlipidemia --anxiety/depression --chronic back pain s/p fracture --osteoporosis --breast cancer s/p bilateral mastectomy and chemotherapy (no radiation) social history: lives in senior community with her husband. three children who are very involved; one who lives in . distant smoking history and no alcohol use. has help once a week with cleaning. family history: father died at age 67 following prostate surgery. mother died of breast cancer at age 78. physical exam: physical exam: bp: 131/60, hr: 75, rr 18, 98% 4l general: patient is short of breath especially on exertion, but no acute distress neck: jvp elevated ~2cm above clavicular line chest: crackles at bases bilaterally; otherwise clear with no wheezes or rhonchi cardiac: 3/6 systolic murmur heard best at right sternal border (3rd intercostal space) radiating to carotid. regular rate and rhythm. abdomen: +bs, soft, non-tender, non-distended extremities: no edema, positive pedal pulses bilaterally pulses: strong carotid, radial, and pedal pulses bilaterally skin: warm and dry pulses: 2+ carotid, radial, and dp pulses bilaterally pertinent results: 07:44pm ck(cpk)-40 07:44pm ck-mb-notdone ctropnt-<0.01 07:44pm magnesium-2.3 09:50am urine hours-random 09:50am urine gr hold-hold 09:50am urine color-yellow appear-clear sp -1.022 09:50am urine blood-tr nitrite-pos protein-100 glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-tr 09:50am urine rbc-0-2 wbc-* bacteria-many yeast-none epi- 09:50am urine hyaline-0-2 08:00am glucose-103* urea n-29* creat-0.9 sodium-143 potassium-4.7 chloride-113* total co2-20* anion gap-15 08:00am estgfr-using this 08:00am ck(cpk)-58 08:00am ctropnt-<0.01 08:00am ck-mb-notdone 08:00am neuts-82.2* lymphs-12.6* monos-3.6 eos-1.1 basos-0.4 08:00am plt count-235 08:00am pt-13.3 ptt-26.9 inr(pt)-1.1 . ct chest : impression: 1. mild interstitial edema. bilateral pleural effusions with adjacent atelectasis. 2. cardiomegaly. 3. severe calcification of the aortic valve and coronary arteries. 4. minimal calcifications in the aortic arch. 5. mediastinal lymphadenopathy, likely reactive. 6. prominent main pulmonary artery suggests pulmonary hypertension. 7. sequela of granulomatous infection. . echo : the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with inferior/inferolateral akinesis. the remaining segments contract normally (lvef = 40-45%). the right ventricular cavity is mildly dilated with borderline normal free wall function. there is severe aortic valve stenosis (valve area 0.7 cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate to severe (3+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. . impression: symmetric lvh with mild regional systoic dysfunction, c/w cad. severe calcific aortic stenosis. mild aortic regurgitation. moderate to severe mitral regurgitation with a substantially calcified mitral annulus. at least mild pulmonary hypertension. . compared with the report of the prior study (images unavailable for review) of , mitral regurgitation severity may have increased. the other findings appear similar.. . carotid ultrasound : impression: 1. 60-69% stenosis of the right internal carotid artery. 2. less than 40% stenosis of the left internal carotid artery. . echo post-valvuloplasty : right ventricular chamber size and free wall motion are normal. significant aortic stenosis is present (not quantified). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. . compared with the prior study (images reviewed) of , the degree of aortic regurgitation is similar. the degree of aortic stenosis has also decreased. calculation of aortic valve area cannot be done as lvot velocities were not measured. . cxr : cardiomediastinal contours are unchanged in appearance. marked improved aeration in the left lower lobe with only minimal residual atelectasis remaining. left hemidiaphragm remains elevated, with adjacent gastric distension in the left upper quadrant. brief hospital course: this is an 85-year-old female with severe as, cad, mr who presents with worsening sob and chest pain. # aortic stenosis: ms. presents with acute on chronic systolic heart failure in the setting of severe aortic stenosis. at first a aortic valve repair was planned, but the procedure was considered too risky in a patient with such high right-sided filling pressures and other comorbidities. (she did however complete a full work-up for ct surgery including cardiac cath, dental consult, panorex, carotid and cardiac ultrasounds). ms. was put on a gentle lasix drip in order to improve respirtory status without compromising preload. eventually, ms. went for an aortic valvuloplasty via catherization. the procedure was successful and a post-valvuloplasty echo showed lessening of degree of aortic stenosis. however, on the day following her valvuloplasty, the patient developed worsening shortness of breath. she was given bolus lasix but still remained hypoxic, requiring a non-rebreather. she was transferred to the ccu further further evaluation and management. in the ccu, she was noted to have a tenuous fluid status. her antihypertensives were held due to hypotension. she was diuresed intermittently with a lasix drip and was torsemide was initially considered but she became hypotensive to the 90s. she began to autodiurese well, and thus diuretics were held with bps maintained above 88. she was eventually transitioned to the floor. metoprolol was restarted as her pulmonary edema was noted to worsen during periods of tachycardia. her lisinopril, amlodipine, and imdur were held throughout the rest of the admission. she may be started on these medications as an outpatient if her bp tolerates. # chest pain: ms. initially complained of some precordial chest pain on admission. most likely due to ischemia from increased demand and decreased supply; presentation was not consistent with acs. ekgs remained stable and ms. remained chest pain free after 1st hospital day. her isosorbide mononitrate (small dose) and prn nitro were continued during the first part of her hospitalization (but used with caution as not to decrease preload too much). she did develop some additional chest discomfort on the evening of ccu transfer; however, her ecg did not show any concerning ischemic changes. patient's imdur and nitro prn were eventually discontinued in light of hypotension. #uti: ms. complained of dysuria on admission. u/a showed evidence of infection but culture showed mixed flora. she was treated with 3 days of ciprofloxacin with good effect. # cad s/p multiple stents: patient with cad and multiple coronary interventions. recent cardiac cath showed patent stents. ms. was continued on her bb, asa, and crestor. she was also restarted on plavix. her ace-i was held due to low sbps. # hypertension: ms. was initially continued on amlodipine and lisinopril. upon ccu transfer, her antihypertensive agents were held due to hypotension and not restarted on discharge. these medications can be added on at the discretion of patient's outpatient cardiologist. # osteoporosis: ms. has severe osteoporosis complicated by vertebral fractures. she was continued on vicodin, gabapentin, and lidocaine patch for pain and vitamin d for bone strength. # cough: ms. complained of a cough, which waxed and waned throughout hospital course. many cxrs were negative for pneumonia, and cough persisted despite improvement in pulmonary edema. ms. was discharged on guaifenesin-codeine and benzonatate to take as needed. medications on admission: metoprolol succinate 25mg po qd lisinopril 2.5 mg po qd vitamin d 400 po qd hydrocodone (dose uncertain): tid gabapentin 300 mg po qhs amlodipine 5 mg po qd aspirin 325 mg po qd isosorbide mononitrate (extended release) 30 mg po qd clopidogrel 75 mg po qd rosuvastatin calcium 10 mg po qd discharge medications: 1. rosuvastatin 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 2. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). disp:*30 capsule(s)* refills:*0* 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 5. hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po every eight (8) hours as needed for pain for 7 days. disp:*20 tablet(s)* refills:*0* 6. oxygen two liters continuous pulse dose for portability. 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. codeine-guaifenesin 10-100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. disp:*1 1* refills:*0* 9. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for cough. disp:*30 capsule(s)* refills:*2* 10. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 11. preservision 226-200-5 mg-unit-mg capsule oral 12. toprol xl 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*0* discharge disposition: home with service facility: care group home care discharge diagnosis: primary: 1. severe aortic stenosis 2. acute on chronic systolic heart failure 3. mitral regurgitation . secondary: 1. coronary artery disease 2. hyperlipidemia 3. chronic low back pain 4. chronic utis discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: dear ms. , it was a pleasure taking care of you on this admission. you were admitted with shortness of breath, which was thought to be an acute exacerbation of your chronic systolic heart failure from severe aortic stenosis. although we had initially planned for aortic valve repair, we decided that the safest option was valvuloplasty. on you underwent aortic valvuloplasty under cardiac catherization. . the following changes were made to your medications: 1. stop taking lisinopril (blood pressure medication) 2. stop taking amlodipine (blood pressure medication) 3. stop taking isosorbide mononitrate (these are all medications that lower your blood pressure, and your blood pressure has been quite low this admission. you can restart them at the discretion of dr. . 4. start taking guaifenesin-codeine 5-10ml every 6 hours as needed for cough 5. start taking benzonatate 100 mg po three times a day as needed for cough 6. we have organized for you to have oxygen at home, please use as directed 7. lidocaine patch (use for 12hrs a day only) please keep all of your follow-up appointments. . return to the hospital if you develop chest pain, shortness of breath, severe headache, nausea, vomiting, diarrhea, bleeding in the groin, blood in your urine or stool, swelling in your legs, fevers or any other concerning signs or symptoms. followup instructions: please call dr. office to make an appointment on monday. his assistant is awaiting your call. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of right heart structures Percutaneous balloon valvuloplasty Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Other chronic pulmonary heart diseases Personal history of malignant neoplasm of breast Percutaneous transluminal coronary angioplasty status Occlusion and stenosis of carotid artery without mention of cerebral infarction Dysthymic disorder Other and unspecified hyperlipidemia Osteoporosis, unspecified Multiple involvement of mitral and aortic valves Acute on chronic systolic heart failure Cough |
allergies: isordil / dilaudid attending: chief complaint: back pain, fever. major surgical or invasive procedure: elective endotracheal intubation for mri. history of present illness: 72m with mds, recently discharged from 12r for diffuse body pain without improvement or diagnosis, initially planned for direct admit back to 12r. however, given slowed mental status, refusing speaking per family, evaluated in ed. initially in ed vs 104.3 114 141/59 18 99. pt refusing conversation but followed commands. labs significant for new renal failure cr 2.7, with k 5.7, ap 377, na 131, wbc 3.5 with 61%n and 9% bands, hct 29.2, plt 128, lactate 1.6. ua pending. infectious workup showed cxr, ct head negative. covered empirically for meningitis vanc, ctx, ampicillin. . family reported severe lower back pain and numbness in lower extremities, fever - concern for epidural abscess. plan for mri without contrast given renal failure, which was initiated but pt unable to tolerate due to agitation. able to get c spine and part of t spine, ? epidimoma, intrathecal mass c1-2. anesthesia intubated with 7.5 on propofol gtt. cxr confirmed placement of ett and og tube. insufficient staffing to get mri in ed. . renal failure - baseline 1.5-1.6. no change in po intake. unclear cause. given kayexalate 30, no ekg changes. no stools. gotten 2l ivf. . vs on transfer: temp 99.6. hr 125 since intubation, previously 90s, bp 135/69, ac 100, tv 450, 5peep, 12 ps, rate 20s. mv 10l. . of note, during recent admission, pt presented with diffuse pain and source not identified. ddx included neutrogen related, mds bony pain, lytic bony lesions (spep pending at discharge, now neg). planned for outpt bone marrow biopsy . . review of systems: pt not answering questions. past medical history: 1. myelodysplastic syndrome 2. obesity 3. peripheral vascular disease s/p bilateral angioplasty 4. atrial flutter 5. angina 6. glaucoma 7. hyperlipidemia 8. coronary artery disease s/p cabg 9. bph 10. gout 11. s/p ccy 12. h/o pancreatitis social history: home: lives with supportive wife occupation: recently started a new job as a mechanical design engineer etoh: rare drugs: denies tobacco: quit approximately 20 years ago; ~20-30 ppy history family history: mother - alcoholism, diabetes maternal grandmother - diabetes paternal grandmother - diabetes physical exam: general: intubated/sedated heent: sclera anicteric, perrla neck: supple, no lad lungs: bilateral bs, transmitted upper airway sounds cv: tachycardic, no murmurs abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: sedated, unresponsive pertinent results: admission labs : cbc: wbc-3.5* rbc-2.96* hgb-9.5* hct-29.2* mcv-99* mch-32.2* mchc-32.6 rdw-20.0* diff: neuts-61 bands-9* lymphs-17* monos-13* eos-0 basos-0 atyps-0 metas-0 myelos-0 smear: hypochrom-normal anisocyt-1+ poikilocy-normal macrocyt-2+ microcyt-normal polychrom-normal other: 04:30pm albumin-3.8 04:30pm lipase-53 04:30pm alt(sgpt)-13 ast(sgot)-36 alk phos-377* tot bili-1.5 04:42pm lactate-1.6 tox screen: 11:15pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg u/a: color-yellow appear-clear sp -1.018 blood-neg nitrite-neg protein-75 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg rbc-1 wbc-1 bacteria-mod yeast-none epi-1 granular-* . micro: blood cultures 5/14, , , - negative urine culture , - negative sputum culture x 2 - negative . ct head: there is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction. mild prominence of the ventricles and sulci is compatible with mild diffuse atrophy which is age-appropriate. there is no acute fracture. included views of the mastoid air cells and paranasal sinuses are clear. there is moderate calcification of the cavernous segments of both internal carotid arteries, left greater than right. impression: no acute intracranial process. . mri: 1. 22 x 7 mm intramedullary mass within the cervical spinal cord from c2 to c3 which is hyperintense on t2-weighted imaging, with areas of lower signal intensity within the mid superior aspect. there may be an associated syrinx. this finding could represent a neoplastic process such as an astrocytoma. 2. there are multiple nodules within the lungs. therefore, an intramedullary spinal metastasis is not excluded. chest ct is recommended. 3. 11 x 8 mm right parotid lesion, t2 hyperintense may represent a cystic mass or node, and less likely a pleomorphic adenoma. 4. multilevel degenerative changes throughout the cervical and thoracic spine, with partial ankylosis of c3 to c5 with bulky anterior osteophytes. 5. rounded t1 hyperintense, t2 hypointense lesion within t6 and t2 hypointense lesions within the right t7 (with posterior extension), may represent metastases. these areas can be re-evaluated at the time of ct. 6. elevated creatinine levels precluded the use of gadolinium. 7. no evidence of epidural abscess. 8. trace secretions within the trachea. findings: i concur with dr. very comprehensive analysis. additionally, there are multiple sternotomy sutures. there is no paravertebral soft tissue swelling to suggest an ongoing inflammatory process. conclusion: intramedullary mass within the upper cervical cord. see above report for differential diagnosis. degenerative changes of the cervical spine. please see above report for numerous additional observations. comment: please note that the present study contained imaging only as far distally as t9, as the patient was unable to continue the procedure at this time. . mri head: non-enhanced study with: 1. no evidence of intracranial mass or cerebral edema. 2. moderate global atrophy. 3. diffusely and uniformly t1-hypointense regional bone marrow signal, as on the recent mr examinations of the spine; this likely relates to the apparently known underlying myelodysplastic syndrome . mri lumbar: findings of concern for metastatic neoplastic disease involving the visualized lower thoracic and lumbar spine, with additional findings as noted above. bone scan : impression: widespread foci of abnormal tracer activity throughout the axial and appendicular skeleton as described above. pattern most compatible with widespread osseous metastasis from an unknown primary. cxr : all these support lines and tubes have now been removed. cardiac size is at the upper limits of normal. no failure is present. there is some loss of the right heart border suggesting infiltrate in right middle lobe. impression: probable right middle lobe pneumonia. cxr : findings: as compared to the previous radiograph, the mid lobe opacity is unchanged. in addition, a small left suprabasal opacity has occurred that could correspond to local atelectasis. otherwise, there is no relevant change. unchanged size of the cardiac silhouette. unchanged absence of pulmonary edema. unchanged absence of pleural effusions. old right-sided clavicular fracture. the study and the report were reviewed by the staff radiologist. pathology pending at time of discharge brief hospital course: 72 yo m with mds, chronic back pain of unknown source with recent neg eval, returns with back pain, fever, ams. . # fever: patient admitted with fever and concurrent rise in wbc from 2s to 3.6 and diff changed from 3 30-40% neutrophils and no bands, to 61%n and 9%bands. given the back pain there was concern for epidural abcess. patient was started on vanc/ctx 2g/ampi for meningitis. mri r/o abcess (no contrast given creatinine of 2.7), but showed metastatic disease to the spine. patient initially did not spike on antibiotics, so thought was that it was covering whatever infectious process was going on. ampicillin was stopped on and ctx was decreased to 1g. then, patient spiked again. so far cultures have been negative including blood and urine. cxr has been unchanged. vs have been stable not suggesting sirs. posibility includes malignancy-related fevers. antibiotics were discontinued on as no obvious source of fever was present. patient again spiked a fever to 101 after his bronchosopy, and was noted to be confused an mildly hypoxic to 91 on ra. a cxr showed evidence of rll infiltrate, so he was treated with 7 days of po levofloxacin. . # lung nodules: multiple very small lung nodules. ct scan images from osh were obtained and reviewed and nodules only seem to be amenable to open lung biopsy or ct-guided biopsy. repeat ct torso showed interval increase in the size of his lung nodules as well as interval increase in the size of a mediastinal lymph node. interventional pulmonary was consulted and performed bronchosopy on with biopsy of an endoluminal lesion, pathology was pending on discharge. . #. spinal masses: mri with multiple masses throughout his spine suggestive of metastatic disease. mri of the head without any metastasis. oncology was consulted and suggested biopsy of the lowest risk spinal lesions. interventional neuro radiology felt that the spinal lesions were not necessarily metastasis and may be related to his mds. a ct torso was performed, which was less suggestive of spinal metastasis. a bone scan was performed which suggested widespread bony metastatic disease. . # acute on chronic renal failure: cr baseline 1.5, stage 3 admitted with cr of 2.7 ua with sg 1.018, pos for protein and bacteria, no wbcs/leuks/epis. he received ivf and had good uop. creatinine trended down to his baseline. . # hyperkalemia: 5.7 on admission. he received kayexalate but no bm. no ekg changes. he was normal throughout the rest of the admission. . # intubation: pt electively intubated for mri given concern for epidural abcess. he was kept intubated given concern for metastatic disease and further work up needed (mri of head). he was succesfuly extuabted on . . # myelodysplastic syndrome: on aranesp and neupogen. some concern that this pain is related to his neupogen, although his pain has not improved despite decreased dose of neupogen. given his worsening anemia and bony pain, there has been consideration of repeating a bone marrow biopsy. alk phos at baseline (300s-400s last week). spep last week with polyclonal igm increase. upep showed was within normal limits. he received neupogen twice with subsequent increases in his wbc count from 1.5 to 7.8. patient received prbc to maintain a hct of over 25. he was treated with neupogen twice during his hospitalization. . # angina/cad s/p cabg - aspirin was held given possible procedure. lisinopril and metoprolol were initially held. . # aflutter: currently sinus. holding metoprolol . # hyperlipidemia - continued zetia . # enlarged prostate - patient was continued on tamsulosin. on exam, prostate was enlarged, asymmetric, firm with irregular surface. psa on admission was 14. per records, psa was 3 in , and 9 in . # gout: patient noted r metatarsal-phalangeal joint pain and swelling, consistent with prior joint flare. he was treated with colchicine with modest improvement of his symptoms. . # type 2 diabetes - held glipizide and metformin given npo and renal failure. pt was put on iss. glipizide and metformin were restarted on discharge. . medications on admission: 1. acetaminophen 1000mg 2. omeprazole 20mg 3. aspirin 325 mg daily 4. ranolazine 500 mg daily 5. lisinopril 20mg daily 6. finasteride 5mg daily 7. metoprolol succinate 100 mg daily 8. ezetimibe 10mg daily 9. tamsulosin 0.4 mg qhs 10. nitropatch 0.2mg/hour daily 11. glipizide-metformin 5-500 mg daily 12. oxycodone 5-10mg q4 13. neupogen injection twice weekly 14. aranesp (polysorbate) 100 mcg/ml solution injection weekly discharge medications: 1. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 2. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 3. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 5. ranolazine 500 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po daily (). 6. nitroglycerin 0.2 mg/hr patch 24 hr sig: one (1) patch 24 hr transdermal q24h (every 24 hours): on for 12 hours, then off for 12 hours. 7. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. 8. acetaminophen 500 mg tablet sig: two (2) tablet po q 12h (every 12 hours). 9. aspirin 325 mg tablet sig: one (1) tablet po once a day. 10. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 11. ezetimibe 10 mg tablet sig: one (1) tablet po once a day. 12. levofloxacin 750 mg tablet sig: one (1) tablet po daily (daily) for 2 days. disp:*2 tablet(s)* refills:*0* 13. colchicine 0.6 mg tablet sig: one (1) tablet po once (once) for 1 days: start on . disp:*1 tablet(s)* refills:*0* 14. oxycodone 30 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po every twelve (12) hours: do not drive or operate heavy machinery as this can cause sedation. disp:*60 tablet sustained release 12 hr(s)* refills:*0* 15. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain: do not operate heavy machinery or drive with this medication as it can cause sleepiness. disp:*60 tablet(s)* refills:*0* 16. glipizide-metformin 5-500 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: discharge diagnosis: malignancy with metastases, unknown primary fever back pain pneumonia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted for back pain and fever. an mri of your back did not show any signs of infection. further imaging with ct and bone scan showed lung nodules, and lesions in your bones suspicious for cancer. a bronchoscopy was performed to take a biopsy of a lymph noed in your mediastinum (chest). after the procedure you developed fevers, confusion and shortness of breath. a cxr was suspicious for pneumonia, so you were treated with antibiotics. also, your pain was controlled with long acting and short acting narcotics. please note the following changes in your medications: 1. please start oxycontin 30 mg by mouth every 12 hours for your pain. this is your basal, long acting pain medication. 2. please start oxycodone 5-10 mg by mouth every 4-6 hours for breakthrough pain. this is your short acting pain medication. *** you should not drive or operate heavy machinery with this medication as it can cause sleepiness *** 3. please continue levofloxacin 750 mg by mouth for 2 more days (last day ). this is the antibiotic for your pneumonia. take this in the morning after you have eaten. 4. please continue to take colchicine 0.6 mg by mouth for 1 more day. take this in the morning of for your gout. please keep all your medical appointments. your lung lymph node biopsy is pending and your oncologist (cancer doctor) should follow up the results of this with you. followup instructions: please follow up with your oncologist dr. . appointment: wednesday, , 9:30am you have an appointment on at - at 2:30 pm. primary care doctor appointment with: , a location: - address: , , phone: Procedure: Closed [endoscopic] biopsy of bronchus Closed endoscopic biopsy of lung Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Peripheral vascular disease, unspecified Unspecified glaucoma Atrial flutter Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Myelodysplastic syndrome, unspecified Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Fever, unspecified Secondary malignant neoplasm of lung Other malignant neoplasm without specification of site Secondary malignant neoplasm of bone and bone marrow Gouty arthropathy, unspecified |
allergies: sulfa (sulfonamide antibiotics) / ramipril / penicillins / codeine attending: chief complaint: leg weakness major surgical or invasive procedure: laminectomies t3-l3 for evacuation of epidural hematoma history of present illness: pqatient was found by daughter on ground at home after fall. unable to move legs. mri scan demonstrated extensive epidural hematoma. she underwent an emergent laminectomy and evacuation of the hematoma. past medical history: on coumadin. htn. social history: lives alone. no etoh/cigarettes family history: hss several daughters who live locally. physical exam: elderly white female- oriented to person and place. no active motor function below the waist with a t10 sensory level prior to surgery. heent- nc/at no jvd , lymphadenopathy lungs clear. abdomen soft non-tender. mild pedal edema. incision clean and dry- staples in place pertinent results: 07:00pm urine color-yellow appear-clear sp -1.023 07:00pm urine blood-sm nitrite-neg protein-30 glucose-300 ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 07:00pm urine rbc-1 wbc-2 bacteria-none yeast-none epi-0 trans epi-<1 07:00pm urine hyaline-2* 07:00pm urine mucous-rare 10:34pm ck(cpk)-1679* 07:00pm ctropnt-0.44* 07:00pm wbc-10.7 rbc-3.63* hgb-12.1 hct-35.4* mcv-98 mch-33.2* mchc-34.0 rdw-13.4 brief hospital course: patient was admitted and underwent emergent spine surgery for paraplegia. she was brought psot-operatively to the sicu intubated and was extubated on pod#2. she regained sensation in her legs and was able to wiggle toes spontaneously. her troponin levels were elevated prior to surgery but stabilized. she was transfferred to the floor and begun on a normal diet. her mental status remained at baseline with dementia according to her diughters. she was fitted for a tlso brace which is to be worn for 8 weeks wheen oob. medications on admission: 1. simvastatin 40 mg tablet sig: 0.5 tablet po daily (daily). 2. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for bowel regimen. 4. docusate sodium 50 mg/5 ml liquid sig: tsps po bid (2 times a day) as needed for bowel regimen. 5. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 6. dronabinol 7. coumadin discharge medications: 1. simvastatin 40 mg tablet sig: 0.5 tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 2. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for bowel regimen. disp:*60 tablet(s)* refills:*0* 4. docusate sodium 50 mg/5 ml liquid sig: tsps po bid (2 times a day) as needed for bowel regimen. disp:*100 ccs* refills:*0* 5. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. dronabinol 2.5 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 7. dabigatran etexilate 75 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 8. hydromorphone 2 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pail. disp:*60 tablet(s)* refills:*0* 9. labetalol 5 mg/ml solution sig: one (1) intravenous q6h (every 6 hours) as needed for sbp>140, hr>75. disp:*100 ccs* refills:*0* discharge disposition: extended care facility: hospital discharge diagnosis: paraparesis s/p epidural hematoma. laminectomies t3-l3 discharge condition: senile dementia at baseline/ able to only wiggle toes biltaerally/ no other significant motor strength in the lower extremities/ retained lower extremity sensation right greater than left discharge instructions: keep incision clean and dry/ staples in place/ oob as tolerated- use tlso brace when oob physical therapy: unable to ambulate secondary to leg weakness/ be mobilized oob to chair/ use tlso brace when oob treatments frequency: keep incision clean and dry- staples to be removed pod#12 followup instructions: 10 days in dr. office Procedure: Enteral infusion of concentrated nutritional substances Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Other exploration and decompression of spinal canal Diagnoses: Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Other persistent mental disorders due to conditions classified elsewhere Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Fall from other slipping, tripping, or stumbling Secondary and recurrent hemorrhage Multiple sites of spinal cord injury without evidence of spinal bone injury |
allergies: hydrochlorothiazide attending: chief complaint: abdominal pain major surgical or invasive procedure: ercp - intubation - extubation - history of present illness: 47 yo m with a history of htn/hl, dmii, obesity who presented with 1 day of ruq pain, found to have gallstone pancreatitis with concern for cholangitis. patient was intubated on admission to . per report of patient's wife, patient ate chili at 1pm on the day prior to admission, and developed epigastric pain directly after. he had ongoing sharp pain which radiated to his back and not related to position. he vomited throughout the night. he was unable to have a bowel movement, and took maalox. he had several bowel movements on the morning of admission prior to coming to the er. he did not have fever, chills or night sweats. he did have elevated blood sugars in the days prior to admission. he has never had biliary colic, cholecystitis or pancreatitis in the past. in the ed inital vitals were t96.8, hr 120, bp 162/91, rr 22 o2sat 98%. labs were notable for wbc 15.3, alt 350, ast 232, alk phos 299, t bili 2.6, lipase 4388. ruq ultrasound revealed multiple stones within distended gallbladder, c/w acute cholecystitis, with common bile duct dilation to 1.3cm without identification of an intra-ductal stone. patient was evaluated by acs team who recommended ercp. patient was given 2l ns, zofran for nausea, morphine for pain control and 1 dose of unasyn, then was sent for ercp. during ercp, patient desaturated while on sedation and required intubation. following intubation, patient was tachycardic and hypertensive. he was difficult to ventilate and so was sedated and paralyzed and given albuterol with improved compliance and tidal volumes. received 1l lr during procedure. during ercp, many gallstones were removed from the biliary tree which were partially obstructive. pus was removed as well. patient was hypertensive and tachycardic after, transferred to intubated. on arrival to the icu, vital signs were t 96.3, hr 116, bp 143/103, o2sat 97%. patient was intubated and sedated at tv 600 rr 14 100% fio2 and peep 8. wife was for further history as stated above, and she completed icu consent. the evening after arriving in the icu, he self-extubated and afterward needed to be on non-invasive ventilation to maintain sats. he was weaned to 3l nc prior to transfer to the floor. past medical history: dm htn morbid obesity premature ejaculation hl seasonal allergies tonsilectomy social history: non smoker, rare etoh, no illicits. works as supervisor for t. married. has five children. family history: no cad, no thromboembolic disease. physical exam: admission exam: vitals: t: 96.3 bp: 143/103 p: 116 r: 18 o2: general: morbidly obese male, intubated and sedated. heent: sclera anicteric neck: jvp difficult to assess due to body habitus lungs: course crackles on right>left, clear to auscultation on left. no wheezes appreciated cv: tachycardic with normal rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: obese, hypoactive bowel sounds, no ttp gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: 07:15am blood wbc-15.3*# rbc-5.77 hgb-14.5 hct-46.2 mcv-80* mch-25.2* mchc-31.4 rdw-14.7 plt ct-311 07:15am blood neuts-94.8* lymphs-2.8* monos-2.2 eos-0.2 baso-0 07:15am blood glucose-320* urean-14 creat-1.2 na-141 k-4.3 cl-97 hco3-31 angap-17 07:15am blood alt-350* ast-232* alkphos-299* totbili-2.6* 05:01am blood alt-385* ast-157* alkphos-287* totbili-3.5* 07:15am blood lipase-4388* 07:15am blood albumin-4.4 05:01am blood calcium-9.3 phos-4.2 mg-1.6 . : 05:01am blood wbc-15.8* rbc-5.17 hgb-13.5* hct-41.7 mcv-81* mch-26.1* mchc-32.4 rdw-14.7 plt ct-275 06:20am blood wbc-11.8* rbc-5.11 hgb-13.0* hct-41.0 mcv-80* mch-25.5* mchc-31.7 rdw-14.6 plt ct-258 06:30am blood wbc-8.9 rbc-5.14 hgb-13.0* hct-40.9 mcv-80* mch-25.3* mchc-31.9 rdw-14.3 plt ct-235 05:01am blood glucose-133* urean-11 creat-1.0 na-143 k-4.1 cl-102 hco3-31 angap-14 06:20am blood glucose-107* urean-10 creat-0.8 na-139 k-4.0 cl-94* hco3-37* angap-12 06:30am blood glucose-112* urean-9 creat-0.7 na-138 k-3.6 cl-96 hco3-29 angap-17 05:01am blood alt-385* ast-157* alkphos-287* totbili-3.5* 06:20am blood alt-234* ast-38 alkphos-268* totbili-0.9 05:01am blood calcium-9.3 phos-4.2 mg-1.6 06:20am blood calcium-9.6 phos-3.7 mg-1.6 06:30am blood calcium-9.3 phos-3.4 mg-1.7 . discharge labs: 06:15am blood wbc-7.8 rbc-5.23 hgb-13.2* hct-41.0 mcv-78* mch-25.2* mchc-32.1 rdw-14.3 plt ct-275 06:15am blood glucose-115* urean-10 creat-0.8 na-140 k-3.5 cl-98 hco3-31 angap-15 06:15am blood alt-94* ast-16 alkphos-190* totbili-0.5 06:15am blood lipase-162* 06:15am blood calcium-9.2 phos-4.0 mg-1.7 . microbiology: 8:25 am urine site: clean catch urine culture (final ): <10,000 organisms/ml. blood culture pending . imaging: cxr : impression: low lung volumes without radiographic evidence for acute process. bibasilar atelectasis. no evidence of free air beneath the diaphragms. . ruq u/s : impression: 1. findings consistent with acute cholecystitis. 2. dilatation of the common duct, measuring up to 13 mm, suggests the presence of a distal cbd stone. 3. small hepatic lobe hypodensities are incompletely characterized and should be further evaluated with mr. 4. echogenic liver, most consistent with fat deposition, although more advanced disease such as cirrhosis and/or fibrosis cannot be excluded. . ercp : esophagus: limited exam of the esophagus was normal stomach: limited exam of the stomach was normal duodenum: limited exam of the duodenum was normal major papilla: a bulging of the major papilla was noted. cannulation: cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. contrast medium was injected resulting in complete opacification. the procedure was mildly difficult. biliary tree fluoroscopic interpretation: the bile duct was opacified with contrast. many round stones ranging in size from 5 mm to 10 mm that were causing partial obstruction were seen at the biliary tree. impression: mild post obstructive dilation was noted. bulging of the major papilla successful cannulation of the bile duct (cannulation) many round stones ranging in size from 5 mm to 10 mm that were causing partial obstruction were seen at the biliary tree. mild post obstructive dilation was noted. a sphincterotomy was performed. multiple stones and pus were extracted successfully using a balloon catheter. otherwise normal ercp to third part of the duodenum . left lower extremity : findings: grayscale and doppler son of the left common femoral, superficial femoral, deep femoral, popliteal, and proximal calf veins were performed. there is normal compressibility, flow and augmentation throughout. impression: no dvt in the left lower extremity. brief hospital course: 47 y/o m with a history of htn, hl, dmii, obesity and asthma presenting with gallstone pancreatitis and possible cholangitis with ercp c/b hypoxic respiratory distress requiring intubation. . # acute cholecystitis complicated by gallstone pancreatitis and cholangitis- patient presented with several days of ruq pain worse with food and was found to have acute cholecystitis complicated by pancreatitis. tbili, transaminases and lipase all elevated on presentation. ercp performed with removal of stones, successful sphincterotomy and removal of pus. patient was given iv unasyn prior to procedure, which was continued after the procedure and then transitioned to oral augmentin for a total 14 day course. following the procedure, the patient was afebrile and hemodynamically stable without signs of sepsis. the patient was advised that he would require a cholecystectomy in weeks as an outpatient. . # hypoxic respiratory distress- patient desaturated under sedation likely due to obesity and potential underlying obesity hypoventilation syndrome vs obstruction. he was intubated successfully, however he was difficult to ventilate. he responded well to sedation, paralysis and albuterol. the patient had asthma so he likely had bronchoconstriction that also worsened oxygenation. the patient self-extubated shortly after arrival to and respiratory status improved. once on the floor he was rapidly weaned off oxygen. he may benefit from an outpatient sleep study for osa. . # hypertension- patient's blood pressure elevated on arrival to icu. initially held home lisinopril, amlodipine and metoprolol while intubated. once his home meds were restarted, the patient's sbp remained 130-160s. this was thought secondary to saline loading from iv ns. after a day of therapy with nitrates, his sbp dropped to his normal range with home medication. . # hyperlipidemia- simvastatin held in the setting of gallstone pancreatitis. plan to restart simvastatin once lfts return to baseline. . # diabetes mellitus type ii- patient followed at for diabetes. last hgba1c checked on and was 8.4% (up from 7.3%). patient on glipizide, liraglutide, and metformin. covered with insulin sliding scale as inpatient. recs, on discharge, restart home dose metformin and glipizide, but discontinue liraglutide as it can contribute to pancreatitis. . code: full emergency contact: wife medications on admission: amlodipine 5mg po daily lisinopril 40mg po daily metoprolol tartrate 50mg po bid aspirin 81mg po daily simvastatin 40mg po daily metformin 1000mg po bid glipizide xr 10mg po bid liraglutide 1.2mg sc daily albuterol inh prn shortness of breath/wheeze fluticasone 220mcg inh clomipramine 75mg po qhs 180mg po daily discharge medications: 1. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 2. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 3. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 4. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 5. glipizide 10 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po twice a day. 6. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed for wheeze. 7. clomipramine 25 mg capsule sig: three (3) capsule po hs (at bedtime). 8. fexofenadine 60 mg tablet sig: three (3) tablet po once a day. 9. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 10. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 10 days. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: gallstone pancreatitis cholangitis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you at . you came to the hospital with abdominal pain, nausea, and vomiting. an ultrasound found gallstones, and lab work showed signs of pancreatitis. you then underwent a procedure called ercp (endoscopic retrograde cholangiopancreatography). this procedure opened up the bile duct to allow the gallbladder to drain. many gallstones were removed. pus was seen in the biliary system, a sign of infection. following the ercp, you had difficulty breathing on your own and were intubated. you were transferred to the icu (intensive care unit) to assist your breathing. you rapidly recovered and removed the breathing tube. you were then transferred to the medicine floor, where you continued to improve. you were treated with nebulizers and supplemental oxygen. after one day on the floor, you no longer needed oxygen therapy and were breathing normally. your pancreatitis, which was caused by the blocked duct in your biliary tree, was treated with iv fluids and pain relief. as you improved, you were able to eat normally without pain and your fever resolved. the infection of your biliary system was treated with antibiotics. you will need to continue antibiotics for a total of 14 days to ensure that this infection is fully resolved. we made the following changes to your medications: - stop liraglutide, as this can worsen your pancreatitis - stop simvastatin. your primary care physician, , restart this when your liver function is back to normal. - start augmentin, an antibiotic to treat the infection of the bile system. you will take this for 10 more days, last day . - hold aspirin until , then restart at your regular dose do not take any aspirin, ibuprofen (advil) or naproxen (aleve) for 5 days following your procedure. you may start taking these medications on . you will need to follow-up with your outpatient physicians: - please follow-up with your physician, , to adjust your diabetes management. please make an appointment within the next two weeks, as we have stopped one of your diabetes medications and do not want your sugar to get out of control. - you have an appointment with dr on . please ask him to do a pre-operative evaluation for your expected surgery. you will also discuss when to restart your simvastatin. - you have an appointment with dr on . at this time you will discuss the surgery to remove your gallbladder. to avoid making your gallbladder more inflammed, please follow a low-fat diet. fatty foods increase the probability of a gallstone attack and can worsen pancreatitis. followup instructions: department: when: monday at 12:00 pm with: , md building: (, ma) campus: off campus best parking: on street parking department: general surgery/ when: wednesday at 9:15 am with: dr /acute care clinic building: lm bldg () campus: west best parking: garage Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Diagnoses: Unspecified essential hypertension Other and unspecified hyperlipidemia Morbid obesity Other specified disorders of biliary tract Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Obesity, unspecified Cholangitis Acute pancreatitis Other respiratory abnormalities Calculus of bile duct with acute cholecystitis, with obstruction |
allergies: penicillins attending: chief complaint: lle ulcers major surgical or invasive procedure: : ultrasound-guided imaging for vascular access bilaterally, femoral catheterization bilaterally with bilateral femoral and extremity arteriography :right axillobifemoral artery bypass graft with ptfe. : evacuation of right anterior chest wall hematoma history of present illness: mr. is an 84m with multiple medical problems who was transferred from for eval of cellulitis/dry gangrene of the left lower extremity. it is unclear how long the cellulitis has been present as there was no discharge summary in the transfer documents and mr. is a poor historian. we do know that he has a known history of pvd with chronic skin changes and severely diminished pulses bilaterally. during an admission to for a hip fracture repair in , noninvasive arterial studies revealed severe bilateral lower extremity arterial occlusive disease, likely location is aortoiliac. no further workup was initiated at that time. past medical history: pmhx: left hip fx s/p repair, pvd, cad with icd, acute renal failure, carotid stenosis s/p repair, copd, macular degeneration, gerd, pud, anemia, chronic systolic heart failure with ef 20% pshx: b/l cea's, appy, ulcer operation (? antrectomy), icd social history: lives with son, widower of 2 years. smokes ppd. non-alcohol beer in the day and whiskey x 3 at night. family history: no family history of early cad or early sudden cardiac death. physical exam: 97.7 73 130/72 14 100%(4l) fs 112 elderly, nad, alert, oriented to self ncat. sclera anicteric. trachea midline rrr, s1,s2 aicd in place over left chest; ctabl healed scar, bs+, soft, ntnd back: sacral decub ext: 1+ edema b/l to ankles; feet cool to touch b/l lle with necrotic 5th toe, dry gangrene eschar over proximal dorsum of foot, heel, and shin/calf ?cellulitis rle with dry gangrene eschar over heel pulses: fem pt dp l weak palp weak dop - - r weak palp dop - - pertinent results: labs on admission: 05:40pm blood wbc-13.7* rbc-3.22*# hgb-10.9*# hct-33.0*# mcv-103* mch-33.9* mchc-33.1 rdw-19.6* plt ct-391 06:10pm blood neuts-76.3* lymphs-9.6* monos-11.3* eos-2.1 baso-0.6 06:10pm blood pt-14.7* ptt-32.4 inr(pt)-1.3* 06:10pm blood glucose-81 urean-27* creat-1.6* na-136 k-5.9* cl-105 hco3-21* angap-16 06:10pm blood albumin-3.1* calcium-8.6 phos-2.8 mg-2.1 07:45am blood digoxin-0.6* imaging: cxa : 1. persistent small right pleural effusion and slight increase in small-to-moderate left pleural effusion. adjacent left retrocardiac opacity may be due to atelectasis or infection. 2. new patchy opacity at right lung base, which may be due to either atelectasis or infection. rapid development since is not consistent with a neoplasm, but followup radiographs are still suggested to ensure resolution. art ext (rest only) : severe bilateral multilevel arterial occlusive disease ct abd/pelvis : 1. extensive atherosclerotic disease in the visualized arteries and aorta. complete occlusion of the abdominal aorta below the takeoff of renal arteries, without opacification of contrast of the common or external iliac arteries. there is complete occlusion of proximal left subclavian artery and origin of splenic artery. common femoral arteries reconstitutes flow from inferior epigastric arteries. visualized portions of axillary arteries are patent. superficial profunda femoral arteries are patent bilaterally. 2. atrophic left kidney presenting with ischemia/infarction of lower pole. 3. bilateral pleural effusion, left more than right, associated with collapse of the left lower lobe. 4. multiple lung lesions, the largest one in right lower lobe that has developed rapidly since and suggest infectious process. a followup ct is recommended after resolution of acute process to evaluate for malignancy. 5. severe emphysema. 6. calcification in myocardium of the left ventricle suggests prior myocardial infarction. 7. patient is status post left hip fracture with open reduction and internal fixation. 8. diverticulosis without evidence of diverticulitis. 9. aneurysm of right common femoral artery. 10. liver abnormalities ...us recommended initially. brief hospital course: patient was admitted as a transfer to the vascular service for further eval and managament of le ulcers, likely caused by severe pvd. physical exam revealed extensive lle dry gangrene ulcers secondary to severe pvd. he also has a small dry gangrene ulcer on the right foot as well. the ulcers were painful to touch and had a small amount of erythema around the ucler edges. otherwise, there was no significant signs of lle cellulitis. no edema. lower ext arterial noninvasives showed significant monophasic waveforms at the common femoral and popliteal arteries bilaterally. the dp and pt were absent. pvrs also showed dampening of the waveforms in the thigh bilaterally, left worse than right. patient was consented and prepped for angiography for . patient received bicarb drip 6 hours before and after angio for a low gfr. he tolerated the procedure well, and the angio showed he had occluded external iliacs bilaterally with no access from the groins. he also underwent a cta which showed complete occlusion of the abdominal aorta below the takeoff of renal arteries, without opacification of contrast of the common or external iliac arteries. common femoral arteries reconstitutes flow from inferior epigastric arteries. visualized portions of axillary arteries are patent. superficial profunda femoral arteries are patent bilaterally. . at this point, it was determined that without a revascularization procedure, the gangrenous ulcers would not likely heal. his blood supply to his legs was from collaterals of his hypogastrics. a cardiology consult was obtained for pre-op purposes. he underwent an echo on which showed and ef of 20-25%, along with severely depressed regional left ventricular systolic function consistent with coronary artery disease. moderate diastolic function. moderate pulmonary hypertension. it was also found that an icd lead was fractured, and ep was consulted, who recommended fixing it down the line once his other issues resolved. he was pre-oped and consented for ax fem bypass on the right and underwent surgery on . he tolerated the procedure, but was transferred to the cv-icu post-op and was put on pressors to maintain his blood pressure, though it is known he has subclavian steal on the left so his pressures are underestimated in that arm. the next day, he was extubated, but over the afternoon, was found to have a large hematoma over his anterior chest wall. he went to the or urgently for evacuation of right anterior chest wall hematoma. he returned to the cvicu post-op and did well, and was extubated the next day. by , he was ready for transfer to the vicu. when he arrived in the vicu, he needed his cordis changed over, and shortly after, he developed sustained v tach requiring an amio drip. he was transferred to the ccu. . ccu/medicine floor course 84 yo male with history of atrial fibrillation, systolic heart failure, severe pvd pod5 of right axillary bypass, who was transferred to the ccu for treatment of wide complex tachycardia. . # wide complex tachycardia: as the rate of the tachycardia was regular and around 140s, the differential diagnosis included ventricular tachycardia and supraventricular tachycardia with aberrancy including atrial flutter with aberrancy. pt has an icd which has a fractured lead, therefore not functioning. he was started on amiodarone drip at 2mg/min with effective resolution of tachycardia. pt was transitioned to po amiodarone and wct did not recur after this inital episode. he was also given beta blockers and his k and mg were repleted to keep a goal k 4 and mag 2. tamsulosin and lasix were held to prevent hypotension. electrophysiology was consulted for repair of the fractured aicd lead, but it was felt that patient was a poor candidate due to his multiple co-morbities and poor functional status. he will continue on amiodarone. . # cad: s/p anterior mi resulting in ischemic cardiomyopathy based on prior notes although no cardiac catheterization or ett in the system. continued aspirin and statin. . # chronic systolic heart failure: tte on this admission shows ef of 20-25% with grade 2 diastolic dysfunction. pt was euvolemic at ccu presentation and lasix was held during his ccu course. upon transfer out to the floor, pt was noted to have anasarca. pt was diuresed with iv lasix. continued home beta blocker and digoxin. . # pvd/dry gangrene of lle: vascular on board. vascular felt that this was not acutely infected and all antibiotics (vancomycin, cipro and flagyl) were discontinued . the necrotic left pinky toe is anticipated to self-amputate in the future. percocet elixir for pain control. wound care - dry guaze then wrap with kerlix daily. pt has a f/u with dr. of vsascular surgery. . # hyperlipidemia: continued statin . # spiculated masses seen on ct : repeat ct on showed that these changes are more consistent with infectious process rather than malignancy. however, pt was not having any active pna symptoms. wbc has decreased. afebrile. coughing stable with benign appearing sputum. ct changes may be indicative of a prior pna that have not fully resolved radiographically. - regardless broad spectrum antibiotics were continued until for toe gangrene per vascular surgery recs . # h/o copd/emphysema: pt was intermittently wheezy however he satted in mid-high 90s on room air. he was given albuterol and atrovent nebs with good effect. . # chronic renal failure: pt was at risk for atn due to contrast from vascular operations. cr hit the nadir at 1.1 however his prior baseline was 1.4-1.5. cr was stable at 1.4 at the time of discharge. renally dosed medications and avoided nephrotoxins. . # rue>lue swelling: at the side of the axillo-fem bypass. dvt was ruled out with negative u/s. it was thought to be related to post-operative state, and the swelling improved with diuresis. . # sacral decub/ leg ulcers: stage 2-3. ~10 cm round area with necrotic center. - turned patient q2hrs - wound consult following - monitor # leukocytosis: patient has had a chronic leukocytosis over the last 2 months. while this may correlate to infectious processes such as pneumonia or related to vascular related infections. he has had a bandemia of % within the last month, with small amounts of promyelocytes, metamyelocytes, and myelocytes. this will require follow-up with hematology as an outpatient to ensure that there is not an underlying hematologic disorder. medications on admission: amiodarone 200mg daily amlodipine 5mg po daily asa 81mg daily captopril 50mg digoxin 0.125mg mwf ferrous sulfate 325mg daily furosemide 20mg daily collagenase ointment daily metoprolol 100mg omeprazole 20mg daily sarna lotion qid simvastatin 20mg daily tamsolusin 0.4mg qhs thiamine 100mg daily tiotropium 1 cap ih mvi w/ minerals vit c discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. digoxin 125 mcg tablet sig: one (1) tablet po monday, wednesday, friday (). 3. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 4. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed. 5. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 7. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 8. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 9. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 10. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 11. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 12. multivitamin tablet sig: one (1) tablet po daily (daily). 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours). 14. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 15. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q2h (every 2 hours) as needed for wheezing. 16. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed: max tylenol 4 g per day. 17. lasix 20 mg tablet sig: one (1) tablet po once a day. 18. collagenase 250 unit/g ointment sig: one (1) appl topical daily (daily). 19. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. discharge disposition: extended care facility: & rehab center - discharge diagnosis: pvd w/ cellulitis/dry gangrene lle decubiti (scaral area, both buttocks and both hip areas) wide complex tachycardia chronic systolic heart failure discharge condition: stable. in sinus, hr in 60s-70s discharge instructions: you were admitted and underwent surgery to fix your peripheral vascular disease. this was complicated by a dangerous heart rhythm. you are on a medication to control this rhythm. you have a fractured defibrillator lead but there are no immediate plans to fix it due to your fragile state and other medical problems. . please keep all outpatient appointments. . if you experience chest pain, palpitations, lightheadedness, fainting, worsening pain in the leg, or any other symptoms concerning to you, please call your doctor or go to the emergency room. . weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet followup instructions: please keep the following appointments: *vascular surgery: dr. at 10:45 am. , suite 5c on , *ortho xray (scc 2) phone: date/time: 8:40 am *orthopedic surgery: , md phone: 9:00 am please also call your primary care doctor to make an appointment to follow up in 1 month. Procedure: Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Incision of chest wall Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Congestive heart failure, unspecified Atrial fibrillation Hematoma complicating a procedure Chronic kidney disease, unspecified Paroxysmal ventricular tachycardia Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Mechanical complication of automatic implantable cardiac defibrillator Old myocardial infarction Macular degeneration (senile), unspecified Other emphysema Chronic systolic heart failure Pressure ulcer, buttock Pressure ulcer, lower back Atherosclerosis of native arteries of the extremities with gangrene Long-term (current) use of aspirin Pressure ulcer, stage II Pressure ulcer, unspecified stage Pressure ulcer, stage III Pressure ulcer, hip |
allergies: penicillins / bactrim / ibuprofen / lipitor attending: chief complaint: s/p syncopal fall major surgical or invasive procedure: none history of present illness: 75f who was at the top of concrete steps holding a door open then her husband heard her scream and saw her at the bottom of the steps with loc for 2-3 minutes. ems was called and patient was a gcs 14 and brought to . a head ct showed bifrontal sah that is traumatic appearing. past medical history: high cholesterol social history: married, retired, lives with husband, denies tobacco and etoh. family history: nc physical exam: on admission: physical exam: gen: wd/wn, comfortable, nad. intermittent vomiting heent: no bruising neck: c-collar in place extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. slight confusion. orientation: oriented to person, place, and date- not year. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch coordination: normal on finger-nose-finger on discharge: gen: elderly woman sitting in chair in nad heent: op clear cv: rrr pulm: ctab abd: soft, nt, nd ext: no edema neuro: ms - wernicke's aphasia, therefore unable to test orientation as pt answers nonsensically. she is able to follow commands through mimicry but not to voice. cn - eomi, perrl 4->3, face symmetrical, tongue midline motor - 5/5 strength throughout although most instructions done through mimicry sensation - intact to lt throughout gait - walking independently, narrow based, good arm swing. pertinent results: head ct bifrontal subarachnoid hemorrhage and r occipital nondisplaced fracture ct head interval development of three foci of intraparenchymal hemorrhage in the left frontal and temporal lobes, which are consistent with progression of contusions in these regions. there is also interval increase in size of bifrontal subarachnoid hemorrhages as well as focus of intraparenchymal hemorrhage in the right temporal lobe. echocardiogram suboptimal image quality. normal study. no structural cardiac cause of syncope identified ct head stable-appearing bifrontal and bitemporal intra- and extra-axial hemorrhage and evolving right cerebellar hemorrhage. lenis : impression: no evidence of bilateral lower extremity dvt. admission labs: 10:18am blood wbc-5.3 rbc-4.51 hgb-14.2 hct-44.2 mcv-98 mch-31.4 mchc-32.0 rdw-12.6 plt ct-241 10:18am blood pt-9.6 ptt-28.4 inr(pt)-0.9 10:18am blood urean-17 creat-0.8 05:45pm blood ck(cpk)-47 10:18am blood ctropnt-<0.01 05:45pm blood ck-mb-2 ctropnt-<0.01 01:56am blood ck-mb-1 ctropnt-<0.01 01:56am blood calcium-9.0 phos-2.7 mg-2.1 03:27am blood hiv ab-negative 03:27am blood hbsag-negative 10:18am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:27am blood hcv ab-negative 10:17am blood ph-7.37 comment-green top 10:17am blood freeca-1.15 10:17am blood hgb-14.1 calchct-42 o2 sat-88 cohgb-2 methgb-1 discharge labs: 05:40am blood wbc-11.0 rbc-4.09* hgb-12.9 hct-39.3 mcv-96 mch-31.6 mchc-32.9 rdw-12.8 plt ct-325 05:39am blood glucose-112* urean-10 creat-0.6 na-137 k-4.3 cl-100 hco3-28 angap-13 05:39am blood calcium-9.3 phos-4.3 mg-2.0 brief hospital course: this is a 73 year old female seen in the emergency room after sustaining a syncopal fall down 7 stairs at church. on , the patient was admitted to neurosurgery in the tsicu. a syncope work-up was ordered. on admission the patient was oriented to self, place, month, not year. on ,in the morning the patient was somulent on am rounds. a nchct was performed which was consistent with worsening contusions. a eeg was performed which showed no seizure activity. in the late afternoon the patient's mental status was improve and patient was sitting up out of bed in a chair. the patients eyes were open spontaneously and the patient was able to follow simple commands. she was imulsive and attempting to get out of her chair. the husband and daughter were updated regarding the patients status at 2100 the patient became very aggitated, was combative and was given ativan 1mg. on , the patient's echo was negative for structural abnormality and ef was 55%. the eeg was discontinued.the patient was oriented to name, pupils were ractive, the patient was able to follow commands in all 4 extremities. there was no pronator drift. the patients husband stated that the patient definitely tripped and fell and was not dizzy and then fell. the carotid ultrasound was discontinued. : nchct was stable and she was transferred to the sdu. her foley was discontinued and she was able to void on her own. she was seen by the physical therapists on and cleared for rehab. her phosphorus was repleted. she was denied rehab from because patient in restraints. on , patient continued to be aggitated and in restraints. on her na was found to be 129 and she was started on nacl tabs 2q6. her exam remained stable and her restraints were discontinued on . on her sodium continued to be low and clinically she was lethargic. a picc line was placed and she was started on a 3% saline drip at 10cc/hr. her serum nas were followed serially and the 3% drip was titrated to maintain na > 135. she was also placed on a strict free water restriction - no free water. on her na was stable at 135. she removed her own picc and the 3% was stopped as her na was within the normal range. on her na remained stable at 137. she was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. her husband has been instrumental during her hospital stay in redirecting her and helping her with taking medications. on and patient remained stable and awaited rehab placement. she c/o leg pain, so bilateral lenis were completed which were negative. medications on admission: epipen prn levothyroxine 75mcg qd lovastatin 40mg qd omeprazole 20mg qd calcium mvi qd discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. levothyroxine 50 mcg tablet sig: 1.5 tablets po daily (daily). 3. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 4. acetaminophen 650 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 5. heparin (porcine) 5,000 unit/ml solution sig: 5,000 units injection tid (3 times a day). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 7. lovastatin 40 mg tablet sig: one (1) tablet po daily (). 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for hr <50, sbp <100. 9. epipen 0.3 mg/0.3 ml pen injector sig: one (1) intramuscular once a day as needed for allergic reaction. 10. calcium 500 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po twice a day. 11. multivitamin tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: hospital - discharge diagnosis: traumatic subarachnoid hemorrhage right occipital nondisplaced fracture syncope discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mrs. , you were seen in the hospital because of a head bleed after a fall. you were monitored, and once you were stable you were able to be sent to rehab. general instructions ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? increase your intake of fluids and fiber to prevent constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace). ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. we made the following changes to your medications: 1) we started you on docusate 100mg twice a day to help prevent constipation. 2) we started you on keppra 500mg twice a day to help prevent seizures. 3) we started you on tylenol 650mg every 6 hours as needed for pain or fever. 4) we started you on subcutaneous heparin three times a day to help prevent blood clots in your legs. you will only need to take this while you are in rehab. 5) we started you on metoprolol tartrate 12.5mg twice a day to help control your heart rate and bp. this medication will likely be stopped in the near future if your heart rate and bp remains controlled. if you experience any of the below listed danger signs, please contact your doctor or go to the nearest emergency room. it was a pleasure taking care of you on this hospitalization. followup instructions: ??????please call ( to schedule an appointment with dr. , to be seen in 4 weeks. ??????you will need a ct scan of the brain without contrast prior to your appointment. this can be scheduled when you call to make your office visit appointment. ??????we recommend you see dr in the traumatic brain injury (tbi) clinic the phone number is . if you have any problems booking this appointment please ask for . Procedure: Central venous catheter placement with guidance Diagnoses: Pure hypercholesterolemia Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Accidental fall on or from other stairs or steps Cerebral edema Syncope and collapse Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness Physical restraints status |
allergies: lisinopril attending: chief complaint: hypoxia major surgical or invasive procedure: right central venous line placement history of present illness: y.o. male with advanced dementia biba from nh with sudden onset sob, dyspneic. . pt is unable to provide history given end stage dementia. per ems records they were called to the pt's nh after he was noted to be hypoxic to 75% on ra. o2 sat increased only to 83-89% on 6l, thus pt was placed on a nrb mask. . in the ed initial vs were noted to be t102.4, hr 116, bp 124/89, rr 28, sat 75% on 15l. labwork was notable for leukocytosis of 11.3, hgb/hct 12.5/41. u/a showed large leuks, large bld, wbc >182, few bacteria. lactate was 3.6 with na 168, bun/cr 39/1.9. cxr was obtained and showed rml pna. pt was given zosyn/vanc for broad coverage for pna as well as uti. he was also placed on bipap given his hypoxia, given tylenol for a fever of 102. right ij was placed in the ed. . ros: unable to obtain past medical history: end stage dementia with delirium >10 yrs cva in with resultant aphasia and r sided weakness; tia cad chf -- icd 8 yrs ago tte in with ef 40-45%, +bubble study with small r --> l shunt recurrent uti's -- h/o ecoli and proteus with sensitivity to ctx, some resistant to cipro bph colon ca with colostomy placed ~45 yrs ago rectal ca with ap resection in vp tia recurrent aspiration pna's multiple admissions to with lgib, pna and uti in - social history: pt has been in and out of nursing homes since a major cva in and has recently been admitted to the va for hypernatremia. most recently, he comes from of where he was noted to be unable to keep up with his oral fluid intake. has a daughter who is hcp. family history: nc physical exam: admission physical exam 99.2 116 150/90 100% 4l nc gen: caucasian male laying down in bed, non verbal in nard heent: , pt does not track movements or follow commands to eval eomi cv: s1, s2, tachycardic 110, rrr resp: course bs, rhonchi over left and right mid thorax abd: no facial grimacing noted with abdominal palpation, + bs x 4, non distended, ostomy bag ext: no c/c/e skin: no rashes/no jaundice/no splinters neuro: pt is non verbal, does not follow commands. discharge physical exam 99.9 86 126/53 24 97%2 ra elderly m in no distress, awake and alert and responds to verbal stimuli but does not answer appropriately (only says "yes" over and over to any question posed) or follow commands. ctab with decreased bs's at l base s1/s2 very faint, difficult to auscultate but no gross murmurs abd soft nt nd no ble edema noted has very gross bue tremor noted, uanble to follow commands, non-conversant pertinent results: 06:47am blood wbc-7.3 rbc-2.98* hgb-8.7* hct-29.1* mcv-98 mch-29.3 mchc-30.0* rdw-15.8* plt ct-170 04:08am blood wbc-7.8 rbc-3.05*# hgb-9.0*# hct-29.4*# mcv-96 mch-29.4 mchc-30.5* rdw-15.6* plt ct-176 02:30am blood wbc-11.3* rbc-4.12* hgb-12.5* hct-41.0 mcv-100* mch-30.3 mchc-30.4* rdw-16.2* plt ct-267 02:30am blood neuts-69.5 lymphs-22.7 monos-4.1 eos-2.6 baso-1.1 11:32am blood urean-29* creat-1.7* na-154* k-3.7 cl-125* hco3-21* angap-12 04:08am blood glucose-133* urean-35* creat-1.9* na-157* k-3.7 cl-125* hco3-24 angap-12 11:39pm blood urean-37* creat-1.9* na-160* k-3.2* cl-129* 07:21pm blood urean-37* creat-1.9* na-164* k-3.5 cl-130* 03:00pm blood urean-34* creat-1.9* na-162* k-3.7 cl-132* 10:23am blood urean-33* creat-1.9* na-163* k-3.7 cl-133* 02:30am blood glucose-157* urean-39* creat-1.9* na-168* k-3.8 cl-132* hco3-23 angap-17 04:08am blood albumin-2.2* calcium-7.7* phos-1.9* mg-1.9 11:32am blood phos-1.5* mg-1.7 11:12am blood type-mix po2-43* pco2-39 ph-7.37 caltco2-23 base xs--2 11:12am blood lactate-3.3* 02:44am blood lactate-3.6* 11:12am blood o2 sat-75 02:15am urine color-dkamb appear-cloudy sp -1.020 02:15am urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-lg 02:15am urine rbc-95* wbc->182* bacteri-few yeast-few epi-1 11:20am urine hours-random creat-170 na-19 k-83 cl-34 11:20am urine osmolal-514 11:20 am urine source: catheter. **final report ** urine culture (final ): yeast. 10,000-100,000 organisms/ml.. 2:21 am urine site: not specified top hold # 64392a . urine culture (preliminary): yeast. 10,000-100,000 organisms/ml.. time taken not noted log-in date/time: 6:45 am urine 0090a. **final report ** legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. (reference range-negative). performed by immunochromogenic assay. a negative result does not rule out infection due to other l. pneumophila serogroups or other legionella species. furthermore, in infected patients the excretion of antigen in urine may vary. blood culture pending x2 ekg baseline artifact. probable sinus tachycardia. left bundle-branch block with marked left axis deviation. no previous tracing available for comparison. suggest repeat tracing and clinical correlation. cxr findings: the tip of the right ij line is in the upper svc. there is a pacemaker in place. there is no pneumothorax. vascular congestion and mild interstitial edema indicate cardiac dysfunction despite normal heart size. bibasilar opacification, more at the left, is either atelectasis or pneumonia. blunting of the left costophrenic is most likely a small pleural effusion. impression: 1. mild pulmonary edema and small left pleural effusion. 2. possible bibasilar pneumonia, suspect aspiration. 3. right ij line ends in upper svc. no pneumothorax or other complication. findings: in comparison with the study of , there is continued enlargement of the cardiac silhouette with mild elevation of pulmonary venous pressure, small effusions, and bibasilar atelectatic change, more prominent on the left. the possibility of supervening pneumonia at the bases cannot be excluded in the appropriate clinical setting. right ij catheter and pacemaker devices remain in place. records obtained from : - ct head : low attenuation of periventricular white matter, volume loss sulcal and ventrular prominence, no acute abnml - ct l spin : djd, disc bulges - ct head : advanced chronic microvascular ischemic changes, atherosclerosis of ica - d/c summary for hypernatremia and uti -- admitted with fever 101, ams, serum na 171, ua with uti. free h2o deficit 10l, na was 150 and pt advanced to po food/water. given ctx x5 days for uti and pt defervesced. had troponin leak. palliative care consulted (severe baseline dementia, cva, no longer oriented. fully dependent on others for care, says very few words at baseline; comfort focused care suggested to family and "do not hospitalize" also suggested) - echo : mild hypertrophy of lv, severe inferior hk, 40-45%, dilated aortic root, 1+ mr, moderate lae, mod tr, pasp 36, - echo : 40-45%, lvh, mild , no signficant valvular disease, otherwise not much different from previous, again visualized r to l shunt brief hospital course: yom with h/o cva in with residual aphasia and weakness, end stage dementia with delirium, cad/chf, and multiple admissions to and the va for recurrent uti's and aspiration pna's who was admitted to micu green after being found hypoxic at of , now discharged back with plans for hospice care. 1. hypoxia: noted to be 75% at nh, 75% on 15l in the ed so placed on bipap and admitted to micu where he was able to be weaned to 4l nc by micu admission and ra by discharge. etiology is likely aspiration given h/o recurrent aspiration, bibasilar opacifications with suspicion of aspiration; also with some mild pulmonary edema (was not diuresed due to hyperna). pt weaned to ra without difficulty through admission. pt initially covered broadly with iv abx -- zosyn, vancomycine, levaquin. after discussion with palliative care, the hcp/daughter stated that it would be against goals of care for pt to be discharged with picc for continued iv therapy; she requested that the team find a suitable oral abx if pt able to take po. pt was switched to amoxicillin-clavulanate for 8 day course. of note, unable to obtain sputum cx but legionella urinary ag negative. of note, after receiving records from , pt has h/o recurrent admissions for aspiration pna's. 2. hypernatremia: na 168 on admission. recent h/o several admissions for hypernatremia, as recently as several weeks ago to the , in which pt was again hyperna to 170 which improved with ivf's. likely due to poor po intake given severe deficits from cva in 3/. pt was hydrated with hypotonic ivf's at an acceptable rate and na improved to 154 by discharge. should continue to attempt oral hydration if able from mental status perspective and recheck na if consistent with goals of care. 3. renal failure: pt with cr 1.9 on admission, down to 1.7 by discharge. his baseline was unclear, but cr noted to be 2.4 at the va on . 4. hct drop: hct 41 on admission was likely hemoconcentrated, and unclear his baseline. dropped to 29.4 after ivf's which was likely dilutional as no source of bleeding, and was stable thereafter. 5. dispo: palliative care met with the pt's daughter/hcp about the non-sustainability of recent management issues regarding the hyperna and it was decided to tranfer pt back to with hospice care. therefore, pt's cvl that was placed in the ed was removed. code: dnr/dni, discharged with plans for hospice care. medications on admission: medications at nursing home (per records): donepezil 10mg qhs finasteride 5mg dsaily memantine 10mg venlafaxine 37.5mg daily honey thick liquids fleet enema prn bisacodyl 10mg prn acetaminophen 650mg q6hrs prn mom prn discharge medications: 1. augmentin 875-125 mg tablet sig: one (1) tablet po twice a day for 6 days: stop abx on . tablet(s) 2. donepezil 10 mg tablet sig: one (1) tablet po hs. 3. finasteride 5 mg tablet sig: one (1) tablet po once a day. 4. memantine 10 mg tablet sig: one (1) tablet po twice a day. 5. venlafaxine 37.5 mg tablet sig: one (1) tablet po once a day. 6. fleet enema 19-7 gram/118 ml enema sig: one (1) rectal prn as needed for constipation. 7. bisacodyl 5 mg tablet sig: two (2) tablet po once a day as needed for constipation. 8. acetaminophen 650 mg tablet sig: one (1) tablet po every six (6) hours as needed for fever or pain. 9. milk of magnesia 400 mg/5 ml suspension sig: one (1) po once a day as needed for constipation. discharge disposition: extended care facility: senior healthcare of discharge diagnosis: primary: aspiration pna, hypernatremia secondary: altered mental status, dementia discharge condition: mental status: confused - always. activity status: bedbound. non verbal discharge instructions: you were admitted to the hospital after you were found to have breathing difficulties at your nursing home. your oxygen level was low so you were placed on a breathing mask and sent to the icu. you were not intubated per your and your family's wishes. whilst in the icu you were diagnosed with a pneumonia and given antibiotics. you were also give some fluids as you were dehydrated and your salt level was high. after discussion with your daughter who is your healthcare proxy it was decided you should go back to your nursing home with hospice care. the only change to your medication regimen is the addition of augmentin (amoxicillin-clavulanate) 875 mg po bid for 6 more days, to end on . followup instructions: none md Procedure: Venous catheterization, not elsewhere classified Diagnoses: Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other persistent mental disorders due to conditions classified elsewhere Pneumonitis due to inhalation of food or vomitus Personal history of malignant neoplasm of large intestine Automatic implantable cardiac defibrillator in situ Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Do not resuscitate status Hyperosmolality and/or hypernatremia Attention to colostomy Personal history, urinary (tract) infection Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus |
allergies: niacin / lovastatin attending: chief complaint: fever major surgical or invasive procedure: intubation and mechanical ventilation () history of present illness: 87 year-old female with copd, alzheimers, prior esbl uti, non-verbal at baseline, transferred from rehab with fever, tachypnea, and hypoxia. she has had productive cough, fever to 103 x2 days. on day prior to admission, chest radiograph was negative for infiltrate, and she was started on levofloxacin for concern for aspiration pneumonia. received several neb treatments without relief, and morphine 4mg iv x1 for respiratory distress. prominent upper airway congestion, cough. prior to transfer to , 101.6, rr 42, 90% nrb. per call-in sheet, had pneumococcal vaccination , no record of influenza vaccination, and prior esbl uti. also on aspiration precautions. . of note, she was inpatient for copd exacerbation, pyelonephritis, and secondary to urinary retention. she was treated initially with vancomycin, levofloxacin, and ceftriaxone and transitioned to bactrim on discharge. . in the ed, 99.5 78 107/56 40 100%nrb. triggered for tachypnea. physical examination notable for dyspnea, use of accessory muscles, and diffuse rhonchi on auscultation. laboratory data significant for wbc 7.7, hematocrit 32.6, normal chemistry panel, troponin-t 0.03; lactate 1.1; positive ua. cxr reportedly unremarkable for acute process. ekg with nsr 90, pvc/pac, no evidence of ischemia. received vancomycin, zosyn, levofloxacin; duonebs; solumedrol; ivf 1.5l ns. on transfer to micu, rr improved to 20s; 81, 94/55, 29, 95% 6l nc. access piv x1. prior to transfer she was confirmed full code with family. . in the micu, patient is nonverbal. she responds to daughter's voice. past medical history: 1. end-stage alzheimers dementia, non-verbal 2. copd 3. pulmonary nodules 4. ?cad ?mi in ; normal dipyridamole thallium in . 5. osteoarthritis 6. cataracts. 7. chronic back pain and hip pain 8. hearing loss 9. varicose veins 10. heart murmur 11. breast cancer in the left breast back in treated with radiation and tamoxifen, which was later changed to arimidex. 12. osteopenia with history of atraumatic vertebral fracture. 13. abnormal endometrial, worked up by ob/gyn in the past. 14. hypercholesterolemia. 15. status post cholecystectomy in . 16. status post umbilical hernia repair. 17. rib fractures. 18. actinic keratoses. 19. posterior vitreous detachment. 20. hypertension. 21. history of vertigo. 22. headaches with negative workup in the past. social history: former criminal lawyer. 3 children. quit smoking 30 years ago; previously was heavy smoker. no alcohol, illicit drug use. family history: non-contributory physical exam: admission physical exam: 99.0, 75, 104/65, 28, 94%6l general: responds with movement to verbal, painful stimuli; tachypneic : dry mucous membranes; oropharynx clear neck: jvp below angle of mandible lungs: coarse breath sounds with expiratory wheezes throughout; no appreciable rhonchi or crackles cv: difficult auscultation given loud breath sounds; rrr, normal s1/s2, no appreciable murmurs abdomen: normoactive bowel sounds; soft, nontender; mildly distended gu: foley in place ext: warm, well-perfused; radial pulses 2+, symmetric; diminished dp/pt pulses; no lower extremity edema neuro: pupils equal and slowly reactive to light; responds to voice, painful stimuli with movement; biceps reflexes 2+, symmetric; unable to ellicit patellar reflexes . discharge physical exam: vitals: 97.0 169/65 63 24(20-30 in last 24hrs) 96%ra gen: elderly female, tahypnic, non-verbal, does not follow commands or make eye contact : , eomi, op clear neck: supple, no jvd pulm: tachypnic to 24, mild wheezing throughout all lung fields, improved from prior exam, no focal findings cv: rrr, normal s1/s2, no appreciable murmurs abdomen: nabs, nt/nd, soft gu: foley in place ext: wwp, 1+ dp/pt/radial pulses, no c/c/e pertinent results: blood counts 05:27am blood wbc-7.7 rbc-4.01* hgb-10.3* hct-32.6* mcv-81*# mch-25.7* mchc-31.6 rdw-14.8 plt ct-280 01:55am blood wbc-7.9 rbc-3.83* hgb-9.7* hct-31.8* mcv-83 mch-25.3* mchc-30.5* rdw-14.7 plt ct-243 05:00am blood wbc-7.8 rbc-4.15* hgb-10.4* hct-32.4* mcv-78* mch-25.0* mchc-32.0 rdw-15.0 plt ct-200 04:51am blood wbc-6.9 rbc-4.04* hgb-10.1* hct-31.6* mcv-78* mch-24.9* mchc-31.9 rdw-15.3 plt ct-230 chemistry 05:27am blood glucose-160* urean-18 creat-0.6 na-141 k-4.3 cl-102 hco3-30 angap-13 07:57pm blood glucose-266* urean-25* creat-0.4 na-139 k-4.0 cl-102 hco3-33* angap-8 04:51am blood glucose-162* urean-17 creat-0.4 na-140 k-3.0* cl-99 hco3-35* angap-9 micro - blood culture - negative - - respiratory viral antigen screen: positive for respiratory viral antigens. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. refer to respiratory virus identification for further information. - - respiratory virus identification reported by phone to # @1600, . positive for influenza a viral antigen. viral antigen identified by immunofluorescence. - urine culture (final ): mixed bacterial flora ( >= 3 colony types), consistent with skin and/or genital contamination. imaging - tte the left atrium is elongated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a prominent fat pad. rue doppler no evidence of dvt in the right upper extremity. brief hospital course: hospital course 87yo f w copd on chronic prednisone, alzheimer's, prior esbl uti, non-verbal at baseline, a/w fever and respiratory distress, now s/p intubation for hypoxia, found to have uti and flu swab positive for influenza a, now s/p tamiflu, abx for hcap, extubated, stable, discharged to rehab. . active # influenza / health care associated pneumonia / copd exacerbation: patient was a/w fever and acute respiratory distress, with positive nasal swab for influenza. patient sent to icu for hypoxia requiring intubation. she treated with oseltamivir, as well as azithro/vanco/meropenem for presumed hcap (given h/o esbl ecoli). course was complicated by presumed copd exacerbation, for which the patient had chronic steroids increased to stress doses. respiratory status improved and patient was extubated. patient completed eight day course of vancomycin and meropenem, five day course azithromycin, five day course oseltamivir. she was continued on nebulizers. . # uti: ua on admission suggestive of uti; given h/o erbl ecoli colonization w indwelling foley, patient started on empiric coverage (as described above). . # end-stage alzheimers demetia: patient at baseline is nonverbal with poor functional status. post-extubation she passed a speech and swallow examination to return to baseline diet ground solids / nectar liquids. given end-stage dementia, patient condition is likely expected to continue to deteriorate. family was counseled on this, and that complications from aspirations (such as pneumonia) were likely. the family was not yet ready to make further decisions regarding goals of care. . # right upper extremity swelling: likely related to picc line. dvt ruled out with upper extremity ultrasound. swelling and erythema stable. . inactive # osteoporosis: continued vitamin d and calcium. . transitional 1. code status: full code confirmed with family; discussed end of life issues with the family and they are reluctant to make any decisions as the patient's daughter (health care proxy) is currently away on vacation; given poor functional status of patient, discussed what to expect from this degenerative disease process with the family; believe that goals of care discussion regarding their thoughts on dnr/dni vs "do not rehospitalize" would be of utility once the health care proxy returns from vacation. 2. pending labs: blood culture from was pending at discharge and will need to be followed up by the patient's physicians at her rehabilitation center. 3. transfer of care: discharge summary sent with patient to rehabilitation. 4. barriers to care: as described above, patient has end-stage dementia with poor functional status; believe that family will benefit from future counseling on end of life decision-making. medications on admission: 1. albuterol neb q4 hours 2. asa 81mg po daily 3. bisacodyl suppository 10mg pr daily except sunday 4. vitamin d 1000 units po daily 5. ipratropium neb q4 hours 6. levofloxacin 500mg po x1 , then 250mg po daily (-) 7. miralax 17g po daily 8. prednisone 10mg po daily (-present) 9. acetaminophen prn 10. morphine 4mg sl at 0245 discharge medications: 1. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation q6h (every 6 hours). 2. aspirin 81 mg tablet sig: one (1) tablet po once a day. 3. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily except sunday. 4. vitamin d 1,000 unit capsule sig: one (1) capsule po once a day. 5. ipratropium bromide 0.02 % solution sig: one (1) inhalation every four (4) hours. 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) dose po daily (daily). 7. prednisone 10 mg tablet sig: four (4) tablet po once a day for 3 days: 40mg daily to continue for 3 days. 8. prednisone 10 mg tablet sig: two (2) tablet po once a day: 20mg daily to continue for 3 days after 40mg daily completes. 9. prednisone 10 mg tablet sig: one (1) tablet po once a day: 10mg daily to continue after completion of 20mg daily, ongoing. 10. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever or pain. 11. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). ml discharge disposition: extended care facility: for the aged - ltc discharge diagnosis: primary viral influenza secondary pnuemonia copd exacerbation discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. vital signs: persistently tachypnic 24-30, afebrile, satting high 90s room air discharge instructions: ms. , it was a pleasure caring for you at . you were admitted with cough and fever. you were found to have influenza and a urinary tract infection. you were having trouble breathing and needed to be intubated to help you breathe. you were treated with antibiotics and an antiviral medication. you were able to be extubated and are now stable and ready to return to your rehabilitation facility. during your hospitalization, the following changes were made to your medications: -started colace -increased prednisone (now being tapered back to your chronic dose) followup instructions: your care will be provided to your by your rehabilitation facility. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Other iatrogenic hypotension Anemia of other chronic disease Other chronic pain Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Obstructive chronic bronchitis with (acute) exacerbation Personal history of malignant neoplasm of breast Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Alkalosis Osteoporosis, unspecified Unspecified hearing loss Other complications due to other vascular device, implant, and graft Pain in joint, pelvic region and thigh Other diseases of lung, not elsewhere classified Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Backache, unspecified Flatulence, eructation, and gas pain Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Other and unspecified mycoses Influenza with pneumonia Pathologic fracture of vertebrae Swelling of limb |
allergies: niacin / lovastatin attending: chief complaint: dyspnea major surgical or invasive procedure: intubation arterial line placement history of present illness: 87 yo f wtih a history of copd on chronic steroids, dementia (nonverbal baseline), and recent admission for pneumonia requiring intubation, influenza and uti who was biba from rehab for worsening dyspnea and productive cough. duration is unclear, and patient unable to provide history. today she was found to be 87% on 4l at 10 pm, and came up to 98% on nrb. she was given atrovent neb, albuterol neb, and morphine 4 mg sl without much effect. prior to transfer vs were 99.8 (rectal), 118/76, 104, 42, 95% ra. . on arrival to the ed, patient was intubated. patient had a cxr consistent with interstitial edema versus infection, stable since prior study. she was treated with vancomycin, and ordered for zosyn but this was not given prior to transfer. she received propafol, etomidate 30 mg iv x1 and succinylcholine 120 mg iv x1 peri-intubation. after intubation she was started on fentanyl and versed drips. on transfer, vs were 98.4, 99, 99/61, with vent settings of tv 450 cc, rr 16, peep 5, 100% fio2. ekg showed sinus tachycardia with peaked t waves, but k was normal. wbc was elevated at 22. she received 1litres of fluid. prior to transfer, vs were 98.4, 101, 92/58, 14, 100%. . of note, patient was admitted to with influenza, hcap and uti. she required intubation in the icu and was treated with oseltamivir, azithro, vanco and meropenem. during this hospital stay family was reluctant to change code status because daughter/hcp was away on vacation. . in the micu, patient is intubated and sedated. . review of systems: limited by patient being on ventilator. appears comfortable past medical history: 1. end-stage alzheimers dementia, non-verbal 2. copd, fev1 81% in 3. pulmonary nodules 4. ?cad ?mi in ; normal dipyridamole thallium in . 5. osteoarthritis 6. cataracts. 7. chronic back pain and hip pain 8. hearing loss 9. varicose veins 10. heart murmur 11. breast cancer in the left breast back in treated with radiation and tamoxifen, which was later changed to arimidex. 12. osteopenia with history of atraumatic vertebral fracture. 13. abnormal endometrial, worked up by ob/gyn in the past. 14. hypercholesterolemia. 15. status post cholecystectomy in . 16. status post umbilical hernia repair. 17. rib fractures. 18. actinic keratoses. 19. posterior vitreous detachment. 20. hypertension. 21. history of vertigo. 22. headaches with negative workup in the past. social history: former criminal lawyer. 3 children. quit smoking 30 years ago; previously was heavy smoker. no alcohol, illicit drug use. family history: non-contributory physical exam: admission exam: t: 98.4 bp: 115/76 p: 100 450 cc rr 16 peep 5 fio2 100% general: sedated, not withdrawing to sternal rub : sclera anicteric, mmm, oropharynx clear, : macular on back bilaterally, extending to left flank neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge exam: t 97.5, bp 105/58, hr 58, rr 22, 100%2l, 2 bm yesterday and 1 bm this am gen: nad, comortable, confused, dementia, alert cardiac: rrr< no mrg pulm: few scattered crackled in lower lung bases bilaterally, no wheezing or rhonchi abd: soft, non distended, non tender ext: no pedal edema, warm pertinent results: admission labs: 01:00am blood wbc-22.2*# rbc-3.85* hgb-10.0* hct-30.8* mcv-80* mch-25.9* mchc-32.4 rdw-17.6* plt ct-367# 01:00am blood neuts-87* bands-1 lymphs-4* monos-7 eos-1 baso-0 atyps-0 metas-0 myelos-0 01:00am blood hypochr-1+ anisocy-1+ poiklo-normal macrocy-normal microcy-1+ polychr-occasional 01:00am blood pt-12.1 ptt-20.0* inr(pt)-1.0 01:00am blood urean-19 creat-0.6 03:01am blood glucose-276* urean-20 creat-0.6 na-133 k-4.5 cl-99 hco3-27 angap-12 01:00am blood alt-22 ast-16 ld(ldh)-254* alkphos-78 03:01am blood ck(cpk)-43 01:00am blood lipase-36 03:01am blood ck-mb-2 ctropnt-0.03* 01:00am blood albumin-3.3* calcium-8.7 phos-2.8 mg-1.8 01:09am blood ph-7.34* comment-green top 01:09am blood glucose-258* lactate-3.0* na-137 k-4.5 cl-99* calhco3-28 01:09am blood hgb-10.4* calchct-31 o2 sat-96 cohgb-1.4 methgb-0 01:09am blood freeca-1.12 05:47am urine color-yellow appear-hazy sp -1.025 05:47am urine blood-neg nitrite-neg protein-tr glucose-300 ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 05:47am urine rbc-2 wbc-6* bacteri-few yeast-none epi-<1 05:47am urine casthy-1* 05:47am urine mucous-rare micro: blood cx x2: pending urine cx x2: yeast sputum: sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): yeast(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs. respiratory culture (final ): rare growth commensal respiratory flora. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. yeast. sparse growth. staph aureus coag +. sparse growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. gram negative rod(s). rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin-------------<=0.25 s trimethoprim/sulfa---- <=0.5 s imaging: cxr: impression: mild interstitial edema with a left lower lobe opacity, which could represent an underlying pneumonia. mitral annular calcifications. video swallow; penetration without aspiration of thin barium. no aspiration with any administered preparations. 09:37am blood wbc-7.0 rbc-3.19* hgb-8.4* hct-25.5* mcv-80* mch-26.4* mchc-33.0 rdw-18.4* plt ct-275 03:30am blood neuts-86.2* lymphs-8.6* monos-4.7 eos-0.2 baso-0.2 09:37am blood plt ct-275 09:37am blood glucose-198* urean-6 creat-0.3* na-138 k-3.5 cl-101 hco3-30 angap-11 03:30am blood ast-13 alkphos-63 totbili-0.3 05:59pm blood ck-mb-3 ctropnt-<0.01 09:37am blood phos-2.4* mg-1.7 03:01am blood caltibc-230* ferritn-85 trf-177* 06:11pm blood vanco-11.4 discharge labs: 05:36am blood wbc-6.1 rbc-3.24* hgb-8.4* hct-26.4* mcv-82 mch-26.0* mchc-31.8 rdw-17.9* plt ct-244 03:30am blood neuts-86.2* lymphs-8.6* monos-4.7 eos-0.2 baso-0.2 05:36am blood glucose-151* urean-6 creat-0.4 na-139 k-3.4 cl-99 hco3-33* angap-10 05:36am blood calcium-8.3* phos-3.1 mg-2.2 brief hospital course: 87 yo f wtih a history of copd on chronic steroids, dementia (nonverbal at baseline), and recent admission for pneumonia requiring intubation and influenza who was admitted from rehab for worsening dyspnea and productive cough secondary to new pneumonia. # respriratory failure: pt with lll opacity on cxr suggestive of pneumonia. given her recent influenza, she was was covered for mrsa with vancomycin. pt also with history of esbl and was started on meropenem (day 1=). pt was initialy closely monitored in the micu where she was intubated. her pulmonary status improved and she was extubated on . pt's fevers improved and her leukocytosis resolved (wbc 22->6). for possible copd exacerbation, she was continued on prednisone 20mg daily. she will taper down to 10mg daily in 3 days. cxr showed some signs of pulmonary edema, esp in the setting of getting ivf while in the micu, and she was diursed with iv lasix (10-20mg daily for 2 days). sputum culture notable for rare growth of coag positive aureus, mssa plus some rare gnr. she had a picc placed for antibiotic course of treatment for presumed hcap. vancomycin was stopped on (completed 5 day course) and she will continue meropenem for total 7 day course (through ). aspiration concern: pt had speech and swallow video study and passed. she was restarted on dysphagia diet of pureed solids and nectar think liquids. explained to pt's family that she is at risk for aspiration. : patient with in dependent areas on back (flank regions bilaterally) and part of stomach. crosses midline so unlikely zoster. likely to be contact dermatitis as existed prior to antibiotic administration. dementia: patient non-verbal at baseline. passed swallow evaluation and was restarted on dysphagia diet. anemia: patient??????s recent hct baseline around 28-31. during this hospitalization, her hct stable around 23-25 and was 26 at time of discharge. likely hemodilutional component in setting of ivf in addition to likely marrow suppresion in setting of acute illness. pending labs: -blood cultures from transition of care: -full code, verified by family -pneumonia: will need to complete course of meropenem -aspiration: family aware of pt's aspiration risk. -anemia: would trend hct while outpatient. hct stable and trending up while inpatient. reccoment cbc check on . if hct continues to decrease, would reccomend anemia workup. medications on admission: # prednisone 20 mg daily # morphine 4 mg q2 h prn # albuterol prn # vitamin d 1000 u # ipratropium neb q4h # dulcolax suppository # miralax 17 g daily # ativan 0.25 mg q4h prn # aspirin 81 mg daily # tylenol 650 mg suppository # albuterol neb q6h # ipratropium neb q6h # senna 17.2 mg daily # zinc oxide topical . per last d/c summary # albuterol sulfate prn # aspirin 81 mg daily # bisacodyl 10 mg pr # vitamin d 1,000 unit daily # ipratropium bromide 0.02 % solution q4h # polyethylene glycol 3350 17 gram daily # prednisone 40 mg x 3 days, 30 mg x 3 days, 20 mg x 3 days, 10 mg ongoing # acetaminophen 650 mg prn # docusate sodium 100 mg discharge medications: 1. prednisone 20 mg tablet sig: one (1) tablet po daily (daily): in the next 3 days, can taper to 10mg daily and continue 10mg. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. bisacodyl 10 mg suppository sig: one (1) suppository rectal at bedtime as needed for constipation. 4. vitamin d 1,000 unit tablet sig: one (1) tablet po once a day. 5. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po once a day. 7. tylenol 325 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain: do not give more then 3g/day. 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 9. meropenem 500 mg recon soln sig: one (1) intravenous every six (6) hours for 3 days: take through for total 7 day course. 10. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day) as needed for constipation. 11. albuterol sulfate 1.25 mg/3 ml solution for nebulization sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing: prn. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: hospital acquired pneumonia chronic obstructive pulmonary disease- acute exacerbation contact dermatitis discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. followup instructions: please make sure to see your primary care doctor within the week after leaving rehab. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Central venous catheter placement with guidance Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Long-term (current) use of steroids Obstructive chronic bronchitis with (acute) exacerbation Personal history of malignant neoplasm of breast Personal history of tobacco use Acute respiratory failure Unspecified hearing loss Old myocardial infarction Methicillin susceptible pneumonia due to Staphylococcus aureus Iron deficiency anemia, unspecified Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Other specified hypotension Acute edema of lung, unspecified Dysphagia, oropharyngeal phase Contact dermatitis and other eczema, unspecified cause Personal history of pathologic fracture |
allergies: niacin / lovastatin attending: chief complaint: agitation major surgical or invasive procedure: picc line placement history of present illness: 87 year old nonverbal female with history of steroid dependent copd (20mg) on home oxygen (2l), end-stage dementia, htn, hl with an indwelling foley presenting from rehab nursing home with agitation. per the patient's daughter, was more restless and agitated last weekend, which was worse this week. she noted an increase in arm movement and twitching overall. the daughter denies any recent coughing or vomiting in her mother. daughter noted her mother's constipation and 10lb weight loss over the past month. in addition, she has had a on her back which was thought to be yeast. rehab did blood work this week which revealed a sodium of 150 but otherwise normal labs and a normal cxr. plan at that point was to push oral hydration. she was given morphine for agitation. however, her restlessness continued and "she was not herself" so her daugheter insisted that she be sent to the ed. . upon arrival to the ed, initial v/s were: 104 74 104/74 36 98% on 2l. her fever was 102 rectally. hyperglycemic to 616 and received 2l of ivf. it came down to 449 after ivf. no insulin given. ua revealed uti, so her chronic indwelling foley was exchanged. urine and blood cultures sent. cxr unremarkable here per ed with the exception of an elevated left hemidiaphragm. labs revealed a lactate of 4.4. she was given vanco/zosyn. she was given a dose of fluconazole given vulvovaginal candidiasis. looks well after fluids, better eye contact. v/s prior to transfer: 102.4 76 117/81 32 98% on 2l after 1 gram rectal tylenol. osm 353. access 20g, working on 2nd piv. on the floor, she is nonverbal, but does not appear to be in any discomfort. past medical history: 1. end-stage alzheimers dementia, non-verbal 2. copd, fev1 81% in 3. pulmonary nodules 4. ?cad ?mi in ; normal dipyridamole thallium in . 5. osteoarthritis 6. cataracts. 7. chronic back pain and hip pain 8. hearing loss 9. varicose veins 10. heart murmur 11. breast cancer in the left breast back in treated with radiation and tamoxifen, which was later changed to arimidex. 12. osteopenia with history of atraumatic vertebral fracture. 13. abnormal endometrial, worked up by ob/gyn in the past. 14. hypercholesterolemia. 15. status post cholecystectomy in . 16. status post umbilical hernia repair. 17. rib fractures. 18. actinic keratoses. 19. posterior vitreous detachment. 20. hypertension. 21. history of vertigo. 22. headaches with negative workup in the past. social history: former criminal lawyer. 3 children. quit smoking 30 years ago; previously was heavy smoker. no alcohol, illicit drug use. family history: non-contributory physical exam: physical exam: vitals: 97.5 74 115/73 78 22 100% on 2l general: alert, oriented, no acute distress, nonverbal : sclera anicteric, mmdry, oropharynx clear neck: supple, neck veins flat, compressible with inspiration, no lad lungs: bibasilar rhonchi cv: rrr, normal s1 + s2, no murmurs, rubs, gallops abdomen: +bs, soft, non-tender, markedly distended, no fluid wave, no rebound tenderness or guarding, no organomegaly, no fluid seen with ultrasound gu: +foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: 01:30pm wbc-11.2*# rbc-4.50# hgb-10.1* hct-33.7*# mcv-75*# plt ct-291 neuts-87.3* lymphs-9.9* monos-2.2 eos-0.1 baso-0.5 pt-11.9 ptt-19.4* inr(pt)-1.0 glucose-616* urean-33* creat-0.9 na-152* k-4.6 cl-113* hco3-25 angap-19 alt-18 ast-13 alkphos-41 totbili-0.4 microbiology: 1:30 pm urine site: catheter **final report ** urine culture (final ): culture workup discontinued. further incubation showed contamination with mixed fecal flora. clinical significance of isolate(s) uncertain. interpret with caution. work up gram negative rods per dr. # . proteus mirabilis. >100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing available on request. pseudomonas aeruginosa. >100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing confirmed by . probable enterococcus. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | pseudomonas aeruginosa | | ampicillin------------ =>32 r ampicillin/sulbactam-- 8 s cefazolin------------- 8 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s 2 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r 1 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s 1 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- =>16 r radiology: lower extremity ultrasounds: bilateral deep venous thrombus, right greater than left as detailed above. left cyst as well. video swallow: with nectar-thickened liquids, there is regurgitation following normal swallowing resulting in laryngeal penetration, this is all the result of a prominent cricopharyngeal bar. with thicker liquids, there is no evidence of laryngeal penetration, though pooling in the vallecula and piriform sinuses is seen. cxr : compared with , the cardiomediastinal silhouette is stable. there is patchy opacity at the left lung base. though the previously seen atelectasis appears to have improved, the degree of patchy opacity has increased. there is minimal blunting of the left costophrenic angle. there is upper zone redistribution, but i doubt overt chf. some parenchymal scarring is likely present in the right upper zone medially, but i suspect this represents a chronic finding. otherwise, no focal infiltrate and no effusion on the right side. discharge labs: 10:20am blood wbc-6.1# rbc-3.42* hgb-7.5* hct-25.5* mcv-74* mch-21.8* mchc-29.3* rdw-17.5* plt ct-238 01:30pm blood neuts-87.3* lymphs-9.9* monos-2.2 eos-0.1 baso-0.5 07:00am blood pt-27.8* ptt-37.3* inr(pt)-2.7* 06:33am blood glucose-122* urean-5* creat-0.3* na-140 k-3.6 cl-103 hco3-34* angap-7* brief hospital course: 87 yo nonverbal female with end stage dementia, copd on home o2, and chronic indwelling foley who presents from rehab with fever and agitation. # severe sepsis: patient presented with altered mental status, found to have fever, leukocytosis with left shift, elevated lactate, and renal dysfunction. differential for source included urosepsis given +ua vs. pneumonia given spine sign. this was felt most likely urosepsis given +leukocyte esterase and +wbc on urinalysis, and ucx with gnr which later speciated to be pseudomonas and proteus with some likely enterococcus as well. patient was initially covered with vanco/zosyn in anticipation of resistant organisms as patient is nursing home resident. she was fluid resuscitated and placed on stress dose steroids for her hypotension, which resolved. her left shift resolved and her u/a cleared. she was transitioned to meropenem and vancomycin when it was discovered she had a history of esbl infections. she was treated for 8 days with vancomycin to cover hcap and 14 days of meropenem (until ) to cover complicated uti given resistant organisms and chronic indwelling foley. # aspiration: patient was noted to aspirate with oxygen desaturations down to the 70's with all consistencies. aspiration was confirmed by video swallowing study as well. given the persistent aspiration, the decision was made by the health care proxy (daughter) to make her dnr/dni, not place a feeding tube, transition to palliative care (which can be provided at rehab) and allow her family to feed her for comfort as this would be in keeping with the patient's wishes. # hypernatremia: na 149 on admit, up to 158 at its peak. her hypernatremia resolved with d5w and lactated ringers for fluid boluses. she was maintained on iv fluids for supplementation during the time of the goals of care discussions, but developed shortness of breath on and the fluids were tapered to off. a cxr at that time noted slight increased pulmonary vascular markings. the patient's shortness of breath improved once the fluids were discontinued, with the agreement of her daughter at the bedside. upon discharge to rehab, ivf should be maintained as needed to maintain hydration and na between 135 and 145. # acute kidney injury: creatinine increased to 0.9 from baseline 0.3, currently 0.4. most likely pre-renal given insensible losses from fever and infection and patient's extreme appearance of hypovolemia on exam. her medications were renally dosed, and her resolved with fluid challenges. # hyperglycemia: pt presented with initial glucose >650, presumed secondary to stress from sepsis, compounded by severe dehydration from osmotic diuresis and home steroids. no history of diabetes. insulin naive. covered by sliding scale while in the hospital and can be continued at rehab although she required only minimal insulin coverage prior to discharge. # copd: no wheezing on exam throughout her hospitalization. she was continued on her home nebullizers and transitioned from stress dose steroids back to her home dose of 20mg prednisone. # acute bilateral lower extremity dvt's: patient was initially placed on a lovenox to warfarin bridge. in discussions with her family regarding goals of care, the decision was made to continue the warfarin at this time, and re-assess the use of this medication with her nursing home team if her condition changed or if she was unable to take medications orally. the patient's inr should be monitored at rehab with a goal inr of . coumadin was held on given significant rise in inr with 5mg po coumadin daily and should be restarted at 3mg po daily to be titrated based on inr. # goals of care: palliative care was consulted during the admission. serial discussions were held at the bedside, with the medical team and daughter during the admission. the patient's daughter reports that her main goal is that the patient remain as comfortable and at peace as she appears during the admission. the daughter notes that she is hopeful to have more time with her mother, although she realizes that the patient has end-stage dementia and that this is contributing to her increasing medical decline. she enjoys the time that she has with her mother, and notes that her brother does as well. she suspects that he will have trouble coping with the patient's worsening prognosis. we encouraged the daughter to seek out support in an ongoing manner from the medical team, including the team, as she reported that the conversations and meetings during this admission had helped 'lift a weight of guilt' from her, as she has faced the severity of her mother's illness. #code: dnr/dni medications on admission: (patient unable to provide, transferred from rehab facility) discharge medications: 1. glucagon (human recombinant) 1 mg recon soln sig: one (1) mg injection q15min () as needed for hypoglycemia protocol. 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath. 3. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) dose po daily (daily). 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 8. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q 12h (every 12 hours). 10. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 12. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm: please titrate to goal inr . 13. meropenem 500 mg recon soln sig: five hundred (500) mg intravenous every six (6) hours for 6 days. 14. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 15. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 16. insulin sliding scale please follow regular insulin sliding scale ac as included in discharge paperwork. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: urosepsis pneumonia aspiration alzheimer's dementia deep venous thrombosis discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: it was a pleasure to care for you during this admission. you were admitted to the hospital with confusion and low blood pressures and were found to have a urinary tract infection and a possible pneumonia, for which you were treated with iv antibiotics. you were also found to have a blood clot in your legs and were started on an anticoagulant called coumadin. you will need to have your inr monitored at your rehab while on this medication. you also had a swallowing study and it was found that you are not able to swallow safely. the decision was made to transition your care to focus on treating the symptoms that were bothering you, after discussions with your family. you are being discharged to complete a course of iv antibiotics and on coumadin for which you must have your inr monitored with a goal inr of . followup instructions: you will be followed by your doctors rehab and by the palliative care service there. ongoing discussions about goals of care, given your daughter's awareness that recurrent infections are likely, case-by-case discussions of indications and timing of use of antibiotics and iv fluids will be helpful. at the time of discharge you should continue iv meropenem until . coumadin should be titrated to goal inr . ivf should be administered to maintain euvolemia and na between 135 and 145. would consider checking labs every other day at rehab until trajectory of outpatient labs can be best discerned. Procedure: Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Severe sepsis Chronic airway obstruction, not elsewhere classified Hypopotassemia Other and unspecified hyperlipidemia Pneumonitis due to inhalation of food or vomitus Other septicemia due to gram-negative organisms Do not resuscitate status Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Candidiasis of vulva and vagina Infection and inflammatory reaction due to indwelling urinary catheter Other dependence on machines, supplemental oxygen |
allergies: sulfa (sulfonamide antibiotics) / iodine containing agents classifier attending: chief complaint: right sided motor seizures major surgical or invasive procedure: left frontal/parietal crani for tumor resection history of present illness: 51 y/o female who initially presented to the ed after having a right sided motor seizure while ridding her bike. ct revealed a left parasagital tumor. past medical history: high cholesterol, migraines social history: lives at home with husband 3 kids 16/19/22 family history: nc physical exam: exam on discharge: awake, alert and oriented x3 perrl, eomi face symmetric, tongue midline strengths: t d b tr g ip q h at g r 1 1 1 1 0 4+ 4+ 3 2 3 1 sensation intact to light touch, symmetric ambulating with cane no clonus tolerating po diet. no pain. voiding without difficulty incision- well healing. staples intact, no drainage x3 days pertinent results: : post operative ct: the patient is status post left frontoparietal craniotomy with resection of large falcine mass in the left frontal lobe. there is postoperative pneumocephalus, fluid, and edema. there is no evidence of hemorrhage, infarct, mass, or mass effect outside of the surgical field. there are no osseous abnormalities other than craniotomy. sinuses and mastoid air cells are well pneumatized. impression: expected postoperative appearance, status post left frontal craniotomy and mass resection. : mri head: impression: status post resection of falx meningioma with expected post-surgical changes. normal enhancement of the superior sagittal sinus is noted. mild meningeal enhancement is seen. no evidence of acute infarcts or hydrocephalus. head ct:impression: expected post-surgical changes as above, showing interval decrease in the volume of pneumocephalus. note added at attending review: there has been a slight increase in the volume of hemorrhage at the surgical site. there is not enough to produce mass effect, but continued close follow up is recommended. this information was paged to dr. at 10:20 am on . head ct: impression: stable appearance of the brain with post surgical changes and persistent left vasogenic edema. no evidence of new abnormalities. eeg: pending. verbal preliminary report- slowing but no definitive seizure activity. mri head: pending brief hospital course: mrs. was admitted on to udergo an elective craniotomy for tumor resections. after a mri for operative planning she was brought to the operating room. she was quite hypertensive pre-operatively. surgical course was uncomplicated. post operatively she was taken to the icu for q one hour neuro checks and blood pressure control, which only required and responed well to a few doses of hydralazine. her physical exam was noted to be a different post operatively, particularly with right extremity weakness particularly in her trap, delts and triceps. she also was noted to have distal right lower extremity weakeness. given the extensive edema that was seen on ct we increased her decadron dose to 6mg q 4 and noted an improvement in her exam by pod #2. post operative head ct and mri were stable, revealing post operative changes. she was safe and stable and transfer to the floor was written for on . pt and ot and were consulted and recommended discharge home with outpatient pt. on pm she developed right sided ascending paresthesias that lasted a few minutes and left her right arm plegic. a head ct was performed but stable. eeg monitoring was ordered and keppra was increased to 1500mg . on her incision began oozing with large clots. her sqh was discontinued. on her neurological exam was slightly improved. a repeat head ct was obtained prior to the eeg leads being attached. this was found to be stable. eeg monitoring was initiated. on eeg monitoring was continued. her neurological exam remained stable. preliminary on eeg is significant for slowing but no definitive seizure activity. at this time it was discontinued and an mri with perfusion was requested. on she was again neurologically stable. mri was completed and she was fitted for an afo brace to be worn when out of bed. she was cleared at this time for discharge home with outpatient pt. medications on admission: lipitor 10mg qd singular 10mg qd ? protonix discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime). 3. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 4. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 7. levetiracetam 500 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*3* 8. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 9. dexamethasone 2 mg tablet sig: taper tablet po taper for 4 weeks: * 2 tabs q6hrs * 2 tabs q8hrs * 2 tabs q12hrs * 1 tab q12hrs * tab q12hrs * tab qday . disp:*qs tablet(s)* refills:*0* discharge disposition: home with service discharge diagnosis: s/p craniotomy and meningioma excision discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. discharge instructions: general instructions ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? you may wash your hair after 72 hours from your surgery, you should initially just use a mild shampoo or just water run over it. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: follow-up appointment instructions/ ??????please return to the office next thursday for removal of your staples/sutures and/or a wound check. this appointment can be made with the np or pa. please make this appointment by calling . if you live quite a distance from our office, please make arrangements for the same, with your pcp. ??????please call ( to schedule an appointment with dr. , to be seen in ___4____weeks. ?????? you have a brain clinic appointment on at 9:30am on 8. Procedure: Excision of lesion or tissue of cerebral meninges Diagnoses: Unspecified essential hypertension Other convulsions Other and unspecified hyperlipidemia Disturbance of skin sensation Benign neoplasm of cerebral meninges Cerebral edema Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Monoplegia of upper limb affecting dominant side |
allergies: penicillins / sulfa(sulfonamide antibiotics) attending: chief complaint: dizziness major surgical or invasive procedure: colonoscopy history of present illness: 67 y/o m with avr on coumadin, diverticulosis, and past history of ulcers and pyloroplasty who presents from with a downtrending hct and evidence of gi bleeding. the patient received a screening colonscopy 5 days ago () at which resulted in the resection and retrieval of 4 polyps and evidence of diverticulosis. by report, the patient tolerated the procedure well and was discharged home. the following day (), mr. some mild dizziness, followed by the need to pass a large bm on at 5am which resulted in significant passage of brbpr. he contaced dr. , the gastroenterologist at who performed his colonoscopy, who advised that he go to the ed. a subsequent colonscopy on was unsatisfactory, and thus the patient was admitted to the wards for observation, where he exhibited a persistently downtrending hct from (42 -> 34.9 -> 33.8 -> 27.7) and expressed significant abdominal discomfort, dizziness and orthostatic hypotension. given these continuing symptoms and decreasing hct, a technetium bleeding scan was performed on which revealed extravasation at hepatic flexure, and the patient was subsequently transfered to the micu. on arrival to the micu, the patients vitals were: t 98.5, hr 93, bp 135/62, rr 22, o2sat 100 on 2l, 93-94 on ra. he reports fatigue, light-headedness and abdominal cramping. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: 1) aortic aneurysm repair 2) st. mechanical valve on lovenox 3) tortuous vertebrobasilar intracranial arteries (by mri/mra ) 4) ulcers and pyloroplasty at age 13 5) seizure disorder (3 seizures in past 6 months) 6) mild emphysema 7) osa, sleeps with oxygen by nasal canula social history: - tobacco: 35 pack-year history. quit 20 yrs ago. - alcohol: occasional drinking. - illicits: none family history: no history of bleeding disorders. physical exam: admission exam: vitals: t: 98.5 bp: 135/82 p: 93 r: 22 o2: 100 on 2l general: alert, oriented, no acute distress heent: sclera anicteric, pale conjunctiva, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, audible s1 click from valve replacement lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: distended, tender to mild palpation in the ruq + rlq and bilateral flanks. hyperactive bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. neuro: grossly intact discharge exam: vitals - 97.7 140/80 68 20 95%ra general - well-appearing man in nad, comfortable, appropriate heent - nc/at, perrl, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, audible s1 click from valve replacement abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) skin - petechial type rash on back neuro - awake, a&ox3, cns ii-xii grossly intact pertinent results: admission labs: 04:16pm blood wbc-16.6* rbc-3.11* hgb-9.9* hct-31.0* mcv-100* mch-31.8 mchc-32.0 rdw-14.4 plt ct-202 04:16pm blood neuts-88.4* lymphs-8.0* monos-3.2 eos-0.3 baso-0.2 04:16pm blood pt-14.6* ptt-35.9 inr(pt)-1.4* 04:16pm blood glucose-112* urean-10 creat-1.1 na-143 k-4.1 cl-109* hco3-26 angap-12 04:16pm blood albumin-3.4* calcium-8.4 phos-2.3* mg-1.8 cbc trends: 09:44pm blood hct-29.8* 09:40am blood wbc-17.0* rbc-2.88* hgb-9.0* hct-28.2* mcv-98 mch-31.2 mchc-31.9 rdw-15.0 plt ct-243 03:38pm blood hct-24.8* 09:36pm blood hct-28.3* 01:36am blood wbc-10.4 rbc-2.60* hgb-8.1* hct-24.8* mcv-95 mch-31.0 mchc-32.5 rdw-15.4 plt ct-192 06:46am blood hct-30.1* 09:54pm blood hct-25.9* 09:55am blood hct-29.0* 12:49am blood hct-27.0* 03:34am blood wbc-7.1 rbc-3.35* hgb-10.0* hct-30.6* mcv-92 mch-29.9 mchc-32.7 rdw-15.2 plt ct-192 discharge labs: 06:05am blood wbc-5.7 rbc-3.31* hgb-9.8* hct-31.1* mcv-94 mch-29.7 mchc-31.6 rdw-14.8 plt ct-249 10:40am blood pt-19.5* ptt-94.5* inr(pt)-1.8* 06:05am blood glucose-99 urean-6 creat-1.1 na-140 k-3.4 cl-103 hco3-28 angap-12 06:05am blood calcium-8.2* phos-3.7 mg-1. ct abdomen and pelvis (): 1. sub-4-mm bilateral lower lobe pulmonary nodules. in view of the patient's smoking history, a ct chest is recommended. 2. layering hyperdensity within the cecum adjacent to the ileocecal valve, which could be consistent with hemorrhage in this area. no active extravasation is identified throughout the abdomen and pelvis. 3. left adrenal adenoma. 4. variant hepatic arterial anatomy with a replaced left hepatic artery arising from the left gastric. the sma is noted to have a common origin from the celiac artery. colonoscopy polyp in the ascending colon diverticulosis of the sigmoid and descending colon tattooing and scarring seen at the site of the former polypectomy at the hepatic flexure 3 clips seen in the rectum, no active bleeding cecal ulcer with vessel at the site of former polypectomy (endoclip, endoclip) linear areas of superficial bleeding in the cecum consistent with barotrauma otherwise normal colonoscopy to cecum brief hospital course: 67 y/o m with avr on coumadin, diverticulosis, and past history of ulcers and pyloroplasty who presented from with a downtrending hematocrit and evidence of gi bleeding. #. gi bleeding: patient presented with hematocrit of 31. given his history and recent colonoscopy, there was concern for persistent bleeding from a retracted polyp at hepatic flexure or from rectal tears. gi and ir were consulted upon admission. a ct scan of the abdomen and pelvis was performed to attempt to localize the bleed but no contrast dye extravasation was observed. his coumadin was held and he was placed on a heparin drip. his ptt goals were reduced daily as the patient continued to have melena. ultimately, the decision was made to stop anti-coagulation to allow the bleeding to stop on its own, which all teams involved expected. he ultimately required 5 units of prbc transfusions, which were performed when his hematocrit fell below 27. on the patient had a colonoscopy which showed a polyp in the ascending colon, diverticulosis of the sigmoid and descending colon, tattooing and scarring seen at the site of the former polypectomy at the hepatic flexure 3 clips seen in the rectum, no active bleeding, cecal ulcer with vessel at the site of former polypectomy (endoclip, endoclip). linear areas of superficial bleeding in the cecum consistent with barotrauma, otherwise normal colonoscopy to cecum. the patient's hct stabilized after his heparin drip was discontinued. the patient was transferred to the floor and ultimately the heparin drip and warfarin were restarted on . the patient's hct remained stable and his inr trended upwards. he was discharged on with plans to continue bridging therapy with lovenox until inr was > 2.5. he will follow-up with his pcp and coumadin clinic at medical group this coming week. #. uti: several days into his hospitalization (on ), he developed dysuria. a urinalysis was performed and was frankly positive for a uti. ceftriaxone was started on the morning of . on a presumptive idenitification of > 100,000 cfu/ml of e. coli was identified. the patient was transitioned to ciprofloxacin and a course of 7 days was planned. the patient was informed of the potential for warfarin potentiation with this medicaiton. #. leukocytosis: patient presented with wbc of 16.6 with a left shift of 88% pmns. patient had no infectious symptoms on presentation and this was attributed to a stress response and resolved by day 3 of admission. #. seizure disorder: will continue keppra 500 mg po bid #. osa: will continue oxygen by nasal cannula at night. transitional issues: - sub-4-mm bilateral lower lobe pulmonary nodules. in view of the patient's smoking history, a ct chest is recommended on ct abd/pelv. should be followed by his pcp. inr with goal 2.5-2.5 medications on admission: 1) morphine 15 mg q4-6hr prn 2) metoprolol 25 mg po daily 3) citalopram 10 mg po daily 4) omeprazole 40 mg po daily 5) coumadin 7.5 mg po daily 6) simvastatin 20 mg po daily, at bedtime 7) keppra 500 mg po bid discharge medications: 1. outpatient lab work please check a cbc in 3 days on thursday, and have results faxed to: fax: ( attn: dr. 2. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 3. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 4. simvastatin 10 mg tablet sig: two (2) tablet po hs (at bedtime). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 6. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 7. warfarin 2.5 mg tablet sig: three (3) tablet po once daily at 4 pm. 8. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 3 days. disp:*6 tablet(s)* refills:*0* 9. lovenox 150 mg/ml syringe sig: one y five (125) mg subcutaneous twice a day: please use until your inr is above 2.5. . 10. outpatient lab work please check your inr daily and have results faxed to your primary care doctor's office. discharge disposition: home discharge diagnosis: lower gi bleed colonic polyp in ascending colon small pulmonary nodules discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , you were admitted to for a lower gastrointestinal bleed after you had polypectomies performed. you were initially admitted to the intensive care unit and given blood until your blood counts stabilized. our gi doctors also performed a colonscopy which did not show any significant active bleeding that required further intervention. your anticoagulation was briefly stopped while you were bleeding but now it has been restarted. you will be discharged with plans to continue lovenox until your inr is above 2.5. a follow-up appointment with your primary care doctor has been made for you. see below for changes made to your home medication regimen: 1) plase use lovenox injections 125mg twice daily until your inr is above 2.5 2) please continue ciprofloxacin 500mg twice daily for 3 additional days you will need to have a blood count checked 3 days after discharge with results faxed to your primary care doctor. please check your inr daily. see below for instructions regarding follow-up care: followup instructions: name: , np location: medical group address: , 3a, , phone: appt: at 11am please check your inr with your home machine tomorrow. be in touch with the clinic at medical for dosing adjustments. Procedure: Endoscopic destruction of other lesion or tissue of large intestine Diagnoses: Obstructive sleep apnea (adult)(pediatric) Urinary tract infection, site not specified Acute posthemorrhagic anemia Accidental puncture or laceration during a procedure, not elsewhere classified Heart valve replaced by other means Hemorrhage complicating a procedure Other specified cardiac dysrhythmias Other emphysema Long-term (current) use of anticoagulants Benign neoplasm of colon Diverticulosis of colon (without mention of hemorrhage) Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy Other and unspecified Escherichia coli [E. coli] |
allergies: no known allergies / adverse drug reactions attending: chief complaint: headache/ r sdh major surgical or invasive procedure: right craniotomy for sdh evacuation history of present illness: 57m who reports a headache that began two days prior after coughing. the headaches progressively worsen and he went to a osh er where a head ct showed a subdural hematoma. patient reports taking two aspirin on the day of admission. past medical history: htn high cholesterol social history: lawyer, lives with family. nonsmoker, drinks 3-4 glasses a day of champagne family history: non-contributory physical exam: on admission: physical exam: o: t: 97 bp: 147/87 hr: 54 r 14 o2sats 97% gen: wd/wn, comfortable, nad. extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch coordination: normal on finger-nose-finger discharge: alert and orientated x 3 no pronator drift incision clean/dry/intact full motor bilateral upper and lower extremities sensation grossly intact to light touch pertinent results: head ct: 10mm acute right subdural hematoma with 12 mm if leftward shift. chest xray: impression: mild hyperinflation. heart size borderline or slightly enlarged. no chf or focal infiltrate. possible trace right pleural fluid. head ct: large right subdural hematoma spanning the parietal, occipital, temporal and frontal lobes measuring 1 cm in maximal axial dimension which causes leftward shift of the normally midline structures slightly increased from prior film. head ct postop: 1. interval evacuation of right subdural hematoma, with moderate amount of pneumocephalus and small residual right parieto-occipital hemispheric subdural hematoma. no new intraparenchymal or extra-axial bleed. 2. resolution of the leftward shift of midline structures. brief hospital course: 57m admitted to the neuro icu with a acute right sdh with midline shift. on admission, his neuro exam was nonfocal. he was made npo for possible or in the morning. a repeat head ct on am showed stable amount of blood product but increased mass effect with worsening midline shift and so he was taken urgently to the or for evacuation. a subgaleal drain was placed. postoperatively he was extubated and transferred to the icu. postop head ct showed near total evacuation of sdh and resolution of midline shift. he remained neurologicaly intact. on morning rounds on he was doing well and deemed fit for transfer to the floor. his foley was removed and his diet was advanced. his jp drain put out minimal and was removed in routine fashion. now dod, patient is afebrile, vss, and neurologically stable. patient's pain is well-controlled and the patient is tolerating a good oral diet. pt's incision is clean, dry and intact without evidence of infection. his drain was removed and a simple interrupted suture was placed. he was evaluated by pt/ot and he was cleared for home. patient is ambulating without issues. he is set for discharge home in stable condition and will follow-up accordingly. medications on admission: lipitor 20mg daily ? bp med (pt unsure of name/dose) discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/ fever. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*0* 4. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 5. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 6. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for headache. disp:*60 tablet(s)* refills:*0* 7. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 8. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). discharge disposition: home discharge diagnosis: right subdural hematoma with midline shift cerebral edema 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 and/or staples have been removed. if your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: ??????please return to the office in days(from your date of surgery) for removal of your staples/sutures and/or a wound check. this appointment can be made with the nurse practitioner. please make this appointment by calling . if you live quite a distance from our office, please make arrangements for the same, with your pcp. ??????please call ( to schedule an appointment with dr. , to be seen in weeks. ??????you will need a ct scan of the brain without contrast. Procedure: Incision of cerebral meninges Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Cerebral edema Subdural hemorrhage |
allergies: no known allergies / adverse drug reactions attending: chief complaint: acute renal failure, hypernatremia, hyperkalemia major surgical or invasive procedure: egd with biopsy history of present illness: 77m w/hx of cva (left sided weakness), htn and dementia presenting from the nursing care facility with concerns for abnormal labs. patient was found to be hyperkalemic. patient has been not taking in good p.o. he has been spitting his pills and food back out when he is given them. he also had one episode of vomiting earlier today, nonbilious nonbloody. he is afebrile and otherwise well. no increased lethargy noted in nursing facility notes. patient is minimally verbal, and therefore unable to obtain history from patient. in the ed, he was chewing on his iv, refusing treatments, he was noted to be incontinent of urine but refusing foley. per report, he was behaving in such manner at the rehab as well. initial vs were: t 95.6 p 83 bp 127/70 r 16 o2 sat. 98%ra. ekg was notable for peaked lateral t waves, no st elevations/depressions. patient was given calcium gluconate, dextrose, insulin, kayexalate, and 2 l fluid and then admitted. on the floor, patient was calmly resting in bed, without any apparent distress. vitals were hr of 52, bp of 125/83, spo2 of 98% on room air. he was minimally verbal. review of sytems: could not be performed due to patient's inability to speak. past medical history: #stage iii ckd - creatinine 1.4 in #cva (left-sided weakness) #hypertension #hyperlipidemia social history: (per records) the patient came from a facility but had recently been living home with his children. past history of smoking but did not smoke in at least 12 months. no recent alcohol. family history: unable to obtain as pt nonverbal. physical exam: on admission: vitals: t: afebrile, sbp 120s, hr 55, rr 12 99%on2l general: elderly, thin male laying in bed frequently moving. alert, doesn't follow commands or answer questions. heent: sclera anicteric, mmm, oropharynx clear lungs: breathing comfortably, ctab cv: rrr, no mrg abdomen: +bs, soft ntnd ext: warm, 2+ pulses, no clubbing, cyanosis or edema large stage iii malodourous ulcer on right heel with green discharge. neuro: oriented to self, unable to follow commands, partly due to language barrier, cnii-xii intact grossly, but weak on left side. discharge physical exam: physical exam: vitals: 98, 128/64, 67, 18, 97 ra general: comfortable today. sitting and interacting heetn: nc at cv: rrr lungs: ctab abdomen: soft, nttp, no guarding extremities: no swelling, pulses 2+ pertinent results: 02:10pm plt count-449* 02:10pm neuts-81.6* lymphs-14.9* monos-2.4 eos-0.7 basos-0.3 02:10pm wbc-11.6* rbc-5.13 hgb-14.9 hct-48.0 mcv-94 mch-29.1 mchc-31.0 rdw-13.7 02:10pm estgfr-using this 05:40pm urine hyaline-3* 05:40pm urine blood-tr nitrite-neg protein-100 glucose-tr ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-lg 05:40pm urine color-yellow appear-hazy sp -1.017 09:12pm pt-12.3 ptt-25.7 inr(pt)-1.1 09:12pm plt count-370 09:12pm calcium-10.1 phosphate-7.2*# magnesium-3.2* 09:12pm glucose-106* urea n-235* creat-10.4* sodium-176* potassium-5.2* chloride-135* total co2-17* anion gap-29* renal us no evidence of hydronephrosis. atrophic echogenic kidneys, likely reflective of chronic renal disease. ecg probable sinus rhythm with atrial premature beats. left anterior fascicular block. voltage criteria for left ventricular hypertrophy. isolated ventricular premature beats. non-specific st-t wave changes. no significant change compared with previous tracing of . read by: , j. intervals axes rate pr qrs qt/qtc p qrs t 75 198 112 406/ -23 egd: impression: stenosis of the lower esophagus (dilation) small hiatal hernia erythema and few nodules in the stomach antrum (biopsy) erythema and erosions in the duodenum compatible with duodenitis otherwise normal egd to third part of the duodenum egd gastric biopsy stomach, antrum, biopsy: - antral mucosa with chronic active gastritis. - no h pylori discharge labs: 05:05am blood wbc-4.6 rbc-2.96* hgb-8.6* hct-25.6* mcv-87 mch-28.9 mchc-33.4 rdw-15.5 plt ct-324 02:10pm blood neuts-81.6* lymphs-14.9* monos-2.4 eos-0.7 baso-0.3 05:05am blood glucose-91 urean-11 creat-1.5* na-139 k-3.9 cl-108 hco3-24 angap-11 05:05am blood calcium-8.2* phos-2.8 mg-1.6 brief hospital course: patient is a 77 m from nursing care with a pmh of ckd - stage iii, (last cr. 1.4) who was found to be hyperkalemic, hypernatremia and in acute renal failure at nursing facility, had been spitting pills, not drinking, and had an episode of non-bilious,non-bloody vomiting. #. acute renal failure - evidence of creatinine at 1.4 4 months ago. the etiology of the renal failure was likely pre-renal, given reports of poor po intake and highly elevated sodium. patient was seen by the renal consult and hemodialysis was deferred. renal ultrasound did not show any sign of hydronephrosis. the patient was given fluids for several days and his creatinine trended down from 10 to his baseline. he began producing appropriate amounts of urine and we were satisfied that his kidney function was appropriate. #hyperkalemia - evidence of peaked t-waves on ekg. patient was given calcium gluconate and insulin as well as kayexalate on the floor. his hyperkalemia was likely caused by acute renal failure. hyperkalemia resolved with fluid resuscitation and resumption of normal urine output. #hypernatremia - likely related to overall dehydration. his free water fluid deficit was approximately 7 l on admission. he was given 1/2ns with goal of lowering his serum sodium by 10 over 24 hours. his electrolytes were monitored q6h to avoid overcorrecting. he was then changed to d5w for correction. his sodium fell to normal levels and his mental status improved. once he was tolerating food, we stopped fluids and watched his sodium and other electrolytes to see if he could maintain normal electrolytes wtih just po food and hydration. he was successful and we discharged him. #htn: the patient was consistently normo/hypotensive while on our service and his antihypertensives were held. once his blood pressures are consistently above 140, we would like his medications to be slowly restarted given his history of stroke. \ #esbl uti - the patient was found to have esbl uti, and so he was started on meropenem. he received 10 of 14 days of the medications, and should continue the medication for 4 more days. he is also to take flagyl for another 18 days after discharge. # cdiff- the patient developed cdiff while in the icu. the patient will continue flagyl until 2 weeks following the cessation of meropenem. # dementia: patient has known baseline dementia. the patient came in more obtunded than his description, which we attributed to hypernatremia. with the resolution of his hypernatremia, the patient became more alert and interactive. we spoke with the daughter, who agreed that he was closer to his baseline at that point. #.goals of care - per discussion with family members, he was minimally interactive at rehab for quite some time. patient remained dnr/ dni. decision made not to place peg tube. after two family meetings, it was decided that the patient would be rehydrated and he would be sent to a nursing home. patient's daughter was informed given severe dementia and aphasia that the odds of patient developing this issue again are extremely high, even with excellent nursing care, and that given he is at the end of his life each intervention should be carefully considered in the context of the goals we hope to achieve in caring for him. his daughter expressed understanding of this and did have "do not hospitalize" status discussed with her though she has not elected to make this his status as yet. weight on discharge is 127 pounds. # code: dnr/dni (discussed with hcp) transitional issues: -if patient develops systolic blood pressure greater than 140, please restart home antihypertensives. -discharge weight 127 lbs medications on admission: hydrocodone-tylenol 5-500 mg po prn for dressing change folic acid 1 mg po daily vitamin b12 500 mcg po daily vitamin c 500 mg po daily plavix 75 mg po daily mvi daily amlodipine 5 mg po daily ramipril 10 mg po daily aggrenox 200-25 mg po bid baclofen 10 mg po daily namenda 10 mg po daily tylenol 650 mg po daily simvastatin 20 mg po daily ranitidine 150 mg po qhs senna qhs discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. multivitamin tablet sig: one (1) tablet po daily (daily). 4. dipyridamole-aspirin 200-25 mg cap, er multiphase 12 hr sig: one (1) cap po bid (2 times a day). 5. baclofen 10 mg tablet sig: one (1) tablet po daily (daily). 6. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 7. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). 10. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours) for 4 days. 11. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback sig: one (1) intravenous q8h (every 8 hours) for 18 days. discharge disposition: extended care facility: nursing and rehab center - discharge diagnosis: 1) esophageal stricture 2) dehydration 3) acute kidney injury 4) dementia discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: mr. , you presented to us dehydrated and malnourished secondary to inability to eat or drink. while with us, we found that your electrolytes were abnormal and that your kidneys had suffered some injury from the dehydration. we first rehydrated you with iv fluids until your electrolytes and kidney function normalized to your normal levels. at that point, we had the gi specialists evaluate your esophagus, and they found that you had a stricture in that area. they opened it with an egd after which you were able to tolerate food and fluids by mouth. we monitored your electrolytes for a few days after the procedure, and determined that you were stable for discharge. here are the changes we made to your medications: stop taking amlodipine stop taking ramipril stop taking hydrocodone . start taking tylenol 1 gram three times a day as needed for pain followup instructions: department: podiatry when: thursday at 9:10 am with: , dpm building: ba ( complex) campus: west best parking: garage Procedure: Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Hyperpotassemia Urinary tract infection, site not specified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Other late effects of cerebrovascular disease Intestinal infection due to Clostridium difficile Do not resuscitate status Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Stricture and stenosis of esophagus Other musculoskeletal symptoms referable to limbs Dementia, unspecified, without behavioral disturbance |
allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p fall down stairs major surgical or invasive procedure: 1. open reduction internal fixation of left parasymphysis fracture of the mandible. 2. extraction of teeth numbers 4, 5, 11, 12, 13, 14, and 23. 3. alveoplasty of upper right quadrant and upper left quadrant. history of present illness: 66f transfer from outside hospital after patient found down in front of her staircase. patient had multiple signs of trauma including subarachnoid hemorrhage and orbital blowout fracture. patient had alcohol onboard with alcohol level in the 200s. patient was transferred for further care. fall was unwitnessed, ?loc. but responsive at the scene. gcs reportedly 15 at the scene. intubated in the ed for airway protection 2/2 blood in the airway. past medical history: pmh: breast ca psh: ccy , lumpectomy social history: 1ppd smoker almost 50 years, alcoholism 14-15 shots per day with recent detox, lives at home family history: noncontributory physical exam: on arrival to : constitutional: somnolent heent: left facial bruising and ecchymosis multiple dental fractures as well as intraoral laceration chest: clear to auscultation cardiovascular: regular rate and rhythm, normal first and second heart sounds abdominal: nontender, soft gu/flank: no costovertebral angle tenderness extr/back: no cyanosis, clubbing or edema skin: warm and dry neuro: speech fluent, moving all 4 extremities pertinent results: ct osh: comminuted rt ramus and left parasymphyseal mandible fractures rt ant and med maxillary wall fx with alveolar ridge left tetrapod type fracture with ant/med/lat wall fractures of maxillary sinus, l zygoma fracture, and l orbital floor non-displaced fx. l orbital rim fx. comminuted nasal bone fx with minimal displacement. no c-spine injury per radiology. mr spine impression: 1. at least partial tear of the cervical nuchal ligament with small amount of surrounding fluid/edema. no evidence of deeper posterior ligamentous or multicolumn injury, as associated with cervical instability. 2. significant multilevel cervical degenerative disease, as described, but no cord signal abnormality. 3. no mr evidence of acute lumbar spine injury. 4. multilevel lumbar degenerative disease, most marked at the l5-s1 level, with facet arthrosis and synovial effusion, and gap measuring up to 3.5 mm, which may be associated with instability. wbc-11.2* hct-38.6 plt ct-137* wbc-4.5 hct-25.1* plt ct-90* wbc-4.2 hct-23.4* plt ct-91* wbc-3.4* hct-22.7* plt ct-123* wbc-4.1 hct-20.5* plt ct-162 hct-24.0* hct-23.6* wbc-4.6 hct-24.3* plt ct-257# creat-0.5 na-142 k-4.0 creat-0.4 na-145 k-4.0 brief hospital course: 66 f s/p fall down stairs in the setting of etoh. she suffered multiple injuries including a small r sah, bil mandible fx, bil ant/med maxillary wall fx, l zygoma, l orbital floor/rim fxs and a nasal bone fracture. she was intubated in the trauma bay as she was not protecting her airway and subsequently admitted to the tsicu. the patient was evaluated by neurosurgery upon admission who reccomended seizure prophylaxis with dilantin for seven days. her course is now completed. she was seen by plastic surgery for her facial fractures who deferred care to the omfs team. she was taken to the or on for open reduction internal fixation of left parasymphysis fracture of the mandible; extraction of teeth numbers 4, 5, 11, 12, 13, 14, and 23; and alveoplasty of upper right quadrant and upper left quadrant. initially she had symptoms of alcohol withdrawl and required hourly ativan. an mri of the c/l spine was preformed and showed no evidence of fracture or injury. while in the icu she spiked mulitple fevers and was diagnosed with a lll pneumonia. bronchoscopy showed purulent thick secretions, and culture grew serratia liquefaciens >100,000 organisms/ml and enterobacter cloacae ~4000/ml. she was started on a 10 day course of antibiotics for this. when she returned from the or with omfs she was extubated but rapidly re-intubated given desaturations. much of this was thought to be secondary to edema. upon resolution of the edema she was easily extubated but failed speech and swallow so was initiated on tube feeds. foley catheter was discontinued but replaced shortly thereafter due to urinary retention. she was started on flomax. mrs. remained hemodynamically stable and mentation continued to improve so she was transferred to the floor. on she was transferred to the surgical floor where she continued to remain hemodynamically stable without respiratory compromise. her mental status continued to improve and she was alert and oriented x 3 at the time of discharge. prior to discharge, occupational therapy evaluated her cognitive status given the tbi and follow up with cognitive neurology was recommended. she remained afebrile and incentive spirometry and pulmonary toileting were continually encouraged. at the time of discharge, her o2 saturation was stable on room air and her iv ceftriaxone for vap was transitioned to po ciprofloxacin, course to be completed on . her wbc count remained within normal limits. she was evaluated by speech and swallow therapy, who said she was okay to take both thin and thick liquids; therefore po's were encouraged and her tube feeds were discontinued. her foley was removed after starting on flomax and she was able to void without difficulty there after, with no further evidence of urinary retention. physical therapy also evaluated her her recommended discharge to an extended care facility for continued acute pt. social work was also consulted at the time of her admission and continued to follow the patient and provide support for her family given the trauma and history of alcohol use. medications on admission: anastrozole 1mg qd, armidex 1 mg qd, fluoxetine 20mg qd, citalopram 40mg qd, campral 333mg 2 tabs qd discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 4. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 5. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 6. anastrozole 1 mg tablet sig: one (1) tablet po qd (). 7. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) inj injection tid (3 times a day). 10. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po daily (daily). 11. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 12. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for gerd. 13. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 14. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 15. cipro 500 mg tablet sig: one (1) tablet po every twelve (12) hours for 3 days. 16. bacitracin 500 unit/g ointment sig: one (1) application topical twice a day: please apply to left submental incision . discharge disposition: extended care facility: discharge diagnosis: primary: s/p fall injuries: small right sah bilateral mandible fracture bilateral ant/med maxillary wall fracture l zygoma, l orbital floor/rim fractures nasal bone fracture secondary: ventilator associated pneumonia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital after suffering a fall down stairs. you sustained multiple injuries including multiple facial fractures and a traumatic injury to your brain. you developed pneumonia while you were intubated, for which you are receiving antibiotics. you are now being discharged to an extended care facility to continue rehabilitation from your accident. please follow up as instructed below. it is important that you keep all of your follow up appointments. continue to take a liquid diet. it is important that you take the supplements recommended by nutrition as you will be on a liquid diet for 6 weeks. you are being given a prescription for narcotic pain medication. take the medication as needed. do not drink alcohol or drive while taking narcotics. narcotics can cause constipation so continue to take an over the counter stool softener such as colace while taking narcotics, and increase your fluid and fiber intake if possible. followup instructions: department: oral and maxillary facial surgery notes: please call the office number to make a hospital follow up appointment for 4-8 days after your hospital discharge. yawkey building , phone: department: general surgery/ when: tuesday at 3:00 pm with: acute care clinic building: lm bldg () campus: west best parking: garage department: cognitive neurology unit when: monday at 3:00 pm with: , md building: ks building (/ complex) campus: east best parking: main garage department: center when: tuesday at 10:45 am with: , m.d. building: sc clinical ctr campus: east best parking: garage md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Closed [endoscopic] biopsy of bronchus Suture of laceration of lip Alcohol detoxification Extraction of other tooth Open reduction of mandibular fracture Alveoloplasty Diagnoses: Acidosis Thrombocytopenia, unspecified Tobacco use disorder Personal history of malignant neoplasm of breast Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Accidental fall on or from other stairs or steps Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Closed fracture of malar and maxillary bones Closed fracture of orbital floor (blow-out) Closed fracture of other facial bones Delirium due to conditions classified elsewhere Open wound of lip, without mention of complication Other and unspecified alcohol dependence, continuous Closed fracture of nasal bones Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Closed fracture of mandible, ramus, unspecified Closed fracture of mandible, symphysis of body Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication Acute respiratory failure following trauma and surgery Other specified periodontal diseases |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: facial trauma major surgical or invasive procedure: none history of present illness: 31 yo male presented to the ed after sustaining multiple bleeding lacerations on his face. patient was running from the police and he was alreadyt bleeding from the face at that point. patient was alert but heavily intoxicated when brought to the er. the cause of his injury is not known. he was sedated and intubated on arrival as he was very combative and needed to protect the airway. past medical history: alcohol abuse social history: patient has a history of alcohol abuse. he is single, lives at home with his parents, currently unemployed. family history: non-contributory. physical exam: gen: a&o, nad heent: no scleral icterus. multiple lacerations w/ bacitracin cv: rrr, no m/g/r pulm: clear to auscultation b/l, no w/r/r abd: soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palbable masses ext: no le edema, le warm and well perfused pertinent results: - shoulder xr - comminuted minimally displaced right distal clavicle fracture - b/l hands - left - there is no acute fracture or dislocation. right - there is no fracture or dislocation. - ct sinus/mandible/maxillofacial w/o contrast - no acute facial bone fracture detected - ct spine - no acute cervical spine fracture or malalignment detected. - ct head - 1. no acute intracranial hemorrhage or fracture is detected. 2. subgaleal hematoma in the right frontoparietal and left periorbital region. left maxillary soft tissue laceration with hyperdense foci, which may represent foreign bodies. recommended clinical correlation. platelet count trended down and then stabilized. 02:40pm blood wbc-18.8* rbc-4.61 hgb-14.1 hct-40.0 mcv-87 mch-30.6 mchc-35.3* rdw-13.4 plt ct-189 05:33am blood wbc-7.8 rbc-4.08* hgb-12.4* hct-35.1* mcv-86 mch-30.5 mchc-35.4* rdw-13.6 plt ct-107* 04:50pm blood wbc-5.3 rbc-3.18* hgb-9.7* hct-27.7* mcv-87 mch-30.4 mchc-34.8 rdw-13.3 plt ct-77* 07:35am blood wbc-4.6 rbc-3.48* hgb-10.3* hct-30.4* mcv-87 mch-29.7 mchc-34.0 rdw-13.1 plt ct-79* brief hospital course: 31 yo male presented to the ed after sustaining multiple bleeding lacerations on his face. the patient was admitted to the acute care service for evaluation and treatment. patient was intubated in the ed for combative behavior and airway protection. patient was extubated the next day and was transfer to regular nursing floor when stable. plastics was consulted for the care of the facial lacerations. plastic surgery service irrigated facial lacerations and closed lacerations. cv: the patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. pulmonary: the patient remained stable from a pulmonary standpoint; vital signs were routinely monitored.. hematology: the patient's complete blood count was examined routinely; platelets intially trended down but stabilized before discharge. prophylaxis: the patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: none discharge medications: 1. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain for 5 days. disp:*50 tablet(s)* refills:*0* 2. chlorhexidine gluconate 0.12 % mouthwash sig: one (1) ml mucous membrane three times a day. disp:*90 ml(s)* refills:*2* discharge disposition: home discharge diagnosis: multiple, severe facial lacerations comminuted right distal clavicle fx 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 or return to the emergency department for any of the following: *you experience new chest pain, pressure, squeezing or tightness. *new or worsening cough, shortness of breath, or wheeze. *if you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience a discharge. *your pain in not improving within 8-12 hours or is not gone within 24 hours. call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *any change in your symptoms, or any new symptoms that concern you. please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon. avoid driving or operating heavy machinery while taking pain medications. please place bacitracin daily to lacerations. please continue a soft diet please rinse mouth with peridex three times a day followup instructions: patient to follow up in plastic surgery clinic on friday following discharge. please call on tuesday for a friday (). thank you. please follow up with acute care service in clinic. please call to schedule an appointment Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Closure of skin and subcutaneous tissue of other sites Diagnoses: Other and unspecified special symptoms or syndromes, not elsewhere classified Unarmed fight or brawl Alcohol abuse, continuous Open wound of other and multiple sites of face, complicated |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache major surgical or invasive procedure: diagnostic angiogram history of present illness: 50 y/o f who presents with worst headache of her life. headache is in frontal area and started suddenly 4 days prior to admission. pain is sharp and initially was in severity. pain did get somewhat better over the next few days, however worsened again today causing pt to present to osh. at osh, pt had non-contrast head ct showing sentinel bleed in basilar area and pt was transferred to for further management. pt states that she did have some dizziness and double vision from her left eye 4 days ago. she denies focal numbness or weakness and has been going to work. past medical history: s/p left elbow surgery social history: social hx: pt smokes pack per day. occasional etoh. sells software, lives with husband. family history: family hx: father with coronary artery disease. physical exam: on admission: t 99.9 p 71 bp 145/90 r 18 sao2 100% mental status: alert and oriented x 3, responds to commands, conversant, appropriate cranial nerves: i: not tested ii: pupils equal round and reactive to light, 4mm-2 bilaterally. iii, iv, vi: extraocular movements intact v, vii: corneal reflex intact bilaterally, face symmetric, no facial weakness or numbness ix, x: gag intact : shoulder shrug xii: tongue protrusion midline motor: b t we wf ip q at g no pronator drift finger to nose intact sensory: sensation to light touch intact throughout -dtrs: tri pat ach l 2 2 2 2 2 r 2 2 2 2 2 exam on discharge: xxxxxxxxxxxxxxxxxx pertinent results: labs on admission; 07:05pm blood wbc-8.2 rbc-4.10* hgb-12.1 hct-37.5 mcv-92 mch-29.6 mchc-32.3 rdw-12.2 plt ct-232 07:05pm blood neuts-77.4* lymphs-18.1 monos-3.5 eos-0.7 baso-0.4 07:05pm blood pt-10.9 ptt-25.6 inr(pt)-0.9 07:05pm blood glucose-109* urean-10 creat-0.7 na-139 k-3.9 cl-104 hco3-26 angap-13 03:59am blood albumin-3.7 calcium-8.7 phos-4.3 mg-1.9 03:59am blood phenyto-13.1 labs on discharge: xxxxxxxxxxxxxxxx ------------------- imaging: ------------------- cta head : findings: initial non-contrast images demonstrate subarachnoid hemorrhage layering within the interpeduncular cistern as well as a small volume at the vertex to the left of midline. no findings of infarct are evident by ct. cta: the intracranial internal carotid arteries are normal, as are the middle and anterior cerebral arteries. minimal atherosclerotic disease is present within the cavernous segments of the internal carotid arteries bilaterally. there is left vertebral artery dominance and both vertebral arteries contribute the formation of a normal-appearing basilar artery. the posterior cerebral arteries are normal. impression: 1. similar volume of localized hemorrhage within the interpeduncular and prepontine cistern with minimal volume of subarachnoid blood near the vertex without additional hemorrhage. 2. no aneurysm is identified, and the findings suggest the possibility for perimesencephalic hemorrhage, though an occult aneurysm is not fully excluded. brief hospital course: the patient was admitted to the icu for close neurological monitoring.she was started on dilantin for seizure prophylaxis. within a few hours she underwent a cerebral angiogram which showed no source of bleeding. later on her first hospitalization day she was transferred to the floor. she underwent both a mra/i of her brain and c-spine which showed no source for bleeding. the patient was monitored for 48 hours with improvement in her symptoms she was neurologically intact. on her day of discharge she underwent a cta which showed a small cluster of vascular channels noted in the midline frontal region which could represent a venous aneurysm with associated dva. it was recommend that ms would have a follow up angiogram on she will be returning for a angiogram. she was aware to return if she developed any new or worsening symptoms. medications on admission: none discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for ha. disp:*30 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): use while on percocet. disp:*40 capsule(s)* refills:*0* 3. phenytoin sodium extended 100 mg capsule sig: three (3) capsule po qhs (once a day (at bedtime)) for 10 days. disp:*30 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: basilar subarachnoid hemorrhage-nonaneurysmal discharge condition: neurologically stable discharge instructions: general instructions ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. ?????? you have been prescribed dilantin (phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. this can be drawn at your pcp??????s office, but please have the results faxed to . call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion, lethargy or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? new onset of the loss of function, or decrease of function on one whole side of your body. followup instructions: follow-up appointment instructions ?????? you will have an angiogram on show time 0900 to 1 daycare. if you have any questions please call ( to schedule an appointment with dr. , to be seen in 4 weeks. Procedure: Arteriography of cerebral arteries Arteriography of cerebral arteries Diagnoses: Tobacco use disorder Subarachnoid hemorrhage |
allergies: mesalamine / aminosalicylic acid / aspirin / lactose / codeine attending: chief complaint: hematemesis major surgical or invasive procedure: ercp with banding of gastric varices and replacement of stent in common bile duct history of present illness: 48m with history of depression, hcv, and etoh cirrhosis who initially presented to an osh on with coffee ground emesis. patient admitted in and of this year to osh with encephalopathy and cellulitis. recent admitted to osh from with hepatic encephalopathy, with course c/b etoh withdrawal/dts requiring intubation and lorazepam drip. patient discharged to rehab on . reports he was feeling well, but several days later developed nausea and vomited dark, coffee ground material. some epigastric pain, but no fevers or chills. has had dark colored stools. was brought to on for evaluation. at , had large volume coffee ground emesis on day of presentation. patient started on ppi gtt, octreotide gtt and admitted to icu with gi consulted. inr 1.4. received ffp and vitamin k. on , underwent egd that showed varices, but no evidence or stigmata of recent bleeding. no bands were placed as patient was difficult to sedate. during course of admission, his hct trended down from 30 to 20. received 3 units prbcs in addition to the ffp. underwent repeat egd on , during which he was noted to have oozing of blood around a previously placed ampullary stent. did remain hemodynamically stable. also had ct abd that showed dilatation of the cbd, intrahepatic, and gallbladder ducts. only a minimal amount of ascites was noted. he was transferred to for ercp and stent removal, as well as further evaluation of his bleeding and ductal obstruction. on arrival to the micu, patient's vs stable. patient reports n/v have resolved, and he denies any abdominal pain. reports chronic pain in his bilateral legs secondary to neuropathy, exacerbated by recent ambulance ride. of note, he had an ampullary stent placed one year ago at for a possible distal stricture. no sphincteromtomy performed due to high inr at time. patient did not follow-up to have stent removed. review of systems: (+) per hpi. reports 25-30 pound weight loss. has chronic bilateral lower extremity pain due to neuropathy. last bm 2 days ago. occasional non-productive cough. (-) denies fever, chills, sweats, headache, shortness of breath, chest pain or discomfort, abdominal pain, diarrhea, dysuria, frequency, or urgency. no rashes or skin changes. past medical history: etoh abuse (history of dts, withdrawal) hcv (vl negative ) cirrhosis (presumably secondary to etoh) history of alcoholic hepatitis depression peripheral neuropathy history of opiate abuse ulcerative colitis diazepam overdose social history: lives alone, though was in rehab prior to admission. fiance recently passed away. history of etoh abuse, though no use over past several weeks. smokes ppd. history of marijuana use in past, though denies recent use. no history of ivdu. has tattoos. family history: no history of liver disease. physical exam: admission exam: vitals: 97.7 90 124/90 12 97% ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, pupils mildly asymmetric with right more constricted but bilaterally reactive to light and accomodation. neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, grade 2/6 systolic murmur at right sternal border, no rubs or gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: tense with mild distention, not tympanic, bowel sounds present, hepatomegaly, no splenomegaly appreciated, bowel sounds present, negative for fluid wave or shifting dullness, mild tenderness to deep palpation in central epigastric region, no rebound or guarding gu: no foley ext: warm, well perfused, 2+ pulses, 1+ pitting edema in bilateral lower extremities to ankles, no clubbing or cyanosis skin: no palmar erythema or spider angiomas, tattoo on right upper extremity. neuro: cnii-xii intact, 5/5 strength upper/lower extremities, decreased sensation and proprioception in feet with tenderness to gentle palpation,grossly normal sensation otherwise, 2+ reflexes bilaterally, gait deferred, no asterixis. discharge exam: 98.1, 93/73, 89, 96ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, pupils mildly asymmetric with right more constricted but bilaterally reactive to light and accomodation. neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, grade 2/6 systolic murmur at right sternal border, no rubs or gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: tense with mild distention, not tympanic, bowel sounds present, hepatomegaly, no splenomegaly appreciated, bowel sounds present, negative for fluid wave or shifting dullness, mild tenderness to deep palpation in central epigastric region, no rebound or guarding gu: no foley ext: warm, well perfused, 2+ pulses, 1+ pitting edema in bilateral lower extremities to ankles, no clubbing or cyanosis skin: no palmar erythema or spider angiomas, tattoo on right upper extremity. neuro: cnii-xii intact, 5/5 strength upper/lower extremities, decreased sensation and proprioception in feet with tenderness to gentle palpation,grossly normal sensation otherwise, 2+ reflexes bilaterally, gait deferred, no asterixis. pertinent results: admission labs: 02:26pm blood wbc-8.6# rbc-3.16* hgb-9.9* hct-28.8* mcv-91# mch-31.4# mchc-34.5 rdw-16.5* plt ct-104* 02:26pm blood neuts-82.7* lymphs-8.1* monos-4.4 eos-4.3* baso-0.6 02:26pm blood pt-14.3* ptt-39.9* inr(pt)-1.3* 02:26pm blood glucose-97 urean-12 creat-0.8 na-135 k-3.7 cl-102 hco3-27 angap-10 02:26pm blood alt-20 ast-38 alkphos-111 totbili-1.7* 02:26pm blood albumin-3.4* calcium-9.2 phos-3.3 mg-1.2* discharge labs: 01:29am blood calcium-8.6 phos-3.5 mg-1.2* 01:29am blood alt-17 ast-33 alkphos-108 01:29am blood glucose-129* urean-11 creat-0.7 na-134 k-3.8 cl-102 hco3-25 angap-11 01:29am blood pt-17.1* ptt-44.9* inr(pt)-1.6* 01:29am blood neuts-80.1* lymphs-9.7* monos-4.7 eos-5.0* baso-0.6 01:29am blood wbc-7.9 rbc-2.98* hgb-9.1* hct-26.9* mcv-90 mch-30.7 mchc-34.0 rdw-16.5* plt ct-92* microbiology: blood cultures 8/30 x2: pending, no growth to date at time of discharge imaging: ercp : the cbd was diffusely dilated to about 16 mm up to the ampulla. the findings were suggestive of papillary stenosis. given that the pt had presented with gi bleeding, a sphincterotomy was not performed. instead, a 10f x 7 cm plastic stent was placed successfully in the cbd with good drainage of bile. impression: previously placed biliary stent removed with snare. diffuse dilation of cbd to about 16 mm upto the ampulla, suggestive of papillary stenosis. given that the pt had presented with gi bleeding, a sphincterotomy was not performed. instead, a 10f x 7 cm plastic stent was placed successfully in the cbd with good drainage of bile egd : findings: esophagus: protruding lesions 5 cords of grade ii varices were seen in the lower third of the esophagus. no active bleeding seen. all 5 cords of varices were banded successfully. total 6 bands were placed. stomach: other portal hypertensive gastropathy was visualized in the body of the stomach duodenum: normal duodenum. impression: varices at the lower third of the esophagus banded successfully. portal hypertensive gastropathy was visualized in the body of the stomach. otherwise normal egd to third part of the duodenum. brief hospital course: 48m with history of etoh abuse, hcv, cirrhosis with grade 2 varices, recent hospitalizations for encephalopathy and c/b etoh withdrawal, transferred to for ercp after presenting to with coffee ground emesis, where he was found to have acute blood loss anemia and oozing at the site of a previously placed stent in the ampulla. now s/p repeat egd/ercp at , where stent was replaced and patient underwent banding of gastric varices. # upper gi bleed: differential diagnosis includes variceal bleed, bleeding secondary to portal hypertensive gastropathy, oozing at site of prior ampullary stent. no evidence of pud on egd. also no evidence of recent variceal bleeding, though patient underwent variceal banding by gi during egd . patient transfused 3 units prbcs at osh prior to transfer, but has remained hemodynamically stable with hct now stable. did not require transfusion at . stent has since been replaced, and per gi no evidence of active bleeding at time of procedure today. pt continued on ppi gtt, octreotide gtt. given history of cirrhosis, continued antibiotics with cipro 400 mg iv bid o be continued on transfer back to . diet advanced to clear liquids after ercp procedure. monitored overnight and hct remained stable at 29. advanced to full diet in am. stable for transfer to floor unit, no icu requirement. gi recommended d/c octreotide ggt and switch pantoprazole to 40mg po bid. # papillary stensosis: findings on ercp suggestive of papillary stenosis (cbd was diffusely dilated to about 16 mm up to the ampulla). per gi, no sphincterotomy performed given recent gi bleeding. plastic stent was removed and re-placed in cbd with good drainage of bile per report. he will need repeat ercp in 1 month for stent pull and sphincterotomy. # etoh/cirrhosis: has been c/b encephalopathy in past. currently no evidence of decompensation, with clear mental status, normal renal function, and no evidence of ascites on exam. also no evidence of variceal bleeding on recent egds. of note, ultrasound last year comments on echogenic focus in the right lower lobe of the liver, for which mri was recommended. given history of recent weight loss, have some concern for hcc. continued lactulose, rifaximin. continued lasix and spironolactone. will need further work-up for echogenic focus in liver if not already done; needs mri. # etoh abuse: recent admission at osh c/b acute etoh withdrawal requiring intubation and lorazepam drip. no signs of withdrawal this admission, as patient has been off etoh for several weeks. continued thiamine, folic acid and started mvi. # neuropathy: likely secondary to etoh. continued pain control with oxycodone. # depression: continued citalopram 40 mg daily. continued trazodone 100 mg hs prn insomnia. transitional issues: -blood cultures pending at time of discharge -will need repeat ercp in 1 month to remove stent and perform sphincterotomy -if not previously done, needs mri to evaluate 0.5 cm echogenic lesion in right lower lobe of the liver seen on ultrasound -patient's code status was full code this admission medications on admission: preadmission medications listed are correct and complete. information was obtained from transfer paperwork. 1. oxycodone (immediate release) 15 mg po q4h:prn pain 2. trazodone 50 mg po hs:prn home med 3. ciprofloxacin 400 mg iv q12h 4. citalopram 40 mg po daily start: in am 5. furosemide 40 mg po daily start: in am 6. lactulose 20 ml po tid 7. octreotide acetate 10 mcg/hr iv drip infusion 8. rifaximin 550 mg po bid 9. spironolactone 100 mg po daily start: in am discharge medications: 1. citalopram 40 mg po daily 2. furosemide 40 mg po daily 3. lactulose 20 ml po tid 4. oxycodone (immediate release) 15 mg po q6h:prn pain 5. rifaximin 550 mg po bid 6. spironolactone 100 mg po daily 7. trazodone 50 mg po hs:prn home med 8. docusate sodium (liquid) 100 mg po bid 9. heparin 5000 unit sc tid 10. pantoprazole 40 mg po q12h 11. senna 1 tab po bid:prn constipation 12. ciprofloxacin hcl 500 mg po q12h discharge disposition: extended care discharge diagnosis: primary: upper gastrointestinal bleeding, papillary stenosis secondary: cirrhosis, alcohol abuse, acute blood loss anemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , it was a pleasure taking care of you during your stay at . you were transferred here for a procedure called an ercp, in which the gastroenterology doctors used a to look in your esophagus, stomach, and small intestine to determine where you might be bleeding. they removed a stent from your bile duct and placed a new stent. they did not see any bleeding. they also saw some dilated blood vessels called varices, which they placed clips on to help prevent them from bleeding. you tolerated these procedures well and remained stable overnight. you are now stable for transfer back to . it is very important that your follow-up with the ercp doctors 1 month. you will need a repeat ercp so that they can remove this new stent. followup instructions: please follow-up with your pcp . within 1 week of your discharge from rehab. please follow-up with ercp within 1 month, so that they can remove your stent. Procedure: Endoscopic excision or destruction of lesion or tissue of esophagus Endoscopic retrograde cholangiopancreatography [ERCP] Replacement of stent (tube) in biliary or pancreatic duct Diagnoses: Other chronic pain Abnormal coagulation profile Tobacco use disorder Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Portal hypertension Unspecified viral hepatitis C without hepatic coma Depressive disorder, not elsewhere classified Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Mechanical complication due to other implant and internal device, not elsewhere classified Hematemesis Alcoholic polyneuropathy Ulcerative colitis, unspecified Other specified disorders of stomach and duodenum Obstruction of bile duct Other and unspecified alcohol dependence, continuous Hemorrhage, unspecified Other specified disorders of liver Esophageal varices without mention of bleeding Opioid abuse, in remission Cannabis abuse, in remission |
allergies: mesalamine / aminosalicylic acid / aspirin / lactose / codeine attending: chief complaint: altered mental status major surgical or invasive procedure: therapeutic paracentesis diagnostic paracentesis ercp diagnostic paracentesis picc line placement history of present illness: mr. is a 48yom with a history of alcoholism (previous dt's), alcoholic cirrhosis (complicated by encephalopathy, varices, portal gastropathy), biliary stenosis s/p numerous ercp/stents, ulcerative colitis who is being directly admitted to due lkikely hepatic encephalopathy. he was recently admitted to micu with coffee-ground emesis though his egd at osh revealed nonbleeding varices and evidence of portal gastropathy. he underwent ercp at because there was bleeding noted from a prior cbd stent, which was retrieved and replaced. a ampullary stricture was noted and plans were made to readdress with sphinchterotomy in a month. during this procedure, 5 cords of grade ii esophageal varices were banded. he was rapidly discharged back to due to stability of his hemodynamics and hemoglobin. prior to the aforementioned episode, patient was admitted to an osh with hepatic encephalopathy complicated by alcohol withdrawal and delirium tremens requiring lorazepam gtt. previous notes suggest osh admissions for encephalopathy also occured in and 6/. today, patient came for ercp because of biliary stricture and dilated cbd previously stented 3-4 times. found to be confused, and thought to be encephalopathic. unable to ascertain how much medications patient was taking. exam was notable for afebrile, bp 90-100/50-60, swollen legs, and mildly distended abdomen. procedure held because of encephalopathy, and eventually will likely return for procedure. low suspicion for biliary obstruction per gi. of note, there has been ongoing concern among providers re. medication compliance, and patient has habit of not going to appoinments. we called the cvs in () to check medications. they said patient has not filled his rifaximin or lactulose since , while he has filled all of his other medications as of . he lives alone although often has girlfriend (hcp) by however has support from his brother and mother. ros otherwise notable for alcohol use. patient says his last drink was friday, when he had 6 drinks. perhaps not most reliable historian, but says he does not drink every day, but every few days. denies recent drug use, new medications, or medication changes. also for some coughing with brown sputum production, although unclear how frequently. also complains of abdominal pain primarily in the middle of the abdomen. patient believes he is in the hospital because of his leg pain, chronic neuropathy. ros: per hpi, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, nausea, vomiting, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: -cirrhosis (presumably secondary to etoh/hepc) c/b grade ii varices (), hepatic encephalopathy, portal hypertension, hematemesis, portal gastropathy -biliary stenosis s/p numerous ercp and cbd stent placements / replacements -history of alcoholic hepatitis -etoh abuse (history of dts, withdrawal ) -hcv (vl negative ) -depression -peripheral neuropathy -ulcerative colitis -history of diazepam overdose -history of opiate abuse social history: lives alone, though was in rehab prior to admission. fiance recently passed away (). history of etoh abuse, though no use over past several weeks. smokes ppd x30 yrs. history of marijuana use in past, though denies recent use. no history of ivdu. has tattoos. walks with a cane peripheral neuropathy. former piano mover and long-haul truck driver, most recent job as a cab driver. hasn't worked for some time above symptoms. family history: no history of liver disease. physical exam: physical examination: vs: 98 97 91/58 18 98% ra general: nad. altered affect. heent: perrl, eomi. supple with low jvp. cardiac: rrr, normal s1, s2. no m/r/g. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use, moving air well and symmetrically. ctab, no crackles, wheezes or rhonchi. abdomen: distended but soft, mildly tender to palpation. hsm. no fluid wave appreciated. extremities: warm and well perfused, no clubbing or cyanosis. 3+ bilaterally past the knees, erythema. feet with blisters. discharge exam vs t98.1 bp:99/67 p:90 rr:20 sao2 100% ra general: cachectic, middle aged male a&ox3 heent: ngt inplace. lungs: ctab. no w/r/r. cardiac: rrr. nl s1, s2, no murmurs auscultated abdomen: soft, nondistended. mildly tender to palpation over liver. nabs. extremities: wwp. neuro: no asterixis. no focal deficits. pertinent results: admission labs: 01:30pm blood wbc-7.9 rbc-2.71* hgb-8.2* hct-24.2* mcv-89 mch-30.1 mchc-33.7 rdw-15.8* plt ct-119* 01:17pm blood pt-51.2* ptt-150* inr(pt)-4.7* 01:30pm blood urean-30* creat-2.1*# na-129* k-3.4 cl-91* hco3-28 angap-13 01:30pm blood alt-28 ast-85* alkphos-148* amylase-19 totbili-4.1* dirbili-2.2* indbili-1.9 06:50pm blood calcium-8.1* phos-2.9 mg-1.4* 01:30pm blood asa-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 06:50pm blood ethanol-neg pertinent results: cxr in comparison with study of , there are lower lung volumes. bibasilar atelectatic changes are seen, though no evidence of acute focal pneumonia or vascular congestion. the dobbhoff tube has been removed peritoneal fluid cytology peritoneal fluid: negative for malignant cells. mesothelial cells, histiocytes and inflammatory cells. abd u/s impression: 1. coarse and echogenic liver with multiple hypoechoic regions scattered throughout the liver corresponding to areas of hypodensity seen on today's noncontrast ct scan highly concerning for a widespread neoplastic process. contrast-enhanced ct scan or mri study is recommended for further characterization of these lesions. correlation with alpha-fetoprotein levels might also prove useful. 2. diffusely coarse and echogenic liver consistent with fatty infiltration and history of alcoholic cirrhosis. 3. heterogeneous echogenic material within the main portal vein raises possibility for nonocclusive portal vein thrombosis. 4. moderate-to-large ascites. ct abd impression: 1. heterogeneous appearance of liver could be related to malignancy, infectious process or cirrhosis. recommend ultrasound to better evaluate if the patient cannot get a contrast-enhanced ct. 2. marked ascites with no evidence of hemorrhage. 3. bilateral pleural effusions, left greater than right. 4. right middle lobe patchy ground-glass opacities, likely infectious versus inflammatory. 5. splenomegaly. 6. no evidence of bowel obstruction. ct head impression: no hemorrhage or edema. global atrophy, more prominent in the frontal lobes bilaterally, likely related to chronic alcohol abuse. cxr : findings: in comparison with study of , there is mild increase in opacification at the right base, consistent with the ct diagnosis of right lower lung pneumonia. less prominent changes are also seen at the left base. this suggests that there may be some elevation of pulmonary venous pressure adding to the overall pattern. there is a dense streak of atelectasis seen at the left base. continued low lung volumes. eeg : abnormal eeg due to markedly abnormal portable eeg due to the slow disorganized background, the lower voltage background over the left side, and the bursts of generalized slowing. the first and final abnormalities signify a widespread encephalopathy affecting both cortical and subcortical structures. the lower voltage background on the left side raises the possibility of material interposed between the cortical surface and recording electrodes, e.g. subdural fluid. problems with recording technique can also explain such findings. there were no clearly epileptiform features or electrographic seizures. abd us: findings: there is generalized paucity of bowel gas with the loop of transverse colon is seen containing air. there is a nonspecific bowel gas pattern. this along with generalized increased abdominal densities is consistent with ascites. a biliary stent is seen in place. the visualized osseous structures are unremarkable. impression: nonspecific bowel gas pattern without evidence of obstruction. ascites. video swallow impression: mild-to-moderate penetration with thin and nectar consistencies. mild aspiration with thin and nectar consistencies. for further details, please refer to the note by the speech and swallow division in the omr mr abdomen/liver : findings: the liver has a nodular contour and is shrunken in keeping with cirrhosis. there is signal loss in the liver between the in-phase and out-of-phase sequence, consistent with hepatic steatosis. focal arterial hyperenhancement is noted within segment vi of the liver (sequence 1501, image 43) - this area has no t2 correlate and does not demonstrate washout on the delayed phase. there is also peripheral arterial hyperenhancement within segment vii (sequence 1501, image 77) - again this area has no t2 correlate and does not demonstrate washout on the delayed phase. both of these areas likely represent transient hepatic intensity differences. the hepatic artery is patent, and there is conventional hepatic arterial anatomy. the portal and hepatic veins are patent. there is a stent in situ within the common bile duct. the common bile and common hepatic ducts remain dilated with the common hepatic duct measuring 1.5 cm in diameter. there is also central intrahepatic duct dilatation. the gallbladder is normal. there is moderate volume ascites within the peritoneal cavity. there is splenomegaly with the spleen measuring 17.8 cm in length. multiple distal esophageal and gastric fundal varices are identified. the pancreatic duct in the head of the pancreas appears prominent, with the distal duct appearing within normal limits. the pancreas is otherwise unremarkable. within the lower pole of the left kidney, there is a subcentimeter focus of t1 hyperintensity (sequence 12, image 25) which does not enhance post-contrast and likely represents a hemorrhagic cyst. the kidneys are otherwise unremarkable. the adrenals are within normal limits. there is a nasogastric tube in situ within the stomach. the visualized small and large bowel is unremarkable. no retroperitoneal adenopathy. there are bilateral pleural effusions - the right-sided pleural effusion has increased in size since the previous ct. bone marrow signal is normal. no destructive osseous lesions. impression: 1. cirrhotic liver with evidence of secondary portal hypertension (splenomegaly and distal esophageal varices). 2. no focal liver lesions. no lesions suspicious for hcc. 3. biliary stent in situ within the cbd with residual intra and extrahepatic duct dilatation. 4. moderate volume ascites. 5. bilateral pleural effusions - the right pleural effusion has increased in size since the previous ct. 6. hemorrhagic cyst within the lower pole of the left kidney. cxr impression: 1. dramatic improvement in bilateral pulmonary edema. mild residual atelectasis at the left lung base. 2. ng tube should be advanced so that the side port is completely within the stomach. egd/ercp esophagus: limited exam of the esophagus was normal stomach: limited exam of the stomach was normal impression: -normal major papilla. -stent in the major papilla (stent removal) -cannulation of the biliary duct was successful and deep with a sphincterotome -a moderate diffuse dilation was seen at the biliary tree with the cbd measuring 16 mm up to the ampulla, suggesting papillary stenosis. -a sphincterotomy was performed in the 12 o'clock position using a sphincterotome. -several balloon sweeps were performed. no stone or sludge were noted. -cytology samples were obtained for histology using a brush in the lower third of the common bile duct (at the level of the ampulla). - -jejunum tube was placed in the proximal jejunum for feeding. otherwise normal ercp to third part of the duodenum cxr feeding tube loops in the stomach and passes out of view. right subclavian central venous catheter ends in the mid svc. aside from mild left basal subsegmental atelectasis, lungs are clear. heart size is normal. no pleural abnormality. video swallow impression: mild penetration with thin and nectar consistencies. no aspiration with any consistency barium. examination is improved from prior exam. for further details, please refer to the full note by the speech and swallow division in the omr. discharge labs: 05:55am blood wbc-8.3 rbc-3.07* hgb-9.4* hct-28.8* mcv-94 mch-30.6 mchc-32.6 rdw-18.4* plt ct-203 05:55am blood pt-12.5 ptt-41.5* inr(pt)-1.2* 05:55am blood glucose-92 urean-17 creat-0.9 na-133 k-4.6 cl-98 hco3-25 angap-15 05:55am blood alt-26 ast-62* alkphos-157* totbili-1.8* 05:55am blood calcium-10.3 phos-4.0 mg-1.8 brief hospital course: mr. is a 48-year-old man with a history of alcohol dependence and withdrawals, cirrhosis with encephalopathy, varices, and portal gastropathy, biliary stenosis with several stents, and ulcerative colitis with recent hospitalizations including late stay for esophageal varices and hemetamesis, along with an early stay at outside hospital with hepatic encephalopathy followed by delirium and alcohol withdrawal, admitted directly to the liver service after showing up at ercp and being found to be confused with recent hx of noncompliance with medications (confirmed with pharmacy and his mother) as well as heavy drinking, particularly after the death of his long time partner and fiance in . # altered mental status and icu course: after initially admitted, patient noted to be confused, agitated, with likely combination of alcohol withdrawal and hepatic encephalopathy. infectious workup on the floor was unremarkable, but ceftriaxone was initiated because of clinical picture and risk of sbp. patient triggered on ciwa repeatedly, becoming more agitated and then started to experience visual hallucinations. because of repeated triggering as well as concern for airway protection, patient was transferred to the icu. in the icu, patient was continued on lactulose/rifaximin regimen (via ng tube) as well as benzodiazepines for withdrawal. there was also concern for continuing infection. peritoneal tap performed which did not fnid evidence of sbp. chest ct showed ground glass opacities suspicious for pneumonia, for which patient was treated with broad spectrum antibiotics for possible aspiration pneumonia (vancomycin and cefepime). head ct was negative for acute process. abdominal ultrasound found no evidence of clot. patient also found to have , which resolved with fluid resuscitation and albumin. patient thereafter returned to the floor briefly, where he continued to be agitated and having hallucinations. flagyl was added for coverage of anaerobes/aspiration. because of respiratory distress with desaturations, worsening encephalopathy, patient returned to the icu again, where antibiotics were continued for a full course for hcap (1 week) and patient was treated aggressively with lactulose for encephalopathy. abdominal ct conducted which was unremarkable. patient was noted to clear over several days. tube feeds were started, and patient was returned to the floor. electrolytes were aggressively repleted. patient remained clear throughout remainder of admission. # etoh/hcv cirrhosis: patient with history of cirrhosis complicated by portal hypertension, varices, variceal bleed. after icu course detailed above, patient continued on lactulose and rifaximin. in addition, lasix and aldactone were initiated. because of diffuse liver nodularity appreciated on ct and ultrasound when patient first admitted (as well as known lesion in the past), mri was conducted, which did not show evidence of hcc. patient did develop a transient leukocytosis on the floor. diagnostic paracentesis performed which showed no evidence for sbp; other infectious workup was unremarkable. leukocytosis resolved without further intervention. plan was for patient to have close follow up with hepatology as well as pcp for continuing management. patient could be reviewed for transplant in ~6 months if able to remain sober. # ercp/biliary stricture: patient initially presented for ercp for stent removal. strictures potentially ulcerative colitis with psc seen on ercp. patient underwent ercp for stent removal and sphincterotomy on after stabilization s/p icu course, without complication. plan was for outpatient follow up as well as follow up of cytology. # hypomagnesemia: patient found to be hypomag on on day of discharge. intravenous mag repletion was attempted but patient lost iv access. therefore, patient was initiated on magnesium oxide po with plan for close follow of electrolytes as an outpatient. # : on admission, patient noted to have with cr as high as 2.1. resolved with fluid resuscitation and albumin as described above. # hcap: patient treated with course of vancomycin/cefepime for hcap as described above. resolved. # nutrition: patient was maintained on tube feeds as described in the icu course. speech and swallow followed closely along with a workup including video swallow studies. patient was advanced as swallowing function improved. he is cleared for nectar thick liquids, ground solids and may be advanced as tolerated. the day before discharge, the patient accidentally pulled the feeding tube while changing clothes. the tube was replaced and advanced to a post-pyloric location in interventional radiology without complication. the tube was bridled. # hyperkalemia: patient's potassium trended up towards the end of admission, felt to be likely potassium sparing diuretic use. patient's dose of lasix was uptitrated with good result. # lower extremity pain/neuropathy: stable. b12 (high) and folate (normal) levels unrevealing. continued amitryptiline. initially held oxycodone due to ams, but titrated up to home dose before discharge. inactive issues: # hyponatremia: likely hypervolemic hyponatremia liver disease. also, accentuated by poor po intake. stable. # ulcerative colitis: not currently on treatment # depression: continued citalopram # hepatitis c: infection cleared pending labs: - cytology from ercp brushings - peritoneal fluid culture - blood cultures 11/6 transitional issues: - patient will need very close follow-up for relapse prevention - patient will need close follow-up for electrolytes (hypomag, hyperk, hyponatremia) (labs checked and with results faxed to dr. - s&s at rehab - transplant eval in 6 months if sober medications on admission: the preadmission medication list is accurate and complete. 1. citalopram 40 mg po daily 2. furosemide 40 mg po daily 3. lactulose 20 ml po tid 4. oxycodone (immediate release) 15 mg po q6h:prn pain 5. rifaximin 550 mg po bid 6. spironolactone 100 mg po daily 7. trazodone 50 mg po hs:prn home med 8. amitriptyline 60 mg po hs 9. omeprazole 20 mg po daily 10. folic acid 1 mg po daily 11. influenza virus vaccine 0.5 ml im now x1 follow influenza protocol document administration in poe discharge medications: 1. folic acid 1 mg po daily 2. furosemide 40 mg po daily 3. lactulose 20 ml po tid 4. oxycodone (immediate release) 15 mg po q6h:prn pain 5. rifaximin 550 mg po bid 6. spironolactone 100 mg po daily 7. multivitamins 1 tab po daily 8. terbinafine 1% cream 1 appl tp 9. thiamine 100 mg po daily 10. amitriptyline 60 mg po hs 11. trazodone 50 mg po hs:prn home med 12. citalopram 40 mg po daily 13. tube feeds nepro full strength; rate: 45 ml/hr; residual check: q4h; hold feeding for residual >= : 200 ml; flush w/ 100 ml water q4h 14. sarna lotion 1 appl tp qid:prn pruritis 15. diphenhydramine 25 mg po q8h:prn pruritis 16. omeprazole 20 mg po daily 17. magnesium oxide 800 mg po daily 18. outpatient lab work on friday please draw cbc,chem10,coags(pt,ptt,inr),lfts(ast,alt,alkphos,tbili) and fax results to dr. 19. outpatient lab work on friday please draw cbc,chem10,coags(pt,ptt,inr),lfts(ast,alt,alkphos,tbili) and fax results to dr. 20. ciprofloxacin hcl 500 mg po q24h for sbp prophylaxis discharge disposition: extended care facility: discharge diagnosis: alcohol withdrawal hepatic encephalopathy healthcare associated pneumonia alcohol/hcv cirrhosis biliary stricture of unknown etiology discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: mr. : it was a pleasure taking care of you. you were admitted to the for treatment of altered mental status. it was likely that your altered mental status was due to both hepatic encephalopathy (especially because you had not been taking lactulose/rifaximin) as well as alcohol withdrawal (because of your heavy alcohol use). in addition, you were found to have a likely pneumonia, for which you were treated with iv antibiotics. after an acute period of treatment requiring time in the icu (intensive care unit), your status improved dramatically. after leaving the icu, we maintained you on tube feeds. our speech and swallow experts advised us to take advancement of your oral intake slowly, because your swallowing muscles was rather weak. you tolerated tube feeds well and we will continue these after you leave. in addition, you had initially presented to the hospital for a follow up ercp procedure. we performed this procedure, in conjunction with an egd/endoscopy, and the stent was removed without complication. several days after returning to the medical floor, you were found to have an elevated white blood cell count (often a reflection of an infection). you felt well otherwise and did not have a fever. we performed an infectious evaluation including a paracentesis (sampling fluid from the belly), which was negative for an infection. your white blood cell count returned to without intervention. you will benefit from close follow up with your primary care physician as well as hepatologist (liver doctor). followup instructions: department: liver center when: thursday at 1:20 pm with: , md building: lm campus: west best parking: garage after discharge from rehab, please set up an appointment to follow up with your primary care physician, . : name: , location: community health center address: 2nd fl, b , , phone: fax: md Procedure: Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Endoscopic sphincterotomy and papillotomy Other closed [endoscopic] biopsy of biliary duct or sphincter of Oddi Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Acidosis Obstructive sleep apnea (adult)(pediatric) Tobacco use disorder Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Portal hypertension Depressive disorder, not elsewhere classified Paralytic ileus Hepatic encephalopathy Unspecified hereditary and idiopathic peripheral neuropathy Obstruction of bile duct Other and unspecified alcohol dependence, continuous Alcohol withdrawal |
allergies: all drug allergies previously recorded have been deleted attending: chief complaint: nstemi at osh major surgical or invasive procedure: cardiac catheterization with bare metal stent to proximal left anterior descending artery history of present illness: the patient is a 83 yo woman with h/o cad s/o cabg in , hyperlipidemia, dm2, and hypertension, who presented from osh with nstemi. per the patient and her family, the patient developed shortness of breath, a productive cough, and increasing pain in her left arm last tuesday. she presented to ed, where she was found to have a right lower lobe infiltrate and was admitted for pneumonia. she was started on ceftriaxone and azithromycin, yet continued to spike daily fevers, so vancomycin was added on . she admitted to increasing pnd, orthopnea, and ankle edema over the past 6 months, so cardiology was consulted given concern for underlying chf given her history of cad. she had a tte on , which showed concentric lvh with mild anteroseptal hyokinesis and 2+ mr. on , the patient had an episode of , non-radiating, substernal chest pressure, which she states was reminiscent of the pain she experienced with her prior mi in . she had associated dizziness and diaphoresis. ecg showed st depressions in ii, iii, and avf as well as v4-v6. cardiac enzymes were found to be elevated, so the patient was trasnferred to the ccu and started on , heparin gtt, , and integrilin. she had a stat repeat tte, which showed global hypokinesis and a lvef of 40%. she was then transferred to for cardiac catheterization. on arrival to , the patient developed acute respiratory distress with o2 sats in the 80s. she received albuterol nebulizations x3, atrovent x1, lasix 40 mg iv, and was placed on a nrb. she was then transferred to the ccu for further evaluation and monitoring. in the ccu, the patient denies current chest pain and states that her breathing has improved. she continues to have a productive cough but feels more comfortable than prior. on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent chills or rigors. she denies exertional buttock or calf pain. she does endorse frequent constipation. cardiac review of systems is notable for absence of palpitations, syncope or presyncope. past medical history: cabg: in . sv to lad, sv to rm, sv to distal circumflex marginal, sv to posterior descending artery.diabetes mellitus dyslipidemia hypertension iron deficiency anemia arthritis social history: the patient currently lives by herself in , ma. her son lives in the same apartment complex, and she has vna to help with adls. - tobacco history: she smoked for 20 years but quit 30 years ago - etoh: rare (doesn't like the taste of beer) - illicit drugs: none family history: the patient's son also had cad s/p cabg. her mother had dm2. physical exam: vs: t 98.0, bp 135/66, hr 96, rr 34, o2 sat 99% on nrb general: elderly woman, pleasant, gregarious, in obvious respiratory distress. heent: perrl, eomi. oropharynx clear and without exudate. conjunctival pallor. no xanthalesma. neck: supple with jvp of 10 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. 2/6 systolic murmur. lungs: poor inspiratory effort. diffuse crackles, rhonchi, and expiratory wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: admission labs/studies: cr: 1.4 glucose: 193 ck: 1125, mb: 131, mbi: 11.6, trop: 2.37 cbc: wbc 15.4, hgb 10.3, hct 31.2 plt 330 pt: 14.4, ptt 53.4, inr 1.3 abg: 7.38/36/124 lactate: 1.9 from osh: cardiac enzymes (osh): ck 919, ck-mb 191.5, trop 15.66 creatinine: 1.1 -> 1.2 hct: 28.7 bnp: 275 u/a (): 1+ leuk esterase, 0-2 wbc, 1+ bacteria influenza a: negative legionella ag: negative strep pneumo ag: negative pertinent studies: ekg (osh on ): st depressions in ii, iii, avf, v4-v6. cxr (osh on ): right lower lobe infiltrate is essentially unchanged when compared to previous examination. the degree of cardiac silhouette enlargement s/o median sternotomy is unchanged. the left lung and pulmonary venous pattern have a normal appearance. no pleural effusions seen. tte (): concentric lvh with mild anteroseptal hypokinesis. lvef 50%. trivial aortic stenosis ( 1.9 cm), 2+ mr. 3+ tr. stat tte (): lvef 40%, global hypokinesis. inferior wall hypokinesis v. akinesis. 4+ mr. cxr (): rll infiltrate, bilateral pleural effusions and pulmonary edema. cardiac cath (): 1. selective coronary angiography in this right dominant system demonstrated three vessel disease. the lmca had no angiographically apparent disease. the lad had a large clot in the proximal vessel which supplied a moderate sized diagonal. there was 70% mid-lad stenosis proximal to the svg-lad touchdown and after the diagonal takeoff, as well as mild disease of the distal vessel. the lcx had a 50% occlusion at theorigin and om1 and om2 were 100% occluded. the native lcx only fills a small om4. the distal avg cx is 100% occluded. the mid rca had 100% occlusion. 2. conduit angiography revealed the svg-om and svg-ramus to be totally occluded. the svg to lad and the svg to rca were widely patent. 3. resting hemodynamics revealed elevated right sided filling pressure with rvedp 18mmhg. there was moderate pulmonary arterial systolic hypertension with pasp of 42mmhg. the ci was preserved at 2.5 l/min/m2. 4. successful thrombectomy (using angiojet) of a large thrombus burden in the proximal lad followed by ptca and stenting with a 3.5x18 mm driver bms with improvement in distal flow (into a moderate size diag, otehr smaller branches) from timi 1 to timi 3. final angiography showed no residual stenosis, dissection or distal emboli. echo (): the left atrium is elongated. the right atrial pressure is indeterminate. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is moderate regional left ventricular systolic dysfunction with anterior akinesis/hypokinesis with mild to moderate hypokinesis elsewhere. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is no pericardial effusion. renal us with dopplers(): 1. atrophic left kidney with cortical thinning. no hydronephrosis bilaterally. 2. some vascularity detected in the right kidney, but pulse wave doppler ultrasound cannot be performed on this person, as she is unable to lie flat and unable to hold her breath. doppler cannot be performed on a continual moving target. cxr (): in comparison with the study of , there has been substantial decrease in the pulmonary vascular congestion. cardiac silhouette remains enlarged. the right-sided pleural effusion has decreased. the area of possible consolidation in the right perihilar region is no longer seen, consistent with it having been a reflection of central pulmonary edema. brief hospital course: # nstemi: the patient was originally admitted and thought to have demand ischemia in the setting of acute infection, as she had st depressions in ii, iii, avf, v4-v6 and elevated cardiac enzymes. she was given , , heparin gtt, integrilin, morphine, ntg sl, metoprolol, and nifedipine at osh. at our hospital, she received a load, continued the heparin gtt, and started an integrillin gtt. she was also started on metoprolol, lisinopril, and atorvastatin. the next morning she went for cardiac catheterization and was found to have a large clot in the proximal lad, 50% occlusion of the lcx and 100% occlusion of om1 and om2. there was also 100% occlusion of the mid-rca and 100% of the distal avg cx. she had elevated right-sided filling pressures and moderate pulmonary arterial systolic htn. she received a bms to the proximal lad. there were no complications during the procedure. the next day, follow-up echo showed lv anterior akinesis/hypokinesis, moderate (2+) mr , and mild (1+) ar. patient did not have a recurrence of chest pain during her stay. # respiratory distress: on admission, the patient was found to be in respiratory distress. cxr at the time showed pulmonary edema and known rll infiltrate (pneumonia was diagnosed at osh). it was felt that she had flash pulmonary edema and she was treated with iv lasix. over the next 3 nights, patient had episodes of agitation and respiratory distress. during these episodes, her 02 sats would be approximately 90% on 4l, and her physical exam revealed diffuse wheezing with crackles and the lung bases. she was started on atrovent and albuterol nebulizers for possible reactive airway disease in the setting of resolving pneumonia. however, her crackles on lung exam and wheezing was concerning for recurrent flash pulmonary edema. therefore, she was also diuresed with iv lasix. however, as the episodes continued, it did not appear that the diuresis was helping her, and was therefore discontinued. she had a renal ultrasound to rule out renal artery stenosis causes transient high blood pressures and contributing to flash pulmonary edema. however, they were unable to evaluate for renal artery stenosis. it was decided that her respiratory distress was most likely due to reactive airways, and she was started on prednisone 60mg po daily and inhaled steroids. # pneumonia: the patient presented to the osh with dyspnea, productive cough, and fevers. she was found to have a rll pna. she was treated with ceftriaxone, azithromycin, and vancomycin, and her wbc was trending down. on admission to our hospital, vancomycin was held and the patient completed a 7 day course of ceftriaxone and azithromycin for pneumonia. # acute kidney injury: the patient's cr on admission was 1.4, which was increased from her baseline of 1.1. urine electrolytes were checked and she was felt to have a prerenal cause of her renal failure. creatinine bumped to 1.9 during her stay, but decreased back to 1.6 by the time of discharge. renal ultrasound showed some atrophy of the left kidney but was a poor study. patient's bun/cr should be followed as an outpatient. renal function should followed as an outpatient. # diabetes mellitus type 2: the patient has a history of dm2, and was managed with glargine and sliding scale insulin. # agitation: the patient with agitation on multiple occasions, most commonly related to respiratory distress. she became acutely delirious with administration of ativan. during most of her agitation episodes, she responded to reorientation through an interpreter and one responded to iv morphine. this agitation decreased after patient was transfered to the floor. # anemia: patient with anemia throughout admission. it was thought to be secondary to iron deficiency and she was on iron sulfate as an outpatient. she was transfused 1 unit of blood during her stay in an effort to decrease her shortness of breath, as it was felt that anemia may be contributing to her dyspnea. during the stay a sample was not obtained and guaiaced. on discharge patient's hct is stable at 29.7. patient requesterd to be full code during this admission. medications on admission: ibuprofen 400 mg lisinopril 20 mg daily lantus 50 units daily lipitor 10 mg daily metformin 500 mg nifedical xr 30 mg daily discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): take every day for one year. disp:*30 tablet(s)* refills:*11* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 4. colace 100 mg capsule sig: one (1) capsule po twice a day. 5. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual every 5 minutes for a total of three as needed for chest pain. 6. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 7. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) vial inhalation q4h (every 4 hours) as needed for wheezing. 9. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 10. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 11. insulin glargine 100 unit/ml cartridge sig: fifty four (54) units subcutaneous once a day. 12. carvedilol 25 mg tablet sig: one (1) tablet po bid (2 times a day). 13. humalog 100 unit/ml cartridge sig: as directed units subcutaneous four times a day: please use according to sliding scale four times daily. discharge disposition: extended care facility: genesis healthcare discharge diagnosis: primary: right lower lobe pneumonia non st elevation myocardial infarction delerium acute blood loss anemia acute on chronic systolic congestive heart failure discharge condition: good. the patient's vs are stable, and she is able to ambulate with assistance. discharge instructions: you had a pneumonia and a heart attack. a cardiac catheterization was done and we placed a bare metal stent in your left coronary artery. you had some weakness in your heart that caused some back up of fluid into your lungs. this was better after the catheterization but we continued to give you diuretics to remove the fluid. you had a lot of wheezes so you were started on prednisone. this medicine should be tapered off, not stopped suddenly. while you were here, we made the following changes to your medicines: 1. we decreased your lisinopril dose to 2.5 mg daily 2. we increased you lantus dose to 54 units daily 3. we increased your lipitor dose to 80 mg daily 4. we discontinued your nifedipine 5. we started you on to keep the stent open. do not miss any or stop taking unless dr. tells you to. 6. we started you on aspirin: to take with the . do not stop taking or miss unless dr. tells you to. 7. we started you on carvedilol to help your heart heal from the heart attack and lower your heart rate. 8. we started you on ipratropium and albuterol nebulizations to helpt your breathing 9. we started you on nitroglycerine for your chest pain. 10. we discontinued your ibuprofen, as your kidney function worsened during this admission. 11. we discontinued your metformin in the setting of your acute renal failure. please restart this when you creatinine decreases less than 1.4. 12. we started you on a humalog insulin sliding scale until you can restart your metformin. please return to the ed or your health care provider if you experience shortness of breath, chest pain, confusion, increased fatigue, fevers, chills, or any other concerning symptoms. please weigh yourself every morning, and call your doctor if your weight > 3 lbs in 1 day or 6 pounds in 3 days. please adhere to a low na (< 2 gm sodium/day) diet. . please make an appt to see dr. when you get out of the facility in . followup instructions: primary care: please follow up with your primary care physician within the next two weeks. , cardiology: , np (np with dr. ) phone: date/time: 2:30 md, Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Angiocardiography of right heart structures Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Aortocoronary bypass status Asthma, unspecified type, unspecified Other and unspecified hyperlipidemia Iron deficiency anemia, unspecified Acute on chronic systolic heart failure Drug-induced delirium Chronic total occlusion of coronary artery Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use |
allergies: no known allergies / adverse drug reactions attending: chief complaint: left leg weakness major surgical or invasive procedure: right sided craniotomy for aspiration of intracranial abcess history of present illness: 65 rhw who works as a rn at -ed came to ed for evaluation of left leg weakness. next, neurology was called. she was apparently aymptomatic till 3-4 days ago and never had any weakness with either le. she has h/o left hip fracture in following a fall and has undergone orif with hardware that time. due to this she has slightly shorter left le but no weakness at baseline. she noted swelling and redness of right shin/ankle region since 3/4 days ago. she is working 10 hr shifts for last few days and has also increased the treadmill exercise every day. she has some pain at achilles region on right and came to ed 2 days ago. she had usg r leg and xray of right ankle which were normal. the pain was thought to be musculoskeletal and she was advised ortho opinion. she is using crutches and boot on right side since that time. she denies any weakness of right leg though its tender. yesterday evening she was washing dishes and noted that the left le was giving away at knee. when she started walking to the living room, she couldnt sustain her weight on left le and nearly had a fall when she was supported by her husband. she had near another fall while she tried to sit on couch and couldnt take her weight on left le. this was fairly sudden in onset. she thought the weakness due to tiredness, she slept and hwne woke up this am, noted that the left le was still weak but was able to stand with crutches. this pm, she noted worsening of weakness on left le esp lifting the foot off ground and knee off ground. she came to ed. on neurologic review of systems, patient denies any history of seizures or unexplained loss of consciousness, headache, vertigo, loss of vision, diplopia, difficulty hearing, tinnitus, difficulty with speech or swallowing, numbness, tingling, tremor, balance or coordination, difficulty with sphincter control, difficulty with thinking or memory, problems sleeping or excessive sleepiness, depressive symptoms. general review of systems was negative except as mentioned above, specifically: no chest pain, orthopnea, nocturnal dyspnea, shortness of breath, leg or abdominal swelling, no cough, wheeze, no fever, chills, recent infections, no weight loss, malaise, change in sleep amount, change in sex drive, no change in bowel habit, constipation, melena, bloody stool, abdominal pain, no dysuria, frequency, change in nocturia. past medical history: osteoporosis left hip sx s/p fall and fracture 9 yrs ago dental disease requiring cleaning every 4 months social history: as rn at ed at . social alcohol glasses / week, non smoker or drugs family history: neg for stroke, positive for breast cancer physical exam: general appearance: comfortable, no apparent distress. heent: nc, op clear, mmm. very minimal cataract formation. neck: supple. bilateral bruits, louder and harsher on left. lungs: cta bilaterally. cardiac: rrr. normal s1/s2. no m/r/g. abdominal: soft, nt, bs+ extremities: right le swollen near shin and medial aspect on right side. tender, warm to touch and swollen comp to left. peripheral pulses 1+. neurologic: mental status: awake and alert, cooperative with exam, normal affect. attentive.orientation: oriented to person, place, date and context. language: normal fluency, comprehension, repetition, naming. no paraphasic errors. normal memory, no evidence of apraxia and neglect. intact. cranial nerves: i: not tested. ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. visual fields are full to confrontation. optic fundi normal. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetric. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. posture normal and no truncal ataxia. tone is decreased in the left le as comp to right. power no adventitious movements, such as tremor, noted. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 5 5 5 5 5 4- 5 4- 4- 5 4 4 r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 hip abductor is over right and on left, adductors on both. reflexes: b t br pa ac right 2 2 2 2 - left 2 2 2 3 2 toes down on right, up on left sensation intact to light touch, vibration (very mild decrease), joint position, pinprick bilaterally. normal finger nose, great toe finger, bilaterally. difficult to test in left le due to weakness gait: couldnt stand without being held. laboratory data: cbc : wbc 17 k, chem 7: normal excpet bs 108 ua: p tox: p lactate 2. pertinent results: mri brain two rim-enhancing lesions with slow diffusion in the right frontal and right occipital lobes, most likely representing abscesses mri right ankle findings most consistent with soft tissue abscess adjacent to, or involving the flexor hallucis longus muscle belly, extending from just above the tibiotalar joint proximally into the lower calf, roughly 11 cm in length. no definite evidence of osteomyelitis is seen. 05:10am blood wbc-11.1* rbc-2.75* hgb-8.7* hct-24.6* mcv-90 mch-31.5 mchc-35.2* rdw-12.7 plt ct-588* 05:48am blood neuts-79* bands-4 lymphs-11* monos-6 eos-0 baso-0 atyps-0 metas-0 myelos-0 05:10am blood plt ct-588* 05:48am blood esr-95* 05:10am blood glucose-92 urean-11 creat-0.5 na-138 k-3.9 cl-103 hco3-26 angap-13 05:10am blood alt-54* ast-37 alkphos-80 totbili-0.2 05:10am blood calcium-8.5 phos-3.1 mg-2.1 05:48am blood %hba1c-5.5 eag-111 05:48am blood triglyc-71 hdl-75 chol/hd-2.1 ldlcalc-72 05:48am blood crp-229.9* ca125-12 06:10am blood hiv ab-negative 5:28 pm mrsa screen source: nasal swab. **final report ** mrsa screen (final ): no mrsa isolated. 3:54 pm abscess site: brain cerebral abscess for cultures. **final report ** gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram positive cocci. in pairs and chains. reported to and read back by dr on @716 pm. wound culture (final ): streptococcus anginosus (milleri) group. moderate growth. of two colonial morphologies. anaerobic culture (final ): no anaerobes isolated. 4:22 pm swab right ankle. **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and chains. smear reviewed; results confirmed. wound culture (final ): streptococcus anginosus (milleri) group. sparse growth. anaerobic culture (final ): no anaerobes isolated. 8:40 am blood culture **final report ** blood culture, routine (final ): no growth. 8:42 pm abscess source: right ankle. **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. brief hospital course: patient was admitted to the hospital with a progressive cellulitis of her right foot, with new onset weakness of her left leg in an upper motor neuron distribution approximately 1 week after a routine dental cleaning. patient was seen by orthopedics and infectious disease, and started on empiric antibiotics with vancomycin, metronidazole and ceftriaxone. orthopedics debrided and washed out deep abscess within her right lower leg. while blood cultures demonstrated no growth to date, wound cultures demonstrated growth of streptocooccus anginosus and patient was subsequently transitioned to ceftriaxone and metronidazole. given progression of her neurologic symptoms to weakness of her left leg and arm in an upper motor neuron distribution, a brain mri was obtained that revealed ring enhancing lesions consistent with brain abscess (report included below). as a result, patient underwent right frontal craniotomy and aspiration of brain abscess with stereotactic navigation, which also revealed growth of streptococcus anginosus. a picc line was placed for long-term antibiotic therapy and patient was discharged to in , with appointments made for follow up with neurology, neurosurgery, orthopedics and infectious disease. she was also treated with iv decadron postoperatively to reduce swelling. it was last weaned to 1mg iv q8hrs on . she will continue until one week following discharge and then discontinue. patient was seen by physical therapy and because of continued left leg paresis who recommended acute rehab. repeat ct scan on showed unchanged right frontal hypodense lesion with a central hyperdensity, right parietooccipital hypodense lesion. there was right vertex craniotomy, with improved trace subjacent pneumocephalus. during her admission, she had anemia which did not require any transfusions. she also had transient hyponatermia which resolved prior to discharge. head mri with and without contrast, indication: 65-year-old woman with redness and swelling of the right shin for a few days, now with acute left leg weakness. comparison: head ct and cta dated . technique: sagittal t1-weighted and axial t1-weighted, t2-weighted, flair, gradient echo, and diffusion-weighted images of the head were obtained. following intravenous gadolinium administration, multiplanar t1-weighted images of the head were obtained. findings: there are two rim-enhancing lesions in the right cerebral hemisphere. the right frontal lesion measures 1.3 cm transverse x 2.0 cm ap x 1.5 cm craniocaudad (series 100, image 83, and series 14, image 95). the right occipital lesion is 1.3 cm transverse x 0.7 cm ap x 1.0 cm craniocaudad (series 100, image 34, and series 14, image 108). the nonenhancing center of these lesions demonstrates actively slow diffusion. the enhancing rim of these lesions demonstrates low signal on t2-weighted images and high signal on pre-contrast t1-weighted images. these findings are highly suggestive of abscesses. the enhancing rim of the right occipital lesion is markedly thinner medially, which is another feature commonly associated with abscesses. there is mild-to-moderate right frontal vasogenic edema and mild right occipital vasogenic edema. there is no mass effect on the ventricles and no shift of normally midline structures. there is no evidence of intracranial blood products on gradient echo images. there is a right posterior temporal developmental venous anomaly (102:72). there is no evidence of an associated cavernous malformation. the major arterial flow voids are preserved. a prominent flow void adjacent to the right occipital condyle corresponds to a large vein, as seen on the preceding cta. impression: two rim-enhancing lesions with slow diffusion in the right frontal and right occipital lobes, most likely representing abscesses. malignancy is much less likely. medications on admission: fosamax 70/week ca/vit d discharge medications: 1. alendronate 70 mg tablet sig: one (1) tablet po qmon (every monday). disp:*4 tablet(s)* refills:*2* 2. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po q 12h (every 12 hours). disp:*60 tablet, chewable(s)* refills:*2* 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for c. disp:*60 capsule(s)* refills:*0* 5. miconazole nitrate 2 % powder sig: one (1) appl topical prn (as needed) as needed for groin rash. disp:*1 * refills:*0* 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 7. ceftriaxone in dextrose,iso-os 2 gram/50 ml piggyback sig: two (2) grams intravenous q12h (every 12 hours). disp:*60 * refills:*2* 8. levetiracetam 250 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 9. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 10. dexamethasone sodium phosphate 4 mg/ml solution sig: one (1) mg injection q8h (every 8 hours). disp:*0 * refills:*2* discharge disposition: extended care facility: - discharge diagnosis: intracranial abcess rle infection 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: ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? you may wash your hair only after sutures and/or staples have been removed. if your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. 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 have been discharged on keppra (levetiracetam), you will not require blood work monitoring. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. follow-up appointment instructions ?????? please return to the office in days(from your date of surgery) for removal of your staples/sutures and/or a wound check. this appointment can be made with the nurse practitioner. followup instructions: - steroids are to be discontinued in one week from discharge. -have your staples/sutures removed on while in rehab or you may call the office to have those removed . -follow up with dr from neurosurgery in 2 weeks with mri head with/without contast call with any question. on , the mri of her brain will be at 7:40am (, basement) and afterwards 9am with dr. at lmob 3b and to schedule appointment. -follow up with orthopedics ( with nurse within 2 weeks. - 12:40pm at center . -please follow up with id. provider: , md phone: date/time: 10:30 - will need weekly lts, cbc with diff, bun/creatinine while on ceftriaxone and have faxed to ( rn - will need follow up with neurology with dr. . Procedure: Diagnostic ultrasound of heart Other incision of brain Arthrocentesis Nonexcisional debridement of wound, infection or burn Other myectomy Diagnoses: Anemia, unspecified Hyposmolality and/or hyponatremia Cellulitis and abscess of leg, except foot Osteoporosis, unspecified Intracranial abscess Other disorders of muscle, ligament, and fascia Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B Late effect of fracture of spine and trunk without mention of spinal cord lesion Monoplegia of lower limb affecting unspecified side Late effects of accidental fall Unequal leg length (acquired) |
allergies: no known allergies / adverse drug reactions attending: chief complaint: intraparenchymal hemorrhage major surgical or invasive procedure: none history of present illness: is an 82 y/o male with uncomfirmed pmhx who was found down outside his car in a pool of vomit and brought into , where he was found to have a right frontal iph with possible sah component. he was subsequently transferred to for neurosurgical evaluation. in the ed, he was noted to be agitated and aaox1. past medical history: (per omr note from from gi) - dysphagia - stomach ulcer nos - pud - benign neoplasia of the large bowel - diverticulosis of the colon - cirrhosis of the liver nos - ? heart disease - achalasia social history: married, no etoh, no tobacco family history: mother had gi cancer, primary unknown physical exam: admission physical exam: o: t: 98.6 bp: 108/87 hr: 98 r 20 o2sats 100% on 2lnc gen: slim elderly male lying in bed, agitated heent: c-collar on lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awakens to loud voice or sternal rub orientation: oriented to person in that he responds to his name but is unable to answer his name when asked language: unable to assess as pt only says "what" or "uh-" cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric on passive movement, but pt unable to cooperate with formal testing. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. maee and very vigorously, but pt unable to cooperate with formal strength exam sensation: intact to noxious throughout reflexes: b t br pa ac right 1 1 1 1 1 left 1 1 1 1 1 toes mute bilaterally coordination: patient unable to cooperate with fnf testing. discharge pe: the patient did not appear to be in distress. pertinent results: admission labs: 11:23pm blood wbc-12.9*# rbc-4.34* hgb-12.8* hct-39.0* mcv-90 mch-29.4 mchc-32.7 rdw-13.8 plt ct-186 11:23pm blood neuts-86.0* lymphs-7.6* monos-6.1 eos-0.1 baso-0.3 10:38pm blood pt-13.9* ptt-27.8 inr(pt)-1.3* 10:38pm blood glucose-157* urean-15 creat-1.1 na-146* k-3.1* cl-100 hco3-27 angap-22* reports: ct head limited study due to motion again (despite repetition) demonstrates a 2.1 x 1.6 cm right frontal parenchymal hemorrhage with subarachnoid extension and new intraventricular extension. additionally, hyperdense material now layers along the posterior right occipital lobe in the region of the right transverse sinus and may be representative of a prominent transverse sinus or a small subdural hematoma. note added in attending review: though both studies demonstrate focally increased soft tissue-attenuation within the left parietovertex scalp extending to overlie the mastoid portion of the left temporal bone, this does not clearly represent a subgaleal hematoma, as has attenuation of only 40-45 . however, this may be seen in an anemic or anticoagulated patient. this should be closely correlated with more detailed clinical information, including trauma and medication history. otherwise, this constellation of findings, in an elderly patient, is otherwise strongly suggestive of cerebral amyloid angiopathy, though intraventricular component is somewhat unusual in that setting. there is no evidence of progressive ventricular dilatation to suggest developing hydrocephalus. mri c-spine: 1. stir hyperintensity in facets at c4-c5 on the right side with synovial effusion in the right c4-c5 facet joint which likely represent degenerative changes. there is also stir hyperintensity in the posterior paraspinal soft tissues at this level on the right, which likely represent edema. there is no evidence of fluid collection. 2. multilevel degenerative change in the cervical spine, most notable at c5-c6 level. 3. multilevel neural foraminal stenosis. 4. heterogeneous nodule within the left lobe of thyroid, which requires further evaluation with ultrasound of thyroid if not already performed. cxr: in the image marked 1st dobhoff attempt, the feeding tube with a wire stylet in place ends in the right lower lobe bronchus. in the image marked 2nd dobhoff attempt, there is no feeding tube visible. dr. was paged 30 seconds after finding was recognized, at 4:48 p.m. et tube is in standard placement. right lung is clear. a band of atelectasis crosses the left lower lung. there is no pneumothorax or pleural effusion. cardiomediastinal silhouette is normal. ct t-spine: impression: 1. no acute fracture in the thoracic spine. wedge deformity of t7 and t12 as well as degenerative changes in the lower thoracic spine. 2. bilateral pleural effusions. 3. secretions within the esophagus. note added at attending review: the t7 compression fracture appears to be most likely acute, rather than chronic. there is a tiny osseous fragment slightly retropulsed into the canal (approximately 2-3mm). there is mild angular kyphosis at this level. the pedicles and posterior elements appear intact, but the anterior and posterior vertebral body cortex is disrupted. the t12 wedge deformity is chronic. there is flowing anterior longitudinal ligament ossification from t11 to l1. ct c-spine: impression: no evidence of fracture or subluxation. moderate degenerative changes. ct l-spine: impression: 1. compression deformity of the l4 vertebral body which is chronicity indeterminate due to lack of comparisons. there is no associated retropulsion. however, there is irregularity of the endplates. differential includes possible infectious process such as discitis, collapsed hemangioma or multiple myeloma. wedge deformity of t12 also age indeterminate. multilevel degenerative changes. 2. small bilateral pleural effusions with overlying atelectasis. 3. calcification within the right kidney, which may be vascular or small nonobstructing stone. 4. diverticulosis without diverticulitis. note added at attending review: the l4 fracture and irregular l3 inferior endplate appear chronic and have not changed since an abdominal ct of . thus, these findings do not raise a concern of recent fracture or of infection. cxr: the et tube tip is approximately 7.8 cm above the carina. the dobbhoff tube tip is not seen and might be potentially coiled in the oropharynx. heart size and mediastinum are stable. lungs are essentially clear except for minimal bibasilar atelectasis. ecg: sinus rhythm. non-specific lateral st-t wave changes. borderline low voltage in the limb leads. compared to the previous tracing of premature beats are absent. r wave transition occurs later which may be due to lead positioning. cxr: endotracheal tube tip is 6.2 cm above the carina. ill-defined and faint, right lower lung opacity is new and the minor fissure is mildly thickened and distinctly seen, suggesting aspiration or atelectasis or asymmetrically mild pulmonary edema. upper lungs are clear. heart size is normal. mediastinal and hilar contours are unremarkable. there is no pleural abnormality. cxr: impression: new right upper lobe partial collapse and contour abnormality of the left main stem bronchus suggests the possibility of mucous plugging causing the atelectasis. a bronchoscopy may be helpful to identify and clear potential mucous plugging. ct head: impression: slightly increased size of right frontal intraparenchymal hematoma, with a similar degree of subarachnoid, subdural, and intraventricular hemorrhage. there is no new mass effect, or acute territorial infarction. cxr: right perihilar opacity has markedly worsened, is a combination of pleural effusion layering in the fissure and adjacent atelectasis, superimposed infection cannot be excluded. moderate-to-large bilateral pleural effusions have increased. cardiac size is accentuated by the projection. there is mild vascular congestion. et tube is in standard position. there is no pneumothorax. chest (portable ap) study date of 3:32 am findings: as compared to the previous radiograph, the patient has been extubated. as a consequence, the lung volumes have decreased. the size of the cardiac silhouette is constant. unchanged minimal pulmonary fluid overload, unchanged small left pleural effusion. unchanged partial shoulder replacement. no newly appeared focal parenchymal opacities. radiology report unilat lower ext veins left port : no deep vein thrombosis seen in the left arm. shoulder 1 view left study date of 1:53 pm possible greater tuberosity fracture with coritcal irregularity of the proximal humeral metadiaphysis concerning for additional or contiguous fx; however these are not well evaluated likely due to difficulties in positioning the patient and are age indeterminate. old mid humeral fx. prior images would be helpful in determining the chronicity of these findings. left ankle x-ray : findings: there is a healed fracture deformity involving the distal fibular shaft. no definite acute fracture is seen. there is soft tissue swelling, lateral greater than medial. there is slight widening of the medial ankle mortise. calcaneal spur is present. vascular calcifications are also seen. left shoulder x-ray (3 views): findings: the visualized left lung and ribs are unremarkable. prior left shoulder hemiarthroplasty. cerclage wires are noted around the proximal humerus metadiaphysis. either heterotopic ossification versus old fracture of the greater tuberosity. post-traumatic deformity of the diaphysis distal to the prosthesis. unchanged ac joint degenerative changes. cxr : findings: a single portable ap chest radiograph was obtained. a nasogastric tube loops in the mid esophagus. moderate pulmonary edema is unchanged. left basilar opacity and small effusion are unchanged. a right sided picc line tip terminates in the mid svc. cxr : findings: as compared to the previous radiograph, the malpositioned nasogastric tube has been removed. the right picc line is in unchanged position. unchanged appearance of the lung parenchyma. no pneumothorax. cxr : findings: there is a right-sided picc line whose distal lead tip is at the mid-to-distal svc. cardiac silhouette is upper limits of normal. there is a persistent left retrocardiac opacity and left-sided pleural effusion which is stable. mild prominence of pulmonary interstitial markings is again seen. overall, these findings are all stable. brief hospital course: is an 82 yo male with uncomfirmed pmhx found down, with a r frontal iph. on the day of admission patient was agitated with an otherwise non-focal neurological exam. he was loaded with fosphenytoin, given platelets and made npo. in the icu he was more awake and purposeful on . his wife confirmed use of omeprazole and vitamins but did not know his pmh. omr notes from were used for clinical reference. he was not oriented enough to clear his c-spine so he was intubated and taken to the mri for a c-spine image. in addition, he had whole spine imaging that showed multiple fractures (at t7, t12 and l4) of questionable chronicity, with the t7 fracture likely new and the t12 and l4 likely subacute or chronic. on he had a dilantin level that corrected to 15. dr from neuroradiology was consulted to evaluate the role of vertebroplasty. he recommended tlso brace at this time, and reconsult if worsening once he was more stable and oob. mr was also noted to have thick secretions therefore was not cleared for extubation. on the patient was noted to have decreased movement in the left ue, dr was made aware but no intervention was necessary. he was also noted to have decreased urine output so he was given multiple boluses of ivf and subsequent lasix. his cough and gag were decreased and cxr revealed worsening so he was bronched and noted to have a lul collapse. on , patient began to open eyes to voice, and was moving all 4 extremities spontaneously. he was successfully extubated and had a picc line placed. the patient was fitted for a tlso brace. on , gi was consulted for enteral access and recommended peg tube. the dilantin level was 11.9. on exam, the patient opened eyes to voice and was oriented to self. the patient followed commands in all extremities. on , the patient was febrile to 101.2 and the patient was pancultured. there was unknown source of fever and the dilantin was changed to keppra. on exam the patient opened eyes to sternal rub, the patient localized with upper extremities and moved lower extremities to sternal rub. the family requested a family meeting and stated taht the patient would not want to be dependent on others and made the patient dnr/dni. a pallative care consult was made as the patient's family would like to move toward care and comfort measures possibly and required guidence. the family was clear with their wishes that the patient would not want a gtube for feedings. on , the family met with palliative care and after thoughtful consideration the patient was made cmo given the wishes to not proceed with a feeding tube. his cervical collar was removed and medications were discontinued per palliative care. medications to promote comfort were prescribed. he was transferred to the floor. on , the patient showed improved mental status but continued to cough with po intake. he remained comfortable and did not appear to be in distress or pain. on , the patient had a fever of 101.3 and was given tylenol. given the goals of care, no cultures were obtained at the time. he was offered a bed at hellenic nursing facility and was transfered there on . medications on admission: omeprazole/mvi discharge medications: 1. morphine 10 mg/5 ml solution sig: 5-10 mg po q1h (every hour) as needed for pain. 2. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual q4h (every 4 hours) as needed for secretions. 3. acetaminophen 650 mg suppository sig: one (1) suppository rectal q6h (every 6 hours) as needed for pain. 4. olanzapine 5 mg tablet, rapid dissolve sig: 0.5 tablet, rapid dissolve po q4h (every 4 hours). 5. ondansetron hcl (pf) 4 mg/2 ml solution sig: 4-8 mg injection q6h (every 6 hours) as needed for nausea/vomiting. 6. lorazepam 2 mg/ml syringe sig: 0.5-2 mg injection q2h (every 2 hours) as needed for anxiety/distress/seizure. 7. morphine 5 mg/ml solution sig: 2-4 mg injection q2h (every 2 hours) as needed for pain. discharge disposition: extended care facility: hellenic - discharge diagnosis: right frontal iph c4 tp fracture t12 wedge fracture dysphagia discharge condition: neurologically stable discharge instructions: general instructions ****** pain medications should be given as needed for comfort. followup instructions: no follow up needed Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Closed [endoscopic] biopsy of bronchus Central venous catheter placement with guidance Diagnoses: Anemia, unspecified Unspecified fall Intracerebral hemorrhage Hypopotassemia Pulmonary collapse Loss of weight Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Fever, unspecified Encounter for palliative care Do not resuscitate status Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Diverticulosis of colon (without mention of hemorrhage) Closed fracture of fourth cervical vertebra Personal history of colonic polyps Achalasia and cardiospasm Personal history of peptic ulcer disease Dysphagia, unspecified Shoulder joint replacement |
allergies: penicillins / sulfa (sulfonamides) / erythromycin base / macrolide antibiotics attending: chief complaint: wet, produtive cough, shortness of breath, dyspnea on exertion, hypoxia and abnormal chest x-ray major surgical or invasive procedure: none. history of present illness: year old female with multiple chronic medical problems presenting with a several week history of wet, produtive cough, shortness of breath, dyspnea on exertion, hypoxia and abnormal chest x-ray. several weeks ago, ms. developed fever, chest congestion and shortness of breath. she had several xray evaluations which demonstrated focal nodular abnormality of the rul and extensive abnormal density at the lung bases with pleural disease and low lung volumes. over time, the lung base lesions increased and small effusions developed. she was treated with antibiotics--levofloxacin, then clindamycin then combination vancomycin/ceftriaxone and flagyl (day 1 ). follow up cxr on was without significant change. during this time, she also had evaluation for influenza and was treated with oseltamivir for 2 days, but this was discontinued, as the h1n1 evaluation was negative. . despite treatment with antimicrobials and supportive medications, the patient failed to improve clinically or on imaging. she continued to have a wet productive cough, low grade fever, night sweats, poor appetite (progressive over disease course) and hypoxia since . in the ed, vitals were: 98.1 96/65 100 18 99% 4l nc. her bp remained low throughout the ed course 78-106/39-51. she was given ceftriaxone, flagyl, asa 325 mg and 2 l ivf and admitted to the icu for hypotension. currently, she is bothered only by her cough, otherwise, she is feeling well. past medical history: 1. chf: ef 60%, 3+ mr, 2+ tr, 1+ ar, mod in 2. atrial fibrillation s/p pacer, not on ac due to falls 3. aaa s/p stent / 4. right breast cancer: s/p lumpectomy and radiation 5. chronic renal insufficiency with baseline 1.5 6. anxiety/depression 7. djd/ddd/recurrent pseudocout, lbp, l4/5 spondylolithesis 8. gerd with stricture s/p dilation 9. anemia--baseline per provided labs is 28-30 social history: widowed, lives at , 2 sons, 4 , worked in clerical work, smoked ppd x 40 years, no alcohol, no drugs family history: heart disease physical exam: 97.6 102/65 101 23 94% 5l nc gen: elderly female, well appearing, no distress, lying comfortably at 30 deg angle, speaks in full sentences heent: perrl, eomi, op clear, mm dry/without lesion neck: jvp at 8 cm h2o, hjr to 10 cm h2o car: irregular, tachycardic, no audible murmur resp: crackles 1/2 up bilaterally, broncial breath sounds left base with egophony abd: s/nt/nd/nabs ext: in teds, no le edema pertinent results: admission labs: =============== 03:55pm wbc-6.9# rbc-3.27* hgb-9.4* hct-29.7* mcv-91 mch-28.7 mchc-31.6 rdw-16.4* 03:55pm neuts-76.5* lymphs-17.4* monos-4.4 eos-1.4 basos-0.3 03:55pm plt count-150 03:55pm ck-mb-notdone 03:55pm ck(cpk)-11* 03:55pm ctropnt-<0.01 03:55pm glucose-107* urea n-20 creat-1.3* sodium-132* potassium-4.7 chloride-96 total co2-31 anion gap-10 03:58pm lactate-1.6 07:13pm lactate-1.0 07:29pm urine rbc-0-2 wbc-0-2 bacteria-few yeast-none epi-0 07:29pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 07:29pm urine color-yellow appear-clear sp -1.019 microbiology ============ blood cultures x 2: pending urine culture: pending 2:27 pm sputum source: expectorated. gram stain (pending): respiratory culture (pending): studies: ======== portable cxr: impression: nonspecific lung opacities predominante in the lung bases but also affect the right upper lobe. the differential diagnosis includes infectious, inflammatory, and neoplastic process. recommend ct chest for further evaluation. ct chest/abdomen/pelvis: multifocal airspace consolidation with airbronchograms in the bilateral lower lobes concerning for superimposed infection. known right apical mass increasing in size with newly apparent left apical mass highly concerning for neoplasm. ill-defined soft tissue densities posterior to the kidneys, stable since prior examinations. stable aaa status post stent. discharge labs: 03:46am blood wbc-5.2 rbc-2.98* hgb-8.7* hct-26.6* mcv-89 mch-29.1 mchc-32.6 rdw-17.2* plt ct-116* 03:46am blood glucose-79 urean-15 creat-1.1 na-136 k-4.3 cl-103 hco3-28 angap-9 03:46am blood calcium-8.3* phos-3.7 mg-1.8 brief hospital course: year old female with multiple chronic medical problems presenting with 3 weeks of pulmonary symptoms and hypoxia without improvement. 1. hypotension: clinically, appeared most consistent with dehydration. bolused ivfs on night of admission with appropriate bp response. 2. lung masses: ct showed known right apical mass increasing in size with newly apparent left apical mass highly concerning for neoplasm. in , ct then had noted r apical mass and positive pet concerning for malignancy. also noted to have thyroid lesion. discussed findings with family. patient was too tenuous for bronchoscopy given high oxygen requirment. family meeting completed and she was confirmed dnr/dni as well comfort being paramount goal. she was started on tessalon perles and morphine iv prn. at rehab, please continue oxygen supplmenentation. 3. pneumonia: likely post-obstructive. pcn allergy. planned 7 day course of levofloxacin and flagyl. day # 1 is . 4. atrial fibrillation: hr usually in 100s per as well as during icu hospitalization. continued rate control with nodal agents as in the d/c medication list. 5. aaa s/p repari: initially held asa and plavix, but as no procedure, restarted these upon discharge. 6. chf: clinically dry on exam, no need for diuretics. 7. chronic pain: continued oxycontin, gabapentin, acetaminophen. continue bowel regimen. patient reports having stools. 8. osteoporosis: ca/vit d. 9. chronic renal insufficiency: at baseline 10. anemia: at baseline 11. hyponatremia: likely hypovolemic hyponatremia, resolved in am after ivfs access: piv, picc, foley communication: with patient hcp is son dnr/ medications on admission: -acetaminophen 650 mg qhs -albuterol nebs four times daily -aspirin 81 mg daily -calcium carbonate 650 mg -vitamin d 1000 u daily -celexa 30 mg daily -plavix 75 mg daily -diltiazem cd 120 mg qhs daily -gabapentin 100 mg tid -ipratropium nebs four times daily -isordil 5 mg daily -metoprolol 100 mg daily qhs -omeprazole 40 mg -zofran 8 mg -oxycontin 10 mg qhs -senna discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours). 3. calcium carbonate 500 mg tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day). 4. cholecalciferol (vitamin d3) 400 unit tablet sig: 2.5 tablets po daily (daily). 5. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 6. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). 7. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). 9. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po bid (2 times a day). 10. oxycodone 10 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po q12h (every 12 hours). 11. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day) as needed for constipation. 12. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 13. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 14. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day). 15. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 16. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 17. morphine sulfate 1 mg iv q4h:prn pain 18. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 19. levofloxacin 25 mg/ml solution sig: seven y (750) mg intravenous q48h (every 48 hours) for 7 days: day 1 is . 20. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback sig: five hundred (500) mg intravenous q8h (every 8 hours). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnosis: 1. lung masses 2. pneumonia secondary diagnosis: 1. atrial fibrillation 2. congestive heart failure discharge condition: stable. needs supplemental oxygen 6 l nc to keep o2 > 90% discharge instructions: you were admitted with shortness of breath and hypotension. your blood pressure improved with oxygen. you were found to have a new left upper lobe mass and the known right upper lobe mass in your lungs. you also have a superimposed pneumonia. after a discussion with your family and in line with your wishes, you will be treated with antibiotics for the pneumonia. you were given supplemental oxygen for comfort as well as cough medications for your cough. please continue all your medications as prescribed. please keep all your medical appointments. if you have any concerning symptoms, please ask your doctors rehab. comfort is paramount. followup instructions: please follow up with your primary care doctor as needed. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Other chronic pain Anemia, unspecified Esophageal reflux Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Personal history of malignant neoplasm of breast Personal history of tobacco use Chronic kidney disease, unspecified Dysthymic disorder Alkalosis Osteoporosis, unspecified Osteoarthrosis, unspecified whether generalized or localized, site unspecified Cardiac pacemaker in situ Encounter for palliative care Personal history of irradiation, presenting hazards to health Orthostatic hypotension Achalasia and cardiospasm Neoplasm of unspecified nature of endocrine glands and other parts of nervous system Neoplasm of uncertain behavior of trachea, bronchus, and lung Spondylolisthesis |
allergies: morphine attending: chief complaint: neck pain and hand weakness major surgical or invasive procedure: suboccipital craniotomy with c1 laminectomy and dural graft history of present illness: pt is a 20-year-old woman who presents with weakness of her hands bilaterally. she has more significant symptoms in her left upper extremity. she has no difficulty with bowel, bladder, or gait. she was involved in a motor vehicle accident in after which she was evaluated in emergency room. she has no abnormal sensation of temperature. she does have some dysesthetic symptoms in the left trapezius and right upper extremity. she has been wearing a soft collar and left arm sling, neither of which has led to any meaningful improvement. past medical history: ankle surgery gallbladder surgery social history: unknown family history: nc physical exam: on examination, the left arm is in a sling and the patient is somewhat uncooperative. nonetheless, we were able to demonstrate normal strength in the deltoid, biceps, and triceps bilaterally. the hand intrinsics were clearly weak bilaterally. her lower extremity strength was normal with the exception of the ankle dorsiflexors, which were graded bilaterally. sensory examination showed patchy deficits in a nondermatomal pattern. there was bilateral clonus. on discharge she is awake alert oriented. she complains of pain but wishes to be discharged. she is not fully cooperative wiht exam. her incision is clean and dry her motor exam is only limeited by her effort and does not appear to have unilateral deficit. she is throughout her ue exam and full on her lowers. she does not have any clonus this am. pertinent results: mri of the cervical spine obtained on demonstrates an extensive cervical syrinx. it is quite large and the parenchyma of the spinal cord is extremely attenuated. there is evidence of a chiari malformation with the descent of the tonsils down to the level of c1. there was no contrasted study. 06:30am blood wbc-10.9 rbc-4.27 hgb-12.4 hct-37.2 mcv-87 mch-29.0 mchc-33.3 rdw-12.5 plt ct-211 06:30am blood plt ct-211 06:30am blood pt-12.7 ptt-26.7 inr(pt)-1.1 06:30am blood glucose-103* urean-7 creat-0.9 na-137 k-4.1 cl-99 hco3-29 angap-13 06:30am blood calcium-9.0 phos-2.8 mg-1.9 brief hospital course: pt was admitted to neurosurgery for elective chiari decompression with c1 laminectomy and dural graft. she tolerated this procedure very well with no complications. post operatively she was transferred to the icu for continued care including sbp control and q1 neuro checks. she was started on a pca for pain control with good relif. her post operative exam remained unchanged and she still had some bilateral hand weakness 4+/5. on the morning of she was seen and was doing well. she was transistioned to po pain medications and sent to the floor in stable condition. on the am of postop day #2 she was stable and wishing to go home. she is tolerating po intake, voiding freely. she was instructed that she not lie in bed all day at home and that she needs to stay as active as possible. family friend at the bedside in attendance. medications on admission: none discharge medications: 1. oxycodone 5 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain: do not drive while taking this medication. disp:*60 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. diazepam 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for spasm. disp:*20 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: chiari malformation cervical syrinx discharge condition: . mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ?????? do not smoke ?????? keep wound clean / no tub baths or pools until seen in follow up/begin daily showers post operative day #4 ?????? no pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? limit your use of stairs to 2-3 times per day ?????? have a family member check your incision daily for signs of infection ?????? you were given a soft cervical collar for comfort only, wear cervical collar as instructed ?????? you may shower briefly without the collar ?????? take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, ibuprofen etc. for 3 months. ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? clearance to drive and return to work will be addressed at your post-operative office visit call your surgeon immediately if you experience any of the following: ?????? pain that is continually increasing or not relieved by pain medicine ?????? any weakness, numbness, tingling in your extremities ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f ?????? any change in your bowel or bladder habits followup instructions: please return to the office in 10 days for removal of your staples please call to schedule an appointment with dr. to be seen in 6 weeks. you will need an mri in 6 weeks to evaluate your syrinx Procedure: Other exploration and decompression of spinal canal Other repair of cerebral meninges Diagnoses: Compression of brain Syringomyelia and syringobulbia |
allergies: no known allergies / adverse drug reactions attending: chief complaint: hypotension major surgical or invasive procedure: right internal jugular vein central line placement () history of present illness: 37 yo f with pmhx panhypopit who was found hypotensive, hypoglycemic, bradycardic at home. she was found to have hr in the 20s on sofa unresponsive, lethargic, inital glc 21, bp 70's, hr 40's. she received 100mg thiamine, 1amp glucagon, 1amp dextrose in the field with rapid improvement in mental status. she was last seen by family in morning. . in the ed, 95.0 68 115/57 20 98%. awake, following commands, not oriented on arrival. fs now 181.labs notable for na:133, lactate:1.6. k 3.0 bicarb 18 mg 1.4 inr: 1.4 wbc 2.8. endocrine c/s: can give levothyroxine 75% iv of home dose about 2 hours after dex dose but sounds mostly like adrenal insufficiency. tox scrren negative. foley placed, urine, urine tox sent. given zosyn/vanco, dexamethasone, lorazepam 2mg/ml, dextrose. on d5 maintenance. 2piv, right ij placed. hr 30-60s, bp 80s-115s, temp to 33deg on bear hugger. qtc564. vitals improved with temperature. ct head normal, cxr nml. line in right place. transfer vs 57 93/75 15 100%2l. qtc narrowed to 505. started on levo for sbp 83, 2mg mag and 4l ivfs. also given calcium gluconate. had ativan 1mg x2 for nausea/vomiting. . in the icu, patient had an odd affect. she was oriented but childlook. she endorsed slight nausea and cough. reports compliance with medication. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: -tss x2008 and again in (latter hospital course c/b hemorrhagic stroke and intermittant seizures. -h/o pituitary macro adenoma -h/o glucocortoid noncompliance resulting in crisis in the past -craniotomy in after head trauma after syncope -bipolar? social history: single, lives with 2 children, unemployed, smokes 1 pack cigarettes every 3 days for 10 years, drinks alcohol occasionally. used marijuana in the past but quit 2 years ago. family history: mother with hl physical exam: admission physical exam: vs: temp: 96.6 bp: 87/54 hr:73 rr:19 o2sat 100% on 2l gen:odd affect, comfortable, nad heent: perrl, eomi, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: cta b/l with good air movement throughout cv: rr, s1 and s2 wnl, no m/r/g abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: no c/c/e skin: no rashes/no jaundice/no splinters neuro: aaox3. cn ii-xii intact. 5/5 strength throughout. no sensory deficits to light touch appreciated. no pass-pointing on finger to nose. 2+dtr's-patellar and biceps pertinent results: 02:00pm blood wbc-2.8* rbc-3.59* hgb-9.9* hct-31.2* mcv-87 mch-27.7 mchc-31.8 rdw-15.8* plt ct-242 01:58am blood wbc-8.0 rbc-3.05* hgb-8.6* hct-26.1* mcv-86 mch-28.1 mchc-32.8 rdw-15.8* plt ct-200 12:12am blood hct-28.7* 05:34am blood wbc-10.7 rbc-3.11* hgb-9.0* hct-26.3* mcv-85 mch-28.9 mchc-34.2 rdw-16.1* plt ct-181 06:17am blood hct-24.8* 03:45pm blood pt-15.5* ptt-57.0* inr(pt)-1.4* 04:28am blood pt-13.2 ptt-31.9 inr(pt)-1.1 02:00pm blood glucose-206* urean-13 creat-0.9 na-132* k-4.9 cl-102 hco3-19* angap-16 08:38am blood glucose-322* urean-6 creat-0.9 na-141 k-4.2 cl-115* 09:52am blood na-148* k-3.6 cl-120* hco3-19* angap-13 06:17am blood glucose-172* urean-7 creat-0.7 na-141 k-3.7 cl-112* hco3-24 angap-9 08:38am blood iron-28* 08:38am blood caltibc-163* vitb12-1717* folate-9.3 ferritn-149 trf-125* 05:34am blood hapto-104 05:34am blood ret aut-1.2 06:17am blood ret aut-1.1* 05:00pm blood albumin-3.0* calcium-6.2* phos-1.8* mg-1.5* 05:34am blood albumin-3.4* calcium-8.1* phos-2.4* mg-2.5 02:00pm blood tsh-<0.02* 08:38am blood free t4-1.2 02:00pm blood cortsol-1.5* 02:00pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:35pm urine blood-neg nitrite-neg protein-neg glucose-250 ketone-80 bilirub-neg urobiln-0.2 ph-5.5 leuks-neg 04:57am urine osmolal-185 03:35pm urine ucg-negative blood culture (): no growth cxr (): no acute intrathoracic process. ct head without contrast (): no acute intracranial process. mild right sphenoidal sinus disease. mild age advanced atrophy. please correlate clinically. tte () the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. there is mild anterior leaflet mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: 37 year old female with past medical history of fsh producing macroadenoma s/p tss x 2 complicated by panhypopituitarism for which she is on chronic prednisone and levothyroxine admitted with hypotension, hypoglycemia, hypothermia and bradycardia likely due to adrenal crisis. 1. adrenal crisis: unsure of the precipitant. could be medical noncompliance with past history even though patient and her sister report compliance. it could also be precipitated by viral upper respiratory tract infection. she was started on iv hydrocortisone in the micu and transitioned to prednisone 20 mg po qdaily on discharge with help of endocrinology. she was empirically started on vancomcyin/zosyn to cover for bacterial infection precipitating adrenal crisis but they were discontinued on day 3 as blood cultures were negative x 48 hours and no source of infection noted on imaging and exam. tte, ekg and cardiac enzymes did not reveal any cardiac pathology. 2. hypernatremia: likely due to central diabetes insipidus. sodium returned to with ddavp admission and urine output returend to less than 200 cc/hr. she was discharged on scheduled 0.1 mg of ddavp at bedtime. she was also instructed to drink to thirst. 3. panhypoptituitarism s/p tss x 2 for pituitary macroadenoma. continued on home levothyroxine 75 mcg po qdaily. glucocorticoid replacement as above. currently not on any estrogen replacement which she could benefit from to prevent osteoporosis. 4. prolong qtc: likely due to sinus bradycardia in setting of electrolyte imbalance. she does not report chest pain. 5. fsh pituitary adenoma. follow up with dr. in 1 week after discharge. defer to primary endocrinologist regarding imaging to determine there are any signs of growth of her adenoma 6. abnormal affect: per baseline per patient's sister. unsure of psychological component. patient reports not being depressed or having ahedonia. ct head showed age advanced atrophy. she refused to speak with social worker. 7. anemia: iron studies showing anemia of chronic disease with concaminant iron deficiency anemia. s/p one unit of prbc in micu. she was started on iron sulfate 325 mg po qdaily with retic count of 1.1 on discharge. 8. hyperglycemia: likely due to increased steroids. was treated with sliding scale insulin follow up for pcp/endocrinology 1. taper steroids per dr. 2. please consider estrogen replacement to help prevent osteoporosis 3. please consider mri head to determine whether her diabetes insipidus is related to growth in her macroadenoma. 4. please check retic count 2 weeks after discharge () to determine whether she has a response to iron sulfate medications on admission: -synthroid 75mcg -prednisone 5mg daily discharge medications: 1. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 2. desmopressin 0.1 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 3. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). disp:*10 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary diagnosis 1. adrenal crisis 2. central diabetes insipidus secondary diagnosis 1. pituitary macroadenoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital after being found at home with low blood pressure, low blood glucose and low heart rate thought to be due to adrenal crisis. you were admitted to the medical intensive care unit and given stress dose steroids. you were also noted to have high sodium levels which were thought to be due to deficiency in another pituitary hormone called vasopression. you were started on a medication called desmopressin to replete this hormone which helped normalize your sodium levels. you were also started on iron as you were thought to be iron deficient causing you to have low blood count. following medication changes were made to your medical regimen start desmopressin 0.1 mg by mouth every night to help with your sodium level and urinate less water start iron 325 mg by mouth once a day to help with your blood count increase prednisone to 20 mg by mouth every day until you see dr. please discuss with your endocrinologist regarding further imaging of your brain with mri to determine whether your pituitary adenoma is increasing in size. followup instructions: name: , m. location: family medicine at ball square address: 645 , , phone: appt: a 2:30pm name: , location: hosp address: , , phone: appt: at 3pm note-the office is working on a sooner appt for you. dr. (colleague of dr. endocrinology department , ( tuesday :50 am Procedure: Central venous catheter placement with guidance Diagnoses: Anemia of other chronic disease Hypocalcemia Tobacco use disorder Long-term (current) use of steroids Adrenal cortical steroids causing adverse effects in therapeutic use Other specified cardiac dysrhythmias Hypotension, unspecified Iron deficiency anemia, unspecified Accidents occurring in other specified places Personal history of noncompliance with medical treatment, presenting hazards to health Glucocorticoid deficiency Hyperosmolality and/or hypernatremia Leukocytosis, unspecified Diabetes insipidus Long QT syndrome Panhypopituitarism Other specified acquired hypothyroidism Benign neoplasm of pituitary gland and craniopharyngeal duct Hypothermia not associated with low environmental temperature |
allergies: no known allergies / adverse drug reactions attending: chief complaint: empyema major surgical or invasive procedure: 1. pigtail catheter placement history of present illness: 74yof with h/o bronchiectasis and pseudomonas colonization s/p bronchosocpy in with pulmonologist dr. as outpt, htn, asthma, hypothyroidism who presented to with r shoulder pain and sob, dry cough, pleuritic. she went to and had afib with rvr to 150s, got cardizem. bp at 105/69, p104, 90%ra and 98% on 3l nc. wbc count 26k with 28% bands, ct chest showed complicated rul and rll pna with probably fissural locules of fluid; moderate partly loculated r pleural effusion mostly subpulmonic in location; no pe. admitted to icu there, bcx's x2 drawn (negative to date by discharge), and started zosyn. dr. did which removed 650 cc's of thick yellow cloudy fluid, with ph 7, wbc 26k with 82% neutros, ldh 747, glucose 4, amylase 28, triglycerides 13, gstain negative and fluid culture pending. repeat wbc was 36k with 13% bands. . regarding afib, pt had cards consult and started dilt gtt which was stopped due to hypotension and apparently on hep gtt, not on at transfer. ruled out for ami. started digoxin for rate control. tsh was 1.9. tte showed ef 55%, mod to severe tr, severe pulmhtn 60mm hg, moderate pericardial effusion without tamponade. started on neo-synephrine by transfer. . by arrival, the neo-synephrine was stopped and sbp noted 104. she denied f/c/ns, presyncope, left sided cp, n/v/abd pain/d, cough, palpitations. endorsed r sided pleuritic cp. past medical history: - bronchiectasis and pseudomonas colonization s/p bronchosocpy in with pulmonologist dr. - htn - asthma - hypothyroidism social history: lives at home and is independent with adl. remote smoking history family history: non-contributory physical exam: admission: 96.7 103 84/52 22 95% 2lnc thin pleasant, soft spoken f in no distress, appears well eomi, no scleral icterus, mouth dry appearing no jvd noted bilateral crackles noted to mid lung field with dullness of breath sounds noted on the r compared to l rrr, slightly tachy, no gross m/g soft abdomen, nt nd, benign no ble edema noted, extremities are warm, well perfused cn 2-12 grossly intact, no focal neuro deficits noted discharge: 98.7, 130/89, 90, 16, 96% on ra thin pleasant, soft spoken f in no distress, appears well no jvd bilateral crackles right greater than left irregularly, irregular soft abdomen, nt nd, benign bilateral le edema pertinent results: admission labs: 08:23pm wbc-38.2* rbc-3.60* hgb-10.3* hct-31.7* mcv-88 mch-28.5 mchc-32.3 rdw-13.7 08:23pm neuts-91* bands-5 lymphs-1* monos-3 eos-0 basos-0 atyps-0 metas-0 myelos-0 discharge labs: 09:04am blood wbc-26.4* rbc-3.37* hgb-9.7* hct-28.9* mcv-86 mch-28.8 mchc-33.5 rdw-14.9 plt ct-492* 09:04am blood neuts-89* bands-0 lymphs-6* monos-4 eos-0 baso-0 atyps-0 metas-1* myelos-0 09:04am blood glucose-100 urean-13 creat-0.8 na-141 k-3.9 cl-105 hco3-28 angap-12 micro: blood cx , : no growth urine cx: no growth pleural fluid cx : no growth c.diff pcr : negative studies: ct chest with contrast :'impression: 1. mixed response to treatment with significant decrease in size in the right subpulmonic effusion with a pigtail drain in situ. increase in size of two of the loculated pleural fluid collections in the right hemithorax. interval decrease in size of multiple loculated fluid collections along the posterior wall of the right chest; however, some of these appear to be intrapulmonary rather than pleural. 2. improved appearance in the right upper lobe consolidation. 3. persistent extensive bronchiectasis. 4. increase in the left pleural effusion. tte : conclusions the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is mildly dilated with borderline normal free wall function. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a small pericardial effusion. the effusion appears circumferential. there are no echocardiographic signs of tamponade. echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. impression: small circumferential pericardial effusion with no echocardiographic signs of tamponade. at least moderate pulmonary hypertension. mild right ventricular dilation with borderline normal function. mild mitral and mild-to-moderate tricuspid regurgitation. normal left ventricular function. brief hospital course: ms. is a 74yo f with bronchiectasis and pseudomonas colonization who presented with large right-sided loculated empyema, moderate pericardial effusion and hypotension. she was admitted to the icu, where she was started on empiric abx, and bolused fluids for hypotension, to which she was responsive. ip was consulted, and a right-sided pig-tail catheter was placed, when her #) bacterial pneumonia complicated by loculated empyema: patient initially presented to where she was found to have a large right sided pleural effusion, thoracentesis studies done there were suggestive of an empyema (ph=7, ldh=747, glucose=4, but culture negative). she was transferred to for further management and thoracic surgery consultation. she was initally managed in the icu where she was seen by the interventional pulmonary service, and right sided chest tube was placed for drainage of her empyema. repeat pleural fluid studies done on admission here were: ph=6.5, glucose=0 and ldh=1694. her antibiotic coverage was broadened to vancomycin in addition to the zosyn, with plans for a 14 day course. she was transferred to the medical floor on , where she continued to be followed by the thoracic surgery service, her chest tube was pulled on and she will follow up with thoracic surgery as an outpatient. she will need 4 more days of iv antibiotics to complete a 14 day course. #) atrial fibrillation: at she was noted to be in atrial fibrillation with a rapid ventricular response, which was new finding for her. on initial presentation she was hypotensive, initially requiring vasopressor support with phenylephrine, which was very quickly weaned off. after her blood pressures stabilized she was started on metoprolol for heart rate control. her dose was uptitrated to 75mg tid, as she had episodes of rvr with lower doses, her heart rate is currently well controlled on this dose. her chads2 score is 1, so she will be started on full strength aspirin at the time of discharge. #) diarrhea: after about one week of antibiotics the patient started having diarrhea, she was ruled out for c.diff with two negative toxins and a negative c.diff pcr and her diarrhea was improving at the time of discharge. #) hypothyroidism: a tsh checked with her new onset atrial fibrillation was 2.4 and her home dose of levothyroxine was continued #) code status: full code transitional issues: 1. she will need to complete 4 more days of vancomycin and zosyn for her pneumonia 2. chest tube care as per page 1 instructions 3. physical therapy to help her regain strength medications on admission: - albuterol prn - levothyroxine 25 mcg daily - advair diskus 100/50 - tenoretic (atenolol and chlorthalidone) unclear dosages discharge medications: 1. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 2. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): please place patch on for 12 hours then off for 12 hours . 3. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 4. piperacillin-tazobactam 2.25 gram recon soln sig: one (1) recon soln intravenous q6h (every 6 hours) for 4 days. 5. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). 6. aspirin 325 mg tablet sig: one (1) tablet po once a day. 7. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours) as needed for wheezing. 8. vancomycin 750 mg recon soln sig: one (1) recon soln intravenous every twelve (12) hours for 4 days. 9. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: three (3) ml inhalation q4hr prn () as needed for wheezing. 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 11. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). discharge disposition: extended care facility: rehabilitation and nursing of discharge diagnosis: primary: community acquired bacterial pneumonia complicated by loculated empyema atrial fibrillation secondary: bronchiectasis asthma hypertension hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ms. , it was a pleasure caring for you at . you were transferred from for management of pneumonia complicated by an empyema, which is a collection of pus between the lining of your lungs. at first you were cared for in the intensive care unit, where you were seen by thoracic surgery who put a chest tube into the collection of fluid around your lungs so it could drain. after your breathing improved, you were able to be transferred to the medical floor. after your chest tube stopped draining, it was removed, you will need to follow up with the thoracic surgeon, dr. after you leave the hospital. your pneumonia was treated with two antibiotics, called vancomycin and zosyn, which you will need to take for three more days after you leave the hospital. during your hospital stay you were also noted to have a new arrhythmia, called atrial fibrillation, with this new heart rhythm your heart was beating very quickly so we started a medication called metoprolol to help control your heart rate. we also started you on aspirin 325mg every day to help prevent stroke associated with this heart rhythm. you were also evaluated by physical therapy who felt that a short rehab stay would help improve your strength. changes made to your medication regimen: 1. started vancomycin 750mg iv every 12 hours for the next 3 days to treat pneumonia 2. started zosyn 2.25g iv every 6 hours for the next 3 days to treat pneumonia 3. started metoprolol 75mg three times per day to help control your heart rate 4. started aspirin 325mg daily 5. stopped tenoretic chest tube site remove dressing saturday morning and cover site with a bandaid until healed. should site drain cover site with a clean dry dressing and change as needed to keep site clean and dry. followup instructions: thoracic surgery: provider: scan phone: date/time: 10:15 on the clinical center radiolgoy: nothing to eat or drink after midnight the night before your cat scan provider: , md phone: date/time: 11:30 on the clinical center . primary care: please call your pcp . at after discharge from rehab for follow up of your hospitalization. Procedure: Insertion of intercostal catheter for drainage Injection or infusion of thrombolytic agent Central venous catheter placement with guidance Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Asthma, unspecified type, unspecified Other chronic pulmonary heart diseases Diarrhea Bronchiectasis without acute exacerbation Empyema without mention of fistula Bacterial pneumonia, unspecified |
allergies: penicillin g attending: chief complaint: tracheoesophageal fistula major surgical or invasive procedure: bronchoscopy endoscopy history of present illness: 69f with hx of nsclc s/p right pneumonectomy, chemo&radiation two years ago, admitted to osh for lll pneumonia on , found to have tracheoesophageal fistula on barium swallow and bronchoscopy, transerred to intubated and sedated for interventional pulmonology evaluation of tracheoesophageal fistula. . patient was initially admitted to hospital , where she was treated for cap with 10 days of levofloxacin, requiring intubation from . her antibiotics were broadened slowly first with aztreonam () then vancomycin (). she underwent bronchoscopy , which showed significant inflammation in the left mainstem bronchus; culture showed rare yeast. post-extubation, she required continuous bipap; she required reintubation on due to progressive hypercarbia. she had been started on vasopressin prior to intubation and was later started on dopamine as well. at midcoast, patient also had a modified barium swallow which showed barium in the trachea, but no obvious fistula. bronchoscopy confirmed tracheoesophageal fistula 1cm tef 5cm from the carina. while at midcoast, she was also noted to have afib and aflutter, but no known prior history. an echo on showed pulmonary hypertension and septal hypokinesis, but normal ef. she was transfered to medical center intubated on pressors dopamine and vasopressin. . at medical center, patient had a bronchoscopy with bal showing gpcs. she underwent ct chest on to rule out pe in setting of mildly elevated ckmb and trop. it appears that she was afebrile throughout her stay at medical. she was started on iv doses of digoxin for her afib which helped keep her rate-controlled and noted to be maintained in sinus rhythm. patient was on insulin drip at outside hospital for hyperglycemia in the setting of tpn and high dose stress iv steroids. on transfer to , patient is on vancomycin (day#4), clindamycin (day#3), aztreonam (day#10), fluconazole (day#2). . on arrival to the micu at , patient is intermittently in stable vt with sbps in 180s, completely asymptomatic, intermittently in rapid afib with rates to 160s. she was given one dose of iv metoprolol 5mg while in afib with rvr which decreased her hrs and let her self-convert to nsr with rate 80s. past medical history: non-small cell lung cancer, stage iiib (t2n2m0), squamous cell - s/p right pneumonectomy ~ - s/p chemo (/taxol, fall ) and radiation (5040 cgy ebrt) at kettering copd, severe - not on home o2 htn social history: married, husband . retired accountant. lives in . tobacco: quit, but smoked 20-40pack-yrs etoh: rare family history: mother died of an mi at 79 father with multiple myeloma physical exam: on admission to micu: itals: t: 97.1 bp: 157/82 p: 110 r: 18 o2: 98% on cmv fio2 40% general: intubated but can answer yes or no questions appropriately and trying to communicate medical history while intubated, no acute distress heent: sclera anicteric, mmm, ng tube with bloody aspirates neck: supple lungs: diffuse rhonchi bilaterally with air movement only on left cv: reg rhythm, rapid rate, no murmurs appreciated abdomen: soft, non-tender, mildly distended, hyperactive bowel sounds, no rebound tenderness or guarding gu: foley in place ext: warm, well perfused, 2+ pulses, + pitting edema of bilateral lower extremities up to sacrum pertinent results: on admission: . 07:25pm blood wbc-27.4* rbc-4.16* hgb-11.3* hct-33.6* mcv-81* mch-27.0 mchc-33.5 rdw-13.9 plt ct-460* 07:25pm blood pt-11.5 ptt-26.2 inr(pt)-1.0 07:25pm blood glucose-76 urean-33* creat-0.3* na-143 k-5.3* cl-101 hco3-35* angap-12 07:25pm blood alt-33 ast-47* ld(ldh)-739* ck(cpk)-60 alkphos-49 totbili-0.4 04:15am blood alt-22 ast-16 ld(ldh)-198 alkphos-40 totbili-0.5 07:25pm blood albumin-3.0* calcium-8.5 phos-3.3 mg-1.8 04:24am blood type- temp-36.0 rates-18/2 tidal v-300 peep-5 fio2-40 po2-43* pco2-63* ph-7.43 caltco2-43* base xs-13 -assist/con intubat-intubated . : blood cx: ng . osh: - tte showed normal ef, septal hypokinesis, pulmonary hypertension . cxr - right lung out with tracheal deviation to the right; right-sided picc line tip in distal subclavian; lll infiltrate mixed with barium . ekg: - - 19:06 - wide complex tachycardia, rate 143, evidence of p-waves though diff morphologies and not necessarily conducting; a capture beat - - 19:28 - afib w rvr, rate 130s; narrow complex; t-wave inversions in inferior leads ii, iii, avf and precordial leads v1-v6 - - 19:33 - nsr rate 80s, inverted t waves in inferior leads ii, iii, avf and in v1-v4; flattened t waves in lateral leads . cxr: rightward mediastinal shift and opacification of the right hemithorax is consistent with prior pneumonectomy. there is no gas in the right pneumonectomy space. heterogeneous opacification at the base of the left lung could be dependent edema or pneumonia, including aspiration. a 2-cm wide elliptical opacity projecting over the left mid lung could be a nodule or fissural pleural fluid since there is pleural fluid, more inferiorly. mediastinum shifted into the opacified right hemithorax cannot be assessed. et tube in standard placement. nasogastric tube should be advanced at least 4 cm to move all the side ports well beyond the gastroesophageal junction . ct torso: impression: 1. right pneumonectomy, with no evidence of cancer recurrence. 2. left lower lobe consolidation, with high-attenuation material suspicious for prior aspiration of enteric contrast material. 3. no ct evidence of tracheoesophageal fistula. please note that this examination was not a dedicated trachea study but no spontaneously patent wall defect is appreciated. 4. volume overload as evidenced by pleural effusions, mesenteric edema, ascites, and anasarca. . mri brain: impressions: 1. no intracranial metastases. 2. small amount of fluid in right mastoid air cells. 3. mild chronic small vessel ischemic change. brief hospital course: 69f with hx nsclc s/p right pneumonectomy/chemo/radiation who presented to osh with lll pneumonia on , found to have tracheoesophageal fistula by bronchoscopy, transferred to for further management of tef. . # hypercarbic and hypoxemic respiratory failure: pt was transferred from osh s/p intubation and antibiotic course for pneumonia. she was transferred after discovery of te fistula. pt remained intubated in the micu for malignancy w/u and ip evaluation of the te fistual. she was taken to the or on for rigid bronch, and while they were there the et tube was changed due to cuffleak with resulting abg showing improvement in oxygenation and a decrease in her previously elevated co2. . # lll pneumonia: cxr showed lll process; pt had completed 10 days of antibiotics for pneumonia. vancomycin was continued for a recent osh sputum culture that had grown gpcs. on hd#3, bilious contents were aspirated from the patient's et tube. she was taken to the or by interventional pulmonology for the fistula on (see below for results). as she was hemodynamically unstable after the procedure, antibiotics were broadened on to vancomycin, aztreonam, and levofloxacin. . # te fistula: the patient had an initial bronchoscopy in the icu on hd#2 that showed a well-demarcated fistula. this was thought to be trauma from prior intubation or cancer recurrence. malignancy w/u was initiated. ct torso and mri brain were negative for evidence of cancer. on hd#3, pt was taken to the or for rigid bronch which showed large incision-shaped tef in trach into esophagus (thought to be from an intubation through necrotic tissue); tracheal stent was placed to seal tef from tracheal side, but she will need an esophageal stent as well to be placed by gi. she was transferred to the on for the esophageal stent to be placed. egd was attempted on at which point she became hypotensive after propofol induction and the procedure was stopped. egd was delayed until at which point the tef was deemed to be too large and a stent seemed futile. . # wide complex tachycardia: on arrival, pt was in stable vt with rates in the 140s-150s. potentially may also have represented svt with aberancy, though cards was informally c/s'd and agreed the rhythm appeared to be stable vt. the patient was given 5 mg iv metoprolol with conversion into sinus rhythm. an ekg showed worsening twi. cards recs did not feel it was ischemic and that her persistent narrow complex tachycarida was likely mat. her lopressor was increased to 5iv q4h on . . # coffee ground material in ng tube: on transfer, there was coffee ground material in the ng tube. aspirate was guaiac positive. gi bleed was thought to be high dose steroids at osh. she was maintained on ppi. hematocrit remained stable and no other coffee ground material was seen. . # afib with rvr: pt was intermittently in afib with rvr and mat along with the wide-complex rhythm discussed above. metoprolol was increased to 5 mg iv q4h with good effect. she was maintained on subq heparin for dvt prophylaxis. # non-small cell lung cancer: the patient is s/p right pneumonectomy ~ - s/p chemo (/taxol, fall ) and radiation (5040 cgy ebrt) at kettering. the patient was taken to the or on for te fistula and biopsies were taken in or of tracheal and esophageal sides; necrotic tissue seen in right bronch stump; biopsy from tracheal side preliminarily shows possible scc recurrence, but biopsy from gi side sent in formalin will take longer to come back . # pt was on pneumoboots and later subq heparin for dvt prophylaxis. communication was with the patient and her husband ( (home) and ( (cell). she remained full code during this admission. trauma icu course: events: - : transfered to tsicu pre-op for diversion of tef, svt to 180's; rate controlled with diltiazem, transiently hypotensive to 70's but resolved. - : or for tef diversion c/b migration of stent, interval enlargement of tef, drains placed x 3. respiratory acidosis resolved with increasing peep/rate. received lasix 10mg for pulmonary edema. - : 2uprbc's w/ 20 iv lasix between. weaning vent. respiratory distress (on cpap ) after 1 unit of blood improved with the lasix. 40 iv lasix total. increased alkalosis holding diuresis as feurea is high. svt (130's) at 3 am, rate controlled with 10 iv lopressor, increased dilt po to 60 qid. - : 20 lasix, dropped hr to 40s on cpap. placed on 100% fio2, - resolved. diamox given, monitoring diuresis - : cpap 5/0 in am, 15 minutes, tachycardic, went into a. fib responsive to iv diltiazem, increased cpap throughout day. met with family briefly. - : family meeting - continue care/full code. - : tf's started, continuing tpn until tfs at goal. metabolic alkalosis largely resolved, likely contraction alkalosis from diuresis in setting of baseline compensatory alkalosis; dc'd diamox and started lasix. good diuresis but pt hypotensive - albumin 12.5g x 2 with improvement. family requests palliative care consult. decreased insulin in tpn given episodes of am hypoglycemia - : d/c'd lasix for weight < preadmission. patient made cmo after extensive conversation with patient, family, palliative care, nursing; icu attending present. the patient expired thereafter. medications on admission: tussionex hctz spironolactone/hctz megace aspirin albuterol budesonide discharge medications: expired discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other enterostomy Other bronchoscopy Other bronchoscopy Arterial catheterization Other intubation of respiratory tract Closed [endoscopic] biopsy of bronchus Esophagogastroduodenoscopy [EGD] with closed biopsy Other operations on trachea Other gastrostomy Cervical esophagostomy Diagnoses: Pneumonia, organism unspecified Acidosis Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Paroxysmal ventricular tachycardia Acute respiratory failure Alkalosis Pressure ulcer, lower back Rash and other nonspecific skin eruption Hematemesis Personal history of irradiation, presenting hazards to health Tracheoesophageal fistula Other specified disorders of esophagus Pressure ulcer, stage II |
allergies: valsartan / darvon / hydrochlorothiazide / lopressor attending: chief complaint: status epilepticus major surgical or invasive procedure: * arrived intubated * transfusion of 2 units of packed red blood cells history of present illness: hpi (per notes, pt's family, dr. at hospital): the pt, "," is an 80 year-old left-handed woman with a past medical history including a fib (on coumadin with therapeutic inr), remote right basal ganglia infarct, and pvd s/p left femoral-dorsalis pedis bypass on at hospital who was transferred to the after she was discovered to be in status epilepticus in the post-operative period. per report, the patient was in her usual state of health when she presented to the hospital for the elective vascular procedure designed to address peripheral vascular disease with non-healing ulcers on the left foot. immediately prior to the procedure, the patient's inr was 2. although the pre-operative plan was to perform an in situ bypass, the veins were not conducive to the procedure. accordingly, a synthetic graft was placed in the course of an eight- to nine-hour operation with lma. although the patient was noted to be oozing intra-operatively, a heparin drip was started per protocol. to compensate for a blood loss of approximately one liter, she was given a total of three (two intra-operatively and one post-operatively) units of packed red blood cells. records indicate the patient's systolic blood pressure was below 80 for approximately 30 minutes; neo was transiently administered. following the procedure, all sedatives and pressors were discontinued. in the two hours immediately following the procedure, the patient was thought to be reponsive to commands. she could reportedly open eyes to voice and squeeze the examiner's hand upon verbal request. subsequently, she received morphine 2 mg iv x 2 presumably for pain. thereafter, she was found to be "unresponsive." on clinical examination, she demonstrated what soulds like decorticate posturing to sternal rub. she was transferred to the icu early for close monitoring. a non-contrast ct of the head was negative for acute hemorrhage and large territorial infarction. per records, she had intact brainstem reflexes with flexor responses bilaterally. on , an eeg revealed evidence of rhythmic sharp and slow waves in the left (and sometimes right) hemisphere. accordingly, dilantin 1 mg iv and ativan 2 mg iv was administered. on examination she was noted to withdraw all extremities to pain with an extensor response on the left. the patient was transferred to the for further evaluation and care. neurological review of systems - unable to obtain general review of systems: - unable to obtain past medical history: past medical history: - htn (bp usually measured as 140-150/80) - hld - chronic a. fib on coumadin (therapeutic inr) - basal ganglia lacunar infarct () - bell's palsy (? left, treated with prednisone, no etiology identified) - gerd - pvd, s/p fem-dp bypass () - ploymyalgia rheumatica - osteoporosis . past surgical history: - tonsillectomy - left fem-dp bypass social history: - lives with her son and daughter - independent in all adls, still makes sunday dinner for the family - had seven children, one of whom is deceased - has children and great-grandchildren - loves bingo and lottery - previously served in the courtesy booth at supermarket . habits - tobacco use: reportedly negative - alcohol use: reportedly negative - recreational drug use: reportedly negative family history: - positive for pvd (mother), stroke (sister - at age 60) - negative for seizure, other neurological conditions, autoimmune conditions physical exam: on admission vitals: t: 96.9 p: 83 r: 27 bp: 129/52 sao2: 100 % on cpap/psv: psv 8, peep 5 general: intubated, sedated. heent: normocepahlic, atruamatic, no scleral icterus noted. eeg leads in place. neck: bandaged. cardiac: regular rate, irregularly irregular rhythm. pulmonary: lungs clear to auscultation bilaterally anteriorly. abdomen: obese. normoactive bowel sounds. soft. non-tender, non-distended. extremities: left lower extremity is bandaged from above the knee to just below the toes. skin: no rashes or concerning lesions noted. neurologic examination: mental status: * degree of alertness: unarousable to voice and noxious stimulation. she does not follow commands. cranial nerves: * i: olfaction not evaluated. * ii: perrl 3 to 2mm and brisk. * iii, iv, vi: eyes midline. * v: corneal reflexes intact bilaterally. * ix, x: some degree of incomplete decerebrate posturing in response to attempts to elicit gag. motor: * bulk: no evidence of atrophy. * tone: normal in upper extremities. ? mildly increased in right lower extremity. left lower extremity not tested. * adventitious movements: no rhytmic ativity noted. strength: * left upper extremity: no appreciable withdrawal to noxious stimulation. * right upper extremity: apparent decerebrate posturing with noxious stimulation. * left lower extremity: spontaneously moves with noxious stimulation (applied to other extremities) * right lower extremity: withdrawal to (noxious and non-noxious) stimulation reflexes: * left: brisk biceps bracheoradialis, lower extremity not evaluated secondary to bandaged wounds * right: brisk biceps, triceps, brachiradialis, 2+ patella * babinski: ubable to test on left (bandaged), mute on right pertinent results: admission lab data: . wbc-23.9* rbc-3.26* hgb-10.1* hct-28.7* mcv-88 plt-118 glucose-162* urea n-29* creat-1.6* sodium-140 potassium-4.1 chloride-110* total co2-22 anion gap-12 calcium-6.8* phosphate-3.6 magnesium-2.2 pt-20.6* ptt-40.3* inr(pt)-1.9* ck-mb-7 ctropnt-0.13* phenytoin-11.3 digoxin-1.2 . mri brain (): impression: multiple acute infarcts involving the left aca, left pca and right cerebellar region. extensive small vessel disease and brain atrophy. . mra head (): impression: extensive flow signal irregularity in both middle cerebral, both anterior cerebral arteries as well as in the basilar artery indicative of atherosclerotic disease with areas of narrowing. . ct head without contrast (): impression: 1. multifocal infarcts, including the left aca, and left pca territories, as well as the right cerebellum, similar in appearance to mri of . no evidence of hemorrhagic transformation. 2. extensive chronic small vessel ischemic disease. . eeg monitoring: : impression: this telemetry captured no pushbutton activations. routine sampling showed a diffusely slow and disorganized background consisting of mixed theta and delta frequencies. this is suggestive of a moderate to severe encephalopathy. there were no clearly epileptiform features on this study; however, the last file of routine sampling did show .5 hz bursts of slowing occurring in the left hemisphere. it was unclear if this was truly left hemispheric or generalized as the right hemisphere was obscured by electrode artifact. . : mpression: this telemetry captured no pushbutton activations. routine sampling showed a diffusely slow and disorganized background consisting of mixed theta and delta frequencies clinically consistent with a moderate encephalopathy. there were occasional bursts of l>r bifrontal slowing which, at times, were rhythmic. they were, however, self-limited, brief, and without sharp features. there were no epileptiform features on this recording. . transthoracic echocardiogram (): conclusions the left atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). a small apical intracavitary gradient is identified. no left ventricular mass/thrombus seen. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid leaflets appear mildly thickened. there is a small echodensity on the anterior tricuspid leaflet (cine loop #55). the echodensity may represent redundant chordal apparatus, however given the severity of associated regurgitation, a vegetation should be considered. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . impression: no asd seen. vigorous biventricular systolic function. possible tricuspid valve vegetation. moderate to severe tricuspid regurgitation. moderate pulmonary hypertension. . carotid duplex (): findings: duplex and color doppler of the left carotid system demonstrates peak systolic velocities to be within normal limits. there is no appreciable plaque or wall thickening. the ica to cca ratio was 0.95 on the left which is within normal limits. . the right carotid system could not be interrogated due to the adjacent central line making interrogation technically not possible. there is antegrade flow involving the left vertebral artery. . impression: widely patent left common carotid system with no plaque or stenosis, patent vertebral artery on the left. the right side cannot be interrogated for technical reasons as stated above. brief hospital course: "" is an 80 year-old left-handed woman with a past medical history including atrial fibrillation (on coumadin with therapeutic inr), remote right basal ganglia infarct, and pvd s/p left femoral-dorsalis pedis bypass graft on at hospital who was transferred to the after she was discovered to be in status epilepticus in the post-operative period. she was admitted to the neurology icu service from to . . neuro at the time of admission, mri-compatible eeg leads were placed and continuous monitoring was initiated. dilantin was continued as seizure prophylaxis. telemetry demonstrated no further epileptiform activity. . upon her arrival, the patient's neurological examination was notable for the absence of arousability to voice and noxious stimulation, lack of withdrawal to noxious stimulation in the left upper extremity, posturing to noxious stimulation in the right upper extremity, and diffusely brisk reflexes. given the significant bilateral deficits, there was concern for global neurological assault. an mri demonstrated strokes in the left anterior cerebral artery, left posterior cerebral artery, and right cerebellar territories with significant atherosclerotic disease. it was thought that the strokes were likely secondary to poor cerebral perfusion in the setting of hypotension and unhealthy, stenotic vessels. in turn, the hypoxia and infarctions were considered probable substrate for seizure. . unfortunately, in the course of the hospitalization, the patient's clinical examination declined; she stopped withdrawing to noxious stimulation and developed some degree of a vestibular oculocephalic reflex. a repeat non-contrast ct of the head failed to reveal evidence of hemorrhagic transformation or other new abnormalities. . cvs in the context of the patient's recent vascular procedure, the vascular team was asked to participate in her care. at their recommendation, carotid duplex studies were performed. while an adjacent central line precluded evaluation of the right side, the left carotid artery appeared patent. a transthoracic echocardiogram showed no evidence of an atrial septal defect or left ventricular mass or thrombus. . heme in the course of hospitalization, the patient's hematocrit dropped from approximately 28 to about 20. accordingly, two units of packed red blood cells were given with an appropriate rise in hematocrit. the drop in hematocrit was attributed to hemodilution and wound oozing. . goals of care in the setting of the patient's clinical deterioration, several conversations were held by phone and in person with the patient's family. children, including the legal health care proxy, affirmed that the patient would not want to live with the new neurological deficits. according to her wishes, the goals of care were transitioned from cure to comfort. the patient was extubated. shortly thereafter, she died. medications on admission: medications on transfer: - ivf "as ordered" - kefzol 1 gram iv q6h - heparin gtt at 500 u/hr - propofol 5-50 mcg/kg/min iv, titrate to sedation - digoxin 0.1 mg iv daily (decreased from outpatient dose of 0.125 mg daily secondary to arf) - diltiazem 5-15 mg/hr, hold for hr <100 (started for a fib w rvr) . allergies: - valsartan --> rash - darvon --> nausea and vomiting - hctz --> nausea and vomiting discharge medications: none discharge disposition: expired discharge diagnosis: none discharge condition: deceased discharge instructions: none followup instructions: none md, Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Diagnoses: Polymyalgia rheumatica Esophageal reflux Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Other chronic pulmonary heart diseases Chronic kidney disease, unspecified Ulcer of other part of foot Other and unspecified hyperlipidemia Anoxic brain damage Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Osteoporosis, unspecified Grand mal status Long-term (current) use of anticoagulants Encephalopathy, unspecified Cerebral artery occlusion, unspecified with cerebral infarction Diseases of tricuspid valve Atherosclerosis of native arteries of the extremities with ulceration Cerebral atherosclerosis Iatrogenic cerebrovascular infarction or hemorrhage |
allergies: penicillins / aspirin attending: chief complaint: sepsis major surgical or invasive procedure: right internal jugular vein central catheter placement history of present illness: mr. is a 60 year old male with pmh cva with left hemiparesis, g tube, stage iv sacral decub, bph with suprapubic catheter admitted with fever, leukocytosis, hypotension. he was given dose of levofloxacin at the nh prior to transfer. of note he has a stage iv sacral decubitus ulcer. abdomen is also noted to be distended and tympanitic. . in the ed vs t99.8 125 135/76 20 100% 3l nc. rectal temp of 103 for which he was given 650mg tylenol pr. he was vanc 1g iv and zosyn 4.5g iv for presumed urosepsis given positive ua and suprapubic tube. a rij was placed per sepsis protocol given fever, leukocytosis, tachycardia and tachypnea. given his reports of abdominal pain he had a ct abdomen which showed massive large bowel dilation with sigmoid up to 9 cm without a transition point. cxr did not show any infiltrate. he was transfused 2 liters ivf and one unit prbc. he was guaiac negative. he was noted to have stage iv sacral decubitus ulcer with strong odor but no purulent drainage. . on arrival to the icu he is alert and oriented x2, he reports pain in his buttocks but denies other complaints. past medical history: cva w/left hemiparesis (4 years ago htn) gtube right lower extremity weakness aphasia bph with suprapubic catheter urethral-scrotal fistula sigmoid volvulus ckd 1-1.6 stage iv sacral decub anemia of chronic disease (bl hct 28) cad htn social history: lives at . originally from . he used to work as a security guard. brother is his hcp family history: noncontributory physical exam: vs: t 99.1 axillary bp 115/61 hr 106 rr38 100% 2l nc urine output: 250cc gen: awake and alert, oriented to person, place, "", stuttering speech, no acute distress heent: nc at pupils 2mm and minimally reactive, equal, eomi, poor dentition, patient will not open mouth on request therfore neck: rij in place, supple, no lad cv: tachycardic, regular, s1 s2 no appreciable murmur lungs: slight basilar crackles, otherwise ctab no wheezing back: stage iv sacral decubitus ulcer, strong odor, no purulent drainage abd: peg tube and suprapubic catheter in place, distended but soft, non tender, no rebound or guarding, normoactive bowel sounds ext: left arm contracted, no pedal edema, dp's palpable rectal: deferred, guaiac negative in ed neuro: patient unable to cooperate with neurological exam, strength in right biceps, able to hold righ arm up against gravity, left arm contracted, able to wiggle toe bilaterally, left toes upgoing, right toes downgoing, unable to lift legs against gravity off bed pertinent results: ct abd impression: 1. massive gaseous distension of the colon, predominantly the sigmoid colon similar to multiple prior studies. no evidence of sigmoid volvulus. this could reflect a neuromuscular motility disorder. 2. multiple renal cysts, unchanged since . 3. sacral decubitus ulcer with possible concomitant sacral osteomyelitis. 4. multiple hepatic hypodensities with largest in the left hepatic lobe is unchanged, others subcentimeter lesions were not definitely seen before, which could be due to different phase of enhancement. ------------------- scrotal u/s impression: 2.6 x 2.4 x 2.7 cm heterogeneous collection in the right scrotum compatible with abscess. 06:50pm blood wbc-18.1*# rbc-2.55* hgb-7.5* hct-22.2* mcv-87 mch-29.2 mchc-33.5 rdw-16.3* plt ct-349 02:10am blood wbc-11.2* rbc-1.95* hgb-5.9* hct-17.4* mcv-89 mch-30.1 mchc-33.7 rdw-16.1* plt ct-239 01:37pm blood wbc-13.8* rbc-2.93*# hgb-8.7*# hct-25.8* mcv-88 mch-29.8 mchc-33.9 rdw-16.4* plt ct-265 04:41am blood wbc-11.9* rbc-2.98* hgb-8.6* hct-26.2* mcv-88 mch-28.8 mchc-32.7 rdw-16.5* plt ct-404 06:50pm blood neuts-93.9* lymphs-3.5* monos-2.3 eos-0.1 baso-0.1 02:10am blood pt-16.2* ptt-36.6* inr(pt)-1.4* 06:00am blood esr-136* 06:50pm blood glucose-99 urean-61* creat-1.6* na-138 k-4.2 cl-103 hco3-20* angap-19 02:10am blood glucose-82 urean-51* creat-1.2 na-141 k-2.7* cl-114* hco3-19* angap-11 04:41am blood glucose-105 urean-18 creat-0.9 na-136 k-4.2 cl-104 hco3-25 angap-11 08:30pm blood alt-21 ast-20 ld(ldh)-137 alkphos-155* amylase-63 totbili-0.4 08:30pm blood lipase-41 05:00am blood calcium-8.3* phos-3.0 mg-1.9 06:30am blood caltibc-156* ferritn-562* trf-120* 06:30am blood calcium-8.7 phos-2.2* mg-1.9 iron-41* 08:30pm blood cortsol-35.8* 06:00am blood crp-97.0* 8:30 pm blood culture blood culture, routine (preliminary): gram positive rods. blood culture, routine (preliminary): bacteroides fragilis group. beta lactamase positive. gram positive rods. staphylococcus, coagulase negative. isolated from one set only. sensitivities performed on request.. anaerobic bottle gram stain (final ): reported by phone to @ 0250 on - . gram negative rod(s). gram positive rod(s). gram positive cocci in clusters. brief hospital course: mr. is a 60 year old male with pmh cva with left hemiparesis, g tube, stage iv sacral decub, bph with suprapubic catheter admitted with sepsis likely urinary source. . #sepsis: admitted from nursing home on to the icu with fever, leukocytosis, hypotension (spb 80s, responsive to iv fluids). u/a was positive so presumed to be urosepsis. started on empiric vanco/zosyn. defervesced overnight, bp remained stable. c. diff was negative. suprapubic tube was replaced by urology. blood cultures from the night of admission grew gnrs (bacteroides) in bottles, coag negative staph in bottles, gprs(not yet speciated in ). urine only grew . so presumed site of entry was from sacral decub wound. id consulted and recommended first stopping vancomycin and then change zosyn to po cipro and flagyl for likely 4 week course. mri of the sacrum was attempted to rule out osteomyelitis but the patient could not tolerate it due to clausterphobia. plastics was consulted but did not want to debride his wound. wound culture grew mrsa and multiple skin bacteria, this is being treated with wound care as below. -very careful wound care -if suspect infection, outpatient plastic surgery follow up for ? debridement. -continue cipro/flagyl for 4 weeks -follow up with id fellow on , at 1:30 pm, please call to confirm. . #stage iv sacral decubitus: likely cva and immobility, no evidence of purulence on admission however strong odor. seen by wound care and plastic surgery. able to visualize bone. followed wound care recs (as listed in d/c planning) with antimicrobial dressing, specialized bed, constant turning. pain was controlled with iv morphine and standing tylenol and transitioned to po morphine. - dressing change as per wound recs -please give patient morphine prior to dressing changes. -standing tylenol . #massive colonic distention: chronic issue for patient, ct scan from with 13 cm distended sigmoid, on this admission ct sigmoid 9cm distended, no evidence of mechanical obstruction or free air. liquid stool on admission likely chronic constipation and agressive bowel reg as c. diff ruled out. abdomen remained benign throughout admission. -continue bowel reg colace, senna, bisacodyl, miralax -fleets enema if needed -rectal tube given significant output and sacral decub . #nsvt - 11 beats of vt on admission, electrolytes wnl -monitor on tele . #acute renal failure: creatinine elevated at 1.6 on admission from baseline of 1, likely prerenal in the setting of sepsis. he has had good urine output of 250ml on arrival to icu and creatinine quickly back to baseline after volume resuscitation. . #anemia: unclear etiology of hct of 17 on admission, as patient's baseline hct 28, transfused one unit prbc on admission and then remained stable at 26-27. no evidence of acute bleed, guaiac negative on admission. gi consulted who did not recommend c-scope. it is possible that the patient's gpr bacteremia could have caused a transient hemolytic anemia, though there was not laboratory evidence. . #bph with suprapubic catheter: u/a positive on admission. urology changed foley on . urine only grew , unlikely to be infection. -change foley one time per month, last changed . #cva with l sided weakness, gtube - no acute issues, patient continued on simvastatin and tube feeds/meds via gtube. . #cad s/p mi: ekg without evidence of ischemia. his anti-hypertensive medications were held in the setting of sepsis and then labetalol restarted when hypotension resolved. continued simvastatin. patient is not on asa due to reported allergy. . #htn: severe hypertension at baseline, however bp low normal after resolution of sepsis. patient restarted on labetalol 100 and his sbp was 120-140. -as needed, would restart lisinopril, norvasc, and hydralazine in that order for goal sbp 120. . #scrotal abscess - urology following, apparently stable. -outpatient urology follow up (please call to schedule) . #suprapubic catheter: -monthly changing (last changed on ) . #incidental kidney mass: -please arrange for patient to have renal ultrasound in 9 months () -f/u in urology clinic after renal ultrasound performed #fen: patient initally npo. then nutrition was consulted and recommended tube feeds which were started. after patient stable on the floor, speech and swallow was consulted and recommended. -pureed (dysphagia); thin liquids pills via g-tube; 1:1 supervision with all oral feeding. -tubefeeding: replete with fiber full strength; goal rate: 80 ml/hr -flush w/ 50 ml water q4h . #communication: hcp is brother or . . #code status: full code medications on admission: -senna 8.6 mg 2 tab(s) -colace sodium 200 mg -miralax - 17 g once a day -fleet enema one enema 3 times a week -bisac-evac 10 mg 1 supp(s) once a day -norvasc 10 mg 1 tab(s) once a day -lisinopril 40 mg 1 tab(s) once a day -labetalol 100 mg 1 tab(s) -hydralazine 25 mg 1 tab(s) tid -heparin 5000 units -colchicine 0.6 mg 1 tab(s) once a day -multiple vitamins 1 tab(s) once a day -simvastatin 10 mg 1 tab qhs -tylenol 1 gram tid -vitamin c 500mg via gtube -nystatin swish and swallow x 5 days -simethicone 80mg tid discharge medications: 1. therapeutic multivitamin liquid : one (1) tablet po daily (daily). 2. ascorbic acid 90 mg/ml drops : five hundred four (504) mg po daily (daily). 3. colchicine 0.6 mg tablet : one (1) tablet po daily (daily). 4. acetaminophen 160 mg/5 ml solution : six y (650) mg po q6h (every 6 hours). 5. polyethylene glycol 3350 100 % powder : seventeen (17) g po daily (daily). 6. simvastatin 10 mg tablet : one (1) tablet po daily (daily). 7. senna 8.6 mg tablet : two (2) tablet po bid (2 times a day). 8. docusate sodium 50 mg/5 ml liquid : two hundred (200) mg po bid (2 times a day). 9. simethicone 80 mg tablet, chewable : one (1) tablet, chewable po tid (3 times a day). 10. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 11. labetalol 100 mg tablet : one (1) tablet po bid (2 times a day). 12. ciprofloxacin 500 mg tablet : one (1) tablet po q12h (every 12 hours) for 4 weeks. 13. metronidazole 500 mg tablet : one (1) tablet po q8h (every 8 hours) for 4 weeks. 14. morphine 15 mg tablet : 1-2 tablets po every four (4) hours as needed for pain: please give prior to dressing changes and as needed for pain. 15. replete/fiber liquid : eighty (80) ml/hr po continuous: please give 250 cc bolus free water q6hrs. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: sepsis polymicrobial bacteremia stage 4 and unstageable sacral and gluteal ulcer chronic scrotal abscess suprapubic catheter for bph discharge condition: stable, stage 4 and unstageable sacral ulcers, scrotal abscess stable. discharge instructions: you came to the hospital with severe infection, we found that you had bacteria growing in your blood that likely cam from an ulcer on your sacrum. we treated your with antbiotics and you improved. we treated your ulcer with wound care. we also noticed that your hematocrit was low and we gave you a blood transfusion. . we made the following changes to your medications: added ciprofloxacin for 4 weeks (last day ) added flagyl for 4 weeks (last day ) changed labetalol 100 twice daily stopped lisinopril,norvasc and hydralazine . if you have fever, vomiting, abdominal pain, worsening diarrhea, shortness of breath, chest pain, pus draining from your wound or any other symptom that is concerning to you please call your doctor or come to the emergency room. . please keep appointments with your doctors as below. followup instructions: dr. , infectious disease clinic , :00am. . provider: ,one date/time: 8:30 . provider: west outpatient radiology phone: date/time: 10:00 . md Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: Anemia of other chronic disease Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Acute kidney failure, unspecified Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Unspecified osteomyelitis, other specified sites Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Chronic kidney disease, unspecified Old myocardial infarction Other inflammatory disorders of male genital organs Pressure ulcer, buttock Pressure ulcer, lower back Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Late effects of cerebrovascular disease, other speech and language deficits Other constipation Septicemia due to anaerobes Late effects of cerebrovascular disease, aphasia Volvulus Gastrostomy status Pressure ulcer, stage IV Volume depletion, unspecified Urethral fistula Personal history, urinary (tract) infection Neurogenic bladder NOS Muscle weakness (generalized) |
allergies: keflex / adhesive tape attending: chief complaint: critical aortic stenosis major surgical or invasive procedure: corevalve placement history of present illness: 86 yo f with cad s/p cabg in (lima to lad, svg to d2, svg to drca and svg to om), interstitial pulmonary fibrosis, dm, htn, hld, with progressive dyspnea on exertion, admitted for corevalve. . briefly, patient has had longstanding aortic stenosis. cardiac catheterizaiton at in which revealed a 90% distal lm stenosis, 80% mlad stenosis followed by t.o, 40% d1 stenosis, 90% ostial rca stenosis and 60% pda stenosis. the svg's to d2 and svg to the drca were patent. the svg to om occluded at ostium, lima to lad patent, distal lad diffusely diseased. on , she underwent stenting of the lm with a 3.5 x 8mm bx velocity stent. . per patient, since , she has been getting progressive short of breath on exertion. she used to be able to perform all adls as well as work around the house. now, she gets very short of breath with minimal exertion, and can only walk from her bed to the recliner. her symptoms are of chest tightness. the dyspnea usually improved after sitting down for a while. she reports one episode of syncope in where she suddenly loss consciousness. it is unclear whether that was also associated with hypoglycemia. . on arrival to the floor, patient was alert and oriented, mildly short of breath when speaking, but other comfortable. vitals were hr 60, bp 125/71, rr 38, o2 sat 94% ra. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. s/he denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations. past medical history: 1. cardiac risk factors: diabetes, dyslipidemia, hypertension 2. cardiac history: -cabg: cabg in at nedh with a lima to lad, svg to d2, svg to drca and svg to om (known occluded). -percutaneous coronary interventions: in , cath showed 90% distal lm stenosis which was stented with a 3.5 x 8mm bx velocity stent. also showed 80% mlad stenosis followed by t.o, 40% d1 stenosis, 90% ostial rca stenosis and 60% pda stenosis. the svg's to d2 and svg to the drca were patent. the svg to om occluded at ostium, lima to lad patent, distal lad diffusely diseased. -pacing/icd: 3. other past medical history: - fractured rib on left from last month from coughing excessively r/t a sinus infection - diabetes type ii, on oral agents - complete hysterectomy and oopherectomy for ovarian ca. no recurrence noted - pulmonary fibrosis - marked restrictive ventilatory defect on pfts and severe fibrosis and low fvc on chest ct. social history: she is a widow. she is retired currently lives with daughter. she does not follow a diet and does not exercise regularly. -tobacco history: never smoked -etoh: none -illicit drugs: denied family history: there is a family history of hypertension, diabetes, and heart disease but not stroke. her mother died at 29 of gall bladder infection and her father died at 69 of stomach cancer. no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death. physical exam: physical exam on admission: vs: t=97.3 bp=125-132/71 hr=60 rr=38 o2 sat=94% ra general: elderly woman, lying in bed, mildly short of breath when speaking heent: perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 6 cm. cardiac: s1, s2 obscured, grade iv/vi crescendo-decrescendo systolic ejection murmur radiating to the carotics lungs: mild shortness of breath. moving air appropriately, dry crackles diffusely abdomen: +bs, soft, multiple scars well healed. non-tender, non-distended. extremities: 1+ edema to the ankles b/l, mild edema in the hands, r>l 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: 12:58am blood wbc-8.3 rbc-3.56* hgb-11.3* hct-33.7* mcv-95 mch-31.7 mchc-33.5 rdw-14.6 plt ct-342 03:08am blood wbc-7.6 rbc-3.48* hgb-10.8* hct-32.5* mcv-93 mch-31.0 mchc-33.2 rdw-14.6 plt ct-355 12:58am blood glucose-177* urean-40* creat-0.9 na-142 k-3.9 cl-105 hco3-30 angap-11 03:08am blood glucose-182* urean-45* creat-1.0 na-138 k-4.3 cl-101 hco3-32 angap-9 03:09am blood alt-25 ast-81* ld(ldh)-328* ck(cpk)-210* alkphos-116* amylase-22 totbili-3.3* 12:58am blood calcium-9.9 mg-1.7 head ct impression: 1. no evidence of cerebral artery occlusion. 2. atherosclerotic disease as mentioned above. 3. lung parenchymal opacities better appreciated on recent lung imaging. mr head findings: extremely limited study. the ventricles and sulci are prominent, suggestive of age-related volume loss. no other findings can be made from this nondiagnostic study. the patient was immediately referred to ct angiogram. echo: conclusions the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. an aortic corevalve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. trace aortic regurgitation and a very small paravalvular leak are seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: well-seated, normally functioning aortic corevalve prosthesis with trace aortic regurgitation and a very small paravalvular leak. normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. mild mitral regurgitation. mild pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , the findings are similar. previously, the very small aortic paravalvular leak was not commented upon, but appears to have been present. electronically signed by , md, interpreting physician 15:48 05:30am blood wbc-9.8 rbc-3.64* hgb-11.6* hct-34.0* mcv-93 mch-31.9 mchc-34.1 rdw-14.7 plt ct-367 05:30am blood glucose-142* urean-33* creat-0.9 na-142 k-4.2 cl-104 hco3-29 angap-13 brief hospital course: medicine course: 86 yo f with cad s/p cabg in (lima to lad, svg to d2, svg to drca and svg to om), interstitial pulmonary fibrosis, dm, htn, hld, with progressive dyspnea on exertion, admitted for corevalve palcement. . # aortic stenosis: patient has critical aortic stenosis with most recent valve area measurement of 0.7 cm2. she is currently showing symptoms of dyspnea on minimal exertion. patient deemed "extreme risk" for surgical aortic valve replacement. patient admitted for corevalve placement. . # interstitial pulmonary fibrosis: new diagnosis for patient, but likely long-standing. dyspnea on exertion is at least particially due to pulmonary disease. recent ct chest showed severe diffuse pulmonary fibrosis and marked restrictive ventilatory defect on pfts. did not require oxygen at baseline. patient continued on home albuterol inhaler and advair. . # coronary artery disease: longstanding, s/p cabg in (lima to lad, svg to d2, svg to drca and svg to om), which on recent cardiac catheterization showed three vessel disease. patient currently asymptomatic. . # diabetes: patient only on glyburide at home, which was held. patient placed on humalog sliding scale. cardiac surgery course: the patient was taken to the operating room on where she underwent corevalve placement with dr. and dr. . overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for observation and recovery. shortly following arrival in cvicu, the patient developed cardiac arrest requiring re-intubation and resuscitation. echo revealed free air in the right atrium and ventricles. she also developed rapid atrial fibrillation and eventually converted to sr with electrical and chemical cardioversion. transvenous wire was placed on at the bedside by dr. for second degree heart block. the patient developed a fever. sputum cultures would grow pseudomonas. the patient was treated with appropriate antibiotics. when the patient was weaned from sedation, she was unable to move the left upper extremity. neurology was consulted for evaluation and she was confirmed to have a cva. eventually extubated on . swallowing eval done and she had confusion. supportive care given while she remained in the cvicu for monitoring. now alert and oriented and following commands. aphasia resolved and lue remains as the only deficit. transferred to the floor on pod # 18. cleared for discharge to rehab hospital in on pod #19. follow up appts were advised. medications on admission: albuterol sulfate - 90 mcg hfa aerosol inhaler - two puffs inhaled 4 times daily fluticasone-salmeterol - 250 mcg-50 mcg/dose disk with device - twoq puffs inhaled twice daily glyburide - (prescribed by other provider) - 2.5 mg tablet - 1 tablet(s) by mouth twice a day isosorbide mononitrate - (prescribed by other provider) - 30 mg tablet extended release 24 hr - 1 tablet(s) by mouth daily levothyroxine - (prescribed by other provider) - 100 mcg tablet - 1 tablet(s) by mouth daily metoprolol tartrate - (prescribed by other provider) - 50 mg tablet - 1 tablet(s) by mouth three times daily simvastatin - (prescribed by other provider) - 80 mg tablet - 1 tablet(s) by mouth daily at hs . medications - otc aspirin - (prescribed by other provider) - 325 mg tablet - 1 tablet(s) by mouth daily calcium carbonate - (prescribed by other provider) - 600 mg (1,500 mg) tablet - one tablet(s) by mouth daily ergocalciferol (vitamin d2) - 2,000 unit capsule - one capsule(s) by mouth daily glucosamine-chondroit-vit c-mn - (prescribed by other provider) - 500 mg-400 mg capsule - two capsule(s) by mouth daily multivitamin-minerals-lutein - (prescribed by other provider) - tablet - one tablet(s) by mouth daily discharge disposition: extended care facility: hospital - discharge diagnosis: primary: critical aortic stenosis s/p corevalve avr diabetes mellitus coronary artery disease cva post-op respiratory failure . secondary: interstitial pulmonary fibrosis discharge condition: mental status: clear and coherent level of consciousness: alert and oriented activity status: max assist- pivots briefly lue- moves thumb only discharge instructions: please shower daily including washing puncture sites in groins with mild soap, no baths or swimming for 1 week until groin sites are healed. please no lotions, cream, powder, or ointments to puncture sites in your groins each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for one month, will be discussed at follow up appointment no lifting or pulling more than 10 pounds for 1 week, and then continue to take it easy for 1 month please call with any questions or concerns **please call integrated aortic valve clinic in cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: dr. office (will arrange for follow up) dr. friday , 1:00 pm 2a dr. ( neurology) thursday @ 11:30 am 8 (neuro) please call to schedule appointments with your primary care dr. , in 3 weeks **please call dr. with any questions or concerns. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Combined right and left heart cardiac catheterization Enteral infusion of concentrated nutritional substances Open and other replacement of aortic valve Insertion of temporary transvenous pacemaker system Atrial cardioversion Closed [endoscopic] biopsy of bronchus Percutaneous balloon valvuloplasty Diagnoses: Other iatrogenic hypotension Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Toxic encephalopathy Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Coronary atherosclerosis of autologous vein bypass graft Cardiac complications, not elsewhere classified Atrial fibrillation Acute on chronic diastolic heart failure Aortic valve disorders Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Pneumonia due to Pseudomonas Cardiac arrest Postinflammatory pulmonary fibrosis Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Examination of participant in clinical trial Iatrogenic cerebrovascular infarction or hemorrhage Other second degree atrioventricular block Flaccid hemiplegia and hemiparesis affecting nondominant side |
allergies: no known allergies / adverse drug reactions attending: chief complaint: altered mental status/hyponatremia major surgical or invasive procedure: picc line history of present illness: mrs. is a 72 y/o woman with a pmhx of chronic hyponatremia (131-133) of uncertain etiology, osteoporosis, and b/l hearing loss p/w ams after being found unresponsive in bed on in the morning by husband. pt started taking bowel prep at 6pm on for routine colonoscopy scheduled for the morning of , and took a second dose at 1:15am, after which she has no memory. husband reports 2x vomiting and confusion. she was brought by ambulance to the ed. . on presentation to ed, initial vital signs were not recorded. code stroke was called for nihss of 9 (inability to follow comands, disorientation, severe aphasia, severe sensory loss). patient was sent for stat head ct that demonstrated old lacunar strokes; cta did not demonstrate vessel cut offs or dissections, and ctp did not show perfusion abnormalities. on further exam, she demonstrated increased tone in her bilateral extremities, dry mucus membranes. labs were significant for na 113, k 3.5, cl 80, hco3 22, cr 0.5, wbc 3.4, hct 35.5, platelet 210, tox screen negative, ua wnl, abg 7.50/29/88. . neuro evaluated patient in ed, did not believe patient was having a stroke, but could not rule out seizures or osmotic demyelinating syndrome. patient was initially treated with 3% hypertonic saline @ 40cc/hr, but only received 20cc prior to being changed to ns 100cc/hr per neuro recommendations. patient was admitted to micu for further evaluation and treatment. vital signs prior to transfer were 76 125/64 19 100%2lnc. at time of transfer, mental status had improved to aox2. past medical history: - chronic hyponatremia (131-133 in past, uncertain etiology, thought to be polydipsia) - diverticulosis - chronic otitis externa - bullosa - hyperlipidemia - depression social history: pt lives at home with husband in . she has a son, daughter-in-law and grandson also in and a daughter in . she is a retired professor and psychology. she eats a healthy diet and exercises regularly. she walks on the treadmill 5 days per week and weight trains twice per week. she drinks 1 glass of wine per day. she has never used tobacco. she smoked marijuana on weekends in the . she did crack for a few months in the late . family history: no history of strokes. mother has dementia, likely . her father had heart disease, 2 mis. physical exam: admission exam: vitals: 98.4 79 122/59 19 99%2lnc general: nad, comfortable heent: sclera anicteric, mmm, op clear neck: supple, no jvd, no hjd lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: rrr, mrg abdomen: soft, nt/nd, quiet bowel sounds, no rebound tenderness or guarding, no organomegaly gu: + foley ext: cool, moist, 1+ pulses, no clubbing, cyanosis or edema . discharge exam: vitals: 99.0 94/58 69 18 98%ra general: nad, comfortable heent: sclera anicteric, mmm, op clear neck: supple, no jvd, no thyromegaly, no lad lungs: clear to auscultation bilaterally, no w/r/rh. cv: rrr, s1, s2, no mrg abdomen: +bs, slightly tense on palpation, nt/nd, no rebound tenderness or guarding, no organomegaly ext: cool, moist, 2+ radial pulses. no clubbing, cyanosis or edema. complete fusion of tarsal bones in l foot with notable deformity. ablated mole on sole of l foot. skin: no rashes or lesions neuro: awake, alert, and oriented to and date. cnii-xii intact. 5/5 strength throughout on motor exam. sensation intact to lt and proprioception. no rigidity. pertinent results: admission labs: 08:20am blood wbc-3.4* rbc-3.90* hgb-13.1 hct-35.5* mcv-91 mch-33.5* mchc-36.8* rdw-12.5 plt ct-210 08:20am blood glucose-161* urean-4* creat-0.5 na-113* k-3.5 cl-80* hco3-22 angap-15 08:20am blood albumin-4.8 calcium-9.0 phos-1.8* mg-2.3 12:30pm blood tsh-2.9 08:20am blood osmolal-235* 08:20am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:05am blood type-art rates-/20 po2-88 pco2-29* ph-7.50* caltco2-23 base xs-0 intubat-not intuba comment-nasal 10:05am blood na-111* . discharge labs: 02:24am blood wbc-5.7# rbc-3.93* hgb-12.9 hct-35.3* mcv-90 mch-32.7* mchc-36.4* rdw-12.5 plt ct-183 08:00am blood glucose-91 urean-15 creat-1.0 na-133 k-4.3 cl-100 hco3-25 angap-12 07:43pm blood calcium-9.6 phos-3.3 mg-2.8* 08:20am blood alt-24 ast-37 ld(ldh)-261* alkphos-54 totbili-1.0 02:24am blood cortsol-25.9* . na trends 08:00 133 19:43 128 13:11 122 08:57 121 05:45 120 02:24 119 22:57 119 22:00 121 20:30 121 18:18 121 16:03 118 12:30 114 08:20 113 . studies: . ekg: bradycardia, from . ct brain perfusion & cta head w/ & w/o contrast (): findings: non-contrast ct head: there is no acute intracranial hemorrhage, mass effect, shift of normally midline structures. there is a hypodense area in the right frontal periventricular location, with mild dilatation of the adjacent portion of the frontal and hence likely old. a small hypodense focus noted adjacent to the right side of the third ventricle is indeterminate. mildly prominent ventricles and extra-axial csf spaces are noted, related to volume loss. no suspicious lytic or sclerotic lesions are noted. there is mild mucosal thickening in the ethmoid air cells. the mastoid air cells are clear. the soft tissues are unremarkable. . ct cerebral perfusion study: the present study does not include the middle cranial fossa structures completely. within this limitation, there is no obvious perfusion deficit, is noted. slightly increased mtt in the thalami on both sides is of uncertain significance. . ct angiogram of the head and neck: the origins of the arch vessels are patent. the major intra- and extra-cranial arteries are patent without focal flow-limiting stenosis, occlusion, or aneurysm more than 3 mm within the resolution. mild contour irregularity of the cavernous carotid segments, with tortuous arteries with mild focal prominence noted on the right side. this may relate to atherosclerotic disease. mild degenerative changes are noted in the cervical spine. the distal cervical internal carotid artery measures 4.9mm on the right and 3.4mm on the left. evaluation of the proximal cervical internal carotid artery is limited due to dental artifacts. this gives the appearance of an apparent narrowing on the vr reformations. mild contour irregularity of the distal cervical internal carotid arteries is noted related to atherosclerotic disease. mucosal thickening is noted in the sphenoid sinus.a few small scattered nodes are noted. there are areas of scarring in the lung apices on both sides. mild fullness is noted in the piriform sinus and can be correlated clinically on the right side. impression: 1. no acute intracranial hemorrhage or mass effect. small hypodense focus adjacent to the third ventricle on the right side is of indeterminate age. hypodense areas noted in the right frontal lobe are likely chronic. 2. while there is no obvious asymmetric perfusion deficit in the imaged portions of the brain, this does not include the mca territory completely. consider mr of the head if not contraindicated to evaluate for acute infarction. 3. patent major intra- and extra-cranial arteries without focal flow-limiting stenosis, occlusion, or obvious aneurysm. mild contour irregularity noted related to atherosclerotic disease. evaluation of the proximal cervical internal carotid artery limited due to artifacts. other details as above. 4. areas of scarring in the lung apices, consider dedicated imaging as clinically indicated. preliminary findings were discussed with dr. by dr. soon after the study in the morning on at approximately 9:10 a.m. . brief hospital course: hospital course patient is 72 y/o woman with a pmhx of baseline hyponatremia (131-133) presents with diarrhea, vomiting, and ams in setting of ssri and bowel prep, found to have na of 113. . active issues: . # hyponatremia - patient presented to ed with na 113, in setting of undergoing bowel prep for colonoscopy and ssri use, but was euvolemic or slightly dry on exam. urine osms were notable for inappropriate concentration, presence of inappropriate na, which would argue more for siadh than a hypovolemic picture. she has uncertain risk factors for siadh other than ssri: could be neoplastic, endocrine, medication effect. her fluoxetine was held on this admission. patient was adequately corrected in icu with continuing improvement via fluid restriction. she had a picc line placed to administer fluids; the picc was removed on discharge. her na was 133 on discharge, and her mental status was baseline. we held fluoxetine on discharge and recommended fluid restriction (1500cc/day) as well as follow-up with pcp for further evaluation and repeat cxr. there is some suspicion that polydipsia may have contributed to her hyponatremia. . # ams - the originally broad differential for her ams was narrowed by reorientation concordant with normalizing na. her mental status is baseline on discharge. . inactive issues: . # depression - we held fluoxetine on this admission as well as on discharge. we recommend outpatient follow-up with pcp to find an alternative. . transitional issues: - siadh remains of unclear etiology - should be worked up with cxr pa/lateral as outpatient - advance diet with fluid restriction - pt was discharged home with 1500cc fluid restriction - discuss what to do with fluoxetine with outpatient pcp was full code on this admission medications on admission: fluoxetine 20 mg daily docusate sodium 200 mg daily calcium 600 + d, 2 tabs daily ciclopirox 0.77% topical cream daily fluocinide 0.05% prn topical cream glucosamine, chondroitin 1500/1000 mg 2 am, 1 pmj daily mult a,c,e aspirin 81 mg daily fish oil 1200 mg daily previoent 5000 + 1.1 sodium fluoride tooth paste discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 2. colace 100 mg capsule sig: two (2) capsule po once a day. 3. calcium 600 + d(3) 600 mg calcium- 200 unit capsule sig: one (1) capsule po once a day. 4. ciclopirox 0.77 % cream sig: one (1) topical once a day: apply to affected area daily. 5. fluocinonide 0.05 % cream sig: one (1) topical once a day: apply to affected area daily. 6. glucosamine 1500 complex 500-400 mg capsule sig: one (1) capsule po three times a day. 7. vitamin a-vitamin c-vitamin e tablet sig: one (1) tablet po once a day. 8. fish oil 1,200-144-216 mg capsule sig: one (1) capsule po once a day. discharge disposition: home discharge diagnosis: primary diagnosis: hyponatremia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mrs. , it was a pleasure taking care of you during your stay at the . you were admitted because you were confused, and had vomiting, and diarrhea. we performed a number of laboratory blood tests and found that you had a very low level of sodium in your blood. during the course of your stay, we have repleted your blood, monitored your sodium levels, and watched them return to your baseline. because your baseline sodium levels are on the low side, we recommend further evaluation with your primary care physician for possible cause. we believe that there were three reasons that you had a low sodium. 1) your bowel prep may have caused salt loss 2) you may drink more fluid than your kidney can tolerate 3) your fluoxetine have have had an idiosyncratic drug reaction known as the syndrome of inappropriate anti-diuretic hormone (siadh). please do not hesitate to contact us with questions or concerns. please make the following changes to your medications: 1. please stop taking fluoxetine 2. please limit your fluid intake to 1500cc/day or about 50 ounces. this is equivalent to 5 small cups or 4 cans of diet coke or 3 regular sized water bottles. fluid includes juice, water, wine, coffee. followup instructions: please follow up with dr. or his nurse practitioner in the next week. you should have further work-up for the cause of your low sodium, including a chest xray. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Osteoporosis, unspecified Metabolic encephalopathy Other disorders of neurohypophysis Aphasia Personal history of poliomyelitis |
allergies: codeine / epinephrine / dyazide / tessalon perle / cartia xt attending: chief complaint: paroxysmal atrial fibrillation major surgical or invasive procedure: bilateral thoracoscopic mini-maze procedures,left atrial appendage ligation history of present illness: this 66 year old white female has a 10 year history of paroxysmal atrial fibrillation. her episodes and sypmtoms have increased recently, despite multidrug therapy. she was evaluated previously for surgical ablation. she was admitted for heparin therapy prior to her thoracoscopic mini-maze procedures. past medical history: paroxysmal atrial fibrillation s/p bilat mini-maze psoriasis diverticulosis obstructive sleep apnea cpap at night reactive depression hypertension gastric reflex hyperlipidemia s./p catarct extractions s/p tonsillectomy s/p right varicose vein stripping s/p hysterectomy social history: writer lives home alone-widowed. no tobacco or alcohol use. family history: strong paternal history of heart disease. mother had parkinson's disease. physical exam: admission: ht 5'7" wt 180 lbs vs t 97.3 bp 144/84 hr 100 rr 15 o2sat 99% ra gen nad alert, anxious. neuro- non focal exam lungs-clear cor-irreg-irreg extremeties: no cce abd- benign pertinent results: echocardiography report , portable tte (complete) done at 11:00:00 am final referring physician information , c. , status: inpatient dob: age (years): 66 f hgt (in): 67 bp (mm hg): 100/60 wgt (lb): 180 hr (bpm): 64 bsa (m2): 1.94 m2 indication: hypotension. s/p maze. ?pericardial effusion. icd-9 codes: 427.31, 423.9, 424.0 test information date/time: at 11:00 interpret md: , md test type: portable tte (complete) son: , rdcs doppler: full doppler and color doppler test location: / 6 contrast: none tech quality: adequate tape #: 2009w000-0:00 machine: vivid i-3 echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.4 cm <= 4.0 cm left atrium - four chamber length: *6.0 cm <= 5.2 cm right atrium - four chamber length: 4.9 cm <= 5.0 cm left ventricle - septal wall thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.0 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 5.4 cm <= 5.6 cm left ventricle - ejection fraction: 50% to 55% >= 55% aorta - sinus level: 3.5 cm <= 3.6 cm aorta - ascending: *3.6 cm <= 3.4 cm aortic valve - peak velocity: 1.0 m/sec <= 2.0 m/sec aortic valve - lvot diam: 1.9 cm mitral valve - e wave: 0.7 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 0.88 tr gradient (+ ra = pasp): 20 mm hg <= 25 mm hg findings left atrium: mild la enlargement. left ventricle: normal lv wall thickness and cavity size. low normal lvef. right ventricle: normal rv chamber size and free wall motion. paradoxic septal motion consistent with prior cardiac surgery. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. trace ar. mitral valve: normal mitral valve leaflets. no mvp. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. mild tr. normal pa systolic pressure. pericardium: no pericardial effusion. conclusions the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is suggested (clip ) but not confirmed in other views. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: no pericardial effusion. mild mitral regurgitation. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. electronically signed by , md, interpreting physician 13:44 08:50am pt-13.0 ptt-26.5 inr(pt)-1.1 08:50am plt count-235 08:50am wbc-5.8 rbc-4.35 hgb-12.5 hct-36.8 mcv-85 mch-28.8 mchc-34.0 rdw-14.6 08:50am glucose-104 urea n-21* creat-0.9 sodium-142 potassium-5.5* chloride-105 total co2-26 anion gap-17 03:15pm %hba1c-5.7 03:15pm albumin-4.2 calcium-9.1 magnesium-1.9 03:15pm lipase-31 03:15pm alt(sgpt)-20 ast(sgot)-21 ld(ldh)-159 alk phos-64 amylase-7 tot bili-0.3 04:21pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-lg 04:21pm urine color-straw appear-clear sp -1.008 06:10am blood wbc-8.4 rbc-4.32 hgb-12.2 hct-36.4 mcv-84 mch-28.3 mchc-33.6 rdw-14.8 plt ct-276 06:10am blood plt ct-276 06:10am blood pt-23.8* inr(pt)-2.3* 06:10am blood glucose-95 urean-23* creat-0.7 na-138 k-4.6 cl-104 hco3-21* angap-18 , f 66 radiology report chest (pa & lat) study date of 6:13 pm , fa6a 6:13 pm chest (pa & lat) clip # reason: eval for pleural effusions medical condition: 66 year old woman s/p bilateral minimaze wet read: jrci sun 8:48 pm interval decrease in size of small to moderate left and small right pleural effusions. no superimposed pneumonia or pneumothorax. dr. dr. brief hospital course: following admission she was begun on heparin. extensive preoperative workup had been completed as an outpatient, including a cardiac mri. there was an incidental finding of a lingular lung nodule, which will be followed with a ct in 6 months. ms. was taken to the operating room on where bilateral thoracoscopic minimaze and ligation of the left atrial appendage were performed. please refer to dr operative report for further details. she tolerated this procedure well and was transferred in critical but stable condition to the surgical intensive care unit. she was soon extubated and her chest tubes were removed. she was placed on her amiodarone bblocker and coumadin for atrial fibrillation. on pod#2 ms. was transferred to the step down unit for further monitoring and progression. she was seen by physical therapy in consultation. during the remainder of her postoperative course her heart rate was difficult to manage. she had a syncopal event associated with an increase in beta-blocker(lopressor 25mg). ep was following ms. throughout her admission. their recommendations were followed, while on amiodarone and digoxin, her atrial fibrillation episodes began to decrease in duration, and were better rate controlled. she continued to progress and on pod#12 she was cleared for discharge to home with vna and a of hearts monitor. all follow up appointments were advised. associates clinic agreed to follow ms. inr/coumadin dosing. medications on admission: amlodipine 2.5 mg daily, atenolol 50 mg daily, lasix 10 mg daily, moexipril 7.5 mg twice a day, aspirin 325 mg daily, ambien 5 mg q.h.s., prilosec 20 mg twice a day, propafenone 300 mg three times a day, multivitamin daily, caltrate 600 plus d twice a day, colace 100 mg daily, ocuvite one tablet daily, and omega-3 fish oil 1200 mg twice a day.lidex 0.05% cream apply to affected areas twice daily-psoriatic plaques discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. pravastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 6. fluocinonide 0.05 % cream sig: one (1) appl topical (2 times a day). 7. tramadol 50 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 8. amiodarone 200 mg tablet sig: two (2) tablet po once a day: 400mg qd x7days then 200mg qd. disp:*40 tablet(s)* refills:*2* 9. indomethacin 25 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*0* 10. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. 11. warfarin 1 mg tablet sig: as directed tablet po once a day: target inr 2-2.5 patient to take 1mg on &2 then as directed by dr . disp:*60 tablet(s)* refills:*2* 12. potassium chloride 10 meq tablet sustained release sig: one (1) tablet sustained release po once a day for 10 days. disp:*10 tablet sustained release(s)* refills:*0* 13. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 14. captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day). disp:*45 tablet(s)* refills:*2* 15. lasix 20 mg tablet sig: as directed tablet po once a day: 20mg qd x7days then 10mg qd. disp:*20 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: paroxysmal atrial fibrillation s/p bilateral mini-maze hypertension psoriasis left lingular lung nodule diverticulosis gerd hyperlipidemia obstructive sleep apnea with cpap at night depression discharge condition: good discharge instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed call with any questions or concerns followup instructions: repeat ct chest 6 months to follow-up lung nodule. dr. in 4 weeks () 6 wound clinic in 2 weeks dr. . in weeks (). - e-mailed to coordinate coumadin follow-up. inr trends should be e-mailed to the office of dr. / clinic at the time of discharge. plan confirmed with dr. colleague dr. . please call for appointments -first inr draw should be on wed. with results sent to dr. Procedure: Excision or destruction of other lesion or tissue of heart, open approach Diagnoses: Obstructive sleep apnea (adult)(pediatric) Esophageal reflux Unspecified pleural effusion Unspecified essential hypertension Atrial fibrillation Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Other diseases of lung, not elsewhere classified Other psoriasis Diverticulosis of colon (without mention of hemorrhage) |
allergies: no known allergies / adverse drug reactions attending: chief complaint: fall with injuries; pain in left hip and left lower extremity major surgical or invasive procedure: open reduction and internal fixation of left subtrochanteric femoral shaft fracture with intertrochanteric fracture plane. history of present illness: 63m with h/o etoh abuse initially presenting on with 15-20 foot fall from ladder while he was "roofing," complicated by comminuted left femur fracture and non-displaced left superior and inferior pubic rami fractures s/p orif . his hospital course was complicated by severe etoh withdrawal with dts, treated in the icu with librium and clonidine. there was also briefly concern about hit, but the anti-pf4 heparin antibody assay was negative. medicine is now consulted for comanagement of etoh withdrawal now that the patient has been called out of the icu to the orthopedics team. . currently, patient appeared comfortable and did not have any specific complaints. he was very appropriate and pleasant. . past medical history: hld, h/o skin cancer. s/p prostatectomy. social history: semi-retired, lives with mother. drinks a 6-pack nightly, denies smoking. family history: nc physical exam: on admission: vitals: hr 106 bp 120/76 rr 22 o2sat 100%/2l a&o x 3 calm and comfortable +etoh on breath lle skin clean and intact. pain with logroll of hip, ttp anterior hip joint. no noticeable deformity, erythema, edema, induration or ecchymosis thighs and legs are soft saph sural dpn spn mpn lpn fhl gs ta pp fire 1+ pt and dp pulses on discharge: avss, nad, a&ox3 dressing c/d/i in place extremity without obvious deformity fhl gs ta pp fire silt lfcn, pfcn, obturator, saphenous, sural, dp, sp, plantar 1+ dp, pt pulses; foot warm, well-perfused compartments soft (thigh, leg, foot) pertinent results: admission labs 12:05pm blood wbc-12.3* rbc-4.16* hgb-14.1 hct-39.7* mcv-96 mch-34.0* mchc-35.6* rdw-12.6 plt ct-157 12:05pm blood pt-11.5 ptt-23.3* inr(pt)-1.1 12:05pm blood fibrino-247 04:22am blood glucose-216* urean-13 creat-0.8 na-138 k-4.2 cl-103 hco3-22 angap-17 12:05pm blood asa-neg ethanol-303* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg discharge labs 05:06am blood wbc-7.0 rbc-3.38* hgb-10.7* hct-31.0* mcv-92 mch-31.6 mchc-34.4 rdw-15.2 plt ct-233 05:06am blood na-138 k-4.2 cl-103 05:00am blood alt-31 ast-46* alkphos-77 totbili-1.3 imaging: trauma ap chest (): the lungs are clear. there is no focal consolidation or pneumothorax. there is no vascular congestion, edema, or pleural effusions. cardiomediastinal and hilar contours are within normal limits. there is a healed fracture of the posterior right seventh and eighth ribs and possible posterior right ninth rib. no other acute rib fracture is apparent. degenerative changes of the left shoulder are partially imaged. trauam pelvis (): multiple surgical clips are seen within the pelvic inlet. sacroiliac joints and pubic symphysis appear within normal limits. there is a comminuted fracture of the proximal left femur which appears to be involving the lesser and greater trochanters, though incompletely evaluated on the single frontal projection. please see concurrent femur radiographs for further details. impression: 1. old right posterior seventh and eigth and possible ninth rib fracture. no acute intrathoracic injury. 2. comminuted left intertrochanteric fracture involving the greater and lesser trochanter with extension to the femoral shaft, though incompletely evaluated on this single frontal view. please see femur radiographs report for further details. . ct abd/pelvis w/contrast (): impression: 1. comminuted left femur fracture with valgus angulation of the distal fracture fragment. non-displaced left superior and inferior pubic rami fractures. 2. t4 anterior wedge compression of indeterminate age however not associated with edema or retropulsion of fragments. clinical correlation recommended. 3. sludge versus small stones within the gallbladder. 4. thyroid nodules. clinical correlation and correlation with prior imaging recommended. 5. moderately distended bladder. . ct c-spine: there is minimal end plate depression with a thin fracture line anterosuperiorly without displacement in the t4 body; there is also mild-moderate loss of height of t4 body in the anterior and mid portions- better seen on the concurrent ct torso sagittal reformations. correlate clinically to decide on the need for further workup. . ct head w/o contrast (): impression: no evidence of acute intracranial hemorrhage or mass effect. superficial subcutaneous contusion and laceration over the left forehead and periorbital soft tissues. mild deformity of the nasal bones without displacement is noted- correlate clinically if this relates to trauma. . left femur ap/lat x-ray (): impression: comminuted intertrochanteric fracture of the left femur with an oblique fracture component in the proximal left femoral diaphysis. nondisplaced fractures of the left superior and inferior pubic rami are partially imaged and better assessed on subsequent ct torso. . echo: the left atrium is elongated. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thicknesses and cavity size are normal. left ventricular systolic function is hyperdynamic (ef>75%). the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the number of aortic valve leaflets cannot be determined. there is no aortic valve stenosis and no aortic regurgitation. the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: normal biventricular cavity sizes with preserved global biventricular systolic function (hyperdynamic left ventricular function). . cxr (): findings: one portable ap view of the chest. the lungs, heart, mediastinum, and pleural surfaces are normal. there is no evidence of pneumonia, effusion, or atelectasis. there is no pulmonary vascular congestion. no pneumothorax. impression: no radiographic evidence of acute cardiopulmonary abnormality. . cxr (): mild linear atelectasis in the left lower lung is new. there are no lung opacities concerning for pneumonia. no pleural effusion or pneumothorax. heart size, mediastinal and hilar contours are normal. impression: no pneumonia. . cxr (): in comparison with the earlier study of this date, there has been placement of a dobbhoff tube that extends to the fundus of the stomach. little change in the appearance of the heart and lungs. . shoulder xr (): no acute fracture or dislocation brief hospital course: mr. ?????? was admitted to the orthopedic service on for left hip and pelvic fracture after being evaluated and treated with closed reduction in the emergency room. he underwent open reduction internal fixation of the left hip without complication on . please see operative report for full details. he was extubated without difficulty and transferred to the recovery room in stable condition. in the early post-operative course in the pacu patient started having autonomic hyperactivity with tachycardia up to 150s as well as hypertension (sbp >170s), confusion, agitation and tremors. he did not have any convulsions, was alert and oriented x1 and required significant amount of valium to control this. he was transferred to the icu for for management of his condition consistent with delirium tremens. upon hemodynamic stabilization he was transferred to the floor on . on , he was transferred to medical service further management of delirium. medical course: # delirium/etoh withdrawal: patient with known history of etoh abuse. serum alcohol on admission was 303. went into withdrawal post operatively. was treated with initially with librium then changed to ativan and finally to valium. he was substantially less delirious after treatment of etoh withdrawal. additionally, conservative measures (including removal of foley catheter, ng tube, and restraints) also improved mental status. folate, thiamine and multivitamin were started while admitted. pt was given resources of outpatient alcohol abuse programs. . # femur/pelvic fracture: pt sustained a comminuted left femur and pelvic fractures. underwent orif and incisions were healing well. wound care is included on discharge paperwork. patient will need to follow up with orthopedics in weeks. pain control was adequate with oxycodone. pt to continue physical therapy while at rehab as wbat. . # anemia: patient developed a post operative anemia likely related to intraoperative blood loss. while on orthopedic service, was transfused 2 units of prbcs. hct remained stable thereafter and was hemodynamically stable. . # thrombocytopenia: initially developed a thrombocytopenia while admitted. hit antibody was tested and was negative. plt count returned to prior to discharge. . # elevated lfts: on admission, pts lfts were consistent with etoh abuse. trended down to near normal. no further intervention was necessary. . # hyperlipidemia: patient continued on simvastatin 10 mg po daily . # shoulder pain: while working with physical therapy on day of discharge, pt reported shoulder pain. xr was completed and was negative for fracture or dislocation. final read is pending on discharge. . # code status: full code. medications on admission: statin, folic acid, vitamin b12, mvi. 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. enoxaparin 40 mg/0.4 ml syringe sig: one (1) syringe subcutaneous hs (at bedtime): while not mobile. can discontinue once full weight bearing. 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 6. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for constipation. 7. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for breakthrough pain. 8. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain/fever. 9. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: - ( hospital of and islands) discharge diagnosis: left lc-1 pelvic fracture left subtrochanteric femoral shaft fracture with intertrochanteric fracture plane. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital because you fell off a ladder while intoxicated. you broke your femur and pelvis. you had your femur fixed in the operating room by the orthopedic surgeons. you experienced withdrawal from alcohol while in the hospital however we were able to help you with medications. you are now going to rehabilitation to help you recover from your fall. please see the attached sheet for your new medications. followup instructions: please call the office of dr. to schedule a follow-up appointment with in 2 weeks at . please follow-up with your primary care physician regarding this admission after you leave rehab. md Procedure: Alcohol detoxification Closed reduction of fracture without internal fixation, femur Other skeletal traction Diagnoses: Thrombocytopenia, unspecified Acute posthemorrhagic anemia Other and unspecified hyperlipidemia Personal history of other malignant neoplasm of skin Alcohol abuse, continuous Accidental fall from ladder Closed fracture of shaft of femur Closed fracture of pubis Alcohol withdrawal delirium |
allergies: meperidine / oxycodone attending: chief complaint: subarachnoid hemorrhage major surgical or invasive procedure: : r evd placement : cerebral angiogram with partial coiling of r mca : cerebral angiogram with interarterial verapamil to l aca/r ica : cerebral angigram with interarterial verapamil to r mca : l evd placement : l evd catheter exchange : r frontal evd placement : trach placement : peg placement : left vp shunt placement history of present illness: this is a 60 year old female history of htn who woke up this am with acute onset severe headache. her son, , reports that at about noon, pt became more confused around the house. she also had vomited. pt was taken to in where a head ct showed a right ich with sah within the cisterns and right sylvian fissure suspicious for r mca rupture. pt transferred to for further management. past medical history: htn psh: hysterectomy social history: lives with son in . 20-pack year smoking habit. rare etoh, no illicit drug use. family history: non-contributory physical exam: on admission: physical exam: hunt and : 3 : 4 gcs 13 e: 4 v: 5 motor:5 o: t: 97.2 hr 53 140-190/70-90s rr 16 98% ra gen: wd/wn, combative and confused --> intubated/sedated heent: atraumatic, normocephalic, eyes clear, nasal passages patent, oropharynx pink without exudate pupils: perrl eoms - full neck: supple. lungs: cta bilaterally, no murmurs. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. no c/c/e. neuro: gcs 13 then intubated/sedated pupils are bilaterally, + gag, + corneals moving all extremities equally reflexes: b t br pa ac right 2+ --------- left 2+ --------- on discharge: eo spont, interactive, smiling, perrl, eom intact, rue purposeful, lue hand movements, ble spont/withdraws. + commands: thumbs up, two fingers on rue; squeezes hand lightly on lue; wiggles toes. patient has history of intermittently not following commands. pertinent results: cta head/neck : impression: extensive sah centered in the right sylvian fissure. no large vascular territorial infarction. no hydrocephalus or shift of the midline structures. there is a 3.5 mm aneurysm at the junction of right m1/m2 segments. bilobed/irregular appearance of the aneurysm, likely due to rupture. head ct : impression: 1. large subarachnoid hemorrhage, predominantly layering in the sylvian fissure, basal cisterns and right hemispheric sulci. 2. stable intraventricular extension of blood. mild interval decrease in the ventricular size, status post placement of an evd. 3. diffuse cerebral edema. head ct : impression: highly limited exam due to head motion. allowing for such overall stable distribution and extent of large subarachnoid hemorrhage, right temporal intra-axial hematoma, and intraventricular extension of blood into occipital horns and third ventricle. status post right frontal approach catheter, with a decreased caliber of ventricular system as compared to one day prior. no evidence of new hemorrhage. head cta/ctp : impression: 1. unchanged right frontal intraparenchymal hemorrhage with bilateral subarachnoid hemorrhage. 2. interval diminution of the right a1 segment of the anterior cerebral artery and both a2 segments of the anterior cerebral arteries as well as the m3/m4 segments of the right mca consistent with vasospasm. head ct : impression: 1. vasogenic edema around a right frontal intraparenchymal hemorrhage is essentially unchanged; however, this limits evaluation for underlying infarct. if this continues to be a clinical concern, an mri may be obtained for further evaluation. 2. redistribution of known subarachnoid and intraventricular hemorrhage with no significant change. lower extremity dopplers : no evidence of deep venous thrombosis in bilateral lower extremities. ct/cta head : 1. increased mass effect on the right lateral ventricle secondary to increased edema around the sylvian fissure hematoma compared to the prior ct of with a new infarct in the right occipital lobe in the posterior cerebral artery territory. 2. improvement in vasospasm since the previous cta examination echo : the left atrium is elongated. the estimated right atrial pressure is 0-5 mmhg. the estimated right atrial pressure is 0-10mmhg (patient may be volume depleted). there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. left ventricular systolic function is hyperdynamic (ef>75%). there is a mild resting left ventricular outflow tract obstruction. right ventricular chamber size and free wall motion are normal. the aortic valve is not well seen. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. ct/cta head : impression: 1. unchanged right temporal parenchymal hematoma and bilateral sulcal subarachnoid hemorrhage since . 2. partial reexpansion of the frontal of the right lateral ventricle, with continued effacement of its other components. 3. the right ventriculostomy catheter tip now terminates in the body of the right lateral ventricle abutting the septum pellucidum, as opposed to the left frontal on the prior study. the left lateral ventricle is stable in size. 4. no change in the caliber of intracranial arteries in comparison to . no evidence of new vasospasm. ct head : impression: 1. replacement of previously visualized right frontal ventriculostomy catheter with a new left frontal ventriculostomy catheter with the catheter tip terminating in the third ventricle. clinical correlation is recommended. 2. continued partial re-expansion of the frontal of the right lateral ventricle with effacement of the other components of the right lateral ventricle. 3. unchanged right temporal parenchymal hematoma and bilateral subarachnoid hemorrhage. ct/cta head : overall, minimal change from the comparison study with no arterial caliber change to suggest vasospasm and unchanged parenchymal hematoma in the right temporal lobe. the ventriculostomy catheter has been replaced, now positioned via a left frontal approach. ct head : 1. overall, minimal change in comparison to prior study. continued visualization of the right temporal parenchymal hemorrhage with stable adjacent mass effect. 2. left frontal ventriculostomy catheter with the catheter tip terminating in the third ventricle. ct head : ct perfusion demonstrates abnormal perfusion in the right > left temporal lobe, right occipital lobe and left parietal lobe, which could be related to vasospasm. ct head : impression: 1. multifocal strokes including the bilateral cerebellar hemispheres, the right occipital hemisphere. there is no new mass effect. 2. left frontal approach ventriculostomy catheter remains in place with its tip in the region of the foramen of . 3. right temporoparietal hematoma adjacent to a coil mass is becoming progressively hypodense over time as expected. there is no new hemorrhage. cta head : worsening vasospasm in bilateral vertebral and right a1 arteries. persistent vasospasm noted in bilateral a2 branches. again seen are multiple infarcts with evolution of the left cerebellar infarct. head ct : ventriculostomy catheter in unchanged position with tip terminating within the third ventricle. unchanged ventricular system size. continued interval increase in intraventricular hemorrhage extending left greater than right, now extending to involve the entire left occipital and the left lateral ventricle. continued evolution of multifocal infarction including bilateral cerebellar infarcts. echo : focused saline contrast study. no thrombus/mass is seen in the body of the left atrium. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. there is no pericardial effusion. lue ultrasound : impression: no evidence of deep vein thrombosis seen within the veins of the left arm. note is made of a flattened waveform in the left subclavian vein which could suggest the presence of a more centrally located thrombus. ble ultrasound : no dvts noted ct head : impression: 1. ventriculostomy catheter in unchanged position with its tip terminating within the third ventricle. 2. however, there has been significant short-interval dilatation of the ventricular chain, including marked enlargement of the fourth ventricle. for example, the third ventricle has increased from 3 mm to 7 mm in maximal transverse dimension. findings are consistent with the clinical impression of evd malfunction. 3. continued evolution of multifocal infarction. ct head: 1. new right frontal approach ventriculostomy catheter with tip terminating within the medial aspect of the frontal of the right lateral ventricle. 2. mildly increased ventricular system size since the most recent examination. continued increased clot burden within the ventricles with new clot demonstrated within the third ventricle, surrounding the prior catheter at the foramen of , and extending along the entire left lateral ventricle. 3. continued evolution of multifocal infarction involving the bilateral cerebellar hemispheres and a right pca territorial distribution. 4. continued evolution of right parenchymal hemorrhage with no new foci of hemorrhage. eeg: impression: this is an abnormal continuous icu monitoring study because of moderate diffuse background slowing, frontal intermittent rhythmic delta activity, and attenuation of faster frequencies with more severe focal slowing over the right hemisphere. the findings are indicative of a moderate diffuse encephalopathy, which is etiologically nonspecific. the right hemisphere shows slower activity than the left, indicative of superimposed right hemispheric dysfunction. compared to the prior continuous recording on , there was mild increase in left hemisphere slow activity but improvement in background over the right hemisphere. there were no electrographic seizures. eeg: impression: this is an abnormal continuous icu monitoring study because of moderate diffuse background slowing, frontal intermittent rhythmic delta activity, and attenuation of faster frequencies with more severe focal slowing over the right hemisphere. the findings are indicative of a moderate diffuse encephalopathy, which is etiologically nonspecific. the right hemisphere shows slower activity than the left, indicative of superimposed right hemispheric dysfunction. compared to the prior days recording, the periods of frontal intermittent rhythmic delta activity are more prominent, suggesting worsening diffuse encephalopathy, midline structural lesion, hydrocephalus, or increased intracranial pressure. eeg: impression: this is an abnormal continuous icu monitoring study because of moderate diffuse background slowing, frontal intermittent rhythmic delta activity, and attenuation of faster frequencies with more severe focal slowing over the right hemisphere. after 8:20 am, the background shows sudden deterioration with severe diffuse slowing and attenuation of faster frequencies. these changes could be secondary a diffuse insult or to medication effect. compared to the prior days recording, background activity became slower at the end of the recording, suggesting worsening cerebral dysfunction or medication effect. no electrographic seizures were present. cxr: heart size is normal. mediastinum is normal. lungs are clear with resolution of previously demonstrated vascular engorgement. no appreciable pleural effusion or pneumothorax is noted. ct head: impression: 1. blood clot around the tip of the right frontal intraventricular catheter within the frontal of the right lateral ventricle, and increased blood in the right occipital . enlargement of the right lateral ventricle. new parenchymal hemorrhage along the right frontal course of the catheter with surrounding edema. 2. decreased blood in the left lateral and third ventricle. unchanged blood in the fourth ventricle. 3. continued evolution of right temporal parenchymal hemorrhage. 4. recent bilateral cerebellar hemispheric infarcts are again noted. ct brain findings: there is interval decrease in the size of a right temporal lobe parenchymal hematoma and bilateral occipital intraventricular hemorrhage. a left frontal approach ventriculostomy catheter terminates appropriately in the region of the foramen of . a right frontal parenchymal hemorrhage is unchanged compared to the prior examination. no new focus of hemorrhage are noted. there is a coil-pack in the region of the right mca with associated artifact. there is right posterior ethmoidal air cell fluid-opacification, unchanged. impression: 1. decrease in the extent of intraventricular and right temporal parenchymal hemorrhage. 2. unchanged right frontal parenchymal hemorrhage. 3. evolving bilateral cerebellar infarcts, with no finding to suggest new infarction. lenis : findings: grayscale, color and doppler images were obtained of bilateral common femoral, superficial femoral, popliteal and tibial veins. normal flow, compression, and augmentation is seen in all of the vessels. impression: no evidence of deep vein thrombosis in either leg. head ct: impression: 1. conversion to a vp shunt from a left frontal approach with stable appearance of ventricles and redistribution of intraventricular hemorrhage in the bilateral occipital horns. 2. unchanged right frontal intraparenchymal hemorrhage with surrounding vasogenic edema. 3. right mca coils. 4. unchanged evolving bilateral cerebellar infarcts. head ct: 1. no new hemorrhage or infarct. 2. left frontal approach ventricular shunt catheter terminating in the frontal of the left lateral ventricle, unchanged in position from prior study. 3. hydrocephalus, interval decrease in vent size. 4. right frontal lobe intraparenchymal hematoma, slightly decreased in size from prior study. 5. area of hypodensity in the right temporal lobe, representing evolution of prior intraparenchymal hemorrhage in that area. coil pack in the right mca with artifact at that level. brief hospital course: 60f admitted with an aneurysmal sah. initial exam was stable but patient's exam became more concerning and a evd was placed in the er as well as being intubated. she was then transported to the neuro icu where she was closely monitored. nimodipine was started and her sbp was kept < 140. early she was taken to angiogram for coiling. her aneurysm was only partially coiled as any additional coils would not stay in place. as the dome of the aneurysm was secured, immediate risk of rerupture was eliminated. patient was angiosealed and sent back to the icu. a repeat head ct was done which was stable, some mild hydrocephalus was noted but evd had been placed earlier with exam change. the evd was then dropped to 15. blood pressure recommendations were 90-160. nicardipine was started. eeg was ordered per sah protocol. post-angio exam was stable with no worsening. a central line and alsius catheter was placed for potential cooling needs. she was extubated on and required some sedation due to aggitation. she was not following commands on the left side so a head ct was obtained. this was stable and the following am her exam was greatly improved. her dilantin level was nontherapeutic and she was bolused. on , a bedside speech and swallow evaluation was done which she passed and she placed on a regular diet. there was some concern for aspiration so a formal evaluation was done on . her diet was modified to purees and thin liquids. she was febrile to 101.7 and a fever work-up was initiated. a cxr showed an area concerning for aspiration but had remained stable from previous imaging, so no antibiotics were initiated. tcds on and were relatively normal. there was some slower velocities on the bilateral mcas but this could be due to limited temporal windows. on , her exam remained stable. her dilantin level was 10.8 with a normal albumin level. on eve patient was noted to have a new left sided weakness, a head cta/ctp was done which showed some moderate vasospasm. her sbp was driven to 180-200 with good effect some improvement was noted to her motor exam. she remained oriented. she was also febrile and csf was sent. on , she underwent a cerebral angiogram for interarterial verapamil. she received 15mg to the l aca and 10 mg to the r ica. she had some moderate spasm distally and this was concerning so the sheath was kept in place for a repeat angio the next morning. post-angio, she had a head ct to evaluate for a r mca infarct which was negative. post-angio she was monitored closely and kept intubated as she was to return to angio the next morning. post-angio exam was stable, she was briskly localizing with her lue and then would move to command. her sbp was driven to 200-220 if able, but 180-200 was acceptable. repeat csf was sent for a fever. sputum cultures were ordered. on she went to angiogram to re-evaluate the spasm and it appeared improved. verapamil 10 mg was injected into the r mca. the aca and ica appeared improved from yesterday. the sheath was removed and pressure was held. the patient returned to the icu with a sbp goal of 180-220 (favoring 200-220). our plan was to extubate and monitor her exam closely. on post-angio exam she was stable. the alsius cath was removed. she was extubated on . post-extubation, she received 500 cc fluid bolus after neo gtt maxed to get sbp >180 goal. on , she required multiple fluid boluses to keep her sbp > 180. she was placed on a second - vasopressin and phenylephrine at max doses. her sbp parameters were lowered to 150-200 without incident. we also liberalized her neuro checks to q 3hrs to promote rest and reduce the risk for delerium. keppra 500mg was started and dilantin to wean off. screening lenis were done which were negative. she was febrile again on and csf was sent, gram stain was negative. on a ct/cta of the head was obtained and this did show improvement in her vasospasm. ct head showed a right occipital infarct. on physical exam she was noted to have a left hemianopsia. her sbp were kept in the range of 150-200 and did require the help of pressors. on she was seen and doing well, her evd was raised to 20cm above the tragus and she had no episodes of increased icp. she was febrile and csf was sent which was positive for gram negative rods. on , early morning csf was resent to confirm previous gram stain, and vancomycin and cefepime was started. id was consulted. the patient again developed left sided hemiparesis, a cta was performed that didn't show any evidence of spasm or stroke. the evd was clamped but her icp rose to 25 and she was re-opened. given the findings of meningitis with gram negative rods growing in her csf, we removed the right frontal evd on and placed a new evd on the left. csf culture grew back acinetobacter baumannii and her blood culture from had gram negative rods. id recommended vancomycin, tobramycin, and meropenem. overnight, she again was not following commands on the left. a ct/cta was done which was stable. her sbp was driven to 200. she also had some aflutter and tachycardia which could have been from electrolyte imbalance, her k was repleted. on am her exam was improved from the night prior. we allowed her sbp to return to 150-200. her evd remains at 20cm. overnight they noted a new rash on her back that appeared to be zoster. early , the evd was not draining as well, the drain was flushed distally but did not improve the drain so a head ct was done to confirm cath tip placement. the ct showed the cath terminated in the third ventricle as before. we pulled back the evd about 1-2cm and the evd was functioning. later in the afternoon, she appeared more somnolent but her exam remained within her usual wax/wane pattern, but her icp rose to 30. tcd was negative for mca vasospasm. a stat head ct/ctp was ordered, this showed general hypoperfusion. a po2 and pco2 was checked. although her pco2 was 30, her po2 was low. she was intubated for airway protection. we also increased her keppra to 1000 mg as a precaution for seizure as she is on meropenem which can lower the seizure threshold. on she was awake and following commands with the upper extrmities. csf was sent for surveillance per id recommendations. on , her icps again rose to the mid 30's, a ct/cta was done which showed bilateral cerebellar infarcts. the evd cath tip was terminating in the foramen of and was pulled back 1cm. stroke was consulted. tpa was flushed x1 with good effect. icps returned to . her sbp was liberalized to 115 and attempting to wean her off the neo gtt. in the evening, her urine na was 68 and osm 215. overnight, her evd continued to drain on and off. she was flushed distally multiple times. her exam became more somnolent but noted to be febrile. her sbp was driven up to 180 and her exam improved. on , her evd stopped draining again at 4:30, she received tpa at 6am. on reassessment at 07:30, her drain was draining at 0cm and below. her exam was stable and her sbp was liberalized to 115-200. she had a echo which showed an ef > 55%. in the afternoon, her icp waveform dampened and her icp was 30. her exam remained unchanged. after multiple attempts to improve this, we changed out her evd catheter as we suspected it was clogged. a repeat head ct showed proper placement of the evd catheter, it was noted she had some increase in ivh. her exam remained unchanged. on , she was off her pressors and her evd was raised from 0 to 15cm. she had a lue ultrasound to rule out infectious phlebitis. this was negative for dvt but did demonstrate a dampened waveform suggestive of a more proximal thrombus. the icu attending was asked to weigh in on this. their plan was to nothing as the dampened waveform is most likely from her left subclanian line and no definitive thrombus was seen. her lines were changed out per id recommendations as her blood cultures remained positive. tips were sent for culture. a new r subclavian was placed. stroke neurology recs for mri and asa are on hold at this time pending possible extubation and possible need for vps if she fails clamping trial on her evd. on , she was febrile and recultured but no csf was sent. she received a 750cc bolus from the previous night for low bp. her evd stopped draining and she received 1mg of tpa through her evd with little improvement around 1pm. she then again received 2mg at 4:30pm with improvement. evd was kept at 0 with adequate output and patient's exam was improved. her hct was noted to be 23 and patient appeared symptomatic with an elevated hr and low bp. she recieved two units of prbc and her hr and bp improved. her tobramycin dose was also increased according to id recommendations/tobramycin levels. early , her evd began to drain sluggishly and her waveform was absent. she was distally flushed and her transducer was flushed. although her evd began draining but only when dropped down to the floor, her waveform remained absent. surveillance csf was sent. 2mg of tpa was flushed at 03:30 am and the drain had not put out any csf. a new evd was placed on the right on which functioned well. we administered 2mg of tpa on the left and it also started to drain. the patient was noted to have a focal motor seizure charecterized by mouth twitching, for confirmation and monitoring the patient was placed on a 24 hour eeg and her keppra was increased to 1500 mg . she continued to improve with bilateral drainage. she continued to require mechanical ventillation. family wanted to wait over the weekend to see if she could wean off the ventillation. on , her left evd was clamped but a few hours later her exam was noted to be more lethargic so it was reopened with return to baseline exam. id increased her dose of vancomycin according to her level. as csf cultures cleared the vancomycin was d/c'd on . tpa was used intrathecal periodically to assist in the clearance of the intraventricular hemorrhage from through . on , the r evd was not functioning and a ct head was performed which showed a new clot around the evd catheter. on , the r evd was discontinued as it continued to not function. on , she underwent a trach and peg placement without any difficulty. her exam remained unchanged. on , she continued on the vent with the goal to wean down to trach mask. she appeared more lethargic but stable. on , she underwent a head ct which remained stable. there was no acute findings that could account for her lethargy. on , she remained lethargic and her evd was dropped to 5cm and csf was sent. on , her exam improved and we continued a weaning trial of the ventilator. leni's were negtaive for dvt. her evd was raised to 15. on , she went to the or for a vp shunt placement. she remained stable post opertively and was able to tolerate some trach mask trials on the 29th. the icu team will continue to wean her vent. on , she was febrile and required the vent again. she was pancultured but no source noted. on , she again was febrile and lfts were sent which were not impressive. on , early am she became suddenly hypotensive and her exam worsened, she was given a small dose of neo and her bp came up and her exam improved. she was not febrile at that time. during the day she appeared brighter and no further issues were had. on , she remained bright and following commands. a repeat head ct was done for follow-up. her ct showed interval decrease in her vent size. her hct remained low at 25.4 but asymptomatic. given her improved clinical exam it was decided to persue further treatment of the aneurysm at a later time. she was discharged on to rehab. medications on admission: unknown antihypertensive discharge medications: 1. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 2. senna 8.8 mg/5 ml syrup sig: 1-2 tablets po daily (daily). 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 4. potassium chloride 20 meq packet sig: packets po prn (as needed) as needed for low k. 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). 6. potassium & sodium phosphates 280-160-250 mg powder in packet sig: one (1) powder in packet po tid (3 times a day). 7. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 8. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for groin rash. 11. docusate sodium 50 mg/5 ml liquid sig: two (2) po bid (2 times a day). 12. ibuprofen 100 mg/5 ml suspension sig: 400-800 mg po q8h (every 8 hours) as needed for fever. 13. acetaminophen 650 mg/20.3 ml solution sig: one (1) po q6h (every 6 hours) as needed for fever. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: subarachnoid hemorrhage r mca aneurysm (ruptured) r intercerebral hemorrhage hydrocephalus intraventricular hemorrhage hypertension cerebral edema failed airway (requiring intubation) fever vasospasm meningitis hypokalemia aflutter bilateral occipital infarcts cerebellar infarcts intracranial hypertension sepsis respiratory failure herpes zoster anemia oral thrush discharge condition: mental status: confused - always. level of consciousness: alert and interactive with periods of lethargy. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: angiogram with embolization and/or stent placement medications: ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort. ?????? no heavy lifting, pushing or pulling (greater than 10 lbs) ???????????? keep incision dry until staples/sutures are out. what to report to office: ?????? changes in vision (loss of vision, blurring, double vision, half vision) ?????? slurring of speech or difficulty finding correct words to use ?????? severe headache or worsening headache not controlled by pain medication ?????? a sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? trouble swallowing, breathing, or talking ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site *sudden, severe bleeding or swelling (groin puncture site) lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call our office. if bleeding does not stop, call 911 for transfer to closest emergency room! followup instructions: please follow-up with dr in 4 weeks for a follow-up, no imaging is required for this appointment. at this appointment we will discuss repeating a cerebral angiogram for treatment planning. please call to make this appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Other bronchoscopy Laparoscopy Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries Arteriography of cerebral arteries Arteriography of cerebral arteries Injection or infusion of other therapeutic or prophylactic substance Injection or infusion of other therapeutic or prophylactic substance Ventricular shunt to abdominal cavity and organs Intravascular imaging of intrathoracic vessels Intravascular imaging of intrathoracic vessels Arterial catheterization Temporary tracheostomy Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils Diagnoses: Other iatrogenic hypotension Anemia, unspecified Obstructive hydrocephalus Tobacco use disorder Unspecified essential hypertension Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Other convulsions Subarachnoid hemorrhage Atrial flutter Sepsis Candidiasis of mouth Intracerebral hemorrhage Hypopotassemia Acute respiratory failure Alkalosis Cerebral edema Mechanical complication due to other implant and internal device, not elsewhere classified Other septicemia due to gram-negative organisms Other and unspecified special symptoms or syndromes, not elsewhere classified Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Cerebral artery occlusion, unspecified with cerebral infarction Tachycardia, unspecified Hemiplegia, unspecified, affecting unspecified side Other alteration of consciousness Apnea Homonymous bilateral field defects Herpes zoster without mention of complication Meningitis due to gram-negative bacteria, not elsewhere classified |
allergies: peanut / chocolate flavor / codeine attending: chief complaint: cc:. reason for micu transfer: respiratory distress/copd exacerbation major surgical or invasive procedure: none history of present illness: ms. is an 83 y/o f with htn, copd and ra who presented to the ed with developing lle erythema over 3 days duration. presented to pcp who suggested she go to the ed for further eval. denied any associated sx including fever/chills or pain. does describe weeping from the lesion. in the ed she developed afib with rvr and was treated with iv and oral metoprolol and admitted to medicine for further work-up of new afib. . on the floor, she was continued on metoprolol for afib. she was treated with ceftriaxone for cellulitis but blood cultures turned positive for strep viridans. thus, a tte was ordered which showed possible aortic valve vegetation. a tee was performed today to better characterize the vegetation but during the procedure she became stridorous. . she was treated with nebulizers and iv steroids for presumed copd exacerbation. she also had magnesium, furosemide x1, and metoprolol iv x 2. she was placed on a nrb with saturations in the 90% and transfered to the micu for further management of her respiratory distress. past medical history: - osteoporosis with t8-9 compression fracture - ra - copd (no pfts in omr) - htn social history: not presently employed. lives independently. has a niece who is rn. no etoh, tobacco or other drug use. family history: father with physical exam: on admission: vs: afebrile, bp 114/70, hr 150s, rr 30s, o2sats 93-99% nrb ga: aox3, severe increased work of breathing with use of abdominal muscles for respiration, no sentence dyspnea heent: jvp elevated to 10-12 cm cards: irregularly irregular, s1 and s2, + murmur best heard over apex pulm: intermittent inspiratory stridor, expiratory wheezes bilaterally, no crackles abd: soft, nt, +bs. no g/rt. neg hsm. extremities: erythema and flaking on skin over left tibia extending down to foot. rle with e/o venous statis changes. on discharge: vs: 97.0 121/77 86 22 94%2l gen: severely kyphotic, elderly female in nad. oriented x3. mood, affect appropriate. cv: rrr with normal s1, s2. no m/r/g. no s3 or s4. chest: respiration unlabored, no accessory muscle use. ctab without crackles, wheezes or rhonchi. does have rhoncorous upper airway sounds. abd: normal bowel sounds. soft, nt, nd. no organomegaly or masses. ext: wwp. digital cap refill <2 sec. no c/c/e. distal pulses intact radial 2+, dp 2+, pt 2+. skin: venous stasis changes in lower extremity; cellulitis is significantly improved pertinent results: on admission: 04:15pm blood wbc-6.9 rbc-4.03* hgb-12.6 hct-38.9 mcv-97 mch-31.3 mchc-32.4 rdw-12.5 plt ct-428 08:10am blood pt-12.2 ptt-22.6* inr(pt)-1.1 03:30pm blood glucose-97 urean-13 creat-0.6 na-145 k-3.5 cl-105 hco3-32 angap-12 08:32am blood alt-28 ast-24 ld(ldh)-158 alkphos-80 totbili-0.3 06:00am blood calcium-8.9 phos-3.7 mg-2.0 on discharge: 05:45am blood wbc-10.4 rbc-3.35* hgb-10.6* hct-32.4* mcv-97 mch-31.5 mchc-32.6 rdw-13.6 plt ct-236 05:50am blood pt-14.5* ptt-30.7 inr(pt)-1.4* 05:45am blood glucose-102* urean-16 creat-0.4 na-139 k-4.0 cl-100 hco3-36* angap-7* 05:45am blood calcium-8.4 phos-2.4* mg-2.1 studies: . tte: impression: aortic valve mass, probably a vegetation. no associated aortic regurgitation. moderate mitral and tricuspid regurgitation . tee esophagus was successfully intubated with tee probe. prior to the acquisition of any pictures the patient developed stridorous breathing which resolved fully following removal of the tee probe. the procedure was aborted at that time. the patient was closely monitored in the tee room until sedation wore off and she fully recovered back to baseline. there was no further stridor noted. . ct head: impression: no acute intracranial process; exam limited by exclusion of the superior-most aspect of the brain. . ct chest: impression: 1. no pneumonia. 2. mild pulmonary edema. moderate right and small left pleural effusions, moderately severe bibasilar atelectasis. new moderate cardiomegaly. 3. new severe multilevel thoracic vertebral compression fractures. . cxr: pfi: improved appearance of right lung with residual right cardiophrenic consolidation with trace right pleural effusion; unchanged retrocardiac consolidation with small left pleural effusion. brief hospital course: assessment and plan: ms. is an 83 y/o f with htn, copd and ra who presented with cellulitis and afib with rvr in the ed. found to be bacteremic on the floor and found to have aortic valve vegitation. . # strep viridans bacteremia - the patient initially presented with cellulitis of her left leg and was treated with oral antibiotics. on day #3 of therapy, blood cultures drawn at admission returned (+) for strep viridans. she was started on iv ceftriaxone on . the patient underwent tte which revealed an aoritc valve vegitation. plan was for tee however, during the procedure, the patient became stridorous (as described in detail below) and required intubation and micu transfer. in the micu, the patient underwent tee which again demonstrated the aortic valve vegitation. on , the patient was hd stable and was able to return to the medicine floor from the micu. a midline was placed for long term antibiotic therapy. the patient will be discharged to a rehab center where she will continue antibiotic therapy for 1 month and follow-up with id as an outpatient. . # respiratory distress: on a tee was attempted however had to be abandoned as the patient became stridorous during the procedure. following this event, the patient was stable on the floor until ~6pm when she began to develop respiratory distress. despite agressive measures including iv steroids, nebs, o2, lasix, and racemic epi the patient required intubation and was transferred to the micu. in the micu the patient was diuresed further and continued on albuterol/ipratropium for copd. was also started on methylpred 60 mg q8h. imaging showed a mild left effusion and atelectasis. extubated on micu day #1 without event. during her icu course, the patient would intermittently develop respiratory distress and stridor, with saturations dipping into the low 80s. she underwent bipap intermittently overnight, then was changed to nasal bipap after her respiratory status improved. on the floor, the patient self-discontinued bipap due to discomfort. seen by ent who scoped to the level of the vocal cords but found no abnormality. etiology of respiratory decompensation is unclear although is believed to be related to possible upper airway edema exacerbated by tee/intubation. also has poor reserve with underlying copd and severe kyphosis. . # afib with rvr - the patient was noted to be in afib with rvr while in the ed. no known h/o afib. in the hospital she was initially controlled with iv metoprolol and loaded with orals. oral metoprolol titrated to 200mg daily and converted to long acting. given chads2 score of 2, anti-coagulation was recommended and the patient was agreeable. started on warfarin without bridge and will continue warfarin on an outpatient basis. goal inr . . # osteoporosis - in house, the patient was incidentally found to have a number of new compression fractures on imaging. is writted for alendronate, vitamin d, and calcium at home although reports not reliably taking the alendronate. she was maintained on calcium and vitamin d in house. received alendronate on mondays per home schedule. she never complained of pain related to compression fractures. . # copd - the patient carries a history of copd. this may have contributed to respiratory decompensation described above. in house she was continued on standing nebulizer therapy. prior to discharge, the patient continued to have a dry, hacking cough and an increased oxygen requirement (2l nc to maintain sats ~94%). given relatively clear imaging, a copd exacerbation was suspected and the patient was discharged with plans to complete a steroid taper and a 5 day course of azithromycin. . # htn - the patient has a h/o htn and was on atenolol at home. this was changed to metoprolol in house and she will be discharged with plans to continue metoprolol. . # ra - has a history of what is apparently rather severe ra. not on any medications to control disease at home. attempted to contact the patient's rheumatologist although he has apparently recently retired. . # transitional issues: 1) continue ceftriaxone to complete a 1 month course and follow-up with infectious disease clinic as scheduled. 2) recommend referral to see a new rheumatologist (former rheumatologist retired) and a pulmonologist. 3) continue metoprolol 200mg daily for atrial fibrillation 4) continue coumadin daily and follow-up with clinic 5) complete steroid taper and course of azithromycin medications on admission: medications: (at home) alendronate - 70 mg tablet weekly atenolol - 25 mg daily fluticasone meloxicam 15 mg tablet daily oxycodone-acetaminophen - 1 tab q6h;prn for pain multivitamin . medications: (on transfer) ipratropium neb 1 neb ih q6h:prn sob/wheezing acetaminophen 325-650 mg po/ng q4h:prn pain or fever albuterol inhaler puff ih q4h:prn wheezing/shortness of breath methylprednisolone sodium succ 125 mg x1 aspirin 81 mg po/ng daily metoprolol succinate xl 200 mg po daily alendronate sodium 70 mg po qmon metoprolol tartrate 5 mg iv x2 metoprolol tartrate 25 mg po/ng once benzonatate 100 mg po tid magnesium sulfate 2 gm iv once ceftriaxone 1 gm iv q24h day 1 methylprednisolone sodium succ 125 mg iv q6h start docusate sodium 100 mg po bid prednisone 40 mg po/ng daily fluticasone propionate 110mcg 2 puff ih racepinephrine 0.5 ml ih once x2 furosemide 20 mg iv once senna 2 tab po/ng hs guaifenesin ml po/ng q4h:prn cough discharge medications: 1. alendronate 70 mg tablet sig: one (1) tablet po once a week: monday. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 3. warfarin 2.5 mg tablet sig: two (2) tablet po at bedtime: please follow up with your clinic for further management of your dosing. disp:*30 tablet(s)* refills:*1* 4. multivitamin tablet sig: one (1) tablet po once a day. 5. ceftriaxone 1 gram recon soln sig: one (1) intravenous once a day: please continue on ceftriaxone until instructed otherwise at your infectious disease clinic follow-up. 6. prednisone 10 mg tablet sig: four (4) tablet po once a day: continue 4 pills daily for 3 days. then 3 pills daily for 3 days then 2 pills daily for 3 days then stop. disp:*28 tablet(s)* refills:*0* 7. metoprolol succinate 200 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* 8. meloxicam 15 mg tablet sig: one (1) tablet po once a day. 9. azithromycin 250 mg tablet sig: one (1) tablet po once a day for 3 days. 10. flovent diskus 100 mcg/actuation disk with device sig: two (2) inhalation twice a day. discharge disposition: extended care facility: - discharge diagnosis: cellulitis, atrial fibrillation, respiratory failure cellulitis, atrial fibrillation, endocarditis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you at ! you were admitted with a skin infection of your leg. in the emergency room you were also found to have an abnormal heart rhythym called atrial fibrillation. you were treated with antibiotics for the skin infection with improvement. you were also treated with a medication to slow your heart rate and were started on a blood thinning medication to prevent stroke. additionally, you were found to have an infection of your bloodstream and of your heart valve. for this you will be discharged on a 4 week course of intravenous antibiotics. see below for changes to your home medication regimen: 1) please start metoprolol 200mg once daily 2) please start warfarin 0.5mg in the evening. you will follow-up with the square- office clinic for further changes to your dosing 3) please continue ceftriaxone until otherwise instructed by the infectious disease clinic 4) please start aspirin 81mg daily 5) please stop atenolol 6) please continue prednisone 4 pills daily for 3 days. then 3 pills daily for 3 days then 2 pills daily for 3 days then stop. 7) please continue azithromycin 250mg daily for 3 additional days to complete a 5 day course 8) please stop roxicet see below for instructions regarding follow-up care: followup instructions: department: infectious disease when: wednesday at 10:00 am with: , md building: lm campus: west best parking: garage please follow-up with your primary care phsyician (, , ) within 7 days of discharge from your rehabilitation facility. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnostic ultrasound of heart Insertion of endotracheal tube Diagnoses: Unspecified essential hypertension Obstructive chronic bronchitis with (acute) exacerbation Acute respiratory failure Cellulitis and abscess of leg, except foot Bacteremia Osteoporosis, unspecified Rheumatoid arthritis Acute and subacute bacterial endocarditis Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: melena major surgical or invasive procedure: egd, colonoscopy planned for friday history of present illness: pt is a 85 yo with h/o hypertension, hyperlipidemia, chronic ischemic heart disease, congestive heart failure, renal failure, chronic lung disease and iron deficiency anemia now with melena x 3 d. pt states he had 1 week of fatigue, weakness, leg cramping which is chronic but worse than usual in the last 3 days. pt used to be independent, but now very weak and in bed. pt states he had darker-looking stools than usual for the last 3 d. his last bm was yesterday am. pt admits to decr appetite, abd pain at umbilicus, with radiation to back and nausea but no vomiting. denies fevers, but admits to "feeling cold". pt was taking motrin for his abd pain the last 3d, but states this is he started having dark stools. pt admits to difficulty breathing but admits this is chronic. . in the ed, initial vs were: t 98.7 p 89 bp 114/34 r 15 o2 sat 96% on ra. hb 4.8 hct 15.9 (baseline 35 in ) mcv 95. patient was given 2u prbcs. 2l ns, 2mg morphine for belly pain, ct abd/pelvis no acute findings. cr 5.3 (baseline 2.6-2.9). ng lavage was negative (~70% sensitivity). . on the floor, pt looks well, hemodynamically stable. pt admits to pain in umbilicus and pain in bilat legs. denies dizziness/fainting spells. states the abd pain gets worse after eating. . review of sytems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denies vomiting, diarrhea, constipation or abdominal pain. no recent change in bladder habits. no dysuria. past medical history: hypertension hyperlipidemia chronic ischemic heart disease congestive heart failure chronic renal failure chronic lung disease iron deficiency anemia social history: married. lives with daughter. remote , no etoh. family history: nc physical exam: vitals: t 98.7 p 89 bp 114/34 r 15 o2 sat 96% on ra. general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: good air movement, crackles at bilat bases, no wheezes cv: distant heart sounds, rrr, 2/6 systolic murmur with no radiation abdomen: soft, obese, non-distended, bowel sounds present, mild ttp near umbilicus, no rebound tenderness or guarding ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs: 10:20pm wbc-9.2 hgb-6.9*# hct-21.5*# mcv-92 plts 287 03:30pm glucose-131* urea n-150* creat-5.3*# sodium-137 potassium-4.7 chloride-101 total co2-17* anion gap-24 03:30pm alt(sgpt)-12 ast(sgot)-18 ck(cpk)-1605* alk phos-76 amylase-61 tot bili-0.2 03:30pm lipase-51 03:30pm ck-mb-25* mb indx-1.6 ctropnt-0.45* 03:30pm albumin-3.3* calcium-7.1* phosphate-7.5*# magnesium-2.1 iron-11* 03:30pm caltibc-278 vit b12-825 folate-4.9 ferritin-23* trf-214 03:30pm tsh->100 03:30pm pt-13.1 ptt-26.0 inr(pt)-1.1 03:00am blood wbc-10.3 rbc-2.67* hgb-8.4* hct-24.6* mcv-92 mch-31.4 mchc-34.2 rdw-18.2* plt ct-289 04:25am blood wbc-5.5 rbc-3.10* hgb-9.3* hct-28.2* mcv-91 mch-30.0 mchc-33.0 rdw-18.5* plt ct-245 04:10am blood wbc-7.2 rbc-3.00* hgb-9.2* hct-27.3* mcv-91 mch-30.7 mchc-33.7 rdw-18.4* plt ct-269 05:10pm blood wbc-7.9 rbc-3.36* hgb-10.1* hct-31.0* mcv-92 mch-30.1 mchc-32.6 rdw-17.9* plt ct-279 10:04am blood hct-27.8* 01:06pm blood hct-27.4* 10:03pm blood hct-29.1* 05:10pm blood wbc-7.9 rbc-3.36* hgb-10.1* hct-31.0* mcv-92 mch-30.1 mchc-32.6 rdw-17.9* plt ct-279 07:20pm blood wbc-8.7 rbc-3.23* hgb-9.7* hct-30.9* mcv-96 mch-30.1 mchc-31.4 rdw-17.9* plt ct-292 03:58am blood wbc-8.8 rbc-3.04* hgb-9.0* hct-29.0* mcv-96 mch-29.7 mchc-31.1 rdw-18.4* plt ct-294 03:30pm blood plt ct-334 05:10pm blood plt ct-279 06:00am blood pt-13.3 ptt-26.7 inr(pt)-1.1 03:58am blood plt ct-294 03:00am blood glucose-124* urean-137* creat-4.8* na-138 k-4.4 cl-102 hco3-19* angap-21* 04:10am blood glucose-132* urean-115* creat-4.4* na-141 k-3.9 cl-106 hco3-22 angap-17 05:00am blood glucose-119* urean-98* creat-4.6* na-138 k-4.8 cl-105 hco3-23 angap-15 06:00am blood glucose-93 urean-98* creat-4.8* na-141 k-4.5 cl-106 hco3-23 angap-17 03:58am blood glucose-137* urean-103* creat-4.8* na-140 k-4.6 cl-104 hco3-21* angap-20 03:00am blood ck(cpk)-2419* 10:03pm blood ck(cpk)-2128* 04:10am blood ck(cpk)-1001* 05:00am blood ck(cpk)-529* 03:00am blood ck-mb-35* mb indx-1.4 ctropnt-0.38* 01:06pm blood ck-mb-33* mb indx-1.6 ctropnt-0.35* 10:03pm blood ck-mb-29* mb indx-1.4 ctropnt-0.39* 03:30pm blood albumin-3.3* calcium-7.1* phos-7.5*# mg-2.1 iron-11* 04:10am blood calcium-7.7* phos-6.1* mg-1.8 06:00am blood calcium-7.8* phos-5.3* mg-2.0 03:58am blood calcium-7.4* phos-5.3* mg-2.0 03:30pm blood tsh->100 04:25am blood tsh-greater th 03:00am blood t4-1.1* t3-46* free t4-0.17* 03:00am blood anti-tg-less than antitpo-less than 06:29am blood freeca-0.91* 06:53pm blood freeca-0.97* 05:53am blood freeca-1.11* 05:58am blood freeca-1.08* 06:25am blood freeca-1.08* 08:03am blood freeca-1.07* 05:00am blood vitamin d 25 hydroxy-pnd . micro: h pylori - **final report ** helicobacter pylori antibody test (final ): negative by eia. (reference range-negative). . . urine culture - **final report ** urine culture (final ): <10,000 organisms/ml. . . images: ct abd/pelvis : cardiomegaly is noted with calcification along the mitral annulus. atelectatic changes are noted at the lung bases bilaterally. the liver appears shrunken with a slightly nodular contour suggesting underlying cirrhosis. calcific density layering dependently in the gallbladder is compatible with stones. there is no biliary ductal dilatation. linear calcific densities along the hilum bilaterally are compatible with atherosclerotic calcification along the renal arterial branches. extensive atherosclerosis along the abdominal aorta and major branch vessels is noted with ectasia of the infrarenal abdominal aorta measuring up to 3.4 x 3.4 cm. the upper abdominal aorta is ectatic measuring 3.7 cm at the level of the diaphragm. there is no free air, free fluid, or lymphadenopathy. no evidence of ileus or obstruction. there is fusion of l4 and l5 vertebral bodies with a l4 spondylolysis noted bilaterally as well as a mild anterolisthesis of the l4 vertebra relative to . degenerative changes are noted at l5-s1 with disc space narrowing and vacuum disc phenomena. . tte: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation may be present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , moderate pulmonary artery systolic hypertension and increased pcwp are now identified. the magnitude of symmetric left ventricular hypertrophy is similar (was overestimated on the prior study). . . renal usn: findings: the right kidney measures 9.3 cm. there is no hydronephrosis. there is no renal mass or calculus identified. arterial flow is present without evidence of parvus tardus. the left kidney measures 8.1 cm. there is no hydronephrosis, renal mass, or calculi identified. there is diffuse thinning of the cortex, consistent with atrophy. dopplers were not obtained of the left kidney given the patient's breathing. impression: 1. atrophy of the left kidney, similar when compared to the prior examination. dopplers of the left kidney were not obtained. 2. normal dopplers of the right kidney 3. ultrasound is not sensitive in the diagnosis of small solid renal masses. . . ekg: lvh, st depression in v4-v6, stable from previous ekg in brief hospital course: # gi bleed - upon presentation, pt noted to have hct 15.9 (down from baseline of 35) however pt remained hemodynamically stable. ng lavage in the ed was negative. pt was started on iv ppi, and ultimately received 5u prbc with hct improvement to 28. his last transfusion was on . egd revealed a large ulcer in the fundus, initially concerning for perforation. ct abdomen and surgical consult were obtained, at which time to evidence of perforation was found. h pylori biopsy was negative. his bleeding was attributed, in part, to recent significant nsaid use for knee pain. . pt's hct remained stable, and he was transferred to the medical floor, with plan for colonoscopy to rule out additional sources of bleeding. however, pt was extremely resistant to completing the colonoscopy prep on the night of and on , after further discussion with the gi service, colonoscopy was felt not urgently necessary given his stable hct, and the presence of a likely source on upper endoscopy. at the time of discharge, gi service recommended follow-up in clinic in 1 week, an appointment was made, with instructions to check cbc on , pending hospice discussion as below. . . # acute on chronic renal failure: most likely hemodynamic changes from significant gi bleeding event, making atn most likely, though some contribution likely from nsaid abuse, and rhabdomyolysis. creatinine initially elevated at 5.3 (baseline is 2.7 in ), and pt was initially hydrated with cautious ivf, given his chf, with some modest improvement in creatinine to 4.4 on , however pt subsequently developed worsening creatinine and oliguria with creatinine of 4.8 on in the setting of lasix 60mg iv tid as per renal recommendations. he was noted to become progressively more volume overloaded, requiring supplemental oxygen to 3l, uremic (nausea, loss of appetite, and asterixis). lisinopril was held. renal ultrasound was negative for obstructive process. . on , discussion held with pt and family about progressively declining renal function, and possible need for dialysis, as his acute renal failure was felt potentialy reversible with short-term hd. pt declined hd after extensive conversation detailing poor prognosis in the absence of improvement in renal function. pt again declined dialysis after discussion with his nephrologist on . plan was made for pt to be discharged with a trial of oral lasix (160 mg po bid, which was his prior home regimen), with follow-up in renal clinic in 7 days from discharge (). . should his oliguria fail to respond to lasix, pt and family understood the possibility of increased respiratory difficulty. given his strong preference not to return to the hospital should this occur, in favor of dying at home, palliative care consult was obtained, and arrange for pt to be evaluated by hospice vna within his home on as below, so that he could be transitioned to home hospice in the event that his oliguria did not improve. his pcp was made aware of this plan on the day of his discharge by telephone. . . # elev troponin: pt's cardiac enzymes and ekg were checked h/o cardiac disease in the setting of acute blood loss. tnt is 0.45, trended down to 0.38 by am, and pt remained asymptomatic. this most likely represented a demand ischemic event in the setting of significant anemia. ekg showed lvh, but otherwise no new changes indicative of ischemia. pt was maintained on beta-blocker, however asa was held bc of concern for bleeding, and statin was held because of elevated ck. . # rhabdomyolysis: pt had elev ck (1000- range), with leg pain. ua with moderate blood, and 2rbcs, c/w rhadbo. he was hydrated with ivf, and his ck improved. his statin was held. tsh was checked and came back elevated (>100), which was treated as below. . # hypocalcemia - possible rhabdo as above, though some contribution from renal dysfunction, and vitamin d level pending at discharge. he received repletion early during his course, however his corrected calcium was within the normal range at discharge. . # anion gap metabolic acidosis: pt had agma intially. diff uncl mudpiles, but most likely to uremia. lactate was wnl, no h/o diabetes so ketoacidosis unlikely. no h/o alcohol or other ingestions. . # chronic diastolic dysfunction: echo in ' shows severe lvh, lvef>55%, moderate lv diastolic dysfunction, mild pulmonary artery systolic hypertension. pt's volume status was monitored closely while transfusing and ivf hydration. pt was given iv lasix as above to facilitate diuresis, and continued on metoprolol tartate 12.5 (decreased from home dose given gi bleed). repeat tte in the icu showed slightly elevated pcwp, but otherwise ef>55%, 1+mr. . # copd: pt was breathing comfortably initially, with known history of copd, however, as his renal failure progressed to oliguria, he was became progressively volume overloaded, and developed symptoms of orthopnea, and increased o2 requirement of 3l on day of discharge, managed as above. otherwise, he was continued on home flovent, combivent. . # goals of care: pt expressed increasing frustration at his hospitalization after arriving on the medical floor. extensive conversation on , and with patient, multiple family members (lead by daughter , who is matriarch), and translator services, took place during which patient and family expressed their desire to bring patient whom, despite ongoing renal failure, with understanding that failure to treat his renal failure, could result in his dying at home because of progressive fluid accumulation. decision was made to make pt dnr/dni on , and he expressed his wishes to be discharged home, and allowed to die at home. palliative care service was consulted, and arrangements were made for home hospice evaluation on , such that if his oliguria failed to improve, and he became more dyspneic, he could be transitioned to home hospice service. . there was some hope that his renal function would improve with diuresis, however pt declined hemodialysis on multiple occasions. as above, he will be discharged home with oral lasix, and asked to follow-up with his nephrologist within 7 days. in the interim, he was asked to return to the emergency department should he have worsening dyspnea, however he states that he would again not want to start dialysis, and would not return to the hospital, preferring to die at home, thus will be evaluated by hospice services as above, which can be cancelled if his oliguria improves. . # comm - daughter, . (hcp) medications on admission: atorvastatin 40 mg tablet once a day calcitriol 0.25 mcg mon, weds fri for 2 weeks fluticasone 110 mcg/actuation aerosol 2 puffs furosemide 160 mg ipratropium-albuterol 18 mcg-103 mcg (90 mcg)/actuation aerosol 2 puffs tid as needed lisinopril 10 mg once a day metoprolol succinate 50 mg once a day omeprazole 20 mg once a day triamcinolone acetonide 0.1 % ointment aspirin 81 mg once a day ferrous sulfate 325 mg twice a day discharge medications: 1. oxygen please provide continuous home oxygen 3-4l by nasal cannula for goal o2 sat >90%. 2. lasix 80 mg tablet sig: two (2) tablet po twice a day. disp:*120 tablet(s)* refills:*2* 3. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 4. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed for sob, wheezing. 5. metoprolol succinate 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 7. levothyroxine 125 mcg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 8. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). disp:*180 capsule(s)* refills:*2* 9. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for knee pain. disp:*56 tablet(s)* refills:*0* 10. outpatient lab work please have your cbc drawn on and have the results to faxed to dr. , your pcp : ( office. fax:(. discharge disposition: home with service facility: hospice discharge diagnosis: primary: acute on chronic renal failure pulmonary edema renal failure uremia renal failure peptic ulcer acute blood loss anemia from peptic ulcer rhabdomyolysis secondary: chronic diastolic heart failure discharge condition: requiring 3-4l oxygen by nasal cannula, denies shortness of breath sitting up in chair, but +orthopnea, lower extremity edema, +asterixis, but cognitively intact per family and translator. discharge instructions: you were admitted to the hospital with bloody stool, and found to have have a large stomach ulcer. you were treated with 5 units of blood, and started on a medication to prevent bleeding in the future. . you developed renal failure in the setting of the bleeding above. your kidney function got worse, and your urine output decreased. you declined dialysis, and are being sent home with a trial of lasix, with the hope that your kidney function improves. . you stated that you do not want to return to the hospital, do not want dialysis, and would like to die at home. hospice was consulted, and will evaluate you in your home on . if your kidney function improves with just lasix treatment, you may discontinue hospice, but you have stated that you want no further interventions. . the following changes were made to your medications: 1. your lasix dose was maintained at 160mg po bid. 2. your lisinopril was held. 3. your aspirin was held. 4. your statin was held because of rhabdomyolysis. 5. you were started on protonix 40mg twice daily, and your prilosec was stopped. . you will be evaluated on for home hospice services. . you should follow-up with dr. in the renal clinic as below, to see if your kidney function improves. . if you have worsening shortness of breath before you are evaluated by hospice, please contact dr. , or the emergency department. once you have been seen by hospice, you should discuss all of your care with your pcp and your hospice physicians. followup instructions: please follow-up with gastroenterology within 1 week pending your hospice discussion above. an appointment has been made for you on with dr. on the , . please call ( with any questions or concerns. provider: , md phone: date/time: 2:30 . please have your blood level drawn in every on . these should be followed by your pcp pending your hospice discussion. . please follow up in the renal clinic with dr. , appointment has been made for you on at 9am. please call ( with any questions or concerns. provider: , md phone: date/time: 9:00 . based on your hospice discussion, please arrange for endocrinology follow-up within 4-6 weeks. the phone number for the endocrinology clinic is (. Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Diagnoses: Acidosis Hypocalcemia Congestive heart failure, unspecified Acute posthemorrhagic anemia Acute kidney failure, unspecified Unspecified acquired hypothyroidism Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Acute on chronic diastolic heart failure Other and unspecified hyperlipidemia Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Rhabdomyolysis |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with placement of bare mental stents x 4 history of present illness: 60 yo male with history of gout, hld, htn, anemia of chronic inflammation presents with substernal chest pain. . patient notes that over the last several days he has had intermittent chest discomfort when at work. he notes that the pain would go away if he stopped relaxed and took a deep breath. the day of presentation the patient developed substernal chest pain without radiation which was associated with palpitations, diaphoresis, shortness of breath. his brother gave him 4 baby aspirins which he chewed and called 911. in the ambulance the patient recieved nitroglycerin without improvement in his chest pain. . in the ed, initial vitals 80 160/80 16 98% 2l. ekg concerning for inferior with a. fib with . code called. patient started on heparin gtt, morphine 4 mg iv, diltiazem 50mg iv x one, plavix 300mg. . in the cath lab, catheterization revealed a 90% mid rca lesions. other vessels without significant disease. case complicated by rca dissection, at one point vessel was lost, entire vessel ballooned with four bare metal stents. patient transiently on dopamine for borderline hypotension. patient in a. fib with and given lopressor 17.5 mg iv total iv. one unit of blood given for hct of 24.9 . bivalrudin given during case given history of iron deficiency anemai. angioseal placed. . in the ccu, patient remains in afib with with stable blood pressure. he reports no chest pain. . on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. past medical history: 1. cardiac risk factors: hypertension, hyperlipidemia 2. cardiac history: none 3. other past medical history: - gout - anemia: admission in with hct of 15 without clear etiology 7 units of prbcs transfused. hemolysis labs negative. stool guaiac negative. bone marrow biopsy with heme/onc negative. last colonoscopy 10 years ago. social history: he is unmarried and has no children. he lives with his brother in . he is currently unemployed, but works odd jobs when he can, usually construction. he has a 42 pack year history. he drinks 4-6 beers a week. he denies use of illicits. family history: hypertension - mother (died at 92) father - unknown medical history, died of unknown causes physical exam: on admission: vs: afebrile bp=114/86 hr=150 rr=15 o2 sat= 100% 2l general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. poor dentition. neck: supple with jvp at base of neck. cardiac: irregular, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: unable to examine posterior lung field as patient post cath. anterior lung field with coarse breath sounds. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: radial 2+ dp 2+ pt 2+ left: radial 2+ dp 2+ pt 2+ on discharge: temp max:101.9 temp current: 99.1 hr:67-83 rr:18 bp:139-183/87-98 o2 sat: 100% ra gen: nad, sitting comfortably in chair cv: rrr, systolic murmur rusb resp: ctab, no rales or wheezes, unlabored abd: s/nt/nd, +bs extr: no peripheral edema, r knee edematous, blottable, no erythema or warmth neuro: a/o, no focal deficits pertinent results: cbc wbc rbc hgb hct mcv mch mchc rdw plt ct 06:50 9.4 4.15* 11.7* 35.5* 86 28.2 33.0 17.1* 242 23:00 30.9* 15:00 32.5* 06:30 10.0 3.77* 10.8 32.3* 86 28.7 33.4 17.3* 223 21:20 30.1* 13:15 29.1* 04:55 8.5 3.01* 8.6* 25.7* 86 28.7 33.5 17.3* 232 21:45 9.8 2.87* 7.9* 24.9*1 87 27.6 31.8 18.0* 273 renal & glucose glucose urean creat na k cl hco3 angap 06:50 109*1 16 0.9 139 4.7 102 26 16 06:30 961 15 0.9 138 4.7 105 24 14 04:55 108*1 23* 0.8 141 4.7 111* 19* 16 21:45 111*1 27* 0.9 142 3.4 106 18* 21* cpk isoenzymes ck-mb ctropnt 13:15 27* 04:55 38* 21:45 0.02* hematologic hapto 04:55 253* studies/procedures - ecg: afib with approx 160, normal axis. st elevation in iii with depresssions v3-v6. right sided leads with 1mm st elevation v4-v6. . - cardiac cath: per report. 90% occlusion of mid rca. case complicated by dissection with near loss of vessel. vessel balloned and 4 bms placed with resolution of flow. final report pending at time of discharge. . - tte: the left atrium is elongated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with inferior hypokinesis to akinesis. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size is normal. with borderline normal free wall function. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (images reviewed) of , regional lv systolic dysfunction is new. the aortic valve area is similar despite lower gradients due to decreased stroke volume. brief hospital course: 60 yo male with hld, htn, gout, anemia who presents with cp found to have inferior s/p cardiac catheterization complicated by rca dissection necessitating placement of bms x 4. active issues: # - pt presented with cp and was found to have inferior on ekg. in the cath lab, catheterization revealed a 90% mid rca lesions. other vessels without significant disease. case complicated by rca dissection, entire vessel ballooned with four bare metal stents. patient transiently on dopamine for borderline hypotension. one unit of blood given for hct of 24.9. bivalrudin given during case given history of iron deficiency anemia. pt started on clopidogrel 75 mg po daily, simvastatin 40mg, metoprolol xl 150 po daily, and losartan 50 mg po daily. echo revealed mild regional left ventricular systolic dysfunction with inferior hypokinesis to akinesis. he was initially started on aspirin 325mg, however this was decreased to 81mg po daily given concern for possible gi bleed. this should be re-evaluated as an out-patient with pcp and gi. patient will follow up with cardiology on . . #afib with - pt was in afib with in cath lab and ccu so given lopressor 17.5 mg iv total during cardiac catheterization. in the ccu, started on esmolol gtt. blood pressures remained stable. pt returned to sinus rhythm, esmolol gtt d/c'ed , remained in sinus for remainder of hospitalization. . #normocytic anemia - hct at 24.9 following catheterization, down from baseline in low 30s. pt responded well to 3 units prbc. ongoing outpt work up of anemia without clear etiology. hemolysis labs negative. gi was consulted given hct drop in setting of dark stools while on plavix and aspirin. given recent , stablization of hct, and normalization of stools, egd was deferred at this time. pt needs to follow-up with gi in 6 weeks for egd and colonoscopy for continued work-up of anemia. he was started on pantoprazole 40mg po bid. he should continue plavix 75mg po daily, however aspirin was decreased from 325mg to 81mg pending further work-up because of increased risk of bleeding. chronic issues: #gout - pt complained of gouty r knee pain, so started on colchicine in addition to his home allopurinol. he was not started on prednisone given the risk of gi bleeding. his pain was well managed with oxydocone 5mg po prn. . #htn - increased blood pressure managment with metoprolol xl 150 po daily, losartan 50mg po. his blood pressure improved to 130's/80s so will need close monitoring and medication adjustment by pcp. . #hl - increased simvastatin to 40mg po daily in setting of recent . transitional issues: full code. blood cultures and urine cultures were sent given low grade fever and are still pending at time of discharge. pt is being discharged home with many new medications and medication changes. these changes were discussed with the patient in detail. he has several follow-up appointments in the next few weeks including pcp (), cardiology (), endocrine and hem/onc(). he will need a referral from his pcp to see gi for egd and colonoscopy. medications on admission: --metoprolol 50mg --simvastatin 20mg daily --cyclobenzaprine 10mg tid --tramadol 50 q6hrs prn pain --prednisone 10mg prn gout flair --asa 325mg daily --allopurinol 200mg daily --losartan 25mg daily discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. simvastatin 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. losartan 50 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 6. colchicine 0.6 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 7. oxycodone 5 mg tablet sig: one (1) tablet po twice a day as needed for knee pain for 2 days: do not take this medication and drive or consume alcohol. disp:*4 tablet(s)* refills:*0* 8. metoprolol succinate 100 mg tablet extended release 24 hr sig: 1.5 tablet extended release 24 hrs po once a day. disp:*45 tablet extended release 24 hr(s)* refills:*2* 9. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*30 patch 24 hr(s)* refills:*2* 10. allopurinol 100 mg tablet sig: two (2) tablet po once a day. 11. cyclobenzaprine 10 mg tablet sig: one (1) tablet po three times a day. 12. tramadol 50 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. discharge disposition: home discharge diagnosis: primary diagnoses: inferior atrial fibrillation with hypertension gout anemia requiring blood transfusion discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you at . you were admitted for chest pain. you were found to be in atrial fibrillation and were diagnosed with a heart attack. we treated your heart attack by placing 4 stents in the arteries to keep the blood flowing. your heart rate returned to during your hospitalization. take all your home medications as directed except for the following medication changes or additions that were made during your hospital stay: 1. increase the dose of losartan to 50 mg by mouth daily. 2. increase simvastatin to 40mg by mouth daily. 3. start taking clopidogrel 75mg by mouth daily. do not stop taking this medication unless instructed by your cardiologist. 4. stop taking aspirin 325 mg and instead take aspirin 81mg until gi follow-up. you must take this medication daily unless instructed otherwise by your cardiologist. 5. change metoprolol to metoprolol xl 150mg by mouth daily. 6. start taking pantoprazole 40mg by mouth twice a day until gi follow-up. 7. start taking colchicine 0.6 mg by mouth twice a day until gout flare resolves. 8. stop prednisone until gi follow-up because of increased risk of bleeding. followup instructions: department: cardiac services when: tuesday at 10:30 am with: , md building: campus: east best parking: garage department: div of gi and endocrine when: wednesday at 1:40 pm with: , md building: ra (/ complex) campus: east best parking: main garage department: hematology/oncology when: wednesday at 4:00 pm with: , md building: sc clinical ctr campus: east best parking: garage name: , location: , , phone: appt: friday, at 1pm note: it is recommended that you have an egd and colonoscopy within the next 6 weeks. please work with dr for help coordinating these procedures. Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Anemia of other chronic disease Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified essential hypertension Gout, unspecified Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified hyperlipidemia Acute myocardial infarction of other inferior wall, initial episode of care |
allergies: no known allergies / adverse drug reactions attending: chief complaint: s/p motor vehicle accident major surgical or invasive procedure: bone marrow biopsy right knee diagnostic arthrocentesis history of present illness: trauma icu history and physical - 61yo male driving after visit to doctor's office for medication adjustements - seeking percocet for knee/back pain. + loc, head-on collision into tree. blood pressure initially persistently in 80's. no injuries found on initial pan-scan other than left sided rib fractures but found to have a hct of 18.5, rechecked at 15.6. transfused 2u prbc in the ed with hct bumped to 22.3. transferred to icu . medicine accept note - 60y/o gentleman with htn and 1 month history of fatigue/malaise who was admitted to the ticu three days ago after mvc and was found to have a hct of 15 with no obvious source of bleeding, so he is being transferred to medicine for syncope and anemia workup. . he has had no issues with memory recently, with the exception of "blacking out" just prior to the crash. he was running errands and he remembers being at the top of the , but nothing else after that. he was told he crashed into a tree. no prodrome, no chest pain or palpitations prior. he has had no arrhythmias during the admission - he did have a troponin leak (peaked 1.04 yesterday but now downtrending) and cardiology was consulted. his trop leak was attributed to demand ischemia in the setting of anemia and he was started on asa with plans for outpatient stress test. he has had a tte and carotid u/s as part of syncope workup. . he does have a left fib fx and lower lip lac but besides this, he has had no other injuries and ct scan x2 have been negative for bleed in the chest/abdomen/pelvis. he was transfused 2u prbc in the ed and 2u prbcs in the ticu with hct stable at ~30 for the past 2 days. guaiac negative x1. . also of note, he has has a fever since yesterday am (100.5 at 8am on ). in retrospect, he notes that he has had a slight cough at home but did not think much of it until now (the cough is worse and is now productive of dark green sputum). denies dysuria, chills, headache, rash. past medical history: pmh: htn, gout psh: open appendectomy in childhood social history: occupation: unemployed but usually works in construction. home: lives with his mother and has no children. close support from brother. : 42 /year history, currently smoking. etoh: 5-6 beers/week. illicits: none. family history: father - died in of unknown cause mother - died at 92 of natural causes 5 brothers, 1 sister - htn physical exam: admission exam hr:80 bp:85/ o(2)sat:100 normal constitutional: comfortable, awake alert oriented, color and backboard heent: normocephalic, atraumatic, pupils equal, round and reactive to light, extraocular muscles intact. there is an inferior lip laceration that is through and through the lip. he has been inframandibular abrasion there is no posterior neck tenderness chest: clear to auscultation, nontender cardiovascular: regular rate and rhythm, normal first and second heart sounds abdominal: soft, nontender pelvic: pelvis stable extr/back: no cyanosis, clubbing or edema there is no evidence of trauma, back is nontender. dre with normal sphincter tone, no gross blood. neuro: speech fluent he is awake alert oriented, nonfocal, appropriate discharge exam vs: afebrile, sbp 100-120, o2sat 98%ra gen: nad heent: lower lip with sutured laceration; no pus cv: s1 and s2, crescendo-decrescendo murmur at rusb pulm: no rhonchi today, no rales, no wheezing extrem: bilateral l>r edema of ankles; no pain with active or passive rom of ankle but has pain with weight-bearing; left elbow with mild erythema and effusion pertinent results: admission labs 12:56pm blood wbc-12.8* rbc-2.15* hgb-5.7* hct-18.5* mcv-86 mch-26.3* mchc-30.5* rdw-15.4 plt ct-209 04:27am blood neuts-82.7* bands-0 lymphs-11.0* monos-4.7 eos-1.4 baso-0.3 04:27am blood hypochr-1+ anisocy-normal poiklo-occasional macrocy-normal microcy-normal polychr-occasional ovalocy-occasional 12:56pm blood pt-12.7 ptt-25.8 inr(pt)-1.1 12:56pm blood fibrino-672* 04:27am blood ret aut-2.3 09:07pm blood glucose-98 urean-36* creat-1.4* na-144 k-4.5 cl-114* hco3-21* angap-14 12:56pm blood ld(ldh)-293* ck(cpk)-164 totbili-0.5 dirbili-0.3 indbili-0.2 09:07pm blood calcium-7.7* phos-4.1 mg-2.0 pertinent labs 12:56pm blood fibrino-672* 04:27am blood ret aut-2.3 07:20am blood ret aut-1.6 12:56pm blood lipase-68* 01:30am blood lipase-34 12:56pm blood ctropnt-0.91* 09:07pm blood ck-mb-11* mb indx-4.0 ctropnt-0.77* 04:27am blood ck-mb-8 ctropnt-0.91* 02:21pm blood ck-mb-6 ctropnt-0.81* 01:30am blood ck-mb-4 ctropnt-1.04* 11:13am blood ck-mb-3 ctropnt-0.82* 12:56pm blood caltibc-352 hapto-332* ferritn-47 trf-271 08:00am blood caltibc-241 ferritn-387 trf-185* 01:30am blood triglyc-125 hdl-41 chol/hd-3.4 ldlcalc-72 07:20am blood tsh-3.8 08:00am blood lh-3.6 01:10pm blood prolact-4.9 07:10am blood testost-52* 08:00am blood cortsol-12.9 testost-64* 07:20am blood psa-0.8 08:00am blood crp->300 07:20am blood pep-no specifi 03:45pm blood hiv ab-negative 07:20am blood erythropoietin-test test result reference range/units erythropoietin 18.7 4.1-19.5 miu/ml discharge labs 07:20am blood wbc-4.7 rbc-3.47* hgb-9.4* hct-29.5* mcv-85 mch-27.1 mchc-31.8 rdw-15.4 plt ct-300 07:20am blood glucose-106* urean-30* creat-1.0 na-139 k-4.8 cl-103 hco3-23 angap-18 07:10am blood alt-20 ast-28 alkphos-98 totbili-0.7 07:20am blood calcium-8.9 phos-3.1 mg-2.2 urinalysis/urine culture 12:38pm urine color-yellow appear-clear sp -1.015 12:38pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-10 bilirub-neg urobiln-neg ph-5.5 leuks-neg 12:38pm urine rbc-2 wbc-1 bacteri-few yeast-none epi-0 3:53 pm urine source: cvs. **final report ** urine culture (final ): no growth. blood cultures and serology blood cultures x2 on , - negative blood cultures x2 on , , , - pending 3:45 pm immunology **final report ** hiv-1 viral load/ultrasensitive (final ): hiv-1 rna is not detected. **final report ** lyme serology (final ): no antibody to b. burgdorferi detected by eia. joint aspiration studies 11:30am joint fluid wbc-* rbc-* polys-88* lymphs-1 monos-11 11:30am joint fluid crystal-many shape-needle locatio-i/e birefri-neg comment-c/w monosodium urate stones 11:30 am joint fluid source: kneeright. **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. ekg baseline artifact. sinus rhythm. diffuse repolarization abnormalities especially in the anterolateral leads which, while non-diagnostic, could be due to ischemia, etc. no previous tracing available for comparison. clinical correlation is suggested. ct head w/o contrast no acute intracranial process. ct c-spine w/o contrast 1. no acute fracture. 2. minimal retrolisthesis of c5 on c6 with degenerative changes at that same level. ct chest/abdomen/pelvis w/contrast 1. nondisplaced fractures of the anterior left 4th and 5th ribs and possible fracture of the left posterior sixth rib. 2. bibasilar atelectasis. 3. minimal periportal edema may be due to fluid administration. 4. dense atherosclerotic calcifications of the abdominal aorta with significant plaque seen in the infrarenal aorta. ct chest/abdomen/pelvis w/o contrast 1. small amount of hyperdense fluid in the pelvis is compatible with hemorrhage, increased from study performed at 13:00 hours. however, the quantity of fluid remains small and no clear source of hemorrhage is identified. 2. no convincing evidence of solid organ injury although there is a suggestion that hemorrhage may be originating from the right retroperitoneum. this is of uncertain signficance however since there is no evidence for solid organ injury or focal hematoma, and there is slightly increased perinephric fluid on both sides which may coincide with fluid resuscitation. 3. distended, fluid-filled stomach. 4. no fracture is identified. known left anterior rib fractures are not included on the field of view. 5. aortic atherosclerosis, without aneurysm. 6. similar mild peripheral interstitial abnormality; correlation with chronic pulmonary symptoms, if any, is recommended. cxr as compared to the previous radiograph, signs of central pulmonary edema have markedly decreased. bilaterally, however, subtle signs of increased perihilar density are still seen. no pulmonary opacities have newly appeared. there is no radiographic evidence of pneumonia, but the further regression of pulmonary edema must be monitored by radiograph. minimal retrocardiac atelectasis. borderline size of the cardiac silhouette. no pleural effusions. cxr resolved pulmonary edema. no evidence of chf. panorex mandible no evidence of mandibular fractures or dislocations. ankle x-ray right ankle talar dome and ankle mortise are intact. there is mild bimalleolar soft tissue swelling. no fracture identified. three views of the left ankle demonstrate normal talar dome and ankle mortise. moderate bimalleolar soft tissue swelling. no fracture identified. foot x-ray bilateral juxtacortical erosions consistent with history of gout. bone marrow biopsy - pending at the time of discharge brief hospital course: mr. is a 60y/o gentleman with htn who was transferred from the ticu to the medicine floor after syncope/mvc in the setting of hct 15, mild aortic stenosis, and carotid stenosis. his anemia was worked up, and he was treated for a gout flare. when he was stable he was discharged home with plans to follow up as an outpatient. . active issues: . #. syncope: possibly due to cerebral hypoperfusion from anemia in the setting of as and carotid stenosis. he had moderate as by tte and he was found to have >70% carotid stenosis bilaterally. telemetry was unremarkable and syncope workup was otherwise unrevealing. during his stay, he ambulated and had no further episodes of syncope. he will have vascular surgery f/u as outpatient for carotid stenosis and will also need cardiology follow-up. he was advised not to drive until his outpatient doctors decided that it is safe to do so. . #. anemia: chronic, normocytic. on presentation his hct was <20, which was disproportionate to the extent of his injuries. he was told in the past that he had b12 deficiency and he has been taking b12; level here is normal. folate is normal. iron studies revealing low iron, low/normal ferritin, normal tibc could suggest anemia of chronic inflammation. hemolysis labs negative though they were checked after tansfused. retiulocyte count 2.4 but again, after transfusion. he was guaiac negative x3. had a normal colonoscopy 10 years ago and denies any dark stools, blood per rectum, hematemesis, hematuria. he had felt fatigued for a month but no concerning weight loss, no pruritus after etoh, no night sweats. tsh, spep/upep, psa normal. testosterone low but hematology felt this was not felt to be a likely cause of his anemia. after initial transfusion, his hct was stable and he did not require any further transfusions. he underwent bone marrow biopsy by hematology and was discharged home. he will be contact with the results and will be set up with a hematology follow-up appointment. he will need o/p colonoscopy. . #. lip laceration: s/p suture and antibiotics. s/p mvc he had a lip injury treated by omfs with a 1 week course of augmentin and a suture. appeared to be healing well by the time of discharge. he has very poor dentition and was started on chlorhexidine mouthwash with advice to find a denist. he will need to f/u in clinic after discharge for suture removal. . #. fever: gout flare. a few days after admission, he developed fevers which were low-grade at first but then he spiked to 102. he had no uti and no pna. was not bacteremic. infected lip laceration was considered but his fevers continued after treatment with augmentin. he was found to have knee and ankle effusions and arthrocentesis by rheumatology revealed gout. he was started on a 1-week course of prednisone and also was started on allopurinol. he defervesced. he will f/u with his new pcp for continued management of gout. . #. troponin leak: resolved, likely represented demand ischemia from anemia in the setting of fast hr on admission. per cards, this presentation may represent ischemia in someone with undiagnosed cad. his risk factors were managed. he was started on asa and a statin. continued a beta blocker. he will f/u with cardiology as an outpatient and may need stress test. . #. htn: reasonably controlled. his bp meds had initially been held but were restarted slowly with some adjustments. hctz was stopped due to gout. amlodipine was stopped because he did not require it to control his bp. he was continued on a lower dose of losartan and metoprolol. continued doxazosin. he will f/u with his new pcp for ongoing management of his blood pressure. . #. low testosterone: incidental finding. am testosterone was checked as part of anemia workup and was found to be 64. he did endorse low libido. he will f/u with endocrinology as an outpatient. . transitional issues . #. code status: full code #. emergency contact: (brother/hcp) #. pending at discharge: final result of bone marrow biopsy; this will be followed up by medical team and hematology and he will be called at home with a hematology follow-up appointment #. follow-up: -pcp: of change of insurance, patient requested new pcp and he was set up to see dr. in ma (phone ). to follow blood pressure and also for further management of gout. -omfs: for lip suture removal -vascular surgery: for carotid stenosis -endocrinology: for low testosterone -cardiology: for ongoing workup/management of any coronary disease and his aortic stenosis -hematology: for further workup/management of his anemia -dentist: for bone/gum health (he was advised to contact his insurance company in order to find a dentist) medications on admission: metoprolol 200mg losartan 100mg amlodipine 10mg doxazosin 2mg hctz 50mg discharge medications: 1. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. losartan 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 3. doxazosin 2 mg tablet sig: one (1) tablet po at bedtime. 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. atorvastatin 80 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 6. allopurinol 100 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 7. amoxicillin-pot clavulanate 250-125 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 3 days: 1 week course (). disp:*9 tablet(s)* refills:*0* 8. prednisone 10 mg tablet sig: 1-3 tablets po as directed for 5 days: sunday: 3 pills at once. monday: 2 pills at once. tuesday: 2 pills at once. wednesday: 1 pill. thursday: 1 pill. then stop. disp:*9 tablet(s)* refills:*0* 9. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane tid (3 times a day): please continue until you are able to follow up with a dentist. disp:*1000 ml(s)* refills:*1* discharge disposition: home discharge diagnosis: primary: syncope, motor vehicle accident secondary: anemia, gout flare discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. (using crutches for gout flare) discharge instructions: you were admitted to the hospital after losing consciousness and having a car accident. your blood level was found to be extremely low, and was not explained by the extent of your physical injuries. during this stay, your anemia (low blood level) was evaluated by hematology, including a bone marrow biopsy. your loss of consciousness may have been due to anemia, and also you have mild narrowings in your neck arteries (carotid stenosis) and heart valve (aortic stenosis), and this may have contributed as well. . during this admission you had a lip injury treated by oral/maxillofacial surgeery with antibiotics and a stitch (the stitch will be removed in clinic in a few days). . also, during this admission you had a fever and were found to have a gout flare so you were started on allopurinol and a short course of prednisone. . finally, you were found to have low testosterone. you have follow-up appointments with a new primary care doctor s to follow-up all of these important issues. your blood level is stable and you are safe to go home. . please do not drive until your outpatient doctors have decided that it is safe to do so. . we made the following changes to your medications: -stop amlodipine -stop hydrochlorothiazide -decrease dose of losartan -decrease dose of metoprolol -start aspirin daily -start atorvastatin -start allopurinol -start prednisone (for 5 more days, then stop) -start augmentin (for 3 more days, then stop) -start chlorhexidine mouthwash followup instructions: primary care name: dr. when: please call your insurance company now to change your primary care physician to dr. . after calling, you will be provided with a referral number. when you have your referral number, please call ( to schedule an appointment 1-2 weeks after your hospital discharge. address: location: phone: ( oral/maxillofacial surgery (for the lip injury and stitch removal) when: wednesday at 11:00am oral surgery clinic yawkey building - , ma phone: vascular surgery (for carotid artery stenosis) when: wednesday at 2:30 pm with: , md building: , bldg () campus: west best parking: garage endocrinology (for low testosterone) when: tuesday at 3:40 pm with: , md building: ra (/ complex) campus: east best parking: main garage cardiology (for your heart health) when: thursday at 9:30am with: building: sc clinical ctr campus: east best parking: garage hematology (to follow up the cause of anemia) after your bone marrow biopsy result is reviewed, you will be contact with a follow-up appointment. if you have not heard back within one week please call (. dentist you have severe tooth/gum disease. please check with your insurance company to see what dentists are in network and make an appointment as soon as possible. Procedure: Biopsy of bone marrow Arthrocentesis Closure of skin and subcutaneous tissue of other sites Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Osteoarthrosis, unspecified whether generalized or localized, site unspecified Family history of ischemic heart disease Open wound of jaw, without mention of complication Fever, unspecified Hypovolemia Closed fracture of two ribs Syncope and collapse Other specified anemias Open wound of lip, without mention of complication Dental caries, unspecified Open wound of knee, leg [except thigh], and ankle, without mention of complication Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle Unspecified endocrine disorder Pain in joint, multiple sites Gouty arthropathy, unspecified |
allergies: morphine attending: chief complaint: mental status change, fever, hypoxia major surgical or invasive procedure: rue avf thrombectomy hemodialysis history of present illness: in summary, pt is a 72 yo f h/o esrd on hd, dm ii, cad, systolic chf (ef 20%) admitted from outpt hd for clotted right avf, ms change, oral temp to 105, and hypoxic to 84% on ra. according to conversation with pt's daughters, pt was noted to be coughing frequently with meals at nursing home. had recently been admitted 1 month ago for ams in setting of hypoglycmie and uti. in ed, t 104.8, bp 138/49, hr 90, rr 32, o2 sat 100% nrb. cxr significant for cardiomegaly with mild pulm edema and new l basilar opacity concerning for pna. given vancomycin, zosyn, 1 l ivfs and admitted to . past medical history: -cad, s/p "silent mi" per patient -chf, systolic dysfunction with ef 20% -3+ mitral regurgitation, 3+ tr -dm, type 2 -esrd on hd -gout -depression -gerd -rheumatoid arthritis -anemia -hypercholesterolemia social history: lives at nursing home. has 6 children that live locally. quit smoking in the ; previously smoked approx 5cigs/day x30 years. rare etoh. family history: multiple family members with dm ii, otherwise non-contributory. physical exam: vitals not documented in admission note gen: opens eyes to stimuli, unable to follow commands heent: perrl, mm dry, neck supple pulm: bibasilar rales cv: nl s1+s2, iii/vi systolic murmur at lusb, flat jvp abd: s/nt/nd, +bs ext: 2+ dp b/l, trace edema. right avf without signs of erythema neuro: patient non-verbal pertinent results: labs on admission: 06:53pm wbc-10.6# rbc-3.50* hgb-12.2 hct-38.9 mcv-111* mch-35.0* mchc-31.5 rdw-19.4* 06:53pm neuts-87.4* lymphs-8.0* monos-3.2 eos-1.0 basos-0.3 06:53pm plt count-241# 06:50pm urine color-yellow appear-clear sp -1.019 06:50pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-tr bilirubin-sm urobilngn-neg ph-5.0 leuk-mod 06:50pm urine rbc-* wbc-21-50* bacteria-few yeast-none epi- 06:50pm urine hyaline-* 06:53pm digoxin-1.1 06:53pm albumin-3.6 calcium-10.5* phosphate-3.5 magnesium-2.1 06:53pm lipase-19 06:53pm alt(sgpt)-24 ast(sgot)-46* alk phos-255* tot bili-0.9 06:53pm glucose-186* urea n-36* creat-4.2* sodium-136 potassium-4.2 chloride-90* total co2-31 anion gap-19 07:01pm lactate-3.3* 07:08pm k+-4.0 micro data: urine cx - 1000 gpc urine cx - no growth urinary legionella antigen negative blood cx - no growth studies: cxr : 1. cardiomegaly with mild pulmonary edema. 2. new left basilar opacity concerning for pneumonia or aspiration. . nchct : no acute intracranial pathology. mri more sensitive for ischemia. . ct abd/pelvis : 1. slightly limited examination due to patient positioning and lack of oral contrast. no intra-abdominal source for infection identified. 2. patchy right middle and lower lobe opacities, some which are clearly compression atelectasis and others of which are suspicious for regions of pneumonia or aspiration. small right effusion. 3. extensive calcified atherosclerotic vascular disease. 4. slight interval decrease in possible exophytic right-sided fibroid. please note it is atypical for the fibroid to not have involuted more in a patient of this age. if alteration in care will occur, can consider further evaluation with a dedicated pelvic ultrasound and/or mri as no dedicated pelvic imaging of this lesion is noted at . . cxr : left lower lobe consolidation is persistent and unchanged. band-like atelectasis in the right base is new. there is no pneumothorax. if any, bilateral small pleural effusions are unchanged, greater on the left side. cardiomegaly is stable. . nchct : 1. no evidence of acute intracranial abnormalities. 2. unchanged marked enlargement of the ventricles since , out of proportion to the enlargement of the sulci, which may be related to central atrophy or normal-pressure hydrocephalus. clinical correlation is advised. . mri head : irregularity of left greater than right mca branch vessels. differential diagnoses include vasculitis, meningitis, or atheromatous change. cerebral atrophy, with ventricular enlargement. there is no obstruction, although communicating hydrocephalus cannot be excluded. . eeg : this is an abnormal routine eeg due to the slow background, the bursts of generalized slowing, and the intermittent projected bicentral slowing. these abnormalities suggest a widespread encephalopathy primarily of metabolic origin. there were no epileptiform features seen. . labs on discharge: na 143 k 4.9 cl 103 hco3 20 bun 47 cr 6.4 glu 113 ca .2 mg 2.3 phos 6.4 brief hospital course: 72 yo female with a pmh significant for esrd on hd, cad, chf with ef 20%, and dm type ii admitted with fever, ms change, hypoxia, and avf failure. . 1) fever: had temperature upon arrival to , which resolved within 24 hours. placed on vancomycin, zosyn for coverage for hospital acquired pna and left basilar opacity was seen on cxr, althought it was unclear if this was truly a new opacity vs. secondary to pulmonary edema. bld cxs with no growth. initial urine cx with 1000 gpc but then subsequent urine cx no growth. urinary legionella antigen negative. unable to obtain sputum cultures. there was also initial concern for meningitis; however, the family declined a lp and the pt's mental status did improve off of meningtic doses of abxs. she was then transferred to the medical floor where she remained afebrile. . 2) ams: ms change improved within 24 hrs of admission and aao x 2 upon transfer to floor. initial w/u with nchct negative, less likely meningitis/encephalitis given ms improvement on non-meningtis abx coverage as above. however, within 2 hrs of initial medical floor evaluation, pt became obtunded to sternal rub. fs 180s, ekg without ischemic changes, attempted abg x 3 without success in l wrist. vss, af throughout. stat nchct without acute change. did notice new neck stiffness on exam, and t here was a question of encephalitis/meningitis but it was felt to be unusual to develop meningitis in hospital. pt's ms eventually improved within 4 hours. neurology was consulted for question of non-convulsive status epilepticus and eeg obtained that showed no epileptiform waveforms but did reveal diffuse slowing suggestive of encephalopathy from metabolic causes. another lp was offered to the family, who again declined. pt was started on ceftriaxone and acylovir in addition to pre-existing vancomycin for meningitic/hsv encephalitis coverage. a mri head revealed irregularity of the mca branch vessels that can be suggestive of small vessel disease, meningitis, or vasculitis. the pt's mental status continued to remain poor, and after d/w the pt's pcp, confirmed that pt has had prior dx of alzheimer's, and the family, it was decided to make the pt comfort measures. abxs were discontinued, procedures should be avoided with the exception of hemodialysis. . 3) esrd/clotted avf: underwent placement of r temporary femoral hd line for hd access in setting of clotted r avf upon admission. the patient underwent avf thrombectomy by transplant surgery on ; however, revision failed and the pt required placement of a tunneled l ij hd catheter by ir on . the family is in agreement to continue hd for now in spite of being comfort measures; however, did agree to not place any further lines for hd access should her lij tunneled catheter fail. the family was made aware of the risks of infection with a tunneled catheter. . 4) cad: continued digoxin, asa, plavix. . 5) systolic chf: chronic. does have pulm edema on cxr, likely underduiresis as pt unable to be dialyzed upon presentation. o2 sats now improved after hd. pt was restarted on beta-blocker and acei upon transfer out of the icu. . 6) dm type ii: continued iss, fs qid. . 7) transaminitis: patient with elevated ast of unknown etiology. appears as if patient has had elevated transaminases since 3/. possibly med effect (i.e statin) but degree of transaminitis not high enough to hold statin in pt with known dm ii and cad. . 8) gout: continued allopurinol. . 9) psych: continued wellbutrin and prozac. . 10) fen: underwent s&s eval who cleared pt for ground solids, nectar thickened liquids with 1:1 supervision with meals. pt has poor po intake, will need to encourage po intake. given comfort measures, would be ok to offer pt thin liquids and solid foods. . 11) code: dnr/dni, comfort measures. the patient was at hemodialysis on the final hospital day prior to going back to nh with hospice care when she was noted to be hypotensive in the 80-90s after have 2.5 l uf taken off. given 1 l ivf bolus which then was followed by report of respiratory distress from hd unit. report of pt then becoming increasing obtunded, and then expired. family and pcp notified, family declined autopsy. medications on admission: phoslo 667 po tid simvastatin 40 mg qpm colace 100 mg senokot 2 tabs qod. compazine 5 mg q8h prn vit e 250 mg daily folate 1 mg daily nephrocaps 1 cap daily asa 81 mg daily allopurinol 150 mg daily digoxin 0.0625 qod lisinopril 7.5 mg daily reglan 10 mg qac plavix 75 mg daily humira 40mg/0.8 ml sc monthly metoprolol 25 mg zantac 75 mg wellbutrin sr 75 mg prozac 30 mg daily ativan 0.5 mg prior to dialysis discharge medications: none, pt expired discharge disposition: expired discharge diagnosis: primary diagnosis: altered mental status rue avf thrombus s/p thrombectomy hospital acquired pneumonia secondary diagnosis: congestive heart failure, systolic coronary artery disease end stage renal disease on hemodialysis diabetes mellitus type ii hypercholesterolemia gout depression anemia discharge condition: expired discharge instructions: you were admitted with fever, confusion, decreased oxygenation, and a clot in your av fistula. you were treated with iv antibiotics for a hospital acquired vs. aspiration pneumonia. a lumbar puncture was declined and you were also on iv antibiotics to treat a possible meningitis. while you av fistula was clotted, you had a temporary dialysis catheter placed for dialysis. this was removed and the transplant surgeons were unable to fix your av fistula. you then had a tunneled hd catheter placed. it was decided after meeting with dr. , the pt's pcp, the pt would be comfort measures with the exception of continued hemodialysis. it was decided that should this current catheter fail, the pt would not have another hd catheter placed. it was decided to make her as comfortable as possible and iv antibiotics were stopped. please take all medications as prescribed. the following changes were made to your regimen: 1) we have discontinued ativan prior to hemodialysis. 2) we have discontinued phoslo and replaced this with renagel as your serum calcium levels were elevated. 3) your medications were held when you were too sleepy to take them safely. it is important to keep you as comfortable as possible. this would mean avoiding hospitalizations in the future. your nursing home can help coordinate your care for comfort. followup instructions: none, expired. Procedure: Other revision of vascular procedure Hemodialysis Venous catheterization for renal dialysis Diagnoses: Pneumonia, organism unspecified End stage renal disease Mitral valve disorders Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Gout, unspecified Depressive disorder, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Chronic systolic heart failure Rheumatoid arthritis Accidents occurring in other specified places Surgical or other procedure not carried out because of patient's decision Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other complications due to renal dialysis device, implant, and graft Arterial embolism and thrombosis of upper extremity |
allergies: morphine attending: chief complaint: mental status change major surgical or invasive procedure: hemodialysis history of present illness: 72 year-old female with a history of stage v ckd on hd, dm, cad, chf ef 30-40% who presented from her nursing home on found lethargic with hypoglycemia (fs 39). after im glucagon, repeat glucose was 25. ems was called and she received 1amp d50 prior to presentation to the ed. of note, the patient has had similar presentation (hypoglycemia, ams) multiple times this year urinary tract infections. patient is wheelchair bound at baseline due to significant ra involvement of lower extremities. she is alert and oriented to person and place but has a poor short term memory per the daughter. she is incontinent of urine/stool at baseline. . in the ed, vs t 101.8 hr 62 bp 111/26 rr 20 pox 98% on 2.5l nc. patient remained lethargic, and was given 2 amps of d50 and d51/2ns . ekg was obtained without changes from baseline. cxr showed mild pulmonary edema. u/a concerning for uti and she was given a dose of levofloxacin. given her fever and ms, lp was considered but the patient's family refused so she was started on vanc/ceftriaxone for empiric therapy for meningitis. blood and urine cultures were sent. in micu, there was again concern for meningitis, but pt.'s family again refused lp so she was started on vanc/ceftriaxone empirically. her glucoseincreased to 80 with multiple amps of d50. by 10:30pm, her gluocse stabilized. insulin held overnight. she tolerated breakfast in the am and glucose rose into the 200s. insulin restarted with sliding scale and she was transitioned to half of her home dose begun (nph 7 in am, 1 qpm). past medical history: -cad, s/p "silent mi" per patient -chf, systolic dysfunction with ef 30-40% -3+ mitral regurgitation, 3+ tr -dm, type 2 -esrd on hd -gout -depression -gerd -rheumatoid arthritis -anemia -hypercholesterolemia social history: lives at nursing home. has 6 children that live locally. quit smoking in the ; previously smoked approx 5cigs/day x30 years. rare etoh. family history: multiple family members with dm ii, otherwise non-contributory. physical exam: vitals: t:97.9 bp: 102/54 hr: 63 rr: 17 o2sat: 100% on 2l gen: somnolent elderly female, responding to noxius stimuli, in no acute distress heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, mmm, op clear neck: jvd to mandible, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline cor: rrr, iii/vi systolic blowing murmur throughout base, no g/r, normal s1 s2, radial pulses +2 pulm: crackles to mid chest b/l, normal respiratory effort abd: soft, nt, nd, +bs, no hsm, no masses ext: no c/c/e, no palpable cords, le cool, faint pulses distally, right toes s/p amputation neuro: initially somnolent, responding to noxious stimuli, following command to squeeze hands b/l. after 30mins, became alert, oriented to person, and place ( which is baseline per daughter). cn ii ?????? xii grossly intact. moves all 4 extremities. strength 5/5 in upper and lower extremities. patellar dtr +1. plantar reflex downgoing. skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. pertinent results: ct head final report indication: 72-year-old with type 2 diabetes, renal failure, chf, and hypoglycemia. evaluate for acute pathology. no prior examinations. non-contrast head ct: there is no acute intracranial hemorrhage, edema, or mass effect. the ventricles and sulci are prominent consistent with age- related involutional changes. right-sided basal ganglia calcifications are noted. the cavernous carotids are moderately calcified. the visualized paranasal sinuses and mastoid air cells are normally pneumatized and aerated. the osseous structures and soft tissues are normal. there is evidence of bilateral cataract surgery. impression: no acute intracranial pathology including no evidence of hemorrhage. echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis (lvef = 20 %). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. the patient meets at least modified care-hf criteria for ventricular dyssynchrony, and may benefit from resynchronization therapy. the right ventricular cavity is dilated with depressed free wall contractility. there are complex (>4mm) atheroma in the aortic root. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is no mitral valve prolapse. there is severe mitral annular calcification. severe (4+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the supporting structures of the tricuspid valve are thickened/fibrotic. moderate to severe tricuspid regurgitation is seen. there is at least moderate pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: hospital course: in the ed, vs t 101.8 hr 62 bp 111/26 rr 20 pox 98% on 2.5l nc. patient remained lethargic, and was given 2 amps of d50 and d51/2ns . ekg was obtained without changes from baseline. cxr showed mild pulmonary edema. u/a concerning for uti and she was given a dose of levofloxacin. given her fever and ms, lp was considered but the patient's family refused so she was started on vanc/ceftriaxone for empiric therapy for meningitis. blood and urine cultures were sent. . in micu, there was again concern for meningitis, but pt.'s family again refused lp so she was started on vanc/ceftriaxone empirically. her glucose increased to 80 with multiple amps of d50. by 10:30pm, her gluocse stabilized. insulin held overnight. she tolerated breakfast in the am and glucose rose into the 200s. insulin restarted with sliding scale and she was transitioned to half of her home dose begun (nph 7 in am, 1 qpm). . the patient was transferred to the floor. she was taken off antibiotics and treated for uti with cipro. her glucose was well controlled on half her home regimen. she also received hd on friday (). . she will need her insulin titrated as tolerated and will complete a 7 day course of cipro. medications on admission: fluoxetine 30mg daily allopurinol 150 mg po daily humira 40 mg/0.8 ml one subcutaneous 1st and 15th of every month aranesp 40 mcg/0.4 ml (1) subcutaneous once a week at hd lisinopril 7.5mg daily metoclopramide 10mg qam, 5mg noon and dinner bupropion sr 150 mg po bid digoxin 0.0625 tablet po every other day ativan 0.5 mg one po prior to dialysis. metoprolol tartrate 25 mg po bid ranitidine hcl 75 mg docusate sodium 100 mg po bid aspirin 81 mg chewable po daily prochlorperazine 5mg q8h prn nausea albuterol neb q4 h cough prn phoslo 667mg tid w/ meals simvastatin 40mg daily nephrocaps 1 po daily insulin nph 15 units in am, 2 units in pm. humalog sliding scale units with meals: bs 0-80mg/dl, 81-150 mg/dl- give 0 units 151-200 mg/dl- give 1 units 201-250 mg/dl- give 2 units 251-300 mg/dl-give 3 units 301-350 mg/dl- give 4 units 351-400 mg/dl- give 5 units > 400 mg/dl notify m.d. discharge medications: 1. fluoxetine 10 mg capsule sig: three (3) capsule po daily (daily). 2. allopurinol 300 mg tablet sig: 0.5 tablet po daily (daily). 3. humira 40 mg/0.8 ml kit sig: one (1) ml subcutaneous 1st and 15th of every month. 4. aranesp (polysorbate) 40 mcg/0.4 ml syringe sig: one (1) ml injection once a week: at hd. 5. lisinopril 5 mg tablet sig: 1.5 tablets po daily (daily). 6. metoclopramide 10 mg tablet sig: 0.5 tablet po before lunch and dinner (). 7. metoclopramide 10 mg tablet sig: one (1) tablet po breakfast (breakfast). 8. bupropion 150 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). 9. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 10. ativan 0.5 mg tablet sig: one (1) tablet po prior to hd. tablet(s) 11. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 12. ranitidine hcl 150 mg tablet sig: 0.5 tablet po bid (2 times a day). 13. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 14. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 15. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 16. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q4h (every 4 hours) as needed for cough. 17. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 18. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 19. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). 20. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 7 days. 21. insulin nph human recomb 100 unit/ml cartridge sig: 7 units qam and 1unit qpm units subcutaneous twice a day: 7 units qam and 1 unit qpm. 22. insulin sliding scale see attached sheet in chart discharge disposition: extended care facility: nursing home - discharge diagnosis: primary: hypoglycemia urinary tract infection chronic kidney disease discharge condition: stable discharge instructions: you came to the hospital with mental status changes and it was felt that this was related to low sugars and a utrinary tract infection. you were treated with an antibiotic called cipro, and your insulin was adjusted. you will need to continue the antibiotic to complete a 7 day course. if you have any futher changes in mental status, weakness, confusion, fevers, chills or any worsening of your condition, please call your pcp or go to the emergency room. please f/u with your pcp as below. weigh yourself every morning, md if weight changes > 3 lbs. adhere to 2 gm sodium diet followup instructions: provider: , m.d. phone: date/time: 11:00 provider: , dpm phone: date/time: 1:50 Procedure: Hemodialysis Diagnoses: Chronic kidney disease, Stage V Abnormal coagulation profile Anemia, unspecified Esophageal reflux Pure hypercholesterolemia Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Rheumatoid arthritis Acute on chronic combined systolic and diastolic heart failure |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: cardiac catheterization history of present illness: mr. is an 89 yo m with htn, hld, dmii, moderate as (valve area 1.0 cm^2) and ckd who presented with worsening chest pain, and admitted for elective cardiac cath. please see dr. admission note for full details. in brief, patient noted worsening exertional chest discomfort over the past few months, with decreased exercise tolerance (unable to walk ?????? mile without chest pain, and less resolution with rest). he had a tte with mildly depressed ef (50%) in , and an exercise stress test showing a mild, fixed inferior wall defect and global mild hypokinesis with a calculated left ventricular ejection fraction is 46 %. as a result of his symptoms and the above test results, he was admitted to on for pre-cath hydration prior to elective cardiac catherization. . in the cath lab today, patient received total fentanyl 82.5 mg iv and midazolam 2 mg iv. right and left heart cardiac catherization was performed. left heart cath revealed 2vd, with a heavily calcified lad 80% proximal, 90% serial mid, and 70% distal disease, lcx 40% proximal stenosis and a 60% stenosis of the ramus, and moderate aortic stenosis. right heart cath revealed both elevated left and right sided pressures. rotablade was performed on the lad (2 more proximal lesions followed by angioplasty). however, at that point, patient became confused, stated his back was hurting and tried to move off of the cath table despite requests to stay down, and contaminated the groin site with his hand. at that point, the cardiac catherization was stopped (no intervention on the distal lesion). he received 10 mg iv haldol total and 20 mg iv lasix, while in the cath lab. urine output unable to be measured due to condom cath being pulled off by patient. an angioseal was placed for arterial closure. he was started on integrillin and transferred to the ccu for closer monitering. . in the ccu, he continued to be confused, and attempted to sit up in bed despite having a venous sheath, and pull on his lines. he received an extra 5 mg of iv haldol and was placed in 4 point wrist restraints. he was able to follow most commands, but unable to answer any review of systems. past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. cardiac history: -cabg: -percutaneous coronary interventions: -pacing/icd: 3. other past medical history: anemia chronic kidney disease (baseline cre 2.1) gout social history: patient was born in , moved to the us in . worked in construction as a labor foreman. married x 54 years, with 3 children and 9 grandchildren. denies tobacco or illicit drug use. occasional etoh use family history: no know fh of cardiac disease, diabetes, no colon/proste/breast cancer. parents lived to 70s to 80s with no known medical problems. children in good health. physical exam: vs: t= afebrile bp= 133/59 hr= 75% rr=15 o2 sat= 95% on ra general: agitated gentleman attempting to get out of bed and pulling at lines. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 6 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. neuro: aox1 ('', but unable to state location or date). unable to concentrate (cannot spell 'world' backwards). cn exam limited due to inability to follow most fine commands, but no gross deficiencies noted in . squeezes both hands on commands, dorsiflexes and plantar flexes feet on command. appropriate gross sensation and proprioception on both arms and legs. downgoing babinski bilaterally. 1+ symmetric reflexes in biceps and achilles tendons. unable to assess cerebellar function or gait due to wrist restraints. . pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: =================== admission labs: =================== 05:55am blood wbc-6.0 rbc-3.00* hgb-10.1* hct-29.9* mcv-100* mch-33.6* mchc-33.6 rdw-13.0 plt ct-224 05:55am blood pt-14.7* ptt-31.4 inr(pt)-1.3* 05:55am blood pt-14.7* ptt-31.4 inr(pt)-1.3* 05:55am blood glucose-77 urean-52* creat-2.3* na-138 k-5.2* cl-108 hco3-24 angap-11 05:30pm blood ck(cpk)-152 05:55am blood calcium-8.5 phos-3.4 mg-2.1 cholest-141 05:55am blood triglyc-111 hdl-27 chol/hd-5.2 ldlcalc-92 03:09pm urine color-yellow appear-clear sp -1.029 03:09pm urine blood-neg nitrite-neg protein-100 glucose-tr ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg 03:09pm urine rbc-2 wbc-<1 bacteri-none yeast-none epi-<1 transe-<1 03:09pm urine castgr-1* ==================== discharge labs: ==================== 05:20am blood wbc-7.4 rbc-2.77* hgb-9.2* hct-27.7* mcv-100* mch-33.2* mchc-33.2 rdw-12.9 plt ct-214 05:20am blood glucose-149* urean-75* creat-2.4* na-138 k-5.0 cl-106 hco3-23 angap-14 05:45am blood calcium-8.4 phos-4.9* mg-2.2 . ==================== imaging/procedures: ==================== cardiac cath : 1. coronary angiography in this left dominant system demonstrated two vessel disease. the lmca had no angiographically apparent disease. the lad was diffusely calcified with a proximal 80% stenosis, 90% mid stenosis, and 70% distal stenosis. the lcx had a 40% proximal stenosis and a 60% stenosis of the ramus. the rca was nondominant and had no angiographically apparent disease. 2. resting hemodynamics revealed elevated right and left sided filling pressures with rvedp 18mmhg and lvedp 21mmhg. there was moderate pulmonary arterial hypertension with pasp 61mmhg. the cardiac index was preserved at 2.33 l/min/m2. the svr was normal at 1300 dynes-sec/cm5. the systemic arterial blood pressure was normal with sbp 132mmhg and dbp 63mmhg. 3. there was moderate aortic stenosis with valve area of 1.0cm2 with mean gradient of 24.3mmhg. 4. successful rotational atherectomy (1.5mm burr) and ptca (2.5mm balloon) of the proximal and mid lad. 5. successful closure of the right femoral arteriotomy site with a 6f angioseal device. final diagnosis: 1. two vessel coronary artery disease. 2. serial lad stenoses. 3. moderate aortic stenosis. 4. successful atherectomy and ptca of the proximal and mid lad. . cxr :the heart size is moderately enlarged, similar compared to prior, and there are bilateral pleural effusions with volume loss in both lower lobes. there is pulmonary vascular re-distribution, but there is less perihilar haze compared to prior. there is volume loss/infiltrate in both lower lobes. impression: continued but slightly improved chf. brief hospital course: 89 yo m with multiple cad risk factors admitted for elective cardiac cath for symptoms of unstable angina and mild systolic dysfunction on tte, found to have 2 vessel disease(including severe lad disease) and moderate aortic stenosis. . # coronaries: the patient has multiple risk factors for cad including htn, hld, dm, ckd. he was directly admitted for cardiac catheterization because of a reversible defect seen on stress testing. cardiac catheterization showed 3 tight lad lesions and a 40% lcx stenosis. only 2 of 3 lad lesions were intervened on, when the patient became agitated and the procedure was terminated with the patient sent to the ccu for close monitoring. he received integrilin post-procedure, and was maintained on aspirin, plavix, high dose statin and metoprolol. additionally, he completed a three day course of cefazolin because of contamination of the groin site during the procedure secondary to the patient's agitation. . # delerium: peri-procedure, the patient exhibited symptoms of delerium including difficulty with concentration. the patient's neurologic exam was non-focal, and the ccu team felt the delerium was multifactorial in the setting of medication effect (benzodiazepines given peri-procedure), especially given ckd with decreased medication clearance, age and lack of sleep in the hospital prior to procedure. he received haldol with good effect and the delerium resolved completely prior to discharge. . # pump: at admission, the patient had no signs or symptoms of chf. however, he received prehydration with normal saline and bicarbonate infusions. during cardiac catheterisation, he was found to have elevated right and left sided pressures consistent with systolic and diastolic dysfunction. additionally, he was found to have moderate aortic stenosis (aortic valve area 1.0 cm^2, mean gradient 24 mm hg) with symptoms of in the as triad (angina, chf). he was diuresed with low dose iv lasix, with good effect. he was continued on metoprolol, and lisinopril held secondary to acute renal failure. . # rhythm: the patient remained in sinus rhythm throughout the hospital stay, with pr prolongation seen on ecg. he was continued on metoprolol. . # diabetes mellitus: the patient's oral hypoglycemics were held while in-house, and he was maintained on a regular insulin sliding scale. . # chronic kidney disease: patient with stage iv ckd, w/ cre clearance of 23. he received pre-cath hydration and iv mucomyst before and after catherization. his creatinine rose after cath to a peak of 2.9, and then began to decline. lisinopril was held for several days prior to hospitalization, and he was instructed to continue to hold this medication until being evaluated by his primary care physician. . # hyperkalemia: the patient's potassium was elevated to 5.9 in the ccu, likely secondary to acute on chronic renal failure after contrast load. he received kayexalate, insulin and d5 and had no ecg changes. his potassium remained stable thereafter. . # htn: lisinopril was held, and the patient continued on metoprolol. # deconditioning: the patient was evaluated by physical therapy prior to discharge, who recommended vna services with a home physical therapy regimen. . . medications on admission: lisinopril 40mg daily (on hold for past 2 days) glipizide 10mg daily actos 15mg daily asa 81mg daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. glipizide 10 mg tablet sig: one (1) tablet po once a day. 3. actos 15 mg tablet sig: one (1) tablet po once a day. 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: final diagnoses: coronary artery disease hypertension diabetes mellitus type 2 chronic kidney disease discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you have a history of progressive chest dyscomfort with exertion and were admitted for a cardiac catheterization to evaluate for coronary artery disease. you were admitted the night prior to the procedure in order to give you intravenous hydration to protect your kidneys from the dye involved in the procedure. you underwent cardiac catheterization on , which showed narrowing of two of your coronary arteries. you became confused and agitated during the procedure, which we think was likely because of sedating medications. we made the following changes to your medications: - start plavix: this is a medication to help prevent blockages in your coronary arteries - start metoprolol: this medication treats your elevated blood pressure - start atorvastatin: this is a medication to treat your elevated cholesterol, and helps to prevent blockages in your coronary arteries - stop your lisinopril until you see your pcp at the end of the week. this medication was stopped prior to the catheterization to help protect your kidneys. your pcp may choose to restart this medication after checking your kidney function at your next visit. . we did not make any further changes to your home medications. please take all medications as prescribed. followup instructions: you have a follow-up appointment with your pcp , md on friday 1:15 pm. tel: provider: , m.d. phone: date/time: 1:20 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Hyperpotassemia Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Aortic valve disorders Acute combined systolic and diastolic heart failure Delirium due to conditions classified elsewhere |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall and sob major surgical or invasive procedure: cardiac catheterization history of present illness: 89yo cm with pmhx significant for cad s/p incomplete atherectomy and pca (), and recent echo () demonstrating chf (ef: 25-30%), moderate as (valve area 1.0), mild->mod ar, mod mr, mod tr, and mild pulm artery systolic htn as as dm2, and cki (baseline cr ?2-2.7) who was admitted to the icu for managment of altered mental status in the setting of hypervolemic hyponatremia. . prior to his admission the patient had been gaining weight (from 172 lbs to 180 lbs) and had b/l effusions on cxr, which prompted his pcp to increased his toresimide on from 10 mg to 20 mg in the am and 5 mg to 10 mg in the pm. over the next week his weight remained stable at 184. and per a prior note his wife reports that the patient had experienced a decrease in urine output, but no cp, sob, pnd, orthopnea, or abdominal pain. . on day of admission the patient was leaning over to put on his slippers and fell over. his wife found him alert and attempting to get up, then called the ems. in the ed he was awake and responsive and his initial vitals were 97.4, 82, 137/89, 16, 91% on 3l nc, but throughout the next couple of hours he became unresponsive and was found to be hyponatremic to 118. head ct was negative. he was guaic-negative. . in the micu it was determined that the patient's hyponatremia was hypervolemic hyponatremia consistent with his history of heart failure and chronic kidney injury. he was placed on a lasix drip and diuresed about 6l, taking into consideration the need to not decrease his preload in the setting of as in order to maintain his co. renal was consulted for his elevated cr, which occurred likely secondary to poor forward flow state and suggested an spep/upep, which was negative for bence protein. his lasix drip was d/c and he continued to auto-diurese. his toresmide was restarted and a heart failure consult was requested. past medical history: diabetes dyslipidemia cad s/p pca in chf ef 25-30% () moderate aortic stenosis mild->moderate ar moderate mr anemia ckd (baseline creatinine difficult to assess 2-2.7) gout recent gi bleed thought , no scope h. pylori positive (was being treated prior to hospital) social history: the patient was born in . he lives in with his wife, with whom he has two daughters and a son. denies any history of tobacco or drug use. he drinks alcohol in small amounts, occasionally (on the weekend). family history: no family history of breast, colon, or prostate cancer. brother had heart disease. children in good health. physical exam: admission physical exam: general: arousable to voice, oriented x2 heent: mmd neck: supple, jvp elevated lungs: +rhales b/l cv: +systolic murmur. s1+, s2+ abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: +foley ext: +edema to thigh b/l. discharge physical exam: vitals: t 96.8 / 146/84 (123-146/67-79) / 78 (74-88) / 20 / 98% on 2l exam: gen: sick appearing elderly male lying in bed with nasal cannula lungs: ctab in upper fields, decreased airmovement in lower lungs (less movement in r than l) cardiac: rrr, 2/6 systolic ejection murmur loudest over aortic valve, diastolic murmur greatest at llsb, s1 and s2 faint, s3, s4 abd: soft, nt, nd, bowel sounds normoactive, no rashes on stomach le: 2+ pulses at dp and pt, + edema up to mid shin, petichial/maculopapular confluent rash over bilat le from below knees to ankles, feet have small amount of purple on toes. r thigh cath site shows no bleeding, erythema, or hematoma. ue: peripheral iv in place, radial pulse 2+, no rash on extermities neuro: alert, oriented x 1 pertinent results: admission labs: cbc: wbc-6.4 rbc-4.03* hgb-13.1* hct-37.2* mcv-92 mch-32.4* mchc-35.1* rdw-14.8 plt ct-230 neuts-79.7* lymphs-11.7* monos-7.2 eos-1.0 baso-0.4 coags: pt-15.1* ptt-32.6 inr(pt)-1.3* chem: glucose-108* urean-74* creat-2.7* na-118* k-5.5* cl-79* hco3-28 angap-17 alt-49* ast-70* ld(ldh)-330* ck(cpk)-641* alkphos-112 totbili-0.9 calcium-8.0* phos-4.9* mg-2.2 osmolal-270* cardiac markers: ck(cpk)-561* ck(cpk)-456* ck-mb-8 probnp-* ctropnt-0.04* ck-mb-8 ctropnt-0.04* ck-mb-7 ctropnt-0.03* . . discharge labs: glucose urean creat na k cl hco3 angap 126* 64* 2.2* 142 4.3 101 37 . hct 33.5 . ========================================== imaging studies: . head ct (): impression: no acute intracranial process. cxr (): impression: increased size of right pleural effusion, now moderate, with persistent small left pleural effusion. subsegmental atelectasis in the right lung base, as well as mild atelectasis in the left lung base. . echo (): conclusions: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is moderate to severe global left ventricular hypokinesis (lvef = 25-30 %). the estimated cardiac index is borderline low (2.0-2.5l/min/m2). no masses or thrombi are seen in the left ventricle. the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis (valve area 1.0 cm2). mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , biventricular systolic function is more depressed suggesting a diffuse process. the severity of aortic regurgitation and mitral regurgitation are increased. the aortic valve gradient is lower, but is likely due to reduced stroke volume. . cardiac cath (): comments: 1. selective coronary angiography of this left dominant system was limited to the left-sided circulation. the lmca had mild disease. the lad was heavily calcified and had serial diffuse 90% stenoses in the proximal, mid, and distal portions of the vessel. angiography of the left circumflex demonstrated a 40% proximal stenosis and a 70% stenosis at the ostium of the om1. there was collateral flow from the lad to the distal circumflex system. 2. resting hemodynamics revealed elevated left and right heart filling pressures with a mean pcw of 35 mmhg and rvedp of 11 mmhg. there was moderate to severe pulmonary arterial systolic and diastolic hypertension with a pasp of 67 mmhg and padp of 30 mmhg. there was moderate systemic arterial hypertension with sbp 152 mmhg. the cardiac index was preserved (3.5 l/min/m2). 3. successful ptca and stenting of distal lad with 2.5x18 mini vision bare metal stent. 4. successful ptca and stenting of mid lad with 2.5x18mm mini vision bare metal stent post dilated to 3.0mm. 5. successful ptca and stenting of proximal lad with 3.0x18mm vision bare metal stent post dilated to 3.0mm. 6. successful closure of right femoral arteriotomy with 6f angioseal. final diagnosis: 1. two vessel coronary artery disease. 2. elevated right and left heart filling pressures 3. moderate systemic arterial systolic hypertension 4. moderate to severe pulmonary arterial systolic and diastolic hypertension 5. normal cardiac index 6. successful pci of distal lad with bms. 7. successful pci of mid lad with bms. 8. successful pci of proximal lad with bms. 9. successful closure of right femoral arteriotomy with 6f angioseal. . echo (): the left atrium is elongated. the right atrium is dilated. left ventricular wall thicknesses and cavity size are normal. there is severe global left ventricular hypokinesis (lvef = 25-30 %). the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the severity of valvular regurgitation is slighlty less. the other findings are similar. . cxr (): impression: slight improvement in chf with persistent bilateral pleural effusions. . microbiology: urine cx (): urine culture (final ): proteus mirabilis. >100,000 organisms/ml.. presumptive identification. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . urine culture (final ): <10,000 organisms/ml. . abg (): 91 63*1 7.39 40* 9 . discharge labs: hct-33.5* chem: glucose-126* urean-64* creat-2.2* na-142 k-4.3 cl-101 hco3-37* angap-8 calcium-7.8* phos-3.2 mg-1.8 brief hospital course: # ms change: patient's mental status change was likely secondary to hyponatremia and improved to baseline upon correction of serum sodium concentration. head ct showed no evidence of acute intracranial process. pt remained a&o x 1 (oriented to self, but not place and time) upon discharge fromthe icu. pt able to carry on conversations with health care team and seemed aware of things around him. . #hyponatremia: the patient's hyponatremia of 118 at presentation was likely secondary to a hypervolemic state from an acute worsening of chronic chf. his serum sodium improved with diuresis and free water restriction to 1.5l/day. by time of discharge he serum sodium was a normal value. . #acute on chronic chf: patient presented with acute decompensation of known systolic heart failure. this was thought related to known coroanry artery disease. he initially received aggressive diuresis and was taken to the cath lab where he had 3 stents placed in lad which was 90% stenosed. he continued to be diuresed with 40mg iv lasix until we felt he was euvolemic. he was then restarted on home dose of torsemide. pt has bilateral pleural effusions which have shown interval resolution with diuresis. he remains on 2l o2 w/ sats in mid 90's. we anticipate that as he mobilizes effusions he will not need continuous o2. le remains + but improving with elevation and compression stocking. . #acute on chronic kidney injury: mild elevation of cr from baseline 2.2 to 2.6 felt to be secondary to heart failure exacerbation. improved w/ diuresis and pt returning to euvolemia. currently cr around 2.2. . #urinary tract infection: urine growing proteus. treated with 10 days of cipro which was completed . . #aortic stenosis: moderate as with valve area 1.0-1.2cm2 on echo . we remained cogniscent of the patient's vavular disease throughout our managment of his volume overload; we were careful to not over-diurese the patient in order to keep his preload appropriate to maintain adequate cardiac output. . #cad: worsening lv function felt to be related to progressive cad. no cp on this admission, mild ce elevation. cardiac cath was performed on as mentioned above with 3 stents placed in his highly diseased lad. pt did well after cath with overall improvement in his heart failure. pt should continue daily espec given new drug elution stents. metoprolol increased to 25mg . his lisinopril decreased to 2.5mg daily. he remains on asa 325 and atorvastatin 80mg daily. #b/l pleural effusions r>l: likely secondary to decompensated heart failure. pt spent most of post-icu course on 2l nc. he would sat between 88-92% on ra when at rest, but any exertion would drop his sats 80% if on ra. at time of discharge pt was still requiring 2l oxygen to maintain adequate sats with any exertion. we anticipate these will continue to resolve and pt will be able to weaned off o2. # fall: fall prior to admission was likely mechanical with possible contribution of hyponatremia leading to confusion leading to fall. a ct head in ed revealed no trauma or ich. we consulted physical therapy to assess the patient's gait and provide rehabilitative inpatient services. the patient will be discharged to a rehab center for rehabilitation. . # dm: we held the patient's glipizide and began insulin with sliding scale adjustment and regular accuchecks. his blood sugar levels were reasonably controlled although the sliding scale was kept conservate due to patient's age and general poor health. glipizide should be restarted at time of discharge. . # rash: pt was found to have two different rashes, one on his bilateral lower extermities from the ankles to the knees and the other over his back and buttocks. he was seen by dermatology who felt eruption on his back is most consistent with miliaria secondary to blockage of the eccrine ducts in an occlusive environment. pt should wear loose fitting cotton clothing to promote drying. rash on legs felt to be contact dermatitis related to pneumoboots. moisturizing cream applied to le. pt was also noted to have a a nodule on his face concerning for a nodular basal cell carcinoma and likely actinic keratoses on the arms. please have the patient follow up with his private dermatologist dr on discharge according to dermatology recommendations. . # h. pylori: pt had been found to be h. pylori positive on by eia. his treatment for this was discontinued during his 3 week hospitalization, but it should be restarted as an outpatient. pt was prescribed an alternative regimen to needing to be off ppi while on and issues with clarithromycin and other current drugs. will send out on renally dosed tetracycline 500mg po tid, metronidazole 500mg po tid, bismuth 2 tabs qid, and renally dose ranitidine 150mg daily. medications on admission: atorvastatin 80 mg tablet daily glipizide 10 mg tablet daily metoprolol tartrate 12.5 mg tablet nitroquick 0.4 mg tablet, sublingual prn chest pain (not used) pantoprazole 40 mg tablet torsemide 20 mg tablet in am, 10 in pm acetaminophen 500 mg aspirin 81 mg ferrous sulfate 325 mg discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po at bedtime. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. acetaminophen 500 mg tablet sig: one (1) tablet po every hours as needed for pain. 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. torsemide 20 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 8. torsemide 20 mg tablet sig: 0.5 tablet po hs (at bedtime). 9. bismuth subsalicylate 262 mg tablet sig: two (2) tablet po four times a day for 14 days. disp:*112 tablet(s)* refills:*0* 10. tetracycline 500 mg capsule sig: one (1) capsule po three times a day for 14 days. disp:*56 capsule(s)* refills:*0* 11. metronidazole 500 mg tablet sig: one (1) tablet po three times a day for 14 days. disp:*42 tablet(s)* refills:*0* 12. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day for 14 days. disp:*14 tablet(s)* refills:*0* discharge disposition: extended care facility: for the aged - macu discharge diagnosis: hyponatremia, acute exacerbation of chronic congestive heart failure, coronary artery disease, aortic stenosis, chronic kidney disease discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , you were recently admitted to the hospital for confusion that occurred because the sodium in your blood got too low because of your heart failure and kidney disease. we were able to use medications to remove your excess fluid and you showed improvement. you were taken to the cardiac catheterization lab and found to have multiple blockages in one of your heart arteries - 3 stents were placed in this artery to improve your blood flow. additionally, you were treated with an antibiotic for 10 days for a urinary infection you developed during your hospitalization. with these treatments your condition improved although you are still requiring supplementary oxygen to maintain your oxygenation while you are moving around. . the following changes were made to your medications: -started 75mg by mouth once each day -lisinopril decreased from 10mg by mouth daily to 2.5mg daily -pantoprazole stopped -> will start raniditine 150mg by mouth once each day in its place as now on -metoprolol increased to 25mg twice a day -new medication tetracycline 500mg by mouth three times each day for 14 days -new medication metronidazole 500mg by mouth three times each day for 14 days -bismuth subsalucylate 2 tablets four times each day for 14 days. . please follow-up with your pcp . and cardiologist dr. as listed below. . please make sure to take your every day. if you fail to take this medication the stents in your heart can become blocked. . please make sure to follow a diet low in salt and do not drink more than 1.5 l of fluid each day. make sure to weigh yourself every morning, and call the doctor if your weight goes up more than 3 lbs. followup instructions: **additionally, he does have a nodule on his face concerning for a nodular basal cell carcinoma and likely actinic keratoses on the arms. please have the patient follow up with his private dermatologist dr on discharge department: cardiac services when: monday at 1 pm with: dr. specialty: congestive heart failure building: sc clinical ctr campus: east best parking: garage name: ,md department: internal medicine when: thursday at 10:30am location: healthcare - medical group address: ,8th fl, , phone: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Left heart cardiac catheterization Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Insertion of three vascular stents Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Aortic valve disorders Acute on chronic systolic heart failure Delirium due to conditions classified elsewhere Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site Helicobacter pylori [H. pylori] Contact dermatitis and other eczema, unspecified cause Prickly heat Photokeratitis |
allergies: nifedipine / nicardipine attending: chief complaint: rollover atv accident major surgical or invasive procedure: : fasciotomies bilateral thighs : i&d bilateral thigh fasciotomies : i&d with closure bilateral thigh fasciotomies and i&d right carpal tunnel wound infection history of present illness: 37-y.o. male with esrd on hd, htn who presents s/p injury with atv with crush injury and concern for compartment syndrome of bilateral thighs found to have hyperkalemia. patient reports riding on an atv on day of admission when it flipped over on him and a tree, and crushed his upper thighs. he had hd on . he reports significant pain and swelling in his bilateral thighs. he denies cp or sob. no fevers, chills, nausea or vomiting. of note had carpel tunnel release 3wks prior by dr. (). past medical history: esrd on hd mwf, hypertension, chronic pain, renal steodystrophy, carpal tunnel syndrome, seizure disorder, restless leg syndrome, cholecystectomy, av fistula social history: tobacco - denies etoh - denies drugs - denies family history: parents w/ htn physical exam: thin male lying supine in apparent discomfort. moaning ble: erythema over the anterior aspect of both thighs. significant tenderness to light palpation over anterior aspect of both thighs. significant pain with passive extension and flexion of the knees bilaterally. palpable femoral, popliteal, dp pulses bilaterally. feet are cool to touch bilaterally, but with cap refill <2sec silt dp/sp/s/s/ /fhl/ta/gsc fire pertinent results: 04:55pm blood wbc-9.9 rbc-3.51* hgb-11.9* hct-35.6* mcv-101* mch-34.0* mchc-33.5 rdw-13.9 plt ct-223 12:29am blood wbc-11.0 rbc-2.52*# hgb-9.0* hct-25.6*# mcv-102* mch-35.9* mchc-35.3* rdw-13.8 plt ct-186 05:48am blood wbc-8.1 rbc-2.48*# hgb-8.2*# hct-23.4*# mcv-94# mch-33.2* mchc-35.2* rdw-15.4 plt ct-116* 09:25am blood wbc-5.0 rbc-2.04* hgb-6.8* hct-18.7* mcv-92 mch-33.6* mchc-36.5* rdw-16.8* plt ct-115* 07:20am blood wbc-6.3 rbc-2.57*# hgb-8.4* hct-23.3* mcv-91 mch-32.7* mchc-36.0* rdw-16.1* plt ct-125* 06:54am blood wbc-8.6 rbc-2.73* hgb-8.8* hct-25.8* mcv-94 mch-32.3* mchc-34.3 rdw-15.6* plt ct-154 04:55pm blood pt-13.3 ptt-25.0 inr(pt)-1.1 03:01am blood pt-14.7* ptt-24.7 inr(pt)-1.3* 09:25am blood pt-13.5* ptt-28.9 inr(pt)-1.2* 04:55pm blood glucose-89 urean-66* creat-11.1* na-131* k-6.7* cl-92* hco3-25 angap-21* 08:25am blood glucose-126* urean-49* creat-8.5*# na-134 k-5.2* cl-93* hco3-28 angap-18 01:18am blood glucose-116* urean-59* creat-9.6*# na-135 k-5.7* cl-94* hco3-27 angap-20 09:25am blood glucose-128* urean-31* creat-6.7*# na-139 k-4.2 cl-95* hco3-36* angap-12 07:20am blood glucose-101* urean-54* creat-10.1*# na-130* k-5.2* cl-93* hco3-29 angap-13 05:55am blood phenyto-3.0* 07:20am blood vanco-1.1* brief hospital course: mr. presented to the emergency department () complaining of bilateral thigh pain after being trapped under an atv following a rollover accident. he was evaluated by the orthopaedic surgery trauma team and found to have an exam concerning for bilateral thigh compartment syndrome. he was consented and taken directly to the operating room for surgical release of his thigh compartments (fasciotomy). intra-operatively, he was closely monitored and remained hemodynamically stable. he tolerated the procedure well without any complication. vac dressings were placed over the open fasciotomy sites. post-operatively, he was transferred to the tsicu given the mechanism of his injury and rhabdomyolysis in the setting of chronic renal failure. renal consultation was obtained as was acute pain service consultion. in the tsicu he was noted to have a large clot within the r thigh vac compromising vac function. on the r thigh wound began oozing through the vac dressing requiring removal of the dressing and packing with dy gauze dressings prn. at that time he was noted to have a hct of 17.5. he subsequently received 1u ffp and 4 units of prbcs for acute blood loss anemia. his post transfusion hct 22.9. he was taken back to the or for i&d of both thigh wounds on where his wounds were minimal necrotic tissue was observed. vacs were replaced and the pt was transferred to the pacu and floor for further recovery. postoperatively he underwent his scheduled hemodialysis. on the floor, pt continued to require significant iv narcotics for persistent pain with aps weighing in on recommended pain control. on pt was noted to have purulent discharged from his r palm at a 3wk old carpal tunnel release surgical site (by dr. ). pt remained hemodynamically stable and returned to the or for washout and closure of his thigh wounds and i&d of his r palm. pt tolerated the procedures well and was transferred to the pacu and floor for further recovery and in stable condition. on pt underwent hd after which he remained hemodynamically stable with his pain was controlled on po medications. he progressed with physical therapy to improve his strength and mobility. medications on admission: phenytoin 200 mg , lisinopril 20 mg , minoxidil 10 mg daily, vitamin b12 1000 mcg daily, lactulose , clonazepam 1 mg 3 tabs 3 x/week, clonazepam 4 mg qhs, nephrocaps daily, propranolol 120 mg , morphine sulfate 60 mg , erogcalciferol 1 cap, famotidine 20 mg , omeprazole 20 mg discharge medications: 1. phenytoin sodium extended 100 mg capsule sig: two (2) capsule po bid (2 times a day). 2. cyanocobalamin (vitamin b-12) 500 mcg tablet sig: two (2) tablet po daily (daily). 3. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2 times a day). 4. morphine 30 mg tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours). disp:*30 tablet extended release(s)* refills:*0* 5. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 6. morphine 30 mg tablet extended release sig: one (1) tablet extended release po noon (at noon). disp:*15 tablet extended release(s)* refills:*0* 7. clonazepam 1 mg tablet sig: two (2) tablet po tid (3 times a day). 8. lisinopril 10 mg tablet sig: one (1) tablet po bid (2 times a day). 9. propranolol 40 mg tablet sig: two (2) tablet po tid (3 times a day). 10. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. 11. vancomycin in d5w 1 gram/200 ml piggyback sig: 1000 mg intravenous hd protocol (hd protochol). 12. calcium carbonate 500 mg (1,250 mg) tablet sig: 2.5 tablets po qidachs (4 times a day (before meals and at bedtime)). 13. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 14. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day) for 4 weeks. discharge disposition: extended care facility: hospital - discharge diagnosis: bilateral thigh compartment syndrome and right carpal tunnel wound infection. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: wound care: -keep incision dry. -do not soak the incision in a bath or pool. -please continue to pack wet saline gauze bandages into the r palmar wound once daily as this will help to keep the wound clean. activity: -continue to be full weight bearing on your both legs and in your upper extremities other instructions - resume your regular diet. - avoid nicotine products to optimize healing. - resume your home medications. take all medications as instructed. - continue your antibiotics as directed. - continue your usual hemodialysis schedule as prescribed by your nephrologist - continue taking the lovenox to prevent blood clots. -you have also been given additional medications to control your pain. please allow 72 hours for refill of narcotic prescriptions, so plan ahead. you can either have them mailed to your home or pick them up at the clinic located on 2. we are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. in addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - narcotic pain medication may cause drowsiness. do not drink alcohol while taking narcotic medications. do not operate any motor vehicle or machinery while taking narcotic pain medications. taking more than recommended may cause serious breathing problems. if you have questions, concerns or experience any of the below danger signs then please call your doctor at or go to your local emergency room. physical therapy: activity: activity: activity as tolerated pt is full weight bearing in all extremities treatments frequency: remove staples 14 days from date of surgery. sutures will be removed at the next clinic appointment. please continue to receive vancomycin dosed at hemodialysis. followup instructions: please follow up with np orthopaedic surgery clinic in 2 weeks. you will need to call to schedule this appointment. please follow up with dr. () in the next 1-2wks for your right carpal tunnel surgery follow up. please call Procedure: Hemodialysis Fasciotomy Fasciotomy Other incision with drainage of skin and subcutaneous tissue Nonexcisional debridement of wound, infection or burn Nonexcisional debridement of wound, infection or burn Other suture of muscle or fascia Other suture of muscle or fascia Other myectomy Other myectomy Other immobilization, pressure, and attention to wound Other immobilization, pressure, and attention to wound Other immobilization, pressure, and attention to wound Other immobilization, pressure, and attention to wound Diagnoses: Hyperpotassemia Hypocalcemia End stage renal disease Renal dialysis status Anemia, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Nontraffic accident involving other off-road motor vehicle injuring driver of motor vehicle other than motorcycle Accidents occurring in other specified places Epilepsy, unspecified, without mention of intractable epilepsy Traumatic compartment syndrome of lower extremity Carpal tunnel syndrome Crushing injury of thigh |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall with right hip pain and fracture major surgical or invasive procedure: open reduction internal fixation right valgus impacted femoral neck fracture with 7.3 mm screws x3. history of present illness: 73 year old woman with past medical history of iddm, seizure disorder and breast cancer who lives alone presenting with right-sided hip, leg and low back pain after slipping off her toilet this morning. patient does not remember any other details at this time. there were no witnesses, and it is not clear how long she was down for. . in the ed, the intitial vs t 96.6 hr 109 bp 138/83 rr 15 and pain was . physical exam showed pain with active and passive r hip rotation. she was given 1g tylenol, 2mg iv morphine and 2l ns. evaluated by ortho. imaging showed subcapital femoral neck fx. guaiac negative, cr 1.8 from b/l of 1.3. k+ 5.8->5.6, ekg notable for new t wave inversions in v1-v4. a ct abdomen and pelvis showed urinary retention and a foley catheter was placed. perceived to have a somewhat altered mental status although unclear baseline. past medical history: seizure disorder (developed dka in ) breast ca s/p mastectomy with prosthetic reconstruction () iddm ra htn glaucoma bilat tkrs . of note, neuropsych evaluation in commented that "her marked attentional impairments raises concerns around her safety, medication compliance, and other areas of functional vulnerability." social history: social history: lives alone. ambulatory at baseline. - tobacco: none - alcohol: none - illicits: none family history: family history: mother died at 47 in surgery (possibly during a hysterectomy). no information was available to her regarding her birth father. she has several step siblings. her daughter is healthy. physical exam: pe on admission to micu: vitals: t 96.8 bp 111/50 p 84 rr 16 o2 99ra general: alert, oriented to place, year and ethnicity but not name of the current president; calm but in visible pain heent: sclera anicteric, dry mm neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly chest: right prosthetic breast gu: foley ext: cold and pale bilaterally with weak but palpable distal pulses bilaterally pertinent results: admission labs: 12:40pm blood wbc-3.1* rbc-3.70* hgb-11.5* hct-32.8* mcv-88 mch-31.1 mchc-35.2* rdw-19.1* plt ct-66* 06:45pm blood neuts-72.0* lymphs-20.1 monos-6.4 eos-0.9 baso-0.7 01:50am blood pt-12.9 ptt-25.7 inr(pt)-1.1 12:40pm blood glucose-90 urean-47* creat-1.8* na-143 k-4.6 cl-112* hco3-22 angap-14 . discharge labs: 06:50am blood wbc-5.5# rbc-4.50 hgb-14.1 hct-41.6 mcv-93 mch-31.3 mchc-33.8 rdw-18.7* plt ct-222 06:50am blood glucose-155* urean-37* creat-1.3* na-138 k-4.9 cl-108 hco3-21* angap-14 06:50am blood alt-30 ast-31 ld(ldh)-597* alkphos-147* totbili-0.5 . cardiac enzyme trend: 12:00pm blood ck 108 ck-mb-10 mb indx-9.3* ctropnt-0.16* 06:45pm blood ck 147 ck-mb-13* mb indx-8.8* ctropnt-0.22* 01:50am blood ck 119 ck-mb-10 mb indx-8.4* ctropnt-0.22* 06:37pm blood ck 72 ck-mb-notdone ctropnt-0.18* 11:45pm blood ck 49 ck-mb-notdone ctropnt-0.16* . radiology: r hip films: findings: there is a nondisplaced, slightly impacted right subcapital hip fracture. no other fractures are identified. mild degenerative changes involving the si joints and lumbar spine are noted. there is a normal bowel gas pattern. impression: right subcapital hip fracture as described above. . ct abd/pelvis impression: 1. right subcapital hip fracture. 2. fibroid uterus. 3. distended bladder with mild left pelvic fullness. 4. bilateral adrenal gland thickening, left greater than right. . ct head impression: no acute intracranial hemorrhage. . ct c-spine impression: 1. no evidence of acute fracture. 2. multilevel degenerative changes as described above. 3. lung apices suggestive of edema, inflammatory, or small airways disease, vs infectious process. 4. 6mm peripherally calcified right thyroid nodule for which further evaluation with ultrasound. . ekg sinus rhythm. the p-r interval is prolonged. there is a late transition with q waves and st-t wave changes in the anterior leads consistent with probable prior anterior myocardial infarction. there are tiny r waves in the inferior leads consistent with possible prior inferior myocardial infarction. compared to the previous tracing st segment changes are new. . cxr impression: no acute cardiopulmonary process. . r hip films findings: in comparison with study of , views from the operating suite show placement of three metallic screws across the previously described fracture of the femur. . echo: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is markedly dilated with severe global free wall hypokinesis. there is abnormal diastolic septal motion/position consistent with right ventricular volume overload. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: markedly dilated right ventricle with severe global hypokinesis. at least moderate pulmonary hypertension. small left ventricular cavity size with preserved systolic function. . carotid ultrasounds impression: there is less than 40% stenosis within the internal carotid arteries bilaterally. . cxr findings: in comparison with the study of , there has been a substantial decrease in the bilateral opacification, which had been more prominent on the left and could have represented either asymmetric pulmonary edema or diffuse aspiration. some residual areas of opacification are seen at the right base laterally and at the left base. these most likely represent residual aspiration or possible atelectasis. . ekg normal sinus rhythm with q waves in the right precordial leads consistent with anterior wall myocardial infarction. q waves in the inferior leads consistent with inferior myocardial infarction. compared to tracing #2 there is no change. brief hospital course: 73f pmhx of dm, seizure disorder and breast cancer, found down on her floor with r hip fx s/p fall, admitted to the icu with hip fx, arf, nstemi, and hypoxia. hospital course by problem: # elevated cardiac enzymes and ekg changes: had elevated troponins in the setting of and new twi both in the setting of anemia. medical regimen included asa 81mg, statin 80mg daily, and beta blocker. ace-i was held given recent acute on chronic renal failure and preserved ef as seen on echo (see below). . # right hip fracture s/p fall. pt was evaluated by orthopedics who planned for minimally invasive pinning procedure pending medical clearance, which was provided by daughter, , as pt was delirious. went to or on , no complications intra-op, but did go back ot the icu for overnight monitoring as she had some hypoxia postoperatively (had received a larga amount of morphine). she commenced pt pod#1, and was significantly limited by pain, but this improved by pod#3 (ay of d/c). she did receive narcotics around the time of pt to aid in progress. pain was also managed with tylenol. she was discharged on lovenox 40mg sq daily for dvt ppx, and with orthopedic followup. # pancyopenia: presented with acute on chronic anemia with baseline in low 30s, as well as thrombocytopenia with nadir platelets in the 40s, and leukopenia to a nadir of 2.1 felt likely methotrexate use with questionable use of folate (marrow suppressive process). she was transfused 3 units in the icu and on hd#2 had a stable hct to 32.8. ddavp was given for low platelets. her methotrexate was held, she received supplemental folic acid, and all cell lines recovered to normal by discharge. she will followup with erh rheumatologist for ? resumption of methotrexate. # acute kidney injury: baseline creatinine = 1.3, but she presented with creatinine 1.8 -> max of 2.2 in setting of fall. normal cks made rhabdo unlikely. felt likely hypoperfusion and prerenal state. pt. was given ivf boluses and cr decreased to 1.3 by discharge. # transaminitis: had elevations of alt, ast and alk phos without elevation in bilis. unclear etiology, felt mild ischemic liver in setting of hypotension. her methotrexate was also held. lfts had entirely normalized by discharge. # iddm: well-controlled by a1c. fs were checked every 4 hours and she was placed on an insuling sliding scale. her lisinopril was held. on discharge,her metformin was continued, but lisinopril was still held in setting of recent acute renal failure. # fall: unclear etiology in pt with h/o seizure d/o and multiple cad risk factors. her cardiac enzymes were followed and trop was trended from 0.16-->0.22-->0.22, so an mi could be the etiology but this could also have been a conseqeunce of her fall. further syncope workup included monitoring on telemetry without significant arryhtmia, sending a tegretol level (normal), repeating ekgs (developed signs of mi), and carotid ultrasounds which were normal. head ct and cspine ct in ed were negative. # hypoxia - pt still had minimal o2 requirement on d/c. has known osa per prior sleep evaluations. also received many liters of ivf and 3 units of blood during her hospital course, so ? some element of hypervolemia, but phsical exam did not support this. echo performed this admission revealed preserved ef of 60-65% but markedly dilated rv with severe global free wall hypokinesis. there was abnormal diastolic septal motion/position consistent with right ventricular volume overload. there was moderate pulmonary artery systolic hypertension. this was thought to possible represent sequelae from her mi. pulmonary embolism was on the differential but given her acute on chronic renal failure, a ct-a was deferred, and the patient was allowed to autodiurese and recover from the imediate postoperative period and wean off of narcotics. if persistent, this could be further worked up as an outpatient. # ra: methotrexate was held during admission given pancytopenia above. # depression: dx with mild depression - effexor therapy was continued # dementia/delerium: unclear circumstances of diagnosis, per record patient reporting forgetfulness, psych testing showing mild attention deficits. she was continued on aricept. she did experience significant delirium during her hospitalization which had improved by her discharge, but was still present in a waxing and nature but easily treated with reorientation and discontinuation of foley catheter, telemetry, and hydration. she does have followup scheduled with her cognitive neurologist. # fen: pt was seen by speech and swallow who recommended: 1. continue current diet of thin liquids and puree. 2. pills whole or crushed with puree. 3. 1:1 supervision for all pos. 4. give pos only when patient is most awake and alert. 5. nutrition consult. 6. recommend repeat swallowing evaluation at rehab prior to upgrading diet. # prophylaxis: will be on lovenox 40mg sq daily until ealry for dvt ppx, also d/c'ed on bowel regimen # communication: with patient and daughter hcp , home: cell: work: # code: full # dispo: to medications on admission: lipitor 20 mg daily tegretol 200 mg tid aricept 10 mg daily lisinopril 5 mg daily meloxicam 15 mg daily metformin 500 mg daily methotrexate 12.5 mg weekly effexor 150 mg daily discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. carbamazepine 200 mg tablet sig: one (1) tablet po tid (3 times a day). 4. enoxaparin 40 mg/0.4 ml syringe sig: forty (40) mg subcutaneous daily (daily) for 25 days: last day of therapy is . 5. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 6. vitamin d 400 unit tablet sig: four (4) tablet po daily (daily). 7. venlafaxine 75 mg capsule, sust. release 24 hr sig: two (2) capsule, sust. release 24 hr po daily (daily). 8. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 12. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 13. metformin 500 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. 14. percocet 2.5-325 mg tablet sig: one (1) tablet po every hours as needed for pain: hold for any cns or respiratory depression (rr <12). can be given prior to physical therapy sessions. discharge disposition: extended care facility: - discharge diagnosis: primary: - right valgus impacted femoral neck fracture. - nstemi vs. demand ischemia - shock liver - pancytopenia likely due to methotrexate - right heart failure secondary: - rheumatoid arthritis - hypertension - depression - seizure disorder - diabetes mellitus type ii - obstructive sleep apnea - dementia - h/o breast cancer discharge condition: mental status: confused - sometimes level of consciousness: alert and interactive activity status: out of bed with assistance to chair or wheelchair discharge instructions: dear ms. , you were admitted to the hospital after falling at home. you were found after being down on the floor for a prolonged time. as a result of the fall, you suffered a fractured right hip, as well as low blood pressure which caused major stress to your heart and liver. your hip fracture was surgically repaired, and as you were given iv fluids, the damage to your heart and liver improved substantially. you will need a course of rehabilitation and aggressive physical therapy to regain your previous level of function. . we also discovered that the right side of your heart is not working well, which will need to be worked up further by your pcp. the meantime we did discharge you with some supplemental oxygen to keep your oxygen levels at a healthy level. . some changes were made to your medications, as follows: 1) your methotrexate was stopped, since it might have been lowering your blood cell counts when you came to the hospital. the blood counts revcovered nicely when you were taken off methotrexate. you can determine when to restart this when you see dr. in followup. 2) your lipitor was increased to 80mg daily 3) you will be receiving daily injections of lovenox, a blood thinner, to prevent blood clots after your hip surgery, for the next 25 days 4) start calcium and vitamin d supplements to help with bone healing 5) start metoprolol 12.5mg to protect the heart 6) start a baby aspirin every day to protect the heart followup instructions: orthopedics: tuesday at 11:20 with ( building, ) . cognitive neurology: provider: , m.d. phone: date/time: 10:30 . primary care: thursday, :20 with dr. . rheumatology: provider: , md phone: date/time: 11:30 Procedure: Closed reduction of fracture with internal fixation, femur Diagnoses: Hyperpotassemia Obstructive sleep apnea (adult)(pediatric) Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute and subacute necrosis of liver Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Personal history of malignant neoplasm of breast Unspecified glaucoma Depressive disorder, not elsewhere classified Other persistent mental disorders due to conditions classified elsewhere Chronic kidney disease, unspecified Long-term (current) use of insulin Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Rheumatoid arthritis Epilepsy, unspecified, without mention of intractable epilepsy Hypovolemia Knee joint replacement Other alteration of consciousness Other nonspecific abnormal serum enzyme levels Other closed transcervical fracture of neck of femur Accidental fall from commode Leiomyoma of uterus, unspecified Nontoxic uninodular goiter |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status, hypoxia major surgical or invasive procedure: ivc filter placement; no plans for filter removal, per vascular surgery attending. egd/colonscopy history of present illness: 73 yo female with hx of recent admission for r hip fracture/pinning with period of hypoxia during the previous admission, now presents from rehab with unresponsiveness, refusal to take meds, hypoxia. in the ed, her triage vitals were t96f, hr 106, bp 124/91, rr 14, sat 90%. cta showed bilateral pulmonary emboli. vascular surgery was consulted via the ed, and considering pt developed pe despite outpt prophylaxis doses of lovenox, an ivc filter was placed, and the patient was started on heparin drip. she was admitted to medicine for ongoing management. on evaluation on the floor, she is a poor historian and reports that she is in the hospital because she was not treated well at rehab. she does recall (with prompting) being told that there are clots in her lungs and that she had a procedure before coming to the floor. multiple attempts to contact her daughter were made, but her phone was busy. . ros: she reports mild difficulty breathing and pain at the site of her recent surgery (right hip), as well as lower extremity swelling. she denies fevers, chills, night sweats, visual changes, sore throat, chest pain, abdominal pain, nausea, vomiting, diarrhea, cough, urinary frequency, dysuria, and constipation. past medical history: seizure disorder (developed dka in ) breast ca s/p mastectomy with prosthetic reconstruction () iddm ra htn glaucoma bilat tkrs . of note, neuropsych evaluation in commented that "her marked attentional impairments raises concerns around her safety, medication compliance, and other areas of functional vulnerability." social history: social history: lived alone prior to recent hospitalization. ambulatory at baseline (with cane). - tobacco: none - alcohol: none - illicits: none family history: family history: mother died at 47 in surgery (possibly during a hysterectomy). no information was available to her regarding her birth father. she has several step siblings. her daughter is healthy. physical exam: admission: vitals: t97.0f, bp 138/87, hr 85, rr 22, sat 100%5l face mask gen: alert and oriented x 2 heent: eomi, perrl, mmm. neck: no lad. jvp wnl. resp: cta b. no wheezes, rales, or rhonchi cv: rrr. pronounced s2. no mrg. abd: +bs. soft, nt/nd. back: stage 2 coccyx ulcer, currently dressed. ext: pitting edema in lle, trace edema in rle. extremities cool but pulses palpable. right hip with staples, mildly tender to palpation. neuro: cn 2-12 grossly intact. oriented to self and place, not time. easily distracted with waxing/ attention. discharge exam: vitals: 96.9f, bp 174/72, hr 72, rr 18, sat 95%ra lungs: bilateral rales at bases heart: regular rate and rhythm abdomen: benign extremities: 1+ pitting edema bilaterally neuro: cn 2-12 intact. oriented to self and place, not time. able to hold coherent conversation, but has mild cognitive/memory deficits pertinent results: cta chest w&w/o c&recons impression: 1. bilateral lobar and segmental pe, without evidence of right heart strain. 2. pulmonary edema with evolving infarcts. close imaging followup is recommended. ct head w/o contrast impression: no acute changes. bilat lower ext veins impression: clot within the left posterior tibial vein. otherwise, normal study. ct abdomen w/o contrast: history: known bilateral pes with 16-point hematocrit drop after initiating heparin. evaluate for bleeding. impression: 1. no evidence of retroperitoneal bleeding. 2. small bilateral pleural effusions and ground-glass opacity with septal thickening, unchanged. 3. subcentimeter liver hypodensities, too small to characterize. 4. gastric diverticulum. 5. bilateral renal hypodensities, some of which are too small to characterize, others of which may represent simple cysts. 6. left adrenal gland thickening. 7. ivc filter placement. 8. fibroid uterus. 9. slight asymmetrical enlargement of the right anterior thigh musculature with vague hyperdensity which may suggest small amount of intramuscular bleeding. 10. diffuse anasarca. 11:48am blood wbc-19.2*# rbc-4.14* hgb-13.0 hct-38.9 mcv-94 mch-31.5 mchc-33.5 rdw-17.7* plt ct-389# 05:40am blood wbc-18.6* rbc-3.00*# hgb-9.6*# hct-28.9*# mcv-96 mch-32.0 mchc-33.2 rdw-17.3* plt ct-293 10:37am blood wbc-19.1* rbc-2.41* hgb-7.6* hct-22.8* mcv-95 mch-31.8 mchc-33.6 rdw-17.1* plt ct-287 06:20am blood wbc-17.4* rbc-3.77* hgb-10.9* hct-33.2* mcv-88 mch-28.9 mchc-32.8 rdw-18.2* plt ct-184 02:30am blood fibrino-356 08:53pm blood esr-9 qg6pd-17.5* 10:37am blood ret aut-5.1* 02:30am blood ret aut-3.5* 11:48am blood glucose-176* urean-18 creat-0.9 na-137 k-4.3 cl-98 hco3-30 angap-13 06:20am blood glucose-64* urean-26* creat-1.0 na-139 k-3.8 cl-104 hco3-29 angap-10 05:40am blood alt-17 ast-25 ld(ldh)-491* alkphos-142* totbili-0.3 06:20am blood ld(ldh)-380* 05:40am blood hapto-<5* 02:30am blood hapto-<5* 01:43pm blood hapto-26* 05:35am blood hapto-49 08:15am blood hapto-69 06:20am blood hapto-72 micro: sensitivities: mic expressed in mcg/ml enterobacter aerogenes | enterococcus sp. | | ampicillin------------ <=2 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 64 i <=16 s piperacillin/tazo----- <=4 s tetracycline---------- =>16 r tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s vancomycin------------ 2 s ct pelvis : impression: 1. no findings to explain hematocrit decrease. 2. diffuse anasarca. chest pa/lat : the current study demonstrates the left picc line tip being located at the junction of the left brachiocephalic vein and svc. cardiomediastinal silhouette is relatively stable. widespread parenchymal opacities are present but improved since the prior study. subpleural interstitial changes are noted and are most likely consistent with chronic interstitial changes rather than acute infection, and as was mentioned, improved compared to the prior images. no focal consolidations to suggest new infection are currently demonstrated, but given the two-week interval compared to the prior imaging, cannot be entirely excluded. no increase in pleural effusion is demonstrated. no substantial evidence for failure is seen. hip x-ray : impression: fixation of right femoral subcapital fracture with unchanged alignment. brief hospital course: 73yf with history of rheumatoid arthritis, breast cancer, recent right hip fracture s/p orif and presumed nstemi during hospitalization, presented with altered mental status and hypoxia from rehab, found to have bilateral pulmonary embolism, possible pneumonia, and a uti. hospitalization was complicated by recurrent drops in her hematocrit, initially thought to be to hemolysis, but was subsequently noted to have an upper gi bleed to a large duodenal ulcer. an ivc filter was placed via vascular surgery consult from the ed, she was started on heparin gtt and antibiotics (vanc, ctx, levo), and she was admitted to the hospitalist service for ongoing care. following admission, she was found to have a very rapid hct drop of unclear source (16 points within 11 hours). her heparin was reversed with iv protamine, a stat ct abd/pelvis was obtained, and she was transferred to the icu for ongoing care. ct scans were without evidence of any significant bleed. hemolysis labs were sent, with very low haptoglobin, elevated ldh. vanc and ceftriaxone were discontinued for concern of possibly inducing hemolysis (although remains extremely unlikely this was the source). pt's heparin gtt was resumed and she was subsequently transferred to floor for ongoing care after further h/h monitoring. she was transfused a total of 5 units of prbc during this hospitalization. hematology was consulted, however it remained unclear why she had her sudden hct drop, but there was likely a contribution of pulmonary infarct and infection driving anemia, based upon findings of toxic granulations on smear. while the haptoglobin was very low which would argue in favor of hemolysis, the bili level remained stable, which would argue against. coombs negative. g6pd negative. her h/h and haptoglobin levels were followed, which continued to improve and stabilize. once her hct was reasonably stable, but she was noted to have a slight decline in her hematocrit in the setting of dark guaiac positive stools. thus, heparin and coumadin were discontinued, a ppi was initiated, and gi was consulted. the patient underwent egd and colonscopy several days after initiation of a ppi that revealed a large duodenal ulcer that was likely the source of bleeding. the ulcer was shallow, without a visible vessel, and was thought the be low risk for bleeding. her heparin was restarted. h pylori serology was sent and was ultimately negative. #) acute on chronic diastolic chf: the patient was noted to be markedly volume overloaded and anasarcic; furosemide was increased to 20mg iv bid, which should be continued until diffuse edema resolves. #) leukocytosis/uti. pt had a leukocytosis during the admission due to uti and pulmonary infarcts. it was thought that pt may possibly have a pneumonia, but this was thought to be less likely. her urine grew enterobacter and enterococcus. she completed a 5 day course of levofloxacin 750 mg. her repeat urine culture was negative. wbc improved by the time of discharge. #) stage ii coccyx ulcer. wound care was consulted and wound care should be continued: mepilex and duoderm wound gel, along with pressure redistribution guidelines. #) diabetes mellitus uncontrolled with complications. held oral hypoglycemics while in the hospital and covered with insulin sliding scale and diabetic diet. #) seizure disorder. continued carbamazepine. #) rheumatoid arthritis. methotrexate was discontinued last admission secondary to pancytopenia. she has follow up with her rheumatologist. #) hypertension. continued metoprolol (home medication, increased dose to 25mg ), lisinopril changed to hydralazine/isosorbide inhouse given mild acute renal failure. lisinopril (home dose 5mg daily) can be restarted as blood pressure tolerates. #) code status. dnr/dni, confirmed with patient during this hospitalization. medications on admission: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. carbamazepine 200 mg tablet sig: one (1) tablet po tid (3 times a day). 4. enoxaparin 40 mg/0.4 ml syringe sig: forty (40) mg subcutaneous daily (daily) for 25 days: last day of therapy is . 5. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 6. vitamin d 400 unit tablet sig: four (4) tablet po daily (daily). 7. venlafaxine 75 mg capsule, sust. release 24 hr sig: two (2) capsule, sust. release 24 hr po daily (daily). 8. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 12. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 13. metformin 500 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. 14. percocet 2.5-325 mg tablet sig: one (1) tablet po every hours as needed for pain: hold for any cns or respiratory depression (rr <12). can be given prior to physical therapy sessions. discharge medications: 1. warfarin 7.5 mg tablet sig: one (1) tablet po once daily at 4 pm. 2. heparin (porcine) in d5w 10,000 unit/100 ml parenteral solution sig: 1150 (1150) units/hour intravenous continuous: according to attached sliding scale. heparin gtt at 1150 units/hr and stable. 3. carbamazepine 200 mg tablet sig: one (1) tablet po tid (3 times a day). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. calcium 500 + d 500 mg(1,250mg) -400 unit tablet sig: one (1) tablet po three times a day. 7. venlafaxine 75 mg capsule, sust. release 24 hr sig: two (2) capsule, sust. release 24 hr po daily (daily). 8. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 9. aspirin 81 mg tablet sig: one (1) tablet po once a day. 10. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 13. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 14. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 15. hydralazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours). 16. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 17. oxycodone 5 mg tablet sig: 0.5 tablet po every six (6) hours as needed for pain. 18. furosemide 10 mg/ml solution sig: two (2) injection injection twice a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: # bilateral pulmonary embolism # pulmonary infarcts # anemia, multifactorial # urinary tract infection # upper gi bleed # duodenal ulcer discharge condition: mental status: clear and coherent level of consciousness: alert and interactive; some mild memory deficits activity status: ambulatory - requires assistance or aid (walker or cane) discharge instructions: followup instructions: department: when: monday at 1:50 pm with: post clinic building: sc clinical ctr campus: east best parking: garage follow up for hospitalization. will be reconnected with primary care physican for the end . department: pulmonary function lab when: wednesday at 7:40 am with: pulmonary function lab building: campus: east best parking: garage department: medical specialties when: wednesday at 8:00 am with: dr & dr building: sc clinical ctr campus: east best parking: garage department: rheumatology when: tuesday at 10:30 am with: , md building: lm campus: west best parking: . garage department: when: thursday at 12:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage department: orthopedics when: tuesday at 9:40 am with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: tuesday at 10:00 am with: , np building: campus: east best parking: garage Procedure: Interruption of the vena cava Esophagogastroduodenoscopy [EGD] with closed biopsy Angiocardiography of venae cavae Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Acute on chronic diastolic heart failure Personal history of malignant neoplasm of breast Unspecified glaucoma Long-term (current) use of insulin Pressure ulcer, lower back Rheumatoid arthritis Epilepsy, unspecified, without mention of intractable epilepsy Other postprocedural status Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Duodenitis, without mention of hemorrhage Knee joint replacement Subendocardial infarction, subsequent episode of care Other pulmonary embolism and infarction Internal hemorrhoids without mention of complication External hemorrhoids without mention of complication Pressure ulcer, stage II Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Leiomyoma of uterus, unspecified Other orthopedic aftercare Gastric diverticulum |
allergies: a.c.e inhibitors / aspirin / valsartan attending: chief complaint: coffee ground emesis major surgical or invasive procedure: esophagogastroduodenoscopy history of present illness: patient is a 76 y/o m with a pmh of htn, dm, cri, and hyperlipidemia who presents from home with emesis. the patient reports that he was in his usoh yesterday until around 9pm when he suddenly felt nauseated and vomited x1. he reports that he had not eated anything since lunch time when he had two sausages that he prepared at home. he reports that the emesis looked like coffee grounds. per the ed the patient's daughter felt that her father "did not look good" and ems was called. the patient had another episode of coffee ground emesis in the ambulance. he denies any fevers, chills, diarrhea or abdominal pain. he does not know if he has had any melena as he "stopped looking at his stools since he stopped taking iron 1 year ago". he denies any h/o hematochezia. the patient denies any history of gi bleeding in the past. he denies taking ibuprofen, however he did take one aspirin yesterday for some l-sided neck pain despite being told he should not take it. . in the emergency department initial vs were t 97.4 bp 125/64 hr 116 rr 20 o2 sat: 100% 4l. hct was checked and was 31.6. he had a melanic stool, guaiac positive. gi evaluated the patient in the ed. an ngl was performed after long discussion with patient which showed small flecks of old blood and no active bleeding. bp remained stable. 2 pivs were placed. he received 40mg protonix iv and 1l ns. he was admitted to the icu for close monitoring and egd in am. . currently the patient feels well but states he does not want to be in the hospital. he denies any further nausea, emesis, diarrhea or abdominal pain. he also denies chest pain, lh, sob, palpitations or other complaints. . ros is otherwise negative for le swelling, pnd, orthopnea, dysuria or difficulty urinating. past medical history: ckd, baseline cr 3-3.5, followed by dr. dm2, last a1c 7.2 in htn elevated psa followed by dr. , s/p bx in showing chronic inflammation and no malignancy hyperlipidemia ? osa chronic anemia, baseline hct 35-38 depression, not treated l cerebellar cva erectile dysfunction central vestibular vertigo social history: lives with his daughter. widower, lost his wife 4 years ago. independant in adls, ambulates with cane. smoked for 40 years, quit 20 years ago. retired post office worker. denies etoh. family history: father had cva in 50s mother had dm and ? colon ca, died in 80s brother cva age 31 physical exam: general: pleasant, alert, comfortable, well appearing, in nad heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. neck supple, no lad, no thyromegaly. cardiac: tachy, regular, normal s1, s2. no murmurs, rubs or . jvp= 6cm lungs: ctab, good air movement biaterally, no wheezes or rales abdomen: nabs. soft, nt, nd. no hsm extremities: no edema or calf pain, ext. warm and well-perfused skin: no rashes, hyperpigmentation in upper anterior chest. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout. + reflexes, equal bl. gait assessment deferred psych: listens and responds to questions appropriately, pleasant pertinent results: labs on admission: 10:52pm ck(cpk)-153 10:52pm ck-mb-8 ctropnt-0.21* 10:52pm hct-29.0* 10:52pm pt-14.2* ptt-22.4 inr(pt)-1.2* 06:00pm urine hours-random urea n-726 creat-103 sodium-34 06:00pm urine osmolal-436 06:00pm urine color-yellow appear-clear sp -1.012 06:00pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 03:05pm glucose-216* urea n-111* creat-4.1* sodium-146* potassium-4.1 chloride-107 total co2-25 anion gap-18 03:05pm estgfr-using this 03:05pm alt(sgpt)-18 ast(sgot)-16 ld(ldh)-232 ck(cpk)-148 alk phos-72 tot bili-0.1 03:05pm ck-mb-9 ctropnt-0.15* 03:05pm albumin-3.2* calcium-8.1* phosphate-4.0 magnesium-2.1 03:05pm wbc-8.5 rbc-3.03* hgb-9.0* hct-26.9* mcv-89 mch-29.7 mchc-33.4 rdw-14.0 03:05pm plt count-191 10:31am glucose-232* na+-144 k+-4.5 cl--101 tco2-23 10:30am wbc-9.5# rbc-3.48* hgb-10.7* hct-31.6* mcv-91 mch-30.8 mchc-33.9 rdw-13.9 10:30am neuts-76.5* lymphs-17.1* monos-5.6 eos-0.4 basos-0.3 10:30am plt count-248 . labs on discharge: 05:25am blood wbc-7.3 rbc-3.08* hgb-9.4* hct-27.7* mcv-90 mch-30.4 mchc-33.8 rdw-14.2 plt ct-139* 05:25am blood glucose-159* urean-87* creat-3.7* na-146* k-4.3 cl-113* hco3-24 angap-13 . microbiology: mrsa screen - negative h pylori serology - pending . imaging: echo: the left atrium and right atrium are normal in cavity size. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: technically suboptimal study. mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. . egd: -erosions in the gastroesophageal junction -nodularity and erythema in the fundus and stomach body compatible with gastritis -ulcers in the pre-pyloric region -congestion in the duodenal bulb compatible with duodenitis -otherwise normal egd to second part of the duodenum brief hospital course: patient is a 76 year old man with history of hypertension, dm type 2, hyperlipidemia and chronic renal insufficiency who presented from home with coffee ground emesis. . 1.) anemia/coffee ground emesis: egd demonstrated several pre-pyloric ulcers, likely etiology of presentation. received a total of 1 unit packed red blood cells, and was treated with pantoprazole with stabilization of his hematocrit in the high 20's on discharge. h pylori serology was sent and is pending on discharge, to be followed up as an outpatient and treated if positive. otherwise patient was discharged on pantoprazole with instructions to follow up with gastroenterology in weeks time. . 2.) hypertension, benign: medications initially held on admission, but all were restarted on discharge. . 3.) tachycardia: on presentation, now resolved with iv fluid hydration. . 4.) abnormal ekg: patient with noted new twi on ekg, likely from tachycardia above. ruled out for mi. echo essentially unremarkable. . 5.) hyperlipidemia: continued statin . 6.) diabetes: held outpatient regimen while npo but restarted on discharge. . 7.) chronic renal insufficiency: baseline creatnine labs appears to be 3-3.5. cr 4.1 on admission, decreased to baseline by time of discharge. . 8.) bph: continued tamsulosin . 9.) history of cva: ticlid held on admission, restarted on discharge. medications on admission: amlodipine - 5 mg daily atorvastatin - 40 mg daily diltiazem hcl - 360 mg sust. release daily doxercalciferol - 0.5 mcg capsule - 1 (one) capsule(s) by mouth twice a day to maintain level of vitamin d furosemide - 40 mg, once a day on odd days, 2 tablets daily on even days insulin glargine - 8 units sc once a day metoprolol succinate - 50 mg daily repaglinide - 1 mg twice a day tamsulosin - 0.4 mg daily ticlopidine - 250 mg twice a day discharge medications: 1. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. diltia xt 120 mg capsule,degradable cnt release sig: three (3) capsule,degradable cnt release po once a day. 4. doxercalciferol 0.5 mcg capsule sig: one (1) capsule po bid (2 times a day). 5. lasix 40 mg tablet sig: two (2) tablet po on even days. 6. lantus 100 unit/ml solution sig: eight (8) units subcutaneous once a day. 7. metoprolol succinate 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 8. repaglinide 1 mg tablet sig: one (1) tablet po twice a day. 9. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 10. ticlopidine 250 mg tablet sig: one (1) tablet po twice a day. 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: primary - acute blood loss anemia, resolved - upper gastrointestinal bleed, stable secondary - hypertension - diabetes, type ii discharge condition: afebrile, vitals stable discharge instructions: you were hosptialized because you had vomited blood. after a thorough work up, the cause of your vomiting was from several ulcers that have stopped bleeding. you recieved one unit of blood and your hematocrit has been stable. you have been started on a new medication called protonix. please take this medication twice daily until you follow up with gastroenterology. please avoid a class of medications called non steroidal anti-inflammatory medications and do not take them without first discussing with your doctor. this includes ibuprofen, motrin, aspirin. please contact physician if develop more blood in vomit, blood in stool, black colored stools or vomit, lightheadedness/dizziness, chest pain/pressure, shortness of , other questions or concerns. followup instructions: please follow up with gastroenterology dr. in weeks to arrange for a repeat endoscopy. can call to schedule appointment. please follow up with these previously scheduled appointmentsp: provider: , m.d. date/time: 1:30 . provider: , dpm phone: date/time: 11:40 . provider: , : date/time: 11:00 Procedure: Esophagogastroduodenoscopy [EGD] with closed biopsy Transfusion of packed cells Diagnoses: Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Depressive disorder, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Duodenitis, without mention of hemorrhage Tachycardia, unspecified Helicobacter pylori [H. pylori] Impotence of organic origin Vertigo of central origin |
allergies: no allergies/adrs on file attending: chief complaint: chest pain, abdominal pain major surgical or invasive procedure: cardiac catheterization history of present illness: 79 year old female who presented to from osh () for concern for stemi, with right upper quadrant pain, leukocytosis and elevated lactate. patient was at an outpatient visit for right upper quadrant pain (patient has an elevated total bilirubin s/p stenting procedure one week prior to admission), which had been increasing over the last few days, as well as a recurrence of jaundice, which she had last had previous to her biliary stent placement. she was sent to the further work-up. she has a history of bile duct mass, thought to be consistent with klatskin's tumor and is s/p stenting . patient presented to the osh ed with 10/10 chest pain that awoke her from sleep. there is no report of dyspnea, nausea, diaphoresis, no fevers or chills. per daughter, patient was somewhat confused the day before admission. ecg at the osh was concerning for stemi, with diffuse st-segment elevations, most prominant in i, ii, avl, v3-6, and st-segment depression in avr. troponin i was 0.26. bedside echo showed hypokinesis with ef 55% and 2+ mitral regurgitation. cardiology at the osh reportedly did not think intervention with primary pci was indicated, per report. patient was administered rocephin and flagyl at the osh due to noted wbc count of 20k. of note, labs from osh also found k 4.5, bun 79, cr 2.9. she was transferred to for further evaluation. . in the ed, initial vital signs were t 97.6, p 74, bp 120/60, r 16, sat 95% ra. ecg was significant for similar st abnormalities, and patient complained of chest pain. patient was started on iv heparin without a bolus. labs were significant for wbc 23k with 90% neutrophils, 3% bands. chemistry labs were hemolyzed. one set of blood cultures were sent. labs also showed ast 197, alt 95, alk phos 662, total bilirubin 27.1, albumin 2.2. troponin was 0.24. she was given 5 mg morphine and 2 mg ondansetron in the ed. patient was taken to catheterization due to concern for stemi. in the catheterization lab found diffuse coronary disease (20% lmca, 40% prox lad, 80% mid-distal lad, diminutive lcx, and to mid-rca with collaterals from left). patient was agitated due to groin pain on the table, venous sheath was pulled, but did not have chest pain. rhc was performed and showed mean ra 12 mmhg, rvedp of 15 mmhg, pcw mean of 20 mmhg; co 3.2 l/min and ci 2.1 l/min/m2. abg performed in the lab showed 7.30/33/174/17 with lactate 5.8. given complexity of disease that would require extensive, high-risk stenting procedural risk was deem high and given normal flow in the arteries with preserved cardiac output, it was determined that medical management was the preferable strategy while the etiology of her lactic acidosis, leukocytosis and agitation were explored. in addition, no intervention was performed as there was no culprit lesion, and diffuse ischemia was thought secondary to underlying supply/demand mismatch in context of other medical problems. has two peripheral ivs in place. . in the ccu, patient is not responding to questions appropriately, per daughter. she is notably tachypneic taking shallow breaths. past medical history: 1. cardiac risk factors: + diabetes, + dyslipidemia, + hypertension 2. cardiac history: none 3. other past medical history: - biliary mass s/p ercp and stenting , suspected cholangiocarcinoma with klatskin tumor and biliary obstruciton - chronic renal insufficiency social history: - tobacco history: extensive former smoker, quit about six months ago - etoh: former social drinker - illicit drugs: none patient is originally from . she worked as a midwife in , and worked as a factory worker since moving to the united states. family history: - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: vs: t=97.6 bp= 95/39 hr= 74 rr= 21 o2 sat= 99% ra general: nad. oriented x1 (to place). jaundiced. tachypneic with shallow breathing. heent: ncat. sclera icteric. perrl, eomi. no pallor or cyanosis of the oral mucosa. neck: supple with jvp not elevated. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. iii/vi holosystolic murmur at apex. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. tachypneic, no accessory muscle use. no noted crackles, wheezes or rhonchi on anterior exam. abdomen: soft, ntnd. normoactive bs. no hsm or tenderness. negative sign. extremities: no c/c/e. no femoral bruits, no groin hematoma. extremities cold. skin: no stasis dermatitis, ulcers, scars, or xanthomas. + jaundice. neuro: aaox1, perrl. pulses: right: carotid 1+ dp 1+ pt 1+ left: carotid 1+ dp 1+ pt 1+ pertinent results: admission labs -------------- 06:00pm blood wbc-23.1* rbc-3.86* hgb-9.9* hct-28.0* mcv-73* mch-25.8* mchc-35.4* rdw-17.9* plt ct-374 06:00pm blood neuts-90* bands-3 lymphs-2* monos-2 eos-0 baso-0 atyps-0 metas-0 myelos-3* 06:00pm blood hypochr-2+ anisocy-1+ poiklo-1+ macrocy-normal microcy-2+ polychr-occasional ovalocy-occasional target-2+ burr-occasional pencil-occasional 07:41pm blood pt-13.4* ptt-95.4* inr(pt)-1.2* 07:41pm blood glucose-191* urean-83* creat-2.4* na-135 k-4.8 cl-96 hco3-16* angap-28* 06:00pm blood alt-95* ast-197* alkphos-662* totbili-27.1* 06:00pm blood ctropnt-0.24* 07:41pm blood ck-mb-3 ctropnt-0.26* 06:00pm blood albumin-2.2* calcium-8.6 phos-7.9* mg-4.3* 06:49pm blood type-art o2 flow-15 po2-174* pco2-33* ph-7.30* caltco2-17* base xs--8 intubat-not intuba 09:09pm blood type-art temp-36.4 po2-72* pco2-32* ph-7.32* caltco2-17* base xs--8 06:06pm blood lactate-4.8* . relevant labs ------------- 02:35pm blood wbc-10.4 rbc-3.75* hgb-10.5*# hct-32.5*# mcv-87 mch-28.1 mchc-32.3 rdw-17.4* plt ct-107*# 09:32am blood neuts-34* bands-26* lymphs-23 monos-3 eos-0 baso-0 atyps-0 metas-8* myelos-6* nrbc-28* 09:32am blood hypochr-2+ anisocy-1+ poiklo-1+ macrocy-1+ microcy-1+ polychr-occasional target-occasional burr-occasional 07:41pm blood fibrino-1114* 02:35pm blood glucose-276* urean-65* creat-2.7* na-143 k-7.7* cl-102 hco3-less than 09:32am blood alt-363* ast-1409* alkphos-405* totbili-14.5* dirbili-12.6* indbili-1.9 02:35pm blood calcium-9.5 phos-16.3*# mg-2.9* 02:42pm blood type-art po2-67* pco2-40 ph-6.75* caltco2-6* base xs--33 02:42pm blood lactate-21.2* microbiology ------------ blood culture x 2 sets: pending blood culture x 1 set: pending urine culture : pending sputum culture : pending . imaging ------- ruq us: 1. central intrahepatic biliary dilation with normal caliber common duct; biliary stent not seen. 2. possible gallbladder fundal adenomyomatosis without evidence for acute cholecystitis. 3. 6-mm avascular echogenic focus in the right lobe of the liver, which most likely represents a hemangioma, but correlation with recent prior mri is recommended, since other types of liver lesions are not completely excluded particularly if there is prior maligancy or underlying liver disease. cxr: the endotracheal tube has been pulled back and the tip is no longer within the right main stem bronchus and is 2 cm above the carina. the right ij central venous line has the distal lead tip in the right atrium and again this could be pulled back 3-4 cm for more optimal placement. the orogastric tube tip and side port are within the fundus of the stomach. biliary stent projects over the right upper abdomen. there are bilateral pleural effusions and the right side has increased slightly. there is persistent moderate pulmonary edema. there is unchanged cardiomegaly. a left retrocardiac opacity is present; likely due to atelectasis and pleural fluid. no pneumothoraces are identified. percutaneous biliary drainage: 1. central biliary obstruction. 2. uncomplicated placement of 8 french internal-external biliary drainage catheter via the right intrahepatic biliary duct under ultrasound and fluoroscopic visualization. brief hospital course: 79 yo female with bile duct mass s/p biliary stent placement one week ago, presents with leukocytosis and lactic acidosis with bilirubin elevation, along with diffuse st elevations. pt went to cath lab and had diffuse disease with good collateral flow. given her tenuous condition, relatively preserved cardiac output, and no concerning lesion for acute thrombosis or plaque rupture, she was not intervened upon. the etiology of her and elevated lactate was sepsis from cholangitis. percutaneous biliary drainage was performed with stent placement, but the patient continued to decompensate in spite of the intervention and antibiotic coverage with zosyn and vancomycin. the patient subsequently passed away. . # septic pt presented with wbc 23k with neutrophilia and bandemia, lactate , with elevated anion gap and bilirubin >20 with ruq pain. in the setting of her known cholangiocarinoma with recent stent placement, this was felt to be ascending cholangitis. pt was aggressively fluid rescuscitated, started on vanc/zosyn, and given pressor support with norepinephrine, phenylephrine, and then vasopressin. pts lactate continued to uptrend reaching a peak of >20 with a severe metabolic acidosis which was treated with bicarbonate. blood cultures grew out e coli. the patient was taken for ptbd and a catheter was placed. despite these interventions, the pt continued to decompensate with worsening organ failure and the patient went into asystole. per the daughter's wishes, the patient was not resuscitated at that time. . # respiratory distress: patient with o2 174-->70s post-catheterization with acidotic breathing pattern. she was intubated for worsening respiratory status and airway protection. she was sedated on midazolam and had pain control with fentanyl. . # st elevations: patient presented to osh with chest pain, troponin elevation and diffuse st elevations. she was taken emergently to the catheterization lab and found to have widespread disease, thought to be chronic in nature. this was not intervened upon given the lack of an acute culprit lesion, relatively preserved cardiac output, and the patient's septic state. heparin and plavix were started then held in setting of hematocrit drop and coagulopathy. . # acute on chronic kidney injury: pt with arf with oliguria. most likely due to patient's sepsis. pt developed multiple subsequent electrolyte abnormalities including hyperkalemia which was treated with multiple rounds of calcium gluconate, dextrose and insulin, and sodium bicarbonate. renal was consulted, but given the patient's state of health, dialyis was not pursued. . # diabetes mellitus: pt was on insulin . code: no cpr per hcp : daughter () medications on admission: metoprolol succinate 50 mg po daily hydrochlorthiazide 25 mg po daily amlodipine 2.5 mg po daily metformin 500 mg po daily lisinopril 5 mg po daily glipizide 10 mg po daily tricor 145 mg po daily oxycodone 5 mg po q6h prn pain ciprofloxacin 500 mg po bid discharge medications: n/a discharge disposition: expired discharge diagnosis: n/a discharge condition: n/a discharge instructions: n/a followup instructions: n/a Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Coronary arteriography using two catheters Insertion of endotracheal tube Right heart cardiac catheterization Other percutaneous procedures on biliary tract Percutaneous hepatic cholangiogram Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Acidosis Hyperpotassemia Coronary atherosclerosis of native coronary artery Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Acute myocardial infarction of other anterior wall, initial episode of care Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Cardiogenic shock Septic shock Do not resuscitate status Cholangitis Obstruction of bile duct Malignant neoplasm of intrahepatic bile ducts |
allergies: amoxicillin attending: chief complaint: hypothermia and found down. major surgical or invasive procedure: none. history of present illness: pt was found down in the snow between two cars, so he was brought to the . in the ed, initial vs were: t 34.4 (93.9) p 110 bp 164/158 r 20 o2 sat not able to obtain. patient was given 1l d5, bananna bag, 2l ns wamr solution. etoh 301 initially. pt was given vanc/zosyn as he has a leukocytosis. pt was put on hard collar and 4 mg ativan given to try to get imaging, but they were not sucsesful to obtain good imaging and neck spine was not cleared. patient was admitted to the icu with vitals 37.1, 130, 159/82, 22, 96% on 4l. ekg w/ sinus tach w/o obvious ischemia. 2 peripherals. lactate 11.5 --> 5.7. . on arrival to the icu, c/o severe heartburn and pain in his toes. states that he went out to a russian restaurant and drank a few bottles of vodka, but denies any other ingestion of other illegal substances or medications. he denies smoking and quit in . denies recent infectious sx - no uri sx, cough, sob, diarrhea, dysuria. he remembers not being able to get into his car and then "freezing on the ground" and not being able to call anyone. he does not think he was assaulted. endorses some heavy drinking but unable to quantify. denies withdrawal seizures. + rhinorrhea. . . in the icu he was hydrated and put on pci pump for pain control. he did not require any diazepam for withdrawal. he was hypertensive to 150-170 sbp, which was thought to be due to pain. his temperature was with tmin 37.1 and tmax 37.8 c. antibiotics were not continued and patient was pan-cultured. so far negative ua and blood cultures with negative cxr for pna. since his ck rose up to aggressive hydration was continued. plastics were consulted for frostbite wounds and recommended wound care and arm lift without any need for surgical intervention at this point. patient was stable for ~24 hours in the icu and now is transfered to a medicine floor. . review of sytems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness. denied cough, shortness of breath. deniedchest tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. past medical history: gerd htn (untreated) social history: quit tob in . he has history of 15 pack-year and quit long time ago, but recurred 2 years ago when his wife left him. he succesfully quit smoking again last . unable to quantify etoh consumption, but patient states that he usually does not drink and does not get drunk with 1 week per week. however, he had huge ammount of alcohol with unknown precipitant this time. no history of alcohol seizures in the past. denies other illicits. self-employed watch-maker. no health insurance. lives alone. r-handed. family history: denies any premature cad, htn, dm or cancer. physical exam: vital signs - temp 100.3 f, bp 163/82 mmhg, hr 108 bpm, rr 23 x', o2-sat 99% ra . general - well-appearing man in nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) with left arm on dressing hanging. dressing was not taken down. toes are with mild bluish coloration in the three left lateral ones. good pulses though and patient can move toes without any pain. all compartments of the leg are soft. skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, dtrs 2+ and symmetric, cerebellar exam intact, gait cannot be evaluated at this time. pertinent results: on admission: 08:15am wbc-21.5* rbc-5.41 hgb-17.1 hct-49.8 mcv-92 mch-31.6 mchc-34.4 rdw-13.5 08:15am neuts-85.3* lymphs-11.3* monos-2.6 eos-0.3 basos-0.6 08:15am plt count-509* 08:26am glucose-172* lactate-11.5* na+-149* k+-4.5 cl--105 tco2-12* 08:15am urea n-20 creat-1.5* sodium-140 potassium-6.1* chloride-97 total co2-9* anion gap-40* 08:15am alt(sgpt)-48* ast(sgot)-80* ck(cpk)-3107* alk phos-90 tot bili-0.2 08:15am lipase-20 08:15am ctropnt-<0.01 08:15am ck-mb-7 08:15am asa-neg ethanol-301* acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 08:15am urine hours-random 08:15am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 08:15am fibrinoge-504* 08:15am urine color-yellow appear-clear sp -1.006 08:15am urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 08:15am urine rbc-0 wbc-0-2 bacteria-few yeast-none epi-0 08:15am urine hyaline-* 08:15am urine amorph-few cxr: slight prominence of the cardiac silhouette and also of the right mediastinal contour is likely due to supine and portable technique. the lungs are well inflated and appear clear. no supine evidence for pneumothorax or large pleural effusion is seen. there is convex left scoliosis of the mid thoracic spine. no evidence of fractures noted within the visualized osseous structures. impression: no definite evidence for acute traumatic injury seen. ct head without contrast: severely limited by motion artifact, despite multiple attempts. no major bleed or mass effect. sulcal effacement in bilateral frontal and occipital lobes is indeterminate in nature, likely secondary to motion, however, cerebral swelling cannot be excluded. recommend repeat study when feasible. brief hospital course: this is a 37 m w/o known pmh found down between 2 parked cars, found to be intoxicated, hypothermic w/ elevated lactate, acute renal failure and leukocytosis and frostbite. . # altered mental status: patient arrived with ams and very combative. ct scan was negative for acute bleeding or edema and metabolic work up was only positive for alcohol level of 301 with otherwise negative tox screen. patient improved with hydration within 24 hours back to baseline. . # etoh intoxication: unclear history of drinking, but patient denied any chornic alcohol intake and that this alcohol binge was an isolated event without any clear precipitat. patient received folate, thiamine and multivitamins as well as hydration. he did not require any valium during the hospitalization. social work was consulted and he was adviced not to do it again and effects of alcohol. medical team also extensively discussed quitting alcohol. . # frostbite: patient seen by plastics for multiple frostbite lessions in left forearm and hand, right fingers and left toes. he was seen by plastic surgery, whoi did not recommend surgical intervention, but only dressing changes and follow up with them. lessions were extremely painful and patient required pca for 1.5 days. he was switched to oral moprhine sr with breakthrough pain. he was able to tolerate up to 30 mg of sr and 15 mg of morphine eveyr 3 hours. it is expected that pain will improve as immflamation and necrotic area improves. he was trained how to do dressing changes, was given prescription for material and will be followed in plastic surgery clinic. . # leukocytosis: mostly pmns with nadir of 21.5 upon admission. ua neg for uti, cxr w/o obvious infiltrates, blood and urine cultures were negative. received vanc/zosyn in ed empirically for "overwhelming infection". patient did not have any signs of infection on physical exam, but had extensive inflammation in frostbite areas. this in combination with dehydration was thought to be the etiology for the leukocytosis. upon discharge his wbc were 8.9. . # acute renal failure: unknown creatinine baseline with a creatinine of 1.5 upon admission. creatinine improved with hydration within 24 hours of admission to 1.0. hydration was continued to protect kidneys from toxicity duet rhambdomyolisis (nadir 22,000). . # hypernatremia: corrected with hydration. . # fen: repleted electrolytes, regular diet. . # prophylaxis: subcutaneous heparin & bowel regimen with standing colace/senna. . # access: 1 peripheral. . # code: full code. . # disposition: to his parents home with new pcp and plastics follow up. medications on admission: ranitidine occasional aspirin discharge medications: 1. multivitamin tablet sig: one (1) tablet po daily (daily). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 5. morphine 15 mg tablet sustained release sig: two (2) tablet sustained release po q12h (every 12 hours). disp:*48 tablet sustained release(s)* refills:*0* 6. morphine 15 mg tablet sig: one (1) tablet po q3h (every 3 hours) as needed for pain. disp:*80 tablet(s)* refills:*0* 7. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. xeroflo gauze dressing 2 x 2 bandage sig: one (1) topical once a day. disp:*40 gauzes* refills:*2* discharge disposition: home discharge diagnosis: primary diagnosis: acute alcohol intoxication frostbite . secondary diagnosis: hypertension gastro-esophageal refllux disease discharge condition: stable, tolerating diet, walking. discharge instructions: you were seen at after being found down in the cold. upon admission your alcohol blood level was very high and you had frostbites in your fingers ant toes. you were seen by plastic surgery who did not think surgery was required at this time point, but you will require follow up with them. you were treated for your alcohol intoxication with hydration, vitamins and monitor for signs of withdrawal. originally your kidneys were not working properly, but they recuperated and now are normal. you had muscle breakdown due to being down. . please come back to the er if you stop peeing, you start getting swollen, severe muscle pain, severe headache, tremors or anything else that concerns you please come to the er. . you will also need to do daily dressing changes with the medicated gauzes and cover your wounds as you were taught. . you must stop drinking and have food follow up with your new primary care. followup instructions: you must call today the free care office at: . . please call the plastic surgery clinic as well as and talk to . . provider: surgery clinic phone: date/time: 3:30 provider: , md phone: date/time: 2:30 Procedure: Alcohol detoxification Diagnoses: Acidosis Hyperpotassemia Anemia, unspecified Esophageal reflux Unspecified essential hypertension Acute kidney failure, unspecified Alcohol abuse, unspecified Hyperosmolality and/or hypernatremia Acute pain due to trauma Rhabdomyolysis Leukocytosis, unspecified Other alteration of consciousness Hypothermia Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Accident due to excessive cold due to weather conditions Frostbite of hand Frostbite of foot Blister of finger(s), without mention of infection |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with stents x2 to om1 percutaneous aortic valvuloplasty history of present illness: 81m hx copd presents with substernal chest pressure without radiation or associated nausea/sob/radiation since 4pm . he presented to osh on am with fairly continuous chest pressure, which he has never experienced before, ekg without ischemic changes but his tropi was 22. he was given asa 325, plavix loaded and transferred on a heparin gtt for cath. . at cath, found to have critical as with valve area 0.4 and 95% om1 lesion as probable culprit, with 40% lmca ostial, 30% lad, 70% mid lcx and a small nondominant rca. in setting of as, no intervention was undertaken for ?ct surgery intervention for avr and cabg. . he was transferred to the ccu for closer monitoring due to poor hemodynamics with a ci of 1.8. on arrival, he only complained of baseline shortness of breath he attributes to his copd. he was chest pain free. past medical history: copd (emphysema), utis, htn, hlp social history: previous smoker, quit 22 years prior. does not drink. family history: non-contributory physical exam: admission exam vitals: pulse 91, bp 100/49, 96% on ra gen: elderly man in nad, aox3 neck: minimal jvd appreciated at 30 degrees cv: distant heart sounds, difficult to auscultate resp: bibasilar crackles, prolonged i:e ratio, expiratory wheezes abd: +bs, abdominal bruit appreciated, soft ntnd -hsm, no pulsatile liver ext: + peripheral edema neuro: aox3 discharge exam general: 81 yo m in mild distress, appears tired and anxious heent: mucous membs dry, no lymphadenopathy, jvp non elevated chest: ctabl, no wheezes cv: s1 s2 normal in quality and intensity irreg irreg, no murmurs rubs or gallops abd: soft, non-tender, non-distended, bs normoactive. not able to palpate bladder. ext: wwp, no edema. dps, pts 2+. left groin without hematoma, ecchymosis. neuro: a/o, no focal defects, speech clear skin: no rash psych: sl anxious. pertinent results: admission labs 08:55pm blood wbc-11.1* rbc-4.28* hgb-12.9* hct-38.5* mcv-90 mch-30.3 mchc-33.6 rdw-13.2 plt ct-233 08:55pm blood neuts-73.5* lymphs-15.2* monos-10.5 eos-0.6 baso-0.4 08:55pm blood pt-12.8* ptt-42.6* inr(pt)-1.2* 08:55pm blood glucose-114* urean-16 creat-0.6 na-137 k-4.1 cl-100 hco3-31 angap-10 08:55pm blood calcium-8.4 phos-2.9 mg-2.0 cholest-151 . discharge labs complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 09:10 10.7 3.40* 10.7* 30.7* 90 31.4 34.8 12.8 284 08:00 11.5* 3.68* 11.4* 33.0* 90 31.0 34.6 13.1 286 basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 09:10 284 09:10 14.0*1 113.6*2 1.3* 02:17 37.5*1 heparin dose: 600 chemistry renal & glucose glucose urean creat na k cl hco3 angap 09:10 4.0 97 37* 9 21:45 135 4.1 95* 08:00 108*1 19 0.8 139 4.0 96 37* 10 estimated gfr (mdrd calculation) estgfr 08:00 using this1 cpk isoenzymes ck-mb 21:45 5 cardiac enzymes 08:55pm blood ck-mb-128* mb indx-10.9* ctropnt-2.59* 07:00am blood ck-mb-56* ctropnt-2.22* . cardiac risk factors 08:55pm blood triglyc-66 hdl-63 chol/hd-2.4 ldlcalc-75 . pertinent studies cardiac cath () comments: 1. selective coronary angiography demonstrated in this left dominant system demonstrated one vessel disease. the lmca had 40% ostial stenosis. the lad had a mid 30% stenosis. the lcx had a mid 70%, 95% major om1. the rca was small non dominant. 2. resting hemodynamics demonstrated right and left elevated filling pressures with rvedp 15mmhg and lvedp 22 mmhg. the pcwp was elevated at baseline 16 mmhg. there was moderate pulmonary arterial hypertension at rest, with pasp 45 mmhg. the cardiac output was low, with ci 1.79 l/min/m2. there was severe aortic stenosis with peak gradient of 60 mmhg and a calculated aortic valve of 0.4 cm2. 3. left ventriculography was deferred. final diagnosis: 1. one vessel coronary artery disease. 2. moderate pulmonary hypertension. 3. severe aortic stenosis. . cxr () ap chest reviewed in the absence of prior chest radiographs: hyperinflation reflects copd. no focal pulmonary abnormality. technical artifact produces misregistration at the lung bases not to be mistaken for pneumothorax or other abnormality. there is no pleural effusion. cardiomediastinal and hilar silhouettes are normal aside from atherosclerotic calcification of the aorta. . echo () conclusions the left atrium is normal in size. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are severely thickened/deformed. there is significant aortic valve stenosis. peak and mean gradients place as in the moderate range, though precise calculation of valve area is limited by technically-suboptimal lvot jet velocity measurement. the mitral valve leaflets are not well seen. there is an anterior space which most likely represents a prominent fat pad. impression: very limited study. normal global biventricular systolic function. aortic stenosis, probably moderate. . chest ct () impression: 1. several bilateral pulmonary nodules, including dominant 8 and 10 mm right apical nodules. in the setting of apical scarring, the apical nodules could potentially be due to nodular scarring. however, in the setting of emphysema, pet-ct should be considered for further evaluation in order to exclude a primary lung cancer. 2. mild-to-moderate centrilobular emphysema in the upper lobes. apparent coexisting panlobular emphysema in lower lobes. considering coexisting moderate bronchiectasis, alpha-1 antitrypsin deficiency should be considered. 3. severe aortic valve and coronary artery calcifications. 4. bilateral hypodense adrenal nodules, most consistent with adenomas. 5. anterior wedge compression fracture of vertebral body t12, age indeterminate, as no priors are available for comparison. . echocardiogram suboptimal image quality. significant aortic stensosis. compared with the prior study (images reviewed) of , the peak transaortic velocity has increased from 2.8 m/s to 3.9 m/s and the peak transaortic pressure gradient has increased from 32 mmhg to 60 mmhg. these findings are more consistent with the visual appearance of the aortic valve with severely thickened leaflets and limited leaflet mobility (at least severe aortic stenosis visually and by velocities/transvalvular gradients), however in the absence of a measurement of the lvot dimensions and a peak lvot velocity tracing a definitive measurement of the aortic valve area cannot be made. . cardiac catheterisation 1. severe aortic stenosis 2. successful balloon valvuloplasty of aortic valve with 22mm tyshak ii balloon with improvement in sbp and gradient 3. successful lfa angioseal. 4. plan for pci lcx later in week. . carotid ultrasounds study: carotid series complete findings: duplex evaluation was performed of bilateral carotid arteries. on the right there is moderate heterogeneous plaque seen in the ica . on the left there is mild heterogeneous plaque seen in the ica. on the right systolic/end diastolic velocities of the ica proximal, mid and distal respectively are 120/24, 95/27, 106/16, cm/sec. cca peak systolic velocity is 106 cm/sec. eca peak systolic velocity is 196 cm/sec. the ica/cca ratio is 1.1 . these findings are consistent with 40-59% stenosis. on the left systolic/end diastolic velocities of the ica proximal, mid and distal respectively are 68/15, 85/22, 76/28, cm/sec. cca peak systolic velocity is 100 cm/sec. eca peak systolic velocity is 108 cm/sec. the ica/cca ratio is .85 . these findings are consistent with <40% stenosis. there is antegrade right vertebral artery flow. there is antegrade left vertebral artery flow. impression: right ica 40-59% stenosis. left ica <40% stenosis. . brief hospital course: 81m hx copd, htn, hlp who presented to osh after ~12-16 hours of chest pressure, found with nstemi with trop of 22, transferred for cath. here found 95% likely culprit major om1 lesion and critical as. . # nstemi/low ci: he had no further chest pain during his hospitalisation here. ck-mb was flat at 5. he underwent cardiac catheterisation which showed critical as and om1 stenosis, and underwent spaced aortic valvuloplasty and bare metal stenting of his om1 during this hospitalisation. these procedures were successful. he was started on aspirin, plavix, atorvastatinno further chest pain. plan for pci to om1 on today. on asa, plavix, statin. beta blocker was not started due to starting amiodarone for rate/rhythm control of atrial fibrillation. he was also started on a heparin drip and transitioned to warfarin. . # critical as: cardiac catheterisation revealed critical aoritc stenosis. he was evaluated by cardiothoracic surgery for possible valve replacement, but felt not to be an operative candidate on account of porcelain aorta and significant copd/ emphysema. the patient underwent valvuloplasty with 50% reduction in gradient. he tolerated the procedure well and has been stable since. . # atrial fibrillation/flutter: patient was noted to have atrial fibrillation/ atrial flutter, and was started on amiodarone, which he will receive tid until . subsequently, please decrease his amiodarone dose to 200 daily. he was also started on a heparin drip and transitioned to warfarin, which he will continue following discharge. . # copd: on spiriva/advair at home. o2 sat >95% on ra here. he had occasional wheeze but no dyspnea or cough. he was continued on albuterol and ipratropium nebulisers and treated with advair and spiriva during his hospitalisation. . # pulmonary nodules: found on ct concerning for malignancy. this finding was discussed with patient and family. he will need to followup with a pet-ct as an outpatient. . # hyperlipidemia: was on simvastatin at home, this was changed to atorvastatin 80 mg post-mi. . # urinary obstruction: patient had poor urine output, but had >800 cc residual urine in his bladder. foley catheter was placed; when removal was attempted, he failed a voiding trial. foley catheter was therefor replaced and he will have a furtehr voiding trial in rehab. tamsulosin was started to treat bph. . # psychosocial: he was seen by social work and provided with support regarding coping following his new diagnosis. . transitional issues: 1. patient is starting warfarin for atrial fibrillation and will need inr monitoring and appropriate warfarin dose titration following discharge. 2. during his hospitalisation, he was ntoed to have urinary retention and foley catheter was placed. please perform a voiding trial in days and remove foley catheter as tolerated. 3. ct chest revealed a pulmonary mass and other nodules. please schedule a pet-ct for further evaluation for possible malignancy. medications on admission: simvastatin, nifedipine, advair, spiriva (does not know dosages). discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po once a day. 2. senna 8.6 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for constipation. 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. 4. warfarin 3 mg tablet sig: one (1) tablet po once a day. 5. atorvastatin 80 mg tablet sig: one (1) tablet po once a day. 6. clopidogrel 75 mg tablet sig: one (1) tablet po once a day. 7. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 8. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) vial inhalation q6h (every 6 hours) as needed for wheezing. 10. ipratropium bromide 0.02 % solution sig: one (1) vial inhalation q6h (every 6 hours) as needed for wheezing. 11. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime) for 1 weeks. 12. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). tablet, delayed release (e.c.)(s) discharge disposition: extended care facility: bay skilled nursing & rehabilitation center - discharge diagnosis: acute on chronic diastolic congestive heart failure critical aortic stenosis s/p valvuloplasty non st elevation myocardial infarction new aflutter urinary retention coronary artery disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you had a heart attack and was taken to for evaluation. a catheterization showed a very tight aortic valve and multiple blockages in your heart arteries. a valvuloplasty was done to open the valve and two bare metal stents were placed in one of your heart arteries which was thought to be the artery responsible for your heart attack. you are on many new medicines to prevent another heart attack and a stroke. it is extremely important for you to take these medicines every day. you had some fluid overload because of the heart attack that was treated with a diuretic to remove the extra fluid. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. you were found to be in an irregular heart rhythm called atrial flutter, amiodarone was started to help regulate the rhythm and warfarin was started to prevent a stroke from the rhythm. . you had trouble urinating and a catheter was replaced in your bladder. it will stay in a week and then be removed again. you will need to see a urologist if you are still having trouble after one week. we made the following changes to your medicines: 1. stop taking nifedipine and simvastatin 2. start aspirin and clopidogrel (plavix) to keep the stent open. do not miss or stop taking clopidogrel for any reason unless dr. tells you it is ok 3. start taking atrovastatin to lower your cholesterol 4. start taking tamsulosin to decrease the swelling in your prostate 5. start taking amiodarone to regulate your heart rhythm 6. start taking senna and colace to prevent constipation 7. start taking warfarin to prevent a stroke from the aflutter 8. start taking albuterol and ipratroprium as needed for wheezing. 9. start taking trazadone as needed for sleep. followup instructions: cardiology: dr. 7, clinical center , thursday at 2:45pm best parking: garage Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Endovascular replacement of aortic valve Diagnoses: Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrial fibrillation Acute on chronic diastolic heart failure Aortic valve disorders Personal history of tobacco use Atrial flutter Other and unspecified hyperlipidemia Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Retention of urine, unspecified Solitary pulmonary nodule Urinary obstruction, not elsewhere classified |
allergies: no known allergies / adverse drug reactions attending: chief complaint: extra axial brain stem mass major surgical or invasive procedure: left craniotomy for excision of brain stem mass history of present illness: this is a 24 yo m, who has a 3 yrs history of vague eye issues which aggravated in with double vision on r gaze. he reports double vision with his left eye on r gaze and he describes skewed images c/w 4th cn palsy. approx. 1 yr ago, he had been through an episode of sudden onset excruciating headaches, which lasted for about 1 week. this came about very sudden, and lasted for a while. he had rather unremarkable ha episodes for most of his life. he was evaluated for lazy eye surgery and worked up for his ha with an mri scan, revealing a l skull base lesion with cysctic and solid components, most likely representing a benign tumor. he currently denies ha, n, v, dz, sz. past medical history: epression/anxiety psh: baby tooth removal ; tooth exposures, ; wisdom tooth extraction social history: student; politial science major; currently unemployed non-smoker; non-drinker; marital status: single family history: nc physical exam: on admission: af vss; 6'1''; ca 180 lbs nad neck: supple, no lnn heent unremarkable rrr no sob nttp warm peripherals, no cce neuro: aao x3; normal mentation; pleasant, cooperative normal recall, fluent speech and comprehension. cn: i not tested ii: vision adequate and no vfc to confrontation iii-vi: left 4th cn palsy v: nl sensation and bite strength vii symmetric viii hears finger rubs bilaterally no swallowing difficulties; palate midline, cough + tongue midline bilaterally full strength, no drift normal sensation to lt, vibration no paresthesias symmetric reflexes 2+ b; babsinski - stand and gait stable; rhomberg - no ataxia, dysmetria or dysdiadochokinesis; fine movement and coordination intact on discharge: a&ox3 perrl eoms intact vision acuity stable with glasses full motor throughout incision: slight oozing at l temporal region stable with pressure dressing. dissolvable sutures in place. pertinent results: osh mri (the imaging institute ri; ) this reveals a l sided skull base tumor at the level of the prepontine cistern that ahs a solid, contrast enhancing component measuring ca 2cm; sharply demarkated and displacing the hypothalamus upwards, the mesial temporal lobe laterally and the brainstem posteriorly; there is a second cystic component in the left posterior brain stem c/w an extension indenting the l brain stem and displacing it. mri brain: impression: surgical planning study demonstrates partially solid and partially cystic enhancing lesion in the left suprasellar cistern as well as in the cavernous sinus deforming the left side of the mid brain and pons. the differential diagnostic consideration includes a schwannoma as suggested previously. ct head: impression: expected postoperative changes as described above without evidence of acute hemorrhage. mri brain: status post resection of left-sided cavernous sinus and prepontine cistern mass with some residual enhancement near the brainstem and mild mass effect. the majority of the solid component and portion of the cystic components have appeared to be resected since the previous study. expected post-surgical changes are seen. the tiny area of diffusion abnormality, best visualized on series 502, image 15 could be due to postoperative change, blood products or due to a tiny area of ischemia. given its small size, it is difficult to characterize. no definite territorial infarcts seen or brainstem infarct identified brief hospital course: mr. was admitted electively for craniotomy for removal of a left sided brainstem lesion. postoperatively he was extubated and transfered to the icu for frequent neuro checks and sbp control less than 140. postop head ct demonstrated some pneumocephalus but no hemorrhage. he remained neurologically stable overnight. on he underwent a brain mri which revealed residual enhancement near the brainstem and edema. he was cleared for transfer to the floor and started on sqh. on , he was stable on examination with improvement in both his ue tremors and visual acuity. his dressing was removed and some oozing was seen at the l temporal region which was re-enforced with a dressing to help clotting. he was evaluated with pt which determined that he needed home pt and vna services for wound checks. medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. bupropion (sustained release) 150 mg po bid discharge medications: 1. bupropion (sustained release) 150 mg po bid 2. phenytoin sodium extended 100 mg po tid rx *dilantin extended 100 mg 1 capsule(s) by mouth three times a day disp #*180 tablet refills:*2 3. oxycodone (immediate release) 5-10 mg po q4h:prn pain rx *oxycodone 5 mg tablet(s) by mouth every four (4) hours disp #*60 tablet refills:*0 4. docusate sodium 100 mg po bid rx *colace 100 mg 1 capsule(s) by mouth twice a day disp #*60 tablet refills:*0 5. dexamethasone 2 mg po q8hrs please take 2mg q8h x1 day starting , then take 1 mg (0.5 tab) q8hx 1 day, then 1mg q12h x 1 day, then 1mg once x 1 day, then off tapered dose - down rx *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8) hours disp #*12 tablet refills:*0 discharge disposition: home with service facility: vns of & counties discharge diagnosis: brain stem mass discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: general instructions ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? your incision was closed with dissolvable sutures. you may shower on the 3rd day after surgery. ?????? 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 have been prescribed dilantin (phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. this can be drawn at your pcp??????s office, but please have the results faxed to . ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: follow-up appointment instructions ??????you have an appointment in the brain clinic on @ 10:30. the brain clinic is located on the of , in the building, . their phone number is . please call if you need to change your appointment, or require additional directions. Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Other repair of cerebral meninges Diagnoses: Benign neoplasm of brain Diplopia Fourth or trochlear nerve palsy |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass graft x 5 (left internal mammary > left anterior descending, saphenous vein graft > obtuse marginal 1, saphenous vein graft > obtuse marginal 2, saphenous vein graft > distal right coronary artery > posterior descending artery) cardiac catheterization history of present illness: 68 year old male with dyspnea on exertion for past 5 months relieved with rest. occasional chest tightness (gerd like) symptoms with exertion. he is able to walk mile before he would experience shortness of breath and relieved almost immediatly with rest. he had stress test at and was interpreted as positive and was sent for cardiac catheterization. he was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. past medical history: borderline diabetes hypercholesterolemia glaucoma seborrheic keratosis social history: lives with:wife occupation:/consultant cigarettes: smoked no other tobacco use:denies etoh: drinks/week illicit drug use: denies family history: father mi in 70's physical exam: pulse:71 resp:18 o2 sat:98/ra b/p 151/92 height:5'9" weight:200 lbs general:nad, alert, cooperative skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular no murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm x, well-perfused edema _____ varicosities: none well healed wound left lateral lower leg neuro: grossly intact pulses: femoral right: +2 left:+2 dp right:+2 left:+2 pt :+2 left:+2 radial right:+2 left:+2 carotid bruit right: none left:none pertinent results: cardiac catheterization : 1. selective coronary angiography of this right dominant system demonstrated three vessel coronary artery disease. the lmca had no angiographically-apparent significant stenosis. the lad had a proximal 99% stenosis, 100% d1 stenosis. right to left collaterals to lad and d1. the lcx had a 60% om1 stenosis, with a long 60% stenosis om2. the rca had a mid 70% stenosis, a 50% ostial and mid 90% pda. 2. limited resting hemodynamics revealed normal systemic arterial pressures at the central aortic level 105/69 mmhg. 3. left ventriculography was deferred. echo pre-cpb: no spontaneous echo contrast is seen in the left atrial appendage. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. post-cpb: the patient is a-paced, on no inotropes. preserved biventricular systolic pressure. trivial mr. . aorta intact. carotid ultrasound impression: right ica no stenosis. left ica <40% stenosis 11:22am blood wbc-12.5* rbc-3.86* hgb-11.3* hct-33.8* mcv-88 mch-29.3 mchc-33.5 rdw-13.4 plt ct-210# 04:41am blood urean-29* creat-1.0 na-140 k-3.9 cl-102 06:45pm blood alt-25 ast-24 alkphos-6* amylase-58 totbili-0.6 04:41am blood mg-2.5 12:45pm blood %hba1c-5.9 eag-123 06:45pm blood triglyc-84 hdl-45 chol/hd-2.7 ldlcalc-58 brief hospital course: mr. was admitted to the on following a cardiac catheterization which revealed severe three vessel coronary disease. the cardiac surgical service was consulted and he was worked up in the usual preoperative manner. a carotid ultrasound was performed which showed a normal right and less then 40% stenosis of the left internal carotid artery. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to five vessels. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. over the next several hours, he awoke neurologically intact and was extubated without complications. on post operative day one he was started on betablockers and lasix for gentle diuresis. he continued to progress and was transferred to the floor. physical therapy worked with him on strength and mobility.chest tubes and pacing wires removed per protocol. continued to make good progress and was cleared for discharge to home with vna on pod #4. all f/u visits were advised. medications on admission: levothyroxine 88 mcg daily metformin 850 mg twice daily simvastatin 40 mg daily aspirin 325 mg daily cholecalciferol 1,000 unit daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. disp:*28 tablet(s)* refills:*0* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*1* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain or fever . disp:*50 tablet(s)* refills:*0* 5. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 6. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*1* 7. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 8. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 9. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*1* 11. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 1 weeks. disp:*7 tablet(s)* refills:*0* 12. potassium chloride 10 meq tablet extended release sig: one (1) tablet extended release po daily (daily) for 1 weeks. disp:*7 tablet extended release(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: coronary artery disease s/p cabg diabetes mellitus type 2 hypercholesterolemia glaucoma seborrheic keratosis discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions: sternal - healing well, no erythema or drainage leg right - healing well, no erythema or drainage edema trace discharge instructions: 1) please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage. 2) please no lotions, cream, powder, or ointments to incisions. 3) each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) no driving for approximately one month and while taking narcotics. driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) no lifting more than 10 pounds for 10 weeks 6) please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: wound check at 10:15am - cardiac surgery office medical building surgeon: dr at 1:30pm cardiologist: dr at 10:40am please call to schedule appointments with your: primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Other iatrogenic hypotension Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Unspecified glaucoma Other and unspecified hyperlipidemia Examination of participant in clinical trial Other seborrheic keratosis |
allergies: no known allergies / adverse drug reactions attending: chief complaint: elective admission for cranitomy and resection of tumor major surgical or invasive procedure: craniotomy for tumor resection and biopsy history of present illness: this is a 79 year old male who presents to clinic today for consent signing for his upcoming craniotomy procedure. he has a known l sided parietal lesion suspicious for metastatic melanoma that is in need of surgical resection. he as last seen in clinic 2 weeks ago and at that time we sent him for a fmri test, as he is r hand dominant. he has no other changes in his symptoms, and per his daughter, he has persistent confusion. no other changes in his health since last appointment. past medical history: 1. hypertension 2. benign prostatic hypertrophy. social history: never smoked, no alcohol. lives with daughter (, home, , cell). recently came back from where he first noticed these symptoms. family history: no familyhistory of premature coronary disease or sudden cardiac death. mother had angina, died at age 84. father ? h/o arrhythmia. physical exam: gen: wd/wn, comfortable, nad. heent: pupils: perrl eoms full without nystagmus neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3mm to 2mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue with r deviation, no fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch, propioception, pinprick and vibration bilaterally. coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin on discharge: neuro intact with occasinal minor confusion, incision is c/d/i, patient is ambulatory without assistance pertinent results: previous mri right frontal lesion ct head post op 1. post-surgical changes at the left frontoparietal region with expected pneumocephalus and tiny blood products. 2. persistent vasogenic edema at the left frontal lobe. 3. enhancing lesion at the right frontal lobe better evaluated on recent mri. post op mri status post resection of left frontal lobe mass with expected post-operative changes. no new lesions are detected. the right frontal enhancing mass appears unchanged. brief hospital course: pt was admitted to neurosurgery service and underwent a right frontal craniotomy for tumor resection on . pt tolerated this procedure very well with no complications. post operatively he was transferred to the icu for continued care including q1 neuro checks and strict blood pressure control. on post op exam he is aox3, following commands and moving all ext with full strength, he has no change from his baseline. a post op head ct showed good resection of lesion with no acute hemorrhage. pt was transferred to the floor on , his diet was advanced, his foley was removed and he was sdeemed fit for discharge on the morning of as he was ambulatory in the hallways without assistance. he as given instructions for followup and discharged on the afternoon of medications on admission: atorvastatin - 10 mg tablet - 1 tablet(s) by mouth once a day dexamethasone - 0.5 mg tablet - 2 tablet(s) by mouth once a day epoetin alfa - (prescribed by other provider) - dosage uncertain hydrocortisone acetate - (dose adjustment - no new rx) - 25 mg suppository - 1 suppository(s) rectally inserted twice a day prn isosorbide mononitrate - (dose adjustment - no new rx) - 60 mg tablet sustained release 24 hr - 1 tablet(s) by mouth once a day levetiracetam - 500 mg tablet - 1 tablet(s) by mouth twice a day omeprazole - (prescribed by other provider; dose adjustment - no new rx) - 20 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth daily ranolazine - 500 mg tablet sustained release 12 hr - 1 tablet(s) by mouth twice a day tamsulosin - (dose adjustment - no new rx) - 0.4 mg capsule, sust. release 24 hr - 1 capsule(s) by mouth twice a day - no substitution discharge medications: . 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever/pain. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 4. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 5. dexamethasone 2 mg tablet sig: per taper tablet po per taper: 2mg q6hours on , 2mg on and continue until follow-up. disp:*90 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: metastatic melanoma 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 and/or staples have been removed. if your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? if you have been prescribed dilantin (phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. this can be drawn at your pcp??????s office, but please have the results faxed to . if you have been discharged on keppra (levetiracetam), you will not require blood work monitoring. ?????? if you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (prilosec, protonix, or pepcid), as these medications can cause stomach irritation. 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. 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: follow-up appointment instructions ??????please return to the office in days (from your date of surgery) for removal of your staples/sutures and/or a wound check. this appointment can be made with the nurse practitioner. please make this appointment by calling . 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 clinic on at 1030am. the brain clinic is located on the of , in the building. their phone number is . please call if you need to change your appointment, or require additional directions. ??????you will need an mri of the brain with and without gadolinium contrast. this is scheduled for 915am on pn the . please cal to confirm your appointment Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Other repair of cerebral meninges Computer assisted surgery with MR/MRA Other intraoperative magnetic resonance imaging Diagnoses: Coronary atherosclerosis of native coronary artery Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Percutaneous transluminal coronary angioplasty status Other and unspecified angina pectoris Secondary malignant neoplasm of brain and spinal cord Personal history of malignant melanoma of skin Secondary malignant neoplasm of other digestive organs and spleen Secondary malignant neoplasm of retroperitoneum and peritoneum Other specified acquired deformity of head |
allergies: no known allergies / adverse drug reactions attending: chief complaint: respiratory failure major surgical or invasive procedure: intubation, mechanical ventialtion history of present illness: mr. is a 57 year old man with a history of relapsed multiple myeloma who presents with mental status changes. per his daughter, was intermittently confused for the past week. he thought he was supposed to come for a platelet transfusion this evening (appointment is tomorrow), so he drove himself to the building but was confused there and was transported the ed. he had a headache prior to arrival to the ed. he has required multiple tranfusions of blood and platelets, every days, last one on . per his records, he called his oncologist's office on with increased daytime sleepiness. he had not been wearing his cpap due to epistaxis. platelets on were 11,000 and anc was 900. . he was last seen by his oncologist on and was due to start his 4th cycle of velcade, bendamustine and dexamethasone but this was held due to low blood counts. . in the ed, initial vitals were: 98.6 98 160/88 22 96%. a stat head ct showed air-fluid levels in the maxillary sinuses without intracranial hemorrhage. he later had a rectal temperature of 103. guaiac was positive with brown stool. cxr also showed pna. hct was 26.0 (last values of 22.7 and 28.6) and platelets were 8. creatinine was 3.5 (baseline 1.2 1/11 per atrius). he was neutropenic with an anc of 754. he was given vanc and cefepime. he was tachypneic and there are reports of hemoptysis. he reportedly became more hypoxic, lethargic and tachypneic and was intubated. he was put on propofol, then fentanyl/versed. vent setting prior to transport: rate 14, fio2 100%, peep 10 o2 sat 97%. he received 2l of ns prior to arrival. . past medical history: multiple myeloma dx , recently treated with velcade, bendamustine, dexamethasone . bacterial endocarditis atrial fibrillation hypertension anemia hypercholesterolemia obesity coagulation disorder with elevated pt/ptt . oncologic history : evaluated for anemia, bone soreness and coagulopathy, found to have mm with igg level of 1.7g with monoclonal igg lambda spike. free labda light chains 1490mg in serum bone marrow 59% plasma cells. had extensive bony lesions and renal insufficiency. : xrt to right femoral neck and l4 spinus process which had a pathological fracture. received 6 cycles of velcade/decadron. tried thalomid and revlimid but did not tolerate either : bmbx showed minimal but persistent involvement with plasma cell dyscrasia, 8% plasma cells. maintained on decadron alone :: developed progression of disease with soft tissue mass at t9-t10 causing cord compression, started high-dose dexamethasone. xrt t8-t10 at : started velcade/decadron, but hospitalized x 2 duet o recurrent fevers, found to have small vegetation on aortic vavle but no positive blood cultures. treated emperically with doxycycline due to possible bartonella, acyclovir, bactrim. : velcade and decadron with doxil on total of 5 cycles. : repeat bmbx 50% plasma cells, inadequate response to chemotherapy : velcade, dexamethasoen, cyclophosphamide, revlimid for a total of 8 cycles. cytoxan held for 6th cycle but then resumed. : developed jaw osteonecrosis; bisphosphonate held : autologous stem cell transplantion with melphalan conditioning. : revlimid started 5mg/day : bmbx 30% plasma cells, revlimid increased to 10mg/day : free lambda light chains 137; revlimid increased to 20mg and dexamethasone 40mg weekly added : revlimid d/c'd due to increasing light chains and cytopenias : resumed cyclophosphamide, velcade, dexamethasone and had progression after 1 cycle : chemotherapy switched to bendamustine, velcade, dexamethasone, received 3 cycles so far . . allergies: nkda . social history: social history: per records, non-smoker . family history: family history: unable to obtain . physical exam: physical exam: vs: temp: 101.6 bp: 131/75 hr: 94 97% on 400x20 (rr 30) peep 10 fio2 100% gen: intubated, sedated nad heent: perrl, eomi, anicteric, dried blood in oropharynx and nares bilaterally. no blood in ett. resp: cta b/l with good air movement throughout cv: tachycardic, s1 and s2 wnl, no m/r/g abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: 3+ pitting edema of feet and anterior shins bilaterally. skin: no rashes. cool extremities. 2+ peripheral pulses. neuro: sedated . pertinent results: . ekg: nsr at 90bpm . imaging: cxr pa & lat: bilateral infiltrates, l>r. ett 2cm above carina. ogt in place. . head ct: air-fluid levels in maxillary sinuses, no ich. brief hospital course: 57m with a history of end-stage multiple myeloma who presented with ams and respiratory failure. viral swab was positive for rsv and he was found to have sepsis with e.coli + psudomonal bacteremia with likely foci of infection being pneumonia and uti. he also had air-fluid levels in his maxilary sinuses concerning for sinus infection. patient was intubated and ventilated on admission. wide-spectrum antibiotics were administered as well as an anti-fungal for possible fungal infection in the setting of his immune supression. his hospital course was complicated by oliguric renal failure and pancytopenia with no response to antibiotics and supportive therapy including iv fluids and blood products. on hospital day 6, in view of his end-stage underlying condition and the development of multi-organ failure and in keeping with his family's wishes goals of care were changed to focus on comfort, patient was extubated and expired shortly thereafter with his family at the bedside. medications on admission: medications at home: vitamin b6 100mg po daily multivitamin 1 tab po daily bactriom ds 1 tab mwf omeprazole 20mg po bid atenolol 100mg po daily compazine 5mg po q6h prn nausea marinol 5mg po daily bupropion sr 200mg po qam ondansetron 8mg po q8h prn morphine sr 15mg po daily acyclovir 400mg po bid dexamethasone ? 4-16mg daily with 40mg weekly discharge medications: na discharge disposition: expired discharge diagnosis: na discharge condition: na discharge instructions: na followup instructions: na md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Anemia, unspecified Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Peripheral stem cells replaced by transplant Acute respiratory failure Septicemia due to escherichia coli [E. coli] Other and unspecified coagulation defects Neutropenia, unspecified Multiple myeloma, in relapse |
allergies: morphine attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: : redo sternotomy, aortic valve replacement (tissue) history of present illness: 86 year old female with a history of aortic valve replacement 14 years ago and hypertension, hyperlipidemia who has noticed dyspnea with minimal exertion and fatigue over the past months. patient states she will fall asleep numerous times throughout the day after any type of activity. she states she will occasionally feel dizzy while walking which she attributes to her vertigo. she will take her antivert and the dizziness will subside. she underwent a cardiac catheterization in which revealed of 0.6 and 20% lad stenosis. she was seen by dr. after her cardiac catheterization and returns today for preadmission testing. past medical history: aortic stenosis hypertension hyperlipidemia gerd vertigo basal call s/p removal from temple x4 (hands and legs) anxiety arthritis hiatal hernia past surgical history: tonsillectomy appendectomy cholecystectomy pancreatomy bowel obstruction surgery right hip replacement avr (bovine) 14 years ago social history: lives with: alone, supportive family occupation: retired tobacco: none etoh: rare family history: non-contributory physical exam: pulse:90 resp:15 o2 sat: 100% 2l nc b/p right: 105/67 left: height: 4'" weight: 64 kg general: skin: dry intact mild bruising noted. heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur 3/6 sem abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: none 2+ bilat. lle edema neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 1+ left: 1+ pt : 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit right: rad murmur left: rad murmur pertinent results: admission labs 11:08am pt-15.8* ptt-39.6* inr(pt)-1.4* 11:08am fibrinoge-132* 10:27am hgb-7.6* calchct-23 12:31pm urea n-21* creat-0.8 sodium-141 potassium-4.8 chloride-113* total co2-20* anion gap-13 discharge labs 04:25am blood wbc-12.7* rbc-3.83* hgb-12.0 hct-35.5* mcv-93 mch-31.2 mchc-33.7 rdw-14.0 plt ct-105* 04:25am blood plt ct-105* 04:27am blood pt-14.4* inr(pt)-1.2* 04:25am blood urean-33* creat-0.7 na-136 k-3.9 cl-99 04:25am blood glucose-78 urean-33* creat-0.8 na-139 k-4.0 cl-102 hco3-26 angap-15 radiology report chest (pa & lat) study date of 11:39 am final report: right lower lobe density has become more round since and while it could represent confluent atelectasis, evolving pneumonia is also considered possible. bilateral pleural effusions are small and have also developed since . mild cardiomegaly is unchanged since . the right internal jugular central venous sheath has been removed. median sternotomy wires are in satisfactory position and alignment. impression: 1. worsening right lower lobe opacity which could represent atelectasis, but consolidation is considered possible. 2. bilateral enlarging small pleural effusions. brief hospital course: the patient was a direct admission to the operating room on where the patient underwent redo sternotomy, avr (porcine). please see the operative report for details. in summary she had: redo aortic valve surgery with a 19-mm st. medical biocor epic tissue valve. her bypass time was 93 minutes with a crossclamp time of 50 minutes. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. the patient was noted to have afriable aorta during the surgery and a decision was made to keep her sedated until the morning after suregery. on pod 1 the patient was weaned from sedation, woke neurologically intact and was extubated. the patient remained hemodynamically stable and weaned from vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. she was noted to be thrombocytopenic with a platelet count of 61,000/ul. hit antibody was sent and was negative. platelets would trend up by discharge. she remained in the icu to monitor hemodynamically until pod3 when she wastransferred to the telemetry floor for further recovery. all tubes lines and drains were removed per cardiac surgery protocol. the patient was seen by the physical therapy service for assistance with strength and mobility. the remainder of her hospital course was uneventful. at the time of discharge on pod5, the patient was ambulating freely, the wound was healing and pain was controlled with ultram. the patient was discharged to health care in good condition with appropriate follow up instructions. medications on admission: alprazolam 0.5 mg q8prn, amlodipine-atorvastatin 5 mg-40 mg tablet 0.5 tablet daily, esomeprazole magnesium 40 mg daily, hydrochlorothiazide 12.5 mg daily, meclizine 12.5 mg q8hr prn, toprol 25 mg daily, potassium chloride 20 meq daily, raloxifene 60 mg daily, aspirin 81 mg daily, calcium carbonate-vitamin d3 600 mg-400 unit daily, multivitamin daily, omega-3 fatty acids-fish oil 360 mg-1,200 mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 3. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). 6. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 7. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. tramadol 50 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain. 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for sob/wheezes. 11. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for heartburn. 12. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (). 13. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for sob/wheezes. 14. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 15. furosemide 20 mg tablet sig: one (1) tablet po once a day. 16. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po once a day. 17. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 18. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for for bm. discharge disposition: extended care facility: center discharge diagnosis: aortic stenosis hypertension hyperlipidemia gerd vertigo basal call s/p removal from temple x4 (hands and legs) anxiety arthritis hiatal hernia past surgical history: tonsillectomy appendectomy cholecystectomy pancreatomy bowel obstruction surgery right hip replacement avr (bovine) 14 years ago discharge condition: alert and oriented x3 nonfocal ambulating with assistance- deconditioned sternal pain managed with tramadol sternal incision - healing well, no erythema or drainage edema trace discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge followup instructions: you are scheduled for the following appointments: wound check at cardiac surgery office surgeon dr. , md phone: date/time: 1:15 please call to schedule the following: cardiologist dr. ,- s. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Esophageal reflux Unspecified essential hypertension Other complications due to heart valve prosthesis Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Anxiety state, unspecified Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Hypovolemia Arthropathy, unspecified, site unspecified |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: retroperitoneal bleed major surgical or invasive procedure: none history of present illness: mr. is a 70 year gentleman with copd admitted to for new onset heart failure and atrial fibrillation. the patient was started on digoxin, lasix, spironolactone & enalapril dose increased. during this course of treatment he developed acute renal failure with creatinine of 1.6 peaking at 2.8, but responding well to fluids. for his atrial fibrillation he was started on a heparin bridge to warfarin. he developed a left-thigh & retroperitoneal hematoma on accompanied by labile hypertension and hypotension to the 80s with a hematocrit drop from 30 to 20. he was given ffp, vitamin k and tranfused with all anti-coagulants held. for his copd he was started on a prednisone taper. . on admission the patient is conversant and complains on of cough productive of sputum and left sided groin pain. he denies dyspnea greater than baseline, chest pain, syncope, lightheadedness, abdominal pain. he denies dark or bloody stools, anorexia, nausea, vomiting, diarrhea. past medical history: chronic obstructive pulmonary disease hypertension obstructive sleep apnea not using bipap hypercholesterolemia benign prostatic hypertrophy gastroesophageal reflux disease social history: lives with his wife and is independent in adls. 35pk year tobacco hx, quit 25 years ago. 5 drinks daily, last drink 7 days prior to admission. denies illicit drug use family history: mother: rheumatic disease physical exam: vs: 99.2, 88 (afib), 144/61, 21, 95% on ra gen: obese man, talkative in nad neck: jvp 7cm cards: irreg. irreg. grade ii/vi systolic murmur best at rusb. pulm: diffuse rhonchi. no wheezes or crackles. abd: normoactive bowel sounds, soft, mildly distended v. obese, nontender back: no flank echymoses thigh: l anterior thigh with fading ecchymoses, r posterior thigh with fading ecchymoses. ext: 2+ dp, no edema pertinent results: 06:20am blood wbc-8.1 rbc-3.38* hgb-10.7* hct-32.1* mcv-93 mch-31.7 mchc-34.2 rdw-14.2 plt ct-129* 07:15pm blood hct-27.1* 09:16pm blood neuts-87.4* lymphs-7.5* monos-4.8 eos-0.1 baso-0.2 07:15pm blood pt-12.7 ptt-24.1 inr(pt)-1.1 06:20am blood plt ct-129* 06:20am blood glucose-110* urean-23* creat-1.2 na-141 k-4.5 cl-102 hco3-32 angap-12 09:16pm blood glucose-127* urean-43* creat-1.8* na-140 k-4.5 cl-103 hco3-31 angap-11 06:20am blood alt-39 ast-30 alkphos-48 totbili-1.1 dirbili-0.3 indbili-0.8 09:16pm blood alt-23 ast-18 ck(cpk)-286* alkphos-37* totbili-0.4 09:16pm blood ck-mb-3 ctropnt-<0.01 03:36am blood ctropnt-0.01 09:16pm blood wbc-7.5 rbc-2.45* hgb-8.0* hct-22.9* mcv-93 mch-32.6* mchc-34.9 rdw-13.7 plt ct-144* 03:36am blood wbc-7.6 rbc-2.44* hgb-8.1* hct-22.4* mcv-92 mch-33.3* mchc-36.3* rdw-14.2 plt ct-134* 06:20am blood albumin-3.9 calcium-9.5 phos-3.4 mg-2.2 iron-116 06:20am blood caltibc-346 vitb12-356 folate-10.5 ferritn-169 trf-266 03:36am blood tsh-1.0 brief hospital course: a 70 year old gentleman transferred from with a rp hematoma, arf and new onset chf & atrial fibrillation. 1) retroperitoneal bleed/hematoma: the patient was transfused a total of 3 units of prbcs while in the micu with an appropriate increase in hct. no further transfusions were required. hct's were checked every four hours. the patient did not require embolization to stabilize the bleeding. antihypertensives and anticoagulants held. 2) acute renal failure: most likely pre-renal azotemia from blood loss and aggressive diuresis at . improved with fluid and blood administration. 3) copd: continued spiriva & atrovent prn. administered flu vaccine & pneumovax. recomended outpatient pulmonary referal and pfts. 4) atrial fibrillation: likely related to atrial stretch. echo with dilated atrium. unlikely ischemia given negative cardiac enzymes. tsh normal and b1 pnd on discharge. cardiology consulted, did not recommend cardioversion considering increased risk of thrombosis following cardioversion and unable to anticoagulate currently. chads score of 2. warfarin was stopped given bleeding. would consider anticoagulation in the future. 5) congestive heart failure: unclear etiology but likely longstanding given atrial enlargement. etiologies may include htn or even restrictive process in setting of etoh use. held beta blockade while patient hemodynamically unstable. discharged on toprol xl with cardiology f/u. discontinued ccb. medications on admission: terazosin 5 mg po qday enalapril 10mg po qday cartia xt 120mg po qday atenolol 25mg po qday simvastatin 20mg po qday omeprazole 20mg po qday cholestyramine 2 scoops daily asa 81mg po qday spriva advair mvi discharge medications: 1. terazosin 5 mg capsule sig: one (1) capsule po once a day. 2. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 4. cholestyramine light oral 5. aspirin 81 mg tablet sig: one (1) tablet po once a day. 6. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) inhalation once a day. 7. advair diskus 250-50 mcg/dose disk with device sig: one (1) inhalation twice a day. 8. toprol xl 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*2* 9. enalapril maleate 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 10. multivitamin tablet sig: one (1) tablet po once a day. 11. albuterol 90 mcg/actuation aerosol sig: one (1) inhalation every 4-6 hours as needed for shortness of breath or wheezing. disp:*1 1* refills:*3* discharge disposition: home discharge diagnosis: retro peritoneal hematoma acute on chronic diastolic congestive heart failure atrial fibrilation discharge condition: good discharge instructions: you were transfered from with bleeding in the back of your belly which was atributed to blood thining medications. we gave you blood products to reverse the thinning properties of your blood. also at you were noted to have congestive heart failure and atrial fibrilation. we gave you medication to help control heart rate (metoprolol). excess fluid from was removed your body with water pills. we are not prescribing any water pills at this time as you did not have edema (swelling) of your extremities when we examined you. please discuss the need for water pills with your regular doctor/cardiologist. it is very important that you maintain a less than 2gm of salt diet daily to prevent a reaccumulation of fluid. please weigh yourself daily and call your primary care physician if you gain more than 3 pounds. . you should discuss with your regular doctor the need for blood thining medication to prevent clots forming in your heart (in the seting of atrial fibrilation). at this point we are not giving you coumadin because of the risk for bleeding. you should start taking aspirin 81mg daily for stroke prevention with atrial fibrillation. . you need to follow up with a pulmonary doctor to have pulmonary function tests and with a cardiologist in order to help determine a long term medication regimen for you congestive heart failure. you should continue the medications toprol xl and enalapril to treat your heart failure. you should also discuss referral to rehab with your primary care physician. have been given a list of phone numbers for further information. we made the following chages in your medicaiton regimen. we added albuterol which you should take in addition to spiriva and advair. also we added metoprolol instead of atenolol for your atrial fibrilation. . also your blood count was noted to be low and you may need outpatient work up for anemia with your regular doctor. please call your regular doctor or return to the ed if you have shortness of breath, chest pain, lightheadedness, swelling of extermities or any other symptoms that concern you. followup instructions: please follow up with your primary care physician . : at 12:00 noon . please follow up with dr. in cardiology on at 3:00pm in the building on the . provider: , md phone: date/time: 3:00 . please maintain your scheduled follow up listed below: provider: , md phone: date/time: 1:30 provider: , md phone: date/time: 9:00 provider: . / dr. phone: date/time: 4:00 provider: ,interpret w/lab no check-in intepretation billing date/time: 4:00 provider: function lab phone: date/time: 3:40 md, Procedure: Transfusion of packed cells Diagnoses: Obstructive sleep apnea (adult)(pediatric) Esophageal reflux Tobacco use disorder Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Acute on chronic diastolic heart failure Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hemoperitoneum (nontraumatic) |
allergies: no known allergies / adverse drug reactions attending: chief complaint: malaise, shortness of breath major surgical or invasive procedure: : pericardiocentesis with drain placement : tracheal intubation : temp pacer wire : intranasal sinus mass biopsy : placement of dual chamber pacemaker : placement of percutaneous g-tube history of present illness: 61 y/o male presents with malaise, doe x 2 days. the patient has not been to a physican in years insurance issues. had been on synthroid in the past but taken off by doctor 4-5 years ago because thought not necessary. he developed general malaise, dyspnea with exertion x 2 days and presented to , where the exam and story consistent with myxedema. labs at notable for ck of 2545, troponin t .15, tsh over 200. cbc with wbc of 3.8 (50% neuts, 33% bands). his initial vs demonstrated a pulse of 46 and a bp of 99/61, t 90.2f. he had occasional depressions to hr 27 but these broke spontaneously after 30 seconds. the patient was given 150mg iv hydrocortisone, 162 asa, thiamine, and 750 iv levaquin. transferred to for further evaluation. at ed initial vitals hr 48 123/68, 15 97% ra. hypothermia to 90.2 rectal. warm blankets were applied. after discussion with endocrine patient started on hydrocortisone 100 q8 and given levothyroxine 500mcg. he was also given vancomycin 1g. based on troponin leak cardiology was consulted; heparin was initiated given concern for nstemi. bedside ultrasound demonstrated moderate sized pericardial effusion. repeat differential with no bands. he was transferred to the micu for further care. on review of systems reports some cough. denies any fever. shortness of breath and doe as above. past medical history: -hypothyroidism -copd social history: lives with mother; helps to care for her. retired, worked in hospital ed as aid/emt for more than 20 years. no etoh, ppd tobacco since he was a teenager, no recreational drugs. family history: no known cardiac history physical exam: on admission to ccu vs: t=97 bp=103/61 hr=70 rr=13 o2 sat= 92% ra general: nad. sitting up in bed, nad heent: coarse facial structure. edema in eyelids. close-set palpebral fissure. dark discoloration. mm dry. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. pericardial drain in place, draining serous fluid, dressing c/d/i. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: 1+ edema in right arm and right leg. dry and darkened skin in both shins. skin: as above pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ reflexes: 1+ right patellar, could not elicit in bicep b/l on discharge: tm 97.8 bp 98/48-108/56 hr 69-74 94% on ra cardiac: 2/6 systolic murmur at rusb pulmonary: diminished bs throughout, crackles at bases, no accessory muscle use abd: soft, nt/nd, g-tube in place ext: edema improved, extensive muscle wasting neuro: a&ox3; weak, hoarse voice but improved since transfer from the icu pertinent results: ================== laboratory results ================== on admission: 02:35am blood wbc-3.4* rbc-3.15* hgb-9.6* hct-27.4* mcv-87 mch-30.3 mchc-34.9 rdw-15.5 plt ct-123* 02:35am blood neuts-83.3* lymphs-10.7* monos-3.2 eos-2.0 baso-0.8 02:35am blood pt-13.5* ptt-24.8 inr(pt)-1.2* 02:35am blood glucose-107* urean-15 creat-1.1 na-132* k-4.0 cl-96 hco3-24 angap-16 04:12pm blood alt-63* ast-134* ld(ldh)-325* ck(cpk)-* alkphos-79 totbili-0.3 04:12pm blood calcium-8.7 phos-2.1* mg-1.5* iron-39* 02:35am blood t4-<1.0* t3-<20* calctbg-1.31* tuptake-0.76* cardiac enzymes: 02:35am blood ck-mb-84* mb indx-4.3 02:35am blood ctropnt-0.16* 10:22am blood ck-mb-88* mb indx-4.5 ctropnt-0.12* 04:12pm blood ck-mb-87* mb indx-4.5 ctropnt-0.10* 03:18am blood ck-mb-79* mb indx-4.8 01:30am blood ck-mb-51* mb indx-5.0 ctropnt-0.09* 06:19am blood ck-mb-27* mb indx-3.9 ctropnt-0.33* 10:00am blood ck-mb-15* mb indx-4.1 01:19am blood ck-mb-7 ctropnt-0.11* tfts: on admission, tsh greater than assay 01:30am blood t4-6.9 t3-95 06:19am blood t4-7.1 t3-121 06:01am blood t4-8.6 t3-73* cortisol levels: normal stim test ============= other results ============= cardiac cath : comments: 1. cardiac tamponade 2. successful pericardiocentesis with 260 cc of straw-colored pericardial fluid removed and pericardial drain advanced into position under flouroscopic guidance without complications. intrapericardial pressure reduced from 20 mmhg to mmhg post pericardiocentesis 3. pericardial drain sutured into position with no issues final diagnosis: 1. cardiac tamponade 2. successful pericardiocentesis with 260 cc of straw-colored pericardial fluid removed and pericardial drain advanced into position under flouroscopic guidance without complications. intrapericardial pressure reduced from 20 mmhg to mmhg post pericardiocentesis. 3. pericardial drain sutured into position without complications. . post cath echo : left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. no definite effusion seen. compared with the prior study (images reviewed) of earlier in the day, the right ventricular cavity is larger and the pericardial effusion has resolved. ct sinus : very large, expansile, soft tissue density lesions centered within the paranasal sinuses with erosion and dehiscence of adjacent bone and left greater than right orbital involvement. there is dehiscence of the posterior wall of the right frontal sinus, with no evidence of frank intracranial extension. this is most suspicious for extensive, severe sinonasal polyposis differential diagnosis includes metastases or more aggressive etiology, fungal infection, etc. ent consult is recommended. if further imaging is clinically necessary, mri of the sinuses and brain with and without gadolinium would better exclude intracranial involvement and better evaluate the adjacent brain. sinus mass pathology diagnosis: respiratory mucosa and submucosa with focal collections of lymphocytes and poorly formed histiocytic granuloma. there is no evidence of lymphoma or non-lymphoid neoplasm in the biopsy. see note. chest ct: impression: 1. no pulmonary embolus. 2. bilateral apical scarring and superior hilar retraction as well as diffuse emphysematous changes and calcified mediastinal and hilar lymphadenopathy, again compatible with changes of prior or remote tb as was previously queried, though other granulomatous processes (sarcoid, silicosis) could cause this appearance. 3. new superimposed ground glass opacities, right upper lobe focal consolidation, and peribronchial thickening may represent superimposed infection, aspiration (as clinically questioned) or inflammatory process. 4. aortic atherosclerotic change. cxr: findings: as compared to the previous radiograph, the patient has been extubated and the nasogastric tube has been removed. the extensive bilateral parenchymal opacities, including the large apical fibrotic zones with extensive pleural thickening are unchanged in extent and severity. there is no newly appeared parenchymal opacity. the size of the cardiac silhouette is unchanged. the presence of a minimal left pleural effusion cannot be excluded on today's radiograph. no other relevant changes, constant left pectoral pacemaker. echo: left ventricular wall thicknesses and cavity size are normal. left ventricular dysnchrony is present. right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. there is a very small pericardial effusion most prominent around the apex (clip #). there are no echocardiographic signs of tamponade. there is a prominent anterior fat pad. bcx , , , : ngtd ucx : ~5000 staph species repeat ucx : neg afb smear: negative x3; ppd negative pericardial fluid cytology: neg for malignancy pericardial fluid culture: negative crypto antigen: neg quanteferion gold: neg b-glucan: neg sputum cx: staph aureus coag + | clindamycin----------- r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ <=0.5 s on discharge: wbc 8; hct 25.8; plts 375 na 132 k 4.5 cl 98 hco3 30 bun 26 cr 0.5 glc 100; ca 9.4 mg 1.7 ph 3.2 brief hospital course: 61 yom admitted for myxedema coma on , who subsequently developed pericardial effusion with tamponade physiology s/p pericardiocentesis with drain placement, complete heart block s/p dual-chamber pacemaker placement, severe nasal polyposis s/p biopsy, with failed swallow test now s/p percutaneous g-tube placement. 1. myxedema coma: pt with untreated hypothyroid for years with tsh elevated to greater than assay, then 83 on admission, initially admitted to micu in myxedema coma treated with stress dose steroids. endocrine consulted and initially started on t3 and t4 supplementation but per endo recs only kept on t4 at 100mcg iv daily. myxedema thought to be the likely the cause of pericardial effusion. tsh trended down throughout admission and t4/t3 levels stabilized. pt also noted to be hypothermic throughout most of admission likely secondary to hypothyroid but this began to improve with supplementation. after g-tube placement on the patient was switched to oral levothyroxine with plans for weekly tfts. the patient was followed by endocrinology in the hospital and was discharged on levothyroxine 112 mcg per day. thyroid function tests should be checked every 2-3 weeks until stabilized. 2. complete av block/pea arrest: pt noted to have episodes of bradycardia associated with urination, often early morning. initially these were asymptomatic but on morning of resulted in a high grade av block with subsequent pea arrest. pt was coded and received atropine for hr and started on neo for blood pressure support. temp pacer wires subsequently placed set with a capture of 50 bpm. pt subsequently noted to have capture ~once per day for several beats each time. in looking at the telemetry strips, it appears that this is likely at the nodal level vs intranodal level, or perhaps vagal in origin. we are still unsure of the etiology of the block, though infiltrative disease such as sarcoid was proposed given prominent lymphadenopathy on chest ct (ruled out with neg ace level). unlikely ischemic given down trending ckmb. pt remained stable with temp pacing wires with permanent pacemaker placed on hd 13 (). the patient tolerated the procedure well. cardiology and device clinic f/u appts were scheduled. 3. respiratory failure: pt intubated and sedated in the setting of his pea arrest code for unresponsiveness. he was continued on cmv with occasional trials of mmv given that he would have occasional periods of apnea. he was sedated with fent/versed. given patient's signficant agitation, he was started on a regimen of iv haldol in preparation for extubation. he was aggressively diuresed with iv lasix. he developed metabolic alkalosis in the setting of aggressive diuresis for significant volume overload. he was given 4 doses of diamox. he was extubated on hd 14 without difficulty and tolerated extubation well. post extubation he was noted to have increasing bronchospasm likely secondary to underlying copd. he was given albuterol and atrovent nebulizer therapy and started on advair. he was readmitted to the micu for worsening respiratory status on and re-intubated. a day later he was extubated. he looked ill requiring facemask and was drooling. ent evaluated his sinuses, larynx and vocal cords and saw no reasons for his upper airway to be causing his distress. he improved over the course of the day after extubation and was transitioned to face mask. he stopped tripoding and was able to lay flat. on the floor, he was initially on 35% face mask (couldn't tolerate nasal cannula due to nasal polyps). he received a 5-day burst of prednisone 60 mg qday. he was started on advair and scheduled nebulizers. on , o2 sats were 94-98% on ra. he was discharged on advair and prn nebulizers as well as pulmonary follow-up. 4. ventilator associated bronchitis: sputum culture positive for mrsa. cxr without focal consolidation. likely ventilator associated bronchitis. he was treated with a course of iv vancomycin and then switched to tmp-sulfa by g-tube once parenteral access was obtained. he completed a 14-day course. 5. frontal sinus mass: given pt??????s agitation and behavioral issues in house as well as his enlarged lacrimal duct, ct head/sinus was obtained and showed large mass in sinuses, infiltrating orbit, frontal bone, dehisence in frontal sinus. ent consulted, said lymphoma vs scc vs polyposis, less likely fungal. biopsy was obtained and demonstrated no evidence of lymphoma or malignant cells consistent with nasal polyp. ent outpatient f/u was scheduled. of note, if oxygen therapy is needed, nasal cannula is not sufficient and patient requires face mask or face tent. 6. hypotension: pt noted to be hypotensive throughout admission even after drainage of his pericardial effusion. became further hypotensive in the setting of his pea arrest requiring neo. unclear etiology, though pt with a low baseline likely to hypothyroidism. stim was normal. his urine output remained adequate. he remained normotensive after transfer to the floor until , when he had recurrence of hypotension. he was bolused with 1 l ns with good response and mivf were started. free water tube flushes were increased. the patient should have routine blood pressure monitoring. 7. hypothyroid: pt with untreated hypothyroid for years with tsh elevated at 83 on admission, initially admitted to micu in myxedema coma treated with stress dose steroids. endocrine consulted and initially started on t3 and t4 supplemenatation but per endo recs only kept on t4 at 100mcg iv daily. tsh trended down throughout admission and t4/t3 levels stabilized. pt also noted to be hypothermic throughout most of admission likely secondary to hypothyroid but this began to improve with supplementation. pt was discharged on levothyroxine 112 mcg per day as above. repeat thyroid function tests should be checked every 2 weeks. 8. possible cavitary lesions: ct chest was obtained given suspicious upper lobe fibrotic changes on cxr. ct should bulous emphysema and initially thought that these could be cavitary lesions so he was ruled out for tb with 3 negative tbs. upon further review of the ct with pulmonary, it appears less likely that these were cavitary lesions and more consistent with emphysema. quanteferion gold was negative. ppd was place and was negative. pulmonary follow-up was scheduled. 9. pericardial effusion: pt presenting with pericardial effusion, initially without tamponade, but subsequently developing hypotension in the micu. repeat echo showing tamponade physiology. pt went to cath lab for pericardiocentesis with subsequent drain placement. etiology likely hypothyroidism. tb ruled out with negative afbs and pericardial fluid culture negative. cytology negative for malignant cells. of note, repeat echo obtained several days later in setting of his code and did not show tamponade. 10. anemia: anemia likely chronic. reticulocyte count low. possible element of long-standing hypothyroid and malnutrition vs infilrtrative process into the bone marrow. no abnormal cells on smear. hemolysis labs negative. transfused 2 units of prbc on hd 7. 11. left lacrimal duct: pt noticed to have left lacrimal duct swelling. ophthalmology consulted who thought it may be infected and recommended giving cipro eye drops qid and erythromycin ointment at bedtime which was continued for ten days. however, upon obtaining head ct this very well be related to mass effect from his frontal sinus mass. 12. agitation/ms changes: early in hospital course, pt was increasingly agitated and combative prior to intubation. he was controlled initially with seroquel which was changed to haldol prior to extubation. he tolerated extubation well on 5mg haloperidol, which was weaned off slowly on the floor with no signs of further agitation. he responded appropriately and followed commands during his stay on the medical service and was very pleasant to staff. 13. speech and swallow: following extubation the patient failed speech and swallow, was noted to be aspirating ice chips. discussed case with ent who felt laryngoscopy not possible given extensive obstructive nature of polyposis. aspiration / vocal cord weakness may be secondary to rencke's edema (related to myxedema state). after transfer to the floor the patient had two repeat speech and swallow evals that revealed persistent dysphagia. ent was called back and said that this was likely due to edema of vocal folds related to severe hypothyroid, which should improve with time. given patient's voice was slowly improving this was thought to be the case and they recommended against attempts at stroboscopy or more aggressive attempts to image chords. speech and swallow was contact on the day of discharge and recommended repeat video swallow study in weeks at . they mentioned they will follow the patient. tube feeds and npo should be continued until repeat study. anticipate that dysphagia will resolve in time. 14. goals of care: pt is a full code, and goals of care discussed with cousin as the patient's mother was not able to make it into the hospital or participate in decisions during hospitalization. medications on admission: none discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 4. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 5. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 6. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 7. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 8. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 9. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 10. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for heartburn. discharge disposition: extended care facility: - discharge diagnosis: primary diagonsis: - myxedema / hypothyroidism - pericardial effusion s/p pericardiocentesis - complete heart block s/p pacemaker - severe nasal polyposis - high aspiration risk . secondary diagnosis: - chronic obstructive pulmonary disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive; at times, lethargic during the day activity status: out of bed to chair with assistance. discharge instructions: it was a pleasure caring for you at the . you were admitted to the hospital with a condition called myxedema due to long-standing hypothyroidism. because of this underlying problem, you developed fluid around your heart, which required drainage, and conduction problems of your heart, which required placement of a pacemaker. you were also intubated twice for respiratory problems. subsequently developed an infection of your trachea and were treated with antibiotics. you were also found to have severe polyps in your nose that affected your sinuses and your eyes. finally, our speech and swallow experts evaluated you and felt that it would be safest to feed you through a tube directly into your stomach until you are stronger and can better protect your airway during eating. . we made the following changes to your medications: we started atorvastatin we started aspirin we started albuterol/ipratropium nebulizers as needed we started advair we started levothyroxine 112 mcg daily; you will need to have your thyroid function re-evaluated every few weeks to be sure you are on the correct dose . your follow-up information is listed below. followup instructions: department: pulmonary function lab when: monday at 12:40 pm with: pulmonary function lab building: campus: east best parking: garage department: pft when: monday at 1 pm department: medical specialties when: monday at 1 pm with: dr. building: sc clinical ctr campus: east best parking: garage department: cardiac services when: wednesday at 3:00 pm with: device clinic building: sc clinical ctr campus: east best parking: garage department: cardiac services when: wednesday at 3:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage department: otolaryngology (ent) when: wednesday at 2:00 pm with: , m.d. building: lm campus: west best parking: . garage Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Pericardiocentesis Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Percutaneous [endoscopic] gastrostomy [PEG] Insertion of temporary transvenous pacemaker system Cardiopulmonary resuscitation, not otherwise specified Closed [endoscopic] [needle] biopsy of nasal sinus Diagnoses: Anemia of other chronic disease Subendocardial infarction, initial episode of care Tobacco use disorder Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Unspecified disease of pericardium Acute respiratory failure Hypotension, unspecified Atrioventricular block, complete Pneumonitis due to inhalation of food or vomitus Cardiac arrest Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Delirium due to conditions classified elsewhere Coma Mixed acid-base balance disorder Edema of larynx Cardiac tamponade Obstructive chronic bronchitis with acute bronchitis Dysphagia, unspecified Stenosis of nasolacrimal duct, acquired Other polyp of sinus |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath and chest heaviness major surgical or invasive procedure: 1. urgent coronary artery bypass graft x4 with left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, obtuse marginal and posterior descending arteries. 2. endoscopic harvesting of the long saphenous vein. history of present illness: 81 year old male with history of end stage renal disease. left av fistula placed on . ever since he has had the procedure he has been experiencing dyspnea on exretion, there has never been a change in pattern and the symptoms have never occured at rest. he is now transferred to for a cardiac catheterization which shows coronary artery disease. he is now referred to cardiac surgery for possible revascularization. past medical history: hypertension hyperlipidemia coronary artery disease s/p 2 stents 15 years ago type 2 diabetes mellitus end stage renal disease stage iv gerd prostate carcinoma s/p total prostatectomy hyperparathyroidism osteoarthritis past surgical history ptfe graft from the brachial artery to the antecubital vein left carotid endarterectomy left total knee replacement total prostatctomy schatzki ring social history: lives with:alone, supportive family around occupation:retired tobacco:quit 40 years ago, ppdx 15-20 years etoh:denies family history: mother died of heart disease physical exam: pulse:63 resp:14 o2 sat:97/ra b/p right:157/59 height:5'9.5" weight:233 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft, non-distended, non-tender extremities: warm, well-perfused no edema or varicosities neuro: grossly intact pulses: femoral right: nd left: nd dp right: dop left: dop pt : dop left: dop radial right: 2+ left: 2+ carotid bruit left > right pertinent results: admission labs: 04:00pm urine rbc-1 wbc-1 bacteria-few yeast-none epi-0 trans epi-<1 04:00pm urine blood-sm nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.5 leuk-neg 04:00pm urine color-straw appear-clear sp -1.016 05:26pm ck-mb-14* mb indx-6.8* ctropnt-0.44* 05:26pm ck(cpk)-206 05:26pm glucose-146* urea n-80* creat-3.8* sodium-143 potassium-4.6 chloride-106 total co2-24 anion gap-18 discharge labs: 07:05am blood wbc-12.2* rbc-3.10* hgb-9.5* hct-29.2* mcv-94 mch-30.6 mchc-32.4 rdw-15.8* plt ct-311 07:05am blood plt ct-311 02:29am blood pt-14.4* ptt-31.4 inr(pt)-1.2* 07:05am blood glucose-127* urean-74* creat-4.6* na-139 k-4.1 cl-101 hco3-24 angap-18 04:52am blood glucose-99 urean-56* creat-3.9* na-139 k-4.3 cl-101 hco3-22 angap-20 11:39pm blood alt-11 ast-29 ld(ldh)-267* alkphos-36* amylase-46 totbili-0.1 11:39pm blood lipase-64* 03:15am blood %hba1c-6.7* eag-146* 04:52am blood pth-134* 06:48am blood hbsag-negative hbsab-negative hbcab-negative 06:48am blood hcv ab-negative radiology report chest (pa & lat) study date of 8:40 am medical condition: 81 year old man with s/p cabg final report: compared to , the lung volumes are improved. small bilateral pleural effusions, right greater than left, with associated atelectasis are stable to slightly improved from . there is no pneumothorax. the cardiac and mediastinal silhouette are stable in this patient status post cabg with intact median sternotomy wires. a right picc terminates in the upper-to-mid svc. there has been interval removal of the right internal jugular catheter. impression: small bilateral pleural effusions, right greater than left, with associated atelectasis. echocardiography report echocardiographic measurements results measurements normal range left atrium - long axis dimension: *5.5 cm <= 4.0 cm left atrium - four chamber length: *6.3 cm <= 5.2 cm left atrium - peak pulm vein s: 0.6 m/s left atrium - peak pulm vein d: 0.4 m/s left atrium - peak pulm vein a: 0.3 m/s < 0.4 m/s right atrium - four chamber length: *5.5 cm <= 5.0 cm left ventricle - septal wall thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 5.1 cm <= 5.6 cm left ventricle - ejection fraction: 50% >= 55% left ventricle - stroke volume: 83 ml/beat left ventricle - cardiac output: 4.57 l/min left ventricle - cardiac index: 2.12 >= 2.0 l/min/m2 left ventricle - lateral peak e': *0.08 m/s > 0.08 m/s left ventricle - septal peak e': *0.07 m/s > 0.08 m/s left ventricle - ratio e/e': 12 < 15 aorta - sinus level: 3.6 cm <= 3.6 cm aorta - ascending: *3.8 cm <= 3.4 cm aortic valve - peak velocity: 1.5 m/sec <= 2.0 m/sec aortic valve - lvot pk vel: 1.00 m/sec aortic valve - lvot vti: 20 aortic valve - lvot diam: 2.3 cm mitral valve - e wave: 0.9 m/sec mitral valve - a wave: 1.1 m/sec mitral valve - e/a ratio: 0.82 mitral valve - e wave deceleration time: 210 ms 140-250 ms pulmonic valve - peak velocity: 1.1 m/sec <= 1.5 m/sec findings left atrium: moderate la enlargement. right atrium/interatrial septum: mildly dilated ra. normal interatrial septum. no asd by 2d or color doppler. left ventricle: mild symmetric lvh. normal lv cavity size. mild regional lv systolic dysfunction. no lv mass/thrombus. no resting lvot gradient. no vsd. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. mild mitral annular calcification. mild thickening of mitral valve chordae. no ms. trivial mr. tricuspid valve: mildly thickened tricuspid valve leaflets. no ts. physiologic tr. indeterminate pa systolic pressure. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: no pericardial effusion. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions the left atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with basal to mid inferior and infero-lateral hypokinesis. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. brief hospital course: the patient was brought to the operating room on where the patient underwent coronary bypass grafting(see operative report for details). in summary he had: 1. urgent coronary artery bypass graft x4 with left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, obtuse marginal and posterior descending arteries. 2. endoscopic harvesting of the long saphenous vein. he tolerated the operation well and post-operatively was transferred to the cvicu in stable condition on an inotrope and pressor to support cardiac function. he was kept sedated overnight, on the morning of pod1 he was extubated without incident. his pressors were weaned. he was seen in consultation by the renal service for his elevated creatinine in the setting of end stage renal disease and was dialyzed to aid in diuresis. his chest tubes and wires were removed. by post-operative day 6 he was transferred to the step-down floor. an ace-inhibitor was initiated for better blood pressure control. by post-operative day he was ready for transfer to the long term acute care rehab center at hospital in . medications on admission: amlodipine - (prescribed by other provider) - 5 mg tablet - 1 (one) tablet(s) by mouth once a day calcitriol - (prescribed by other provider) - 0.25 mcg capsule - 1 (one) capsule(s) by mouth once a day hydrochlorothiazide - (prescribed by other provider) - 25 mg tablet - 1 (one) tablet(s) by mouth once a day metoprolol tartrate - (prescribed by other provider) - 25 mg tablet - 1 (one) tablet(s) by mouth twice a day omeprazole - (prescribed by other provider) - 20 mg capsule, delayed release(e.c.) - 1 (one) capsule(s) by mouth once a day simvastatin - (prescribed by other provider) - 80 mg tablet - 1 (one) tablet(s) by mouth once a day medications - otc aspirin - (prescribed by other provider) - 325 mg tablet - 1 (one) tablet(s) by mouth once a day discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for temperature >38.0. 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 8. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). 9. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 10. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: puffs inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 11. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). 12. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 13. insulin lispro 100 unit/ml solution sig: sliding scale units subcutaneous qac&hs. discharge disposition: extended care facility: northeast - discharge diagnosis: coronary artery disease pmh: hypertension hyperlipidemia coronary artery disease s/p 2 stents 15 years ago type 2 diabetes mellitus end stage renal disease stage iv gerd prostate carcinoma s/p total prostatectomy hyperparathyroidism osteoarthritis past surgical history ptfe graft from the brachial artery to the antecubital vein left carotid endarterectomy left total knee replacement total prostatctomy schatzki ring discharge condition: alert and oriented x3 nonfocal exam ambulating, gait steady sternal pain managed with percocet sternal incision - healing well, no erythema or drainage edema + bilat discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: surgeon dr. on @1pm cardiologist dr. , d. please call to schedule the following: primary care dr., c. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Venous catheterization, not elsewhere classified (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Hemodialysis Other cystoscopy Dilation of urethra Diagnoses: Acidosis Other iatrogenic hypotension End stage renal disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Personal history of malignant neoplasm of prostate Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Paralytic ileus Bladder neck obstruction Secondary hyperparathyroidism (of renal origin) Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Knee joint replacement Stricture and stenosis of esophagus Hypotension of hemodialysis |
allergies: barbiturates / nifedipine / propranolol attending: chief complaint: sepsis major surgical or invasive procedure: intubation tracheostomy history of present illness: mr. is a 60yo m with history of cad s/p pci, hepatitis c and dm who presents with two days of sweats and dizziness described as lightheadedness. patient originally complained of suprapubic pain. in the er, initial vitals were 96.2, 56, 72/52, 16, 96%. he was diaphoretic and pale. patient was given 1l ns with improvement of his pressure. he was found to have an inner thigh abscess that was lanced and sent to ct a/p which showed small right inner thigh abscess without deep or intrapelvic extension and nodular liver. when he returned, he was hypotensive again and had agonal breathing. he was intubated and r ij was placed. while in the ed, he received 1mg epinephrine while awaiting better access and then 5l of ns, vancomycin, zosyn, 100mg iv hydrocortisone, levophed, dopamine and phenylephrine. he was admitted to the micu for undifferentiated shock. vitals on transfer were p 70 bp 80/47, 95%v fio2 100, peep 10, tv 600 r 14 with abg 7.32/46/145/25. on arrival to the micu, patient was intubated and sedated. past medical history: cardiac risk factors:(+)diabetes,(+)dyslipidemia,(+)hypertension cardiac history: -diastolic dysfunction -pci: with des to mid-lad, with des x2 to lcx and om3 . other past medical history (adapted from previous notes): -hepatitis c -ibs -history of iv opiate/polysubstance abuse, detailed in social history social history: -smoking/tobacco: 50 py, quit for about 60 days, now back to ppd. -etoh: none -illicits: clean for 2 years & attends na meetings daily; history of iv heroine and iv cocaine abuse as well as other illicits -lives at/with: wife and son, unemployed on disability family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.. physical exam: on admission: general: intubated and sedated but initially moving all 4 extremities heent: sclera anicteric, mmm, ett in place neck: supple, jvp not elevated, no lad lungs: coarse breath sounds bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ bounding pulses bilateral dps, pts, radials, no clubbing, cyanosis or edema discharge exam: general: alert and interactive, makes eye contact and follows commands, not verbally communicative, difficult to assess orientation heent: dobhoff in place (not post-pyloric) neck: trach mask in place pertinent results: admission labs: 11:16pm type-art temp-35.6 rates-/20 tidal vol-600 peep-14 po2-78* pco2-31* ph-7.36 total co2-18* base xs--6 -assist/con intubated-intubated 11:16pm lactate-1.0 10:06pm lactate-1.6 10:06pm freeca-1.03* 09:58pm glucose-366* urea n-26* creat-1.7* sodium-141 potassium-4.6 chloride-105 total co2-21* anion gap-20 09:58pm alt(sgpt)-22 ast(sgot)-24 ck(cpk)-76 alk phos-60 tot bili-0.8 09:58pm ck-mb-2 ctropnt-<0.01 09:58pm wbc-21.6* rbc-4.32* hgb-12.6* hct-37.7* mcv-87 mch-29.1 mchc-33.4 rdw-14.3 06:26pm urine hours-random urea n-632 creat-69 sodium-87 potassium-35 chloride-80 06:26pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 04:50pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg : hcv viral load (final ): 2,580,000 iu/ml. : rapid plasma reagin test (final ): nonreactive. echo: left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve is not well seen. the mitral valve leaflets are not well seen. there is no pericardial effusion. impression: suboptimal image quality. grossly preserved biventricular systolic function. no pericardial effusion. ct ab/pel: no acute intra-abdominal or pelvic pathology to explain the patient's clinical circumstance with small area of right groin induration status post incision and drainage. cta chest: thyroid is normal in appearance. patient is intubated with endotracheal tube in appropriate position. left internal jugular catheter is seen with tip in the distal svc. nasogastric tube is seen with side port at the level of ge junction, could be advanced 5-7 cm. coronary and aortic atherosclerotic calcifications are noted. there is no pericardial or pleural effusion with bibasilar atelectasis. the lungs are otherwise clear. no pulmonary embolus or acute aortic syndrome is identified. the aorta and major branches are patent with a normal three-vessel arch. trachea and central airways are patent to segmental level. no mediastinal, hilar, supraclavicular, or axillary lymphadenopathy is seen. though this study is not tailored for subdiaphragmatic evaluation, imaged upper abdomen demonstrates nodular liver concerning for cirrhosis as mentioned. nchct: 1. no evidence of an acute intracranial process. 2. fluid in the sphenoid sinuses and left posterior ethmoid, and opacification of the mastoid air cells, which is most likely related to endotracheal intubation. however, given the patient's altered mental status, please correlate clinically whether any sign of infection may be present. ct torso: ct of thorax: satisfactory position of the endotracheal tube approximately 5 cm above the carina. a right-sided central line tip is positioned at the cavoatrial junction. the nasoenteral feeding tube tip is positioned in the distal second part of duodenum. left-sided basal consolidation hasworsened since the prior study with complete consolidation and volume loss of the left lower lobe. consolidation involving the basal segment of right lower lobe is stable. there are no pleural effusions and no pericardial effusion. ct of abdomen: the liver has an irregular outline in keeping with established cirrhosis. surgical clips in the gallbladder fossa are consistent with prior cholecystectomy. a 4-mm calcified focus in segment vi is likely secondary to a calcified granuloma. within limits of a non-contrast study, there are no focal lesions. the pancreas outlines normally. the spleen is slightly enlarged measuring 15 cm in craniocaudal dimension. normal appearance of both kidneys and both adrenal glands. no hydronephrosis. the aorta, internal and external iliac branches are within normal limits. no aneurysm formation. ct of pelvis: no pelvic free fluid. no enlarged inguinal or pelvic lymph nodes are identified. soft tissue densities in the anterior abdominal wall likely represent injection sites. no pathologically enlarged upper abdominal or mediastinal lymph node. air within the urinary bladder is likely secondary to instrumentation. note, the rectal drainage tube balloon is positioned within the sigmoid colon. there is mild stranding involving the medial aspect of the right inner thigh at the site of a treated previous cutaneous infection. no thigh fluid collection or hematoma is identified. punch biopsy of sacrum: right lower back 4 mm punch. 60 year old man, intubated, status post multiple antibiotics now with erythematous eruption with tiny pustules on buttocks and back. differential diagnosis: ag ep vs milleria pustulosa vs candidiasis. eeg: abnormal portable eeg due to the low voltage slow background throughout. this indicates a widespread encephalopathy. medications, metabolic disturbances, and infection are among the most common causes. hypotension and hypoperfusion are other possible causes. there were no areas of prominent focal slowing (although encephalopathies may obscure focal findings), and there were no pileptiform features. discharge labs: wbc hgb hct mcv mch mchc rdw plt ct 9.6 9.9* 29.3* 89 29.9 33.8 15.2 300 . differential neuts bands lymphs monos eos 75.4* 13.6* 3.8 6.4* 0.9 . glucose urean creat na k cl hco3 124* 49* 1.9* 145 3.9 108 26 . and : c. diff negative . calcium phos mg 9.3 5.7* 2.2 . rpr negative . tsh 2.4, free t4 0.91 . cortisol 28.1 . b12 909 . hep c viral load: 2,580,000 iu/ml . alt 27 ast 28 alk phos 56 t bili 0.5 ldh 286 . triglycerides 267 . brief hospital course: mr. is a 60 year-old man with history of coronary artery disease with stents, hepatitis c and diabetes mellitus who presented with undifferentiated shock. # shock: patient presented to the ed with two days of dizziness, altered mental status and suprapubic pain. while in the ed he became hypotensive and developed worsening respiratory distress that necessitated intubation. he was not initially responsive to fluid resuscitation and was started on vasopressors and empiric vancomycin and pipercillin/tazobactam. pulmonary embolism and cardiac causes were ruled out. his pressors were weaned off by hospital day two and he had no further signifcant episodes of hypotension. etiology of shock remains unclear. # persistant fevers: patient was noted to have left lower lobar opacity on imaging at time of presentation. he receieved vancomycin, pipercillin/tazobactam, and levofloxacin. blood, urine and sputum cultures along with legionella antigens were sent at presentation and were all no growth over the course of his stay save a single sputum culture which grew back mold. beta-glucan and galactomanan were sent and were negative. he had persistent fevers but no source of infection was found and infectious disease was consulted. all antibiotics were stopped on and his fever curve began to trend down and he was consistently afebrile at the time of his transfer from the micu. # delirium: throughout the patient's icu course, attempts to wean him from sedation were complicated by persistent delirium. several causes for his persistent delirium were pursued, including thyroid abnormalities, hepatic encephalopathy, and seizure. thyroid studies were normal, ammonia was normal, and his eeg showed no epileptiform activity. his mental status began to improve on and he became more alert, followed commands, and was able to answer simple yes/no questions. his intermittent agitation was controlled with diazepam 5 mg tid and trazodone 100 mg hs for sleep. the diazepam should be tapered off slowly as tolerated. # respiratory failure: patient presented to the micu from the ed with sudden respiratory failure requiring emergent intubation. he was a difficult intubation. he was found to have a left lower lobe pneumonia and was treated with a 14 day course of vancomycin, pipercillin/tazobactam, and levofloxacin. due to his persistent altered mental status, he was considered a poor candidate for extubation and on interventional pulmonology placed a tracheostomy tube, which the patient tolerated well and was able to come off the ventilator the following day. he only briefly was placed back on mechanical ventilation on in the setting of agitation but with stable respiratory status at that time. he was subsequently maintained with good oxygen saturations on a trach mask and was successfully fitted for a passy-muir valve. # candadiasis: around hospital day seven patient was noted to have developed a blanching, errythematous rash with perifolicular pustules along his back and sacrum. he was seen by dermatology, who biopsied the rash which was found to be candidiasis. he was treated with miconazole cream which should be continued until the rash has resolved. # coronary artery disease: he has a significant cad history with recent drug eluting stents in . patient was ruled out for mi with negative ekg, normal enzymes, and a echo showing preserved ejection fraction. he continued to receive his clopidogrel and aspirin through out his stay. # hypertension: he has hypertension at baseline for which he was on medications prior to admission. once his shock resolved, he began to have episodes when his systolic blood pressures rose into the 200s. these episodes seemed to coincide with agitation or pain. he initially required iv boluses of labetalol and clonidine but has since been stablized on his current regimen of po labetalol 400mg q6 hours and verapamil 40mg q8 hours which should be continued. these medications may be adjusted back to his home regimen as tolerated. # acute renal failure: at presentation his creatinine was elevated at 1.6 (unclear baseline, but last creatinine in system recorded as 1.1 from ). urine sediment showed muddy brown casts consitent with atn from a likely prerenal state in the setting of hypotension. he maintained good urine output that was responsive to fluids and lasix. his creatinine improved to 1.4 over the course of his micu stay, increased to 1.9 upon discharge in the setting of diuresis. diuretics are being held upon discharge. # diabetes mellitus: was placed on standing nph which was uptitrated to 40units in addition to humalog insulin sliding scale while in the micu and his glucose was well-controlled. home dose metformin was held in setting of renal failure. sliding scale insulin is given q6 hours while on tube feeds but can be changed to qachs as patient starts eating pos and comes off tube feeds. patient is discharged on nph/regular 70/30 mixed insulin which may need to be adjusted as patient's diet is advanced. # hepatitis c: patient's abdominal imaging was suggestive of cirrhotic changes and a hcv viral load obtained during his admission was 2.5 million copies/ml. he should be offered treatment as an outpatient. # thigh abscess: patient had a small fluid collection on his right inner thigh seen to be very superficial on ct. he had an i and d in the ed and was treated with broad specturm abx for pna. abscess was well healed by hospital day #3. transitional issues: 1) hcv: offer treatment vl 2.5 million copies/ml. 2) trach: d/c when possible. pt has not required mechanical ventilation for over four days. 3) hypertension: continue current medication regimen of labetalol and verapamil, and adjust as needed while in rehab. 4) agitation: continue diazepam tid and wean slowly. 5) diabetes mellitus: discharged on nph/regular 70/30 mix 40 units with q6 hour humalog sliding scale. will need to adjust sliding scale to qachs as patient stops tube feeds and begins taking po. adjust nph as needed. 6) coronary artery disease: continue aspirin and clopidogrel. 7) candidiasis: continue miconazole cream until rash has resolved. 8) speech and swallow: pt will require a speech and swallow evaluation tomorrow to start eating pos 9) physical and occupational therapy evaluation and treatment: pt has been in icu for three weeks, has been out of bed to chair in the last few days, requires extensive physical and occupational therapy rehabilitation. 10) the patient has a picc line inserted in left arm. medications on admission: 1. metformin 500 mg tablet extended rel 24 hr sig: three (3) tablet extended rel 24 hr po once a day. 2. simvastatin 80 mg tablet sig: one (1) tablet po once a day. 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 5. verapamil 240 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. 6. furosemide 20 mg tablet sig: three (3) tablet po daily (daily). 7. labetalol 200 mg tablet sig: two (2) tablet po bid (2 times a day). 8. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 9. humulin 70/30 100 unit/ml (70-30) suspension sig: 65units with breakfast, 70units with dinner subcutaneous once a day. 10. multivitamin tablet sig: one (1) tablet po daily (daily). 11. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). discharge medications: 1. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. valium 5 mg tablet sig: one (1) tablet po three times a day. 4. atorvastatin 80 mg tablet sig: one (1) tablet po at bedtime. 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 6. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 7. verapamil 40 mg tablet sig: one (1) tablet po q8h (every 8 hours). 8. labetalol 200 mg tablet sig: two (2) tablet po q6h (every 6 hours). 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) cartridge inhalation q6h (every 6 hours) as needed for dyspnea. 10. miconazole nitrate 2 % cream sig: one (1) appl topical (2 times a day) as needed for candidiasis. 11. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 12. senna 8.8 mg/5 ml syrup sig: five (5) ml po bid (2 times a day) as needed for contipation. 13. insulin nph & regular human 100 unit/ml (70-30) suspension sig: forty (40) units subcutaneous twice a day. 14. dextrose 50% in water (d50w) syringe sig: one (1) amp intravenous prn (as needed) as needed for hypoglycemia protocol. 15. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever. 16. docusate sodium 50 mg/5 ml liquid sig: units po bid (2 times a day). 17. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 18. trazodone 50 mg tablet sig: two (2) tablet po hs (at bedtime) as needed for insomnia. 19. sodium chloride 0.9% flush 10 ml iv prn line flush temporary central access-icu: flush with 10ml normal saline daily and prn. 20. sodium chloride 0.9% flush 10 ml iv prn line flush temporary central access-icu: flush with 10ml normal saline daily and prn. 21. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: shock of unclear etiology delirium hypertension pneumonia acute renal failure hypernatremia candidal rash discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. requires pt and ot evaluation after 3 weeks of icu stay. discharge instructions: dear mr. , you were admitted to the intensive care unit at because you had low blood pressures and trouble breathing. you were requiring medications to keep up your blood pressure initially as well. you were intubated requiring the mechanical ventilator to help you breath for two and half weeks. you underwent tracheostomy tube placement into your neck to help wean off the ventilator machine, which you are no longer requiring. you were also intermittently having very high blood pressures. after a few weeks in the intensive care unit, you were also having confusion/delirium. you were felt safe to be discharged to the rehab macu facility where your delirium will continue to improve. you will also receive a lot of physical and occupational therapy to help build up your strength again. during your stay in the intensive care unit, we discovered that your hepatitis c is very active. after you have recovered fully from this illness, you would benefit from undergoing treatment for the hepatitis c. please discuss this with your primary care physician after discharge from the rehabilitation facility. the following changes have been made to your medications: - please stop your lisinopril for now - please stop your metformin for now until your kidney function improves - please start verapamil 40mg every 8 hours - please stop verapamil extended release 240mg for now - please increase labetalol 400mg frequency (from twice daily) to once every 6 hours - please decrease dose of nph/regular insulin 70/30 mix to 40 units twice daily - please start humalog sliding scale (as attached) every 6 hours (should be changed to before meals and at bedtime once pt able to eat meals) - please start miconazole 2% cream 1 appl tp twice daily to fungal rash - please start heparin 5000units three times daily while at rehabilitation facility until ambulating regularly please be sure to follow up with your primary care physician 1-2 weeks of being discharged from the rehabilitation facility. it was a pleasure taking care of you, and we wish you a speedy recovery. followup instructions: please follow up with your primary care doctor within 1-2 weeks of discharge from the rehabilitation facility. please be sure to ask your primary care doctor to refer you to a liver specialist to see if you should be treated for your hepatitis c. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Other bronchoscopy Temporary tracheostomy Other incision with drainage of skin and subcutaneous tissue Closed biopsy of skin and subcutaneous tissue Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Severe sepsis Unspecified viral hepatitis C without hepatic coma Percutaneous transluminal coronary angioplasty status Acute respiratory failure Cellulitis and abscess of leg, except foot Septic shock Morbid obesity Encephalopathy, unspecified Hyperosmolality and/or hypernatremia Other candidiasis of other specified sites Other alteration of consciousness Body Mass Index 40.0-44.9, adult |
allergies: sulfasalazine attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass grafting x4, with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the obtuse marginal artery and a reverse saphenous vein y-graft to the ramus intermedius artery and the first diagonal artery. history of present illness: 64 year old male complains of exertional chest pain and tightness in the last 3 months. he had a stress test on that was positive and was referred for a cardiac catheterization. he was found to have left main disease and is now being referred to cardiac surgery for revascularization. past medical history: coronary artery disease, s/p cabg this admission alcohol abuse (last drink 1 year ago) wernicke's encephalopathy multiple falls with injury/fractures (left humerus and shoulder)- has only had 1 fall in the last year since arriving at the nursing home hypertension copd gerd current smoker social history: lives with:lives at nursing home due to financial issues contact: (sister) phone# occupation:does not currently work cigarettes: smoked no yes last cigarette hx:currently smokes 8 cigarettes a day x 2 years and history of 3ppd x 50 years other tobacco use:none etoh: none in the past year, history of alcohol abuse illicit drug use:none family history: sister with placed at age of 50 physical exam: pulse:59 resp:16 o2 sat:99/ra b/p right:156/77 left:142/70 height:5'" weight:131 kgs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs wheezes bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + obese extremities: warm , well-perfused edema +2 varicosities: +1 chronic venous stasis neuro: grossly intact pulses: femoral right: cath site left: +2 dp right: +1 left: +1 pt : +1 left: +1 radial right: +2 left: +2 carotid bruit right: 0 left: 0 pertinent results: 05:12am blood wbc-13.4* rbc-3.30* hgb-10.1* hct-29.1* mcv-88 mch-30.5 mchc-34.6 rdw-14.3 plt ct-193# 04:36am blood wbc-14.0* rbc-3.20* hgb-9.9* hct-28.2* mcv-88 mch-31.1 mchc-35.2* rdw-13.9 plt ct-113* 05:12am blood glucose-143* urean-17 creat-0.8 na-130* k-4.0 cl-94* hco3-30 angap-10 04:36am blood glucose-136* urean-17 creat-0.7 na-132* k-4.7 cl-97 hco3-28 angap-12 , intra-op tee conclusions pre-cpb: no spontaneous echo contrast is seen in the left atrial appendage. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post-cpb: the patient is a-paced, on no inotropes. preserved biventricular systolic fxn. mr remains 1+. no ai. aorta intact. brief hospital course: the patient was brought to the operating room on where the patient underwent cabg x 4. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. the patient was transferred to the telemetry floor for further recovery. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to roscommon at in in good condition with appropriate follow up instructions. medications on admission: folic acid - (prescribed by other provider) - 1 mg tablet - 1 (one) tablet(s) by mouth once a day furosemide - (prescribed by other provider) - 20 mg tablet - 1 (one) tablet(s) by mouth once a day ipratropium-albuterol - (prescribed by other provider) - 0.5 mg-3 mg (2.5 mg base)/3 ml solution for nebulization - 1 (one) unit dose vial inhaled three times a day metoprolol succinate - (prescribed by other provider) - 50 mg tablet extended release 24 hr - 1 (one) tablet(s) by mouth once a day nitroglycerin - (prescribed by other provider) - 0.4 mg tablet, sublingual - 1 (one) tablet(s) sub lingually every 5 minutes up to 3 times as need for chest pain simvastatin - (prescribed by other provider) - 40 mg tablet - 1 (one) tablet(s) by mouth at bedtime medications - otc aspirin - (prescribed by other provider) - 81 mg tablet, delayed release (e.c.) - 1 (one) tablet(s) by mouth once a day multivitamin - (prescribed by other provider) - capsule - 1 (one) capsule(s) by mouth once a day discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 6. multivitamin tablet sig: one (1) tablet po daily (daily). 7. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for dyspnea. 10. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for dyspnea. 11. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*65 tablet(s)* refills:*0* 12. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 13. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 14. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po daily (daily) as needed for constipation. 15. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 16. lasix 40 mg tablet sig: one (1) tablet po twice a day for 10 days. 17. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po twice a day for 10 days. discharge disposition: extended care facility: roscommon extended care center discharge diagnosis: alcohol abuse (last drink 1 year ago), werneke's encephalopathy, multiple falls with injury/fractures (left humerus and shoulder), hypertension, copd, gerd, current smoker, s/p orif(humerus) discharge condition: alert and oriented x3 nonfocal ambulating with cane incisional pain managed with oral anagesics incisions: sternal - healing well, no erythema or drainage leg left - healing well, no erythema or drainage. edema + pitting edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: recommended follow-up: you are scheduled for the following appointments surgeon: dr. at 1pm in the medical office building cardiologist: dr. at 10:20 am **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** please call to schedule appointments with your primary care dr. - make appointment for 4-5 weeks Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Esophageal reflux Tobacco use disorder Unspecified essential hypertension Hyposmolality and/or hyponatremia Other and unspecified alcohol dependence, in remission Chronic airway obstruction, not elsewhere classified Other and unspecified angina pectoris Family history of ischemic heart disease History of fall Personal history of allergy to sulfonamides Other and unspecified manifestations of thiamine deficiency |
allergies: no known allergies / adverse drug reactions attending: chief complaint: dehydration/failure to thrive major surgical or invasive procedure: ileostomy reversal history of present illness: 60m w hx of muir ( syndrome with associated sebaceous tumors, cutaneous keratoacanthomas, and visceral carcinomas) and recurrent colorectal adenoca s/p recent open completion proctosigmoidectomy w/ipaa, distal pancreatectomy and splenectomy approx 1 month ago, now p/w acute renal failure and ftt since surgery, worsening over past week. was recently admitted last week to for "dehydration." felt better afterwards and was doing well over the weekend, but with nausea/bile tinged vomiting for last 3-4 days. also with decreased uop, with last void yesterday. notes that was npo for pouch study overnight until yesterday, and has felt particularly poors since then. over last month, patient with 30 pound weight loss since surgery as well as limited appetite, transient chest pain associated with eating, dyspnea on exertion, increased ostomy output makign it difficult to sleep. denies fevers/chills, no abdominal pain or cramping. in clinic today, vs were: 97.5 100/71 80 16 100% ra was noted to look rather ill. patient feeling poorly. admitted for hydration from clinic. found to have k of 7.7. received 1l ns, ns running at 150, calcium gluconate 4g, amp d50 + 10 unit insulin. patient made 4 cc urine since admission. renal consulted. transferred to micu for potential emergent dialysis. on arrival to the micu, patient's vs. 97.4 91 135/80 15 100% ra past medical history: past medical history: muir syndrome-recurrent colorectal ca, associated skin cancers, rectal adenocarcinoma htn demand nstemi in setting of gib hl possible axis i/ii disorder past surgical history: open completion proctosigmoidectomy w/ipaa (ileal pouch-anal anastomosis) and distal pancreatectomy and splenectomy on . partial colectomy () transverse colectomy () multiple skin cancer resections social history: social history: - tobacco: denies - alcohol: denies - illicits: denies - occupation: former chemist, now a clerk at a hardware store - social: attended for 2 years, lives alone family history: family history: - mother: healthy - father: died young of mi - sister: cancer in her 40s - brother: cancer in his 40s - p. aunt: endometrial cancer physical exam: on admission: general: alert, oriented. uncomfortable appearing. heent: sclera anicteric, mm dry, oropharynx clear, eomi neck: jvp flat, no lad cv: distant heart sounds, rrr, normal s1 + s2 lungs: clear to auscultation bilaterally in anterior fields, no wheezes, rales, ronchi abdomen: +well healed surgical scar. nondistended. tender to palpation throughout, particularly in ruq, luq. central ostomy bag with solid/liquid green colored output. +bowel sounds. gu: +foley ext: cool, perfused, no clubbing, cyanosis, edema neuro: cnii-xii intact, strength/sensation grossly intact, gait deferred. pertinent results: cxr findings: no previous images. the heart is normal in size and there is no vascular congestion or pleural effusion. specifically, no acute pneumonia. pouchogram findings: after a scout image was obtained, a 16 french foley catheter was inserted into the anus and advanced to just below the anastomotic site. 50 cc of contrast was gently hand injected. contrast is seen filling the j-pouch and flowing into the ileum without holdup. no extraluminal contrast is noted. post-evacuation scout image showed no evidence of leak. there was a faint linear radiopacity extending to the right of the ileal j-pouch which might suggest a leak, however this finding was present on scout and post-evacuation images in unchanged positions, ruling this out as a possible leak. impression: no evidence of anastomotic leak. ekg: nsr. normal axis. peaked t waves. no acute ischemia. ctabdomen findings: ct abdomen: there are mild coronary artery calcifications and a trace pericardial effusion. there are moderate bilateral pleural effusions with associated compressive atelectasis. evaluation of the intra-abdominal solid organs and vasculature is limited without the administration of intravenous contrast material. within these limitations, there are no focal liver lesions or intra- or extra-hepatic biliary dilatation. the gallbladder is contracted. the patient is status post distal pancreatectomy, splenectomy and completion of total proctocolectomy. remaining pancreatic head and body appear unremarkable. there are suture lines seen at the distal pancreas. there is moderate amount of intra-abdominal ascites with a loculated fluid collection at the distal pancreas measuring 2.6 x 2.1 cm. additional second loculated fluid collection is seen in the splenectomy bed measuring 3.7 x 3.3 cm. these collections measure simple fluid; however, cannot exclude superinfection due to lack of contrast. there is mild fullness of the collecting system of the right kidney. the kidneys otherwise appear unremarkable without any focal lesions or stones. the adrenal glands are unremarkable. the gastric wall is markedly thickened. the intra-abdominal small bowel demonstrates air-fluid levels, but there is no definite obstruction. contrast passes all the way through into the left lower quadrant ileoostomy. there is atherosclerotic calcification of the aorta extending into the iliac arteries. ct pelvis: air within the bladder, is likely from recent instrumental manipulation. the patient is status post j-pouch with anastomosis within the pelvis. there is free fluid within the pelvis. there is no lymphadenopathy or free air. osseous structures: there are no concerning lytic or sclerotic lesions. there are degenerative changes of the hip joints. there are degenerative changes in the spine where there are anterior osteophytes. soft tissues: note is made of generalized anasarca. there are two new soft tissue nodules within the anterior abdominal wall measuring 0.6 cm on the left and 1.2 cm on the right. impression: 1. new intra-abdominal ascites with loculated fluid collections in the pancreatic and splenectomy surgical beds. 2. marked wall thickening of the stomach of uncertain etiology. consider correlation with endoscopy. 3. new moderate bilateral pleural effusions. generalized anasarca. 4. new skin nodules in the anterior abdominal wall. ruq u/s: 1. patent hepatic vasculature including the main portal vein and intrahepatic branches. patent ivc and intrahepatic veins. left hepatic artery not interrogated. the patient can be recalled for additional imaging. 2. small right pleural effusion. no evidence of intrahepatic biliary dilatation. : renal u/s: normal renal ultrasound with normal renal doppler. no evidence of renal artery stenosis. egd with biopsy: stable, mild gastric fold thickening, biopsies sent brief hospital course: # hyperkalemia: patient with acute on chronic renal failure with hyperkalemia 7.5, cr 7.5, peaked t waves on ekg. likely poor po intake, nausea/vomiting, increased ostomy output leading to profound hypovolemia accompanyed by tachycardia as well as likely low solute state with hyponatremia. patient received aggressive fluid repletion in addition to temporizing measures with bicarb, calcium gluconate, and insulin + dextrose. albuterol nebs were held due to tachycardia. kayexelate was held given bowel surgery. fluid repletion was performed with ns and d5 with bicarb. uop initially was scant, but picked up with fluid resuscitation. renal reviewed urine and found muddy brown casts, suggesting that largely prerenal etiology had progressed to involve intrinsic renal pathology. emergent dialysis was considered, but did not become necessary with treatment. finger sticks glucose were followed closely in context of insulin in context of renal failure. patient did well and improved clinically from volume standpoint as well as from k standpoint. # acute on chronic renal failure: patient presented with gap acidosis, hyperphos, est. gfr 7. urine sodium < 10 suggested prerenal cause, but likely had progressed to involve intrinsic renal pathology with atn. received aggressive fluid resuscitation as above. # ileostomy reversal: because the patient was in the hospital, and his j pouch had adequately healed from prior surgery, he was taken to the or on for ileostomy reversal. he tolerated this procedure well. on pod 1 he was started on sips while awaiting return of bowel function. the previous ostomy site was packed with dressings . by pod 2 the patient was passing small clots of blood but had not passed flatus. his diet was advanced to clears, however the patient had a small amount of emesis x 1 that evening. the patient was made npo the following day while awaiting return of bowel function. he continued to pass bloody clots and his hematocrit had been trending down since the operation, so he was transfused 2 units of blood on pod 4, and hct improved from 22.1 to 29.0. on pod 5 the patient continued to experience nausea and vomiting, so an ng tube was placed, and left in until pod 6. on pod , the patients diet was slowly advanced to regular, and bowel function returned. the patient began passing frequent soft/liquid stools without blood, and flatus. he had low normal urine output, so he received 1l boluses and we encouraged greater po intake. he was started on a regimen of immodium and metamucil to control stool output. on pod 11 the patient was deemed appropriate for discharge on immodium 2 qid and psyllium wafers 1.5 . his social issues were resolved, and he was discharged home on . medications on admission: acetaminophen 1000 mg po q8h carvedilol 25 mg po bid pantoprazole 40 mg po q24h pravastatin 80 mg po daily tamsulosin 0.4 mg po hs iron 325 mg finasteride 5 mg q24h remeron 15 mg qhs discharge medications: 1. carvedilol 25 mg po bid rx *carvedilol 25 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 2. pravastatin 80 mg po daily rx *pravastatin 80 mg 1 tablet(s) by mouth once a day disp #*30 tablet refills:*0 3. pantoprazole 40 mg po q24h rx *pantoprazole 40 mg 1 tablet(s) by mouth once a day disp #*30 tablet refills:*0 4. tamsulosin 0.4 mg po hs rx *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day disp #*30 capsule refills:*0 5. acetaminophen 650 mg po q6h:prn pain 6. oxycodone (immediate release) 5-10 mg po q4h:prn pain hold for increased sedation or rr<12 rx *oxycodone 5 mg 1 tablet(s) by mouth q4-6hrs disp #*20 tablet refills:*0 7. loperamide 2 mg po qid rx *loperamide 2 mg 1 tablet by mouth q6hrs disp #*120 capsule refills:*0 8. psyllium wafer 1.5 waf po bid rx *psyllium 1.5 wafers by mouth twice a day disp #*3 packet refills:*0 9. mirtazapine 15 mg po hs rx *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime disp #*30 tablet refills:*0 10. finasteride 5 mg po daily rx *finasteride 5 mg 1 tablet(s) by mouth once a day disp #*30 tablet refills:*0 discharge disposition: home with service facility: caregroup vna discharge diagnosis: dehydration discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the inpatient colorectal surgery service from rehab with renal failure related to extreme dehydration and failure to thrive. it is thought that this was likely caused by ileostomy output and poor intake of fluids by mouth. you were admitted to the intensive care unit and given a large volume of fluids and your renal failure recovered well. a ctscan was done to evaluate the areas of your previous colectomy, splenectomy, and distal pancreatectomy and these were stable. on the ct it was noticed that your stomach wall appeared to be slightly thickened. this was evaluated by the gastroenterology team and you had a test to look into the stomach which showed likely gastritis (inflammation of the stomach) likely related to iron supplements. this is treated with discontinuing iron and giving you protonix to protect your stomach. no other intervention was needed. because you were in the hospital, and the jpouch was healed, it was appropriate to takedown the ileosotmy. you tolerated this procedure well. after the procedure, you suffered from a post-operative ileus which required placment of an nasogastric tube and you also had a small amount of bleeding from the staple line at the site of the ileostomy takedown. you have recovered and your bowel function has returned and you are now ready to return home. it is critical that you do not return home and allow yourself to become dehydrated. please call the office if you experience any of the following signs of dehydration: weakness, dzziness, fainting, loss of conciousness, decreased amount of urine production, fast heart rate, or extreme thirst. please go to the emergency room if you experience any of these symptoms. please monitor your bowel function closely. you have had a bowel movement prior to your discharge. some loose stool and passing of small amounts of dark, old appearing blood are expected however, if you notice that you are passing bright red blood with bowel your please seek medical attention. if you are passing loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. you do not have a which primary responsibility in the body is to absorb water. it is also not uncommon after an ileostomy takedown to have frequent loose stool until you are taking more regular food however this should improve. the muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve. if you do not show improvement in these symptoms within 2-4 days please call the office for advice. occasionally, patients will need to take a medication to slow their bowel movements as their bodies adjust to the new normal without an ileostomy. you should take loperamide 2mg 4 times per day, as well as 1.5 metamucil (psyllium) wafers twice a day. if you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. you have a small wound where the old ileostomy once was. this should be covered with a dry sterile gauze dressing. the wound no longer requires packing with gauze packing strip. please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. you may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. please apply a new gauze dressing after showering. you have 2 small skin nodules and these should be covered with dry sterile gauze dressings until evaluated by dermatology. you should continue to monitor your blood sugar closely 4 times daily prior to meals and at bedtime. please follow the insulin sliding scale as ordered. you must make a follow-up appoinment with the clinic as you were prior to your original discharge from the hospital. no heavy lifting for at least 6 weeks after surgery unless instructed otherwise by dr. or dr. . you may gradually increase your activity as tolerated but clear heavy exercise with dr. or dr. . you will be prescribed a small amount of the pain medication oxycodone. please take this medication exactly as prescribed. you may take tylenol as recommended for pain. please do not take more than 4000mg of tylenol daily. do not drink alcohol while taking narcotic pain medication or tylenol. please do not drive a car while taking narcotic pain medication. thank you for allowing us to participate in your care! our hope is that you will have a quick return to your life and usual activities. you will have a visiting nurse coming to your house to make sure you have everything that you need. good luck! followup instructions: please call the colorectal surgery clinic at to make an appointment for follow-up appointment with , np or , np for 2-3 weeks after discharge. at this appointment, an additional visit with dr. for your second post-operative check will be arranged for you. please call to schedule a follow up appointment with dr. as an outpatient you have the following appointment : department: surgical specialties when: thursday at 1:30 pm with: , md building: sc clinical ctr campus: east best parking: garage please make a follow-up appointment at the clinic for managment of your blood sugar by calling . please call and ask for - or leave voice message for her. you should also call to schedule regular follow up with your primary care physician. Procedure: Closure of stoma of small intestine Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Hyperpotassemia Acute kidney failure with lesion of tubular necrosis Hyposmolality and/or hyponatremia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Personal history of other malignant neoplasm of skin Loss of weight Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Old myocardial infarction Paralytic ileus Personal history of malignant neoplasm of large intestine Other ascites Hypovolemia Other specified gastritis, without mention of hemorrhage Family history of malignant neoplasm of gastrointestinal tract Attention to ileostomy Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus Other digestive system complications Iron and its compounds causing adverse effects in therapeutic use |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: left hemisphere mass major surgical or invasive procedure: craniotomy for mass resection history of present illness: 62yo left handed male presenting with right sided weakness and facial weakness, found to have left centrum semiovale mass. pt was noted by family to lean to his right side and have dysarthria three days ago. pt often returns from daily trips to the bar intoxicated and family was unsure if this was related to a stroke. they encouraged pt to seek medical evaluation, but he declined. today the patient fell off of the bar stool multiple times and was noted to have a clear right facial droop and was sent to an outside hospital for evaluation. there a head ct revealed l hemishere mass with surrouding edema. tx to for further care. at present the pt denies any ha or h/o ha's. he fell a few days ago and sustained a r forearm abrasion. + dysarthria. + l arm and leg clumsiness. no sensory loss. he denies visual loss. family reports pt does not have regular medical care. past medical history: undescended testicle- reduced at age 18 prior to military service. social history: single, works intermittently as a housepainter, army veteran, 45 pack year active smoker, drinks heavily on a daily basis. denies illicit or iv drug use. family history: mother- d. 87 cancer ? ovarian father- d. 87 prostate ca brother- 65 hepatic ca brother- esophageal ca sister- metastatic ca physical exam: on admission: physical exam: o: t: 99 bp: 178/88 hr: 97 r: 16 o2sats 99% gen: wd/wn, comfortable, nad heent: ncat, + rhinophyma, mmm neck: supple. lungs: + exp wheezes. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. recall: objects at 5 minutes. language: + dysarthria. speech fluent with good comprehension and repetition. naming intact. no paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, to mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: right umn facial palsy. diminished sensation on r. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: r arm pronator drift. normal bulk and tone bilaterally. no abnormal movements. strength full power throughout. sensation: intact to light touch, propioception, pinprick and bilaterally. graphestesia on the r hand is impaired vs. the left. reflexes: b t br pa ac right 3 3 2 3 2 left 2 2 2 3 2 r toe upgoing, l toe down. coordination: slowing of on r. on discharge : ***************** pertinent results: mri brain : post-contrast brain mri demonstrates an enhancing mass in the left centrum semiovale with surrounding edema and mass effect on the left lateral ventricle with mild midline shift. an additional 1 cm mass is identified at the convexity in the right frontal lobe near midline. the findings are suggestive of metastatic disease. ct torso : 1. right suprahilar mass with multiple pulmonary nodules and left adrenal nodule. findings likely represent metastatic lung cancer. 2. numerous hypodensities in the liver are too small to characterize, these most likely represent cysts, however, given patient's current imaging findings, cannot exclude metastatic etiology. mr : the functional mri demonstrates the expected activation areas at more than 1 cm from the largest ring-enhancing lesion involving the left centrum semiovale. the language paradigm demonstrates the major activation areas on the right cerebral hemisphere, likely consistent with dominance, a small area of activation is demonstrated anterior to the mass lesion during the language paradigm. an additional small mass lesion is demonstrated at the frontoparietal convexity and right parasagittal region, with areas of activation during the movement of the feet adjacent to this area. fmri : the functional mri demonstrates the expected activation areas at more than 1 cm from the largest ring-enhancing lesion involving the left centrum semiovale. the language paradigm demonstrates the major activation areas on the right cerebral hemisphere, likely consistent with dominance, a small area of activation is demonstrated anterior to the mass lesion during the language paradigm. an additional small mass lesion is demonstrated at the frontoparietal convexity and right parasagittal region, with areas of activation during the movement of the feet adjacent to this area. ct head : 1. excision of left centrum semiovale mass with minimal expected postoperative hemorrhage, but no new or unexpected other site of hemorrhage. 2. continued edema and compression of left lateral ventricle with mild right parafalcine herniation. 3. additional enhancing mass seen on mr four days ago, again not appreciated. mr : impression: 1. status post left craniotomy and resection of a ring-enhancing mass. there is a thin area of enhancement surrounding the resection cavity that may be post-surgical in nature, although a small area of residual tumor cannot be excluded. there is extensive surrounding edema, which is stable in extent and with a stable appearance of the rightward midline shift. 2. small focus of enhancement in the right frontal lobe, unchanged since the prior study. brief hospital course: the patient was admitted to the neurosurgery service on with a new left sided brain mass. he was placed on keppra for seizure prophylaxis and was monitored with q2 hour neuro checks. the patient has a cxr due to his smoking history. it revealed a possible mass. he then had a ct of the chest which confirmed there was a mass present. pulmonary was consulted but they agreed that the patient should have his brain lesion resected prior to any other biopsies. on the patient went to the or for resection of the brain mass. the prelminary pathology is consistent with carcinoma he remained neurologically stable and floor orders were written on and he was transferred to 11. on his dysarthra was much improved and it was determined that he would be trasnferred to omed and the . on he was transferred to the and omed for the remainder of his care. he remained asymptomatic without complaints while on the omed service. he was set up with appropriate outpatient care with a new pcp and new medical oncologist. ***his brain biopsy was pending at time of discharge*** medications on admission: none discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 7. multivitamin tablet sig: one (1) tablet po daily (daily). 8. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 9. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 10. dexamethasone 4 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*2* discharge disposition: home with service facility: vna and hospice discharge diagnosis: l centrum semiovale mass pulmonary mass adrenal mass dysphagia discharge condition: neurologically stable discharge instructions: you were admitted for removal of a brain mass. this is likely metastasis from another cancer, likely the lung. you remained stable and pain free through your post-operative course. you will need to keep all of your follow up appointments below. general instructions wound care: ?????? you or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? keep your incision clean and dry. ?????? you may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? do not apply any lotions, ointments or other products to your incision. ?????? do not drive until you are seen at the first follow up appointment. ?????? do not lift objects over 10 pounds until approved by your physician. diet usually no special diet is prescribed after a craniotomy. a normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. medications: ?????? take all of your medications as ordered. you do not have to take pain medication unless it is needed. it is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? do not use alcohol while taking pain medication. ?????? medications that may be prescribed include: o narcotic pain medication such as dilaudid (hydromorphone). o an over the counter stool softener for constipation (colace or docusate). if you become constipated, try products such as dulcolax, milk of magnesia, first, and then magnesium citrate or fleets enema if needed). often times, pain medication and anesthesia can cause constipation. ?????? you have been discharged on keppra (levetiracetam), you will not require blood work monitoring. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc, as this can increase your chances of bleeding. ?????? you are being sent home on steroid medication(tapered dose), make sure you are taking a medication to protect your stomach (prilosec, protonix, or pepcid), as these medications can cause stomach irritation. make sure to take your steroid medication with meals, or a glass of milk. activity: the first few weeks after you are discharged you may feel tired or fatigued. this is normal. you should become a little stronger every day. activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. in general: ?????? follow the activity instructions given to you by your doctor and therapist. ?????? increase your activity slowly; do not do too much because you are feeling good. ?????? you may resume sexual activity as your tolerance allows. ?????? if you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? do not drive until you speak with your physician. ?????? do not lift objects over 10 pounds until approved by your physician. ?????? avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? do your breathing exercises every two hours. ?????? use your incentive spirometer 10 times every hour, that you are awake. when to call your surgeon: with any surgery there are risks of complications. although your surgery is over, there is the possibility of some of these complications developing. these complications include: infection, blood clots, or neurological changes. call your physician immediately if you experience: ?????? confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? double, or blurred vision. loss of vision, either partial or total. ?????? hallucinations ?????? numbness, tingling, or weakness in your extremities or face. ?????? stiff neck, and/or a fever of 101.5f or more. ?????? severe sensitivity to light. (photophobia) ?????? severe headache or change in headache. ?????? seizure ?????? problems controlling your bowels or bladder. ?????? productive cough with yellow or green sputum. ?????? swelling, redness, or tenderness in your calf or thigh. call 911 or go to the nearest emergency room if you experience: ?????? sudden difficulty in breathing. ?????? new onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? a seizure that lasts more than 5 minutes. important instructions regarding emergencies and after-hour calls ?????? if you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. your medication changes: start keppra start dexamethasone start famotidine start folic acid followup instructions: follow up appointment instructions 1. please return to the office in 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 . if you live quite a distance from our office, please make arrangements for the same, with your pcp. 2. you have an appointment in the brain clinic on at 1pm with dr. . the brain clinic is located on the of , in the building, . this is a multi-disciplinary appointment. their phone number is . please call if you need to change your appointment, or require additional directions. you will not need an mri of the brain as this was done during your hospitalization 3. you will follow up with dr. in neurosurgery: at 9:15 am located at the medical office building (across the street from the emergency room on .) you are to go to the , #3b. phone:. ***you are scheduled for a cat scan the very same day, at 8:15 am. you are to go to the at in the clinical center building on the . 4. medical thoracic oncology: you will need to call the thoracic oncology office at to schedule an appointment in the next 2 weeks. you should contact in the office. 5. we have set you up with a primary care doctor since you do not have one. since all of your appointments are at , you have been set up here. if you prefer to see someone closer to your home, you should call and cancel this appointment. appointment #1 md: dr. post discharge clinc specialty: internal medicine date/ time: 1:10pm location: building central suite, ma phone number: special instructions for patient: this is a follow up from your hospitalization. you will be establishing care with a new primary care physican next month. appointment #2 md: dr. specialty: internal medicine date/ time: 1:45pm location: building , ma phone number: Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Tobacco use disorder Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of upper lobe, bronchus or lung Unspecified disorder of adrenal glands Cerebral edema Dysarthria Enlargement of lymph nodes Other musculoskeletal symptoms referable to limbs Dysphagia, unspecified |
allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: chief complaint: melanoma (scheduled il-2 treatment) . reason for micu transfer: hypotension major surgical or invasive procedure: central line placement and removal history of present illness: ms. is a 63f with a history of melanoma originally diagnosed who is admitted for cycle 1 week 2 of hd il-2 therapy. her melanoma history is pertinent for presenting lesion on left thigh removed but felt benign; two years later it recurred and biopsy was notable for 1.88 mm thick melanoma with microscopic deposits in senitinel nodes. she was initially treated with 32 weeks of interferon but course was terminated due to peripheral neuropathy. she was then observed, and did well for 5 years but re-presented with hip pain; she was ultimately found to have necrosis of the femoral neck (biopsy unrevealing) but also lesions in liver and lung. she underwent hip stabilization surgery on and biopsy confirmed melanoma. re-staging was pertinent for stable liver/lung lesions and normal ldh so high-dose il-2 therapy was recommended. she underwent a first treatment cycle , which was complicated by pulmonary edema (two doses held) and toxic encephalopathy (two doses held; mental status improved to baseline). she developed an erythematous, pruritic rash treated symptomatically, as well as n/v/d. she also developed arf with peak creatinine of 2.6 and oliguria. lfts were elevated to peak ast 90, alt 116. finally, she was noted to have ck elevated to 707 and ck-mb elevated to 162 felt to be consistent with myocardititis; these enzymes trended down and she was discharged home, where she reports doing fairly well in the interval time. she is recovered well from week 1o f theraoy and is here to begin week of hd il-2 on cycle 1. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. reports eating and drinking ok while at home. diarrhea earlier today. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: past medical history: - melanoma - hypertension - hypercholesterolemia - depression - hypothyroidism - s/p hip stabilization - s/p tah with bso for fibroids social history: lives alone in . widowed but has two adult sons ages 23 and 28. continues to work as a teacher (teaches early childhood development) and also has a part-time job working at . plans to retire from teaching at the end of this academic year. has a sister who lives in ma and will serve as emergency contact. - tobacco: none - alcohol: very rare - illicits: none family history: father died of melanoma. physical exam: admission exam: vs: 97.4-103-20-146/32 pain (extremity) ht 64.25 inches, wt: 193 lbs general: alert, oriented, no acute distress. does seem slightly short of breath with speaking extensively but denies subjective sob. heent: sclera anicteric, dry mucous membranes, oropharynx mildly injected but no active thrush. neck: supple, jvp hard to assess given body habitus, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: bilateral le edema with thigh edema significantly worse on left; this is baseline per patient. skin: diffuse, confluent, maculopapular, erythematous, blanching rash over face, torso, extremities associated with dry/flaking skin. pertinent results: 04:00am blood glucose-114* urean-42* creat-3.0*# na-130* k-5.1 cl-102 hco3-19* angap-14 04:00am blood glucose-83 urean-58* creat-2.5* na-129* k-4.5 cl-99 hco3-22 angap-13 04:00am blood glucose-116* urean-33* creat-1.8*# na-133 k-5.4* cl-104 hco3-19* angap-15 04:11am blood na-136 k-3.4 cl-106 hco3-21* angap-12 brief hospital course: ms. was admitted to for cycle 1, week 2 of hd il-2 therapy for metastatic melanoma. during this week, she received 8 of 14 potential doses. her dose was 52.6 million units iv q8hrs. her dosing schedule was changed to dosing on day 2 given the previous week's neurotoxicity and other side effects. she was also placed on telemetry given myocarditis observed during the previous week. she underwent cvl placement and with confirmation, she began treatment on . her iv fluid was maintained at 50 ml/hr given pulmonary edema seen on week 1 however increased back to 75 ml/hr with hyperkalemia and acute renal failure. her course was complicated hypotension hypovolemic shock requiring further elevation of the pressor support and ultimately being transferred to icu for further support on day +5. her blood pressure was stabilized on day 6 and was transferred out of the icu in stable condition. she had acute renal failure with peak cr of 3.0, her urine out put, daily labs were closely monitored and had continuous ivf for support. she had hypokalemia and hyperkalemia without ecg changes on the telemetry and these were corrected accordingly. other side effects she experienced were hypomagnesemia, nausea, vomiting, and pruritus. they were corrected and controlled accordingly throughout the week. on day 7, she was dc'ed to home in stable condition after cvl removal without incident. medications on admission: medications at home: pharmacy is in . - acetaminophen 325-650 mg q.i.d. p.r.n. pain. - sarna lotion topically q.i.d. p.r.n. pruritus. - cephalexin 500 mg b.i.d. times 5 days. - diphenhydramine 25-50 mg q.i.d. p.r.n. pruritus. - lomotil 1-2 tablets b.i.d. p.r.n. diarrhea. - cymbalta 60 mg p.o. daily. - lasix 20 mg p.o. daily times 5 days or until you reach pretreatment weight. - levothyroxine 125 mcg p.o. daily. - lorazepam 0.5-1 mg t.i.d. p.r.n. nausea, vomiting. - oxycodone 5-10 mg q.4 h. p.r.n. pain. - prochlorperazine 10 mg q.i.d. p.r.n. nausea, vomiting. - zantac 150 mg p.o. b.i.d. p.r.n. indigestion. - eucerin cream topically. - bp meds at home (patient does not know names/doses; likely lisinopril-hctz 20-25 mg po daily and metoprolol succinate 25 mg po qhs per omr records; will attempt to confirm with pharmacy) discharge medications: 1. diphenhydramine hcl 25 mg capsule sig: capsules po q6h (every 6 hours) as needed for pruritis. disp:*60 capsule(s)* refills:*0* 2. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for pruritus. disp:*1 bottle* refills:*0* 3. cephalexin 500 mg capsule sig: one (1) capsule po bid (2 times a day) for 5 days. disp:*10 capsule(s)* refills:*0* 4. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days: please take until pre treatment weight is acheived. 193 lbs. disp:*5 tablet(s)* refills:*0* 5. gabapentin 100 mg capsule sig: capsules po tid (3 times a day) as needed for itching. disp:*90 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: metastatic melanoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: please call rn with any issues followup instructions: provider: scan phone: date/time: 2:00 provider: . / phone: date/time: 3:00 provider: , : date/time: 3:00 Procedure: Venous catheterization, not elsewhere classified High-dose infusion interleukin-2 [IL-2] Diagnoses: Acidosis Hyperpotassemia Other iatrogenic hypotension Pure hypercholesterolemia Malignant neoplasm of liver, secondary Unspecified essential hypertension Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Secondary malignant neoplasm of other specified sites Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Dermatitis due to drugs and medicines taken internally Secondary malignant neoplasm of lung Personal history of malignant melanoma of skin Disorders of magnesium metabolism Secondary malignant neoplasm of bone and bone marrow Oliguria and anuria Shock, unspecified Unspecified pruritic disorder Encounter for antineoplastic immunotherapy |
allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: right cerebellar lesion. major surgical or invasive procedure: : posterior fossa craniotomy and tumor resection. history of present illness: ms. is a 63 y/o female with metastatic melanoma on study drug pd1 antibody was recently seen with worst headache of life. she reports she was cleaning when she experienced sudden onset diffuse headache which was associated eventually with nausea and vomiting. when symptoms did not remit she took herself to hospital near her home where she underwent a ct scan that demonstrated an area of acute right cerebellar hemorrhage. she was transferred to for further care. after stabilization and further work up she was cleared for discharge home. she returns for posterior fossa craniotomy and resection. past medical history: past medical history: - melanoma with metastatic disease to lung, bone, and liver - hypertension - hypercholesterolemia - depression - hypothyroidism - s/p hip stabilization - s/p tah with bso for fibroids social history: lives alone in . widowed but has two adult sons ages 23 and 28. continues to work as a teacher (teaches early childhood development) and also has a part-time job working at . plans to retire from teaching at the end of this academic year. has a sister who lives in ma and will serve as emergency contact. - tobacco: none - alcohol: very rare - illicits: none family history: father died of melanoma. physical exam: physical examination on admission: 98.4 107 140/74 16 98%ra gen nad, alert and oriented heent perrla, mmm cv rrr chest ctab abd soft ext wwp cn 2-12 intact strength/sensation and reflexes equal and intact in ues and /l cerebellar intact to finger-nose-finger; gate grossly normal physical examination on discharge: t 98.8, hr 83, bp 133/77, rr 20, o2 98% ra. gen: nad; alert and oriented x3. eyes open spontaneously. heent: peerla; pupil size 6mm-4mm bilaterally. eoms intact bilaterally. follows complex commands. face symmetric; tongue midline. comprehension intact. cn ii-xii grossly intact. motor: upper and lower extremity strength 5/5 bilaterally. no pronator drift. incision: clean, dry and intact without edema, erythema or discharge. sutures in place. mild dysmetria bilaterally. pertinent results: ct head: suboccipital craniectomy and postoperative changes in the right cerebellum. partially improved mass effect on the fourth ventricle and partially improved leftward shift of the cerebellar vermis. mri brain: blood products in the right cerebellar surgical bed and thin linear enhancement along the surgical cavity margins, without clear evidence for a residual mass. recommend follow up after blood products resolve. 05:30am blood plt ct-237 05:30am blood pt-10.2 ptt-28.6 inr(pt)-0.9 05:30am blood glucose-101* urean-19 creat-0.5 na-134 k-4.3 cl-100 hco3-26 angap-12 05:30am blood wbc-10.5 rbc-4.55 hgb-12.1 hct-36.8 mcv-81* mch-26.7* mchc-33.0 rdw-15.2 plt ct-237 brief hospital course: this is a 63 year-old-female that electively presented and underwent a posterior fossa craniotomy and resection of mass with dr . the patient tolerated the surgery was without complication. she was extubated and transferred to the icu for close neurological observation. the post operative head ct revealed expected post operative changes. she remained stable overnight. on , the patient was neurologically intact and the surgical dressing is clean dry and intact. the patient exhibited full strength there was no pronator drift. face was symetric. toungue was midline. pupils were equal and reactive. the foley catheter was discontinued and the patients diet was advanced. the intravenous fluid was discontinued and the patient was initiated on subcutaneous heparin dor deep vein thrombosis prophylaxis. a physical therapy consult was placed and the patient was transferred to the floor when a bed was available. the patient continued her decadron taper. she had complainted of headache and neck pain and was started on tizdanadine for muscle spasm prn. she was feeling well on and was working with pt. she continued on her steroid taper and was covered by an insulin sliding scale. she was being screened for rehab. on she was neurologically intact on examination with the exception of mild dysmetrial bilaterally. the incision was clean, dry and intact with non-dissolvable sutures in place. it was determined she would be discharged to rehabilitation today. medications on admission: duloxetine 60mg po daily. hydrochlorothiazide 25mg po daily. levothyroxine sodium 150mcg po daily. lisinopril 20mg po daily. loperamide 2mg po qid prn diarrhea. metoprolol succinate xl 25mg po daily. dexamethasone 4mg po q6h. diazepam 5 mg po q8h prn anxiety/vertigo. docusate sodium 100mg po bid. prochlorperazine 25mg pr q12h prn nausea. polyethylene glycol 17 g po daily until bowel movement. pantoprazole 40mg po q24h. heparin 5000 units sc tid. discharge medications: 1. dexamethasone 2 mg po per taper take 3mg po x1 tonight () at 18:00. then take 2mg po q8 x24 hours (start ). then take 2mg po bid x24 hours (start ). then stop. 2. acetaminophen-caff-butalbital tab po q8h:prn headache max apap 4g/24 hrs 3. bisacodyl 10 mg po/pr daily:prn constipation 4. docusate sodium 100 mg po bid:prn constipation 5. duloxetine 60 mg po daily 6. heparin 5000 unit sc tid 7. hydrochlorothiazide 25 mg po daily hold for sbp <100. 8. levothyroxine sodium 150 mcg po daily 9. lisinopril 20 mg po daily hold for sbp <100. 10. metoprolol succinate xl 25 mg po daily hold for sbp <100 and/or hr <60. 11. pantoprazole 40 mg po q24h take this medication while taking dexamethasone. once finished with dexamethasone taper, stop this medication. 12. senna 1 tab po bid:prn constipation 13. tizanidine 2 mg po tid:prn muscle spasm 14. insulin sc sliding scale fingerstick qachs insulin sc sliding scale using hum insulin 15. oxycodone (immediate release) 5-10 mg po q6h:prn pain rx *oxycodone 5 mg tablet(s) by mouth q6 prn disp #*30 tablet refills:*0 discharge disposition: extended care facility: northeast rehabilation discharge diagnosis: right cerebellar hemorrhagic lesion. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: craniotomy for tumor excision ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? your wound was closed with non-dissolvable sutures. you must wait until after they are removed to wash your hair. you may shower before this time using a shower cap to cover your head and the incision. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) & senna while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? if you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (prilosec, protonix, or pepcid), as these medications can cause stomach irritation. make sure to take your steroid medication with meals, or a glass of milk. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. ?????? make sure to continue to use your incentive spirometer while at home. followup instructions: ??????your sutures need to be removed 10-14 days from surgery. this can be done at your follow-up appointment in the brain clinic. if there are any problems they can contact the physician assistant or practitioner. please make this appointment by calling . 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 clinic for follow-up on at 2:30 pm. the brain clinic is located on the of , in the building, . their phone number is . please call if you need to change your appointment, or require additional directions. Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Pure hypercholesterolemia Malignant neoplasm of liver, secondary Unspecified essential hypertension Long-term (current) use of steroids Unspecified acquired hypothyroidism Depressive disorder, not elsewhere classified Secondary malignant neoplasm of brain and spinal cord Cerebral edema Secondary malignant neoplasm of lung Personal history of malignant melanoma of skin Unspecified intracranial hemorrhage Secondary malignant neoplasm of bone and bone marrow |
allergies: bp medication attending: chief complaint: angina major surgical or invasive procedure: rota and des x3 - rca history of present illness: mrs. is a 72yo f with htn, dyslipidemia, emphysema, ra on prednisone who presented on for catheterization in the setting of exertional dyspnea and chest pressure with ekg changes with diffuse rca disease s/p rota with desx3. post procedure, she felt well throughout the day and was admitted to cnp service. overnight she developed right sided lower abdominal pain and right groin pain and was noted to have a hematoma at the access site. she had a vasovagal episode (with sbp in 60's) this am on walking to the bathroom. her bp has been relatively low to the sbp 90s. her pain worsened and her hct noted to drop by 10 points (was 40 at osh prior to admission). sent for ct a/p, found to have large rp bleed. blood pressures in 90-100's. transferred to ccu for further monitoring. past medical history: 1. cardiac risk factors: dyslipidemia, hypertension 2. cardiac history: -percutaneous coronary interventions: single vessel rca: rota and des x3 on -pacing/icd: none 3. other past medical history: emphysema gerd mild ventricular and supraventricular ectopic activity rheumatoid arthritis on prednisone cataracts bilateral anxiety arthritis tonsillectomy appendectomy cholecystectomy oophorectomy c-section x4 hysterectomy social history: lives alone. patient has four grown children. occupation: at home. cares for grandchildren ages 9 & 12. tobacco: 1 ppd x since age 17 etoh: none home services: no family history: father mi at age 42; deceased at age 52. mother had angina.; deceased at age 80. brother deceased at age 49 from mi. brother deceased from emphysema. physical exam: admission exam: vs: t98.9 94/50 (89-123) 82 16 94/2l general: fatigued heent: dry mm, op clear neck: no jvd cards: rrr, normal s1,2 no mrg pulm: ctab no rrw abd: significant tenderness to palpation over right lower and mid quadrants. no rebound or guarding. positive bowel sounds ext: 2cm right groin hematoma, tender to palp but no bruit. 2+distal pulses discharge exam: 97.6 82-90 102-133/54/74 (133/74) 18 94% ra general: well appearing heent: dry mm, op clear neck: no jvd cards: rrr, normal s1,2, diastolic murmur pulm: ctab no rrw abd: tenderness to palpation over right lower and mid quadrants. no rebound or guarding. positive bowel sounds ext: no right groin hematoma, slight tender to palp but no bruit. 2+distal pulses pertinent results: admission labs: 05:45pm blood hct-34.4* plt ct-342 06:08am blood wbc-6.4 rbc-3.47* hgb-10.6* hct-31.5* mcv-91 mch-30.4 mchc-33.5 rdw-14.7 plt ct-305 05:45pm blood na-134 k-3.7 cl-101 06:08am blood calcium-8.9 phos-3.3 mg-1.8 discharge labs: 06:55am blood wbc-8.0 rbc-3.98* hgb-12.0 hct-34.9* mcv-88 mch-30.1 mchc-34.3 rdw-14.9 plt ct-289 12:50pm blood hct-33.3* 06:55am blood glucose-90 urean-15 creat-0.8 na-141 k-3.8 cl-104 hco3-28 angap-13 06:55am blood calcium-9.4 phos-2.8 mg-2.0 cardiac enzymes: 05:45pm blood ck-mb-2 08:40am blood ck-mb-2 05:45pm blood ck(cpk)-53 08:40am blood ck(cpk)-51 hematocrit trend: 05:45pm blood hct-34.4* plt ct-342 06:08am blood wbc-6.4 rbc-3.47* hgb-10.6* hct-31.5* mcv-91 mch-30.4 mchc-33.5 rdw-14.7 plt ct-305 08:40am blood hct-30.9* plt ct-290 01:20pm blood wbc-8.7 rbc-3.47* hgb-10.7* hct-31.1* mcv-90 mch-30.9 mchc-34.6 rdw-14.7 plt ct-342 06:03pm blood hct-29.6* 01:10am blood hct-31.2* 04:26am blood wbc-7.1 rbc-3.55* hgb-11.4* hct-30.9* mcv-87 mch-32.0 mchc-36.8* rdw-15.1 plt ct-247 08:03am blood hct-32.5* 03:07pm blood hct-34.8* 08:40pm blood hct-32.6* 06:55am blood wbc-8.0 rbc-3.98* hgb-12.0 hct-34.9* mcv-88 mch-30.1 mchc-34.3 rdw-14.9 plt ct-289 12:50pm blood hct-33.3* 10:06 am urine source: cvs. **final report ** urine culture (final ): mixed bacterial flora ( >= 3 colony types), consistent with fecal contamination. cardiac catheterization : 1. severe coronary artery disease: see above comments 2. successful rotational atherectomy/ptca/stenting of the ostial/proximal rca with a promus rx 4.0x18 mm -dilated with an nc 4.0 mm balloon. (see ptca comments) 3. successful rotational atherectomy/ptca/stenting of the mid rca with a promus rx 3.5x12 mm with a promus rx 3.5x15 mm des (proximally) which were all post-dilated with an nc 3.5 mm balloon. (see ptca comments) 4. r 8fr femoral artery angioseal closure device was deployed without complications; r 8fr femoral vein sheath removed with manual compression applied in the cath lab (see ptca comments) 5. asa 325 mg indefinitely; plavix (clopidogrel) 75 mg daily for at least 12 months for des ct abdomen/pelvis non contrast : 1. large retroperitoneal hemorrhage in the pelvis, centered on the right, adjacent to the urinary bladder. 2. 11-mm right lower lobe pulmonary nodule is concerning for carcinoma and only partially visualized and therefore needs further workup with chest ct. femoral artery ultrasound : no evidence of pseudoaneurysm. brief hospital course: mrs. is a 72yo f with htn, dyslipidemia, emphysema, ra on prednisone who presented on for catheterization in the setting of exertional dyspnea and chest pressure with ekg changes with diffuse rca disease s/p rota with desx3. post procedure, she felt well throughout the day and was admitted to cnp service. overnight she developed right sided lower abdominal pain and right groin pain and was noted to have a hematoma at the access site. she had a vasovagal episode (with sbp in 60's) that am on walking to the bathroom. her bp had been relatively low to the sbp 90s. her pain worsened and her hct noted to drop by 10 points (was 40 at osh prior to admission). sent for ct a/p, found to have large rp bleed. blood pressures in 90-100's. transferred to ccu for further monitoring. ccu course: patient was admitted to the ccu in the setting of an rp bleed after coronary catheterization. she received 2 units prbcs with eventual stabilization of her hematocrit (initial serial measurements fell in the low thirties, but eventually showed appropriate increase to 34.8). she was also started on bactrim for a dirty ua in the setting of increased urinary frequency. given stabilization of hematocrit and hemodynamic stability (blood pressures remained in the 90s-100s throughout) she was transferred out of the ccu back to for further management. she fared well on the cardiology floor and had no further complications. her hematocrit remained stable after serial assays, and she remained hemodynamically stable after 24 hours of telemetric monitoring. she was subsequently discharged home. the rest of her medical problems are enumerated below: 1. coronary artery disease s/p intervention: she had a rota and desx3 of the right coronary artery in response to exertional dyspnea. she had no further symptoms in house. her post procedure cardiac enzymes were normal. she was discharged on a medical regimen of aspirin, plavix (12months), toprol xl, valsartan, and atorvastatin. 2. ?urinary tract infection: she had leukocytes in her urine though it was a contaminated sample, and the culture grew mixed flora. she did have suprapubic tenderness, so she was treated with bactrim ds 1 tab for 3 days, though her pain may have been related to pelvic irritation from the rp bleed. 3. hypertension: due to her tenuous hemodynamics during the rp bleed, her valsartan was restarted at a lower dose of 80mg daily. her hctz was held on discharge. 4. ra: on prednisone. added calcium and vitamin d for bone protection. 5. copd: continued proair inhaler 6. smoking: counseling provided, will followup with pcp 7. pulmonary nodule: ct abdomen and pelvis revealed a pulmonary nodule for which dedicated chest ct should be ordered as an outpatient. this was communicated to her pcp. 8: anxiety: continued ativan 9. gerd: continue ppi pending tests at discharge: none transitional care issues: - dedicated ct chest to evaluate pulmonary nodule - outpatient followup of hct - ongoing smoking cessation counseling medications on admission: -diovan 160mg daily -hctz 25mg daily -atorvastatin 10mg daily -nexium 40mg daily - calcium 600mg -vitamin d 1000mg daily -ativan 1mg prn, 2mg qhs prn insomnia -proair -prednisone 5mg daily -lac hydrin cream prn dry skin -plavix 75mg daily -imdur 30mg daily - ntg sl prn -toprol xl 25mg daily discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). disp:*30 tablet extended release 24 hr(s)* refills:*2* 3. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day: do not take this medication until you are able to follow up with your pcp. 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 8. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tabs sublingual as instructed as needed for chest pain. 9. proair hfa 90 mcg/actuation hfa aerosol inhaler sig: puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po once a day. 11. fish oil-dha-epa 1,200-144-216 mg capsule sig: one (1) capsule po once a day. 12. ativan 1 mg tablet sig: one (1) tablet po twice a day as needed for anxiety: take as previously prescribed. 13. calcium 600 600 mg (1,500 mg) tablet sig: one (1) tablet po twice a day. 14. valsartan 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 15. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*3 tablet(s)* refills:*0* 16. outpatient lab work please check hematocrit discharge disposition: home discharge diagnosis: primary: coronary artery disease secondary: retroperitoneal hemorrhage urinary tract infection hypertension hyperlipidemia copd rheumatoid arthritis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms , you had a cardiac catheterization to evaluate symptoms of chest discomfort and abnormal findings on an ekg. the angiogram showed narrowing in the right coronary artery. this was treated by placing 3 drug coated stents to reopen the area. the other 2 heart arteries are without significant narrowings. you have had some changes to your medications. aspirin is 325mg daily plavix is 75mg daily and is taken without interruption once a day for 12 months. aspirin and plavix are taken to decrease the risk for a bloodclot from forming in the stents. do not stop aspirin or plavix unless instructed only by dr . stopping aspirin or plavix prematurely may put you at risk for a lifethreatening heart attack. please continue in you efforts to stop smoking. review options to help with this with dr or dr . medications: added: aspirin 325 mg daily, bactrim twice a day (for one more day) changed: decreased valsartan to 80 mg daily removed: imdur on hold: hctz you may discuss restarting your usual blood pressure medications and doses at your outpatient appointment with dr. followup instructions: please call your pcp tomorrow to check in and to arrange a follow-up appointment this week - you should have your blood count and blood pressure checked. if these are stable, your medications should be increased to their previous dose. dr at 9:45 Procedure: Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Insertion of temporary transvenous pacemaker system Insertion of drug-eluting coronary artery stent(s) Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Insertion of three vascular stents Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Tobacco use disorder Urinary tract infection, site not specified Unspecified essential hypertension Cardiac complications, not elsewhere classified Hematoma complicating a procedure Other and unspecified hyperlipidemia Anxiety state, unspecified Other specified cardiac dysrhythmias Other and unspecified angina pectoris Other emphysema Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Rheumatoid arthritis Syncope and collapse |
allergies: no known allergies / adverse drug reactions attending: chief complaint: unresponsive major surgical or invasive procedure: none history of present illness: 88yo woman with pmh cad on plavix was found down by her daughter at 7am today. initially she was arousable and complained of headache. she was taken to osh by ambulance where she reportedly decompensated in the ed requiring intubation. bp was recorded as 184/84. head ct revealed large posterior fossa iph. she was life flighted to and neurosurgery consultation was requested. past medical history: celiac disease cad dm pacemaker hysterectomy mi s/p stents and plasty. most recently in @ social history: married, lives with husband and daughter. no e/t/d family history: non-contributory physical exam: physical exam: gcs: e-3 v-1 m-6 o: bp: 184/84 hr: 83 r 14 o2sats 100% gen: intubated and sedated (prop held for exam) heent: pupils: 3mm sluggish b/l. + corneals, + gag neck: hard collar extrem: warm and well-perfused neuro: mental status: eo to voice cranial nerves: ii: pupils equally round and reactive to light 3mm, very sluggish mm bilaterally. motor: mae's. b/l ue's antigravity to command on discharge: no , to noxious pertinent results: 03:00pm plt count-226 03:00pm pt-13.8* ptt-18.8* inr(pt)-1.2* 03:00pm neuts-92.9* lymphs-4.2* monos-1.9* eos-0.6 basos-0.4 03:00pm wbc-10.3 rbc-3.86* hgb-12.2 hct-35.5* mcv-92 mch-31.5 mchc-34.3 rdw-13.6 03:00pm calcium-9.6 phosphate-3.1 magnesium-1.3* 03:00pm ck-mb-3 ctropnt-<0.01 03:00pm ck(cpk)-48 03:00pm estgfr-using this 03:00pm glucose-186* urea n-20 creat-1.0 sodium-136 potassium-4.5 chloride-102 total co2-21* anion gap-18 03:08pm glucose-181* lactate-3.1* k+-4.7 03:45pm type-art po2-252* pco2-38 ph-7.38 total co2-23 base xs--1 intubated-intubated 05:40pm urine mucous-rare 05:40pm urine rbc-1 wbc-125* bacteria-few yeast-none epi-<1 renal epi-<1 05:40pm urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.5 leuk-lg 05:40pm urine color-straw appear-hazy sp -1.026 chest (portable ap) study date of 2:50 pm findings: endotracheal tube ends 3.0 cm above the carina. an ng tube passes beyond the ge junction into the antrum of the stomach. there are low lung volumes but no evidence of pleural effusion or pneumothorax. mild left retrocardiac opacity likely represents atelectasis. impression: 1. et tube ends 3 cm above the carina. 2. left basilar opacity, likely atelectasis, but aspiration is not excluded. cta head w&w/o c & recons study date of 3:38 pm preliminary report !! wet read !! no evidence of aneuryms. however, reformats which are necessary for interpretation are still pending. ct head w/o contrast study date of 11:12 pm findings compatible with rapidly-evolving obstructive hydrocephalus due to extensive intraventricular hemorrhage, predominately in the fourth ventricle, with extension into prepontine cisterns and occipital horns. focal hemorrhage may also be present in the left cerebellum. left parietal and left supratentorial subdural hemorrhage are not well seen on preceding outside exam. brief hospital course: pt was admitted to the neurosurgery service for close observation. upon admission a discussion was held with the daughter (official hcp). she wished to make her mother dnr. she was told the risk of developing hydrocephalus and need for evd placement. she said she would think about this but was not sure if she would want to proceed with it. overnight on - the patient became less responsive. a head ct was obtained which revealed developing hydrocephalus. the daughter was and said that she did not want to proceed with the evd. the patient was made cmo at that time and extubated at approximately 6am. the daughter the icu later in the morning and requested that the patient be transferred to so that she would be closer to home. the bed facilitator was and once transport was arranged she was discharged. medications on admission: medications prior to admission: nitroglycerine plavix glucophage metoprolol gemfibrozil alprazolam isosorbide mononitrate flagyl discharge medications: 1. morphine (pf) in d5w 100 mg/100 ml (1 mg/ml) parenteral solution sig: 5-20 mg intravenous titrate to (titrate to desired clinical effect (please specify)). 2. scopolamine base 1.5 mg patch 72 hr sig: one (1) patch 72 hr transdermal once (once) for 1 doses. 3. midazolam in 0.9 % nacl 1 mg/ml solution sig: 5-20 mg intravenous titrate to (titrate to desired clinical effect (please specify)). discharge disposition: extended care discharge diagnosis: cerebellar hemorhage, hydrocephelus discharge condition: activity status: bedbound. level of consciousness: lethargic but arousable. mental status: confused - always. discharge instructions: pt is dnr/dni and cmo. transfer to per family's request. followup instructions: n/a md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Coronary atherosclerosis of native coronary artery Obstructive hydrocephalus Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Percutaneous transluminal coronary angioplasty status Intracerebral hemorrhage Cardiac pacemaker in situ Celiac disease Do not resuscitate status |
allergies: no drug allergy information on file attending: chief complaint: consulted for sdh found on head ct major surgical or invasive procedure: none history of present illness: 85 male sent to er with mental status changes from the nursing home. there is no report of a fall or any other trauma. the patient is unable to provide a history at this time and his health care proxies are unavailable. he had a head ct which revealed a sdh and small sah. neurosurgery was consulted for evaluation. past medical history: prostate cancer social history: lives at nursing home with wife family history: non-contributory physical exam: upon admission: t:98.6 bp:119/76 hr:117 rr:18 o2sats:100% ra gen: wd/wn, comfortable, nad. heent: pupils:pupils surgical bilaterally. eoms-intact ears: patient is nearly deaf. neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person. language: + dysarthria, speech is not fluent cranial nerves: i: not tested ii: pupils surgical bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power in the uppers and in the lowers. he did not participate with all muscle groups in the lowers. did not participate with pronator drift testing. sensation: intact to light touch bilaterally. toes downgoing bilaterally upon discharge: patient is oriented x 1 upon discharge. his pupils are surgical bilaterally. he is following commands. he appears to have some neglect on the right side but does move the right side somewhat. his left side is strong, purposeful. he has a foley catheter in place. pertinent results: ct head : findings: the study is compared with the initial nect of and the interval unenhanced and enhanced mr examinations of . over the three-day interval, there has been little change in the overall appearance of the heterogeneous but predominantly hyperattenuating lobulated process centered in the extra-axial space of the left parietovertex. this appears to "mold" to the contour of the subjacent convexity, where there is focal low-attenuation in the immediate subcortical white matter, corresponding to the flair-signal abnormality in this region, which may represent edema secondary to venous congestion, gliosis, or both. the overall appearance is most suggestive of a partially calcified en plaque meningioma, though there is no specific evidence of "reactive change" in the suprajacent inner table of the skull. there has been no other short-interval change. impression: no short-interval change in the overall appearance, with the lobulated, predominantly hyperdense, process, in the extra-axial space at the left parietovertex, given its stability and mr more likely an en plaque meningioma, partially calcified, accounting for the mr . moreover, the findings on both this exam and the recent enhanced mr study raise the serious possibility of at least partial invasion of the immediately subjacent superior sagittal sinus, without definite thrombosis, and possible venous obstruction-related edema in local white matter. if this will affect therapeutic decision, dedicated mr venography might be considered. mri brain : findings: the study is significantly limited due to patient motion artifacts. there is enhancement noted in the area of known hemorrhage in the left parieto- occipital region, compared to the pre-contrast sequences done on the prior study. however, the etiology of enhancement is not clear as there is significant amount of hemorrhage in this location, as seen on the prior ct and mr studies. mildly dilated ventricles are visualized, not adequately assessed. impression: 1. study significantly limited due to motion artifacts. enhancement noted in the left parieto-occipital region, partly extending along the dura, the etiology of which is uncertain, as this is in the region of the known hemorrhage. repeat evaluation, after resolution of the hemorrhage can be considered, to evaluate for any underlying vascular or space-occupying lesion. close followup with ct scan can also be considered as clinically indicated. brief hospital course: the patient was admitted on to the neurosurgery service after a mental status change at the nursing home. he was admitted with a presumed sdh on the ct scan. however, the patient had an mri which revealed a mass resembling a meningioma. there was no hemorrhage there. the patient was transferred out of the icu on . he was evaluated by pt and a speech/swallowing therapist. pt felt that he was safe to be discharged back the his nursing home on . on he was also able to take in thin liquids and pureed solids without difficulty. he had his foley catheter removed on but had urinary retention. a coud?????? catheter was placed that night and he was discharged with it in place. flomax was started as well and bladder training was begun. he may be able to have it removed in a day or so at the nursing home. the patient should follow up with a urologist. the patient was made dnr/dni in the hospital by his health care proxy as well as for the ambulance ride. palliative care and medical consults were obtained to assist in management of the patient. his medications were optimized due to his mental status changes. additionally a family meeting with all 3 teams occurred. it was felt that surgery would not benefit the patient and that quality of life was important. we all agreed that being at the nursing home with his wife would be the best for him at this time. the nursing home staff may want to consider a "do not hospitalize" policy with this patient and his health care proxy. medications on admission: lisinopril 10 mg po daily atenolol 25 mg po daily omeprazole 10 mg po daily hydrochlorothiazide 12.5 mg po daily vesicare 5 mg oral daily ferrous sulfate 325 mg po daily meclizine 25 mg po qid mirtazapine 7.5 mg po hs cholestyramine 4 gm po daily trazadone 25 mg po hs oxycodone sr (oxycontin) 10 mg po q12h docusate sodium 100 mg po bid senna 1 tab po bid bisacodyl 10 mg po/pr daily discharge medications: 1. omeprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 2. cyanocobalamin 1,000 mcg/ml solution sig: one (1) injection daily (daily) for 3 days. 3. vitamin b-12 1,000 mcg tablet sig: one (1) tablet po once a day. 4. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 6. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 9. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 10. oxycodone 5 mg tablet sig: 0.5-1.0 tablet po q4h (every 4 hours) as needed: pain. *****the po vitamin b12 should begin after the injections are completed. discharge disposition: extended care facility: academy manor of - discharge diagnosis: meningioma discharge condition: neurologically improved compared to admission discharge instructions: ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion, lethargy or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? new onset of the loss of function, or decrease of function on one whole side of your body. followup instructions: no follow up with dr. needed. call with questions. your medications were adjusted while in the hospital. please take as directed in the following pages. you had a foley catheter placed on due to urinary retention. follow up with a urologist at the nursing home or at - call for an appointment in the urology office on the . Procedure: Venous catheterization, not elsewhere classified Diagnoses: Other chronic pain Anemia, unspecified Esophageal reflux Other persistent mental disorders due to conditions classified elsewhere Other B-complex deficiencies Other and unspecified hyperlipidemia Hypotension, unspecified Malignant neoplasm of prostate Benign neoplasm of cerebral meninges Unspecified hearing loss Encounter for palliative care Encephalopathy, unspecified Other and unspecified coagulation defects Secondary malignant neoplasm of bone and bone marrow Adult failure to thrive Other alteration of consciousness Other specified retention of urine Dizziness and giddiness Other specified analgesics and antipyretics causing adverse effects in therapeutic use Benign essential hypertension Parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics causing adverse effects in therapeutic use |
allergies: no known allergies / adverse drug reactions attending: chief complaint: labile blood pressure major surgical or invasive procedure: none history of present illness: patient is a 72 year old male with history of orpharyngeal cancer status post radiation 13 years ago, peg tube in to diminish recurrence of aspiration pneumonia and three recent admissions over past two months for aspiration pneumona, acute kidney injury and icu admission once which led to rehab at woodbriar and then home on . over the past week, he was readmitted to for hypotension from - thought to be due to adrenal insufficiency treated with prednisone 100 mg daily and then was readmitted from - for steroid induced altered mental status. over the past couple of days, he has had labile hypertension and hypotension documented by his wife at home and by which led to his presentation to ed today. in the ed, initial vs were 98.3 195/98 68 22 100%ra. he was given levaquin in the ed for cxr concerning for lll pneumonia. his labs were notable for leukocytosis of 19.2, sodium of 129, potassium of 5.3 and creatinine of 1.7. he was admitted to medicine service for further evaluation and management of his pneumonia and laboratory abnormalities along with bp management. on the floor, he reported no complaints. past medical history: oropharyngeal cancer s/p radiation adrenal insufficiency aspiration pneumonia interstitial lung disease hypertension prostatic hypertrophy depression gastric ulcer with perforation hyperlipidemia seizure hx of dvt and pe social history: retired electronics manufacture representative; wife is a teacher and his heavily involved in his care. has two daughters who are involved in his life as well. no current alcohol, tobacco or ivdu. family history: no family history of heart disease physical exam: admission exam 98.2 72 184/96 18 99%ra gen: male in no acute distress heent: nc/nt/anicteric. perrla. eomi. mmm heart: regular rate and rhythm. no murmurs or gallops appreciated lungs: bibasilar crackles and rhonchi bilaterally upto mid lung bases abdomen: g-tube intact without erythema or discharge. soft, nontender and nondistended. nabs. external: no edema. no rash discharge exam vs: 98.1 98.5 96-199/50-130 66-98 16-18 94-99% ra gen: well-appearing man, nad, awake, a&o x3 heent: perrl, eomi, dry mm, op clear neck: supple, post-surgical and post-rtx changes on left (taut skin, reduced muscle mass) cv: rrr, nl s1 s2, no mrg resp: ctab, no rales wheezes or ronchi abd: soft, non-tender, non-distended, no rebound or guarding ext: warm, well-perfused, no cyanosis clubbing or edema pertinent results: admission labs 03:35pm wbc-19.2* rbc-4.65 hgb-14.4 hct-45.2 mcv-97 mch-30.8 mchc-31.7 rdw-15.6* 03:35pm neuts-92.5* lymphs-5.0* monos-2.0 eos-0.2 basos-0.3 03:35pm plt count-224 03:35pm glucose-119* urea n-53* creat-1.7* sodium-129* potassium-5.3* chloride-91* total co2-25 anion gap-18 03:35pm probnp-394* 05:41pm lactate-2.8* pertinent labs: 08:50pm blood tsh-2.0 05:45am blood free t4-1.6 04:01am blood cortsol-3.7 03:05pm blood cortsol-6.6 03:40pm blood cortsol-13.0 metanephrines (plasma) test name flag results units reference value --------- ---- ------- ----- --------------- metanephrines, fract., free normetanephrine, free h 2.3 nmol/l < 0.90 metanephrine, free <0.22 nmol/l < 0.50 aldosterone test result reference range/units aldosterone, lc/ms/ms 4 ng/dl adult reference ranges for aldosterone, lc/ms/ms: upright 8:00-10:00 am < or = 28 ng/dl upright 4:00-6:00 pm < or = 21 ng/dl supine 8:00-10:00 am ng/dl renin test result reference range/units plasma renin activity, 1.35 0.25-5.82 ng/ml/h lc/ms/ms discharge labs: 07:25am blood wbc-7.4 rbc-3.75* hgb-11.6* hct-36.9* mcv-98 mch-30.9 mchc-31.4 rdw-16.1* plt ct-151 09:10am blood glucose-99 urean-41* creat-1.9* na-135 k-4.3 cl-97 hco3-32 angap-10 09:10am blood calcium-8.3* phos-2.8 mg-2.0 micro mrsa screen mrsa screen-final inpatient sputum gram stain-final; respiratory culture-final {staph aureus coag +} inpatient gram stain (final ): this is a corrected report . <10 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive rod(s). 4+ (>10 per 1000x field): gram negative rod(s). quality of specimen cannot be assessed. previously reported without gram positive rod(s) on . respiratory culture (final ): heavy growth commensal respiratory flora. staph aureus coag +. moderate growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. tetracycline sensitivity testing performed by sensititre. vancomycin sensitivity testing performed by sensititre and e-test. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- 8 i trimethoprim/sulfa---- <=0.5 s vancomycin------------ 2 s sputum gram stain-final; respiratory culture-final inpatient urine legionella urinary antigen -final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final emergency blood culture blood culture, routine-final emergency cxr findings: frontal and lateral chest radiographs were performed. there is no pleural effusion or pneumothorax. left base opacity is is best appreciated on the frontal view. the mediastinum is unremarkable. the cardiac silhouette is top normal. impression: possible left lower lobe pneumonia. follow up after treatment is recommended to evaluate resolution. renal us impression: 1. normal kidneys bilaterally. no evidence of renal artery stenosis echocardiogram the left atrium and right atrium are normal in cavity size. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the estimated cardiac index is high (>4.0l/min/m2). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a prominent fat pad. impression: mild symmetric left ventricular hypertrophy with normal biventricular cavity sizes and preserved regional with excellent global biventricular systolic function. no valvular pathology or pathologic flow identified. cxr 1. new patchy bibasilar lung opacities which may reflect recurrent aspiration pneumonia given clinical suspicion for this entity. 2. these findings are superimposed on bibasilar interstitial lung disease, which could be due to a variety of etiologies including chronic aspiration, ipf and nsip. if warranted clinically, dedicated chest ct with high-resolution technique may be considered following resolution of the acute basilar opacity. brief hospital course: 72m with hx oropharyngeal cancer s/p rtx, s/p peg in , admitted for labile blood pressure # labile blood pressure: his blood pressuress while admitted ranged from systolic in high 50s to 220s. he had an unclear diagnosis of adrenal insufficiency from his prior hospitalization. here, an am cortisol was low and his cortisol did not rise appropriately with the stim test. he was started on hydrocortisone though his blood pressures did not significantly improve and he continued to have wide swings in his blood pressure. endocrinology was consulted who suggested this pattern was not entirely consistent with ai. pheochromocytoma was considered but urine metanephrines were negative. serum metanephrines were also negative but normatenephrines were mildly elevated. he did not have any lesions in his adrenal glands or anywhere else in his abdomen. endocrinology did not believe this truly indicated pheochromocytoma. he was started on low dose metoprolol and doxazosin however his blood pressure dropped and these were stopped. he was later transferred to the micu for invasive arterial bp measurement which was consistent with his non-invasive monitoring - wide swings in bps without symptoms; he was not given hydrocortisone nor ivf, and his bp recovered on its own. he was started on midodrine to avoid his symptomatic low blood pressures. his bp continued to have wide variations but the variation decreased to systolics 80-180s without symptoms. the cause of his labile blood pressure was felt to be from baroreceptor failure possibly from his prior radiation treatment. he was counseled on the warning signs of hypotension and hypertension. #adrenal isufficiency: cortisol failed to stimulate appropriately however his bp did not improve after steroid replacement. his high blood pressures are also inconssitent with this diagnosis. there was no clear cause of his adrenal insufficiency since he was not on chronic steroids and did not have any anatomic abnormalities on his abdominal ct. endocrinology suggested continuing prednisone and tapering as an outpatient as directed by endocrinology. # left lower lobe pneumonia: he has had repeated episodes of aspiration pneumonias. during this admission he did not have any fevers and his wbc count was difficult to interpret in the setting of intermittent steroid use. he did have a cough and some radiographic evidence of pna so he was treated with a seven day course of levafloxacin. his sputum culture did grow mrsa and commensals several days into his treatment. he was significantly improving so he was not broadened to vancomycin or linezolid. . # hemoptysis: he had an episode of hemoptysis which appeared to be from epistaxis. hct initially decreased slightly but was stable thorugh the rest of his admission. # htn: he was treated with antihypertensive meds prior to admission. these were stopped because of his episodic hypotension. he was started on midodrine as above. # ckd: at baseline # gerd: continued ppi # depression: continued mirtazapine, trazodone for sleep transitional issues -continued blood pressure monitoring -steroid taper as directed by endocrinology -mrsa sputum culture: if he develops symptoms of pneumonia mrsa coverage should be considered. -serum free normetaphrines were elevated at 2.3; free metanephrines were normal. aldosterone level was normal. renin level is pending at the time of discharge. -other labs of note on last check: hct 36.9, creatinine 1.0 -echocardiogram showed a prominent anterior fat pad. medications on admission: atenolol 12.5 mg po qnoon lansoprazole 30 mg po qdaily melatonin 3 mg po qhs mitrazapine 15 mg po qhs duoneb prednisone 60 mg po on ; 40 mg po ; 20 mg po lactose-free food/fiber (jevity 1.2 cal oral) alufosin 10 mg po qdaily discharge medications: 1. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 2. melatonin 3 mg tablet : one (1) tablet po at bedtime. 3. mirtazapine 15 mg tablet : one (1) tablet po hs (at bedtime). 4. midodrine 5 mg tablet : one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 5. prednisone 10 mg tablet : one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: all care of greater discharge diagnosis: labile hypertension baroreflex failure adrenal insufficiency discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , thank you for coming to the . you were in the hospital because your blood pressure was fluctuating widely. we believe this was from baroreflex failure with some component of adrenal insufficiency. we started you on a medication called midodrine which has helped keep your blood pressure from going too low. we also started you on prednisone. you should continue taking this medication until you see the endocrinologist. we also treated you for a pneumonia. you finished the course of antibiotics but if you continue to have cough or develop fevers you should speak with your primary care doctor. medication recommendations please start: -midodrine 5 mg three times daily -prednisone 10 mg daily please stop: -atenolol -alufosin followup instructions: name: dandamudi,saroja location: - address: , , phone: appointment: thursday 11:40am *please discuss with your primary care provider about your follow up appointment in endocrinology and if he can help get you a sooner appointment. name: , md location: department: endocrinology address: , , phone: appointment: thursday 11:00am Procedure: Enteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Acidosis Hyperpotassemia Esophageal reflux Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Depressive disorder, not elsewhere classified Candidiasis of mouth Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Postinflammatory pulmonary fibrosis Personal history of venous thrombosis and embolism Glucocorticoid deficiency Personal history of irradiation, presenting hazards to health Other specified hypotension Epistaxis Leukocytosis, unspecified Gastrostomy status Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Effects of radiation, unspecified Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS) |
allergies: no known allergies / adverse drug reactions attending: chief complaint: altered mental status major surgical or invasive procedure: intubation history of present illness: 40 year old woman with a pmh alcohol abuse, depression, anxiety, admitted for loss of consciousness after falling onto a stopped bus. the patient was found by ems unresponsive, slumped against a poll. on arrival to the ed, the patient had a gsc of 3, and was intubated for airway protection. following intubation, large amounts of blood were suctioned from the ed tube. blood subsequently decresed to the point patient is producing blood-tinged sputum. . in the ed, vs: 130s/80s, hr 80-90; rr 18 o2 100% on fio2 100%, vt 500, peep 5. patient received 2l ivf. patient underwent head ct that showed general atrophy with calcifications in frontal lobe (confirmed w/neurosurg no sign of ich). c-spine ct negative. cxr clear. stox/utox significant for etoh of 519. . on transfer, vs: 96.9 118/71 80 20 100% cmv 40% fio2; rr 20; peep 5. patient intubated and mildly sedated, but awake and following commands. denies pain. denies history of past admissions for alcohol intoxication or withdrawal seizures. however, patient has had several ed visits in past 6 months for alcohol intoxication. per siblings, patient was a social drinker until , when she started having panic attacks and worsening depression. she began to see a psychiatrist and was started on lorazepam and celexa for depression. depression has recently worsened, and patient has begun drinking to the point that friends have reached out to siblings to notify them of her alcohol abuse. she endorses one episode of visual hallucinations and dry heaving in setting of trial of abstinance from alcohol. per sister, the patient has never endorsed si. no past psych hospitalizations. past medical history: depression, panic disorder; one episode of visual hallucinations associated with alcohol abstinence; guttate psoriasis; recent cyclical dry-heaving related to menstrual cycles (mid-workup with outpatient physician); surgical correction of amblyopia as child social history: lives alone. works at health club as spa masseuse. smokes cigarettes (quantity unknown - per sister); since , has started drinking large quantities of etoh; multiple ed visits for intoxication. family unaware of recreational drug use. family history: no history of lung problems; family hx of hypothyroidism physical exam: admission physical exam: vs: 96.9 118/71 80 20 100% cmv fio2 40% rr 20 peep 5 gen: intubated, mildly sedated; neck collar in place; small amount of blood in et tube; opens eyes and moves spontaneously heent: no scleral icterus card: normal s1, s2, no murmurs, rubs or gallops resp: clear to auscultation bilterally abd: soft, non-tender, non-distended; no organomegaly; + bs ext: non-edematous; dp and pt pulses 2+ neuro: mild ansiocoria l 4mm, r 3mm; pupils reactive to light; eomi; squeezes eyes shut to command; upper ext 4-5/5 strength (unable to assess fully due to restraints); lower ext skin: pinpoint round macules with scale on arms, legs and around umbilicus; 3x5 cm scraped lesion on left forhead, bleeding; small bleeding scrapes on knees bilaterally discharge physical exam: vs: bp 142/88 hr 88 r 18 t 100% o2 ra gen: patient sleeping comfortably, alert to verbal stimuli, oriented x 3 with sad affect heent: no scleral icterus card: normal s1, s2, no murmurs, rubs or gallops resp: clear to auscultation bilterally abd: soft, non-tender, non-distended; no organomegaly ext: no clubbing/cyanosis/edema neuro: perrl, eomi, cn ii-xii intact, 5/5 strength all extremities, no tactile hallucinations or sensory deficits, no tremors appreciated skin: some facial sweating, pinpoint round macules with scale on arms, legs and around umbilicus from psoriasis at baseline; 3x5 cm lesion on left forhead, small bleeding scrapes on knees bilaterally pertinent results: 02:44pm blood wbc-8.4 rbc-3.70* hgb-11.7* hct-34.4* mcv-93 mch-31.5 mchc-34.0 rdw-16.1* plt ct-239 02:49am blood wbc-8.5 rbc-3.21* hgb-10.4* hct-29.9* mcv-93 mch-32.3* mchc-34.7 rdw-16.1* plt ct-194 02:44pm blood plt ct-239 02:44pm blood pt-11.4 ptt-24.5 inr(pt)-0.9 02:44pm blood pt-11.4 ptt-24.5 inr(pt)-0.9 02:44pm blood glucose-107* urean-10 creat-0.5 na-140 k-3.9 cl-108 hco3-27 angap-9 02:49am blood glucose-91 urean-9 creat-0.5 na-145 k-4.0 cl-114* hco3-26 angap-9 02:44pm blood alt-22 ast-24 alkphos-72 totbili-0.2 02:49am blood alt-24 ast-29 alkphos-60 totbili-0.2 02:44pm blood albumin-4.1 calcium-8.0* phos-3.6 mg-1.9 02:49am blood albumin-3.6 calcium-7.3* phos-2.6* mg-1.7 02:44pm blood asa-neg ethanol-519* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 02:43pm blood type-art rates-/16 tidal v-500 fio2-100 po2-318* pco2-57* ph-7.26* caltco2-27 base xs--2 aado2-341 req o2-62 intubat-intubated vent-controlled 06:31pm blood type-art rates-16/ tidal v-500 peep-5 fio2-40 po2-169* pco2-37 ph-7.38 caltco2-23 base xs--2 intubat-intubated vent-controlled ct head : 1. foci of hyperdensity along the anterior medial left frontal lobe may represent vascular malformation, prior trauma, or underlying lesion- less likely to represent acute intraparenchymal hemorrhage (though not excluded). recommend short interval repeat ct to assess for stability. if lesion does not demonstrate typical evolution of blood products, could be further assessed with mri. 2. prior infarct in left internal capsule. 3. global atrophy. ct neck : 1. no fracture or malalignment evident. 2. multilevel degenerative change identified. 3. left thyroid nodule. further evaluation with non-emergent outpatient thyroid ultrasound is recommended. ecg : sinus rhythm. normal tracing. no previous tracing available for comparison. cxr : impression: endotracheal tube in ostium of the right mainstem bronchus. retraction noted on a short interval subsequent study suggesting clinical team noted abnormality prior to official radiology interpretation. microbiology: - blood culture : no growth - blood culture : no growth - mrsa screen : no mrsa isolated brief hospital course: 40 year old woman with unknown pmh admitted for ams/+loc after falling off a stopped bus, found to have blood etoh of 519. intubated and sedated, but hemodynamically stable. she was extubated soon after admission to the icu and called out to the general medical wards the next day. she was noted to have flat affect but denied suicidal ideation and was otherwise well. she was discharged with a plan to follow up with her and pcp. #ams: patient was intubated in the ed for gcs of 3, s/p fall with +loc. upon transfer to the floor, the patient was intubated but awake and alert. she self-extubated the night of admission while on a spontaneous breathing trial and was stable, with good saturations on room air. etoh level found to be 519, otherwise tox screen negative. elevated alcohol was found to be source of ams. glucose within normal limits. ekg without evidence of acute ischemia. patient afebrile, with normal wbc count, normal cxr, and normal u/a. therefore, infection unlikely source of ams. patient's mental status cleared within sevaral hours of admission. she remained clear following callout to the general medical wards. #elevated etoh: patient admitted with acute alcohol intoxication in the setting of 3 years of chronic alcohol abuse. per family, the patient has had recent visual hallucinations in the setting of alcohol abstinence. on laboratory data and physical exam, no evidence of chronic liver disease. no anion gap to suggest injestion of other toxic etoh, such as methanol or ethylene glycol. patient was started on thiamine, folate, and ciwa scale for alcohol withdrawal. she was seen by social work, who felt that she was in the precontemplative stage of alcohol cessation. she did not exhibit symptoms of alcohol withdrawal, so home lorazepam was restarted after callout from the icu. she had an otherwise uneventful course as far as withdrawal. she agreed that she would contact her outpatient for follow up within one week. #history of depression/panic attacks: chronic, but worsening over the past several months. patient has had recent outpatient increase in celexa and lorazepam. no history of past hospitalizations for psychiatric issues. the patient denies si. on admission, she was restarted on her home celexa. lorazepam was initially held, as patient was put on ciwa scale for alcohol withdrawal, but restarted when patient was called out to the general medical wards. she agreed that she would contact her outpatient for follow up within one week. #transitional issues: - patient found to have thyroid incidentaloma on lateral neck ct. recommended outpatient ultrasound. - head ct findings concerning for calcification - unlikely ich. however, recommended repeat scan to f/u. - code status: full code (discussed with patient) medications on admission: celexa 50 mg daily lorazepam 0.5 mg prn anxiety discharge medications: 1. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. citalopram 20 mg tablet sig: 2.5 tablets po daily (daily). 4. lorazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 5. clobex 0.05 % spray, non-aerosol sig: one (1) topical as directed as needed for psoriasis. discharge disposition: home discharge diagnosis: primary: - altered mental status - inability to protect airway; intubation - alcohol intoxication secondary: - depresssion - anxiety - panic disorder discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , it was a pleasure to care for you during this hospitalization. you were admitted to after you were found unresponsive and intoxicated with alcohol. you were initially intubated to help your breathing, and as a result of this procedure you had some bleeding from trauma to your airway. you recovered well in the icu and the breathing tube was removed without complication. you spoke with our social worker about resources to help you control your alcohol intake, and you were otherwise medically stable. we have made the following changes to your medication regimen: - begin taking thiamine 100 mg by mouth daily - begin taking folic acid 1 mg by mouth daily please follow up with your doctor as reommended below. followup instructions: 1. primary care name: , location: medical associates address: , , phone: appointment: tuesday 1:45pm - ask your doctor if you feel you need additional resources or support to help you stop drinking alcohol 2. mental health - please call your outpatient and arrange to be seen this coming thursday to discuss this hospitalization and other sources of stress. md Procedure: Insertion of endotracheal tube Diagnoses: Other iatrogenic hypotension Anemia, unspecified Nausea with vomiting Dysthymic disorder Disorders of phosphorus metabolism Altered mental status Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection Other psoriasis Intravenous anesthetics causing adverse effects in therapeutic use Acute alcoholic intoxication in alcoholism, continuous Panic disorder without agoraphobia Noncollision motor vehicle traffic accident while boarding or alighting injuring passenger in motor vehicle other than motorcycle |
allergies: cephalosporins / ceclor / keflex / flagyl attending: chief complaint: shortness of breath major surgical or invasive procedure: cardiac catherization cvvh history of present illness: 65 yo male with ckd, dm, recent hospitalization for chf exacerbation/pulm edema, found to have new lbbb, transferred for cardiac cath. he was recently admitted with decompensation in heart failure 10 d ago and opted for medical management at that time. echo done then showed ef 25-30% with apical and anterior hypokinesis. he presented again on friday with pulmonary edema and was treated with lasix, zaroxylyn and dialysis on saturday with improvement. he normally gets dialysis in on a mon- wed fri. he was transferred from to for cardiac cath. at time of transfer, lungs were clear, sats hight 90s on r/a. vital signs on transfer: temp 97.9, hr 88 sinus with lbbb, rr 14, bp 114/67. of note, he was recently started on 75/25 for diabetes d/t high sugars. sugar today 138, npo since mn, no coverage prior to transfer. . he underwent cardiac cath which showed extensive 3 vessel disease. currently, he reports no complaints. no pain. would like to eat immediately. past medical history: cri: newly started dialysis, has an hd cath right chest wall. wants future peritoneal dialysis- s/p peritoneal catheter placed 2 weeks ago, not yet using it. diabetes on sliding scale regular at home, cad with new lbbb, severe cardiomyopathy, anxiety, pad s/p right bka with prosthesis, htn, lipids, hypokalemia, anemia social history: lives at home with his wife who was just d/c'd from hospital on saturday d/t leg injury no smoking, occasional alcohol family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: on admission general: nad. oriented x3. mood, affect appropriate. heent: sclera anicteric. eomi. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. . on discharge: vs: 99 90-102/50-60s 70-80s 97%ra wt: 107.8kg general: nad. oriented x3. mood, affect appropriate. heent: sclera anicteric. eomi, op clear without exudates, lesions. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. bibasilar crackles, no wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness, pd catheter in place: locked extremities: wwp, trace pretibial edema. pertinent results: on admission: 03:30pm blood wbc-9.6 rbc-3.36*# hgb-10.3*# hct-31.7*# mcv-94 mch-30.5 mchc-32.4 rdw-16.9* plt ct-280 03:30pm blood pt-16.2* inr(pt)-1.4* 03:30pm blood glucose-244* urean-61* creat-5.4*# na-137 k-4.2 cl-96 hco3-22 angap-23* 03:30pm blood albumin-3.4* calcium-8.1* phos-5.5* mg-1.7 potassium 08:53pm blood k-4.9 04:00am blood k-4.8 10:47pm blood k-5.9* 02:30pm blood k-6.6* 11:26am blood k-4.6 02:48am blood k-4.2 . on discharge: 06:00 wbc rbc hgb hct mcv mch mchc rdw plt ct 8.8 3.05* 8.9* 28.5* 93 29.3 31.4 16.8* 254 . glucose urean creat na k cl hco3 angap 134 46* 5.4* 138 4.1 96 30 16 . hga1c: 7.6 . cholest triglyc hdl chol/hd ldlcalc 112 83 35 3.2 60 . inr: 2.4 . microbiology: urine culture: ngtd blood culture: ngtd peritoneal culture: ngtd c. diff toxin x2: negative imaging: cardiac cath: comments: 1. selelctive coronary angiography in this left dominant system revealed 3 vessel coronary artery disease. the lm had a ostial 35% stenosis. the lad was heavily calcified; proximal-mid diffuse 50% involving d3 and s1, followed by 70% at s2; mild-moderate origin stenoses of modest caliber diffusely diseased d1-d3; mid 40-50% at tiny d4 after s2; mid 90% after large d5; diffuse disease in distal lad which wraps around the apex. the lcx was heavily calcified; proximal 55%; major om1 proximal 80% after om2; lpda proximal 90% (after lpls). rca was non-dominant; proximal diffuse disease to 70%. 2. limited resting hemodynamics revealed severely elevated left sided filling pressures with an lvedp of 38mmhg. there was severe pulmonary artery hypertension with a pasp of 64mmhg. there was a preserved cardiac index of 2.36l/min/m2. there was normal systemic arterial pressure of 118/81mmhg. final diagnosis: 1. severe diffuse three vessel cad in a left dominant system. 2. severe left ventricular diastolic heart failure in setting of newly diagnosed severe left ventricular systolic heart failure. 3. severe pulmonary arterial hypertension. 4. succesful removal of lue arterial and venous sheaths with good hemostasis. 5. urgent dialysis today given left-sided filling pressures approaching 40mmhg. 6. cardiac surgery evaluation for suitability for cabg. 7. d/c plavix. no prasugrel. 8. reinforce secondary preventative measures against cad, mi, severe lv systolic and diastolic heart failure. vein mapping: impression: small thickened bilateral greater saphenous and left short saphenous veins. viability study (fdg-pet): impression: 1. no activity in the lv apex. 2. greatly diminished activity in the mid and apical inferior wall. 3. preserved activity in the anterior wall. 4. diminished, but present activity in the septum and lateral wall. tte (s/p diuresis and cvvh): left ventricular wall thicknesses and cavity size are normal. there is severe global left ventricular hypokinesis (lvef <20 %). the right ventricular cavity is moderately dilated with severe global free wall hypokinesis. the aortic valve leaflets are moderately thickened. no aortic regurgitation is seen. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. compared with the prior study (images reviewed) of , the left ventricular cavity size is slightly smaller with similar systolic function. the estimated pulmonary artery systolic pressure is slightly lower. brief hospital course: 66-year-old male with cad, systolic and diastolic chf (ef 20-25 %), diabetes, ckd stage v recently initiated on hd, pad, hl with recent silent nstemi vs. demand ischemia leading to acute heart failure and resultant fluid overload transferred to for c. cath showing severe three vessel disease. # coronary artery disease: patient with known cad with elevated troponin in setting of heart failure exacerbation who presented recently to with two heart failure episodes with dyspnea likely in setting of ischemia given elevated troponin, new lbbb on ekg, and severe cardiomyopathy on echo. c. cath showing severe three vessel disease with subsequent cardiac surgery consult. echo at showed lvef 15% with dilated left ventricle with severe global systolic dysfunction most consistent with multivessel cad. decision was made to obtain a pet ct viability study. the interpretation of the study is as follows: normal tracer uptake is seen in the basal and mid anterior left ventricular myocardium. fdg avidity is mildly diminished in the septum and lateral wall compared to the anterior wall.no fdg avidity is seen in the apex. activity is greatly diminished in the mid and apical inferior wall, with preservation of the basal inferior wall. the lv cavity is enlarged. small bilateral pleural effusions are present. diffuse coronary artery calcifications are seen. impression: 1. no activity in the lv apex. 2. greatly diminished activity in the mid and apical inferior wall. 3. preserved activity in the anterior wall. 4. diminished, but present activity in the septum and lateral wall. the ct surgery service at did not feel that he was an appropriate surgical candidate and potential risks outweighed potential benefits. with the assistance of dr. , contact was made with the medical center cardiology service (dr. ) for consideration of cabg or high-risk revascularization with vad placement and a second opinion. however, pt will need to see dr. at first before referral is scheduled. regarding medications he was re-started on plavix 75 mg po qd; continued on metoprolol and aspirin. he was also placed on anticoagulation for new apical akinesis for a duration of 3 months. at discharge, inr was 2.4 on 3mg warfarin. outpatient issues: -- monitor bp with plan to start acei if blood pressure allows. -- continue close monitoring of inr as outpatient with coumadin dose adjusted as needed. # acute severe left ventricular diastolic heart failure in setting of newly diagnosed severe left ventricular systolic heart failure (ef 25-30%): patient with echo showing 15% with markedly dilated left ventricular with concentric lvh, regional wall motion abnormalities including akinetic segments. given left-sided filling pressures approaching 40 mm hg, transferred to ccu for rrt in setting of borderline hypotension and fluid overload. etiology of failure likely in setting of recent ischemia as above with long-standing hypertension and diabetes. no infection, apparent alcohol abuse, major anemia, or other precipitants causing destabilization. cvvh performed in the ccu, and the patient was net negative 6 l and no longer requiring supplemental oxygen. he was continued on metoprolol tartrate 12.5 mg po bid. acei was held during acute heart failure and was not started at discharge because of mild orthostasis. weight at discharge was 107.8kg. outpatient issues: -- monitor bp with plan to start acei if blood pressure allows for afterload reduction and cardiac remodeling. -- fluid management per nephrology . # fever. patient had tm 100.5 on that appears to have occurred while cvvh was stopped secondary to line clot. no localizing symptoms except sore throat. cxr possibility suggested pneumonia but not definitive. peritoneal dialysate cell count and differential showing increased wbc 155 with 75 % polys but patient has not received peritoneal dialysis. however, the peritoneal culture was not drawn properly as there was no dwell. other cultures including blood and urine showed no growth. wbc initially trended to maximum of 15.5 and downtrended. he did not appear systemically ill, and empiric antibiotics were not started. infectious disease was consulted with impression of no obvious source. ua mildly positive however culture with no growth. additional infectious work-up: c.difficile negative x2, blood cultures on discharge with no growth. patient afebrile prior to discharge with white blood count within normal limits. . # mild pulmonary artery hypertension: likely secondary to left ventricular failure (who class ii) and heart failure. advise outpatient work-up for secondary etiologies such as sleep apnea given habitus. he would benefit from sleep study as apneic as multiple desaturations on pulse oximetry in icu while sleeping. . # esrd (ckd stage v): patient recently initiated on dialysis secondary to recurrent episodes of volume overload refractory to medical management. he has an hd catheter placed until pd access matures in . he is on m-w-f schedule at . he underwent cvvh in the ccu as above and was transitioned to intermittent hemodialysis once blood pressures tolerated. he will need once weekly infusion of dialysate through pd catheter, this was done on (see page 1). . # diabetes (last a1c 7.6): patient on 75/25 insulin regimen at home, taking from 15-40 units three times a day. he had labile blood glucose during icu stay. he was switched to glargine insulin during hospital stay with poor glucose control despite increasing glargine and humalog sliding scale. after discussion with pharmacy and concern that 75/25 might not be available at rehab, his glargine was increased to 45 units and humalog sliding scale was increased. his a1c was 7.6 on admission indicating his glucose was moderately well controlled at home. he should return to his previous insulin regimen once he returns home. . # pad: no abi or other data to evaluate extent. he was continued on above anti-platelet . . # hyperlipidemia: lipid panel at goal. he was continued on atorvastatin 80 mg po qd. . # normocytic anemia: patient with mild anemia. likely secondary to esrd. iron studies not suggestive of iron deficiency. epo was started during hd sessions on . . emergency contacts: wife , (h). (c); son (c), (h) . his code status was confirmed to be full. . arrangements were made for outpatient follow-up with dr. who specializes in heart failure. he will continue with outpatient dialysis per previous arrangements. medications on admission: home medications: updated from home list atorvastatin 80 mg qday allopurinol 200 mg po daily fibercon one tablet twice daily imodium as needed florajen3 probiotic 2 once a day omeprazole 20 mg po daily hydralazine 50 mg po ? bid isosorbide dinitrate 10 tid metoprolol succinate 25 daily lispro/protam 75/25 - between 15-40 units 3 times per day. plavix 75 daily (last dose unknown) aspirin 81 daily nitrostat sl as needed discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 2. allopurinol 100 mg tablet sig: one (1) tablet po once a day. 3. psyllium packet sig: one (1) packet po bid (2 times a day). 4. lactobacillus acidophilus oral 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 7. heparin (porcine) 1,000 unit/ml solution sig: 4,000-11,000 units injection prn (as needed) as needed for line flush: withdraw 4 ml prior to flushing with 10 ml ns followed by heparin as above according to volume per lumen. . 8. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 9. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain/fever. 10. lorazepam 1 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. 11. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 12. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea. 13. sevelamer hcl 400 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 14. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 15. insulin lispro 100 unit/ml solution sig: 0-14 units subcutaneous four times a day: before meals and at hs per sliding scale. 16. insulin glargine 100 unit/ml solution sig: forty six (46) units subcutaneous at bedtime. 17. coumadin 3 mg tablet sig: one (1) tablet po once a day: please have inr checked weekly with coumadin adjusted accordingly. discharge disposition: extended care facility: hospital - discharge diagnosis: primary: coronary artery disease chronic renal disease on hemodialysis secondary: hypertension diabetes discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to for cardiac catherization. you underwent a diagnostic cardiac catherization which showed extensive blockages in the arteries that lead to your heart. we performed a test called a viability study that evaluated whether clearing the blockages in your arteries would improve your heart function. this study was negative so you would not be helped by a bypass operation. your heart is now weak so we have started you on a medicine regimen that will help to maximize the heart function. your weak heart meant that fluid is not pumped well through the heart and backed up in your lungs. you underwent a blood filtering process to remove fluid from your body and you were started on hemodialysis to continue to remove excess fluid. your dialysis catheter was sluggish so the radiologist changed it on . we have arranged for you to see the following physicians after you go to rehab. 1. dr.: heart failure specialist. you have an appt in but we are working on an earlier appt, hopefully later this month 2. dr. : a general cardiologist who will see you in . 3. please make an appt to see dr. when you get out of rehabilitation . we made the following changes to your medicines: 1. stop taking hydralazine and isordil 2. start taking tylenol for pain 3. start taking lorazepam as needed for anxiety 4. start taking loperamide as needed for diarrhea 5. start taking sevelamer to lower your phosphate 6. start taking nephrocap vitamins 7. decrease allopurinol to 100 mg daily 8. take metamucil instead of fibercon for diarrhea 9. change 75/25 insulin to glargine while you are at rehab. humalog sliding scale as noted to be given before meals and at bedtime. 10. start taking coumadin to prevent clot formation . please continue your other home medications as prescribed. followup instructions: the following appointments have been made for you: name: , md location: internal medicine associates address: , , , phone: appointment: wednesday 11:00am department: cardiac services when: monday at 9:00 am with: dr. building: sc clinical ctr campus: east best parking: garage . please make an appt to see dr. when you get out of rehab. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Hemodialysis Venous catheterization for renal dialysis Arteriography of other specified sites Diagnoses: Other primary cardiomyopathies Hyperpotassemia Anemia in chronic kidney disease End stage renal disease Renal dialysis status Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Pure hypercholesterolemia Mitral valve disorders Congestive heart failure, unspecified Gout, unspecified Other chronic pulmonary heart diseases Peripheral vascular disease, unspecified Personal history of tobacco use Occlusion and stenosis of carotid artery without mention of cerebral infarction Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Anxiety state, unspecified Hypotension, unspecified Long-term (current) use of insulin Other left bundle branch block Fever, unspecified Diarrhea Obesity, unspecified Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Below knee amputation status Irritable bowel syndrome Acute on chronic combined systolic and diastolic heart failure |
allergies: patient recorded as having no known allergies to drugs attending: addendum: **patient is not on allopurinol or flomax** discharge disposition: extended care facility: northeast - md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Interruption of the vena cava Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Application of external fixator device, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Open reduction of fracture with internal fixation, femur Removal of implanted devices from bone, tibia and fibula Closed reduction of fracture with internal fixation, tibia and fibula Diagnoses: Other iatrogenic hypotension Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Gout, unspecified Pulmonary collapse Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Closed fracture of patella Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Accidents occurring in residential institution Flail chest Closed fracture of unspecified part of fibula with tibia Street and highway accidents Closed fracture of eight or more ribs Closed fracture of acetabulum Closed fracture of ilium Abnormal sputum Injury to other gastrointestinal sites, without mention of open wound into cavity Closed fracture of lower end of femur, unspecified part Functional quadriplegia |
allergies: patient recorded as having no known allergies to drugs attending: chief complaint: single-car mvc, amnestic to event major surgical or invasive procedure: 1. open reduction internal fixation of left femur distal fracture with 9-hole plate. 2. traction and closed reduction of right tibia pilon and fibula fracture with application of multi-plate internal fixator for restoration of alignment. 3. removal of external fixator for r pilon fracture 4. open reduction internal fixation r pilon (distal tibia and distal fibular) fracture. 5. tracheostomy. 6. percutaneous endoscopic gastrostomy. 7. inferior vena cava filter (bard g2) placement. history of present illness: 55yo m mvc head on collision w/parked trailer, unknown speed. amnestic to event. aaox3 upon arrival. io infiltrated during transport. past medical history: htn, gout, chronic low back pain social history: married. self-employed courrier. unk etoh, tobacco, drugs family history: unk pertinent results: . radiographic studies: ct cspine: "1. no acute cervical fracture. 2. mild rotation of c1 compared to c2, likely positional, but cannot completely exclude rotatory subluxation." ct head: "no acute intracranial hemorrhage or fracture." ct tspine: "again noted is a fracture of the t8 vertebral body with minimal displacement of fracture fragments extending into the posterior one-third of the vertebral body. no definite involvement of the pedicles is seen." ct torso: "1. no ct findings to explain the patient's fevers. no evidence of pneumonia. 2. unchanged bibasilar atelectasis and small pleural effusions. 3. unchanged diffuse fatty infiltration of the liver. 4. dense material within the gallbladder could represent vicarious excretion of contrast from previous radiographic studies, versus concentrated bile. 5. unchanged stranding adjacent to the hepatic flexure of the colon, most consistent with mesenteric hematoma. there may also be a small adjacent subcapsular liver hematoma." microbiology studies: 9:00 pm urine source: catheter. urine culture (final ): enterococcus sp.. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- =>16 r vancomycin------------ 2 s 10:49 am urine source: catheter. . urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- =>16 r vancomycin------------ 2 s 5:36 am urine source: catheter. . urine culture (final ): no growth. . 8:48 am sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). 4+ (>10 per 1000x field): gram positive cocci. in pairs, chains, and clusters. 1+ (<1 per 1000x field): gram positive rod(s). smear reviewed; results confirmed. respiratory culture (final ): moderate growth oropharyngeal flora. staph aureus coag +. moderate growth. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- 0.25 s oxacillin-------------<=0.25 s penicillin g---------- =>0.5 r trimethoprim/sulfa---- <=0.5 s . 10:40 am bronchoalveolar lavage gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive rod(s). smear reviewed; results confirmed. respiratory culture (final ): oropharyngeal flora absent. staph aureus coag +. >100,000 organisms/ml.. sensitivities performed on culture # from . . 5:36 am sputum source: endotracheal. gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. quality of specimen cannot be assessed. respiratory culture (final ): no growth. . brief hospital course: : admitted to ticu, rij cvl placed. serial hct overnight. requiring phenylephrine for bp support. : weaned neo -> pt. off early afternoon then temp to 101.6, bp down, and tachy to 120s -> restarted neo -> changed to levo in the evening -> weaned off early am, gave 1u prbcs; gave one dose of ablumin; spine ordered tlso brace; repeat ct of abdomen stable; uop marginal but picking up in last several hours; cks trending down; bump in cr overnight -> but now trending down : transfused 2 u prbc, spiked temp of 101.9 : checking q8h hct, gets agitated when off sedation : temp to 101.3 in am -> pan cultured, tlso delivered -> neuro still rec log roll and brace when hob>30deg, bronch for copious secretions ll>rl -> bal sent; urine w/low number of enterococcus in culture -> ua still negative; ett with cuff leak -> one-way stop cock placed on balloon and improved balloon integrity : vanc started, colchicine started for gout, to or in am w ortho and trach/peg , enterococcus in urine and bal w coag + staph. : started on strength feeds and meds switched to d5w diluent. uc resent. spiked temp overnight and was pancultured. : foley replaced; vanco to continue for the next 2 days -> then switch to nafcillin for mssa pna; tf held in anticipation of or --> to go with trauma for trach/ped/ivc :blenis negative, peep decreased, or case cancelled, tfs restarted and held again after midnight : went to or for trach, peg, ivc filter. dc'd vanco, started on nafcillin. to start using gj tube evening. will have full strenth tfs at 85cc/hr with 125cc free water q 4h. started on metoprolol via j tube. pancultured overnight. : a-line resited to l radial, ps for good part of the day - then with pco2 near 60 -> switched to cmv; spike fever at 0445 am to 101.2 -> pan cultured, given tylenol -> will need cvl changed out : 2u prbcs given; or for rle orif; weaned to trach mask; weaning sedation; methadone started; ordered; mental status clearing. new scv line. : trial of trach mask, switched back to psv. received dulcolax supp to move bowels, continue free water, wearing tls support and knee brace, requested podiatry consult for gout, speech and swallow and pt consult. awaiting trapeze and new bed. . : continued to spike fevers and rising wbc; a repeat ct torso was obtained that demonstrated no changes to his prior ct. again, tolerated short periods of trach collar. he was restarted on colchine for a presumptive gout flare. from the period of , his wbc normalized and he did not spike any fevers. abgs and vbgs did demonstrate hypercarbia. he still required periods of cpap/ps during the day/night. given his persistent hypercarbia, his tube feeds were changed from replete with fiber to pulmacare tube feedings, of a lower carbohydrate composition. his cvl was removed and a picc was placed with confirmation of position. speech and swallow attempted passy-muir valve trials, but he only tolerated a brief period and recommended continued therapy in rehab. he currently has a shiley #8, extended length, cuffed. medications on admission: paroxetine 20mg daily amitryptiline 25mg daily trazadone 150mg daily norvasc 10mg daily atenolol 50mg simvastatin 40mg daily actos 45mg daily allopurinol 100mg daily indomethacin 50mg tid:prn discharge medications: 1. chlorhexidine gluconate 0.12 % mouthwash sig: five (5) ml mucous membrane (2 times a day). 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed. 4. nystatin 100,000 unit/ml suspension sig: five (5) ml po q8h (every 8 hours) as needed for oral thrush. 5. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed for itching. 6. oxycodone 5 mg/5 ml solution sig: five (5) ml po q3h (every 3 hours) as needed for pain / aggitation. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 8. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 10. insulin regular human 100 unit/ml solution sig: one (1) inj injection asdir (as directed). 11. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). 12. haloperidol 2 mg tablet sig: one (1) tablet po qid (4 times a day) as needed. 13. atenolol 50 mg tablet sig: one (1) tablet po bid (2 times a day). 14. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 15. dicloxacillin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours): to end on . 16. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 17. colchicine 0.6 mg tablet sig: one (1) tablet po bid (2 times a day). 18. paroxetine hcl 20 mg tablet sig: one (1) tablet po daily (daily). 19. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). tablet(s) 20. indomethacin 25 mg capsule sig: one (1) capsule po tid (3 times a day). 21. erythromycin 5 mg/g ointment sig: one (1) gtt ophthalmic qid (4 times a day). discharge disposition: extended care facility: northeast - discharge diagnosis: left distal femur fracture, right tibial and fibular fracture, mesenteric hematoma, left 5,7,10 rib fractures, right iliac fracture extending to the acetabulum, superior sternal fracture, t8 vertebral body fracture. ventilator-associated pneumonia ventilator-dependence discharge condition: afebrile. vital signs stable. intermittently tolerating trach mask for short intervals. ice chips po w/tube feeds at goal through the peg. discharge instructions: do not take anything by mouth except ice chips until you are evaluated again by speech and swallow. you need to wear your tlso brace until your are told not to by dr . 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 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. followup instructions: please follow up with dr in trauma clinic in 2 weeks. call to make an appointment. you will need a repeat chest xray before this appointment, make sure to let the secretary know when you make your appointment. please follow up regarding your t8 fracture with dr in 4 weeks. call ( to schedule this appointment. you will need to have repeat lumbar and thoracic xrays before this visit. let the secretary know this when you make your appointment. please follow up in 1 week with dr for your femur, tibia, and fibula fractures. call ( to make an appointment. you will also need repeat xrays of your left femur and right tibia and fibula before this appointment, let the secretary know this when you schedule your appointment. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Interruption of the vena cava Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Application of external fixator device, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Open reduction of fracture with internal fixation, femur Removal of implanted devices from bone, tibia and fibula Closed reduction of fracture with internal fixation, tibia and fibula Diagnoses: Other iatrogenic hypotension Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Gout, unspecified Pulmonary collapse Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Closed fracture of patella Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Accidents occurring in residential institution Flail chest Closed fracture of unspecified part of fibula with tibia Street and highway accidents Closed fracture of eight or more ribs Closed fracture of acetabulum Closed fracture of ilium Abnormal sputum Injury to other gastrointestinal sites, without mention of open wound into cavity Closed fracture of lower end of femur, unspecified part Functional quadriplegia |
allergies: no known allergies / adverse drug reactions attending: addendum: upon review with radiologist, dr., there is a suggestion of new small lung nodule on the left projecting over the second anterior rib seen on pa and lat cxr . recommend follow up with primary care physician for further investigation given his past medical history. discharge disposition: home with service facility: vna md Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Aortography Implant of pulsation balloon Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Depressive disorder, not elsewhere classified Pulmonary collapse Other and unspecified hyperlipidemia Anxiety state, unspecified Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Postsurgical hypothyroidism Personal history of malignant neoplasm of larynx |
allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain, hypotension during catheterization major surgical or invasive procedure: urgent coronary artery bypass graft x4; left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, obtuse marginal-1 and obtuse marginal-2 cardiac cath history of present illness: 68 year old man has a history of hypertension, hyperlipidemia and throat cancer s/p surgical resection, radiation and chemotherapy in . he reports that about three weeks ago he felt a sudden crushing chest discomfort across his entire chest at rest. his wife noted that he looked quite pale. the entire episode lasted approximately 20 minutes before eventually resolving spontaneously. because of this event, he contact his pcp who referred him for stress testing on . he was only able to exercise 3 minutes before needing to stop due to severe chest discomfort, dyspnea and fatigue. he was referred for left heart catheterization. he was referred to cardiac surgery for revascularization and possibly and aortic valve replacement and mitral valve replacement. during catheterization he transiently became unstable and an iabp was placed. past medical history: hypertension hyperlipidemia throat and neck cancer s/p surgery, radiation and chemotherapy hypothyroidism (as a result of thyroid resection at the time of cancer surgery) gerd anxiety/depression mild arthritis involving the left shoulder left ankle fracture s/p surgery screws/pins/plate s/p tonsillectomy s/p throat and neck cancer s/p resection social history: - tobacco history: none - etoh: rare social - illicit drugs: none works as a semi-truck driver, lives in with his wife family history: - mother: died at 88yo of ad and chf - father: died at 58 following an mi physical exam: pulse: resp: o2 sat: b/p 94/ height:5'9" weight:200 lbs general:a&ox3, nad skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema _____ varicosities: none neuro: grossly intact pulses: femoral right: left: dp right: left: pt :2+ left:2+ radial right:2+ left:2+ carotid bruit none right:2+ left:2+ pertinent results: cath: 1. coronary angiography in this right dominant system demonstrated 2 vessel cad. the lmca had a distal 20% lesion. the lad had a 95% lesion in the mid segment of the vessel with a thrombotic appearance. the d1 branch had an 80% lesion. there was an 80% lesion in the large upper pole of the om1 and an 80% lesion in om2. the rca had a proximal 30% lesion. 2. immediately following access in the right radial artery, the patient developed severe profound hypotension which was slow to improve following iv fluids, atropine and dopamine. right heart cath then performed from right cfv access. hemodynamics performed at this point showed pulmonary artery systolic hypertension with a pasp of 35mmhg. there evidence of prominant v waves during systolic hypotension likely due to ischemic mitral regurgitation, that resolved with normotension. cardiac output was normal at 8.84 l/min. 3. left ventriculography demonstrated a normal ejection fraction of 60% and mild mitral regurgitation. aortography demonstrated a dilated aortic root. 4. successful placement of iabp via rfa. . echo: overall left ventricular systolic function is mildly depressed (lvef= 45-50 %) secondary to hypokinesis of the distal septum and apex. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. an aortic dissection cannot be excluded. a linear, ill defined structure is seen along the posterior wall of the ascending aorta with independent motion is suggestive of a dissection (clip ), but the structure is not respected by color doppler (clip), making an artifact more likely . mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is an anterior space which most likely represents a prominent fat pad. 04:45am blood wbc-10.8 rbc-3.35* hgb-10.3* hct-31.0* mcv-93 mch-30.8 mchc-33.2 rdw-14.3 plt ct-178 11:30am blood wbc-6.4 rbc-4.14* hgb-12.8* hct-36.8* mcv-89 mch-30.9 mchc-34.8 rdw-13.5 plt ct-201 04:57am blood pt-13.7* ptt-27.6 inr(pt)-1.3* 04:50pm blood pt-11.7 ptt-51.6* inr(pt)-1.1 04:45am blood glucose-120* urean-23* creat-0.8 na-137 k-4.5 cl-100 hco3-25 angap-17 11:30am blood glucose-144* urean-17 creat-1.0 na-141 k-4.2 cl-107 hco3-23 angap-15 brief hospital course: mr. a cardiac cath on which revealed severe coronary artery disease. during catheterization he transiently became unstable and an iabp was placed. he surgical work-up and on he was brought to the operating room where he an urgent coronary artery bypass graft x 4 (left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, obtuse marginal-1 and obtuse marginal-2) with dr..please see operative report for surgical details. he tolerated the procedure well and was transferred to the cvicu intubated and sedated. within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. on post-op day one his iabp was removed. he was started on beta-blockers/statin/aspirin and diuresed towards his pre-op weight. later this day he was transferred to the step-down floor for further care and monitoring. physical therapy was consulted for evaluation of his strength and mobility. the remainder of his postoperative course was essentially uneventful. he continued to progress and was cleared for discharge to home on pod# 4 with vna and pt services. all follow up appointments were advised. medications on admission: fluoxetine 80 mg daily hydrochlorothiazide 25 mg daily levothyroxine 100 mcg daily nadolol 1200 mg daily omeprazole 20 mg daily simvastatin 10 mg daily aspirin 81 mg daily multivitamin 1 tablet daily discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 4. fluoxetine 20 mg capsule sig: four (4) capsule po daily (daily). disp:*120 capsule(s)* refills:*2* 5. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 7. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 8. lasix 40 mg tablet sig: one (1) tablet po once a day for 10 days. disp:*10 tablet(s)* refills:*0* 9. potassium chloride 10 meq tablet extended release sig: one (1) tablet extended release po once a day for 10 days. disp:*10 tablet extended release(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 4 past medical history: hypertension hyperlipidemia throat and neck cancer s/p surgery, radiation and chemotherapy hypothyroidism (as a result of thyroid resection at the time of cancer surgery) gerd anxiety/depression mild arthritis involving the left shoulder left ankle fracture s/p surgery screws/pins/plate s/p tonsillectomy s/p throat and neck cancer s/p resection discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesia incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema: 1+ bilateral lower extremities discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. cardiologist: dr. please call to schedule appointments with your primary care dr. n. padala in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Aortography Implant of pulsation balloon Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Depressive disorder, not elsewhere classified Pulmonary collapse Other and unspecified hyperlipidemia Anxiety state, unspecified Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Postsurgical hypothyroidism Personal history of malignant neoplasm of larynx |
allergies: no known allergies / adverse drug reactions attending: chief complaint: left sided subdural hematoma major surgical or invasive procedure: left sided craniotomy for subdural hematoma evacuation history of present illness: this is a 17 year old male who was playing football at 330 pm today when he hit his head against another player. there was no loss of consciousness. the patient was brought to and has had 3 episodes of vomiting since the accident. he reported ringing in the ears immediately after the accident. the head ct at the osh was consistent with possible epidural hematoma per the osh. the patient was transferred here for further treatment and evaluation. currently, the patient denies nausea, numbness, tingling, weakness, or bowel and bladder dysfunction. he has a headache a level 2 on a pain scale. past medical history: appendectomy social history: football player. high school senior. two teenage brothers. family history: non-contributory physical exam: gen: anxious comfortable, heent: no laceration, no raccoon/battle sign, no hemotympanum or rhinorrhea. pupils: 4-3mm eoms: intact neck: hard cervical collar extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. recall: objects at 5 minutes. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 4 to 3 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch, proprioception, pinprick and vibration bilaterally. toes downgoing bilaterally coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin . . discharge exam: tolerating po. pain well controlled. wound clean and intact. non-focal neurological examination. pertinent results: discharge labs: 03:59am blood wbc-9.5 rbc-3.62* hgb-10.7* hct-32.0* mcv-89 mch-29.7 mchc-33.5 rdw-12.4 plt ct-191 03:59am blood pt-15.1* ptt-28.1 inr(pt)-1.3* 03:59am blood glucose-94 urean-9 creat-0.9 na-135 k-3.9 cl-101 hco3-24 angap-14 . . radiology: initial ct head left frontoparietal extra-axial hematoma extending along the falx cerebri, unchanged from the prior exam. while the morphology centrally of the hemorrhage suggests an epidural source, the location (crossing the coronal suture) cofnirms subdural localization. stable midline shift to the right by about 6 mm. no fracture. ct c-spine no fracture or abnormal alignment ct head post-op 1. expected postoperative changes status post evacuation of a left hemispheric subdural hematoma including minimal residual blood products and pneumocephalus. 2. marked reduction in rightward shift of normally midline structures, as described above. 3. no new intracranial hemorrhage or acute large vascular territorial infarction. ct head w/o contrast study date of 4:29 am impression: 1. since , slight re-accumulation of left subdural blood, with maximal depth of 5 mm, and little mass effect. 2. slight, 2mm rightward shift and mild left cerebral hemispheric edema, unchanged. 3. no central herniation. brief hospital course: patient presented to from an osh as a trasnfer for subdural hematoma. he was emergently evaluated in the emergency room and imaging was reviewed. it was felt that emergent intervention via left craniotomy for evacuation of the subdural hematoma was warranted. he was taken to the operating room for evacuation of the blood and a subgaleal drain was placed. he tolerated the procedure well, was extubated in the operating room, and transferred to the icu post-operatively for management and observation. his jp drain was placed to bulb suction and he remained stable overnight in the icu. on the morning of he was stable and his pain was well controlled. his jp drain was deemed fit for removal at 1200 on and it was removed without incident and 3 staples were placed over the exit site. he was transitioned to the floor on and there were no issues post icu transfer. he was transitioned from phenyton to levetiracetam for seizure prophylaxis (he did not have a seizure during his stay) and this will be continued until he is assessed in 4 weeks. he was assessed by pt and ot who deemed him safe for discharge on . he will schadule follow-up with dr with repeat ct head in 4 weeks. he will also schedule neurology follow-up with dr . he has been advised to have a wound check and staple removal at his pcp's office in days from date of surgery and will make an appointment to see his pcp as soon as possible post discharge. medications on admission: none discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) for 5 doses. disp:*10 tablet, delayed release (e.c.)(s)* refills:*0* 3. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for headache. disp:*40 tablet(s)* refills:*0* 4. keppra 750 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*1* 5. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po q6h (every 6 hours) as needed for headache. disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: subdural hematoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you during your stay at the . you presented to hospital after sustaining a head injury whilst playing football but did not lose consciousness and were found to have a collection of bood around your brain called a subdural hematoma. given the size of this bleeding which is due to rupture of veins on the surface of the brain, you went on to have an operation so that the resultant blood clot could be removed. the operation was succsessful and you did well following your operation. you were started on pain killers and anti-seizure medications given a risk of seizures following irritation of the brain following your injury. you have not had a seziure and do not have epilepsy and hence there are no driving restrictions for this. after evaluation by pysical therapy and occupational therapy, were deemed fit for discharge. you should make an appointment to see dr in 4 weeks and we will evaluate you with a repeat ct scan at this time. further follow-up will be organised as appropriate depending on the scan results and how you are doing clinically. sometimes patients can have some memory problems and issues with concentration following head injuries (although you have the benefit of not having lost consciousness at the time) and you should therefore follow-up as below with dr who is a neurologist who will assess memory, concentration and other areas of brain function following your head injury. you should see your pcp as soon as possible following discharge. medication changes: we started keppra 750mg twice daily which you should take until follow-up with neurosurgery at which point the need for continuation of this will be addressed we started laxatives we started fioricet 1-2 tabs as needed and this should be taken first as a pain killer for headaches. eventually this can be weaned to regular tylenol. we started oxycodone 5-10mg as needed every 4 hours for pain. this should be taken sparingly and only if fioriccet is not effective. this can be sedating so be cautious of this. patient instructions: no contact sports for a minimum of 6 months ?????? have a friend/family member check your incision daily for signs of infection. ?????? take your pain medicine as prescribed. ?????? exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? you may wash your hair only after sutures and/or staples have been removed. if your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. 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 have been prescribed keppra for anti-seizure medicine, take it as prescribed. you will not require blood work monitoring for this medication. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? fever greater than or equal to 101?????? f. followup instructions: make an appointment to see your pcp as soon as possible following discharge. ??????please make an appointment to have your staples removed at your pcp days (from your date of surgery) and a wound check. ??????please call ( to schedule an appointment with dr. , to be seen in 4 weeks. ??????you will need a ct scan of the brain without contrast at that time. you can schedule this when making your appointment with dr. . please follow up with dr at name: , md professor neurology office phone: ( office location: e/ks 284 department: neurology organization: you should make an appointment for evaluation within two weeks of being home. he specializes in evaluation of function of post traumatic brain injury patients. Procedure: Incision of cerebral meninges Other repair of cerebral meninges Diagnoses: Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Other accidents Activities involving american tackle football |
Subsets and Splits